The Relationship between Health-Related Quality of Life, Subjective Scar Estimation, and Activity Performance in Adult Burn Patients 6 and 12 Months after Injury

Round 1

Reviewer 1 Report

Line 37 - I recommend including "trauma-stress reactions" to capture psychosocial risk factors impacting quality of life. Psychological distress is common and often persists up to 2yrs in the burn population in addition to pain, depression, and anxiety.

Giannoni-Pastor A et. al. Prevalence and Predictors of Posttraumatic Stress Symptomatology Among Burn Survivors: A Systematic Review and Meta-Analysis. J Burn Care Res. doi: 10.1097/BCR.0000000000000226 PMID: 25970798

Lines 111-115 & 208-210 adjust different size font

Very interesting topic. Include a statement to encourage large, multi-center collaboration as you established the feasibility for the need of a larger clinical investigation. 

Author Response

Thank you for valuable comments! The article you recommended added more weight to the text. We also checked for different size fonts and added that a multi-center collaboration would be desirable.

 

Line 37 - I recommend including "trauma-stress reactions" to capture psychosocial risk factors impacting quality of life. Psychological distress is common and often persists up to 2yrs in the burn population in addition to pain, depression, and anxiety.

Giannoni-Pastor A et. al. Prevalence and Predictors of Posttraumatic Stress Symptomatology Among Burn Survivors: A Systematic Review and Meta-Analysis. J Burn Care Res. doi: 10.1097/BCR.0000000000000226 PMID: 25970798

• Thank you for important in-put. The following text is inserted in the article:

The result of a review by Giannoni-Pastor et al. shows a prevalence of psychological distress of up to 25 % more than two years after the burn injury [6].

Lines 111-115 & 208-210 adjust different size font.

• Thank you for observing this! The fonts have been adjusted.

Very interesting topic. Include a statement to encourage large, multi-center collaboration as you established the feasibility for the need of a larger clinical investigation. 

• An important comment! A statement concerning the importance of a multi-center collaboration in future research has been added.

Reviewer 2 Report

The present manuscript is formulated with scientific precision in all parts. The methodology is well comprehensible. The authors discuss the results and limitations of the study very clearly.

Author Response

Thank you for encouraging words! No comments were made from the referee for us to respond to.

Reviewer 3 Report

The Authors present a paper:" The relationship between health-related quality of life, subjective scar estimation and activity performance in adult burn patients 6 and 12 months after injury" quite interesting but with the huge limit of a very small sample size of collected patients. I understand the meaning of the study but the controversial final consideration are based on a very smalll number of patients.

There is no mention on the requested time to fill out the questionnaires and what type of procedure and/or suggestion could be delivered to people affected by severe burns to be patient? or to train the capability of accepting their situation for a longer time?

What is the realistic meaning of this study not easy to be performed?

Author Response

Thank you for important comments. Below you can see our response:

 

The Authors present a paper:" The relationship between health-related quality of life, subjective scar estimation and activity performance in adult burn patients 6 and 12 months after injury" quite interesting but with the huge limit of a very small sample size of collected patients. I understand the meaning of the study but the controversial final consideration are based on a very smalll number of patients.

There is no mention on the requested time to fill out the questionnaires and what type of procedure and/or suggestion could be delivered to people affected by severe burns to be patient? or to train the capability of accepting their situation for a longer time?

What is the realistic meaning of this study not easy to be performed?

• We are aware of the limitation in the sample size and also state this at the end of the discussion.
• This study aimed at investigating correlations between different data. Next step will be to try out different interventions to help patients to an acceptable life situation.

Reviewer 4 Report

Review Report “The relationship between health-related quality of life, subjective scar estimation, and activity performance in adult burn patients 6 and 12 months after injury” (ebj-188701)

Dear authors,

the following aspect should be edited in their manuscript:

1.)    A demographic overview of the included patients is missing (e.g. etiology of burns, affected sites, intensive care stay, burn grades, therapy: conservative therapy or surgical etc.). These results should be integrated into the discussion section.

2.)    A detailed explanation of the different "n" in Table 1 is missing. A flow chart of the patient drop outs provides a better overview.

3.)    A more detailed description of Table 3, since the "ranks" are not clear to the reader.

4.)    Line 164 – 167: Explanation why DASH was taken in this study, knowing that only hand/arm injuries can be analyzed and the rest of the burns are excluded.

5.)    Numerical values or p-values are indicated with a dot (".") and not with a comma (","). Please correct. P-values of 0.000 do not exist, if then p < 0.001 (e.g. line 129)

6.)    Especially the TBSA does not look normally distributed (large range with low mean). Please use median instead of mean for no normally distributed values, and accordingly the interquartile range instead of standard deviation.

7.)    Table 1: Please use for mean standard deviation, and for median interquartile range

8.)    Classification into adequate TBSA groups (e.g. TBSA < 5% vs higher TBSA; see line 38 -40) and renewed correlation analyses depending on the extent of burns. Quality of Life is dependent on the extent of burning.

Author Response

Thank you for important comments on the text! We have revised according to your proposals of change.  Please see the comments under each paragraph:

 

Review Report “The relationship between health-related quality of life, subjective scar estimation, and activity performance in adult burn patients 6 and 12 months after injury” (ebj-188701)

Dear authors,

the following aspect should be edited in their manuscript:

1.) A demographic overview of the included patients is missing (e.g. etiology of burns, affected sites, intensive care stay, burn grades, therapy: conservative therapy or surgical etc.). These results should be integrated into the discussion section.

• Thank you for your suggestion! It gives a better picture of the patient group, even if these data are not part of the research question. The following text is added in the article:

The etiology of burns was 72% flame, 18% scald, 6% chemical and 4% electrical injury. Eight patients (16%) had full thickness burns only, 16 patients (33%) had partial thickness burns only and 25 patients (51%) had both full and partial thickness burns. Data (TBSA%) from one patient is missing.

2.)    A detailed explanation of the different "n" in Table 1 is missing. A flow chart of the patient drop outs provides a better overview.

• Thank you for making us aware of this! An explanation as to the differing numbers is placed in the discussion.

3.)    A more detailed description of Table 3, since the "ranks" are not clear to the reader.

• A short explanation is added below the table.

4.)    Line 164 – 167: Explanation why DASH was taken in this study, knowing that only hand/arm injuries can be analyzed and the rest of the burns are excluded.

• Thank you for an important view! The following text is added to the article:

The reason for using DASH in this study at all originates from an earlier routine at the burn center. After this study was completed, this routine has been supplemented with a more overall activity performance measure.

5.)    Numerical values or p-values are indicated with a dot (".") and not with a comma (","). Please correct. P-values of 0.000 do not exist, if then p < 0.001 (e.g. line 129)

• Thank you! This has been corrected.

6.)    Especially the TBSA does not look normally distributed (large range with low mean). Please use median instead of mean for no normally distributed values, and accordingly the interquartile range instead of standard deviation.

• Thank you for your observation! The median reflects the result in a better way. The result has been completed with median.

7.)    Table 1: Please use for mean standard deviation, and for median interquartile range.

• Thank you for your input. We chose mean, range, median and SD values to give as complete a picture as possible of the data.

8.)    Classification into adequate TBSA groups (e.g. TBSA < 5% vs higher TBSA; see line 38 -40) and renewed correlation analyses depending on the extent of burns. Quality of Life is dependent on the extent of burning.

• Thank you for your comment. We have not seen a significant correlation between QoL and TBSA, but if so, your suggestion to form TBSA groups would have been the next step to see if there is a “breaking point”.

Reviewer 5 Report

Abstract:   

The abstract is well written and concise.   

Introduction:

One would question the use of impairment focused health related quality of life scales on burn survivors’ perceptions. This should be addressed by the research team as the ability to regain preinjury status is an important component of patient centred care. There are a number of published studies focusing on addressing hand function and activity performance post burn injury. I strongly advise the research team to review and include these. Some references below.

Sizoo SJ, van Baar ME, Jelsma N, van Zuijlen PP, Nieuwenhuis MK. Outcome measures to evaluate the function of the hand after burns; a clinical initiative. Burns open. 2021 Jul 1;5(3):162-7.

Bache SE, O’Connor EF, Drake PJ, Philp B, Dziewulski P. Development and validation of the Burnt Hand Outcome Tool (BHOT): a patient-led questionnaire for adults with hand burns. Burns. 2018 Dec 1;44(8):2087-98.

 

Methods:

The authors state in the introduction that burns rehabilitation occurs for years post injury, however have only chosen 6 and 12 months as follow up time points. The rationale for these time points requires explanation and the rationale for not following up burn survivors for time frames longer than this should be included.

 The authors state that no exclusion criteria applied, however if burn survivors did not have an upper limb burn injury, I would question the validity of using the DASH.  What provisions were made for individuals who had cognitive impairments? A review of the inclusion and exclusion criteria is required.

There are no details regarding the recruitment process, how much time were burn survivors provided with to consider if they would like to participate in the study? Was there an op out option? Who recruited them? Please outline this process to reduce the risk of bias.

Only the treating occupational therapy completed all of the outcome measures at the follow up time points. This creates bias for the data collection- please address this.

More transparency is required regarding the data analysis, who performed this? How was bias minimised? 

 

Results:

The first section of the results requires the inclusion and exclusion criteria to be outlined in the methods to demonstrate the reliability of the findings.

The location of the burn injury on the body should be outlined as there is significant evidence that scarring on visible body parts can impact quality of life.

Baillie SE, Sellwood W, Wisely JA. Post-traumatic growth in adults following a burn. Burns. 2014 Sep 1;40(6):1089-96.

Sinha I, Nabi M, Simko LC, Wolfe AW, Wiechman S, Giatsidis G, Bharadia D, McMullen K, Gibran NS, Kowalske K, Meyer WJ. Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: A Burn Model System National Database study. Burns. 2019 Mar 1;45(2):293-302.

Burn depth should also be outlined to further validate the findings.

Only 44% believed their quality-of-life scores had improved at 12 months, please outline what psychological supports usual standard of care for burn survivors at this facility. What referral processes were put into place at the outset of the study protocol to support these findings?

 

Discussion:

More rationale is required to support the choice of the DASH. This is specifically and outcome measure for arm, shoulder and hand. This would not be valid for individuals with lower limb burns only.

The information pertaining to the numbers included in the study should be in the results. Please review. The correlation between the findings of this study and Nitescu et al. (2012) requires further development and discussion.

Line 183 re: hobbies and work- while the subcomponents of the DASH look at these modalities – this was not explicit in the results. This should be outlined in the results to warrant discussion here – as this stands it is speculative.

The correlation between and Drurey et al (2005) study and the results require review. The mean TSBA for this study was 13.5% yet the argument is being made for burn survivors with TBSA > 60%.

As per previous comments TBSA does not correlate with burn impact. Location of the burn injury, mechanism of injury and support networks are all variables and this should be discussed in further detail.

 

Conclusion:

The outcome measure used for activity participation does not support the conclusion. The limitations should be addressed before the conclusion  

 

Author Response

Thank you so much for valuable comments and reflections!

Below you can see our answers and actions according to your feed-back:

 

Abstract:   

The abstract is well written and concise.   

Introduction:

One would question the use of impairment focused health related quality of life scales on burn survivors’ perceptions. This should be addressed by the research team as the ability to regain preinjury status is an important component of patient centred care. There are a number of published studies focusing on addressing hand function and activity performance post burn injury. I strongly advise the research team to review and include these. Some references below.

Sizoo SJ, van Baar ME, Jelsma N, van Zuijlen PP, Nieuwenhuis MK. Outcome measures to evaluate the function of the hand after burns; a clinical initiative. Burns open. 2021 Jul 1;5(3):162-7.

Bache SE, O’Connor EF, Drake PJ, Philp B, Dziewulski P. Development and validation of the Burnt Hand Outcome Tool (BHOT): a patient-led questionnaire for adults with hand burns. Burns. 2018 Dec 1;44(8):2087-98.

• Thank you for your comment! This study did not focus on hand function that is why it is not explained in the study.

Methods:

The authors state in the introduction that burns rehabilitation occurs for years post injury, however have only chosen 6 and 12 months as follow up time points. The rationale for these time points requires explanation and the rationale for not following up burn survivors for time frames longer than this should be included.

• Follow-ups at 6 and 12 months are done regularly at our burn unit. Some patients of course need our help and assistance for a longer period and get it. But we do not see the patients on a regular basis for longer than one year.

 The authors state that no exclusion criteria applied, however if burn survivors did not have an upper limb burn injury, I would question the validity of using the DASH.  What provisions were made for individuals who had cognitive impairments? A review of the inclusion and exclusion criteria is required.

• Thank you for making us observant to this! We have completed with the exclusion criteria.
• Thank you, this needs to be clarified! An explanation as to the use of DASH has been added in the discussion.
• Good reflection! No further provisions were made for individuals with cognitive impairments if they fulfilled the inclusion criteria.

There are no details regarding the recruitment process, how much time were burn survivors provided with to consider if they would like to participate in the study? Was there an op out option? Who recruited them? Please outline this process to reduce the risk of bias.

• The patients were recruited by any of the treating occupational or physical therapists. The patients got oral and written information and were always informed about the possibility to at any time point end the participation in the study.

Only the treating occupational therapy completed all of the outcome measures at the follow up time points. This creates bias for the data collection- please address this.

More transparency is required regarding the data analysis, who performed this? How was bias minimised? 

• The author contributions at the end of the article accounts for who did what in every step.

 

Results:

The first section of the results requires the inclusion and exclusion criteria to be outlined in the methods to demonstrate the reliability of the findings.

• Thank you for your comment on this! We have completed with the exclusion criteria.

The location of the burn injury on the body should be outlined as there is significant evidence that scarring on visible body parts can impact quality of life.

Baillie SE, Sellwood W, Wisely JA. Post-traumatic growth in adults following a burn. Burns. 2014 Sep 1;40(6):1089-96.

Sinha I, Nabi M, Simko LC, Wolfe AW, Wiechman S, Giatsidis G, Bharadia D, McMullen K, Gibran NS, Kowalske K, Meyer WJ. Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: A Burn Model System National Database study. Burns. 2019 Mar 1;45(2):293-302.

• This is an important point of view that we unfortunately did not address in this study. It will be important in future research.

Burn depth should also be outlined to further validate the findings.

• Important point of view! We have completed with more demographic data.

Only 44% believed their quality-of-life scores had improved at 12 months, please outline what psychological supports usual standard of care for burn survivors at this facility. What referral processes were put into place at the outset of the study protocol to support these findings?

• This study aims at finding out of there are any correlations and connections. We did not try out any new treatments. However, we have been more aware of patients’ needs even after one year and our goal is to catch the patients in need of further rehabilitation end refer them to relevant care.

Discussion:

More rationale is required to support the choice of the DASH. This is specifically and outcome measure for arm, shoulder and hand. This would not be valid for individuals with lower limb burns only.

• Thank you for your observation! An explanation as to the use of DASH has been added in the discussion.

The information pertaining to the numbers included in the study should be in the results. Please review. The correlation between the findings of this study and Nitescu et al. (2012) requires further development and discussion.

• Good reflection! We also discussed where to put the numbers but eventually decided that it should be in the discussion.

Line 183 re: hobbies and work- while the subcomponents of the DASH look at these modalities – this was not explicit in the results. This should be outlined in the results to warrant discussion here – as this stands it is speculative.

• The connections mentioned to leisure, hobbies and work are only the reflection of the authors. The different DASH components were not included in this study, only the EQ VAS. That is why it is not mentioned in the results.

The correlation between and Drurey et al (2005) study and the results require review. The mean TSBA for this study was 13.5% yet the argument is being made for burn survivors with TBSA > 60%.

• Thank you for your observation! We have made a clarification to bring attention to the difference in TBSA between the studies.

As per previous comments TBSA does not correlate with burn impact. Location of the burn injury, mechanism of injury and support networks are all variables and this should be discussed in further detail.

• Important point of view! We have completed with more demographic data.

Conclusion:

The outcome measure used for activity participation does not support the conclusion. The limitations should be addressed before the conclusion  

• The disposition of the article follows the EBJ guidelines which made it difficult to change the order of the sections.

Round 2

Reviewer 3 Report

The authors followed the reviewers suggestions and made the paper in a more appropriate shape. Further they clearly explained the reasons of their choices

Author Response

Thank you for your suggestions and your feedback!

Reviewer 5 Report

Thank you for the opportunity to review the revised manuscript for “The relationship between health-related quality of life, subjective scar estimation, and activity performance in adult burn patients 6 and 12 months after injury”. The exclusion criteria have not been fully addressed. More details are required for transparency. In the discussion the impact of variables such as location of the burn injury, mechanism of injury and support networks should be discussed. The conclusion requires revision. 

 

Abstract

Nil comments

 

Introduction

The authors state there is no evidence pertaining to “the influence of hypertrophic scars on hand function and/or activity performance”. This is not correct and should be revised. Some published articles are provided as a starting point.  

Aghajanzade, M., Momeni, M., Niazi, M., Ghorbani, H., Saberi, M., Kheirkhah, R., ... & Karimi, H. (2019). Effectiveness of incorporating occupational therapy in rehabilitation of hand burn patients. Annals of burns and fire disasters, 32(2), 147.

Richard, R., Baryza, M. J., Carr, J. A., Dewey, W. S., Dougherty, M. E., Forbes-Duchart, L., ... & Young, A. (2009). Burn rehabilitation and research: proceedings of a consensus summit. Journal of Burn Care & Research, 30(4), 543-573.

 

Materials and Methods

Thank you for addressing who completed the recruitment process, this information is important to include in the manuscript to reduce bias. Clarity has been provided regarding the recruitment process; however, it is still not clear if potential participants had time to consider their involvement. Please provide details around this in the manuscript to ensure no coercion occurred. Line 80- exclusion needs to be removed as this has ben added. More specific details for the exclusion criteria are required, what underlying disease are you referring too?

 

Results

As previously, the exclusion criteria need to be outlined in full to validate the results. The burn depths have been added thank you. As per the first review the location of the burns on the body should be included.

This point has not been sufficiently addressed ­Only 44% believed their quality-of-life scores had improved at 12 months, please outline what psychological supports usual standard of care for burn survivors at this facility. What referral processes were put into place at the outset of the study protocol to support these findings?

This question is asking what is standard at this facility and if a patient became distressed during data collection what was in place to support them? E.g., referral to a GP or psychologist at the outpatient could review?

Discussion

Thank you for providing rationale for the DASH. It would be beneficial to include what is the overall activity performance measure which has been implemented because of this study to give weight to your results. The impact of variables such as location of the burn injury, mechanism of injury and support networks should be discussed to strengthen the argument that TBSA sized does not correlate to burn impact.

 

Conclusion:

As not all patients had upper limb burns, they did not complete the DASH therefore it is not clear how the conclusion was reached, as this was the activity performance measure for this study. 

 

Author Response

Thank you for valuable thoughts and suggestions! We have done our best to meet them. Please see our comments below and the changes in the manuscript.

Thank you for the opportunity to review the revised manuscript for “The relationship between health-related quality of life, subjective scar estimation, and activity performance in adult burn patients 6 and 12 months after injury”. The exclusion criteria have not been fully addressed. More details are required for transparency. In the discussion the impact of variables such as location of the burn injury, mechanism of injury and support networks should be discussed. The conclusion requires revision. 

Abstract

Nil comments

Introduction

The authors state there is no evidence pertaining to “the influence of hypertrophic scars on hand function and/or activity performance”. This is not correct and should be revised. Some published articles are provided as a starting point.  

Aghajanzade, M., Momeni, M., Niazi, M., Ghorbani, H., Saberi, M., Kheirkhah, R., ... & Karimi, H. (2019). Effectiveness of incorporating occupational therapy in rehabilitation of hand burn patients. Annals of burns and fire disasters, 32(2), 147.

Richard, R., Baryza, M. J., Carr, J. A., Dewey, W. S., Dougherty, M. E., Forbes-Duchart, L., ... & Young, A. (2009). Burn rehabilitation and research: proceedings of a consensus summit. Journal of Burn Care & Research, 30(4), 543-573.

• Thank you for your comment! We have added information about the influence that hand burns have on hand function (Aghajanzade et al.) but still have not found any research as to the patients’ subjective experience of their scars, which is the focus of this study. The second article above is a description of treatments and thus not on line with this study.

Materials and Methods

Thank you for addressing who completed the recruitment process, this information is important to include in the manuscript to reduce bias. Clarity has been provided regarding the recruitment process; however, it is still not clear if potential participants had time to consider their involvement. Please provide details around this in the manuscript to ensure no coercion occurred. Line 80- exclusion needs to be removed as this has ben added. More specific details for the exclusion criteria are required, what underlying disease are you referring too?

• Thank you! We have added a detailed, clarifying description according to your suggestions.

Results

As previously, the exclusion criteria need to be outlined in full to validate the results. The burn depths have been added thank you. As per the first review the location of the burns on the body should be included.

• Thank you! The burn location was not registered in this study. A clarifying reflection on this is added in the discussion.

This point has not been sufficiently addressed ­Only 44% believed their quality-of-life scores had improved at 12 months, please outline what psychological supports usual standard of care for burn survivors at this facility. What referral processes were put into place at the outset of the study protocol to support these findings?

This question is asking what is standard at this facility and if a patient became distressed during data collection what was in place to support them? E.g., referral to a GP or psychologist at the outpatient could review?

• Thank you for your comment! This study is not evaluating treatments or procedures, only a mapping of existing correlations in this patient group. The result itself might however be used to develop routines. However, we have added information in the discussion on how our routines work, according to your suggestion, when we meet patients in need of support.

Discussion

Thank you for providing rationale for the DASH. It would be beneficial to include what is the overall activity performance measure which has been implemented because of this study to give weight to your results. The impact of variables such as location of the burn injury, mechanism of injury and support networks should be discussed to strengthen the argument that TBSA sized does not correlate to burn impact.

• Thank you for a good point! The new activity performance measure has been added.
• We have added a comment on the burn location and the etiology in the discussion. And also, about the support network /referral.
• We have added data on the number of patients with burns to their upper limb, apart from the existing information in table 1, in the Result section, to get a better picture of the DASH subgroup.
• We also added a reflection on the study design, as a limitation, to explain the missing data retrospectively.

Conclusion:

As not all patients had upper limb burns, they did not complete the DASH therefore it is not clear how the conclusion was reached, as this was the activity performance measure for this study. 

• Thank you! We have clarified the limitation about using the DASH in this study, but we placed it in the discussion among other limitations.