Patient-reported scar quality of adults after burn injuries: A five-year multicenter follow-up study

Gender differences in relation to stigmatization and depressive symptoms after burns

OBJECTIVES

The aim of this study was to investigate the moderating role of gender in the relationship between burn severity, perceived stigmatization and depressive symptoms at multiple time points postburn.

MATERIALS AND METHODS

This multi-center study included data from two cohorts. Cohort 1 consisted of 215 burn survivors, participating in a longitudinal study with measures at 3 and 12 months postburn. Cohort 2 consisted of 180 burn survivors cross-sectionally assessed at 5 - 7 years postburn. Both cohorts completed self-reported measures of perceived stigmatization and depressive symptoms. The number of acute surgeries (i.e., no surgery, 1 surgery or 2 or more surgeries) was used as indicator of burn severity. Relations between number of surgeries, depressive symptoms, and perceived stigmatization, including possible indirect effects, were evaluated with gender-specific path models.

RESULTS

In both men and women, number of surgical operations was related to higher levels of depressive symptoms and perceived stigmatization at 3 months after burn. In women, number of operations was still directly related to both constructs at 12 months after burn, which was cross-sectionally confirmed in the 5-7 years after burn cohort. In men, from 3 to 12 months after burn, depressive symptoms and perceived stigmatization were bidirectionally related, and, through these effects, number of surgeries was indirectly related to both outcomes. In the cross-sectional 5-7 years after burn cohort, number of operations was related to stigma but not to depressive symptoms of men.

CONCLUSION

Number of operations had a different effect on psychosocial adaptation of male and female burn survivors. In women, a persistent direct link from number of operations to both depressive symptoms and perceived stigmatization was found over time. In men, the effect of number of operations was most evident in the short-term, after which perceived stigmatization and depressive symptoms became interrelated. This indicates that burn severity remains a factor of significance in psychological adjustment in women, whereas in men, this significance seems to decrease over time.

Long-Term Functional Outcomes after Hand Burns: A Monocentric Controlled Cohort Study

Background: Hand burns are involved in 80-90% of severe burn injuries. Even though hands correspond to a small total burn surface area (TBSA) of less than 5%, the loss of their functionality has a significant impact on the patient's life. Studies that provide long-term results regarding hand functionality after hand burns are scarce. Therefore, this study aimed to investigate functional long-term results in a patient-centric approach regarding burn depth, unilateral and bilateral hand involvement, and (non-)isolated hand burns as potential influencing factors in patients with hand burns. Methods: We conducted a controlled cohort study of patients with burned hands treated at our department between 2005 and 2022. Healthy age-, sex-, and handedness-matched participants were used as controls. Data on the demographics, burn-related injuries, and treatments were collected. For a patient-centric approach, we used the Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick-DASH) and the Michigan Hand Questionnaire (MHQ) as patient-reported outcome measures for functional long-term evaluation, and the Patient and Observer Scar Assessment Scale (patient scale) for assessing long-term scar quality. Results: We enrolled 61 patients with 88 affected hands and 63 matched control participants. Up to 77.1% of the participants were male, with a mean age of 50.7 (±15.5) years and a follow-up of 8.1 (±4.7) years. The mean TBSA was 13.9% (±15.8), with 72.4% of the hands presenting with deep partial-thickness and full-thickness burns and most of the patients had only one hand affected (55.7%). The hand burn patients perceived significantly worse long-term functional scores in every domain of the MHQ as well as in the "overall function" and "work" of the Quick-DASH. Superficial hand burns negatively affected the two-handed activities of daily living (p = 0.013) and aesthetic appearance (p = 0.005) when both hands were involved. Isolated hand burns were associated with more difficulties in work performance (p = 0.03), whereas patients with bilateral hand involvement perceived more pain (p = 0.025). Conclusions: The patients with hand burns can achieve satisfactory long-term functional outcomes over time, but they do not reach the same long-term hand functionality as the healthy matched control group. Our study revealed that factors such as burn depth, unilateral or bilateral hand involvement, and (non-)isolated hand burns indeed have an impact on certain aspects of perceived long-term hand functionality.

The Short- and Long-Term Outcome Priorities of a Western Australian Adult Burn Population

To optimize patient recovery, understanding which outcomes are most important to burn patients is key. However, research to determine what outcomes are patient priorities is limited. Therefore, we assessed what outcomes are most important to Western Australian burn patients, separately in the short-term (<6 months) and long-term (6-24 months) after injury. Adult patients who had a burn injury 3-36 months ago completed a survey, rating the importance of 36 short- and long-term outcomes. The survey items were ranked according to the number of patients reporting the outcome as "very important." Results were compared between subgroups based on age, gender, burn size, and number of surgeries. Ninety-three patients were included. In the short-term, "not having a wound infection" (87.1%), "good wound healing" (83.9%), and "walking or moving around" (74.7%) were the most important outcomes. "Lifting or moving something" (67.6%), "walking or moving around" (66.2%), and "being independent" (66.2%) were reported as most important in the long-term. Scar-related outcomes were more important to females and to patients with multiple surgeries; mental health outcomes were priorities for females and patients with major burns; walking and moving around to males and older patients; and social and financial outcomes were rated highly by patients with major burns and multiple surgeries. In conclusion, the most important outcomes were consistent across time periods, indicating the importance of core outcomes in longitudinal follow-up. The wide range of priority outcomes and differences between subgroups underlines the need for multidisciplinary care and a patient-centered approach to support patients.

Outcomes that matter most to burn patients: A national multicentre survey study in the Netherlands

BACKGROUND

The use of patient-reported outcomes to improve burn care increases. Little is known on burn patients' views on what outcomes are most important, and about preferences regarding online Patient Reported Outcome Measures (PROMs). Therefore, this study assessed what outcomes matter most to patients, and gained insights into patient preferences towards the use of online PROMs.

METHODS

Adult patients (≥18 years old), 3-36 months after injury completed a survey measuring importance of outcomes, separately for three time periods: during admission, short-term (<6 months) and long-term (6-24 months) after burn injury. Both open and closed-ended questions were used. Furthermore, preferences regarding the use of patient-reported outcome measures in burn care were queried.

RESULTS

A total of 140 patients were included (response rate: 27%). 'Not having pain' and 'good wound healing' were identified as very important outcomes. Also, 'physical functioning at pre-injury level', 'being independent' and 'taking care of yourself' were considered very important outcomes. The top-ten of most important outcomes largely overlapped in all three time periods. Most patients (84%) had no problems with online questionnaires, and many (67%) indicated that it should take up to 15 minutes. Patients' opinions differed widely on the preferred frequency of follow-up.

CONCLUSIONS

Not having pain and good wound healing were considered very important during the whole recovery of burns; in addition, physical functioning at pre-injury level, being independent, and taking care of yourself were deemed very important in the short and long-term. These outcomes are recommended to be used in burn care and research, although careful selection of outcomes remains crucial as patients prefer online questionnaires up to 15 minutes.

Application of fractional carbon dioxide laser monotherapy in keloids: A meta-analysis

BACKGROUND

There is no evidence-based guidance on the use of fractional CO2 laser in the excision of scars.

AIM

To explore the effectiveness and safety of fractional CO2 laser in the treatment of keloids.

METHODS

In this meta-analysis, we searched the PubMed, Embase, and Cochrane databases from inception to April 2023. We only included studies reporting fractional CO2 laser treatment of keloids. We excluded duplicate published studies, incomplete studies, those with incomplete data, animal experiments, literature reviews, and systematic studies.

RESULTS

The pooled results showed that the Vancouver Scar Scale (VSS) parameters of height weighted mean difference (WMD) = -1.10, 95% confidence interval (CI): -1.46 to -0.74), pigmentation (WMD = -0.61, 95% CI: -1.00 to -0.21), and pliability (WMD = -0.90, 95% CI: -1.17 to -0.63) were significantly improved after fractional CO2 laser treatment of keloids. However, vascularity did not significantly change. Additionally, the total VSS was significantly improved after treatment (WMD = -4.01, 95% CI: -6.22 to -1.79). The Patient Scars Assessment Scale was significantly improved after treatment (WMD = -15.31, 95% CI: -18.31 to -12.31). Regarding safety, the incidences of hyperpigmentation, hypopigmentation, pain, telangiectasia, and atrophy were 5%, 0%, 11%, 2% (95% CI: 0%-6%), and 0% (95% CI: 0%-4%), respectively.

CONCLUSIONS

Fractional CO2 laser is effective in the treatment of keloids and can effectively improve the height, pigmentation, and pliability of scars, and patients are satisfied with this treatment. Further studies should explore the role of combination therapy.

Working Towards Holistic Scar Assessment and Improved Shared Decision Making in Global Burn Care

Cutaneous burn scars impact various aspects of life. Scar treatment is mainly evaluated on scar characteristics. Consensus is needed on which other outcomes to capture, ensuring they are relevant to patients, clinicians, and researchers. The aim of this study was to identify, discuss and analyze outcomes related to cutaneous burn scarring, incorporating the voice of patients and views of healthcare professionals. For this, a Delphi process consisting of two survey rounds and a consensus meeting was initiated. Burn scar-related outcomes were identified from an existing comprehensive list of 100 outcomes by an international panel of patients, healthcare professionals and researchers. Fifty-nine outcomes were identified from the Delphi process as related to scarring (≥60% votes). Outcomes less impactful in relation to scar outcomes included psychosocial issues, sense of normality, understanding of treatment, costs and systemic issues. To represent a holistic assessment of outcomes related to cutaneous burn scarring, this Delphi process established a battery of outcomes currently included in scar quality assessment tools, and an expanded set of less frequently considered outcomes. Future work in this area must include the patient voice from developing countries. This is essential to identify globally applicable outcomes related to scarring.

Microneedling in Abdominal Scarring after DIEP-flap Breast Reconstruction to Improve Scar Quality: A Randomized Controlled Split Scar Trial

Background

Deep inferior epigastric perforator (DIEP) flap breast reconstruction leads to large scars in the breast and abdominal region. Common symptoms related to abdominal scarring include changes in color, stiffness, thickness, and irregularity of the skin. The aim of this study was to examine whether microneedling improves the abdominal scar quality after DIEP-flap breast reconstruction.

Methods

A prospective randomized controlled within subject comparison design (N = 30) was used to study the effect of microneedling treatments on the abdominal scar, versus no treatment. Three electrically powered microneedling sessions were performed every 4 weeks on one side of the abdominal scar. Abdominal scar assessment was performed at baseline and 3-, 6-, and 9-month follow-up using the Patient and Observer Scar Assessment Scale (POSAS). Treated and untreated sides were compared using a t test or Wilcoxon signed-rank test in case the data were not normally distributed.

Results

Twenty-seven women completed the study. Microneedling treatment led to lower POSAS scores compared with the untreated scar side after the 3- and 9-month follow-up. At the 9-month follow-up, the POSAS total score (Mdn = 17, interquartile range = 18.3 versus Mdn = 21.4, interquartile range = 17.5) was statistically lower for the treated side compared with the untreated side, implying a better-appraised scar quality. The observer POSAS total score was statistically lower for the treated side compared with the untreated side.

Conclusions

Based on patient and observer ratings, overall abdominal scars after DIEP-flap surgery improve significantly after microneedling treatment. Scar symptoms reduce faster under the influence of microneedling treatment compared with no treatment.

Hypertrophic Scar

Hypertrophic scars frequently develop post-burn, and are characterized by their pruritic, painful, raised, erythematous, dyschromic, and contractile qualities. This article aims to synthesize knowledge on the clinical and molecular development, evolution, management, and measurement of hypertrophic burn scar for both patient and clinician knowledge.

Impact of childhood burns on academic performance: a matched population-based cohort study

OBJECTIVE

This study aimed to compare academic performance and high school completion of young people hospitalised for a burn compared with young people not hospitalised for an injury.

DESIGN

A retrospective population-based matched case-comparison cohort study.

PARTICIPANTS

Young people aged ≤18 years hospitalised for a burn during 2005-2018 in New South Wales, Australia, with age, sex and residential postcode-matched peers not hospitalised for any injury during 1 July 2001 and 31 December 2018.

MAIN OUTCOME MEASURES

Performance below the national minimum standard (NMS) on the National Assessment Plan for Literacy and Numeracy assessments and not completing high school.

RESULTS

Young females hospitalised for a burn had a 72% higher risk of poorer reading compared with their peers (adjusted relative risk (ARR) 1.72; 95% CI 1.33 to 2.23), while young males hospitalised with a burn showed no higher risk (ARR 1.14; 95% CI 0.91 to 1.43). Young males (ARR 1.05; 95% CI 0.81 to 1.35) and females (ARR 1.34; 95% CI 0.93 to 1.94) hospitalised with a burn had no higher risk of not reaching the NMS for numeracy compared with peers. Young people hospitalised with a burn had at least twice the risk of not completing year 10 (ARR 3.86; 95% CI 1.68 to 8.86), year 11 (ARR 2.45; 95% CI 1.89 to 3.18) and year 12 (ARR 2.09; 95% CI 1.63 to 2.67) compared with matched counterparts.

CONCLUSIONS

Young females hospitalised with a burn displayed poorer academic performance for reading compared with matched peers, while males and females were more likely to leave school earlier. Identifying unmet learning support needs of young burn survivors should be investigated.

Long-term scarring outcomes and safety of patients treated with NovoSorbⓇ Biodegradable Temporizing Matrix (BTM): An observational cohort study

Background/Aim

NovoSorb^Ⓡ Biodegradable Temporizing Matrix (BTM) is a relatively novel, biodegradable polyurethane-based dermal regeneration template. The aim of this study was to evaluate the long-term scarring outcomes and safety of BTM in patients who underwent dermal reconstruction involving ≥5% of the total body surface area.

Methods

This was a postmarket, multicenter, observational cohort study involving evaluation of long-term outcomes in patients treated with BTM. A total of 55 patients (35 from Royal Adelaide Hospital, South Australia, and 20 from Victoria Adult Burns Service, The Alfred, Victoria) who underwent dermal repair with BTM between 2011 and 2017 were screened for inclusion in this study. All patients had BTM implanted for ≥18 months.

Results

Fifteen eligible patients with a mean (SD) age of 49.1 (14.3) years completed study assessments. These patients had a total of 39 areas treated with BTM. Using the Patient and Observer Scar Assessment Scale, scar quality was reported to be good by both observers and patients, with a mean (SD) observer score across all lesions of 3.6 (1.2) and mean (SD) overall opinion of 3.8 (1.2) as well as a mean (SD) patient score of 3.5 (1.2) and overall opinion of 5.0 (2.2). No adverse events or adverse device effects were reported or identified.

Conclusion

The long-term scar quality is comparable to published studies. BTM is safe in the long term with no additional risks or adverse consequences being identified.

Scar Management and Dyschromia: A Summary Report from the 2021 American Burn Association State of the Science Meeting

Burn scars, and in particular, hypertrophic scars, are a challenging yet common outcome for survivors of burn injuries. In 2021, the American Burn Association brought together experts in burn care and research to discuss critical topics related to burns, including burn scars, at its State of the Science conference. Clinicians and researchers with burn scar expertise, as well as burn patients, industry representatives, and other interested stakeholders met to discuss issues related to burn scars and discuss priorities for future burn scar research. The various preventative strategies and treatment modalities currently utilized for burn scars were discussed, including relatively noninvasive therapies such as massage, compression, and silicone sheeting, as well as medical interventions such as corticosteroid injection and laser therapies. A common theme that emerged is that the efficacy of current therapies for specific patient populations is not clear, and further research is needed to improve upon these treatments and develop more effective strategies to suppress scar formation. This will necessitate quantitative analyses of outcomes and would benefit from creation of scar biobanks and shared data resources. In addition, outcomes of importance to patients, such as scar dyschromia, must be given greater attention by clinicians and researchers to improve overall quality of life in burn survivors. Herein we summarize the main topics of discussion from this meeting and offer recommendations for areas where further research and development are needed.

Laser-assisted drug delivery of synthetic alpha melanocyte stimulating hormone and L-tyrosine leads to increased pigmentation area and expression of melanogenesis genes in a porcine hypertrophic scar model

OBJECTIVES

One symptom of hypertrophic scar (HTS) that can develop after burn injury is dyschromia with hyper- and hypopigmentation. There are limited treatments for these conditions. Previously, we showed there is no expression of alpha melanocyte stimulating hormone (α-MSH) in hypopigmented scars, and if these melanocytes are treated with synthetic α-MSH in vitro, they respond by repigmenting. The current study tested the same hypothesis in the in vivo environment using laser-assisted drug delivery (LADD).

METHODS

HTSs were created in red Duroc pigs. At Day 77 (pre), they were treated with CO₂ fractional ablative laser (FLSR). Synthetic α-MSH was delivered as a topical solution dissolved in  l-tyrosine (n = 6, treated). Control scars received LADD of  l-tyrosine only (n = 2, control). Scars were treated and examined weekly through Week 4. Digital images and punch biopsies of hyper, hypo-, and normally pigmented scar and skin were collected. Digital pictures were analyzed with ImageJ by tracing the area of hyperpigmentation. Epidermal sheets were obtained from punch biopsies through dispase separation and RNA was isolated. qRT-PCR was run for melanogenesis-related genes: tyrosinase (TYR), tyrosinase-related protein-1 (TYRP1), and dopachrome tautomerase (DCT). Two-way ANOVA with multiple comparisons and Dunnett's correction compared the groups.

RESULTS

The areas of hyperpigmentation were variable before treatment. Therefore, data is represented as fold-change where each scar was normalized to its own pre value. Within the LADD of NDP α-MSH + l-tyrosine group, hyperpigmented areas gradually increased each week, reaching 1.3-fold over pre by Week 4. At each timepoint, area of hyperpigmentation was greater in the treated versus the control (1.04 ± 0.05 vs. 0.89 ± 0.08, 1.21 ± 0.07 vs. 0.98 ± 0.24, 1.21 ± 0.08 vs. 1.04 ± 0.11, 1.28 ± 0.11 vs. 0.94 ± 0.25; fold-change from pre-). Within the treatment group, pretreatment, levels of TYR were decreased -17.76 ± 4.52 below the level of normal skin in hypopigmented scars. After 1 treatment, potentially due to laser fractionation, the levels decreased to -43.49 ± 5.52. After 2, 3, and 4 treatments, there was ever increasing levels of TYR to almost the level of normally pigmented skin (-35.74 ± 15.72, -23.25 ± 6.80, -5.52 ± 2.22 [p < 0.01, Week 4]). This pattern was also observed for TYRP1 (pre = -12.94 ± 1.82, Week 1 = -48.85 ± 13.25 [p < 0.01], Weeks 2, 3, and 4 = -34.45 ± 14.64, -28.19 ± 4.98, -6.93 ± 3.05 [p < 0.01, Week 4]) and DCT (pre = -214.95 ± 89.42, Week 1 = -487.93 ± 126.32 [p < 0.05], Weeks 2, 3, and 4 = -219.06 ± 79.33, -72.91 ± 20.45 [p < 0.001], -76.00 ± 24.26 [p < 0.001]). Similar patterns were observed for scars treated with LADD of  l-tyrosine alone without NDP α-MSH. For each gene, in hyperpigmented scar, levels increased at Week 4 of treatment compared to Week 1 (p < 0.01).

CONCLUSIONS

A clinically-relevant FLSR treatment method can be combined with topical delivery of synthetic α-MSH and l-tyrosine to increase the area of pigmentation and expression of melanogenesis genes in hypopigmented HTS. LADD of  l-tyrosine alone leads to increased expression of melanogenesis genes. Future studies will aim to optimize drug delivery, timing, and dosing.

Modified Colson flap with subcutaneous liposuction for one-stage donor site removal: A case series

OBJECTIVES

The aim of this study was to evaluate the functional and cosmetic results of an innovative procedure for modified Colson flap-graft consisting of immediate defatting of the flap by a liposuction cannula.

METHODS

A cross-sectional study was performed among patients with deep hand burns requiring a modified Colson flap between 2018 and 2021. Outcomes included functional and cosmetic assessment of the hand through a quality-of-life questionnaire, a sensitivity scale and a scar assessment scale.

RESULTS

During this period, 7 patients were operated on using our technique. One patient was lost to follow-up; 7 patients with a median age of 44 years were included, with a total of 10 burned hands. The burns were thermal in 5 out of 7 cases and the coverage concerned the whole hand in 50% of the cases. The flaps all received cannula defatting. The median time to flap weaning was 23 days (20 to 30 days). The median follow-up was 16 months. One case required remote flap weaning. The median POSAS (Patient and Observer Scar Assessment Scale) per patient was 4 and 2 per observer. The median BMRCSS (British Medical Research Council Sensory Scale) was 122. One case had recovered S2 sensitivity, the other cases had S3 or S4 sensitivity.

CONCLUSION

Immediate defatting is one of the factors in tegumental quality allowing rapid functional recovery of the hand. The cannula defatting technique does not appear to require additional defatting time. The use of the liposuction cannula allows a one-step, homogeneous, and easier defatting, with a lower risk of devascularization.

Burn injury characteristics, referral pattern, treatment (costs), and outcome in burn patients admitted to a hospital with or without a specialized Burn Centre (BURN-Pro)

PURPOSE

Data on the epidemiology, treatment, and outcome of burn patients treated at non-burn centre hospitals are not available. The primary aim was to compare the burn characteristics of patients admitted to a hospital with or without a specialized burn centre.

METHODS

This multicentre, prospective, cohort study enrolled patients with burns admitted to a hospital without a burn centre and patients with < 10% total body surface area (TBSA) burned admitted to the burn centre. Primary outcome measure was the burn-related injury characteristics. Secondary outcome measures were adherence to the Emergency Management of Severe Burns (EMSB) referral criteria, treatment (costs), quality of life, and scar quality.

RESULTS

During the 2-year study period, 48 patients were admitted to a non-burn centre and 148 patients to the burn centre. In the non-burn centre group, age [44 (P₂₅-P₇₅ 26-61) versus 30 (P₂₅-P₇₅ 8-52) years; P = 0.007] and Injury Severity Score [2 (P₂₅-P₇₅ 1-4) versus 1 (P₂₅-P₇₅ 1-1); P < 0.001] were higher. In the burn centre group, the TBSA burned was significantly higher [4% (P₂₅-P₇₅ 2-6) versus 2% (P₂₅-P₇₅ 1-4); P = 0.001], and more surgical procedures were performed (in 54 versus 7 patients; P = 0.004). At 12 months, > 85% of the non-burn centre group and > 75% of the burn centre group reported no problems in quality of life. Scar quality score was < 1.5 in both groups, with significantly poorer scores in the burn centre group (P ≤ 0.007).

CONCLUSION

Both groups differed in patient, burn, and treatment characteristics. At 12 months, quality of life and scar quality were good in both groups. Significantly poorer scar quality scores were found in the burn centre group. This might be related to their larger burns and more frequent surgery. The organization of burn care in the Netherlands seems to work adequately. Patients are treated locally when possible and are transferred when necessary.

Wound Pain as a Determinant of Function in Patients Hospitalised for Burns

Burn wounds most often occur on visible parts of the body. They therefore cause fear of disfigurement and rejection by those around them. In addition, they cause pain. The main aim of this study was to analyse factors affecting the functioning of patients hospitalised for burns. The study included 57 patients hospitalised for burns. Each person was surveyed twice: on day seven after admission and on the day of discharge from the hospital. The following research tools were used: a personal questionnaire to collect clinical data and the scales of the Katz Activities of Daily Living (ADL), the short-form McGill Pain Questionnaire (SF-MPQ), the Beck Depression Inventory (BDI) and the Satisfaction with Appearance Scale (SWAP). On the discharge day, compared to day 7, there was an improvement in the patient's level of functioning in all areas analysed. Pain intensity (p < 0.0001), depression (p < 0.0001) and dissatisfaction with appearance (p = 0.0239) decreased significantly. Improvements in daily functioning were also obtained (p < 0.0001). Multiple regression was performed to estimate the effect of selected variables on patients' level of functioning. Burn area (p = 0.0126), pain level (questionnaire part B: p = 0.0004 and questionnaire part C: p = 0.0208) and gender (p = 0.0413) had a significant impact on the level of daily functioning. Pain complaints are the most crucial predictor affecting the functional status and depression levels in burn wound patients. Increased levels of depression promote dissatisfaction with one's appearance.

Is massage an effective intervention in the management of post-operative scarring? A scoping review

BACKGROUND

Scar massage is a widely used treatment modality in hand therapy. This intervention is thoroughly discussed in the literature relating to burns rehabilitation, however, the evidence for its use in treating linear scars following surgery is limited.

PURPOSE OF STUDY

To collate the empirical literature on scar massage for the treatment of postsurgical cutaneous scars.

STUDY DESIGN

Scoping review.

METHODS

Medline, EMBASE, CINAHL, AMED, Scopus, ProQuest Dissertations & Theses Global, and the Joanna Briggs Institute were searched from inception to December 2020. Two researchers used a data extraction tool to record key demographic, intervention and outcome data, and to apply the Oxford Levels of Evidence for each study.

RESULTS

Twenty-five studies met the inclusion criteria, reporting on a combined sample of 1515 participants. Only two papers addressed hand or wrist scars (92 participants). While all studies reported favorable outcomes for scar massage, there were 45 different outcome measures used and a propensity towards non-standardized assessment. Intervention protocols varied from a single session to three treatments daily for 6 months. The results from 13 studies were confounded by the implementation of additional rehabilitation interventions.

CONCLUSIONS

The overall findings suggest that while there may be benefits to scar massage in reducing pain, increasing movement and improving scar characteristics; there is a lack of consistent research methods, intervention protocols and outcome measures. This scoping review highlights the heterogenous nature of research into scar massage following surgery and supports the need for further research to substantiate its use in the clinical setting.

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

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

Scar formation from the perspective of complexity science: a new look at the biological system as a whole

A burn wound is a complex systemic disease at multiple levels. Current knowledge of scar formation after burn injury has come from traditional biological and clinical studies. These are normally focused on just a small part of the entire process, which has limited our ability to sufficiently understand the underlying mechanisms and to predict systems behaviour. Scar formation after burn injury is a result of a complex biological system-wound healing. It is a part of a larger whole. In this self-organising system, many components form networks of interactions with each other. These networks of interactions are typically non-linear and change their states dynamically, responding to the environment and showing emergent long-term behaviour. How molecular and cellular data relate to clinical phenomena, especially regarding effective therapies of burn wounds to achieve minimal scarring, is difficult to unravel and comprehend. Complexity science can help bridge this gap by integrating small parts into a larger whole, such that relevant biological mechanisms and data are combined in a computational model to better understand the complexity of the entire biological system. A better understanding of the complex biological system of post-burn scar formation could bring research and treatment regimens to the next level. The aim of this review/position paper is to create more awareness of complexity in scar formation after burn injury by describing the basic principles of complexity science and its potential for burn care professionals.

Early Laser for Burn Scars (ELABS): protocol for a multi-centre randomised, controlled trial of both the effectiveness and cost-effectiveness of the treatment of hypertrophic burn scars with Pulsed Dye Laser and standard care compared to standard care alone [version 1; peer review: 2 approved]

This paper outlines the protocol for a study that is being carried out at multiple centres across the UK in the next three years. It is a Research for Patient Benefit (RfPB) study funded by the National Institute for Healthcare Research (NIHR). The aim is to assess the effectiveness of treating hypertrophic burns scars with pulsed dye laser (PDL) at an early stage of scar formation. The objective is to improve Quality of Life for the patient by improving both the appearance and quality of burn scarring, as well as reducing its psychological impact. This is a parallel-arm randomised, controlled trial to compare PDL and standard care against standard care alone. The difference is measured between baseline and six-month follow-up. Recruits are within three months of healing from a burn injury; with wounds showing a defined potential for hypertrophic scarring. A total of 120 patients are recruited in a multi-centre study; with randomisation in a 1:1 allocation to each arm. The treatment arm receives 3 PDL treatments at six-week intervals in addition to standard care, whereas the control arm receives standard care alone. The primary outcome is the patient-rated part of the Patient and Observer Scar Scale (POSAS). Psychological and psycho-social impact is evaluated using the CARe burn scale (UWE, Bristol) and Quality Adjusted Life Years (QALY) is determined using the Short-Form Health Survey (SF-12). The study evaluates both the cost-effectiveness through an economic analysis and the patient-reported experience of the treatment by phone interviews.

Wound Closure After Port Implantation-a Randomized Controlled Trial Comparing Tissue Adhesive and Intracutaneous Suturing

BACKGROUND

Wound healing after pectoral port implantation is a major factor determining the success or failure of the procedure. Infection and wound dehiscence can endanger the functionality of the port system and impede chemotherapy. The cosmetic result is important for patient satisfaction as well.

METHODS

From August 2015 to July 2017, adult patients with an indication for port implantation were entered into a prospective, randomized and controlled single-center study. The skin incision was closed either with tissue adhesive or with an intracutaneous suture. The primary endpoints were the total score of the scar evaluated by the patient and the investigator on the POSAS scale (Patient and Observer Scar Assessment Scale: 6 [normal skin] to 60 points), blinded assessment of photographic documentation by ten evaluating physicians, and the patient's reported quality of life. The calculation of case numbers was based only on the patients' overall POSAS assessment, which was tested for non-inferiority. The secondary endpoints were other complications (infection, dehiscence) and the duration of wound closure (trial registration number NCT02551510).

RESULTS

156 patients (60 ± 13 years, 64% women) participated in the study. The patientassessed total POSAS score of tissue adhesive revealed non-inferiority to suturing (adhesive 11.7 ± 5.8 vs. suture 10.1 ± 4.0, p for non-inferiority <0.001). Both the investigators in their POSAS assessments and the blinded physician evaluators in their assessment of photographically documented wounds rated wound closure by suturing better than closure with tissue adhesive. No significant differences were found between groups with respect to quality of life or the frequency of wound infection or dehiscence.

CONCLUSION

Closure of the upper cutaneous layer with tissue adhesive is a suitable and safe method of wound closure after port implantation.

Mekeres' Psychosocial Internalization Scale: A Scale for the Evaluation of Aesthetic Prejudice in Victims of Accidents and Violence

Background and objectives: One important forensic activity is the assessment of aesthetic injuries where expert criteria and analysis are insufficiently outlined due to the subjective elements related to the traumatized victim. Unaesthetic morphological changes may occur due to various circumstances committed under the Penal Code, resulting in permanent unaesthetic morphological scarring. Considering that most of the existing scales for the assessment of aesthetic prejudices refer only to morphometric changes, our aim was to create a modern method for the evaluation of aesthetic damage that also considers its social and psychological consequences. Materials and Methods: In this study, we developed the Mekereș Psychosocial Internalization Scale (MPIS), which proposes a clear boundary between the presence or absence of aesthetic damage. The traumatized person is evaluated after a minimum of six months (in the case of an average scar, necessary for defining the character of the scar) to assess changes in the physiognomy or even alterations in the victim’s aesthetic perception of their own body. Our study was conducted on 103 patients with scars, and the results were compared to 101 controls (subjects without scars). Results: Individuals with scars have a distorted perception (compared to controls) of the support provided by significant people [t (202) = 2.473; p = 0.01]. Hypothetically, they will most likely exhibit a nuanced socio-cognitive and psycho-emotional vulnerability that may be the source of future dysfunctions. The fidelity of the MPIS scale was estimated by employing Cronbach’s alpha coefficient, resulting in a value of 0.934 (15 items). The exploratory factorial analysis with Varimax rotation mode sustains a single dominant factor, indicating a good internal consistency. The results of this study provide evidence regarding the psychosocial or psychometric worthiness of MPIS. Conclusions: MPIS can be used for research and as an instrument to assess aesthetic damage or disfigurement by forensic physicians and lawyers.

Longitudinal monitoring and prediction of long-term outcome of scar stiffness on pediatric patients

Background

Hypertrophic scarring after burn injury is one of the greatest unmet challenges in patients with burn injuries. A better understanding of the characteristics of scar maturation and early prediction of the long-term outcome of scarring are prerequisites for improving targeted therapies and pivotal for patient counselling.

Methods

Repeated measurements of scar stiffness in 11 pediatric patients were performed over the course of 1 year using 2 suction devices, the Cutometer and the Nimble. In addition, the observer pliability score of the Patient and Observer Scar Assessment Scale was applied. This longitudinal study allowed quantification of the ability of each of the measured parameters to reflect scar maturation, as indicated by change in skin pliability/stiffness, over time (using linear regression); the ability to distinguish individual patients (intraclass correlation coefficient (ICC)); the correlation of the devices (Spearman correlation coefficient); and the ability to predict long-term scar maturation based on early scar assessment (using receiver operating characteristic).

Results

All the tools used showed significant longitudinal decrease of scar stiffness from 3 months until 12 months after the injury. The Nimble (ICC_patient ^Nimble = 0.99) and the Cutometer (ICC_patient ^Cuto = 0.97) demonstrated an excellent ability to distinguish between individual patients. The Nimble seemed to be able to predict the 12-month pliability of scars based on early (3-month) measurements (area under the curve (AUC)_12m ^POSAS = 0.67; AUC_12m ^C = 0.46; AUC_12m ^N = 0.79).

Conclusions

The results of this preliminary study suggest that all 3 tools provide suitable means to quantify alterations in scar stiffness over time. Initial evidence suggests the Nimble is most favorable for predicting changes in stiffness associated with long-term scar maturation. Further studies with a larger sample size are required to validate tissue suction as a clinical tool for analysis of changes of scar stiffness over time.

Cutting into wound repair

The skin is home to an assortment of fibroblastic lineages that shape the wound repair response toward scars or regeneration. In this review, we discuss the distinct embryonic origins, anatomic locations, and functions of fibroblastic lineages, and how these distinct lineages of fibroblasts dictate the skin's wound response across injury depths, anatomic locations, and embryonic development to promote either scarring or regeneration. We highlight the supportive role of the fascia in dictating scarring outcomes; we then discuss recent findings that indicate fascia mobilization by its resident fibroblasts supersede the classical de novo deposition program of wound matrix formation. These recent findings reconfigure our traditional view of wound repair and present exciting new therapeutic avenues to treat scarring and fibrosis across a range of medical settings.

Scar quality in children with burns 5-7 years after injury: A cross-sectional multicentre study

Long-term scar formation is an important adverse consequence in children with burns, however, information regarding scar quality in the long-term is lacking. Therefore, we evaluated scar quality and its predictors in children with burns 5-7 years after injury. Parents of children with mild/intermediate burns (≤10% total body surface area burned), and of children with severe burns (>10% burned) completed the patient scale of the Patient and Observer Scar Assessment Scale (POSAS 2.0) for their children's-in their opinion-worst scar 5-7 years post-burn. Outcomes and predictive factors of scar quality were studied, and, for children with severe burns, POSAS parent scores were compared with observer scores. We included 103 children with mild/intermediate burns and 28 with severe burns (response rate: 51%). Most children (87%) had scars that differed from normal skin, with most differences reported for colour, and least for pain. Except for colour, children with severe burns had significantly higher scores (difference 0-2 points) on all scar characteristics (representing poorer scar quality) compared with children with mild/intermediate burns. Parent POSAS scores were on average 2.0-2.6 points higher compared to observer scores. Number of surgeries predicted both the mean POSAS and the mean overall opinion of a scar. In conclusion, 5-7 years post-burn, the scar of the majority of children differed from normal skin, especially on the characteristic colour. The uncovered insights are useful in counselling of children and their parents on expectations of the final outcome of their (children's) scar(s), and help in further targeting scar prevention strategies for the individual child.

The development of burn scar contractures and impact on joint function, disability and quality of life in low- and middle-income countries: A prospective cohort study with one-year follow-up

OBJECTIVE

The aim of this study was to assess the development of burn scar contractures and their impact on joint function, disability and quality of life in a low-income country.

METHODS

Patients with severe burns were eligible. Passive range of motion (ROM) was assessed using lateral goniometry. To assess the development of contractures, the measured ROM was compared to the normal ROM. To determine joint function, the normal ROM was compared to the functional ROM. In addition, disability and quality of life (QoL) were assessed. Assessments were from admission up to 12 months after injury.

RESULTS

Thirty-six patients were enrolled, with a total of 124 affected joints. The follow-up rate was 83%. Limited ROM compared to normal ROM values was observed in 26/104 joints (25%) at 12 months. Limited functional ROM was observed in 55/115 joints (48%) at discharge and decreased to 22/98 joints (22%) at 12 months. Patients who had a contracture at 12 months reported more disability and lower QoL, compared to patients without a contracture (median disability 0.28 versus 0.17 (p = 0.01); QoL median 0.60 versus 0.76 (p = 0.001)). Significant predictors of developing joint contractures were patient delay and the percentage of TBSA deep burns.

CONCLUSION

The prevalence of burn scar contractures was high in a low-income country. The joints with burn scar contracture were frequently limited in function. Patients who developed a contracture reported significantly more disability and lower QoL. To limit the development of burn scar contractures, timely access to safe burn care should be improved in low-income countries.

Activity impairment, work status, and work productivity loss in adults 5-7 years after burn injuries

An important aspect of the rehabilitation of burn patients is social participation, including daily activities and work. Detailed information on long-term activity impairment and employment is scarce. Therefore, we investigated activity impairment, work status, and work productivity loss in adults 5–7 years following burn injuries, and investigated associations with burn-specific health-related quality of life (HRQL) domains. Adult participants completed the Work Productivity and Activity Impairment General Health questionnaire and the Burn Specific Health Scale-brief (BSHS-B) 5–7 years post-burn. Outcomes were compared between participants with mild/intermediate and severe burns (>20% total body surface area burned). Seventy-six (36%) of the 213 participants experienced some degree of activity impairment due to burn-related problems 5–7 years post-burn. Seventy percent of the population was employed; 12% of them experienced work productivity loss due to burn-related problems. Nineteen percent reported changes in their work situation (partly) because of the burn injury. A higher proportion of participants with severe burns had activity impairments (56% vs 29%; P = .001) and work productivity loss (26% vs 8%; P < .001) compared to participants with mild/intermediate burns. Activity impairment and work productivity loss were both associated with burn-related work problems and lower mood, measured with the BSHS-B. In conclusion, a substantial part of the study population experienced activity impairment and work productivity loss, was unemployed, and/or reported changes in their work situation due to their injury. Particularly patients with severe burns reported productivity loss and had lower employment rates. This subscribes the importance of addressing work-related functioning in the rehabilitation of burn patients.

Patient-reported scar quality of donor-sites following split-skin grafting in burn patients: Long-term results of a prospective cohort study

BACKGROUND

Skin grafting is the current gold standard for treatment of deeper burns. How patients appraise the donor-site scar is poorly investigated. The aim of this study was to evaluate long-term patient-reported quality of donor-site scars after split skin grafting and identify possible predictors.

METHODS

A prospective cohort study was conducted. Patients were included in a Dutch burn centre during one year. Patient-reported quality of donor-site scars and their worst burn scar was assessed at 12 months using the Patient and Observer Scar Assessment Scale (POSAS). Mixed model analyses were used to identify predictors of scar quality.

RESULTS

This study included 115 donor-site scars of 72 patients with a mean TBSA burned of 11.2%. The vast majority of the donor-site scars (84.4%) were rated as having at least minor differences with normal skin (POSAS item score ≥2) on one or more scar characteristics and the overall opinion on 80.9% of the donor-site scars was that they deviated from normal skin 12 months after surgery. The overall opinion on the donor-site scar was 3.2 ± 2.1 vs. 5.1 ± 2.4 on the burn scar. A younger age, female gender, a darker skin type, and location on the lower leg were predictors of reduced donor-site scar quality. In addition, time to re-epithelization was associated with scar quality.

CONCLUSION

This study provided new insights in long-term scar quality of donor-sites. Donor-site scars differed from normal skin in a large part of the population 12 months after surgery. Results of this study can be used to inform patients on the long-term outcomes of their scars and to tailor preventive or therapeutic treatment options.

Systematic Review of Stem-Cell-Based Therapy of Burn Wounds: Lessons Learned from Animal and Clinical Studies

Treatment of severe burn wounds presents a daunting medical challenge, and novel approaches promoting healing and reducing scarring are highly desirable. The application of mesenchymal stem/stromal cells (MSCs) has been suggested as a novel treatment. In this paper, we present systematic reviews of pre-clinical and clinical studies of MSC therapy for second- or third^-degree thermal burn wounds. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, the PubMed and Embase databases were searched, and interventional studies of MSC therapy using rodent models (21 studies) or human burn patients (three studies) were included in the pre-clinical and clinical reviews, respectively, where both overall outcome and wound-healing-phase-specific methodologies and effects were assessed. The pre-clinical studies demonstrated a promising effect of the application of MSCs on several wound healing phases. The clinical studies also suggested that the MSC treatment was beneficial, particularly in the remodeling phase. However, the limited number of studies, their lack of homogeneity in study design, relatively high risk of bias, lack of reporting on mode of action (MOA), and discontinuity of evidence restrict the strength of these findings. This comprehensive review presents an overview of available methodologies to assess the MOA of MSC treatment for distinct wound healing phases. Furthermore, it includes a set of recommendations for the design of high-quality clinical studies that can determine the efficacy of MSCs as a therapy for burn wounds.

Early physiotherapy experience with a biodegradable polyurethane dermal substitute: Therapy guidelines for use

OBJECTIVE

The purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre.

METHOD

A retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales.

RESULTS

Clearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury.

CONCLUSION

A steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.

The added value of extending the EQ-5D-5L with an itching item for the assessment of health-related quality of life of burn patients: an explorative study

INTRODUCTION

Health-related quality of life (HRQL) is an important outcome in burn care and research. An advantage of a generic HRQL instrument, like the EQ-5D, is that it enables comparison of outcomes with other conditions and the general population. However, the downside is that it does not include burn specific domains, like scar issues or itching. Adding extra items to a generic instrument might overcome this issue. This study explored the potential and added value of extending the EQ-5D-5L with a burn-specific item, using a itching item as an example.

METHODS

The EQ-5D-5L and the Patient and Observer Scar Assessment Scale (POSAS) was completed by adult patients 5-7 years after injury. A separate POSAS itching item was used to study the added value of an itching item for the EQ-5D-5L. The EQ-5D-5L + Itching was created by adding the POSAS itching item to the EQ-5D-5L. Five psychometric properties were compared between EQ-5D-5L and EQ-5D-5L + Itching: distribution (e.g. ceiling), informativity cf. Shannon's indices, convergent validity, dimension dependency, and explanatory power respectively.

RESULTS

A total of 243 patients were included, of whom 49% reported any itching on the POSAS. Adding an itching item to the EQ-5D-5L decreased the ceiling effect, and resulted in increased absolute informativity (H' = 4.76 vs. H' = 3.64) and relative informativity (J' = 0.34 vs. J' = 0.31). The extra itching item decreased the convergent validity (Spearman's rank correlation coefficient = -0.51 vs. -0.59). Mutual dependency of dimensions existed, showing that all other items were dominant over the itching item. Adding the itching item to the standard EQ-5D-5L barely improved explanatory power (49.3% vs. 49.0%).

CONCLUSIONS

PThe present study showed adding a burn-specific item to the EQ-5D-5L is possible and has potential. However, 5 to 7 years after injury, adding an itching item to the EQ-5D-5L provides little additional information; the gain in terms of added value is relatively small. Apart from instances where itching information is specifically needed, a strong case is not present for adding an itching item to the EQ-5D-5L for long-term (>5 yr after burns) HRQL assessment in burn patients. In early time periods after burn, the added value might be greater and we recommend exploring this potential in future studies, ideally on multiple timepoints after burn.

Long-term medical treatment of patients with severe burns at exposed sites

BACKGROUND

Body parts such as the face and hands are highly exposed during daily life and burns may accumulate in these areas. In addition, residual wounds, scar hyperplasia and contracture often exist in the late stage of a deep burn in these areas, which may affect patients’ appearance, movements, and mental health. However, inadequate attention has been paid to this issue which can result in problems, such as difficulty in healing, possibility of carcinoma, chronic pain and a heavy mental burden.

AIM

To investigate the long-term medical treatment of patients with severe burns at exposed sites following a mass burn casualty event.

METHODS

A retrospective analysis of 13 patients with severe burns at exposed sites was performed to determine their respective long-term medical treatment. A combined wound dressing scheme consisting of traditional Chinese and Western medicine was introduced to repair residual wounds. Active and passive functional exercises with massage, Chinese herbal baths and compression fixation were proposed to ameliorate the condition of the hands. A combination of physical, chemical and photoelectrical measures was adopted for anti-scar treatment. A psychological intervention and recovery guide was provided which corresponded to the patients’ psychological status.

RESULTS

Compared to patients who did not simultaneously receive the same treatment, patients who underwent systematic treatment recovered with a lower wound infection rate (P < 0.05), a shorter healing time (13.6 ± 3.2 d) compared with (19.1 ± 3.5 d) and more bearable pain during wound dressing at three days, one week and two weeks after a Chinese herbal bath (P < 0.05). Satisfactory results were achieved with regard to restored function of patients’ joints and blood supply to nerve endings, closure of the eyelids and the size of mouth opening tended to be normal, and only 7.1% of patients were diagnosed with severe scar hyperplasia and contracture deformity compared with 30.7% in the control group. In addition, the color, thickness, vascular distribution and softness score of the scars improved (P < 0.01), and the effects of the psychological intervention was remarkable as shown by the Self-Rating Anxiety Scale and Self-Rating Depression Scale.

CONCLUSION

A better prognosis can be achieved in patients in the late stage of a burn with active residual wound repair, limb functional exercise, anti-scar and psychological rehabilitation.

Assessment of laser-assisted delivery vs intralesional injection of botulinum toxin A in treatment of hypertrophic scars and keloids

Keloids and hypertrophic scars could impair the psychological, physical, and cosmetic aspects of the patient's quality of life. Unfortunately, there is no curative treatment available till now. This study aimed to evaluate the efficacy and safety of intralesional vs topical botulinum toxin A combined with Fractional CO₂ laser in the treatment of hypertrophic scars and keloids. Twenty patients with Keloids and hypertrophic scars were enrolled in the study. Each scar was divided into two halves, one subjected to intralesional injection of botulinum toxin type A once a month for 4 months and the other was subjected to four sessions of CO₂ laser therapy at 1 month interval followed by topical application of botulinum toxin A. Significant improvement was noted in Vancouver Scar Scale in hypertrophic scars in laser group than intralesional botulinum toxin A. In keloid cases, the improvement was significantly higher with intralesional botulinum toxin A. Clinical improvement showed significant negative correlation with scar duration and size. Botulinum toxin A is a promising treatment for hypertrophic scars and keloids. The use of fractional CO₂ laser as a mode of delivery enhanced the efficacy of botox in hypertrophic scars.

Biological dermal templates with native collagen scaffolds provide guiding ridges for invading cells and may promote structured dermal wound healing

Dermal substitutes are of major importance in treating full thickness skin defects. They come in a variety of materials manufactured into various forms, such as films, hydrocolloids, hydrogels, sponges, membranes, and electrospun micro- and nanofibers. Bioactive dermal substitutes act in wound healing either by delivery of bioactive compounds or by being constructed from materials having endogenous activity. The healing success rate is highly determined by cellular and physiological processes at the host-biomaterial interface during crucial wound healing steps. Hence, it is important to design appropriate wound treatment strategies with the ability to work actively with tissues and cells to enhance healing. Therefore, in this study, we investigated biological dermal templates and their potential to stimulate natural cell adherence, guidance, and morphology. The most pronounced effect was observed in biomaterials with the highest content of native collagen networks. Cell attachment and proliferation were significantly enhanced on native collagen scaffolds. Cell morphology was more asymmetrical on such scaffolds, resembling native in vivo structures. Importantly, considerably lower expression of myofibroblast phenotype was observed on native collagen scaffolds. Our data suggest that this treatment strategy might be beneficial for the wound environment, with the potential to promote improved tissue regeneration and reduce abnormal scar formation.

Exploring the relation between the EQ-5D-5L pain/discomfort and pain and itching in a sample of burn patients

BACKGROUND

The EQ-5D domain pain/discomfort (PD) uses one item to capture pain and other aspects of discomfort, like itching. This study explored how pain, itching and the EQ-5D-5L PD domain relate to each other in a sample of burn patients.

METHODS

Adult burn patients completed the EQ-5D-5L and the Patient and Observer Scar Assessment Scale (POSAS) 5-7 years after sustaining their injury. The POSAS includes a separate pain and an itching item. Spearman's correlation coefficient established the association between the EQ-5D-5L PD and the POSAS pain and itching item. With multivariable regression analysis the linear association between the POSAS pain and itching item and EQ-5D-5L PD domain was tested.

RESULTS

Data from 245 patients were included. Mean EQ-5D-5L index value was 0.87 and 39.2% reported at least slight problems on the EQ-5D-5L PD domain. Most patients gave corresponding answers on the EQ-5D-5L PD domain and on the POSAS pain (73%) and itching (70%) item. Spearman correlation coefficients of the EQ-5D-5L PD domain with the POSAS pain and itching were 0.468 (p < 0.001) and 0.473 (p < 0.001), respectively. Among respondents with pain and without itching and respondents with itching and without pain, Spearman correlation coefficients were 0.585 (p = 0.076) and 0.408 (p = 0.001), respectively. POSAS pain (unstandardized Beta = 0.14) and POSAS itching (unstandardized Beta = 0.08) were significantly associated with EQ-5D-5L PD domain (p < 0.001).

CONCLUSIONS

Our findings indicate that, in a sample of burn patients, pain and itching are captured by the broader EQ-5D-5L PD domain. The EQ-5D-5L PD domain can thus be used to assess pain and itching in relation to HRQL, but the POSAS pain and itching items are more sensitive. The EQ-5D-5L is, however, no replacement of the POSAS when the POSAS is used for its primary aim; assessment of scar quality.

TRIAL REGISTRATION

Netherlands Trial Register (NTR6407).

Reliability testing of the Matching Assessment using Photographs of Scars App

The Matching Assessment using Photographs with Scars assessment tool, published in 2005, enables accurate relocation and reassessment of scars. While used in Australia, uptake has been hampered by its paper manual format. With electronic records and increasing use of smart devices in health, here we report the development of the Matching Assessment using Photographs with Scars manual into a mobile application format: ClinMAPS^TM Pro. At the time of development, no other digital scar assessment applications were available. For clinical validation, the digitized Matching Assessment using Photographs with Scars module within ClinMAPS^TM Pro was used for intra- and inter-rater reliability testing. Convenience sampling was utilized to recruit burns patients representing 44 scars, based on predetermined power calculations. Three therapists, one experienced and two novice, acted as the assessors. Each therapist assessed preselected scars with the digitized Matching Assessment using Photographs with Scars. Re-assessment of the same scar sites occurred 3 to 7 days later. Inter-rater reliability testing scores of the new electronic assessment application showed fair to moderate agreement (combined Fleiss Kappa = 0.38-0.49, P < .0001). Intra-rater reliability scores between initial and repeat measures showed moderate to almost perfect agreement (Cohen's Kappa = 0.43-0.90, P < .0001). It was noted that for an experienced rater, intra-rater agreement demonstrated substantial to almost perfect agreement. Intraclass correlation coefficients calculated to allow for comparison between other published scar assessment tools demonstrated excellent reliability for all scar assessment parameters for both intra- (=0.76-0.91) and inter- (=0.76-0.98) reliability. Notably, reliability testing results confirm its intra- and inter-rater reliability. Our findings validate this novel concept for digitization of the previously paper-based scar assessment manual and prove that the Matching Assessment using Photographs with Scars within the ClinMAPS^TM Pro application is now readily available for clinicians and researchers internationally.

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

Background

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

Methods and findings

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

Conclusions

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