Functional Recovery and Emotional Burden After Burn Injury: A Quality of Life Assessment in Romanian Burn Survivors

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Revised Review Report

The authors present an interesting and clinically relevant manuscript addressing functional recovery and emotional burden after burn injury in a Romanian cohort. However, several points require clarification and refinement to improve scientific accuracy, consistency, and reporting quality.

1. The main question addressed by the research

The manuscript addresses the long-term functional and emotional consequences after burn injury, with specific emphasis on post-traumatic quality of life outcomes in burn survivors. Overall, the conclusions provide a reasonably accurate overview of the post-burn trajectory and highlight the importance of long-term multidisciplinary follow-up.

2. The topic

The topic is relevant and clinically important. As correctly stated by the authors, there is an increasing need for multidisciplinary follow-up after burn injury, including psychological and social support. The manuscript also fits within the growing interest in PROM-based evaluation after burns.

However, the scope of the study requires clearer definition. Since 94.74% of burns in the cohort were thermal burns, the authors should explicitly define the study population as predominantly thermal burn patients and clarify the generalizability of the findings to other burn etiologies.

3. This work compared with existing literature

The manuscript contributes to the increasing body of literature emphasizing the importance of PROMs in long-term burn follow-up.

4. Specific methodological improvements

Several methodological aspects require further clarification. The eligibility criteria are currently too broad and should be more clearly specified. The authors should clarify whether all age groups or only adults were included, whether all burn types were eligible or whether the cohort mainly consisted of thermal burns, and whether both conservatively and surgically treated patients were included. These clarifications are essential for reproducibility and interpretation of the results.

In addition, the rationale behind the selected study period should be better explained. The authors should clarify why patients treated between January 2022 and December 2023 were selected and why the questionnaires were specifically administered between February and March 2026. This timing introduces heterogeneity in follow-up duration, which may significantly influence quality-of-life outcomes.

The manuscript also lacks important information regarding surgical treatment. Data concerning the number of surgical procedures and the type of surgery performed (e.g. grafting or reconstructive procedures) should be included, given the known impact of surgery on functional and psychological recovery after burns.

5. The conclusions

The conclusions are generally in line with the presented data and adequately reflect the observed discrepancy between functional and emotional recovery after burn injury.

There are several points still require improvement.

In the abstract, the terminology should be simplified and standardized. The term “female gender patients” should be replaced by “women” to improve readability and consistency with standard scientific writing.

Furthermore, the sentence stating that depressive symptoms were significantly associated with functional limitations, work impairment, and sexual difficulties should also include p-values for consistency with the other statistical results presented in the abstract.

The introduction would also benefit from refinement. The current definition of burns is incomplete because it does not include cold-induced injuries such as frostbite. The authors should either use a WHO-based definition, clearly state that the manuscript specifically concerns thermal burns, or expand the definition to include cold injuries.

6. 6. The references

The references are generally appropriate, relevant, and sufficiently up to date for the topic addressed.

7. 7. Additional comments regarding tables and figures

Several improvements regarding data presentation are recommended. The statement that male patients were significantly younger than female patients should preferably be integrated into Table 1, together with the mean age per gender and corresponding p-value, rather than repeated extensively in the text.

In addition, the readability of the figures should be improved. Figures 1 and 2 would benefit from the addition of percentage labels within the bar segments to improve interpretability. Figure 3 should include clearer percentage values per gender together with direct statistical annotations and p-values. Figure 4 would benefit from displaying both absolute numbers and percentages directly on the graph, particularly because comparisons between second- and third-degree burns are central to the manuscript. Similarly, Figure 5 should include percentages, n-values, and clearer statistical comparison indicators.

Comments on the Quality of English Language

Can be improved

Author Response

Dear reviewer,

We would like to thank you for your careful evaluation of our manuscript. We are grateful for the insightful comments and constructive suggestions, which have substantially improved the clarity, structure and methodological transparency of the manuscript. Please find attached a point-by-point response and the revised manuscript, with responses to in green highlight.

Kind regards

Maria Marinescu MD PhD

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The study examined functional recovery and emotional burden among burn survivors in Romania.

It would be helpful to provide a more detailed description of the Burn Specific Health Scale–Brief (BSHS-B), including the translation and cultural adaptation procedures. Please clarify how the translation was conducted, the number of items within each domain, and which items or domains were included in the present study.

For the exploratory factor analysis (EFA), please specify whether Pearson or polychoric correlations were used and provide justification for the chosen approach. In addition, the sample size of 38 appears relatively small for conducting EFA; therefore, further justification for sample adequacy is needed. Reporting the factor loadings after Varimax rotation would also strengthen the manuscript. Please clarify how the final two-factor structure (function and emotion/sexuality) was determined.

The manuscript would also benefit from reporting ceiling and floor effects at the scale level.

In addition, the paper reports numerous correlations among items, scales, and demographic variables. It would be helpful to clearly state the a priori hypotheses underlying these analyses. Please also clarify how many statistical tests were conducted and whether any adjustment for multiple comparisons was applied. Currently, the analyses appear somewhat exploratory and selective. A more structured and hypothesis-driven analytical framework would strengthen the paper.

       

Author Response

Dear reviewer,

We would like to thank you for your careful evaluation of our manuscript. We are grateful for the insightful comments and constructive suggestions, which have substantially improved the clarity, structure and methodological transparency of the manuscript. Please find attached a point-by-point response and the revised manuscript, with responses in red highlight.

Kind regards

Maria Marinescu MD PhD

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review your manuscript titled “Functional Recovery and Emotional Burden After Burn Injury: A Quality of Life Assessment in Romanian Burn Survivors”. The manuscript addresses an important and clinically relevant topic, namely the long-term functional and emotional consequences of burn injury. The study contributes data from Eastern Europe, a region where evidence on burn-related quality of life remains limited, and the use of the BSHS-B questionnaire in a Romanian cohort is potentially valuable. The manuscript is generally well written, clinically coherent, and supported by an extensive literature review. However, several methodological and reporting issues substantially limit the robustness and interpretability of the findings.

-Study design and representativeness:

The study includes only 38 participants out of 147 eligible burn survivors contacted. This corresponds to a low response rate and raises substantial concerns regarding selection bias and representativeness. The authors should explicitly report the response rate as a percentage and discuss the potential impact of non-response bias.

-Psychometric validation of the Romanian BSHS-B is insufficient

The manuscript states that the BSHS-B has not been previously validated in Romanian and reports preliminary psychometric analyses. However, the validation process is incomplete and methodologically insufficient for claiming applicability in a Romanian population. You can read the reference:

Cruchinho, P., López-Franco, M. D., Capelas, M. L., Almeida, S., Bennett, P. M., Miranda da Silva, M., Teixeira, G., Nunes, E., Lucas, P., Gaspar, F., & Handovers4SafeCare (2024). Translation, Cross-Cultural Adaptation, and Validation of Measurement Instruments: A Practical Guideline for Novice Researchers. Journal of Multidisciplinary Healthcare, 17, 2701–2728. https://doi.org/10.2147/JMDH.S419714

The current sample size (n=38) is also extremely limited for exploratory factor analysis involving 33 items. The adequacy of factor analysis should therefore be interpreted very cautiously. The authors should substantially temper statements regarding validation and instead frame this as a preliminary exploratory application of the instrument.

-Statistical concerns and multiple comparisons

A large number of inferential statistical tests were performed on a very small sample. The manuscript reports multiple chi-square analyses, Kendall tau correlations, subgroup analyses, and cross-tabulations. This raises several concerns as increased risk of type I error, sparse contingency tables with expected cell counts likely below acceptable thresholds, limited statistical power and overinterpretation of statistically significant findings. The authors should report whether assumptions for chi-square testing were met. Consider Fisher’s exact test where appropriate. Clarify whether corrections for multiple testing were considered. Reduce the number of subgroup analyses or clearly define them as exploratory and avoid causal or overly strong interpretive language.

The manuscript currently presents several associations as clinically meaningful despite extremely small subgroup cell sizes.

-Timing of assessment is unclear and heterogeneous

The study included burns occurring between January 2022 and December 2023, while questionnaires were administered in February–March 2026. This means follow-up duration varies substantially between participants. However no median follow-up duration is reported, no stratification by follow-up interval is provided and no analysis examines whether emotional or functional outcomes differed according to time since injury. This issue is highly important because QoL trajectories after burns are time-dependent.

The authors should report follow-up duration explicitly, provide mean/median time since burn, discuss heterogeneity of recovery periods and consider including follow-up duration in analyses.

-Sexuality domain interpretation is weak

The sexual domain analysis is based on a single item and appears underdeveloped. Furthermore possible underreporting is acknowledged, age distribution is relatively high (mean >55 years) and relationship status and sexual activity baseline are unknown. Interpretation should therefore be substantially toned down.

The manuscript has potential value if methodological limitations are more transparently acknowledged and interpretations are moderated accordingly.

Author Response

Dear reviewer,

We would like to thank you for your careful evaluation of our manuscript. We are grateful for the insightful comments and constructive suggestions, which have substantially improved the clarity, structure and methodological transparency of the manuscript. Please find attached a point-by-point response and the revised manuscript, with responses in blue highlight.

Kind regards

Maria Marinescu MD PhD

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors are to be congratulated for carefully addressing the reviewers’ comments and implementing the suggested revisions.

I believe the manuscript has improved significantly in quality and I can recommend it for publication.

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

The authors addessed all my comments.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have meticulously made improvements to the manuscript in response to the requests made.