A ten-year review of lower extremity burns in diabetics: small burns that lead to major problems

The Effects of the COVID-19 Pandemic on Burn Clinic

The COVID-19 pandemic has led to anxiety and fears for the general public. It is unclear how the behavior of people with acute burns and the services available to them has changed during the pandemic. The aim of our observational study was to evaluate our clinic’s experience with patients presenting with burns during the first ten months of the COVID-19 pandemic and determine if delays in presentation and healthcare delivery exist within our burn population. Patients referred to our clinic from March 1, 2020 to Dec 15, 2020 were reviewed for time of presentation after injury. We defined a true delay in presentation of >5 days from date of injury to date of referral for patients who were not inpatients at our facility or received initial care elsewhere prior to referral. Of the 246 patients who were referred to our clinic, during this time period, 199 patients (80.89%) attended their appointments. Our in-person clinic volume from referrals increased in July 2020 with a sharp decrease in August 2020. Our total clinic volume decreased in 2020 from 2019 by about 14%. Referrals to our clinic decreased in 2020 from 2019 by about 34%. Video telehealth visits did not account for the decrease in visits. There was low incidence of delays in presentation to our clinic during the pandemic. Additional investigation is necessary to see if the incidence of burn injury decreased. Despite the pandemic, our clinic remained ready and open to serve the burn population.

Foot Burns in Persons with Diabetes—Outcomes from the National Trauma Data Bank

Diabetes Mellitus (DM) complicates the treatment of burn injuries. Foot burns in diabetic patients are challenging problems with unfavorable outcomes. National-scale evaluations are needed, especially with regard to limb salvage. We aim to characterize lower extremity burns in persons with DM and evaluate the likelihood of amputation. The National Trauma Data Bank (NTDB) was queried from 2007-2015 extracting encounters with primary burn injuries of the feet using International Classification of Diseases (ICD) 9 th Edition codes. Logistic regression modeled predictors of lower extremity amputation. Covariables included age, sex, race/ethnicity, comorbidities including DM, % burn total body surface area (TBSA), mechanism, and region of burn center. Poisson regression evaluated temporal incidence rate changes in DM foot burns. Of 116,796 adult burn encounters, 7,963 (7%) had foot burns. Of this group, 1,308 (16%) had DM. 5.6% of encounters with DM foot burns underwent amputation compared to 1.5% of non-DM encounters (p<0.001). Independent predictors of lower extremity amputation included DM (OR 3.70, 95% CI 2.98 – 4.59), alcohol use, smoking, chronic kidney disease, burn size >20%, African American/Black race, male sex, and age>40 years (all p<0.01). The incidence of DM foot burns increased over the study period with an incidence rate ratio (IRR) of 1.07 (95% CI 1.05 – 1.10, p<0.001). In conclusion, DM was associated with nearly a 4-fold increase in amputation after adjusting for covariables. Furthermore, the incidence of DM foot burns is increasing. Strategies for optimizing care in persons with DM foot burns are need to improve limb salvage.

Comparison of clinical outcomes of lower extremity burns in diabetic and non-diabetic patients: a retrospective analysis

Diabetes mellitus is an increasingly prevalent chronic disease that leads to long-term health consequences. Some long-term clinical sequelae of diabetes include coronary artery disease, peripheral vascular disease, peripheral neuropathy, and impaired wound healing. These can increase hospital stay and complications such as wound infections and amputations among patients with lower extremity burns. A retrospective analysis was performed of all isolated lower extremity burns from a single tertiary burn care centre from 2006-2017. Patients were stratified by diabetic status and the incidence of lower extremity amputations was the primary outcome. Multivariable regression was used to model the association between diabetes and amputations, adjusting for patient and injury characteristics. A total of 198 patients were identified as meeting inclusion criteria, 160 were non-diabetic and 38 were diabetic. Age was significantly different between non-diabetic and diabetic patients; mean age was 46 ± 18 years versus 62 ± 17 years (p<0.0001). Length of stay was also significantly different, median length of stay was 11 (IQR 7-15) versus 18 (IQR 12-24) (p<0.001), with diabetic patients staying longer. There was a significantly greater proportion of diabetic patients that had an amputation (control 4% versus diabetic 29%; p<0.0001). After adjustment for patient and injury characteristics, there was a significant association between diabetes and amputation (p=0.002). Among patients with isolated lower extremity burns, those with a pre-existing condition of diabetes had a longer hospitalization and increased amputations, despite similar size of burn. Diabetes is an important risk factor to acknowledge in patients with these injuries to optimize care.

In Patients with Lower Extremity Burns and Osteomyelitis, Diabetes Mellitus Increases Amputation Rate

In this retrospective analysis, we investigated the rate of radiologically confirmed osteomyelitis, extremity amputation and healthcare utilization in both the diabetic and non-diabetic lower extremity burn populations to determine the impact of diabetes mellitus on these outcomes. The burn registry was used to identify all patients admitted to our tertiary burn center from 2014 to 2018. Only patients with lower extremity burns (foot and/or ankle) were included. Statistical analysis was performed using Student's t test, chi-squared test, and Fischer's exact test. Of the 315 patients identified, 103 had a known diagnosis of diabetes mellitus and 212 did not. Seventeen patients were found to have osteomyelitis within three months of the burn injury. Fifteen of these patients had a history of diabetes. Notably, when non-diabetics were diagnosed with osteomyelitis, significant differences were observed in both length of stay and cost in comparison to their counterparts without osteomyelitis (36 vs 9 days; p=0.0003; $226,289 vs $48,818, p=0.0001). Eleven patients required an amputation and 10 (90.9%) of these patients had comorbid diabetes and documented diabetic neuropathy. Compared to non-diabetics, the diabetic cohort demonstrated both a higher average length of stay (13.7 vs 9.2 days, p-value=0.0016) and hospitalization cost ($72,883 vs $50,500, p-value=0.0058). Our findings highlight that diabetic patients with lower extremity burns are more likely to develop osteomyelitis than their non-diabetic counterparts and when osteomyelitis is present, diabetic patients have an increased amputation rate. Further study is required to develop protocols to treat this population, with the specific goal of minimizing patient morbidity and optimizing healthcare utilization.

Burn Prevention in the Elderly: Identifying Age and Gender Differences in Consumer Products Associated With Burn Injuries

Elderly suffer worse outcomes from burns; thus, it is important to identify the causes of burns in the elderly to develop burn prevention campaigns. We performed a 10-year review of burns that were registered in the NEISS database. We included patients at least 65 years old and analyzed the top five products that caused burn injury. In adults 65 to 74 years old, hot water was the most common cause of burns. Women suffered more burns by candles and cookware. Heaters/heating systems and gasoline were among the top five causes of burns in only men. For the age group 75 to 84 years old, the most common burn was from hot water in women and gasoline in men. For women, the top five included candles, nightwear, and cookware. Only men suffered gasoline burns. The majority of daywear, home/room fire, and ranges/ovens caused burns occurred in men. The majority of burns from hot water, ranges/ovens, electric heating pads, and bathtubs/showers occurred in women. For men, burns from gasoline, structural fires, and heaters are more prevalent. This data can be used to develop age- and gender-specific prevention campaigns to reduce the risk of burn injury.

Clinical outcomes following burn injury across the continuum of chronic glycemic control

Diabetes has been associated with poor outcomes following burn injury. There is limited data related to prediabetes in burn injury, and no studies to date have compared clinical outcomes inpatients without diabetes, with prediabetes, and with diabetes. Therefore, this study aimed to compare clinical outcomes after burn injury across the continuum of pre-injury glucose control. A propensity score weighted cohort study of adult patients admitted for initial management of burn injury was performed. Patients were categorized as no diabetes, prediabetes or diabetes based on their admission hemoglobin A1c and past medical history. The primary outcome was length of stay per percent Total Body Surface Area (TBSA) burn. Secondary outcome measures included length of stay, all-cause hospital mortality, disposition at discharge, re-grafting of same site, and amputations. A total of 2450 patients were screened; 1137 patients were included for evaluation (236 diabetes, 191 prediabetes, 710 no diabetes). After inverse probability weighing to adjust for potentially confounding factors, patients in the diabetes group had longer length of stay/%TBSA burn than both the no diabetes group (ratio of geometric means (95% CI) = 1.65 (1.25, 2.18), p < 0.001) and the prediabetes group (ratio (95% CI) = 1.49 (1.10, 2.02), p = 0.01). No statistically significant differences in secondary outcomes were observed between groups other than a higher rate of amputations in the diabetes group (2.7%) compared to the no diabetes (0.7%, p = 0.047) and prediabetes (0%, p = 0.04) groups. Further studies are needed to delineate the differences across the continuum of pre-injury glucose control in order to identify mechanisms to optimize burn-related outcomes.

Foot ulcers associated with external trauma among people with diabetes: An integrative review of the origin of trauma and outcomes

BACKGROUND

Foot ulcers are common among people with diabetes. These ulcers are caused by a number of factors including trauma. To date, research findings on the origin of external trauma and the outcome of foot ulcers resulting from an external trauma have not been summarised.

OBJECTIVE

To examine the origin of external trauma that contribute to the development of foot ulcers among people with diabetes and the outcome of such ulcers.

DESIGN

An integrative review.

SETTINGS

Hospital/community.

PARTICIPANTS

Patients with diabetes and foot ulcer.

METHOD

The Joanna Briggs framework was used to underpin this integrative review. Six different databases (CINAHL +, Medline, SCOPUS, Embase, ProQuest and Web of Science databases) were searched systematically to find research publications reporting traumas that contributed to foot ulcers sustained by people with diabetes. The search was limited to articles published in English. The search revealed 3193 articles that were filtered to 78 articles to be assessed at the full-text level and 45 articles were subsequently included. Quality appraisal was conducted independently by two reviewers, using the Joanna Briggs Institute (JBI) Critical Appraisal tools. Data were extracted into a form developed for the purpose of this review. Narrative synthesis was used to manage the extracted verbatim details on the origin of external trauma contributing to foot ulcers and the outcomes.

RESULTS

The origins of external trauma were summarised into two domains and further specified into 16 categories. The identified traumas were mainly minor and originated within the home environment. The most commonly reported origins of external trauma were puncture wounds, ill-fitting shoes and self-care practices that caused foot ulcers. Twenty-seven studies reported outcomes following the development of an ulcer. Twenty-two studies reported amputation as an outcome and mortality was reported in 10 studies. It was not clear whether these outcomes were directly related to the foot ulcer or related to other diabetes-related complications.

CONCLUSIONS

The majority of ulcers occurred in the home environment and were preventable in nature. The assessment of an individual's local context, particularly the home and actions to reduce risk is a priority. The extent of the risks related to external trauma need to be more widely communicated through clinical guidelines and training opportunities for frontline staff.

TWEETABLE ABSTRACT

The main origins of external foot trauma among people with diabetes were puncture wounds, ill-fitting footwear and self-care practices.

Burn Wound Colonization, Infection, and Sepsis

Background: Infection is a major cause of morbidity and mortality among burn patients, and it is important to understand the progression of wound colonization to wound infection to systemic sepsis. Methods: After a review of the literature we describe the clinical characteristics of burn wound colonization, infection, and sepsis, and conclude with best practices to decrease these complications. Results: Burn wounds are initially sterile after the thermal insult but become colonized by gram-positive organisms and subsequently by gram-negative organisms. Some populations are especially susceptible to initial or subsequent colonization by drug-resistant organisms. An increase in fungal colonization has been observed because of the widespread use of topical antibiotic agents. Male gender, older age, lower extremity burn, scald burn, full-thickness burn, delay in treatment, and pre-existing diabetes place patients at increased risk of infection. These infections range from cellulitis that requires systemic antibiotic agents, to invasive burn wound infection that requires prompt treatment with antibiotic agents and excision. Fungal wound infections pose a special challenge and cause substantial morbidity. Infection that leads to systemic sepsis is difficult to define in burn patients because of the body's compensatory hypermetabolic response to the burn injury. Potential sources of sepsis include wound infections and common nosocomial infections. The American Burn Association Sepsis criteria, defined in 2007, has demonstrated poor specificity for identifying sepsis and septic shock. The best approach to decrease wound infections is prevention. Practices that have been beneficial include isolation rooms, handwashing, appropriate wound care, early excision and grafting, antibiotic stewardship, and nutritional support. Conclusions: A burn patient remains at a substantial risk of wound infection despite advances in care. A burn care provider must understand the natural progression of colonization to infection to sepsis, and the multidisciplinary approach to wound care to limit the morbidity and mortality from these infectious.

Foot burns: A comparative analysis of diabetic and non-diabetic patients

INTRODUCTION

Foot burns represent a small part of the body with many challenges. The impact of diabetes on clinical outcomes adds further issues in management that clinicians must consider in their management. These factors have serious implications on morbidity and long term sequelae. Our aim is to analyse epidemiological trends of foot burns and examine the differences between diabetic and non-diabetics at Concord hospital from 2014 to 2019.

METHODS

A retrospective audit from 2014-19 at Concord General Repatriation Hospital Burns Unit summarised patient demographics, burn injury, diabetic status, operations and length of stay. All foot burn injuries from 2014-19 of all ages and gender that attended Concord burns hospital were included in this study.

RESULTS

We treated 797 patients who presented with foot burns, of which 16.2% were diabetic. The average age was higher in diabetics (60.72 years) than non-diabetics (39.72 years) and more males suffered burns compared to females in both groups (p < 0.001). There was a larger portion of elderly patients (greater than 65 years old, 15.1% of total) who sustained foot burns in the diabetic group compared to the non-diabetic group (p < 0.001). The most affected season was summer (27.0%), but diabetic patients were 1.7 times more likely to sustain injury in winter than non-diabetics. Diabetics were 3.8 times more likely to have contact burns compared to non-diabetic patients (p < 0.001). In a multivariable linear regression analysis, factors that contributed to increased length of stay included elderly status, place of event, diabetic status, number of operations, ICU admission, wound infection, amputation, and admission [F (16, 757 = 41.149, p < 0.001, R² = 0.465].

CONCLUSIONS

With the increase of diabetes, our multidisciplinary approach to diabetic foot care should include nursing, medical and surgical disciplines to identify patients at risk. The data highlights that a focus on prevention and education for diabetes is central to optimize glycaemic control and burn management, whilst providing a multidisciplinary network on discharge.

Altered pain processing in patients with type 1 and 2 diabetes: systematic review and meta-analysis of pain detection thresholds and pain modulation mechanisms

The first signs of diabetic neuropathy typically result from small-diameter nerve fiber dysfunction. This review synthesized the evidence for small-diameter nerve fiber neuropathy measured via quantitative sensory testing (QST) in patients with diabetes with and without painful and non-painful neuropathies. Electronic databases were searched to identify studies in patients with diabetes with at least one QST measure reflecting small-diameter nerve fiber function (thermal or electrical pain detection threshold, contact heat-evoked potentials, temporal summation or conditioned pain modulation). Four groups were compared: patients with diabetes (1) without neuropathy, (2) with non-painful diabetic neuropathy, (3) with painful diabetic neuropathy and (4) healthy individuals. Recommended methods were used for article identification, selection, risk of bias assessment, data extraction and analysis. For the meta-analyses, data were pooled using random-effect models. Twenty-seven studies with 2422 participants met selection criteria; 18 studies were included in the meta-analysis. Patients with diabetes without symptoms of neuropathy already showed loss of nerve function for heat (standardized mean difference (SMD): 0.52, p<0.001), cold (SMD: -0.71, p=0.01) and electrical pain thresholds (SMD: 1.26, p=0.01). Patients with non-painful neuropathy had greater loss of function in heat pain threshold (SMD: 0.75, p=0.01) and electrical stimuli (SMD: 0.55, p=0.03) compared with patients with diabetes without neuropathy. Patients with painful diabetic neuropathy exhibited a greater loss of function in heat pain threshold (SMD: 0.55, p=0.005) compared with patients with non-painful diabetic neuropathy. Small-diameter nerve fiber function deteriorates progressively in patients with diabetes. Because the dysfunction is already present before symptoms occur, early detection is possible, which may assist in prevention and effective management of diabetic neuropathy.

Osteomyelitis Increases the Rate of Amputation in Patients With Type 2 Diabetes and Lower Extremity Burns

In patients with diabetes mellitus (DM), amputation rates exceed 30% when lower extremity osteomyelitis is present. We sought to determine the rate of osteomyelitis and any subsequent amputation in our patients with DM and lower extremity burns. We performed a single-site, retrospective review at our burn center using the institutional burn center registry, linked to clinical and administrative data. Adults (≥18 years old) with DM admitted from January 1, 2014 to December 31, 2018 for isolated lower extremity burns were eligible for inclusion. We evaluated demographics, burn characteristics, comorbidities, presence of radiologically confirmed osteomyelitis, length of stay (LOS), inpatient hospitalization costs, and amputation rate at 3 months and 12 months after injury. We identified 103 patients with DM and isolated lower extremity burns. Of these, 88 patients did not have osteomyelitis, while 15 patients had radiologically confirmed osteomyelitis within 3 months of the burn injury. Compared to patients without osteomyelitis, patients with osteomyelitis had significantly increased LOS (average LOS 22.7 days vs 12.1 days, P = .0042), inpatient hospitalization costs (average $135,345 vs $62,237, P = .0008), amputation rate within 3 months (66.7% vs 5.70%, P &lt; .00001), and amputation rate within 12 months (66.7% vs 9.1%, P &lt; .0001). The two groups were otherwise similar in demographics, burn injury characteristics, access to healthcare, and preexisting comorbidities. Patients with DM and lower extremity burns incurred increased LOS, higher inpatient hospitalization costs, and increased amputation rates if radiologically confirmed osteomyelitis was present within 3 months of the burn injury.

Burns in Diabetes Mellitus Patients among Indian Population: Does it Differ from the Rest?

Background

Burn injuries in adults can be complicated due to various underlying factors. Of all the co-morbidities complicating wound healing and prognosis of the patient post burn injury, diabetes mellitus is the most common in India. We therefore aimed to explore the epidemiology, interventions, complications, and outcomes in diabetic patients with burn injury.

Aim

To analyze demographic characteristics, clinical and microbiological profile and outcome of diabetic burns patients in comparison with nondiabetic burns patients.

Materials and methods

This study was a retrospective analysis of diabetic and nondiabetic burns patients admitted to Apollo speciality clinics, Vanagaram, a tertiary care facility in Chennai over a period of 3 years. Data such as age, gender, type and degree of burns, percentage of burns and length of stay, mortality rate, infection rate, type of infections, surgical procedures, and medical complications were analyzed in comparison with nondiabetic burns patients.

Results

Among ninety-four burns patients admitted to our hospital over a period of 3 years, 18 patients (19%) were diabetics and 76 patients (81%) were nondiabetics. Mean age of diabetics was 58.2 years (SD-17.1) and nondiabetics was 36.3 years (SD-16.4). Surgical intervention with split skin graft was performed in 50% of diabetics and 48.7% of nondiabetics. Average length of stay of diabetics was 12.6 days and nondiabetics was 16.2 days (p value: 0.334). Diabetic patients with burns were noted to have higher rate of infection (67% vs 61.8%, p value: 0.803) and mortality (44% vs 35.5%, p value: 0.482).

Conclusion

The clinical course is different between diabetic and nondiabetic patients with burns injury. Although length of stay and surgical interventions were not significantly different, diabetes as a comorbidity appears to increase the risk of infections and mortality in patients with burns.

How to cite this article

Vadala R, Princess I, Ebenezer R, Ramakrishnan N, Krishnan G. Burns in Diabetes Mellitus Patients among Indian Population: Does it Differ from the Rest? Indian J Crit Care Med 2020;24(1):11–16.

Increased risk of blood transfusion in patients with diabetes mellitus sustaining non-major burn injury

BACKGROUND

Due to the increased mortality and morbidity associated with blood transfusion, identifying modifiable predictors of transfusion are vital to prevent or minimise blood use. We hypothesised that burn patients with diabetes mellitus were more likely to be prescribed a transfusion. These patients tend to have increased age, number of comorbidities, infection risk and need for surgery which are all factors reported previously to be associated with blood use.

OBJECTIVE

To determine whether patients with diabetes mellitus who have sustained a burn ≤20% total body surface area (TBSA) are at higher risk of receiving red blood cell transfusion compared to those without diabetes mellitus.

METHOD

This was a retrospective cohort study including patients admitted to the major Burns Unit in Western Australia for management of a burn injury. Only the first hospital admission between May 2008 to February 2017 were included.

RESULTS

Among 2101 patients with burn injuries ≤20% TBSA, 48 (2.3%) received packed red blood cells and 169 (8.0%) had diabetes. There were 13 (7.7%) diabetic patients that were transfused versus 35 (1.8%) non-diabetic patients. Patients with diabetes were 5.2 (p = 0.034) times more likely to receive packed red blood cells after adjusting for percentage TBSA, haemoglobin at admission or prior to transfusion, number of surgeries, total comorbid burden and incidence of infection. As percentage TBSA increases, the probability of packed red blood cell transfusion increases at a higher rate in DM patients.

CONCLUSIONS

This study showed that diabetic patients with burn injuries ≤20% TBSA have a higher probability of receiving packed red blood cell transfusion compared to patients without diabetes. This effect was compounded in burns with higher percentage TBSA.

Lower Extremity Burns, Complications, and Outcome

We have encountered many burn cases with lower extremity burn with adverse outcome. The study was a retrospective cohort study in 2 years, mean (SD) of follow up was 12(7) months. All demographic data, cause burn, time, total burn surface area (TBSA), presence lower extremity burn and its burn surface area (BSA), foot burn, delay in treatment, smoking, infection, morbidity, co-morbid diseases, length of stay (LOS), amputation, mortality, and outcome were gathered from patients’ files. Statistical analysis was done with SPSS 21software. We had 14,215 burn patients, of them 995 were admitted according to criteria of ABA. Six hundred and ten (61.3%) were male and 358 (37%) female. Male to female ratio was 1.58:1. The mean age ± SD was 33.64 ±23.45. Mean (SD) of lower extremity BSA was 12.09 ± 9.18%. The patients who had 10 to 19% burn, had 3 times more risk of mortality than patients with 0 to 9% burn (P &lt; .018). And those with 20 to 29% burn had 35 times more risk of mortality comparing to patients with 0 to 9% burn. The difference was significant too. (P &lt; .000). Delay in treatment, presence of co-morbid diseases and diabetes would not do any increase in mortality. The sex, weight, cause of burn, diabetes, and delay in treatment have not any influence on the death risk. But age and lower extremity BSA have influence on the risk of death. According to statistical study: with every 1-year increase in age, death rate increased by 4% (P &lt; .0001). With every 1% increase in lower extremity BSA, death rate increase by 9% (P &lt; .0005) and with every 1 day increase in LOS, the death rate increase by 4%. Statistical study shows lower extremity burn, TBSA, age, and LOS have great influence on the outcome of these patients. Sex, weight, cause of burn, and delay in treatment have not affected the risk of mortality.

Neuropathy May Be an Independent Risk Factor for Amputation After Lower-Extremity Burn in Adults With Diabetes

IN BRIEF Treatment of lower-extremity burn injuries in adults with diabetes can be complex, and some diabetes-related factors can lead to impaired healing of such wounds, putting patients at risk of amputation. In this retrospective review of adult patients with lower-extremity burns, patients with pre-injury neuropathy and higher A1C levels were more likely to require amputations after their burn injury. The authors conclude that lower-extremity burn injuries in patients with diabetes require close follow-up and possibly referral to a burn specialist for interventions and treatment strategies to offset more serious complications.

Burn Injuries in Patients with Paralysis: A National Perspective on Injury Patterns and Outcomes

The affect of paralysis-related comorbidities on outcomes in burn-injured patients has not been explored. We hypothesize that comorbid paralysis is associated with increased morbidity in this population. All burned patients with prior diagnoses of paralysis were identified from the National Burn Repository (Version 8.0). One-to-one matching of nonparalyzed burn-injured patients was performed, and nonparametric analysis was used to compare the groups. We identified 432 paralyzed patients, who were predominantly male (70.6%) and Caucasian (57.6%), with an average age of 40.8 ± 19.0 years. The identified level of disability was distinguished as paraplegia (59.5%), hemiplegia (16.9%), quadriplegia (13.9%), or other (9.8%). A majority of injuries occurred in the home (75.2%), primarily due to scalds (48.1%). More than half sustained small injuries with affected total body surface area <5%. Lower extremities were frequently injured (72.2%), with 41.0% affecting exclusively the lower extremities. While the paralysis population had significantly longer hospital lengths of stay, nonparalyzed patients had longer intensive care unit length of stay and ventilator days (P < .001). There was no statistically significant difference in mortality rate between paralyzed and nonparalyzed patients (4.4% vs 4.9%, P = .550). Patients with paralysis are susceptible to small scald injuries in the home. Comorbid paralysis places patients at risk for longer, more indolent hospital stays, when compared with matched nonparalyzed patients with more critical illness. Further investigation is needed regarding the pathophysiologic mechanisms predisposing paralyzed burn patients to increased morbidity.

Sun heated surfaces are an environmental hazard for young children

AIMS

Children commonly sustain heat contact type burn injuries from sun heated surfaces during the summer months in hot, sunny climates. The aim of this study was to review the causes and outcomes in a series of heat contact type burns sustained by children who touched hot sun heated surfaces.

METHODS

A retrospective chart review was performed to identify all children who sustained burn injuries due to naturally heated surfaces and were treated between January 2012 and December 2017 at Children's Hospital Colorado. Demographics of the subjects and clinical data regarding their burn injuries were collected.

RESULTS

A total of 58 children were identified over the study period, involving 118 burn wounds. The median age was 17 months (interquartile range = 14-23), and 33 were male (57%). Mean total body surface area (TBSA) was 1.4% (standard deviation = 1). A foot was the most commonly involved area, affecting 36 subjects (62%). The most common causes of these burn injuries were metal thresholds (n = 7, 12%) and metal covers or lids (n = 5, 9%) outside the home. The depth of the burn injury was partial thickness in 57 children (98%). The mean time to heal was 12 ± 6 days, and the majority of injuries occurred in June (n = 28, 48%).

CONCLUSION

Heat contact type burn injuries from sun heated surfaces commonly affect children ⩽2 years of age during the summer months, and the majority of these injuries occur around the home environment. They are preventable injuries, and this information should be used for prevention and education materials for parents and healthcare providers, who reside in hot, sunny climates.

The effect of diabetes on burn patients: a retrospective cohort study

BACKGROUND

Hyperglycemia during the acute phase after burn is associated with increased morbidity and mortality. There is little knowledge regarding the effect of pre-existing hyperglycemia in the form of diabetes on the outcomes after severe burns. The objective is to determine the impact of diabetes on clinical outcomes after burns.

METHODS

Single-center cohort study where adult diabetic (n = 76) and non-diabetic (n = 1186) burn patients admitted between 2006 and 2016 were included. Diabetic patients were stratified into those with well-controlled diabetes (n = 24) and poorly controlled diabetes (n = 33) using a HbA1c of 7% as a cutoff; additionally, diabetics were divided into well-controlled glycemia (n = 47) and poorly controlled glycemia (n = 22) based on daily blood glucose measurements during hospitalization.

RESULTS

On univariate analysis, diabetics had a significantly increased median length of stay per percent total body surface area burn (2.1 vs. 1.6 days; p = 0.0026) and a greater number of overall morbidity (1.39 ± 1.63 vs. 0.8 ± 1.24; p = 0.001). After adjustment for patient characteristics, diabetics were associated with significantly increased total morbidity (RR 1.5; 95% CI 1.1-1.9). At discharge, almost two thirds of diabetics needed an escalation of anti-diabetic medication and a quarter had newly developed insulin dependency. There were no differences in morbidity or mortality in the diabetic subgroups.

CONCLUSIONS

Diabetics had a longer hospitalization and increased morbidity, regardless of the quality of their anti-diabetic therapy prior to injury. Additionally, diabetes in burn patients is associated with an increased risk of total morbidity.

Limitations to the use of bromelain-based enzymatic debridement (NexoBrid®) for treating diabetic foot burns: a case series of disappointing results

BACKGROUND

Bromelain-based enzymatic debridement with Nexobrid® (Mediwound) is an alternative to traditional surgical tangential excision of deep dermal and full thickness burns. Early literature suggests that Nexobrid debridement could reduce the number of operations, infection rates, inpatient stay and the necessity for skin grafting to wounds by preserving viable tissue. To our knowledge there are no previous studies reporting the use of NexoBrid for treating burns in patients with established diabetic foot disease.

CASE PRESENTATION

We conducted a retrospective case series and identified four patients with diabetic foot burns that were treated with Nexobrid® debridement. All of these patients developed further eschar and deepening of their wounds a few days after NexoBrid was applied, requiring further surgery and skin grafting.

CONCLUSIONS

We would recommend judicious use of this new product in patients with diabetic foot wounds.

Comparative effectiveness of different wound dressings for patients with partial-thickness burns: study protocol of a systematic review and a Bayesian framework network meta-analysis

INTRODUCTION

Selecting a suitable wound dressing for patients with partial-thickness burns (PTBs) is important in wound care. However, the comparative effectiveness of different dressings has not been studied. We report the protocol of a network meta-analysis designed to combine direct and indirect evidence of wound dressings in the management of PTB.

METHODS AND ANALYSIS

We will search for randomised controlled trials (RCTs) evaluating the wound-healing effect of a wound dressing in the management of PTB. Searches will be conducted in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Wounds Group Specialised Register and CINAHL. A comprehensive search strategy is developed to retrieve articles reporting potentially eligible RCTs. Besides, we will contact the experts in the field and review the conference proceedings to locate non-published studies. The reference lists of articles will be reviewed for any candidate studies. Two independent reviewers will screen titles and abstracts of the candidate articles. All eligible RCTs will be obtained in full text to perform a review. Disagreement on eligibility of an RCT will be solved by group discussion. The information of participants, interventions, comparisons and outcomes from included RCTs will be recorded and summarised. The primary outcome is time to complete wound healing. Secondary outcomes include the proportion of burns completely healed at the end of treatment, change in wound surface area at the end of treatment, incidence of adverse events, etc.

ETHICS AND DISSEMINATION

The result of this review will provide evidence for the comparative effectiveness of different wound dressings in the management of PTB. It will also facilitate decision-making in choosing a suitable wound dressing. We will disseminate the review through a peer-review journal and conference abstracts or posters.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42016041574; Pre-results.

Roles of p300 and cyclic adenosine monophosphate response element binding protein in high glucose-induced hypoxia-inducible factor 1α inactivation under hypoxic conditions

Aims/Introduction

Given the high prevalence of diabetes and burn injuries worldwide, it is essential to dissect the underlying mechanism of delayed burn wound healing in diabetes patients, especially the high glucose‐induced hypoxia‐inducible factor 1 (HIF‐1)‐mediated transcription defects.

Materials and Methods

Human umbilical vein endothelial cells were cultured with low or high concentrations of glucose. HIF‐1α‐induced vascular endothelial growth factor (VEGF) transcription was measured by luciferase assay. Immunofluorescence staining was carried out to visualize cyclic adenosine monophosphate response element binding protein (CREB) localization. Immunoprecipitation was carried out to characterize the association between HIF‐1α/p300/CREB. To test whether p300, CREB or p300+CREB co‐overexpression was sufficient to rescue the HIF‐1‐mediated transcription defect after high glucose exposure, p300, CREB or p300+CREB co‐overexpression were engineered, and VEGF expression was quantified. Finally, in vitro angiogenesis assay was carried out to test whether the high glucose‐induced angiogenesis defect is rescuable by p300 and CREB co‐overexpression.

Results

Chronic high glucose treatment resulted in impaired HIF‐1‐induced VEGF transcription and CREB exclusion from the nucleus. P300 or CREB overexpression alone cannot rescue high glucose‐induced HIF‐1α transcription defects. In contrast, co‐overexpression of p300 and CREB dramatically ameliorated high glucose‐induced impairment of HIF‐1‐mediated VEGF transcription, as well as in vitro angiogenesis. Finally, we showed that co‐overexpression of p300 and CREB rectifies the dissociation of HIF‐1α‐p300‐CREB protein complex in chronic high glucose‐treated cells.

Conclusion

Both p300 and CREB are required for the function integrity of HIF‐1α transcription machinery and subsequent angiogenesis, suggesting future studies to improve burn wound healing might be directed to optimization of the interaction between p300, CREB and HIF‐1α.

Diabetic cornea wounds produce significantly weaker electric signals that may contribute to impaired healing

Wounds naturally produce electric signals which serve as powerful cues that stimulate and guide cell migration during wound healing. In diabetic patients, impaired wound healing is one of the most challenging complications in diabetes management. A fundamental gap in knowledge is whether diabetic wounds have abnormal electric signaling. Here we used a vibrating probe to demonstrate that diabetic corneas produced significantly weaker wound electric signals than the normal cornea. This was confirmed in three independent animal models of diabetes: db/db, streptozotocin-induced and mice fed a high-fat diet. Spatial measurements illustrated that diabetic cornea wound currents at the wound edge but not wound center were significantly weaker than normal. Time lapse measurements revealed that the electric currents at diabetic corneas lost the normal rising and plateau phases. The abnormal electric signals correlated significantly with impaired wound healing. Immunostaining suggested lower expression of chloride channel 2 and cystic fibrosis transmembrane regulator in diabetic corneal epithelium. Acute high glucose exposure significantly (albeit moderately) reduced electrotaxis of human corneal epithelial cells in vitro, but did not affect the electric currents at cornea wounds. These data suggest that weaker wound electric signals and impaired electrotaxis may contribute to the impaired wound healing in diabetes.

Variation of surface temperatures of different ground materials on hot days: Burn risk for the neuropathic foot

The purpose of this study is to assess the relationship between ambient temperature and surface temperatures of commonly used building/ground materials, in order to estimate the risk of contact thermal injury. It is an observational study where the air ambient temperature and the surface temperatures of slate, metal, cement, sand, brick and bitumen, were measured, in shaded and unshaded conditions, on cloudy and cloudless days in summer in Adelaide, South Australia. All unshaded surfaces reached temperatures capable of causing significant sole of foot burns given requisite exposure time in both clear and overcast conditions, even with a relatively low ambient temperature. Shade imparted total protection from irreversible thermal injury for all of the ambient temperatures assessed. Although surface temperatures were reduced in overcast conditions, the temperatures recorded were still capable of causing thermal injury. Peripheral neuropathy prolongs heat exposure times, often resulting in significant and complex injury, requiring lengthy treatment and generating potentially poor functional outcomes. This study provides a reference point for the enactment of preventative measures for at risk population groups such a diabetics.

Foot burns and diabetes: a retrospective study

BACKGROUND

Diabetes in conjunction with a foot burn can compound the challenges in wound healing; however, the impact of diabetes on outcomes of patients with foot burns has not been examined.

METHODS

A retrospective notes audit was conducted at the Concord Hospital Burns Unit for patients with foot burns who were admitted from 1(st) January 2012 to 31(st) December 2013. Data were collected for 15 subjects with foot burns and diabetes and 18 subjects with foot burns and no diabetes as a control group. Subjects were matched for percentage total body surface area of burns.

RESULTS

The mean inpatient and total lengths of stay for the diabetic group were 21.27 days and 64.80 days, which were significantly longer (P = 0.090 and P = 0.054) than the 9.61 days and 30.56 days in the control, based on a significance level of 0.10. The diabetic group was significantly older (P = 0.001), at 56.60 years versus 39.44 years in the control. Significantly (P = 0.033) more patients with diabetes were not working (n = 12/15 or 80.00 % versus n = 7/18 or 38.89 %) compared to the control. The diabetic group had higher rates of regrafting (n = 3/15 or 20.00 % versus n = 1/18 or 5.55 %) than the control and significantly (P = 0.013) more amputations (n = 5/15 or 33.33 % versus n = 0 or 0.00 %) compared to the control. Fewer patients with diabetes were prescribed pressure garments (n = 2/15 or 13.33 % versus n = 9/18 or 50.00 %), which was significant (P = 0.034). The increased age of patients in the diabetic group correlates with results from other studies. Healing time may be reflected by total length of stay, which was more than double for patients with diabetes, increasing demand and cost of inpatient and outpatient services.

CONCLUSION

This study highlights the importance of recognizing the potential for poorer outcomes for patients with diabetes and indicates the need for more burn prevention education and promotion in this 'at risk' patient group.

Epidemiology of foot burns in a Dutch burn centre

Background

Although the feet involve a small percentage of the total body surface area, they can have major effects in daily life, caused by prolonged bed rest, hospitalization and high risk of both early and late complications. The aim of this study was to define the aetiology, treatment and outcomes of foot burns, with special interest in paediatric patients, patients with diabetic disease and burns acquired at the workplace.

Methods

This is a retrospective cohort study of 82 patients who were admitted to one of the three burn centres in the Netherlands during the period 2004 to 2013. The patients had a median age of 43.5 years (range 0.01–85.9), and included 14 children and 8 diabetics. Data were collected from the hospital records.

Results

Scalding was the most common cause of the injury. Almost all patients required surgical management. It is notable that most of hospitalized patients (82 %) were not admitted on the day of injury. Children had a significantly shorter length of stay compared to adults (p = 0.01). The eight patients with diabetes had a significantly longer length of hospital stay, more complications and more often residual defects compared to the non-diabetic patients. In 13 patients, the injury took place at work. Half of these burns were caused by scalding, and foot burns caused by chemicals at work were rare (two patients).

Conclusions

Although the incidence of foot burns is low, there is a significant morbidity due to complications and long hospital stay. The following three points are suggested. Immediate referral to a burn centre is essential. It is important to educate diabetic patients on the risk of complications and adverse outcomes after burn injury. Preventative measures at the workplace are worth considering.