Head and neck burns are associated with long-term patient-reported dissatisfaction with appearance: A Burn Model System National Database study.

INTRODUCTION: Burns affecting the head and neck (H&N) can lead to significant changes in appearance. It is postulated that such injuries have a negative impact on patients' social functioning, quality of life, physical health, and satisfaction with appearance, but there has been little investigation of these effects using patient reported outcome measures. This study evaluates the effect of H&N burns on long-term patient reported outcomes compared to patients who sustained burns to other areas. METHODS: Data from the National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System National Database collected between 1996 and 2015 were used to investigate differences in outcomes between those with and without H&N burns. Demographic and clinical characteristics for adult burn survivors with and without H&N burns were compared. The following patient-reported outcome measures, collected at 6, 12, and 24 months after injury, were examined: satisfaction with life (SWL), community integration questionnaire (CIQ), satisfaction with appearance (SWAP), short form-12 physical component score (SF-12 PCS), and short form-12 mental component score (SF-12 MCS). Mixed regression model analyses were used to examine the associations between H&N burns and each outcome measure, controlling for medical and demographic characteristics. RESULTS: A total of 697 adults (373 with H&N burns; 324 without H&N burns) were included in the analyses. Over 75% of H&N injuries resulted from a fire/flame burn and those with H&N burns had significantly larger burn size (p<0.001). In the mixed model regression analyses, SWAP and SF-12 MCS were significantly worse for adults with H&N burns compared to those with non-H&N burns (p<0.01). There were no significant differences between SWL, CIQ, and SF-12 PCS. CONCLUSIONS: Survivors with H&N burns demonstrated community integration, physical health, and satisfaction with life outcomes similar to those of survivors with non-H&N burns. Scores in these domains improved over time. However, survivors with H&N burns demonstrated worse satisfaction with their appearance. These results suggest that strategies to address satisfaction with appearance, such as reconstructive surgery, cognitive behavior therapy, and social skills training, are an area of need for survivors with H&N burns.

Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline

OBJECTIVE: To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. PARTICIPANTS: The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. EVIDENCE: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS: Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. CONCLUSION: Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.

Psychological problems reported by young adults who were burned as children.

This study assessed long-term psychosocial sequelae of young adult pediatric burn survivors. Subjects were 101 young adults (43 females and 58 males) between the ages of 18 and 28 years who were at least 2 years (average, 14 years) postburn at least 30% TBSA (mean = 54 +/- 20%). Educational status was 25% high school dropouts, 28% high school graduation only, 32% some college, and 5% completed college. Seventy-seven percent either worked or attended school; 28% had had a long-term partner. When assessed by Achenbach's Young Adult Self-Report (YASR) scale and compared with its published reference group, the males reported differences only in the somatic complaints, but the females endorsed significantly more externalizing and total problems, specifically withdrawn behaviors, somatic complaints, thought problems, aggressive behavior, and delinquent behavior. Despite these problems suffered by some female pediatric burn survivors, the overall outcome revealed that most pediatric burn survivors are making the transition into adulthood with minimal unexpected difficulty.

Anxiety: current practices in assessment and treatment of anxiety of burn patients.

Anxiety is an affective response commonly experienced by persons after emotional and physical trauma, as well as associated with aversive medical treatments. The scientific information related to the conceptualization, assessment, and treatment of anxiety is limited. In order to develop a pilot protocol for anxiety management, nursing directors at 64 burn centers were surveyed. At 89% of the centers, anxiety measures were not used. Most of the teams assess informally through observation of patient (n=21), dialogue with patient (n=12), or both observation and dialogue with patient (n=15). Assessors of anxiety range in breadth from nurse only to the entire burn team, including pastoral care representatives and family. The class of medication most frequently endorsed in treating anxiety is the benzodiazipine, most often lorazepam (Ativan). A number of non-pharmacologic techniques are used to manage anxiety, e.g., muscle relaxation, breathing, imagery. Consideration should be given to assessing anxiety systematically, so knowledge can be gleaned and applied to conceptualization of symptom presentation and application of treatment resources.

On changing curricula: lessons learned at two dissimilar medical schools.

Two dissimilar U.S. medical schools--the University of Pittsburgh School of Medicine and the University of Texas Medical Branch at Galveston-changed their curricula for the first two years of medical education from ones that were lecture-dominated and departmentally run to ones that are centrally governed, multi-modal, goal-oriented, and fully integrated, with mechanisms to continue curricular change into the last two years of medical education. The change at each school was in response to national education philosophy, the recommendations of the Liaison Committee for Medical Education after the most recent site visit, and faculty's and students' concerns and interests. The change process took place over a three- to four-year period at each school, involved students, faculty, and administration, and utilized task forces and retreats as communication vehicles. The barriers encountered (e.g., belief by some that the curriculum needed no change; concern over loss of departments' control) and the processes employed to overcome them and to radically change the curricula (e.g., commitment of the central administration and dean to the change, involvement of all segments of the school in the change process, appointment of department chairs on task forces, and creation of a strong curriculum committee that gave authority to faculty and students) were essentially identical. The resulting curricula were also largely similar in their main characteristics, but there were notable differences, based on the goals and concerns of the two institutions.

Randomized, placebo-controlled pilot study of divalproex sodium in the treatment of acute exacerbations of chronic schizophrenia.

Experimental and clinical data suggest that GABA-ergic drugs such as valproate may have a potential role in the treatment of schizophrenia. The authors designed a 21-day prospective, double-blind, randomized, placebo-controlled pilot study of divalproex sodium as add-on treatment to haloperidol in 12 hospitalized patients with acute exacerbations of chronic schizophrenia. All patients received haloperidol 10 mg/day for 3 days and 15 mg/day for the remaining 18 days. In addition, five patients were randomly assigned to receive divalproex augmentation and seven to receive placebo. The divalproex dose was adjusted to a target serum concentration of 75 microg/mL for 2 weeks; placebo replaced divalproex during the third and last weeks to determine any carryover effect. Psychiatric rating scales were administered at baseline and on days 7, 14, and 21. Although the placebo group improved with haloperidol treatment, the divalproex group demonstrated greater improvement. On day 21, the divalproex group had greater improvement from baseline on the Clinical Global Impression Scale (p < or = 0.04), Brief Psychiatric Rating Scale (p < or = 0.13), and Schedule for Assessment of Negative Symptoms scores (p < or = 0.007). After divalproex withdrawal on day 15, a carryover effect was observed during week 3. The authors concluded that the addition of divalproex sodium to standard antipsychotic drugs may prove effective in relieving the symptoms of acute schizophrenia. Future studies may benefit from the design of this pilot study. However, it is premature to apply this augmentation strategy in the clinical setting just yet because of the small sample size and the likely heterogeneity of the disorder.

Evaluating the psychosocial adjustment of 2- and 3-year-old pediatric burn survivors.

Very little information has been published about 2- and 3-year-old children who have experienced major burns. This study used a standardized instrument to measure the behavioral adjustment of these young burn survivors, and the results were compared with those of a nonclinical normative sample. Thirty-three pediatric burn survivors with 50%+/-28% total body surface area burns were evaluated 1.2+/-0.7 years postburn. Parental observations were assessed with the use of the Child Behavior Checklist for 2- and 3-Year-Olds, a 99-item standardized checklist designed to identify behavior problems. Forty of the questions are specific to 2- and 3-year-olds, and the scores of male and female children are not differentiated. The raw scores of the children with burns were statistically compared with the reported normative sample for this version of the Child Behavior Checklist. Pediatric burn survivors in this sample exhibited significantly more internalizing behaviors than the children in the normative group. Parents reported children who had been burned to be more depressed and to have more somatic complaints and sleep problems. Determining the relationship of behavior problems to posttrauma sequelae and preburn environmental factors would assist with the establishment of appropriate psychosocial interventions.

Imipramine treatment in pediatric burn patients with symptoms of acute stress disorder: a pilot study.

OBJECTIVE: Pediatric burn patients often exhibit acute stress disorder (ASD) symptoms. Information on psychopharmacological treatment of ASD symptoms in children is scarce. This pilot study used a prospective, randomized, double-blind design to test whether thermally injured children suffering ASD symptoms benefit from imipramine. METHOD: Twenty-five children, aged 2 to 19 years, received either imipramine or chloral hydrate for 7 days. A structured interview (clinically useful, but validity and reliability not yet established) was used to assess the presence and frequency of ASD symptoms both before treatment and 3 times during the treatment period. RESULTS: Eleven females and 14 males participated, with a mean total burn surface area of 45% (SD = 23%) and mean age of 8 years (SD = 6). Imipramine was more effective than chloral hydrate in treating ASD symptoms (chi 2 [1, N = 25] = 5.24, p < .02). Five of 13 were positive responders to chloral hydrate (38%). Ten of 12 were positive responders to low-dose imipramine (83%). CONCLUSIONS: This pilot study suggests a place for cautious initial use of imipramine to reduce ASD symptoms in burned children. Care must be taken to minimize cardiovascular risks in an off-label application of imipramine in children, especially those receiving additional medications.

Critical review of GABA-ergic drugs in the treatment of schizophrenia.

GABA-ergic medications may have a potential role in the treatment of schizophrenia. Laboratory evidence has generally supported the ability of gamma-aminobutyric acid (GABA) to reduce dopaminergic activity and has suggested that GABA may be effective in combating hypofrontality by acting on mesoprefrontocortical tracts in patients resistant to treatment with antipsychotic drugs. Although the results of clinical trials of several GABA-ergic compounds have been inconclusive because of methodologic limitations and drug toxicity, benzodiazepines and valproate seem to be associated with favorable treatment outcomes, especially when combined with typical antipsychotic agents. This study concludes that further investigation of the use of GABA in schizophrenia is likely to improve the understanding of the psychopathology of this illness and to expand our treatment alternatives. Also provided are suggestions to enhance the design of future studies, improve the potential for favorable treatment outcomes, and assist in predicting patients' responses to GABA-ergic medications.

An approach to the timely treatment of acute stress disorder.

A convergent postburn psychopharmacologic treatment for children for acute stress disorder (ASD) symptoms has not been established. Both the application of what has been learned through treatment of similar symptoms experienced by adults with posttraumatic stress disorder and the examination of safe treatment options for children led to the clinical decision to use imipramine for 25 pediatric patients with acute burns. The treatment histories of these patients were retrospectively reviewed to see if further exploration into the efficacy of imipramine was warranted. Eighty percent of the children experienced remission of hyperarousal symptoms (eg, trouble staying asleep, trouble falling asleep) and intrusive reexperiencing symptoms (eg, nightmares). Twelve percent of the children experienced a decrease in the frequency or intensity of ASD symptoms. Eight percent had no relief of ASD symptoms. Initial findings suggest that imipramine assists children who have postburn ASD symptoms by decreasing the hyperarousal and intrusive reexperiencing symptoms of ASD.

Impact of disfiguring burn scars on adolescent sexual development.

It is popularly believed that disfiguring scars compromise the burned adolescent's ability to establish satisfactory dating relationships and to develop positive identities as sexually attractive people. The purpose of this study was to test that belief by obtaining information about the sexual behaviors and beliefs of adolescents who have disfiguring scars. Nineteen adolescents, ages 13 to 20 and at least 1 year postburn, completed a sexuality survey entitled What Young People Believe and Do--Revised. When compared with the available information, adolescents with disfiguring burn scars appear to have thoughts, feelings, and behaviors that are similar to those of nonburned adolescents. The severity of disfigurement as measured by numbers of affected body areas does not seem to be related to the sexual behaviors of the teenagers in this sample.

Relationship between parental emotional states, family environment and the behavioural adjustment of pediatric burn survivors.

The purpose of this study was to examine the relationship between psychosocial adjustment of the burned child and characteristics of the child's family. It hypothesized that parents who perceived their children without major behavioural problems would possess supportive family values and would, themselves, be better adjusted psychologically than those parents who perceived their children as possessing multiple behavioural problems. A stratified random sampling technique was used to select 35 (29 boys, 6 girls) paediatric burn survivors, ages 9 to 18, 1-5 years post-burn, with burn sizes ranging from 3 to 92% burn. Subjects' parents were administered the Child Behaviour Checklist (CBCL), the Family Environment Scale (FES), the Impact of Events Scale (IES), and the Beck Depression Inventory (BDI). The subjects were divided into two groups on the basis of the total problem CBCL scores. i.e. troubled (T > or = 60) or untroubled (T<60). One-way ANOVA tests revealed no significant differences between the two groups in the way parents reacted to trauma (IES) and parental depression (BDI). Significant differences (p<0.01) were revealed between the two groups on FES subscales. The parents of the untroubled group scored higher on 'Cohesion' and 'Organization' and lower on 'Conflict'. These parents also scored higher (p< or =0.05) on 'Achievement Orientation'. The results indicate that work with the family to promote cohesion. to decrease conflict, to enhance stability and to promote expectation of positive achievement must he a part of the rehabilitation of the burned child.

Policy development for the control of sex-offending behavior.

Sexual violence is among the foremost problems that our society faces today. Addressing this problem will require more direct public education, effective and accessible resources for victims, punishment for offenders, and treatment of offenders to prevent recidivism. Although the 74th Texas legislative session began a concentrated approach to addressing this problem, further legislation is needed to provide a cost-effective method to increase public safety from sexual violence over the long term.

Chorioamnionitis does not affect fetal urine production in patients with premature rupture of membranes.

The objective of this study was to evaluate fetal urine production rate in patients with premature rupture of membranes in the presence or absence of chorioamnionitis and to determine its clinical usefulness. Fetal urine production was evaluated in 30 women between 24 and 39 weeks' gestational age with ruptured membranes. Fetal bladder measurements were determined every 3-5 min for 30-90 min. Chorioamnionitis was defined by both clinical criteria and histological examination of the placenta. The last determination of fetal urine production rate prior to delivery was compared in patients with and without histologic and/or clinical chorioamnionitis. Fetal urine production rate was corrected for gestational age using birth weight prior to analysis. A total of 96 assessments of fetal urine production were performed (range 1-16 per patient). Twelve subjects (40%) had no evidence of chorioamnionitis (group 1), 10 (33%) had histologic chorioamnionitis alone (group 2), and eight (27%) had both clinical and histologic chorioamnionitis (group 3). The mean (+/- SD) urine production rates in these groups were 9.43 +/- 3.15 ml/kg/hr, 10.65 +/- 3.43 ml/kg/hr, and 9.97 +/- 2.81 ml/kg/hr, respectively. The difference in fetal urine production rate between the three groups was not statistically significant. A power analysis revealed that individual group sizes were adequate to document a 50% increase in fetal urine production rate with a type II error of < 10%. There were no documented cases of fetal infection based on neonatal cultures. The presence of histologic or clinical chorioamnionitis does not significantly affect fetal urine production in patients with premature rupture of membranes. The prospective assessment of fetal urine production rate does not appear to be clinically useful as an early indicator of chorioamnionitis.

Altered newborn gender distribution in patients with low mid-trimester maternal serum human chorionic gonadotropin (MShCG).

OBJECTIVE: to determine if the sex ratio (male/female) is altered in infants born to patients with low mid-trimester maternal serum human chorionic gonadotropin (MShCG). STUDY DESIGN: Between 2/1/90 and 1/3/91, 3,116 patients underwent prenatal screening using second-trimester maternal serum alpha-fetoprotein (MSAFP), MShCG, and maternal serum unconjugated estriol (MSuE3). Among these, there were 132 patients with low second-trimester MShCG (< 0.4 MoM), normal MSAFP and MSuE3. The gender distribution of these term, normal newborns was compared to that of 237 controls, matched for race, maternal age, and referral source and delivered at term to mothers with normal mid-trimester MSAFP, MSuE3, and MShCG. The gender distribution of these two groups of newborns was also compared to that of 78 term newborns from the same obstetrical population delivered to mothers with second-trimester MShCG > 2.5 MoM and normal MSAFP and MSuE3. All patients had a complete obstetrical history. RESULTS: Forty-nine percent of the controls were male vs. 62% of the group with slow second-trimester MShCG (P < .01). Within the group with low MShCG, 59% of infants were male when the MShCG was between 0.19 and 0.4 MoM (A) and 80% when the MShCG was < 0.2 MoM (B) (control vs. A vs. B P < .005). The sex ratio in the high-MShCG group was similar to control. CONCLUSION: The data suggest that gender distribution is different from normal in patients with low mid-trimester MShCG.

Comorbidity of gender dysphoria and other major psychiatric diagnoses.

Previous studies suggest that many transsexuals evidence an Axis I diagnosis according to the DSM-IV classification (e.g., psychoses, major affective disorder). The current study examined retrospectively the comorbidity between gender dysphoria and major psychopathology, evaluating the charts of 435 gender dysphoric individuals (318 male and 117 female). All had undergone an extensive evaluation, addressing such areas as hormonal/surgical treatment, and histories of substance abuse, mental illness, genital mutilation, and suicide attempts. In addition, a subgroup of 137 individuals completed the MMPI. Findings revealed over two thirds were undergoing hormone reassignment, suggesting a commitment to the real-life cross-gender process. One quarter had had problems with substance abuse prior to entering treatment, but less than 10% evidenced problems associated with mental illness, genital mutilation, or suicide attempts. Those completing the MMPI (93 female and 44 male) demonstrated profiles that were notably free of psychopathology (e.g., Axis I or Axis II criteria). The one scale where significant differences were observed was the Mf scale, and this held true only for the male-to-female group. Psychological profiles as measured by the MMPI were more "normal" in the desired sex than the anatomic sex. Results support the view that transsexualism is usually an isolated diagnosis and not part of any general psychopathological disorder.

Acetaminophen in the management of background pain in children post-burn.

This retrospective review evaluated the pain management of 395 acutely burned pediatric patients who were treated by a pain management protocol emphasizing acetaminophen as the initial medication to control background pain. Pain was assessed by using standardized instruments based on observations by patients, nurses, and parents. Morphine was added when scheduled acetaminophen (10-15 mg/kg/4 hr) did not control background pain. Fifty percent of the children received only acetaminophen to control background pain. Younger children and children with the smallest burns, regardless of age, were likely to be managed with acetaminophen alone. Most peak serum concentrations of acetaminophen were less than 10 micrograms/mL. When needed, children also received medication for painful procedures, anxiety, and posttraumatic stress symptoms. These additional medications were not more frequently given to children receiving only acetaminophen for background pain. These data suggest that acetaminophen is a safe, useful medication for the control of post-burn background pain in some children.

Positive self-regard as a coping mechanism for pediatric burn survivors.

Pediatric burn survivors are reported to present optimistic pictures of themselves; it has been suggested that their reports of high self-esteem may reflects a coping mechanism. The purpose of this study was to compare burned children's self-perceptions of competence and adequacy to normative population with the use of two standardized instruments. A random sample of 32 pediatric burn survivors was administered two standardized instruments: the Piers-Harris and the Harter Self-Perception Profiles for children and adolescents. Paired t tests revealed significantly higher self-concepts by the burned children than the nonclinical reference groups on five of the six Piers-Harris clusters and on two of the nine Harter Self-Perception Profiles domains. Also, the relationship between the children's perceived self-worth in each domain, and the importance they attributed to that domain, indicate that the burned children are satisfied with themselves in those areas they perceive as important. Results from both tests suggest that the burn survivors' report of positive self-esteem may reflect a necessary defense mechanism in the adjustment process, which should be supported by the burn team.