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1.  The domestic iron. A danger to young children 
Objectives—To study the epidemiology of thermal injury caused by the domestic iron in children 5 years old or less.
Methods—Retrospective review of case notes held in the accident and emergency (A&E) department of a large teaching hospital over a 36 month period. Data regarding demographics, site and extent of injury, mechanism of injury and outcome were retrieved.
Results—62 thermal injuries were identified in 59 patients. Of these, 60 were contact burns and two were scalds. The male to female ratio was 2:1. The mean age was 24 months. Fifty five per cent were aged between 1 and 2 years old. The hand was the commonest site of injury (63%) and, of these, two thirds were on the palm. Interestingly 10% occurred on the face. Iron contact burns accounted for 23.5% of all contact burns in this age group over this period. The majority of contact burns were partial thickness and most were less than 1% body surface area. Inadequate supervision is a recurring theme in many of these cases. A suspicion of non-accidental injury was raised in 10 cases and confirmed in nine of these.
Conclusions—Iron burns are common in young children, particularly boys aged between 1 and 2 years old. Most can be treated in the A&E clinic. The potential for serious injury does exist. Non-accidental injury always needs to be considered. Efforts at prevention and increasing public awareness are needed.
PMCID: PMC1725390  PMID: 10819384
2.  Home injury patterns in children: A comparison by hospital sites 
Paediatrics & Child Health  2003;8(7):433-437.
Many intervention studies typically require data from several centres to ensure adequate power. The usual intention is to pool data after testing for heterogeneity. Sites that differ in sample characteristics may, on the one hand, complicate the assessment of the intervention, but on the other hand, they may add important insights through analysis of site-specific findings.
The aims of the present paper were to compare the distribution of injuries and risk factors among children participating in a five-centre study of a home-based injury prevention program, and to contrast parental injury awareness and knowledge with home safety measures.
Five children’s hospitals in Canada agreed to participate in a case-control study combined with a randomized controlled trial. Patients were children zero to seven years of age presenting to a hospital emergency department with a fall, burn, ingestion or choking. Two controls were matched to each case, one with another injury and another with a minor illness. A home visitor completed a home hazard assessment based on observed safety measures. To determine whether data could be pooled, comparisons across sites were made with respect to types of injuries seen, sociodemographic characteristics, observed hazards and the parents’ reported beliefs about severity of injuries, safety measures, preventability of injuries and susceptibility to injuries.
There were few differences between the five hospitals. The mean age was 2.2 years (range 1.4 to 3.3). There were 219 falls (56%), 80 burns (20.4%), 54 poisonings (13.8%), and 38 chokings (9.7%), all distributed in a proportionately similar manner, except for poisoning, at each site. There were significantly more well-educated fathers at one hospital and younger parents with less education at another. Homes were generally lacking five recommended safety measures. However, most parents at all sites perceived their home as being very safe for any of the specific injuries, and their child as being at low risk of sustaining any of these injuries.
The similarity across sites supports the pooling of these data regarding hospital-treated injuries in young children in urban Canada. Most parents at all sites perceived their home as being very safe in spite of their homes lacking one-quarter of the recommended safety measures. This discrepancy between parental perception and home safety highlights the needs for further education and prevention efforts.
PMCID: PMC2791653  PMID: 20019950
Children; Injury; Parental knowledge; Safety
3.  Home safety measures and the risk of unintentional injury among young children: a multicentre case–control study 
Young children may sustain injuries when exposed to certain hazards in the home. To better understand the relation between several childproofing strategies and the risk of injuries to children in the home, we undertook a multicentre case–control study in which we compared hazards in the homes of children with and without injuries.
We conducted this case-control study using records from 5 pediatric hospital emergency departments for the 2-year period 1995–1996. The 351 case subjects were children aged 7 years and less who presented with injuries from falls, burns or scalds, ingestions or choking. The matched control subjects were children who presented during the same period with acute non-injury-related conditions. A home visitor, blinded to case-control status, assessed 19 injury hazards at the children's homes.
Hazards found in the homes included baby walkers (21% of homes with infants), no functioning smoke alarm (17% of homes) and no fire extinguisher (51% of homes). Cases did not differ from controls in the mean proportion of home hazards. After controlling for siblings, maternal education and employment, we found that cases differed from controls for 5 hazards: the presence of a baby walker (odds ratio [OR] 9.0, 95% confidence interval [CI] 1.1–71.0), the presence of choking hazards within a child's reach (OR 2.0, 95% CI 1.0–3.7), no child-resistant lids in bathroom (OR 1.6, 95% CI 1.0–2.5), no smoke alarm (OR 3.2, 95% CI 1.4–7.7) and no functioning smoke alarm (OR 1.7, 95% CI 1.0–2.8).
Homes of children with injuries differed from those of children without injuries in the proportions of specific hazards for falls, choking, poisoning and burns, with a striking difference noted for the presence of a baby walker. In addition to counselling parents about specific hazards, clinicians should consider that the presence of some hazards may indicate an increased risk for home injuries beyond those directly related to the hazard found. Families with any home hazard may be candidates for interventions to childproof against other types of home hazards.
PMCID: PMC1586091  PMID: 16998079
4.  Iron burns: a problem in adults as well as children 
Burns from domestic irons are potentially preventable injuries which can result in significant morbidity. Several studies have reported these injuries in children but there are no reports to date in adults. Epidemiology, management and outcome of these injuries is described, and possible preventative strategies are discussed. We present a retrospective case note review of 50 adult and paediatric patients with electric iron burns. Cases were identified from data collected for a national burns database. Information regarding demographics, burn characteristics, treatment and long term outcome was gathered from the medical records. 42 children and 8 adults sustained a burn from an iron during the 4-year study period. The majority of paediatric patients were under 4 years of age. Most burns were small (< 1% TBSA) but despite this 30 (60%) patients were admitted to hospital and 13 (26%) required at least one surgical procedure. In children, most burns occurred at home and were commonly due to pulling the flex or knocking the iron from its surface. In adults, 50% of injuries were associated with epilepsy. Burns from domestic irons are relatively common and cause significant morbidity despite their small size. A bimodal presentation is seen with injuries occurring either before the age of 4 years or during adulthood, when they are typically associated with an underlying medical condition. Education campaigns and design features such as a retractable cord may further reduce the incidence of this type of burn.
PMCID: PMC3978587  PMID: 24799845
contact burns; epidemiology; prevention; adult; paediatric
5.  Burns From Hot Wheat Bags: A Public Safety Issue 
Eplasty  2011;11:e36.
Introduction: Wheat bags are therapeutic devices that are heated in microwaves and commonly used to provide relief from muscle and joint pain. The Royal Adelaide Hospital Burns Unit has observed a number of patients with significant burn injuries resulting from their use. Despite their dangers, the products come with limited safety information. Methods: Data were collected from the Burns Unit database for all patients admitted with burns due to hot wheat bags from 2004 to 2009. This was analyzed to determine the severity of the burn injury and identify any predisposing factors. An experimental study was performed to measure the temperature of wheat bags when heated to determine their potential for causing thermal injury. Results: 11 patients were admitted with burns due to hot wheat bags. The median age was 52 years and the mean total body surface area was 1.1%. All burns were either deep dermal (45.5%) or full thickness (54.5%). Ten patients required operative management. Predisposing factors (eg, neuropathy) to thermal injury were identified in 7 patients. The experimental study showed that hot wheat bags reached temperatures of 57.3°C (135.1°F) when heated according to instructions, 63.3°C (145.9°F) in a 1000 W microwave and 69.6°C (157.3°F) on reheating. Conclusions: Hot wheat bags cause serious burn injury. When heated improperly, they can reach temperatures high enough to cause epidermal necrosis in a short period of time. Patients with impaired temperature sensation are particularly at risk. There should be greater public awareness of the dangers of wheat bag use and more specific safety warnings on the products.
PMCID: PMC3160380  PMID: 21915357
6.  Burn Injuries in Enugu, Nigeria - Aetiology and Prevention. A Six-year Retrospective Review (January 2000 - December 2005) 
Background.Burn injuries frequently occur in our homes and workplaces and during travels. They are a common presentation at the National Orthopaedic Hospital, Enugu, Nigeria, which is a regional centre for burns care and for plastic surgery, orthopaedic surgery, and trauma patients. Most burn injuries are preventable, and campaigns to arouse greater awareness are necessary to reduce the number of occurrences. Objectives.The objectives of this study are to highlight the causes of burn injuries and to characterize age and sex incidences, as also the severity of burn injuries. It is hoped that formidable preventive measures will be suggested to aid public enlightenment campaigns in fighting the scourge of burn injuries. Materials and method. A retrospective review of patient's folders from Jan. 2000 to Dec. 2005 showed that 414 cases of burn-injured patients were treated at the emergency unit of the National Orthopaedic Hospital, Enugu. Results. Flame burns accounted for 48.3% of burn injuries followed by scalds with 40.6%; chemical burns accounted for 6.3%, while electrical and friction burns accounted for 4.6% and 1.0% respectively. Males made up 60.4% of the cases and females 39.6% (ratio, 1.5:1). The age group most commonly affected was that of children aged between 0 and 10 yr, accounting for 37.2% of cases, followed by the 21-30 yr age group with 22.7%. Altogether, 95.0% of the patients were aged less than 50 yr. With regard to flame burns, 51.5% were due to petrol flames (premium motor spirit), while 33.0% were due to kerosene. Cooking gas explosions accounted for 7.5% of the cases and diesel (automotive gas oil) 1.0%. Of the scalds, hot water accounted for 89.3% and hot oil 7.7%. As to chemical burns, 84.6% were due to acids, with alkalis, corrosive creams, and others making up the rest. With regard to electrical injury, current passage accounted for 63.2% of cases and flash burns for 36.8%.
PMCID: PMC3188203  PMID: 21991150
7.  A modified surgical technique in the management of eyelid burns: a case series 
Contractures, ectropion and scarring, the most common sequelae of skin grafts after eyelid burn injuries, can result in corneal exposure, corneal ulceration and even blindness. Split-thickness or full-thickness skin grafts are commonly used for the treatment of acute eyelid burns. Plasma exudation and infection are common early complications of eyelid burns, which decrease the success rate of grafts.
Case presentation
We present the cases of eight patients, two Chinese women and six Chinese men. The first Chinese woman was 36 years old, with 70% body surface area second or third degree flame burn injuries involving her eyelids on both sides. The other Chinese woman was 28 years old, with sulfuric acid burns on her face and third degree burn on her eyelids. The six Chinese men were aged 21, 31, 38, 42, 44, and 55 years, respectively. The 38-year-old patient was transferred from the ER with 80% body surface area second or third degree flame burn injuries and third degree burn injuries to his eyelids. The other five men were all patients with flame burn injuries, with 7% to 10% body surface area third degree burns and eyelids involved. All patients were treated with a modified surgical procedure consisting of separation and loosening of the musculus orbicularis oculi between tarsal plate and septum orbital, followed by grafting a large full-thickness skin graft in three days after burn injury. The use of our modified surgical procedure resulted in 100% successful eyelid grafting on first attempt, and all our patients were in good condition at six-month follow-up.
This new surgical technique is highly successful in treating eyelid burn injuries, especially flame burn injuries of the eyelid.
PMCID: PMC3212825  PMID: 21843322
8.  Cement Burns 
Objective: Cement burns account for relatively few admissions to a burn unit; however, these burns deserve separate consideration because of special features of diagnosis and management. Cement burns, even though potentially disabling, have rarely been reported in literature. Methods: A retrospective review was performed of all patients admitted with cement burns injuries to the national burns unit at the St James's Hospital in Dublin, Ireland, over a 10-year period for the years 1996–2005. Results: A total of 46 patients with cement burns were admitted. The majority of patients were aged 16–74 years (mean age = 32 years). Eighty-seven percent of injuries occurred in an industrial and 13% in a domestic setting. The upper and lower extremities were involved in all the patients, and the mean total body surface area affected was 6.5%. The mean length of hospital stay was 21 days with a range of 1–40 days. Thirty-eight (82%) were surgically managed involving debridement and split-thickness skin graft (SSG) and four (9%) were conservatively managed. A further four did not have data available. Conclusion: Widespread inexperience in dealing with this group of cement burns patients and delays in referral to burns unit highlights the potential for greater levels of general awareness and knowledge in both prevention and treatment of these burns. As well, early debridement and split-thickness skin grafting at diagnosis constitutes the best means of reducing the high socioeconomic costs and allows for early return to work.
PMCID: PMC2064966  PMID: 18091981
9.  Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) 
Executive Summary
In July 2010, the Medical Advisory Secretariat (MAS) began work on a Chronic Obstructive Pulmonary Disease (COPD) evidentiary framework, an evidence-based review of the literature surrounding treatment strategies for patients with COPD. This project emerged from a request by the Health System Strategy Division of the Ministry of Health and Long-Term Care that MAS provide them with an evidentiary platform on the effectiveness and cost-effectiveness of COPD interventions.
After an initial review of health technology assessments and systematic reviews of COPD literature, and consultation with experts, MAS identified the following topics for analysis: vaccinations (influenza and pneumococcal), smoking cessation, multidisciplinary care, pulmonary rehabilitation, long-term oxygen therapy, noninvasive positive pressure ventilation for acute and chronic respiratory failure, hospital-at-home for acute exacerbations of COPD, and telehealth (including telemonitoring and telephone support). Evidence-based analyses were prepared for each of these topics. For each technology, an economic analysis was also completed where appropriate. In addition, a review of the qualitative literature on patient, caregiver, and provider perspectives on living and dying with COPD was conducted, as were reviews of the qualitative literature on each of the technologies included in these analyses.
The Chronic Obstructive Pulmonary Disease Mega-Analysis series is made up of the following reports, which can be publicly accessed at the MAS website at:
Chronic Obstructive Pulmonary Disease (COPD) Evidentiary Framework
Influenza and Pneumococcal Vaccinations for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Smoking Cessation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Community-Based Multidisciplinary Care for Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Long-term Oxygen Therapy for Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Noninvasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients With Stable Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Hospital-at-Home Programs for Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Home Telehealth for Patients with Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis
Cost-Effectiveness of Interventions for Chronic Obstructive Pulmonary Disease Using an Ontario Policy Model
Experiences of Living and Dying With COPD: A Systematic Review and Synthesis of the Qualitative Empirical Literature
For more information on the qualitative review, please contact Mita Giacomini at:
For more information on the economic analysis, please visit the PATH website:
The Toronto Health Economics and Technology Assessment (THETA) collaborative has produced an associated report on patient preference for mechanical ventilation. For more information, please visit the THETA website:
The objective of this analysis was to compare hospital-at-home care with inpatient hospital care for patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) who present to the emergency department (ED).
Clinical Need: Condition and Target Population
Acute Exacerbations of Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. This airflow limitation is usually both progressive and associated with an abnormal inflammatory response of the lungs to noxious particles or gases. The natural history of COPD involves periods of acute-onset worsening of symptoms, particularly increased breathlessness, cough, and/or sputum, that go beyond normal day-to-day variations; these are known as acute exacerbations.
Two-thirds of COPD exacerbations are caused by an infection of the tracheobronchial tree or by air pollution; the cause in the remaining cases is unknown. On average, patients with moderate to severe COPD experience 2 or 3 exacerbations each year.
Exacerbations have an important impact on patients and on the health care system. For the patient, exacerbations result in decreased quality of life, potentially permanent losses of lung function, and an increased risk of mortality. For the health care system, exacerbations of COPD are a leading cause of ED visits and hospitalizations, particularly in winter.
Hospital-at-home programs offer an alternative for patients who present to the ED with an exacerbation of COPD and require hospital admission for their treatment. Hospital-at-home programs provide patients with visits in their home by medical professionals (typically specialist nurses) who monitor the patients, alter patients’ treatment plans if needed, and in some programs, provide additional care such as pulmonary rehabilitation, patient and caregiver education, and smoking cessation counselling.
There are 2 types of hospital-at-home programs: admission avoidance and early discharge hospital-at-home. In the former, admission avoidance hospital-at-home, after patients are assessed in the ED, they are prescribed the necessary medications and additional care needed (e.g., oxygen therapy) and then sent home where they receive regular visits from a medical professional. In early discharge hospital-at-home, after being assessed in the ED, patients are admitted to the hospital where they receive the initial phase of their treatment. These patients are discharged into a hospital-at-home program before the exacerbation has resolved. In both cases, once the exacerbation has resolved, the patient is discharged from the hospital-at-home program and no longer receives visits in his/her home.
In the models that exist to date, hospital-at-home programs differ from other home care programs because they deal with higher acuity patients who require higher acuity care, and because hospitals retain the medical and legal responsibility for patients. Furthermore, patients requiring home care services may require such services for long periods of time or indefinitely, whereas patients in hospital-at-home programs require and receive the services for a short period of time only.
Hospital-at-home care is not appropriate for all patients with acute exacerbations of COPD. Ineligible patients include: those with mild exacerbations that can be managed without admission to hospital; those who require admission to hospital; and those who cannot be safely treated in a hospital-at-home program either for medical reasons and/or because of a lack of, or poor, social support at home.
The proposed possible benefits of hospital-at-home for treatment of exacerbations of COPD include: decreased utilization of health care resources by avoiding hospital admission and/or reducing length of stay in hospital; decreased costs; increased health-related quality of life for patients and caregivers when treated at home; and reduced risk of hospital-acquired infections in this susceptible patient population.
Ontario Context
No hospital-at-home programs for the treatment of acute exacerbations of COPD were identified in Ontario. Patients requiring acute care for their exacerbations are treated in hospitals.
Research Question
What is the effectiveness, cost-effectiveness, and safety of hospital-at-home care compared with inpatient hospital care of acute exacerbations of COPD?
Research Methods
Literature Search
Search Strategy
A literature search was performed on August 5, 2010, using OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, EBSCO Cumulative Index to Nursing & Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database for studies published from January 1, 1990, to August 5, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists and health technology assessment websites were also examined for any additional relevant studies not identified through the systematic search.
Inclusion Criteria
English language full-text reports;
health technology assessments, systematic reviews, meta-analyses, and randomized controlled trials (RCTs);
studies performed exclusively in patients with a diagnosis of COPD or studies including patients with COPD as well as patients with other conditions, if results are reported for COPD patients separately;
studies performed in patients with acute exacerbations of COPD who present to the ED;
studies published between January 1, 1990, and August 5, 2010;
studies comparing hospital-at-home and inpatient hospital care for patients with acute exacerbations of COPD;
studies that include at least 1 of the outcomes of interest (listed below).
Cochrane Collaboration reviews have defined hospital-at-home programs as those that provide patients with active treatment for their acute exacerbation in their home by medical professionals for a limited period of time (in this case, until the resolution of the exacerbation). If a hospital-at-home program had not been available, these patients would have been admitted to hospital for their treatment.
Exclusion Criteria
< 18 years of age
animal studies
duplicate publications
grey literature
Outcomes of Interest
Patient/clinical outcomes
lung function (forced expiratory volume in 1 second)
health-related quality of life
patient or caregiver preference
patient or caregiver satisfaction with care
Health system outcomes
hospital readmissions
length of stay in hospital and hospital-at-home
ED visits
transfer to long-term care
days to readmission
eligibility for hospital-at-home
Statistical Methods
When possible, results were pooled using Review Manager 5 Version 5.1; otherwise, results were summarized descriptively. Data from RCTs were analyzed using intention-to-treat protocols. In addition, a sensitivity analysis was done assigning all missing data/withdrawals to the event. P values less than 0.05 were considered significant. A priori subgroup analyses were planned for the acuity of hospital-at-home program, type of hospital-at-home program (early discharge or admission avoidance), and severity of the patients’ COPD. Additional subgroup analyses were conducted as needed based on the identified literature. Post hoc sample size calculations were performed using STATA 10.1.
Quality of Evidence
The quality of each included study was assessed, taking into consideration allocation concealment, randomization, blinding, power/sample size, withdrawals/dropouts, and intention-to-treat analyses.
The quality of the body of evidence was assessed as high, moderate, low, or very low according to the GRADE Working Group criteria. The following definitions of quality were used in grading the quality of the evidence:
Summary of Findings
Fourteen studies met the inclusion criteria and were included in this review: 1 health technology assessment, 5 systematic reviews, and 7 RCTs.
The following conclusions are based on low to very low quality of evidence. The reviewed evidence was based on RCTs that were inadequately powered to observe differences between hospital-at-home and inpatient hospital care for most outcomes, so there is a strong possibility of type II error. Given the low to very low quality of evidence, these conclusions must be considered with caution.
Approximately 21% to 37% of patients with acute exacerbations of COPD who present to the ED may be eligible for hospital-at-home care.
Of the patients who are eligible for care, some may refuse to participate in hospital-at-home care.
Eligibility for hospital-at-home care may be increased depending on the design of the hospital-at-home program, such as the size of the geographical service area for hospital-at-home and the hours of operation for patient assessment and entry into hospital-at-home.
Hospital-at-home care for acute exacerbations of COPD was associated with a nonsignificant reduction in the risk of mortality and hospital readmissions compared with inpatient hospital care during 2- to 6-month follow-up.
Limited, very low quality evidence suggests that hospital readmissions are delayed in patients who received hospital-at-home care compared with those who received inpatient hospital care (mean additional days before readmission comparing hospital-at-home to inpatient hospital care ranged from 4 to 38 days).
There is insufficient evidence to determine whether hospital-at-home care, compared with inpatient hospital care, is associated with improved lung function.
The majority of studies did not find significant differences between hospital-at-home and inpatient hospital care for a variety of health-related quality of life measures at follow-up. However, follow-up may have been too late to observe an impact of hospital-at-home care on quality of life.
A conclusion about the impact of hospital-at-home care on length of stay for the initial exacerbation (defined as days in hospital or days in hospital plus hospital-at-home care for inpatient hospital and hospital-at-home, respectively) could not be determined because of limited and inconsistent evidence.
Patient and caregiver satisfaction with care is high for both hospital-at-home and inpatient hospital care.
PMCID: PMC3384361  PMID: 23074420
10.  Epilepsy and Full-Thickness Burns 
This paper presents various aspects of severe burns involving epileptic patients, who may suffer dramatic accidents during seizure attacks. Epileptics may fall onto an open fire or hot surface (e.g. a kitchen range) and they may upset containers full of boiling liquids, suffering deep burns and scalds. In our experience in this field, the most commonly affected body areas are the face and hands, the trunk, and the lower limbs. All such injuries are full-thickness burns, owing to the very long contact of the skin surface with the lesional agent. Three cases are presented of epileptics with severe burns who were admitted to the Burn Unit of Targu Mures Teaching Hospital, Romania, where they were hospitalized; conservative debridement using polyurethanefoam (PUR-foam) dressings was the standard procedure, which all the patients received. Split-thickness skin grafting was the final method for closing the granulating bed resulting from the conservative debridement. We have found that conservative debridement using PUR-foam dressings is a cheaper and more reliable alternative than sharp debridement (which may remove healthy tissue at the same time as burn eschars).
PMCID: PMC3188250  PMID: 21991200
epilepsy; major seizure attacks; full-thickness burns; conservative debridement; PUR-foam dressings; split-thickness skin grafts
11.  Bubble Hair and Other Acquired Hair Shaft Anomalies due to Hot Ironing on Wet Hair 
Bubble hair is an acquired hair shaft abnormality characterized by multiple airfilled spaces within the hair shaft. It is a result of thermal injury. We report a classic case of 22-year-old female who complained of dry brittle hair of two-week duration. Patient had used hot iron on wet hair twice to straighten hair. Hair microscopy was diagnostic and showed multiple air-filled spaces within the hair shaft.
PMCID: PMC3250009  PMID: 22223976
Bubble hair; hair ironing; thermal injury
12.  The Evolution of the Epidemic of Charcoal-Burning Suicide in Taiwan: A Spatial and Temporal Analysis 
PLoS Medicine  2010;7(1):e1000212.
Shu-Sen Chang and colleagues describe the epidemiology of an epidemic of suicide by charcoal burning in Taiwan and discuss possible reasons for its spread.
An epidemic of carbon monoxide poisoning suicide by burning barbecue charcoal has occurred in East Asia in the last decade. We investigated the spatial and temporal evolution of the epidemic to assess its impact on the epidemiology of suicide in Taiwan.
Methods and Findings
Age-standardised rates of suicide and undetermined death by charcoal burning were mapped across townships (median population aged 15 y or over = 27,000) in Taiwan for the periods 1999–2001, 2002–2004, and 2005–2007. Smoothed standardised mortality ratios of charcoal-burning and non-charcoal-burning suicide and undetermined death across townships were estimated using Bayesian hierarchical models. Trends in overall and method-specific rates were compared between urban and rural areas for the period 1991–2007. The epidemic of charcoal-burning suicide in Taiwan emerged more prominently in urban than rural areas, without a single point of origin, and rates of charcoal-burning suicide remained highest in the metropolitan regions throughout the epidemic. The rural excess in overall suicide rates prior to 1998 diminished as rates of charcoal-burning suicide increased to a greater extent in urban than rural areas.
The charcoal-burning epidemic has altered the geography of suicide in Taiwan. The observed pattern and its changes in the past decade suggest that widespread media coverage of this suicide method and easy access to barbecue charcoal may have contributed to the epidemic. Prevention strategies targeted at these factors, such as introducing and enforcing guidelines on media reporting and restricting access to charcoal, may help tackle the increase of charcoal-burning suicides.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, about a million people take their own lives. Most people who die by suicide are mentally ill but some people take their lives because stressful events (the loss of a partner, for example) have made life seem worthless or too painful to bear. Strategies to reduce suicide rates include better treatment of mental illness and programs that help people at high risk of suicide deal with stress. Suicide rates can also be reduced by limiting access to common suicide methods. These methods differ from place to place. Hanging is the predominant suicide method in many countries but, in Hong Kong, for example, jumping from a high building is the commonest method. Suicide methods also vary over time. In 1998, a woman in Hong Kong took her life by burning barbecue charcoal in a sealed room (a process that produces high levels of the toxic gas carbon monoxide). This method was unheard of before and was extensively reported by the mass media; by the end of 2004, charcoal-burning suicide became the second most common form of suicide in Hong Kong.
Why Was This Study Done?
The epidemic of charcoal-burning suicide that started in Hong Kong has rapidly spread to other countries in East Asia, including Taiwan, where it is also now the second most common method of suicide. It would be useful to identify the factors that have contributed to the spread of this particular form of suicide because such knowledge might help to improve strategies for preventing charcoal-burning suicide. One way to identify these factors is to examine the space–time clustering of charcoal-burning suicides. Clustering of specific types of suicides in both time and space usually occurs in settings such as institutions where the individuals who die by suicide have been in social contact. By contrast, clustering of specific types of suicide in time more than place is often associated with media coverage of events such as celebrity suicides, which can lead to imitative suicides. In this study, therefore, the researchers investigate the evolution of the epidemic of charcoal-burning suicide over time and across areas in Taiwan.
What Did the Researchers Do and Find?
The researchers obtained data on suicides and undetermined deaths (most “missed” suicides are recorded as undetermined deaths) from 1999 to 2007 from the Taiwan Department of Health. They then used statistical methods to estimate the standardized mortality rates (the ratio of the observed to the expected numbers of deaths) of charcoal-burning and non-charcoal-burning suicides and undetermined deaths in different areas of Taiwan. The proportion of suicides that were charcoal-burning suicides rose from 0.1% in 1991 to 26.6% in 2007, they report, and the epidemic of charcoal-burning suicide was more marked in urban than in rural areas. However, there was no single point of origin of the epidemic. Finally, they report, rates of charcoal-burning suicide were consistently higher in urban than in rural areas throughout the study period, a result that means that, although overall suicide rates were higher in rural than in urban regions of Taiwan prior to the epidemic of charcoal-burning suicide, the difference has now almost disappeared.
What Do These Findings Mean?
These findings suggest that the epidemic of charcoal-burning suicide may underlie recent changes in the geography of suicide in Taiwan. However, the study's findings may not be numerically accurate because of some of the assumptions made by the researchers. For example, there is no specific code for charcoal-burning suicides in official records so the researchers assumed that suicides classified as “poisoning using nondomestic gas” were all charcoal-burning suicides, although other studies have shown that nearly 90% of deaths in the category were indeed charcoal-burning suicides. Nevertheless, the observed geographical pattern of charcoal-burning suicides and the changes in this pattern over time suggest that widespread media coverage and easy access to barbecue coal in supermarkets and convenience stores may have contributed to the epidemic of charcoal-burning suicide and to the increase in overall suicide rate in Taiwan and elsewhere in East Asia. Thus, guidelines that encourage responsible media reporting of charcoal-burning suicide (that is, reporting that does not contain detailed descriptions of the method or suggest that this type of suicide is easy and painless) and strategies that restrict access to barbecue charcoal may help to halt the epidemic of charcoal-burning suicide in East Asia.
Additional Information
Please access these Web sites via the online version of this summary at
Another PLoS Medicine research article by David Studdert and colleagues investigates the relationship between changes in vehicle emissions laws and the incidence of suicide by motor vehicle exhaust gas in Australia
The World Health Organization provides information on the global burden of suicide and on suicide prevention (in several languages); see also the article Methods of Suicide: International Suicide Patterns Derived from the WHO Mortality Database
The US National Institute of Mental Health provides information on suicide and suicide prevention
The UK National Health Service Choices website has detailed information about suicide and its prevention
MedlinePlus provides links to further resources about suicide (in English and Spanish)
The Taiwan Suicide Prevention Center provides information on suicide and its prevention in Taiwan (in Chinese)
The Centre for Suicide Research and Prevention, the University of Hong Kong, provides information on suicide and its prevention in Hong Kong (in Chinese and English)
PMCID: PMC2794367  PMID: 20052273
13.  Acute kidney injury is common, parallels organ dysfunction or failure, and carries appreciable mortality in patients with major burns: a prospective exploratory cohort study 
Critical Care  2008;12(5):R124.
The purpose of this study was to determine the incidence, time course, and outcome of acute kidney injury after major burns and to evaluate the impact of possible predisposing factors (age, gender, and depth and extent of injury) and the relation to other dysfunctioning organs and sepsis.
We performed an explorative cohort study on patients with a TBSA% (percentage burned of total body surface area) of 20% or more who were admitted to a national burn centre. Acute kidney injury was classified according to the international consensus classification of RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease). Prospectively collected clinical and laboratory data were used for assessing organ dysfunction, systemic inflammatory response, and sepsis.
The incidence of acute kidney injury among major burns was 0.11 per 100,000 people per year. Of 127 patients, 31 (24%) developed acute kidney injury (12% Risk, 8% Injury, and 5% Failure). Mean age was 40.6 years (95% confidence interval [CI] 36.7 to 44.5), TBSA% was 38.6% (95% CI 35.5% to 41.6%), and 25% were women. Mortality was 14% and increased with increasing RIFLE class (7% normal, 13% Risk, 40% Injury, and 83% Failure). Renal dysfunction occurred within 7 days in 55% of the patients and recovered among all survivors. Age, TBSA%, and extent of full thickness burns were higher among the patients who developed acute kidney injury. Pulmonary dysfunction and systemic inflammatory response syndrome were present in all of the patients with acute kidney injury and developed before the acute kidney injury. Sepsis was a possible aggravating factor in acute kidney injury in 48%. Extensive deep burns (25% or more full thickness burn) increased the risk for developing acute kidney injury early (risk ratio 2.25).
Acute kidney injury is common, develops soon after the burn, and parallels other dysfunctioning organs. Although acute kidney injury recovered in all survivors, in higher acute kidney injury groups, together with cardiovascular dysfunction, it correlated with mortality.
PMCID: PMC2592761  PMID: 18847465
14.  Fungal infections in burns: Diagnosis and management 
Burn wound infection (BWI) is a major public health problem and the most devastating form of trauma worldwide. Fungi cause BWI as part of monomicrobial or polymicrobial infection, fungaemia, rare aggressive soft tissue infection and as opportunistic infections. The risk factors for acquiring fungal infection in burns include age of burns, total burn size, body surface area (BSA) (30–60%), full thickness burns, inhalational injury, prolonged hospital stay, late surgical excision, open dressing, artificial dermis, central venous catheters, antibiotics, steroid treatment, long-term artificial ventilation, fungal wound colonisation (FWC), hyperglycaemic episodes and other immunosuppressive disorders. Most of the fungal infections are missed owing to lack of clinical awareness and similar presentation as bacterial infection coupled with paucity of mycology laboratories. Expedient diagnosis and treatment of these mycoses can be life-saving as the mortality is otherwise very high. Emergence of resistance in non-albicans Candida spp., unusual yeasts and moulds in fungal BWI, leaves very few fungi susceptible to antifungal drugs, leaving many patients susceptible. There is a need to speciate fungi as far as the topical and systemic antifungal is concerned. Deep tissue biopsy and other relevant samples are processed by standard mycological procedures using direct microscopy, culture and histopathological examination. Patients with FWC should be treated by aggressive surgical debridement and, in the case of fungal wound infection (FWI), in addition to surgical debridement, an intravenous antifungal drug, most commonly amphotericin B or caspofungin, is prescribed followed by de-escalating with voriconazole or itraconazole, or fluconazole depending upon the species or antifungal susceptibility, if available. The propensity for fungal infection increases, the longer the wound is present. Therefore, the development of products to close the wound more rapidly, improvement in topical antifungal therapy with mould activity and implementation of appropriate systemic antifungal therapy guided by antifungal susceptibility may improve the outcome for severely injured burn victims.
PMCID: PMC3038393  PMID: 21321655
Burns; fungal infections; moulds; yeasts
15.  Topical Nanoemulsion Therapy Reduces Bacterial Wound Infection and Inflammation Following Burn Injury 
Surgery  2010;148(3):499-509.
Nanoemulsions are broadly antimicrobial oil-in-water emulsions containing nanometer-sized droplets stabilized with surfactants. We hypothesize that topical application of a nanoemulsion compound (NB-201) can attenuate burn wound infection. In addition to reducing infection, nanoemulsion therapy may modulate dermal inflammatory signaling and thereby lessen inflammation following thermal injury.
Male Sprague-Dawley rats underwent a 20% total body surface area (TBSA) scald burn to create a partial thickness burn injury. Animals were resuscitated with Ringer’s lactate and the wound covered with an occlusive dressing. Eight hours after injury, the burn wound was inoculated with 1×106 CFU of Pseudomonas aeruginosa. NB-201, NB-201 placebo, 5% mafenide acetate solution or 0.9% saline (control) was applied onto the wound at 16 and 24 hrs following burn injury. Skin was harvested 32 hrs post-burn for quantitative wound culture and determination of inflammatory mediators in tissue homogenates.
NB-201 reduced mean bacterial growth in the burn wound by a thousand fold, with only 11% animals having P. aeruginosa counts greater than 105 CFU/g tissue versus 91% in the control group (p<0.0001). Treatment with NB-201 attenuated neutrophil sequestration in the treatment group as measured by myeloperoxidase assay and by histology. It also, significantly reduced levels of pro-inflammatory cytokines (IL-1β and IL-6) and the degree of hair follicle cell apoptosis in skin when compared to saline-treated controls.
Topical NB-201 substantially reduced bacterial growth in a partial thickness burn model. This reduction in the level of wound infection was associated with an attenuation of the local dermal inflammatory response and diminished neutrophil sequestration. NB-201 represents a novel potent antimicrobial and antiinflammatory treatment for use in burn wounds.
PMCID: PMC2891388  PMID: 20189619
Apoptosis; Cytokine; Myeloperoxidase; Partial thickness burn; Tissue edema
16.  Adherence to Referral Criteria for Burns in the Emergency Department 
Eplasty  2008;8:e26.
Objective: To audit the referral patterns of burns in an emergency department compared with national referral guidelines. Methods: A retrospective case note audit of patients attending an emergency department with a diagnosis of “burn” in a 1-year period. Results: Only one quarter of the patients were managed according to the suggested national referral criteria for burns. Large and full thickness burns were managed appropriately but those at important anatomical sites and in patients at the extremes of age were managed less well. Conclusion: Increased awareness of the national referral guidelines, along with further education of staff within this department, may improve management of burn injuries. It is likely that referral patterns are similar in other emergency departments and may be improved by training staff in the assessment and management of burns. Increased adherence to the guidelines is likely to improve patient outcome at the expense of increased patient numbers and workloads in regional burns units that have implications for funding and service provision.
PMCID: PMC2380084  PMID: 18536778
17.  A Computer Program to Evaluate Experimental Therapies for Treating Burned Patients 
Determining the worth of new therapies for burn patients has been difficult because of the rarity of the burn injury and the disparate survival chances associated with different sizes of burns. Recently a burn survival model has been developed that estimates the risk of death from a burn as a function of the patient's age, sex, area of full thickness (third degree) burn, area of partial thickness burn, involvement of the perineum, and time from burn to admission. An alternative risk model uses the total area burned in place of the areas of partial thickness burn and full thickness burn, and is appropriate if the amount of full thickness burn is not determined accurately. This paper describes a program that uses these risk models to correct or standardize for demographic and severity factors, then, after that adjustment, tests whether a group of burn patients who received a new or experimental therapy shows a significantly better survival rate than that predicted by a baseline model. The program is a simple one written in Fortran for easy adaptation to other computer systems.
PMCID: PMC2203672
18.  Acute Dorsal Hand Burns in Children 
Hand burns in children, whether isolated or part of massive burns, require special attention. A crucial element in this respect is the preservation and full restoration of hand function. Most cases of severe sequelae after burns are associated with hand burns. From January 2002 to November 2004, 125 children with hand burns and other body burns were treated at the Centre of Burns and Plastic Surgery in Sofia, Bulgaria. This review presents our experience with 71 children with 89 burned hands in the region of the dorsal surface of the hand. Forty-nine hands had isolated dorsal surface burns, and 40 had combined burns, i.e. both dorsal and volar. Of all the hands treated, 69 had superficial burns, which epithelialized spontaneously. Twenty hands with deep dermal and full-thickness burns were subjected to sheet autografting. The review includes many details of the systematic approach to this type of burns. Optimal recovery of hand function can be achieved by accurate planning of treatment. Tracking of long-term results is also included in the general plan of behaviour in this type of burn. Our approach is conservative for superficial burns and active - with early excision and prompt closure with sheet autograft or, in extensive burns, allografting followed by covering with an autograft.
PMCID: PMC3188013  PMID: 21991015
19.  A retrospective analysis of ambulatory burn patients: focus on wound dressings and healing times 
In this study, we retrospectively analysed healing times of ambulatory burn patients after silver-based dressings were introduced in late December 2005, and compared the results with those obtained before.
Data were collected in November–December 2005 and in January–February 2006. We excluded from the study: (i) admitted patients; (ii) patients with mixed superficial partial thickness and deep partial thickness burns; (iii) patients with full-thickness burns; and (iv) operated patients that came for follow-up. We recorded the age, sex, cause (flame vs scald), burn depth, dressings used and healing times.
We selected 347 patients corresponding to 455 burned areas (64.4% superficial and 35.6% deep; 47.7% treated in 2005 and 52.3% in 2006). During the years 2005 and 2006, there was an increase in the use of silver-based dressings (2005, 9.7%; 2006, 38.7%; chi-squared test, P < 0.001) and a decrease in the use of paraffin gauzes (2005, 66.4%; 2006, 40.3%; chi-squared test, P < 0.001). The healing time of overall burns and of superficial burns showed no significant differences between 2005 and 2006. However, in deep partial thickness burns, a significant reduction was present (2006, 19; 2005, 29 days; Student's t-test, P < 0.01). Among all dressings, paraffin gauzes had the shortest healing times in superficial burns (5 days); with silver-based dressings in deep burns, the healing times were nanocrystalline silver (16 days) and silver carboxymethylcellulose (21 days).
Results of our retrospective study would suggest that paraffin gauzes are a valuable option in superficial burns, while silver-based dressings are preferable in deep burns.
PMCID: PMC3025243  PMID: 19995488
Burn dressings; Ambulatory burns; Healing times
20.  Chemical burns from assault: a review of seven cases seen in a Nigerian tertiary institution 
Chemical burns represent a major challenge for reconstructive surgeons. They are caused by exposure to acids, alkalis or other corrosive substances which result in various degrees of injury. This report highlights the challenges faced in managing such patients in a Nigerian teaching hospital. The medical records of seven patients (four females and three males) treated for chemical burns injury from January 2001 to December 2010 were retrospectively reviewed. All patients were younger than 30, with a mean age of 23.3. Most of them (85.7%) had sustained full thickness burns ranging from 8% to 33% of their body surface area. All cases were result of assaults. The male to female ratio was 1:1.3, and the average duration of hospital stay was 7.5 months. The face was affected in all patients. Patients presented with multiple deformities, like ectropion of eyelids, keratopathies, blindness, nasal deformities, microstomia, loss or deformities of the pinna, mentosternal contractures, and severe scarring of the face. Twenty-nine surgical procedures were performed, which included nasal and lip reconstruction, ectropion release, commissuroplasty, contracture release, and wound resurfacing. Management of chemical burns, especially in a developing country lacking specialised burn centres with appropriate facilities, is challenging. Prevention through public awareness campaigns, legislation for control of corrosive substances, and severe punishment for perpetrators of assaults using these substances will go a long way in reducing the incidence of chemical burns.
PMCID: PMC3575146  PMID: 23467188
chemical; burn; assault
21.  Paediatric injuries due to home treadmill use: an emerging problem 
The use of home exercise equipment is increasing and treadmills are becoming more popular. This has brought with it an emerging but preventable problem. We present our experience, highlight the importance and promote public awareness of this type of injury. To our knowledge this has not been reported previously in the UK.
A retrospective review was conducted of the medical records at two regional burn units of children who sustained treadmill-related injuries between July 2003 and July 2009. Data on patient demographics, mechanism of injury, management, surgical intervention and outcome were recorded.
Twenty-nine children (15 boys, 14 girls) sustained treadmill-related injuries. The mean age was 3.8 years (range: 1–13 years). All injuries occurred at home and the majority of children trapped their hand under the running belt when an adult was using the machine. Most of the injuries were to the upper limb (97%) with less than 1% of the total body surface area burnt. More than two-thirds of patients had deep burns and 17 (58%) required surgical intervention. Five patients developed hypertrophic scars. All patients achieved a good functional outcome.
Treadmills can pose a significant danger to children. These injuries are preventable. Regulatory authorities, manufacturers and parents should take steps to prevent this emerging health problem.
PMCID: PMC3954134  PMID: 22340206
Treadmill-related injuries; Burns; Paediatric; Prevention
22.  Skin regeneration with conical and hair follicle structure of deep second-degree scalding injuries via combined expression of the EPO receptor and beta common receptor by local subcutaneous injection of nanosized rhEPO 
Acceleration of skin regeneration is still an unsolved problem in the clinical treatment of patients suffering from deep burns and scalds. Although erythropoietin (EPO) has a protective role in a wide range of organs and cells during ischemia and after trauma, it has been recently discovered that EPO is not tissue-protective in the common β subunit receptor (βCR) knockout mouse. The protective capacity of EPO in tissue is mediated via a heteroreceptor complex comprising both the erythropoietin receptor (EPOR) and βCR. However, proof of coexpression of these heterogenic receptors in regenerating skin after burns is still lacking.
To understand the role of nanosized recombinant human erythropoietin (rhEPO) in wound healing, we investigated the effects of subcutaneous injections of EPO on skin regeneration after deep second-degree scalding injuries. Our aim was to determine if joint expression of EPOR and βCR is a prerequisite for the tissue-protective effect of rhEPO. The efficiency in wound regeneration in a skin scalding injury mouse model was examined. A deep second-degree dermal scald injury was produced on the backs of 20 female Balb/c mice which were subsequently randomized to four experimental groups, two of which received daily subcutaneous injections of rhEPO. At days 7 and 14, the mice were sacrificed and the effects of rhEPO were analyzed with respect to grade of re-epithelialization (wound closure) and stage of epidermal maturation. This was investigated using different histological parameters of epithelial covering, such as depth of the epidermal layer, epidermal stratification, and presence of conical and hair follicle structures.
Expression of EPOR, βCR, and growth hormone receptor at the mRNA and protein levels was demonstrated with reverse transcriptase polymerase chain reaction and Western blot analysis. After rhEPO treatment, the rate of re-epithelialization of the scalding injury was increased and the time to final wound closure was reduced. In addition, the quality of regenerated skin was improved. In this investigation, for the first time, we demonstrated coexpression of EPOR and βCR at the RNA and protein levels in vivo using a deep second-degree scalding injury mouse model. These results highlight the potential role of rhEPO in the improved treatment of burns patients, which might be crucial for the development of innovative new therapy regimes.
Local injection of nanosized rhEPO directly to the injury site rather than systemic administration for deep second-degree scalding injuries achieved complete skin regeneration with conical and hair follicle structure via combined expression of EPOR and βCR.
PMCID: PMC3298388  PMID: 22419870
burns; nanosize; common β subunit; erythropoietin; receptor; local injection
23.  Role of Autophagy and Apoptosis in Wound Tissue of Deep Second‐degree Burn in Rats 
Academic Emergency Medicine  2014;21(4):383-391.
The pathogenesis of burn wound progression is poorly understood. Contributing factors include continuous loss of blood perfusion, excessive inflammation, and elevated apoptosis levels in wound tissue. Macroautophagy (here referred to simply as “autophagy”) is associated with many chronic diseases. The authors hypothesized that autophagy is involved in burn wound progression in a rat model of deep second‐degree burn.
Deep second‐degree burns were modeled using a brass rod heated to 100°C applied for 6 seconds to the back skin of Wistar rats. Full‐thickness biopsies were obtained from burned and nonburned controls at several times postburn. Western blotting and immunohistochemical (IHC) staining determined expression of the autophagy markers Light Chain 3 (LC3) and beclin‐1. Apoptosis was determined by terminal‐deoxynucleoitidyl transferase mediated nick end labeling (TUNEL) assay and laser Doppler flowmetry (LDF)‐measured tissue perfusion. Myeloperoxidase (MPO) activity assay measured inflammation. Hematoxylin and eosin (H&E) and Masson's trichrome staining–determined pathology and wound depth.
The LC3 and beclin‐1 protein level in burn wounds decreased to one‐fourth of normal levels (p < 0.01) over 24 hours and then began to increase but still did not reach their normal level. TUNEL‐positive cells in burn wounds were 3.7‐fold (p < 0.01) elevated over 48 hours and then decreased slightly, yet still remained higher than in normal skin. The burn wound progressed in depth over 72 hours. In addition, significant decrease in LDF values and upregulation of MPO activity were observed. Enhanced LC3‐positive cells were observed in the deep dermal layer of burn wounds as shown by IHC staining.
A reduction in autophagy and blood flow and an increase in apoptosis and inflammation were observed in burn wounds early during the course of burn injury progression. This suggests that autophagy, complemented by apoptosis, play important roles in burn progression. Enhanced autophagy in the deep dermis may be a prosurvival mechanism against ischemia and inflammation after burn injury.
PMCID: PMC4114170  PMID: 24730400
24.  Head and Neck Burns: Acute and Late Reconstruction.Data of Burn Injury Management in 2007 
Modern burn care is based on operative wound management. The evidence is clear that prompt excision and closure can be lifesaving for patients even with large burns. Facial burns that are full-thickness need grafting. Deep dermal facial burns need surgery in the third week post-burn. Deep burns to the eyelids should be excised and grafted early in order to prevent cicatricial ectropion and corneal exposure. Following healing from burns, the reconstruction of severe deformities and scars of the face, head, and neck confronts the surgeon with some of the most challenging problems in reconstructive surgery. Our purpose is to provide some retrospective data on acute and late reconstruction of head and neck burns in 2007. Eighty-one patients are considered who were operated on in the Burns and Plastic Surgery Service of the University Hospital Centre in Tirana, Albania, suffering from burns and also from burn deformities in the head and neck regions. A description is given of the different types of operative techniques used for head and neck reconstruction as also of developmental aspects of burned face deformities (physical and psychological) and of their correction. In all, 246 patients with burns and burn deformities were subjected to surgery in 2007. Of these we have extracted 81 cases in which the pathology concerned the head and the neck, including 13 cases of full-thickness facial burns needing excising and grafting. The other 68 cases were burn deformities. This last group of patients included 19 with facial deformities, 14 with perioral deformities, 12 with burn alopecia, ten with upper and lower eyelid deformities, nine with ear deformities, and four with cervical deformities. The operative techniques used were skin grafts (split-thickness or full-thickness), composite grafts, pedicle flaps, and tissue replacement. In burn alopecia cases, we used tissue expansion for the correction. Head and neck burns constitute some of the most challenging problems in acute wound care and in the subsequent rehabilitation and reconstruction.With knowledge of the reconstruction techniques available, plus an accurate diagnosis of tissue deficiency and secondary distortion, a carefully performed surgical plan is the first step for achieving improvements in a burn-deformed face.
PMCID: PMC3188193  PMID: 21991138
25.  Regional Changes in Charcoal-Burning Suicide Rates in East/Southeast Asia from 1995 to 2011: A Time Trend Analysis 
PLoS Medicine  2014;11(4):e1001622.
Using a time trend analysis, Ying-Yeh Chen and colleagues examine the evidence for regional increases in charcoal-burning suicide rates in East and Southeast Asia from 1995 to 2011.
Please see later in the article for the Editors' Summary
Suicides by carbon monoxide poisoning resulting from burning barbecue charcoal reached epidemic levels in Hong Kong and Taiwan within 5 y of the first reported cases in the early 2000s. The objectives of this analysis were to investigate (i) time trends and regional patterns of charcoal-burning suicide throughout East/Southeast Asia during the time period 1995–2011 and (ii) whether any rises in use of this method were associated with increases in overall suicide rates. Sex- and age-specific trends over time were also examined to identify the demographic groups showing the greatest increases in charcoal-burning suicide rates across different countries.
Methods and Findings
We used data on suicides by gases other than domestic gas for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore in the years 1995/1996–2011. Similar data for Malaysia, the Philippines, and Thailand were also extracted but were incomplete. Graphical and joinpoint regression analyses were used to examine time trends in suicide, and negative binomial regression analysis to study sex- and age-specific patterns. In 1995/1996, charcoal-burning suicides accounted for <1% of all suicides in all study countries, except in Japan (5%), but they increased to account for 13%, 24%, 10%, 7%, and 5% of all suicides in Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore, respectively, in 2011. Rises were first seen in Hong Kong after 1998 (95% CI 1997–1999), followed by Singapore in 1999 (95% CI 1998–2001), Taiwan in 2000 (95% CI 1999–2001), Japan in 2002 (95% CI 1999–2003), and the Republic of Korea in 2007 (95% CI 2006–2008). No marked increases were seen in Malaysia, the Philippines, or Thailand. There was some evidence that charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong, Taiwan, and Japan (for females), but not in Japan (for males), the Republic of Korea, and Singapore. Rates of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong but appeared to be greatest in people aged 15–24 y in Japan and people aged 25–64 y in the Republic of Korea. The lack of specific codes for charcoal-burning suicide in the International Classification of Diseases and variations in coding practice in different countries are potential limitations of this study.
Charcoal-burning suicides increased markedly in some East/Southeast Asian countries (Hong Kong, Taiwan, Japan, the Republic of Korea, and Singapore) in the first decade of the 21st century, but such rises were not experienced by all countries in the region. In countries with a rise in charcoal-burning suicide rates, the timing, scale, and sex/age pattern of increases varied by country. Factors underlying these variations require further investigation, but may include differences in culture or in media portrayals of the method.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, almost one million people die by suicide globally; suicide is the fifth leading cause of death in women aged 15–49 and the sixth leading cause of death in men in the same age group. Most people who take their own life are mentally ill. For others, stressful events (the loss of a partner, for example) have made life seem worthless or too painful to bear. Strategies to reduce suicide rates include better treatment of mental illness and programs that help people at high risk of suicide deal with stress. Suicide rates can also be reduced by limiting access to common suicide methods. These methods vary from place to place. Hanging is the predominant suicide method in many countries, but in Hong Kong, for example, jumping from a high building is the most common method. Suicide methods also vary over time. For example, after a woman in Hong Kong took her life in 1998 by burning barbecue charcoal in a sealed room (a process that produces the toxic gas carbon monoxide), charcoal burning rapidly went from being a rare method of killing oneself in Hong Kong to the second most common suicide method.
Why Was This Study Done?
Cases of charcoal-burning suicide have also been reported in several East and Southeast Asian countries, but there has been no systematic investigation of time trends and regional patterns of this form of suicide. A better understanding of regional changes in the number of charcoal-burning suicides might help to inform efforts to prevent the emergence of other new suicide methods. Here, the researchers investigate the time trends and regional patterns of charcoal-burning suicide in several countries in East and Southeast Asia between 1995 and 2011 and ask whether any rises in the use of this method are associated with increases in overall suicide rates. The researchers also investigate sex- and age-specific time trends in charcoal-burning suicides to identify which groups of people show the greatest increases in this form of suicide across different countries.
What Did the Researchers Do and Find?
The researchers analyzed method-specific data on suicide deaths for Hong Kong, Japan, the Republic of Korea, Taiwan, and Singapore between 1995/1996 and 2011 obtained from the World Health Organization Mortality Database and from national death registers. In 1995/1996, charcoal-burning suicides accounted for less than 1% of all suicides in all these countries except Japan (4.9%). By 2011, charcoal-burning suicides accounted for between 5% (Singapore) and 24% (Taiwan) of all suicides. Rises in the rate of charcoal-burning suicide were first seen in Hong Kong in 1999, in Singapore in 2000, in Taiwan in 2001, in Japan in 2003, and in the Republic of Korea in 2008. By contrast, incomplete data from Malaysia, the Philippines, and Thailand showed no evidence of a marked increase in charcoal-burning suicide in these countries over the same period. Charcoal-burning suicides were associated with an increase in overall suicide rates in Hong Kong in 1998–2003, in Taiwan in 2000–2006, and in Japanese women after 2003. Finally, the annual rate of change in charcoal-burning suicide rate did not differ by sex/age group in Taiwan and Hong Kong, whereas in Japan people aged 15–24 and in the Republic of Korea people aged 25–64 tended to have the greatest rates of increase.
What Do These Findings Mean?
These findings show that charcoal-burning suicides increased markedly in several but not all East and Southeast Asian countries during the first decade of the 21st century. Moreover, in countries where there was an increase, the timing, scale, and sex/age pattern of the increase varied by country. The accuracy of these findings is likely to be limited by several aspects of the study. For example, because of the way that method-specific suicides are recorded in the World Health Organization Mortality Database and national death registries, the researchers may have slightly overestimated the number of charcoal-burning suicides. Further studies are now needed to identify the factors that underlie the variations between countries in charcoal-burning suicide rates and time trends reported here. However, the current findings highlight the need to undertake surveillance to identify the emergence of new suicide methods and the importance of policy makers, the media, and internet service providers working together to restrict graphic and detailed descriptions of new suicide methods.
Additional Information
Please access these websites via the online version of this summary at
A PLOS Medicine research article by Shu-Sen Chang and colleagues investigates time trends and regional patterns of charcoal-burning suicide in Taiwan
The World Health Organization provides information on the global burden of suicide and on suicide prevention (in several languages); it also has an article on international patterns in methods of suicide
The US National Institute of Mental Health provides information on suicide and suicide prevention
The UK National Health Service Choices website has detailed information about suicide and its prevention
MedlinePlus provides links to further resources about suicide (in English and Spanish)
The International Association for Suicide Prevention provides links to crisis centers in Asia
The charity Healthtalkonline has personal stories about dealing with suicide
PMCID: PMC3972087  PMID: 24691071

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