Towards the Holistic Assessment of Scar Management Interventions
Evan Ross
Round 1
Reviewer 1 Report
Thank you for inviting me to review this paper. I am a strong advocate of qualitative research and its value in identifying areas of importance for patients - this is the basic tenant of this commentary, ie that widely used scar assessment tools do not necessarily assess the aspects that are most relevant to patients and there is a need to ensure that scar evaluation and evaluations of scar interventions are patient-centred. I am therefore very supportive of the arguments made in this article and would like to see this paper published.
The author makes a strong argument for the need for evaluation of scar interventions to be patient-centred, and refer to the more widely used measures in burns.
Its good to see consideration of the need to clearly define and conceptualise psychosocial adaption. I think this section could be expanded slightly, to explain to readers less familiar with the literature in this area what the challenges are, e.g. the complexity of the issues involved, the variety of terminology used (adaptation? adjustment? adjustment/adaptation to what, exactly?)
One important aspect that warrants further attention in this piece is the issue of proxy assessment, for example parent reports of children's adaptation and assessment of children's scars. I think readers would find it useful if the author were to add a paragraph considering the advantages, limitations and use of proxy measures in this context, and identify which of the widely used scales have proxy versions available. This is especially relevant given the number of paediatric burns and the extent of paediatric burns research and clinical interventions.
Finally, two minor points:
line 67 - this should end with a colon, not a full stop
line 78 CARE should be CARe, and this is a PROM of burns broadly not just of scars (it can be used in the wound healing stage, prior to a scar). This would benefit from clarification.
Author Response
Reviewer 1 – response to comments
Comment: Thank you for inviting me to review this paper. I am a strong advocate of qualitative research and its value in identifying areas of importance for patients - this is the basic tenant of this commentary, ie that widely used scar assessment tools do not necessarily assess the aspects that are most relevant to patients and there is a need to ensure that scar evaluation and evaluations of scar interventions are patient-centred. I am therefore very supportive of the arguments made in this article and would like to see this paper published.
The author makes a strong argument for the need for evaluation of scar interventions to be patient-centred, and refer to the more widely used measures in burns.
Response: thank you for your kind words.
Comment: It’s good to see consideration of the need to clearly define and conceptualise psychosocial adaption. I think this section could be expanded slightly, to explain to readers less familiar with the literature in this area what the challenges are, e.g. the complexity of the issues involved, the variety of terminology used (adaptation? adjustment? adjustment/adaptation to what, exactly?)
Response: I have added some further detail and references related to psychosocial adaptation in this section. I have tried to keep this brief to maintain the flow of the piece.
Comment: One important aspect that warrants further attention in this piece is the issue of proxy assessment, for example parent reports of children's adaptation and assessment of children's scars. I think readers would find it useful if the author were to add a paragraph considering the advantages, limitations and use of proxy measures in this context, and identify which of the widely used scales have proxy versions available. This is especially relevant given the number of paediatric burns and the extent of paediatric burns research and clinical interventions.
Response: Many thanks for this comment. I agree this is a crucial point. Rather than try to provide a comprehensive overview of this issue in this brief piece, which was not necessarily the intention, I have amended the second paragraph at the end of the “what is required” section to make note of the importance of this point. I think there is scope for an up-to-date review of measures, patient-centred conceptualisations etc. but this is not the intention of this piece.
Comment: Finally, two minor points:
line 67 - this should end with a colon, not a full stop
Response: I have amended this.
Comment: line 78 CARE should be CARe, and this is a PROM of burns broadly not just of scars (it can be used in the wound healing stage, prior to a scar). This would benefit from clarification.
Response: I have amended this and changed the sentence to read “the scar-specific quality of life tool the BBSIP” to make clear that I am not terming CARe as scar-specific.
Reviewer 2 Report
As a strong proponent of psychosocial measurement and quality of life issues in burn recovery, I am very much in agreement with the author as to the need for holistic assessment of the effect of scarring. This is a well thought out and clearly articulated call to increase the attention paid to quality of life issues relevant to the burn patient, with an emphasis on methodological standardization.
Author Response
Reviewer 2 – Response to comments
As a strong proponent of psychosocial measurement and quality of life issues in burn recovery, I am very much in agreement with the author as to the need for holistic assessment of the effect of scarring. This is a well thought out and clearly articulated call to increase the attention paid to quality of life issues relevant to the burn patient, with an emphasis on methodological standardization.
Response: thank you for your kind words.
Reviewer 3 Report
The commentary is short and concise and addressed important patient issues towards scar management in general.
The overall message is well documented and there are some minor areas, which could be improved for message flow.
Minor corrections:
Line 10: whether and how burn or scar-related quality-of-life measures could be included….
Line 14: the end of the phrase could be changed to -…. And psychosocial adaptation along with an associated assessment.
Lines 14-16: The phrase could be presented with more emphasis: In order to ensure that future evidence-based decisions are made in a patient-centred manner, uniform and standardized protocols would benefit a holistic evaluation of scar management interventions.
Keywords: the single word assessment could be changed to “scar assessment”. Treatment burden could be changed to “scar treatment experience”.
Line 20: The issue could be changed to “Scar Management Issue and Consensus”
Lines 24-25 could come before Lines 22-23
Line 24: At present, clinical research….
Line 23: Consensus is needed regarding what to assess in clinical research studies, which tools and measures to use, and establish what time points are critical.
Line 41: In a UK interview study, (comma)
Line 48: showed and not shows and was not is. (past tense for the review)
Line 54: impact and not impacts
Line 60: Proposition instead of What is required- Optimization of patient-centred scar management
Line 62: comma after 2020,
Line 62: instead of repeating debate, a suggestion of …called for open discussion regarding….
Line 63: delete space after burns, suggesting
Lines 64, 66, 68, 72, 77, 83, 103, 117: quality-of-life
Line 67: I suggest to put a colon after "include", and then list the proposals in this way ((1)Whether health.....(page 68). (2) Secondly....(page 82). (3) Thirdly....(page 94). (4) Finally....(page 107))
Line 68: the phrase seems to be incomplete as written. Propose- It could firstly be questioned whether health or scar-related quality-of-life…..
Line 71: a comma after PGT,
Line 74: …clinical research assessment
Line 75: Currently, (with a comma)
Line 82: At present,… (with a comma)
Line 86: emerging clinical research field
Line 89: eliminate one ) after 20))
Line 90: delete space before Perharps…
Line 95: focus of further clinical research…
Line 100: Propose non-specific instead of “ slippery”
Line 101: delete space before In…
Line 102: Comma after In health research,
Line 102: delete space before Presently,…
Line 102: comma after Presently,
Line 105: comma after Recently,
Line 107; comma after Finally,
Line 110: comma after settings,
Line 111: follow-up
Lines 112-113: delete space before Participants…
Line 113: in this clinical research
Line 114: a short definition of BBSIP and e-PROMs would be useful along with a couple of phrases on these tools.
Line 114: delete space before This finding…
Line 118: follow-up
Line 118: Proposition- …a further open discussion and planning would be beneficial concerning the holistic evaluation of scar management interventions to ensure that future….
Author Response
Reviewer 3 - Response to comments
The commentary is short and concise and addressed important patient issues towards scar management in general.
The overall message is well documented and there are some minor areas, which could be improved for message flow.
Response: thank you for your kind words.
Minor corrections:
Line 10: whether and how burn or scar-related quality-of-life measures could be included….
Line 14: the end of the phrase could be changed to -…. And psychosocial adaptation along with an associated assessment.
Lines 14-16: The phrase could be presented with more emphasis: In order to ensure that future evidence-based decisions are made in a patient-centred manner, uniform and standardized protocols would benefit a holistic evaluation of scar management interventions.
Keywords: the single word assessment could be changed to “scar assessment”. Treatment burden could be changed to “scar treatment experience”.
Line 20: The issue could be changed to “Scar Management Issue and Consensus”
Lines 24-25 could come before Lines 22-23
Line 24: At present, clinical research….
Line 23: Consensus is needed regarding what to assess in clinical research studies, which tools and measures to use, and establish what time points are critical.
Line 41: In a UK interview study, (comma)
Line 48: showed and not shows and was not is. (past tense for the review)
Line 54: impact and not impacts
Line 60: Proposition instead of What is required- Optimization of patient-centred scar management
Line 62: comma after 2020,
Line 62: instead of repeating debate, a suggestion of …called for open discussion regarding….
Line 63: delete space after burns, suggesting
Lines 64, 66, 68, 72, 77, 83, 103, 117: quality-of-life
Line 67: I suggest to put a colon after "include", and then list the proposals in this way ((1)Whether health.....(page 68). (2) Secondly....(page 82). (3) Thirdly....(page 94). (4) Finally....(page 107))
Line 68: the phrase seems to be incomplete as written. Propose- It could firstly be questioned whether health or scar-related quality-of-life…..
Line 71: a comma after PGT,
Line 74: …clinical research assessment
Line 75: Currently, (with a comma)
Line 82: At present,… (with a comma)
Line 86: emerging clinical research field
Line 89: eliminate one ) after 20))
Line 90: delete space before Perharps…
Line 95: focus of further clinical research…
Line 100: Propose non-specific instead of “ slippery”
Line 101: delete space before In…
Line 102: Comma after In health research,
Line 102: delete space before Presently,…
Line 102: comma after Presently,
Line 105: comma after Recently,
Line 107; comma after Finally,
Line 110: comma after settings,
Line 111: follow-up
Lines 112-113: delete space before Participants…
Line 113: in this clinical research
Line 114: a short definition of BBSIP and e-PROMs would be useful along with a couple of phrases on these tools.
Line 114: delete space before This finding…
Line 118: follow-up
Line 118: Proposition- …a further open discussion and planning would be beneficial concerning the holistic evaluation of scar management interventions to ensure that future….
Response: Many thanks for your comprehensive review of the manuscript. I have adopted the majority of the suggested changes in the revised manuscript.
Reviewer 4 Report
This is a useful commentary which provides a valuable overview of the literature on scar management and quality of life. The only substantive issue that I would raise is that the perspective seems to be firmly UK-centric (or perhaps at most within other English-speaking countries), which is surprising for a journal with of an international character. Perhaps this is reflective of the state of the literature, but it would still be useful to comment on any cross-national or cross-cultural perspectives that might be relevant in this case.
Author Response
Reviewer 4 - Response to comments
This is a useful commentary which provides a valuable overview of the literature on scar management and quality of life. The only substantive issue that I would raise is that the perspective seems to be firmly UK-centric (or perhaps at most within other English-speaking countries), which is surprising for a journal with of an international character. Perhaps this is reflective of the state of the literature, but it would still be useful to comment on any cross-national or cross-cultural perspectives that might be relevant in this case.
Response: Many thanks for the kinds words. I think to an extent this is reflective of the literature at the moment and the development of tools in English-speaking countries. However, some of the patient-centred concepts do cross cut qualitative research in different national and cultural settings. I have added a note to this effect and also added a sentence (lines 83-85) to further emphasise this important point.
