Satisfaction with life after burn: A Burn Model System National Database Study.

OBJECTIVES: While mortality rates after burn are low, physical and psychosocial impairments are common. Clinical research is focusing on reducing morbidity and optimizing quality of life. This study examines self-reported Satisfaction With Life Scale scores in a longitudinal, multicenter cohort of survivors of major burns. Risk factors associated with Satisfaction With Life Scale scores are identified. METHODS: Data from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Burn Model System (BMS) database for burn survivors greater than 9 years of age, from 1994 to 2014, were analyzed. Demographic and medical data were collected on each subject. The primary outcome measures were the individual items and total Satisfaction With Life Scale (SWLS) scores at time of hospital discharge (pre-burn recall period) and 6, 12, and 24 months after burn. The SWLS is a validated 5-item instrument with items rated on a 1-7 Likert scale. The differences in scores over time were determined and scores for burn survivors were also compared to a non-burn, healthy population. Step-wise regression analysis was performed to determine predictors of SWLS scores at different time intervals. RESULTS: The SWLS was completed at time of discharge (1129 patients), 6 months after burn (1231 patients), 12 months after burn (1123 patients), and 24 months after burn (959 patients). There were no statistically significant differences between these groups in terms of medical or injury demographics. The majority of the population was Caucasian (62.9%) and male (72.6%), with a mean TBSA burned of 22.3%. Mean total SWLS scores for burn survivors were unchanged and significantly below that of a non-burn population at all examined time points after burn. Although the mean SWLS score was unchanged over time, a large number of subjects demonstrated improvement or decrement of at least one SWLS category. Gender, TBSA burned, LOS, and school status were associated with SWLS scores at 6 months; scores at 12 months were associated with LOS, school status, and amputation; scores at 24 months were associated with LOS, school status, and drug abuse. CONCLUSIONS: In this large, longitudinal, multicenter cohort of burn survivors, satisfaction with life after burn was consistently lower than that of non-burn norms. Furthermore mean SWLS scores did not improve over the two-year follow-up period. This study demonstrates the need for continued efforts to improve patient-centered long term satisfaction with life after burn.

The rehabilitation/school matrix: a model for accommodating the noncompliant child with severe burns.

Some children with severe burns may have difficulty following therapeutic recommendations after discharge from a burn center. Noncompliance may result in complications that affect function, surgical management, community reintegration, and successful reentry into school. We present a case study in which a child with significant compliance issues was managed in a coordinated interdisciplinary model. This model extended from acute recovery through reintegration into the classroom. A behavior-modification program was implemented across different levels of care. Educational reentry was facilitated by including a transitional period in a special-needs classroom in a freestanding special-needs school. Requirements for using educational resources to which some children are legally entitled are reviewed. Rehabilitation services that interface with the educational system for children with burns may improve outcomes as these children reintegrate into the community.

Coping with the stress of a painful medical procedure.

To evaluate its effect on procedure-related distress, the focus of attention was manipulated by providing training to hospitalized acute burn patients (n=42). Participants were randomly assigned to attention focusing (i.e. attending to procedural sensations) or music distraction (i.e. attention diverting) coping interventions, or to usual care during the target dressing change. Coping behavior (i.e. distraction, focusing, and three confounding methods, ignoring, catastrophizing, reinterpreting), tension and intrusiveness were evaluated 24 h retrospectively (i.e. for the prior procedure), during the targeted procedure, and 30 min after the target procedure. When coping during the target procedure by ignoring, reinterpreting, and catastrophizing were covaried, the music distraction group experienced significantly fewer intrusions, and the attention focus group had more intrusions. Additionally, secondary analyses revealed that coping by ignoring during the prior day's procedure significantly predicted higher procedural tension during, and more intrusions following, the targeted procedure. Suppression-based forms of emotion-focused coping may be enhanced by training in the use of an explicit distractor.

Even minimal symptoms of depression increase mortality risk after acute myocardial infarction.

Mild to moderate levels of depressive symptoms as characterized by Beck Depression Inventory (BDI) scores of > or =10 are associated with decreased survival after acute myocardial infarction (AMI). We investigated whether lower levels of depressive symptoms are also associated with increased mortality risk after AMI. We prospectively studied 285 patients with AMI who survived to discharge for evidence, at the time of hospitalization, of a DSM-IIIR mood disorder (using a structured clinical interview) and for symptoms of depression (using the BDI). The overall mortality rate at 4 months was 6.7%. Multiple logistic regression (chi-square 35.79, p < or =0.001) revealed that the independent predictors of mortality were: age > or =65 years, left ventricular ejection fraction <35%, diabetes mellitus, and any depression (DSM-IIIR mood disorder or BDI > or =10) present at the time of AMI. Among patients > or =65 years old with left ventricular ejection fraction <35%, the 4-month mortality was 12%. However, in this same group, those with any depression at the time of AMI had a 4-month mortality of 50% (relative risk 4.1, p = 0.01). Among patients aged > or =65 years, the mortality according to BDI scale grouping 0 to 3, 4 to 9, and 10+ was 2.6%, 17.1%, and 23.3%, respectively (p <0.002). Highest mortality rates were observed in patients with most severe depressive symptoms. However, compared with those without depression, higher mortality was also observed at very low levels of depressive symptoms (BDI 4 to 9) not generally considered clinically significant and below the level usually considered predictive of increased post-AMI mortality.

Brief cognitive interventions for burn pain.

This study tested the efficacy of 2 brief cognitive interventions in supplementing regular medical treatment for pain during burn dressing change. Forty-two burn inpatients were randomly assigned to 3 groups: sensory focusing, music distraction, and usual care. Patients reported pain, pain relief satisfaction with pain control, and pain coping strategies. The sensory focusing group reported greater pain relief compared to the music distraction group and a reduction in remembered pain compared to the usual care group, although group differences were not observed on serial pain ratings. In addition, after controlling for burn size and relevant covariates, regression analyses indicated that catastrophizing predicted pain, memory for pain, and satisfaction with pain control. Refinement of the sensory focusing intervention is warranted to reduce catastrophic thinking and improve pain relief

Barriers to employment among working-aged patients with major burn injury.

The purpose of this study was to examine the prevalence of preexisting and burn-related impairments and to describe their association with preburn employment status. Data gathered during the acute hospitalization were analyzed on a consecutive series of burn patients aged 16 to 64 years (N = 770) enrolled in a prospective, longitudinal, multicenter study. Patients who were unemployed before the injury were more likely than those who were employed to report being alcohol-dependent (36 vs 18%), abusing other drugs (22 vs 10%), having received psychiatric treatment in the past year (21 vs 6%), and having preexisting physical disability (23 vs 3%); all were significant at P < .001). Of the unemployed patients who received toxicologic screening at admission, 49% tested positive for alcohol and 39% positive for other drugs, percentages that were significantly higher than 26 and 31%, respectively, for the employed. With adjustment for age, sex, race, and education, variables that were most predictive of preinjury unemployment status were preexisting physical disability (odds ratio, 51.0; 95% confidence interval, 7.7-336.9) and being alcohol-positive at admission (odds ratio, 2.8; 95% confidence interval, 1.2-6.8). Unemployed and employed patients also differed significantly in injury patterns and clinical outcomes, with inhalation injury and psychiatric distress being more prevalent among the unemployed and both hand burns and hand surgery among the employed. The greater prevalence of preexisting impairments among survivors who were unemployed before the injury helps explain why preburn employment status is such a powerful determinant of postburn work outcomes, and suggests the need to include psychosocial services in a program of comprehensive rehabilitation.

Personality predictors of injury-related posttraumatic stress disorder.

This longitudinal, cohort study examined the effect of personality traits on the emergence of posttraumatic stress disorder (PTSD) in a recently traumatized, civilian, mixed-gender sample with significant injuries. Burn survivors (N = 70) were administered the NEO-Personality Inventory (NEO-PI) and the Structured Clinical Interview for DSM III-R (SCID) at hospital discharge and readministered the SCID 4 and 12 months later. Overall, the sample of burn survivors scored significantly higher on neuroticism and extraversion and lower on openness, agreeableness, and conscientiousness relative to a normative national sample. Furthermore, multivariate analysis of variance revealed that PTSD symptom severity groups (i.e., single symptom, multiple symptoms, subthreshold PTSD, PTSD) were differentially related to neuroticism and extraversion. Planned comparisons indicated that neuroticism was higher and extraversion was lower in those who developed PTSD compared with those who did not develop PTSD.

Effect of early body image dissatisfaction on subsequent psychological and physical adjustment after disfiguring injury.

OBJECTIVE: The impact of body image dissatisfaction on quality of life after severe burn injury was investigated after controlling for other determinants of outcome (i.e., injury, distress, and preburn quality of life). METHODS: The postburn quality of life (2-months postdischarge) of groups with and without body image dissatisfaction was studied after controlling for preburn quality of life (measured 2-3 days postadmission). The patient population (N = 86) was 77.9% men, had an average total body surface area burned of 17.02%, and average full-thickness burn of 6.09%. Forty percent had facial injuries, 68.6% required surgery, most were injured by flame (39.5%), and 76.8% were employed. RESULTS: Multivariate analysis of covariance (covarying preburn level of Mental quality of life, facial injury, and size of burn) contrasting body image dissatisfaction groups found significantly lower psychosocial adjustment at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 3.61; p<.01). A second MANCOVA (covarying the preburn level of Physical quality of life and both facial injury and size of burn) found significantly lower physical functioning at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 2.78; p < .03). Adding two more covariates (depression and posttrauma distress) eliminated the effect of body image dissatisfaction on postburn Physical but not Mental adjustment. CONCLUSIONS: Body image dissatisfaction affects quality of life after severe burn injury. Distress moderates this impact on aspects of physical but not psychosocial health.

Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction.

BACKGROUND: Patients with depression are at greater risk of cardiac death in the first few months after a myocardial infarction (MI). This study was performed to determine whether depression affects adherence to recommendations intended to reduce the risk of cardiac events after an MI. METHODS: All consenting patients admitted to a university-affiliated teaching hospital during an 18-month period were interviewed 3 to 5 days following an acute MI using the Beck Depression Inventory to assess symptoms of depression and using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, to determine the presence of major depression and/or dysthymia. Accessible survivors (n=204; 116 men and 88 women) were interviewed by telephone 4 months later using the Medical Outcomes Study Specific Adherence Scale to measure self-reported adherence to recommendations to modify cardiac risk. RESULTS: Patients who were found in the hospital to have symptoms of at least mild to moderate depression (Beck Depression Inventory score > or =10, n=35 [17.2%]) or to have major depression and/or dysthymia (n=31 [15.2%]) reported lower adherence to a low-fat diet, regular exercise, reducing stress, and increasing social support 4 months later. Those with major depression and/or dysthymia also reported taking medications as prescribed less often than those without major depression and/or dysthymia. Diabetic patients with major depression and/or dysthymia were less likely to follow a diet for patients with diabetes than diabetic patients without depression. CONCLUSIONS: Patients with depression following an acute MI are less likely to adhere to recommended behavior and lifestyle changes intended to reduce the risk of subsequent cardiac events. This finding could explain why depression in the hospital is related to long-term prognosis in patients recovering from an MI.

The 2000 Clinical Research Award. Describing and predicting distress and satisfaction with life for burn survivors.

We investigated ratings of emotional distress and satisfaction with life at discharge from the hospital and at a 6-month follow-up in a multisite sample of 295 adults hospitalized for the care of a major burn injury. Several psychosocial variables (history of alcohol abuse, marital status, and previous mental health) and some medical variables (days of intensive care, pulmonary complications, and hand burns) accounted for significant variance in the prediction of outcomes. Brief Symptom Inventory (distress) scores were higher and Satisfaction With Life Scale scores were significantly lower than those of a normative population at both measurement points. The results show the utility of biosocial models in which psychological and physical variables interact to influence adjustment and quality of life.

Prolonged adjustment difficulties among those with acute posttrauma distress following burn injury.

This study examined the impact of mild to moderate symptoms of in-hospital posttrauma distress (PTD) following severe burn injury on quality of life (QOL) at 2-month follow-up after controlling for preburn QOL, injury severity, and state Negative Affectivity (depression, body image dissatisfaction) and dispositional optimism-pessimism. Participants' (n = 86) self-report established PTD and non-PTD groups (median split on Davidson Trauma Scale). After covarying preburn level of psychosocial QOL, PTD groups differed on psychosocial functioning at follow-up. This effect remained after covarying injury severity, state NA, dispositional optimism-pessimism, and preburn Mental domain QOL. PTD groups also differed significantly on physical functioning at follow-up after covarying preburn physical functional status. This effect was removed by controlling preburn Physical domain QOL and either injury severity or state NA and dispositional optimism-pessimism. Therefore, PTD is related to significant impairments in the physical and psychosocial adjustment of survivors of severe burns regardless of pretrauma level of adjustment. Injury severity and state NA and dispositional optimism-pessimism moderate the impact of PTD on physical but not psychosocial adjustment.

Work status and attrition from longitudinal studies are influenced by psychiatric disorder.

Participants (n=95) were assessed at the time of discharge and at 4 and 12 months after discharge in regard to work status and psychiatric history both before and after the burn injury. Complex psychiatric comorbidity and substance abuse disorders that occurred before the burn injury each significantly raised the risk of unemployment before the burn injury; preburn substance abuse also affected unemployment at 4 months after the burn injury. Trends for higher unemployment rates at 12 months after discharge also were noted among those with a preburn history of complex psychiatric comorbidity and alcohol use, anxiety, or mood disorder. Preburn substance-use disorder raised the risk of attrition from the 12-month study; whereas, those diagnosed at the time of discharge with post-traumatic stress disorder or with two or more current psychiatric disorders after the burn injury dropped out less often. The greater risk for unemployment and attrition observed among subjects with psychiatric disorders before the burn injury suggests the need for routine screening, tracking, and assistance in accessing supportive or rehabilitative services to remove barriers to employment.

Preburn psychiatric history affects posttrauma morbidity.

A sample of inpatient, burn-injured adults (N = 95) were assessed upon discharge, and 4 and 12 months later with a structured interview and DSM-III-R criteria. The prevalence of disorder in this sample was contrasted with published data on a representative national community-dwelling comparison group in the National Comorbidity Study. The prevalence of lifetime affective, alcohol, and substance use disorders was significantly higher, and lifetime anxiety disorders significantly lower, in the burn-injured sample. The 12-month postburn prevalences of alcohol, and substance use disorders were significantly greater in the burn-injured sample. The risk of postburn disorder was significantly greater for the subjects who had a preburn history of affective, alcohol, or substance use disorder. The risk for developing posttraumatic stress disorder (PTSD) was elevated in the subjects with a preburn affective disorder but not preburn anxiety disorder. Finally, postburn PTSD was associated with a greater length of stay, and greater preburn comorbidity predicted preburn employment status and tended to lengthen hospitalization.

Psychologic factors involved in the decision to undergo reconstructive surgery after burn injury.

Burn injuries often result in permanent changes in physical appearance and function. Although reconstructive surgery is often considered to improve function or physical appearance, or a combination, variables that may predict use of surgery are relatively unknown. Burn survivors (N = 46; 48% male) were assessed at an evaluation for potential reconstructive surgery. Measures of adjustment, distress, and personality were administered. Several psychologic and demographic variables differed among those who did versus those who did not subsequently undergo surgery. Social, sexual, and family relationships were poorer among those who later used surgery, and surgery patients had higher scores on somatization. Subjects who had not returned to work, and individuals with private insurance or managed care, were significantly less likely to follow-up with reconstructive surgery. Contrary to hypothesized results, indexes of burn severity and the injury location were not significantly different between the two groups. Results suggest that interventions designed to aid adjustment after injury may result in the best surgical candidates completing reconstruction.

Preinjury psychiatric illness and postinjury adjustment in adult burn survivors.

The impact of preinjury DSM-III-R anxiety, mood, and alcohol and substance abuse disorders, determined by using the Structured Clinical Interview for DSM-III-R, nonpatient version (SCID-NP), on postinjury adjustment was examined prospectively in a consecutive series of 98 adult patients admitted to a regional burn center and followed for 1 year. The subjects were grouped according to SCID diagnoses: 1) any preburn mood and/or anxiety diagnosis; 2) preburn alcohol abuse or dependence diagnosis; or 3) any preburn diagnosis (i.e., any of the above diagnoses). These groups showed greater impairment in many functional domains at discharge than the subjects who had no preburn disorder. By 4 months postinjury, the "no diagnosis" and the preburn diagnosis groups had comparable levels of adjustment, and this comparability was maintained at the 1-year follow-up. Similarly, trait neuroticism had an early negative impact on adjustment, while trait extroversion had both an early and late positive effect on adjustment.

Development and utilization of a psychometric instrument for measuring quality of life in burn patients, 1976 to 1996.

Our Burn Specific Health Scale was initially developed in 1978. Using a number of existing health scales, including the sickness impact profile, a depression scale, and the activities of daily living scale, and a large number of burn specific items derived from staff and patients, we eventually developed an 80 item instrument. This instrument was divided into four domains each containing 20 items of equal weight. The instrument was validated sequentially with intrarater, interrater and global validation systems, and subsequently compared with a number of other health and mental scales during which it performed very well. We now have longitudinal data which link this measurement system of quality of life to pre-injury educational level, to post-injury, stress disorder and predictability of return to work. The results indicate that total burn size has little to do with quality of life after recovery, and that a number of other factors play a bigger role, which will be presented.