Wim E. Tuinebreijer

The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation.

At present, various scar assessment scales are available, but not one has been shown to be reliable, consistent, feasible, and valid at the same time. Furthermore, the existing scar assessment scales appear to attach little weight to the opinion of the patient. The newly developed Patient and Observer Scar Assessment Scale consists of two numeric scales: the Patient Scar Assessment Scale (patient scale) and the Observer Scar Assessment Scale (observer scale). The patient and observer scales have to be completed by the patient and the observer, respectively. The patient scales consistency and the observer scales consistency, reliability, and feasibility were tested. For the Vancouver Scar Scale, which is the most frequently used scar assessment scale at present, the same statistical measurements were examined and the results of the observer scale and the Vancouver scale were compared. The concurrent validity of the observer scale was tested with a correlation to the Vancouver scale. Furthermore, the authors examined which specific characteristics significantly influence the general opinion of the patient and the observers on the scar areas. Four independent observers have each used the observer scale and the Vancouver scale to assess 49 burn scar areas of 3 × 3 cm belonging to 20 different patients. Subsequently, the patients completed the patient scale for their scar areas. The (internal) consistency of both the patient and the observer scales was acceptable (Cronbachs alpha, 0.76 and 0.69, respectively), whereas the consistency of the Vancouver scale appeared not to be acceptable (alpha, 0.49). The reliability of the observer scale completed by a single observer was acceptable (r = 0.73). The reliability of the Vancouver scale completed by a single observer was lower (r = 0.69). The observer scale showed better agreement than the Vancouver scale because the coefficient of variation was lower (18 percent and 22 percent, respectively). The concurrent validity of the observer scale in relation to the Vancouver scale is high (r = 0.89, p < 0.001). Linear regression of the general opinions on scars of the observer and the patient showed that the observers opinion is influenced by vascularization, thickness, pigmentation, and relief, whereas the patients opinion is mainly influenced by itching and the thickness of the scar. Such an impact of itching and thickness of the scar on the patients opinion is an important and novel finding. The Patient and Observer Scar Assessment Scale offers a suitable, reliable, and complete scar evaluation tool.

Rasch analysis of the Patient and Observer Scar Assessment Scale (POSAS) in burn scars

PurposeThe Patient and Observer Scar Assessment Scale (POSAS) is a questionnaire that was developed to assess scar quality. It consists of two separate six-item scales (Observer Scale and Patient Scale), both of which are scored on a 10-point rating scale. After many years of experience with this scale in burn scar assessment, it is appropriate to examine its psychometric properties using Rasch analysis.MethodsCross-sectional data collection from seven clinical trials resulted in a data set of 1,629 observer scores and 1,427 patient scores of burn scars. We examined the person–item map, item fit statistics, reliability, response category ordering, and dimensionality of the POSAS.ResultsThe POSAS showed an adequate fit to the Rasch model, except for the item surface area. Person reliability of the Observer Scale and Patient Scale was 0.82 and 0.77, respectively. Dimensionality analysis revealed that the unexplained variance by the first contrast of both scales was 1.7 units. Spearman correlation between the Observer Scale Rasch measure and the overall opinion of the clinician was 0.75.ConclusionThe Rasch model demonstrated that the POSAS is a reliable and valid scale that measures the single-construct scar quality.

Reliability, validity and clinical utility of three types of pain behavioural observation scales for young children with burns aged 0-5 years

&NA; Pain measurement is a prerequisite for individualized pain management and research into pain interventions. There is a need for reliable and valid pain measures for young children with burns. The aim of this study was to investigate whether the pain observation scale for young children (POCIS), the COMFORT behaviour scale (COMFORT‐B) and the nurse observational visual analogue scale (VAS obs) are reliable, valid and clinically useful instruments to measure pain in children with burns aged 0–5 years. Participating trained nurses (N = 102) rated pain of 154 children during hospitalization. Two trained nurses simultaneously assessed pain at fixed intervals by using the previous mentioned measures. Cronbachs alpha for POCIS was .87 for background and .89 for procedural pain. Intraclass Correlation Coefficients (ICCs) were .75 for background and .81 for procedural pain. COMFORT‐B observations yielded Cronbachs alpha of .77 for background and .86 for procedural pain and ICCs of .83 for background and .82 for procedural pain. The VAS obs resulted in ICCs of .55 for background and .60 for procedural pain. Correlation coefficient between POCIS and COMFORT‐B was .79 (p < .01), Standardized response mean was 1.04 for both POCIS and COMFORT‐B. Background pain measured with POCIS and COMFORT‐B was lower than procedural pain (p < .001). Nurses found POCIS easier and quicker to use, but COMFORT‐B was found to indicate pain more accurately. Both POCIS and COMFORT‐B are reliable, valid and practical scales for pain measurement in young children with burns and can be used in practice and research. The VAS obs was found to be unreliable.

Objective color measurements: clinimetric performance of three devices on normal skin and scar tissue.

Color measurements are an essential part of scar evaluation. Thus, vascularization (erythema) and pigmentation (melanin) are common outcome parameters in scar research. The aim of this study was to investigate the clinimetric properties and clinical feasibility of the Mexameter, Colorimeter, and the DSM II ColorMeter for objective measurements on skin and scars. Fifty scars with a mean age of 6 years (2 months to 53 years) were included. Reliability was tested using the single-measure interobserver intraclass correlation coefficient. Validity was determined by measuring the Pearson correlation with the Fitzpatrick skin type classification (for skin) and the Patient and Observer Scar Assessment Scale (for scar tissue). All three instruments provided reliable readings (intraclass correlation coefficient ≥ 0.83; confidence interval: 0.71–0.90) on normal skin and scar tissue. Parameters with the highest correlations with the Fitzpatrick classification were melanin (Mexameter), 0.72; ITA (Colorimeter), −0.74; and melanin (DSM II), 0.70. On scars, the highest correlations with the Patient and Observer Scar Assessment Scale vascularization scores were the following: erythema (Mexameter), 0.59; LAB2 (Colorimeter), 0.69; and erythema (DSM II), 0.66. For hyperpigmentation, the highest correlations were melanin (Mexameter), 0.75; ITA (Colorimeter), −0.80; and melanin (DSM II), 0.83. This study shows that all three instruments can provide reliable color data on skin and scars with a single measurement. The authors also demonstrated that they can assist in objective skin type classification. For scar assessment, the most valid parameters in each instrument were identified.

A systematic review on burn scar contracture treatment: searching for evidence

Treating burn scar contracture remains a challenging problem for reconstructive surgeons. At present, no consensus exists on when to use what kind of technique. Therefore, a systematic review was performed on the effectiveness of the different surgical techniques after burn scar contracture release. Electronic databases were searched using a predefined search strategy. Studies evaluating the outcome of surgical techniques for the treatment of burn scar contractures were included. The methodological quality was tested and the data were summarized. One thousand six hundred fourty-nine papers were identified of which 17 met the inclusion criteria. Three papers reported on a controlled trial, 14 were cohort studies, including 10 of a pre-post operative design and 4 of a comparative design. The papers described outcomes of grafts, flaps with random or defined vascularization, and dermal substitutes. All studies had methodological shortcomings and most used inappropriate statistical methods. The current evidence on the effectiveness of reconstruction techniques for burn scar contractures was summarized. Due to the scarcity and low quality of the included studies, no definitive conclusions could be reached about the effectiveness of different techniques. Therefore, no direct implications for daily practice could be made. However, recommendations could be given for improvement of the quality of further primary research on the effectiveness of surgical treatment strategies for burn scar contracture release.

Construct validity of two pain behaviour observation measurement instruments for young children with burns by Rasch analysis

TOC summary The POCIS and COMFORT‐B measure background and procedural pain as unidimensional and enable adequate measurements for scientific research and daily practice in burn care. ABSTRACT In this study, construct validity of 2 pain behaviour observation measurement instruments for young children aged 1 to 56 months (mean age was 20 months) with burns is assessed by using Rasch analysis. The Rasch model, wherein data should meet the model expectations, assumes that an instrument measures one unidimensional construct, and focuses on the items of measurement instruments. The Pain Observation Scale for Young Children (POCIS) and the COMFORT Behaviour Scale (COMFORT‐B) measure background and procedural pain as unidimensional. Adequate measurements for scientific research and daily practice can now be obtained.

Differential item functioning in the Observer Scale of the POSAS for different scar types

AbstractPurposenTo investigate whether the Observer Scale of the Patient and Observer Scar Assessment Scale (POSAS) can serve as a generic measure for scar quality across different scar types.MethodsnA collection of POSAS scores derived from several clinical trials on burn (nxa0=xa0404), linear (nxa0=xa0384), and keloidal scars (nxa0=xa0282) was analyzed using the partial credit model of the Rasch analysis package RUMM2030.ResultsDifferential item functioning (DIF) was observed for the Observer Scale of the POSAS between the three scar types for the items pliability, thickness, and surface area, which could be solved by item splitting. The items pigmentation and thickness showed disordered thresholds, considerable misfit, and unpredictability.ConclusionUsers of the Observer Scale of the POSAS must be aware that the raw scores obtained from burn, linear, and keloidal scars cannot be compared without the scar-specific DIF adjustment of the items pliability, thickness, and surface area.

Predictive validity of short term scar quality on final burn scar outcome using the Patient and Observer Scar Assessment Scale in patients with minor to moderate burn severity

BACKGROUNDnThe aim of this study was to assess the predictive validity of the Patient and Observer Assessment Scale (POSAS), in order to determine whether it can be used to predict final scar quality.nnnMETHODSnPatients with a maximum TBSA burned of 20% who were treated in a Dutch burn center and participated in two scar assessments at 3 months and >18 months post-burn were included. Scar quality assessment consisted of the POSAS, Dermaspectrometer® (color) and Cutometer® (elasticity). Predictive validity was determined in three ways: (1) the discriminative ability to distinguish good from reduced long term scar quality, (2) correlations between POSAS items score at the two subsequent assessments and (3) linear regression was conducted to identify POSAS items as independent predictors. Additionally, reliability, construct validity and interpretability were assessed.nnnRESULTSnA total of 141 patients were included with a mean TBSA burned of 5.2% (±4.5). The ability of the Patient scale to discriminate between good and reduced long term scar quality was adequate with an area under the curve (AUC) of 0.728 (CI 0.640-0.804), the ability of the Observer scale was good with an AUC of 0.854 (CI 0.781-0.911). Correlations between items scored T3 and T>18 were at least adequate. On item level, pain and stiffness (Patient) and pliability and relief (Observer) were identified as significant predictors for reduced long term scar quality. The POSAS was reliable, construct validity was adequate at three months but declined at >18 months.nnnCONCLUSIONnThis study found that final scar quality can be adequately predicted by an early POSAS assessment at three months.