Adolescent survivors of burn injuries and their parents’ perceptions of recovery outcomes: Do they agree or disagree?

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

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.

Differences in parent-perceived and patient-reported quality of life among young adult burn patients: A prospective longitudinal study

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.

Predictors and Correlates of Pediatric Postburn Pruritus in Preschool Children of Ages 0 to 4

Pruritus is a common problem following burn injuries; however, the literature to date has focused on adult survivors and/or pediatric survivors of large burns. The current study examines acute postburn pruritus in children under the age of 4 years (N = 256) with smaller burns (mean TBSA = 3.99%), which represents the most common type of patient typically treated in pediatric burn centers. Parents rated their child for pruritus, irritability, and sleep disturbances; additionally, parents completed a self-report of distress. Nearly half (47.3%) were rated by parents as displayed some level of pruritus, with the greatest proportion rated as mild. Regression analysis indicated that child minority status, greater burn TBSA, and more days elapsed since burn predicted higher levels of pruritus. In turn, pruritus was positively correlated with child irritability, delayed sleep onset, sleep disturbance, and parent distress. Thus, our results indicate that parent-rated pruritus in young pediatric burn patients is important to evaluate, as itch is significantly associated with other important clinical outcomes as early as the first month of the burn for pediatric patients and their parents.

Burn injury

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

A Road Less Travelled: using Experience Based Co-Design to map children's and families' emotional journey following burn injury and identify service improvements

BACKGROUND

The emotional impact after a child's burn injury is poorly understood. Greater insight into the emotional journey can aid services' ability to meet patients/families' needs. To bridge the gap, this study employed an abbreviated form of Experience Based Co-Design (EBCD) to explore the emotional/experiential aspects of moderate to severe burn injuries in children.

METHOD

Following EBCD, parents and health professionals were invited to share their experiences. Interviews were analysed and a short film was produced and shown at a focus group event for health professionals and families. Both positive and negative aspects of the journey were identified along with potential service improvements.

RESULTS

Families' journeys could be described by the following five distinct phases: life overturned, dawning reality, riding the emotional roller-coaster, aftershocks and, adapting to a new normal. Key areas for improvements were: communication, isolation, dressing changes and managing expectations.

DISCUSSION

EBCD facilitated collaborative discussion between researchers, families and health professionals. Families felt empowered to shape the future of burn care and health professionals felt included. Study challenges were mainly in participant engagement and the scheduling of interviews and the focus event. Overall the study outcome was successful in generating ideas for service improvements, and the production of a training video for healthcare professionals.

Study of negative pressure wound therapy as an adjunct treatment for acute burns in children (SONATA in C): protocol for a randomised controlled trial

BACKGROUND

Although negative pressure wound therapy (NPWT) is widely used in the management of several wound types, its efficacy as a primary therapy for acute burns has not yet been adequately investigated, with research in the paediatric population particularly lacking. There is limited evidence, however, that NPWT might benefit children with burns, amongst whom scar formation, wound progression and pain continue to present major management challenges. The purpose of this trial is to determine whether NPWT in conjunction with standard therapy accelerates healing, reduces wound progression and decreases pain more effectively than standard treatment alone.

METHODS/DESIGN

A total of 104 children will be recruited for this trial. To be eligible, candidates must be under 17 years of age and present to the participating children's hospital within 7 days of their injury with a thermal burn covering <5% of their total body surface area. Facial and trivial burns will be excluded. Following a randomised controlled parallel design, participants will be allocated to either an active control or intervention group. The former will receive standard therapy consisting of Acticoat™ and Mepitel™. The intervention arm will be treated with silver-impregnated dressings in addition to NPWT via the RENASYS TOUCH™ vacuum pump. Participants' dressings will be changed every 3 to 5 days until their wounds are fully re-epithelialised. Time to re-epithelialisation will be studied as the primary outcome. Secondary outcomes will include pain, pruritus, wound progression, health-care-resource use (and costs), ease of management, treatment satisfaction and adverse events. Wound fluid collected during NPWT will also be analysed to generate a proteomic profile of the burn microenvironment.

DISCUSSION

The study will be the first randomised controlled trial to explore the clinical effects of NPWT on paediatric burns, with the aim of determining whether the therapy warrants implementation as an adjunct to standard burns management.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN12618000256279 . Registered on 16 February 2018.

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

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

Body image in paediatric burns: a review

Burn injuries in children can result in life-long disfigurement. As medical and surgical techniques of burn management improve survival prospects more than ever before, body image adjustment is increasingly a central consideration in the care of burn-injured individuals. An appreciation that both physiological and psychosocial processes underpin such injuries is key to understanding wound healing. Perceptions of idealized body images in Western society challenge children and their families as they grow up with and adapt to disfigurement from burns. Whilst many studies have examined the psychosocial recovery of adults with burn injuries, few have considered the impact on burn-injured children. This paper explores the models of body image and discusses the relevance of these to research and practice in understanding how to manage burns in children.

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The LIBRE Profile.

RESULTS

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

CONCLUSIONS

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

One-Year Comparison of a Community-Based Exercise Program Versus a Day Hospital-Based Exercise Program on Quality of Life and Mental Health in Severely Burned Children

OBJECTIVE

To compare the effects of long-term psychosocial functioning and mental health of a "day hospital"-based exercise program (DAYEX) versus a community-based exercise program (COMBEX).

DESIGN

A prospective design that consisted of 2 groups (DAYEX and COMBEX).

SETTING

A children's hospital specialized in burn care.

PARTICIPANTS

Patients (N=18; DAYEX [n=9], COMBEX [n=9]) were assessed at intensive care unit discharge and up to 1 year postburn.

INTERVENTIONS

The Child Health Questionnaires (CHQ-Child Form [CHQ-CF87] and CHQ-Parent Form [CHQ-PF28]) were used to assess changes in quality of life from discharge to 1 year postburn.

MAIN OUTCOME MEASURES

CHQ-PF28 and CHQ-CF87.

RESULTS

Demographic characteristics and total body surface area burned were similar in both groups. Length of hospital stay was significant in the COMBEX group. CHQ-CF87 and CHQ-PF28 documented significant improvements in both groups between discharge and 1 year. Significance was evident in Physical Functioning, Bodily Pain, Self-Esteem, Change in Health, and Family Activities. CHQ-CF87 showed improvement in Family Cohesion in COMBEX more than DAYEX. CHQ-PF28 showed improvement in Role/Social Limitations-Emotional, Bodily Pain, and Family Activities in COMBEX more than DAYEX.

CONCLUSIONS

The proposed COMBEX program is feasible and beneficial physically, psychosocially, and mentally. The results show some improvements in the COMBEX group in optimizing function and health in severely burned children. The COMBEX group performed at least as well as the DAYEX group. Larger-scale studies are needed to validate current findings.

The Use of Virtual Reality Facilitates Dialectical Behavior Therapy® "Observing Sounds and Visuals" Mindfulness Skills Training Exercises for a Latino Patient with Severe Burns: A Case Study

Sustaining a burn injury increases an individual's risk of developing psychological problems such as generalized anxiety, negative emotions, depression, acute stress disorder, or post-traumatic stress disorder. Despite the growing use of Dialectical Behavioral Therapy® (DBT®) by clinical psychologists, to date, there are no published studies using standard DBT® or DBT® skills learning for severe burn patients. The current study explored the feasibility and clinical potential of using Immersive Virtual Reality (VR) enhanced DBT® mindfulness skills training to reduce negative emotions and increase positive emotions of a patient with severe burn injuries. The participant was a hospitalized (in house) 21-year-old Spanish speaking Latino male patient being treated for a large (>35% TBSA) severe flame burn injury.

Methods: The patient looked into a pair of Oculus Rift DK2 virtual reality goggles to perceive the computer-generated virtual reality illusion of floating down a river, with rocks, boulders, trees, mountains, and clouds, while listening to DBT® mindfulness training audios during 4 VR sessions over a 1 month period. Study measures were administered before and after each VR session.

Results: As predicted, the patient reported increased positive emotions and decreased negative emotions. The patient also accepted the VR mindfulness treatment technique. He reported the sessions helped him become more comfortable with his emotions and he wanted to keep using mindfulness after returning home.

Conclusions: Dialectical Behavioral Therapy is an empirically validated treatment approach that has proved effective with non-burn patient populations for treating many of the psychological problems experienced by severe burn patients. The current case study explored for the first time, the use of immersive virtual reality enhanced DBT® mindfulness skills training with a burn patient. The patient reported reductions in negative emotions and increases in positive emotions, after VR DBT® mindfulness skills training. Immersive Virtual Reality is becoming widely available to mainstream consumers, and thus has the potential to make this treatment available to a much wider number of patient populations, including severe burn patients. Additional development, and controlled studies are needed.

Childhood burn survivors' and their siblings' perceptions of their body image

A mixed-method, qualitative dominant design was implemented to understand how visible changes in appearance, and function, govern childhood burn survivors' and their siblings' perceptions of their body image (BI). Thirteen cases (n=21 participants) contributed to this analysis. Each "case" represented a family unit. Findings were internal to the person (grouped as self-esteem, and personality type). Other findings were external to the person (grouped as the social environment and interpersonal experiences of the siblings). Findings suggest that the children focused on developing a positive BI satisfaction. Research is needed to better understand how this occurs despite visible appearance changes.

The year in burns 2012

Approximately 2457 research articles were published with burns in the title, abstract, and/or keyword in 2012. This number continues to rise through the years; this article reviews those selected by the Editor of one of the major journals in the field (Burns) and his colleague that are most likely to have the greatest likelihood of affecting burn care treatment and understanding. As done previously, articles were found and divided into these topic areas: epidemiology of injury and burn prevention, wound and scar characterization, acute care and critical care, inhalation injury, infection, psychological considerations, pain and itching management, rehabilitation, long-term outcomes, and burn reconstruction. Each selected article is mentioned briefly with comment from the authors; readers are referred to the full papers for further details.