Benchmarks for Multidimensional Recovery After Burn Injury in Young Adults: The Development, Validation, and Testing of the American Burn Association/Shriners Hospitals for Children Young Adult Burn Outcome Questionnaire

Parecoxib sodium attenuates acute lung injury following burns by regulating M1/M2 macrophage polarization through the TLR4/NF-κB pathway

High temperature-induced burn injury often leads to an excessive inflammatory cascade resulting in multiple organ dysfunction syndrome, such as acute lung injury (ALI), in addition to skin tissue damage. As a specific COX2 inhibitor, parecoxib sodium suppresses the inflammatory response during burn injury. The effect of parecoxib sodium on ALI induced by burn injury and the associated molecular mechanism still need to be investigated. The role of parecoxib sodium in burn injury-induced ALI through the TLR4/NF-κB pathway was explored in the present study. A burn-induced ALI mouse model was constructed, and M1/M2 macrophages in lung tissue and markers involved in the TLR4/NF-κB signalling pathway were evaluated in bronchoalveolar lavage fluid (BALF) and MH-S mouse alveolar macrophages in vitro. The results indicated that parecoxib sodium attenuated lung injury after burn injury, decreased iNOS and TNF-α expression, increased IL-10 expression in BALF, and regulated the CD86-and CD206-mediated polarization of M1/M2 macrophages in lung tissue along with MH-S mouse alveolar macrophages. The effect of parecoxib sodium might be reversed by a TLR4 agonist. Overall, the results suggested that parecoxib sodium can regulate the polarization of M1/M2 macrophages through the TLR4/NF-κB pathway to attenuate ALI induced by skin burns.

Evaluation of patient-reported outcome measures in burn-specific tools: A systematic review

INTRODUCTION

Patient-reported outcome measures (PROMs) are now well-established tools to evaluate the quality of patient-centred care. Due to the multi-faceted and multi-disciplinary nature of the practice of burn care, as well as the range of significant potential sequelae, PROM's should form a fundamental component of burn quality improvement programs. We aim to 1. Explore biological, psychological, and social considerations that are currently listed in burn-specific PROM tools, as well as their efficacy, 2. Evaluate biological, psychological, and social factors that are considered in new burn-specific PROM tools or those under development, and 3. Identify any opportunities with respect to burn-specific PROM tools, in order to inform future investigation in this area.

METHODS

A search was performed of MEDLINE (Ovid), EMBASE, CINAHL, and the Cochrane Library databases. Two independent reviewers screened article titles/abstracts and then the full texts using Covidence. All studies were graded independently according to the Quality Rating Scheme for Studies and Other Evidences.

RESULTS

The initial search yielded 552 references. Based on ab initio inclusion and exclusion criteria, 133 full-text studies were assessed for eligibility, and 21 articles were ultimately included in the systematic review. Due to study heterogeneity, a qualitative synthesis was conducted. Existing burn-specific PROMs covered a range of biological, psychological, and social factors affecting adult and paediatric patients with burn injury, but several studies required additional PROMs for a thorough evaluation. Burn-specific PROM tools under development are poised to fill this deficit.

CONCLUSION

Major burn injuries are a unique form of trauma, requiring coordinated management that considers numerous factors not relevant to other patient populations. Further research is necessary to validate existing burn-specific PROM tools and to develop more comprehensive burn-specific PROM measures that more comprehensively incorporate the bio-psycho-social model of health.

Understanding Neural Factors in Burn-related Pruritus and Neuropathic Pain

Post-burn pruritus and neuropathic pain significantly affect the quality of life of affected individuals in several domains including psychosocial well-being, sleep and general impairment in activities of daily living. Whilst neural mediators involved in itch in the non-burns setting have been well investigated, there remains a lacuna of literature examining the pathophysiological and histological changes unique to burn-related pruritus and neuropathic pain. The aim of our study was to conduct a scoping review into the neural factors that contribute to burn-related pruritus and neuropathic pain. A scoping review was conducted to provide an overview of the available evidence. The PubMed, EMBASE and Medline databases were searched for publications. Data regarding neural mediators implicated, population demographics, total body surface area (TBSA) affected and sex was extracted. In total, 11 studies were included in this review with a total of 881 patients. The most frequently investigated neurotransmitter was the Substance P (SP) neuropeptide which appeared in 36% of studies (n = 4), followed by calcitonin gene-related peptide (CGRP) in 27% of studies (n = 3). Post-burn pruritus and neuropathic pain are symptomatic experiences that are predicated upon a heterogeneous group of underlying mechanisms. What is clear from the literature, however, is that itch and pain may occur secondary to the influence of both neuropeptides, such as SP, and other neural mediators including Transient receptor protein channels. Of the articles included for review, they were characterized by small sample sizes and large differences in statistical methodology and reporting.

Trajectory Curves for Purposes of Benchmarking and Predicting Clinical Outcomes: A Scoping Review

Trajectory curves are valuable tools to benchmark patient health status and predict future outcomes. A longitudinal study is underway to examine social participation after burn injury using the Life Impact Burn Recovery Evaluation (LIBRE) Profile with the goal of developing trajectory curves for specific domains that focus on social reintegration. We conducted a scoping review to inform and understand trajectory curves applied in clinical settings to compare outcomes for an individual to a matched cohort of comparable patients or predicted expected outcomes over time. This scoping review utilized a PubMed search from January 2014 to August 2019 for the following terms: "trajectory curves" or "trajectory models" and "clinic" or "clinical." Only articles that specifically referenced longitudinal and clinical research designs were included in the scoping review. Articles were assessed using standard scoping review methods and categorized based on clinical application of trajectory curves for either benchmarking or prediction. The initial literature review identified 141 manuscripts and 34 met initial inclusion criteria. The reviewed articles support the clinical use of trajectory curves. Findings provide insight into several key determinants involved with the successful development and implementation of trajectory curves in clinical settings. These findings will inform efforts to use the LIBRE Profile to model social participation recovery and assist in developing effective strategies using trajectory curves to promote social reintegration after burn injury.

Establishment of a core outcome set for burn care research: development and international consensus

Objective

To develop a core outcome set for international burn research.

Design

Development and international consensus, from April 2017 to November 2019.

Methods

Candidate outcomes were identified from systematic reviews and stakeholder interviews. Through a Delphi survey, international clinicians, researchers, and UK patients prioritised outcomes. Anonymised feedback aimed to achieve consensus. Pre-defined criteria for retaining outcomes were agreed. A consensus meeting with voting was held to finalise the core outcome set.

Results

Data source examination identified 1021 unique outcomes grouped into 88 candidate outcomes. Stakeholders in round 1 of the survey, included 668 health professionals from 77 countries (18% from low or low middle income countries) and 126 UK patients or carers. After round 1, one outcome was discarded, and 13 new outcomes added. After round 2, 69 items were discarded, leaving 31 outcomes for the consensus meeting. Outcome merging and voting, in two rounds, with prespecified thresholds agreed seven core outcomes: death, specified complications, ability to do daily tasks, wound healing, neuropathic pain and itch, psychological wellbeing, and return to school or work.

Conclusions

This core outcome set caters for global burn research, and future trials are recommended to include measures of these outcomes.

The CARe Burn Scale-Adult Form: Identifying the Responsiveness and Minimal Important Difference (MID) Values of a Patient Reported Outcome Measure (PROM) to Assess Quality of Life for Adults with a Burn Injury

The CARe Burn Scales are a suite of burn-specific PROMs for adults, children, young people, and parents affected by burns. This study aimed to determine the responsiveness and minimal important difference (MID) values of the Adult Form for use in adult burn care and research. Participants were recruited by 11 UK Burn Services. They completed online or paper versions of the CARe Burn Scale -Adult Form and a set of appropriate comparison validated measures and anchor questions at baseline (T1, up to 4 weeks post-burn), 3 months (T2), and 6 months post-burn (T3). A total of 269 participants took part at baseline and 226 (84%) were retained at the 6-month follow-up. Spearman's correlation analysis and effect sizes based on Cohen's d thresholds were reported and MID values calculated. MID values were created for all subscales and ranged from 4-15. The CARe Burn Scale-Adult Form is responsive to change over time and can therefore be used to reliably inform the management of adults' burn injury treatment and recovery. It is freely available for clinical and research use.

Validation of PROMIS-29 domain scores among adult burn survivors: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study

BACKGROUND

Patient-reported outcomes are important for understanding recovery after burn injury, benchmarking service delivery and measuring the impact of interventions. Patient-Reported Outcomes Measurement Information System (PROMIS)-29 domains have been validated for use among diverse populations though not among burn survivors. The purpose of this study was to examine validity and reliability of PROMIS-29 scores in this population.

METHODS

The PROMIS-29 scores of physical function, anxiety, depression, fatigue, sleep disturbance, ability to participate in social roles, and pain interference were evaluated for validity and reliability in adult burn survivors. Unidimensionality, floor and ceiling effects, internal consistency, and reliability were examined. Differential item functioning was used to examine bias with respect to demographic and injury characteristics. Correlations with measures of related constructs (Community Integration Questionnaire, Satisfaction with Life Scale, Post-Traumatic Stress Checklist-Civilian, and Veteran's Rand-12) and known-group differences were examined.

RESULTS

Eight hundred and seventy-six burn survivors with moderate to severe injury from 6 months to 20 years postburn provided responses on PROMIS-29 domains. Participants' ages ranged from 18 years to 93 years at time of assessment; mean years since injury was 3.4. All PROMIS domain scores showed high internal consistency (Cronbach's α = 0.87-0.97). There was a large ceiling effect on ability to participate in social roles (39.7%) and physical function (43.3%). One-factor confirmatory factor analyses supported unidimensionality (all comparative fit indices >0.95). We found no statistically significant bias (differential item functioning). Reliability was high (>0.9) across trait levels for all domains except sleep, which reached moderate reliability (>0.85). All known-group differences by demographic and clinical characteristics were in the hypothesized direction and magnitude except burn size categories.

CONCLUSION

The results provide strong evidence for reliability and validity of PROMIS-29 domain scores among adult burn survivors. Reliability of the extreme scores could be increased and the ceiling effects reduced by administering PROMIS-43, which includes six items per domain, or by administering by computerized adaptive testing.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, level III.

"Living Well" After Burn Injury: Using Case Reports to Illustrate Significant Contributions From the Burn Model System Research Program

The Burn Model System (BMS) program of research has been funded since 1993 by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The overarching aim of this program is to improve outcomes and quality of life for people with burns in the areas of health and function, employment, and community living and participation. This review reports on BMS contributions that have affected the lives of individuals with a significant burn injury using case reports to associate BMS contributions with recovery. In January 2020, current BMS grantee researchers assessed peer-reviewed BMS publications from 1994 to 2020. Using case report methodology, contributions were linked to three individuals treated at one of the four Burn Model System institutions. With over 25 years of NIDILRR funding, unique BMS contributions to patient recovery were identified and categorized into one of several domains: treatment, assessment measures, sequelae, peer support, employment, and long-term functional outcomes. A second review for significant results of BMS research that add to the understanding of burn injury, pathophysiology, and recovery research was identified and categorized as injury recovery research. The case study participants featured in this review identified select NIDILRR research contributions as having direct, personal benefit to their recovery. The knowledge generation and clinical innovation that this research program has contributed to our collective understanding of recovery after burn injury is considerable. Using case study methodology with three adult burn survivors, we highlight the impact and individual significance of program findings and reinforce the recognition that the value of any clinical research must have relevance to the lives of the study population.

Mortality prognostication scores do not predict long-term, health-related quality of life after burn: A burn model system national database study

OBJECTIVE

Despite improved mortality rates after burn injury, many patients face significant long-term physical and psychosocial disabilities. We aimed to determine whether commonly used mortality prognostication scores predict long-term, health-related quality of life after burn injury. By doing so, we might add evidence to support goals of care discussions and facilitate shared decision-making efforts in the hours and days after a life-changing injury.

METHODS

We used the multicenter National Institute of Disability, Independent Living and Rehabilitation Research Burn Model System database (1994-2019) to analyze SF-12 physical (PCS) and mental component (MCS) scores among survivors one year after major burn injury. Ninety percent of the observations were randomly assigned to a model development dataset. Multilevel, mixed-effects, linear regression models determined the relationship between revised Baux and Ryan Scores and SF-12 measures. Additionally, we tested a model with disaggregated independent and other covariates easily obtained around the time of index admission: age, sex, race, burn size, inhalation injury. Residuals from the remaining 10% of observations in the validation dataset were examined.

RESULTS

The analysis included 1606 respondents (median age 42 years, IQR 28-53 years; 70% male). Median burn size was 16% TBSA (IQR 6-30) and 13% of respondents sustained inhalation injury. Higher revised Baux and Ryan Scores and age, burn size, and inhalation injury were significantly correlated with lower PCS, but were not correlated with MCS. Female sex, black race, burn size, and inhalation injury correlated with lower MCS. All models poorly explained the variance in SF-12 scores (adjusted r² 0.01-0.12).

CONCLUSION

Higher revised Baux and Ryan Scores negatively correlated with long-term physical health, but not mental health, after burn injury. Regardless, the models poorly explained the variance in SF-12 scores one year after injury. More accurate models are needed to predict long-term, health-related quality of life and support shared decision-making during acute burn care.

Sexual activity and romantic relationships after burn injury: A Life Impact Burn Recovery Evaluation (LIBRE) study

BACKGROUND

Engaging in healthy sexual activity and romantic relationships are important but often neglected areas of post-burn rehabilitation. The degree to which persons with burn injuries engage in sexual activity and romantic relationships is not well understood. This study examined demographic and clinical characteristics predicting engagement in sexual activity and romantic relationships in a sample of adult burn survivors compared to a general United States sample.

METHODS

Data for the adult burn survivor sample were from 601 adult burn survivors who participated in field-testing for the calibration of the Life Impact Burn Recovery Evaluation (LIBRE) Profile, a burn-specific instrument assessing social participation on six scales including sexual activity and romantic relationships. Comparison data were obtained from a general population sample of 2000 adults through sample matching. Demographic predictors of sexual activity and romantic relationship status were examined in each sample using modified Poisson regression analyses. Clinical predictors of engaging in sexual activity and romantic relationships were also examined in the LIBRE sample.

RESULTS

Participants were slightly more likely to report being sexually active in the adult burn survivor sample than in the general sample (65% vs. 57%, p < 0.01). There was not a significant difference in romantic relationship status between the two samples (64% vs. 62%, p = 0.31). In multivariable regression analyses, men in both samples were more likely to report being in a sexual relationship (RR in LIBRE sample = 1.23, 95% CI 1.08-1.39; RR in general sample = 1.10, 95% CI 1.02-1.18). Participants in both samples who were not working were less likely to report being sexually active or in a romantic relationship (RRs ranging from 0.73 to 0.83, p < 0.05 for all estimates). In the adult burn survivor sample, respondents with hand burns were more likely to report being sexually active and in a romantic relationship (RR = 1.16, 95% CI 1.01-1.33). Time since burn injury, burn size, and burns to other critical areas were not significantly associated with either outcome in adjusted analyses.

CONCLUSIONS

The likelihood of engaging in sexual activity and romantic relationships is similar among adult burn survivors and the comparison group representing a general United States sample of adults. Further research addressing sexual activity and romantic relationships after burn injuries will help to foster better patient-clinician dialogue, pinpoint barriers, design interventions, and allocate appropriate resources.

Translation and Cross-cultural Validation of the English Young Adult Burn Outcome Questionnaire (YABOQ) in Spanish

The Young Adult Burn Outcome Questionnaire (YABOQ) is a validated, English-language patient-reported outcome assessment of young adults' recovery from burn injury across 15 scale domains. We evaluated the cross-cultural validity of a newly developed Spanish version of the YABOQ. Secondary data from English- and Spanish-speaking burn survivors (17 to 30 years of age) were obtained from the Multicenter Benchmarking Study. We conducted classic psychometric analyses and evaluated the measurement equivalence of the English and Spanish YABOQs in logistic and ordinal logistic regression differential item functioning analyses. All multi-item scales in the Spanish YABOQ demonstrated adequate reliability except the Pain and Itch scales. One item in the Perceived Appearance scale showed differential item functioning across English- and Spanish-speaking burn survivors, but the observed differential item functioning had no clinically significant impact on scale-level Perceived Appearance scores. Our findings support the cross-cultural validity of the YABOQ Physical Function, Perceived Appearance, Sexual Function, Emotion, Family Function, Family Concern, Satisfaction with Symptom Relief, Satisfaction with Role, Work Reintegration and Religion scales among English- and Spanish-speaking young adult burn survivors. This work supports the use of these English and Spanish YABOQ scales to assess the effect of therapeutic interventions on young adults' burn outcomes in pooled analyses and to assess disparities in young adults' burn outcomes across language groups.

Social Interactions and Social Activities After Burn Injury: A Life Impact Burn Recovery Evaluation (LIBRE) Study

Social interactions and activities are key components of social recovery following burn injuries. The objective of this study is to determine the predictors of these areas of social recovery. This study provides a secondary analysis of a cross-sectional survey of adult burn survivors. The Life Impact Burn Recovery Evaluation-192 was administered to 601 burn survivors for the field-testing of the Life Impact Burn Recovery Evaluation Profile. Survivors aged 18 years and older with injuries ≥5% total BSA or burns to critical areas (hands, feet, face, or genitals) were eligible to participate. Multivariate linear regression analyses were used to determine predictors of the Social Activities and Social Interactions scale scores. A total of 599 people completed the Social Interactions and Social Activities scales. Of these, 77% identified as White Non-Hispanic, 55% were female, 55% were unmarried, and 80% had burns to critical areas. Participants had a mean age of 45 years, a mean time since burn injury of 15 years, and a mean burn size of 41% total BSA. Younger age (P < .01) and being married/living with a significant other (P ≤ .01) were associated with higher Social Activities and Social Interactions scale scores. Individual item responses reveal that survivors had lower scores on items related to participating in outdoor activities (30.4%) or feeling uncomfortable with their appearance (32.4% report dressing to avoid stares). Social interactions and activities are long-term challenges for burn survivors. It is important for clinicians to identify patients who may struggle with social recovery in order to focus on future community-based interventions.

Burn injury

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.

Recovery of health-related quality of life after burn injuries: An individual participant data meta-analysis

Background

A prominent outcome measure within burn care is health related quality of life (HRQL). Until now, no model for long-term recovery of HRQL exists for adult burn patients which requires large samples with repeated measurements. Re-use and the combination of existing data is a way to achieve larger data samples that enable the estimation of long-term recovery models. The aim of this secondary data analysis was to assess the recovery of HRQL after a burn injury over time.

Methods and findings

Data from ten European studies on generic HRQL assessed in adult burn patients (either with the EQ-5D or SF-36) from five different countries were merged into one dataset. SF-36 outcomes were transformed into EQ-5D outcomes. A 24-month recovery of HRQL (EQ-5D utility) was modeled using a linear mixed-effects model and adjusted for important patient and burn characteristics. Subgroups of patients with mild and intermediate burns (≤20% total body surface area (TBSA) burned) and with major burns (>20% TBSA burned) were compared. The combined database included 1687 patients with a mean age of 43 (SD 15) years and a median %TBSA burned of 9% (IQR 4–18). There was large improvement in HRQL up to six months after burns, and HRQL remained relatively stable afterwards (studied up to 24 months post burn). However, the estimated EQ-5D utility scores remained below the norm scores of the general population. In this large sample, females, patients with a long hospital stay and patients with major burns had a delayed and worse recovery. The proportion of patients that reported problems for the EQ-5D dimensions ranged from 100% (pain/discomfort at baseline in patients with major burns) to 10% (self-care ≥3 months after injury in patients with mild and intermediate burns). After 24 months, both subgroups of burn patients did not reach the level of the general population in the dimensions pain/discomfort and anxiety/depression, and patients with major burns in the dimension usual activities. A main limitation of the study includes that the variables in the model were limited to age, gender, %TBSA, LOS and time since burn as these were the only variables available in all datasets.

Conclusions

The 24-month recovery model can be used in clinical practice to inform patients on expected HRQL outcomes and provide clinicians insights into the expected recovery of HRQL. In this way, a delayed recovery can be recognized in an early stage and timely interventions can be started in order to improve patient outcomes. However, external validation of the developed model is needed before implementation into clinical practice. Furthermore, our study showed the benefit of secondary data usage within the field of burns.

Identifying patient concerns during consultations in tertiary burns services: development of the Adult Burns Patient Concerns Inventory

OBJECTIVES

Identifying the issues and concerns that matter most to burns survivors can be challenging. For a number of reasons, but mainly relating to patient empowerment, some of the most pressing concerns patients may have during a clinical encounter may not naturally be the focal point of that encounter. The Patient Concerns Inventory (PCI) is a tried and tested concept initially developed in the field of head and neck cancer that empowers patients during a clinical encounter through provision of a list of prompts that allows patients to self-report concerns prior to consultation. The aim of this study was to develop a PCI for adult burns patients.

DESIGN

Content for the PCI was generated from three sources: burns health-related quality of life tools, thematic analysis of one-to-one interviews with 12 adult burns patients and 17 multidisciplinary team (MDT) members. Content was refined using a Delphi consensus technique, with patients and staff members, using SurveyMonkey.

SETTING

Within outpatient secondary care.

PARTICIPANTS

Twelve adult burns patients and MDT members from two regional burns centres.

RESULTS

A total of 111 individual items were generated from the three sources. The Delphi process refined the total number of items to 58. The main emergent domains were physical and functional well-being (18 items), psychological, emotional and spiritual well-being (22 items), social care and social well-being (7 items) and treatment-related concerns (11 items).

CONCLUSIONS

The Adult Burns Patient Concerns Inventory is a 58-item, holistic prompt list, designed to be used in the outpatient clinic. It offers a new tool in burn care to improve communication between healthcare professionals and patients, empowering them to identify their most pressing concerns and hence deliver a more focused and targeted patient-centred clinical encounter.

The Effect of Facial Burns on Long-Term Outcomes in Young Adults: A 5-Year Study

Long-term functional outcomes in young adults with facial burns remain poorly studied. This 5-year (2003-2008) prospective multicenter study includes burn survivors (age 19-30 years) who completed the Young Adult Burn Outcome Questionnaire (YABOQ) from 0 to 36 months after baseline survey administration. A composite canonical score was developed from 15 YABOQ domains using discriminant analysis, maximizing the difference at the baseline between burn-injured patients with face involved and not involved. A generalized linear model with the generalized estimation equation technique was used to track the changing pattern of the composite score over time. Individual domain scores with high correlation to the canonical score were used to evaluate recovery patterns in facial burns. A total of 153 burned (31% with face burns) and 112 nonburned subjects completed 620 questionnaires. Canonical analysis showed that early postburn, facial burns were associated with a difference in outcome, but this overall difference diminished over time. Regression analysis showed that for survivors with facial injury, Emotion and Sexual Function scores were persistently lower (worse), while Religion scores were persistently higher. Satisfaction with Role was initially better than the nonface burned group, but over time got worse, while Perceived Appearance was initially worse in the face burned group but this difference diminished over time. Social Function Limited by Appearance was initially similar between the groups, but over time the group with face burns scored lower. The overall difference in recovery between survivors with and without facial burns diminished over time while the individual domains had various patterns of recovery.

Introduction to the NIDILRR Burn Model System (BMS) Program: Selected Findings II

A special supplement to the Archives of Physical Medicine and Rehabilitation in 2007 reported selected findings of research from the first 13 years of the BMS Centers and Database Coordinating Center. This special supplement is the second such effort and reports on the growth of the BMS National Longitudinal Database (BMS NDB) since that time and select new research findings from the BMS centers.

A scoping review of burn rehabilitation publications incorporating functional outcomes

OBJECTIVE

The objective for this manuscript is two-fold: determine the scope of clinical rehabilitation research involving burn-injured persons and assess whether research outcomes include function, return to needed, and desirable routines. Has this research addressed rehabilitation needs of the burn injured?

METHODS

We performed a scoping review of literature (1990-2016) using the method of Arksey and O'Malley. Search terms included "rehabilitation", "function", "burn injury" and "work". Two independent reviewers identified articles that met criteria for abstract and full review. Variables of interest were counts of the number of intervention studies, studies performed in outpatient settings/inpatient settings, or both; count of the distribution of outcome measures that included impairment, function, participation, return to prior roles and percent of burns rehabilitation publications as a function of total rehabilitation articles published.

RESULTS

Sixty-four articles were selected for review and 22 employed an intervention. Nine articles were intervention trials that used functional measures. Of the 22 intervention trials 3 (14%) were performed while subjects were inpatients, 9 (41%) while they were outpatients, and 10 (45%) while they were both. There were 67 articles that met inclusion for work-related studies. Fourteen were intervention trials, 9 utilized functional outcomes and 5 used impairment outcomes exclusively. Less than 1% of clinical rehabilitation research addresses burns injury and <1% of the randomized trials in rehabilitation relates to burn injury CONCLUSIONS: There are few studies, few intervention trials and among these, very few that use function or return to community based activity as outcomes for people with burn injury.

Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns

BACKGROUND

There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients.

METHODS

We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010.

RESULTS

Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability.

CONCLUSION

The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

The Use of a Brief Measure to Assess Longitudinal Changes in Appearance Concerns for Youth Recovering From Burn Injuries

Burns are among the most common injuries to children, and, although survival rates have improved, many burn survivors are left with scars and/or other visible differences, which may be associated with anxiety, depression, and/or low self-esteem. A better understanding of the prevalence and persistence of these problems in child and adolescent burn survivors might lead to an expanded paradigm of care and possibly to better outcomes. The present study provides longitudinal prevalence data for the Appearance Concerns (AC) subscale of the parent-reported Burn Outcomes Questionnaire (BOQ) for 5- to 18-year-old children and identifies patient characteristics associated with higher risk for appearance concerns. Subjects were 799 pediatric burn survivors who were assessed prospectively using the parent-reported BOQ5-18, which was administered soon after their discharge from acute care and again every 3 to 6 months for up to 4 years. Approximately 20% of all youth were reported to have appearance concerns over the first 2 years, after which the rate declined gradually, falling to around 10% after 3 years. This study showed that such concerns were prevalent and persistent years after burn injuries and suggested that larger burns, facial burns, and country of origin outside of the United States were all associated with higher scores on the AC subscale. These findings highlight the importance of assessing appearance concerns in the long-term care of young burn survivors and suggest that the BOQ5-18 AC subscale could be used to identify individuals with heightened appearance concerns and to measure their response to interventions.

Correlation of the expression of inflammatory factors with expression of apoptosis-related genes Bax and Bcl-2, in burned rats

Correlation of the expression of inflammatory factors with expression of apoptosis-related genes, B-cell lymphoma 2 (Bcl-2) and Bcl-2 associated X protein (Bax), in burned rats was investigated. Forty healthy Sprague-Dawley rats were selected and randomly divided into SHAM group (n=10), I° burn group (n=10), II° burn group (n=10) and III° burn group (n=10). Changes in tumor necrosis factor-α (TNF-α), Bax messenger ribonucleic acid (mRNA), Bcl-2 mRNA, Bax protein and Bcl-2 protein expression levels were detected. The correlation of TNF-α, Bax and Bcl-2 with the degree of burn in rats was observed, and the correlation of TNF-α with Bax and Bcl-2 was also analyzed. Moreover, Bax mRNA and Bcl-2 mRNA were detected via reverse transcription-quantitative polymerase chain reaction, and TNF-α, Bax protein and Bcl-2 protein were detected via enzyme-linked immunosorbent assay. In burn groups, TNF-α, Bax mRNA and Bax protein levels were significantly increased at each time point compared with those at the previous time point (P<0.05), but Bcl-2 mRNA and protein levels were significantly decreased compared with those at the previous time point (P<0.05). At the same time point, TNF-α, Bax mRNA, Bcl-2 mRNA, Bax protein and Bcl-2 protein expression levels had statistically significant differences between any given two groups (P<0.05). The TNF-α expression level was positively correlated with Bax expression levels and negatively correlated with Bcl-2 expression levels. Additionally, TNF-α, Bax mRNA and Bax protein had positive correlations with the degree of burn and time after burn, while Bcl-2 mRNA and Bcl-2 protein had negative correlations with the degree of burn and time after burn. Continuous monitoring of changes in the TNF-α level can be used as a means to evaluate the degree of burn and apoptosis, and to prevent the deepening of burn wounds, thus facilitating the early clinical evaluation of prognosis.

The Development and Validity of the Adult Burn Outcome Questionnaire Short Form

Patient Reported Outcome Measures (PROMs) are useful for understanding the health needs and outcomes of the general public. We aim to develop a burn-specific metric-Adult Burn Outcome Questionnaire (ABOQ)-that is brief and can be administered electronically to all burn survivors over the age of 18. The 14-item ABOQ was developed from the already validated Young Adult Burn Outcome Questionnaire (YABOQ) long form. The ABOQ questionnaire, along with Patient-Reported Outcomes Measurement System-10 (PROMIS-10), was administered to 120 outpatient burn survivors at three hospitals. Clinical validity of the ABOQ was measured by testing associations between ABOQ items and burn size, the PROMIS-10 generic items and composite scales using correlational analysis including multivariate canonical analysis. Nine out of 14 ABOQ items were significantly correlated with burn size (correlations ranging from -0.25 to -0.46, P < .01). The canonical correlation between ABOQ and burn size was 0.68 (P = .0002). The overall canonical correlation between two instruments was also significant (P < .0001). At the item level, at least 25% of the variation in each of the five ABOQ items could be explained by PROMIS-10 items and composite scores, while six other items could only be accounted for by less than 15% of the variation. ABOQ short form assessment can be used to efficiently measure burn outcomes across a range of relevant clinical domains with credible validity. A large proportion of the variation in ABOQ scores was not accounted for by PROMIS-10, suggesting that ABOQ provided additional health-related information specifically for the burn population beyond the generic instrument.

Reliability & validity of the LIBRE Profile

BACKGROUND

The Life Impact Burn Recovery Evaluation (LIBRE) Profile^© was developed using Item Response Theory methods to assess social participation after a burn injury. The LIBRE Profile measures six areas of social participation: Relationships with Family & Friends, Social Interactions, Social Activities, Work & Employment, Romantic Relationships, and Sexual Relationships. It can be administered through a computerized adaptive test or through fixed short forms. The goal of this study was to further examine the psychometric properties of the LIBRE Profile, including reliability and validity.

METHODS

We examined the validity of the LIBRE Profile by administering the six LIBRE Profile scales as well as legacy measures that assessed similar constructs. We calculated the Pearson correlations between the LIBRE Profile scales and the scores on the same-domain and cross-domain legacy measures to evaluate convergent and divergent validity. We then administered the LIBRE Profile scales a second time, seven to ten days after the first administration, to a sample of adult burn survivors to evaluate test-retest reliability. We calculated repeatability coefficients, standard error of measurement, and minimal detectable change to establish the threshold beyond which the amount of change observed across an episode of care cannot be explained as measurement error.

RESULTS

For reliability, the repeatability coefficients ranged from 7.31 to 9.27 and SEMs ranged from 2.62 to 3.39 for all six scales. MDC₉₀ values ranged from 6.08 to 7.86 points, and MDC₉₅ values ranged from 7.26 to 9.40 points. All correlations between the LIBRE Profile scales and legacy measures are significant (p<0.05) and in the expected directions for both convergent and divergent validity.

CONCLUSIONS

This study provided evidence for the reliability and validity of the LIBRE Profile, one of the first tools that measures exclusively the social participation after a burn injury.

Health related quality of life in adults after burn injuries: A systematic review

OBJECTIVES

Measurement of health-related quality of life (HRQL) is essential to qualify the subjective burden of burns in survivors. We performed a systematic review of HRQL studies in adult burn patients to evaluate study design, instruments used, methodological quality, and recovery patterns.

METHODS

A systematic review was performed. Relevant databases were searched from the earliest record until October 2016. Studies examining HRQL in adults after burn injuries were included. Risk of bias was scored using the Quality in Prognostic Studies tool.

RESULTS

Twenty different HRQL instruments were used among the 94 included studies. The Burn Specific Health Scale-Brief (BSHS-B) (46%), the Short Form-36 (SF-36) (42%) and the EuroQol questionnaire (EQ-5D) (9%) were most often applied. Most domains, both mentally and physically orientated, were affected shortly after burns but improved over time. The lowest scores were reported for the domains 'work' and 'heat sensitivity' (BSHS-B), 'bodily pain', 'physical role limitations' (SF-36), and 'pain/discomfort' (EQ-5D) in the short-term and for 'work' and 'heat sensitivity', 'emotional functioning' (SF-36), 'physical functioning' and 'pain/discomfort' in the long-term. Risk of bias was generally low in outcome measurement and high in study attrition.

CONCLUSION

Consensus on preferred validated methodologies of HRQL measurement in burn patients would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of HRQL after burns. We recommend to develop a guideline on the measurement of HRQL in burns. Five domains representing a variety of topics had low scores in the long-term and require special attention in the aftermath of burns.

Development of a Conceptual Framework to Measure the Social Impact of Burns

Measuring community reintegration following burn injury is important to assess the efficacy of therapies designed to optimize recovery. This project aims to develop and validate a conceptual framework for understanding the social impact of burn injuries in adults. The framework is critical for developing the item banks used for a computerized adaptive test. We performed a comprehensive literature review and consulted with clinical experts and burn survivors about social life areas impacted by burn injury. Focus groups with burn survivors and clinicians were conducted to inform and validate the framework. Transcripts were coded using grounded theory methodology. The World Health Organization's International Classification of Functioning, Disability and Health, was chosen to ground the content model. The primary construct identified was social participation, which contains two concepts: societal role and personal relationships. The subdomains chosen for item development were work, recreation and leisure, relating with strangers, and romantic, sexual, family, and informal relationships. Qualitative results strongly suggest that the conceptual model fits the constructs for societal role and personal relationships with the respective subdomains. This conceptual framework has guided the implementation of a large-scale calibration study currently underway which will lead to a computerized adaptive test for monitoring the social impacts of burn injuries during recovery.

Developing Item Response Theory–Based Short Forms to Measure the Social Impact of Burn Injuries

OBJECTIVE

To develop self-reported short forms for the Life Impact Burn Recovery Evaluation (LIBRE) Profile.

DESIGN

Short forms based on the item parameters of discrimination and average difficulty.

SETTING

A support network for burn survivors, peer support networks, social media, and mailings.

PARTICIPANTS

Burn survivors (N=601) older than 18 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The LIBRE Profile.

RESULTS

Ten-item short forms were developed to cover the 6 LIBRE Profile scales: Relationships with Family & Friends, Social Interactions, Social Activities, Work & Employment, Romantic Relationships, and Sexual Relationships. Ceiling effects were ≤15% for all scales; floor effects were <1% for all scales. The marginal reliability of the short forms ranged from .85 to .89.

CONCLUSIONS

The LIBRE Profile-Short Forms demonstrated credible psychometric properties. The short form version provides a viable alternative to administering the LIBRE Profile when resources do not allow computer or Internet access. The full item bank, computerized adaptive test, and short forms are all scored along the same metric, and therefore scores are comparable regardless of the mode of administration.

Measuring the Social Impact of Burns on Survivors

Many burn survivors experience social challenges throughout their recovery. Measuring the social impact of a burn injury is important to identify opportunities for interventions. The aim of this study is to develop a pool of items addressing the social impact of burn injuries in adults to create a self-reported computerized adaptive test based on item response theory. The authors conducted a comprehensive literature review to identify preexisting items in other self-reported measures and used data from focus groups to create new items. The authors classified items using a guiding conceptual framework on social participation. The authors conducted cognitive interviews with burn survivors to assess clarity and interpretation of each item. The authors evaluated an initial pool of 276 items with burn survivors and reduced this to 192 items after cognitive evaluation by experts and burn survivors. The items represent seven domains from the guiding conceptual model: work, recreation and leisure, relating to strangers, romantic, sexual, family, and informal relationships. Additional item content that crossed domains included using self-comfort and others' comfort with clothing, telling one's story, and sense of purpose. This study was designed to develop a large item pool based on a strong conceptual framework using grounded theory analysis with focus groups of burn survivors and their caregivers. The 192 items represent 7 domains and reflect the unique experience of burn survivors within these important areas of social participation. This work will lead to developing the Life Impact Burn Recovery Evaluation profile, a self-reported outcome measure.

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.

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.

Quantifying Risk Factors for Long-Term Sleep Problems After Burn Injury in Young Adults

Restorative sleep is an important component of quality of life. Disturbances in sleep after burn injury were reported but all based on uncontrolled or nonstandardized data. The occurrence and the effect of long-term sleep problems in young adult burn survivors have not been well defined. This 5-year (2003-2008) prospective multicenter longitudinal study included adults with burn injuries ages 19 to 30 years who completed the Young Adult Burn Outcome Questionnaire (YABOQ) up to 36 months after injury. The items measured 15 patient-reported outcomes including physical, psychological, and social statuses and symptoms such as itch and pain. Scores of these 15 YABOQ outcome domains were standardized to a mean of 50 and a SD of 10 based on an age-matched nonburned reference group of young adults. Sleep quality was assessed using the item 'How satisfied are you now with your sleep,' rated by a 5-point Likert scale. Patients responding with very and somewhat dissatisfied were classified as having sleep dissatisfaction and the remaining as less or not dissatisfied. The associations between sleep dissatisfaction (yes/no) and YABOQ outcome domains were analyzed longitudinally using mixed-effect generalized linear models, adjusted for %TBSA burned, age, gender, and race. Generalized estimating equations were used to take into account correlated error resulting from repeated surveys on each patient over time. One hundred and fifty-two burn survivors participated in the YABOQ survey at baseline and during the follow-up who had at least one survey with a response to the sleep item. Among them, sleep dissatisfaction was twice as prevalent (76/152, 50%) when compared with the nonburned reference group (29/112, 26%). The likelihood of a burn survivor being dissatisfied with sleep was reduced over time after the burn injury. Sleep dissatisfaction following burns was significantly associated, in a dose-dependent manner, with increasing burn size (P = .001). Better sleep was associated with better outcomes in all domains (P < .05) except Fine Motor Function, and this association was significantly more apparent in the longer term compared with the shorter term with the same domains (P < .05). Dissatisfaction with sleep is highly prevalent following burn injuries in young adults. Lower satisfaction with sleep is associated with poorer scores in nearly all quality of life measures. Satisfaction with sleep should be addressed during the long-term clinical follow-up of young adults with burn injuries. Further research should be undertaken to understand the components of sleep quality that are important to burn survivors and which ones might be modified and tested in future intervention studies.

Is Real-Time Feedback of Burn-Specific Patient-Reported Outcome Measures in Clinical Settings Practical and Useful? A Pilot Study Implementing the Young Adult Burn Outcome Questionnaire

Long-term follow-up care of survivors after burn injuries can potentially be improved by the application of patient-reported outcome measures (PROMs). PROMs can inform clinical decision-making and foster communication between the patient and provider. There are no previous reports using real-time, burn-specific PROMs in clinical practice to track and benchmark burn recovery over time. This study examines the feasibility of a computerized, burn-specific PROM, the Young Adult Burn Outcome Questionnaire (YABOQ), with real-time benchmarking feedback in a burn outpatient practice. The YABOQ was redesigned for formatting and presentation purposes using images and transcribed to a computerized format. The redesigned questionnaire was administered to young adult burn survivors (ages 19-30 years, 1-24 months from injury) via an ipad platform in the office before outpatient visits. A report including recovery curves benchmarked to a nonburned relatively healthy age-matched population and to patients with similar injuries was produced for the domains of physical function and social function limited by appearance. A copy of the domain reports as well as a complete copy of the patient's responses to all domain questions was provided for use during the clinical visit. Patients and clinicians completed satisfaction surveys at the conclusion of the visit. Free-text responses, included in the satisfaction surveys, were treated as qualitative data adding contextual information about the assessment of feasibility. Eleven patients and their providers completed the study for 12 clinical visits. All patients found the ipad survey and report "easy" or "very easy" to use. In nine instances, patients "agreed" or "strongly agreed" that it helped them communicate their situation to their doctor/nurse practitioner. Patients "agreed" or "strongly agreed" that the report helped them understand their course of recovery in 10 visits. In 11 visits, the patients "agreed" or "strongly agreed" that they would recommend this feedback to others. Qualitative comments included: "it helped organize my thoughts of recovery," "it opened lines of communication with the doctor," "it showed me how far I have come, and how far I need to go," and "it raised questions I would not have thought of." Only four of 12 provider surveys agreed that it helped them understand a patient's condition; however, in two visits, the providers stated that it helped identify a pertinent clinical issue. During two visits, providers stated that a treatment plan was discussed or recommended based on the survey results. Separately, qualitative comments from the providers included "survey was not sensitive enough to identify that this patient needed surgery for their scars." This is the first report describing clinical use of a burn-specific patient reported outcome measure. Real-time feedback using the ipad YABOQ was well received for the most part by the clinicians and burn survivors in the outpatient clinic setting. The information provided by the reports can be tested in a future randomized controlled clinical study evaluating impacts on physician decisions.

Convergent and discriminant validity of quality of life measures used in burn populations

INTRODUCTION

The primary goal of this study was to investigate convergent validity, i.e. overlapping constructs, of the Burn Specific Health Scale-Brief (BSHS-B), the Short Form-36 items Health Survey (SF-36) and the European Quality Of Life Five Dimensions (EQ-5D) within the International Classification of Functioning Disability and Health (ICF) framework. A secondary goal was to examine the discriminant validity of the questionnaires according to burn severity (no surgery versus 1 or more surgeries).

METHODS

A prospective multi-centre study in adult patients with burns was conducted. At the 9 months assessment, two generic questionnaires, i.e. the SF-36 and EQ-5D, and the BSHS-B were completed. Pearson correlations were used to evaluate convergent validity. Linear discriminant analysis was used to evaluate discriminant validity.

RESULTS

At 9 months post-burn data from 184 persons were available of which 131 (71%) were male, mean TBSA burned was 11.8% (SD=10.2). Sixty five (34%) patients did not need surgery, 128 (66%) patients required one or more surgeries. Higher convergence was shown between the generic SF-36 and the condition specific BSHS-B whereas the EQ-5D showed lower convergence with the BSHS-B especially in the domain Activity. The generic scales discriminated across all scales whereas not all BSHS-B scales were able to differentiate problem levels across burn severity groups.

CONCLUSION

This study demonstrates that the ICF is useful to classify scales in order to identify overlapping areas as well as to uncover gaps in relation to patient reported outcomes. Both the SF-36 and EQ-5D showed the ability to distinguish levels of functioning across burn severity groups. As the BSHS-B performed less well and relevant domains of functioning were not addressed, there is room for improvement and modification of this condition specific questionnaire to better capture burn patients' functioning.

Recovery trajectories after burn injury in young adults: does burn size matter?

The impact of burn size on mortality is well known, but the association of burn size with the trajectories of long-term functional outcomes remains poorly studied. This prospective multi-center study included burned adults ages 19 to 30 years who completed the Young Adult Burn Outcome Questionnaire at initial baseline contact, 2 weeks, and at 6 and 12 months after initial questionnaire administration. Non-burned adults of comparable ages also completed the questionnaire as a reference group. The association between functional recovery and TBSA burned was analyzed longitudinally using generalized linear models with the generalized estimation equation technique. Functional status was characterized in 15 domains: physical function, fine motor function, pain, itch, social function limited by physical function, perceived appearance, social function limited by appearance, sexual function, emotion, family function, family concern, satisfaction with symptom relief, satisfaction with role, work reintegration, and religion. Scores were standardized to a mean of 50 and a SD of 10 based on non-burned controls. There were 153 burned and 112 non-burned subjects with a total of 620 questionnaires. TBSA burned was 11 ± 14% (mean ± SD); 31% had face involvement and 57% had hand involvement. The lag time from burn injury to questionnaire administration was on average 7 ± 7.7 months, with a maximum of 36 months. Lower recovery levels were associated with increasing burn size for physical function, pain, itch, work reintegration, emotion, satisfaction with symptom relief, satisfaction with role, family function, and family concern (P value ranged from .04-<.0001). No significant differences in recovery levels were found with increasing burn size for fine motor function, social function limited by physical function, sexual function, and religion; these areas tracked toward the age-matched non-burned group regardless of burn size. Perceived appearance and social function limited by appearance remained below the non-burn levels throughout the 3-year period regardless of burn size. Three-year recovery trajectories of survivors with larger burn size showed improvements in most areas, but these improvements lagged behind those with smaller burns. Poor perceived appearance was persistent and prevalent regardless of burn size and was found to limit social function in these young adult burn survivors. Expectations for multidimensional recovery from burns in young adults can be benchmarked based on burn size with important implications for patient monitoring and intervening in clinical care.

Measuring the impact of burn scarring on health-related quality of life: Development and preliminary content validation of the Brisbane Burn Scar Impact Profile (BBSIP) for children and adults

INTRODUCTION

No burn-scar specific, health-related quality of life (HRQOL) measure exists. This study aimed to develop a patient-reported, evaluative HRQOL measure to assess the impact of burn scarring in children and adults.

METHOD

Semi-structured interviews, content validation surveys, and cognitive interviews were used to develop and test content validity of a new measure - the Brisbane Burn Scar Impact Profile (BBSIP).

RESULTS

Participants comprised Australian adults (n=23) and children (n=19) with burn scarring; caregivers of children with burn scarring (n=28); and international scar management experts (n=14). Items distinct from other burn scar measures emerged. Four versions of the BBSIP were developed; one for children aged 8-18 years, one for adults, one for caregivers (as proxies for children aged less than 8-years), and one for caregivers of children aged 8-18 years. Preliminary content validity of the BBSIP was supported. Final items covered physical and sensory symptoms; emotional reactions; impact on social functioning and daily activities; impact of treatment; and environmental factors.

CONCLUSION

The BBSIP was developed to assess burn-scar specific HRQOL and will be available at http://www.coolburns.com.au under a creative commons license. Further testing is underway.

Burns in children: standard and new treatments

Outcomes of patients with burns have improved substantially over the past two decades. Findings from a 2012 study in The Lancet showed that a burn size of more than 60% total body surface area burned (an increase from 40% a decade ago) is associated with risks and mortality. Similar data have been obtained in adults and elderly people who have been severely burned. We discuss recent and future developments in burn care to improve outcomes of children.