The Costs of Burn Victim Hospital Care around the World: A Systematic Review

Rehabilitation in adults with burn injury: an overview of systematic reviews

PURPOSE

To systematically evaluate evidence from published systematic reviews for the effectiveness of rehabilitation interventions in adults with burn injury.

MATERIALS AND METHODS

A comprehensive literature review conducted using medical and health science electronic databases up to 31 July 2022. Two independent reviewers selected studies, extracted data, and assessed methodological study quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR-2), and the certainty of evidence for reported outcomes using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool.

RESULTS

Twenty-one systematic reviews evaluated five categories of interventions: physical, psychological, technology-aided modalities, educational and occupational programs, complementary and alternative medicine. Outcomes included fitness level, hand function, oedema, pain, pruritus, psychological state, quality of life, range of motion, return to work, strength, scar characteristics, level of impairment and burn knowledge. The methodological quality was rated as "critically low" for all reviews. Quality of evidence for the effectiveness of evaluated interventions ranged from "moderate to very low."

CONCLUSIONS

Beneficial effects of inhaled aromatherapy and extracorporeal shockwave therapy on pain reduction; inhaled or massage aromatherapy, music therapy on anxiety were reported. Safety of interventions was not evaluated, due to the lack of adverse event reporting in primary studies and the included reviews.

Comparing collagenase and silver sulfadiazine in deep second-degree burn treatment

The indications for collagenase ointment (CO) and its efficacy are not clearly established in the treatment of second-degree burn wounds. To evaluate the efficacy of CO versus silver sulfadiazine ointment (SSD) in the treatment of second-degree burn wounds. A total of 170 eligible patients with deep second-degree burns, aged 18-65 years, with injuries occurring within 48-96 h, and having a total wound area of less than 30% of the total body surface area were included from 5 centers in China. The primary outcome was the wound healing time, and the secondary outcomes were the clearance time of wound necrotic tissues, wound healing rate, and wound inflammation. The study included 85 patients in SSD group and 84 in CO group in the modified intention-to-treat (mITT) population. The median time of wound healing was comparable in both groups (10 days vs. 10.5 days P = 0.16). The time for wound necrotic tissue removal was significantly shortened by CO compared with SSD (5 vs. 10 days P < 0.01). Wound inflammation, pain, wound healing rate, and scar were compared with SSD (all P-values > 0.05). No adverse events, such as infection or allergic reactions to the drugs and materials used, were reported. Both CO and SSD could heal the burn wounds at 10 days of treatment. However, CO significantly shortened the time of wound necrotic tissue removal by 5 days. Trial Registration: ChiCTR2100046971.

A single-center, open-labeled, randomized, 6-month, parallel-group study to assess the safety and efficacy of allogeneic cultured keratinocyte sheet transplantation for deep second-degree burn wounds: rationale and design of phase I/II clinical trial

BACKGROUND

Burn-related injuries are a major global health issue, causing 180,000 deaths per year. Early debridement of necrotic tissue in association with a split-thickness skin graft is usually administered for some of the 2nd- and 3rd-degree injuries. However, this approach can be complicated by factors such as a lack of proper donor sites. Artificial skin substitutes have attracted much attention for burn-related injuries. Keratinocyte sheets are one of the skin substitutes that their safety and efficacy have been reported by previous studies.

METHODS

Two consecutive clinical trials were designed, one of them is phase I, a non-randomized, open-label trial with 5 patients, and phase II is a randomized and open-label trial with 35 patients. A total number of 40 patients diagnosed with 2nd-degree burn injury will receive allogenic keratinocyte sheet transplantation. The safety and efficacy of allogeneic skin graft with autograft skin transplantation and conventional treatments, including Vaseline dressing and topical antibiotic, will be compared in different wounds of a single patient in phase II. After the transplantation, patients will be followed up on days 3, 7, 10, 14, 21, and 28. In the 3rd and 6th months after the transplantation scar, a wound closure assessment will be conducted based on the Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale.

DISCUSSION

This study will explain the design and rationale of a cellular-based skin substitute for the first time in Iran. In addition, this work proposes this product being registered as an off-the-shelf product for burn wound management in the country.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials (IRCT) IRCT20080728001031N31, 2022-04-23 for phase I and IRCT20080728001031N36, 2024-03-15 for phase II.

Autologous Skin Cell Suspension for Full-Thickness Skin Defect Reconstruction: Current Evidence and Health Economic Expectations

Despite differing etiologies, acute thermal burn injuries and full-thickness (FT) skin defects are associated with similar therapeutic challenges. When not amenable to primary or secondary closure, the conventional standard of care (SoC) treatment for these wound types is split-thickness skin grafting (STSG). This invasive procedure requires adequate availability of donor skin and is associated with donor site morbidity, high healthcare resource use (HCRU), and costs related to prolonged hospitalization. As such, treatment options that can facilitate effective healing and donor skin sparing have been highly anticipated. The RECELL® Autologous Cell Harvesting Device facilitates preparation of an autologous skin cell suspension (ASCS) for the treatment of acute thermal burns and FT skin defects. In initial clinical trials, the approach showed superior donor skin-sparing benefits and comparable wound healing to SoC STSG among patients with acute thermal burn injuries. These findings led to approval of RECELL for this indication by the US Food and Drug Administration (FDA) in 2018. Subsequent clinical evaluation in non-thermal FT skin wounds showed that RECELL, when used in combination with widely meshed STSG, provides donor skin-sparing advantages and comparable healing outcomes compared with SoC STSG. As a result, the device received FDA approval in June of 2023 for treatment of FT skin defects caused by traumatic avulsion or surgical excision or resection. Given that health economic advantages have been demonstrated for RECELL ± STSG versus STSG alone when used for burn therapy, it is prudent to examine similarities in the burn and FT skin defect treatment pathways to forecast the potential health economic advantages for RECELL when used in FT skin defects. This article discusses the parallels between the two indications, the clinical outcomes reported for RECELL, and the HCRU and cost benefits that may be anticipated with use of the device for non-thermal FT skin defects.

The effectiveness of the psychosocial empowerment program in early adjustment among adult burn survivors

BACKGROUND

Burns constitute a major global health challenge, causing not only physical trauma, but also significant psychosocial and emotional disturbances. The complexity of these injuries requires comprehensive rehabilitation programs that address both the physical and psychosocial aspects of recovery. Despite advances in medical care, there is a lack of standardized, accessible, and sustainable psychosocial interventions for burn survivors, particularly in the transition from hospital to home. This study aimed to develop and evaluate a nurse-led psychosocial empowerment intervention for early adjustment among burn survivors after hospital discharge.

METHODS

The study adopted a quasi-experimental framework. A convenient sample of 80 adult burn survivors was randomly divided into an intervention group, receiving the psychosocial empowerment program, and a control group, continuing standard care from November 2022 to May 2023. The effectiveness of the program was evaluated using various tools that measure satisfaction with appearance, coping abilities, and symptoms of post-traumatic stress disorder (PTSD). The intervention focused on enhancing resilience, self-efficacy, and adaptive coping, through targeted skill building in stress management, adaptability to coping, social reintegration, emotion regulation, and problem-solving.

RESULTS

Participants in the intervention group demonstrated significant improvements in body image satisfaction, coping abilities, and symptoms of PTSD compared to the control group.

CONCLUSIONS

The psychosocial empowerment program effectively addressed the psychosocial needs of burn survivors and enhanced their early adjustment after hospital discharge. The findings highlight the critical role of psychosocial support in the rehabilitation of burn survivors and underscore the need to integrate such interventions into standard post-discharge care. Future research should focus on the long-term effects of these interventions and their applicability in diverse settings.

The clinical outcomes of xenografts in the treatment of burn patients: a systematic review and meta-analysis

BACKGROUND

Although autografts are not feasible in patients with extensive burn wounds, allografts and xenografts can be used for temporary coverage. In this systematic review and meta-analysis, we compared the outcomes of xenografts and the standard treatment of burn wounds.

METHODS

International online databases were searched for English articles comparing xenografts with routine treatment in the burn patients. The random-effects model was used to estimate standardized mean differences (SMD) or odds ratios (OR) with a 95% confidence interval (CI).

RESULTS

From a total of 7144 records, 14 studies were included in our review after screening by title and abstracts followed by full-texts. No significant difference in hospital stays was found between the mammalian xenografts and control groups (SMD [95% CI] = - 0.18 [- 0.54-0.18]). The mean number of dressing changes was significantly lower in both mammalian xenografts compared to the controls (SMD [95% CI] = - 1.01 [- 1.61-- 0.41]) and fish xenografts compared to controls (SMD [95% CI] = - 6.16 [- 7.65-- 4.66]). In the fish xenografts, re-epithelialization time was significantly lower compared to controls (SMD [95% CI] = - 1.18 [- 2.23-- 0.14]).

CONCLUSIONS

Xenografts showed a significantly lower number of dressing changes and fish xenografts showed significant benefit in re-epithelialization compared to routine treatment. The beneficial results of xenografts suggest further research in the use of different types of xenografts in patients with extensive burn.

Cost Analysis and Influencing Factors Amongst Severe Burn Patients

This study analyzed the structure and determined the factors affecting the cost of treatment of severe burns patients. The results showed that the average total costs for a patient was 3275.9 USD. The daily cost of hospitalization was 113.3 USD, the treatment cost for 1% burn surface area was 109.5 USD with the highest proportion for medication and consumable medical equipment (43.2%), followed by surgery and procedures (30.2%). The treatment costs increased with increasing age, burn extent and deep burn area (p < .05) and were significantly higher in the group of patients with inhalation injury, electrical burns and in non-survivors (p < .01). Multivariate regression analysis found that burn extent, deep burn area and inhalation injury independently influenced the treatment cost of burn patients.

Mortality Rate and Years of Life Lost Due to Burns in Southern Iran During 2004-2019: A Population-Based Study

BACKGROUND

Burns constitute one of the most important etiologies of infection and mortality worldwide, with the most significant number of cases in low- and middle-income countries. This is a cross-sectional study on deaths due to burns in southern Iran.

METHODS

In this study, data on all deaths due to burns in southern Iran between 2004 and 2019 was extracted from the population-based Electronic Death Registry System (EDRS). The Joinpoint Regression method was used to examine the trend of crude mortality rate, standardized mortality rate, and years of life lost (YLL) rate. In order to measure YLL, the number of deaths and life expectancy for different age and gender groups were used, for which the standard life table was considered.

RESULTS

During this study, 2175 deaths due to burns occurred, 50.6% (1106 cases) of which were in men and 38.7% (841 cases) were in the 15-29 age group. The crude and the standardized mortality rate had a decreasing trend during the study years. The total number of YLL was 25260 (0.8 per 1000) in men, 25,785 (0.8 per 1000) in women, and 51,045 (0.8 per 1000) in both genders during the 16 years of the study.

CONCLUSION

Considering the high mortality rate in the 15-29 age group, which consists of the active and productive labor force, necessary actions are needed in order to improve safety equipment and to make the workplace safe.

Use of Symptom Checklist 90 for exploring psychological factors among the parents of children hospitalized for burn injuries in Shanghai: a cross-sectional study

To better improve the conditions for the recovery of children with burn injuries, timely understanding of the psychological status of parents is important. A cross-sectional survey on it using convenience sampling was conducted at two hospitals. Besides basic information, the Symptom Checklist 90, Eysenck Personality Questionnaire, Social Support Rate Scale, and Simplified Coping Style Questionnaire were used, and the key factors were identified via multivariate linear regression analysis and path analysis. A total of 196 guardians were recruited, 180 valid and completed questionnaires were obtained, including 58 men (32.2%) and 122 women (67.8%), and their average age was 30.3 years (standard deviation = 7.6). Of these, 151 participants (83.9%) were parents. Multivariate analysis revealed that children's age, parent gender, P score, negative coping style, and religion were the main factors that affected parents' psychology. Moreover, path analysis showed that P score, children's age, and negative coping style had the greatest impact on the total average score. These results suggest that during hospitalization, the following three factors should be focused on: older children, higher parental psychoticism, and increased negative coping style.

Economic Burden of Denatured Alcohol-Induced Burns: A 20-Year Retrospective Study

Burn care has rapidly improved over the past decades, but health innovations are expensive. We present the first study focusing on the economic burden of exclusive denatured alcohol-induced burns. The goal of this study was to determine costs for the public health system due to inpatients’ burn care because of these specific burns. Moreover, we aimed to observe the incidence of methylated spirit-related burns in the past 20 years. We performed an observational retrospective study in our burn unit including all patients with a denatured alcohol-related burn injury from 1 January 2001 to 31 December 2020. A total of 503 patients with a mean burn size of 24% were hospitalized; the mean annual total costs per patient was €43,879, varying from €31,518 to €63,274.00€; the total costs for denatured alcohol-related burns during the period 2001–2020 was €21,145,076. We noted an increasing incidence of denatured alcohol-related burns and related costs over the years, especially in the last decade. Our results highlight that burns by methylated spirits are still a real and expanding problem. Therefore, authorities should focus on sales rules, characteristics of the containers, and education of people who misuse denatured alcohol, based on historical habits of use. To reduce the socioeconomic costs of burns, future intervention strategies and studies from the dermatology community and burn specialists should focus on prevention programs and prompt wound healing to shorten the length of hospital stay, enable quick return to work, and improve the outcomes of patients with burns.

A Next-Generation Sequencing of Plasma Exosome-Derived microRNAs and Target Gene Analysis with a Microarray Database of Thermally Injured Skins: Identification of Blood-to-Tissue Interactions at Early Burn Stage

BACKGROUND

Plasma exosome-derived microRNA (miRNA) profiles following thermal injury and their relationship with gene expression derangements in burned skin remain unexplored. This study focused on the identification of key miRNA-mRNA axes in potential blood-to-tissue interactions at early burn stage.

METHODS

Plasma exosomes were obtained from 6 severe burn patients 4-7 days post injury and 6 healthy volunteers. Next-generation sequencing (NGS) of exosomal small RNAs presented the differentially expressed miRNAs (DEMs). Target genes of the DEMs were predicted in the mirDIP database. Dataset GSE8056 was enrolled to acquire differentially expressed genes (DEGs) in burned skin compared to normal skin. Overlap between the DEGs and target genes of the DEMs were focus genes. The protein-protein interaction (PPI) network and enrichment analyses of the focus genes demonstrated hub genes and suggested underlying mechanisms and pathways. The hub genes and upstream DEMs were selected to construct key miRNA-mRNA axes.

RESULTS

The NGS of plasma exosome-derived small RNAs identified 85 DEMs (14 downregulated miRNAs and 71 upregulated miRNAs) with 12,901 predicted target genes. Dataset GSE8056 exhibited 1861 DEGs in partial-thickness burned skins 4-7 days postburn. The overlap between DEGs and target genes of DEMs displayed 1058 focus genes. The top 9 hub genes (CDK1, CCNB1, CCNA2, BUB1B, PLK1, KIF11, AURKA, NUSAP1 and CDCA8) in the PPI network of the focus genes pointed to 16 upstream miRNAs in DEMs, including 4 downregulated miRNAs (hsa-miR-6848-3p, has-miR-4684-3p, has-miR-4786-5p and has-miR-365a-5p) and 12 upregulated miRNAs (hsa-miR-6751-3p, hsa-miR-718, hsa-miR-4754, hsa-miR-6754-3p, hsa-miR-4739, hsa-miR-6739-5p, hsa-miR-6884-3p, hsa-miR-1224-3p, hsa-miR-6878-3p, hsa-miR-6795-3p, hsa-miR-550a-3p, and hsa-miR-550b-3p). A key miRNA-mRNA network in potential blood-to-tissue interactions at early burn stage was therefore constructed.

CONCLUSION

An NGS and bioinformatic analysis in the study identified key miRNA-mRNA axes in potential blood-to-tissue interactions at early burn stage, suggesting plasma exosome-derived miRNAs may impact on the alteration patterns of gene expressions in a burn wound.