Psychopathology and psychological problems in patients with burn scars: epidemiology and management

Identifying priority policy issues and health system research questions associated with recovery outcomes for burns survivors in India: a qualitative inquiry

OBJECTIVES

This study aimed to identify priority policy issues and health system research questions associated with recovery outcomes for burns survivors in India.

DESIGN

Qualitative inquiry; data were collected through semistructured in-depth interviews and focus group discussions.

SETTING

Nine sites in urban and rural settings across India, through primary, secondary and tertiary health facilities.

PARTICIPANTS

Healthcare providers, key informants, burns survivors and/or their carers.

RESULTS

Participants acknowledged the challenges of burns care and recovery, and identified the need for prolonged rehabilitation. Challenges identified included poor communication between healthcare providers and survivors, limited rehabilitation services, difficulties with transportation to health facility and high cost associated with burns care. Burns survivors and healthcare providers identified the stigma attached with burns as the biggest challenge within the healthcare system, as well as in the community. Systems barriers (eg, limited infrastructure and human resources), lack of economic and social support, and poor understanding of recovery and rehabilitation were identified as major barriers to recovery.

CONCLUSIONS

Though further research is needed for addressing gaps in data, strengthening of health systems can enable providers to address issues such as developing/providing, protocols, capacity building, effective coordination between key organisations and referral networks.

Applying Quality Function Deployment Model in Burn Unit Service Improvement

Quality function deployment (QFD) is one of the most effective quality design tools. This study applies QFD technique to improve the quality of the burn unit services in Ghotbedin Hospital in Shiraz, Iran. First, the patients' expectations of burn unit services and their priorities were determined through Delphi method. Thereafter, burn unit service specifications were determined through Delphi method. Further, the relationships between the patients' expectations and service specifications and also the relationships between service specifications were determined through an expert group's opinion. Last, the final importance scores of service specifications were calculated through simple additive weighting method. The findings show that burn unit patients have 40 expectations in six different areas. These expectations are in 16 priority levels. Burn units also have 45 service specifications in six different areas. There are four-level relationships between the patients' expectations and service specifications and four-level relationships between service specifications. The most important burn unit service specifications have been identified in this study. The QFD model developed in the study can be a general guideline for QFD planners and executives.

Using a Biopsychosocial Model to Understand Long-Term Outcomes in Persons With Burn Injuries

OBJECTIVE

To determine the importance of preburn adjustment, injury-related variables, and selection of coping style in various outcome measures using a biopsychosocial model.

DESIGN

Longitudinal study.

SETTING

Outpatient burn clinics.

PARTICIPANTS

Burn survivors (N=231) who participated in this study as part of a larger burn model system study of 645 patients with major burn injuries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The 36-Item Short-Form Health Survey was used to assess preburn adjustment. Other outcome measures entered into the model included the Ways of Coping Checklist Revised, the Brief Symptom Inventory, the Beck Depression Inventory-II, and the Davidson Trauma Scale.

RESULTS

Correlational and mediational analyses revealed that preburn emotional health predicted better adjustment at year 1 and more posttraumatic stress disorder symptoms at year 2. Better preburn emotional health was also related to less use of avoidance coping strategies, which was found to be a mediator of the effect of preburn emotional health and posttraumatic stress disorder symptoms. Burn injury characteristics were not significantly associated with psychological adjustment at either year 1 or year 2.

CONCLUSIONS

The results indicate that there is a complex relation between premorbid mental health and the selection of coping strategies that affect long-term adjustment in persons recovering from a burn injury. This relation seems to have greater effect on long-term outcomes than does preburn emotional or physical health alone or the severity of the burn.

Three Years After Black Saturday: Long-Term Psychosocial Adjustment of Burns Patients as a Result of a Major Bushfire

Despite increasing evidence that burn injuries can result in multiple psychological sequelae, little is known about the long-term psychosocial adjustment to burns sustained in a major bushfire. The aim of the present study was to assess long-term psychological distress and health-related quality of life in Australian burns patients as a result of the 2009 Black Saturday bushfires. Eight male and five female burns patients with a mean age of 53.92 (SD = 11.82) years who received treatment at a statewide burns service participated in the study. A battery of standardized questionnaires was administered to assess general psychological distress, burns-specific and generic health-related quality of life, alcohol use, and specific psychological symptoms of posttraumatic stress disorder, depression, and anxiety. The results revealed that more than 3 years after Black Saturday 33% of the burns patients still suffered "high" to "very high" levels of general distress, whereas 58% fulfilled partial or full criteria for posttraumatic stress disorder. Furthermore, participants still experienced significantly impaired physical health functioning as compared to their preinjury status including limitations in work-based activities, increased bodily pain, and lower vitality overall. The trajectory of distress varied for participants. Some individuals experienced little distress overall, whereas others displayed a decline in their stress levels over time. Notwithstanding, some patients maintained high levels of distress throughout or experienced an increase in distress at a later stage of recovery. The results point to the importance of psychosocial screening to identify distress early. Follow-up assessments are crucial to diagnose individuals with chronic or late onset of distress.

Scarless wound healing: Transitioning from fetal research to regenerative healing

Since the discovery of scarless fetal skin wound healing, research in the field has expanded significantly with the hopes of advancing the finding to adult human patients. There are several differences between fetal and adult skin that have been exploited to facilitate scarless healing in adults including growth factors, cytokines, and extracellular matrix substitutes. However, no one therapy, pathway, or cell subtype is sufficient to support scarless wound healing in adult skin. More recently, products that contain or mimic fetal and adult uninjured dermis were introduced to the wound healing market with promising clinical outcomes. Through our review of the major experimental targets of fetal wound healing, we hope to encourage research in areas that may have a significant clinical impact. Additionally, we will investigate therapies currently in clinical use and evaluate whether they represent a legitimate advance in regenerative medicine or a vulnerary agent. WIREs Dev Biol 2018, 7:e309. doi: 10.1002/wdev.309 This article is categorized under: Adult Stem Cells, Tissue Renewal, and Regeneration > Regeneration Plant Development > Cell Growth and Differentiation Adult Stem Cells, Tissue Renewal, and Regeneration > Environmental Control of Stem Cells.

Postoperative Delirium in Severely Burned Patients Undergoing Early Escharotomy: Incidence, Risk Factors, and Outcomes

The aim of this study is to investigate the incidence, related risk factors, and outcomes of postoperative delirium (POD) in severely burned patients undergoing early escharotomy. This study included 385 severely burned patients (injured <1 week; TBSA, 31-50% or 11-20%; American Society of Anesthesiologists physical status, II-IV) aged 18 to 65 years, who underwent early escharotomy between October 2014 and December 2015, and were selected by cluster sampling. The authors excluded patients with preoperative delirium or diagnosed dementia, depression, or cognitive dysfunction. Preoperative, perioperative, intraoperative, and postoperative information, such as demographic characteristics, vital signs, and health history were collected. The Confusion Assessment Method was used once daily for 5 days after surgery to identify POD. Stepwise binary logistic regression analysis was used to identify the risk factors for POD, t-tests, and χ tests were performed to compare the outcomes of patients with and without the condition. Fifty-six (14.55%) of the patients in the sample were diagnosed with POD. Stepwise binary logistic regression showed that the significant risk factors for POD in severely burned patients undergoing early escharotomy were advanced age (>50 years old), a history of alcohol consumption (>3/week), high American Society of Anesthesiologists classification (III or IV), time between injury and surgery (>2 days), number of previous escharotomies (>2), combined intravenous and inhalation anesthesia, no bispectral index applied, long duration surgery (>180 min), and intraoperative hypotension (mean arterial pressure < 55 mm Hg). On the basis of the different odds ratios, the authors established a weighted model. When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). When the score of a patient's weighted odds ratios is more than 6, the incidence of POD increased significantly (P < .05). Further, POD was associated with more postoperative complications, including hepatic and renal function impairment and hypernatremia, as well as prolonged hospitalization, increased medical costs, and higher mortality.

Children with Burn Injury Have Impaired Cardiac Output during Submaximal Exercise

INTRODUCTION

Burn trauma damages resting cardiac function; however, it is currently unknown if the cardiovascular response to exercise is likewise impaired. We tested the hypothesis that, in children, burn injury lowers cardiac output (Q˙) and stroke volume (SV) during submaximal exercise.

METHODS

Five children with 49% ± 4% total body surface area (BSA) burned (two female, 11.7 ± 1 yr, 40.4 ± 18 kg, 141.1 ± 9 cm) and eight similar nonburned controls (five female, 12.5 ± 2 yr, 58.0 ± 17 kg, 147.3 ± 12 cm) with comparable exercise capacity (peak oxygen consumption [peak V˙O2]: 31.9 ± 11 vs 36.8 ± 8 mL O2·kg·min, P = 0.39) participated. The exercise protocol entailed a preexercise (pre-EX) rest period followed by 3-min exercise stages at 20 W and 50 W. V˙O2, HR, Q˙ (via nonrebreathing), SV (Q˙/HR), and arteriovenous O2 difference ([a-v]O2diff, Q˙/ V˙O2) were the primary outcome variables.

RESULTS

Using a 2-way factorial ANOVA (group [G] × exercise [EX]), we found that Q˙ was approximately 27% lower in the burned than the nonburned group at 20 W of exercise (burned 5.7 ± 1.0 vs nonburned: 7.9 ± 1.8 L·min) and 50 W of exercise (burned 6.9 ± 1.6 vs nonburned 9.2 ± 3.2 L·min) (G-EX interaction, P = 0.012). SV did not change from rest to exercise in burned children but increased by approximately 24% in the nonburned group (main effect for EX, P = 0.046). Neither [a-v] O2diff nor V˙O2 differed between groups at rest or exercise, but HR response to exercise was reduced in the burn group (G-EX interaction, P = 0.004). When normalized to BSA, SV (index) was similar between groups; however, Q˙ (index) remained attenuated in the burned group (G-EX interaction, P < 0.008).

CONCLUSIONS

Burned children have an attenuated cardiovascular response to submaximal exercise. Further investigation of hemodynamic function during exercise will provide insights important for cardiovascular rehabilitation in burned children.

Women's recovery, negotiation of appearance, and social reintegration following a burn

The gendered nature of postburn coping has received scant research attention in South Africa, a country that has a high rate of burns with significant concentrations among women. In this study, narratives that emerged from in-depth interviews with seven women were examined. The narratives emphasized essential needs of these burn survivors for personal support, the complexities of negotiating intimate relationships, struggles with the humiliation from family and friends, in some instances strained relationships with children, the support found through religious beliefs and institutions, and often frustratingly slow psychological acceptance of scars. These difficulties faced by women survivors of burns have highlighted the need to include religion/spirituality, intimate male partners, and women's children into the psychological recovery process, in an attempt to assist women's journey to psychological and emotional healing after burn.

Cutaneous Scarring: Basic Science, Current Treatments, and Future Directions

Significance: Scarring of the skin from burns, surgery, and injury constitutes a major burden on the healthcare system. Patients affected by major scars, particularly children, suffer from long-term functional and psychological problems. Recent Advances: Scarring in humans is the end result of the wound healing process, which has evolved to rapidly repair injuries. Wound healing and scar formation are well described on the cellular and molecular levels, but truly effective molecular or cell-based antiscarring treatments still do not exist. Recent discoveries have clarified the role of skin stem cells and fibroblasts in the regeneration of injuries and formation of scar. Critical Issues: It will be important to show that new advances in the stem cell and fibroblast biology of scarring can be translated into therapies that prevent and reduce scarring in humans without major side effects. Future Directions: Novel therapies involving the use of purified human cells as well as agents that target specific cells and modulate the immune response to injury are currently undergoing testing. In the basic science realm, researchers continue to refine our understanding of the role that particular cell types play in the development of scar.

A mixed methods evaluation of medical tattooing for people who have experienced a burn injury

INTRODUCTION

There are no existing studies examining the psychological merits of using facial medical tattooing (MT) following burn injury. This study evaluated an MT service supported by The Katie Piper Foundation. It examined accessibility, satisfaction and whether there were improvements in quality of life (QoL).

METHODS

Thirty-five service-users were invited to participate in a cross-sectional online survey. Twenty-five (71%) responded (24 women; age range = 21-64 years), and of these five (4 women; age range = 26-59 years) also participated in telephone interviews, which were analysed using descriptive thematic analysis.

FINDINGS

The service was largely considered easy to access (22/25) and convenient (25/25). Most service-users (22/25) were satisfied with the results of MT. Some areas of dissatisfaction were described, by a minority of service-users, including: the procedure being painful (1/25); the tattoo being below expectation or fading over time (3/25). The majority reported that MT had improved confidence (22/25); mood (19/25); and ability to socialise (19/25). The procedure improved some service-users' ability to carry out essential activities (14/25) and enjoyable activities (16/25). The qualitative responses provided during interview, indicated that all respondents found the procedure useful to their adjustment, although a minority (3/5) found it painful and also commented on fading (1/5). All described MT as contributing to a sense of increased normality.

CONCLUSIONS

MT had the largest impact on emotional wellbeing and interpersonal domains of QoL. MT services should now improve awareness of the procedure, lobby for further support to provide wider access to the procedure, and routinely use measures assessing psychosocial outcomes.

Risk factors for peri-traumatic distress and appearance concerns in burn-injured inpatients identified by a screening tool

INTRODUCTION

Psychosocial screening of burn-injured patients is a National Burn Care Guideline and is increasingly used to identify individuals most in need of support. It can also generate data that can inform our understanding of patient reported concerns following a burn injury.

METHOD

As part of routine care, 461 patients admitted to a burns unit were screened soon after admission using a psychosocial screen designed by the service. The questionnaire included items on pre-existing social support, coping, emotional and psychological difficulties, as well as current trauma symptoms and current level of concern about changed appearance following the burn.

RESULTS

Overall, patients reported low levels of appearance concerns (mean 3.7/10) and trauma symptoms (18% reporting flashbacks) in the initial days following a burn injury. In those who did report concerns, there were some significant associations with demographic and other variables. Patients who experienced flashbacks were younger and had a larger total body surface area (TBSA) burn. Higher levels of appearance concern were associated with younger women, larger TBSA and facial burns. However, the relationships found were weak and frequently confounded by other factors.

CONCLUSION

Overall, the findings indicate that initial trauma symptoms and appearance concerns are not inevitable in this group and there is no substitute for screening in identifying who is most at risk.

A qualitative exploration of psychosocial specialists' experiences of providing support in UK burn care services

INTRODUCTION

A burn can have a significant and long-lasting psychosocial impact on a patient and their family. The National Burn Care Standards (2013) recommend psychosocial support should be available in all UK burn services; however, little is known about how it is provided. The current study aimed to explore experiences of psychosocial specialists working in UK burn care, with a focus on the challenges they experience in their role.

METHODS

Semi-structured telephone interviews with eight psychosocial specialists (two psychotherapists and six clinical psychologists) who worked within UK burn care explored their experiences of providing support to patients and their families.

RESULTS AND DISCUSSION

Thematic analysis revealed two main themes: burn service-related experiences and challenges reflected health professionals having little time and resources to support all patients; reduced patient attendance due to them living large distances from service; psychosocial appointments being prioritised below wound-related treatments; and difficulties detecting patient needs with current outcome measures. Therapy-related experiences and challenges outlined the sociocultural and familial factors affecting engagement with support, difficulties treating patients with pre-existing mental health conditions within the burn service and individual differences in the stage at which patients are amenable to support.

CONCLUSION

Findings provide an insight into the experiences of psychosocial specialists working in UK burn care and suggest a number of ways in which psychosocial provision in the NHS burn service could be developed.

Therapeutic potential of Pak1 inhibition for pain associated with cutaneous burn injury

Painful burn injuries are among the most debilitating form of trauma, globally ranking in the top 15 leading causes of chronic disease burden. Despite its prevalence, however, chronic pain after burn injury is under-studied. We previously demonstrated the contribution of the Rac1-signaling pathway in several models of neuropathic pain, including burn injury. However, Rac1 belongs to a class of GTPases with low therapeutic utility due to their complex intracellular dynamics. To further understand the mechanistic underpinnings of burn-induced neuropathic pain, we performed a longitudinal study to address the hypothesis that inhibition of the downstream effector of Rac1, Pak1, will improve pain outcome following a second-degree burn injury. Substantial evidence has identified Pak1 as promising a clinical target in cognitive dysfunction and is required for dendritic spine dysgenesis associated with many neurological diseases. In our burn injury model, mice exhibited significant tactile allodynia and heat hyperalgesia and dendritic spine dysgenesis in the dorsal horn. Activity-dependent expression of c-fos also increased in dorsal horn neurons, an indicator of elevated central nociceptive activity. To inhibit Pak1, we repurposed an FDA-approved inhibitor, romidepsin. Treatment with romidepsin decreased dendritic spine dysgenesis, reduced c-fos expression, and rescued pain thresholds. Drug discontinuation resulted in a relapse of cellular correlates of pain and in lower pain thresholds in behavioral tests. Taken together, our findings identify Pak1 signaling as a potential molecular target for therapeutic intervention in traumatic burn-induced neuropathic pain.

The Patient and Observer Scar Assessment Scale to Evaluate the Cosmetic Outcomes of the Robotic Single-Site Hysterectomy in Endometrial Cancer

Objective

The objective of this study was to evaluate the cosmetic outcome of robotic single-site hysterectomy (RSSH) in early-stage endometrial cancer.

Methods

We prospectively collected patient demographics, operative times, complications, pathologic results, and length of stay on all patients who underwent RSSH for early-stage endometrial cancer. The Patient and Observer Scar Assessment Scale (POSAS) was used for the evaluation of the cosmetic outcome.

Results

Forty-five patients were included in our study from January 2012 to October 2015. The median age of patients was 63 years (range, 35–84 years), and the median body mass index was 26.5 kg/m2 (range, 18–39 kg/m2). No laparoscopic/laparotomic conversion was registered. The median docking time, console time, and total operative time were 7 minutes (range, 4–14 minutes), 46 minutes (range, 20–100 minutes), and 90 minutes (range, 45–150 minutes), respectively. The median blood loss was 50 mL (range, 10–150 mL). Nine patients underwent pelvic lymphadenectomy, and the median number of pelvic lymph nodes was 13 (range, 10–32). The median time to discharge was 3 days (range, 2–6 days). No intraoperative complications occurred, whereas we did observe 1 early postoperative complication. The oncological outcome was directly comparable to the literature. Patients reported low pain scores and high satisfaction in terms of postoperative scarring. The POSAS scores confirmed excellent cosmetic outcome of RSSH.

Conclusion

Robotic single-site hysterectomy provided an efficient option for gynecologic oncologic surgery. The POSAS revealed high objective and patient-evaluated outcome, and patients were highly satisfied with the overall outcome of the appearance of their scars.

Abnormal expression of the vitamin D receptor in keloid scars

Keloids are abnormal fibroproliferative scars that pose a significant challenge to patients and clinicians. The molecular basis for keloid formation remains incompletely understood, and currently no universally effective treatments exist. It is well recognized that keloids are more prevalent in populations with darkly pigmented skin, such as African Americans, but the basis for the link between skin color and keloid risk is not known. Pigmentation reduces vitamin D production in the skin. Because most of the body's vitamin D is produced in the skin, rates of vitamin D deficiency are higher in populations with darker skin pigmentation. In addition to regulation of calcium homeostasis, vitamin D plays important roles in cell proliferation, differentiation, cancer progression, inflammation, and fibrosis. The activities of vitamin D are dependent on the vitamin D receptor (VDR), a member of the steroid nuclear receptor superfamily. The ligand-bound VDR acts as a transcription factor; thus, nuclear localization is required for ligand-dependent regulation of target gene expression. The current study investigated expression and nuclear localization of VDR in keloid scars (N=24) and biopsies of normal skin (N=24). Immunohistochemistry with two different antibodies demonstrated reduced VDR protein levels in a majority of keloid scars. Further, the percentage of epidermal cells displaying nuclear VDR localization was significantly lower in keloid scars compared with normal skin samples. Interestingly, analysis of VDR-positive nuclei among different normal skin samples showed a significant reduction in nuclear localization in epidermis of black donors compared with white donors. The results suggest that VDR may play a role in keloid pathology, and hint at a possible role for VDR in the increased susceptibility to keloid scarring in individuals with darkly pigmented skin.

Perceived social support among patients with burn injuries: A perspective from the developing world

BACKGROUND

Social support is among the most well-established predictors of post-burn psychopathology after burn. Despite a disproportionately large burden of burns in the developing world, the nature of social support among burn patients in this context remains elusive. We, therefore, seek to investigate social support and its biopsychosocial determinants among patients with burn injuries in Pakistan.

METHODS

A cross-sectional study of 343 patients presenting with burn injuries at four teaching hospitals in the Punjab province of Pakistan was conducted. Patient evaluation consisted of a multi-part survey of demographic status, clinical features, and social support as measured by the validated Urdu translation of the Multidimensional Scale of Perceived Social Support (MSPSS). Multiple regression analysis was performed to evaluate associations between patient characteristics and MSPSS score.

RESULTS

Mean overall MSPSS score was 57.64 (std dev 13.57). Notable positive predictors of social support include male gender, Punjabi ethnicity, burn surface area, and ego resiliency.

CONCLUSION

Our study reveals a troubling pattern of inadequate social support among certain subgroups of Pakistani burn patients. Addressing these inequities in the provision of social support must be prioritized as part of the global burn care agenda.

Laser in the management of burn scars

BACKGROUND AND OBJECTIVE

Burn scars are associated with significant morbidity ranging from contractures, pruritus, and disfigurement to psychosocial impairment. Traditional therapies include silicone gel, compression garments, corticosteroid injections, massage therapy, and surgical procedures, however, newer and advanced therapies for the treatment of burn scars have been developed. Lasers, specifically ablative fractional lasers, show potential for the treatment of burn scars.

METHODS

Both MeSH and keyword searches of the PubMed, Medline and Embase databases were performed and relevant articles were read in full for the compilation of this review.

RESULTS

Fifty-one relevant observational studies, clinical trials, and systematic reviews published in English from 2006 to 2016 were reviewed and summarized.

CONCLUSION

Laser therapy is effective for the treatment of burn scar appearance, including measures such as pigmentation, vascularity, pliability, and thickness. Ablative fractional laser therapy, in particular, shows significant potential for the release of contractures allowing for improved range of motion of affected joints. Patients may benefit from the use of lasers in the treatment of burn scars, and the safety profile of lasers allows the benefits of treatment to outweigh the risks. Laser therapy should be included in burn scar treatment protocols as an adjuvant therapy to traditional interventions.

Trauma type as a conditional risk factor for posttraumatic stress disorder in a referred clinic sample of adolescents

INTRODUCTION

Traumatic experiences that are varied in type and severity may lead to the development of Posttraumatic Stress Disorder (PTSD). Some trauma types present a higher conditional risk for PTSD owing to their nature and impact on growth and functioning. Few studies have investigated the conditional risk of PTSD in clinic referred adolescents in low- and middle-income countries. The aim of the study was to determine the conditional risk for PTSD based on various trauma types (car accidents, other serious accidents, fires, witnessing a natural disaster, witnessing a violent crime, being confronted with traumatic news, witnessing domestic violence, physical abuse and sexual abuse) and to stratify risk by gender.

METHOD

Adolescents exposed to at least one Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) qualifying trauma were referred to a research clinic in Cape Town, South Africa (n = 216). PTSD status was assessed using a clinician administered interview. Conditional risk was determined using backwards stepwise multiple logistic regression analysis for 1) the whole sample, 2) females only and 3) males only. Gender differences in exposure to trauma types were determined using chi-square tests and cross-tabulation.

RESULTS

The prevalence of PTSD was 48.1% in the whole sample. Age (β = .16, p = .048, OR 1.17), fire exposure (β = 2.32, p = .036, OR 10.12) and sexual abuse (β = .93, p = .001, OR 2.54) were significant predictors of PTSD in the whole sample with the model explaining 12.4% of the variance in PTSD status. Age (β = .22, p = .041, OR 1.24) and sexual abuse (β = .87, p = .018, OR 2.39) were significant predictors of PTSD in female participants and explained 9.8% of the variance in PTSD status. Being a victim of a violent crime (β = .78 p = .100, OR 2.19) was the only remaining predictor of PTSD in male participants and showed a trend towards significance. The model explained 7% of the variance in PTSD status.

CONCLUSIONS

The findings underscore the importance of timely identification of trauma, particularly, sexual abuse and violence. Longitudinal tracking of adolescents exposed to different trauma types may identify those in need of treatment and enhance our understanding of the lasting impact of trauma.

Development of the life impact burn recovery evaluation (LIBRE) profile: assessing burn survivors’ social participation

PURPOSE

Measuring the impact burn injuries have on social participation is integral to understanding and improving survivors' quality of life, yet there are no existing instruments that comprehensively measure the social participation of burn survivors. This project aimed to develop the Life Impact Burn Recovery Evaluation Profile (LIBRE), a patient-reported multidimensional assessment for understanding the social participation after burn injuries.

METHODS

192 questions representing multiple social participation areas were administered to a convenience sample of 601 burn survivors. Exploratory factor analysis and confirmatory factor analysis (CFA) were used to identify the underlying structure of the data. Using item response theory methods, a Graded Response Model was applied for each identified sub-domain. The resultant multidimensional LIBRE Profile can be administered via Computerized Adaptive Testing (CAT) or fixed short forms.

RESULTS

The study sample included 54.7% women with a mean age of 44.6 (SD 15.9) years. The average time since burn injury was 15.4 years (0-74 years) and the average total body surface area burned was 40% (1-97%). The CFA indicated acceptable fit statistics (CFI range 0.913-0.977, TLI range 0.904-0.974, RMSEA range 0.06-0.096). The six unidimensional scales were named: relationships with family and friends, social interactions, social activities, work and employment, romantic relationships, and sexual relationships. The marginal reliability of the full item bank and CATs ranged from 0.84 to 0.93, with ceiling effects less than 15% for all scales.

CONCLUSIONS

The LIBRE Profile is a promising new measure of social participation following a burn injury that enables burn survivors and their care providers to measure social participation.

Outcomes Assessment After Hand Burns

Accurately assessing function and disability after hand burns is imperative to improving the management of patients. The biological, social, and psychological impact of these injuries should be considered. The International Classification of Functioning Disability (ICF) and Health Core Sets for Hand Conditions provides a guide to what should be measured and reported. Although many outcomes measures instruments are available to assess patients with hand or burn injuries, few are validated in the subpopulation of hand burns. Further efforts are required to investigate the ability of current assessment instruments to evaluate hand burn outcomes within the ICF framework.

Pre-existing psychiatric disorder in the burn patient is associated with worse outcomes

OBJECTIVE

To compare patient and burn characteristics between patients who had a pre-existing psychiatric diagnosis and patients who did not in a Burn Unit at an academic hospital.

BACKGROUND

Psychosocial issues are common in patients recovering from a burn; however, little is known regarding hospital course and discharge outcomes in patients with a pre-existing psychiatric diagnosis presenting with a burn. Baseline medical comorbidities of burn patients have been shown to be a significant risk for in-hospital mortality.

METHODS

A retrospective chart review of 479 consecutive patients admitted to the Burn Unit of an academic hospital in Halifax, Nova Scotia between March 2nd 1995 and June 1st 2013 was performed. Extensive data regarding patient and burn characteristics and outcomes was collected. Patients with and without pre-existing psychiatric diagnoses at the time of hospital admission were compared.

RESULTS

Sixty-three (13%) patients had a psychiatric diagnosis, with the most common being depression (52%). Forty-percent (n=25/63) of these patients had multiple pre-existing psychiatric diagnoses. Patients with a psychiatric diagnosis had a greater total-body-surface-area (TBSA)% covered by a third-degree burn (p=0.001), and were more likely to have an inhalation injury (p<0.001). These patients were also significantly more likely to experience 6 of the 10 most prevalent in-hospital complications and had a higher mortality rate (p=0.02). They were less likely to be discharged home (p=0.001), and more likely to go to a home hospital (p=0.04) or rehabilitation facility (p=0.03). Psychiatric diagnosis was associated with significantly more placement issues (e.g. rehab bed unavailability, homeless) upon discharge from the Burn Unit (p=0.01). The risk of death in burn patients with pre-existing psychiatric disorders was about three times the risk of death in patients with no psychiatric disorders when adjusting for other potential confounders (95% CI, 1.13-9.10; p-value 0.03).

CONCLUSION

Presence of a pre-existing psychiatric disorder in the burn patient was associated with worse outcomes and was a significant predictor of death. Psychiatric diagnoses should be identified early in burn treatment and efforts should be made to ensure a comprehensive approach to inpatient support and patient discharge to reduce unfavorable burn outcomes and placement issues.

The Use of Silgel STC-SE, a Topical Silicone Gel for the Treatment and Reduction of Hypertrophic and Keloid Scars

BACKGROUND

A single-center study assessing the efficacy of Nagor's Silgel STC-SE silicone gel to reduce the appearance of hypertrophic and keloid scars.

METHODS

A 16-week controlled study of 36 patients with hypertrophic or keloid scars. The subjects were divided between 2 cohorts: one assessing recently healed scars (<6 mo) and other assessing older scars (6 mo to 2 y). The efficacy of Silgel STC-SE on the scar was evaluated by skin hydration, skin moisture evaporation, skin elasticity, basic scar measurements, subjective patient questionnaire data, and image analysis. All subjects had data collected at baseline and weeks 1, 4, 8, 12, and 16. Photographs were taken for image analysis at baseline, week 8, and week 16. Statistical analysis was conducted on all data.

RESULTS

Twenty-nine patients completed the study (27 presented with hypertrophic scars and 2 with keloid scars), and 90% reported a marked improvement in their scar appearance. Patient questionnaire data showed great satisfaction with the product. Image analysis showed visual improvement with a statistically significant reduction of the "red" color of scars. Overall, scar dimensions were significantly reduced. There was a significant decrease from baseline levels in average scar length. Skin elasticity, skin hydration, and skin moisture evaporation did not change significantly from baseline.

CONCLUSIONS

The results of this study indicate that Silgel STC-SE is an effective treatment in reducing the appearance and red color of hypertrophic scars up to 2 years old. Further study is required to draw significant conclusion in regard to the treatment of keloid scars.

Bioactive 3D-Shaped Wound Dressings Synthesized from Bacterial Cellulose: Effect on Cell Adhesion of Polyvinyl Alcohol Integrated In Situ

We investigated wound dressing composites comprising fibrils of bacterial cellulose (BC) grown by fermentation in the presence of polyvinyl alcohol (PVA) followed by physical crosslinking. The reference biointerface, neat BC, favoured adhesion of fibroblasts owing to size exclusion effects. Furthermore, it resisted migration across the biomaterial. Such effects were minimized in the case of PVA/BC membranes. Therefore, the latter are suggested in cases where cell adhesion is to be avoided, for instance, in the design of interactive wound dressings with facile exudate control. The bioactivity and other properties of the membranes were related to their morphology and structure and considered those of collagen fibres. Bioactive materials were produced by simple 3D templating of BC during growth and proposed for burn and skin ulcer treatment.

Increased burn healing time is associated with higher Vancouver Scar Scale score

Increased burn wound healing time has been shown to influence abnormal scarring. This study hypothesised that scar severity increases commensurate to the increase in time to healing (TTH) of the wound. Wound healing and scar data from burn patients treated by the Burn Service of Western Australia at Royal Perth Hospital were examined. The relationship between TTH and scar severity, as assessed by the modified Vancouver Scar Scale (mVSS), was modelled using regression analysis. Interaction terms evaluated the effect of surgery and total body surface area - burn (TBSA) on the main relationship. Maximum likelihood estimation was used to account for potential bias from missing independent variable data. The sample had a median age of 34 years, TTH of 24 days, TBSA of 3% and length of stay of five days, 70% were men and 71% had burn surgery. For each additional day of TTH, the mVSS score increased by 0.11 points (P ≤ 0.001) per day in the first 21 days and 0.02 points per day thereafter (P = 0.004). The relationship remained stable in spite of TBSA or surgical intervention. Investigation of the effect of missing data revealed the primary model underestimated the strength of the association. An increase in TTH within 21 days of injury is associated with an increase in mVSS or reduced scar quality. The results confirm that efforts should be directed toward healing burn wounds as early as possible.

Factor structure of the Persian version of general, social, and negative self-consciousness of appearance domains of Derriford Appearance Scale 59: an application in the field of burn injuries

BACKGROUND

The Derriford Appearance Scale 59 (DAS59) is a widely used measure of the spectrum of psychological distress and dysfunction that is characteristic of disfigurement. Also, disfigurement due to burn injury leads to feeling guilty or less socially competent, avoiding social situations, suicide, poor self-esteem, sexual difficulties, and depression. Therefore, the purpose of this study was to translate and culturally adapt three subscales of DAS59 into Persian language and to investigate its factor structure for Iranian burned patients.

METHOD

Translation-back translation of the scale into Persian was done. The internal consistency of the translated scale was evaluated by Cronbach's alpha. Next, construct validity of the translated instrument was assessed by exploratory factor analysis using principal components and rotation of varimax methods. This research involved a convenience sample of 189 adult burned patients with disfigurement in their face, head, ears, neck, hands, and legs.

RESULT

The Cronbach's alpha for overall scale, subscales 1, 2, and 3 were 0.93, 0.93, 0.89, and 0.80, respectively. The best solution from the principal components analysis of the 40 items of the DAS59 revealed three factors corresponding to the three subscales with 20 items: factor 1 (general self-consciousness of appearance) consisted of 9 statements accounting for 33.23% of the variance (eigenvalue =9.23); factor 2 (social self-consciousness of appearance) consisted of 7 statements accounting for 22.91% of the variance (eigenvalue =1.53); and factor 3 (negative self-concept) consisted of 4 statements accounting for 14.98% of the variance (eigenvalue =1.13).

CONCLUSION

The factor structure of the three subscales of DAS59 provides a widely acceptable, psychometrically robust, factorial self-report scale to assess distress and dysfunction in problems of appearance among Iranian burned patients, and facilitates further research into the efficacy of treatment approaches for problems of appearance and early investigation of therapeutic outcome.

Adjunctive hyperbaric oxygen therapy in severe burns: Experience in Taiwan Formosa Water Park dust explosion disaster

BACKGROUND

Despite major advances in therapeutic strategies for the management of patients with severe burns, significant morbidity and mortality is observed. Hyperbaric oxygen therapy (HBOT) increases the supply of oxygen to burn areas. The aim of this study was to determine whether HBOT is effective in the treatment of major thermal burns.

METHODS

On June 27, 2015 in New Taipei, Taiwan, a mass casualty disaster occurred as fire erupted over a large crowd, injuring 499 people. Fifty-three victims (20 women and 33 men) were admitted to Tri-Service General Hospital. Thirty-eight patients underwent adjunctive HBOT (HBOT group), and 15 patients received routine burn therapy (control group). Serum procalcitonin (PCT) level, a sepsis biomarker, was measured until it reached normal levels (<0.5μg/L). The records of all patients from June 2015 to March 2016 were analyzed retrospectively. Outcome measures that were compared between the groups included the use of tracheostomy and hemodialysis, total body surface area (TBSA) and the number of skin graft operations, length of hospital stay, infection status, and mortality.

RESULTS

The mean age of the patients was 22.4 years, and the mean TBSA was 43%. All the patients survived and were discharged without requiring limb amputation or being permanently disabled. Patient characteristics did not differ significantly between the groups. PCT levels returned to normal significantly faster (p=0.007) in the HBOT group.

CONCLUSION

Multidisciplinary burn care combined with adjunctive HBOT improves sepsis control compared with standard treatment without HBOT. Prospective studies are required to define the role of HBOT in extensive burns.

Social Support and Resilience Among Patients with Burn Injury in Lahore, Pakistan

INTRODUCTION

Social support and ego resiliency play a great role in maintaining the physical and mental health of patients with burn injuries. The present study has been designed to compare ego resiliency levels and the degree of social support in patients with a burn injury and their healthy counterparts.

METHODS

This study was conducted in two teaching hospitals in Lahore, Pakistan from May 2015 to July 2015. A total of 80 burn patients presenting in outpatient departments of general surgery, plastic surgery, and burn centers of these hospitals were surveyed conveniently, and for comparison, 80 patients presenting in outpatient departments with minor ailments, for routine checkups or follow-ups were recruited. The questionnaire comprised three sections: demographics, the Urdu versions of the Ego Resiliency Scale (ER-89), and the Multidimensional Scale of Perceived Social Support (MSPSS). All data were analyzed in SPSS v. 20 (IBM Corp., Armonk, NY).

RESULTS

Patients with a burn injury were associated with lower scores on the social support scale as well as its subscales assessing support from the significant other, family and friends than their healthy counterparts. However, no significant differences in scores on the ego resiliency scale were reported between these two groups.

CONCLUSION

Patients with a burn injury perceived low social support levels from society, which negatively affects their health outcomes. However, their resilience levels were not significantly different from their healthy counterparts.

Prevalence and Predictors of Posttraumatic Stress Symptomatology Among Burn Survivors: A Systematic Review and Meta-Analysis

Burns can be a traumatic and stressful experience, although each patient may respond in very different ways. The aim of this study was to explore the variability on posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) prevalence and evaluate the specific weight of different variables on PTSD development among adult burn patients. A systematic review was carried out to explore the prevalence of ASD and PTSD and identify their predictors. Meta-analytical methods were used to explore the strength of association between PTSD and the latter. From an initial pool of 190 studies, 24 were used in the systematic review, and only 19 studies could be used for the meta-analysis because of different methodological limitations. The prevalence of ASD at baseline ranged from 2 to 30% and prevalence of PTSD ranged from 3 to 35% at 1 month, 2 to 40% between 3 and 6 months, 9 to 45% in the year postinjury and ranged 7 to 25% more than 2 years later. Life threat perception was the strongest predictor for PTSD occurrence, followed by acute intrusive symptoms and pain associated with burn injuries. Predictive variables identified in this research may be useful in targeting burn patients who are at risk for developing posttraumatic stress symptoms and stress-related psychological symptoms.

Validation of the French version of the Burn Specific Health Scale-Brief (BSHS-B) questionnaire

INTRODUCTION

The Burn Specific Health Scale-Brief questionnaire is a widely validated tool for estimating the health related quality of life and for assessing the best multidisciplinary management of burn patients. The aim of this study was to translate the BSHS-B into French and to investigate its reliability and validity.

METHODS

According to the procedure proposed by the Scientific Advisory Committee of the Medical Outcomes Trust, the Burn Specific Health Scale-Brief (BSHS-B) was translated from the English version into French. In order to test the reliability of the French version of the BSHS-B, 53 burn patients French speakers completed the BSHS-B and SF-36 questionnaires from two to four years after burn. Ten of them have been re-tested at 6 months after the first evaluation. To evaluate clinical utility of the BSHS-F, internal consistency, construct validity (using SF-36) and stability in time were assessed using Cronbach's alpha statistic, Spearman rank test, and intra-class correlation coefficient respectively.

RESULTS

The French version of the BSHS-B Cronbach's alpha coefficient was 0.93 and was >0.80 for all the sub-domains. French version of the BSHS-B and the SF-36 were positively correlated, all the associations were statistically significant (p<0.01). Intra-class correlation coefficients for test-retest ranged between 0.95 and 0.99 for the sub-domains. The intra-class correlation coefficient (ICC) for the total score was 0.98.

CONCLUSION

The French version of the BSHS-B shows a robust rate of internal consistency, construct validity and stability in time, supporting its application in routine clinical practice as well as in international studies.

Factors predicting health status and recovery of hand function after hand burns in the second year after hospital discharge

INTRODUCTION

Hands are the most commonly burnt body part given humans' innate response to guard their face from injury, and are known to have detrimental functional and psychological consequences. Conflicting evidence exists regarding the impact of hand burns on long-term health status and global functioning. The objective of this study was to identify patient and clinical characteristics that predict health status and hand function of people at 12-24 months after hand burn.

METHODS

The Burns Specific Health Scale-Brief (BSHS-B) and the Brief Michigan Hand Outcome Questionnaire (Brief MHQ) were administered to community-dwelling adults who were between one and two years after admission to a statewide burns service for burns including one or both hands. Demographic, injury, and treatment data were collected to identify which factors predict health status and hand function in the second year after admission. Linear regression analyses adjusted for total burn surface area and burn depth were conducted to identify important predictors or outcomes.

RESULTS

The sample (n=41) was 80.5% male, with a mean age of 44.5 years and total body surface area (TBSA) of 8.4%. Psychiatric illness (regression coefficient -56.6, confidence interval (95% CI) -76.70, -36.49) and female gender (-20.3; 95% CI -0.77, -40.29) were key predictors of poorer global health status on the BSHS-B. Females also scored worse on body image (-5.35; 95% CI -1.83, -8.87) and work (-4.13; 95% CI -0.64, -7.62) domains of BSHS-B. The need for reconstructive or secondary surgery (-38.84; 95% CI -58.04, -19.65) and female gender (-16.30; 95% CI -4.03, -28.57) were important predictors of poorer hand function.

CONCLUSION

Women and those with a history of psychiatric illness are particularly vulnerable to poorer outcomes in health status and/or hand function after burns, and may benefit from more intensive rehabilitation support and long-term follow-up.

Return to work after specialised burn care: A two-year prospective follow-up study of the prevalence, predictors and related costs

BACKGROUND

Burn injuries may cause long-term disability and work absence, and therefore result in high healthcare and productivity costs. Up to now, detailed information on return to work (RTW) and productivity costs after burns is lacking.

AIMS

The aim of this study was to accurately assess RTW after burn injuries, to identify predictors of absenteeism and to calculate healthcare and productivity costs from a societal perspective.

METHODS

A prospective cohort study was conducted in the burn centre of Rotterdam, the Netherlands, including all admitted working-age patients from 1 August 2011 to 31 July 2012. At 3, 12 and 24 months post-burn, patients were sent a questionnaire: including the Work and Medical Consumption questionnaire for the assessment of work absence and medical consumption and the EQ-5D-3L plus a cognitive dimension to assess post-burn and pre-burn quality of life (QOL). Cost analyses were from a societal perspective according the micro-costing method and the friction cost method was applied for the calculation of productivity loss. Univariate logistic regression was used to identify predictors of absenteeism at three months.

RESULTS

A total of 104 patients were included in the study with a mean total body surface area (TBSA) burned of 8% (median 4%). 66 respondents were pre-employed, at 3 months 70% was back at work, at 12 months 92% and 8% had not returned to work at time of final follow-up at 24 months. Predictors of absenteeism at 3 months were: TBSA, length of stay, ICU-admission and surgery. Mean costs related to loss in productivity were €11.916 [95% CI 8.930-14.902] and accounted for 30% of total costs in pre-employed respondents in the first two years.

CONCLUSION

This two-year follow-up study demonstrates that burn injuries cause substantial and prolonged productivity loss amongst burn survivors with mixed burn severity. This absenteeism contributes to already high societal costs of burn injuries. Predictors of absenteeism found in this study were primarily fixed patient and treatment related factors, future studies should focus on modifiable factors, in order to improve RTW outcomes. Also, more attention in the rehabilitation trajectory is needed to optimally support RTW in burn survivors.

Secondary hemochromatosis as a result of acute transfusion-induced iron overload in a burn patient

Background

Red blood cell transfusions are critical in burn management. The subsequent iron overload that can occur from this treatment can lead to secondary hemochromatosis with multi-organ damage.

Case Presentation

While well recognized in patients receiving chronic transfusions, we present a case outlining the acute development of hemochromatosis secondary to multiple transfusions in a burn patient.

Conclusions

Simple screening laboratory measures and treatment options exist which may significantly reduce morbidity; thus, we believe awareness of secondary hemochromatosis in those treating burn patients is critical.

Psychotropic drugs and risk of burn injury in individuals with mental illness: a 10-year population-based case-control study

PURPOSE

We aimed to investigate the association between psychotropic treatment and risk of burn injury in individuals with mental illness.

METHODS

A nested case-control study was conducted by using the National Health Insurance Research Database in Taiwan. A total of 3187 cases with burn injury under International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 940-949 and 19 122 matched controls were identified from 2003 to 2012. Four kinds of psychotropic agents (antipsychotics (APs), antidepressants (ADs), benzodiazepines, and z-drugs) were examined. Psychotropic exposure status was measured, and a set of potential confounding factors was adjusted in the analyses. Conditional logistic regressions were applied to determine the effect of psychotropic use on burn injury.

RESULTS

A significant increased risk of burn injury was observed among psychotropic users compared with non-users (adjusted odds ratio (AOR) = 1.45, 95%CI = 1.31-1.61). When classifying psychotropic users into current, new, continuous, and past users, a significant elevated risk of burn injury was found across all groups (AOR = 1.76, 95%CI = 1.54-2.00 in current users; AOR = 2.02, 95%CI = 1.55-2.65 in new users; AOR = 1.72, 95%CI = 1.50-1.96 in continuous users; and AOR = 1.35, 95%CI = 1.21-1.51 in past users). When assessing each individual kind of examined psychotropic agents, a significant elevated risk of burn injury was found among users of APs, ADs, benzodiazepines, and z-drugs except for current and continuous users of z-drugs.

CONCLUSIONS

The results demonstrate an elevated risk of burn injury among individuals with current psychotropic use. The findings underscore the need for greater attention to be given to the cognitive performance and psychomotor abilities of individuals taking psychotropic medications in order to prevent the occurrence of burn injury. Copyright © 2016 John Wiley & Sons, Ltd.

Administration of adipose-derived stem cells enhances vascularity, induces collagen deposition, and dermal adipogenesis in burn wounds

Current treatment options for severe burn wounds are often insufficient in reconstructing skin and soft tissue defects. Adipose-derived stem cells (ASCs), a readily available source of multipotent stem cells, represent a promising therapy for the treatment of full-thickness burn wounds. Full-thickness burn wounds were created on the paraspinal region of athymic mice. A one-time, sub-eschar injection of 6.8×10(6) ASCs in PBS or PBS alone was administered at 24-h postoperatively. Time to healing was quantified using Image J analysis. At days 4, 7, 14, and 21, mice were sacrificed and tissues were excised for molecular and histological analysis. ASCs were able to survive in burn wounds as determined by the presence of PKH labeling and human PPARγ expression within the wounds. CD-31 staining demonstrated increased vascularity in ASC-treated wounds at POD 4 (p<0.05). Molecular studies showed enhanced adipogenesis, as well as type III and type I collagen deposition in the ASC treated group (p<0.05). An increase in the mRNA expression ratio of type III to type I collagen was also observed following ASC treatment (p<0.05). By enhancing vascularity, collagen deposition, and adipogenesis, ASCs show promise as an adjunctive therapy for the current treatment of full thickness burn wounds.

Fear-avoidance in Recovered Burn Patients: Association with Psychological and Somatic Symptoms

Fear-avoidance, an important model in the understanding of chronic pain, has not yet been studied in patients with burns. The purpose of this study was to investigate if recovered burn patients have fear-avoidance beliefs and to explore the association with psychological and somatic symptoms. Eighty-four recovered burn patients completed self-report questionnaires. The results showed that there were fear-avoidance beliefs, but not to a large extent. Beta coefficients from multiple regression analyses indicated a strong association between fear-avoidance and problems with work, heat sensitivity and arousal symptoms. The model was capable of explaining 73 per cent of the variance in fear-avoidance beliefs.

Increased cutaneous wound healing effect of biodegradable liposomes containing madecassoside: preparation optimization, in vitro dermal permeation, and in vivo bioevaluation

Madecassoside (MA) is highly potent in treating skin disorders such as wounds and psoriasis. However, the topical wound healing effect of MA was hampered by its poor membrane permeability. In order to overcome this shortcoming, MA liposomes were designed and prepared by a double-emulsion method to enhance transdermal and wound healing effects. In this study, response surface methodology was adopted to yield the optimal preparation conditions of MA double-emulsion liposomes with average particle size of 151 nm and encapsulation efficiency of 70.14%. Moreover, MA double-emulsion liposomes demonstrated superior stability and homogeneous appearance in 5 months; their leakage rate was <12% even at 37°C and <5% at 4°C within 1 month. In vitro skin permeation, skin distribution, and burn wound healing of MA liposomal formulations were conducted for the first time to evaluate MA delivery efficiency and wound healing effect. The transdermal property and wound cure effect of MA double-emulsion liposomes were superior to those of MA film dispersion liposomes, and both the methods were endowed with an excellent performance by polyethylene glycol modification. In conclusion, double-emulsion liposome formulation was an applicable and promising pharmaceutical preparation for enhancing MA delivery toward wound healing effect and improving wound-healing progress.

Health-related quality of life (EQ-5D) early after injury predicts long-term pain after burn

BACKGROUND

Chronic pain after burn can have severe physical and psychological effects on former patients years after the initial injury. Although the issue of pain after burn has gained increased attention over the past years, prospective, longitudinal studies are scarce. Our aim was to prospectively investigate consecutive burn patients for pain severity over time and to evaluate the prevalence and characteristics of post-burn pain to 2-7 years after the burn. As an additional aim, the effects of burn and individual-related factors, especially health-related Quality of Life (HRQoL), were investigated.

METHOD

Sixty-seven consecutive burn patients were assessed during acute care at 3, 6, 12 and 24 months, as well as at 2-7 years post-burn. HRQoL, symptoms of post-traumatic stress disorder (PTSD) and other psychiatric disorders were investigated. During the interviews that took place 2-7 years after the injury (mean 4.6±1.9 years), current chronic post-burn pain was assessed using the Brief Pain Inventory-Short Form (BPI-SF).

RESULTS

One-third of the patients still reported pain 2-7 years after the injury. Pain severity and interference with daily life were mainly mild to moderate though they were found to be associated with significantly lower HRQoL. Chronic pain after burn was associated with both burn- and individual-related factors. In logistic regression analysis HRQoL at 3 and 12 months and symptoms of PTSD at 12 months were independent factors in predicting chronic pain after burn.

CONCLUSION

Pain after burn becomes a chronic burden for many former burn patients and decreases HRQoL. A novel finding in this study was that HRQoL assessed early after burn was a predictor for the development of chronic pain. This finding may help to predict future pain problems and serve as an indicator for pain preventive measures.

Long-term scar quality in burns with three distinct healing potentials: A multicenter prospective cohort study

The laser Doppler imager is used in cases of indeterminate burn depth to accurately predict wound healing time at an early stage. The laser Doppler imager classifies burns into three estimated healing potentials as follows: high, <14 days; intermediate, 14-21 days; and low, >21 days. At this time, the relationship between these healing potentials and long-term scar quality is unknown. The objective of this study was to determine the long-term scar quality of burns with three distinct healing potentials. The secondary objectives were to compare treatment strategies in intermediate wounds, to study the effect of the timing of surgery on low healing potential wounds and to identify predictors of reduced scar quality. Hence, in a prospective cohort study, scar quality was determined in patients whose burns were assessed with laser Doppler imaging. Scar Quality was assessed with objective and subjective measurement tools, including overall scar quality (Patient and Observer Scar Assessment Scale) as a primary outcome and color and elasticity parameters. A total of 141 patients (>19 months postburn) with 216 scars were included. Wounds with high and intermediate healing potential did not significantly differ regarding scar quality. Wounds with a low healing potential had a significantly lower scar quality. Analysis of 76 surgically treated low healing potential wounds showed no significant differences in the primary outcome regarding the timing of surgery (≤14 days vs. >14). Predictors of reduced long-term scar quality were darker skin type and multiple surgeries. In conclusion, scar quality was strongly related to the healing potential category. Scar quality was very similar in high and intermediate healing potential wounds. No positive effects were found on scar quality or on healing time in surgically treated wounds with intermediate healing potential, advocating a conservative approach. Further studies should focus on the optimal timing of surgery in low healing potential wounds.

Satisfaction With Appearance Scale-SWAP: Adaptation and validation for Brazilian burn victims

AIM

Methodological study that aimed to adapt the Satisfaction with Appearance Scale (SWAP) into Brazilian Portuguese language and to assess the validity, the reliability and the dimensionality of the adapted version in a sample of Brazilian burn victims.

METHODS

We carried out the adaptation process according to the international literature. Construct validity was assessed by correlating the adapted version of SWAP scores with depression (Beck Depression Index), self-esteem (Rosenberg Self-Esteem Scale), health-related quality of Life (Short Form Health Survey-36) and health status of burn victims (Burn Specific Health Scale-Revised), and with gender, total body surface area burned, and visibility of the scars. We tested dimensionality using Exploratory Factor Analysis (EFA) and the reliability by means of Cronbach's alpha.

RESULTS

Participants were 106 adult burned patients. The correlations between the Brazilian version of the SWAP scores and the correlated construct measures varied from moderate to strong (r=.30-.77). The participants who perceived their burn sequelae was visible reported being more dissatisfied with their body image than the participants who answered that their scars would not be visible (p<.001). Cronbach's alpha for the adapted version was 0.88 and the item-total correlation varied from moderate to strong (r=.35-.73). The EFA resulted in three factors with a total explained variance percentage of 63.2%.

CONCLUSION

The Brazilian version of the SWAP was valid and reliable for use with Brazilian burn victims.

Postburn neck anterior contracture treatment in children with scar-fascial local trapezoid flaps: a new approach

One of the dramatic consequences of burns is scar contracture and deformities of the neck. Cervical contracture in children is especially dangerous, leading to face disfigurement and kyphosis; therefore, early reconstruction is indicated. Despite the existence of many various surgical techniques, the successful neck contracture treatment in pediatric patients remains a challenge for surgeons. Eleven children (aged 5 to 14 years) with postburn neck anterior contractures were studied to develop a new approach for reconstruction that would employ the use of local scar-fascial flaps. The new approach and technique for postburn pediatric contracture treatment was developed which is especially effective in the treatment of children who cannot undergo complex and long surgical procedures that are aimed at both contracture elimination and neck skin restoration. The technique consists of two trapezoid scar-fascial flaps mobilization which includes all the anterior neck surfaces and consists of scars, fat layer, platysma, and deep cervical fascia. Counter transposition of flaps with tension elongated neck anterior surface was 100 to 200%. The contracture was fully eliminated, and neck contours, mentocervical angle, and head movement were restored. In case of severe contracture, residual wound in submandibular region and above clavicles were skin-grafted. The full range of head motion (functional results) was achieved in all the 11 patients. The flaps continued to grow and the skin grafts shrinkage was moderate. Local trapeze-flap plasty allows neck contracture elimination in children in the cases when a more complex technique is impossible or undesirable to use. Early surgical intervention prevents secondary complications, allotting enough time for patients to mature and be ready for more complex procedures.