Rhonda S. Robert

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.

Long-term psychosocial adaptation of children who survive burns involving 80% or greater total body surface area

OBJECTIVE To examine the psychosocial adjustment of survivors of massive pediatric burn injuries, the change in adjustment across time, and the impact on parents. BACKGROUND Patients/parents were assessed at regular intervals postburn using standardized tests of adjustment. Patients who could not be included in standardized longitudinal assessments were administered questionnaires by mail/telephone. METHODS The Child Behavior Checklist, the Teacher Report Form, the Youth Self Report Form, and the Parenting Stress Index were utilized to assess adjustment. RESULTS On all objective measures, the group of survivors and their parents were within normal limits. Adjustment neither improved nor deteriorated over time. CONCLUSION Children who survive massive burn injuries can achieve positive psychosocial adaptation.

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 Achenbachs 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.

Psychosocial and functional outcomes in long-term survivors of osteosarcoma: a comparison of limb-salvage surgery and amputation.

Traditionally, physicians have believed that limb‐salvage surgery has functional and cosmetic advantages over amputation, yet the literature is equivocal. Therefore, we sought to compare the psychosocial and functional outcomes in osteosarcoma survivors after limb‐salvage surgery and amputation. We hypothesized there to be neither psychosocial nor functional outcome differences between groups.

Prevalence of major psychiatric illness in young adults who were burned as children

Objective: To determine the prevalence of major psychiatric illness in a group of young adults who suffered significant burn injury as children. Method: A total of 101 persons (58 males, 43 females), aged 21 ± 2.6 years, 14.0 ± 5.4 years postburn of 54% ± 20% total body surface area, were assessed for serious past and present mental illness by using a Structured Clinical Interview (SCID) for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Axis I diagnoses. Results: The SCID findings demonstrated that the prevalence of any Axis I major mental illness was 45.5% for the past month (current) and 59.4% for lifetime. These rates of overall disorder and the rates for most specific disorders were significantly higher than those found in the US population of comparable age. Logistic regression was used to examine demographic and burn characteristics as predictors of current and lifetime psychiatric disorder within the burn survivor sample. The female gender was significantly associated with higher rates of any current disorder. Other demographic and burn characteristics were not significantly related to the overall prevalence of current or lifetime disorder. Only a small number of those with disorders reported any current mental health treatment. Conclusions: Significant burn injury as a child leads to an increased risk of developing a major mental illness. Young adults who suffered major burn injury as children should be screened for these illnesses to initiate appropriate treatment. TBSA = total body surface area; SCID = Structured Clinical Interview; NCS = National Comorbidity Survey; DIS = Diagnostic Interview Schedule; CIDI = Composite International Diagnostic Interview; PTSD = posttraumatic stress disorder.

Treating thermally injured children suffering symptoms of acute stress with imipramine and fluoxetine: A randomized, double-blind study

INTRODUCTION For pediatric burn patients with the symptoms of acute stress disorder (ASD) a first line medication is not widely agreed upon. A prospective, randomized, placebo controlled, double-blind design was used to test the efficacy of imipramine and fluoxetine. METHOD Patients 4-18 years of age with symptoms of ASD were randomized to 1 of 3 groups: imipramine, fluoxetine, or placebo for 1 week. Daily imipramine dose was 1mg/kg, with the maximum dose being 100mg. Daily fluoxetine dose was 5mg for children weighing >or=40 kg; 10mg for those weighing between 40 and 60 kg; 20mg for those weighing >60 kg. RESULTS Sixty participants, 16 females and 44 males, had an average body surface area burn of 53% (S.D.=18) and average age of 11 years (S.D.=4). Imipramine subjects received an average daily dose of 1.00+/-0.29 mg/kg. Fluoxetine subjects received an average daily dose of 0.29+/-0.16 mg/kg. Between group differences were not detected. Fifty-five percent responded positively to placebo; 60% responded positively to imipramine; and 72% responded positively to fluoxetine. CONCLUSION Within the parameters of this study design and sample, placebo was statistically as effective as either drug in treating symptoms of ASD.

A Double-Blind Study of the Analgesic Efficacy of Oral Transmucosal Fentanyl Citrate and Oral Morphine in Pediatric Patients Undergoing Burn Dressing Change and Tubbing

Burn wound care is extremely painful. The pain leads to added anxiety and therefore a distressing treatment that can negatively impact healing. Pain and anxiety management with oral transmucosal fentanyl citrate was compared with this institutions standard procedural pain medication, morphine. With a double-blinded, reverse crossover, time-randomized, and placebo-controlled design, the efficacy of morphine and fentanyl citrate was assessed with patients undergoing two consecutive days of tubbing. Pain and anxiety was assessed before, during, and after the tubbing procedure using the Faces Pain Rating Scale (Whaley and Wong, 1987) and the Fear Thermometer (Silverman and Kurtines, 1996). Data were analyzed with repeated measures analysis of variance. Pain and anxiety appeared better managed with fentanyl citrate. Generalization is limited by small sample size, yet findings warrant additional investigation.

Physical and psychologic rehabilitation outcomes for pediatric patients who suffer 80% or more TBSA, 70% or more third degree burns

Advances in medical management have dramatically decreased the mortality of children with massive burn injuries, which raises many questions about the expected quality of life for these young survivors. In this article, we address this issue by examining the functional and psychological adaptation of 41 young survivors with 88% mean total body surface area (TBSA) burns and 85% mean third degree TBSA burns. Patient scores were compared with normative data on standardized psychological measures of adjustment and on performance of age appropriate activities of daily living (ADL) skills. Thirty-three of the 41 patients (80%) were independent in basic ADL skills. Eighty-six percent of the patients who were aged 10 years and older were independent in advanced ADL skills. Patients with amputated fingers were significantly more dependent in ADL skills than those without amputations (P < .05). Mean psychosocial adjustment scores were within normal limits and were not significantly related to functional independence in ADL skills.

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.

Functional, psychosocial and professional outcomes in long-term survivors of lower-extremity osteosarcomas: amputation versus limb salvage.

As the number of osteosarcoma survivors increases, the impact of quality of life and function needs to be addressed. Limb salvage is the preferred treatment when patients have treatment options; yet, the questionable long-term durability and complications of prostheses, combined with ambiguous function, leave some doubt regarding the best clinical and surgical options. Comparisons between limb salvage patients, amputees and controls also require further investigation. Amputation would leave the patients with a lifelong requirement for an external prosthetic leg associated with an overall limited walking distance. While artificial limbs are much more sophisticated than those used in the past, phantom limb sensations remain a substantial and unpredictable problem in the amputee. Complications such as stump overgrowth, bleeding, and infection, also require further elucidation. Limb salvage surgery using endoprosthesis, allografts or reconstruction is performed in approximately 85% of patients affected by osteosarcoma located in the middle and/or distal femur. One drawback in limb-salvage surgery in the long-term survivor is that endoprostheses have a limited life span with long-term prosthetic failure. The inherent high rate of reoperation remains a serious problem. Replacing a damaged, infected or severely worn-out arthroplastic joint or its intramedullary stem is difficult, especially in the long-stem cemented endoprostheses used in the 1980s. Limb lengthening procedures in patients who have not reached maturity must also be addressed. Periprosthetic infections, compared to other indications for joint reconstruction, were found to be more frequent in patients treated for neoplastic conditions and their outcome can be devastating, resulting in total loss of joint function, amputation, and systemic complications. Quality of life in terms of function, psychological outcome and endpoint achievements such as marriage and employment apparently do not differ significantly between amputee and nonamputee osteosarcoma survivors. Amputee patients nonetheless appear to have made satisfactory adjustments to their deficits with or without a functional external prosthesis. It also appeared that amputee patients had a similar psychological and quality of life outcome as limb salvage patients. There was no evidence of excessive anxiety or depression or deficits in self-esteem compared with the normal population or matched controls. A number of long-term survivors also achieved high ranking in the professional and commercial work place. These positive aspects should be recognized and emphasized to patients and their parents when discussing the outcome.