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There has been an increasing emphasis on placing patients at the center of clinical care and health care research and, in particular, assessing outcomes and experiences from the patient's perspective. One of the most widely used patient-reported outcome instruments is the Veterans RAND 12-item Health Survey (VR-12). This article reviews the VR-12 development and its applications over the last 2 decades, including research and potential uses in clinical care.

This qualitative study documents and analyzes COVID-19’s impacts on burn care in twelve nations. Burn care saw valuable improvements in surgical techniques, skin grafting, and other acute treatments during the decades before the COVID-19 pandemic which increased severely burned patients’ survival rates and quality of life. Detailed interviews, conducted in the 12 nations reveal that the COVID-19 pandemic greatly affected the delivery of acute and rehabilitation services for burn patients. Resources have been suctioned away from non-COVID healthcare and burn care has not been spared. Acute, post-acute rehabilitation, and mental health services have all suffered. Weak preparation has deeply burdened health care services in most nations, resulting in lower access to care. Access problems have accelerated innovations like telehealth in many nations. The spread of misinformation through social and traditional media has contributed to the varied responses to COVID-19. This compounded problems in health care delivery. Burn care providers delivered services for survivors during extremely difficult circumstances by continuing to furnish acute and long-term services for patients with complex disease. Emphasis on future pandemic preparedness will be vital because they undermine all aspects of burn care and patient outcomes. As the COVID-19 pandemic continues to unfold around the world, it will be important to continue to monitor and analyze the adaptability of nations, health care systems, and burn care providers.

The National Academy of Medicine's 2019 consensus study on clinician burnout identified a need for research evaluating the impact of clinician distress on health care quality. This study examined the association between clinician distress and the inappropriate use of antibiotic prescriptions for acute respiratory tract infections (RTIs) in adult outpatients.A retrospective cohort study was conducted using electronic health record visit data linked to annual wellness surveys administered to all clinicians at Boston Medical Center from May 4 to June 20, 2017, and June 5 to July 6, 2018. Included were outpatient visits occurring in Family Medicine, General Internal Medicine, or the emergency department in which an acute RTI for an otherwise healthy adult was listed as a primary diagnosis. The study examined the association of clinician depression, anxiety, and burnout with the visit-level odds of a clinician inappropriately prescribing an antibiotic for an acute RTI.Out of the 2,187 visits eligible for inclusion, 1,668 visits were included in the final sample. Overall, 33.8% and 51.0% of clinicians reported depression/anxiety and burnout symptoms, respectively. Each 1 standard deviation increase in a clinician's composite depression and anxiety score was associated with a 28% increase (odds ratio = 1.28, 95% confidence interval = 1.02-1.61) in the adjusted odds of an inappropriate antibiotic prescription for an acute RTI. Clinician burnout had no significant association with inappropriate antibiotic prescribing for acute RTIs.These findings suggest that clinician depression and anxiety may be important indicators of health care quality in routine outpatient care.

Alzheimer's disease (AD) and COVID-19 share common risk factors including hypertension. Angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) are frequently prescribed antihypertension medications.This study analyzed 436,823 veterans tested for SARS-CoV-2 infection. We conducted both classical and propensity score weighted logistic models to compare COVID-19 outcomes between patients with AD or mild cognitive impairment (MCI) to those without cognitive impairment, and examined effect of ACEI/ARB prescription.There was a statistically significant association between AD and increased odds of infection and mortality. MCI was not found to be a risk factor for infection. Subjects with MCI exhibited poor clinical outcomes. Prescribing ARBs but not ACEIs was significantly associated with a lower risk of COVID-19 occurrence among AD and MCI patients.Exploring beneficial effects of existing medications to reduce the impact of COVID-19 on patients with AD or MCI is highly significant.There is significant association between Alzheimer's disease (AD) and increased risk of COVID-19 infection and odds of mortality. Subjects with mild cognitive impairment (MCI) defined by claims data exhibit poor clinical outcomes, but MCI was not found to be a risk factor for severe acute respiratory syndrome coronavirus 2 infection. Prescribing angiotensin II receptor blockers was significantly associated with a lower risk of COVID-19 occurrence among AD/MCI patients.

Background and Objectives The Veterans RAND 12-Item Health Survey (VR-12) is a generic patient-reported outcome measure of physical and mental health status. An adapted version of the VR-12 was developed for use with older adults living in long-term residential care (LTRC) homes in Canada: VR-12 (LTRC-C). This study aimed to evaluate the psychometric validity of the VR-12 (LTRC-C). Research Design and Methods Data for this validation study were collected via in-person interviews for a province-wide survey of adults living in LTRC homes across British Columbia (N = 8,657). Three analyses were conducted to evaluate validity and reliability: (1) confirmatory factor analyses were conducted to validate the measurement structure; (2) correlations with measures of depression, social engagement, and daily activities were examined to evaluate convergent and discriminant validity; and (3) Cronbach’s alpha (r) statistics were obtained to evaluate internal consistency reliability. Results A measurement model with 2 correlated latent factors (representing physical health and mental health), 4 cross-loadings, and 4 correlated items resulted in an acceptable fit (root-mean-square error of approximation = 0.07; comparative fit index = 0.98). Physical and mental health were correlated in expected directions with measures of depression, social engagement, and daily activities, though the magnitudes of the correlations were quite small. Internal consistency reliability was acceptable for physical and mental health (r > 0.70). Discussion and Implications This study supports the use of the VR-12 (LTRC-C) to measure perceived physical and mental health among older adults living in LTRC homes.

Introduction Sexual satisfaction is often unaddressed in clinical care despite it being an important aspect of healing and quality of life for burn survivors. Previous literature has focused predominantly on physical function rather than perceived satisfaction. This study aimed to determine the associations of sexual satisfaction with psychosocial outcomes and assess sexual satisfaction recovery over time after burn injury. Methods Patients consenting to provide data to the Burn Model System (BMS) National Database injured after 2015, aged greater than 18 years at the time of burn injury, and alive at discharge were included in the analysis. Sexual satisfaction was collected at six months and then every year for five years post-injury using two PROMIS sexual satisfaction items, a composite T-score was derived, where a higher score indicated higher sexual satisfaction. Analyses included sexual satisfaction scores as outcomes with mixed models that included repeated measures controlling for correlated error of the outcomes and covariates that included demographics. Psychosocial measures analyzed included: PROMIS-29 Anxiety, Depression, Fatigue and Sleep scores; VR-12 mental component score (MCS) and physical component score (PCS); and the Post-Traumatic Growth Inventory (PTGI) total score. Results The analysis identified 561 individuals with sexual satisfaction data for at least one time point. The population demographics included a median age of 46 years (IQR 34, 59), reported sex (female = 171 (30.5%)), and median TBSA burned 10% (IQR 3, 26). Increasing age (p < 0.0001) and marital status with those ‘Divorced’ (p=0.004) or ‘Single’ (p=0.0003) were associated with lower sexual satisfaction. There was no association with TBSA burn size. Within psychosocial metrics, we found that the CIQ Social Integration score (p < 0.0001), VR-12 MCS (p=0.008), PTGI Total Score (p=0.01), and PROMIS 29 Sleep Disturbance score (p=0.0004) were also significantly associated. Change in scores were associated with the VR-12 MSC (p=0.03), where an increased MCS score predicted improved sexual satisfaction by final follow-up. Conclusions A significant association was found between sexual satisfaction and social integration, mental health, and post-traumatic growth. Applicability of Research to Practice These findings suggest that interventions to improve the sexual satisfaction of burn survivors should focus on the importance of social integration, mental health, and sleep quality.

People living with burn injury often face long-term physical and psychological sequelae associated with their injuries. Few studies have examined the impacts of burn injuries on long-term health and function, life satisfaction, and community integration beyond 5 years postinjury. The purpose of this study was to examine these outcomes up to 20 years after burn injury.Data from the Burn Model System National Longitudinal Database (1993-2020) were analyzed. Patient-reported outcome measures were collected at discharge (preinjury status recall) and 5 years, 10 years, 15 years, and 20 years after injury. Outcomes examined were the SF-12/VR-12 Physical Component Summary and Mental Component Summary, Satisfaction with Life Scale, and Community Integration Questionnaire. Trajectories were developed using linear mixed models with repeated measures of outcome scores over time, controlling for demographic and clinical variables.The study population included 421 adult burn survivors with a mean age of 42.4 years. Lower Physical Component Summary scores (worse health) were associated with longer length of hospital stay, older age at injury and greater time since injury. Similarly, lower Mental Component Summary scores were associated with longer length of hospital stay, female sex, and greater time since injury. Satisfaction with Life Scale scores decrease negatively over time. Lower Community Integration Questionnaire scores were associated with burn size and Hispanic/Latino ethnicity.Burn survivors' physical and mental health and satisfaction with life worsened over time up to 20 years after injury. Results strongly suggest that future studies should focus on long-term follow-up where clinical interventions may be necessary.Prognostic and Epidemiologic; Level III.

The transition from early childhood to teen years (5–12) is a critical time of development, which can be made particularly challenging by a burn injury. Assessing postburn recovery during these years is important for improving pediatric survivors’ development and health outcomes. Few validated burn-specific measures exist for this age group. The purpose of this study was to generate item pools that will be used to create a future computerized adaptive test (CAT) assessing postburn recovery in school-aged children. Item pool development was guided by the previously developed School-Aged Life Impact Burn Recovery Evaluation (SA-LIBRE5–12) conceptual framework. The item pool development process involved a systematic literature review, extraction of candidate items from existing legacy measures, iterative item review during expert consensus meetings, and parent cognitive interviews. The iterative item review with experts consisted of six rounds. A total of 10 parent cognitive interviews were conducted. The three broad themes of concern were items that needed 1) clarification, needed context, or were vague, 2) age dependence and relevance, and 3) word choice. The cognitive interviews indicated that survey instructions, recall period, item stem, and response choices were interpretable by respondents. Final item pool based on parental feedback consists of 57, 81, and 60 items in physical, psychological, and family and social functioning, respectively. Developed item pools (n = 198) in three domains are consistent with the existing conceptual framework. The next step involves field testing the item pool and calibration using item response theory to develop and validate the SA-LIBRE5–12 CAT Profile.

Acute pediatric burn injuries often result in chronic sequelae that affect physical, psychological, and social outcomes. To date, no review has comprehensively reported on the impact of burn injuries across all three domains in school-aged children. The aim of this systematic review was to identify published literature that focuses on the impact of burn injuries on physical, psychological, or social functioning, and report upon the nature of study characteristics and their outcomes. We included literature published after 1980, focusing on burn outcomes in children aged 5 to 18 years. Each eligible study was systematically reviewed and primary outcomes were classified into outcome domains based on existing frameworks. Fifty-eight studies met inclusion criteria, and reported on physical (n = 24), psychological (n = 47), and social (n = 29) domains. The majority of the studies had sample sizes of

Modern, reliable, and valid outcome measures are essential to understanding the health needs of young children with burn injuries. Burn-specific and age-appropriate legacy assessment tools exist for this population but are hindered by the limitations of existing paper-based instruments. The purpose of this study was to develop item pools comprised of questions appropriate for children aged 1-5 with burn injuries. Item development was based on a framework provided by previous work to develop the Preschool Life Impact Burn Recovery Evaluation (LIBRE) Conceptual Model. The Preschool LIBRE Conceptual Model work established four sub-domains of functioning for children with burns aged 1-5. Item development involved a systematic literature review, a qualitative item review process with clinical experts, and parent cognitive interviews. Four item pools were established: (1) communication and language development; (2) physical functioning; (3) psychological functioning and (4) social functioning for preschool-aged children with burn injuries. We selected and refined candidate items, recall periods, survey instructions, and response option choices through clinical and parental feedback during the qualitative review and cognitive interview processes. Item pools are currently being field-tested as part of the process to calibrate and validate the Preschool1-5 LIBRE Computer Adaptive Test (CAT) Profile.

Background A stronger safety climate in nursing homes may reduce avoidable adverse events. Yet efforts to strengthen safety climate may fail if nursing homes are not ready to change. To inform improvement efforts, we examined the link between organizational readiness to change and safety climate. Methods Seven safety climate domains and organizational readiness to change were measured with validated Community Living Center/CLC Employee Survey of Attitudes about Resident Safety and Organizational Readiness to Change Assessment. Safety climate domains comprised of safety priorities, supervisor commitment to safety, senior management commitment to safety, safety attitudes, environmental safety, coworker interactions around safety, and global rating of CLC. We specified models with and without readiness to change to explain CLC- and person-level variance in safety climate domains. Results One thousand three hundred ninety seven workers (frontline staff and managers) responded from 56 US Veterans Health Administration CLCs located throughout the US. Adding readiness to change reduced baseline CLC-level variance of outcomes (2.3–9.3%) by > 70% for interpersonal domains (co-workers, supervisors, and senior management). Readiness to change explained person-level variance of every safety climate domain (P Conclusions Organizational readiness to change predicted safety climate. Safety climate initiatives that address readiness to change among frontline staff and managers may be more likely to succeed and eventually increase resident safety.

Pediatric burn injuries can alter the trajectory of the survivor’s entire life. Patient-centered outcome measures are helpful to assess unique physical and psychosocial needs and long-term recovery. This study aimed to develop a conceptual framework to measure pediatric burn outcomes in survivors aged 5 to 12 years as a part of the School-Aged Life Impact Burn Recovery Evaluation Computer Adaptive Test (SA-LIBRE5–12 CAT) development. This study conducted a systematic literature review guided by the WHO International Classification of Functioning—Child and Youth and domains in the American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire5–18. Interviews with eight parents and seven clinicians were conducted to identify important domains in child recovery. One clinician focus group with four clinicians was completed to identify gaps in the preliminary framework, and semiweekly expert consensus meetings were conducted with three experts to solidify the framework. Qualitative data were analyzed by grounded theory methodology. Three major thematic outcome domains emerged: 1) Physical Functioning: fine motor and upper extremity, gross motor and lower extremity, pain, skin symptoms, sleep and fatigue, and physical resilience; 2) Psychological Functioning: cognitive, behavioral, emotional, resilience, and body image; and 3) Family and Social Functioning: family relationships, and parental satisfaction, school, peer relations, and community participation. The framework will be used to develop item banks for a CAT-based assessment of school-aged children’s health and developmental outcomes, which will be designed for clinical and research use to optimize interventions, personalize care, and improve long-term health outcomes for burned children.

Background Disparities in US physician burnout rates across age, gender, and specialty groups as measured by the Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI) are well documented. We evaluated whether disparities in US physician burnout are explained by differences in the MBI’s functioning across physician age, gender, and specialty groups. Methods We assessed the measurement equivalence of the MBI across age, gender, and specialty groups in multi-group item response theory- (IRT-) based differential item functioning (DIF) analyses using secondary, cross-sectional survey data from US physicians (n = 6577). We detected DIF using two IRT-based methods and assessed its impact by estimating the overall average difference in groups’ subscale scores attributable to DIF. We assessed DIF’s practical significance by comparing differences in individuals’ subscale scores and burnout prevalence estimates from models unadjusted and adjusted for DIF. Results We detected statistically significant age-, gender-, and specialty- DIF in all but one MBI item. However, in all cases, average differences in expected subscale-level scores due to DIF were Conclusions Age-, gender-, and specialty-related disparities in US physician burnout are not explained by differences in the MBI’s functioning across these demographic groups. Our findings support the use of the MBI as a valid tool to assess age-, gender-, and specialty-related disparities in US physician burnout.

Sociodemographic characteristics may influence responses on self-reported measures. Differential item functioning (DIF) is when individuals expected to have the same ability level on a construct of interest have a different probability of endorsing an item on an item response theory (IRT) scale due to population characteristics. The goal of this study was to identify DIF for items in an outcome instrument by sociodemographic factors and, one controlling for DIF, assess true differences in function by those same factors. The Work Disability Functional Assessment Battery 2.0 (WD-FAB 2.0) is an IRT-based self-reported measure of activity limitations relevant to work. Two samples from WD-FAB developed were used: 3793 SSA disability claimants randomly drawn from a pool of 16,500 claimants and a general sample if 2100 working age adults. We used a two-step IRT-based DIF method for three pairs of respondent characteristics: age, gender, and race/ethnicity, and calculated the weighted absolute difference between item characteristic curves. Independent two-group T-tests assessed differences in scores across groups. Seventeen items displayed DIF. Men had higher scores than women on two physical and two mental function scales. Older respondents had lower physical and higher mental function scores. The lower education group had lower mental function scores. DIF impacts function measurement and is important when assessing psychometric characteristics of instruments. Self-report measures should include diverse samples to conduct similar analyses. WD-FAB 2.0 scores are now reflections of function with reduced bias related to gender, race/ethnicity, or age.

Objectives Adverse events in nursing homes are leading causes of morbidity and mortality, prompting facilities to investigate their antecedents. This study examined the contribution of safety climate—how frontline staff typically think about safety and act on safety issues—to adverse events in Veterans Affairs (VA) nursing homes or Community Living Centers (CLCs). Design Cross-sectional study. Setting and Participants A total of 56 CLCs nationwide, 1397 and 1645 CLC staff (including nurses, nursing assistants, and clinicians/specialists), respectively, responded to the CLC Employee Survey of Attitudes about Resident Safety (CESARS) in 2017 and 2018. Methods Adverse events (pressure ulcers, falls, major injuries from falls, and catheter use) were measured using the FY2017-FY2018 Minimum Data Set (MDS). Safety climate was defined as 7 CESARS domains (safety priorities, supervisor commitment to safety, senior management commitment to safety, personal attitudes toward safety, environmental safety, coworker interactions around safety, and global rating of CLC). The associations between safety climate domains and each adverse event were determined separately for each frontline group, using beta-logistic regression with random effects. Results Better ratings of supervisor commitment to safety were associated with lower rates of major injuries from falls [odds ratio (OR) 0.33, 95% confidence interval (CI) 0.11-0.97, clinicians] and catheter use (OR 0.42, 95% CI 0.21-0.85, nurses), and better ratings of environmental safety were associated with lower rates of pressure ulcers (OR 0.23, 95% CI 0.09-0.61, clinicians), major injuries from falls (OR 0.48, 95% CI 0.24-0.93, nurses), and catheter use (OR 0.55, 95% CI 0.32-0.93, nursing assistants). Better global CLC ratings were associated with higher rates of catheter use. No other safety climate domains had significant associations. Conclusions and Implications Nursing homes may reduce adverse events by fostering supportive supervision of frontline staff and a safer physical environment.

OBJECTIVE: To assess the association of burn size and community participation as measured by the LIBRE Profile. SUMMARY BACKGROUND DATA: Burn size is an established clinical predictor of survival following burn injury. It is often a factor in guiding decisions surrounding early medical interventions, however, literature is inconclusive on its relationship to quality of life outcomes. METHODS: This is a secondary data analysis of a cross-sectional survey of adult burn survivors. Self-reported data were collected between October 2014 and December 2015 from 601 burn survivors aged ≥18 years with ≥5% total body surface area (TBSA) or burns to critical areas. Sociodemographic characteristics were compared between participants with small burns (≤40% TBSA burned) and large burns (>40% TBSA burned). Ordinary least squares regression models examined associations between burn size and LIBRE Profile scale scores with adjustments for gender, current work status, burns to critical areas, and time since burn injury. RESULTS: The analytic sample comprised 562 participants with data available for burn size. 42% of respondents had large burns (>40% TBSA burned) and 58% reported smaller burns (TBSA ≤40%). In adjusted regression models, patients with large burns tended to score lower on the Social Activities and Work & Employment scales (p40% TBSA scored lower for several individual items in the Social Activities scale and one item in the Work & Employment scale (p

Objectives: Measuring the perceived mental and physical health status of older adults living in long-term residential care (LTRC) is central to patient-centered care. This study examined the qualit...

INTRODUCTION: Electrical injuries exhibit significant acute and long-term sequelae. Amputation and neurological deficits are common in electrical injury survivors. There is a paucity of information on the long-term outcomes of this population. Therefore, this study examines the long-term outcomes of electrical injuries by comparing them to fire/flame injuries. METHODS: Data from the Burn Model System National Database collected between 1996 and 2015 was examined. Demographic and clinical characteristics for adult burn survivors with electrical and fire/flame injuries were compared. Satisfaction With Life Scale (SWLS), Short Form-12 Physical Composite Score (SF-12 PCS), Short Form-12 Mental Composite Score (SF-12 MCS), and employment status were examined at 24 months post-injury. Linear and logistic regression models were used to assess differences in outcome measures between groups, controlling for demographic and clinical variables. RESULTS: A total of 1147 adult burn survivors (111 with electrical injuries; 1036 with fire/flame injuries) were included in this study. Persons with electrical injuries were more likely to be male and injured at work (p

Individual-level socioeconomic disparities impact burn-related incidence, severity and outcomes. However, the impact of community-level socioeconomic disparities on recovery after burn injury is poorly understood. As a result, we are not yet able to develop individual- and community-specific strategies to optimize recovery. Therefore, we aimed to characterize the association between community-level socioeconomic disparities and long-term, health-related quality of life after burn injury.We queried the Burn Model System National Longitudinal Database for participants who were 14 years with a zip code and who had completed a health-related quality of life (HRQOL) questionnaire (VR-12) 6 months after injury. BMS data were deterministically linked by zip code to the Distressed Communities Index (DCI), which combines seven census-derived metrics into a single indicator of economic well-being, education, housing and opportunity at the zip code level. Hierarchical linear models were used to estimate the association between community deprivation and HRQOL 6 months after burn injury, as measured by mental (MCS) and physical (PCS) component summary scores of the SF12/VR12.342 participants met inclusion criteria. Participants were mostly male (n = 239, 69 %) and had a median age of 48 years (IQR 33-57 years). Median %TBSA was 10 (IQR 3-28). More than one-third of participants (n = 117, 34 %) lived in a community within the highest two distress quintiles. After adjusting for age, race/ethnicity, number of trips to the operating room (OR) and pre-injury PCS, neighbourhood distress was negatively associated with 6-month PCS (ß-0.05, 95 % CI [-0.09,-0.01]). Increasing age and lower pre-injury PCS were also negatively associated with 6-month PCS. There was no observed association between neighbourhood distress and 6-month MCS after adjustment for age, participant race/ethnicity, number of trips to the OR and pre-injury MCS. Higher pre-injury MCS was associated with 6-month MCS (ß0.54, 95 % CI [-0.41,0.67]).Community distress is associated with lower PCS at 6 months after burn injury but no association with MCS was identified. Pre-injury HRQOL is associated with both PCS and MCS after injury. Further study of the factors underlying the relationship between community distress and physical functional recovery (e.g., access to rehabilitation services, availability of adaptations) is required to identify potential interventions.

While remarkable improvements have been made to acute hospital burn care in recent decades, it is not matched by improvements in post-acute care, including physical rehabilitation and mental health. Progress in acute hospital treatment of burn survivors now highlights the next important step—addressing care once a patient leaves intensive treatment and is discharged to the community. Long-term physical rehabilitation and mental health services are vital to improving quality of life for burn survivors. Using qualitative methods, we apply an adapted Reeve framework to assess and compare post-acute physical rehabilitation and mental health care across 13 countries on 6 continents. Twenty semistructured interviews were conducted with burn surgeons and rehabilitation specialists. One major theme that emerged was the importance of training and resources to the quality of post-acute care. This exploratory study suggests the value of investing scarce resources in a range of low-cost interventions to improve follow-up burn care. One intervention identified here is short-term training in post-acute rehabilitation and mental health to upgrade and standardize best clinical practices to address as-yet unmet post-discharge needs of burn survivors.

Background: Maggot debridement therapy (MDT), or the use of maggots in dead tissue removal, has been shown to be beneficial in wound healing. Yet MDT in the US is often only used once conventional debridement methods have failed. Method: In this study, nine health professionals, experienced in MDT, were interviewed in order to identify and analyse the perceived societal barriers to MDT acceptance and usage in the US. Results: Through qualitative analysis, using the grounded theory framework, this study found that among those interviewed, insurance reimbursement restrictions and stigmatisation of medicinal maggots were the factors driving resistance to MDT use. Conclusion: Specifically, the ‘yuck’ factor and the perception of MDT as an ‘ancient’ modality contributed towards MDT stigma; in addition, lack of outpatient insurance coverage deterred MDT use. These findings provide useful information regarding the perceptual and systemic barriers that prevent greater acceptance of MDT. Ultimately, these barriers must be understood if we are to facilitate MDT implementation and improve MDT usage in the future.

Determining the sustainability of antibodies targeting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is essential for predicting immune response against the Coronavirus disease 2019 (COVID-19). To quantify the antibody decay rates among the varying levels of anti-nucleocapsid (anti-N) Immunoglobulin G (IgG) in convalescent COVID-19 patients and estimate the length of time they maintained SARS-CoV-2 specific antibodies, we have collected longitudinal blood samples from 943 patients over the course of seven months after their initial detection of SARS-CoV-2 virus by RT-PCR. Anti-N IgG levels were then quantified in these blood samples. The primary study outcome was the comparison of antibody decay rates from convalescent patients with high or low initial levels of antibodies using a mixed linear model. Additional measures include the length of time that patients maintain sustainable levels of anti-N IgG. Antibody quantification of blood samples donated by the same subject multiple times shows a gradual decrease of IgG levels to the cutoff index level of 1.4 signal/cut-off (S/C) on the Abbott Architect SARS-CoV-2 IgG test. In addition, this study shows that antibody reduction rate is dependent on initial IgG levels, and patients with initial IgG levels above 3 S/C show a significant 1.68-fold faster reduction rate compared to those with initial IgG levels below 3 S/C. For a majority of the donors naturally occurring anti-N antibodies were detected above the threshold for only four months after infection with SARS-CoV-2. This study is clinically important for the prediction of immune response capacity in COVID-19 patients.

The Young Adult Burn Outcome Questionnaire (YABOQ) is a validated, English-language patient-reported outcome assessment of young adults’ recovery from burn injury across 15 scale domains. We evaluated the cross-cultural validity of a newly developed Spanish version of the YABOQ. Secondary data from English- and Spanish-speaking burn survivors (17 to 30 years of age) were obtained from the Multicenter Benchmarking Study. We conducted classic psychometric analyses and evaluated the measurement equivalence of the English and Spanish YABOQs in logistic and ordinal logistic regression differential item functioning analyses. All multi-item scales in the Spanish YABOQ demonstrated adequate reliability except the Pain and Itch scales. One item in the Perceived Appearance scale showed differential item functioning across English- and Spanish-speaking burn survivors, but the observed differential item functioning had no clinically significant impact on scale-level Perceived Appearance scores. Our findings support the cross-cultural validity of the YABOQ Physical Function, Perceived Appearance, Sexual Function, Emotion, Family Function, Family Concern, Satisfaction with Symptom Relief, Satisfaction with Role, Work Reintegration and Religion scales among English- and Spanish-speaking young adult burn survivors. This work supports the use of these English and Spanish YABOQ scales to assess the effect of therapeutic interventions on young adults’ burn outcomes in pooled analyses and to assess disparities in young adults’ burn outcomes across language groups.

Introduction Dallas ages one to five are learning to make friends and interact with peers in situations where their social functioning may have a direct relationship with their mood. Dallas may be isolated from peers during the acute phase of burn recovery and face rejection by their peers during recovery. This could influence their psychological health through feelings of anxiety, loneliness, social withdrawal and/or defiant behavior. This study evaluates the relationship between social and psychological functioning using the data collected from the field-tested Preschool-LIBRE1-5 instrument. Methods Parents of burn survivors (n=426) completed Preschool-LIBRE1-5. Items from the psychological (48 items) and social (37 items) functioning domains were coded on a 5-point Likert scale ranging from 0 (never) to 4 (always) where higher scores denote better functioning. Confirmatory factor analysis was conducted for individual items in the social and psychological domains respectively. Regression model assessed the relationship between the social and psychological domains, controlling for demographic characteristics (gender, race, ethnicity, age at survey completion, burn size, and pain severity). Results Factor analysis identified three factors for social functioning: play, peer relations, and peer rejection. The psychological items confirmed a single factor that included dysregulation (negative behaviors and sleep), externalization (impulsivity and aggression), internalization (general anxiety and depression), and trauma (fear and avoidance). Distress items, also in the internalizing subdomain, weren’t strongly confirmed as part of this single scale. The subdomains with the lowest and highest mean scores in psychological domain were dysregulation (2.68 + 0.58) and depression (3.50 + 0.37), and in social domain were peer relation (2.39 + 0.95) and peer rejection (3.42 + 0.64) respectively. Adjusted regression analysis demonstrate that the social functioning domain has a significant relationship with psychological status (p < 0.004). Conclusions Analysis suggests a significant association between social functioning and psychological status. Results provide a basis for understanding the importance of these domains in relationship to each other.

Introduction Burn survivors experience significant social participation challenges in their recovery. However, enrolment and compliance with face-to-face interventions for such issues are often limited by time, location, and financial resources. Digital technologies are increasingly utilized in healthcare and provide a flexible, accessible, and low-cost treatment option. Given the sparse literature on this topic in the burn field, this review evaluated digital interventions for social participation in adults with long-term physical conditions to inform future use in the burn population. Methods MEDLINE, EMBASE, CINAHL and PsycINFO databases were searched using keywords and Medical Subject Headings (MeSH) terms related to ‘digital intervention’ and ‘social participation’ for studies published in English between January 2010 and May 2021. Studies that adopted digital technology interventions to improve social participation in adults with long-term physical conditions were included. Study quality was evaluated using Oxford Levels of Evidence. Data on study methodology, digital intervention and findings related to social participation were summarized. Results The search yielded a total of 4646 articles, of which 158 were full-text screened and 14 met inclusion and exclusion criteria. There were five randomized controlled trials, two non-randomized clinical trials and seven one-group pretest-posttest clinical trials. Twenty-five different measurement tools were utilized to assess social participation and two of them were used twice. Three types of digital interventions were implemented to improve social participation: group support, individual skill training or counselling, and education and support. The group support intervention developed a social network among affected people through videoconference, app, or virtual reality platform (3 of 4 studies with positive results). Individual skill training or counselling utilized phone calls or videoconference to help participants with activity participation and interpersonal relationships (2 of 6 studies with positive results). The education and support intervention used messages and website information to increase participants’ knowledge and provide support (3 of 3 studies with positive results). Conclusions This review presents evidence of different digital interventions’ effect on improving social participation in adults with long-term physical conditions. However, the existing literature is limited by the heterogeneity of outcome measures and varied methodology quality that preclude larger generalizations.

Introduction Quality sleep is an essential part of post-injury recovery. Sleep deprivation, including that due to pain, may hinder and slow recovery progression. Therefore, it is vital to assess long-term sleep outcomes post-burn injury. This study examined the association of sleep items with the severity of pain in pediatric burn survivors one to five years of age, using Preschool LIBRE1-5 (Life Impact Burn Recovery Evaluation) parent-reported data. Methods The Preschool LIBRE1-5 was administered to 426 parents of burn survivors during field-testing. Three sleep-specific items within the psychological domain were assessed: “My child had frightening dreams or nightmares,” “My child had trouble staying asleep,” and “My child had trouble falling asleep at night.” Each item was scored on a 5-point Likert scale from 0 = never to 4 = always. Pain was assessed on a 4-point severity scale, from 0 = not severe to 3 = very severe and dichotomized (1= not severe and 0 = mild, moderate, and very severe). For sleep items, higher scores denote better functioning. Odds ratios for each of the three items were calculated using logistic regression to measure the association between pain severity with sleep. Lower odds ratios denote that greater pain severity is associated with more sleep problems. The multiple logistic and linear regression analysis included covariates for age at time of survey, gender, race, total body surface area burned (TBSA), Hispanic (yes/no), wound dressings, and burns to critical areas (hands, face, foot). Multiple imputations were used for missing values. Results The sample characteristics included: mean age of 3.1 + 1.4 years, mean time since burn injury of 1.2 + 1.3 years, mean TBSA of 4.2 + 7.9, 55.2% male, and 74.2% white. In the multiple logistic regression analyses, burn survivors with severe pain had significant trouble falling asleep (OR = 0.44, 95% CI [0.24, 0.81]) and staying asleep at night (OR = 0.45, 95% CI [0.24, 0.83]). No association was found with pain severity and frightening dreams or nightmares (OR = 0.8, 95% CI (0.37, 1.75). The multiple linear regression analysis showed that higher scores on pain scales were associated with poor sleep outcomes (R²= 9.5%, p = 0.0016). As pain scores increased, the sleep summed score decreased by 0.46 standard deviation. Conclusions There are important associations between pain severity and sleep outcomes. Pain management and interventions for sleep improvement may lead to better outcomes in the pediatric burn population.

Introduction Social engagement, primarily through peer interactions, is an active-coping strategy that is key to community re-integration after a burn injury. For young children, social engagement encourages standard development, with burn injuries potentially affecting their likelihood to engage with others. We utilized the parent-report Preschool-LIBRE1-5 (Life Impact Burn Recovery Evaluation) to explore factors that can influence a child’s social engagement. Methods Our participants were 426 parents of burned children ages one through five who completed the Preschool-LIBRE1-5. Four variables involving social engagement were assessed: “frequency of child avoiding other children,” “frequency of child playing alone,” “frequency of child wanting to be left alone,” and “frequency of child liking to be around other children.” Responses from a 5-point Likert scale ranging from never to always were recoded on a 3-point Likert scale such that a higher score indicated increased social engagement. A nominal logistic regression analysis was conducted with each social engagement variable as a separate dependent variable for each model. The age of the patient when the survey was completed and gender were independent variables. The models also were adjusted by the presence of a hand burn, a face burn, burn size, race, and ethnicity. A bootstrap analysis was conducted to assess internal validity of the significant findings. Results The sample characteristics included: mean age of 3.1+1.4 years, mean time since burn injury of 1.2+1.3 years, mean total body surface area (TBSA) of 4.2+7.9, 55.2% male, and 74.2% white. Findings did not reach significance for three of the dependent variables. However, the dependent variable “frequency of child liking to be around other people” was significant with an increased odds of 35.8% for older children compared to younger ones. (OR [95% CI] =1.358 [1.027, 1.795]). Further, boys were much less likely to want to be left alone (OR [95% CI] = 2.97[1.36,6.5]). Among 500 bootstrap samples, 59% and 79% of the samples replicated the significant findings respectively. Conclusions In preschool children with burn injuries, burn location, race, and ethnicity were not associated with the social engagement items tested in this study. Boys did show a higher likelihood of peer engagement suggesting that gender may influence a child’s desire to be alone.

Introduction Children ages one to five years old are naturally curious and build their personality and social skills through interactions with others. Positive peer relations are especially important after a burn injury as bullying and peer rejection can delay development of social skills. This study assessed the association between burn injuries and burn survivors’ ability to connect with and maintain peer relations in this age group using the Preschool-LIBRE 1-5 (Life Impact Burn Recovery Evaluation). Methods The Preschool-LIBRE1-5 was field-tested with 426 parents of burn survivors. Each item was scored on a 5-point Likert scale ranging from 0 (never) to 4 (always). Data was recoded for selected items such that higher scores denote better functioning. Classic test theory methods were used to assess the peer relation items from a social functioning domain. Individual items and mean scores in the domain were examined. Multiple linear regression analyses (controlling for gender, race and ethnicity, pain severity, burn injury to critical area, burn size, and age at survey completion) measured the association between demographic and clinical characteristics and calculated a peer relation score based on multiple imputation samples. Results The mean age was 3.06 + 1.41 years, mean time since injury of 1.16 + 1.34 years, mean total body surface area (TBSA%) of 4.21 + 7.92, and 55.16% male and 74.18% white. Items from peer relations item pool (n=15) were identified as a unidimensional scale (α=0.92, item-total correlations for all 15 items >0.4, ratio of the 1st and 2nd eigenvalues (8.729/1.287=6.78) = > 4). The mean peer relation score was 2.86 + 0.76. The two items with the lowest and highest score were “My child would ask for things nicely when playing with other children” (x̄ = 2.09) and “My child liked to play near and be with family members and friends (x̄ = 3.59) respectively. Results indicated that age was a significant predictor, such that older age at survey completion was significantly associated with higher peer relation score (β = 0.16, p < 0.0001). With each year of age increase, peer relationship score increased by 0.16 + 0.21 points. Conclusions Preschool-aged burn survivors, as reported by parents, often had the ability to connect with peers through imitation and participating in play activities, and maintained peer relationships well. These findings emphasize the importance of promoting early interventions that build social skills, allowing for positive interactions with peers and improving social functioning in the long-term.

Introduction Use of prescription pain medication after burn injury is commonly required. However, little is known about long-term pain medication use and its association with outcomes. Therefore, the purpose of this study is to assess patterns of prescription pain medication use after discharge and the association between these medications and quality of life outcomes. Methods Data from the Burn Model System National Longitudinal Database (2015-2021) were analyzed. Pain medication use was assessed at pre-injury (recall at discharge), discharge (medical record) and follow-up (self-report at 6, 12, and 24 months after injury). Outcome measures included: VR-12 Physical and Mental Component Summary scores (PCS and MCS), Community Integration Questionnaire (CIQ), Posttraumatic Stress Disorder Checklist (PCL), Satisfaction with Life Scale (SWLS), and NeuroQOL Stigma. The population was divided into two groups, those taking and not taking prescription pain medications at one year. Regression analyses examined associations between prescription pain medication use and outcomes at 12 months, controlling for age, gender, race, ethnicity and burn size. Results Of the 645 participants, 15% reported prescription pain medication use prior to their burn. At discharge, 81% reported use of an opioid and 46% reported use of a neuropathic pain medication. At 12 months, 32% of individuals indicated prescription pain medication use. The pain medication group exhibited larger burn size (24.0% vs 15.2%) and longer hospital stays (40.4 vs 25.0 days) than the non-pain medication group (p< 0.0001 for all). Additionally, 25% of individuals who reported pre-injury pain medication use also reported use at 12 months. Regression analyses demonstrated that pain medication use was associated with worse physical health (PCS: coefficient 8.69, p< 0.0001) mental health (MCS: 6.31, p< 0.0001), stigma (NeuroQOL Stigma: 3.91, p< 0.0001), and satisfaction with life (SWLS: -3.66, p< 0.0001) at one year. Additionally, pain medication use was associated with 45% decreased odds of being employed (coefficient 0.55, p=0.029) and approximately 3 times greater odds of having post-traumatic stress disorder at 12 months (coefficient 3.25, p< 0.0001). Conclusions There are significant associations between prescription pain medication use and worse physical, mental and employment outcomes at twelve months. This information may be used to trigger screening and manage long-term recovery outcomes.

Introduction There is little published research on the long-term outcomes of military service members with burn injuries. Military service members are often exposed to extraordinary challenges and adverse experiences that might influence their recovery from a burn injury. Therefore, to better understand the outcomes of service members with burn injuries, this study compares characteristics and health outcomes between burn survivors who have and do not have a history of military service. Methods Data from the Burn Injury Model System National Longitudinal Database (2015-2021) were analyzed. Military and civilian groups were identified by the following question administered at hospital discharge: “have you ever served in the military?”. The database does not identify if military service members were active duty at time of injury. Demographic and clinical characteristics as well as outcome measures at one year after injury were compared between groups. Patient reported outcome measures included: Veterans Rand 12-Item Health Survey (VR-12) physical and mental health, Satisfaction with Life Scale (SWL), 4-D Itch, Post Traumatic Stress Disorder (PTSD) Check List, self-reported PTSD diagnosis, and employment status. Multivariate regression analyses examined associations between outcome measures and military service status, controlling for age, gender, burn size, race, and ethnicity. Results The study population included 672 burn survivors, 105 with and 567 without military service history, respectively. Participants with military service history were more likely to be male (93% vs. 65%, p < 0.001), older (55 vs. 45 years, p < 0.001) and have Medicare/Medicaid insurance (46.6% vs. 37.2%, p< 0.01) than those without military service history. Race, ethnicity, education, marital status, injury etiology, burn size, length of stay, burns to critical areas, amputation, and number of surgeries were not significantly different between groups. Regression analyses also demonstrated that none of the outcome measures examined (VR-12, SWL, 4-D Itch, PTSD Check List, self-reported PTSD, employment) were significantly different between groups at one-year after injury (p >0.05). Conclusions No significant differences in outcomes were found in the BMS Database between burn survivors with and without a history of military service. Harmonization of these data with other military service datasets will help us better understand long-term outcomes of this population.

Introduction Between the ages of one and five, children gain increased mobility and begin to explore their surroundings. This makes them a particularly vulnerable age group for burn-related injuries, which can influence a child’s physical and psychosocial development. Previous research in adult burn survivors associated larger burn size with poorer functional outcomes for social activities. Currently, there are limited data on the association in preschool aged survivors between burn size and functioning. The aim of this study is to understand how demographic characteristics, particularly burn size, correlate with the global functioning items using data from the Preschool-LIBRE1-5 study. Methods The Preschool-LIBRE1-5 was field-tested with 426 parents of burn survivors. Eight global items assessed change in functioning in four domains (physical, psychological, communication & language, and social) compared to pre-burn functioning. Demographic variables included gender, race, age at survey completion, total body surface area burned (TBSA), ethnicity, and pain severity. Post-burn abilities were assessed with “Following the burn injury, my child lost abilities he/she had before the burn injury in…”, measured with a yes or no response and compared to other children without burns with, “Compared to other children in the same age, in general, how would you rate your child’s…”, measured with a 5-point Likert scale ranging from much worse to much better. Multivariate logistic regression with multiple imputation for missing values were used to measure the association between demographic characteristics and global items. Results The population had a mean age at time of burn injury of 1.9 + 1.1 years and mean TBSA% of 4.2 + 8.0. Of the 426 participants, 305 have a TBSA < 5%, 45 have a TBSA between 5%-15% and 45 have a TBSA >15%. Larger TBSA was associated with lower odds of abilities in functional status for all four global functioning items. Adjusted odd ratios with 95% CI’s included communication and language 0.57(0.35,0.93), physical function 0.55(0.37,0.83), social function 0.33(0.2,0.52), and psychological/behavioral function 0.49(0.31,0.75). There was also a negative correlation of larger TBSA with weaker social abilities of the child compared to other children without burns. Conclusions The findings of this study show a negative association between a child’s burn size and parent-reported functioning in the four domains post-burn injury. These findings may help clinicians improve pediatric recovery and rehabilitation.

Background Low back pain (LBP) is one of the most prevalent conditions for which patients seek physical therapy in the United States. The American Physical Therapy Association categorizes direct access to physical therapist services into 3 levels: limited, provisional, and unrestricted. Objective The objective of this study was to evaluate the association of level of access to physical therapist services with LBP-related health care utilization and costs. Design This was a retrospective cohort study of patients with new-onset LBP between 2008 and 2013; data were from OptumLabs Data Warehouse. Methods We identified 59,670 individuals who were 18 years old or older, who had new-onset LBP, and who had commercial or Medicare Advantage insurance through a private health plan. We examined 2 samples. The first was health care utilization among individuals who saw a physical therapist first in states with either unrestricted access or provisional access. The second was LBP-related costs among individuals who saw either a physical therapist or a primary care physician first. Results Individuals who saw a physical therapist first in states with provisional access had significantly higher measures of health care utilization within 30 days, including plain imaging and frequency of physician visits, than individuals who saw a physical therapist first in states with unrestricted access. Compared with individuals who saw a primary care physician first, pooled across provisional-access and unrestricted-access states, those who saw a physical therapist first in provisional-access states had 25% higher relative costs at 30 days and 32% higher relative costs at 90 days, whereas those who saw a physical therapist first in unrestricted-access states had 13% lower costs at 30 days and 32% lower costs at 90 days. Limitations This was a claims-based study with limited information on patient characteristics, including severity and duration of pain. Conclusions Short-term LBP-related health care utilization and costs were lower for individuals in unrestricted-access states than in provisional-access states.