ABSTRACT

OBJECTIVES: Burns are a global public health problem and one of the major causes of disability, with more than 8 million disability-adjusted life-years. Our aim was to contribute a comprehensive analyses of existing burn data from Central India.
MATERIALS AND METHODS: We reviewed secondary data of burn patients from 5 years (March 2016 to March 2021) from a single center (Choithram Hospital & Research Centre, India). All burn patients except those with nonhealing and old burn wounds were included. We examined the following: age, sex, socioeconomic status, type of burn, total burn surface area, comorbidities, treatment, and outcome, with data analyzed using Statistical Package for Social Sciences version 20.0.
RESULTS: Our study included 770 patients (median age of 28.0 y). Male-to-female ratio was 1.26:1. Burns were common in the reproductive age group of 21 to 40 years (48.6%) and in people of a lower socioeconomic status (65.2%). There was predominance of flame burns (82.0%). The most common mode of burning was accidental (79.4%). The median (interquartile range) of total burn surface area among patients was 25% (12%-45%). Flame burns resulted in significantly greater injury (total burn surface area 30.0%) compared with electric (total burn surface area 23.0%) and scald burns (total burn surface area 11.5%). The commonest comorbidities were hypertension (5.2%) and diabetes (4.7%). We observed significant associations between outcome and age, sex, comorbidities, and treatment modalities. Homograft, autograft, or collagen/other dressing or a combination of these compared with conservative treatment resulted in better healing and reduced hospital stay (P < .001).
CONCLUSIONS: Age, sex, type of burn, total burn surface area, comorbidities, and treatment modalities were significantly associated with outcome of burn patients.

KEY WORDS: Autograft, Burn epidemiology, Collagen dressing, Homograft, Mortality

INTRODUCTION
Burns are a global public health problem and one of the major causes of disability, with more than 8 million disability-adjusted life-years.¹ Burns are the second largest group of injuries after road traffic accidents.² Nearly 10% of burn patients require hospitalization, and nearly 50% of those hospitalized cannot withstand their injuries.2 Almost 2.4 × 105 people with burn injuries have permanent disability, disfigurement, disturbed psychological outcomes with postburn stress disorders, and need for long-term rehabilitation.³ A remarkable number of these burns can be ascribed to thermal burns.⁴ In 2017, the global, age-standardized incidence of burns was 119 per 100 000 people.⁵ Other factors known to influence the prevalence and clinical outcomes are sex, socioeconomic status, total burn surface area (TBSA), and treatment modality.^6,7

Because of the wide spectrum of severity of burn injuries, care is needed by specialized burn surgeons and multimodality treatment. Burn patients not only require acute primary treatment in the form of initial fluid resuscitation, electrolyte repletion, infection management, pain control, and wound covers by split-thickness skin grafts or flaps but also require subsequent rehabilitation and reconstruction to prevent long-term disability. Although >90% of all burns are preventable, burns remain a significant cause of morbidity and mortality worldwide.⁸ In 2010, the Government of India announced the National Programme for Prevention of Burn Injuries with the aim of preventing and managing burn injuries; however, its impact is not yet noticeable.⁹

The number of burns is approximate.2 The availability of adequate region-specific epidemiological data can help in framing the strategy for the prevention and management of burns. To the best of our knowledge, few studies have presented data from Central India. Thus, we aimed to analyze the clinicoepidemiological profile and treatment outcomes of burn patients in a tertiary care hospital in Central India, including analyzing the incidence of burn injury among different age groups, males versus females, and socioeconomic statuses. We used discharge against medical advice (DAMA) and discharge on request (DOR) information to form associations between outcomes (survival or death) and age, sex, TBSA, and comorbidities (if any). The effectiveness of different treatment modalities was also analyzed.

MATERIALS AND METHODS
This single-center study included secondary data on 770 patients who sustained burn injuries over 5 years (March 2016 to March 2021) and who were admitted to the burn unit of the Choithram Hospital and Research Centre, a private charitable hospital in the center of Madhya Pradesh, India. It is a tertiary referral center that receives patients from all over the country, yet primarily extends its services to nearly 3.5 million people in Indore. The study population comprised patients of all age groups and both sexes. Outpatients and patients admitted for nonhealing burns and old burn wounds were excluded. The present study was conducted after obtaining approval from the Institutional Ethics Committee (ECR/204/INST/MP/2013). The confidentiality of patient information was maintained. The data generated during this study are not publicly available due to patient privacy concerns. Deidentified data are available upon reasonable request from the corresponding author.

The hospital records of patients were retrieved, and detailed demographic characteristics of patients, including age, sex, socioeconomic status,¹⁰ cause of burn, mode/reason for burn, area of burn, TBSA (calculated according to the rule of nine),¹¹ duration of hospital stay, treatment, and outcomes of interest, were recorded. The various treatment modalities for burns included conservative treatment, treatments aided with dressings such as collagen dressings, antimicrobial silver dressings, debridement/tangential excision with autografts, homografts, vacuum-assisted closure (VAC), fasciotomies, amputation, any neurosurgery, orthopedic intervention, abdominal surgery, and combinations of these.

Statistical analyses
We used SPSS (Statistical Package for Social Sciences) version 20.0 (IBM) for data analyses. Data were analyzed for probability distribution using the Kolmogorov-Smirnov test, and P < .05 indicated that the data were not normally distributed. Continuous data are presented as the median and interquartile range (IQR), and categorical data are presented as percentages. We used the Kruskal-Wallis test followed by post hoc analysis for intergroup comparisons. We assessed associations between the categorical variables using the chi-square test. P < .05 was considered statistically significant.

RESULTS
The study included 770 patients. The median age of the patients was 28 years (IQR, 17-38 y). Patients as young as 2 months to as old as 84 years were included in the study (Table 1). The male-to-female ratio was1.26:1 (Table 1). Most of the patients were married (64.4%), and most belonged to the lower socioeconomic class (38.70%), with fewer patients belonging to the upper class (8.05%) (Table 1).

The most common type of burn injury was due to flames (82.0%) (Table 1, Figure 1). The prevalence of electric burns was significantly higher among men, whereas flame burns were significantly more prevalent among women (chi-square 35.303, df 4, P < .001) (Figure 2). The median TBSA of the patients was 25% (IQR, 12%-45%). The median duration of hospital stay was 5 days (IQR, 2-10 days). The common comorbidities seen in patients with burns were hypertension (5.2%), diabetes (4.7%), psychiatric illness (2.9%), and asthma (1.0%) (Table 1).

The survival rate of patients, as evident from the number of patients getting discharged, was 62.3%. However, 27.1% of patients did not survive (Table 2).

The age of patients, TBSA, and duration of stay of patients getting discharged and getting discharged on request did not differ significantly (P > .05). The duration of stay and the TBSA of patients who died were significantly greater than these measurements in patients who survived (P < .05) (Table 3).

The discharge rate among males (74.7%) was significantly greater than that among females (46.8%) (chi-square value 66.628, P < .001) (Table 2). Among patients who died, a significantly greater proportion (197/209) were injured by flame burns. The median (IQR) age, TBSA, and duration of stay of patients with flame burns were 30.0 years (21.0-40.0 y), 27.5% (15.0%-50.0%), and 5.0 days (2.25-10.0 days), respectively, which were significantly higher than those of patients with electric burns and scald burns. The median (IQR) TBSA of patients who did not survive (60.0% [44.5%-82.5%]) was significantly greater than that of patients who were discharged (15.0% [10.0%-25.0%]) (P < .001) (Table 3).

In analyses between different age groups and outcomes, we found a statistically significant association (chi-square value 109.557, P < .001) (Table 4). The discharge rate was found to be significantly associated with the <1 year and 1- to 10-year age groups, with 92.9% and 96.9% of patients being discharged, respectively (Table 4). Significantly more people in the ≥61 years age group died (53.3%) (Table 4).

The presence of comorbidities was found to jeopardize outcomes, with significantly greater numbers of deaths among patients with multiple comorbidities followed by patients with any 1 comorbidity (P < .05). The discharge rate of patients without any comorbidity was significantly high (chi-square value 16.494, P < .05). We found treatment modalities to be significantly associated with outcomes. Survival and discharge were significantly higher in patients who received either homografts or autografts or collagen/other dressings or a combination of these (Table 5).

Outcomes were significantly associated with differences in median age, TBSA, and days of stay in the hospital (P < .05). Post hoc analysis revealed that the median age, TBSA, and duration of stay of patients who were discharged were significantly less than in patients who were discharged against medical advice or patients who did not survive (P < .05).

DISCUSSION
The present study analyzed the details of 770 patients who visited the hospital with burn injuries. We found burn injuries to be more common in males (55.8%) than in females (44.2%). However, the death rate was higher among females (40.0%) than males (17.0%). A few other studies from India and across the world have also reported a higher prevalence of burn injury among men but a higher death rate among women.^12,13 In contrast, there are a few studies that reported a higher prevalence among females versus males.^4,14-17 In the present study, the higher death rate among females could be attributed to the higher prevalence of flame burns, resulting in a greater TBSA of 27.5% (15.0%-50.0%) compared with electric and scald burns, which resulted in TBSA values of 23.0% (11.0%-38.5%) and 11.5% (6.0%-20.75%), respectively. The higher risk of burns in females could be attributed to open fire cooking or inherently unsafe cooking stoves, which can ignite loose clothing. Open flames used for heating and lighting also pose risks, and self-directed or interpersonal violence was also identified as a risk factor.¹⁸ Lack of fire extinguishers, lacunae in fire disaster management, and unavailability of primary treatment could be responsible for more damage from flame burns.¹⁸ In many states in India, there is lack of fire stations, public awareness, conduction of regular mock exercises, and adequate modern equipment to manage fire accident, which results in a high number of fire accidents and thus flame burns.¹⁹

We observed a significantly greater death rate among patients with flame burns (37.1%), followed by electric burns (22.5%) and then scald burns (3.1%). Flame burns result in full-thickness burns and severe burn injuries.¹⁶ In accordance with the present finding, McGwin and colleagues⁶ also found flame burns to be more prevalent among females. With regard to the death rate, we observed a higher discharge rate for males (74.7%) than for females (46.8%). The rate of discharge against medical advice was higher for females (12.9%) than for males (7.7%). A reason can be the apathy of the family toward the treatment of women. The failure to recognize burn injuries among women as a major concern is rooted in gender inequality.⁹

Overall, the mortality rate reported in our study was lower than that reported in other studies. We observed a mortality rate of 27.1%, whereas Shankar and colleagues²⁰ reported a mortality rate of 41.6% among burn patients. Another study reported a case fatality rate of 29.3% among burn patients admitted to a hospital in Mangalore.²¹ The comparatively lower death rate in our study could be due to the availability of good facilities and experienced staff in the hospital. The hospital was equipped with a separate burn intensive care unit and skin bank and followed strict antibiotic protocols.

We also observed more burn injuries in the working age population. Other studies showed a similar association of the working population with burn injuries.²² Wani and colleagues also reported highest incidence of burn injury in the 21- to 40-year age group.16 In a study done in a developing country, the reported mean age of burn patients was 25.2 ± 17.77 years.²³ We found no significant difference in median age of patients who had flame (25.0 years [17.5-35.0]) and electric (30.0 years [21.0-40.0]) burn injuries.

We found that the median age of patients with scald burns was significantly lower (2.5 years [1.125-7.0]). A study on pediatric burn injury also reported scald burns to be the most frequent type of burn injury among children.²⁴ Burn injuries in children could be attributed to children’s impulsiveness, lack of awareness, higher activity levels, natural curiosity, and total dependency on their caregiver.²⁵ Scald burns could also be an element of child abuse; a typical injury of this type involves a pattern consistent with a scald injury in a typical “stocking” distribution.²⁴

In our study, accidents (79.4%) was the most common underlying root of burns, although homicidal (11.3%) and suicidal (9.2%) burns were not uncommon. Similar findings were reported in a study in which researchers analyzed 10 years of data of burn patients.²⁶ Currently, homicidal deaths could be assigned to interpersonal/marital disharmony or other factors. In our study, 2.9% of patients presented with psychiatric illness as a comorbidity. The suicidal burn rate was 9.22%. This high rate of suicidal burns could be attributed to marital disharmony, prolonged illness leading to stress, low socioeconomic status, or financial problems.²⁷ The role of any psychiatric illness and depression in suicidal burns requires further evaluation.

Burn injury rates were found to be influenced by socioeconomic status. Most burn patients (38.7%) in our study were from the lower class. A linear increase in the burn rate was reported with an increase in poverty. Substandard housing and family dynamics could be responsible for the high prevalence of burns in patients with low socioeconomic status.²⁸ Improper use of kerosene oil causes major domestic burn injuries.²⁹ Prevention strategies such as education-based initiatives and replacing kerosene lamps (often implicated in burns) with LED (light emitting diode) or solar-powered lamps could reduce the incidence of burns and the annual household lighting consumption.³⁰ The provision of community-based firefighting equipment such as water pipes could be effective in preventing casualties.

Total burn surface area is the involvement of surface area of the body due to burn and is one of the most important clinical parameters and tools for treatment planning; it also affects the probable outcome of burn patients. We found that 82.1% of patients had flame burns, with these patients having the highest percent TBSA. Tian and colleagues³¹ also reported that flame-sustained burns were associated with increased TBSA, with percent TBSA above 30.1%; among scald burns, percent TBSA ranged from 10.1% to 30%. In our study, the median TBSA of people who died was 60.0% (44.5%-82.5%), which was in accordance with the findings of Jeschke and colleagues³² who reported that burns of 40% to 45% TBSA represented a crucial cut-off value for a substantially increased risk of developing adverse outcomes.

We also found a significant association between mortality and the older age group (≥61 years). One study revealed a linear increase in mortality with increasing age; patients aged >65 years have an lethal dose, 50%, of 30% to 40% TBSA, which was significantly lower than the lethal dose, 50%, for children and adults age <65 years.³² Elderly patients were at higher risk of developing complications such as pneumonia, pulmonary edema, congestive heart failure, and multiorgan dysfunction. Altered immune responses and changes in the inflammatory response associated with aging could also contribute to morbidity and mortality in elderly burn patients.¹³

Comorbidities were present in 11.4% of our study patients. The most common comorbid condition was hypertension (5.2%), followed by diabetes mellitus (4.7%). The survival rate among patients without comorbidities was nearly 75%, whereas the survival rates among patients with single comorbidities and multiple comorbidities were 63.5% and 44.0%, respectively. Comorbidities were significantly associated with outcome (P < .05). Similar findings were reported by Salehi and colleagues.³³ Significantly more patients with comorbidities died, as there could be a high possibility of wound infections, bacteremia, sepsis, multiorgan dysfunction, and acute respiratory distress syndrome among such patients.³⁴

Patients in our study who received interventions had better outcomes than those who received conservative treatment. Our burn center is a well-equipped, with an operation theatre, burn intensive care unit, trained nursing staff, and skin bank, making it possible to perform autografts, homografts, collagen dressing, antimicrobial silver dressing, VAC, fasciotomy, and amputation. Collagen dressing can achieve early healing and more subjective mobility than conventional treatment alone.³⁵ The combination of homografts and autografts is considered the gold standard in the management of major burns. Statistically significant differences in rejection time, need for another graft, percentage of rejected area, and mortality have been shown in patients who receive only homografts versus combined grafts.³⁶ In contrast, treatment of elderly patients by early excision and grafting was shown to be of no benefit and may have resulted in a higher mortality rate. The reason behind this could be the presence of age-related comorbidities in the patients included in their study.³⁷ In our study, most of the patients with a large TBSA and poor prognosis were treated conservatively, as a number of factors outside the control of the burn service may also influence outcome, including motivation of the patient, psychological morbidity before the burn injury, family support, and socioeconomic background.³⁸

Data from other areas of India are shown in Table 6. Results of the studies from other part of the India had findings similar to our study.^4,12,14-17

Limitations
Because this was a record-based study, a few aspects could not be analyzed, such as the reason behind the comparatively high frequency (10.0%) of DAMA. This might be related to many patients/families finding it difficult to finance further in-hospital treatment. Additionally, the DAMA group might also actually include some further deaths occurring after discharge. A major drawback was no interrogation into the reason behind homicide and suicide. In addition, enquiries into the complications and reasons for death could not be performed.

Conclusions
Further research is needed to evaluate the reason behind the reason for burn injury and the reason behind death, DAMA, or DOR. Burn injuries are more common among people in the age group of 21 to 40 years and in people belonging to a low socioeconomic status. Flame burn is the most common type of burn injury. Burn injury is more common among males but death rate is higher among females. Age, sex, type of burn, total burn surface area involved, comorbidities, and treatment modalities were significantly associated with outcomes of patients with burn injury. Early surgical excision, wound debridement, the use of antimicrobial dressings, and skin grafting have been recommended for patients with burns to improve outcomes and increase the survival rate of burn patients.

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