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Weber DC, Beer J, Kliebsch UL, Teske C, Baust K, Walser M, Pica A, Bachtiary B, Timmermann B, Calaminus G. Quality-of-life evaluations in children and adolescents with Ewing sarcoma treated with pencil-beam-scanning proton therapy. Pediatr Blood Cancer 2022; 69:e29956. [PMID: 36052578 DOI: 10.1002/pbc.29956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND With improved survival rates for children with cancer, quality-of-life (QoL) issues have increasingly become the focus of attention. We report the QoL of children with Ewing sarcoma (EWS) treated with pencil-beam-scanning proton therapy (PT). METHODS A PEDQOL (QoL questionnaire for children 4-18 years) self/proxy questionnaire was used to prospectively assess the QoL of 23 children <18 years with EWS treated with PT. This questionnaire evaluates eight different domains. Children (self-rating) and parents (proxy-rating) filled out the questionnaire at the start of PT (E1), 2 months after treatment (E2), and thereafter once yearly (E≥3). RESULTS Compared with healthy controls, parents rated the QoL of their children at E1 significantly worse in all but two (cognition and social functioning-family) domains. At E4, significant differences between the two groups only remained in three of eight domains. At E1, children self-rated their QoL significantly worse in the domain Physical functioning (p = .004) and significantly better in the domain Body image (p = .044) compared to healthy controls, whereas no significant differences were observed at E4. For the longitudinal comparison E1 versus E4, according to parents, Emotional functioning, Cognition and Social functioning-peers were slightly decreased 2 years after PT. The children rated Emotional functioning and Body image poorly 2 years after PT. CONCLUSIONS Children with EWS usually recovered seemingly well to normal QoL levels 2 years after the end of PT. They tended to rate their QoL substantially higher than their parents. However, in the longitudinal analysis at 2 years, children rated their Emotional functioning and Body image scores poorly.
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Affiliation(s)
- Damien C Weber
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen West, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Radiation Oncology, University Hospital of Zürich, Zürich, Switzerland
| | - Jürgen Beer
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen West, Switzerland.,Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ulrike L Kliebsch
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen West, Switzerland
| | - Carmen Teske
- Department of Pediatric Hematology and Oncology, Working group Quality of Life, University Hospital Bonn, Bonn, Germany
| | - Katja Baust
- Department of Pediatric Hematology and Oncology, Working group Quality of Life, University Hospital Bonn, Bonn, Germany
| | - Marc Walser
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen West, Switzerland.,Department of Radiation Oncology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Alessia Pica
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen West, Switzerland
| | - Barbara Bachtiary
- Center for Proton Therapy, Paul Scherrer Institute, ETH Domain, Villigen West, Switzerland
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Centre (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Gabriele Calaminus
- Department of Pediatric Hematology and Oncology, Working group Quality of Life, University Hospital Bonn, Bonn, Germany
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A comparison of parent-reported and self-reported psychosocial function scores of the PedsQL for children with non-severe burn. Burns 2022:S0305-4179(22)00237-6. [DOI: 10.1016/j.burns.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/04/2022] [Accepted: 09/04/2022] [Indexed: 11/19/2022]
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3
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Cuttle L, Fear M, Wood FM, Kimble RM, Holland AJA. Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:269-278. [PMID: 35051408 DOI: 10.1016/s2352-4642(21)00350-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/28/2021] [Accepted: 11/01/2021] [Indexed: 12/11/2022]
Abstract
Paediatric burn injuries are common, especially in children younger than 5 years, and can lead to poor physical and psychosocial outcomes in the long term. In this Review, we aim to summarise the key factors and interventions before hospital admission and following discharge that can improve the long-term outcomes of paediatric burns. Care can be optimised through first aid treatment, correct initial assessment of burn severity, and appropriate patient referral to a burns centre. Scar prevention or treatment and patient follow-up after discharge are also essential. As most burn injuries in children are comparatively small and readily survivable, this Review does not cover the perioperative management associated with severe burns that require fluid resuscitation, or inhalational injury. Burns disproportionately affect children from low socioeconomic backgrounds and those living in low-income and middle-income countries, with ample evidence to suggest that there remains scope for low-cost interventions to improve care for those patients with the greatest burden of burn injury. Current knowledge gaps and future research directions are discussed.
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Affiliation(s)
- Leila Cuttle
- Centre for Children's Health Research, Faculty of Health, School of Biomedical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Mark Fear
- Burn Injury Research Unit, School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, School of Biomedical Sciences, The University of Western Australia, Perth, WA, Australia; Burns Service of Western Australia, Perth Children's Hospital and Fiona Stanley Hospital, Perth, WA, Australia
| | - Roy M Kimble
- Centre for Children's Burns and Trauma Research, The University of Queensland, South Brisbane, QLD, Australia; Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Andrew J A Holland
- The Children's Hospital Burns Research Institute, The Children's Hospital at Westmead, The University of Sydney, NSW, Westmead, Australia
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Patel KF, Rodríguez-Mercedes SL, Grant GG, Rencken CA, Kinney EM, Austen A, Hou C, Brady KJS, Schneider JC, Kazis LE, Ryan CM. Physical, Psychological, and Social Outcomes in Pediatric Burn Survivors Ages 5 to 18 Years: A Systematic Review. J Burn Care Res 2022; 43:343-352. [PMID: 34922361 PMCID: PMC9272085 DOI: 10.1093/jbcr/irab225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Acute pediatric burn injuries often result in chronic sequelae that affect physical, psychological, and social outcomes. To date, no review has comprehensively reported on the impact of burn injuries across all three domains in school-aged children. The aim of this systematic review was to identify published literature that focuses on the impact of burn injuries on physical, psychological, or social functioning, and report upon the nature of study characteristics and their outcomes. We included literature published after 1980, focusing on burn outcomes in children aged 5 to 18 years. Each eligible study was systematically reviewed and primary outcomes were classified into outcome domains based on existing frameworks. Fifty-eight studies met inclusion criteria, and reported on physical (n = 24), psychological (n = 47), and social (n = 29) domains. The majority of the studies had sample sizes of <100 participants, burn size of <40%, and findings reported by parents and/or burn survivors. Only eight of 107 different measures were used in three or more studies. Parents and burn survivors generally reported better physical and social outcomes and worse psychological functioning compared to non-burn populations. Physical disabilities were associated with psychological and social functioning in several studies. Follow-up data reported improvements across domains. This review demonstrates the importance of physical, psychological, and social status as long-term outcomes in burn survivors. Mixed findings across three outcome domains warrant long-term research. Findings of this review will guide the foundation of comprehensive burn and age-specific instruments to assess burn recovery.
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Affiliation(s)
- Khushbu F. Patel
- Department of Clinical Research, Shriners Hospitals for Children – Boston®, Massachusetts, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, USA
| | | | | | - Camerin A. Rencken
- Department of Clinical Research, Shriners Hospitals for Children – Boston®, Massachusetts, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, USA
| | - Erin M. Kinney
- Department of Clinical Research, Shriners Hospitals for Children – Boston®, Massachusetts, Massachusetts, USA
| | - Amelia Austen
- Department of Clinical Research, Shriners Hospitals for Children – Boston®, Massachusetts, Massachusetts, USA
| | - Carina Hou
- Department of Clinical Research, Shriners Hospitals for Children – Boston®, Massachusetts, Massachusetts, USA
| | - Keri J. S. Brady
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Massachusetts, USA
| | - Jeffrey C. Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lewis E. Kazis
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Research Institute, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Colleen M. Ryan
- Department of Clinical Research, Shriners Hospitals for Children – Boston®, Massachusetts, Massachusetts, USA
- Department of Surgery, Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Shriners Hospitals for Children – Boston®, Massachusetts, USA
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5
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Jaworski W, Jaworski A, Kufel J, Grabowski A, Korlacki W. Deep and extensive pediatric burns: retrospective evaluation of scheme of patients at the Department of Children’s Developmental Defects Surgery and Traumatology SUM. POLISH JOURNAL OF SURGERY 2022; 94:31-39. [DOI: 10.5604/01.3001.0015.7679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
<b> Introduction:</b> Burns are one of the most common injuries among children. Despite the scale of the problem, there is no generally accepted algorithm for dealing with burn wounds in children in Poland. </br></br> <b>Aim:</b> The aim of our study was to evaluate our treatment scheme as well as the long-term effects of burn treatment in our department. </br></br> <b>Material and methods:</b> We conducted a telephone survey with the parents of patients treated at our ward in 01.01.2016–01.01.2021 due to thermal burns. To assess the cosmetic effect of treatment, the modified Vancouver Scar Scale (mVSS) was used, as well as the evaluation of parents’ satisfaction with the treatment of patients on a scale from 1 to 10. Criteria to be included were the thermal burn of the skin to at least a 2b degree and/or burns with not less than 8% of the Total Body Surface Area (TBSA), as well as answering all the questions included in the questionnaire. The inclusion criteria were met by 38 out of 97 hospitalized patients. </br></br> <b>Results:</b> 26.32% of patients achieved 0 points on the mVSS, 21.05% achieved 1 point, 15.79% achieved 2 points, 15.79% achieved 3 points, 2.63% patients received 4 points, 5.26% patients received 5 points, 5.26% patients received 7 points, 2.63% patients received 8 points, 2.63% patients received 9 points, 2.63% of patients received 10 points, none of the patients received 6 and 11 points higher. 3% of parents rated their satisfaction at 5 points, 3% of caretakers as 7 points, 8% as 8 points, 8% as 9 points, and 89% as 10 points. </br></br> <b>Discussion:</b> Our treatment algorithm brings good therapeutic effects and is also very well received by the patients' parents. In order to carry out a nationwide standardization of the treatment of childhood burn wounds, it would be necessary to conduct a similarly constructed study in a multicenter setting.
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Affiliation(s)
- Wojciech Jaworski
- Department of Surgery for Child Developmental Defects and Traumatology in Zabrze, Independent Public Clinical Hospital No. prof. Stanisław Szyszko of the Medical University of Silesia in Katowice, Poland
| | - Aleksander Jaworski
- Department of Surgery for Child Developmental Defects and Traumatology in Zabrze, Independent Public Clinical Hospital No. prof. Stanisław Szyszko of the Medical University of Silesia in Katowice, Poland
| | - Jakub Kufel
- Student Scientific Association at the Department of General and Endocrine Surgery, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Andrzej Grabowski
- Department of Surgery for Child Developmental Defects and Traumatology in Zabrze, Independent Public Clinical Hospital No. prof. Stanisław Szyszko of the Medical University of Silesia in Katowice, Poland
| | - Wojciech Korlacki
- Department of Surgery for Child Developmental Defects and Traumatology in Zabrze, Independent Public Clinical Hospital No. prof. Stanisław Szyszko of the Medical University of Silesia in Katowice, Poland
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Nikitina IL, Kelmanson IA. Health-related quality of life in 4-to-6-year-old children with type 1 diabetes mellitus estimated by children and their mothers. Eur J Pediatr 2022; 181:549-560. [PMID: 34424400 PMCID: PMC8380516 DOI: 10.1007/s00431-021-04239-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/29/2021] [Accepted: 08/10/2021] [Indexed: 02/07/2023]
Abstract
Administration of pediatric Health Related Quality of Life (HRQoL) inventories frequently assesses both the child and parent perspectives in young children with type 1 diabetes mellitus (T1DM), but parent-proxy and child self-reports may differ, and little is known on these discrepancies. The aim is to evaluate HRQoL estimated by young children with T1DM and by their mothers, potential discrepancies in the children-maternal estimates and the factors influencing these discrepancies. Thirty-five 4-to-6-year-old children (19 boys) with T1DM admitted to the Pediatric Endocrinology Department were approached with the self-report KINDL questionnaire for children aged 4-6 years (Kiddy-KINDL for children). Their mothers were approached with the parental version (Kiddy-KINDL for parents). Both versions enable measuring child HRQoL in physical, emotional wellbeing, self-esteem, family, friends, everyday functioning, and the disease dimensions, as well as KINDL total on a 0-100 scale. Statistically significant differences were found between children's and maternal estimates on the KINDL total and "Disease" scales, in that the maternal proxy-reports produced lower values. A statistically significant difference between self- and proxy-reports was found for the KINDL "Emotional wellbeing" scale values, and the maternal proxy-reports yielded higher estimates compared with children's self-reports. These associations remained significant after adjustment for major potential confounders. Maternal education, maternal marital status, insulin regimen, and achievement of glycemic control modified the effect of child-maternal discrepancies.Conclusion: Attempts should be made to improve parental understanding of child problems related to his/her disease with due account to individual family social and demographic characteristics. What is Known: • HRQoL in children with T1DM has been advocated as an important complementary outcome to clinical and laboratory markers. • Self-and parental proxy-reports on HRQoL may differ, but little is known on these discrepancies and on the factors influencing them in young children with T1DM. What is New: • Mothers tend to underestimate general and disease-related components of HRQoL but likely to overestimate psychological wellbeing of their ill young children with T1DM. • Maternal education, marital status, insulin regimen, and achievement of glycemic control modify estimations of HRQoL and child-maternal discrepancies.
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Affiliation(s)
- Irina L. Nikitina
- Department of Children’s Diseases, Institute for Medical Education of the V.A.Almazov National Medical Research Centre, Akkuratova Str., 2, 197341 St. Petersburg, Russia
| | - Igor A. Kelmanson
- Department of Children’s Diseases, Institute for Medical Education of the V.A.Almazov National Medical Research Centre, Akkuratova Str., 2, 197341 St. Petersburg, Russia
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7
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Agreement between proxy- and self-report scores on PROMIS health-related quality of life domains in pediatric burn survivors: a National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study. Qual Life Res 2021; 30:2071-2080. [PMID: 33638744 DOI: 10.1007/s11136-021-02796-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To examine agreement between pediatric burn survivor self- and caregiver proxy-report on multiple PROMIS domains and examine factors associated with differences between self- and proxy-reports. METHODS Children 8-17 years of age and their caregivers completed PROMIS measures (physical function, depression, peer relationships, pain interference, and anger) between 6 months and 15 years after injury. Self- and proxy-report scores were compared using Wilcoxon sign rank test, Cohen's effect size, and intraclass correlation coefficients (ICC) and by agreement across severity of symptoms based on recommended cutoffs. Ordinary least squares regression analyses examined child- (self-report score, age, gender, and ethnicity) and proxy-related (relationship to child) factors associated with score differences. RESULTS Two hundred and seventy four child-caregiver pairs completed the PROMIS measures. Mean child age was 13.0 (SD:3) years. Caregivers reported significantly worse scores than the child on physical function, pain, and anger (all p ≤ 0.01). The effect sizes were small across all domains except physical function. Similarly, ICCs were all of moderate agreement. The percentage of dyads in agreement by severity groups was high with only 5%-9% of pairs discordant. Only higher self-report score was associated (all p < 0.05) with greater differences across all domains in regression analyses. CONCLUSIONS This study supports the use of pediatric proxy PROMIS depression, physical function, peer relationships, pain interference, and anger scales in pediatric burn patients. Although agreement was moderate to good, assessing proxy-report alone as a surrogate should only be considered when self-report is not possible or practical. Caregivers typically report slightly worse severity of symptoms than children across all domains.
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8
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Differences in parent-perceived and patient-reported quality of life among young adult burn patients: A prospective longitudinal study. Burns 2021; 47:1878-1889. [PMID: 33707088 DOI: 10.1016/j.burns.2021.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/17/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE This study examines the differences in parent-perceived and patient-reported quality of life (QoL) among young adult burn patients three years after injury and the factors affecting these differences. METHOD The sample comprised 35 burn patients from the Formosa Fun Coast Water Park dust explosion and their parents. The study was conducted from June 2016 to August 2018. We used self-report questionnaires to collect socio-demographic data, the adapted Chinese version of the Burn Specific Health Scale-Brief, and the Impact of Events Scale for Burn. RESULTS The analysis indicated that simple abilities recovered the fastest, while body image recovered the slowest. The variation trends of these factors were similar but parents' scores were lower than patients' scores. Parents' post-traumatic stress disorder (PTSD) scores were higher than that of patients, but were not statistically significant. Parents' gender and PTSD levels and patients' burn area affected differences in parent-perceived QoL among patients. PTSD levels were significantly higher among mothers. CONCLUSIONS For parents, PTSD is a common response to their children experiencing burn injuries. Parents' observations of warning signs enable early medical intervention. Establishing a family-centered care plan, providing psychological support for both parents and patients, and forming a continuous care system with efficient communication can support patients' return to society.
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9
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Rensen N, Steur LMH, Schepers SA, Merks JHM, Moll AC, Kaspers GJL, Van Litsenburg RRL, Grootenhuis MA. Determinants of health-related quality of life proxy rating disagreement between caregivers of children with cancer. Qual Life Res 2020; 29:901-912. [PMID: 31820207 PMCID: PMC7142061 DOI: 10.1007/s11136-019-02365-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Proxy reports of health-related quality of life (HRQoL) are commonly used in pediatric oncology. However, it is not known if caregivers' reports differ. This study therefore aims to compare paternal and maternal proxy reports, and explore determinants of couple disagreement (sociodemographic and medical characteristics, and parental QoL and distress). METHODS Both parents completed the PedsQL generic (child's HRQoL), Short Form-12 (own QoL) and Distress Thermometer for Parents. To assess agreement in child HRQoL, intra-class correlation coefficients (ICCs) were calculated. Differences between fathers/mothers were assessed with paired t tests. Systematic disagreement patterns were visualized with Bland-Altman plots. Characteristics of parental couples with a mean proxy difference in the highest quartile (highest proxy score minus lowest proxy score) were explored with multiple logistic regression analysis. RESULTS Parents of 120 children with cancer (87% post-treatment, mean age 11.0 ± 5.7 years) participated. No significant differences were found between paternal and maternal proxy scores, and agreement was good on all scales (ICCs 0.65-0.83). Bland-Altman plots revealed no systematic disagreement patterns, but there was a wide range in magnitude of the differences, and differences went in both directions. Couples with a mean proxy difference (irrespective of which direction) in the highest quartile (± 20 points) were more likely to have a child in active treatment, with retinoblastoma or relapsed disease, and to diverge in their own QoL. CONCLUSIONS If proxy reports of only one parent are available, clinicians may reasonably assume that paternal and maternal reports are interchangeable. However, if in doubt, respondent's sex is not of major importance, but clinicians should be aware of patient's and family's characteristics.
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Affiliation(s)
- Niki Rensen
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Lindsay M H Steur
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Sasja A Schepers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Psychosocial Department, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Johannes H M Merks
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Annette C Moll
- Department of Ophthalmology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
| | - Gertjan J L Kaspers
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Raphaële R L Van Litsenburg
- Pediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit, Amsterdam, The Netherlands.
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
| | - Martha A Grootenhuis
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Psychosocial Department, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
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.
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Affiliation(s)
- Marc G Jeschke
- Ross Tilley Burn Center, Department of Surgery, Sunnybrook Health Science Center, Toronto, Ontario, Canada.
- Departments of Surgery and Immunology, University of Toronto, Toronto, Ontario, Canada.
| | - Margriet E van Baar
- Association of Dutch Burn Centres, Maasstad Hospital, Rotterdam, Netherlands
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, Netherlands
| | - Mashkoor A Choudhry
- Burn and Shock Trauma Research Institute, Alcohol Research Program, Stritch School of Medicine, Loyola University Chicago Health Sciences Division, Maywood, IL, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nicole S Gibran
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Sarvesh Logsetty
- Departments of Surgery and Psychiatry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Davis AM, Canter KS, Pina K. The importance of fathers in pediatric research: These authors are on to something important. Transl Behav Med 2020; 9:570-572. [PMID: 31094429 DOI: 10.1093/tbm/ibz053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Pediatric obesity remains a prevalent health issue in the United States and around the world. Treatments are challenged by a lack of meaningful improvements in child healthy weight. The current commentary describes an intervention study with a unique approach: engaging fathers. The commentary describes why this approach is unique and promising in terms of future directions for the field to consider.
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Affiliation(s)
- Ann M Davis
- Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO, USA.,Department of Pediatrics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kimberly S Canter
- Department of Pediatrics, Nemours Children's Health System, Wilmington Delaware, USA
| | - Kimberly Pina
- Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, Missouri, USA
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12
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Gibson JAG, Yarrow J, Brown L, Evans J, Rogers SN, Spencer S, Shokrollahi K. Identifying patient concerns during consultations in tertiary burns services: development of the Adult Burns Patient Concerns Inventory. BMJ Open 2019; 9:e032785. [PMID: 31892660 PMCID: PMC6955499 DOI: 10.1136/bmjopen-2019-032785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- John Alexander Gerald Gibson
- The Welsh Centre for Burns & Plastic Surgery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
- Postgraduate Medical Institute (PGMI), Faculty of Health & Social Care, Edge Hill University, Ormskirk, UK
| | - Jeremy Yarrow
- The Welsh Centre for Burns & Plastic Surgery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Liz Brown
- The Welsh Centre for Burns & Plastic Surgery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Janine Evans
- The Welsh Centre for Burns & Plastic Surgery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Simon N Rogers
- Postgraduate Medical Institute (PGMI), Faculty of Health & Social Care, Edge Hill University, Ormskirk, UK
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sally Spencer
- Postgraduate Medical Institute (PGMI), Faculty of Health & Social Care, Edge Hill University, Ormskirk, UK
| | - Kayvan Shokrollahi
- Postgraduate Medical Institute (PGMI), Faculty of Health & Social Care, Edge Hill University, Ormskirk, UK
- Mersey Regional Burns Centre, Saint Helen's and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
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13
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Health-related quality of life in children after burn injuries: A systematic review. J Trauma Acute Care Surg 2018; 85:1110-1118. [DOI: 10.1097/ta.0000000000002072] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Mother, father and child traumatic stress reactions after paediatric burn: Within-family co-occurrence and parent-child discrepancies in appraisals of child stress. Burns 2018; 44:861-869. [DOI: 10.1016/j.burns.2018.01.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/29/2017] [Accepted: 01/05/2018] [Indexed: 01/31/2023]
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Shahid F, Ismail M, Khan S. Assessment of quality of life in post burn survivors: A cross-sectional single-center first validation study from Pakistan. BURNS OPEN 2018. [DOI: 10.1016/j.burnso.2017.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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16
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Akkerman M, Mouton LJ, Dijkstra F, Niemeijer AS, van Brussel M, van der Woude LH, Disseldorp LM, Nieuwenhuis MK. Perceived fatigue following pediatric burns. Burns 2017; 43:1792-1801. [DOI: 10.1016/j.burns.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/26/2017] [Accepted: 05/08/2017] [Indexed: 11/16/2022]
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17
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Pan R, Dos Santos BD, Nascimento LC, Rossi LA, Geenen R, Van Loey NE. School reintegration of pediatric burn survivors: An integrative literature review. Burns 2017. [PMID: 28624354 DOI: 10.1016/j.burns.2017.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The school is an essential context for children's social interaction with peers and to develop academic skills. Therefore, a fast reintegration can help children with burns to normalize their life. Thus, school reintegration is an important outcome after burns. The aim of this review was to systematically synthesize the literature addressing school reintegration programs of pediatric burns survivors. METHODS Five electronic databases were searched independently by two reviewers. The search yielded 13 eligible publications. A qualitative content analysis was conducted. RESULTS The two themes identified centered around (1) the roles, obstacles, and support for the different stakeholders (i.e., the child, parents and teacher) and (2) the contents of the school reintegration programs in which subthemes such as purpose, planning, essential elements, team, and effect were distinguished. The results show that return to school should start as soon as the child is admitted to the hospital and the program should acknowledge the different stakeholders' needs and tailor the program to these needs. CONCLUSION The review emphasizes the necessity of an integrated school reintegration program empowering both the child, the parents and the teachers and tailored to the child's specific situation. Furthermore, it offers recommendations for further improvement of the field.
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Affiliation(s)
- Raquel Pan
- Pontifical Catholic University of Minas Gerais at Poços de Caldas, Department of Nursing, Poços de Caldas, MG, Brazil.
| | - Bruna Domingos Dos Santos
- Psychiatric Nursing program, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
| | - Lucila Castanheira Nascimento
- Maternal-Infant and Public Health Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
| | - Lídia Aparecida Rossi
- General and Specialized Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil.
| | - Rinie Geenen
- Utrecht University, Department of Psychology, Utrecht, The Netherlands.
| | - Nancy E Van Loey
- Association of Dutch Burn Centers, Utrecht University, Department of Clinical & Health Psychology, Beverwijk, Utrecht, The Netherlands.
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18
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Wurzer P, Forbes AA, Hundeshagen G, Andersen CR, Epperson KM, Meyer WJ, Kamolz LP, Branski LK, Suman OE, Herndon DN, Finnerty CC. Two-year follow-up of outcomes related to scarring and distress in children with severe burns. Disabil Rehabil 2016; 39:1639-1643. [PMID: 27685196 DOI: 10.1080/09638288.2016.1209579] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE We assessed the perception of scarring and distress by pediatric burn survivors with burns covering more than one-third of total body surface area (TBSA) for up to 2 years post-burn. METHODS Children with severe burns were admitted to our hospital between 2004 and 2012, and consented to this IRB-approved-study. Subjects completed at least one Scars Problems and/or Distress questionnaire between discharge and 24 months post burn. Outcomes were modeled with generalized estimating equations or using mixed linear models. Significance was accepted at p < 0.01. RESULTS Responses of 167 children with a mean age of 7 ± 5 years and burns covering an average 54 ± 14% of TBSA were analyzed. Significant improvements over the 2-year period were seen in reduction of pain, itching, sleeping disturbance, tightness, range of motion, and strength (p < 0.01). There was a significantly increased persistent desire to hide the scarred body areas over time (p < 0.01). The perception of mouth scarring, inability to portray accurate facial expressions, and skin coloration did not improve over the follow-up period. CONCLUSIONS According to self-assessment questionnaires, severely burned children exhibit significant improvements in their overall perception of scarring and distress. However, these patients remain self-conscious with respect to their body image even 2 years after burn injury. Implications for Rehabilitation According to self-assessment questionnaires, severely burned children perceive significant improvements in scarring and distress during the first 2 years post burn. Significant improvements were seen in reduction of pain, itching, sleeping disturbances, tightness, range of motion, and strength (p < 0.01). Burn care providers should improve the treatment of burns surrounding the mouth that with result in scarring, and develop strategies to prevent skin discoloration. Careful evaluation of pain and sleeping disorders during the first year post burn are warranted to improve the patient rehabilitation. Overall, significantly more female patients expressed a persistent desire to hide their scarred body areas. The rehabilitation team should provide access to wigs or other aids to pediatric burn survivors to address these needs.
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Affiliation(s)
- Paul Wurzer
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA.,c Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery , Medical University of Graz , Graz , Austria
| | - Abigail A Forbes
- d School of Medicine , University of Texas Medical Branch Galveston , Galveston , TX , USA
| | | | - Clark R Andersen
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA
| | - Kathryn M Epperson
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA
| | - Walter J Meyer
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA
| | - Lars P Kamolz
- c Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery , Medical University of Graz , Graz , Austria
| | - Ludwik K Branski
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA.,c Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery , Medical University of Graz , Graz , Austria
| | - Oscar E Suman
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA
| | - David N Herndon
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA
| | - Celeste C Finnerty
- a Department of Surgery , University of Texas Medical Branch Galveston , Galveston , TX , USA.,b Shriners Hospitals for Children , Galveston , TX , USA.,e Institute of Translational Sciences, University of Texas Medical Branch and Shriners Hospitals for Children , Galveston , TX , USA
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19
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Yi-Frazier JP, Hilliard ME, Fino NF, Naughton MJ, Liese AD, Hockett CW, Hood KK, Pihoker C, Seid M, Lang W, Lawrence JM. Whose quality of life is it anyway? Discrepancies between youth and parent health-related quality of life ratings in type 1 and type 2 diabetes. Qual Life Res 2016; 25:1113-21. [PMID: 26466834 PMCID: PMC4936832 DOI: 10.1007/s11136-015-1158-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Health-related quality of life (HRQOL) is a critical diabetes outcome, yet differences between youth and parent-proxy ratings can make interpretation difficult. This study aims to explore potential differences between self- and parent-reports of Pediatric Quality of Life Inventory (PedsQL) scores from youth with type 1 (T1D) or type 2 diabetes (T2D) and to evaluate associations between discrepancies, PedsQL scores, and glycemic control (HbA1c). METHODS Youth and parents in the SEARCH for Diabetes in Youth Study (T1D: age 5-18, n = 3402; T2D: age 8-18, n = 353) completed the PedsQL Generic and Diabetes Modules, and youth provided a blood sample to assess HbA1c. Discrepancies (youth minus parent PedsQL ratings) were calculated and examined by age and diabetes type, and associations with youth PedsQL scores and HbA1c were evaluated. RESULTS Discrepancies existed between youth and parent-proxy reports of generic and diabetes PedsQL scores in T1D and T2D (all p values < 0.01). Higher (more favorable) ratings were reported by youth except for those 5-7-years old, where parents' scores were higher. When parent-proxy scores were higher, discrepancies were largest when the child reported low PedsQL scores. Higher HbA1c was associated with larger discrepancies (youth scores higher) for adolescents with T1D. CONCLUSIONS Discrepant PedsQL ratings suggest that parents may often underestimate youths' HRQOL except in the youngest children. Although examining both reports is optimal, the youth report should be prioritized, particularly for young children with T1D and for adolescents with either T1D or T2D.
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Affiliation(s)
- Joyce P Yi-Frazier
- Department of Endocrinology, Seattle Children's Research Institute, Seattle, WA, 98101, USA.
| | - Marisa E Hilliard
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Nora F Fino
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michelle J Naughton
- Division of Population Sciences, The Ohio State University, Columbus, OH, 43201, USA
| | - Angela D Liese
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Christine W Hockett
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, 80045, USA
| | - Korey K Hood
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, 94305, USA
| | - Catherine Pihoker
- Department of Endocrinology, Seattle Children's Research Institute, Seattle, WA, 98101, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, 98105, USA
| | - Michael Seid
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Wei Lang
- Division of Population Sciences, The Ohio State University, Columbus, OH, 43201, USA
| | - Jean M Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
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20
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Egberts MR, van de Schoot R, Boekelaar A, Hendrickx H, Geenen R, Van Loey NEE. Child and adolescent internalizing and externalizing problems 12 months postburn: the potential role of preburn functioning, parental posttraumatic stress, and informant bias. Eur Child Adolesc Psychiatry 2016; 25:791-803. [PMID: 26608402 PMCID: PMC4932136 DOI: 10.1007/s00787-015-0788-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 10/22/2015] [Indexed: 11/28/2022]
Abstract
Adjustment after pediatric burn injury may be a challenge for children as well as their parents. This prospective study examined associations of internalizing and externalizing problems in children and adolescents 12 months postburn with preburn functioning, and parental acute and chronic posttraumatic stress symptoms (PTSS) from different perspectives. Child, mother, and father reports of 90 children (9-18 years), collected within the first month and 12 months postburn, were analyzed. Results indicated that overall, child and parental appraisals of pre- and postburn behavioral problems were not significantly different from reference data. Rates of (sub)clinical postburn behavioral problems ranged from 6 to 17 %, depending on the informant. Pre- and postburn behavioral problems were significantly related, but only from the parents' perspective. Path models showed an association between parental PTSS 12 months postburn and parental reports of child internalizing problems, as well as a significant indirect relationship from parental acute stress symptoms via PTSS 12 months postburn. Notably, no associations between parental PTSS and child reports of postburn behavioral problems were found. In conclusion, parental observations of child externalizing problems appear to be influenced by their perspectives on the child's preburn functioning, while parental observations of internalizing problems are also related to long-term parental PTSS. However, these factors seem of no great value in predicting behavioral problems from the child's perspective, suggesting substantial informant deviations. To optimize adjustment, clinical burn practice is recommended to adopt a family perspective including parent perception of preburn functioning and parental PTSS in assessment and intervention.
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Affiliation(s)
- Marthe R. Egberts
- />Association of Dutch Burn Centres, P. O. Box 1015, 1940 EA Beverwijk, The Netherlands , />Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands
| | - Rens van de Schoot
- />Department of Methodology and Statistics, Faculty of Social Sciences, Utrecht University, Utrecht, The Netherlands , />Optentia Research Program, Faculty of Humanities, North-West University, Vanderbijlpark, South Africa
| | - Anita Boekelaar
- />Burn Centre Red Cross Hospital, Beverwijk, The Netherlands
| | | | - Rinie Geenen
- />Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands
| | - Nancy E. E. Van Loey
- />Association of Dutch Burn Centres, P. O. Box 1015, 1940 EA Beverwijk, The Netherlands , />Department of Clinical and Health Psychology, Utrecht University, Utrecht, The Netherlands
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21
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Willebrand M, Sveen J. Perceived support in parents of children with burns. Gen Hosp Psychiatry 2016; 38:105-8. [PMID: 26596191 DOI: 10.1016/j.genhosppsych.2015.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Children sustaining burns that require treatment in a burn center have a need for multiprofessional aftercare services over a prolonged time. So far, there is little research into satisfaction with care and support after pediatric burns. The aim was to investigate parents' perception of support after pediatric burn and associations with parent, child and injury characteristics. METHOD Parents (n=101) of children aged 0.4-17.8 years completed questionnaires on support, parent's psychological symptoms and health of the child. Time since injury was 0.1-9.0 years. RESULTS Perceived lack of psychosocial, medical, societal or family support was reported by 21% of the parents. Lack of support was not associated with injury or sociodemographic characteristics, but it was significantly associated with parents' symptoms of general anxiety, depression and injury-related fear avoidance, as well as parents' ratings of their child's general health and heat sensitivity. CONCLUSION Perceived support did not differ on account of burn severity or sociodemographic status. However, care providers should be more attentive to and supportive of parents signaling poorer general health in their child and cognitive beliefs that the child is at risk for harm when active and parents who themselves show signs of psychological symptoms.
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Affiliation(s)
- M Willebrand
- Department of Neuroscience (Psychiatry), Uppsala University, 751 85 Uppsala, Sweden.
| | - J Sveen
- Department of Neuroscience (Psychiatry), Uppsala University, 751 85 Uppsala, Sweden.
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