Andrew M. Munster

Personality predictors of injury-related posttraumatic stress disorder

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

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

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

Inhibition of apoptosis in polymorphonuclear neutrophils from burn patients.

Normal human polymorphonuclear neutrophils (PMN) undergo rapid apoptosis during in vitro culture. In contrast, apoptosis is inhibited in PMN from patients with severe burns. This inhibition is not an inherent property of the cells but is caused by thermolabile factors present in the plasma. Endotoxin and the proinflammatory cytokines interleukin‐1 (IL‐1), interleukin‐6 (IL‐6), and tumor necrosis factor‐alpha (TNF‐α) do not appear to be directly responsible. The ability of burn plasma to inhibit apoptosis was reduced by neutralizing antibodies to human granulocyte macrophage colony‐stimulating factor (GM‐CSF). GM‐CSF levels could not be detected in the burn plasma. However, the incubation of burn‐derived or normal leukocyte populations consisting primarily of PMN in burn plasma induced the production of GM‐CSF. The results suggest that activation of GM‐CSF synthesis by factor(s) in burn plasma may play a role in regulating inflammation by the inhibition of apoptosis.

The effect of early surgical intervention on mortality and cost-effectiveness in burn care, 1978-91

A 14-year (1978-91) single centre analysis was performed involving 3561 patients. Several variables thought to influence burn outcome were included in the analysis, as was length of stay, interval between surgical interventions on each patient, and cost of care. Mortality rate declined by over 2 per cent (from 9.8 per cent during the first 7 years to 7.3 per cent in the second 7 years, P < 0.001). Multiple regression showed that percentage burn, presence of inhalation injury, and age had a significant effect on mortality. These variables, as well as the DRG distribution, were statistically evenly distributed over the 14-year study. There was a statistically significant decrease in length of stay (23 days in 1979 to 14.2 days in 1990), which significantly correlated with a decrease in interval between surgical interventions (14.76 days in 1979 to 6.12 days in 1990). The average annual increase of hospital charges for burn care grew at 9.6 per cent annually, higher than the consumer price index during the same time (5.8 per cent) but substantially lower than the hospital market as a whole (10.8 per cent). Mortality rate of major burns has decreased significantly in this study, while burn severity indices remained constant. Increase in cost of care was substantially lower than that of general hospital care. This apparent cost efficiency is driven by a decreased length of stay closely correlated with aggressive surgical intervention for closure of the burn wound.

Development and Validation of the Satisfaction with Appearance Scale: Assessing Body Image among Burn-Injured Patients.

The Satisfaction With Appearance Scale (SWAP) is a 14-item questionnaire, assessing both the subjective appraisal and social-behavioral components of body image among burn survivors. Burn survivors requiring hospitalization (n = 165) completed a packet of psychometric instruments, including the SWAP at 1-week postdischarge. The SWAP demonstrated a high level of intemal consistency (Cronbachs alpha, r a = .87; the mean interitem correlation, r ii = .32, the mean item-total correlation, r ii = .53). Eighty-four participants were retested approximately 2 months after the initial assessment to evaluate test-retest reliability (r ii , = .59). A principal-components analysis with a varimax rotation yielded 4 easily interpretable factors accounting for 66% of the total variance. The correlations of the SWAP total score with other selected psychometric measures provided evidence for both convergent and discriminant validity. This initial evaluation of the SWAP suggests that it is both a reliable and valid measure of body image for a burn-injured population.

Burns of the hand and upper limb—a review

This review article addresses the principles and controversies associated with thermal injury to the hand and upper limb. Accepted principles are outlined and areas of controversy are discussed in a balanced manner. The importance of hand burns is described functionally and epidemiologically. Burns appropriate to outpatient care are defined and treatment discussed, including debridement, topical therapy, rehabilitation and follow-up. The general principles of inpatient management are given, including the controversial issue to timing of surgery and treatment of the exposed tendon or joint. The extent of surgery, methods of wound closure and difficult problem of palm burns are also discussed. Reconstructive principles are outlined and a problem oriented approach to the most common reconstructive problems given.

American Burn Association/Shriners Hospitals for Children burn outcomes questionnaire: construction and psychometric properties

To develop a standardized, practical, self-administered questionnaire to monitor pediatric patients with burns and to evaluate the effectiveness of comprehensive pediatric burn management treatments, a group of experts generated a set of items to measure relevant burn outcomes. Children between the ages of 5 and 18 years were assessed in a cross-sectional study. Both parent and adolescent responses were obtained from children 11 to 18 years old. The internal reliability of final scales ranged from 0.82 to 0.93 among parents and from 0.75 to 0.92 among adolescents. Mean differences between parent and adolescent were small; the greatest difference occurred in the appearance subscale. Parental scales showed evidence of validity and potential for sensitivity to change. In an effort to support the construct validity of the new scales, they were compared with the Child Health Questionnaire and related to each other in clinically sensible ways. These burn outcomes scales reliably and validly assess function in patients with burns, and the scales have been developed in such a way that they are likely to be sensitive to change over time.

Translocation: Incidental phenomenon or true pathology?

OBJECTIVEnThis study was conducted to determine if reduction of early postburn endotoxemia influences the cytokine cascade, clinical manifestations of sepsis, and mortality rate.nnnSUMMARY BACKGROUND DATAnTranslocational endotoxemia has been demonstrated postburn in animals and humans. Endotoxin is known to induce the cytokine cascade, which leads to the clinical manifestations of sepsis. Whether reduction of postburn endotoxemia could influence the induction of cytokines has not been demonstrated.nnnMETHODSnIn a prospective, randomized study, 76 burn patients were given polymyxin intravenously or served as control subjects. Polymyxin B was given intravenously for 1 week postburn in doses designed to neutralize circulating endotoxemia.nnnRESULTSnIn the polymyxin group, there was a statistically significant reduction in the plasma endotoxin concentration. There was, however, no reduction in the sepsis score or the interleukin-6 levels, and no differences in mortality rates were seen between the two groups.nnnCONCLUSIONSnEarly postburn translocational endotoxemia can be treated with anti-endotoxin agents such as polymyxin B. This, however, does not influence the cytokine cascade or the mortality rate. The systemic inflammatory response syndrome is caused by cytokine induction from the injury and is unaffected by a reduction in the plasma endotoxin concentration.

Clinical predictors of myocardial damage after high voltage electrical injury

Myocardial damage after high voltage electrical body injury is a serious and often life-threatening situation. The purpose of this pilot study was to identify early clinical predictors of myocardial damage in patients with high voltage electrical injury. Twenty-four patients with high voltage electrical injuries and no evidence of arc burns were evaluated. In 13/24 patients the diagnosis of myocardial damage was confirmed by total creatine kinase (CK) and creatine kinase MB (CK-MB) isoenzyme elevation (group A). In these patients the total CK range was 1373 to 52,544 mU/ml. In 11/24 patients CK-MB was negative (group B) indicating absence of myocardial damage. ECG changes occurred in 10/13 group A and 4/11 group B patients (p less than .095). No patient in either group gave a history suggestive of myocardial ischemia after the electrical injury. The pathways of electricity through the body, as mapped by a line drawn between the wound(s) of entrance and exit, were vertical in all group A patients, i.e., from upper to lower body segment, vs. 5/11 group B patients with evidence of a vertical pathway (p less than .003). Group A patients also had greater body surface burns (16.0 +/- 2.7%) vs. group B patients (4.0 +/- 1.6%, p less than .001). The presence of a vertical pathway and the magnitude of percent surface burns were found to be the most significant clinical predictors of myocardial damage in multiple logistic regression analysis (p less than .0001).(ABSTRACT TRUNCATED AT 250 WORDS)

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

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