Iliopoulou E., Michelakis D., Michail A., Lochaitis A.

Department of Plastic Surgery and Burn Injury, KAT General Hospital, Kifissia, Greece

SUMMARY. The purpose of our retrospective study is to present statistical, epidemiological, and socioeconomic data related to Greek society and to compare data from other studies (1983-1987) and other countries. The paper refers to the period 1993-2001 (1840 admissions) and the data refer to age, sex, body location, immigrants, death rate, changes in the socioeconomic profile of burn injury, TBSA, and outcome, on the basis of the records in our department of plastic surgery. A comparison between the old statistics and the new clearly shows a development and improvement of the treatment of burn injury. The outstanding features of the new statistics are the decline in the workload in our clinic (from 241 admissions in 1997 to 146 in 2001), the decrease in overall mortality (from 11.7% in 1983-1987 to 5.43% in 1993-2001), and the rise in the proportion of jobless immigrants in the total number of patients (Greek to foreigner ratio). Our clinic provides 14 beds in a burns unit without any cardiorespiratory support equipment, where the physicians offer their knowledge and personal effort to the strenuous task of burn patient treatment.

Introduction

Our retrospective study summarizes the function of a clinic, although evaluation of its qualitative contribution to public health may be difficult. The purpose of the study is to present statistical, epidemiological, and socioeconomic data related to Greek society and to compare data from other studies (1983-1987) and other countries. Altogether, we considered 1840 admissions in the period 1993-2001, with data related to age, sex, body location, immigrant rate and changes in the socioeconomic profile of burn injury, TBSA, and outcome on the basis of the records of the Department of Plastic Surgery and Burns of the KAT General Hospital in Kifissia, Greece. Our clinic provides 14 beds in a burns unit without any cardiorespiratory support equipment, where physicians offer their knowledge and personal effort to the strenuous end of burn patient treatment. The increase in number of intensive care unit beds in our hospital (from 10 in 1993 to 20 in 2001) reduced the necessity to develop these utilities in our burns unit.

Patients and method

The overall number of admissions to our clinic in the period 1993-2001 was 1840. The male to female ratio was 1.7:1.0 (1160:680). Figs. 1-6 present the distribution of admissions by sex, cause, total number, percentage of foreigners, TBSA, and outcome.

Results and discussion

This retrospective study summarizes the function of a clinic, although an evaluation of its qualitative contribution to public health is rather difficult. The purpose of the study is to present statistical, epidemiological, and socioeconomic data of Greek society and to compare these with data from other studies (1983-1987) and other countries. The paper refers to the period 1993-2001, and the data relate to age, sex, location, immigrant rate and changes in the socioeconomic profile of the burn injuries, TBSA, and outcome, on the basis of the records kept in the archives of the Department of Plastic Surgery and Burns in the KAT General Hospital (Kifissia, Greece).

Children and the elderly belong to high-risk groups. The comparison of statistical studies conducted in our clinic in the periods 1983-19871 and 1992-19972 with the results of the present study produced the findings listed below.

Admissions. The annual workload at our clinic fluctuated from year to year but started to decline, especially after 1997 (241 cases) compared with 2001 (146 cases). This was mainly due to:

• the opening of other burns units (Thriasio in Eleusis, G. Papanikolaou in Salonika);
• better public information as to burn risks;
• better communication and co-operation with peripheral and regional hospitals with regard to burn casualties and treatment;
• improvement in financial standards and status in Greek families, with the upgrading of old-fashioned, accident-prone heating and cooking devices (wood, charcoal stoves, and gas devices).

Sex. In the 1983-1987 study the male/female ratio was 2.3:1,1 declining in 1993-2001 to 1.7:1, but differing in the study related to psychiatric disease (1:1.4) and domestic accidents (1:1.27).2,3 This was higher than that found in Lindblad’s study,4 where the ratio of domestic accidents was 1:1 (this was because of the profile of the Greek family, with women still mainly busy in the house). Demographic data provided by National Statistic Service of Greece5 show that in the last 30 years women have constitute the majority of the population (Table I) but are less frequently involved in work accidents, since Greek society has not yet reached the point of giving equal job opportunities to the two sexes. The percentage of jobless women reached 60% of the total number of unemployed persons6 and as a result they were involved less than men in work accidents and more in domestic accidents. Women were more involved in burn injuries related to psychiatric disease, with a high percentage of suicide attempts - 24 cases (8:16) - especially in young women aged 20 yr and the elderly (up to 60 yr).2 Life expectancy for a 30-yr-old adult is longer in women (50 to 68 yr) than in men (44.6 yr).5 In both the Greek and the international literature on burn injury, men are in excess (67% in Brazil).7,8 The male/female ratio (1.7:1) coincides with Ioannovitch’s data9 and our numbers are in accordance with the former study, as regards the increase in the female percentage of advanced age. Thus, after 1996, there was a rise in the female proportion, especially in the 60-100-yr age group (113:141).

Type of burn. Thermal injuries dominated (up to 94.67%), with electrical (3.91%) and chemical burns (2.02%) following at a distance. The frequency of electrical burns did not change much (8 cases per year), although their percentage did (Ioannovitch: thermal burns, 80.2%; chemical burns, 16.18%; electrical burns 3.6%, out of a total of 4114 cases).5,9 The reason may be the enhancement of safety and improved preventive measures against work accidents taken by the Electrical Company.

Cause. Industrial and domestic accidents constituted the majority of burn casualties. In 2% of cases, criminal or terrorist acts - both self-inflicted (suicide attempts) or against others (anniversary of polytechnic school revolt, jealousy, political disagreement, quarrels between immigrants) - were identified as the cause of injury. The great majority (95%) of “non-industrial” burn injuries occurred in or around the home. Fires in the home or in apartment buildings occurred rarely, since Greece is a Mediterranean country and wood is not generally used as a construction material and prefabricated houses are practically non-existent. Reports from Brazil gave 78.6% of work and household burn accidents, while 46.5% of burn cases in women were the result of suicide attempts, compared with 8.9% in men.7,8

Extent. There was a higher incidence, i.e. 76% of cases, of small burns (1-15% TBSA), while large burns (60-100% TBSA) constituted 5.59% of overall admissions. Many researchers have suggested that the number of what are normally defined as “minor burns” may in fact be ten times more than that recorded for patients admitted. The actual number of severely burned patients is greater than that recorded (40 = 2.17%) because when intubated patients reach our hospital they are admitted directly to the intensive care unit (ICU) and are not recorded by us. Strange as it may seem, this is the case in our National Health System: burn units lack the necessary equipment to support intubated patients. Ioannovitch5,9 reported a 60.5% rate of small burns (up to 10% TBSA), while De Souza8 reported 68% of cases as being up to 20% TBSA.

Age. Greece is in line with the European trend of a percentage increase in the number of senior citizens and a gradual drop in the birth rate and student population (11.5% fall in the decade 1985-1995).10 The age-related distribution of the population shows increasing aging (age, 15-64 yr: 67%; over 65 yr: 16.73%). This will reach 34% in 2020.9 The 78.69% distribution of our patients in the 40-60-yr-old group is consistent with Greek demographic data and is increasing in favour of senior citizens. The norm for the Greek family is to live together and to maintain a close relationship with older relatives.

We also found an increase in the incidence of small burns in the elderly. The survival rate improved as a result of early, effective surgical treatment and, most importantly, of a shift in therapeutic philosophy (early mobilization, physiotherapy, medical and social support, anticoagulant = low heparin treatment). It is standard procedure in our hospital to admit senior citizens regardless of the extent of their burns.

Mortality. Overall mortality rate decreased from 11.7% in (1983-1987)1 to 5.43% (1993-2001). This is almost the same as the UK (5.9%) in 198011 but clearly lower than in some other countries, e.g. Brazil (18.8% in 1998 and 8.4% in 2001)7,8 and Turkey (35.7% in 1987).12 However, mortality increased with age and remained high in patients with large burns (in 1983-1987 patients aged over 40 yr with 70-80% TBSA burns had a mortality rate of 83%, compared with 67% in the period 1993-2001). Also, emergency room deaths were fewer in number, but this finding was not statistically important. It was mainly attributable to:

• early initiation of anti-shock treatment near the accident site;
• faster transfer to a specialized centre (ambulance service, air transport);
• improvements in burn care methodology in the past 14 years (new antiseptics and antibiotics, disposable materials, early surgical treatment, successful excision and grafting in the elderly);13
• faster and easier admission to the ICU. There has in fact been a gradual rise in the number of patients admitted to our ICU (1993, 4 cases; 1998, 9 cases), following an increase in the number of ICU beds in our hospital (from 10 in 1993 to 20 in 2001). For many years physicians in the ICU were reluctant to admit burn patients because they were under the wrong impression that the increase in microbial flora might be dangerous for the other intubated patients.14 It is also worth mentioning that since 1997 there has been an increase in the number of patients returning to our burns unit who were initially admitted owing to the gravity of their condition (inhalation injury, concomitant trauma);
• better evaluation of the gravity and prognosis of burn injury and individualization of each single case, rather than an overall improvement in the Greek National Health System.

Ratio of Greeks to foreigners. Greece is a Mediterranean country with an area of 131,986 km2 and a population of about 9.8 million. Since 1993 there has been a rise in the number of legal and illegal immigrants in the population (7%) coming from former socialist countries (Albania, Romania, Russia, Ukraine).15 The profile of the foreigners has changed - until 1990 they were usually single and poor, and presented a high rate of domestic accidents (due to unsafe domestic gas devices), but not many work accidents. Because of their low income, their habit of cooking with these dangerous gas devices caused a lot of domestic accidents. However, this situation began to change around 1993, as the immigrants’ social profile gradually altered: half of them were married, had health insurance, and possessed a better financial standing; they also suffered fewer domestic accidents (owing to the exclusive use of electric appliances) but a higher percentage of work accidents. The statistics report 176,119 immigrants in 1981 and 797,093 in 2001, with a predicted rise to about 3.5 million in 2015.15,16 These people were mainly aged over 40 yr (working immigrants lacking sufficient, if indeed any, professional specialization). Although many immigrants complied with the government requirement to obtain a work permit, only one half (750,000) were registered in the last population census in 2001 - 75% had a steady job, 92% gave a permanent address, and 67% had a work permit enabling them to enjoy insurance and coverage for hospital expenses.14,17,18 They were also integrated into Greek programmes and projects and benefited from the educational system and a programme of accommodation, including also language learning and immigrant counselling, with a budget of _ 260,000,000.15 In our country there is no discrimination against burn injury victims, and all immigrants are admitted - medical care and treatment in Greek hospitals are free of charge.

Conclusion

A statistical study of admissions to governmental hospitals in such a small country as Greece (9.8 million inhabitants) does not offer much information about the level of the health system. A comparison between old and more recent statistics clearly shows the development and improvement of burn injury treatment. The outstanding features of the most recent statistical data relative to 1840 admissions to the KAT hospital in the period 1993-2001 were the decline in the workload in our clinic (from 241 admissions in 1997 to 146 in 2001), the improvement in the treatment of burn injury with a decrease in overall mortality (from 11.7% in 1983-1987 to 5.43 in 1993-2001), and the rise in the number of unemployed immigrants in the total number of patients (Greeks to foreigners ratio).

A good knowledge of epidemiology is desirable for many reasons, including:

• better accident prevention (elimination of dangerous devices, changes in household heating methods);
• better planning of burns facilities in the national health system;
• better understanding of the type and pathophysiology of injury.

A comparison with relevant studies from other countries was difficult since chiladren and early adolescent burn victims are not admitted to our hospital but to specialized paediatric units. Also, there is a paucity of national data concerning burns epidemiology. The total number of admissions (1840 in seven years) was lower than the 3044 reported in the UK,11 greater than data reported in Brazil,7,8 and fewer than in all Greece9,19 - though still high, since our clinic admits 56% of all victims of burn accidents occurring in Greece.

Socioeconomic status is a strong risk factor in burn injury, together with extremes of age and the male sex. We are unable to present any financial data because Greeks are usually reluctant to talk about their financial position; however, most of our victims lived in comparatively poor districts.

As said, the socioeconomic profile of burn injury in immigrants has changed. Before 1990 they were mainly illegal immigrants, single, with a low income and a high percentage of domestic and work accidents. After 1993 the majority were legal, half were married, and they enjoyed health insurance and better living conditions without risk factors for domestic accidents; however, they were still prone to work accidents.

RESUME. Les Auteurs de cette étude rétrospective se sont proposés de présenter des données statistiques, épidémiologiques et socioéconomiques relatives à la société grecque et de comparer celles d’autres études (1983-1987) et d’autre pays. Les Auteurs s’occupent de la période 1993-2001 (1840 hospitalisations) et présentent des données sur l’âge, le sexe, la zone corporelle atteinte, les immigrants, le taux de mortalité, les modifications dans le profil socioéconomique des brûlures, la surface corporelle totale brûlée et le résultat final, sur la base des archives du Département de Chirurgie Plastique des Auteurs. La comparaison entre les statistiques plus récentes et les autres moins récentes indique clairement le développement et l’amélioration du traitement des brûlures. Les aspects les plus importants des statistiques nouvelles sont la réduction du numéro des cas (241 cas en 1997 confronté à 146 en 2001), la diminution de la mortalité globale (11,7% en 1983-1987 et 5,43% en 1993-2001), et l’incrément du numéro d’immigrants sans emploi dans le numéro total des patients (rapport numérique grecs/étrangers). La clinique des Auteurs possède 14 lits dans une unité des brûlures sans aucun appareillage de support cardiorespiratoire, où les médecins offrent leur expérience et leurs efforts personnels dans la tache ardue du traitement des patients brûlés.

Bibliography

1. Iliopoulou E., Lochaitis A., Poulikakos L., Bei A.: Statistical and epidemiological data of 800 burn patients in a 5-year period (1983-1987). Ann. Medit. Burns Club, 3: 116-8, 1990.
2. Iliopoulou E., Biskinis S., Poulikakos L. et al.: The psychiatric approach in burn injury. Arch. APPAC, 19: 75, 1998.
3. Lochaitis A., Iliopoulou E., Komninakis E. et al.: Burns as a result of domestic accidents and their prevention. Burns, 18: 5, 1992.
4. Lindblad B.E., Terkelsen C.J., Christensen H.: Epidemiology of domestic burns related to products. Burns, 16: 89-91, 1990.
5. National Statistic Service of Greece. The result of the late census of 18 March 2001.
6. Kopsini C.: Jobless 478,000 citizens. Kathimerini News, 18 September 1999.
7. De Souza D.A., Marchesan W.G., Greene L.J.: Epidemiological data and mortality rate of patients hospitalized with burns in Brazil. Burns, 24: 433-8, 1998.
8. De Souza D.A., Manco A.R.M.X., Marchesan W.G. et al.: Epidemiological data of patients hospitalized with burns and other traumas in some cities in the southeast of Brazil from 1991 to 1997. Burns, 28: 2, 2002.
9. Ioannovitch I., Alexakis D., Panayotou P. et al.: Epidemiological data on burns injuries in Greece - a statistical evaluation. Ann. Medit. Burns Club, 1: 23-6, 1987.
10. Drettaki M.: Lower birth rate, fewer students. Kathimerini News, 14 November 1999.
11. Kemble H.J.V., Lamb B.: “Practical Burns Management”, Hodder & Stoughton, 1987.
12. Haberal M., Oner Z., Bayraktar U. et al.: Epidemiology of adults’ and children’s burns in a Turkish burn centre. Burns, 13: 134, 1987.
13. Settle J.A.D.: “Principles and Practice of Burns Management”, Churchill Livingstone, 1996.
14. Martyn J.A.J.: “Acute Management of Burned Patients”, W.B. Saunders, Philadelphia, 1990.
15. Galati P.: 260 million euros for immigrants’ accession into Greek society. Kathimerini News, 8 December, 2002.
16. Karanatsi E.: Traditionally and elderly Europeans - Data from EUROSTAT. Kathimerini News, 29 August 1999.
17. The social profile of Europe’s “15”. Kathimerini Newspaper, 3 January 1999.
18. Sotirchou A., Scordili M.: Immigrants, but only 25% crossed our border illegally. Elefterotypia News, 26 March, 2002.
19. Panayotou P., Alexakis Strigglis Ch. et al.: Epidemiological data on burn injuries in Greece - a statistical evaluation. Burns, 17: 47, 1991.