Xia Zhaofan

Epidemiology of pediatric burns requiring hospitalization in China: a literature review of retrospective studies

OBJECTIVE. This review was an effort to systematically examine the nationwide data available on pediatric burns requiring hospitalization to reveal burn epidemiology and guide future education and prevention. METHODS. The China Biomedical Disk Database, Chongqing VIP Database, and China Journal Full-Text Database were searched for articles reporting data on children and their burns from January 2000 through December 2005. Studies were included that systematically investigated the epidemiology of pediatric burns requiring hospitalization in China. Twenty-eight articles met the inclusion criteria, all of which were retrospective analyses. For each study included, 2 investigators independently abstracted the data related to the population description by using a standard form and included the percentage of patients with burn injury who were <15 years old; gender and distribution of age; type of residential area; place of injury; distribution of months and time; reasons for burn; anatomical sites of burn; severity of burn; and mortality and cause of death. These data were extracted, and a retrospective statistical description was performed with SPSS11.0 (SPSS Inc, Chicago, IL). RESULTS. Of the pediatric patients studied, the proportion of children with burn injury ranged from 22.50% to 54.66%, and the male/female ratio ranged from 1.25:1 to 4.42:1. The ratio of children aged ≤3 years to those >3 years was 0.19:1 to 4.18:1. The rural/urban ratio was 1.60:1 to 12.94:1. The ratio of those who were burned indoors versus outdoors was 1.62 to 17.00, and there were no effective hints on the distribution of seasons and anatomical sites of burn that could be found. The peak hours of pediatric burn were between 17:00 and 20:00. Most articles reported the sequence of reasons as hot liquid > flame > electricity > chemical, and scalding was, by far, the most predominant reason for burn. The majority of the studies reported the highest proportion involved in moderate burn, and the lowest proportion was for critical burn. The mortality rate ranged from 0.49% to 9.08%, and infection, shock, and multiple organ dysfunction syndrome were the most common causes of death. CONCLUSIONS. Considering the national proportion of children, a high proportion of hospitalized patients with burn injury were children; those who were male, aged ≤3 years, and lived most of the time indoors were especially susceptible. Great attention should be paid when hot water is used or during suppertime. This compilation and analysis of hospitalization-based information has proved useful in establishing the rational priorities for prevention; a family-school-factory-government mode of preventive strategy has come into being and was performed effectively.

Randomized, multicenter, double-blind, and placebo-controlled trial using topical recombinant human acidic fibroblast growth factor for deep partial-thickness burns and skin graft donor site

Wound healing is a dynamic and complex biologic process that could be accelerated by growth factors. To investigate the efficacy of topical recombinant human acidic fibroblast growth factor (rh‐aFGF) treatment in deep partial‐thickness burn or skin graft donor sites, we designed a randomized, multicenter, double‐blind, and placebo‐controlled clinical trial. The healing rate, fully healed rate, and healing time were evaluated to assess the efficacy of rh‐aFGF application. Laboratory examinations and abnormal signs were used to assess the side and toxic effects. The results showed that the healing rate of burn wounds and skin graft donor sites treated by rh‐aFGF was significantly higher than that by placebo, and the mean healed time of burn wounds and skin graft donor sites in the rh‐aFGF group was significantly the shorter than that in the placebo group. In conclusion, topical administration of rh‐aFGF can accelerate the wound healing process and shorten the healed time. It is a potential therapeutic application for promoting healing of deep partial‐thickness burns or skin graft donor sites.

ISBI PRACTICE GUIDELINES FOR BURN CARE

Practice guidelines (PGs) are recommendations for diagnosis and treatment of diseases and injuries, and are designed to define optimal evaluation and management. The first PGs for burn care addressed the issues encountered in developed countries, lacking consideration for circumstances in resource-limited settings (RLS). Thus, the mission of the 2014-2016 committee established by the International Society for Burn Injury (ISBI) was to create PGs for burn care to improve the care of burn patients in both RLS and resource-abundant settings. An important component of this effort is to communicate a consensus opinion on recommendations for burn care for different aspects of burn management. An additional goal is to reduce costs by outlining effective and efficient recommendations for management of medical problems specific to burn care. These recommendations are supported by the best research evidence, as well as by expert opinion. Although our vision was the creation of clinical guidelines that could be applicable in RLS, the ISBI PGs for Burn Care have been written to address the needs of burn specialists everywhere in the world.

The direct hospitalisation costs of paediatric scalds: 2-Year results of a prospective case series

OBJECTIVE To reveal the characteristic and distribution of length of hospital stay (LOS) and direct hospitalisation costs of paediatric scald. METHODS A prospective case series observation was performed from January 2005 to December 2006 at the Burn Center, Changhai Hospital, Shanghai, China. The information, such as demographics, clinical diagnosis and treatments since admission, of the paediatric scald patients included in the series was recorded. The direct cost of a treatment event was recorded into the price system when it was incurred. All cost data were summarised on completion of the study. The distribution of LOS and the hospitalisation costs were recorded by gender, age, total burn area, depth of burn, blood transfusion and patterns of treatment. Mann-Whitney signed-rank test was used to assess the differences between continuous, non-normally distributed variables, and multiple linear regression was used to model LOS and direct hospitalisation costs. Statistical analyses were undertaken with SPSS 15.0 statistical software. RESULTS Patients aged 3 years or less accounted for more than half of the total LOS and hospitalisation costs, patients with burn area less than 10%TBSA (total burn surface area) accounted for more than 70% of the total LOS and more than half of the hospitalisation costs and patients with second-degree burn accounted for more than 78% of the total LOS and hospitalisation costs. Depth of burn, area of burn, patterns of treatment and blood transfusion were independent predictors of LOS; whereas LOS, area of burn and blood transfusion were independent predictors of hospitalisation costs. CONCLUSION Paediatric scalds have particular characteristics in terms of distribution of LOS and direct hospitalisation costs and the factors influencing them. The data presented in this study should assist burn care practitioners and hospital epidemiologists estimate and compare the economic burden of paediatric burns at other institutions; it may also be useful in resource allocation and cost-effectiveness analysis of treatment versus prevention strategies.

Analgesia effect of a fixed nitrous oxide/oxygen mixture on burn dressing pain: study protocol for a randomized controlled trial

BackgroundProcedural burn pain is the most intense acute pain and most likely type of burn injury pain to be undertreated due to the physician’s fear of the adverse effect of analgesia and lack of anesthetist present. At our institution, in most of the cases, local burn detersion and debridement were performed at the ward level without any analgesics. This article describes a study designed to test the analgesia effect of a fixed nitrous oxide/oxygen mixture on burn dressing pain.Methods/designThe experiment was carried out in three centers. The patients were given a number from 1 to 240. A randomization list was produced by a statistician according to our preliminary study. Due to the severity of the pain suffered, ethically it was decided to help as many as possible, so patients given the letters A, B or C were treated using a canister with the appropriate letter containing preprepared nitrous oxide/oxygen mixture (NOOM). Those with D were given oxygen only, from an identical-looking canister labeled D. Neither patients, nor doctors, nor nurses, nor data collector knew what was in each canister, thus they were all blind. The nursing officer who implemented the intervention handed the doctors envelopes containing the patients’ name and allocation of A, B, C or D. Thus, patients receiving NOOM or oxygen were in the ratio 3:1. Parameters, including pain severity, blood pressure, heart rate, digital oxygen saturation and the Chinese version of the burn specific pain anxiety scale (C-BSPAS), were taken before, during and after dressing for each group. A video and audio record was taken individually for later communication coding and outcome analysis. Rescue analgesic was recorded.DiscussionBased on the findings from our previous qualitative study that physician’s reluctance to order narcotic analgesia is due to its adverse effect and from our pilot experiment, this study aims to test the hypothesis that a fixed nitrous oxide/oxygen mixture will promote better burn dressing pain alleviation and outcomes. Analyses will focus on the effects of the experimental intervention on pain severity during dressing (primary outcomes); physiological parameters, C-BSPAS and acceptance of both health care professionals and patients (secondary outcomes). If this model of analgesia for burn pain management implemented by nurses proves successful, it could potentially be implemented widely in hospital and prehospital settings and improve patients’ satisfaction and quality of life.Trial registration(Clinical Trials Identifier: CHICTR-TRC11001690).

mTOR partly mediates insulin resistance by phosphorylation of insulin receptor substrate-1 on serine307 residues after burn

Mammalian target of rapamycin (mTOR) is an important mediator for cross talk between nutritional signals and metabolic signals of insulin by downregulating insulin receptor substrate proteins. Therefore, mTOR inhibition could become a therapeutic strategy in insulin-resistant states, including insulin resistance induced by burn. We tested this hypothesis in the rat model of 30% TBSA full thickness burn, using the mTOR inhibitor rapamycin. Rapamycin (0.4 mg/kg, i.p.) was injected 2 h before euglycemic-hyperinsulinemic glucose clamps at 4 days after burn. IRS-1, phospho-serine³⁰⁷, phospho-tyrosine of IRS-1 and phospho-mTOR in muscle tissue were determined by immunoprecipitation and Western blot analysis or immunohistochemistry. Plasma TNF-α, insulin and C-peptide were determined before and after euglycemic-hyperinsulinemic glucose clamps. Our data showed that TNF-α, insulin and C-peptide significantly increased in the early stage after burn (P < 0.01). The infused rates of total 10% glucose (GIR, mg/kg min) significantly decreased at 4 days after burn. The level of IRS-1 serine³⁰⁷ phosphorylation in muscle in vivo significantly increased after burn (P < 0.01), while insulin-induced tyrosine phosphorylation of IRS-1 significantly decreased (P < 0.01). Inhibition of mTOR by rapamycin inhibited the phosphorylation of mTOR, reduced serine³⁰⁷ phosphorylation, elevated tyrosine phosphorylation and partly prevented the decrease of GIR after burn. However, TNF-α, insulin and C-peptide were not decreased by rapamycin treatment postburn. Taken together, these results indicate that the mTOR pathway is an important modulator of the signals involved in the acute regulation of insulin-stimulated glucose metabolism, and at least, partly contributes to burn-induced insulin resistance. mTOR inhibition may become a therapeutic strategy in insulin-resistant states after burn.

Effect of thermal injury on relative anaplerosis and gluconeogenesis in the rat during infusion of [U-13C] propionate.

A new approach for the analysis of hepatic metabolism after burn injury is introduced. Relative anaplerotic, pyruvate recycling and gluconeogenic fluxes were measured by 13C NMR isotopomer analysis of blood glucose from rats with 40% body surface area injury, and from rats exposed to sham injury. A short chain fatty acid, [U-13C] propionate which is avidly extracted by the liver, was infused intravenously to deliver 13C into the citric acid cycle. There was no difference in the multiplets detected in the glucose carbon-2 (C-2) anomer from blood or liver after 45 or 60 min of infusion of propionate, indicating that steady-state isotopic conditions were achieved. Gluconeogenesis relative to citric acid cycle flux was not altered by burn injury; in both sham and burn groups the rate of glucose production was about equal to flux through citrate synthase. In the sham group of animals the rate of entry of carbon skeletons into the citric acid cycle was about four times citric acid cycle flux in animals after thermal injury. Similarly, flux through pyruvate kinase (again relative to citrate synthase) was significantly increased in burn injury.

Effects of early excision and grafting on cytokines and insulin resistance in burned rats

UNLABELLED Burn wound excision and grafting is a common clinical practice that decreases patient morbidity and mortality. It is not known, however, if the salutary effects of this procedure are related to effects on interleukin 6 (IL-6) and tumor necrosis factor (TNF-) α, and to reducing insulin resistance after burn. Sprague-Dawley rats were randomly divided into three groups: control, burn, burn ± excision groups. Rats in burn group were given a third-degree scald burn covering 30% total body surface area (TBSA) and no wound excision. Rats in burn ± excision group were subjected to a 30% third-degree burn followed by complete excision and allografting of the injury site within 15 min after burn. The rats in control group were treated in the same manner as the burn group, except that they were immersed in a room-temperature water. Glucose tolerance tests (GTT) were observed at 3 days after burn, euglycemic-hyperinsulinemic glucose clamps were performed at 4 days after burn and interleukin 6 (IL-6) and tumor necrosis factor (TNF-) α were determined after euglycemic-hyperinsulinemic glucose clamps. The levels of IL-6 and TNF-α increased after burn. Significant differences in GTT were observed between control and burn groups, and the rate of glucose infused measured in burned rats was significantly decreased compared with that in control at 4 days after burn. Early excision and grafting significantly decreased levels of IL-6 and TNF-α, and further reduced insulin resistance following thermal injury compared with burn group. CONCLUSION Early excision and grafting appeared to have an effect on inflammatory mediators and further reduced insulin resistance induced by major burns.

Basic investigation into the present burn care system in China: Burn units, doctors, nurses, beds and special treatment equipment

OBJECTIVE The aim of the study was to survey the current burn units in China to understand the burn care system in the country and supply basic data for the National Burn Repository of China (NBRC) and further research. METHOD A questionnaire was developed and sent to burn unit directors in China via e-mail, which was followed up with reminder text messages to obtain information for the study. RESULTS Of the 405 hospitals from the 31 provinces in mainland China that responded to the questionnaire, 63.7% of the responses came from Grade 3A hospitals, and the most popular model of organisation was the Burns and Plastic Surgery arrangement (63.0%). An average of 9.43±0.351 doctors work in each burn unit with 70.4% of all units having 4-11 doctors. The ratio of chief surgeon to associate chief surgeon to attending surgeon to resident surgeon and surgeon assistant was 1:1.8:2.2:2.3. An average of 30% of all doctors in each burn unit held postgraduate degrees, and more than 90% of all surgeons held a bachelors degree or higher. There were 16.48±0.637 nurses per burn unit, 56.5% of burn units had 8-15 nurses, and the ratio of chief nurse to associate chief nurse to supervisor nurse to nurse practitioner to junior nurse was 1:11.8:57.0:82.1:86.1. More than 80% of all nurses had received a college education or above. However, only 30% of nurses held bachelors degrees or higher, while only 0.66% of nurses had received postgraduate degrees. A total of 39.91±1.50 beds were available in each burn unit and 45% of burn units had 20-39 beds. Up to 70% of the total beds were prepared for patients with burn, and more than 10% of the beds were specifically for patients with severe burn. The ratios of doctors to nurses, beds to doctors, beds to nurses, and beds to doctors and nurses were 0.64±0.01, 4.48±0.12, 2.67±0.09, and 1.66±0.06, respectively. The workload of each doctor and nurse was most heavy in units with 40-59 beds. In addition, we estimated that there were 0.05, 0.5, 0.8, and 1.9 burn units, burn doctors, nurses, and beds, respectively, per 100,000 members of the population in mainland China. Chinese burn units lack special burn treatments, nursing equipment, and operation apparatuses. CONCLUSION To the best of our knowledge, this is the first survey of the present burn care system in China. These results confirm that the burn care system is not equivalent to the national power of this country and the system lacks a great number of trained burn professionals. Burn doctors and nurses bear a heavy burden of work. This report supplies basic data to spur further research. We propose creating a burn unit registration system and a special database in China.

Modified Evans blue fluorimetry for determination of pulmonary vascular permeability in rats sustaining burns, and delayed fluid resuscitation of burn shock

Abstract The present experiment used modified Evans blue fluorimetry to determine changes in pulmonary vascular permeability using a delayed resuscitation model of burn shock in rats. The results showed that pulmonary vascular permeability in the immediate resuscitation (IR) group regressed to normal 12–24 h following the burn whereas it regressed slowly in the delayed resuscitation (DR) group. The study showed that Evans blue fluorimetery is a reliable and sensitive method for determining pulmonary vascular permeability, and dimethyl formamide is a preferable extracting solution which provides a quick and convenient means for scientific research.