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Published in final edited form as: J Burn Care Res. 2014 Nov-Dec;35(6):e406–e412. doi: 10.1097/BCR.0000000000000026

The role of seizure disorders on burn injury and outcome in sub-Saharan Africa

Laura P Boschini 1, Anna F Tyson 1, Jonathan C Samuel 1,2,3, Claire E Kendig 1, Stephano Mjuweni 2, Carlos Varela 2, Bruce A Cairns 1,3, Anthony G Charles 1,2,3
PMCID: PMC4229410  NIHMSID: NIHMS560674  PMID: 24918949

Abstract

OBJECTIVE

Patients with epilepsy have higher incidence and severity of burn injury. Few studies describe the association between epilepsy and burns in low-income settings, where epilepsy burden is highest. We compared patients with and without seizure disorder in a burn unit in Lilongwe, Malawi.

METHODS

We conducted a retrospective study of patients admitted to the Kamuzu Central Hospital burn ward from July 2011 to December 2012. Descriptive analysis of patient characteristics and unadjusted and adjusted analyses of risk factors for mortality were conducted for patients with and without seizure disorder.

RESULTS

Prevalence of seizure disorder was 10.7% in our population. Adults with burns were more likely to have seizure disorder than children. Flame injury was most common in patients with seizure disorder, whereas scalds predominated among patients without seizure disorder. While mortality did not differ between the groups, mean length of stay was longer for patients with seizure disorder, 42.1 days versus 21.6 days.

CONCLUSION

Seizure disorder continues to be a significant risk factor for burn injury in adults in Malawi. Efforts to mitigate epilepsy will likely lead to significant decreases in burns among adults in sub Saharan Africa and must be included in an overall burn prevention strategy in our environment.

Introduction

Burn injuries claim over 300,000 lives each year [1]. An estimated 11 million more patients survive their burn injuries to be left with the economic and psychological sequelae of disability, disfigurement, and social stigma [2]. In 2010, burns injuries accounted for over 19 million disability-adjusted life-years (DALYs), an increase of 11% from 1990 [3]. Burns are primarily a disease of poverty, with a majority of this burden borne by those in low- and middle-income countries (LMICs), where 90% of burn deaths occur [2].

Epilepsy is a common non-communicable neurologic disorder and a well-known risk factor for burns. Seizure disorders occur affect, over 50 million people worldwide [4]. Eighty percent of those affected with active seizure disorder live in developing countries [4], where the median lifetime prevalence has been estimated at 14 per 1000 people [5]. In contrast, the lifetime prevalence of epilepsy in the developed world is 5.8 per 1000 [6]. In sub-Saharan Africa, an estimated 4.4 million people have active epilepsy, defined as one or more seizures over the past five years [7].

The difference in the prevalence of active seizures between developed and developing countries is rooted in epidemiology and access to anti-seizure medications. The leading etiologies of epilepsy in low-income countries are trauma, central nervous system infections, and perinatal complications [4]. Head injury, resulting from birth complications falls, road traffic injuries, or interpersonal violence, is the most important causes of seizure disorders worldwide. Endemic infections, such as neurocysticercosis, falciparum malaria, schistosomiasis, HIV, toxoplasmosis, tuberculosis, meningitis and encephalitis, along with inadequate management of childhood febrile illnesses also contribute to the high incidence of seizure disorder in sub-Saharan Africa [5,8]. Plasmodium falciparum infection in childhood, for example, is associated with a 37.5% chance of developing seizures [9]. The high burden of Schistosoma infection in Malawi also increases the risk of seizures, although this infection is less frequently associated with epilepsy than malarial infection. Perinatal complications are common in Africa, where two thirds of women requiring emergency obstetric care are unable to receive it [10]. Obstructed labor is associated with an increased risk of hypoxic–ischemic encephalopathy and resultant seizure disorder in the infant [11]. Despite extensive knowledge of the increased prevalence of seizure disorders in LMICs, less than 40% of patients with seizure disorder in LMICs receive a specific diagnosis and adequate treatment due to limited availability of diagnostic testing and medication [12].

Few epidemiologic studies have assessed the association between injury and seizure disorders in sub-Saharan Africa, where the burden of both injury and seizure disorders is high [8,13]. Malawi has no trained burn surgeons or neurologists [8], therefore characterizing the burden of epilepsy on burn injury is particularly important to guide potential injury prevention opportunities. To address this gap we conducted a comparison of patients with and without seizure disorder in a burn unit in Lilongwe, Malawi.

Methods

This study is a retrospective analysis of prospectively collected burn registry data from patients admitted to the Kamuzu Central Hospital (KCH) burn unit from July 2011 to December 2012. KCH is an 800-bed tertiary care hospital in the capital city of Lilongwe, which serves as a referral center for approximately 5 million people in the Central Region of Malawi [14,15]. The burn unit at KCH was established in 2011 and averages 24 admissions per month. Pediatric and adult patients are admitted to the same unit, which consists of 31 beds and is staffed by 6 full-time nurses and 2 clinical officers, all with additional training in burns care, with consultant surgeon oversight. A burn registry was established to collect patient demographics, clinical characteristics, and outcome. Specifically, variables utilized in this study include age, sex, date of admission, mechanism of injury, time to presentation to hospital, total body surface area (TBSA) burned, presence of seizure disorder, date and type of operative procedures, length of hospital stay, the use of traditional medicine and survival. Traditional African medicine prior to presentation to our burn unit refers to the practice herbalism and African spirituality usually consisting of an herbal remedy (lotion or potion to the burn wound) that not only purports healing abilities, but also has symbolic and spiritual significance. Once admitted to the burn unit, all patient are treated in similar manner based on burn injury and associated medical issues by unit staff and family regardless of any associated seizure diagnosis.

We performed univariate analysis to describe the initial cohort and bivariate analysis to compare patient characteristics, hospital course, and outcome between patients with and without seizure disorders. After dividing the cohort by seizure status, we used Pearson’s Chi-square test for categorical variables and t-tests for continuous variables. We then performed logistic regression modeling to examine the relationship between seizure status and mortality. The model was adjusted for age, TBSA, and burn mechanism, which have previously been identified as the main confounders for mortality in this population. A multiple linear regression was used to compare the average length of stay between patients with and without seizure disorder, again adjusting for age, TBSA, and burn mechanism. Finally, we repeated the linear and logistic regression models for subgroup analysis of the adult and pediatric populations. For all calculations, a p-value of less than 0.05 was considered statistically significant. All statistical analysis was performed using Stata/SE 12.1 (StataCorp LP, College Station, TX). The University of North Carolina Institutional Review Board and the Malawi National Health Sciences Review Committee approved this study.

Results

A total of 435 patients were admitted to the KCH burn unit during the study period. Of these, 45 had a prior diagnosis of seizure disorder, resulting in a 10.7% prevalence of seizure disorder in this population. The mean age of burn patients with seizures was significantly higher than that of patients without seizures because a higher proportion of burned adults also suffered from epilepsy (Figure 1). Flame burns were far more common among patients with epilepsy than those without, in whom scald burns were more common. Scald burns describe the pediatric population without seizures. (Figures 2). In patients with seizure disorders, there was a statistically significant increase in hospital length of stay compared with those without seizures (51 and 20 days, respectively, p<0.05) and a length of stay to TBSA ratio of 6.5 and 1.6, respectively (Table 1).

Figure 1. Percentage of Children and Adults*, Stratified by Seizure Disorder Status.

Figure 1

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*Pediatric (0-15 years), Adult (>15 years)

Figure 2. Percentage of Burn Mechanisms by Children and Adults*, Stratified by Seizure Disorder Status.

Figure 2

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*Pediatric (0-15 years), Adult (>15 years)

Table 1.

Patient Characteristics of Burn Patients, Stratified by Seizure Disorder Status

Overall Mean (±SD) or % (n=435) Seizures Mean or % (n=45) No Seizures Mean or % (n=376)
Age (yrs)* 10 (±15.1) 23 (±18.8) 9.0 (±14.1)
 Pediatric (0-15 yrs) 79% 40% 83.0%
 Adult (>15 yrs) 21% 60% 17.0%
Sex
 Male 53% 58% 52%
 Female 47% 42% 48%
TBSA (%) 19 (±17.8) 15 (±14.5) 19 (±18.2)
Mechanism*
 Scald 55% 12% 61%
 Flame 44% 88% 39%
Traditional Medicine 19% 11% 19%
Length of Stay (days)* 23 (±33.8) Median: 11 51 (±66.6) Median: 38 20 (±26.0) Median: 10
Length of Stay-to-TBSA ratio 2. (±3.34) 6 (±6.68) 2 (±2.1)
Mortality 18.5% 16.3% 18.8%
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*

Significantly different between seizure and non-seizure groups (p-value<0.05)

For patients with seizure disorders, increased length of stay and decreased TBSA were associated with improved survival. For patients without seizure disorders, younger age, scald burns, increased length of stay and decreased TBSA were associated with improved survival (Table 2). The association between increased length of stay and decreased survival is attributable to the fact that burn mortality occurred earlier in the hospital course. Overall, mortality in burn patients with seizure disorder was not statistically significantly different in either the crude logistic regression or after adjusting for age, burn mechanism, and TBSA. Length of stay, however, was significantly different between the two groups, with a mean length of stay for patients with and without seizures of 42 and 22. days, respectively, after adjusting for age, TBSA, and mechanism. In the subgroup analysis, pediatric patients with and without epilepsy were not significantly different in term of overall mortality of length of stay. Adult patients with and without epilepsy did not differ in overall mortality, but retained a statistically significant difference in length of stay: measuring 64.0 days and 29.3 days, respectively (Table 3).

Table 2.

Unadjusted Associations Between Patient Characteristics and Survival in Burn Patients with and without Seizure Disorder

Seizures No Seizures
Mean or % Mortality p-value* Mean or % Mortality p-value*
Age (yrs) 21/35† 0.08 8/13† <0.05
 Pediatric (0-15 yrs) 18% 0.8 17% 0.06
 Adult (>15 yrs) 15% 27%
Sex
 Male 21% 0.4 20% 0.5
 Female 11% 17%
Mechanism
 Scald 0% 0.3 13% <0.05
 Flame 19% 28%
Traditional Medicine 0% 0.4 20% 0.5
Length of Stay (days)* 60/5† 0.04 23/9† <0.05
TBSA (%) 10/36† <0.05 14.3/40† <0.05
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*

Tests based on Pearson’s Chi-squared for categorical variables and t-tests for continuous variables

†

First value is mean for patients who survived and second value is mean for patients who died

Table 3.

Comparisons Between Length of Stay for Burn Patients with and without Seizure Disorder after adjusting for Age, TBSA, and Burn Mechanism

Total Population Adults (>15 years) Children (≤15 years)
n Mean Length of Stay (days) p n Mean Length of Stay (days) p n Mean Length of Stay (days) p
Unadjusted
 Seizures 43 51 <0.05 26 64 <0.05 17 33 0.01
 No Seizures 362 20 60 29 302 19
*Adjusted
 Seizures 41 42 <0.05 24 64 <0.05 17 25 0.3
 No Seizures 324 22 55 30 269 19
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*

Based on the beta estimates from a multiple linear regression model, adjusted for age, TBSA, and mechanism

Discussion

Our results show that adult burn patients have a higher rate of seizure disorder than the general population and that, while overall mortality is not altered, length of stay is significantly lengthened in our adult burn population with seizure disorder. The prevalence of epilepsy in Malawi is estimated at 2.8% [16]. The prevalence of seizure disorder in our burn cohort is 10.7%, which is higher than reported previously among burn patients in Malawi [17]. The prevalence of seizure disorder among our adult patients was particularly high: 29.7% compared to 5.5% in the pediatric population.

As demonstrated by these data, the diagnosis of seizure disorder is not an independent predictor of mortality. The short-term outcome of burn patients with a preexisting diagnosis of seizure disorder is more dependent on the total body surface area of the burn. However, the presence of seizure disorder is associated with increased hospital length of stay, even after adjusting for TBSA. Whereas length of stay for patients without seizure disorder is closer to the one day-per-percent burn dictum [18], length of stay for patients with seizure disorder is nearly quadrupled. One explanation for this finding could be a difference in burn depth. Full-thickness burns require hospital admission and surgery to promote healing, retain function, and reduce scarring. In a previous retrospective review of a burn center registry, 72% of epileptic patients had full-thickness burns, compared to 68% in the general burn population [19]. Although estimated burn depth was not available in our study, the majority of epileptic patients in our registry sustained flame burns, which often result in deeper burns compared to scald burns [20]. Increased burn depth has not been shown to lengthen hospital length of stay in the developed world [21]. However, early excision is limited in our setting and eschar must lift prior to delayed excision and grafting; therefore, we expect that increased depth leads to prolonged length of stay in our environment.

Another factor contributing to increased hospital length of stay may be the associated cognitive and psychiatric comorbidities in people with epilepsy [22]. Conditions such as depression, attention deficit disorder, anxiety, aggression, and autism afflict 19-80% [23] of persons with seizure disorders, compared to 4.3-26.4% of the general population [24]. Both epilepsy and learning disabilities have been observed to lengthen hospital stay in burn patients [25]. Anecdotal evidence from our own unit suggests the same association, although further research would be needed to support these observations.

Burns are one of the most common causes of injury in people with seizure disorders [26], yet the importance of the association is often under-appreciated [27]. The unpredictable onset of seizure activity and the subsequent inability of the patient to withdraw from the heat source contribute to an increased incidence of burns in epileptic patients as well as increased severity of the injury. Patients with seizure disorders are most often burned while engaged in necessary household tasks or self-care activities [28-31]. Injury prevention education geared toward patients with seizure disorders focuses on driving, falls, swimming, and working with machinery, but often excludes burn safety and prevention [32], contributing to the proliferation of burn injuries. In sub-Saharan Africa, cultural beliefs also play a role in strengthening the association between epilepsy and burns. In Nigeria, burning of the feet with fire, liquid or ash has been documented as a traditional remedy for epilepsy [33]. In Malawi, as in many African countries, the erroneous belief that epilepsy is transmitted through the bodily fluids of a seizing person leads to fear of touching a person who is seizing [34]. This fear, combined with the widespread belief that seizures are caused by witchcraft, prevents family members or onlookers from pulling a seizing person out of a fire. Photosensitive epilepsy, characterized by an abnormal response to light, may also potentially contribute to burn injuries [35].

The average lag time from onset of seizures to seeking care at a health care facility in Malawi has been estimated at 6.5 years. In fact, initial contact with a healthcare provider occurs most frequently when patients seek care for burns [36]. With burn injury as a potential, albeit unfortunate, gateway into the health care system, this opportunity to initiate epilepsy care must not be missed. In our center the internist-run epilepsy unit is consulted upon admission of any burn patient with seizure disorder, and antiepileptic therapy is administered. Scarcity of personnel and resources, however, limit the number of times these patients are seen by the internists and the degree to which their antiepileptic regimen can be titrated while in hospital. The degree of follow up these patients receive for their seizure disorder after discharge is unknown. Further studies are needed to characterize the extent and etiology of the treatment gap in this population and to determine the feasibility of incorporating epilepsy treatment into burn care and follow up.

Education and prevention campaigns to diminish burn injuries in persons with seizure disorders have been met with mixed results. Knowledge of the increased risk of burn injury in epileptic children and promotion of safe cook stoves as prevention have been included in health personnel training programs for some time [37]; however, this alone has been insufficient to decrease the prevalence of seizure-related burn injury in Malawi. Prevention of seizure-related burn injury can be divided into standard burn prevention and seizure management. Standard burn prevention interventions, including accessible instructional materials, better supervision of children, and home safety measures have been shown to be useful in sub-Saharan African settings. The most effective campaigns have been those that incorporate prevention message repetition with caregiver education, community involvement, and policy implementation [38].

The limitations of our study include our inability to determine the seizure status of our outpatient burn cohort. As a result, our calculated prevalence of epilepsy in burn patients may be inaccurate. As mentioned previously, our burn registry also does not capture burn thickness, which could influence hospital course and outcome. Additionally, our registry records epilepsy as a comorbidity and does not always specify whether the burn occurred during a seizure. Although most burns in epileptics are known to occur during seizure activity, we recognize that we cannot make that distinction with our data.

Developed countries have seen a reduction in the number of burn injuries in patients with epilepsy with the transition from open flame and kerosene for cooking and warmth to central heating and cooking with electricity and gas [20]. In contrast, burns in epileptic patients in the developing world remain high. Lack of healthcare resources in the developing world presents barriers for both the appropriate treatment of epilepsy and burn injuries. We advocate for the implementation of an aggressive national seizure prevention and treatment campaign as part of an injury reduction strategy. Furthermore, the opportunity for using admissions for seizure-related burn injury as an entry into epilepsy care must not be missed. This dual strategy, if pursued by both burn and epilepsy care providers would advance the goal of morbidity and mortality reduction in both the burn and seizure disorder patient populations.

Supplementary Material

Table 1
Table 2
Table 3

Acknowledgments

We thank Johnson and Johnson, the NC Jaycee Burn Center, and the University of North Carolina Department of Surgery for generous financial support to develop and maintain the burn unit at KCH. We also thank the NC Jaycee Burn Center and Direct Relief International (Santa Barbara, California) for providing burn supplies and the UNC Project for continued administrative support.

Study data were collected and managed using REDCap electronic data capture tools hosted at the University of North Carolina at Chapel Hill [39]. REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing: 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for importing data from external sources.

This work was supported by the National Institutes of Health Office of the Director, Fogarty International Center, Office of AIDS Research, National Cancer Center, National Heart, Blood, and Lung Institute, and the NIH Office of Research for Women’s Health through the Fogarty Global Health Fellows Program Consortium comprised of the University of North Carolina, Johns Hopkins, Morehouse, and Tulane (1R25TW009340-01) and the American Recovery and Reinvestment Act. The Fogarty International Center of the National Institutes of Health also supported this work under Award Number K01TW009486. Johnson and Johnson.

References

  • 1.Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–128. doi: 10.1016/S0140-6736(12)61728-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Peck MD. Epidemiology of burns throughout the world. Part I: Distribution and risk factors. Burns. 2011;37(7):1087–100. doi: 10.1016/j.burns.2011.06.005. [DOI] [PubMed] [Google Scholar]
  • 3.Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197–223. doi: 10.1016/S0140-6736(12)61689-4. [DOI] [PubMed] [Google Scholar]
  • 4.World Health Organization. Atlas: Epilepsy Care in the World. Geneva: World Health Organization; 2005. [Google Scholar]
  • 5.Newton CR, Garcia HH. Epilepsy in poor regions of the world. Lancet. 2012;380(9848):1193–201. doi: 10.1016/S0140-6736(12)61381-6. [DOI] [PubMed] [Google Scholar]
  • 6.Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Estimation of the burden of active and life-time epilepsy: a meta-analytic approach. Epilepsia. 2010;51(5):883–90. doi: 10.1111/j.1528-1167.2009.02481.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Paul A, Adeloye D, George-Carey R, et al. An estimate of the prevalence of epilepsy in Sub-Saharan Africa: A systematic analysis. J Glob Health. 2012;2(2):20405. doi: 10.7189/jogh.02.020405. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.World Health Organization. Epilepsy in the WHO African Region: bridging the gap. Geneva: World Health Organization; 2004. [Google Scholar]
  • 9.Idro R, Ndiritu M, Ogutu B, et al. Burden, Features, and Outcome of Neurological Involvement in Acute Falciparum Malaria in Kenyan Children. JAMA. 2007;297(20):2232–40. doi: 10.1001/jama.297.20.2232. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Pearson L, Larsson M, Fauveau V, et al. Childbirth care. In: Lawn J, Kerber K, editors. Opportunities for Africa’s newborns: Practical data, policy and programmatic support for newborn care in Africa. Geneva: World Health Organization on behalf of The Partnership for Maternal Newborn and Child Health; 2006. pp. 63–78. [Google Scholar]
  • 11.Mung’ala-Odera V, White S, Meehan R, et al. Prevalence, incidence and risk factors of epilepsy in older children in rural Kenya. Seizure. 2008;17:396–404. doi: 10.1016/j.seizure.2007.11.028. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Senanayake N, Roman GC. Epidemiology of epilepsy in developing countries. Bull World Health Organ. 1993;71(2):247–58. [PMC free article] [PubMed] [Google Scholar]
  • 13.Bhalla K, Harrison JE, Shahraz S, et al. Availability and quality of cause-of-death data for estimating the global burden of injuries. Bull World Health Organ. 2010;88(11):831–8C. doi: 10.2471/BLT.09.068809. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Samuel JC, Campbell E, Mjuweni S, et al. The Epidemiology, Management, Outcomes and Areas for Improvement of Burn Care in Central Malawi: an Observational Study. J Int Med Res. 2011;39:873–9. doi: 10.1177/147323001103900321. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Kiser M, Beijer G, Mjuweni S, et al. Photographic assessment of burn wounds: A simple strategy in a resource-poor setting. Burns. 2013;39(1):155–161. doi: 10.1016/j.burns.2012.04.003. [DOI] [PubMed] [Google Scholar]
  • 16.Amos A, Wapling L. Research: Epilepsy in Malawi. Report for Federation of Disability Organisation in Malawi in Partnership with Sue Rider Foundation in Malawi. Leonard Cheshire Disability and Inclusive Development Centre. 2011 [Google Scholar]
  • 17.Komolafe OO, James J, Makoka M, et al. Epidemiology and mortality of burns at the Queen Elizabeth Central Hospital Blantyre, Malawi. Cent Afr J Med. 2003;49(11-12):130–4. [PubMed] [Google Scholar]
  • 18.Johnson LS, Shupp JW, Pavlovich AR, et al. Hospital length of stay--does 1% TBSA really equal 1 day? J Burn Care Res. 2011;32(1):13–9. doi: 10.1097/BCR.0b013e318204b3ab. [DOI] [PubMed] [Google Scholar]
  • 19.Rimmer RB, Bay RC, Foster KN, et al. Thermal injury in patients with seizure disorders: an opportunity for prevention. J Burn Care Res. 2007;28(2):318–23. doi: 10.1097/BCR.0B013E318031A161. [DOI] [PubMed] [Google Scholar]
  • 20.Josty IC, Narayanan V, Dickson WA. Burns in patients with epilepsy: changes in epidemiology and implications for burn treatment and prevention. Epilepsia. 2000;41(4):453–6. doi: 10.1111/j.1528-1157.2000.tb00188.x. [DOI] [PubMed] [Google Scholar]
  • 21.Andel D, Kamolz LP, Niedermayr M, et al. Which of the abbreviated burn severity index variables are having impact on the hospital length of stay? J Burn Care Res. 2007;28(1):163–6. doi: 10.1097/BCR.0B013E31802C9E8F. [DOI] [PubMed] [Google Scholar]
  • 22.Austin JK. The 2007 Judith Hoyer lecture. Epilepsy comorbidities: Lennox and lessons learned. Epilepsy Behav. 2009;14(1):3–7. doi: 10.1016/j.yebeh.2008.10.019. [DOI] [PubMed] [Google Scholar]
  • 23.Garcia-Morales I, de la Pena Mayor P, Kanner AM. Psychiatric comorbidities in epilepsy: identification and treatment. Neurologist. 2008;14(6 (suppl 1)):S15–25. doi: 10.1097/01.nrl.0000340788.07672.51. [DOI] [PubMed] [Google Scholar]
  • 24.Demyttenaere K, Bruffaerts R, Posada-Villa J, et al. Prevalence, severity, and unmet need for treatment of mental disorders in the world health organization world mental health surveys. JAMA. 2004;291(21):2581–90. doi: 10.1001/jama.291.21.2581. [DOI] [PubMed] [Google Scholar]
  • 25.Othman D, Jones O. Burns patients with epilepsy or a learning disability have a greater length of stay in hospital than those patients with a history of drug or alcohol abuse. Burns. 2011;37(3):546–7. doi: 10.1016/j.burns.2010.10.011. [DOI] [PubMed] [Google Scholar]
  • 26.Buck D, Baker GA, Jacoby A, et al. Patients’ experiences of injury as a result of epilepsy. Epilepsia. 1997;38(4):439–44. doi: 10.1111/j.1528-1157.1997.tb01733.x. [DOI] [PubMed] [Google Scholar]
  • 27.Kinton L, Duncan JS. Frequency, causes, and consequences of burns in patients with epilepsy. J Neurol Neurosurg Psychiatry. 1998;65(3):404–5. doi: 10.1136/jnnp.65.3.404. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Ansari Z, Brown K, Carson N. Association of epilepsy and burns: A case control study. Aust Fam Physician. 2008;37(7):584–9. [PubMed] [Google Scholar]
  • 29.Al-Qattan MM. Burns in epileptics in Saudi Arabia. Burns. 2000;26(6):561–3. doi: 10.1016/s0305-4179(00)00011-5. [DOI] [PubMed] [Google Scholar]
  • 30.Karacaoĝlan N, Uysal A. Deep burns following epileptic seizures. Burns. 1995;21(7):546–9. doi: 10.1016/0305-4179(95)00032-7. [DOI] [PubMed] [Google Scholar]
  • 31.Minn YK. Who burned and how to prevent? Identification of risk for and prevention of burns among epileptic patients. Burns. 2007;33(1):127–8. doi: 10.1016/j.burns.2006.04.021. [DOI] [PubMed] [Google Scholar]
  • 32.Hampton KK, Peatfield RC, Pullar T, et al. Burns because of epilepsy. BMJ. 1988;296(6637):1659–60. doi: 10.1136/bmj.296.6637.1659. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Alabi GH, Omolase CO. Feet burning: a traditional medical practice associated with significant burns in patients with seizures: 4 Case reports. Burns. 2012;38(1):e5–8. doi: 10.1016/j.burns.2011.09.019. [DOI] [PubMed] [Google Scholar]
  • 34.Baskind R, Birbeck GL. Epilepsy-associated stigma in sub-Saharan Africa: the social landscape of a disease. Epilepsy Behav. 2005;7(1):68–73. doi: 10.1016/j.yebeh.2005.04.009. [DOI] [PubMed] [Google Scholar]
  • 35.Harding GF, Harding PF. Photosensitive epilepsy and image safety. Appl Ergon. 2010;41(4):504–8. doi: 10.1016/j.apergo.2008.08.005. [DOI] [PubMed] [Google Scholar]
  • 36.Watts AE. A model for managing epilepsy in a rural community in Africa. BMJ. 1989;298:805–7. doi: 10.1136/bmj.298.6676.805. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Dekker PA. Epilepsy: A manual for medical and clinical officers in Africa. Geneva: World Health Organization; 2002. [Google Scholar]
  • 38.Parbhoo A, Louw QA, Grimmer-Somers K. Burn prevention programs for children in developing countries require urgent attention: A targeted literature review. Burns. 2010;36:164–75. doi: 10.1016/j.burns.2009.06.215. [DOI] [PubMed] [Google Scholar]
  • 39.Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap) - A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–81. doi: 10.1016/j.jbi.2008.08.010. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

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Supplementary Materials

Table 1
NIHMS560674-supplement-Table_1.pdf (43.6KB, pdf)
Table 2
NIHMS560674-supplement-Table_2.pdf (51.7KB, pdf)
Table 3
NIHMS560674-supplement-Table_3.pdf (55KB, pdf)

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