Patient experiences of burn scars in adults and children and development of a health-related quality of life conceptual model: A qualitative study

Top ten research priorities in global burns care: findings from the James Lind Alliance Global Burns Research Priority Setting Partnership

Burns are a global issue that can result in lifelong multimorbidities and disproportionately affect people in low-resource settings. Prioritising research of importance to patients and health-care professionals improves evidence-based care. This prioritisation setting partnership was undertaken in global burn care (focusing on thermal non-electrical burns) by establishing a James Lind Alliance research priority setting partnership. Over 2 years, two online multilingual surveys with patients, carers, and clinicians, 16 interviews, and a virtual priority setting workshop were conducted to identify and prioritise questions for research. Survey responses were received from participants in 88 countries (1617 survey one respondents; 630 survey two respondents). A short-list of 19 research priorities were ranked at an online workshop attended by 28 participants (14 health-care professionals, ten burn survivors, and four carers or advocates) from 15 countries to produce the final top ten research priorities. These priorities provide opportunities for researchers, funders, and clinicians to shape the future of burns research and improve burns care globally.

Enablers and barriers to participation in physical activity programs while hospitalized after burn injury: The patient perspective

BACKGROUND

Physical activity is an essential component of burn rehabilitation; however, the patient experience of factors that contribute to physical activity participation while hospitalized after burn injury has not yet been described. This study aimed to identify enablers and barriers to participation in physical activity while hospitalized after burn injury from the patient perspective.

METHODS

A qualitative descriptive study design was undertaken. Purposive sampling was used to recruit adults with burn injuries admitted to the burn center between February and July 2022. Semi-structured interviews were conducted by a research assistant not involved in clinical care, audio-recorded and transcribed verbatim. All de-identified transcripts were analyzed using an inductive thematic approach and organized into major themes.

RESULTS

Twenty participants (18 males) with average age of 47 years and mean burn size of 13.8 % total body surface area were included. Factors which influenced patients' ability to participate in physical activity were summarized into six major themes: 1) Burn injury factors; 2) Patient factors; 3) Staff support; 4) Family support; 5) Peer support; 6) Environmental factors. Pain, fear of causing further pain or harm and beliefs regarding the need for rest to achieve wound healing were identified as major barriers to physical activity performance. Family support and supportive care from staff were highly valued enablers.

CONCLUSION

This is the first study to describe the patient experience of physical activity participation while hospitalized after a burn injury. Understanding the patient perspective is integral to developing appropriate multi-component interventions to promote increased physical activity early after burn injury.

Institutional Factors Associated with Equitable Cancer Care Provision for Culturally and Linguistically Diverse Populations in Queensland, Australia: A Critical Race Theory Analysis

BACKGROUND

Cancer inequities for Culturally and Linguistically Diverse (CALD) populations have been demonstrated in Australia. Historically, research has focused on individual factors, but addressing structural and institutional determinants is crucial for equitable care provision. This study utilised Critical Race Theory to examine institutional factors impacting equitable care provision.

METHODS

We undertook a qualitative exploration of a large tertiary hospital in metropolitan Queensland. Institutional barriers, facilitators, and staff experiences regarding equitable care were explored through semi-structured interviews (n = 21). Participants included oncology registered nurses (n = 6), oncology doctors (n = 5), specialist nurses (n = 7), and executive-level staff (n = 3). Data were analysed using The Framework Method.

RESULTS

Findings revealed an inflexible health system with strong deficit framing of CALD patients. A reliance on assumptions and informal mechanisms to address the needs of CALD patients resulted in suboptimal practises such as simplified information sharing, use of unqualified interpreters, limited treatment access, and avoidance of psycho-social discussions. Staff reported experiencing moral conflict when providing care discordant with their professional values.

CONCLUSIONS

This study demonstrates the need for cultural and structural reform within Australian health services. Adapting services to promote equity will have demonstrable benefits for patient outcomes, quality of care, and staff wellbeing.

Have the recent advancements in wound repair and scar management technology improved the quality of life in burn patients?

BACKGROUND

The negative physical and psychosocial impact of scars, in particular burn scars, has been well documented. Altered personal appearance together with impaired function related to pain, heat intolerance, and contracture formation may last a lifetime and eventually can lead to low self-esteem and poor social and psychological adjustments. Though most patients recover within the first years and many report generally good life satisfaction and moderate quality of life (QoL), some severely burned patients continue to report impaired QoL almost 10 years after injury. It is repeatedly mentioned in the literature that patients' QoL and health-related quality of life (HRQoL) can be improved by improving wound healing and burn scar quality. Determining whether advances in burn wound healing and scar management modalities are positively impacting the lives of surviving patients is the aim of this review.

METHODS

A systematic literature review was used to identify studies measuring QoL of patients surviving severe burn injuries following various interventions to improve burn wound healing and scar quality.

RESULTS

A limited number of studies was identified. Given the limited available data, a narrative review approach including qualitative studies and reviews in addition to identifying common themes, trends, and gaps in the existing literature was deemed more appropriate for a comprehensive analysis.

CONCLUSION

The assumption that progress made in recent decades to improve burn wound healing and scar quality would improve QoL remains largely hypothetical. Except for functional release of burn scar contractures, improved scar aesthetic quality does not necessarily translate into improved QoL of surviving patients. Well-designed comparative studies are largely lacking.

Parent-Reported Burn-Specific Health-Related Quality of Life in Children 5-7 Years After Burns: A Multicenter Cross-Sectional Study

Surviving a burn can dramatically alter a child's life, yet few studies examined long-term health-related quality of life (HRQL). This study assessed HRQL 5-7 years post-burn in children with mild/intermediate and severe burns and identified associated factors. Parents of children (5- < 18 years) who were hospitalized or had burn surgery between 08/2011 and 09/2012 completed the Burn Outcomes Questionnaire (BOQ). Outcomes were compared between two subgroups: children with mild/intermediate burns (<10% total body surface area (TBSA) burned) versus severe burns ((1) aged <10 years old at the time of injury with >10% (TBSA) burned; (2) aged ≥10 years with >20% TBSA burned; or (3) >5% full-thickness burns). A total of 102 children were included (mean age at survey: 8.4 (3.0) years; mean former TBSA: 7.1%). At a mean of 5.7 years post-burn, many parents rated their child's health as excellent (46.1%) or very good (35.3%), with few reporting issues with 'pain' (2.3%), 'physical function and sports' (1.6%), and 'upper extremity function' (0.9%). Parents of children with severe burns indicated significantly more problems with 'appearance' (89.2% versus 71.5%; p = 0.014) and 'parental concern' (94.1% versus 84.8%; p = 0.021). Upper limb burns, facial burns, burn size, length of hospital stay, full-thickness burns, and the number of surgeries predicted poorer outcomes. In general, these findings indicate positive long-term HRQL, though especially children with full-thickness burns and/or surgical interventions face a higher risk of reduced HRQL. The results can be used to inform children and their families about the long-term implications. Furthermore, healthcare professionals can use these insights to identify children at higher risk of poorer long-term HRQL.

Navigating Laser Treatments for Scars: The Physical and Emotional Journey

INTRODUCTION

The physical and emotional burden that scars impose on people's lives has been the concern of dermatological research for quite some time. Usually, the available literature on the topic draws a grim image containing solely dry medical facts. The present study deviates from this approach by reflecting a solution-centered study which has also touched on the quotidian life of an average person. The overall intention of the present experiment was to inspect how a holistic approach to scars in dermatology can be crucial for the patient's quality of life.

METHODS

This pilot study compiles data collected through the Patient and Observer Scar Assessment Scale (POSAS) and the Dermatology Life Quality Index (DLQI) from the same set of patients within the span of a year. Sixty patients with diverse scar profiles were asked to rate POSAS and DLQI in every session. A combination of EBDs was used based on the scar examination. Student's t-test was run to validate the data.

RESULTS

The evaluations by POSAS and DLQI indicate significant improvement in the physical aspect of the scar as well as the patient quality of life a year after the first treatment. According to mean values collected from POSAS, there is a direct correlation between average patient evaluations and physician assessments. Thus, EBDs prove to be efficient in improving the QoL of scar patient. The 20 patients who had reported mild side effects after treatments recovered fully within a few days after the sessions. No patient reported severe side effects.

DISCUSSION

Apart from the physical indications that scars bring about into patients' lives, the psychological repercussions caused by scars have a major effect on the QoL of the patients. These repercussions can be divided into individual and social. At the individual level, scars have a profoundly negative effect on the image of the self which leads to several different psychological complications by time. At the social level, scars affect the radius of physical movement besides the quality of the patient's activities. Therefore, EBDs as effective treatment methods can improve itchiness, pain, and so forth, of the patient, and can also improve the psychological aspect.

CONCLUSION

All in all, the present study aims to produce a more panoramic perspective on the concern of scars in the field of dermatology, centering around EBDs as a solution for improving scar patient QoL. With a focus on the efficacy of EBDs in the scar treatment, and with reference to studies on the topic, it is safe to assume that the earlier the scar treatment initiates, the better the outcomes. Departing from this point, in the future of cosmetic dermatology, prepping the skin by EBD treatments before surgery is imaginable.

Ultrasound measurement of traumatic scar and skin thickness: a scoping review of evidence across the translational pipeline of research-to-practice

OBJECTIVES

To identify the ultrasound methods used in the literature to measure traumatic scar thickness, and map gaps in the translation of these methods using evidence across the research-to-practice pipeline.

DESIGN

Scoping review.

DATA SOURCES

Electronic database searches of Ovid MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature and Web of Science. Grey literature searches were conducted in Google. Searches were conducted from inception (date last searched 27 May 2022).

DATA EXTRACTION

Records using brightness mode (B-mode) ultrasound to measure scar and skin thickness across the research-to-practice pipeline of evidence were included. Data were extracted from included records pertaining to: methods used; reliability and measurement error; clinical, health service, implementation and feasibility outcomes; factors influencing measurement methods; strengths and limitations; and use of measurement guidelines and/or frameworks.

RESULTS

Of the 9309 records identified, 118 were analysed (n=82 articles, n=36 abstracts) encompassing 5213 participants. Reporting of methods used was poor. B-mode, including high-frequency (ie, >20 MHz) ultrasound was the most common type of ultrasound used (n=72 records; 61% of records), and measurement of the combined epidermal and dermal thickness (n=28; 24%) was more commonly measured than the epidermis or dermis alone (n=7, 6%). Reliability of ultrasound measurement was poorly reported (n=14; 12%). The scar characteristics most commonly reported to be measured were epidermal oedema, dermal fibrosis and hair follicle density. Most records analysed (n=115; 97%) pertained to the early stages of the research-to-practice pipeline, as part of research initiatives.

CONCLUSIONS

The lack of evaluation of measurement initiatives in routine clinical practice was identified as an evidence gap. Diverse methods used in the literature identified the need for greater standardisation of ultrasound thickness measurements. Findings have been used to develop nine methodological considerations for practitioners to guide methods and reporting.

Working Towards Holistic Scar Assessment and Improved Shared Decision Making in Global Burn Care

Cutaneous burn scars impact various aspects of life. Scar treatment is mainly evaluated on scar characteristics. Consensus is needed on which other outcomes to capture, ensuring they are relevant to patients, clinicians, and researchers. The aim of this study was to identify, discuss and analyze outcomes related to cutaneous burn scarring, incorporating the voice of patients and views of healthcare professionals. For this, a Delphi process consisting of two survey rounds and a consensus meeting was initiated. Burn scar-related outcomes were identified from an existing comprehensive list of 100 outcomes by an international panel of patients, healthcare professionals and researchers. Fifty-nine outcomes were identified from the Delphi process as related to scarring (≥60% votes). Outcomes less impactful in relation to scar outcomes included psychosocial issues, sense of normality, understanding of treatment, costs and systemic issues. To represent a holistic assessment of outcomes related to cutaneous burn scarring, this Delphi process established a battery of outcomes currently included in scar quality assessment tools, and an expanded set of less frequently considered outcomes. Future work in this area must include the patient voice from developing countries. This is essential to identify globally applicable outcomes related to scarring.

Becoming Experts in Their Own Treatment: Child and Caregiver Engagement With Burn Scar Treatments

Children who experience a severe burn injury not only require acute medical care but may also need ongoing rehabilitation. To mitigate the potential long-term consequences of scarring and the impact of scarring on their everyday lives, children may be expected to use a variety of time-consuming and multi-component non-invasive scar treatments (such as pressure garments and silicone gels). These treatments may pose unique challenges for children and their caregivers. With limited research previously addressing how Australian children navigate the use of scar treatments at home, this study aimed to develop a grounded theory of children and their caregivers' engagement with non-invasive burn scar treatments. Using a constructivist grounded theory approach, interviews were completed with 20 caregivers and 7 children, and a theory of children and their caregivers becoming experts in the use of non-invasive burn scar treatments was developed. Through persistence and flexibility, they continued to develop expertise. Engaging with scar treatments was an evolving process over time for children with burns and their caregivers. Theoretical categories identified included 'making it work', 'finding the balance' and 'seeking reassurance' and highlighted the remarkable strengths and adaptability of children and their caregivers. Through trial and error, children and their caregivers developed their own unique strategies for engaging with scar treatments. These insightful results may inform the development of interventions to support children and their caregivers' day-to-day engagement with non-invasive burn scar treatments and guide health professionals recommending these treatments.

Exploring what is important during burn recovery: a qualitative study investigating priorities of patients and healthcare professionals over time

OBJECTIVES

This qualitative study aimed to investigate: (1) priorities of patients and healthcare professionals during recovery from a burn injury, (2) how priorities change over time and (3) how priorities map to outcomes currently reported in burns research.

DESIGN

Semi-structured interviews were conducted. Interviews were audio recorded, transcribed and analysed thematically.

SETTING, PARTICIPANTS

A total of 53 patients and healthcare professionals were recruited from four National Health Service (NHS) burn services across England and Wales across England and Wales. Patient participants (n=32) included adults, adolescents and parents of paediatric patients, with a variety of burn injuries in terms of severity and cause of burn injury. Healthcare professionals (n=21) were NHS staff members involved in burn care and included professionals with a range of clinical experience and roles (eg, nurses, surgeons, occupational therapists, physiotherapist, administration).

RESULTS

Ten themes relating to priorities (outcomes) during recovery from a burn injury were identified for patients and professionals. Of those, six were identified for patients and professionals ('pain and discomfort', 'psychological well-being', 'healing', 'scarring', 'function', 'infection'), three were unique to professionals ('patient knowledge, understanding and support', 'sense of control', 'survival') and one was unique to patients ('uncertainty'). Results highlighted that importance of these priorities changes over time (eg, 'survival' was only a concern in the short term). Likewise, priorities differed between patients and professionals (eg, 'pain' was important to patients throughout their recovery, but not for professionals). Seven out of 10 themes overlapped with outcomes commonly assessed in burn research.

CONCLUSION

Professionals' and patients' priorities (important outcomes) change over time after burn injury and differ between those groups. Burn care research should consider measuring outcomes at different time points during the recovery from a burn injury to accurately reflect complexity of burn recovery.

A meta-ethnography of developing and living with post-burn scars

INTRODUCTION

Post-burn scarring is often cosmetically unappealing and create discomfort. This makes it crucial to understand the experience of individuals living with scars which can offer insights into their recovery. This review sought to develop an in-depth understanding of living with post-burn scars.

DESIGN

A systematic review and meta-ethnography approach were employed. We utilized an interpretive approach to inductively generate codes. These codes were examined iteratively using a constant comparison strategy following which they were re-interpreted to formulate themes which formed the basis of undertaking a narrative synthesis.

RESULTS

Twenty-five studies were retained. The analytical process yielded two themes: emergence of a new identity and living with the redefined self. The experience of living with scars is entwined with the initial trauma as the scars served as a permanent reminder of the injury. Emergence of a new identity involved a process of meaning making, mourning the loss of the old self, confronting the new self, reconciling the remains of the old self with the new, rebuilding a new identity, and navigating through functional restrictions. These processes were particularly challenging for persons involved in self-immolation. Positive coping and changing one's perspective emerged as strategies to facilitate living with the redefined self.

CONCLUSION

Living with scars is a challenging process which is more difficult for persons whose injuries are due to self-immolation (act of burning oneself). The findings highlight a latent yet ongoing process towards subjective recovery. Clinicians need to be aware of the processes and incorporate these into rehabilitation programmes.

CLINICAL RELEVANCE

Burn survivors need ongoing professional support to adjust to and live with the scars. Victims of self-immolation should be considered for early psychosocial support.

Burn Patient Perspectives on Disability Weights and the Philosophy of Disability: A Gap in the Literature

Background

Disability-adjusted life years (DALY) have a ubiquitous presence in academic global health, including attempts to understand the global burden of burn injuries.

Objective

The present scoping review aimed to examine whether disability weights (DWs) were informed by burn patient perspectives and secondarily to determine whether literature indicates which of the three most common philosophical models of disability best aligns with burn patient experiences.

Methods

A review of six databases was conducted and The Critical Appraisal Skills Program (CASP) checklist was utilized.

Results

Out of a total of 764 articles, zero studies solicited patient perspectives of DWs. Four articles contained data that could be extrapolated to patient perspectives on disability. All articles utilized semi-structured interviews of burn survivors and reported thematic elements including return to work, self-image, and social integration. Patients reported similar themes that burn injuries were disabling injuries and instrumentally detrimental, with modulation based on the patient's social circumstances.

Conclusions

This scoping review highlights a significant gap in literature. First, no studies were found directly investigating burn patient perspectives on burn DWs. Current DWs have been derived from expert opinions with limited input from patients. Second, the limited primary patient data gleaned from this review suggest patients consider their injuries as instrumentally detrimental, which aligns most closely with the welfarist view of disability. More explicit investigations into the philosophical model of disability best aligning with burn patient experiences are needed to ground the health economics of burns in sound theory.

Pediatric First-Degree Burn Management With Honey and 1% Silver Sulfadiazine (Ag-SD): Comparison and Contrast

Background The cardinal area of managing fire wounds is guided by adequately evaluating the burn-induced lesion's profundity and size. Superficial second-degree burns are often treated through daily reinstating with fresh sterile bandaging with appropriate topical antimicrobials to allow rapid spontaneous epithelialization. Around the world, a wide variety of substances are used to treat these wounds, from honey to synthetic biological dressings. Objective This study intended to determine honey's therapeutic potential compared with 1% silver sulfadiazine (Ag-SD) in arsenal-caused contusion medicament fulfillment. Methods A total of 70 cases were evaluated in this research work after fulfilling the required selection criteria during the study period of January 2014 to December 2014 and January 2017 to December 2017. Purposive selection criteria were adopted in the study to select research patients. The patients in Group-1 (n = 35) relied on honey as medication, while patients in Group-2 (n = 35) relied on 1% Ag-SD. Results In Group-1, exudation (68.4%) and sloughing (82.9%) were substantially reduced by Days 3 and 5 of therapeutic intervention, respectively. However, in Group-2, a reduction of exudation (17.1%) and sloughing (22.9%) occurred after Days 3 and 5 of treatment, respectively. Completion of the epithelialization process was observed among Group-1 and Group-2 cases. It was detected after Days 7 and 10 of treatment at 36.3% and 77% (Group-1) and 27% and 67% (Group-2), respectively. Around 3 ml of 1% honey was required per body surface area per dressing in Group-1. On the other hand, in Group-2, 2 gm Ag-SD was needed per body surface area per dressing. Conclusion Patients treated with honey found better clinical outcomes in managing superficial partial-thickness burns.

No statistically significant difference in long term scarring outcomes of pediatric burns patients treated surgically vs. those treated conservatively

Introduction

Paediatric burns are a common clinical presentation. The long-term scar outcomes in paediatric burns patients are relatively unknown as most are discharged after 6 weeks follow up, apart from the small number that are followed up by scar services depending on geographical availability. We aimed to determine whether the long-term scarring outcomes are significantly different in those who had surgical treatment with Versajet® debridement and Biobrane®, vs. those treated conservatively with non-adherent Mepitel® and Acticoat® dressings, in a cohort of paediatric burns patients.

Methods

The parents of all paediatric burns patients admitted to Stoke Mandeville Hospital from October 2014 to September 2017 were contacted by telephone to fill in the paediatric Brisbane Burn Scar Impact Profile (BBSIP), the only patient reported outcome measure (PROM) specifically aimed at children. The results from the questionnaires underwent statistical analysis to see if there was a significant difference in questionnaire scores between children treated surgically vs. those treated conservatively.

Results

A total of 107 children were admitted in the timeframe, responses were received from 34 patients with 13 having been treated surgically and 21 having been treated conservatively. In all 58 questions that make up the BBSIP, there was no statistically significant difference observed in the scores of those treated surgically vs. those treated conservatively. For 31 questions on the BBSIP, the lowest score indicating the best outcome was observed in all patients in both groups.

Discussion

Surgical management for burns is always the last resort. Our results could be interpreted to suggest clinicians need not fear the longer-term impact a scar may have when deciding whether to treat a paediatric burns patient surgically or conservatively. This study is the first to assess longer-term scar outcomes using the BBSIP. A larger data set and comparison with other burn units in the UK may help to provide more information on scar outcomes between different methods of surgical and conservative treatment. We found no statistically significant difference in the long-term scar outcomes as assessed by the BBSIP in paediatric burn patients treated with Versajet® debridement and Biobrane®, vs. those treated conservatively with non-adherent Mepitel® and Acticoat® dressings.

The role of burn camp in the recovery of young people from burn injury: A qualitative study using long-term follow-up interviews with parents and participants

BACKGROUND

Children and adolescents recovering from burn injury are at heightened risk of psychosocial problems. An integrative form of psychosocial intervention is burn camp. However, evidence about burn camp effectiveness is equivocal.

OBJECTIVES

This study examined the role of therapeutic camp experiences in the recovery journeys of children and adolescents who had experienced burn injury and been treated in a tertiary pediatric hospital in Brisbane, Australia.

METHODS

Retrospective semi-structured interviews were conducted with youths and parents. Inductive reflexive thematic analysis was used with pooled interview data.

RESULTS

The participants were eight youths who attended at least one burns camp (between 2009 and 2019) and 15 parents of youth campers. An overwhelming majority (96%) reported a positive experience of camp, that they would return, and that they recommended the camp to other youth with burns. The four strengths of the camp experience were fun, adventurous activities; social relatedness (friendships, socializing); camp setting and experience; and acceptance. The four impacts of the camp on youth campers were normalizing ("I'm not the only one", shared experience); social support (making new friendships, social confidence, mentoring others); psychological recovery (happier, mentally stronger, more resilient, independence building); and confidence (increased self-confidence, increased social confidence, leadership development).

CONCLUSIONS

Although this is the first known research about burn camp in Australia, the findings are similar to a handful of other qualitative studies about burn camp experiences and impacts. Recommendations include future research on aspects of camp experiences that contribute to targeted outcomes, the role of staff and previous camp participants as mentors, and comparisons with other psychosocial interventions for youth burn survivors.

Matching Qualitative Inquiry Design and Practice to Contemporary Burns Research Questions: Are We Getting It Right?

Qualitative methodology has continued to develop through scholarly inquiry, with its application to burn scar research progressed substantially since early use. Concerns were raised in 2015 that qualitative inquiry in burn care and rehabilitation used a limited range of qualitative research approaches. The aim of this commentary paper is to consider how broadly the suite of methodologies available within the qualitative research paradigm have been applied to burn scar research since that call. Observations from a scan of qualitative burn scar papers published since 2015 to March 2022 (n = 36) are presented. Less commonly used qualitative methodologies (such as interpretive design, interpretive phenomenological analysis, narrative inquiry, grounded theory, explanatory case study) and their contribution to burn scar research is discussed. Examples are presented to consider how the application of qualitative methodological approaches (including post-qualitative research methodologies) can be ultimately used to inform meaningful outcomes.

Effects of multiple modes of UltraPulse fractional CO2 laser treatment on extensive scarring: a retrospective study

The main therapeutic options for extensive scarring (e.g., > 20% of the total body surface area, or TBSA) after burns and trauma have focused on conservative treatments, such as compression, moisturization, and topical agent application. However, these treatments may not achieve optimal effects due to the large size and complexity of the scars. UltraPulse fractional CO₂ laser treatment is a novel approach that is currently a subject of intense interest; this treatment is most widely used to improve texture, pliability, and pigmentation in all types of scars. However, no studies on the independent use of UltraPulse fractional CO₂ laser treatment for extensive scars have been reported. This retrospective study evaluated a total of 21 patients, whose scars covered 20 to 65% TBSA. Scar thickness was measured by ultrasonography before treatment. Personalized treatment modalities and parameters were set according to the scar type and thickness. Scar formation and treatment effects were evaluated by photography, the Patient and Observer Scar Assessment Scale (POSAS), and patients’ judgment of effectiveness. Where the scars covered joints, joint function was assessed by measuring the maximum range of motion (ROM). With laser therapy, scars became flatter and lighter; furthermore, pruritus, pain, and discomfort decreased significantly. POSAS scores significantly decreased after laser therapy, including the item scores for pain and pruritus. There were no instances of joint contracture, ROM reduction, apparent functional impairment, serious adverse events, or comorbidities. This study demonstrates the safety and efficiency of UltraPulse fractional CO₂ laser treatment for extensive scarring.

Cost-effectiveness of adjunctive negative pressure wound therapy in paediatric burn care: evidence from the SONATA in C randomised controlled trial

Negative pressure wound therapy (NPWT) has been shown to improve clinical outcomes for children with burns by accelerating wound re-epithelialisation. Its effects on healthcare costs, however, remain poorly understood. The aim of this study was to evaluate the cost-effectiveness of NPWT from a healthcare provider perspective using evidence from the SONATA in C randomised controlled trial, in which 101 children with small-area burns were allocated to either standard care (silver-impregnated dressings) or standard care in combination with adjunctive NPWT. The primary outcome, time to re-epithelialisation, was assessed through a blinded photographic review. Resource usage and costs were prospectively recorded for each participant for up to 6 months. Incremental cost-effectiveness ratios and dominance probabilities were estimated and uncertainty quantified using bootstrap resampling. Mean costs per participant—including dressings, labour, medication, scar management, and theatre operations—were lower in the NPWT group (AUD $903.69) relative to the control group (AUD $1669.01). There was an 89% probability that NPWT was dominant, yielding both faster re-epithelialisation and lower overall costs. Findings remained robust to sensitivity analyses employing alternative theatre costs and time-to-re-epithelialisation estimates for grafted patients. In conclusion, adjunctive NPWT is likely to be a cost-effective and dominant treatment for small-area paediatric burns (ANZCTR.org.au:ACTRN12618000256279).

Patient experience of scar assessment and the use of scar assessment tools during burns rehabilitation: a qualitative study

Background

Scar assessment plays a key role during burns aftercare, to monitor scar remodelling and patients’ psychosocial well-being. To aid assessment, subjective scar assessment scales are available that use health-care professionals’ and patients’ opinions to score scar characteristics. The subjective scales are more widely used in clinical practice over objective scar measures. To date, there is no research that considers patients’ views on scar assessment and the role of subjective and objective assessment tools. Therefore, the aim of this qualitative study was to explore patients’ perspectives on scar assessment and the utility of scar assessment tools during burns rehabilitation.

Methods

Semi-structured interviews were conducted with 10 adult burn patients who were being reviewed in clinic for scarring. Participants were recruited via their clinical care team and research nurses at the Queen Elizabeth Hospital, Birmingham, UK. Topics covered during interview included patient experience of scar assessment, the use of scar assessment tools and discussion surrounding important factors to be addressed when assessing scars. A thematic analysis using the Framework Method was conducted.

Results

Participants identified key subthemes that contribute towards the overarching theme of patient-centred scar assessment. These are: patient-led care; continuity in care; learning how to self-manage scarring; and psychological assessment. Links were demonstrated between these subthemes and the remaining themes that describe scar assessment strategies, indicating their potential patient-centred contributions. The subjective opinions of clinicians were found to be valued above the use of subjective or objective scar assessment tools. Scar assessment scales were perceived to be a beneficial method for self-reflection in relation to psychosocial functioning. However, minimal feedback and review of completed assessment scales led to uncertainty regarding their purpose. Patients perceived objective tools to be of primary use for health-care professionals, though the measures may aid patients’ understanding of scar properties.

Conclusions

Scar assessment tools should be used to support, rather than replace, health-care professionals’ subjective judgements of scarring. Adapting the way in which clinicians introduce and use scar assessment tools, according to patient needs, can support a patient-centred approach to scar assessment.

"More than Scabs and Stitches": An Interview Study of Burn Survivors' Perspectives on Treatment and Recovery

Sustaining a burn injury often results in a life-long recovery process. Survivors are impacted by changes in their mobility, appearance, and ability to carry out activities of daily living. In this study, we examined survivors' accounts of their treatment and recovery in order to identify specific factors that have had significant impacts on their well-being. With this knowledge, we may be better equipped to optimize the care of burn patients. We conducted inductive, thematic analysis on transcripts of in-depth, semi-structured interviews with 11 burn survivors. Participants were purposefully selected for variability in age, gender, injury size and mechanism, participation in peer support, and rurality. Survivors reported varied perceptions of care quality and provider relationships. Ongoing issues with skin and mobility continued to impact their activities of daily living. Many survivors reported that they did not have a clear understanding or realistic expectations of the recovery process. Wound care was often described as overwhelming and provoked fear for many. Even years later, trauma from burn injury can continue to evolve, creating fears and impediments to daily living for survivors. To help patients understand the realistic course of recovery, providers should focus on communicating the nature of injury and anticipated recovery, developing protocols to better identify survivors facing barriers to care, and referring survivors for further support.

Daily Quality-of-life Impact of Scars: An Interview-based Foundational Study of Patient-reported Themes

Background:

Scars negatively impact mental health. Prior patient interview studies on cutaneous scars have elicited opinions pertaining to psychosocial effects, appearance, and symptoms. There remains a need for patient-reported opinions in broader contexts, including career and sexual well-being, to better understand patients’ experiences with their cutaneous scars.

Methods:

In this qualitative study, patients with cutaneous scars participated in semi-structured interviews. Transcripts were analyzed using a constant comparative approach using the data software QDAMiner, to generate a thematic framework encompassing patients’ experience with cutaneous scars.

Results:

In total, 37 patients aged 25–79 years (mean 45, SD 17.9) were interviewed. Patients presented with keloid (2/37, 5%), hypertrophic (5/37, 14%), atrophic (4/37, 11%), and linear surgical (18/37, 49%) scars. Opinions fell under 8 overarching themes. Patients spoke commonly about psychological and social well-being (references to the frequency of thinking about a scar and talking about scars with others were mentioned 56 times by 26 patients and 103 times by 29 patients, respectively, for example). Discussions of sexual well-being and career were elicited but rarer (references to feeling uncomfortable when naked and negative impacts on professional networking were mentioned 17 times by 7 patients and 5 times by 3 patients, respectively, for example).

Conclusions:

The relationship between determinants of patients’ opinions of their scars and their impact on quality-of-life is complex. These results expand upon the existing knowledge of the effects scars have on quality-of-life and can contribute to the development and validation of future scar outcome measures.

Improving the patient-centred care of children with life-altering skin conditions using feedback from electronic patient-reported outcome measures: protocol for a hybrid effectiveness-implementation study (PEDS-ePROM)

INTRODUCTION

Using patient-reported outcome measures (PROMs) with children have been described as 'giving a voice to the child'. Few studies have examined the routine use of these measures as potentially therapeutic interventions. This study aims to investigate: (1) the effectiveness of feedback using graphical displays of information from electronic PROMs (ePROMs) that target health-related quality of life, to improve health outcomes, referrals and treatment satisfaction and (2) the implementation of ePROMs and graphical displays by assessing acceptability, sustainability, cost, fidelity and context of the intervention and study processes.

METHODS AND ANALYSIS

A hybrid II effectiveness-implementation study will be conducted from February 2020 with children with life-altering skin conditions attending two outpatient clinics at a specialist paediatric children's hospital. A pragmatic randomised controlled trial and mixed methods process evaluation will be completed. Randomisation will occur at the child participant level. Children or parent proxies completing baseline ePROMs will be randomised to: (1) completion of ePROMs plus graphical displays of ePROM results to treating clinicians in consultations, versus (2) completion of ePROMs without graphical display of ePROM results. The primary outcome of the effectiveness trial will be overall health-related quality of life of children. Secondary outcomes will include other health-related quality of life outcomes (eg, child psychosocial and physical health, parent psychosocial health), referrals and treatment satisfaction. Trial data will be primarily analysed using linear mixed-effects models; and implementation data using inductive thematic analysis of interviews, meeting minutes, observational field notes and study communication mapped to the Consolidated Framework for Implementation Research.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Children's Health Queensland Human Research Ethics Committee (HREC/2019/QCHQ/56290), The University of Queensland (2019002233) and Queensland University of Technology (1900000847). Dissemination will occur through stakeholder groups, scientific meetings and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12620000174987).

The impact of scars on health-related quality of life after breast surgery: a qualitative exploration

PURPOSE

The purpose of this research was to explore women's experiences after breast surgery with scar characteristics and symptoms, and its impact on their health-related quality of life (HRQOL).

MATERIAL AND METHODS

A qualitative study using semi-structured face-to-face interviews was conducted among women following prophylactic, oncologic, or reconstructive breast surgery in the Netherlands. A directed content analysis was performed using guiding themes. Themes were "physical and sensory symptoms," "impact of scar symptoms," "personal factors," "impact of scar interventions," and "change over time."

RESULTS

The study population consisted of 26 women after breast surgery. Women experienced a wide range of symptoms like adherence, stiffness, pain, and uncomfortable sensations. Scar characteristics as visibility, location, texture, and size, influenced satisfaction with their appearance. The impact of scar symptoms is reflected in physical, social, emotional, and cognitive functioning, thereby affecting HRQOL. The experienced impact on HRQOL depended on several factors, like personal factors as the degree of acceptance and environmental factors like social support.

CONCLUSION

Women can experience a diversity of scar characteristics and symptoms, which play a central role in the perceived impact on HRQOL. Since scarring can have a considerable impact on HRQOL, scarring after prophylactic, oncologic and reconstructive breast surgery should be given more attention in clinical practice and research.

IMPLICATIONS FOR CANCER SURVIVORS

Considering scarring as a common late effect after breast surgery and understanding the variety of experiences, which could impact HRQOL of women, can be beneficial in sufficient information provision, expectation management, and informed decision making.

Ensuring that the outcome domains proposed for use in burns research are relevant to adult burn patients: a systematic review of qualitative research evidence

Background

There have been several attempts to define core outcome domains for use in research focused on adult burns. Some have been based in expert opinion, whilst others have used primary qualitative research to understand patients' perspectives on outcomes. To date there has not been a systematic review of qualitative research in burns to identify a comprehensive list of patient-centred outcome domains. We therefore conducted a systematic review of qualitative research studies in adult burns.

Methods

We searched multiple databases for English-language, peer-reviewed, qualitative research papers. We used search strategies devised using the SPIDER tool for qualitative synthesis. Our review utilized an iterative three-step approach: (1) outcome-focused coding; (2) development of descriptive accounts of outcome-relevant issues; and (3) revisiting studies and the broader theoretical literature in order to frame the review findings.

Results

Forty-one articles were included. We categorized papers according to their primary focus. The category with the most papers was adaptation to life following burn injury (n = 13). We defined 19 outcome domains across the 41 articles: (1) sense of self; (2) emotional and psychological morbidity; (3) sensory; (4) scarring and scar characteristics; (5) impact on relationships; (6) mobility and range of joint motion; (7) work; (8) activities of daily living and self-care; (9) treatment burden; (10) engagement in activities; (11) wound healing and infection; (12) other physical manifestations; (13) financial impact; (14) impact on spouses and family members; (15) analgesia and side effects; (16) cognitive skills; (17) length of hospital stay; (18) access to healthcare; and (19) speech and communication. We suggest that sense of self is a core concern for patients that, to date, has not been clearly conceptualized in the burns outcome domain literature.

Conclusions

This outcome domain framework identifies domains that are not covered in previous attempts to outline core outcome domains for adult burn research. It does so with reference to existing theoretical perspectives from the sociology and psychology of medicine. We propose that this framework can be used as a basis to ensure that outcome assessment is patient-centred. Sense of self requires further consideration as a core outcome domain.

"On the Recovery Journey:" An Integrative Review of the Needs of Burn Patients From Immediate Pre-Discharge to Post-Discharge Period Using the Omaha System

BACKGROUND

To establish a conceptual understanding of the needs of burn patients, the specific research question asked is: "What are the needs of burn patients from 1-week pre-discharge to the post-discharge period?"

METHODS

Whittemore and Knafl's integrative review approach was used to answer the review question. The databases searched were the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Embase, and Scopus. Thirty-two primary studies were retained at the end of the screening process. Directed content analysis was undertaken, with the Omaha system as an organizing framework.

RESULTS

Recovery after burns is not a linear process, but an intricate one filled with varied needs in the physiological (pain, skin, neuro-musculo-skeletal, and infection), psychosocial (social contact, role changes, spirituality, grief, mental health, and sexuality), health-related behavior (nutrition, sleep and rest patterns, and physical activity), and environmental (income) domains of the Omaha system. The nature and intensity of these needs change over time, suggesting that recovery for the burn patient is an ongoing process.

CONCLUSIONS

Several needs exist from 1 week before discharge to the post-discharge period. The mutual relationship and evolving nature of these needs create an avenue for a flexible, regular, holistic transitional program, similar to the support offered to persons living with chronic conditions.

CLINICAL RELEVANCE

Hospital discharge does not imply an end to the recovery of burn patients, and burn survivors still require holistic care even after discharge. The review shows the applicability of the Omaha system in exploring and classifying the needs of burn survivors and situates nursing at the core of such a program. It is possible that a nurse-led program of care needs to be considered.

Challenges Facing Women Survivors of Self-Immolation in the Kurdish Regions of Iran: A Qualitative Study

OBJECTIVES

Women confront many problems after self-immolation, so the purpose of this study was to explore the challenges facing women survivors of self-immolation in the Kurdish Regions of Iran.

METHOD

This study used a qualitative approach and conventional content analysis. Data were collected through semi-structured interviews with 19 Kurdish women who attempted self-immolation in Iran. They were sampled through purposeful sampling and snowball sampling. The Lincoln and Guba criteria were used to strengthen the research.

RESULTS

The results of data analysis were categorized into five main categories: 1-psychological problems, 2-lack of social and legal supportive structures, 3-incomplete treatment, 4-poor self-care, and 5-social problems. These categories consist of 19 subcategories.

CONCLUSION

Having been rescued from self-immolation, the women confront many challenges returning to normal life. Reducing these women's problems and paving the way for their return to life requires multi-dimensional and community-based interventions. Therefore, all social organizations and institutes can cooperate and each of them paves part of the way.

Systematic Review on the Content of Outcome Measurement Instruments on Scar Quality

Supplemental Digital Content is available in the text.

Measurements of scar quality are essential to evaluate the effectiveness of scar treatments and to monitor scars. A large number of scar scales and measurement devices have been developed, which makes instrument selection challenging. The aim of this study was to provide an overview of the content (ie, included items) of all outcome measurement instruments that measure scar quality in different types of scars (burn, surgical, keloid, and necrotizing fasciitis), and the frequency at which the instruments and included items are used.

Analysis and Evaluation of Conceptual Model for Health-Related Quality of Life Employing Fawcett and DeSanto-Madeya's Critique Framework

Health-related quality of life is increasingly used as a predictor in nursing research and practice because its multidimensional constructs encompass the holistic spectrum of care. This article comprehensively analyzes and evaluates the conceptual model of health-related quality of life of Ferrans and colleagues using Fawcett and Desanto-Madeya's 2013 framework. The model encompasses all relevant concepts and propositions in its theoretical foundation while maintaining consistency with the nursing metaparadigm. Also, the model has comprehensive content, appropriate context, and social and theoretical significance. To maximize the model's empirical and pragmatic adequacy, researchers should carefully define the variables associated with each concept.

Measuring the Impact of Burn Injury on the Parent-Reported Health Outcomes of Children 1 to 5 Years: A Conceptual Framework for Development of the Preschool Life Impact Burn Recovery Evaluation Profile CAT

Due to the rapid developmental growth in preschool-aged children, more precise measurement of the effects of burns on child health outcomes is needed. Expanding upon the Shriners Hospitals for Children/American Burn Association Burn Outcome Questionnaire 0 to 5 (BOQ0–5), we developed a conceptual framework describing domains important in assessing recovery from burn injury among preschool-aged children (1–5 years). We developed a working conceptual framework based on the BOQ0–5, the National Research Council and Institute of Medicine’s Model of Child Health, and the World Health Organization’s International Classification of Functioning, Disability, and Health for Children and Youth. We iteratively refined our framework based on a literature review, focus groups, interviews, and expert consensus meetings. Data were qualitatively analyzed using methods informed by grounded theory. We reviewed 95 pediatric assessments, conducted two clinician focus groups and six parent interviews, and consulted with 23 clinician experts. Three child health outcome domains emerged from our analysis: symptoms, functioning, and family. The symptoms domain describes parents’ perceptions of their child’s pain, skin-related discomfort, and fatigue. The functioning domain describes children’s physical functioning (gross and fine motor function), psychological functioning (internalizing, externalizing, and dysregulation behavior; trauma; toileting; resilience), communication and language development (receiving and producing meaning), and social functioning (connecting with family/peers, friendships, and play). The family domain describes family psychological and routine functioning outcomes.

The longitudinal validity, reproducibility and responsiveness of the Brisbane Burn Scar Impact Profile (caregiver report for young children version) for measuring health-related quality of life in children with burn scars

BACKGROUND

The measurement of health-related quality of life (HRQoL) provides information about the perceived burden of the health condition and treatments from a lived experience. The Brisbane Burn Scar Impact Profile (caregiver report for young children, BBSIP^0-8), developed in 2013, is a proxy-report measure of burn scar-specific HRQoL. The aim of this study was to report its psychometric properties in line with an evaluative purpose.

METHODS

Caregivers of children up to 8 years of age at risk of burn scarring were recruited into a prospective, longitudinal cohort study. Caregivers completed the BBSIP^0-8, Pediatric Quality of Life Inventory and Patient Observer Scar Assessment Scale at baseline (approximately ≥85% of the total body surface area re-epithelialised), 1-2 weeks after baseline and 1-month after baseline. Psychometric properties measured included internal consistency, test-retest reliability, validity and responsiveness.

RESULTS

Eighty-six caregivers of mostly male children (55%), of a median age (IQR) of 1 year, 10 months (2 years, 1 month) and total body surface area burn of 1.5% (3.0%) were recruited. Over one third of participants were grafted and 15% had contractures or skin tightness at baseline. Internal consistency of ten item groups ranged from 0.73 to 0.96. Hypothesised correlations of changes in the BBSIP^0-8 items with changes in criterion measures supported longitudinal validity (ρ ranging from -0.73 to 0.68). The majority of item groups had acceptable reproducibility (ICC = 0.65-0.83). The responsiveness of five item groups was supported (AUC = 0.71-0.90).

CONCLUSION

The psychometric properties tested support the use of the BBSIP^0-8 as an evaluative measure of burn scar-related health-related quality of life for children aged below eight years in the early post-acute period of rehabilitation. Further investigation at longer time period after burn injury is indicated.

Effectiveness of interventions for optimising adherence to treatments for the prevention and management of scars: protocol for a systematic review and meta-analysis

INTRODUCTION

Treatments used in the management of scarring following wounds of the skin can be complex and time consuming, and patients may experience difficulties adhering to these treatments. Therefore, the aim of this systematic review is to identify the types of interventions that have been used to optimise adherence to treatment for preventing or reducing skin scars in adults and children and to determine the effectiveness of these interventions.

METHODS AND ANALYSIS

Databases (PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and OTSeeker) will be searched using the developed search strategy to identify eligible randomised trials. Adults and children using scar treatments to prevent or manage scarring as a result of a dermal wound (which may occur following burn injury, surgery, lacerations, piercings, vaccinations, acne and other conditions affecting the skin) will be included. Any intervention with the potential to effect adherence will be included. Titles and abstracts located through searching will be screened by two independent reviewers. Full text of studies will also be screened to determine eligibility for final inclusion. Two reviewers will assess the quality of included studies using the Cochrane 'risk of bias' tool. Data extraction forms will be developed and two reviewers will extract the data. A third reviewer will be used at each stage to ensure consensus is achieved. Meta-analysis and meta-regression will be completed if appropriate, otherwise a narrative synthesis of results will be undertaken.

ETHICS AND DISSEMINATION

No ethical approval is necessary for this systematic review as no patients will be directly involved. Results of this systematic review will be disseminated through journal publications and relevant conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018095082.

Comparative effectiveness of Biobrane®, RECELL® Autologous skin Cell suspension and Silver dressings in partial thickness paediatric burns: BRACS randomised trial protocol

BACKGROUND

Mixed partial thickness burns are the most common depth of burn injury managed at a large Australian paediatric hospital specialty burns unit. Prolonged time until re-epithelialisation is associated with increased burn depth and scar formation. Whilst current wound management approaches have benefits such as anti-microbial cover, these are not without inherent limitations including multiple dressing changes. The Biobrane® RECELL® Autologous skin Cell suspension and Silver dressings (BRACS) trial aims to identify the most effective wound management approach for mixed partial thickness injuries in children.

METHODS

All children presenting with an acute burn injury to the study site will be screened for eligibility. This is a single-centre, three-arm, parallel group, randomised trial. Children younger than 16 years, with burns ≥ 5% total body surface area involving any anatomical location, up to 48 h after the burn injury, and of a superficial partial to mid-dermal depth, will be included. A sample size of 84 participants will be randomised to standard silver dressing or a Regenerative Epithelial Suspension (RES™) with Biobrane® or Biobrane® alone. The first dressing will be applied under general anaesthesia and subsequent dressings will be changed every 3 to 5 days until the wound is ≥ 95% re-epithelialised, with re-epithelialisation time the primary outcome. Secondary outcomes of acute pain, acute itch, scar severity, health-related quality of life, treatment satisfaction, dressing application ease and healthcare resource use will be assessed at each dressing change and 3, 6 and 12 months post-burn injury.

DISCUSSION

The findings of this study can potentially change the wound management approach for superficial partial to mid-dermal burns in children locally and worldwide.

TRIAL REGISTRATION

The Australian New Zealand Clinical Trials Registry (ACTRN12618000245291) approved prospective registration on 15 February 2018. Registration details can be viewed at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374272&isReview=true.

Towards a clinical and empirical definition of burn scarring: A template analysis using qualitative data

OBJECTIVE

This study aimed to describe the nature, scope or meaning of the concept 'burn scar', from the perspective of adults and children with burn scarring, caregivers of children with burn scarring and health professionals who were considered experts in the treatment of burn scarring. The impact of the identified characteristics on burn scar health-related quality of life (HRQOL) was also examined.

METHOD

Using a phenomenological qualitative approach, 43 transcripts from semi-structured interviews with people with burn scars (n=10 adults and n=11 children), their caregivers (n=9) and health professionals (n=13) were analyzed using template analysis.

RESULTS

Ten characteristics of burn scars were identified by health professionals: 'stretchability', 'hardness', 'raised', 'thickness', 'surface area', 'scar sensitivity', 'scar surface appearance', 'hydration', 'fragility', and 'color'. However, 'thickness', 'scar surface area' and 'hydration' were not described by children with burn scars and 'scar surface area' was not described by adults with burn scars or caregivers. All groups (adults, children, caregivers and health professional) perceived that the burn scar characteristics of 'stretchability' and 'scar sensitivity' impacted upon all indicators of burn scar HRQOL. The burn scar characteristics of 'fragility', 'scar surface appearance' and 'color' were largely perceived by all groups to impact upon the emotional and physical indicators of burn scar HRQOL alone.

CONCLUSIONS

This study identified there are differences in the burn scar characteristics considered important by health professionals and those characteristics that adult/child/caregivers perceived to impact on indicators of burn scar HRQOL. It is recommended that outcome measures of burn scarring include the burn scar characteristics of 'stretchability' and 'scar sensitivity' at a minimum. The inclusion of 'fragility', 'scar surface appearance' and 'color' should also be considered.

Outcomes important to burns patients during scar management and how they compare to the concepts captured in burn-specific patient reported outcome measures

BACKGROUND

Pressure garment therapy (PGT) is an established treatment for the prevention and treatment of hypertrophic scarring; however, there is limited evidence for its effectiveness. Burn survivors often experience multiple issues many of which are not adequately captured in current PGT trial measures. To assess the effectiveness of PGT it is important to understand what outcomes matter to patients and to consider whether patient-reported outcome measures (PROMs) can be used to ascertain the effect of treatments on patients' health-related quality of life. This study aimed to (a) understand the priorities and perspectives of adult burns patients and the parents of burns patients who have experienced PGT via in-depth qualitative data, and (b) compare these with the concepts captured within burn-specific PROMs.

METHODS

We undertook 40 semi-structured interviews with adults and parents of paediatric and adolescent burns patients who had experienced PGT to explore their priorities and perspectives on scar management. Interviews were audio-recorded, transcribed and thematically analysed. The outcomes interpreted within the interview data were then mapped against the concepts captured within burn-specific PROMs currently in the literature.

RESULTS

Eight core outcome domains were identified as important to adult patients and parents: (1) scar characteristics and appearance, (2) movement and function, (3) scar sensation, (4) psychological distress, adjustments and a sense of normality, (5) body image and confidence, (6) engagement in activities, (7) impact on relationships, and (8) treatment burden.

CONCLUSIONS

The outcome domains presented reflect a complex holistic patient experience of scar management and treatments such as PGT. Some currently available PROMs do capture the concepts described here, although none assess psychological adjustments and attainment of a sense of normality following burn injury. The routine use of PROMs that represent patient experience and their relative contribution to trial outcome assessment versus clinical measures is now a matter for further research and debate.

Psychometric properties of the Brisbane Burn Scar Impact Profile in adults with burn scars

Objective

The aim of the study was to determine the longitudinal validity, reproducibility, responsiveness and interpretability of the adult version of the Brisbane Burn Scar Impact Profile, a patient-report measure of health-related quality of life.

Methods

A prospective longitudinal cohort study of patients with or at risk of burn scarring was conducted at three assessment points (at baseline around the time of wound healing, one to two weeks post-baseline and 1-month post-baseline). Participants attending a major metropolitan adult burn centre at baseline were recruited. Participants completed the Brisbane Burn Scar Impact Profile and the 36-item Short Form Health Survey and Patient Observer Scar Assessment Scale. Intraclass Correlation Coefficients (ICCs), smallest detectable change, percentage of those who improved, stayed the same or worsened and Area under the Receiver Operating Characteristic Curve (AUC) were used to test the aim.

Results

Data were included for 118 participants at baseline, 68 participants at one to two weeks and 57 participants at 1-month post-baseline. All groups of items had acceptable reproducibility, except for the overall impact of burn scars (ICC = 0.69), the impact of sensations which was not expected to be stable (ICC = 0.63), mobility and daily activities (ICC = 0.63, 0.67 respectively). The responsiveness of six out of seven groups of items able to be tested against external criterion was supported (AUC = 0.72–0.75). Hypothesised correlations of changes in the Brisbane Burn Scar Impact Profile items with changes in criterion measures generally supported longitudinal validity (e.g., nine out of thirteen hypotheses using the SF-36 as an external criterion were supported). Internal consistency estimates, item-total and inter-item correlations indicated there was likely redundancy of some groups of items, particularly in the relationships and social interaction, appearance and emotional reactions items (Chronbach’s alpha range = 0.94–0.95).

Conclusion

Support was found for the reproducibility, longitudinal validity, responsiveness and interpretability of most groups of Brisbane Burn Scar Impact Profile items and some individual items in the test population. Potential redundancy of items should be investigated further.

Ultrasound is a reproducible and valid tool for measuring scar height in children with burn scars: A cross-sectional study of the psychometric properties and utility of the ultrasound and 3D camera

OBJECTIVE

The aim of this study was to investigate the reproducibility and validity of measuring scar height in children using ultrasound and 3D camera.

METHOD

Using a cross-sectional design, children with discrete burn scars were included. Reproducibility was tested using Intraclass Correlation Coefficient (ICC) for reliability, and percentage agreement within 1mm between test and re-test, standard error of measurement (SEM), smallest detectable change (SDC) and Bland Altman limits of agreement for agreement. Concurrent validity was tested using Spearman's rho for support of pre-specified hypotheses.

RESULTS

Forty-nine participants (55 scars) were included. For ultrasound, test-retest and inter-rater reproducibility of scar thickness was acceptable for scarred skin (ICC=0.95, SDC=0.06cm and ICC=0.82, SDC=0.14cm). The ultrasound picked up changes of <1mm. Inter-rater reproducibility of maximal scar height using the 3D camera was acceptable (ICC=0.73, SDC=0.55cm). Construct validity of the ultrasound was supported with a strong correlation between the measure of scar thickness and observer ratings of thickness using the POSAS (ρ=0.61). Construct validity of the 3D camera was also supported with a moderate correlation (ρ=0.37) with the same measure using maximal scar height.

CONCLUSIONS

The ultrasound is capable of detecting smaller changes or differences in scar thickness than the 3D camera, in children with burn scars. However agreement as part of reproducibility was lower than expected between raters for the ultrasound. Improving the accuracy of scar relocation may go some way to address agreement.

Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children: study protocol for a randomised controlled trial

BACKGROUND

Abnormal scar development following burn injury can cause substantial physical and psychological distress to children and their families. Common burn scar prevention and management techniques include silicone therapy, pressure garment therapy, or a combination of both. Currently, no definitive, high-quality evidence is available for the effectiveness of topical silicone gel or pressure garment therapy for the prevention and management of burn scars in the paediatric population. Thus, this study aims to determine the effectiveness of these treatments in children.

METHODS

A randomised controlled trial will be conducted at a large tertiary metropolitan children's hospital in Australia. Participants will be randomised to one of three groups: Strataderm® topical silicone gel only, pressure garment therapy only, or combined Strataderm® topical silicone gel and pressure garment therapy. Participants will include 135 children (45 per group) up to 16 years of age who are referred for scar management for a new burn. Children up to 18 years of age will also be recruited following surgery for burn scar reconstruction. Primary outcomes are scar itch intensity and scar thickness. Secondary outcomes include scar characteristics (e.g. colour, pigmentation, pliability, pain), the patient's, caregiver's and therapist's overall opinion of the scar, health service costs, adherence, health-related quality of life, treatment satisfaction and adverse effects. Measures will be completed on up to two sites per person at baseline and 1 week post scar management commencement, 3 months and 6 months post burn, or post burn scar reconstruction. Data will be analysed using descriptive statistics and univariate and multivariate regression analyses.

DISCUSSION

Results of this study will determine the effectiveness of three noninvasive scar interventions in children at risk of, and with, scarring post burn or post reconstruction.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12616001100482 . Registered on 5 August 2016.

Patients' perspectives on quality of life after burn

BACKGROUND

The concept quality of life (QOL) refers to both health-related outcomes and one's skills to reach these outcomes, which is not yet incorporated in the burn-related QOL conceptualisation. The aim of this study was to obtain a comprehensive overview of relevant burn-specific domains of QOL from the patient's perspective and to determine its hierarchical structure.

METHODS

Concept mapping was used comprising a focus group (n=6), interviews (n=25), and a card-sorting task (n=24) in burn survivors. Participants sorted aspects of QOL based on content similarity after which hierarchical cluster analysis was used to determine the hierarchical structure of burn-related QOL.

RESULTS

Ninety-nine aspects of burn-related QOL were selected from the interviews, written on cards, and sorted. The hierarchical structure of burn-related QOL showed a core distinction between resilience and vulnerability. Resilience comprised the domains positive coping and social sharing. Vulnerability included 5 domains subdivided in 13 subdomains: the psychological domain included trauma-related symptoms, cognitive symptoms, negative emotions, body perception and depressive mood; the economical domain comprised finance and work; the social domain included stigmatisation/invalidation; the physical domain comprised somatic symptoms, scars, and functional limitations; and the intimate/sexual domain comprised the relationship with partner, and anxiety/avoidance in sexual life.

CONCLUSION

From the patient's perspective, QOL following burns includes a variety of vulnerability and resilience factors, which forms a fresh basis for the development of a screening instrument. Whereas some factors are well known, this study also revealed overlooked problem and resilience areas that could be considered in client-centred clinical practice in order to customize self-management support.

Effects of small-fiber neuropathy induced by resiniferatoxin on skin healing and axonal regrowth after burn

BACKGROUND

Damage to the peripheral nervous system influences wound healing and, after a deep burn, imperfect cutaneous nerve regeneration occurs. A third-degree burn model was developed in rats combined with the use of resiniferatoxin (RTX), known to promote sensory neuropathy.

METHODS

Rats were injected intraperitoneally either with RTX or vehicle. A mechanical sensory assay and the hot plate thermal sensory test were performed. The structural integrity of the sciatic nerve was assessed using transmission electron microcopy. After RTX injection, third-degree thermal burns were performed. Wound closure was monitored and samples were collected for histological analysis, immunohistochemistry and immunoblotting for neuronal markers.

RESULTS

RTX promoted both mechanical and thermal hypoalgesia. This transient RTX-mediated sensory deficit occurred without damaging the integrity of nerve fibers and induced a significant depletion of neuropeptides in both neuronal bodies and intraepidermal nerve fibers. Although wound closure rates were similar in both groups, the kinetic of granulation tissue remodeling was delayed in the RTX group compared with control group. A significant reduction of the peripherin expression in the RTX group was observed indicating impaired axonal regrowth of small fibers within the wound.

CONCLUSION

Our study confirms the important roles of innervation during skin healing and the defect of nerve regeneration after burn.