Surgical management of burn wounds: Clinical and Patient-reported outcomes

PART I Health-Related Quality of Life after burn injury In order to reveal and summarize the current knowledge on HRQL after burns, an extensive systematic literature review was performed. Results of Chapter 2 and Chapter 4 show that HRQL is increasingly studied after burn injury and no consensus consists on what specific HRQL instrument(s) should be used in adults or children after burn injuries. In adults, participation restrictions due to physical functional limitations and emotional distress remained, including limitations of regular daily activities like work. In addition, burn patients seemed to be on average more anxious and/or depressed compared to the general population and a large number of patients continued experiencing pain and/or discomfort in the long term. In children, especially appearance and parental concern remained a problem (Chapter 4). Patients with major burns experienced evidently more problems than patients with mild burns, and patients with psychological problems before or shortly after the injury are frequently seen to maintain problems in the long-term and should therefore be carefully monitored (Chapter 3). In children, the psychological impact is barely studied. Paediatric patients with major burns, facial burns, hand burns, and comorbidity experienced a poorer long-term HRQL and required special attention. PART II Clinimetric studies on outcomes In Chapter 5 measurement properties of instruments that have been used to assess HRQL in burn patients were critically assessed. Results showed that the Burns Specific Health Scale-brief (BSHS-B) and the Brisbane Burn Scar Impact Profile (BBSIP), have somewhat more favourable properties compared to other instruments. To further improve the understanding of HRQL after burn injury, consensus on uniformly validated instrument(s), time assessment points and data presentation is needed. In Chapter 6, the minimal important change (MIC) and minimal clinically important difference (MCID), two important interpretability aspects, of the patient part of the Patient and Observer Scar Assessment Scale version 2.0 (POSAS 2.0) were explored. Patients seem to consider minor differences (less than 0.75 on the 1–10 scale) in POSAS scores as clinically important scar quality changes. MCID values ranged from -0.39 and -0.08. These values can be used to evaluate the effects of burn treatment at the same time (i.e. the difference between two trial arms) and to perform sample-size calculations. PART III Outcomes of burn surgery The retrospective analyses in Chapter 7 show that the use of the VERSAJET™ hydrosurgery system (Smith+Nephew, London UK) in Dutch burn care is substantial and that it is more often used in younger patients, scalds, burns on irregularly contoured body areas and in patients with a larger % total body surface area (TBSA) burned. Results of the HyCon trial in Chapter 9 show that scar quality and pliability outcomes were better for hydrosurgical debrided burns. This was probably the result of significant enhanced preservation of dermis during debridement, which was demonstrated with histology measures. Donor-site scarring is an important harm that patients should be informed about if split skin grafting is considered. Results of a prospective cohort study show in Chapter 10 that patients’ and clinicians’ perceptions of scar quality only slightly improved during scar maturation. However, caregivers seem to underestimate the impact of scars on patients. Chapter 11 provides further insights in long-term patient reported scar quality of donor-sites. Even one year after surgery 37% of the patients reported a poor overall opinion on the donor-site scar (i.e. POSAS score ≥ 4). Especially colour of the donor site-scars was judged to remain deviant from normal skin. A younger age, female gender, a darker skin type, location on the lower leg and prolonged time to re-epithelization predict reduced patient-reported donor-site scar quality.