Implementation outcomes of a digital, trauma-informed care, educational intervention targeting health professionals in a paediatric burns setting: A mixed methods process evaluation.

Trauma-informed care practices are associated with a culture of safety following traumatic experiences, including medical trauma. An interactive, web-based training package ('Responsive CARE') was developed for voluntary uptake by paediatric burns health professionals to increase staff knowledge about trauma-informed practice. This paper reports on a mixed methods process evaluation conducted alongside a preliminary effectiveness study of 'Responsive CARE'. The process evaluation was conducted using The Consolidated Framework for Implementation Research (CFIR) and a logic model, to examine feasibility of both the intervention and implementation strategy. Health practitioners (including senior managers) delivering care to children and caregivers attending an outpatient burns service were eligible to enrol in 'Responsive CARE'. Qualitative interview data and quantitative metadata were used to evaluate the implementation outcomes (adoption, acceptability, fidelity, feasibility and preliminary effectiveness). Children and caregivers attending an outpatient service for change of burn wound dressing or burn scar management during the 3-month control or 3-month intervention period were eligible to enrol in the effectiveness study. The impact on child pain and distress, as well as cost, was investigated using a pretest-posttest design. Thirteen (from anticipated 50 enrolled) health professionals (all female) with mean 10 years (SD=11) of experience with paediatric burns hospital-based outpatient care completed an average of 65% (range 36% to 88%) of available content. Twenty-five semi-structured interviews were completed with health practitioners (21 female) and with 14 caregivers (11 female). Four themes were identified as influencing feasibility and acceptability of the intervention: 1) Keeping a trauma-informed lens; 2) Ways of incorporating trauma-informed care; 3) Working within system constraints; and 4) Being trauma-informed. Preliminary effectiveness data included 177 participants (median age 2 years, and median total body surface area burn 1%). Causal assumptions within the logic model were unable to be fully tested, secondary to lower-than-expected adoption and fidelity. We found no significant difference for pain, distress and per-patient hospital care costs between groups (pre- and post-intervention). Future implementation strategies should include organizational support to keep a trauma-informed lens and to incorporate trauma-informed principles within a medical model of care. Despite efforts to co-design a staff education intervention and implementation approach focused on stakeholder engagement, adaptations are indicated to both the intervention and implementation strategies to promote uptake highlighting the complexity of changing clinician behaviours.

Ultrasound measurement of traumatic scar and skin thickness: a scoping review of evidence across the translational pipeline of research-to-practice.

OBJECTIVES: To identify the ultrasound methods used in the literature to measure traumatic scar thickness, and map gaps in the translation of these methods using evidence across the research-to-practice pipeline. DESIGN: Scoping review. DATA SOURCES: Electronic database searches of Ovid MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature and Web of Science. Grey literature searches were conducted in Google. Searches were conducted from inception (date last searched 27 May 2022). DATA EXTRACTION: Records using brightness mode (B-mode) ultrasound to measure scar and skin thickness across the research-to-practice pipeline of evidence were included. Data were extracted from included records pertaining to: methods used; reliability and measurement error; clinical, health service, implementation and feasibility outcomes; factors influencing measurement methods; strengths and limitations; and use of measurement guidelines and/or frameworks. RESULTS: Of the 9309 records identified, 118 were analysed (n=82 articles, n=36 abstracts) encompassing 5213 participants. Reporting of methods used was poor. B-mode, including high-frequency (ie, >20 MHz) ultrasound was the most common type of ultrasound used (n=72 records; 61% of records), and measurement of the combined epidermal and dermal thickness (n=28; 24%) was more commonly measured than the epidermis or dermis alone (n=7, 6%). Reliability of ultrasound measurement was poorly reported (n=14; 12%). The scar characteristics most commonly reported to be measured were epidermal oedema, dermal fibrosis and hair follicle density. Most records analysed (n=115; 97%) pertained to the early stages of the research-to-practice pipeline, as part of research initiatives. CONCLUSIONS: The lack of evaluation of measurement initiatives in routine clinical practice was identified as an evidence gap. Diverse methods used in the literature identified the need for greater standardisation of ultrasound thickness measurements. Findings have been used to develop nine methodological considerations for practitioners to guide methods and reporting.

Transition Moments for STEOM-CCSD with Core Triples.

Similarity-transformed equation-of-motion coupled-cluster theory (STEOM-CC) is an alternative approach to equation-of-motion coupled-cluster theory for excited states (EOMEE-CC), which uses a second similarity transformation of the Hamiltonian, followed by diagonalization in a small (CI singles-like) excitation space, even when single and double excitations are included in the transformation. In addition to vertical excitation energies, transition moments measure the strength of the interactions between states determining absorption, emission, and other processes. In STEOM-CCSD, transition moments are calculated in a straightforward manner as biorthogonal expectation values using both the left- and right-hand solutions, with the main difference from EOMEE-CC being the inclusion of the transformation operator. We recently developed an extension of STEOM-CCSD to core excitations, CVS-STEOM-CCSD+cT, which includes triple excitations and the well-known core-valence separation for the core ionization potential calculations. In this work, we derived transition moments for core-excited states with core triple excitations, including both ground-to-core-excited and valence-to-core-excited transitions. The improvement of the computed transition moments of the CVS-STEOM-CCSD+cT method is compared to standard CVS-STEOMEE-CCSD and CVS-EOMEE-CCSD for our previously published small-molecule benchmark set.

Open-Shell Tensor Hypercontraction.

The extension of least-squares tensor hypercontracted second- and third-order Møller-Plesset perturbation theory (LS-THC-MP2 and LS-THC-MP3) to open-shell systems is an important development due to the scaling reduction afforded by THC and the ubiquity of molecular ions, radicals, and other open-shell reactive species. The complexity of wavefunction-based quantum-chemical methods such as Møller-Plesset and coupled cluster theory is reflected in the steep scaling of the computational costs with the molecular size. The least-squares tensor hypercontraction (LS-THC) method is an efficient, single-step factorization for the two-electron integral tensor but can also be used to factorize the double excitation amplitudes, leading to significant scaling reduction. Here we extend this promising method to open-shell variants of LS-THC-MP2 and -MP3 by using diagrammatic techniques and explicit spin summation. The accuracy of the resulting methods for open-shell species is benchmarked on standard test systems such as regular alkanes as well as realistic systems involving bond breaking, radical stabilization, and other effects. We find that open-shell LS-THC-MPn methods exhibit errors highly comparable to those produced by closed-shell LS-THC-MPn and are highly insensitive to particular chemical interactions, geometries, or even moderate spin contamination.

Becoming Experts in Their Own Treatment: Child and Caregiver Engagement With Burn Scar Treatments.

Children who experience a severe burn injury not only require acute medical care but may also need ongoing rehabilitation. To mitigate the potential long-term consequences of scarring and the impact of scarring on their everyday lives, children may be expected to use a variety of time-consuming and multi-component non-invasive scar treatments (such as pressure garments and silicone gels). These treatments may pose unique challenges for children and their caregivers. With limited research previously addressing how Australian children navigate the use of scar treatments at home, this study aimed to develop a grounded theory of children and their caregivers' engagement with non-invasive burn scar treatments. Using a constructivist grounded theory approach, interviews were completed with 20 caregivers and 7 children, and a theory of children and their caregivers becoming experts in the use of non-invasive burn scar treatments was developed. Through persistence and flexibility, they continued to develop expertise. Engaging with scar treatments was an evolving process over time for children with burns and their caregivers. Theoretical categories identified included 'making it work', 'finding the balance' and 'seeking reassurance' and highlighted the remarkable strengths and adaptability of children and their caregivers. Through trial and error, children and their caregivers developed their own unique strategies for engaging with scar treatments. These insightful results may inform the development of interventions to support children and their caregivers' day-to-day engagement with non-invasive burn scar treatments and guide health professionals recommending these treatments.

Cost-effectiveness of scar management post-burn: a trial-based economic evaluation of three intervention models.

Optimal burn scar management has the potential to markedly improve the lives of children, but can require substantial healthcare resources. The study aimed to examine the cost-effectiveness of three scar management interventions: pressure garment; topical silicone gel; combined pressure garment and topical silicone gel therapy, alongside a randomised controlled trial of these interventions. Participants were children (n = 153) referred for burn scar management following grafting, spontaneous healing after acute burn injury, or reconstructive surgery. Healthcare resource use was costed from a health service perspective (6-months post-burn time-horizon). The mean total scar management cost was lowest in the topical silicone gel group ($382.87 (95% CI $337.72, $443.29)) compared to the pressure garment ($1327.02 (95% CI $1081.46, $1659.95)) and combined intervention $1605.97 ($1077.65, $2694.23)) groups. There were no significant between-group differences in Quality Adjusted Life Year estimates. There was a 70% probability that topical silicone gel dominated pressure garment therapy (was cheaper and more effective), a 29% probability that pressure garment therapy dominated combined therapy, and a 63% probability that topical silicone gel dominated combined therapy. In conclusion, topical silicone gel was the cheaper intervention, and may be favoured in the absence of clear clinical effect favouring pressure garment therapy or a combination of these management approaches.Trial registration: ACTRN12616001100482 (prospectively registered).

Accurate Core-Excited States via Inclusion of Core Triple Excitations in Similarity-Transformed Equation-of-Motion Theory.

The phenomenon of orbital relaxation upon excitation of core electrons is a major problem in the linear-response treatment of core-hole spectroscopies. Rather than addressing relaxation through direct dynamical correlation of the excited state via equation-of-motion coupled cluster theory (EOMEE-CC), we extend the alternative similarity-transformed equation-of-motion coupled cluster theory (STEOMEE-CC) by including the core-valence separation (CVS) and correlation of triple excitations only within the calculation of core ionization energies. This new method, CVS-STEOMEE-CCSD+cT, significantly improves on CVS-EOMEE-CCSD and unmodified CVS-STEOMEE-CCSD when compared to full CVS-EOM-CCSDT for K-edge core-excitation energies of a set of small molecules. The improvement in both absolute and relative (shifted) peak positions is nearly as good as that for transition-potential coupled cluster (TP-CC), which includes an explicit treatment of orbital relaxation, and CVS-EOMEE-CCSD*, which includes a perturbative treatment of triple excitations.

Introducing a MAP for adherence care in the paediatric cystic fibrosis clinic: a multiple methods implementation study.

BACKGROUND: People with cystic fibrosis are required to adhere to a burdensome daily treatment regimen. Comprehensive adherence protocols can support more consistent use of adherence interventions and improve treatment adherence rates. This study aimed to explore the feasibility, acceptability, and appropriateness of implementing an adherence protocol into the outpatient cystic fibrosis clinic of a tertiary, paediatric hospital. METHODS: This implementation study employed a pre-post observation design, using multiple methods. Focus groups and semi-structured interviews were conducted pre-implementation to understand clinician and consumer perspectives on adherence care. A multicomponent adherence protocol (including multidisciplinary written treatment plans, digital mental health screening and customised communication tools) was then implemented as standard care for a three-month implementation phase. Quantitative data was collected throughout using purpose-designed audit tools and surveys. The Replicating Effective Practice (REP) Framework guided the implementation process. Analysis was informed by The Consolidated Framework for Implementation Research (CFIR) to identify factors that support or challenge the integration of adherence protocols into standard care. RESULTS: Thirteen clinicians, eight parents and two adolescents participated in focus groups or interviews that informed development of the tailored multicomponent adherence protocol for implementation. Medical chart audits demonstrated that the protocol was used with 44-57% of eligible consumers three months after introduction. Eighteen clinicians and five consumers participated in post-implementation phase questionnaires. The protocol was considered acceptable and appropriate to clinicians and consumers. Changes in clinicians' practice behaviour were short-lived peaks in response to targeted intervention strategies throughout the implementation phase, such as audit and feedback. CONCLUSIONS: An adherence protocol is not an "off the shelf" solution to the adherence challenge in a hospital outpatient setting. Despite the tailored adherence protocol being considered appropriate and acceptable to clinicians and consumers, low fidelity indicates limited feasibility in the outpatient clinic setting, where multi-disciplinary members are all considered responsible for adherence care interventions. Key implementation factors and strategies to consider prior to introducing an adherence protocol are described. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001730190 (Retrospectively registered).

The role of burn camp in the recovery of young people from burn injury: A qualitative study using long-term follow-up interviews with parents and participants.

BACKGROUND: Children and adolescents recovering from burn injury are at heightened risk of psychosocial problems. An integrative form of psychosocial intervention is burn camp. However, evidence about burn camp effectiveness is equivocal. OBJECTIVES: This study examined the role of therapeutic camp experiences in the recovery journeys of children and adolescents who had experienced burn injury and been treated in a tertiary pediatric hospital in Brisbane, Australia. METHODS: Retrospective semi-structured interviews were conducted with youths and parents. Inductive reflexive thematic analysis was used with pooled interview data. RESULTS: The participants were eight youths who attended at least one burns camp (between 2009 and 2019) and 15 parents of youth campers. An overwhelming majority (96%) reported a positive experience of camp, that they would return, and that they recommended the camp to other youth with burns. The four strengths of the camp experience were fun, adventurous activities; social relatedness (friendships, socializing); camp setting and experience; and acceptance. The four impacts of the camp on youth campers were normalizing ("I'm not the only one", shared experience); social support (making new friendships, social confidence, mentoring others); psychological recovery (happier, mentally stronger, more resilient, independence building); and confidence (increased self-confidence, increased social confidence, leadership development). CONCLUSIONS: Although this is the first known research about burn camp in Australia, the findings are similar to a handful of other qualitative studies about burn camp experiences and impacts. Recommendations include future research on aspects of camp experiences that contribute to targeted outcomes, the role of staff and previous camp participants as mentors, and comparisons with other psychosocial interventions for youth burn survivors.

Understanding the meaning of trauma-informed care for burns health care professionals in a pediatric hospital: A qualitative study using interpretive phenomenological analysis.

BACKGROUND: Trauma-informed care includes a range of practices that build a culture of safety, empowerment, and healing. Limited information is available regarding the lived experience of trauma-informed care by healthcare professionals treating burns in a multidisciplinary setting. OBJECTIVE: The primary aim of this study was to understand what 'trauma-informed care' means to staff and students working in burns at a tertiary pediatric hospital. METHODS: Semi-structured interviews and focus group were conducted with healthcare professionals (medical, nursing, allied health, pre-graduate students) working in paediatric burn care (or their line manager). Analysis of the dataset was undertaken using qualitative methods (interpretive phenomenological approach and qualitative content analysis). RESULTS: Eleven interviews and one focus group were completed and transcribed verbatim. Three superordinate themes were applicable across the five cohorts: 'what does trauma-informed care mean?', 'being able to deliver trauma-informed care' (agency) and 'impact of the setting'. Eleven components of trauma-informed care practice (for example, everyday interactions with patients and colleagues, screening and assessment) and service-level approaches (for example, service provider training) were described by participants. CONCLUSIONS: Healthcare professionals' experiences of delivering trauma-informed care in a burns centre highlighted the need to clarify the concept of 'trauma-informed care' as a first step. Enabling the workforce to understand trauma-informed care and apply it in everyday interactions with patients and colleagues, and a strategic commitment to practice change needs to be actioned more systematically to support implementation of a trauma-informed care approach in pediatric health services.

Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children 12-months postburn: A parallel group randomised controlled trial.

OBJECTIVE: The longer-term effectiveness of silicone and pressure burn scar interventions was evaluated at 12-months postburn. DESIGN: Parallel group, randomised trial. SETTING: Hospital outpatient clinics, research centre. PARTICIPANTS: Children referred for burn scar management following grafted or spontaneously healed acute burn injuries or scar reconstruction surgery. INTERVENTIONS: Participants were randomised to: (1) topical silicone gel only, (2) pressure garment only, or (3) combined topical silicone gel and pressure garment. MAIN MEASURES: Primary outcomes were scar thickness (blinded ultrasound measurement) and itch intensity (caregiver proxy-report, numeric rating scale). RESULTS: Of 153 participants randomised who received the interventions (silicone n = 51, pressure garment n = 49, combined n = 53), 86 were followed-up at 12-months postburn (n = 34, n = 28, n = 24). No differences were identified for the primary outcomes using intention-to-treat analysis. Scar thickness mean difference (95% confidence interval) = 0.00 cm (-0.04, 0.05); -0.03 cm (-0.07, 0.02); 0.03 cm (-0.02, 0.08) and scar itch = 0.09 (-0.88, 1.06); -0.21 (-1.21, 0.79); 0.30 (-0.73, 1.32) for silicone vs pressure; silicone vs combined and combined vs pressure respectively. No serious adverse effects occurred. CONCLUSION: Similar to short-term results, the combined intervention offered no statistically or clinically significant benefit for improving the primary outcomes compared to each intervention alone. No differences in the primary outcomes were identified between the silicone and pressure alone groups.

Improving the patient-centred care of children with life-altering skin conditions using feedback from electronic patient-reported outcome measures: protocol for a hybrid effectiveness-implementation study (PEDS-ePROM).

INTRODUCTION: Using patient-reported outcome measures (PROMs) with children have been described as 'giving a voice to the child'. Few studies have examined the routine use of these measures as potentially therapeutic interventions. This study aims to investigate: (1) the effectiveness of feedback using graphical displays of information from electronic PROMs (ePROMs) that target health-related quality of life, to improve health outcomes, referrals and treatment satisfaction and (2) the implementation of ePROMs and graphical displays by assessing acceptability, sustainability, cost, fidelity and context of the intervention and study processes. METHODS AND ANALYSIS: A hybrid II effectiveness-implementation study will be conducted from February 2020 with children with life-altering skin conditions attending two outpatient clinics at a specialist paediatric children's hospital. A pragmatic randomised controlled trial and mixed methods process evaluation will be completed. Randomisation will occur at the child participant level. Children or parent proxies completing baseline ePROMs will be randomised to: (1) completion of ePROMs plus graphical displays of ePROM results to treating clinicians in consultations, versus (2) completion of ePROMs without graphical display of ePROM results. The primary outcome of the effectiveness trial will be overall health-related quality of life of children. Secondary outcomes will include other health-related quality of life outcomes (eg, child psychosocial and physical health, parent psychosocial health), referrals and treatment satisfaction. Trial data will be primarily analysed using linear mixed-effects models; and implementation data using inductive thematic analysis of interviews, meeting minutes, observational field notes and study communication mapped to the Consolidated Framework for Implementation Research. ETHICS AND DISSEMINATION: Ethical approval was obtained from Children's Health Queensland Human Research Ethics Committee (HREC/2019/QCHQ/56290), The University of Queensland (2019002233) and Queensland University of Technology (1900000847). Dissemination will occur through stakeholder groups, scientific meetings and peer-reviewed publications. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12620000174987).

Transition-potential coupled cluster.

The problem of orbital relaxation in computational core-hole spectroscopies, including x-ray absorption and x-ray photoionization, has long plagued linear response approaches, including equation-of-motion coupled cluster with singles and doubles (EOM-CCSD). Instead of addressing this problem by including additional electron correlation, we propose an explicit treatment of orbital relaxation via the use of "transition potential" reference orbitals, leading to a transition-potential coupled cluster (TP-CC) family of methods. One member of this family, in particular, TP-CCSD(12), is found to essentially eliminate the orbital relaxation error and achieve the same level of accuracy for the core-hole spectra as is typically expected of EOM-CCSD in the valence region. These results show that very accurate x-ray absorption spectra for molecules with first-row atoms can be computed at a cost essentially the same as that for EOM-CCSD.

Effectiveness of interventions for optimising adherence to treatments for the prevention and management of scars: A systematic review.

OBJECTIVES: To identify the adherence interventions used with people receiving treatments to prevent or manage scarring, the effectiveness of these interventions, and the theoretical frameworks on which these interventions were based. DATA SOURCES: Databases (PubMed, Embase, Web of Science, CINAHL, PsychINFO and OTseeker) were searched (09.10.2020) with no date or language restrictions. Grey literature databases, clinical trial registries and references lists of key papers were also searched. REVIEW METHODS: Eligible randomised controlled trials included people using treatments for scarring following skin wounds, interventions that may improve adherence, and outcomes measuring adherence. Risk of bias (selection, performance, detection, attrition, reporting) and certainty of evidence (inconsistency, imprecision, indirectness, publication bias) were assessed. RESULTS: Four randomised trials were included with 224 participants (17 children) with burn scars. Interventions involved educational (three trials) or technology-based components (four trials) and ranged in length from two weeks to six months. All four trials reported greater adherence rates in the intervention group compared with standard practice [standardised mean difference = 1.50 (95% confidence interval (CI) = 0.91-2.08); 2.01 (95% CI 1.05-2.98); odds ratio = 0.28 (95% CI = 0.11-0.69)]. One trial did not report original data. The certainty of evidence was very low. CONCLUSION: Adherence interventions using education or technology for people receiving burn scar treatment may improve adherence. Further studies are needed particularly in children, with a focus on including outcomes of importance to patients (e.g. quality of life) and identifying core components of effective adherence interventions using theoretical frameworks.

Understanding Young People and Their Care Providers' Perceptions and Experiences of Integrated Care Within a Tertiary Paediatric Hospital Setting, Using Interpretive Phenomenological Analysis.

INTRODUCTION: Benefits of integrated care include improved health outcomes and more satisfaction with experiences of care for consumers. For children and young people with chronic and complex health conditions, their care may be fragmented due to the multitude of healthcare providers involved. This paper describes the experiences of integrated care in a paediatric tertiary hospital. THEORY AND METHODS: Using an Interpretive Phenomenological Analysis approach, semi-structured interviews were conducted with children and young people, their parents and healthcare providers to explore stakeholders' integrated care experiences. RESULTS: Nineteen interviews were completed (6 children and young people, 7 parents and 6 healthcare providers) and transcribed verbatim. Two recurrent themes were applicable across the three cohorts: 'agency and empowerment' and 'impact of organisational systems, supports and structures'. DISCUSSION AND CONCLUSION: Stakeholders' experiences of integrated care highlighted the need to examine the discrepancies between healthcare strategies, policies and service delivery within a complex, and often inflexible organisational structure. Power imbalance and family agency (including directly with children and young people) needs to be addressed to support the implementation of integrated care.

A web-based educational intervention to implement trauma-informed care in a paediatric healthcare setting: protocol for a feasibility study using pre-post mixed methods design.

BACKGROUND: Adoption of responsive trauma-informed practices by staff in hospital-based paediatric care may help mitigate downstream costs associated with treatment delivery due to reduced pain and distress for children and care providers, improved health-related quality of life and increased satisfaction with care. A web-based education intervention (termed Responsive CARE) was developed to build self-efficacy of staff in a paediatric medical setting. This protocol paper describes a feasibility study (including preliminary effectiveness) of the implementation of Responsive CARE in a tertiary, outpatient burn clinical setting. METHODS: A pre-post, mixed methods design will be employed. Children and caregivers attending hospital for change of burn wound dressings or burn scar management during the 3-month control or 3-month intervention period will be eligible, with follow-up to 6-months post-baseline. All children and caregiver/s will receive "standard care" including burn interventions focused on wound healing, scar management, itch management (both pharmacological and non-pharmacological), counselling, age-appropriate procedural support and burn rehabilitation. Health professional participants will be those involved in the management of children with burns during the study period or their senior managers. Health professional participants who attend a weekly educational clinical meeting will be invited to complete the intervention during a 1-month timeframe between the control and intervention period (or upon their commencement in burn outpatients during the intervention period) using an individualised log-in process. A purposive sample of caregivers and health professionals will be sought for participation in semi-structured interviews. Qualitative data will be analysed using Framework analysis. Feasibility will be evaluated via interviews, digital records of intervention usage and technical assistance logs. The primary outcome measures of effectiveness (pain, itch and distress) will be measured using self-report or behavioural observation. Quantitative data will primarily be analysed descriptively and using generalised linear models. DISCUSSION: This study will provide insights into factors that impact upon the feasibility of a web-based trauma-informed care education intervention in a clinical practice setting. This knowledge may support other education approaches within healthcare settings related to improving and supporting patients to reduce the risk of healthcare interactions that result in paediatric medical traumatic stress.

Effectiveness of topical silicone gel and pressure garment therapy for burn scar prevention and management in children: a randomized controlled trial.

OBJECTIVE: To determine the effectiveness of silicone and pressure garments (alone and in combination) in children receiving scar management post-burn. DESIGN: Multicentre, parallel-group, randomized controlled trial. SETTING: Hospital outpatient clinics, colocated research centre, or the participant's home. PARTICIPANTS: Children (0-18 years) referred for burn scar management. INTERVENTIONS: Participants were randomized to (1) topical silicone gel only, (2) pressure garment therapy only, or (3) combined topical silicone gel and pressure garment therapy. MAIN MEASURES: Primary outcomes included scar thickness and itch intensity at the primary end-point of six months post-burn injury. The outcome assessor and data analyst were blinded for scar thickness. RESULTS: Participants (N = 153; silicone n = 51, pressure n = 49, combined n = 53) had a median (inter-quartile range) age of 4.9 (1.6, 10.2) years and percent total body surface area burn of 1% (0.5%, 3%) and were 65% male. At six months post-burn injury, intention-to-treat analysis identified thinner scars in the silicone (n = 51 scar sites) compared to the combined group (n = 48 scar sites; mean difference (95% confidence interval) = -0.04 cm (-0.07, -0.00), P = 0.05). No other between-group differences were identified for scar thickness or itch intensity at six months post-burn. CONCLUSION: No difference was identified in the effectiveness of silicone and pressure interventions alone. No benefit to a combined silicone and pressure intervention was identified for the prevention and management of abnormal scarring in children at six months post-burn injury, compared to the silicone or pressure interventions alone.

Effectiveness of interventions for optimising adherence to treatments for the prevention and management of scars: protocol for a systematic review and meta-analysis.

INTRODUCTION: Treatments used in the management of scarring following wounds of the skin can be complex and time consuming, and patients may experience difficulties adhering to these treatments. Therefore, the aim of this systematic review is to identify the types of interventions that have been used to optimise adherence to treatment for preventing or reducing skin scars in adults and children and to determine the effectiveness of these interventions. METHODS AND ANALYSIS: Databases (PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and OTSeeker) will be searched using the developed search strategy to identify eligible randomised trials. Adults and children using scar treatments to prevent or manage scarring as a result of a dermal wound (which may occur following burn injury, surgery, lacerations, piercings, vaccinations, acne and other conditions affecting the skin) will be included. Any intervention with the potential to effect adherence will be included. Titles and abstracts located through searching will be screened by two independent reviewers. Full text of studies will also be screened to determine eligibility for final inclusion. Two reviewers will assess the quality of included studies using the Cochrane 'risk of bias' tool. Data extraction forms will be developed and two reviewers will extract the data. A third reviewer will be used at each stage to ensure consensus is achieved. Meta-analysis and meta-regression will be completed if appropriate, otherwise a narrative synthesis of results will be undertaken. ETHICS AND DISSEMINATION: No ethical approval is necessary for this systematic review as no patients will be directly involved. Results of this systematic review will be disseminated through journal publications and relevant conference presentations. PROSPERO REGISTRATION NUMBER: CRD42018095082.

Variability of pressure at the pressure garment-scar interface in children after burn: A pilot longitudinal cohort study.

BACKGROUND: Current consensus for the ideal pressure range at the pressure garment to scar interface is 15-25mmHg. Interface pressure variability has been reported at new pressure garment fitting in children. Pressure reductions up to 25% have been recorded over one month in adults. METHOD: A pilot longitudinal cohort study was completed with children aged less than 18 years receiving pressure garment therapy after burn. Interface pressure was measured at first pressure garment fitting, one month and three months after fitting. Analysis was conducted using Linear Mixed Models. RESULTS: Thirty-four children were recruited to the study, 62% were male. Participants had a median (IQR) age of 3 (6) years. At the first garment fitting, 32% of stationary and 25% of dynamic measurements were within 15-25mmHg. Pressure variations were recorded at one and three months with scar location (p=0.03) and %TBSA (p=0.006) identified as predictors of stationary interface pressure. No statistically significant predictors of dynamic pressure were identified. DISCUSSION: Interface pressure variability was recorded over time during children's wear of the first pressure garment after burn. Further investigation of factors contributing to pressure changes, subsequent impact on adherence and the effect of sub-optimal pressure application on burn scar outcomes is indicated.

Reliability and clinical utility of the Pliance X for measuring pressure at the interface of pressure garments and burn scars in children.

BACKGROUND: Reliable, clinically acceptable pressure measuring devices are important to accurately record interface pressure. The Pliance X is a device that may overcome previous device limitations (i.e. pressure garment distortion, temperature dependent sensors). This research aimed to identify the test-retest reliability and clinical utility of the Pliance X in children receiving pressure garment therapy post-burn. METHODS: Data was collected as part of a pilot longitudinal cohort study. Immediate test-retest reliability was investigated at baseline and analysed using Intra-Class Correlation Coefficients (ICCs). Clinical utility was evaluated at baseline using the criteria of appropriate, accessible, practicable and acceptable. RESULTS: Thirty-one children completed baseline measurements. Participants had a median age of three years (IQR: 1.5, 7.5), and 61% were male. Test-retest reliability of the Pliance X was close to acceptable for clinical use for stationary interface pressure (ICC=0.87, n=27). The Pliance X was appropriate and acceptable for children of all ages who were not distressed. DISCUSSION: Further reliability testing is required, including inter-rater reliability testing. The device's clinical utility could be improved with alternate sensor styles and an instant mean pressure reading to enable immediately clinically useful information on the interface pressure.