Clinimetric Properties of the Steep Ramp Test to Assess Cardiorespiratory Fitness, Its Underlying Physiological Responses, and Its Current Applications: A Scoping Review.

OBJECTIVE: 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. DATA SOURCES: 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. STUDY SELECTION: Eligible studies involved the SRT as research subject or measurement instrument and were available as full text articles in English or Dutch. DATA EXTRACTION: Two independent assessors performed data extraction. Data addressing clinimetric properties, physiological responses, and applications of the SRT were tabulated. DATA SYNTHESIS: 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. CONCLUSIONS: 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.

Fatigue in children and adolescents after burns: evaluating the problem using longitudinal data.

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

The Role of Burn Centers in the Treatment of Necrotizing Soft-Tissue Infections: A Nationwide Dutch Study.

Patients with extensive and complex wounds due to Necrotizing Soft-Tissue Infections (NSTI) may be referred to a burn center. This study describes the characteristics, outcomes, as well as diagnostic challenges of these patients. Patients admitted to three hospitals with a burn center for the treatment of NSTI in a 5-year period were included. Eighty patients (median age 54 years, 60% male) were identified, of whom 30 (38%) were referred by other centers, usually after survival of the initial septic phase. Those referred from other centers, compared to those primarily admitted to the study hospitals, were more likely to have group A streptococcal involvement (62% vs 35%, p = .02), larger wounds (median 7% vs 2% total body surface area, p < .001), and a longer length of stay (median 49 vs 22 days, p < .001). Despite a high incidence of septic shock (50%), the mortality rate was low (12%) for those primarily admitted. Approximately half (53%) of the patients were initially misdiagnosed upon presentation, which was associated with delay to first surgery (16 hours vs 4 hours, p < .001). Those initially misdiagnosed had more (severe) comorbidities, and less frequently reported pain or blue livid discoloration of the skin. This study underlines the burn centers' function as referral centers for extensively affected patients with NSTI. Besides the unique wound and reconstructive expertise, the low mortality rate indicates these centers provide adequate acute care as well. A major remaining challenge remains recognition of the disease upon presentation. Future studies in which factors associated with misdiagnosis are explored are needed.

Reliability and validity of a frailty assessment tool in specialized burn care, a retrospective multicentre cohort study.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Improvement of burn care by video interaction guidance.

AIMS: To evaluate the effect of video interaction guidance on improving the nurse-child relationship during the wound care procedures. Additionally, determine whether the interactional behavior of nurses is related to pain and distress experienced by children. METHODS: The interactional skills of seven nurses receiving video interaction guidance were compared with those of ten other nurses. The nurse-child interactions were video-taped during wound care procedures. Of the nurses receiving video interaction guidance, three wound dressing changes were videotaped before they received video interaction guidance and three after. The interaction between nurse and child was scored with the Nurse-child interaction taxonomy by two experienced raters. The COMFORT-B behavior scale was used to assess pain, and distress. All raters were blinded regarding video interaction guidance allocation and the sequence of tapes RESULTS: Five nurses in the intervention group (71 %) showed clinically relevant progress on the taxonomy while only four nurses (40 %) showed similar progress in the control group [p = .10]. A weak association was found between the nurses' interactions and the children's pain and distress [r = -.30, p = .002]. CONCLUSIONS: This is the first study to show that video interaction guidance can be used as a tool to train nurses to become more effective during patient encounters. Furthermore, nurses' interactional skills are positively associated with a child's pain and distress level.

Virtual Reality as Pain Relief in Burn Care: A Pilot Randomized Controlled Trial on the Effectiveness on Pain During Multiple Dressing Changes.

This pilot Randomized Controlled Trial (RCT) aimed to investigate the effectiveness of Virtual Reality (VR)-distraction on pain during multiple Wound Dressing Changes (WDCs). Furthermore, associations between demographic, clinical, and psychological factors and pain during WDC were determined. Participants were randomized to either the VR-condition or Care As Usual (CAU)-condition. Both groups received standard wound care and pain medication. The VR-group additionally received VR-distraction. The primary outcome measure was pain intensity (VAT 0-10). Secondary outcome measures were pain medication (Fentanyl spray and/or Piritramide) and satisfaction with WDC (VAT 0-10). Only 38 patients (VR-group: n = 21; CAU-group: n = 17) of the 128 intended patients were included during the study period due to several limitations (strict exclusion criteria and restrictions of the VR-equipment). No significant differences were found between both groups on pain intensity and medication. Both groups were also equally satisfied with WDC. Age showed a significant negative correlation with pain during WDC. In view of the small sample size, this study has restricted power and should be considered a pilot. Nevertheless, a RCT with between-subjects design across multiple WDCs was feasible and, given the speed of VR-developments, we expect larger, better powered RCTs to be possible in the near future, for which our experiences and recommendations are relevant.

Short-term and long-term increased mortality in elderly patients with burn injury: a national longitudinal cohort study.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Stromal vascular fraction-enriched fat grafting as treatment of adherent scars: study design of a non-randomized early phase trial.

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.

Hydrosurgical and conventional debridement of burns: randomized clinical trial.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: One year after surgery scar quality and pliability was better for hydrosurgically debrided burns, probably owing to enhanced histological preservation of dermis. REGISTRATION NUMBER: Trial NL6085 (NTR6232 (http://www.trialregister.nl)).

Aetiology of severe burn incidents in children under 5 years of age in the Netherlands: A prospective cohort study.

BACKGROUND: Risk factors and mechanisms of injury may change over time. Since knowledge on aetiology of severe burn incidents in children under 5 years of age in the Netherlands is outdated, this study aimed to identify current risk factors and mechanisms of severe burn injury in children under 5 years of age in the Netherlands to direct future prevention campaigns. METHODS: Information on personal-, environmental- and behavioural circumstances as well as the mechanism of burn injury was prospectively collected in all burn centres during one year from patient records and structured interviews with parents. RESULTS: Boys around 18 months of age, who, while in upright position, pulled down a cup of hot tea over themselves, were overrepresented. Children in families with more children, having a migration background, living in urbanised neighborhoods or with a low socioeconomic status (SES) are at increased risk for severe burn injury. Most incidents happened in their own home with the parents in close proximity to the child. CONCLUSION: Outcomes of this prospective cohort study provide up-to-date and extensive knowledge on the aetiology of severe burn incidents in children under 5 years of age in the Netherlands, and provide directions for prevention policy and campaigns.

Access to Burn Care in Low- and Middle-Income Countries: An Assessment of Timeliness, Surgical Capacity, and Affordability in a Regional Referral Hospital in Tanzania.

This study investigates patients' access to surgical care for burns in a low- and middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50% reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within 3 weeks for 74% in this group. Of contracture patients, 74% had sought healthcare after the acute burn injury. Of the same group, only 4% had been treated with skin grafts beforehand, and 70% never received surgical care or a referral. Together, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively affecting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socioeconomic factors that determine patient mortality and disability.

The impact of early information concerning the surgical operations on anxiety in patients with burns.

AIMS: 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. DESIGN: An observational prospective pre-test post-test study. METHODS: 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). RESULTS: 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). CONCLUSION: 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.

Questionnaires to Assess Facilitators and Barriers of Early Mobilization in Critically Ill Patients; Which One to Choose? A Systematic Review.

Implementing and performing early mobilization is a complex process requiring multidisciplinary input and cooperation. To gain insight in its facilitators and barriers, various surveys have been developed. A systematic review was conducted, to identify the psychometric properties, feasibility and suitability of questionnaires to assess facilitators and barriers of early mobilization in critically ill patients. Data were extracted regarding a.o. definition of early mobilization, development, psychometric properties, content and themes, question format. The search identified 537 publications of which 13 unique questionnaires were included. The questionnaires showed wide variation in extensiveness of development. Only six questionnaires actually assessed validity and reliability. Which questionnaire to choose depends on the aim of its use, required level of detail and specifics of the ICU, though three questionnaires were recommended as their definition of early mobilization covered a broad range of activities, including nursing related mobility activities. International consensus on what constitutes early mobilization is desirable.

Predictability of exercise capacity following pediatric burns: a preliminary investigation.

PURPOSE: Describe the course of exercise capacity in pediatric burn patients during the initial 6 months after hospital discharge, and examine whether its recovery can be predicted from burn characteristics, sociodemographic characteristics, and/or prior assessment. MATERIALS AND METHODS: Exercise capacity was assessed at discharge, and 6 weeks, 3 months, and 6 months after discharge using the Steep Ramp Test (SRT). RESULTS: Twenty-four pediatric patients with burns affecting 0.1-34% of total body surface area were included. At group level, exercise capacity was low at discharge and did not reach healthy reference values within 6 months, despite significant improvement over time. At individual level, the course of exercise capacity varied widely. Six months after discharge, 48% of participants scored more than one standard deviation below healthy age- and sex-specific reference values. SRT outcomes at 6 weeks and 3 months were the best predictors of exercise capacity 6 months after discharge, explaining, respectively, 76% and 93% of variance. CONCLUSIONS: Forty-eight percent of participants did not achieve healthy reference values of exercise capacity and were therefore considered "at risk" for diminished functioning. Our preliminary conclusion that early assessment of exercise capacity with the SRT can timely identify those patients, needs to be strengthened by further research.IMPLICATIONS FOR REHABILITATIONPediatric burns can be considered as a chronic medical condition because of the lifelong consequences.Exercise capacity is reduced following- even minor -pediatric burns.Recovery patterns vary widely: some pediatric burn patients achieve healthy levels of exercise capacity without specific intervention, while others do not.The Steep Ramp Test can be used to assess exercise capacity, identifying those "at risk" for adverse outcomes at an early stage.Patients "at risk" should be encouraged to play sports and adopt an active lifestyle.

The Effectiveness of Burn Scar Contracture Release Surgery in Low- and Middle-income Countries.

Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC. METHODS: This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively. RESULTS: A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R 2 = 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. CONCLUSIONS: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions.

Topical treatment for facial burns.

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.

A taxonomy to assess the interaction between nurses and children: Development and reliability.

AIMS AND OBJECTIVES: The aim of this study was to develop a valid and reliable instrument to assess the nurse-child interaction during medical or nursing interventions. BACKGROUND: Communication is an important competency for the professional practice of nurses and physicians. The nurse-patient relationship is fundamental for high-quality care. It has been suggested that if nurses have more skills to interact with children, care will be less distressing and less painful for the children. DESIGN: A qualitative observational psychometric study; the GRRAS checklist was used. METHODS: In-depth video-analyses, taxonomy development (19 videos) and testing it is psychometric properties (10 videos). Three observers micro-analysed video recordings of experienced nurses changing children's wound dressing in a specialised Burn Centre. RESULTS: The nurse-child interaction taxonomy (NCIT) was developed to observe and score the interactional behaviour between nurse and child. The taxonomy has three main patterns: being considerate, attuning oneself, and procedural interventions, subdivided in eight dimensions. These dimensions contain 16 elements that can be observed and scored on a 7-point scale. Intra-rater, inter-rater reliability and agreement were good. CONCLUSIONS: This study shows that interaction between nurses and children can be assessed reliably with the NCIT by an experienced observer or alternatively, scoring by two observers is recommended. RELEVANCE TO CLINICAL PRACTICE: The development of the taxonomy is an important step to find evidence for the best way for nurses to interact with children during nursing interventions or medical events and as such, ultimately, contributes to providing the best care possible.

Course of prevalence of scar contractures limiting function: A preliminary study in children and adolescents after burns.

BACKGROUND: Scar contracture is a well-known sequela of burns that is specifically relevant as it may limit function. Reports regarding the course of scar contractures, however, are scarce and, moreover, not focussed on function. This study describes the course of prevalence of scar contractures that limit function in children and adolescents after burns. METHOD: Range of motion (ROM) of extremity joints of 20 children and adolescents after burns were assessed at discharge (T0) and at six weeks (T1), three months (T2), and six months (T3) after discharge. A scar contracture limiting function was defined as a measured ROM lower than the functional ROM, i.e., ROM used to perform daily activities by unimpaired subjects. RESULTS: At discharge (T0), 89.5% of the subjects had one or more scar contractures that limited function. Six months later (T3), this prevalence was 76.5%. At discharge (T0), less function limiting scar contractures were found for the upper extremity (29.7%) than the lower extremity (53.3%). Over time, prevalence of contractures in both extremities fluctuated between 22% and 35%. CONCLUSIONS: The majority of children and adolescents (13/17) still had scar contractures limiting function six months after discharge (T3). Substantial longitudinal studies over a longer period of time are needed to increase our knowledge on the course of these scar contractures in order to support improvements in burn care. TRIAL REGISTRATION: The study is approved by the Regional Committee for Patient-Oriented Research Leeuwarden in the Netherlands (NL45917.099.13).

Rating scales for shoulder and elbow range of motion impairment: Call for a functional approach.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): study protocol for a randomized controlled trial.

BACKGROUND: Deep dermal burns require tangential excision of non-viable tissue and skin grafting to improve wound healing and burn-scar quality. Tangential excision is conventionally performed with a knife, but during the last decade hydrosurgery has become popular as a new tool for tangential excision. Hydrosurgery is generally thought to be a more precise and controlled manner of burn debridement leading to preservation of viable tissue and, therefore, better scar quality. Although scar quality is considered to be one of the most important outcomes in burn surgery today, no randomized controlled study has compared the effect of these two common treatment modalities with scar quality as a primary outcome. The aim of this study is, therefore, to compare long-term scar quality after hydrosurgical versus conventional tangential excision in deep dermal burns. METHODS/DESIGN: A multicenter, randomized, intra-patient, controlled trial will be conducted in the Dutch burn centers of Rotterdam, Beverwijk, and Groningen. All patients with deep dermal burns that require excision and grafting are eligible. Exclusion criteria are: a burn wound < 50 cm2, total body surface area (TBSA) burned > 30%, full-thickness burns, chemical or electrical burns, infected wounds (clinical symptoms in combination with positive wound swabs), insufficient knowledge of the Dutch or English language, patients that are unlikely to comply with requirements of the study protocol and follow-up, and patients who are (temporarily) incompetent because of sedation and/or intubation. A total of 137 patients will be included. Comparable wound areas A and B will be appointed, randomized and either excised conventionally with a knife or with the hydrosurgery system. The primary outcome is scar quality measured by the observer score of the Patient and Observer Scar Assessment Scale (POSAS); a subjective scar-assessment instrument, consisting of two separate six-item scales (observer and patient) that are both scored on a 10-point rating scale. DISCUSSION: This study will contribute to the optimal surgical treatment of patients with deep dermal burn wounds. TRIAL REGISTRATION: Dutch Trial Register, NTR6232 . Registered on 23 January 2017.