To evaluate the effect of (new) treatments or analyse prevalence and risk factors of contractures, rating scales are used based on joint range of motion. However, cut-off points for levels of ...severity vary between scales, and it seems unclear how cut-off points relate to function. The purpose of this study was to compare severity ratings of different rating scales for the shoulder and elbow and relate these with functional range of motion.
Often used contracture severity rating scales in orthopedics, physiotherapy, and burns were included. Functional range of motion angles for the shoulder and elbow were derived from a recent synthesis published by our group. Shoulder flexion and elbow flexion range of motion data of patients three months after a burn injury were rated with each of the scales to illustrate the effects of differences in classifications. Secondly, the shoulder and elbow flexion range of motion angles were related to the required angles to perform over 50 different activities of daily living tasks.
Eighteen rating scales were included (shoulder: 6, elbow: 12). Large differences in the number of severity levels and the cut-off points between scales were determined. Rating the measured range of motions with the different scales showed substantial inconsistency in the number of joints without impairment (shoulder: 14-36%, elbow: 26-100%) or with severe impairment (shoulder: < 10%-29%, elbow 0%-17%). Cut-off points of most scales were not related to actual function in daily living.
There is an urgent need for rating scales that express the severity of contractures in terms of loss of functionality. This study proposes a direction for a solution.
Providing an overview of the clinimetric properties of the steep ramp test (SRT)—a short-term maximal exercise test—to assess cardiorespiratory fitness (CRF), describing its underlying physiological ...responses, and summarizing its applications in current clinical and research practice.
MEDLINE (through PubMed), CINAHL Complete, Cochrane Library, EMBASE, and PsycINFO were searched for studies published up to July 2023, using keywords for SRT and CRF.
Eligible studies involved the SRT as research subject or measurement instrument and were available as full text articles in English or Dutch.
Two independent assessors performed data extraction. Data addressing clinimetric properties, physiological responses, and applications of the SRT were tabulated.
In total, 370 studies were found, of which 39 were included in this study. In several healthy and patient populations, correlation coefficients between the work rate at peak exercise (WRpeak) attained at the SRT and oxygen uptake at peak exercise during cardiopulmonary exercise testing (CPET) ranged from .771-.958 (criterion validity). Repeated measurements showed intraclass correlation coefficients ranging from .908-.996 for WRpeak attained with the first and second SRT (test-retest reliability). Physiological parameters, like heart rate and minute ventilation at peak exercise, indicated that the SRT puts a lower burden on the cardiopulmonary system compared to CPET. The SRT is mostly used to assess CRF, among others as part of preoperative risk assessment, and to personalize interval training intensity.
The SRT is a practical short-term maximal exercise test that is valid for CRF assessment and to monitor changes in CRF over time in various healthy and patient populations. Its clinimetric properties and potential applications make the SRT of interest for a widespread implementation of CRF assessment in clinical and research practice and for personalizing training intensity and monitoring longitudinal changes in CRF.
Highlights • A systematic review concerning prevalence and determinants of burn scar contractures. • The few available studies demonstrate a prevalence at discharge of 38–54%. • With longer time ...after burn, the prevalence of contractures was lower. • Determinants: severe burns, flame burns, children, female patients, cervical spine, upper extremity. • Longitudinal studies are needed to improve prevention and treatment of contractures.
The population of elderly patients with burn injuries is growing. Insight into long-term mortality rates of elderly after burn injury and predictors affecting outcome is limited. This study aimed to ...provide this information.
A multicentre observational retrospective cohort study was conducted in all three Dutch burn centres. Patients aged ≥65 years, admitted with burn injuries between 2009 and 2018, were included. Data were retrieved from electronic patient records and the Dutch Burn Repository R3. Mortality rates and standardized mortality ratios (SMRs) were calculated. Multivariable logistic regression was used to assess predictors for in-hospital mortality and mortality after discharge at 1 year and five-year. Survival analysis was used to assess predictors of five-year mortality.
In total, 682/771 admitted patients were discharged. One-year and five-year mortality rates were 8.1 and 23.4%. The SMRs were 1.9(95%CI 1.5-2.5) and 1.4(95%CI 1.2-1.6), respectively. The SMRs were highest in patients aged 75-80 years at 1 year (SMRs 2.7, 95%CI 1.82-3.87) and five-year in patients aged 65-74 years (SMRs 10.1, 95%CI 7.7-13.0). Independent predictors for mortality at 1 year after discharge were higher age (OR 1.1, 95%CI 1.0-1.1), severe comorbidity, (ASA-score ≥ 3) (OR 4.8, 95%CI 2.3-9.7), and a non-home discharge location (OR 2.0, 95%CI 1.1-3.8). The relative risk of dying up to five-year was increased by age (HR 1.1, 95%CI 1.0-1.1), severe comorbidity (HR 2.3, 95%CI 1.6-3.5), and non-home discharge location (HR 2.1, 95%CI 1.4-3.2).
Long-term mortality until five-year after burn injury was higher than the age and sex-matched general Dutch population, and predicted by higher age, severe comorbidity, and a non-home discharge destination. Next to pre-injury characteristics, potential long-lasting systemic consequences on biological mechanisms following burn injuries probably play a role in increased mortality. Decreased health status makes patients more prone to burn injuries, leading to early death.
Topical treatment for facial burns Van Baar, Margriet E; Hoogewerf, Cornelis J; Hop, M Jenda ...
Cochrane database of systematic reviews,
07/2020, Letnik:
2020, Številka:
7
Journal Article
Recenzirano
Odprti dostop
Background
Burn injuries are an important health problem. They occur frequently in the head and neck region. The face is the area central to a person's identity that provides our most expressive ...means of communication. Topical interventions are currently the cornerstone of treatment of burns to the face.
Objectives
To assess the effects of topical interventions on wound healing in people with facial burns of any depth.
Search methods
In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In‐Process & Other Non‐Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta‐analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.
Selection criteria
Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review.
Data collection and analysis
Two review authors independently performed study selection, data extraction, risk of bias assessment and GRADE assessment of the certainty of the evidence.
Main results
In this first update, we included 12 RCTs, comprising 507 participants.
Most trials included adults admitted to specialised burn centres after recent burn injuries.
Topical agents included antimicrobial agents (silver sulphadiazine (SSD), Aquacel‐Ag, cerium‐sulphadiazine, gentamicin cream, mafenide acetate cream, bacitracin), non‐antimicrobial agents (Moist Exposed Burn Ointment (MEBO), saline‐soaked dressings, skin substitutes (including bioengineered skin substitute (TransCyte), allograft, and xenograft (porcine Xenoderm), and miscellaneous treatments (growth hormone therapy, recombinant human granulocyte‐macrophage colony‐stimulating factor hydrogel (rhGMCS)), enzymatic debridement, and cream with Helix Aspersa extract).
Almost all the evidence included in this review was assessed as low or very low‐certainty, often because of high risk of bias due to unclear randomisation procedures (i.e. sequence generation and allocation concealment); lack of blinding of participants, providers and sometimes outcome assessors; and imprecision resulting from few participants, low event rates or both, often in single studies.
Topical antimicrobial agents versus topical non‐antimicrobial agents
There is moderate‐certainty evidence that there is probably little or no difference between antimicrobial agents and non‐antimicrobial agents (SSD and MEBO) in time to complete wound healing (hazard ratio (HR) 0.84 (95% confidence interval (CI) 0.78 to 1.85, 1 study, 39 participants). Topical antimicrobial agents may make little or no difference to the proportion of wounds completely healed compared with topical non‐antimicrobial agents (comparison SSD and MEBO, risk ratio (RR) 0.94, 95% CI 0.68 to 1.29; 1 study, 39 participants; low‐certainty evidence). We are uncertain whether there is a difference in wound infection (comparison topical antimicrobial agent (Aquacel‐Ag) and MEBO; RR 0.38, 95% CI 0.12 to 1.21; 1 study, 40 participants; very low‐certainty evidence). No trials reported change in wound surface area over time or partial wound healing. There is low‐certainty evidence for the secondary outcomes scar quality and patient satisfaction. Two studies assessed pain but it was incompletely reported.
Topical antimicrobial agents versus other topical antimicrobial agents
It is uncertain whether topical antimicrobial agents make any difference in effects as the evidence is low to very low‐certainty. For primary outcomes, there is low‐certainty evidence for time to partial (i.e. greater than 90%) wound healing (comparison SSD versus cerium SSD: mean difference (MD) –7.10 days, 95% CI –16.43 to 2.23; 1 study, 142 participants). There is very low‐certainty evidence regarding whether topical antimicrobial agents make a difference to wound infection (RR 0.73, 95% CI 0.46 to 1.17; 1 study, 15 participants). There is low to very low‐certainty evidence for the proportion of facial burns requiring surgery, pain, scar quality, adverse effects and length of hospital stay.
Skin substitutes versus topical antimicrobial agents
There is low‐certainty evidence that a skin substitute may slightly reduce time to partial (i.e. greater than 90%) wound healing, compared with a non‐specified antibacterial agent (MD –6.00 days, 95% CI –8.69 to –3.31; 1 study, 34 participants).
We are uncertain whether skin substitutes in general make any other difference in effects as the evidence is very low certainty. Outcomes included wound infection, pain, scar quality, adverse effects of treatment and length of hospital stay.
Single studies showed contrasting low‐certainty evidence. A bioengineered skin substitute may slightly reduce procedural pain (MD –4.00, 95% CI –5.05 to –2.95; 34 participants) and background pain (MD –2.00, 95% CI –3.05 to –0.95; 34 participants) compared with an unspecified antimicrobial agent. In contrast, a biological dressing (porcine Xenoderm) might slightly increase pain in superficial burns (MD 1.20, 95% CI 0.65 to 1.75; 15 participants (30 wounds)) as well as deep partial thickness burns (MD 3.00, 95% CI 2.34 to 3.66; 10 participants (20 wounds)), compared with antimicrobial agents (Physiotulle Ag (Coloplast)).
Miscellaneous treatments versus miscellaneous treatments
Single studies show low to very low‐certainty effects of interventions. Low‐certainty evidence shows that MEBO may slightly reduce time to complete wound healing compared with saline soaked dressing (MD –1.7 days, 95% CI –3.32 to –0.08; 40 participants). In addition, a cream containing Helix Aspersa may slightly increase the proportion of wounds completely healed at 14 days compared with MEBO (RR 4.77, 95% CI 1.87 to 12.15; 43 participants). We are uncertain whether any miscellaneous treatment in the included studies makes a difference in effects for the outcomes wound infection, scar quality, pain and patient satisfaction as the evidence is low to very low‐certainty.
Authors' conclusions
There is mainly low to very low‐certainty evidence on the effects of any topical intervention on wound healing in people with facial burns. The number of RCTs in burn care is growing, but the body of evidence is still hampered due to an insufficient number of studies that follow appropriate evidence‐based standards of conducting and reporting RCTs.
Frailty is a predictor of adverse outcomes in elderly patients. The Canadian Study of Health and Aging Clinical Frailty Scale (CFS) is an often-used frailty assessment instrument. However, the CFS’s ...reliability and validity in patients with burn injuries are unknown. This study aimed to assess the CFS’s inter-rater reliability and validity (predictive validity, known group validity and convergent validity) in patients with burn injuries treated to specialized burn care.
A retrospective multicentre cohort study was conducted in all three Dutch burn centres. Patients aged ≥ 50 years with burn injuries, with a primary admission in 2015–2018, were included. Based on information in the electronic patient files, a research team member scored the CFS retrospectively. Inter-rater reliability was calculated using Krippendorff’s α. Validity was assessed using logistic regression analysis. Patients with a CFS ≥ 5 were considered frail.
In total, 540 patients were included, with a mean age of 65.8 years (SD 11.5) and a Total Body Surface Area (TBSA) burned of 8.5%. The CFS was used to assess frailty in 540 patients and the reliability of the CFS was scored for 212 patients. Mean CFS was 3.4(SD 2.0). Inter-rater reliability was adequate, Krippendorff’s α 0.69 (95%CI 0.62–0.74). A positive frailty screening was predictive of a non-home discharge location (OR 3.57, 95%CI 2.16–5.93), a higher in-hospital mortality rate (OR 1.06–8.77), and a higher mortality rate within 12 months after discharge (OR 4.61, 95%CI 1.99–10.65) after adjustment for age, TBSA, and inhalation injury. Frail patients were more likely to be older (for<70 vs. ≥70 years odds ratio 2.88, 95%CI 1.95–4.25) and their comorbidities were more severe (ASA ≥3 vs 1–2 OR 6.43, 95%CI 4.26–9.70) (known group validity). The CFS was significantly related (rSpearman=0.55) to the Dutch Safety Management System (DSMS) frailty screening, reflecting a fair-good correlation between the CFS and DSMS frailty screening outcomes.
The Clinical Frailty scale is reliable and has shown its validity, including its association with adverse outcomes in patients with burn injury admitted to specialized burn care. Early frailty assessment with the CFS must be considered, to optimize early recognition and treatment of frailty.
•The CFS is a reliable and valid tool to assess frailty in elderly burn patients.•The CFS is a promising screening tool in specialised burn care that can contribute to optimised and timely care in patients with burn injuries.•The CFS can distinguish frail patients from non-frail patients in known groups.•The CFS can predict some adverse outcomes like discharge location and mortality after discharge.•Patients aged 50 years and over appeared to be frail, underlining the importance of adequate frailty screening and prevention measures.
Abstract
Background
In the last decades, autologous fat grafting has been used to treat adherent dermal scars. The observed regenerative and scar-reducing properties have been mainly ascribed to the ...tissue-derived stromal vascular fraction (tSVF) in adipose tissue. Adipose tissue’s components augment local angiogenesis and mitosis in resident tissue cells. Moreover, it promotes collagen remodeling. We hypothesize that tSVF potentiates fat grafting-based treatment of adherent scars. Therefore, this study aims to investigate the effect of tSVF-enriched fat grafting on scar pliability over a 12-month period.
Methods and design
A clinical multicenter non-randomized early phase trial will be conducted in two dedicated Dutch Burn Centers (Red Cross Hospital, Beverwijk, and Martini Hospital, Groningen). After informed consent, 46 patients (≥18 years) with adherent scars caused by burns, necrotic fasciitis, or degloving injury who have an indication for fat grafting will receive a sub-cicatricic tSVF-enriched fat graft. The primary outcome is the change in scar pliability measured by the Cutometer between pre- and 12 months post-grafting. Secondary outcomes are scar pliability (after 3 months), scar erythema, and melanin measured by the DSM II Colormeter; scar quality assessed by the patient and observer scales of the Patient and Observer Scar Assessment Scale (POSAS) 2.0; and histological analysis of scar biopsies (voluntary) and tSVF quality and composition. This study has been approved by the Dutch Central Committee for Clinical Research (CCMO), NL72094.000.20.
Conclusion
This study will test the clinical efficacy of tSVF-enriched fat grafting to treat dermal scars while the underlying working mechanism will be probed into too.
Trial registration
Dutch Trial Register NL 8461. Registered on 16 March 2020
•Patients in burn centres experience clinically high levels of anxiety.•The LDI-scan can be used as a basis for sharing information.•Share information with patients on their need for surgery as it ...reduces anxiety.
Stress has been linked to poor coping with health-related issues, poor adaptation, a decrease of quality of life, poor recovery and poor wound healing. Therefore, it is important to address patients’ uncertainty and feelings of anxiety. The aim of this study was to examine the effect of providing early treatment information based on an LDI-scan to patients with burns on their feelings of anxiety.
An observational prospective pre-test post-test study.
Patients with intermediate burns (n = 59) admitted to our burn centre in 2016 were evaluated for anxiety using a visual analogue scale (VAS-A) before and after an LDI-scan was made. Two groups were compared: a group that heard whether surgery would or would not be recommended for wound closure (certain group) versus a group that heard to wait and see whether an operation was determined to be helpful (uncertain group).
Before the LDI-scan was made, both groups showed clinically high levels of anxiety (median VAS scores above 5). After the information gathered with the LDI was discussed with the patient, anxiety dropped significantly (median VAS below 3; p = .001). No significant differences between the groups were observed (p > .05).
In contrast to other studies, anxiety was significantly reduced in all our study groups after information was shared. Early communication of knowledge by health care professionals is important regardless whether it includes treatment uncertainty.
Describe prevalence and severity of fatigue in children and adolescents with burns during six months after hospital discharge, identify potential explanatory variables, and examine the relationship ...with exercise capacity.PURPOSEDescribe prevalence and severity of fatigue in children and adolescents with burns during six months after hospital discharge, identify potential explanatory variables, and examine the relationship with exercise capacity.Fatigue was assessed using the Pediatric-Quality-of-Life-Inventory-Multidimensional-Fatigue-Scale (PedsQL-MFS) at discharge, and six weeks, three-, and six months after discharge. PedsQL-MFS scores ≥1 SD below the age-group specific non-burned reference mean were considered to signify fatigue.MATERIALS AND METHODSFatigue was assessed using the Pediatric-Quality-of-Life-Inventory-Multidimensional-Fatigue-Scale (PedsQL-MFS) at discharge, and six weeks, three-, and six months after discharge. PedsQL-MFS scores ≥1 SD below the age-group specific non-burned reference mean were considered to signify fatigue.Twenty-two children and adolescents (13 boys/9 girls, age 6-18 years, with burns covering 2-34% of total body surface area) were included. The prevalence of fatigue decreased from 65% (11/17) at discharge to 28% (5/18) six months after discharge. At group level, fatigue severity decreased over time, reaching healthy reference values from six weeks after discharge and beyond. At individual level, the course of fatigue severity varied widely. Fatigue severity at six months after discharge could not be predicted by age, sex, or burn severity (p = 0.51, p = 0.58, p = 0.95, respectively). The association with exercise capacity was weak (r = 0.062-0.538).RESULTSTwenty-two children and adolescents (13 boys/9 girls, age 6-18 years, with burns covering 2-34% of total body surface area) were included. The prevalence of fatigue decreased from 65% (11/17) at discharge to 28% (5/18) six months after discharge. At group level, fatigue severity decreased over time, reaching healthy reference values from six weeks after discharge and beyond. At individual level, the course of fatigue severity varied widely. Fatigue severity at six months after discharge could not be predicted by age, sex, or burn severity (p = 0.51, p = 0.58, p = 0.95, respectively). The association with exercise capacity was weak (r = 0.062-0.538).More than a quarter of pediatric burn patients reported fatigue six months after discharge. Further research in larger populations is required, including also the impact of burn-related fatigue on daily functioning and quality of life.Trial registration number: OND1353942Implications for rehabilitationFatigue should be recognized as a potential consequence of (pediatric) burns, even several months post burnFatigue should be assessed regularly after discharge in all children and adolescents with burns, as it seems not possible to predict its severity from age, sex, or burn severity characteristicsThe weak association between exercise capacity and self-reported fatigue suggests that burn-related fatigue is not simply a consequence of a reduced exercise capacity.CONCLUSIONSMore than a quarter of pediatric burn patients reported fatigue six months after discharge. Further research in larger populations is required, including also the impact of burn-related fatigue on daily functioning and quality of life.Trial registration number: OND1353942Implications for rehabilitationFatigue should be recognized as a potential consequence of (pediatric) burns, even several months post burnFatigue should be assessed regularly after discharge in all children and adolescents with burns, as it seems not possible to predict its severity from age, sex, or burn severity characteristicsThe weak association between exercise capacity and self-reported fatigue suggests that burn-related fatigue is not simply a consequence of a reduced exercise capacity.
Tangential excision of burned tissue followed by skin grafting is the cornerstone of burn surgery. Hydrosurgery has become popular for tangential excision, with the hypothesis that enhanced ...preservation of vital dermal tissue reduces scarring. The aim of this trial was to compare scar quality after hydrosurgical versus conventional debridement before split-skin grafting.
A double-blind randomized within-patient multicentre controlled trial was conducted in patients with burns that required split-skin grafting. One wound area was randomized to hydrosurgical debridement and the other to Weck knife debridement. The primary outcome was scar quality at 12 months, assessed with the observer part of the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included complications, scar quality, colour, pliability, and histological dermal preservation.
Some 137 patients were randomized. At 12 months, scars of the hydrosurgical debrided wounds had a lower POSAS observer total item score (mean 2.42 (95 per cent c.i. 2.26 to 2.59) versus 2.54 (95 per cent c.i. 2.36 to 2.72; P = 0.023)) and overall opinion score (mean 3.08 (95 per cent c.i. 2.88 to 3.28) versus 3.30 (95 per cent c.i. 3.09-3.51); P = 0.006). Patient-reported scar quality and pliability measurements were significantly better for the hydrosurgically debrided wounds. Complication rates did not differ between both treatments. Histologically, significantly more dermis was preserved with hydrosurgery (P < 0.001).
One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis.
Trial NL6085 (NTR6232 (http://www.trialregister.nl)).
PDF
