Jayme Adriano Farina

Curbing Inflammation in Burn Patients

Patients who suffer from severe burns develop metabolic imbalances and systemic inflammatory response syndrome (SIRS) which can result in multiple organ failure and death. Research aimed at reducing the inflammatory process has yielded new insight into burn injury therapies. In this review, we discuss strategies used to curb inflammation in burn injuries and note that further studies with high quality evidence are necessary.

Reliability and validity of the Impact of Event Scale (IES): version for Brazilian burn victims

AIMS The aims of this study were to assess the internal reliability (internal consistency), construct validity, sensitivity and ceiling and floor effects of the Brazilian-Portuguese version of the Impact of Event Scale (IES). DESIGN Methodological research design. METHOD The Brazilian-Portuguese version of the IES was applied to a group of 91 burned patients at three times: the first week after the burn injury (time one), between the fourth and the sixth months (time two) and between the ninth and the 12th months (time three). The internal consistency, construct validity (convergent and dimensionality), sensitivity and ceiling and floor effects were tested. RESULTS Cronbachs alpha coefficients showed high internal consistency for the total scale (0·87) and for the domains intrusive thoughts (0·87) and avoidance responses (0·76). During the hospitalisation (time one), the scale showed low and positive correlations with pain measures immediately before (r=0·22; p<0·05) and immediately after baths and dressings (r=0·21; p<0·05). After the discharge, we found strong and negative correlations with self-esteem (r=-0·52; p<0·01), strong and positive with depression (r=0·63; p<0·01) and low and negative with the Bodily pain (r=-0·24; p<0·05), Social functioning (r=-0·34; p<0·01) and Mental health (r=-0·27; p<0·05) domains of the SF-36 at time two. Regarding the sensitivity, no statistically significant differences were observed between mean scale scores according to burned body surface (p=0·21). The floor effect was observed in most of the IES items. CONCLUSION The adapted version of the scale showed to be reliable and valid to assess postburn reactions on the impact of the event in the group of patients under analysis. RELEVANCE TO CLINICAL PRACTICE The Impact of Event Scale can be used in research and clinical practice to assess nursing interventions aimed at decreasing stress during rehabilitation.

Reliability and validity of the Brazilian-Portuguese version of the Burns Specific Pain Anxiety Scale (BSPAS).

BACKGROUND Pain and anxiety are a common problem in all recovery phases after a burn. The Burns Specific Pain Anxiety Scale (BSPAS) was proposed to assess anxiety in burn patients related to painful procedures. OBJECTIVES To assess internal consistency, discriminative construct validity, dimensionality and convergent construct validity of the Brazilian-Portuguese version of the Burns Specific Pain Anxiety Scale. DESIGN In this cross-sectional study, the original version of the BSPAS, adapted into Brazilian Portuguese, was tested for internal consistency (Cronbachs Alpha), discriminative validity (related to total body surface area burned and sex), dimensionality (through factor analysis), and convergent construct validity (applying the Visual Analogue Scale for pain and State-Anxiety-STAI) in a group of 91 adult burn patients. RESULTS The adapted version of the BSPAS displayed a moderate and positive correlation with pain assessments: immediately before baths and dressings (r=0.32; p<0.001), immediately after baths and dressings (r=0.31; p<0.001) and during the relaxation period (r=0.31; p<0.001) and with anxiety assessments (r=0.34; p<0.001). No statistically significant differences were observed when comparing the mean of the adapted version of the BSPAS scores with sex (p=0.194) and total body surface area burned (p=0.162) (discriminative validity). The principal components analysis applied to our sample seems to confirm anxiety as one single domain of the Brazilian-Portuguese version of the BSPAS. Cronbachs Alpha showed high internal consistency of the adapted version of the scale (0.90). CONCLUSION The Brazilian-Portuguese version of the BSPAS 9-items has shown statically acceptable levels of reliability and validity for pain-related anxiety evaluation in burn patients. This scale can be used to assess nursing interventions aimed at decreasing pain and anxiety related to the performance of painful procedures.

Effect of Acute Thermal Injury in Status of Serum Vitamins, Inflammatory Markers, and Oxidative Stress Markers: Preliminary Data

The objective of this study was to evaluate the vitamin status, inflammatory markers, and oxidative stress markers in adult patients up to 3 days after thermal injury. This prospective study was conducted with 11 patients 24 to 72 hours after thermal injury (Burn Group), total surface area ranging from 10 to 41%, 34.3 ± 9.3 years, 82% of males, body mass index of 22.3 ± 2.9 kg/m2. We included 11 healthy adults (Control Group), 36.5 ± 7.6 years, 73% of males, and body mass index of 23.8 ± 2.5 kg/m2. Laboratory data were measured (plasma total protein, albumin, transferrin, lymphocyte counts, zinc, and iron), as well as serum vitamins (folic acid, vitamin B12, and vitamins A, C, and E), inflammatory stress markers (C-reactive protein, ferritin, and acid &agr;1-glycoprotein) and oxidative stress markers such as glutathione peroxidase (GPx) and thiobarbituric acid reactive substances. The inflammatory stress was characterized by lower levels of total protein (median difference 1.2 g/dL, 95% CI: 0.4–2.1) and albumin (median difference 0.9 g/dL, 95% CI: 0.5–1.5), and higher levels of C-reactive protein (median difference −8.12 mg/dL, 95% CI: −11.62 to 4.61) and &agr;-1 glycoprotein acid (median difference −28.56 mg/dL, 95% CI: −51.57 to −5.07) in burn patients. Decreased serum levels of vitamin A (median difference 1.10 &mgr;mol/L, 95% confidence interval [CI]: 0.42–1.66) and vitamin C (median difference 0.82 mg/dL, 95% CI: 0.50–1.04) were also detected. There was no statistical evidence of difference in the serum levels of glutathione peroxidase and thiobarbituric acid reactive substances between burn patients and controls, respectively. Even though there is an inflammatory stress, the obtained data showed that oxidative stress markers are normal 24 to 72 hours after burn injury. The decrease in negative acute phase protein may account for the diminished serum levels of vitamin A, which seems to be related to inflammatory stress. The marked decrease in the serum levels of vitamin C can be justified by augmented cutaneous loss and consumption in the regeneration of vitamin E.

Reliability and Validity of the Body Image Quality of Life Inventory: Version for Brazilian Burn Victims

The aims of this study were to adapt the Body Image Quality of Life Inventory (BIQLI) into Brazilian Portuguese (BP) and to assess the psychometric properties of the adapted version. Construct validity was assessed by correlating the BIQLI-BP scores with the Rosenbergs Self-Esteem Scale, with Burns Specific Health Scale-Revised (BSHS-R), and with gender, total body surface area burned, and visibility of the scars. Participants were 77 adult burn patients. Cronbachs alpha for the adapted version was .90 and moderate linear correlations were found between body image and self-esteem and between BIQLI-BP scores and two domains of the BSHS-R: affect and body image and interpersonal relationships. The BIQLI-BP showed acceptable levels of reliability and validity for Brazilian burn patients.

Preventing infections due to intravascular catheters in burn victims

Venous catheters are associated with severe complications that present high morbidity and mortality rates. The objective of this study was to identify the available scientific evidence regarding nursing interventions for the prevention of infections related to the presence of central or peripheral venous catheters in burn patients. We performed a search of the PubMed, Latin American and Caribbean Center on Health Sciences Information and Cochrane databases from March 2008 to March 2009. There is only limited evidence regarding interventions that may have a positive impact in preventing venous catheter-related infection in burn victims. We recommend the interpretation of the CDC guidelines as a basis to organize protocols to prevent catheter-related infection in burns.

Inflammatory and oxidative stress after surgery for the small area corrections of burn sequelae

PURPOSE To compare vitamin levels, inflammatory and oxidative stress markers before and after skin autograft surgery to correct burn scar areas. METHODS This prospective study was conducted with 8 patients with a median age of 28 years (range, 16 to 40 years) that had burn sequelae and were admitted to a Burn Unit for correction of small burn scar areas [3.3 (1.0-5.0) % of the corporal surface]. The volunteers were evaluated before and 48 hours after excision of scar tissue and skin autograft. Routine laboratory data, along with a food questionnaire and anthropometry were collected in the preoperative period. Serum vitamin A, C, E, B(12) and folic acid levels, inflammatory markers (C-protein reactive, alpha-1-acid glycoprotein, ferritin) and oxidative stress markers (reduced glutathione - GSH and Thiobarbituric Acid Reactive Substances - TBARS) were determined at preoperative and postoperative phases. Data were analyzed with two-sample Wilcoxon test. RESULTS All volunteers were clinically stable and had adequate nutritional status at admission. After surgery, C-reactive protein serum levels increased [0.4 (0.01-1.0) vs. 2.5 (0.6-4.7) mg/dL, p=0.01] and vitamin A levels decreased [3.4 (2.1-4.2) vs. 2.4 (1.6-4.1) µmol/L, p=0.01]. No changes occurred in other vitamins, ferrritin, alpha-1-acid glycoprotein, GSH and TBARS levels. CONCLUSION Minimal metabolic changes were produced after skin autograft in small areas of well-nourished patients without active infection or inflammation.

Validation of the Perceived Stigmatization Questionnaire for Brazilian adult burn patients

Currently, there is no questionnaire to assess perceived stigmatization among people with visible differences in Brazil. The Perceived Stigmatization Questionnaire (PSQ), developed in the United States, is a valid instrument to assess the perception of stigmatizing behaviours among burn survivors. The objective of this cross-sectional and multicentre study was to assess the factor structure, reliability and validity of the Brazilian Portuguese version of the PSQ in burn patients. A Brazilian version of the 21-item PSQ was answered by 240 adult burn patients, undergoing rehabilitation in two burns units in Brazil. We tested its construct validity by correlating PSQ scores with depression (Beck Depression Index-BDI) and self-esteem (Rosenberg Self-Esteem Scale-RSE), as well as with two domains of the Revised Burn Specific Health Scale—BSHS-R: affect and body image, and interpersonal relationships. We used Confirmatory Item Factor Analysis (CIFA) to test whether the data fit a measurement model involving a three-factor structure (absence of friendly behaviour; confusing/staring behaviour; and hostile behaviour). We conducted Exploratory Factor Analyses (EFA) of the subscale in a 50% random sample of individuals (training split), treating items as ordinal categorical using unweighted least squares estimation. To assess discriminant validity of the Brazilian version of the PSQ we correlated PSQ scores with known groups (sex, total body surface area burned, and visibility of the scars) and assessed its reliability by means of Cronbachs alpha and using test-retest. Goodness-of-fit indices for confirmatory factor analysis were satisfactory for the PSQ, but not for the hostile behaviour subscale, which was modified to improve fit by eliminating 3 items. Cronbach’s alphas for the PSQ refined version (PSQ-R) ranged from 0.65 to 0.88, with test-retest reliability 0.87 for the total score. The PSQ-R scores correlated strongly with depression (0.63; p < 0.001), self-esteem (-0.57; p < 0.001), body image (-0.63; p < 0.001), and interpersonal relationships (-0.55; p < 0.001). PSQ-R total scores were significantly lower for patients with visible scars (effect size = 0.51, p = 0.029). The PSQ-R showed reliability and validity comparable to the original version. However, the cross-cultural structure of the subscale “hostile behaviour” and sensitivity to change of the PSQ should be further evaluated.

Does postauricular fascial flap reduce suture complications in otoplasty

Abstract Numerous suture techniques and covering flaps have been described to minimize complications related to sutures in otoplasty. The split postauricular fascial flap is one of such techniques, and it has been used to pad otoplasty suture. The aim of this study was to evaluate complications related to nonabsorbable cartilage sutures in otoplasty, using a variation of the split postauricular fascial flap. In this retrospective case series, we analyzed otoplasty patients in whom simplified split postauricular fascial flap was utilized. A postauricular skin ellipse was de-epithelialized (preserving dermis) and a longitudinally split in half. Flaps were dissected, and they were positioned on the cartilage to promote additional soft tissue coverage to the sutures. The lateral flap covered conchoscaphal sutures while the medial flap covered the conchomastoid sutures. Both the flaps were not sutured to cartilage. Early and late postoperative complications were evaluated. A total of 142 patients were included. Twenty-four (16.9%) patients developed late complications: 13 (9.1%) patients had palpable and visible sutures, nine (6.3%) had suture extrusion and two (1.4%) had hypertrophic scars. In this case series, the simplified split postauricular flap did not prevent or reduce late complications related to suture extrusion in otoplasty. It is possible that suturing the entire length of the flaps may play a role in our results. So, anchoring the flap and possibly tightening it a little may be an important technical step to prevent extrusion of sutures whenever the postauricular flap is used.

Revisiting Escharotomy in Patients With Burns in Extremities.

Escharotomy incisions must be made in the inelastic skin eschar that is typical of circumferential third-degree burns. Later, the necrotic tissue must be debrided and substituted with a skin graft. Many reports on this topic have revealed that concepts and techniques vary widely. This study aims to present a critical review of the literature about escharotomy in burns and to highlight a different strategy to perform escharotomy in patients with burned extremities. We conducted a critical review in Pubmed/MEDLINE using the keywords “escharotomy” and “burns.” In the present study, we included 22 articles published from 1955 to 2015 (60 years) that contain the aforementioned keywords. With respect to the extremities, most of the publications recommend that medial and lateral longitudinal incisions be performed and that care must be taken to avoid deep structures, particularly nerves. Moreover, the publications mention that escharotomy might result in thick, hypertrophic, retracting, and painful scars. We advocate that incisions performed only on the lateral and medial borders of the extremities are usually unnecessary, and that they contribute to the creation of misconceptions about burns. In addition, these incisions can somehow trigger complications that can be avoided by using the concept of escharotomy in multiple directions, as highlighted in this review.