Health status after recovery from burn injury

Development and Validation of Indicators for Population Injury Surveillance in Hong Kong: Development and Usability Study

BACKGROUND

Injury is an increasingly pressing global health issue. An effective surveillance system is required to monitor the trends and burden of injuries.

OBJECTIVE

This study aimed to identify a set of valid and context-specific injury indicators to facilitate the establishment of an injury surveillance program in Hong Kong.

METHODS

This development of indicators adopted a multiphased modified Delphi research design. A literature search was conducted on academic databases using injury-related search terms in various combinations. A list of potential indicators was sent to a panel of experts from various backgrounds to rate the validity and context-specificity of these indicators. Local hospital data on the selected core indicators were used to examine their applicability in the context of Hong Kong.

RESULTS

We reviewed 142 articles and identified 55 indicators, which were classified into 4 domains. On the basis of the ratings by the expert panel, 13 indicators were selected as core indicators because of their good validity and high relevance to the local context. Among these indicators, 10 were from the construct of health care service use, and 3 were from the construct of postdischarge outcomes. Regression analyses of local hospitalization data showed that the Hong Kong Safe Community certification status had no association with 5 core indicators (admission to intensive care unit, mortality rate, length of intensive care unit stay, need for a rehabilitation facility, and long-term behavioral and emotional outcomes), negative associations with 4 core indicators (operative intervention, infection rate, length of hospitalization, and disability-adjusted life years), and positive associations with the remaining 4 core indicators (attendance to accident and emergency department, discharge rate, suicide rate, and hospitalization rate after attending the accident and emergency department). These results confirmed the validity of the selected core indicators for the quantification of injury burden and evaluation of injury-related services, although some indicators may better measure the consequences of severe injuries.

CONCLUSIONS

This study developed a set of injury outcome indicators that would be useful for monitoring injury trends and burdens in Hong Kong.

The CARe Burn Scale-Adult Form: Translation and linguistic validation into Finnish

BACKGROUND

Burn injury can dramatically deteriorate health-related quality of life. Effective burn care may minimize the impact of the burn injury and ensure optimal functional outcome. This requires continuous improvement in burn care and assessment of treatment results. The aim of this study was to translate, culturally adapt and linguistically validate the CARe Burn Scale-Adult Form, a burn-specific patient-reported outcome measure, into Finnish.

METHODS

The translation process followed the International Society for Pharmacoeconomics and Outcomes Research guidelines consisting of forward and backward translations, pilot-testing and cognitive debriefing interviews of five burn patients, and proofreading before finalizing. The process involved expert panel meetings and continuous discussion between the developers of the Scale and the research group.

RESULTS

In the forward translation 10 amendments were required. After the backward translation, 12 items were reworded. Cognitive debriefing interviews led to three alterations enhancing the comprehensiveness and accuracy of the translation. The translation was reviewed by burn occupational therapists for practicality, resulting in 12 modifications. Minor grammatical changes were made after proofreading.

CONCLUSION

The Finnish version is the first foreign translation of the CARe Burn Scale. It is equivalent to the original Scale and ready for psychometric validation with burn patients in Finland.

A quantitative systematic review assessing the impact of burn injuries on body image

This study systematically reviewed the quantitative evidence for the impact of burn injuries on body image. Primary research assessing body image using standardized scales published in peer-reviewed journals were systematically searched using the electronic databases PubMed, Scopus, CINHAL, and PsycINFO in January 2020. Studies reporting relationships between characteristics related to burn injury and body image outcomes were included. Quality was assessed using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies. Included studies varied in comparison methods and body image measures, with most reporting cross-sectional relationships. Among the 33 included studies, 12 reported a negative association between burn severity and body image, 14 reported no significant association, six showed mixed (negative and null) results across the burn injury measures, and one reported more positive body image among burn survivors compared to those without burns. This review identified evidence supporting the association between burn severity and lower satisfaction with body image. Individuals with body image concerns, particularly those with higher burn severity and women, may benefit most from interventions that address self-acceptance and coping mechanisms. Further cross-sectional studies with representative control groups and longitudinal studies with longer follow-up periods are required.

Spiritual Transcendence and Psychological Adjustment: The Moderating Role of Personality in Burn Patients

The current study examined the moderating role of personality traits (neuroticism and extraversion) on the relationship between spiritual transcendence and positive change, and spiritual transcendence and distress in burn patients. The sample (N = 98) comprised adult burn patients (age = 25-50) admitted to three hospitals in Lahore, Pakistan. They were assessed according to a demographic information sheet, the NEO Personality Inventory (McCrae and Costa in J Personal Soc Psychol 52:81-90, 1987), the Spiritual Transcendence Index (Seidlitz et al. in J Sci Study Relig 41:439-453, 2002), the Depression, Anxiety, Stress Scales-21 (Lovibond and Lovibond in Manual for the Depression Anxiety Stress scales, Psychology Foundation, Sydney, 1995), and the Perceived Benefit Scales (McMillen and Fisher in Soc Work Res 22(3):173-186, 1998). Stepwise moderated regression analysis showed that both personality traits (neuroticism and extraversion) played a moderating role in the relationship between spiritual transcendence and positive change, and spiritual transcendence and distress in burn patients. The findings highlight the potential role spiritual transcendence may have in understanding and improving the psychological adjustment of burn patients.

Psychological Reactions, Social Support, and Coping Styles in Pakistani Female Burn Survivors

This study was aimed to explore the level of psychological distress and posttraumatic stress among female burn survivors in Pakistan. It was also intended to study the kind of social support available to these burn survivors in a society where women right violation is common. The sample consisted of 35 female burn victims selected from two hospitals. General Health Questionnaire, posttraumatic stress disorder Checklist-Specific, and Social Support Scale were used to measure study variables in addition to a short open-ended questionnaire to identify coping strategies of these burn survivors. Consistent with the hypothesis, results found a high level of psychological reaction among female burn survivors. About one-quarter of the sample (23%) presented severe symptoms of psychological distress whereas 20% of the sample reported to experience severe posttraumatic stress disorder symptoms. There was a significant inverse relationship between psychological reactions and social support as hypothesized. Majority of female burn victims found to use emotion-focused coping (EFC) mainly including prayers, emotional discourse, and using drugs. The findings of the study would be helpful to plastic surgeons, dermatologists, psychologists, and social workers to understand the patient's psychological reactions, their copying styles, and the role of social support in the rehabilitation program for these survivors.

The Effect of Pre-Discharge Training on the Quality of Life of Burn Patients

Introduction: Many physical, psychological, social and economic complications have been reported after discharge, which have a negative impact on the quality of life of burn patients. The present research examines the effect of pre-discharge training program on the life quality of patients with burns.

Methods: This is a pre and post-experimental study with control group that was conducted in 2015 in teaching hospital Sina. The control group received the typical instructions upon being discharged from hospital while the experimental group received in-person training in the form of question-answer, pamphlets and a researcher-made instruction booklet. The patients’ life quality was evaluated when they were being discharged, a month and then three months after they were discharged.

Results: The result showed that the quality of life has a significant statistical difference across the three time points. And these differences are compared using Bonferroni’s adjustment multiple comparisons indicating that pre-discharge training affects the quality of life scores and this effect continues over time.

Conclusion: The results show that the pre-discharge training has significantly improved the life quality among the burns patients. The improvement of life quality is also correlated with the quantitative variable of total body surface area percent (TBSA %). Thus, planning and designing in-discharge training programs based on the existing context, combined with training packages focusing on the patients’ needs could be a very significant step in more successful implementation of the follow-up programs on the burn patients and improving their quality of life.

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 structured home-based exercise program on depression status and quality of life in burn patients

BACKGROUND

Burns can cause life-threatening injuries and severe limitations. This study aimed to evaluate the effects of the structured home-based exercise program on depression status and quality of life in burn patients.

MATERIALS AND METHODS

This study was carried out in the Wound and Burn Treatment Department of University of Health Sciences, Dr. Lütfi Kırdar Kartal Education and Research Hospital, Istanbul. Thirty burn patients voluntarily participated in this study. Patients' demographic data such as burn area and grade, percentage, type, number of grafts, and duration of hospitalization were recorded. The quality of life was evaluated using the Short Form-36 (SF-36), and depression status was evaluated using Beck Depression Inventory (BDI). The home-based exercise program was defined by the clinical physiotherapist on the day when the patient was discharged. The home-based exercise program was applied for 3 weeks. Evaluations were performed at discharge and repeated after 3 weeks at the end of the exercise program.

RESULTS

Of the 30 patients who completed the study (age range, 21-61 years; mean, 34.9±12.99 years), 96.7% (n=29) were male and 3.3% (n=1) were female. A statistically significant difference was observed between BDI and SF-36 scores before and after the home-based exercise program (p<0.05). BDI scores decreased after the home-based exercise program, whereas SF-36 scores increased.

CONCLUSION

Our study concludes that burn patients who underwent the structured home-based exercise programs attained acceleration of their physical, social, and psychological integrity. Thus, establishing a structured home-based exercise program according to the burn type and clinical course should be continued.

Validation of a Taiwanese Version of the Burn-Specific Health Scale-Brief

The purposes of this study were to translate the brief version of the Burn-Specific Health Scale (BSHS-B) into traditional Chinese (Taiwanese) and to evaluate its psychometric properties to measure quality of life of burn patients in Taiwan. The BSHS-B-Taiwanese was translated and reviewed by an expert committee. Patients were invited to participate in this study while they visited the outpatient burn clinic. One hundred and eight burn patients participated in this study by filling out the BSHS-B-Taiwanese and SF-36 Taiwanese version. Forty-one of 108 patients completed a retest on the BSHS-B-Taiwanese. A ceiling effect was found for psychosocial functioning and all domains of the BSHS-B-Taiwanese. Internal consistency shown by Cronbach's alpha was all above 0.70 except for the interpersonal relationships domain. Of these, Cronbach's alpha ≥0.9 was found in the work, heat sensitivity, and body image domains. Test-retest reliabilities ranged from 0.74 to 0.93 except for the simple activity domain. As for the criterion validity, most of the BSHS-B-Taiwanese version was shown to have fair to moderate correlations with the SF-36-Taiwanese in corresponding domains. The discriminant validity of the BSHS-B-Taiwanese was demonstrated by significant score differences in several domains between subgroups of different severity regarding length of hospital stay and TBSA. Our finding suggests that the BSHS-Taiwanese is generally reliable and valid. A shorter version of BSHS-B-Taiwanese together with a generic instrument, such as SF-36, can be used to measure the quality of life of burn patients in Taiwan.

Epidemiologic characteristics of death by burn injury from 2000 to 2009 in Colombia, South America: a population-based study

Background

Burns are one of the most severe traumas that an individual can suffer. The World Health Organization (WHO) affirms that injuries related to burns are a global public health problem mainly in low- and middle-income countries. The first step towards reducing any preventable injury is based on accurate information. In Colombia, the basic epidemiological characteristics of burn injuries are unknown. The objectives were establishing the causes, high-risk populations, mortality rate, and tendencies of burn deaths.

Methods

Observational, analytical, population-based study based on official death certificate occurred between 2000 and 2009. All codes of the International Classification of Diseases-10th Revision (ICD-10) related to burns were included. The mortality rates were standardized using the WHO world average age weights 2000–2025. To determine the tendency, an average annual percent change (AACP) was calculated.

Results

A total of 5448 deaths due to burns were identified; 78.4 % were men. The crude and adjusted burn mortality rate was 1.270 and 1.302 per 100,000, respectively. The AACP was −5.25 %. Electrical injury caused the greatest number of deaths (49.5 %), followed by fire and lightning injuries. A total of 1197 (22.1 %) children were under 15 years old. The causes of deaths were different among age groups. 59.4 % deaths occurred outside health institutions.

Conclusions

This study is a first step in identifying the main causes of death and groups with higher mortality rates. Electricity is the main cause of deaths due to burn injury. Further research is required in order to generate awareness among government and community for reducing the number of injuries and burn deaths in our country.

Assessment of quality of life (QoL) of burn patients in India using BSHS-RBA scale

INTRODUCTION

The Burn Specific Health Scale-Brief (BSHS-B) is a popular instrument to measure quality of life (QoL) in burn patients. The current study aims at identifying the prognostic variables for our burn population using the BSHS-RBA (revised, brief and adapted) scale.

MATERIALS AND METHODS

The study was conducted on 60 post-burn patients using the BSHS-RBA scale. The questionnaire was administered by an interview as majority of patients were illiterate. The socio-demographic and clinical variables were analyzed against domain scores and total scores of the scale, using Mann-Whitney test and Kruskal Wallis test.

RESULTS

The median age of the sample was 28 years, of which 60% were females. Their median TBSA burn was 30%. The median time since burn at the time of interview was 10 months. Higher scores were noted in the domains of simple abilities and mobility, hand function and interpersonal relationship, while poorer scores were recorded in domains of skin sensitivity and body image.

DISCUSSION

The mean score in our study was 2.36, which is quite less as compared to reports from high income countries (range: 2.58-3.36). This study provides an insight on an aspect of burn care outcome, which can be reasonably expected in low income countries with the available standard of care. Being a female, presence of hand and face burn, requirement of corrective surgeries and inability to resume work were factors associated with poor QoL.

CONCLUSION

Strategies to improve QoL of burn patients should target psychological aspects, work rehabilitation (early release of contractures) and skin hypersensitivity (including itching) to derive maximum benefit.

Early rehabilitative exercise training in the recovery from pediatric burn

PURPOSE

The purpose of this study was to determine the effects of early outpatient exercise on muscle mass, function, and fractional synthetic rate in severely burned children.

METHODS

Forty-seven children with ≥40% total body surface area burn performed a 12-wk standard of care rehabilitation (SOC, n = 23) or rehabilitative exercise training (RET, n = 24) immediately after hospital discharge. Dual-energy x-ray absorptiometry was used to assess lean body mass (LBM) at discharge, posttreatment, and 12 months post-burn. Muscle function was evaluated with a Biodex Isokinetic Dynamometer, and peak aerobic fitness (V˙O2peak) was measured using a modified Bruce treadmill protocol posttreatment. Stable isotope infusion studies were performed in a subset of patients (SOC, n = 13; RET, n = 11) at discharge and posttreatment to determine mixed-muscle fractional synthetic rate.

RESULTS

Relative peak torque (RET, 138 ± 9 N·m·kg, vs SOC, 106 ± 9 N·m·kg) and V˙O2peak (RET, 32 ± 1 mL·kg·min, vs SOC, 28 ± 1 mL·kg·min) were greater at posttreatment with RET compared with those with SOC. In addition, RET increased whole-body (9% ± 2%) and leg (17% ± 3%) LBM compared with SOC. Furthermore, the percentage change in whole-body (18% ± 3%) and leg (31% ± 4%) LBM from discharge to 12 months post-burn was greater with RET compared to SOC. Muscle fractional synthetic rate decreased from discharge to posttreatment in both groups (6.9% ± 1.1% per day vs 3.4 ± 0.4% per day); however, no differences were observed between treatment groups at each time point.

CONCLUSIONS

Early outpatient exercise training implemented at hospital discharge represents an effective intervention to improve muscle mass and function after severe burn injury.

Long term outcomes data for the Burns Registry of Australia and New Zealand: Is it feasible?

BACKGROUND

Incorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care.

AIMS

To evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry.

METHODS

Five Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed.

RESULTS

463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates.

CONCLUSIONS

The low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.

Towards more efficient burn care: Identifying factors associated with good quality of life post-burn

BACKGROUND

As minor burn patients constitute the vast majority of a developed nation case-mix, streamlining care for this group can promote efficiency from a service-wide perspective. This study tested the hypothesis that a predictive nomogram model that estimates likelihood of good long-term quality of life (QoL) post-burn is a valid way to optimise patient selection and risk management when applying a streamlined model of care.

METHOD

A sample of 224 burn patients managed by the Burn Service of Western Australia who provided both short and long-term outcomes was used to estimate the probability of achieving a good QoL defined as 150 out of a possible 160 points on the Burn Specific Health Scale-Brief (BSHS-B) at least six months from injury. A multivariate logistic regression analysis produced a predictive model provisioned as a nomogram for clinical application. A second, independent cohort of consecutive patients (n=106) was used to validate the predictive merit of the nomogram.

RESULTS AND DISCUSSION

Male gender (p=0.02), conservative management (p=0.03), upper limb burn (p=0.04) and high BSHS-B score within one month of burn (p<0.001) were significant predictors of good outcome at six months and beyond. A Receiver Operating Curve (ROC) analysis demonstrated excellent (90%) accuracy overall. At 80% probability of good outcome, the false positive risk was 14%. The nomogram was validated by running a second ROC analysis of the model in an independent cohort. The analysis confirmed high (86%) overall accuracy of the model, the risk of false positive was reduced to 10% at a lower (70%) probability. This affirms the stability of the nomogram model in different patient groups over time. An investigation of the effect of missing data on sample selection determined that a greater proportion of younger patients with smaller TBSA burns were excluded due to loss to follow up.

CONCLUSION

For clinicians managing comparable burn populations, the BSWA burns nomogram is an effective tool to assist the selection of patients to a streamlined care pathway with the aim of improving efficiency of service delivery.

Polish adaptation and validation of burn specific health scale - brief

BACKGROUND

The Burn Specific Health Scale - Brief is a well-described, specific tool to assess health condition (quality of life) of burnt patients. This project was aimed at creating a Polish adaptation and validation of the Burn Specific Health Scale - Brief.

METHOD

Adaptation of the tool was performed in two stages. The first stage involved translation, back translation, evaluation by a panel of judges and a pre-test of the tool. The second stage consisted of surveying 202 burned patients. Those data were used to conduct a psychometric analysis. Reliability was checked by determining the Cronbach's α internal consistency coefficient and conducting the test-retest procedure (ICC). Content validity was evaluated by a panel of judges. Criterion validity was determined using SF-36. Construct validity was determined using known-groups validation.

RESULTS

Reliability of the tool, determined using the internal consistency coefficient (Cronbach's α=0.94) and the test-retest procedure (ICC=0.89), proved to be high. Criterion validity, determined using the relationship of results of comparable BSHS-B and SF-36 subscales, obtained a satisfactory level with a correlation of r=0.55-0.89 (p<0.01). Analysis of inter-group differences showed that patients who stayed at a hospital for more than 10 days (p=0.002), patients after surgical intervention (p=0.018), patients with a burn larger than 19% of the TBSA (p=0.01) and patients with 3rd degree burns (p=0.001) have much poorer results than the rest of the subjects.

DISCUSSION

The Polish version of BSHS-B is a reliable and valid tool for assessing quality of life of burned patients. It may be used to plan the burn treatment process and evaluate its outcomes.

The Chinese language version of the abbreviated burn specific health scale: a validation study

BACKGROUND

The Burn Specific Health Scale (BSHS) is designed to measure burn-specific, health-related quality of life (HRQoL). The aim of the present study was to evaluate the reliability and validity of the Chinese version of the abbreviated BSHS (BSHS-A).

METHODS

The English version of the BSHS-A was translated into Chinese using a standardised procedure. The participants were 457 patients classified into three severity groups (mild, moderate and severe). All patients completed the Chinese BSHS-A questionnaire, the Short Form-36 (SF-36) and the EuroQol 5-Dimensions (EQ-5D). To evaluate clinical utility of the BSHS-A, we used Cronbach's alpha (internal consistency), intraclass correlation coefficients (ICCs; test-retest reliability) and construct validity (using the SF-36 and EQ-5D).

RESULTS

Cronbach's alpha for all subscales was >0.80, demonstrating high internal consistency of the BSHS-A (Chinese version). The ICC was >0.70 for each patient group. Strong correlations were observed between the BSHS-A and SF-36 and EQ-5D scales. Neither floor nor ceiling effects were found.

CONCLUSION

The present study demonstrated that the BSHS-A (Chinese version) has good psychometric properties, showing suitable internal consistency and test-retest reliability. The BSHS-A may, thus, be useful for assessing HRQoL in Chinese burn victims. However, adaptations may be required to reduce its length.

Influencing factors of the quality of life in Chinese burn patients: Investigation with adapted Chinese version of the BSHS-B

OBJECTIVE

The study aims to evaluate the quality of life (QOL) in burn patients in China and find out principal influencing factors, so as to provide evidence for interventions.

METHODS

A total of 271 burn patients in three major burn units in China were asked to fill in the adapted Chinese version (ACV) of the Burn Specific Health Scale-Brief (ACV BSHS-B) in order to seek out the principal influencing factors in combination with a self-designed demographic and disease condition questionnaire. Multivariable linear regression was used to analyse the principal influencing factors.

RESULTS

The findings showed that there were seven principal influencing factors for the overall ACV BSHS-B score. They were: percent total body surface area (TBSA) burned (with the standardised regression coefficient being -0.594), burn area of lower limber (0.241), itch level (-0.227), pain level (-0.220), gender (0.217), mechanical ventilation (0.216) and hand deformity (-0.141).

CONCLUSION

QOL decreased in burn patients to different degrees depending on the intensity of burns. With a better understanding of influencing factors of burn patients' QOL, the medical and nursing staff can take specific countermeasures to help patients gain a higher QOL.

Development of quality of life scale in Chinese burn patients: cross-cultural adaptation process of burn-specific health scale - brief

PURPOSE

This study was designed to develop and test a Chinese burn patient-specific quality of life (QOL) scale based on the burn-specific health scale - brief (BSHS - B) to provide an effective assessment tool to measure quality of life in Chinese burn patients.

METHOD

Delphi method was used after the translation, back translation and pre-commissioning tests of BSHS - B, to amend the description of the items for cultural adaptation. The adapted Chinese version (ACV) of the BSHS - B was tested for internal consistency and validity of construct on a group of 271 burn patients from three major burn units in China.

RESULTS

Thirty-eight items within six domains of ACV BSHS-B were developed with scoring '0-4' in each item. The mean total score for our study group was 98.36 (standard deviation (S.D.)=37.86), ranging from 13 to 150. The total Cronbach's alpha value was 0.97 and total split-half reliability was 0.98, demonstrating that the internal consistency of the ACV was very high. Pearson correlations among the six domains of ACV BSHS - B were statistically significant. Exploratory factor analysis results showed that the six-factor function explained 78.30% of total variance; each entry in the corresponding domain had a factor-loading value higher than 0.4, indicating that the scale has a good validity.

CONCLUSION

The ACV of the BSHS - B showed good reliability and validity, and can be used as a tool for assessing the QOL in Chinese burn patients.

Validation of the Persian version of the Burn Specific Health Scale-Brief

BACKGROUND

The Burns Specific Health Scale-Brief (BSHS-B) is easy to apply, can be self-administered, and is considered a suitable instrument to measure general health and the physical, mental, and social aspects of burn victims' life.

AIM

The purpose of this study was to translate and culturally adapt the BSHS-B into the Persian language and to investigate its psychometric properties.

METHODS

The BSHS-B was translated and adapted for Iranian patients. 200 patients (94.34%) filled out the questionnaire. The psychometric properties of the scale, including its internal consistency, test-retest reliability, and construct validity through the known-groups technique were evaluated.

RESULTS

The Cronbach's alpha coefficient of total scores of the questionnaire was 0.94, demonstrating reasonable internal consistency of the instrument. The test-retest coefficients were reported to be between 0.81 and 0.96. The scale's construct validity was statistically significant. Principal components' factor analysis was used to derive an instrument called the Burn Specific Health Scale-Brief in eight domains. The domains described patients' functions in terms of "Heat sensitivity", "Affect", "Hand function & simple abilities", "Treatment regimens", "Work", "Sexuality", "Interpersonal relationships", and "Body image".

CONCLUSIONS

The reliability and validity of the adapted version of the BSHS-Brief was shown to be satisfactory. Thus, it can be used to investigate quality of life of Iranian patients suffering from burn.

Epidemiology and impact of scarring after burn injury: a systematic review of the literature

The purpose of this study was to perform a systematic review of the existing literature on the incidence of hypertrophic scarring and the psychosocial impact of burn scars. In a comprehensive literature review, the authors identified 48 articles published since 1965 and written in English which reported the incidence and risk factors for hypertrophic scarring or assessed outcomes related to scarring. Most studies had important methodological limitations limiting the generalizability of the findings. In particular, the absence of standardized valid measures of scarring and other outcome variables was a major barrier to drawing strong conclusions. Among studies on hypertrophic scarring, the prevalence rate varied between 32 and 72%. Identified risk factors included dark skin, female gender, young age, burn site on neck and upper limb, multiple surgical procedures, meshed skin graph, time to healing, and burn severity. With regard to psychosocial outcomes, two studies compared pediatric burn survivors with a nonburn comparison group on a body image measure; neither study found differences between groups. Across studies, burn severity and location had a modest relationship with psychosocial outcome variables. Psychosocial variables such as social comfort and perceived stigmatization were more highly associated with body image than burn characteristics. To advance our knowledge of the epidemiology of scars and the burden of scars, future studies need to implement more rigorous methodologies. In particular, standardized valid measures of scarring and other outcomes should be developed. This process could be facilitated by an international collaboration among burn centers.

Burn Specific Health up to 24 months after the Burn-A prospective validation of the simplified model of the Burn Specific Health Scale-Brief

BACKGROUND

Outcome after burn injury is a multidimensional concept, but few multidimensional, injury-specific outcome measures have been psychometrically evaluated. A recent cross-sectional study using the Burn Specific Health Scale-Brief (BSHS-B) found three psychometrically sound health domains: function, skin involvement, and affect and relations. The aim of this study was to reexamine the psychometric properties of the BSHS-B using a prospective study design.

METHODS

Ninety-four consecutive adult patients with burns were included and asked to fill in questionnaires, the BSHS-B, the Hospital Anxiety and Depression Scale, and the short-form 36 (SF-36), at 6 months, 12 months, and 24 months postburn.

RESULTS

The factor structure was replicated and the three domains, function, skin involvement, and affect and relations, had excellent internal consistency. Over time the scores of function and skin involvement increased, indicating health improvement, whereas the domain affect and relations did not change over time. At 6 months and 12 months postburn, all domains were associated with burn severity. The function domain was highly associated with the SF-36 subscales physical functioning and role-physical, the affect and relations domain was highly associated with the Hospital Anxiety and Depression Scale and the SF-36 subscales denoting psychological health, and the domain skin involvement was highly associated with subscales indicating role-concerns, social functioning, vitality, and mental health.

CONCLUSION

The psychometric properties of the BSHS-B domains were excellent and they had intelligible concurrent associations with other measures. Thus, the simplified model of the BSHS-B is a reliable, valid, and useful tool in describing postburn health over time.

Prognostic scoring systems in burns: a review

Survival after burn has steadily improved over the last few decades. Patient mortality is, however, still the primary outcome measure for burn care. Scoring systems aim to use the most predictive premorbid and injury factors to yield an expected likelihood of death for a given patient. Age, burn surface area and inhalational injury remain the mainstays of burn prognostication, but their relative weighting varies between scoring systems. Biochemical markers may hold the key to predicting outcomes in burns. Alternatively, the incorporation of global scales such as those used in the general intensive care unit may have relevance in burn patients. Outcomes other than mortality are increasingly relevant, especially as mortality after burns continues to improve. The evolution of prognostic scoring in burns is reviewed with specific reference to the more widely regarded measures. Alternative approaches to burn prognostication are reviewed along with evidence for the use of outcomes other than mortality. The purpose and utility of prognostic scoring in general is discussed with relevance to its potential uses in audit, research and at the bedside.

Biopsychosocial factors that interfere in the rehabilitation of burn victims: integrative literature review

This study aimed to identify the biopsychosocial factors that influence the rehabilitation of burn victims, through an integrative literature review, from January 1987 to January 2007. Articles were searched in databases Scielo, Pubmed and Lilacs, resulting in 982 articles, of which 45 were selected, after the analysis and categorization processes. Most studies were descriptive and qualitative. The most frequently associated factors to the rehabilitation process were: mental health state before the accident, coping strategies and family support, besides the severity of the burn and the total body surface area burned. The quality of the selected studies, most classified as evidence level VI, shows the scarce production of strong evidences in this knowledge area, which needs more investment, considering the important implications of the sequelae of burns in the social reintegration of these people.

Gender differences in the quality of life and coping patterns after discharge in patients recovering from burns in China

The purpose of this study was to investigate gender differences in quality of life and coping patterns after discharge for patients with burns in China. Cross-sectional survey research design and purposive sampling were used in this study, for which 92 subjects, including 56 males and 36 females, were recruited from a medical centre in central China. Quality of life was measured by the burn-specific health scale-brief (BSHS-B) and coping patterns were measured with the coping with burns questionnaire (CBQ), while demographic data was collected using a demographic questionnaire. An independent t-test and bivariate correlate were employed to analyse the data. The study results showed significant differences in quality of life between genders and coping patterns. There was a statistically significant gender difference in the sub-domain of the BSHS-B score for affect and relations, p < 0.05, and for coping patterns: emotion support, p < 0.05. The findings indicated that optimism/problem solving, revolution/adjustment and avoidance were the most commonly used coping patterns for males and females. The rank orders were same. The study indicated that women are more sensitive to relationships with family after discharge and tend to exhibit depressive symptoms. For women, emotional support is more important than it is for men. A number of significant positive and negative correlations were found among the variables.

Use of healthcare a long time after severe burn injury; relation to perceived health and personality characteristics

PURPOSE

The aim of the study was to evaluate which factors are associated with the use of healthcare a long time after severe burn injury.

METHOD

After a review process based on clinical reasoning, 69 former burn patients out of a consecutive group treated at the Uppsala Burn Unit from 1980--1995 were visited in their homes and their use of care and support was assessed in a semi-structured interview. Post-burn health was assessed with the Burn-Specific Health Scale-Brief (BSHS-B) and personality was assessed with the Swedish universities Scales of Personality (SSP).

RESULTS

The participants were injured on average eight years previously. Thirty-four had current contact with healthcare due to their burn injury and had significantly lower scores on three BSHS-B-domains: Simple Abilities, Work and Hand function, and significantly higher scores for the SSP-domain Neuroticism and the SSP-scales Stress Susceptibility, Lack of Assertiveness, and lower scores for Social Desirability. There was no relation to age, gender, time since injury, length of stay, or to the surface area burned.

CONCLUSIONS

A routine screening of personality traits as a supplement to long-term follow-ups may help in identifying the patient's need for care.

The cultural adaptation and validation of the "Burn Specific Health Scale-Revised" (BSHS-R): version for Brazilian burn victims

BACKGROUND

The Burns Specific Health Scale-Revised (BSHS-R) is of easy application, can be self-administered, and it is considered a good scale to evaluate various important life aspects of burn victims.

OBJECTIVES

To translate and culturally adapt the BSHS-R into the Brazilian-Portuguese language and to evaluate the internal consistency and convergent validity of the translated BSHS-R.

METHODS

The cultural adaptation of the BSHS-R included translation and back-translation, discussions with professionals and patients to ensure conceptual equivalence, semantic evaluation, and pre-test of the instrument. The Final Brazilian-Portuguese Version (FBPV) of the BSHS-R was tested on a group of 115 burn patients for internal consistency and validity of construct (using the Rosenberg Self-Esteem Scale (RSES) and the Beck Depression Inventory (BDI)).

RESULTS

All values of Cronbach's alpha were greater than .8, demonstrating that the internal consistency of the FBPV was very high. Self-esteem was highly correlated with affect and body image (r=.59, p<.001), and with interpersonal relationships (r=.51, p<.001). Correlations between the domains of the FBPV and the BDI were all negative but larger in magnitude than the correlations with RSES. Depression was highly correlated with affect and body image (r=-.77, p<.001), and with interpersonal relationships (r=-.67, p<.001).

CONCLUSIONS

The results showed that the adapted version of the BSHS-R into Brazilian-Portuguese fulfills the validity and reliability criteria required from an instrument of health status assessment for burn patients.

The risk factors of psychosocial problems for burn patients

Many burn patients experience psychosocial problems such as personality change, post-traumatic stress disorder, family trouble, and financial burden. The purpose of this study was to identify the risk factors of these psychosocial problems that prevented burn patients from developing appropriate adjustments after burn. Six hundred eighty-six adult burn inpatients were interviewed. Most of them suffered from burns less than 10% of total body surface area. They were asked to fill in a questionnaire for this study, which was a psychosocial problem checklist of 17 items. Descriptive analysis, factor analysis, Chi-square test, and multiple logistic regression analysis were used to analyze the results. Lack of family support and living expense burden were the two significant risk factors for psychosocial problems including, burn treatment problems, rehabilitation problems, and welfare information problems on both acute and chronic burn patients. Medical expense burden was the risk factor among chronic burn patients. These findings suggested that active interventions by the burn team including mental health professionals (psychologist, psychiatrist or social worker) might reduce psychosocial problems of burn patients and encourage social rehabilitation.

Improving the ability to predict mortality among burn patients

BACKGROUND

Early efforts to predict death following severe burns focused on age and burn size; more recent work incorporated inhalation injury and pneumonia. Gender, co-morbid illness, and co-existent trauma have been implicated in burn mortality but have rarely been incorporated into predictive models.

METHODS

The National Burn Repository (NBR) and the National Trauma Data Bank (NTDB) provided data on 68,661 (54,219 and 14,442, respectively) burn patients that was used to develop and validate, respectively, a predictive model of burn mortality. Logistic regression was used to model the odds of mortality with respect to age, gender, % body surface area burned (BSAB), co-existent trauma, inhalation injury, pneumonia, and co-morbid illness. Performance of the predictive model was assessed using a deviance statistic, receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow (HL) statistic.

RESULTS

The predictive model that demonstrated optimal performance included the variables age, percent total BSAB, inhalation injury, co-existent trauma, and pneumonia. The area under the ROC curve for this model was 0.94 and the HL statistic was 16.0. The inclusion of additional variables, i.e., gender, co-morbid illness, did not improve the performance of the model despite reduction in the model deviance. When the predictive model was applied to the validation data source, the area under the ROC curve was 0.87 and the HL statistic was 10.0, indicating good discrimination and calibration.

CONCLUSION

The results of this study suggest that a comprehensive predictive model of burn mortality incorporating certain variables not previously considered in other models provides superior predictive ability.

Dermatology Life Quality Index (DLQI) Scores in Burn Victims After Revival

This study aimed to evaluate reliability and validity of the Dermatology Life Quality Index (DLQI) in Iranian burned patients and to examine this question, "Does burn severity or other demographical characteristics affect the patient's perception of his or her quality of life after burn injury?" In this study, we used the Persian version of DLQI questionnaire; its reliability and validity has been confirmed earlier in vitiligo patients. The questionnaire was administered to a group of patients with burn scars after revival. The internal consistency of the questionnaire was assessed by Cronbach's alpha coefficient. Validity was performed using convergent validity. In all, 109 patients (mean age, 28.94) enrolled in the study. The scores of DLQI ranged from 4 to 28 (mean +/- SD, 17.76 +/- 5.55). Reliability analysis showed satisfactory result (Cronbach's alpha, 0.75). Cronbach's alpha coefficient in the patients with a Burn Index >or=15% was greater than those with <15%, which is an acceptable result. The Persian version of the DLQI is a reliable and valid instrument for assessing the impacts of burn scars on quality of life. The life quality index of all the patients irrelevant to age and sex were significantly impaired.

Reliability and Validity of the Dutch Version of the American Burn Association/Shriners Hospital for Children Burn Outcomes Questionnaire (5–18 Years of Age)

The American Burn Association/Shriners Hospital for Children Burn Outcomes Questionnaire (BOQ) is a self-administered questionnaire to monitor functional outcome after burns in children and adolescents. This study aimed to assess feasibility, reliability, and validity of the Dutch BOQ. The BOQ was adapted into Dutch and tested in a population of children and adolescents aged 5 to 15 years who were primary admissions to a Dutch or Belgian burn center (n = 6) during the period of March 2001 through February 2004. To assess validity, the Child Health Questionnaire (CHQ) and the EuroQol-5D (EQ-5D) were included. Response rate was 53% among parents (n = 145) and 48% among adolescents (n = 52). Internal consistency of the BOQ scales was good (Cronbach's alpha >0.7 in all but one scale). Test and retest results were similar; there were no significant differences between parents and adolescents in this respect. Expected high correlations between BOQ scales and conceptually equivalent CHQ and EQ-5D scales were found in eight of 12 comparisons. Eleven scales showed significant differences in the expected direction between children with a long length of stay versus those with a short length of stay. The Dutch BOQ can be used to evaluate functional outcome after burns in children aged 5 years and older. Our study showed that the Dutch BOQ is a feasible instrument with good reliability and validity.

Quality of Life After Burn Injury: The Impact of Joint Contracture

We sought to investigate quality of life, and to specifically assess how joint contracture affects it, in patients with burn injuries. The study is involved 22 adults with burn injuries. Patients were divided into two groups according to the presence (n = 11) or absence (n = 11) of any joint contracture. Patient age, sex, date of burn injury, burn type, location, and extent of burn (TBSA) were recorded for each case. Each individual underwent a thorough musculoskeletal system examination, with special focus on range of motion of the joints. Quality of life was evaluated using the Short Form 36 (SF-36). Eight (36.4%) of the patients were women, and 14 (63.6%) were men, and their mean age (+/- SE) was 24.7 +/- 4.68 years. The mean interval from injury to the study assessment was 21.45 +/- 14.69 months. Eleven patients (50%) had at least one joint contracture. The patients with one or more contractures had significantly lower scores for the SF-36 subscales of physical functioning, physical role limitations, bodily pain, and vitality (P = .05, P = .01, P = .04, and P = .02, respectively). In the 22 patients overall, TBSA was negatively correlated with the scores for the SF-36 subscales vitality and emotional role limitations (r = -.586 and r = -.805, respectively). Joint contracture does impact burn patients' quality of life, especially with respect to physical functioning, physical role limitations, bodily pain, and vitality. In addition, the amount of BSA burned is correlated with psychosocial problems and poorer quality of life, regardless of whether joint contractures develop.

Long-term risk factors for impaired burn-specific health and unemployment in patients with thermal injury

The success of acute burn therapy has led to an increased demand for high-quality rehabilitation. When optimizing burn care programs, knowledge of long-term risk factors associated with impaired health and unemployment of the patient may be significant. The health and work status of 95 patients (82.1% males; mean age 43.7 (S.D.: 14.5) years; mean total body surface burn 18.5 (S.D.: 14.2) % were assessed 47.0 (S.D.: 23.8) months after injury, using the Norwegian version of the abbreviated burn-specific health scale (BSHS-N) and a questionnaire asking for socio-demographic and medical characteristics. A regression model demonstrated that the BSHS-N total score was significantly reduced by chronic pain (P<0.001), psychological illness (P<0.001), and living alone (P=0.030), as well as full-thickness facial (P=0.011) and foot (P=0.013) burns. Unemployment was significantly associated with housing and economic problems (P=0.001), chronic pain (P=0.001), the extent of full-thickness injury (P=0.005), the presence of deformities (P=0.037), the number of operations (P=0.001) and the length of hospital stay (P=0.016). Thus, socio-demographic factors, non-burn-related morbidity and the injury itself significantly impaired long-term physical and psychosocial health and work status.

Impaired Generic Health Status But Perception of Good Quality of Life in Survivors of Burn Injury

BACKGROUND

Although it is recognized that burn survivors face a variety of challenges related to physical, psychologic and social late-effects of their injury, the impact of thermal injury on the lives of patients is not fully understood. To learn more about burn patient needs and to obtain information relevant to the design of clinical programs for treatment and aftercare, self-reports on how burn patients perceive their health and quality of life may be of significant value.

METHODS

The generic health status (evaluated by SF-36) and overall quality of life (evaluated by the Quality of Life Scale [QOLS]) of 95 adult burn patients (total body surface area burned = 18.5 +/- 14.2% [mean +/- SD]; 82.1% men) were assessed 47.0 +/- 23.8 months postburn and compared with population norms.

RESULTS

The burn patient generic health status was significantly poorer than expected from general population scores, with reduced scores in the Physical Function (p < 0.001), Role Physical (p < 0.01), General Health (p < 0.001), Social Function (p < 0.001), and Role Emotional (p < 0.001) domains of the SF-36. Despite their reduced health status, overall quality of life was perceived as good, with QOLS scores similar to those of the general population. Patients living alone, unemployed, having nonburn physical illness, psychologic disorders, chronic pain, or having sustained full thickness injuries were found to be at particular risk.

CONCLUSIONS

Forty-seven months postinjury, burn patients still experienced a significant reduction of generic health, reporting limitations related to both physical and psychosocial SF-36 domains. On the other hand, the patients as a group reported overall quality of life similar to that of the norm population, suggesting that they were able to feel satisfaction with their new situation of life. Identification of several risk factors for reduced generic health status and overall quality of life support the need for specialized multidisciplinary aftercare for burn patients.

Reliability and validity of the Health Outcomes Burn Questionnaire for infants and children in The Netherlands

The Health Outcomes Burn Questionnaire (HOBQ) is a self-administered questionnaire to monitor outcome after burns in young children. This study aimed to assess feasibility, reliability and validity of the Dutch version of the HOBQ. The HOBQ was adapted into Dutch and tested in a population of children aged 0-4 years with a primary admission to a Dutch burn centre in March 2001-February 2004. Parents of 413 children were sent a questionnaire. To assess validity, a generic outcome instrument was included, the Infant Toddler Quality of Life Questionnaire (ITQOL). The response rate was 50.0% (n=196). Mean self-reported completion time was 16.7 min. The internal consistency of all the HOBQ-scales was good (Cronbach's alpha's>0.69). Test-retest results showed no differences in 7 out of 10 scales. High correlations between HOBQ-scales and conceptually equivalent ITQOL and scales were found in 5 out of 7 comparisons. The majority of the HOBQ-scales (7 out of 10) showed significant differences in the expected direction between children with a long versus short length of stay. Our data support the reliability and validity of the Dutch HOBQ. The HOBQ can be used as a research tool, to monitor functional outcome after burns in young children. Further research in other samples is recommend to fully establish the reliability and validity of the HOBQ.

Functional outcome after burns: a review

We conducted a Medline search (1966-11/2003) on empirical studies into the consequences of burns. The International Classification of Functioning, disabilities and health (ICF) was used to classify dimensions of functional outcome. We included 50 studies, reporting a wide spectrum of ICF-dimensions. The current state of knowledge on the functional outcome after burns was hard to summarise, due to the wide variety in study designs and outcome assessment methods. Some indications on the major functional problems after burns were gained. Problems in mental function were described in subgroups of patients, both in children/adolescents and adults. Restrictions in range of motion were observed in about one-fifth of burn patients, even 5 years after injury. Problems with appearance were reported often (up to 43%), even in patients with minor burns (14%). Problems with work were reported in 21-50% of the adult patients, with permanent incapacity for work in 1-5%. None of the publications gave sufficient information to fully estimate the functional consequences of burns. We recommend the development of a standard core set for measurement and reporting of functional outcome after burns.

Long term functional outcomes and quality of life following severe burn injury

This study was designed to examine functional and psychological outcome of severely burned patients adults. Adult patients (n=38) admitted to the Royal Brisbane hospital with burns >40% TBSA were assessed two years post injury using the Abbreviated BSHS and a supplemental questionnaire relating to specific physiotherapy and occupational health issues. An average return to driving occurred at 36 weeks and return to work at 51 weeks. Involvement of the hands and face significantly altered the physical domain of the questionnaire and the sub-domain examining role. Genital burns altered the sexual sub-domain, but this was not gender dependant. Mobility and self care were significantly altered when a burn was >20% TBSA full thickness. The study demonstrates that these patients can develop functional independence and good quality of life. The long term outlook for patients with large burns is generally positive. Consequently, burn care professionals can be reassured that the effort is worthwhile.

High risk for accidental death in previously burn-injured adults

This study investigated the long-term mortality in 1182 burn patients admitted at a single burn centre in 1984-2003. One thousand and forty-nine patients were discharged alive, of which 999 (95.2% of all discharged) were available for follow-up (mean observation time: 9.6+/-5.5 (S.D.) years). One hundred and twenty-two patients had died after discharge but before follow-up. For 111 patients, the official information recorded from their death certificates revealed that 83 patients (mainly in the higher age groups) had died due to a variety of natural causes. Twenty-three patients (M:F=18:5) (age: 37.7+/-11.3 years), previously hospitalised for burns, had later suffered accidental or violent deaths, including suicide (5), assault (2), and deaths related to substance and/or alcohol abuse (12). Additionally, five other deaths were recorded as sudden death, with no additional specific information as to the cause of death. This study shows that the rates of accidental or violent death in previously burned adult patients (around 40 deaths per 1000 years at risk) may be an order of magnitude higher than that in the average Norwegian population.

Burden of Burn: A Norm-Based Inquiry into the Influence of Burn Size and Distress on Recovery of Physical and Psychosocial Function

This prospective, longitudinal study examined the influence of baseline physical and psychological burden on serial assessments of health-related quality of life among adults with major burns from three regional burn centers (n = 162). Physical burden groups were defined by % TBSA burned: <10%, 10% to 30%, or >30%. Psychological burden groups were defined by in-hospital distress using the Brief Symptom Inventory Global Severity Index T-score with scores of < 63 or > or = 63. Analyses compared groups across level of burden and with published normative data. Assessments reflected health and function (Short Form 36) during the month before burn, at discharge, and at 6 and 12 months after burn. Physical functioning was significantly more impaired and the rate of physical recovery slower among those with either large physical burden or large psychological burden. Notably, psychosocial functioning also was more impaired and the rate of psychosocial recovery slower among those with greater psychological burden. These results suggest that, in addition to aggressive wound closure, interventions that reduce in-hospital distress may accelerate both physical and psychosocial recovery.

Measuring functional outcome in paediatric patients with burns: methodological considerations

Methodological criticisms of research undertaken in the area of paediatric burns are widespread. To date, quasi-experimental research designs have most frequently been used to examine the impact of impairments such as scarring and reduced range of motion on functional outcomes. Predominantly, these studies have utilised a narrow definition of functioning (e.g. school attendance) to determine a child's level of participation in activities post-burn injury. Until recently, there had been little attempt to develop and/or test a theoretical model of functional outcome with these children. Using a conceptual model of functional outcome based on the International Classification of Functioning, Disability and Health, this review paper outlines the current state of the research literature and presents explanatory case study methodology as an alternative research design to further advance the study of functional outcome post-burn injury.