Predictors of health status and health-related quality of life 12 months after severe burn

Negative pressure wound therapy in burns: a prospective, randomized-controlled trial

BACKGROUND

Negative-pressure-wound-therapy (NPWT) has become a widely used tool for the coverage and active treatment of complex wounds, including burns. This study aimed to evaluate the effectiveness of NPWT in acute burns of upper and lower extremities and to compare results to the standard-of-care (SOC) at our institution.

METHODS

Patients that were admitted to our institution between May 2019 and November 2021 with burns on extremities between 0.5 % and 10 % of the total body surface area (%TBSA) were included and randomized to either NPWT or SOC (polyhexanide gel, fatty gauze, and cotton wool). Treatment was performed until complete wound healing. Patients that required skin grafts, received additional NPWT after grafting independent on the initial group allocation.

RESULTS

Sixty-five patients suffering from burn injury between May 2019 and November 2021 were randomized into treatment with NPWT (n = 33) or SOC (n = 32); of these, 33 patients (NPWT) and 28 patients (SOC) had complete data sets and were included in the analysis. Both groups were similar regarding age (39.8 ± 13.7 vs. 44.8 ± 16.2 years,p = 0.192), total burn size (3.1 ± 2.3 vs. 3.4 ± 2.8 %TBSA,p = 0.721) and treated wound size (1.9 ± 1.2 vs. 1.5 ± 0.8 %TBSA,p = 0.138). We found no differences regarding healing time (11.0 ± 4.9 vs. 8.6 ± 3.8,p = 0.074, and significant differences in a number of dressing changes throughout the study (2.4 ± 1.5 vs 4.2 ± 1.9,p < 0.001). The Kaplan-Meier time-to-event analysis exhibited no statistically significant difference in the time to healing or skin grafting (p = 0.085) in NPWT group compared with SOC group. The median time to healing or skin grafting was 10(8-11) days for NPWT and 9(7-11) days for SOC. The hazard ratio for healing or skin graft was HR= 0.64(0.38-1.08). The results of the time-to-event analysis as well as the Kaplan-Meier curve on the PPS confirmed this result. We found no differences in secondary surgical operations 15.2 vs 21.4 % pain or functional outcomes.

CONCLUSIONS

In this study, we found no significant difference between the two groups in terms of time to detect wound healing. We also found no difference regarding further operations for wound closure, pain and/or scarring. However, dressing changes were significantly less frequent for patients that were treated with NPWT, which may be a psychological and logistical advantage.

Early predictors of health-related quality of life outcomes at 12 months post-burn: ABLE study

There remains a paucity of evidence on the early predictors of long-term Health-Related Quality of Life (HRQoL) outcomes post-burn in hospitalised adults. The overall aim of this study was to identify the factors (personal, environmental, burn injury and burn treatment factors) that may predict long-term HRQoL outcomes among adult survivors of hospitalised burn injuries at 12 months post-burn. A total of 274 participants, aged 18 years or over, admitted to a single state-wide burn centre with a burn injury were recruited. Injury and burn treatment information were collected from medical records or the hospital database and surveys collected demographic and social data. HRQoL outcome data were collected at 3-, 6- and 12-months using the 12-Item Short Form Survey (SF-12 v1) and Burns Specific Health Scale-Brief (BSHS-B). Personal, environmental, burn injury and burn treatment factors were also recorded at baseline. Analyses were performed using linear and logistic regression. Among 274 participants, 71.5 % (N=196) remained enrolled in the study at 12 months post-burn. The majority of participants reported HRQoL outcomes comparable with population norms and statistically significant improvements in generic (SF-12 v1) and condition-specific (BSHS-B) outcomes over time. However, for participants with poor HRQoL outcomes at 12-months post-burn, Univariable predictors included longer hospital length of stay, unemployment at the time of injury, a diagnosed pre-injury mental health condition, inadequate pre-burn social support, intentional injury, recreational drug use pre-injury and female gender. The early multivariable predictors of insufficient HRQoL outcomes were female gender, a previously diagnosed mental health condition, unemployment, inadequate social support, intentional injury, and prolonged hospital length of stay. These results suggest potential factors that could be used to screen and burns patients for psychosocial intervention and long-term follow up.

Risks of mental disorders among inpatients with burn injury: A nationwide cohort study

OBJECTIVE

This investigation identified the association between burn injuries and the risk of mental disorders in patients with no documented pre-existing psychiatric comorbidities. We also examined the relationship of injury severity and the types of injury with the likelihood of receiving new diagnoses of mental disorders.

METHODS

This population-based retrospective cohort study used administrative data extracted from the Taiwanese National Health Insurance Research Database (NHIRD) between 2000 and 2013. In total, 10,045 burn survivors were matched with a reference cohort of 40,180 patients without burn injuries and were followed to determine if any mental disorder was diagnosed. Patients diagnosed with mental disorders in the five years before study initiation were excluded to ensure incident diagnoses throughout the research duration. Generalized estimating equations in Cox proportional hazard regression models were used for data analysis.

RESULTS

In general, burn injury survivors have a 1.21-fold risk of being diagnosed with new mental disorders relative to patients without burn injuries. Total body surface area (TBSA) of ≧ 30% (aHR: 1.49, 95% CI: 1.36-1.63) and third- or fourth-degree burns (aHR: 1.49, 95% CI: 1.37-1.63) had a significantly greater risk of being diagnosed with mental disorders in comparison to the reference cohort. Patients TBSA 10-29% (aHR: 0.85, 95% CI: 0.77-0.93) and first- or second-degree burn victims (aHR: 0.89, 95% CI: 0.81-0.97) had relatively lower risk of mental disorders than the reference cohort.

CONCLUSION

Burn injuries were associated with an increased risk of mental disorders. Additional research in this field could elucidate this observation, especially if the inherent limitations of the NHIRD can be overcome.

Current Approaches to Wound Repair in Burns: How far Have we Come From Cover to Close? A Narrative Review

Burn injuries are a significant global health concern, with more than 11 million people requiring medical intervention each year and approximately 180,000 deaths annually. Despite progress in health and social care, burn injuries continue to result in socioeconomic burdens for victims and their families. The management of severe burn injuries involves preventing and treating burn shock and promoting skin repair through a two-step procedure of covering and closing the wound. Currently, split-thickness/full-thickness skin autografts are the gold standard for permanent skin substitution. However, deep burns treated with split-thickness skin autografts may contract, leading to functional and appearance issues. Conversely, defects treated with full-thickness skin autografts often result in more satisfactory function and appearance. The development of tissue-engineered dermal templates has further expanded the scope of wound repair, providing scar reductive and regenerative properties that have extended their use to reconstructive surgical interventions. Although their interactions with the wound microenvironment are not fully understood, these templates have shown potential in local infection control. This narrative review discusses the current state of wound repair in burn injuries, focusing on the progress made from wound cover to wound closure and local infection control. Advancements in technology and therapies hold promise for improving the outcomes for burn injury patients. Understanding the underlying mechanisms of wound repair and tissue regeneration may provide new insights for developing more effective treatments in the future.

Response of bone mineral density and balance performance in post-burn patients with selected Qigong training: A single-blind randomized controlled trial

BACKGROUND

Decreased bone mineral density (BMD) is a common condition after a burn with significant complications that would be a global health problem. Also, balance can further worsen due to burning complications. Therefore, this study aims to analyze the additive effects of selected Qigong training exercises for 2 months to the standard physiotherapy regimen on bone mineral density and balance control post-thermal burn injuries.

METHODS

110 participants (75 males and 35 females), aged 25-50, with deep second and third-degree thermal burns affecting the trunk and lower extremities, and a total body surface area (TBSA) of 30-45%, allocated randomly into two equal groups of 55. Group A has Qigong training along with its standard physiotherapy regimen, and the control group (Group B) has only a standard physiotherapy regimen. For eight weeks, the interventions were used four times a week. The bone mineral density (BMD), T-score of the lumbar spine, the overall stability index (OSI), and the dynamic limits of stability (DLOS) were assessed pre-intervention and after eight weeks of intervention.

RESULTS

A two-way mixed MANOVA showed that there was a significant increase in BMD, T-score, and DLOS and a significant decrease in OSI in a favor of the Qigong training group after eight weeks of treatment compared with that of the control group. Both groups showed a significant improvement in BMD, T- score, DLOS, and OSI post-treatment compared with that at the baseline. There were statistical significances in the favor of the Qigong training group after eight weeks of treatment (P < 0.001).

CONCLUSION

In patients with repaired second and third-degree thermal burns of the trunk and lower legs, Qigong training activities combined with a standard physiotherapy regimen for 2 months were more helpful in increasing bone mineral density and improving balance control than the standard physiotherapy regimen alone.

Investigation of the monocyte/high-density lipoprotein ratio as a prognostic criterion in burn patients

In this study, it was aimed to investigate the monocyte/high-density lipoprotein ratio as a prognostic criterion in adult burn patients. A descriptive and cross-sectional method was adopted in this study. The sample included 177 patients with burn injuries. This study was conducted in a research and training hospital in Turkey. Data were collected by the researchers in the burn unit. Descriptive methods, Kruskal-Wallis, Mann-Whitney U, ROC curve, and correlation analyses were used for the statistical analyses of the data. While 66.1% of the patients were second-degree burn patients, 96.6% of all patients recovered and were discharged from the hospital, and the rest died. In this study, the monocyte/high-density lipoprotein ratios of the patients decreased as their clinical condition worsened. The mean C-reactive protein value of the patients was 8.52 ± 5.02 on the 7th day. A statistically significant correlation was found between an increase in monocyte counts and a decrease in high-density lipoprotein concentrations at the 24th hour, 3rd day and 7th day after the burn (p < 0.01). The monocyte/high-density lipoprotein ratio can be considered a biomarker in the identification and follow-up of sepsis and morbidity durations in burn patients. A low monocyte/high-density lipoprotein ratio in burn patients can provide an insight into the severity of sepsis.

Post Intensive Care Syndrome (PICS) physical, cognitive, and mental health outcomes 6-months to 7 years after a major burn injury: A cross-sectional study

OBJECTIVES

The Post Intensive Care Syndrome (PICS) has been described in intensive care (ICU) survivors, being present in 50% of patients surviving 12 months, with well-defined risk factors. Severely burned patients combine many of these risk factors, but the prevalence of PICS has not yet been documented in burns. The study aimed to answer this question and identify associations of PICS with clinical characteristics.

METHODS

Cross-sectional descriptive study of major burn survivors admitted to the burn ICU between 2013 and 2019. Main inclusion criteria: major burns>20 %BSA and ICU admission. The PICS components were assessed using three questionnaires: 1) Physical with Burn Specific Health Scale-Brief (BSHS-B); 2) Cognitive health with MacNair Cognitive Difficulties Self-Rating Scale (CDS); 3) Mental health with the Hospital Anxiety and Depression Scale (HADS) questionnaire. PICS was considered present if at least one component out of three was abnormal. Data as mean±SD.

RESULTS

Among the 288 patients admitted during the period, 132 met the inclusion criteria: 53 patients were finally enrolled. They were aged 44 ± 18 years at the time of injury and burned 24 ± 20 BSA % and stayed 25 ± 44 days in the ICU. PICS was identified in 35 patients (66 %): more than one component was altered in 21 patients (60 %). Principal risk factors were more than 3 general anesthetics, prolonged mechanical ventilation (>4 days), ICU stay (>8 days), and hospital stay (>25 days) CONCLUSION: PICS occurred in 66 % of major burns with two or three components affected simultaneously in 60 %, i.e. more frequently than in general ICU patients.

The Impact of Burn Size on Community Participation: A Life Impact Burn Recovery Evaluation (LIBRE) Study

OBJECTIVE

To assess the association of burn size and community participation as measured by the LIBRE Profile.

SUMMARY OF BACKGROUND DATA

Burn size is an established clinical predictor of survival after burn injury. It is often a factor in guiding decisions surrounding early medical interventions; however, literature is inconclusive on its relationship to quality of life outcomes.

METHODS

This is a secondary data analysis of a cross-sectional survey of adult burn survivors. Self-reported data were collected between October 2014 and December 2015 from 601 burn survivors aged ≥18 years with ≥5% total body surface area (TBSA) or burns to critical areas. Sociodemographic characteristics were compared between participants with small burns (≤40% TBSA burned) and large burns (>40% TBSA burned). Ordinary least squares regression models examined associations between burn size and LIBRE Profile scale scores with adjustments for sex, current work status, burns to critical areas, and time since burn injury.

RESULTS

The analytic sample comprised 562 participants with data available for burn size. 42% of respondents had large burns (>40% TBSA burned) and 58% reported smaller burns (TBSA ≤40%). In adjusted regression models, patients with large burns tended to score lower on the Social Activities and Work & Employment scales ( P < 0.05) and higher on the Family & Friends scale ( P < 0.05). Participants with burns >40% TBSA scored lower for several individual items in the Social Activities scale and one item in the Work & Employment scale ( P < 0.05).

CONCLUSIONS

Increasing burn size was found to be negatively associated with selected items of Work & Employment and Social Activities, but positively associated with aspects of Family & Friend Relationships. Future longitudinal studies are necessary to assess and understand the long-term social impact of burn injuries on adult populations.

Combination of sodium butyrate and probiotics ameliorates severe burn-induced intestinal injury by inhibiting oxidative stress and inflammatory response

Burns are a common traumatic injuries with considerable morbidity and mortality rates. Post-burn intestinal injuries are closely related to oxidative stress and inflammatory response. The aim of the current study was to investigate the combined effect of sodium butyrate (NaB) and probiotics (PROB) on severe burn-induced oxidative stress and inflammatory response and the underlying mechanism of action. Sprague-Dawley rats with severe burns were treated with NaB with or without PROB. Pathomorphology of skin and small intestine tissue was observed using hematoxylin and eosin staining and severe burn-induced apoptosis in small intestine tissue was examined via terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling assay. The release of factors related to inflammation was quantified using ELISA kits and qRT-PCR and levels of oxidative stress markers were evaluated using biochemical assays. Furthermore, mitochondrial morphological changes in small intestinal epithelial cells were observed using transmission electron microscopy. In addition, the underlying mechanism associated with the combined effect of NaB and PROB on severe burn-induced oxidative stress and inflammatory response was investigated using western blotting. The combination of NaB and PROB exerted protective effects against severe burn-induced intestinal barrier injury by reducing the levels of diamine oxidase and intestinal fatty acid binding protein. Combined NaB and PROB treatment inhibited severe burn-induced oxidative stress by increasing superoxide dismutase levels and decreasing those of malondialdehyde and myeloperoxidase levels. Severe burn-induced inflammation was suppressed by combined NaB and PROB administration, as demonstrated by the decreased mRNA expression of tumor necrosis factor-α, interleukin-6, interleukin-1β, and high mobility group box-1 in the small intestine. In addition, this study showed that combined NaB and PROB administration increased nuclear factor-erythroid 2-related factor 2 (Nrf2) protein expression and decreased the phosphorylation of nuclear factor (NF)-κB and extracellular signal-regulated kinase 1/2 (ERK 1/2). In conclusion, our findings indicate that combined NaB and PROB treatment may inhibit severe burn-induced inflammation and oxidative stress in the small intestine by regulating HMGB1/NF-κB and ERK1/2/Nrf2 signaling, thereby providing a new therapeutic strategy for intestinal injury induced by severe burn.

Global burden of thermal burns, 1990-2017: Unbalanced distributions and temporal trends assessed from the Global Burden of Disease Study 2017

BACKGROUND

Many studies demonstrate that being burned has both physical and psychological sequelae that affect quality of life. Further, these effects may be more prevalent in some regions and populations. We sought to access the unbalanced distributions and temporal trends concerning the health burden of thermal burns.

METHODS

Data were collected from the Global Burden of Disease Study 2017, and the disability-adjusted life year (DALY)¹ was used as a measure of health burden. Linear regression was used to evaluate the relationship between the age-standardized DALY rate and socio-demographic index.² Joinpoint regression analysis and comparison line charts were all applied to assess the temporal trends of burns.

RESULTS

The age-standardized DALY rate of global thermal burns decreased by 43.7%, from 197 (95% CI: 152-228) per 100,000 in 1990 to 111 (95% CI: 93-129) per 100,000 in 2017. The burden was borne mainly by children 1-4 years of age and people over 80 years. Socio-demographic index was negatively correlated with the age-standardized DALY rate. In low-middle and low socio-demographic index regions, the decreasing trends were slower than other regions with an average annual percentage change of -2.1% (95% CI: -2.2 to -2.0) and -2.1% (95% CI: -2.1 to -2.0), respectively. Among six geographical regions, Africa presented the highest age-standardized DALY rates of 352 (95% CI: 275-410) per 100,000 in 1990 and 208 (95% CI: 175-236) per 100,000 in 2017, and also the slowest average decreasing trend, with an average annual percentage change of -1.9% (95% CI: -2 to -1.8).

CONCLUSIONS

The global burden of thermal burns shows a downward trend from 1990 to 2017, and regions with lower socio-demographic index and Africa show greater burdens and smaller downward trends.

Life after Burn, Part I: Health-Related Quality of Life, Employment and Life Satisfaction

Background and Objectives: As advances in medicine are proceeding, so are treatment goals shifting from sheer mortality rates to improving HRQoL and social reintegration after burn injury. Following this trend, we aimed to assess HRQoL, employment and life satisfaction after burn injury to gain insight on confounding factors. Materials and Methods: This single-center follow-up study was conducted using the SF-36 V1.0 in German and further questions evaluating employment and life satisfaction. It reached 128 adult in-patients (recall 33.0%) with former burn injuries, treated between 2012 and 2019 at the Division of Plastic, Aesthetic and Reconstructive Surgery at the University Hospital of Graz. The questionnaire outcomes were set into relation with clinical data obtained from the medical records. Statistical analysis was performed with SPSS 27.0 for Windows. Results: Of the 128 participants, 72.7% were male and 27.3% female. The mean age at the time of injury was 40.0 ± 15.7 years and mean %TBSA among the study population was 9.2 ± 11.0%. The male patients had sustained more extensive injuries (p = 0.005). However, the female patients scored significantly (p < 0.05) and consistently lower in all the domains of the SF-36, except for “bodily pain” (p = 0.061). Moreover, the female patients scored lower in all the domains of life satisfaction, although significant differences were only found in the domains of fulfillment (p = 0.050) and mental wellbeing (p = 0.015). Furthermore, employment status differed significantly between the male and female patients before as well as after the burn injury. Proportionally less women were employed at both time points. Overall, unemployment had declined. Conclusions: Life satisfaction after burn injury in this study cohort seems to be good. Return to work has shown a promising trend. Strikingly, HRQoL and life satisfaction were lower in women after burn injury. Further research on the reasons for this gender discrepancy might improve HRQoL and life satisfaction after burns.

Life after Burn, Part II: Substance Abuse, Relationship and Living Situation of Burn Survivors

Background and Objectives: After burns, social reintegration is a primary long-term objective. At the same time, substance-abuse disorders are more common in burn patients. The aim of this study was to assess prevalence of substance abuse pre- and postburn as well as living situation and relationship status relative to patient-reported health-related quality of life (HRQoL). Patients and Methods: Burn survivors treated as inpatients between 1 January 2012 and 31 December 2019 were retrospectively identified. Collected clinical data included: age, gender, time since injury, burn extent (%TBSA), and substance abuse. Patient-reported living situation, relationship status, smoking habits, alcohol and drug consumption pre- and postburn as well as the SF-36 study were ascertained via telephone survey. Inductive statistical analysis comprised uni- and multivariate testing. A p < 0.05 was considered as statistically significant. Results: A total of 128 patients, 93 (72.7%) men, with a mean age of 40.0 ± 15.7 years were included. Mean TBSA was 9.2 ± 11.0% and significantly lower in women (p = 0.005). General health SF-36 scores were significantly lower in women (67.6 ± 29.8) than men (86.0 ± 20.8, p = 0.002). Smoking decreased from 38.8% pre- to 31.1% postburn. A significant reduction in alcohol consumption was noted over time (p = 0.019). The rate of never-drinkers was 18.0% pre- and 27.3% postburn. Drug abuse was rare both pre- (7.8%) and postburn (5.3%). Living situation remained stable. None of the participants depended on assisted living or lived in a care facility postburn. In total, 75.8% and 67.2% were in a relationship pre- and postburn. Patients with higher alcohol consumption postburn were significantly more often male (p = 0.013) and had higher SF-36 general health scores (p < 0.001). Conclusions: HRQoL is better in men than in women after burn injury. A slight decrease in substance abuse postburn was noted. The connection between HRQoL and substance abuse after burn injuries needs to be investigated further in the future.

The Impact of Burn Survivor Preinjury Income and Payer Status on Health-Related Quality of Life

The costs required to provide acute care for patients with serious burn injuries are significant. In the United States, these costs are often shared by patients. However, the impacts of preinjury finances on health-related quality of life (HRQL) have been poorly characterized. We hypothesized that lower income and public payers would be associated with poorer HRQL. Burn survivors with complete data for preinjury personal income and payer status were extracted from the longitudinal Burn Model System National Database. HRQL outcomes were measured with VR-12 scores at 6, 12, and 24 months postinjury. VR-12 scores were evaluated using generalized linear models, adjusting for potential confounders (eg, age, sex, self-identified race, burn injury severity). About 453 participants had complete data for income and payer status. More than one third of BMS participants earned less than $25,000/year (36%), 24% earned $25,000 to 49,000/year, 23% earned $50,000 to 99,000/year, 11% earned $100,000 to 149,000/year, 3% earned $150,000 to 199,000/year, and 4% earned more than $200,000/year. VR-12 mental component summary (MCS) and physical component summary (PCS) scores were highest for those who earned $150,000 to 199,000/year (55.8 and 55.8) and lowest for those who earned less than $25,000/year (49.0 and 46.4). After adjusting for demographics, payer, and burn severity, 12-month MCS and PCS and 24-month PCS scores were negatively associated with Medicare payer (P < .05). Low income was not significantly associated with lower VR-12 scores. There was a peaking relationship between HRQL and middle-class income, but this trend was not significant after adjusting for covariates. Public payers, particularly Medicare, were independently associated with poorer HRQL. The findings might be used to identify those at risk of financial toxicity for targeting assistance during rehabilitation.

Evaluation of the psychometric properties of the burn specific health scale-brief: A National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study

OBJECTIVE

The Burn Specific Health Scale-Brief (BSHS-B) is a commonly used burn specific health outcome measure that includes 40 items across nine subscales. The objective of this study was to use both classical and modern psychometric methods to evaluate psychometric properties of the BSHS-B.

METHODS

Data were collected post burn injury by a multisite federally funded project tracking long term outcomes. We examined dimensionality, local dependence, item fit, and functioning of response categories, homogeneity, and floor and ceiling effects. Items were fit to Item Response Theory models for evaluation.

RESULTS

A total of 653 adults with burn injury completed the BSHS-B. Factor analyses supported unidimensionality for all subscales, but not for a total score based on all 40 items. All nine of the subscales had significant ceiling effects. Six item pairs displayed local dependence suggesting redundance and 11 items did not fit the Item Response Theory models. At least 15 items have too many response options.

CONCLUSIONS

Results identified numerous psychometric issues with the BSHS-B. A single summary score should never be used for any purpose. Psychometric properties of the scale need to be improved by removing redundant items, reducing response categories and modifying or deleting problematic items. Additional conceptual work is needed to, at a minimum, revise the work subscale and optimally to revisit and clearly define the constructs measured by all the subscales. Additional items are needed to address ceiling effects.

A Cross-sectional Survey of Health Professionals Across Australia and New Zealand to Determine What Outcome Measures Are Important From a Clinical Perspective Post Hand Burn Injury

Outcome measures are used in healthcare to evaluate clinical practice, measure efficiencies and to determine the quality of health care provided. The Burns Trauma Rehabilitation: Allied Health Practice Guidelines advocates for the collection of outcome measures post burn injuries across different time points. These guidelines recommend multiple tools which can be utilized when measuring outcomes post burn injuries. The aim of this study was to gather information from specialist clinicians regarding their clinical practice and the outcome measurement tools used post hand burn injuries. This cross-sectional study used a survey design to collect data at one given point in time across a sample population. A total of 43 clinical specialists allied health professionals responded to the survey. Respondents indicated that their patients considered hand dexterity was the most important outcome. Three months post burn injury was the most common timepoint for measurement (n = 31, 72.1%) followed by six months (n = 27, 62.8%). Patient report of hand function (n = 42, 97.7%) and observation (n = 41, 95.3%) were the most frequently reported assessment methods. The Jamar Dynamometer (n = 40, 93%), goniometer (n = 39, 90.7%) and pinch gauge (n = 36, 83.7) were the most frequency cited assessment tools. The findings of this study suggest that clinical specialist allied health collect some outcome measures in their routine practice. Based on the respondent's perceptions of barriers when using outcome measures and lack of reliable/validated tools to measure hand burn outcomes, there is a need for further studies in this area.

Efficacy of whole-body vibration on balance control, postural stability, and mobility after thermal burn injuries: A prospective randomized controlled trial

OBJECTIVE

To investigate the additive effects of whole-body vibration (WBV) training to the traditional physical therapy program (TPTP) on balance control, postural stability, and mobility after thermal burn injuries.

DESIGN

A single-blinded, randomized controlled study.

SETTING

Outpatient physical therapy setting.

PARTICIPANTS

Forty participants, 20-45 years old, with deep second-degree thermal burn involving the lower limbs and trunk, with 35%-40% total body service area, were randomly allocated either into the study group or the control group.

INTERVENTION

The study group received WBV plus TPTP while the control group received the TPTP only. Interventions were applied three sessions a week for eight weeks.

OUTCOME MEASURES

Anteroposterior stability index (APSI), mediolateral stability index (MLSI), overall stability index (OSI), timed-up and go (TUG), and Berg balance scale (BBS) were measured at baseline and after eight weeks of interventions.

RESULTS

There were statistically significant differences in APSI, MLSI, OSI, BBS, and TUG in favor of the WBV group after eight weeks of intervention (P < 0.001). After eight weeks of intervention, the mean (SD) for APSI, MLSI, OSI, BBS, and TUG scores were 1.87 ± 0.51, 41.36 ± 0.18, 1.95 ± 0.56, 47.2 ± 6.12, and 8.15 ± 1.05 seconds in the WBV group, and 2.41 ± 0.71, 2.21 ± 0.54, 2.68 ± 0.73, 40.65 ± 4.7, and 10.95 ± 2.44 seconds in the control group, respectively.

CONCLUSIONS

The whole-body vibration training combined with the TPTP was more beneficial in improving APS, MLS, OSI, TUG, and BBS than TPTP alone. It might be considered a useful adjunctive therapy in treating patients with healed wounds with a deep second-degree burn of the trunk and lower limbs.

The Economics of Burn Injuries Among Children Aged 0 to 4 Years in British Columbia

Children under the age of 5 years have the highest rate of hospitalization and mortality from burns. Studies of costs associated with pediatric burns have included a limited number of patients and focused on inpatient and complication costs, limiting our understanding of the full economic burden of pediatric burns. This study aimed to develop a costing model for burn injuries among children to estimate the economic burden of child burns in British Columbia, Canada. Costs of services and resources used by children aged 0 to 4 years old who were treated at BC Children's Hospital (BCCH) between January 1, 2014 and March 15, 2018 for a burn injury were estimated and summed, using a micro-costing approach. The average cost of burn injuries per percentage of total body surface area (%TBSA) was then applied to the number of 0 to 4 years old children treated for a burn injury across British Columbia between January 1 and December 31, 2016. Based on 342 included children, a 1-5%, 6-10%, 11-20%, and >20% burn, respectively cost an average of $3338.80, $13,460.00, $20,228.80, and $109,881.00 to society. The societal cost of child burns in BC in 2016 totaled $2,711,255.01. In conclusion, pediatric burn injuries place an important, yet preventable economic burden on society. Preventing even a small number of severe pediatric burns or multiple small burns may have considerable economic impacts on society and allow for the reallocation of healthcare funds toward other clinical priorities.

Occupational reintegration after severe burn injury: a questionnaire study

BACKGROUND

As a consequence of improved survival rates after burn injury occupational reintegration of burn survivors has gained increasing significance. We aimed to develop a precise patient questionnaire as a tool to evaluate factors contributing to occupational reintegration.

MATERIAL AND METHODS

A questionnaire comprising 20 questions specifically evaluating occupational reintegration was developed under psychological supervision. The single-center questionnaire study was implemented in patients with burn injuries who were admitted to the 6‑bed burn intensive care unit (BICU) of the General Hospital of Vienna, Austria (2004-2013). The questionnaire was sent to burn survivors of working age (18-60 years) with an abbreviated burn severity index (ABSI) of 6 or greater, a total burn surface area (TBSA) of 15% or greater, and a BICU stay of at least 24 h.

RESULTS

A total of 112 burn survivors met the inclusion criteria and were contacted by mail. Of the 112 patients 11 (10%) decided to participate in the study and 218/220 questions (99%) in 11 patients were answered. Out of 11 patients 7 (64%) reported successful return to work and 4 of 11 (36%) did not resume their occupation. Advanced age, longer BICU and hospital stays, higher TBSA, burn at work, lower education, and problems with esthetic appearance seemed to impair patients' return to their occupation.

CONCLUSION

When implementing the questionnaire, severely burned patients with higher age, lower education, and longer hospital and BICU stay seemed at high risk for failed reintegration in their profession after burn injury.

Health-Related Quality of Life and Its Associated Factors Among Burn Patients at Governmental Referral Hospitals of Amhara Regional State, Northwest Ethiopia, 2020: Institutional-Based Cross-Sectional Study

INTRODUCTION

Burns can have a considerable negative impact on physical and psychosocial functioning that affects the quality of life. The physical and psychological manifestations may compromise the quality of life of burned patients. The aim is to assess health-related quality of life and associated factors among burn patients at Amhara regional state governmental referral hospitals, Northwest Ethiopia, 2020.

METHODS

Institution-based cross-sectional study was conducted from June 01 to July 15, 2020, in Amhara National regional state governmental referral hospitals. Systematic random sampling technique was used, and data were collected using structured Burn Specific Health Scale Brief Questionnaire through face-to-face interview and document review from patients time since burn 15 days and above. Data were entered into Epidata, and analysis was done by SPSS version 25. Descriptive statistics were computed, and binary logistic regression analysis was used to determine the association between the dependent and independent variables. Variables with a p-value of ≤0.05 in the multivariable analysis were considered statistically significant.

RESULTS

Of 423 study participants, 95.7% responded completely. Among the respondents, 58.8% (group mean and median of 18.38 and 21) for physical domain and 57% (group mean and median of 44.73 and 53) for generic domains had a poor health-related quality of life. Overall poor health-related quality of life was 57.5% with a mean of 63.12. Third-degree burn, exposed burnt body part, total body surface area burned ≥20%, having an amputation and having a co-morbid illness with (P = 0.001) were associated with poor health-related quality of life.

CONCLUSION AND RECOMMENDATION

This study revealed that more than half of the burn survivors had poor health-related quality of life. There shall be strengthened long-term physical and psychosocial domains (generic) intervention for burn survivors by giving more concern for those with the identified risk factors.

Common mistakes in the choice of topical agents for emergency care of burns: Experimental study

The aim of the research was a histological study of the tissue structure of experimental animals with burns in dynamics using various topical agents after the injury. Experimental simulation of burn injuries was performed on 40 rats, which were divided into the main and control groups. Depending on the nature of care provided, the animals of the main group were divided into subgroups: in the 1st subgroup a uniform layer of sunflower oil was applied, in the 2nd subgroup dexpanthenol was sprayed, in the 3rd subgroup prompt neutralization of traumatic action was performed with a gauze napkin soaked in water. Animals from the control group were not treated. The examination involved a histological study. The results confirmed the negative impact of applying oil to the burnt area as a means of first aid, which caused more pronounced degenerative changes of the dermis and its structures with the involvement of hypodermis in the pathological process, prolonging the duration of healing. As for the use of dexpanthenol spray for burn injuries, the histological changes of tissues did not differ much from those in animals of the control group, which did not receive any care. At the same time, histological findings of the tissues of animals treated with moistened wipes was characterized by less pronounced pathological changes. Histological analysis of tissue changes of the burnt area in dynamics objectively proved the effectiveness of water as the main pathogenetic element of emergency care in an experiment.

The efficacy of resistance training in addition to usual care for adults with acute burn injury: A randomised controlled trial

Resistance training immediately after a burn injury has not been investigated previously. This randomised, controlled trial assessed the impact of resistance training on quality of life plus a number of physical, functional and safety outcomes in adults with a burn injury. Patients were randomly assigned to receive, in addition to standard physiotherapy, four weeks of high intensity resistance training (RTG) or sham resistance training (CG) three days per week, commenced within 72h of the burn injury. Outcome data was collected at six weeks, three and six months after burn injury. Quality of life at 6 months was the primary endpoint. Data analysis was an available cases analysis with no data imputed. Regression analyses were used for all longitudinal outcome data and between-group comparisons were used for descriptive analyses. Forty-eight patients were randomised resistance training (RTG) (n=23) or control group (CG) (n=25). The RTG demonstrated improved outcomes for the functional domain of the Burn Specific Health Scale-Brief (p=0.017) and the Quick Disability of Arm Shoulder and Hand (p<0.001). Between group differences were seen for C-reactive protein and retinol binding protein (p=0.001). Total quality of life scores, lower limb disability, muscle strength and volume were not seen to be different between groups (p>0.05). Resistance training in addition to usual rehabilitation therapy showed evidence of improving functional outcomes, particularly in upper limb burn injuries. Additionally, resistance training commenced acutely after a burn injury was not seen to be harmful to patients.

Individual recovery of health-related quality of life during 18 months post-burn using a retrospective pre-burn measurement: an exploratory study

Purpose

This study explored the individual trajectories of health-related quality of life (HRQL) compared to recalled pre-burn level of HRQL and investigated whether burn severity and post-traumatic stress disorder (PTSD) symptoms increase the risk of not returning to pre-burn level of HRQL.

Methods

Data were obtained from 309 adult patients with burns in a multicenter study. Patients completed the EQ-5D-3L questionnaire with a Cognition bolt-on shortly after hospital admission, which included a recalled pre-injury measure, and, again, at 3, 6, 12 and 18 months post-burn. Burn severity was indicated by the number of surgeries, and PTSD symptoms were assessed with the IES-R at three months post-burn. Pre- and post-injury HRQL were compared to norm populations.

Results

Recalled pre-injury HRQL was higher than population norms and HRQL at 18 months post-burn was comparable to population norms. Compared to the pre-injury level of functioning, four HRQL patterns of change over time were established: Stable, Recovery, Deterioration, and Growth. In each HRQL domain, a subset of patients did not return to their recalled pre-injury levels, especially with regard to Pain, Anxiety/Depression, and Cognition. Patients with more severe burns or PTSD symptoms were less likely to return to pre-injury level of functioning within 18 months post-burn.

Conclusion

This study identified four patterns of individual change. Patients with more severe injuries and PTSD symptoms were more at risk of not returning to their recalled pre-injury HRQL. This study supports the face validity of using a recalled pre-burn HRQL score as a reference point to monitor HRQL after burns.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02678-0) contains supplementary material, which is available to authorized users.

Quantifying Burn Injury-Related Disability and Quality of Life in the Developing World: A Primer for Patient-Centered Resource Allocation

BACKGROUND

Untreated or undertreated burns are commonly encountered by plastic surgeons on medical trips in India and represent a major cause of disability. We sought to utilize validated patient-reported outcomes instruments to identify the patient population with the greatest burn-related disability in order to appropriately allocate plastic surgery resources to those in greatest need.

METHODS

The Quick Disability of the Arm, Shoulder, and Hand, RAND 36-Item Short Form Health Survey, and Burn-Specific Health Scale-Revised, Brief, and Adapted questionnaires were administered via an interpreter during a plastic surgery trip to Jharkhand, India, in January 2018. Demographics, comorbidities, and burn-specific history were recorded.

RESULTS

Twenty-eight postburn patients were surveyed (mean age, 17.0 ± 9.2 years; male:female ratio, 1:2.5). Mean time from injury was 4.74 years. No patient had received formal, primary burn care. Mechanism of injury: flame (39%), oil (32%), scalding water (14%), and other (14%). Fifty-four percent were extremity burns; 25%, facial; and 18%, neck burns. The Burn-Specific Health Scale-Revised, Brief, and Adapted demonstrated that the most significantly impacted domains for all patients were body image and skin sensitivity, with more than 80% of patients complaining of issues with skin sensitivity. In addition, children (aged <18 years) had diminished body image domain scores. RAND SF-36 scores were lowest in the energy (73.1 ± 25.0) and general health (76.5 ± 13.8) domains, and females with extremity burns demonstrated statistically significant decreases in their physical limitation domain scores (85.9 ± 17.3, P < 0.05). Females with extremity burns also had statistically significant lower scores in the energy domain (64.09 ± 25.75) as compared with their male counterparts with extremity burns (100 ± 0, P = 0.045). In general, females scored lower than did males in multiple domains, and those results reached statistical significance in the energy (65.9 ± 24.6 vs 93.6 ± 10.9), emotional (77.2 ± 21.5 vs 95.4 ± 11.2), and general health domains (71.1 ± 11.9 vs 90.0 ± 7.5) with P < 0.05. Children demonstrated significantly diminished scores in the emotional (75.5 ± 24.6) and general health (79.1 ± 11.8) domains.

CONCLUSION

These data demonstrate the significant impact on quality of life that untreated burns have in this population. Male and female children with extremity burns and adult women with extremity burns were most significantly affected in multiple domains. Consequently, children and adult women with extremity burns appear to be the patient cohort with the greatest opportunity to impact their quality of life. These data may be utilized to improve patient triage and resource allocation for future surgical trips but could also be of significant benefit to internal health agencies and ministries for the same purpose.

Sex-Based Differences in Inpatient Burn Mortality

BACKGROUND

Among burn patients, research is conflicted, but may suggest that females are at increased risk of mortality, despite the opposite being true in non-burn trauma. Our objective was to determine whether sex-based differences in burn mortality exist, and assess whether patient demographics, comorbid conditions, and injury characteristics explain said differences.

METHODS

Adult patients admitted with burn injury-including inhalation injury only-between 2004 and 2013 were included. Inverse probability of treatment weights (IPTW) and inverse probability of censor weights (IPCW) were calculated using admit year, patient demographics, comorbid conditions, and injury characteristics to adjust for potential confounding and informative censoring. Standardized Kaplan-Meier survival curves, weighted by both IPTW and IPCW, were used to estimate the 30-day and 60-day risk of inpatient mortality across sex.

RESULTS

Females were older (median age 44 vs. 41 years old, p < 0.0001) and more likely to be Black (32% vs. 25%, p < 0.0001), have diabetes (14% vs. 10%, p < 0.0001), pulmonary disease (14% vs. 7%, p < 0.0001), heart failure (4% vs. 2%, p = 0.001), scald burns (45% vs. 26%, p < 0.0001), and inhalational injuries (10% vs. 8%, p = 0.04). Even after weighting, females were still over twice as likely to die after 60 days (RR 2.87, 95% CI 1.09, 7.51).

CONCLUSION

Female burn patients have a significantly higher risk of 60-day mortality, even after accounting for demographics, comorbid conditions, burn size, and inhalational injury. Future research efforts and treatments to attenuate mortality should account for these sex-based differences. The project was supported by the National Institutes of Health, Grant Number UL1TR001111.

Assessment and determinants of global outcomes among 445 mass-casualty burn survivors: A 2-year retrospective cohort study in Taiwan

PURPOSE

To study outcomes among survivors of the mass-casualty powder explosion on 27 June 2015, at Formosa Fun Coast Waterpark, New Taipei City, Taiwan.

METHODS

Using retrospective data on Taiwanese survivors, we analyzed prehospital management, burns assessment and prognosis, functional recovery, and medical costs, followed-up through 30 June 2017. We related outcomes to burn extent, categorized according to the percentages of total body surface area with second/third-degree burns (%TBSA) or autologous split-thickness skin grafts (%STSG), and an investigational scale: f{SASG} = (%TBSA + %STSG)/2, stratified by %STSG. Analyses included casualty dispersal, comparisons between %TBSA, %STSG and f{SASG}, and their relationships with length of hospitalization, times to rehabilitation and social/school re-entry, physical/mental disability, and medical costs. We also investigated how burn scars restricting joint mobility affected rehabilitation duration.

RESULTS

445 hospitalized casualties (excluding 16 foreigners, 23 with 0% TBSA and 15 fatalities) aged 12-38 years, had mean TBSA of 41.1%. Hospitalization and functional recovery durations correlated with %TBSA, %STSG and f{SASG} - mean length of stay per %TBSA was 1.5 days; more numerous burn scar contractures prolonged rehabilitation. Females had worse burns than males, longer hospitalization and rehabilitation, and later school/social re-entry; at follow-up, 62.3% versus 37.7% had disabilities and 57.7% versus 42.3% suffered mental trauma (all p ≤ 0.001). Disabilities affecting 225/227 people were skin-related; 34 were severely disabled but 193 had mild/moderate impairments. The prevalence of stress-related and mood disorders increased with burn extent. Treatment costs (mean USD-equivalents ∼$48,977/patient, ∼$1192/%TBSA) increased with burn severity; however, the highest %TBSA, %STSG and f{SASG} categories accounted for <10% of total costs, whereas TBSA 41-80% accounted for 73.2%.

CONCLUSIONS

Besides %TBSA, skin-graft requirements and burn scar contractures are complementary determinants of medium/long-term outcomes. We recommend further elucidation of factors that influence burn survivors' recovery, long-term physical and mental well-being, and quality of life.

The Epidemiology of Burn Injuries in Saudi Arabia: A Systematic Review

Burns are potentially catastrophic injuries that disproportionately affect non-Western countries. We summarize results on the epidemiology of burn injuries in Saudi Arabia of all eligible papers through 2019, specifically evaluating the age and gender of patients, the location and mechanism of injury, burn size and severity, and outcomes. Between July 5 and July 10, 2019, a comprehensive literature review was performed on MEDLINE, EMBASE, Google Scholar, and the Cochrane Library. For this search, "Saudi Arabia," coupled with the search terms "burn," "thermal burn," "flame burn," "chemical burn," "electrical burn," and "contact burn" to identify all abstracts potentially relating to the topic of interest. Eleven studies, encompassing 3308 patients, met eligibility criteria. Younger children (variably defined as ≤10-12) accounted for 52% of all burns. Males outnumbered females by an overall ratio of 1.42:1. About 83% of burns occurred at homes. Scald injuries accounted for 62.4% of injuries, followed by flame-induced burns (28.7%), electrical burns (3.3%), and chemical burns (2.8%). Pertaining to burn extent and severity, 80% to 100% of the burns were limited to <40% total body surface area, while roughly 60% were second-degree burns. Most patients remain in the hospital for 1 to 4 weeks. The overall mortality across studies including patients of all ages was 6.9%, while just 0.76% in the two studies restricted to pediatric patients. Scald injuries involving young children comprise the lion's share of burn injuries in Saudi Arabia. Increased public awareness is necessary to reduce the incidence and severity of these potentially catastrophic injuries.

"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.

Impact of Profound Burn on the Quality of Life of Women Attended at the Referral Outpatient Clinic in the State of Pernambuco

Analyze the influence of deep-degree burns on the quality of life (QoL) of women at treatment in ambulatory after hospital discharge. A cross-sectional study was conducted at a reference public hospital for burns in Recife, Pernambuco, Brazil, from August 2017 to May 2018. Fifty adult women over 20 years old who suffered deep burns and were in outpatient rehabilitation treatment were included. The variables studied were biological, sociodemographic, and clinical. The dynamometry and goniometry tests and the instruments to verify the QV Burn-Specific Health Scale-Revised were included in the analysis. Multiple linear regression models were fitted to identify factors associated with the six domains of the QoL instrument. The results identified a greater negative influence of burns on the QoL of women when associated with the variables: dark-black skin color, low levels of education, low income, motion impairment in right upper limb and lesions less than 6 months in the face, head and neck region. It should be noticed that the overall QoL score presented a median of 92.0, a score considered high, revealing an important QoL impairment. Deep-degree burn victims had a great impact on physical, emotional, and psychological abilities, acting harmfully on their self-image and causing difficulties in the execution of their daily and professional life activities, which are reinforced by aspects such as social position, level of education, and extent and duration of injury, resulting in a low QoL.

Soluble Suppression Of Tumorigenicity-2 Predicts Hospital Mortality in Burn Patients: An Observational Prospective Cohort Pilot Study

BACKGROUND

The IL33/ST2 pathway has been implicated in the pathogenesis of different inflammatory diseases. Our aim was to analyze whether plasma levels of biomarkers involved in the IL33/ST2 axis might help to predict mortality in burn patients.

METHODS

Single-center prospective observational cohort pilot study performed at the Burns Unit of the Plastic and Reconstructive Surgery Department of the Vall d'Hebron University Hospital (Barcelona). All patients aged ≥18 years old with second or third-degree burns requiring admission to the Burns Unit were considered for inclusion. Blood samples were taken to measure levels of interleukins (IL)6, IL8, IL33, and soluble suppression of tumorigenicity-2 (sST2) within 24 h of admission to the Burns Unit and at day 3. Results are expressed as medians and interquartile ranges or as frequencies and percentages.

RESULTS

Sixty-nine patients (58 [84.1%] male, mean age 52 [35-63] years, total body surface area burned 21% [13%-30%], Abbreviated Burn Severity Index 6 [4-8]) were included. Thirteen (18.8%) finally died in the Burns Unit. Plasma levels of sST2 measured at day 3 after admission demonstrated the best prediction accuracy for survival (area under the receiver-operating curve 0.85 [0.71-0.99]; P < 0.001). The best cutoff point for the area under the receiver-operating curve index was estimated to be 2,561. In the Cox proportional hazards model, after adjusting for potential confounding, a plasma sST2 level ≥2,561 measured at day 3 was significantly associated with mortality (hazard ratio 6.94 [1.73-27.74]; P = 0.006).

CONCLUSIONS

Plasma sST2 at day 3 predicts hospital mortality in burn patients.

An Examination of Follow-up Services Received by Vulnerable Burn Populations: A Burn Model System National Database Study

While disparities in healthcare outcomes and services for vulnerable populations have been documented, the extent to which vulnerable burn populations demonstrate disparities in long-term care is relatively underexplored. This study's goal was to assess for differences in long-term occupational or physical therapy (OT/PT) and psychological service use after burn injury in vulnerable populations. Data from the Burn Model System National Database (2006-2015) were analyzed. The vulnerable group included participants in one or more of these categories: 65 years of age or older, nonwhite, no insurance or Medicaid insurance, preinjury receipt of psychological therapy or counseling, preinjury alcohol and/or drug misuse, or with a preexisting disability. Primary outcomes investigated were receipt of OT/PT and psychological services. Secondary outcomes included nine OT/PT subcategories. Outcomes were examined at 6, 12, and 24 months postinjury. One thousand one hundred thirty-six burn survivors (692 vulnerable; 444 nonvulnerable) were included. The vulnerable group was mostly female, unemployed at time of injury, and with smaller burns. Both groups received similar OT/PT and psychological services at all time points. Adjusted regression analyses found that while the groups received similar amounts services, some vulnerable subgroups received significantly more services. Participants 65 years of age or older, who received psychological therapy or counseling prior to injury, and with a preexisting disability received more OT/PT and psychological or peer support services at follow-up. Overall, vulnerable and nonvulnerable groups received comparable OT/PT and psychological services. The importance of long-term care among vulnerable subgroups of the burn population is highlighted by this study. Future work is needed to determine adequate levels of follow-up services.

A Study of the Relationship Among Burned Patients' Resilience and Self-Efficacy and Their Quality of Life

INTRODUCTION

Among the most common causes of death and disabilities worldwide, burn injuries can affect all aspects of the life quality of the burned patients. Despite the apparent impacts of resilience and self-efficacy on the quality of life, few studies have addressed the relationship among these variables in burned patients. Accordingly, the present study aimed to investigate the relationship among burned patients' resilience and self-efficacy and their quality of life.

METHODS

The present study was a descriptive, cross-sectional research conducted on 305 burned patients hospitalized in the largest burns hospital in the south-east of Iran. In this regard, the subjects were selected based on total population sampling. Data were collected using a questionnaire consisting of four sections as follows: a demographic survey, Connor-Davidson Resilience Scale (CD-RISC), Lev Self-efficacy Scale, and Burn Specific Health Scale-Brief. The collected data were then analyzed using descriptive tests, Pearson correlation, and linear regression at a significance level of P<0.05 in SPSS 22.

RESULTS

The results show that there were significant positive correlations between the patients' resilience and self-efficacy (P<0.001, r=0.31), resilience and quality of life (P<0.001, r=0.58), and self-efficacy and quality of life (P<0.001, r=0.63).

CONCLUSION

It appears that burned patients' self-confidence and ability in adjusting with their conditions after injury are correlated with their quality of life. Thus, it is recommended that healthcare policymakers adopt some strategies to improve resilience and self-efficacy in burned patients for enabling them to effectively cope with the stressful conditions that they face as a result of their injuries.

A Scoping Review on the Long-Term Outcomes in Persons with Adult-Acquired Burn Injuries

Adult-acquired burn injuries are a life-altering event that can lead to debilitating functional or psychological impairments. With advancements in health care resulting in decreased mortality rates, survivors of burn injuries can expect to live longer. This warrants a shift in focus to better understand what happens to adults once they are discharged from the hospital into the community. Therefore, the purpose of this scoping review was to map the literature regarding the long-term outcomes of community-dwelling adult-acquired burn survivors. A computer-assisted literature search was conducted on literature from January 1, 2000 to August 31, 2018 utilizing four large databases (MEDLINE, EMBASE, CINHAL, and PsycINFO). Articles were included if they had a minimum of five individuals with a burn injury as a result of an accidental injury who were at least 18 years of age at the time of injury. Fifty-four articles were found suitable for inclusion in this review. The majority of studies were conducted in the United States and were longitudinal in design. Four themes were apparent from the articles: postburn complications, psychosocial outcomes, quality of life, and community participation. Data are lacking with respect to outcomes more than 5 years postburn as well as qualitative research. Furthermore, more literature is needed to understand the impact of postburn complications, coping strategies, and posttraumatic growth as well as barriers to community participation. Overall, there is an emerging body of literature that describes the long-term outcomes of adult-acquired burn survivors up to 5 years postburn.

Early and late-recorded predictors of health-related quality of life of burn patients on long-term follow-up

BACKGROUND

Unintentional and intentional burn injuries vary across age groups, gender, income, and global region. In high-income countries, the trend over the last several years has been a reduction in burn incidence, burn severity, length of hospital stay, and mortality rate. However, there is a lack of data on predictors of the health-related quality of life (HRQoL) of major burn survivors extending beyond a follow-up period of 10 years.

PATIENTS AND METHODS

This single-center cross-sectional study is considering 42 long-term severe burn survivors with deep partial thickness burns and an affected total body surface area (TBSA) of ≥20%. For study eligibility design a minimum follow-up of 10 years was obligatory. Entitled individuals were asked to fill in the generic Short Form 36 (SF-36) questionnaire. The physical (PCS) and mental (MCS) component scores of the SF-36 were used as the primary outcome variables. Putative predictor variables were drawn from medical records. Burn-specific functionality and scar tissue quality were assessed using the Burn Specific Health Scale-Brief (BSHS-B) questionnaire and the Patient and Observer Scar Assessment Scale (POSAS), respectively. Correlation between putative predictor variables and SF-36 norm scores were evaluated by Pearson- and Point-Biserial correlation as well as multivariate linear regression. The SF-36 norm scores were compared to the general German population.

RESULTS

Mean follow-up was 14 (±3) years with a minimum and maximum of 10 and 28 years, respectively. Mean age at the time of the incident was 37 (±17) years. The majority of individuals were male (74%). The mean burn size was 39 (±17) % (TBSA) with 76% of the individuals showing a full thickness burn. SF-36 norm scores were not statistically different from the general population. Statistically significant independent predictor variables of the physical summary score were: age at the time of the injury (-0.381), time since injury (-0.466), length of hospital stay (-0.356), limb amputation (-0.318), unemployment (-0.433), work (0.593), hand function (0.601), body image (0.518), affect (0.355), simple abilities (0.602), burns involving the hands (-0.339) and back (-0.343), POSAS patient- (-0.521) and observer scores (-0.483). In multivariate analysis, work (4.315), the POSAS Score (-2.082) and the age at the time of the incident (-0.242) were statistically significant predictors. Statistically significant independent predictor variables of the mental summary score were: duration of mechanical ventilation (-0.459), hand function (0.415), body image (0.502), sexual activity (0.625), social support (0.542), burns involving the back (-0.315) and affect (0.692). In multivariate analysis, affect (13.844) and the length of mechanical ventilation (-0.115) were statistically significant independent predictor variables.

CONCLUSION

Ten years after the burn incident, the quality of life was on average comparable to the one in the general population. Multiple variables seem to influence the physical and mental long-term outcome. Herein presented data may support in adapting and designing follow-up strategies tailored to a patient's burn-specific circumstances.

Insecure adult attachment style is associated with elevated psychological symptoms in early adjustment to severe burn: A cross-sectional study

Research into recovery and adjustment after burn injury has indicated a link between psychopathological symptoms including traumatic stress, distress, depression and anxiety, and worse psychosocial and physical outcomes. The severity of psychological symptoms does not always correlate with that of the burn injury, and symptoms can be ongoing in certain patients for extensive periods, leading to a need for early screening in burns patients for psychological vulnerabilities. One potential factor influencing recovery from the psychological impact of burn injury is adult attachment style, specifically secure and insecure attachment, as this describes how an individual organizes their stress regulation. This cross-sectional study measured: (a) attachment style (via the Relationship Questionnaire [RQ]): (b) negative psychological symptoms (via the Depression Anxiety and Stress Scale [DASS]); and, (c) post-traumatic symptoms (via the Davidson Trauma Scale [DTS]) in a cohort of burns patients (n = 104, 51 analysed) in a severe burns unit in Australia during the acute phase of their recovery. Secure attachment style was inversely related to psychopathological symptoms. Secure participants scored significantly lower scores on the DASS (M = 17.63, SD = 17.07) compared to self-rated insecure participants [(M = 42.38, SD = 34.69), p < .01] and on the DTS (M = 14.22, SD = 15.42) compared to insecure participants [(M = 40.54, SD = 35.72), p < .01]. Similar results were found in analyses controlling for covariates of gender, age and burn severity as potential confounders. This research suggests attachment style may play an important role in psychosocial recovery from severe burn injury.

Impacts of low-energy extracorporeal shockwave therapy on pain, pruritus, and health-related quality of life in patients with burn: A randomized placebo-controlled study

BACKGROUND

The management of post-burn pain and pruritus remain a potent challenge because of their bad effects on health-related quality of life (HRQOL). The main purpose of this study was to evaluate the impacts of low-energy extracorporeal shockwave therapy (low-energy ESWT) in the management of pain, pruritus, and HRQOL in patients with burn.

METHODS

Forty-five adult patients with burn, their age ranged from 18 to 55 years, were included in the study, they randomly assigned into 22 patients in the study group (low-energy ESWT) and 23 patients in the placebo group. The study group received low-energy ESWT (0.05-0.20mJ/mm², a frequency of 4Hz with total shocks from 1000 to 2000 shocks) once per week for 4 successive weeks, while the placebo group received ESWT without energy. Both groups received traditional physical therapy program of selective different exercises (respiratory, range of motion, endurance, strengthening, balance, mobilization, stretching, and gait training) 3days per week for 4 weeks. Numerical Rating Scale (NRS) for pain and for pruritus, Pressure Pain Threshold (PPT), 12-Item Pruritus Severity Scale (12-PSS), and Burn Specific Health Scale-Brief (BSHS-B) were measured before and after treatment procedures in both groups.

RESULTS

NRS were decreased significantly in the study group than in the placebo group (P<0.05). PPT, 12-PSS, and BSHS-B scores were improved more significantly in the study group than in the placebo group (P<0.05) while body image and burn associated issues were improved at the same level in both groups (P>0.05).

CONCLUSION

The findings suggest that low-energy ESWT with traditional regular physical therapy may relive post-burn pain and pruritus, and improve HRQOL, particularly in adult patients with burn.

Burn Patients' Perceptions of Their Care: What Can We Learn From Postdischarge Satisfaction Surveys?

Little is understood about the inpatient experience from the burn patients' perspectives. Rather, hospitals emphasize quantitative feedback as part of the ongoing process improvement. Comments returned with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) administrative survey may provide important patient perspectives. They analyzed quantitative and qualitative HCAHPS data to identify areas for care improvement. They reviewed our burn center HCAHPS results over 2 years. They analyzed "top-box" result in each defined HCAHPS category, which is the most frequently reported best result in each composite, including survey scores ≥9 (out of 10). They performed qualitative content analysis of open-text responses via a HIPAA-compliant analysis software. They developed a hierarchy of major expressed themes and organized them using HCAHPS-validated satisfaction domains. A total of 610 inpatient HCAHPS surveys (21% response rate) were returned. Seventy-five percent of respondents ranked their burn center as ≥9 (out of 10) in care scores. Content analysis identified three main components of the inpatient experience: 1) provider/nurse communication, 2) hospital environment, and 3) the discharge experience. Caring, respect, handoff coordination, explanations, listening, and confidence in provider constituted the six key communication themes. Patients generally reported that burn providers listened to their concerns, but others requested clearer explanations of their condition and care. Responses about hospital environment highlighted excessive noise and disrupted sleep, and variable responses related to cleanliness. Challenges in the discharge experience included difficulties procuring wound care supplies and discharge medications. Qualitative data from HCAHPS helped identify major target areas for burn center performance improvement. Analysis of HCAHPS direct patient feedback is useful in process improvement, whereas numerical data alone do not provide sufficient actionable information.

Predictors of health-related quality of life after burn injuries: a systematic review

Background

Identifying predictors of health-related quality of life (HRQL) following burns is essential for optimization of rehabilitation for burn survivors. This study aimed to systematically review predictors of HRQL in burn patients.

Methods

Medline, Embase, Web of Science, Cochrane, CINAHL, and Google Scholar were reviewed from inception to October 2016 for studies that investigated at least one predictor of HRQL after burns. The Quality in Prognostic Studies tool was used to assess risk of bias of included studies.

Results

Thirty-two studies were included. Severity of burns, postburn depression, post-traumatic stress symptoms, avoidance coping, less emotional or social support, higher levels of neuroticism, and unemployment postburn were found to predict a poorer HRQL after burns in multivariable analyses. In addition, weaker predictors included female gender, pain, and a postburn substance use disorder. Risk of bias was generally low in outcome measurement and high in study attrition and study confounding.

Conclusions

HRQL after burns is affected by the severity of burns and the psychological response to the trauma. Both constructs provide unique information and knowledge that are necessary for optimized rehabilitation. Therefore, both physical and psychological problems require attention months to years after the burn trauma.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2071-4) contains supplementary material, which is available to authorized users.

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.

Effects of Estrogen on Bacterial Clearance and Neutrophil Response After Combined Burn Injury and Wound Infection

Females have a higher rate of mortality following burn injury, largely due to differences in sepsis-related mortality. The present study seeks to understand the underpinnings of the estrogen's immunomodulatory effects in a murine model of burn injury and infection. Gonad-intact and ovariectomized female mice were subjected to a 15% total BSA scald injury and then inoculated with 3000 CFU of Pseudomonas aeruginosa by topical application to the wound. Animals were killed at 1, 2, or 7 days after injury. Tissue and whole blood were collected. Cultures were performed of all tissues to assess for bacteria content. Lungs were examined for histologic appearance and homogenates were analyzed for chemokines and myeloperoxidase activity. Mortality reached 95% by 3 days after injury for gonad intact mice, whereas in ovariectomized mice it was 76% at 7 days. Blood and tissue samples from gonad intact mice had significantly higher levels of P. aeruginosa compared with ovariectomized mice. Histologic assessment of lungs demonstrated a similar overall cellularity in ovariectomized mice relative to gonad intact mice 1 day after injury, but increased neutrophil count in gonad intact mice. This correlated with chemotactic signaling as lung homogenates had lower levels of KC in ovariectomized mice (128.0 ± 19.8 vs 48.3 ± 5.7 pg/mg protein). Also, myeloperoxidase was significantly lower in lung homogenates of ovariectomized mice (1.12 ± 0.34 vs 0.56 ± 0.08 units/mg protein). Ovariectomy confers an early, but brief survival advantage in female mice after burn injury and wound infection. This appears to be secondary to enhanced bacterial clearance.

Cognitive appraisal of exposure to specific types of trauma - a study of gender differences

Background

The role of gender in posttraumatic cognitions has increasingly been approached. The current study comparatively evaluates posttraumatic cognitions in men and women exposed to specific nonsexual trauma (motor vehicle accidents, work – related accidents, burns).

Methods

Posttraumatic cognitions and posttraumatic stress symptoms were comparatively assessed in 53 men and 37 women treated in 3 Romanian primary care units after specific accidental trauma. Posttraumatic Cognitions Inventory (PTCI) was used to assess posttraumatic cognitions, and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT) was used to assess posttraumatic stress symptoms.

Results

Men with significant posttraumatic stress symptoms endorsed more negative cognitions than women. Men with posttraumatic disability more consistently endorsed some negative cognitions regarding instrumentality, strength and control than their female counterparts. Women and men without posttraumatic disability reported similarly low levels of negative posttraumatic cognitions. Time elapsed since trauma increased most negative cognitions in men.

Conclusions

The intensity of PTSD symptoms and presence of posttraumatic disability influence negative cognitions after exposure to accidental trauma. Women experiencing clinically significant PTSD symptoms endorse more cognitions regarding instrumentality, strength and control than male counterparts. Women with permanent disability after trauma report less cognitions involving emotionality, dependence and low self – efficacy than male counterparts. In the absence of permanent posttraumatic disability, men and women endorse similar levels of negative cognitions after accidental trauma. With time elapsed since trauma, men perceive decreasing self – efficacy, problem – solving and emotional control, while women perceive decreasing interpersonal cooperation. Despite limitations (cross-sectional design, lack of normative data for PTCI to ascertain culturally – specific gendered cognitions), this study supports the gender – sensitive approach of accidental trauma, especially when its consequences are pervasive, disabling and increasingly burdensome.

Electronic supplementary material

The online version of this article (10.1186/s12905-017-0468-x) contains supplementary material, which is available to authorized users.

Factors influencing psychological, social and health outcomes after major burn injuries in adults: cohort study protocol

INTRODUCTION

The goal of burn care is that 'the quality of the outcome must be worth the pain of survival'. More research is needed to understand how best to deliver care for patients with burns to achieve this aim. Loss of independence, function as well as loss of income for patients with burns and carers cause a significant burden at both individual and societal levels. Much is being done to advance knowledge in the clinical care field; however, there has been a paucity of research exploring psychosocial outcomes. This paper describes the study background and methods, as implemented in an Australian cohort study of psychosocial outcomes after major burn injuries.

METHODS AND ANALYSIS

In this inception cohort study, a target sample of 230 participants, aged 18 years or over, admitted to a single statewide burns centre with a burn injury are identified by hospital staff for inclusion. Baseline survey data are collected either in person or by telephone within 28 days of the injury and participants then followed up with telephone interviews at 3, 6 and 12 months postburn. Injury and burns treatment information is collected from medical records. Social support is measured as a predictor variable using the Multidimensional Scale of Perceived Social Support. Outcome data are collected via standardised measures in the domains of Quality of Life (SF-12, EQ-5D, BSHS-B), depression (PHQ-9), post-traumatic stress disorder (PCL-C, PAS), community integration (CIQ-R) and Quality-Adjusted Life Years (EQ-5D). Additional survey questions measure life satisfaction, return to work and public services utilisation at 12 months postinjury. Data analysis methods will include analysis of variance, Pearson correlation and hierarchical multiple regression analyses.

ETHICS AND DISSEMINATION

Hospital-based and University of Queensland Human Research Ethics Committees have approved the protocol. Results from the study will be disseminated at national and international conferences, in peer-reviewed journals and in a doctoral thesis.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry (ACTRN12616000828426). Retrospectively registered on 23 June 2016; pre-results.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of pre-injury health-related quality of life: a systematic review

Background

Insight into the change from pre- to post-injury health-related quality of life (HRQL) of trauma patients is important to derive estimates of the impact of injury on HRQL. Prospectively collected pre-injury HRQL data are, however, often not available due to the difficulty to collect these data before the injury. We performed a systematic review on the current methods used to assess pre-injury health status and to estimate the change from pre- to post-injury HRQL due to an injury.

Methods

A systematic literature search was conducted in EMBASE, MEDLINE, and other databases. We identified studies that reported on the pre-injury HRQL of trauma patients. Articles were collated by type of injury and HRQL instrument used. Reported pre-injury HRQL scores were compared with general age- and gender-adjusted norms for the EQ-5D, SF-36, and SF-12.

Results

We retrieved results from 31 eligible studies, described in 41 publications. All but two studies used retrospective assessment and asked patients to recall their pre-injury HRQL, showing widely varying timings of assessments (soon after injury up to years after injury). These studies commonly applied the SF-36 (n = 13), EQ-5D (n = 9), or SF-12 (n = 3) using questionnaires (n = 14) or face-to-face interviews (n = 11). Two studies reported prospective pre-injury assessment, based on prospective longitudinal cohort studies from a sample of initially non-injured patients, and applied questionnaires using the SF-36 or SF-12. The recalled pre-injury HRQL scores of injury patients consistently exceeded age- and sex-adjusted population norms, except in a limited number of studies on injury types of higher severity (e.g., traumatic brain injury and hip fractures). All studies reported reduced post-injury HRQL compared to pre-injury HRQL. Both prospective studies reported that patients had recovered to their pre-injury levels of physical and mental health, while in all but one retrospective study patients did not regain the reported pre-injury levels of HRQL, even years after injury.

Conclusions

So far, primarily retrospective research has been conducted to assess pre-injury HRQL. This research shows consistently higher pre-injury HRQL scores than population norms and a recovery that lags behind that of prospective assessments, implying a systematic overestimation of the change in HRQL from pre- to post-injury due to an injury. More prospective research is necessary to examine the effect of recall bias and response shift. Researchers should be aware of the bias that may arise when pre-injury HRQL is assessed retrospectively or when population norms are applied, and should use prospectively derived HRQL scores wherever possible to estimate the impact of injury on HRQL.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-017-0127-3) contains supplementary material, which is available to authorized users.