Cognitive Behavioral Treatment for Acute Posttrauma Distress: A Randomized, Controlled Proof-of-Concept Study Among Hospitalized Adults With Burns.

OBJECTIVE: (1) To evaluate the feasibility of conducting a randomized controlled trial (RCT) of the Safety, Meaning, Activation and Resilience Training (SMART) intervention vs nondirective supportive psychotherapy (NDSP) in an acutely hospitalized adult survivor of burn injury sample; and (2) to assess the preliminary effect of SMART on acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD) symptom reduction as secondary prevention. DESIGN: Proof-of-concept, parallel group RCT design. SETTING: Regional burn center. PARTICIPANTS: Acutely injured, hospitalized adult survivors of burn injury (N=50) were randomly assigned to SMART (n=28) or nondirective supportive psychotherapy (n=22). Due to dropout and missing data, final sample size was 40, SMART (n=21) and nondirective supportive psychotherapy (n=19). INTERVENTIONS: SMART is a manualized, 4-session cognitive behavioral therapy-based psychological intervention targeting ASD, PTSD, and MDD symptoms. NDSP is a manualized, 4-session protocol. MAIN OUTCOME MEASURES: Davidson Trauma Scale ([DTS]; diagnostic proxy for ASD and PTSD; clinical cutoff=40, with higher score=higher severity) and the Patient Health Questionnaire-9 ([PHQ-9]; diagnostic proxy for MDD; clinical cutoff=10, with higher score=higher severity) at pretreatment, immediate posttreatment, and 1 month posttreatment. RESULTS: At baseline, median DTS scores and PHQ-9 scores were above clinical cutoffs and did not differ across groups. At 1 week and 1 month posttreatment, median DTS and PHQ-9 scores were beneath clinical cutoffs in the SMART group; scores remained above clinical cutoffs in the NDSP group at these time points. CONCLUSIONS: It is feasible to conduct an RCT of SMART in hospitalized adult survivors of burn injury. SMART has the potential to yield clinically significant outcomes. Additional studies are needed to replicate and extend these findings.

National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System: Review of Program and Database.

The Burn Model System (BMS) centers program was created in 1994 to evaluate the long-term outcomes of burn injuries. As part of this multicenter program, a comprehensive longitudinal database was developed to facilitate the study of a number of functional and psychosocial outcomes after burn injury. In this article, we provide an overview of the data collection procedures, measures selection process, and an overview of the participant data collected between 1994 and 2016. Surveys were administered during hospitalization and at 6, 12, and 24 months after discharge, and in the most recent funding cycle, data collection at every 5 years postinjury was added. More than 7200 people with burn injury were eligible to participate in the BMS National Longitudinal Database. Of these, >5900 (82%) were alive at discharge and consented to follow-up data collection. The BMS National Longitudinal Database represents a large sample of people with burn injury, including information on demographic characteristics, injury characteristics, and health outcomes. The database is publicly available and can be used to examine the effect of burn injury on long-term outcomes.

Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries.

INTRODUCTION: Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries. METHODS: Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years. RESULTS: SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010). CONCLUSION: SIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention.

Fatigue Following Burn Injury: A Burn Model System National Database Study.

Fatigue is a commonly reported but not well-documented symptom following burn injury. This study's objective was to determine the frequency and severity of fatigue over time and to identify predictors of fatigue in the adult burn population. Data from the Burn Model System National Database (April 1997 to January 2006) were analyzed. Individuals over 18 years of age who were alive at discharge were included. The vitality subscale of the Short-Form 36 Item Health Survey was examined at preinjury and discharge and at 6, 12, and 24 months postinjury. Mean and number of low vitality scores were calculated at each time interval. Descriptive statistics were generated for demographic and medical data. Cross-sectional regression models analyzed predictors of vitality at 6, 12, and 24 months postinjury. The study included 945 subjects. The population was 72.5% male and had a mean age of 40.6 years and mean burn size of 17.4%. Fatigue symptoms were present in a majority of the population (74.6%) and were most commonly reported at discharge. Although fewer burn survivors reported fatigue symptoms at each subsequent follow-up (P < .001), approximately one-half (49%) of the population continued to report fatigue symptoms at 24 months postinjury. Larger burn size was the only variable that was significant or approaching significance at all follow-up time points (P < .0167). Fatigue symptoms are common after burns and many burn survivors continue to report symptoms at 2 years postinjury. Burn survivors did not return to preinjury fatigue levels, highlighting the importance of understanding and monitoring fatigue.

Cody.

Advances in burn management over the past 2 decades have resulted in improved survival and reduced morbidity. The treatment of a single patient following a 90% total body surface area injury illustrates the intensity of labour and coordinated hospital care required for such catastrophically injured patients. Data were extracted from the medical records and from personal recollections of the individual members of the multidisciplinary team as well as from the patient. The clinical course and management of complications are described chronologically as a series of overlapping phases from admission to discharge.

Validation of the Community Integration Questionnaire in the adult burn injury population.

PURPOSE: With improved survival, long-term effects of burn injuries on quality of life, particularly community integration, are important outcomes. This study aims to assess the Community Integration Questionnaire's psychometric properties in the adult burn population. METHODS: Data were obtained from a multicenter longitudinal data set of burn survivors. The psychometric properties of the Community Integration Questionnaire (n = 492) were examined. The questionnaire items were evaluated for clinical and substantive relevance; validation procedures were conducted on different samples of the population; construct validity was assessed using exploratory factor analysis; internal consistency reliability was examined using Cronbach's α statistics; and item response theory was applied to the final models. RESULTS: The CIQ-15 was reduced by two questions to form the CIQ-13, with a two-factor structure, interpreted as self/family care and social integration. Item response theory testing suggests that Factor 2 captures a wider range of community integration levels. Cronbach's α was 0.80 for Factor 1, 0.77 for Factor 2, and 0.79 for the test as a whole. CONCLUSIONS: The CIQ-13 demonstrates validity and reliability in the adult burn survivor population addressing issues of self/family care and social integration. This instrument is useful in future research of community reintegration outcomes in the burn population.

Clinical and psychiatric characteristics of self-inflicted burn patients in the United States: comparison with a nonintentional burn group.

The main objective of the present study was to examine whether self-inflicted burn patients would differ from nonintentional, nonwork related burn patients on psychiatric and personality characteristics. Sociodemographic and injury related factors were also compared. Self-inflicted (N = 15) and nonintentional (N = 178) burn patient samples were drawn from a larger study examining physical and psychosocial outcomes following major burn. Psychiatric/personality factors included self-reported psychiatric treatment history, alcohol/drug use, preburn mental health (Short Form Health Survey-12 MCS) and neuroticism (NEO five factor inventory). Sociodemographic factors and injury related factors were obtained through medical records. Comparisons between the self-inflicted and the nonintentional groups were made using Fisher's exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. The self-inflicted group was 11.5 times more likely to report prior psychiatric treatment relative to the nonintentional burn group (P < .001) and 4.3 times more likely to have previously abused alcohol (P = .02). Compared to nonintentional burn patients, self-inflicted burn patients reported worse preburn mental health (P < .001). There were no differences on TBSA (P = .52) or sociodemographic characteristics (P values > .08). Relative to survivors of nonintentional burns, self-inflicted burn patients in the United States demonstrate high psychiatric comorbidity. Standards of care must be developed to optimize treatment procedures and recovery outcomes in this subgroup.

Noise levels in a burn intensive care unit.

INTRODUCTION: Increased noise levels in hospitals, critical care units, and peri-operative areas have been associated with higher levels of sleep deprivation and patient stress. The World Health Organization (WHO) guidelines stipulate a limit of 35 decibels (dB(A)) equivalent continuous sound level (LEq) during the day and 30 dB(A) LEq at night in patients' rooms. To date, no quantitative studies of noise levels have been performed in burn units. The objective of this study was to quantify noise levels in a burn critical care unit to ascertain compliance with guidelines in order to minimize this potential insult. METHODS: An A-weighted sound pressure level meter was used to measure the ambient noise levels in a burn intensive care unit. Maximum and minimum sound pressure levels were measured at 30-min intervals on 10 days over a 1 month period. Measurements were obtained during shift changes and random times during the day and night-time. Descriptive statistical analyses were performed, to calculate means and standard deviations. Noise measurements at specified times were compared using analysis of variance (ANOVA). RESULTS: Mean dB(A) LEq values for shift changes, day, and night-time were 65.9 ± 2.8, 65.7 ± 2.6, and 60.9 ± 5.2 dB(A), respectively. There was no significant difference in dB(A)(max) or dB(A)(min) between shift changes, day or night-time (p>0.05). However, night-time minimum values were consistently lower. There was no significant difference between sound pressure level (SPL) inside and outside patients' rooms (p>0.05) at any time. CONCLUSIONS: Irrespective of time or location, the mean dB(A) LEq in the burn unit was significantly greater than World Health Organization (WHO), National Institute for Occupational Safety and Health (NIOSH), and the Environmental Protection Agency (EPA) recommendations. Guidelines for decreasing noise exposure are necessary to reduce potential negative effects on patients, visitors, and staff.

Pruritus in adult burn survivors: postburn prevalence and risk factors associated with increased intensity.

Pruritus (itching) is a common and distressing complaint after injury. The purpose of this study was to investigate self-reported postburn pruritus in a large, multisite cohort study of adult burn survivors. Descriptive statistics, general linear regression, and mixed model repeated measures analyses were employed to test statistical significance. Two cohorts of adult burn survivors were studied. Group 1 participants (n = 637) were injured from 2006 to 2010 and were followed up prospectively for 2 years from the time of injury. Prevalence and severity of pruritus were compared across multiple subgroups. Prevalence of pruritus at discharge, 6, 12, and 24 months following injury were 93, 86, 83, and 73%, respectively. Regression results established that %TBSA-burn and %TBSA-grafted were correlated to itch intensity values. Group 2 participants (n = 336) were injured 4 to 10 years before an assessment using the validated 5-D Itch Scale. Many patients (44.4%) reported itching in the area of the burn, graft, or donor site. Within this group, 76% reported itching for <6 hours/day, and 52 and 29% considered itch intensity to be mild or moderate, respectively. This study confirms that the prevalence of burn pruritus is high, initially affecting >90% and persisting for >40% of long-term burn survivors. New predictors for postburn itch were identified to include younger age, dry skin, and raised/thick scars. Characterization of the impact of postburn pruritus on leisure, vocation, and sleep are quantified for those long-term survivors suffering from postburn pruritus.

Quality-of-life loss of people admitted to burn centers, United States.

PURPOSE: To estimate quality-of-life loss per serious burn survivor in a large U.S. cohort. METHODS: Longitudinal functional assessments of all 1,587 people receiving primary treatment in 5 burn centers between 2000 and 2009 included pre-burn (retrospective), at time of discharge, and 6, 12, and 24 months post-injury. We assessed adults with RAND Short Form (SF) 12 and children with SF-10 or Child Health Questionnaire, the child surveys scored using standard norms-based scoring. A literature review identified 20 quality-adjusted life year utility scorings for SF-12 and 27 scorings for EQ-5d response distributions predicted from SF-12 scores. We computed composite scores for each patient and time period by applying 32 scorings that met quality/non-duplication criteria. RESULTS: Mean quality-of-life scores were 0.805 4 weeks pre-burn, 0.562 at discharge, rebounded through 1 year, and stabilized at 0.735 (0.750 for TBSA burned below 25 %, 0.722 for TBSA burned of 25-50 %, and 0.695 for larger burns). As a percentage of initial levels, burns reduced short-term quality of life by 30 %. Long-term loss averaged 11 %, ranging from 9 % for TBSA burned below 25-13 % for TBSA burned above 50 %. Children recovered faster and more fully. CONCLUSION: Burns cause substantial losses in quality of life, with long-term losses comparable to traumatic brain injury.

Measuring coping behavior in patients with major burn injuries: a psychometric evaluation of the BCOPE.

Burn injuries involve significant physiological, psychological, and social challenges with which individuals must cope. Although the brief COPE (BCOPE) is frequently used, knowledge of its factor structure and construct validity is limited, thus limiting confidence with interpreting results. This study assessed psychometric properties of the BCOPE in hospitalized patients with burn injury. Participants had a major burn injury (n = 362). Measures assessed coping behavior and physical, psychological, and social functioning. Exploratory factorial analysis was conducted to evaluate patterns of coping strategies. To assess construct validity, the BCOPE scale scores were correlated with the distress measures across time points. Exploratory factorial analysis revealed seven factors accounting for 51% of total variance. The pattern matrix indicated four items loaded onto factor 1 (active coping = 0.47-0.80) and four onto factor 2 (avoidant coping = 0.59-0.73). The remaining factors were consistent with original scale assignments reported by Carver (Int J Behav Med 1997;4:92-100). Construct validity of BCOPE scales (active and avoidant) was demonstrated by their association with the Davidson trauma scale, short form-12, and satisfaction with appearance scale. The results indicate that the BCOPE is valid, reliable, and can be meaningfully interpreted. Research using these factors may improve knowledge about interrelationships among stress, coping, and outcome, thus building the evidence base for managing distress in this population.

Peritraumatic heart rate and posttraumatic stress disorder in patients with severe burns.

OBJECTIVE: Previous studies have suggested a link between heart rate (HR) following trauma and the development of posttraumatic stress disorder (PTSD). This study expands on previous work by evaluating HR in burn patients followed longitudinally for symptoms of acute stress disorder (ASD) and PTSD. METHOD: Data were collected from consecutive patients admitted to the Johns Hopkins Burn Center, Baltimore, Maryland, between 1997 and 2002. Patients completed the Stanford Acute Stress Reaction Questionnaire (n = 157) to assess symptoms of ASD. The Davidson Trauma Scale was completed at 1 (n = 145), 6 (n = 106), 12 (n = 94), and 24 (n = 66) months postdischarge to assess symptoms of PTSD. Heart rate in the ambulance, emergency room, and burn unit were obtained by retrospective medical chart review. RESULTS: Pearson correlations revealed a significant relationship between HR in the ambulance (r = 0.32, P = .016) and burn unit (r = 0.30, P = .001) and ASD scores at baseline. Heart rate in the ambulance was related to PTSD avoidance cluster scores at 1, 6, 12, and 24 months. In women, HR in the ambulance was correlated with PTSD scores at 6 (r = 0.65, P = .005) and 12 (r = 0.78, P = .005) months. When covariates (gender, ß-blockers, Brief Symptom Inventory Global Severity Index score) were included in multivariate linear regression analyses, ambulance HR was associated with ASD and PTSD scores at baseline and 1 month, and the interaction of ambulance HR and gender was associated with PTSD scores at 6 and 12 months. Multivariate logistic regression results were similar at baseline and 12 months, which included an HR association yet no interaction at 6 months and a marginal interaction at 1 month. CONCLUSIONS: While peritraumatic HR is most robustly associated with PTSD symptom severity, HR on admission to burn unit also predicts the development of ASD. Gender and avoidance symptoms appear particularly salient in this relationship, and these factors may aid in the identification of subgroups for which HR serves as a biomarker for PTSD. Future work may identify endophenotypic measures of increased risk for PTSD, targeting subgroups for early intervention.

Functional and psychosocial outcomes of older adults after burn injury: results from a multicenter database of severe burn injury.

A number of factors increase the susceptibility of older adults to burn injury. The majority of studies of older adults have focused on patient and injury factors related to mortality risk. However, little is known about the long-term functional and psychological outcomes of older adults after severe burn. The purpose of this study is to examine the long-term outcomes of older adults after burn injury. The authors performed an analysis of the outcomes of older adults (age 55 years or older) enrolled in a prospective study of burn injury outcomes. Change in living situation as well as distress, functional impairment, and quality of life were examined at discharge and at 6, 12, and 24 months after hospital discharge. Mixed effects modeling was performed to compare differences across age groups and time as well as to account for missing data. A total of 737 patients aged 55 years or older were enrolled and followed in the National Institute on Disability and Rehabilitation Research burn program. Patients in all age groups had significant deficits in Short Form-36, Functional Independence Measure, and Brief Symptom Inventory scores at time of discharge. Recovery of physical and psychosocial functioning was greatest from discharge to 6 months in patients aged 55 to 74 years and greatest at 1 year for patients aged 75 years or older. This study confirms that severe burn injury significantly impacts both functional outcome and psychosocial quality of life in older adults. However, the impact seems to be age related as are recovery trajectories. Rehabilitation programs lasting up to 1 year after injury could be of tremendous benefit in helping older adults achieve maximal potential recovery.

Comparing parent and child perceptions of stigmatizing behavior experienced by children with burn scars.

This study examined perceptions of stigmatization in a sample of 85 pediatric burn survivors and their parents. Survivors and a parent independently completed the Perceived Stigmatization Questionnaire (PSQ) rating the frequency that the child experienced three types of stigmatizing behaviors: absence of friendly behavior, confused and staring behavior, and hostile behavior. The sample was divided into a high (top 25%) and low (bottom 75%) perceived stigmatization groups. The mean ratings of parents did not significantly differ from that of children reporting low stigmatization. The mean PSQ parent ratings were significantly lower than those of children reporting high stigmatization. Additionally, the concordance on PSQ subscale scores within child-parent dyads was significantly lower in children reporting high stigmatization relative to child-parent dyads of children reporting low stigmatization. Children surviving burns may experience stigmatization that is under-perceived by their parents. Clinicians should be alert to this potential discrepancy.

Perceived stigmatization and social comfort: validating the constructs and their measurement among pediatric burn survivors.

OBJECTIVE: The current study implemented a four-step process to evaluate the measurement properties of the Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire (SCQ) among long-term pediatric burn survivors. METHODS: First, a series of confirmatory factor analyses (CFAs) compared the hypothesized four-factor model--3 perceived stigmatization factors (absence of friendly behavior, confused and staring behavior, and hostile behavior)--and one social comfort factor to three other models. Second, we tested the measurement invariance of the instruments between pediatric and adult burn survivor samples. Third, possible differences in structural parameters across groups were tested. Fourth, we tested whether the three perceived stigmatization factors and the social comfort factor loaded on one second-order factor. Participants included 369 pediatric and 347 adult burn survivors. RESULTS: The four-factor model was superior to the comparison models. The PSQ and SCQ demonstrated measurement invariance. Factor variance, factor covariance, and the latent means of the PSQ did not vary across groups. The adult group had a significantly lower latent mean on the SCQ than the pediatric group. The three factors of the PSQ and the one-factor SCQ loaded on one second-order factor. CONCLUSION: The results of this study lend support to both the construct validity of perceived stigmatization and social comfort and the potential value of the PSQ and SCQ for studying the social experience of people with visible differences.

Posttraumatic stress disorder and pain impact functioning and disability after major burn injury.

This study sought to clarify the prospective and concurrent associations of posttraumatic stress disorder (PTSD) and pain with functioning and disability after burn injury. The sample was composed of consecutive patients admitted to a regional burn center with major burn injuries (N = 171) who were followed at 1, 6, 12, and 24 months postdischarge. The predictor measures were the McGill Pain Questionnaire and Davidson Trauma Scale, and the outcome measures were Short Form-36 Health Survey subscales administered at 6, 12, and 24 months after discharge. Linear mixed-effects analyses were conducted to evaluate pain and PTSD as predictors of functional outcomes. Higher PTSD symptom severity soon after hospital discharge was prospectively related to poorer physical and social functioning and greater psychosocial disability (P < .001). However, significant PTSD-by-time interactions also predicted future physical functioning and disability, indicating that the deleterious effects of early PTSD were ameliorated by time. In addition, at each follow-up, PTSD symptoms were concurrently related to greater physical and psychosocial disability, poorer social functioning, and less vitality (P < .001). More severe pain at each follow-up, but not PTSD, was correlated with poorer concurrent physical functioning (P < .002). Significant interaction terms indicated that the concurrent effect of PTSD on psychosocial disability, social functioning, and vitality attenuated during the 24-month recovery period. These findings suggest that assessing PTSD and pain following burn injury may aid in predicting future functioning. Future work should confirm this and evaluate whether aggressively treating both PTSD and pain helps improve functioning after major burn injury.

Growth curve trajectories of distress in burn patients.

Psychological adjustment after a major burn injury is a significant concern to providers and patients alike. Although efforts have been made to identify associated risk factors, little is known about heterogeneity in the levels or trajectories of adjustment in this population. This study used a novel application of Growth Mixture Modeling to identify subgroups of patients based on their longitudinal self-reported distress using the Brief Symptom Inventory (BSI). Data were drawn from the database of the Burn Model Systems project, a prospective, multisite, cohort study of major burn injury survivors. The BSI was used to assess symptoms in-hospital and at 6, 12, and 24 months postburn. Participants' T scores on the BSIs Global Severity Index provided a continuous measure of psychological distress. Analyses were conducted using participants' Global Severity Index T scores to discern distinct classes of respondents with similar trajectories across the 2-year follow-up. Results from the Growth Mixture Modeling analysis produced an ordered four-class model of psychological recovery from a major burn. Groups represented the equivalent of high, subthreshold, mild, and minimal symptom severity. Covariates significantly affected the intercept and slope of each class, as well as prediction of group assignment. These analyses demonstrate differences between individual recoveries after a major burn. Psychological distress symptoms remain largely stable over time and highlight the psychological vulnerability of this patient population.

Self-assessed physical health predicts 10-year mortality after myocardial infarction.

PURPOSE: In spite of their widespread use in other fields, global measures of health are not commonly used in determining the prognosis of patients with myocardial infarction (MI). The objective of the present study was to ascertain the relationship between self-assessed physical health at the time of the MI and long-term mortality. METHODS: This was a prospective cohort study of 284 patients with MI admitted to an academic community hospital between July 1995 and December 1996 who completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). The physical component scale from the SF-36 was used as a self-assessment of physical health. All-cause mortality was assessed 10 years later by using the Social Security Death Index. RESULTS: Patients with lower self-reported physical health were significantly more likely to be women; older; depressed; have a history of coronary artery disease; have a family history of MI; have a non-Q wave MI; have a Killip class 3 or 4 MI; have hypertension, diabetes mellitus, renal insufficiency, and chronic obstructive pulmonary disease; and have a longer hospitalization period. Patients with higher physical component scores had significantly lower mortality in the 10 years after MI and this persisted after adjusting for confounders (hazard ratio = 0.97 [95% CI 0.96-0.99], P = .001). CONCLUSIONS: These data suggest that self-assessed physical health provides information on the long-term prognosis of patients with MI above and beyond that provided by traditional risk predictors.