Gender differences in relation to stigmatization and depressive symptoms after burns.

OBJECTIVES: The aim of this study was to investigate the moderating role of gender in the relationship between burn severity, perceived stigmatization and depressive symptoms at multiple time points postburn. MATERIALS AND METHODS: This multi-center study included data from two cohorts. Cohort 1 consisted of 215 burn survivors, participating in a longitudinal study with measures at 3 and 12 months postburn. Cohort 2 consisted of 180 burn survivors cross-sectionally assessed at 5 - 7 years postburn. Both cohorts completed self-reported measures of perceived stigmatization and depressive symptoms. The number of acute surgeries (i.e., no surgery, 1 surgery or 2 or more surgeries) was used as indicator of burn severity. Relations between number of surgeries, depressive symptoms, and perceived stigmatization, including possible indirect effects, were evaluated with gender-specific path models. RESULTS: In both men and women, number of surgical operations was related to higher levels of depressive symptoms and perceived stigmatization at 3 months after burn. In women, number of operations was still directly related to both constructs at 12 months after burn, which was cross-sectionally confirmed in the 5-7 years after burn cohort. In men, from 3 to 12 months after burn, depressive symptoms and perceived stigmatization were bidirectionally related, and, through these effects, number of surgeries was indirectly related to both outcomes. In the cross-sectional 5-7 years after burn cohort, number of operations was related to stigma but not to depressive symptoms of men. CONCLUSION: Number of operations had a different effect on psychosocial adaptation of male and female burn survivors. In women, a persistent direct link from number of operations to both depressive symptoms and perceived stigmatization was found over time. In men, the effect of number of operations was most evident in the short-term, after which perceived stigmatization and depressive symptoms became interrelated. This indicates that burn severity remains a factor of significance in psychological adjustment in women, whereas in men, this significance seems to decrease over time.

Perceived stigmatization and fear of negative evaluation: Two distinct pathways to body image dissatisfaction and self-esteem in burn survivors.

OBJECTIVE: Scars resulting from burn injury can pose social and psychological problems that may affect body image and self-esteem. This study aimed to investigate whether burn severity, age and female gender are associated with body image dissatisfaction and self-esteem, through an association with perceived stigmatization and fear or negative evaluation. DESIGN & MAIN OUTCOME MEASURES: Burn survivors (N = 224) completed the Fear of Negative Evaluation scale (FNE) and the Perceived Stigmatization Questionnaire (PSQ) at 3 months post-burn, and the Rosenberg Self-Esteem scale (RSE) and the Satisfaction with Appearance scale (SWAP) at 6 months post-burn. Path analysis was used to test the relationships. RESULTS: Body image dissatisfaction and self-esteem were moderately associated. Burn severity was directly and indirectly associated with body image dissatisfaction through perceived stigmatization. Female gender and age were indirectly associated with body image dissatisfaction though fear of negative evaluation. Age was indirectly associated with both perceived stigmatization and fear of negative evaluation. Perceived stigmatization and fear of negative evaluation were associated with self-esteem through body image dissatisfaction, the first indirectly and the latter both directly and indirectly. CONCLUSIONS: Findings highlight that both burn-specific factors and psychological vulnerability should be taken into account to deal with social challenges that may affect body image and self-esteem after burns.

No indications for altered EEG oscillatory activity in patients with chronic post-burn itch compared to healthy controls.

A large proportion of patients with burn injuries develop chronic itch, which impacts quality of life. The underlying pathophysiological mechanisms are poorly understood. This cross-sectional pilot study investigates whether altered cortical oscillatory processes are involved in chronic post-burn itch. Continuous electroencephalography (EEG) data were recorded during rest and stimulation of non-injured skin, inducing itch (histamine and electrical) and cold-pressor task pain for 15 adults with chronic post-burn itch and 15 matched healthy controls. Quantitative metrics comprised oscillatory power and peak frequencies in theta, alpha, and beta bands. No statistical differences between patients and healthy controls were found in oscillatory activity during rest or stimulation, with Bayesian analysis suggesting equivocal evidence. However, post-traumatic stress symptoms and duration of chronic itch may be associated with changes in oscillatory activity. A lack of differences in cortical oscillatory processing and itch levels at non-injured sites, suggests that itch symptoms have a localised character in this sample of patients with post-burn itch. For future studies, a biopsychological approach with integration of peripheral and central nervous system techniques, linear and non-linear EEG analysis, injured and non-injured stimulation sites, and incorporation of individual characteristics is recommended. Insight into pathophysiological mechanisms underlying chronic post-burn itch could improve diagnostics and treatments.

Posttraumatic stress symptoms and interpersonal processes in burn survivors and their partners.

Background: A burn event can elicit symptoms of posttraumatic stress disorder (PTSD) in survivors and their partners and may impact the way these couple members interact with each other. They may try to protect each other from further emotional distress by avoiding talking about the burn event, but they may also show concern towards each other.Objective: The aim of this study was to investigate bidirectional relationships between survivor's and partner's PTSD symptoms and two interpersonal processes: partner-oriented 'self-regulation', which is avoidance-oriented, and 'expressed concern', which is approach-oriented.Method: In this longitudinal multi-centre study, 119 burn survivors and their partners participated. Measures of PTSD symptoms, self-regulation, and expressed concern were administered in the acute phase following the burns, and follow-ups took place up to 18 months postburn. Intra- and interpersonal effects were examined in a random intercept cross-lagged panel model. Exploratory effects of burn severity were also investigated.Results: Within individuals, survivor's expressed concern predicted later higher levels of survivor's PTSD symptoms. In their partners, self-regulation and PTSD symptoms reinforced each other in the early phase postburn. Between the two couple members, partner's expressed concern predicted later lower levels of survivor's PTSD symptoms. Exploratory regression analyses showed that burn severity moderated the effect of survivor's self-regulation on survivor's PTSD symptoms, indicating that self-regulation was continuously related to higher levels of PTSD symptoms over time within more severely burned survivors, but not in less severely burned survivors.Conclusion: PTSD symptoms and self-regulation reinforced each other in partners and possibly also in more severely burned survivors. Partner's expressed concern was related to lower levels of survivor's PTSD symptoms, whereas survivor's expressed concern was related to higher levels of survivor's PTSD symptoms. These findings emphasize the importance of screening for and monitoring PTSD symptoms in burn survivors and their partner and of encouraging couple's self-disclosure.

PTSD symptoms in burn survivors and their partners are related to both avoidance- and approach-oriented interpersonal processes.In partners, higher levels of self-regulation were bidirectionally related to higher levels of posttraumatic stress symptoms.Concern expressed by partners may mitigate posttraumatic stress symptoms in burn survivors.

Activity Impairment, Work Status, and Work Productivity Loss in Adults 5-7 Years After Burn Injuries.

An important aspect of the rehabilitation of burn patients is social participation, including daily activities and work. Detailed information on long-term activity impairment and employment is scarce. Therefore, we investigated activity impairment, work status, and work productivity loss in adults 5-7 years following burn injuries, and investigated associations with burn-specific health-related quality of life (HRQL) domains. Adult participants completed the Work Productivity and Activity Impairment General Health questionnaire and the Burn Specific Health Scale-brief (BSHS-B) 5-7 years post-burn. Outcomes were compared between participants with mild/intermediate and severe burns (>20% total body surface area burned). Seventy-six (36%) of the 213 participants experienced some degree of activity impairment due to burn-related problems 5-7 years post-burn. Seventy percent of the population was employed; 12% of them experienced work productivity loss due to burn-related problems. Nineteen percent reported changes in their work situation (partly) because of the burn injury. A higher proportion of participants with severe burns had activity impairments (56% vs 29%; P = .001) and work productivity loss (26% vs 8%; P < .001) compared to participants with mild/intermediate burns. Activity impairment and work productivity loss were both associated with burn-related work problems and lower mood, measured with the BSHS-B. In conclusion, a substantial part of the study population experienced activity impairment and work productivity loss, was unemployed, and/or reported changes in their work situation due to their injury. Particularly patients with severe burns reported productivity loss and had lower employment rates. This subscribes the importance of addressing work-related functioning in the rehabilitation of burn patients.

Pain and Posttraumatic Stress Symptom Clusters: A Cross-Lagged Study.

Pain and posttraumatic stress disorder (PTSD) frequently co-occur but underlying mechanisms are not clear. This study aimed to test the development and maintenance of pain and PTSD symptom clusters, i.e., intrusions, avoidance, and hyperarousal. The longitudinal study included 216 adults with burns. PTSD symptom clusters, indexed by the Impact of Event Scale-Revised (IES-R), and pain, using a graphic numerical rating scale (GNRS), were measured during hospitalization, 3 and 6 months post-burn. Cross-lagged panel analysis was used to test the relationships between pain and PTSD symptom clusters. Cross-lagged results showed that in-hospital intrusions predicted pain and avoidance 3 months post-burn. In-hospital pain predicted intrusions and avoidance 3 months post-burn and a trend was found for hyperarousal (90% CI). In the second wave, intrusions predicted pain and hyperarousal. Pain predicted hyperarousal. This study provides support for an entangled relationship between pain and PTSD symptoms, and particularly subscribes the role of intrusions in this bidirectional relationship. To a lesser extent, hyperarousal was unidirectionally related to pain. These results may subscribe the driving role of PTSD, particularly intrusions, which partly supports the Perpetual Avoidance Model.

Prevalence and course of posttraumatic stress disorder symptoms in partners of burn survivors.

Background: Partners of burn survivors may develop posttraumatic stress disorder (PTSD) symptoms in response to the potential life threatening nature of the burn event and the burn survivor's medical treatment. Objective: This longitudinal study examined the prevalence, course and potential predictors of partners' PTSD symptoms up to 18 months post-burn. Methods: Participants were 111 partners of adult burn survivors. In a multi-centre study, PTSD symptoms were assessed with the Impact of Event Scale-Revised during the acute phase and subsequently at 3, 6, 12 and 18 months post-burn. Partners' appraisal of life threat, anger, guilt and level of rumination were assessed as potential predictors of PTSD symptoms in an exploratory piecewise latent growth model. Results: Acute PTSD symptoms in the clinical range were reported by 30% of the partners, which decreased to 4% at 18 months post-burn. Higher acute PTSD symptoms were related to perceived life threat and higher levels of anger, guilt, and rumination. Over time, mean symptom levels decreased, especially in partners with high levels of acute PTSD symptoms, perceived life threat and rumination. From three months onward, PTSD symptoms decreased less in partners of more severely burned survivors. At 18 months post-burn, higher levels of PTSD symptoms were related to higher acute PTSD symptoms and more severe burns. Conclusions: One in three partners reported clinical levels of acute PTSD symptoms, of which the majority recovered over time. Perceived life threat, feelings of anger and guilt, and rumination may indicate the presence of acute PTSD symptoms, whereas more severe burns predict long-term PTSD symptom levels. The results highlight the need to screen for acute PTSD symptoms and offer psychological help to partners to alleviate acute elevated stress levels if indicated.

Antecedentes: Las parejas de sobrevivientes de quemaduras pueden desarrollar síntomas de trastorno de estrés postraumático (TEPT) en respuesta a la naturaleza potencialmente mortal de las quemaduras y al tratamiento médico del sobreviviente de quemaduras.Objetivo: Este estudio longitudinal examinó la prevalencia, el curso y predictores potenciales de los síntomas de TEPT de la pareja hasta 18 meses después de la quemadura.Métodos: Los participantes fueron 111 parejas de adultos sobrevivientes de quemaduras. En un estudio multicéntrico, los síntomas de TEPT se evaluaron con la Escala de Impacto de Eventos Revisada durante la fase aguda y posteriormente a los 3, 6, 12 y 18 meses de la quemadura. La apreciación de las parejas de la amenaza de vida, ira, culpa y nivel de rumiación fueron evaluados como posibles predictores de síntomas de TEPT en un modelo exploratorio de crecimiento latente por partes.Resultados: El 30% de las parejas informó síntomas de TEPT agudo en rango clínico, que disminuyó a un 4% a los 18 meses después de la quemadura. Los síntomas agudos más altos de TEPT se relacionaron con la percepción de una amenaza para la vida y mayores niveles de ira, culpa y rumiación. Con el tiempo, los niveles promedio de síntomas disminuyeron, especialmente en parejas con altos niveles de síntomas agudos de TEPT, amenaza vital percibida y rumiación. A partir de los 3 meses, los síntomas del TEPT disminuyeron menos en las parejas de los sobrevivientes con quemaduras más graves. Pasados 18 meses de la quemadura, los niveles más altos de síntomas de TEPT se relacionaron con síntomas de TEPT agudos más altos y quemaduras más graves.Conclusiones: Una de cada tres parejas informó niveles clínicos de síntomas agudos de TEPT, de los cuales la mayoría se recuperó con el tiempo. La percepción de amenaza a la vida, los sentimientos de ira y culpa y la rumiación pueden indicar la presencia de síntomas agudos de TEPT, mientras que quemaduras más graves predicen síntomas de TEPT a largo plazo. Los resultados resaltan la necesidad de realizar tamizaje para síntomas agudos de TEPT y ofrecer ayuda psicológica a las parejas para aliviar los niveles elevados de estrés agudo, si está indicado.

Reliability and structural validity of the Dutch version of Perceived Stigmatization Questionnaire in adults with burns.

OBJECTIVE: Burn scars can attract attention from others which can be perceived as stigmatizing behavior with negative psychological consequences. The Perceived Stigmatization Questionnaire (PSQ) is a validated instrument measuring the perception of stigmatization in burn survivors. The objective of this study was to examine the psychometric properties of the Dutch version of the PSQ, specifically its factor structure, reliability, and associations with other relevant constructs. METHOD: Patients (N = 220) completed the PSQ at 3 months after burn. The factor structure was examined with explorative (EFA) and confirmatory (CFA) factor analyses at 3 and 12 months after burn, and reliability was examined using Cronbach's alpha. Three months measurements were used to examine associations of the PSQ with 'depressive mood' (Beck Depression Inventory, BDI-II), 'interpersonal relations' and 'body image' (Burn Specific Health Scale-Brief, BSHS-B), and two scales of the Illness Invalidation Inventory (3*I). RESULTS: A four factor model showed the best fit to the data. Two factors, 'confused/staring behavior' and 'hostile behavior', were identical to the original PSQ. The third original factor, 'absence of friendly behavior', was now divided into two factors separating absence of friendly behavior of strangers and other people. Internal consistency ranged from .60 to .88. Especially the 'confused/staring behavior' factor was related to the other questionnaire scores. CONCLUSION: The current study shows acceptable reliability and structural validity of the Dutch version of the PSQ in a 4-factor solution. Further research into measurement invariance across languages is recommended to establish a uniform multicultural instrument.

Bio-Psychological Predictors of Acute and Protracted Fatigue After Burns: A Longitudinal Study.

OBJECTIVE: Fatigue after burns is often attributed to the hyperinflammatory and hypermetabolic response, while it may be best understood from a bio-psychological perspective, also involving the neuro-endocrine system. This longitudinal multi-center study examined the course of fatigue up to 18 months postburn. The contribution of bio-psychological factors, including burn severity, pain, and acute PTSD symptoms, to the course and persistence of fatigue was studied in a multifactorial model. METHODS: Participants were 247 adult burn survivors. Fatigue symptoms were assessed with the Multidimensional Fatigue Inventory during the acute phase and subsequently at 3, 6, 12, and 18 months postburn, and were compared to population norms. Age, gender, burn severity, acute PTSD symptoms and pain were assessed as potential predictors of fatigue over time in a latent growth model. RESULTS: At 18 months postburn, 46% of the burn survivors reported fatigue, including 18% with severe fatigue. In the acute phase, higher levels of fatigue were related to multiple surgeries, presence of pain, and higher levels of acute PTSD symptoms. Fatigue gradually decreased over time with minor individual differences in rate of decrease. At 18 months, pain and acute PTSD symptoms remained significant predictors of fatigue levels. CONCLUSIONS: Protracted fatigue after burns was found in almost one out of five burn survivors and was associated with both pain and acute PTSD symptoms. Early detection of PTSD symptoms and early psychological interventions aimed at reducing PTSD symptoms and pain may be warranted to reduce later fatigue symptoms.

Individual recovery of health-related quality of life during 18 months post-burn using a retrospective pre-burn measurement: an exploratory study.

PURPOSE: This study explored the individual trajectories of health-related quality of life (HRQL) compared to recalled pre-burn level of HRQL and investigated whether burn severity and post-traumatic stress disorder (PTSD) symptoms increase the risk of not returning to pre-burn level of HRQL. METHODS: Data were obtained from 309 adult patients with burns in a multicenter study. Patients completed the EQ-5D-3L questionnaire with a Cognition bolt-on shortly after hospital admission, which included a recalled pre-injury measure, and, again, at 3, 6, 12 and 18 months post-burn. Burn severity was indicated by the number of surgeries, and PTSD symptoms were assessed with the IES-R at three months post-burn. Pre- and post-injury HRQL were compared to norm populations. RESULTS: Recalled pre-injury HRQL was higher than population norms and HRQL at 18 months post-burn was comparable to population norms. Compared to the pre-injury level of functioning, four HRQL patterns of change over time were established: Stable, Recovery, Deterioration, and Growth. In each HRQL domain, a subset of patients did not return to their recalled pre-injury levels, especially with regard to Pain, Anxiety/Depression, and Cognition. Patients with more severe burns or PTSD symptoms were less likely to return to pre-injury level of functioning within 18 months post-burn. CONCLUSION: This study identified four patterns of individual change. Patients with more severe injuries and PTSD symptoms were more at risk of not returning to their recalled pre-injury HRQL. This study supports the face validity of using a recalled pre-burn HRQL score as a reference point to monitor HRQL after burns.

Expert Elicitation for Latent Growth Curve Models: The Case of Posttraumatic Stress Symptoms Development in Children With Burn Injuries.

Experts provide an alternative source of information to classical data collection methods such as surveys. They can provide additional insight into problems, supplement existing data, or provide insights when classical data collection is troublesome. In this paper, we explore the (dis)similarities between expert judgments and data collected by traditional data collection methods regarding the development of posttraumatic stress symptoms (PTSSs) in children with burn injuries. By means of an elicitation procedure, the experts' domain expertise is formalized and represented in the form of probability distributions. The method is used to obtain beliefs from 14 experts, including nurses and psychologists. Those beliefs are contrasted with questionnaire data collected on the same issue. The individual and aggregated expert judgments are contrasted with the questionnaire data by means of Kullback-Leibler divergences. The aggregated judgments of the group that mainly includes psychologists resemble the questionnaire data more than almost all of the individual expert judgments.

Mothers' emotions after pediatric burn injury: Longitudinal associations with posttraumatic stress and depressive symptoms 18 months postburn.

BACKGROUND: Various emotions are implicated in posttraumatic stress disorder (PTSD). Longitudinal studies examining temporal associations between emotions and posttraumatic stress may reveal who is at risk of chronic psychological problems. This study examined the longitudinal relationships of mothers' trauma-related emotions with posttraumatic stress and depressive symptoms after pediatric burn injury. METHODS: Data from two cohort studies were used (n = 296). Mothers reported the intensity of burn-related emotions within the first month (T1) and 12 months postburn (T2). The Impact of Event Scale (IES) and the Hospital and Anxiety Depression Scale (HADS-D; depression subscale) were administered at T1 and 18 months postburn (T3). RESULTS: Based on two exploratory factor analyses, emotion variables were combined into acute and long-term basic emotions (fear, sadness, horror, anger) and self-conscious emotions (guilt, shame). The path model showed a positive relationship between acute and long-term basic emotions. Higher long-term basic emotions were related to persistence of posttraumatic stress and depressive symptoms. Acute self-conscious emotions showed associations with posttraumatic stress and depressive symptoms at T1 and were longitudinally related to depressive, but not posttraumatic stress, symptoms. LIMITATIONS: The posttraumatic stress measure was not based on DSM-5 PTSD criteria and results require replication using these criteria. CONCLUSIONS: This study suggests that mothers' acute self-conscious and long-term basic emotions in relation to their child's burn injury are involved in the development of posttraumatic stress and depressive symptoms. Clinically, assessing and monitoring parents' early posttraumatic stress, depressive symptoms and burn-related emotions may be useful to identify parents at risk.

Improved and standardized method for assessing years lived with disability after burns and its application to estimate the non-fatal burden of disease of burn injuries in Australia, New Zealand and the Netherlands.

BACKGROUND: Burden of disease estimates are an important resource in public health. Currently, robust estimates are not available for the burn population. Our objectives are to adapt a refined methodology (INTEGRIS method) to burns and to apply this new INTEGRIS-burns method to estimate, and compare, the burden of disease of burn injuries in Australia, New Zealand and the Netherlands. METHODS: Existing European and Western-Australian health-related quality of life (HRQL) datasets were combined to derive disability weights for three homogenous burn injury groups based on percentage total body surface area (%TBSA) burned. Subsequently, incidence data from Australia, New Zealand, and the Netherlands from 2010 to 2017 were used to compute annual non-fatal burden of disease estimates for each of these three countries. Non-fatal burden of disease was measured by years lived with disability (YLD). RESULTS: The combined dataset included 7159 HRQL (EQ-5D-3 L) outcomes from 3401 patients. Disability weights ranged from 0.046 (subgroup < 5% TBSA burned > 24 months post-burn) to 0.497 (subgroup > 20% TBSA burned 0-1 months post-burn). In 2017 the non-fatal burden of disease of burns for the three countries (YLDs/100,000 inhabitants) was 281 for Australia, 279 for New Zealand and 133 for the Netherlands. CONCLUSIONS: This project established a method for more precise estimates of the YLDs of burns, as it is the only method adapted to the nature of burn injuries and their recovery. Compared to previous used methods, the INTEGRIS-burns method includes improved disability weights based on severity categorization of burn patients; a better substantiated proportion of patients with lifelong disability based; and, the application of burn specific recovery timeframes. Information derived from the adapted method can be used as input for health decision making at both the national and international level. Future studies should investigate whether the application is valid in low- and middle- income countries.

Recovery of health-related quality of life after burn injuries: An individual participant data meta-analysis.

BACKGROUND: A prominent outcome measure within burn care is health related quality of life (HRQL). Until now, no model for long-term recovery of HRQL exists for adult burn patients which requires large samples with repeated measurements. Re-use and the combination of existing data is a way to achieve larger data samples that enable the estimation of long-term recovery models. The aim of this secondary data analysis was to assess the recovery of HRQL after a burn injury over time. METHODS AND FINDINGS: Data from ten European studies on generic HRQL assessed in adult burn patients (either with the EQ-5D or SF-36) from five different countries were merged into one dataset. SF-36 outcomes were transformed into EQ-5D outcomes. A 24-month recovery of HRQL (EQ-5D utility) was modeled using a linear mixed-effects model and adjusted for important patient and burn characteristics. Subgroups of patients with mild and intermediate burns (≤20% total body surface area (TBSA) burned) and with major burns (>20% TBSA burned) were compared. The combined database included 1687 patients with a mean age of 43 (SD 15) years and a median %TBSA burned of 9% (IQR 4-18). There was large improvement in HRQL up to six months after burns, and HRQL remained relatively stable afterwards (studied up to 24 months post burn). However, the estimated EQ-5D utility scores remained below the norm scores of the general population. In this large sample, females, patients with a long hospital stay and patients with major burns had a delayed and worse recovery. The proportion of patients that reported problems for the EQ-5D dimensions ranged from 100% (pain/discomfort at baseline in patients with major burns) to 10% (self-care ≥3 months after injury in patients with mild and intermediate burns). After 24 months, both subgroups of burn patients did not reach the level of the general population in the dimensions pain/discomfort and anxiety/depression, and patients with major burns in the dimension usual activities. A main limitation of the study includes that the variables in the model were limited to age, gender, %TBSA, LOS and time since burn as these were the only variables available in all datasets. CONCLUSIONS: The 24-month recovery model can be used in clinical practice to inform patients on expected HRQL outcomes and provide clinicians insights into the expected recovery of HRQL. In this way, a delayed recovery can be recognized in an early stage and timely interventions can be started in order to improve patient outcomes. However, external validation of the developed model is needed before implementation into clinical practice. Furthermore, our study showed the benefit of secondary data usage within the field of burns.

Parents' memories and appraisals after paediatric burn injury: a qualitative study.

Background: It is well established that a paediatric burn injury can lead to parental post-traumatic stress symptoms. The content of parents' memories and appraisals may reveal the traumatic experiences that need attention. Objective: To inform clinical practice, the aim of this study was to qualitatively examine parents' (intrusive) memories and appraisals, and associated emotions, concerning the injury, the hospitalisation, and its consequences. Method: Approximately three to six months after the burn event, semi-structured interviews were conducted with parents of 18 children (0-16 years old) that had been hospitalised for a burn injury. Thematic analysis was carried out to obtain themes. Results: A central element in parents' memories and appraisals was a sense of external or internal threat. Intrusive memories were predominantly related to the accident and first aid (i.e. threat of the injury), whereas parents' memories about the child's suffering were emotional but not experienced as intrusive. Later appraisals of the burn injury and its consequences included negative appraisals of the child's increased vulnerability, responsibility of self or other, the child's prolonged suffering and (risk of) permanent change, as well as appraisals of positive outcome and recovery. Emotions commonly reported in the context of memories and appraisals were fear, sadness, guilt, and relief. Conclusions: This study offers insight into the traumatic nature of paediatric burn injury from the parent's perspective and provides directions for the delivery of trauma-informed (after)care.

Antecedentes: está bien establecido que una lesión por quemadura pediátrica puede provocar síntomas de estrés postraumático en los padres. El contenido de los recuerdos y de su evaluación por parte de los padres, puede revelar las experiencias traumáticas que necesitan atención.Objetivo: Informar la práctica clínica, el objetivo de este estudio fue examinar cualitativamente los recuerdos (intrusivos) de los padres y sus evaluaciones, y las emociones asociadas, en relación con la lesión, la hospitalización y sus consecuencias.Método: Aproximadamente de tres a seis meses después del evento de quemadura, se realizaron entrevistas semiestructuradas con padres de 18 niños (de 0 a 16 años de edad) que habían sido hospitalizados por una lesión por quemadura. Se realizó un análisis temático para obtener los temas.Resultados: Un elemento central en los recuerdos y evaluaciones de los padres era una sensación de amenaza externa o interna. Los recuerdos intrusivos se relacionaban predominantemente con el accidente y los primeros auxilios (i.e. la amenaza de lesión), mientras que los recuerdos de los padres sobre el sufrimiento del niño eran emocionales, pero no experimentado como intrusivo. Las evaluaciones posteriores de la lesión por quemaduras y sus consecuencias incluyeron evaluaciones negativas del aumento en la vulnerabilidad del niño, responsabilidad de sí mismo o de otro, el sufrimiento prolongado del niño y (el riesgo de) cambio permanente, así como una evaluación de resultados positivos y recuperación. Las emociones comúnmente reportadas en el contexto de los recuerdos y las valoraciones fueron el miedo, la tristeza, la culpa y el alivio.Conclusiones: este estudio ofrece información sobre la naturaleza traumática de la lesión por quemadura pediátrica desde la perspectiva de los padres y brinda instrucciones para brindar atención (posterior) a los traumas.

Health related quality of life 5-7 years after minor and severe burn injuries: a multicentre cross-sectional study.

INTRODUCTION: Burn injury can affect health-related quality of life (HRQL). Knowledge concerning long-term HRQL in burn patients is limited. Therefore our aim was to evaluate long-term HRQL and to study predictors of impaired long-term HRQL. METHODS: All adults with a length of stay (LOS) of ≥1 day (2011-2012) were invited. Also, adults with severe burns, i.e., >20% total body surface area (TBSA) burned or TBSA full thickness>5% (2010-2013) were invited. Participants completed the EuroQol(EQ)-5 D-5L + C and visual analogue scale (EQ-VAS) 5-7 years after burns. RESULTS: This study included 256 patients (mean %TBSA 10%); 187 patients with minor burns and 69 patients with severe burns. Mean EQ-5D summary was 0.90 and EQ-VAS 83.2 in the minor burn patients, and 0.79 and 78.1 in the severe burn patients. Some problems in at least one dimension were experienced by 81% of patients with severe burns and 45% of those with minor burns. However, a minority reported severe or extreme problems; 15% of those with severe burns and 6% of those with minor burns. Patients with severe burns reported significantly more problems, except for anxiety/depression. In both patient groups most problems were reported on pain/discomfort. Length of hospital stay, gender and age were associated with lower long-term HRQL (EQ-VAS) in multivariate analyses, whereas only length of stay was associated with a lower summary score. CONCLUSIONS: The majority of patients experienced some problems with HRQL 5-7 years post burn. This emphasizes that burns can have a negative impact on an individual's HRQL, particularly in more severely burned patients, that persists for years. The HRQL dimensions most frequently affected include pain/discomfort and anxiety/depression. Patients with a prolonged hospital stay, females and older patients are at higher risk of poor HRQL in the long-term.

Course and Predictors of Pruritus Following Burns: A Multilevel Analysis.

Itch is a common problem after burns. Although the topic receives increasing attention, the number of prospective studies is limited. The aim of this study was to assess the influence of acute traumatic stress symptoms, controlled for injury characteristics, age and sex, on itch over a period of 18 months using multilevel analysis. A total of 226 respondents provided itch scores. Participants completed the Burn Itch Questionnaire during admission (n = 208) and at 3 (n =179), 12 (n =143) and 18 (n =99) months post-burn. They completed the Impact of Event Scale to assess acute traumatic stress symptoms during admission. Skin graft requirement, a higher level of acute traumatic stress symptoms and younger age were statistically significant predictors of a higher itch score. Younger age was particularly associated with higher itch scores during admission, whereas the effect of skin grafting was particularly observed at 3 months post-burn. This study replicates the predictive role of traumatic stress symptoms, which warrants further research.

Predictors of health-related quality of life after burn injuries: a systematic review.

BACKGROUND: Identifying predictors of health-related quality of life (HRQL) following burns is essential for optimization of rehabilitation for burn survivors. This study aimed to systematically review predictors of HRQL in burn patients. METHODS: Medline, Embase, Web of Science, Cochrane, CINAHL, and Google Scholar were reviewed from inception to October 2016 for studies that investigated at least one predictor of HRQL after burns. The Quality in Prognostic Studies tool was used to assess risk of bias of included studies. RESULTS: Thirty-two studies were included. Severity of burns, postburn depression, post-traumatic stress symptoms, avoidance coping, less emotional or social support, higher levels of neuroticism, and unemployment postburn were found to predict a poorer HRQL after burns in multivariable analyses. In addition, weaker predictors included female gender, pain, and a postburn substance use disorder. Risk of bias was generally low in outcome measurement and high in study attrition and study confounding. CONCLUSIONS: HRQL after burns is affected by the severity of burns and the psychological response to the trauma. Both constructs provide unique information and knowledge that are necessary for optimized rehabilitation. Therefore, both physical and psychological problems require attention months to years after the burn trauma.

Mother, father and child traumatic stress reactions after paediatric burn: Within-family co-occurrence and parent-child discrepancies in appraisals of child stress.

AIM: The current study examined occurrence and within-family associations of traumatic stress reactions after child burn injury, while in the same model addressing the role of parents' own symptoms in their reports of child symptoms. METHODS: One-hundred children (8-18 years old), and their mothers (n=90) and fathers (n=74) were assessed within the first month (T1) and three months (T2) after burn. Parents and children rated child traumatic stress reactions on the Children's Responses to Trauma Inventory (CRTI) and parents rated their own reactions on the Impact of Event Scale (IES). Cross-sectional associations at the two occasions were examined using a structural equation model. RESULTS: Occurrence of traumatic stress symptoms in the clinical range was higher in parents (T1: 24-50%; T2: 14-31%) than children (T1: 0-11%; T2: 3-5%, depending on whether children, mothers or fathers reported on symptoms). Traumatic stress symptoms of mothers at T1 and of both parents at T2 were significantly related to child self-reported symptoms. Moreover, mothers who experienced higher stress symptoms themselves gave higher ratings of their child's symptoms at both time points, while for fathers, this was only found at T2. CONCLUSIONS: The current study demonstrates the impact of pediatric burn injury on the family level, and shows simultaneous existence of within-family interrelatedness of traumatic stress and an influence of parents' own symptoms on their perception of child symptoms. Findings highlight the need for trauma symptom screening in all family members and for considering informants' symptoms to understand the child's functioning in particular.

Bayesian PTSD-Trajectory Analysis with Informed Priors Based on a Systematic Literature Search and Expert Elicitation.

There is a recent increase in interest of Bayesian analysis. However, little effort has been made thus far to directly incorporate background knowledge via the prior distribution into the analyses. This process might be especially useful in the context of latent growth mixture modeling when one or more of the latent groups are expected to be relatively small due to what we refer to as limited data. We argue that the use of Bayesian statistics has great advantages in limited data situations, but only if background knowledge can be incorporated into the analysis via prior distributions. We highlight these advantages through a data set including patients with burn injuries and analyze trajectories of posttraumatic stress symptoms using the Bayesian framework following the steps of the WAMBS-checklist. In the included example, we illustrate how to obtain background information using previous literature based on a systematic literature search and by using expert knowledge. Finally, we show how to translate this knowledge into prior distributions and we illustrate the importance of conducting a prior sensitivity analysis. Although our example is from the trauma field, the techniques we illustrate can be applied to any field.