Factors Affecting Burn Contracture Outcome in Developing Countries: A Review of 2506 Patients

Economic Evaluation of a Global Reconstructive Surgery Visiting Educator Program

Objective

The objective of this study was to quantify the cost-effectiveness and economic value of a reconstructive surgery visiting educator trip program in a resource-constrained setting.

Background

Reconstructive surgical capacity remains inadequate in low- and middle-income countries, resulting in chronic disability and a significant economic toll. Education and training of the local surgical workforce to sustainably expand capacity have been increasingly encouraged, but economic analyses of these interventions are lacking.

Methods

Data were analyzed from 12 visiting educator trips and independently-performed surgical procedures at 3 Vietnamese hospitals between 2014 and 2019. A cost-effectiveness analysis was performed using standardized methodology and thresholds to determine cost-effectiveness. Sensitivity analyses were performed with disability weights, discounting, and costs from different perspectives. Economic benefit was estimated using both the human capital method and the value of a statistical life method, and a benefit-cost ratio was computed.

Results

In the base case analysis, the visiting educator program was very cost-effective at $581 per disability-adjusted life year (DALY) averted. Economic benefit was between $21·6 million and $29·3 million, corresponding to a 12- to 16-fold return on investment. Furthermore, when considering only costs to the organization, the cost decreased to $61 per DALY averted, with a 113- to 153-fold return on investment for the organization.

Conclusions

Visiting educator programs, which build local reconstructive surgical capacity in limited-resource environments, can be very cost-effective with significant economic benefit and return on investment. These findings may help guide organizations, donors, and policymakers in resource allocation in global surgery.

Treatment of Severe Postburn Contracture of the Elbow via Distraction With External Circular Frame in Pediatric Patient

BACKGROUND

Although external circular frame (ECF) has been widely used for the correction of knee and ankle deformities, few studies reported the use of ECF for the treatment of severe postburn elbow contracture and stiffness (SPECS). The purpose of this retrospective study was to investigate the effectiveness and safety of the distraction using ECF in treating SPECS.

METHODS

After institutional review board approval, we implemented a retrospective single-center case series study composed of consecutive patients treated for SPECS at Chinese PLA General Hospital between January 2010 and January 2018. After scar release and skin grafting, distraction with ECF was performed for 4 to 6 weeks, and the frame was retained for 2 more weeks before removal. Four weeks of splinting and at least 1 year of rehabilitation were recommended. Patient demographics, active and passive range of motion (ROM) of the elbow at different time points (preoperative, postdistraction, and final follow-up), and complications were collected from the electronic medical record. The primary outcome was the long-term improvement of the ROM. Other outcomes included complications and recurrence.

RESULTS

The ECF was used to treat SPECS in 6 patients (3 males and 3 females, average age of 11.7 ± 2.6 years). Scar release and distraction with ECF significantly increased both active (from 3° preoperative to 38.7° postdistraction) and passive (from 3.5° preoperative to 48.3° postdistraction) ROM over an average distraction duration of 5.2 weeks. The long-term improvement of active and passive ROM was 38° ± 13.4° and 46° ± 14.7°, respectively, over a median follow-up of 4.1 years. Pin-tract infection occurred in 2 patients and were treated with local wound care and oral antibiotics. A tendon readhesion developed in 1 of the 6 patients because of noncompliance with splinting and physiotherapy, and was treated with revision surgery.

CONCLUSIONS

The 3C strategy (i.e., contracture release, coverage of the defect with skin grafting, and correction of articular angle with gradual distraction using the ECF) is able to increase the ROM with minor complications. We recommend distraction with ECF as part of the treatment arsenal, particularly for severe contractures in which 1-stage correction is unfeasible because of considerable soft tissue shortening.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up

OBJECTIVE

The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country.

METHODS

Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury.

RESULTS

Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns.

CONCLUSION

The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study with long-term follow-up in a Low- and Middle-Income Country

OBJECTIVE

Burn scar contractures limit range of motion (ROM) of joints and have substantial impact on disability and the quality of life (QoL) of patients, particularly in a Low- and Middle-Income Country (LMIC) setting. Studies on the long-term outcome are lacking globally; this study describes the long-term impact of contracture release surgery performed in an LMIC.

METHODS

This is a pre-post cohort study, conducted in a referral hospital in Tanzania. Patients who underwent burn scar contracture release surgery in 2017-2018 were eligible. ROM (goniometry), disability (WHODAS 2.0) and QoL (EQ-5D) were assessed. The ROM data were compared to the ROM that is required to perform activities of daily living without compensation, i.e. functional ROM. Assessments were performed preoperatively and at 1, 3, 6 and 12 months postoperatively.

RESULTS

In total, 44 patients underwent surgery on 115 affected joints. At 12 months, the follow-up rate was 86%. The mean preoperative ROM was 37.3% of functional ROM (SD 31.2). This improved up to 108.7% at 12 months postoperatively (SD 42.0, p < 0.001). Disability-free survival improved from 55% preoperatively to 97% at 12 months (p < 0.001) postoperatively. QoL improved from 0.69 preoperatively, to 0.93 (max 1.0) at 12 months postoperatively (p < 0.001). Patients who regained functional ROM in all affected joints reported significantly less disability (p < 0.001) and higher QoL (p < 0.001) compared to patients without functional ROM.

CONCLUSIONS

Contracture release surgery performed in an LMIC significantly improved functional ROM, disability and QoL. Results showed that regaining a functional joint is associated with less disability and higher QoL.

Management of paediatric burns in low- and middle-income countries: assessing capacity using the World Health Organization Surgical Assessment Tool

BACKGROUND

Burns are a leading cause of global disease burden, with children in low- and middle-income countries (LMICs) disproportionately affected. Effective management improves outcomes; however, the availability of necessary resources in LMICs remains unclear. We evaluated surgical centres in LMICs using the WHO Surgical Assessment Tool (SAT) to identify opportunities to optimize paediatric burn care.

METHODS

We reviewed WHO SAT database entries for 2010-2015. A total of 1121 facilities from 57 countries met the inclusion criteria: facilities with surgical capacity in LMICs operating on children. Human resources, equipment and infrastructure relevant to paediatric burn care were analysed by WHO Regional and World Bank Income Classifications and facility type.

RESULTS

Facilities had an average of 147 beds and performed 485 paediatric operations annually. Discrepancies existed between procedures performed and resource availability; 86% of facilities performed acute burn care, but only 37% could consistently provide intravenous fluids. Many, particularly tertiary, centres performed contracture release and skin grafting (41%) and amputation (50%).

CONCLUSIONS

LMICs have limited resources to provide paediatric burn care but widely perform many interventions necessary to address the burden of burns. The SAT may not capture innovative and traditional approaches to burn care. There remains an opportunity to improve paediatric burn care globally.

Quantifying Burn Injury-Related Disability and Quality of Life in the Developing World: A Primer for Patient-Centered Resource Allocation

BACKGROUND

Untreated or undertreated burns are commonly encountered by plastic surgeons on medical trips in India and represent a major cause of disability. We sought to utilize validated patient-reported outcomes instruments to identify the patient population with the greatest burn-related disability in order to appropriately allocate plastic surgery resources to those in greatest need.

METHODS

The Quick Disability of the Arm, Shoulder, and Hand, RAND 36-Item Short Form Health Survey, and Burn-Specific Health Scale-Revised, Brief, and Adapted questionnaires were administered via an interpreter during a plastic surgery trip to Jharkhand, India, in January 2018. Demographics, comorbidities, and burn-specific history were recorded.

RESULTS

Twenty-eight postburn patients were surveyed (mean age, 17.0 ± 9.2 years; male:female ratio, 1:2.5). Mean time from injury was 4.74 years. No patient had received formal, primary burn care. Mechanism of injury: flame (39%), oil (32%), scalding water (14%), and other (14%). Fifty-four percent were extremity burns; 25%, facial; and 18%, neck burns. The Burn-Specific Health Scale-Revised, Brief, and Adapted demonstrated that the most significantly impacted domains for all patients were body image and skin sensitivity, with more than 80% of patients complaining of issues with skin sensitivity. In addition, children (aged <18 years) had diminished body image domain scores. RAND SF-36 scores were lowest in the energy (73.1 ± 25.0) and general health (76.5 ± 13.8) domains, and females with extremity burns demonstrated statistically significant decreases in their physical limitation domain scores (85.9 ± 17.3, P < 0.05). Females with extremity burns also had statistically significant lower scores in the energy domain (64.09 ± 25.75) as compared with their male counterparts with extremity burns (100 ± 0, P = 0.045). In general, females scored lower than did males in multiple domains, and those results reached statistical significance in the energy (65.9 ± 24.6 vs 93.6 ± 10.9), emotional (77.2 ± 21.5 vs 95.4 ± 11.2), and general health domains (71.1 ± 11.9 vs 90.0 ± 7.5) with P < 0.05. Children demonstrated significantly diminished scores in the emotional (75.5 ± 24.6) and general health (79.1 ± 11.8) domains.

CONCLUSION

These data demonstrate the significant impact on quality of life that untreated burns have in this population. Male and female children with extremity burns and adult women with extremity burns were most significantly affected in multiple domains. Consequently, children and adult women with extremity burns appear to be the patient cohort with the greatest opportunity to impact their quality of life. These data may be utilized to improve patient triage and resource allocation for future surgical trips but could also be of significant benefit to internal health agencies and ministries for the same purpose.

A Systematic Review on Classification, Identification, and Healing Process of Burn Wound Healing

Because of the intrinsic complexity, the classification of wounds is important for the diagnosis, management, and choosing the correct treatment based on wound type. Generally, burn injuries are classified as a class of wounds in which injury is caused by heat, cold, electricity, chemicals, friction, or radiation. On the other hand, wound healing is a complex process, and understanding the biological trend of this process and differences in the healing process of different wounds could reduce the possible risk in many cases and greatly reduce the future damage to the injured tissue and other organs. The aim of this review is to provide a general perspective for the burn wound location among the other types of injuries and summarizing as well as highlighting the differences of these types of wounds with emphasizing on factors affecting thereof.

Multimethod assessing the prognosis affecting factors of hospitalized children with burns in Zunyi, southwest China

BACKGROUND

Burns are a common type of injury in children worldwide, which cause a large number of casualties each year. This study aimed to explore the clinical epidemiological characteristics and assess the prognosis affecting factors of hospitalized children with burns using multimethods.

METHODS

This was a cross-sectional study of pediatric burns in southwest China. Demographic characteristics and mechanism of burns were surveyed and clinical data, the length of hospital stay (LOS) and outcome were extracted from the medical records. The prognosis affecting factors of burns were analyzed by both logistic regression and path analysis.

RESULTS

A total of 111 children with burns were surveyed (63.06% males). The median age was 2.08 years (interquartile range, IQR 1.25-3.75), and most patients (69.37%) were under 3 years old. Hot liquid was the major etiology (79.28%) and most burns occurred at home (83.78%). The total body surface area (TBSA) was mainly less than 10% (56.88%) with deep partial thickness (59.63%); however, 55.86% children did not receive any first-aid measures after burns. Path analysis showed that skin grafting surgery could reduce LOS, while TBSA greatly prolonged LOS. Multivariate analysis showed that age (hazard ratio, HR = 1.65) and burn depth (HR = 13.49) were risk factors for scarring. The TBSA (HR = 3.52) and burn depth (HR = 10.52) were risk influencing factors for limb mobility.

CONCLUSION

In southwest China children under 3 years old, scald burns are most common, and most burns occur at home. It seems that TBSA, skin grafting, age and burn depth are best predictors of the prognosis in hospitalized children with burns.

Epidemiology and Outcome Analysis of 470 Patients with Hand Burns: A Five-Year Retrospective Study in a Major Burn Center in Southwest China

Background

This retrospective study aimed to investigate the epidemiology of burns to the hand, including the causes, demographic data, management, and outcome in a single center in Southwest China between 2012 and 2017.

Material/Methods

A retrospective study included 470 patients with hand burns who were treated at a single hospital in Southwest China between 2012 and 2017. Demographic, injury-related, and clinical data were obtained from the clinical electronic data collection system.

Results

In 470 patients, men were more commonly admitted to hospital with hand burns (73.62%). Children under 10 years (29.57%) were the main patient group. Hospital admissions occurred in the coldest months, from December to March (55.11%). In 60.21% of cases, hand burns occurred outside the workplace. Fire (40.42%), electricity (30.85%), and hot liquids (20.21%) were the main causes of hand burns. Data from 428 patients showed that burns with a larger total body surface area and deeper burns were associated with surgery and amputation. Burn depth was a risk factor for skin grafting, and lack of burn cooling before hospital admission increased the risk of amputation. Data from 117 patients with localized burns showed that full-thickness burns and lack of cooling before admission were associated with an increased hospital stay.

Conclusions

The findings suggest that in Southwest China, prevention programs for children aged 0–9 years, injuries occurring in winter and non-workplace sites, and fire burns were imperative.

Pediatric burn contractures in low- and lower middle-income countries: A systematic review of causes and factors affecting outcome

In low- and lower middle-income countries (LMICs), timely access to primary care following thermal injury is challenging. Children with deep burns often fail to receive specialized burn care until months or years post-injury, thus suffering impairments from hypertrophic scarring or joint and soft tissue contractures. We aimed to examine the correlation between limited access to care following burn injury and long-term disability in children in LMICs and to identify specific factors affecting the occurrence of late burn complications. A systematic literature search was conducted to retrieve articles on pediatric burns in LMICs using Medline, Embase, the Cochrane Library, LILACS, Global Health, African Index Medicus, and others. Articles were assessed by two reviewers and reported in accordance with PRISMA guidelines. Of 2896 articles initially identified, 103 underwent full-text review and 14 met inclusion criteria. A total of 991 children who developed long-term burn sequelae were included. Time from injury to consultation ranged from a few months to 17 years. Factors associated with late complications included total body surface area burned, burn depth, low socio-economic status, limited infrastructure, perceived inability to pay, lack of awareness of surgical treatment, low level of maternal education, and time elapsed between burn injury and reconstructive surgery.

The Correlation Between Quality of Life and Acceptability of Disability in Patients With Facial Burn Scars

The purpose of our research is to understand the status of the quality of life and level of disability acceptance in patients with facial burn scars and to explore the correlation between quality of life and disability acceptance and how to improve nursing care for these patients. Patients with facial burn scars were investigated in an outpatient clinic of tertiary hospitals from September 2015 to February 2016. A cross-sectional survey was conducted. The questionnaires used included demographic data and investigations using the burn scars table, Burn-Specific Health Scale-Brief (BSHS-B), and acceptance disability scale (ADS). Differences between participants in terms of demographic characteristics, quality of life, and disability acceptance were assessed using two-tailed independent t-tests. The total score of quality of life and disability acceptance in facial burn scar patients was 137.06 ± 17.05 and 185.68 ± 23.74, respectively. The results of Spearman correlation analysis showed that the overall quality of life score of facial burn scar patients was positively correlated with disability acceptance (r = 0.245, p = 0.007). The quality of life of facial burn scar patients will improve with the improvement of disability acceptance level. Therefore, medical staff can improve the quality of life of patients by improving their disability acceptance level.

Joint contractures in severe burn patients with early rehabilitation intervention in one of the largest burn intensive care unit in China: a descriptive analysis

Background

Joint contracture is the major clinical complication in burn patients, especially, the severe burn patients. This study aimed to investigate the number and severity of joint contractures in patients with burns affecting greater than or equal to 50% of the total body surface area (TBSA) undergoing early rehabilitation in a burn intensive care unit (BICU).

Methods

We analyzed burn patients with burns affecting greater than or equal to 50% of the TBSA admitted to a BICU who received early rehabilitation within 7 days post-injury from January 2011 to December 2015. Demographic and medical information was collected. The range of motion (ROM) of different joints was measured 1 month post-admission. Spearman’s correlation coefficient and logistic regression analysis was used to determine predictors of the presence and severity of contractures.

Result

The average affected TBSA of the included burn patients was 67.4%, and the average length of stay in the BICU was 46.2 ± 28.8 days. One hundred and one of 108 burn patients (93.5%) developed at least one joint contracture. The ROM in 67.9% of the affected joints was mildly limited. The majority of contractures in severe burn patients were mild (37.7%) or moderate (33.2%). The wrist was the most commonly affected joint (18.2%), followed by the shoulder, ankle, hip, knee, and elbow. A predictor of the presence of contractures was the length of hospital stay (p = 0.049). The severe contracture was related to the area of full-thickness burns, the strict bed rest time, and the duration of rehabilitation in BICU. The length of rehabilitation stay (days) in patients with moderate contracture is 54.5% longer than that in severe contracture (p = 0.024)

Conclusion

During the long stay in BICU, the length of rehabilitation stay in a BICU could decrease the severity of contractures from severe to moderate in the patients with equal to 50% of the TBSA. Hence, this research reveals the important role of early rehabilitation interventions in severe burn patients.

Electronic supplementary material

The online version of this article (10.1186/s41038-019-0151-6) contains supplementary material, which is available to authorized users.

Systematic review of the use of big data to improve surgery in low- and middle-income countries

Background

Technological advances have led to the generation of large amounts of data, both in surgical research and practice. Despite this, it is unclear how much originates in low‐ and middle‐income countries (LMICs) and what barriers exist to the use of such data in improving surgical care. The aim of this review was to capture the extent and impact of programmes that use large volumes of patient data on surgical care in LMICs.

Methods

A PRISMA‐compliant systematic literature review of PubMed, Embase and Google Scholar was performed in August 2018. Prospective studies collecting large volumes of patient‐level data within LMIC settings were included and evaluated qualitatively.

Results

A total of 68 studies were included from 71 LMICs, involving 708 032 patients. The number of patients in included studies varied widely (from 335 to 428 346), with 25 reporting data on 3000 or more LMIC patients. Patient inclusion in large‐data studies in LMICs has increased dramatically since 2015. Studies predominantly involved Brazil, China, India and Thailand, with low patient numbers from Africa and Latin America. Outcomes after surgery were commonly the focus (33 studies); very few large studies looked at access to surgical care or patient expenditure. The use of large data sets specifically to improve surgical outcomes in LMICs is currently limited.

Conclusion

Large volumes of data are becoming more common and provide a strong foundation for continuing investigation. Future studies should address questions more specific to surgery.