الفهرس 
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Abstract
Burns are a destructive form of injury; severely endangering the life and health of human. Burns in Egypt are considered as major health problems that are associated with high mortality and morbidity.
This study was prospectively carried out at the Burn Unit, Department of Plastic Surgery; Benha Educational Hospital, during the period starting from the 1st of September 2009, until the end of October 2010. All patients (203 patients) were admitted to the burn unit during this period, involved in the epidemiological study but only 50 patients underwent biochemical, histopathological and immunohistochemical study.
The aim of the epidemiological study was to provide important information about the epidemiologic patterns of acute burns, as well as etiological and demographical factors influencing the incidence, to assess outcomes in relation to burn size.
The biochemical study provide clinical assessment of the activities of various enzymes in sera of patients sustaining burns of various severities over the first 10 days after injury, which may serve as a useful criterion in predicting the possibility of acute liver damage. Also, the purpose was to investigate the relationship between the severity of burn and liver enzymes.
Regarding the histopathological study, the aim was establishing a method of burn dating by examining the order and time at which components of the healing response are present in a set of burns of known age; it may be possible to apply this information to burns for forensic purposes. Also, to investigate the time course of infiltrated leukocytes in deep wounds, and their relationship with injury severity in burned patients.
The immunohistochemical study was done to investigate the different effect of burn injury on CD4 and CD8 T cells in relation to time and severity and suggests the possible mechanisms of this effect.
2- Epidemiological study:
A special burn sheet was designed and data for every patient were recorded in a separate one including:
• Age.
• Gender.
• Residence.
• Marital status.
• Interval between burn and hospital admission.
• Seasonal variation.
• Place of burn.
• Causes of burn.
• Anatomical sites of burn.
• Percentage of burned surface area (TBSA) or Burn severity.
• Burn depth (Degree of burn).
• Circumstances of burn.
• Outcome of patients.
2-Biochemical, Histopathological and Immunohistochemical study:
The patients were informed and gave written consent before they were included in this study.
Inclusion criteria:
• Ages; between 18 and 60 years.
• Admission to hospital within 24 hours post burn.
• Burn size of more than 10% TBSA and not more than 65% TBSA, with at least 1% deep partial-thickness burn area.
• Hospital staying period at least: 2 weeks.
• Patients who consented to biopsy and blood sample (informed written consent).
Exclusion criteria:
• Age: 60 years or greater
• Patients with systemic disease likely to affect the level of enzymes.
• Patients who refused to give the informed consent.
• Patients who had been admitted only for less than 2 weeks or any patients who don’t fulfill the other inclusion criteria.
(A) Biochemical Study:
The blood samples were collected at the time of admission, subsequently on 5th and 10th day after hospitalization.
(B) Histopathological and Immunohistochemical study:
Punch-biopsy specimens were taken from the deep partial-thickness burn wounds at 3 days, 1 week and 2 weeks post burn.
-The results of the epidemiological study revealed that:
• Most of patients 59 (29.1%) were in the age group <5 years.
• Most of patients 114 (56.2%) patients were females and 89 (43.8%) were males.
• Female predominance was seen in all age groups except <5 years. Children under 5 years showed male predominance (69.5%).
• Most of patients 174 (85.7%) were admitted within hours of burn but 29 (14.3%) patients had delayed admission.
• There were 60 (20.6%) patients married and 143 (70.4%) unmarried.
• Most of patients 138 (67.9%) came from rural areas but only 65 (32.1 %) came from urban areas.
• The highest proportion of hospital admissions had occurred in winter (32.0%), followed by spring (28.1%), then summer and autumn (24.6% and 15.3 % respectively).
• Home (indoor) was the most common place of burning 160 (78.8%) followed by outdoor 38 (18.7%). Burning at the place of employment (work area) was account for only 2.5% of patients.
• Of indoor burn, the highest percentage was for children under 5 year age group (35.6%) and it forms the least percentage (5.3%) of outdoor. Of work area burn, the highest percentage (60%) of patients for the age group 25-34 year.
• Flame burn represented the highest proportion (60.6%) followed by scald (34.4%) then contact burn (3.0%). Chemical and electrical burns were the least common cause.
• Children less than 5 years of age seemed to be the most vulnerable to burn caused by scald constituting (81.4%) of that category, while flame burn was the most common among other age groups.
• Female’s predominance was seen in all types of burn except in scald and electrical burn, in which males were predominating.
• The most common site of the body affected by burn was the upper limb (72.9%) followed by lower limbs (66.5%), head and neck (53.7%), abdomen and back (30.1%), chest (20.2%) and genital area and buttock (10.3%). Inhalation injuries accounted for (18.2%).
• The most common sites of body affected by flame burn were the upper limbs (82.9%) then the head and neck (76.4%) and the lower limbs (74.8%).
• According to the severity of burn; there were 22 (10.8%) patients with mild burn (<10%), 121 (59.6%) moderate burn (10-30%), 39 (19.3%) severe burn (31-50%) and 21 (10.3%) extremely severe burn (>50%).
• The mean of TBSA of the female patients was higher (25%) than that of the male (19%).
• Most of mild burn (45.5%) caused by scald, while most of (66.9%) moderate burn, (59.0%) severe burn and (76.2%) extremely severe burn caused by flame burn.
• There were 159 (78.3%) patients presented with 1st degree burn, 202 patients with 2nd degree burn (of them 120 (59.1%) superficial thicknesses and 82 (40.4%) deep partial thickness burns) and 71 (35.0%) patients with 3rd degree burn.
• Most of full thickness burn caused by flame burn (81.3%), while most of 2nd deep partial thickness burn caused by scald (62.2%). Most of electrical and chemical burn cause full thickness burn with percentage of 2.8% of each. Contact burn cause mainly 2nd deep partial thickness with percentage of 4.9%.
• Accidental burning was observed in most of cases 196 (96.6%) but only 7 (3.4%) suicidal burning.
• Suicidal cases had a higher mean of age (42.1 year) than accidental cases (21.1 year).
• It was noted that the all suicidal cases were females. Out of 169 accidental cases, 107 (54.6%) were females and 89 (45.4%) were males.
• Out of 196 accidental cases, 153 (78.1%) cases burned at home, 38 (19.4%) cases burned at outdoor and only 5 cases (2.5%) burned at work place. All suicidal cases 7 (100%) burned at home.
• Flame burn was the most common cause of accidental (59.7%) and suicidal burn (85.7%).There was non-significant relation between manner and cause of burn with p>0.05.
• According to the outcome of patients, there were 79 (38.9%) of cases improved without complications, 26 (12.8%) improved with complications as (hypertrophic scars, keloid or disfigurements) and 11 (5.4%) of cases died, 80 (39.5%) left against medical advice and 7 (3.4%) cases referred to another hospital.
• The patients died had the highest mean of age (38.1 y) among the cases.
• Out of 11 patients died, 7 (63.6%) patients were females and only 4 (36.4%) males.
• There were 49 (62.0%) patients with flame burn, 26 (32.9%) patient with scald, 3 (3.8%) patients with contact burn and 1 (1.3%) patients with electrical burn improved without complication. There were 11 burn-related deaths identified, of which flame burn was responsible for 63.6% (7 cases) deaths and 36.4% (4 cases) from scald.
• Most of mild and moderate cases were improved without complication (59.1% and 50.4% respectively). Most of severe burn was improved with complication (46.1%). Most of extremely severe burn patients were died (28.6%).
- The results of the biochemical study revealed that:
• The mean values for ALP and amylase on admission were significantly elevated in the patients as compared to control but ALT and AST showed non-significant relation (P> 0.05). The mean values for ALT, AST, ALP and amylase 5 and 10 days after burn were significantly elevated in the patients as compared to the controls.
• The trends in the mean AST and ALT values show increase till 5th day then decline on 10th day however, it does not reach the value on the day of admission, whereas ALP and amylase activities continue to rise till 10th day.
• The serum levels of enzymes (ALT, AST, ALP and amylase) did not show satisfactory correlation with burn size on admission, whereas good correlation were observed after 5th and 10th day.
• On admission, there were non-significant difference between the enzymes levels (ALT, AST, ALP and amylase) and severity of burn. There were significant relations between the enzymes levels (ALT, AST, ALP and amylase) and severity of burn at 5th and 10th day.
• There were no significant relations between outcome of burned patients and serum level of AST, ALT, ALP and amylase at the different times of study.
- The results of the histopathology study revealed that:
• The histopathological changes 3 days after burn showed that, epidermal ulceration. The deeper layers of the dermis showed diffuse congestion of capillaries and edema. There were areas of loss of the original structure (necrosis), and few tiny perivascular hemorrhages. The collagen masses show a patchy irregular staining (destructed collagen). There were few polymorph nuclear leucocytes (PMNLs) (neutrophils) infiltration, scattered out and near dermal capillary and few macrophage with moderately burned patients, but with severe (and extremely severe) burn there were very few infiltrated leucocytes between necrotic and normal cell.
• At one week post burn, the epidermis showed regeneration from the basal layer. The dermis showed congestion of blood vessels which were surrounded by inflammatory cell infiltration. There were some collagen depositions. Some edema was still present in the dermis and there were several clusters of fibroblast. After moderate burn, there were large numbers of inflammatory cells between necrotic and viable tissue and consisted of polymorph nuclear leukocytes in the majority and few mononuclear cells (MNCs) but after severe burn only few leucocytes migrated into the wounds.
• At 2 weeks post burn, there was an epidermal growth. Collagen fibers of dermis were more dense than normal, and there were numerous scattered fibroblasts. After moderate burn, there were more complete, thicker and more continuous zone of infiltrated leukocytes than before, and mononuclear cells were the main cellular components in the wounds, but after severe burn single and thin zone of obvious infiltrated leucocytes and included mostly PMNLs and few MNCs between necrotic tissue and normal tissue.
• Burn wound with a large number of neutrophils and few macrophages is probably less than a few days old. When macrophages predominate, the wound is probably 1-2 weeks old. The changes of infiltrated leukocyte zone of wound following burns were closely related to the injury severity, as the different severity of burn patients had different timing and amounts of leukocyte infiltrates in the burn wound.
- The results of the immunohistochemical study revealed that:
• In moderate burn, the mean values for CD4 at 3 days showed highly significant decrease in the patients as compared to controls. But 1 week, there was very small decrease in CD4 means. At 2 weeks, the mean value of CD4 improved but doesn’t reach to normal value. The mean values for CD8 at 3 days and 2 weeks post burn were significantly decreased in patients as compared to controls, while the mean value for CD8 at one week post burn was not significantly different as compared to controls.
• In severe and extremely severe burn, the mean values for CD4 at 3 days, 1 week and 2 weeks post burn were significantly decreased in patients as compared to controls. The mean values for CD8 at 3 days and 1 week post burn were decreased significantly than that of control, but 2 weeks post burn the mean value increased significantly than that of control.
• In severe burn cases, the CD4/CD8 ratio was significantly decreased than control at all times post burn.
• The mean value of CD4 was significantly decreased in severe and extremely severe burn than moderate burn at different times of study.
• The mean value of CD8 was significantly decreased in severe and extremely severe burn than moderate burn at 3 days and 1 week. But at 2 weeks, the mean value of CD8 was significantly increased in severe and extremely severe burn than moderate burn.
RECOMMENDATIONS
1. Prevention is the only positive attitude towards reduction of burns accidents through awareness of populations about the significant negative impacts of burns on patients, their family and society.
2. At the national level, a national burns prevention programme should be started and require educating the public, in particular mothers and, especially, in rural areas. Also, financial assistance for treatment and rehabilitation of the burned patients should also be ensured.
3. Environmental modification, i.e. product modification of stoves. Safety precautions in manufacturing and using butane gas cylinders to prevent their explosions.
4. Safe home and kitchen environments should be ensured particularly with reference to children and women. Awareness and education of mothers about the risky activities of their children would help to reduce the incidence of childhood burn injuries.
5. Children should be always supervised especially in the bathroom or kitchen. Keep matches, gasoline, lighters and all other flammable materials locked away and out of their reach, also appliance cords should be out of children’s reach and cover unused electrical outlets with safety devices. Keep any hot foods or liquids out of reach of children and raising the awareness of the risks of scald injury and fire through the education of children at school.
6. Smoke (alarms) detectors should be used at homes and factories to prevent inhalation injuries and to detect fires in their early stages.
7. More attention should be paid to industrial security especially for domestic appliances, with strict control over the execution of laws concerning industrial security.
8. Regarding electrical burns, occupational safety protocols should be developed, especially for the high risk groups such as linemen. The use of protective gloves, shoes and masks, etc., should be encouraged. The transformers, meters and live wires should be well protected and inaccessible to the public. The power poles should also be well away from roadsides, playgrounds and rooftops, etc.
9. Measures should be instituted to prevent the rising trend of suicidal burns among women in particular.
10. Early management of burn injury and referral to specializedcenter after doing the first aides without delay.
11. Establishment of more burn units and centers and a major challenge to improve quality of burn care services.
12. Total body surface area of burn shows the strongest association with burn fatality, so interventions to decrease the severity of injury, if occurred, is keystone to decrease the fatality.
13. All doctors, public health authorities and non-governmental organizations should make collaborative efforts to address this challenging public health issue.
14. Further studies should be conducted to confirm and improve upon the results of this study.
15. In clinical practice, daily wound hydrotherapy for patients with major burn should not be initiated until 7 days after injury for moderate burn patients or 14 days after injury for severe burn patients.
16. The understanding of the relationship between the severity of injury and the changes of infiltrated leukocyte zone of wound following burns will benefit the wound care and achieve better therapeutic efficacy, make appropriate decisions in wound management and antibiotic application, and elucidate the local cellular factors in the delayed rejection of skin allograft which usually occurs in seriously burned patients.
17. The clinical implications of the results of biochemical study are important in patient management. Monitoring of serum enzymes such as ALP and amylase has important prognostic value in the management of thermal injury. Taking adequate therapeutic and prophylactic measures, to counteract free radical activity in the initial stages, can prevent the distant organ injury and the resulting complications.