Article

Health-related quality of life 6 months after burns among hospitalized patients: Predictive importance of mental disorders and burn severity

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Abstract

Major burns are likely to have a strong impact on health-related quality of life (HRQoL). We investigated the level of and predictors for quality of life at 6 months after acute burn. Consecutive acute adult burn patients (n=107) admitted to the Helsinki Burn Centre were examined with a structured diagnostic interview (SCID) at baseline, and 92 patients (86%) were re-examined at 6 months after injury. During follow-up 55% (51/92) suffered from at least one mental disorder. The mean %TBSA was 9. TBSA of men did not differ from that of women. Three validated instruments (RAND-36, EQ-5, 15D) were used to evaluate the quality of life at 6 months. All the measures (RAND-36, EQ-5, 15D) consistently indicated mostly normal HRQoL at 6 months after burn. In the multivariate linear regression model, %TBSA predicted HRQoL in one dimension (role limitations caused by physical health problems, p=0.039) of RAND-36. In contrast, mental disorders overall and particularly major depressive disorder (MDD) during follow-up (p-values of 0.001-0.002) predicted poor HRQoL in all dimensions of RAND-36. HRQoL of women was worse than that of men. Self-perceived HRQoL among acute burn patients at 6 months after injury seems to be mostly as good as in general population studies in Finland. The high standard of acute treatment and the inclusion of small burns (%TBSA<5) in the cohort may partly explain the weak effect of burn itself on HRQoL. Mental disorders strongly predicted HRQoL at 6 months. Copyright © 2014 Elsevier Ltd and ISBI. All rights reserved.

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... With respect to location, a majority of the studies were conducted in the United States (n = 17), [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] followed by Australia and New Zealand (n = 9), [45][46][47][48][49][50][51][52][53] and Sweden (n =7). [54][55][56][57][58][59] Other locations included Norway (n = 3), [60][61][62] Canada (n = 3), 16,63,64 the rest of Europe (n = 9; Italy, 65,66 United Kingdom, 67,68 Finland, 69 Lithuania, 70 Netherlands, 71 Spain, 72 and Turkey 73 ), Asia (n = 3; India, 74 South Korea, 75 Taiwan 76 ), and other parts of the world (n = 2; Brazil 77 and Pakistan 78 ). Many different study designs were utilized with the most common being longitudinal study designs (ie, prospective longitudinal, longitudinal observational, and longitudinal survey) (n = 27). ...
... 27,29,32,[34][35][36][37]39,40,42,43,45,47,49,50,[52][53][54][55][57][58][59]63,65,66,71,74,79 A cross-sectional study design was used in 19 articles (ie, prospective cross sectional, prospective observational, prospective cohort, case control, and exploratory). 16,28,31,33,38,41,48,51,56,60,62,64,67,69,70,72,73,[75][76][77] Four articles were qualitative in design. 30,60,61,63 One other study conducted a retrospective single-cohort analysis of prospectively collected data (n = 1) 46 and another completed a retrospective review. ...
... ticipants. 16,[64][65][66][67][68][69][70][71][72]74,75,[77][78][79] Only one qualitative study included all women 63 and one other study did not include a sex breakdown. 73 Burn Injury Characteristics. ...
Article
Adult-acquired burn injuries are a life-altering event that can lead to debilitating functional or psychological impairments. With advancements in healthcare resulting in decreased mortality rates, survivors of burn injuries can expect to live longer. This warrants a shift in focus to better understand what happens to adults once they are discharged from the hospital into the community. Therefore, the purpose of this scoping review is to map the literature regarding the long-term outcomes of community-dwelling adult acquired burn survivors. A computer-assisted literature search was conducted on literature from January 1, 2000 to August 31, 2018 utilizing four large databases (MEDLINE, EMBASE, CINHAL and PsychINFO). Articles were included if they had a minimum of five individuals with a burn injury as a result of an accidental injury who were at least 18 years of age at the time of injury. Fifty-four articles were found suitable for inclusion in this review. The majority of studies were conducted in the United States and utilized longitudinal study designs. Four themes were apparent from the articles: post-burn complications, psychosocial outcomes, quality of life, and community participation. Data is lacking with respect to outcomes more than five years post-burn, as well as qualitative research. Furthermore, more literature is needed to understand the impact of post-burn complications, coping strategies and post-traumatic growth as well as barriers to community participation. Overall, there is an emerging body of literature that describes the long-term outcomes of adult acquired burn survivors up to five years post-burn.
... Evidence suggests that besides injury severity and physical comorbidities, substance-abuse disorders and psychiatric comorbidities have an impact on social reintegration postburn. In addition, substance abuse and psychiatric diagnoses have been observed more frequently in burn patients [8][9][10][11]. At present, it is not clear whether substance-abuse disorders are aggravated by burn injuries or not. Furthermore, the association between substance abuse and postburn HRQoL and social reintegration has not been investigated. ...
... The collective reviewed by Palmu et al. had similar mean age, gender distribution, and %TBSA. Likewise, injury mechanisms were comparable with flame burns being the most common cause [9]. Of note, the present study included only inpatient cases, but also those admitted for pain management primarily. ...
... Substance abuse and psychiatric diseases have been associated with prolonged and frequently complicated in-hospital treatment, as well as prolonged and less successful rehabilitation postburn [8,9,[18][19][20]. Compared to published data, the prevalence of psychiatric comorbidities and substance-abuse disorders as documented in the hospital information system was fairly low. ...
Article
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Background and Objectives: After burns, social reintegration is a primary long-term objective. At the same time, substance-abuse disorders are more common in burn patients. The aim of this study was to assess prevalence of substance abuse pre- and postburn as well as living situation and relationship status relative to patient-reported health-related quality of life (HRQoL). Patients and Methods: Burn survivors treated as inpatients between 1 January 2012 and 31 December 2019 were retrospectively identified. Collected clinical data included: age, gender, time since injury, burn extent (%TBSA), and substance abuse. Patient-reported living situation, relationship status, smoking habits, alcohol and drug consumption pre- and postburn as well as the SF-36 study were ascertained via telephone survey. Inductive statistical analysis comprised uni- and multivariate testing. A p < 0.05 was considered as statistically significant. Results: A total of 128 patients, 93 (72.7%) men, with a mean age of 40.0 ± 15.7 years were included. Mean TBSA was 9.2 ± 11.0% and significantly lower in women (p = 0.005). General health SF-36 scores were significantly lower in women (67.6 ± 29.8) than men (86.0 ± 20.8, p = 0.002). Smoking decreased from 38.8% pre- to 31.1% postburn. A significant reduction in alcohol consumption was noted over time (p = 0.019). The rate of never-drinkers was 18.0% pre- and 27.3% postburn. Drug abuse was rare both pre- (7.8%) and postburn (5.3%). Living situation remained stable. None of the participants depended on assisted living or lived in a care facility postburn. In total, 75.8% and 67.2% were in a relationship pre- and postburn. Patients with higher alcohol consumption postburn were significantly more often male (p = 0.013) and had higher SF-36 general health scores (p < 0.001). Conclusions: HRQoL is better in men than in women after burn injury. A slight decrease in substance abuse postburn was noted. The connection between HRQoL and substance abuse after burn injuries needs to be investigated further in the future.
... Living with pain is a challenge and chronic pain can have a negative impact on health-related quality of life (HRQoL) [7,8]. Several studies have reported that, over time, the HRQoL of burn patients approaches the HRQoL levels of the general population [9][10][11][12]. However, in those burn patients reporting lower HRQoL larger total body surface area (TBSA) [9,11,12], presence of mental disorders such as major depression [9] or PTSD [10], and higher pain levels [12] are important determining factors. ...
... Several studies have reported that, over time, the HRQoL of burn patients approaches the HRQoL levels of the general population [9][10][11][12]. However, in those burn patients reporting lower HRQoL larger total body surface area (TBSA) [9,11,12], presence of mental disorders such as major depression [9] or PTSD [10], and higher pain levels [12] are important determining factors. ...
... Several studies have reported that, over time, the HRQoL of burn patients approaches the HRQoL levels of the general population [9][10][11][12]. However, in those burn patients reporting lower HRQoL larger total body surface area (TBSA) [9,11,12], presence of mental disorders such as major depression [9] or PTSD [10], and higher pain levels [12] are important determining factors. ...
Article
Full-text available
Background: Chronic pain after burn can have severe physical and psychological effects on former patients years after the initial injury. Although the issue of pain after burn has gained increased attention over the past years, prospective, longitudinal studies are scarce. Our aim was to prospectively investigate consecutive burn patients for pain severity over time and to evaluate the prevalence and characteristics of post-burn pain to 2-7 years after the burn. As an additional aim, the effects of burn and individual-related factors, especially health-related Quality of Life (HRQoL), were investigated. Method: Sixty-seven consecutive burn patients were assessed during acute care at 3, 6, 12 and 24 months, as well as at 2-7 years post-burn. HRQoL, symptoms of post-traumatic stress disorder (PTSD) and other psychiatric disorders were investigated. During the interviews that took place 2-7 years after the injury (mean 4.6±1.9 years), current chronic post-burn pain was assessed using the Brief Pain Inventory-Short Form (BPI-SF). Results: One-third of the patients still reported pain 2-7 years after the injury. Pain severity and interference with daily life were mainly mild to moderate though they were found to be associated with significantly lower HRQoL. Chronic pain after burn was associated with both burn- and individual-related factors. In logistic regression analysis HRQoL at 3 and 12 months and symptoms of PTSD at 12 months were independent factors in predicting chronic pain after burn. Conclusion: Pain after burn becomes a chronic burden for many former burn patients and decreases HRQoL. A novel finding in this study was that HRQoL assessed early after burn was a predictor for the development of chronic pain. This finding may help to predict future pain problems and serve as an indicator for pain preventive measures.
... Moreover, Spronk et al. have observed in two recent studies that female patients, together with patients who had a longer LOS and had sustained more extensive burn injuries, suffered from lower HRQoL post-burn [28] and that, although weaker than burn severity, psychological factors and unemployment, female gender seems to be a negative predictor for HRQoL [29]. Furthermore, a Finnish study [30] found that, although most patients had regained mostly normal HRQoL after 6 months post-injury, women had worse outcomes than men, as well as patients with mental disorders and especially major depressive disorder. It also discovered that the cohort women suffered more often from mental disorders and alcohol abuse and were more often unemployed. ...
... Furthermore, time since injury and time since discharge did not influence the answers to the burn-specific questions. Several studies [30,[33][34][35], which had followed-up their patients between 6 months and 11.5 years post-burn, showed that HRQoL after burn injuries was affected in the short-term but increased and stabilized within the first few years. In the present study, the time since injury ranged from 17 to 107 months with a mean of 61.1 ± 25.4 months. ...
Article
Full-text available
Background and Objectives: As advances in medicine are proceeding, so are treatment goals shifting from sheer mortality rates to improving HRQoL and social reintegration after burn injury. Following this trend, we aimed to assess HRQoL, employment and life satisfaction after burn injury to gain insight on confounding factors. Materials and Methods: This single-center follow-up study was conducted using the SF-36 V1.0 in German and further questions evaluating employment and life satisfaction. It reached 128 adult in-patients (recall 33.0%) with former burn injuries, treated between 2012 and 2019 at the Division of Plastic, Aesthetic and Reconstructive Surgery at the University Hospital of Graz. The questionnaire outcomes were set into relation with clinical data obtained from the medical records. Statistical analysis was performed with SPSS 27.0 for Windows. Results: Of the 128 participants, 72.7% were male and 27.3% female. The mean age at the time of injury was 40.0 ± 15.7 years and mean %TBSA among the study population was 9.2 ± 11.0%. The male patients had sustained more extensive injuries (p = 0.005). However, the female patients scored significantly (p < 0.05) and consistently lower in all the domains of the SF-36, except for “bodily pain” (p = 0.061). Moreover, the female patients scored lower in all the domains of life satisfaction, although significant differences were only found in the domains of fulfillment (p = 0.050) and mental wellbeing (p = 0.015). Furthermore, employment status differed significantly between the male and female patients before as well as after the burn injury. Proportionally less women were employed at both time points. Overall, unemployment had declined. Conclusions: Life satisfaction after burn injury in this study cohort seems to be good. Return to work has shown a promising trend. Strikingly, HRQoL and life satisfaction were lower in women after burn injury. Further research on the reasons for this gender discrepancy might improve HRQoL and life satisfaction after burns.
... Not only psychiatric illness, but also the use of psychotropic medications itself may indirectly increase the risk of burns, due to their sedative effect (5). Psychological distress during the hospital stay has been significantly associated with greater physical disability at one year after the burn injury (6,7). Therefore, early identification and treatment of psychiatric illness in burn patients is imperative to help patients return to a satisfactory functional level with minimal delay. ...
... The relationship of mental illness with burn injuries is bidirectional. Psychiatric morbidity in patients with burns has been reported to increase duration of hospital stay, rates of re-grafting, time to return to satisfactory daily functioning levels and lead to poor health related quality of life (6,7,26). ...
... location of injury to face hands and feet, impaired hand function and joint contractures have all been reported as injury-specific threats to patient self-perceived health. 3,5,7,[9][10][11] Moreover, pain and discomfort, pre-and post-injury psychopathology and substance abuse seem to impair health and functioning. 5,6,11,12 Partnership, living situation and employment are also factors strongly associated with self-reported functioning and wellbeing after burns. ...
... 3,5,7,[9][10][11] Moreover, pain and discomfort, pre-and post-injury psychopathology and substance abuse seem to impair health and functioning. 5,6,11,12 Partnership, living situation and employment are also factors strongly associated with self-reported functioning and wellbeing after burns. 5,9,13 On the other hand, social support, self-efficacy, optimism, resilience or feelings of post-traumatic growth seem to improve perceived recovery after burns. ...
Article
The aim of the present study was to examine burn patient health status, quality of life and work status 16.2 (1.7) [mean (SD)] years after burn injury, and to compare the findings with similar questionnaire data from the same people obtained 11.5 years earlier. Data on burn-specific health (BSHS-N), generic health (SF-36), overall quality of life (QOLS), injury characteristics, socio-demography and work were obtained in 2001 from 95 adult burn patients. In 2013, 78 participants were still eligible, and 34 of them (age: 53.4 [9.4] [mean (SD)], total body surface burn: 17.8% [12.7%]; full thickness injury: 4.4% [5.1%]) answered a follow up study. In 2001, the burn patients reported impaired health status, but an overall quality of life comparable to the Norwegian general population. In particular, the participants were satisfied with their close relationships. At follow up 11.5 years later, the perceived burn-specific and generic health remained unchanged, whereas overall quality of life had improved significantly (QOLS score 77.2 (10.2) vs. 73.1 (12.1), p=0.003), with the largest improvements in the items related to satisfaction with helping others, work, physical active pastimes and independence. The results indicate that self-perceived functioning and wellbeing expressed by burn-specific and generic health status remain stable after the first years post injury. The improvement in overall quality of life 16.2 years post injury suggests long-term processes of growth.
... A number of predictors of HRQL after burn injuries have been established. Specifically, burn severity, as measured by length of hospital stay and number of surgeries, and psychological factors, such as post-traumatic stress disorder (PTSD) symptoms, are consistently associated with HRQL over time [10,18,19]. PTSD is one of the most prevalent mental health problems after a burn injury: around 9% of patients are typically diagnosed with PTSD, about 15% show sub-threshold symptom levels 1 year post-injury, and up to 43% report substantial symptoms 1 year post-burn [20,21]. ...
... These findings are in line with previous research that included a recalled pre-burn measure, that found a positive relationship between larger burn size and physical but not psychological impairment [10] or found a relation between more severe burns and protracted recovery of HRQL in general [11,13,15]. These findings support earlier studies at group level [4,10,18,19] by showing that substantial PTSD symptoms were associated with a higher risk for both a long-term affected physical and mental HRQL, whereas more severe burn were associated with a higher risk for a reduced physical HRQL. ...
Article
Full-text available
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.
... High standards of care in the acute phase and the inclusion of burns less than 5 percent in the study may have had a poor impact of the injury on the quality of life. 22 According to the literature, there is a close relationship between the burn percentage and the quality of life of the burned patients. In this regard, the present study also showed that there is a significant relationship between quality of life scores and burn percentage, so that an increase in the burn percentage leads to a decrease in the quality of life. ...
... 28 Also, the results of the study by Palmu et al., showed that quality of life in women are worse than men. 22 At the same time, in this regard, Pishnamazi et al., and the study of Tahir et al., support our findings. 8,9 The findings of this study showed that there is no significant relationship between quality of life and hospital stay, while the results of the study by Kimmo et al., showed that patients with more than one month of hospitalization were more concerned about their general health. ...
Article
Full-text available
Introduction: Many physical, psychological, social and economic complications have been reported after discharge, which have a negative impact on the quality of life of burn patients. The present research examines the effect of pre-discharge training program on the life quality of patients with burns. Methods: This is a pre and post-experimental study with control group that was conducted in 2015 in teaching hospital Sina. The control group received the typical instructions upon being discharged from hospital while the experimental group received in-person training in the form of question-answer, pamphlets and a researcher-made instruction booklet. The patients’ life quality was evaluated when they were being discharged, a month and then three months after they were discharged. Results: The result showed that the quality of life has a significant statistical difference across the three time points. And these differences are compared using Bonferroni’s adjustment multiple comparisons indicating that pre-discharge training affects the quality of life scores and this effect continues over time. Conclusion: The results show that the pre-discharge training has significantly improved the life quality among the burns patients. The improvement of life quality is also correlated with the quantitative variable of total body surface area percent (TBSA %). Thus, planning and designing in-discharge training programs based on the existing context, combined with training packages focusing on the patients’ needs could be a very significant step in more successful implementation of the follow-up programs on the burn patients and improving their quality of life.
... elämänlaatuun ja toimintakykyyn todettiin suuremmaksi kuin itse palovamman vakavuusasteen vaikutus (%TBSA). Näissä etenkin palovamman jälkeinen masennus seurantavaiheessa ennusti elämänlaadun ja toimintakyvyn merkittävää heikkenemistä (22,23). Seurasimme myös niitä työkyisiä palovammapotilaita, jotka eivät olleet työttömiä palovamman tapahtuessa. ...
Article
Full-text available
Currently a large proportion of patients with severe burn injuries survive. This gives increasing challenges also for psychological recovery after the trauma. More than half of burn patients have mental disorders already before the burn injury but also patients who previously had no mental disorders may suffer from them. Some of the hospitalize burn patients have injuries due to suicidal attempts. Only a small proportion of burn patients receive appropriate psychiatric care although psychosocial interventions specifically planned for burn victims exist. More frequent screening of symtoms of mental disorders and psychiatric consultation, also after acute care in hospital, could lead to better management of post-burn psychiatric care as well as better management of the burn treatment and rehabilitation itself.
... This finding supports Van Loey et al.'s [23] prospective multicentre study, which found that the second strongest predictor of long-term HRQoL, behind number of surgeries, was psychiatric illness. Palmu, Partonen [24] also found that mental disorders more strongly predicted poorer HRQoL after injury than injury factors. It is important to consider that perhaps the psychiatric illness may be linked to the cause of b u r n s x x x ( 2 0 1 6 ) x x x -x x x the burns in the first place. ...
Article
Introduction: Hands are the most commonly burnt body part given humans' innate response to guard their face from injury, and are known to have detrimental functional and psychological consequences. Conflicting evidence exists regarding the impact of hand burns on long-term health status and global functioning. The objective of this study was to identify patient and clinical characteristics that predict health status and hand function of people at 12-24 months after hand burn. Methods: The Burns Specific Health Scale-Brief (BSHS-B) and the Brief Michigan Hand Outcome Questionnaire (Brief MHQ) were administered to community-dwelling adults who were between one and two years after admission to a statewide burns service for burns including one or both hands. Demographic, injury, and treatment data were collected to identify which factors predict health status and hand function in the second year after admission. Linear regression analyses adjusted for total burn surface area and burn depth were conducted to identify important predictors or outcomes. Results: The sample (n=41) was 80.5% male, with a mean age of 44.5 years and total body surface area (TBSA) of 8.4%. Psychiatric illness (regression coefficient -56.6, confidence interval (95% CI) -76.70, -36.49) and female gender (-20.3; 95% CI -0.77, -40.29) were key predictors of poorer global health status on the BSHS-B. Females also scored worse on body image (-5.35; 95% CI -1.83, -8.87) and work (-4.13; 95% CI -0.64, -7.62) domains of BSHS-B. The need for reconstructive or secondary surgery (-38.84; 95% CI -58.04, -19.65) and female gender (-16.30; 95% CI -4.03, -28.57) were important predictors of poorer hand function. Conclusion: Women and those with a history of psychiatric illness are particularly vulnerable to poorer outcomes in health status and/or hand function after burns, and may benefit from more intensive rehabilitation support and long-term follow-up.
... This finding supports Van Loey et al.'s [23] prospective multicentre study, which found that the second strongest predictor of long-term HRQoL, behind number of surgeries, was psychiatric illness. Palmu, Partonen [24] also found that mental disorders more strongly predicted poorer HRQoL after injury than injury factors. It is important to consider that perhaps the psychiatric illness may be linked to the cause of the burns in the first place. ...
Article
Introduction: Hands are the most commonly burnt body part given humans’ innate response to guard their face from injury, and are known to have detrimental functional and psychological consequences. Conflicting evidence exists regarding the impact of hand burns on long-term health status and global functioning. The objective of this study was to identify patient and clinical characteristics that predict health status and hand function of people at 12–24 months after hand burn. Methods: The Burns Specific Health Scale-Brief (BSHS-B) and the Brief Michigan Hand Outcome Questionnaire (Brief MHQ) were administered to community-dwelling adults who were between one and two years after admission to a statewide burns service for burns including one or both hands. Demographic, injury, and treatment data were collected to identify which factors predict health status and hand function in the second year after admission. Linear regression analyses adjusted for total burn surface area and burn depth were conducted to identify important predictors or outcomes. Results: The sample (n = 41) was 80.5% male, with a mean age of 44.5 years and total body surface area (TBSA) of 8.4%. Psychiatric illness (regression coefficient -56.6, confidence interval (95% CI) -76.70, -36.49) and female gender (-20.3; 95% CI -0.77, -40.29) were key predictors of poorer global health status on the BSHS-B. Females also scored worse on body image (-5.35; 95% CI -1.83, -8.87) and work (-4.13; 95% CI -0.64, -7.62) domains of BSHS-B. The need for reconstructive or secondary surgery (-38.84; 95% CI -58.04, -19.65) and female gender (-16.30; 95% CI -4.03, -28.57) were important predictors of poorer hand function. Conclusion: Women and those with a history of psychiatric illness are particularly vulnerable to poorer outcomes in health status and/or hand function after burns, and may benefit from more intensive rehabilitation support and long-term follow-up.
... Many studies have described the long term outcomes after hospitalisation for burn in adults. Most have been single centre studies [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26], and have studied a small number of patients [8,10,[13][14][15][16]19,21,25,26], often from select sub-groups of the burns population such as hand burns, very severe burns or the elderly [8,10,13,15,17,19,25,26], resulting in limited generalisability to the wider population of admitted burn patients. In contrast, multi-centre studies of burn long term outcomes are few [27][28][29][30][31][32], and only the National Institute on Disability and Rehabilitation Research Burn Model system database appears to be ongoing [27,28,30]. ...
Article
Background: Incorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care. Aims: To evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry. Methods: Five Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed. Results: 463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates. Conclusions: The low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.
... The presence of a pre-existing psychiatric disorder in burn patients is associated with worse outcomes in the treatment of burns and is an important predictor of morbidity. In addition, the development of psychiatric disorder after burn injury is reported to be a factor negatively affecting the quality of life (9)(10)(11) .In the burn injury process and during the treatment, mental illnesses can be seen in patients due to severe pain, prolongation of treatment process, being confined to bed, and changes in body image (12) . In this respect, it is important that patients are also evaluated from a psychiatric point of view after the initial emergency intervention in the burn unit, and psychiatrists should be included in the burn treatment team (13) . ...
Article
Full-text available
Objective: The aim of this study was to examine psychiatric disorders after burn trauma and burn-related features in adults. Method: The records of the cases who were hospitalized in the burn center between January 2015 and January 2019 and for whom psychiatric consultation was requested were retrospectively reviewed. Sociodemographic characteristics, burn-related features, psychiatric diagnoses, and treatments of the patients were examined. Results: The mean rate of psychiatric consultations requested in a burn center within a four-year period was 34.05% and 49 (28.5%) of these consulted cases had a work-related accident. Mean hospitalization time was 37.2±24 days and the most common burn type was a fire/flame injury. In the majority of the study sample (63.4%) the total body surface area burnt was more than 20%. Nineteen (11%) cases had a history of psychiatric disorder. The most common psychiatric diagnosis before burn injury was alcohol-drug addiction (n=14, 73.7%). The most common diagnosis after psychiatric consultation was adjustment disorder (31.9%). Among psychotropic drugs the initial treatment was started most frequently treatment with benzodiazepines (30.8%) and antipsychotics (58.1%). In 33 deceased cases, the most common psychiatric diagnosis was delirium with a rate of 42.4%. Conclusion: The incidence of psychiatric disorders before and after burn injury was found to be high in the individuals. Conditions with a high risk of morbidity and mortality, such as delirium, should be diagnosed and treated priorly. Due to the early and long-term effects of burn trauma, a multidisciplinary approach should be developed and psychiatrists should be included in the management of treatment.
... Partial-thickness wounds are created in B Spring 2020, Volume 10, Number 2 SGDS that must be treated by re-epithelialization. The epithelialization takes 10-14 days to complete [7,8]. Various dressings have been suggested for managing these wounds [9]. ...
Article
Background: There are various methods to dress the Skin Graft Donor Site (SGDS), but some are very expensive and not available in Iran. This study aimed to compare three different dressings for the management of the SGDS. Methods: Ninety-six patients participated in the study, and they were randomly divided into three groups. Donor sites were dressed with one of these methods: Vaseline gauze or method A, mupirocin 2% or method B, and nitrofurazone or method C. In each method, the dressing layer was covered by 5 layers of dry gauze. The three groups were compared regarding the epithelialization time, infection, pain, and cost. Results: The epithelialization time was significantly longer in group A compared with groups B and C (P
... The disabilities ensuing from burns, in addition to dis gurement, often bring about stigma-tization and social exclusion. The research conducted on the quality of life of major burn survivors over the medium and long term is quite telling, with serious injuries and psychological issues being the two most signi cant factors [3][4][5]. Mental health conditions in burn survivors can be associated with longer lengths of stay in hospital and worse medical outcomes such as increased burn wound infections, nutritional de ciencies, and skin graft failures [6]. ...
Chapter
While the experience of burn injury is associated with intense psychological reactions that will usually vanish over time, burn survivors have a higher rate of premorbid mental health problems, and a higher lifetime risk of mental health disorders. They need personalized mental health care from the moment they are admitted to the burn unit until their reintegration into the community. This chapter aims to identify the common psychological and psychiatric issues faced by burn survivors and to discuss the specialized mental health interventions and the systematic, stepped care, and biopsychosocial approaches to which all members of an interdisciplinary team should commit to facilitate the recovery and rehabilitation of burn survivors.
... So far, only a few studies have measured the HRQoL among Finnish burn patients. In those studies either generic HRQoL measures [7,8] or a non-validated Finnish translation of a burn-specific measure [9] were used. Burn-specific patient-reported outcome measures (PROMs) are, nevertheless, necessary since generic questionnaires only detect general health outcomes and fail to include all of the important aspects of burn-specific health needs [6,10]. ...
Article
Background Burn injury can dramatically deteriorate health-related quality of life. Effective burn care may minimize the impact of the burn injury and ensure optimal functional outcome. This requires continuous improvement in burn care and assessment of treatment results. The aim of this study was to translate, culturally adapt and linguistically validate the CARe Burn Scale—Adult Form, a burn-specific patient-reported outcome measure, into Finnish. Methods The translation process followed theInternational Society for Pharmacoeconomics and Outcomes Research guidelines consisting of forward and backward translations, pilot-testing and cognitive debriefing interviews of five burn patients, and proofreading before finalizing. The process involved expert panel meetings and continuous discussion between the developers of the Scale and the research group. Results In the forward translation 10 amendments were required. After the backward translation, 12 items were reworded. Cognitive debriefing interviews led to three alterations enhancing the comprehensiveness and accuracy of the translation. The translation was reviewed by burn occupational therapists for practicality, resulting in 12 modifications. Minor grammatical changes were made after proofreading. Conclusion The Finnish version is the first foreign translation of the CARe Burn Scale. It is equivalent to the original Scale and ready for psychometric validation with burn patients in Finland.
Article
Introduction: This qualitative study aims to explore former burn patients' perception of burn-specific health and investigate how these experiences correspond to the subscales in the Burn Specific Health Scale-Brief (BSHS-B). Method: Respondents were former burn patients, admitted to the Uppsala Burn Centre between 2000 and 2007. A total of 20 respondents with a Total Body Surface Area (TBSA) of 20% or larger, were approached at 10-17years after burn and interviewed using a semi-structured guide. Data was analyzed using thematic analysis. Results: Despite extensive burn injuries, respondents said they led a close-to-normal life. Their descriptions validated the significance of the existing themes of BSHS-B. Additional themes of importance for health after burn were skin related problems, morphine de-escalation, the importance of work, stress and avoidance, mentality and the healthcare system. Conclusion: The BSHS-B alone may not be sufficient in providing a comprehensive picture of former burn patients' self-perceived health in the long-term perspective. Investigating supplementary areas reflecting former patients' sociocultural and attitudinal environment, as well as personal factors, may be of great importance.
Article
Burn injuries are significant medical traumas often resulting in substantial psychosocial distress. Early identification of psychosocial concerns is crucial to developing individualized treatments to improve psychosocial functioning. Few studies have examined the prevalence of a broad range of psychosocial concerns in an adult outpatient burn setting. In this study, we developed and implemented a screening instrument to identify patients experiencing acute psychosocial distress/risk and patients with mental health difficulties necessitating a psychology consult. The instrument assessed depression, anxiety, substance abuse, post-traumatic stress, perceived safety at home, and suicidal ideation. Adult patients (N = 179) completed the screener during an initial outpatient clinic visit. Responses on the screener were used to identify patients as “high risk” (i.e., endorsing suicidal ideation and/or feeling unsafe at home), “moderate risk” (i.e., endorsing no-acute mental health symptoms), or “low risk” (i.e., few to no symptoms endorsed). Patients in the “high risk” category were immediately evaluated by the attending physician, who then determined whether emergency treatment was needed. Patients in the “moderate risk” category were referred to the on-site psychology team for in-person or phone consultation within three days of screener completion. Of the 179 individuals screened, a majority endorsed low to no psychosocial distress (N = 124; 69.3%). About one-third (N = 52) indicated moderate levels of psychosocial distress, and 2 patients (1%) endorsed acute psychosocial distress. This novel screening tool was effectively implemented in an outpatient burn clinic, and demonstrates considerable promise for identifying psychosocially-vulnerable patients in an adult burn survivor population.
Article
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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.
Article
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Objectives Measurement of health-related quality of life (HRQL) is essential to qualify the subjective burden of burns in survivors. We performed a systematic review of HRQL studies in adult burn patients to evaluate study design, instruments used, methodological quality, and recovery patterns. Methods A systematic review was performed. Relevant databases were searched from the earliest record until October 2016. Studies examining HRQL in adults after burn injuries were included. Risk of bias was scored using the Quality in Prognostic Studies tool. Results Twenty different HRQL instruments were used among the 94 included studies. The Burn Specific Health Scale–Brief (BSHS-B) (46%), the Short Form–36 (SF-36) (42%) and the EuroQol questionnaire (EQ-5D) (9%) were most often applied. Most domains, both mentally and physically orientated, were affected shortly after burns but improved over time. The lowest scores were reported for the domains ‘work’ and ‘heat sensitivity’ (BSHS-B), ‘bodily pain’, ‘physical role limitations’ (SF-36), and ‘pain/discomfort’ (EQ-5D) in the short-term and for ‘work’ and ‘heat sensitivity’, ‘emotional functioning’ (SF-36), ‘physical functioning’ and ‘pain/discomfort’ in the long-term. Risk of bias was generally low in outcome measurement and high in study attrition. Conclusion Consensus on preferred validated methodologies of HRQL measurement in burn patients would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of HRQL after burns. We recommend to develop a guideline on the measurement of HRQL in burns. Five domains representing a variety of topics had low scores in the long-term and require special attention in the aftermath of burns.
Article
Background Necrotizing fasciitis (NF) is a debilitating soft tissue infection that results in disfiguring scars and often amputations. While mortality rates have improved, long-term outcomes in survivors of NF are poorly understood. Objectives The objective of this study is to analyze the impact of NF on survivors' health-related quality of life (HRQoL) influenced by age, sex, comorbidities, %TBSA, and confidence with appearance. Methods We surveyed 56 adult patients with NF treated at either of two regional referral centers in Manitoba, Canada, between January 1, 2004, and December 31, 2014. Necrotizing soft tissue infections involving the fascial planes were identified during surgical debridement. HRQoL was measured by the Medical Outcomes Short Form-36. Derriford Appearance Scale-24, age, sex, comorbidities, and %TBSA were recorded, and group comparisons and stepwise regression models were developed for the mental and physical component scores separately. Results Mean Mental Component Score (MCS) was 44.5 ± 14.3 and mean Physical Component Score (PCS) was 36.5 ± 11.5; both means were lower than the Canadian population norm of 50. Although stepwise linear regression analyses with block entry indicated influence from age, sex, and comorbid conditions for the MCS and PCS, the only factors that were statistically significant in the final models were confidence with appearance for the MCS and %TBSA for the PCS. Conclusions NF has long-term impact on mental and physical health-related quality of life. Distress regarding confidence with appearance affects mental quality of life, whereas the size of the injured area impacted physical quality of life. These findings can help guide targeted interventions that could potentially improve recovery from NF.
Article
Objective: To assess the association of burn size and community participation as measured by the LIBRE Profile. Summary of background data: Burn size is an established clinical predictor of survival after burn injury. It is often a factor in guiding decisions surrounding early medical interventions, however, literature is inconclusive on its relationship to quality of life outcomes. Methods: This is a secondary data analysis of a cross-sectional survey of adult burn survivors. Self-reported data were collected between October 2014 and December 2015 from 601 burn survivors aged ≥18 years with ≥5% total body surface area (TBSA) or burns to critical areas. Sociodemographic characteristics were compared between participants with small burns (≤40% TBSA burned) and large burns (>40% TBSA burned). Ordinary least squares regression models examined associations between burn size and LIBRE Profile scale scores with adjustments for sex, current work status, burns to critical areas, and time since burn injury. Results: The analytic sample comprised 562 participants with data available for burn size. 42% of respondents had large burns (>40% TBSA burned) and 58% reported smaller burns (TBSA ≤40%). In adjusted regression models, patients with large burns tended to score lower on the Social Activities and Work & Employment scales (P < 0.05) and higher on the Family & Friends scale (P < 0.05). Participants with burns >40% TBSA scored lower for several individual items in the Social Activities scale and one item in the Work & Employment scale (P < 0.05). Conclusions: Increasing burn size was found to be negatively associated with selected items of Work & Employment, and Social Activities, but positively associated with aspects of Family & Friend Relationships. Future longitudinal studies are necessary to assess and understand the long-term social impact of burn injuries on adult populations.
Article
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Introduction Cutaneous burns can have a catastrophic effect on people’s lives and may restrict opportunities for employment due to physical impairment and psychosocial deficits. Failure or delay in return to work can result in loss of income and support for the family unit. It can also negatively affect life role and identity and present difficulties with future opportunities. Current literature indicates multiple discrete influences on return to work as a result of burn injury but an understanding of how working-aged adults resume employment after burn injury is lacking. This scoping review will provide a comprehensive overview of the current literature by mapping and consolidating knowledge in this area of burn recovery and thus provide an informative basis for developing return-to-work programmes for survivors of burn injury. Methods and analysis This scoping review protocol will follow the Arksey and O’Malley’s (2005) methodological framework. A comprehensive search strategy has been developed with subject expert librarians. These databases were used: OvidSP: Medline, Embase, PsycINFO, PubMed and Cochrane Central Register of Controlled Trials and EBSCOhost: CINAHL and Scopus. Reference lists of selected full text will be hand searched for additional literature. To enhance consistency and rigour, all reviewers will undertake a calibration exercise before paired reviewers independently screen all records using Rayyan. Full-text articles meeting the study inclusion criteria will be retrieved and examined. Extracted data will be analysed using the International Classification of Functioning, Disability and Health. Ethics and dissemination Ethics approval is generally not required for scoping reviews. Findings of this scoping review will be reported in a peer-reviewed journal and presented at conferences.
Article
Background: Although burn patients with preexisting mood disorders have been shown to have diminished clinical recovery, acute mental disorders (AMD) are often unrecognized despite a link with post-traumatic stress disorder and social maladjustment later on. This study assessed the clinical profile of a large cohort of burn patients who developed AMD compared to those with chronic mental illness (CMI) and those without mental health problems to assess the impact of AMI on burn outcomes. Methods: Admission data on 96,451 patients with third degree flame burns was abstracted from the Nationwide Inpatient Sample (NIS) Database from 2001 to 2011. AMD was defined as adjustment disorder (ICD-10 codes F43.2-F43.29) and acute stress disorder (F43.0), while CMI was defined as major depressive disorder (F33.0-F33.9) and bipolar disorder (F31.0-F31.9). Data was compared across three subgroups: AMD, CMI, and patients without any mood disorders. Categorical variables were compared using the Chi-square test, and continuous variables were compared using Student t-test and analysis of variance (ANOVA). Multivariate analysis using the "backward Wald" method was performed to calculate odds ratios (OR) and determine independent factors which increased the risk of developing AMD after burn. Results: 979 (1%) burn patients were diagnosed with AMD, compared to 5971 (6.2%) with CMI and 89,501 (92.8%) without mood disorders at the time of the burn. Patients with AMD were significantly younger, predominantly male and Caucasian. Patients with AMD had a higher frequency of multiple third-degree burn sites. AMD patients had a significantly longer length of hospitalization and shorter actuarial survival. More AMD patients lacked social or family support, suffered from alcoholism or illicit drug abuse, and had a history of psychological trauma or self-inflicted injuries compared to other groups. After burn, 4.9% of AMD patients developed burn wound infections, 5.0% had nutritional deficiencies, 1.7% had skin graft failure, 0.7% had acute psychosis, and 3.7% had suicidal ideation, p<0.05. Multivariate analysis identified age 10-39 (OR 4.6), alcoholism (OR 1.4), drug abuse (OR 1.9), psychoses (OR 1.4), and total body surface are (TBSA) 10-39% third degree burns (OR 1.8) as independently associated with developing AMD, p<0.005. Conclusion: The development of AMD in burn patients is associated with poor clinical outcomes including longer hospitalization, decreased survival, and increased complication rates. Premorbid psychopathology, substance abuse and age were associated with a higher incidence AMD after burn than was the severity of the burn wound itself. Routine screening for psychological symptoms of AMD should be performed in all burn patients to avoid increased rates of short and long-term morbidity and mortality.
Article
Background There are an estimated 11 million burn injuries requiring medical attention every year worldwide. Although potentially deadly, burn injuries are now considered a chronic disease with multiple lifetime physical and psychological sequelae. However, it remains unclear how these events affect patients’ utility scores. We aimed to conduct a systematic review to summarize the utility scores of burn injury survivors. Methods We conducted on March 18th, 2020 a systematic review of the published literature using a search strategy designed in collaboration with a research librarian. Our search strategy aimed to identify studies that provided burn injury survivors’ utility scores via a standardized indirect instrument. Results We identified 15 studies that reported burn injury survivors’ utility scores. Most studies used the EQ-5D instruments to assess patients’ utility scores. Results varied substantially between studies, ranging from a low of 0.11 to a high of 0.94. Our review identified two key trends. First, utility scores seem to be negatively correlated with the severity of the burn injury. Second, utility scores in adults tend to increase in function of the time since injury. Conclusion Unfortunately, due to differences in study design and settings, patient populations and instruments used to assess patients’ utility scores, we were unable to combine all study results into a single value. In spite of this limit, results we identified support previous trends identified by others regarding the relationship between utility scores and the burn injury severity and/or the time since injury.
Article
Introduction Delirium is a potentially modifiable, acutely altered mental state, commonly characterised as a hospital-acquired complication. Studies of adult inpatients with acute burns with and without delirium identify causative risks related to the injury or treatment and outcomes related to the patient and healthcare system. We compare patients with and without delirium, providing a high-level quantitative synthesis of delirium risks and outcomes to inform guidelines and future research. Methods A systematic review, meta-analysis and GRADE evaluation of risks and outcomes associated with delirium in adults with acute burns was conducted using PRISMA guidelines and PROSPERO protocol CRD42021283055. The Newcastle-Ottawa Scale was used to assess quality. Results Investigators reviewed ten studies. ASA score ≥ 3, Total Body Surface Area Percentage (TBSA) > 10%, surgery needed, ICU admission, hospital and also Intensive Care Unit (ICU) lengths of stay all had statistically significant associations with delirium, with low-very low certainty on GRADE evaluation. Limitations were heterogeneous studies, review methodology and study bias. Conclusion Delirium represents a significant risk to comorbid patients with burns that need hospitalisation, ICU care and surgery. Further research is needed to precisely categorise delirium along the clinical journey to identify modifiable factors, prevention, and proactive therapy.
Article
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Health-related quality of life (HRQOL) is an important parameter after medical treatments. Knowledge of (predictors of) diminished quality of life can help improve medical outcome. The aim of this study was to quantify health loss in patients with burns and to assess the contribution of injury extent, age, gender, and psychologic factors to HRQOL and speed of recovery. A multicenter prospective cohort design was used to address these aims. Data were obtained from 260 adults with burns. Patients completed the EQ-5D at 3 weeks, 3, 6, 9, and 18 months after burn and psychologic questionnaires during hospitalization. Patients' scores were compared with an age- and gender-weighted normpopulation. Patients suffered from substantial health losses at short term, but after 18 months the majority reached a HRQOL comparable with the norm population with the exception of patients requiring two or more surgeries. The best predictor of long-term HRQOL and the speed of recovery was the number of surgeries, followed by psychologic problems. Both predicted baseline and trajectories of improvement. Symptoms of traumatic stress were most debilitating over time. Both injury severity and psychologic problems play a pivotal role in reduced HRQOL and the speed of recovery. The number of surgeries seems to give a practically useful indication of the expected recovery speed that could aid in decision making and provides adequate information for patients in the aftermath of their initial surgical treatment. Screening for traumatic stress is recommended.
Article
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Reliable measures are required for proper cost-utility analysis after critical care. No gold standard is available, but the EQ-5D health-related quality of life instrument (HRQoL) has been proposed. Our aim was to compare the EQ-5D with another utility measure, the 15D, after critical illness. A total of 929 patients filled in both the EQ-5D and 15D HRQoL instruments 6 and 12 months after treatment at an intensive care or high-dependency unit. The difference in the medians and distributions of the scores of the instruments was tested with Wilcoxon signed-rank test and their association with Spearman rank correlation. Discriminatory power was compared by the ceiling effect and agreement between the instruments regarding the direction of the minimal clinically important change in the HRQoL scores between 6 and 12 months was tested with the McNemar-Bowker test and Cohen's kappa. The utility scores produced by the instruments and their distributions were different. Agreement between the instruments was only moderate. The 15D appeared more sensitive than the EQ-5D both in terms of discriminatory power and responsiveness to clinically important change. The agreement between the two utility measures was only moderate. The choice of the instrument may have a substantial effect on cost-utility results. Our results suggest that the 15D performs well after critical illness, but further large cohort studies comparing different utility instruments in this patient population are warranted before the gold standard for utility measurement can be announced.
Article
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Recently, Ware and Sherbourne published a new short-form health survey, the MOS 36-Item Short-Form Health Survey (SF-36), consisting of 36 items included in long-form measures developed for the Medical Outcomes Study. The SF-36 taps eight health concepts: physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, general mental health, social functioning, energy/fatigue, and general health perceptions. It also includes a single item that provides an indication of perceived change in health. The SF-36 items and scoring rules are distributed by MOS Trust, Inc. Strict adherence to item wording and scoring recommendations is required in order to use the SF-36 trademark. The RAND 36-Item Health Survey 1.0 (distributed by RAND) includes the same items as those in the SF-36, but the recommended scoring algorithm is somewhat different from that of the SF-36. Scoring differences are discussed here and new T-scores are presented for the 8 multi-item scales and two factor analytically-derived physical and mental health composite scores.
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To assess the growth of quality of life measures and to examine the availability of measures across specialties. Systematic searches of electronic databases to identify developmental and evaluative work relating to health outcome measures assessed by patients. Types of measures: disease or population specific, dimension specific, generic, individualised, and utility. Specialties in which measures have been developed and evaluated. 3921 reports that described the development and evaluation of patient assessed measures met the inclusion criteria. Of those that were classifiable, 1819 (46%) were disease or population specific, 865 (22%) were generic, 690 (18%) were dimension specific, 409 (10%) were utility, and 62 (1%) were individualised measures. During 1990-9 the number of new reports of development and evaluation rose from 144 to 650 per year. Reports of disease specific measures rose exponentially. Over 30% of evaluations were in cancer, rheumatology and musculoskeletal disorders, and older people's health. The generic measures--SF-36, sickness impact profile, and Nottingham health profile--accounted for 612 (16%) reports. In some specialties there are numerous measures of quality of life and little standardisation. Primary research through the concurrent evaluation of measures and secondary research through structured reviews of measures are prerequisites for standardisation. Recommendations for the selection of patient assessed measures of health outcome are needed.
Article
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This prospective, longitudinal study examined the influence of baseline physical and psychological burden on serial assessments of health-related quality of life among adults with major burns from three regional burn centers (n = 162). Physical burden groups were defined by % TBSA burned: <10%, 10% to 30%, or >30%. Psychological burden groups were defined by in-hospital distress using the Brief Symptom Inventory Global Severity Index T-score with scores of < 63 or > or = 63. Analyses compared groups across level of burden and with published normative data. Assessments reflected health and function (Short Form 36) during the month before burn, at discharge, and at 6 and 12 months after burn. Physical functioning was significantly more impaired and the rate of physical recovery slower among those with either large physical burden or large psychological burden. Notably, psychosocial functioning also was more impaired and the rate of psychosocial recovery slower among those with greater psychological burden. These results suggest that, in addition to aggressive wound closure, interventions that reduce in-hospital distress may accelerate both physical and psychosocial recovery.
Article
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Health-related quality of life (HRQoL) is an essential outcome of health care, but there is no gold standard of HRQoL measurement. We investigated the impact of major chronic conditions on HRQoL using 15D and EQ-5D in a representative sample of Finns. Information on chronic somatic conditions was obtained by interviews. Psychiatric disorders were diagnosed using a structured interview (M-CIDI). Tobit and CLAD regression analysis was used to estimate the impact of conditions on HRQoL at the individual and population level. Adjusted for other conditions and sociodemographic variables, Parkinson's disease had the largest negative impact on HRQoL at the individual level, followed by anxiety disorders, depressive disorders and arthrosis of the hip and knee. Based on prevalence, arthrosis of the hip or knee, depression, back problems and urinary incontinence caused the greatest loss of HRQoL at the population level. The results obtained with the two HRQoL measures differed markedly for some conditions and the EQ-5D results also varied with the regression method used. Musculoskeletal disorders are associated with largest losses of HRQoL in the Finnish population, followed by psychiatric conditions. Different HRQoL measures may systematically emphasize different conditions.
Article
Objectives: To assess the growth of quality of life measures and to examine the availability of measures across specialties. Design: Systematic searches of electronic databases to identify developmental and evaluative work relating to health outcome measures assessed by patients. Main outcome measures: Types of measures: disease or population specific, dimension specific, generic, individualised, and utility. Specialties in which measures have been developed and evaluated. Results: 3921 reports that described the development and evaluation of patient assessed measures met the inclusion criteria. Of those that were classifiable, 1819 (46%) were disease or population specific, 865 (22%) were generic, 690 (18%) were dimension specific, 409 (10%) were utility, and 62 (1%) were individualised measures. During 1990-9 the number of new reports of development and evaluation rose from 144 to 650 per year. Reports of disease specific measures rose exponentially. Over 30% of evaluations were in cancer, rheumatology and musculoskeletal disorders, and older people's health. The generic measures—SF-36, sickness impact profile, and Nottingham health profile—accounted for 612 (16%) reports. Conclusions: In some specialties there are numerous measures of quality of life and little standardisation. Primary research through the concurrent evaluation of measures and secondary research through structured reviews of measures are prerequisites for standardisation. Recommendations for the selection of patient assessed measures of health outcome are needed.
Article
The history and description of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) is presented. The SCID-II is a clinician-administered semistructured interview for diagnosing the 11 Axis II personality disorders of the Diagnostic and Statistical Manual of Mental Disorders, pins the Appendix category self-defeating personality disorder. The SCID-II is unique in that it was designed with the primary goal of providing a rapid clinical assessment of personality disorders without sacrificing reliability or validity. It can be used in conjunction with a self-report personality questionnaire, which allows the interview to focus only on the Items corresponding to positively endorsed questions on the questionnaire, thus shortening the administration time of the interview.
Article
To study the effectiveness of the treatment of patients with severe burns, the authors collected health-related quality of life (HRQoL) data with the 15D instrument, 17 to 29 months after treatment had commenced at the national burns unit. The costs of each patient's secondary care treatment were followed for a mean of 66 months. During the 1-year study period, 107 patients were treated at the burns unit, eight for scar surgery, the remainder for primary treatment of a burn injury; 19 had died or could not be located during the time of the HRQoL survey. Of the remaining 88 patients, 43 (49%; mean [SD] age 45.7 [14.8] years; 70% men) returned the questionnaire. Their mean (SD) HRQoL score (0.909[0.113]) was only slightly, and not significantly, lower than that of the age- and sex- standardized general population (0.928[0.080]). The mean (SD) secondary care cost of burn treatment of for all the 107 patients, over the 60- to 72-month observation time, was 42,838 USD (73,569 USD; range 1319-34,8741 USD). The largest portion of the total cost was because of inpatient treatment (61%) followed by operations (22%), and outpatient visits. In addition to the costs of burns treatment, the patients consumed other secondary care services to a value of nearly 12,229 USD. The HRQoL in patients treated for severe burns is good, thus the observed high-treatment costs can be considered acceptable.
Article
Objective: Health-related quality of life (HRQoL) has gained increasing interest as an important indicator of adaptation after a burn injury. Our objective was to compare HRQoL of medium severity hospitalized burn victims with no need for intensive care treatment with that of the general population. Methods: The 15D HRQoL questionnaire at discharge, and 6, 12 and 24 months thereafter. Results: 44 patients filled in the baseline questionnaire between June 2007 and December 2009. At discharge the mean (SD) HRQoL score (on a scale of 0-1) of the patients was worse in comparison with that of the general population (0.839 (0.125) vs. 0.936 (0.071)), p<0.001. The most striking differences (p<0.001) were seen on the dimensions of sleeping, usual activities, discomfort and symptoms, and sexual activity. At the 2-year follow-up the mean HRQoL score had increased from 0.835 (0.121) to 0.856 (0.149), but the difference was not statistically significant. Of the dimensions, moving and usual activities improved statistically significantly. Conclusions: HRQoL of patients hospitalized for treatment of burns is, at discharge, compromised compared with that of the general population. During follow-up HRQoL showed slight improvement but remained at a clearly lower level.
Article
BACKGROUND:: Health-related quality of life (HRQOL) is an important parameter after medical treatments. Knowledge of (predictors of) diminished quality of life can help improve medical outcome. The aim of this study was to quantify health loss in patients with burns and to assess the contribution of injury extent, age, gender, and psychologic factors to HRQOL and speed of recovery. A multicenter prospective cohort design was used to address these aims. METHODS:: Data were obtained from 260 adults with burns. Patients completed the EQ-5D at 3 weeks, 3, 6, 9, and 18 months after burn and psychologic questionnaires during hospitalization. Patient's scores were compared with an age- and gender-weighted norm population. RESULTS:: Patients suffered from substantial health losses at short term, but after 18 months the majority reached a HRQOL comparable with the norm population with the exception of patients requiring two or more surgeries. The best predictor of long-term HRQOL and the speed of recovery was the number of surgeries, followed by psychologic problems. Both predicted baseline and trajectories of improvement. Symptoms of traumatic stress were most debilitating over time. CONCLUSIONS:: Both injury severity and psychologic problems play a pivotal role in reduced HRQOL and the speed of recovery. The number of surgeries seems to give a practically useful indication of the expected recovery speed that could aid in decision making and provides adequate information for patients in the aftermath of their initial surgical treatment. Screening for traumatic stress is recommended.
Article
To prospectively investigate proportions of burn patients receiving psychiatric consultation or care, and whether care actually received relates to estimated psychiatric need or burn severity. Consecutive acute hospitalized adult burn patients were examined with the Structured Clinical Interview for DSM IV-TR (SCID-I) at baseline and six months after injury. During follow-up, 55% (51/92) suffered from some mental disorder. Estimated need for psychiatric care was classified as unequivocal, probable or nonexistent. The proportions of patients receiving psychiatric consultation and/or different levels of psychiatric care and specific psychiatric interventions during follow-up and predictors for care were investigated. During the follow-up, 21% of acute burn patients received psychiatric care, and 20%, psychiatric consultation. Of patients with unequivocal need, 48% (12/25) received psychiatric care, and 28%, psychiatric consultation; with probable need, 21% received psychiatric care, and 37%, consultation. Pre-burn psychiatric history (OR=7.54), severe burns (OR=6.76) and estimated need for psychiatric care (OR=6.23) significantly predicted psychiatric care. After hospitalized burn injury, only half of the patients with mental disorders and unequivocal need for psychiatric care actually received such care. Psychiatric consultations and care follow the course of acute burn treatment, not of later emerging mental disorders. Previous psychiatric history strongly influences care decisions.
Article
To prospectively investigate variations in prevalences of mental disorders after burn, and correlation between burn severity and mental disorders among hospitalized burn patients. A cohort of 107 consecutive acute adult burn patients was examined with structured diagnostic interview (SCID-I) at baseline, and 92 patients (86%) at 6 months after injury. Prevalences of mental disorders for the whole 6-month follow-up period, plus 1-month point prevalences in acute care and in a second 6-month interview were assessed, and the two point prevalences were compared. Burn severity was estimate by %TBSA. During the 6-month follow-up 55% (51/92) of burn patients had at least one mental disorder, including 12% (11/92) with post-traumatic stress disorder (PTSD). In a multinomial regression, %TBSA exposure independently and strongly predicted risk for mental disorders, especially for anxiety disorders and delirium. The overall point prevalence of mental disorders decreased significantly (p=0.036) from acute care (45%) to 6 months (33%). After burn, more than half of the patients suffer from some type of mental disorder, but the prevalence declines over time after the acute phase. The disorders are not limited to depression and PTSD. A strong relationship likely exists between burn severity and some post-burn mental disorders.
Article
To investigate mental disorders among acute hospitalized burn patients. Consecutive acute adult burn patients (n=107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered. The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q=6.40, df=1, p=0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q=13.00, df=1, p<0.001) in acute care. Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.
Article
Outcome assessment after burn is complex. Determination of quality of life is often measured using the Burns Specific Health Scale (BSHS), a validated tool in the burn population. The SF-36 is a generic quality of life questionnaire that is validated for numerous populations, but not in burns. The aim of the study was to examine the validity of SF-36, using the BSHS as a reference. 280 burn patients were recruited at Royal Perth Hospital. Each completed SF-36 and BSHS-B at regular intervals to 2 years after burn. Regression modelling was used to assess the temporal validity and the relative sensitivity of the measures. SF-36 domains and BSHS-B demonstrated significant associations at all time points (r=0.37-0.76, p<0.002). In the months after burn, SF-36 domains: role physical; bodily pain; social function and role emotional outperformed BSHS-B total score and domain scores. Greater measurement sensitivity was demonstrated in all SF-36 summary and subscales measures (except General Health) when compared to BSHS-B and sub-domains. This study demonstrated SF-36 as a valid measure of recovery of quality of life in the burn patient population. The data suggests that SF-36 components were more sensitive to change than the BSHS-B from ∼1 month after injury.
Article
Information is required about recovery after injury, including general health measures such as the EQ-5D. This project aimed to: (1) search for studies of injury outcome using the EQ-5D, (2) describe EQ-5D administration and analysis, (3) summarize reliability and validity, and (4) report EQ-5D outcomes. A systematic search was undertaken for publications (January 1990 to May 2008). Studies were excluded if the EQ-5D was not used or if injury was a secondary outcome or resulted from a degenerative condition. Of 79 potentially eligible articles retrieved, 35 were excluded and 44 remained. Sample sizes ranged between n = 14 and n = 3,231. Two thirds of studies described injury outcomes, the remainder focused on specific treatments after injury. Of studies reporting EQ-5D index scores, most used the UK value set, and 29% did not specify a value set. In 16 studies, the EQ-5D was self-completed by participants, and in others, administration was by interviewer, proxy, or unspecified. Time of administration varied between 6 days and 7 years after injury. The absence of a cognitive dimension in the EQ-5D was a concern. Given the global impact of injury-related disability, our search supports calls for comprehensive population-level research exploring outcomes. Many studies considered only specific treatments after injury, had small sample sizes, or were undertaken in wealthy countries. Although noting reservations about the EQ-5D, such as the absence of a cognitive dimension; the EQ-SD being freely available to nonprofit-making organizations, and with many language versions available, seems suitable for studies in wealthy and poorer nations alike.
Article
Health-related quality of life (HRQoL) is an important aspect of adaptation after burn. The EQ-5D is a standardized generic instrument for assessing HRQoL. Its psychometric properties in a group of burn injured individuals are, however, not known. Seventy-eight consecutive patients admitted to a burn unit were included in a prospective longitudinal study. The participants completed the EQ-5D during acute care, and at 3, 6, and 12 months after the burn. At 6 and 12 months after the burn they also completed the Short-Form 36 Health Survey (SF-36) and the Burn Specific Health Scale-Brief (BSHS-B). High feasibility of the EQ-5D was demonstrated through a high response rate and a low proportion of missing or invalid answers. The floor and ceiling effects were small. Construct validity was demonstrated through good differentiation between health states and good discrimination of health states over time. The EQ-5D was associated with burn severity and discriminated between clinical subgroups in an expected manner. Criterion validity was demonstrated through significant correlations between the EQ-5D and subscales of the SF-36 and the BSHS-B. The EQ-5D has good psychometric properties, it is short and easy to administer and thus useful in assessment of HRQoL after burn.
Article
We have developed and validated an abbreviated Burn-Specific Health Scale. The scale is self-administered by the patient, easy to score, and divided for purposes of analysis into several domains of life function. This scale has potential usefulness in many areas of burn care.
Article
The outcome of burn care is conventionally measured in terms of mortality. To extend our understanding beyond this level, and specifically to develop insight into the morbidity and other sequelae or burn injury, we have constructed a Burn-Specific Health Scale (BSHS). The scale is composed of 114 items, based on the selection of items from a much larger pool by a group of professional and patient judges. The scale has been utilized to quantify dysfunction and distress across six major domains of health. Preliminary internal consistency and reliability testing of the scale has proved satisfactory. We present here the results of testing in 40 initial patients, with the following conclusions: 1) The psychosocial performance of patients with major burns lags behind their performance in other areas, and we need to explore alternate clinical strategies for their support; 2) The BSHS can be used to determine both individual and group performance and needs for intervention; 3) The postburn recovery is dynamic and undergoes marked changes for a prolonged period of time, at least 1 year post-hospitalization: this must be considered when such patients are being evaluated for various purposes, e.g., disability.
Article
A sample of inpatient, burn-injured adults (N = 95) were assessed upon discharge, and 4 and 12 months later with a structured interview and DSM-III-R criteria. The prevalence of disorder in this sample was contrasted with published data on a representative national community-dwelling comparison group in the National Comorbidity Study. The prevalence of lifetime affective, alcohol, and substance use disorders was significantly higher, and lifetime anxiety disorders significantly lower, in the burn-injured sample. The 12-month postburn prevalences of alcohol, and substance use disorders were significantly greater in the burn-injured sample. The risk of postburn disorder was significantly greater for the subjects who had a preburn history of affective, alcohol, or substance use disorder. The risk for developing posttraumatic stress disorder (PTSD) was elevated in the subjects with a preburn affective disorder but not preburn anxiety disorder. Finally, postburn PTSD was associated with a greater length of stay, and greater preburn comorbidity predicted preburn employment status and tended to lengthen hospitalization.
Article
It has become increasingly common for preference-based measures of health-related quality of life to be used in the evaluation of different health-care interventions. For one such measure, The EuroQol, designed to be used for these purposes, it was necessary to derive a single index value for each of the 243 health states it generates. The problem was that it was virtually impossible to generate direct valuations for all of these states, and thus it was necessary to find a procedure that allows the valuations of all EuroQol states to be interpolated from direct valuations on a subset of these. In a recent study, direct valuations were elicited for 42 EuroQol health states (using the time trade-off method) from a representative sample of the UK population. This article reports on the methodology that was adopted to build up a "tariff" of EuroQol values from this data. A parsimonious model that fits the data well was defined as one in which valuations were explained in terms of the level of severity associated with each dimension, an intercept associated with any move away from full health, and a term that picked up whether any dimension in the state was at its most severe level. The model presented in this article appears to predict the values of the states for which there are direct observations and, thus, can be used to interpolate values for the states for which no direct observations exist.
Article
Outcome studies after burn injury have become increasingly important as overall mortality from injury has decreased. The present study, concerning physical and psychosocial aspects, is the second part of our larger survey of outcome after burn. The basis of our study instrument was the Abbreviated Burn Specific Health Scale. A postal survey was conducted among 315 patients aged 15-65 years, treated at Töölö Hospital Burns Unit between 11 November 1988 and 31 December 1994. The study series analysed consisted of 124 patients, whose mean total body surface area (TBSA) burned was 13.0%, mean full-thickness (FT) burns 6.2%, mean age 37 years and mean time of hospital treatment 16 days. Statistical analyses were performed with non-parametric tests and a probability level of 0.05 as the limit of statistical significance. Physical function was affected by the severity of the burn and by hand burns. Body image was influenced by FT burns but not by hand or facial injuries. Sexual life was affected by FT burns larger than 20%. Patients older than 25 years, those with TBSA greater than 30%, FT greater than 20% or time of hospitalization over one month were concerned about their general health. The effect of burns on patients' physical and psychosocial life was, however, slight, even with respect to severe injuries.
Article
The 15D is a generic, comprehensive, 15-dimensional, standardized, self-administered measure of health-related quality of life (HRQoL) that can be used both as a profile and single index score measure. This paper examines the acceptability, reliability, validity, discriminatory power and responsiveness to change of its health state descriptive system and valuation system and presents some examples of applications. As a profile measure on roughly comparable dimensions the 15D performs equally well as the Nottingham Health Profile (NHP) and SF-20, in some respects even better, and clearly better than EQ-5D. The remaining nine to ten dimensions of the 15D provide a large reserve in terms of discriminatory power and responsiveness to change. The valuation system is based on an application of the multiattribute utility theory. The single index score (15D score) on a 0-1 scale, representing the overall HRQoL, is calculated from the health state descriptive system by using a set of population-based preference or utility weights. The 15D scores are shown to be highly reliable, sensitive and responsive to change, generalisable at least in Western-type societies, and particularly valid for deriving quality-adjusted life years (QALYs) gained for resource allocation purposes. The instrument is recommended by the Washington Panel and is available in several languages for clinical economic evaluation and population studies.
Article
The Burn Specific Health Scale (BSHS) is an outcome scale designed specifically for burn patients. The scale has been abbreviated (BSHS-A) and revised (BSHS-R). We used a factor analytic approach to further improve the scale for clinical use. Two hundred forty-eight of 350 former patients (70.9%) treated at the Uppsala Burn Unit between 1980 and 1995 responded to 94 questions from previous versions of the BSHS. Principal components factor analyses were used to derive an instrument with 40 items called the Burn Specific Health Scale-Brief (BSHS-B), resulting in nine well-defined domains with intercorrelations ranging from 0.11 to 0.56, and Chronbach's factor alphas ranging from 0.75 to 0.93. The domains describe function with respect to Heat Sensitivity, Affect, Hand Function, Treatment Regimens, Work, Sexuality, Interpersonal Relationships, Simple Abilities, and Body Image. The BSHS-B is a valid but shorter alternative to the previously described BSHS-A. Important domains of postburn distress are captured better in the BSHS-B than in the BSHS-R.
Article
This article compares preference-based utilities from the multiattribute utility instrument 15D with those derived from the EQ-5D and the Short Form 36 (SF-6D) in patients with HIV/AIDS. In particular, we wanted to examine if the finer descriptive system of the 15D would result in better discriminative capacity or responsiveness. In a prospective observational study of 60 Norwegian patients with HIV/AIDS from two hospitals, the authors compared scores, assessed associations with disease staging systems, and assessed test-retest reliability and responsiveness of the instruments. On average, the 15D gave higher utility scores than the other two measures, the mean utility scores were: 15D--0.86, SF-6D--0.73, and EQ-5D Index--0.77. Test-retest reliability was acceptable for all measures, with intraclass correlation coefficients between 0.78 and 0.94. The correlation between scores of the 3 scales was substantial (p = 0.74-0.80). There was no major difference in responsiveness between the measures. The different measures gave different utility values in this sample of patients with HIV/AIDS, although many of the measurement properties were similar. There was no evidence for better discriminative capacity or responsiveness for the 15D, than for the two other multiattribute measures.
Article
Quality of life is a major criterion when decisions regarding resuscitation, reconstruction, and rehabilitation of patients with massive burn injuries are being considered. There has been little research focusing on quality of life following burn injuries involving more than 50 percent total body surface area in the adult population. The authors' goals were to describe quality of life and identify specific clinical and functional indices that predict good quality of life following massive burn injuries. Using a prospective study design, 47 patients who survived a massive burn between 1980 and 2001 were recruited from a single burn unit. Clinical data were collected from hospital records, function was assessed using the Abbreviated Burn-Specific Health Scale, and quality of life was assessed using the Short Form-36 survey. The Short Form-36 scores were compared with population norms. Univariate and multivariate regression analyses were used to identify factors predicting Short Form-36 scores. Overall, the mean age was 28 +/- 1.8 years, 96 percent (45 of 47) were men, and the mean burn size was 64 +/- 2.1 percent total body surface area. Compared with Canadian population norms, burn patients had significantly lower Short Form-36 scores in the domains of role physical (69.1 versus 82.1, p = 0.0067) and general health perception (67.2 versus 77.0, p = 0.00014). At the time of injury, the amount of total full-thickness burn predicted follow-up Short Form-36 physical summary scores (R2 = 15 percent, p < 0.001). At the time of follow-up, addition of the patient's hand function significantly contributed to the prediction of Short Form-36 physical summary scores (R2 = 44 percent, p < 0.001). At the time of injury, the age of the patient predicted follow-up Short Form-36 mental summary scores (R2 = 25 percent, p < 0.001). At the time of follow-up, addition of the patient's perceived level of social support significantly contributed to the prediction of Short Form-36 mental summary scores (R2 = 44 percent, p < 0.001). Survivors of massive burn injury reported a good quality of life in most Short Form-36 domains. The authors identified the size of the total full-thickness injury and the age of the patient as factors available at the time of injury that predict quality of life. The addition of hand function and the patient's perceived level of social support at the time of follow-up improved prediction of quality of life. Accordingly, this information on quality of life after massive burn injury could aid in decision making at the time of resuscitation, reconstruction, and rehabilitation.
Article
Psychiatric history has been suggested to have an impact on long-term adjustment in burn survivors. A rigorous, prospective, longitudinal approach was used to study psychiatric history in a population-based burn sample and its impact on symptomatology of depression and posttraumatic stress disorder (PTSD) at a 12-month follow-up. Seventy-three consecutive patients admitted to the Uppsala Burn Unit were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for psychiatric disorders, of whom 64 were also assessed after 12 months. Forty-eight patients (66%) presented with at least one lifetime psychiatric diagnosis; major depression (41%), alcohol abuse or dependence (32%), simple phobia (16%), and panic disorder (16%) were most prevalent. At 12-months postburn, 10 patients (16%) met criteria for major depression, 6 (9%) for PTSD, and 11 (17%) for subsyndromal PTSD. Patients with lifetime anxiety disorder and with lifetime psychiatric comorbidity were more likely to be depressed at 12 months, whereas those with lifetime affective disorder, substance use disorder and psychiatric comorbidity were more likely to have symptoms of PTSD. Two-thirds of burn survivors exhibit a history of lifetime psychiatric disorders. Those with a psychiatric history have a higher risk of postburn psychiatric problems.
RAND-36 as a measure of healthrelated quality of life. Reliability, construct validity and reference values in the Finnish general population. Helsinki: National Research and Development Centre for Welfare and Health
  • A Aalto
  • A Aro
  • J Teperi
Aalto A, Aro A, Teperi J. RAND-36 as a measure of healthrelated quality of life. Reliability, construct validity and reference values in the Finnish general population. Helsinki: National Research and Development Centre for Welfare and Health; 1999.
National Research and Development Centre for Welfare and Health
  • Helsinki
Helsinki: National Research and Development Centre for Welfare and Health; 1999.
Comparison of two utility instruments, the EQ-5D and the 15D, in the critical care setting
  • T Vainiola
  • V Pettila
  • R P Roine
  • Rä Sä Nen
  • P Rissanen
  • A M Sintonen
Vainiola T, Pettila V, Roine RP, Rä sä nen P, Rissanen AM, Sintonen H. Comparison of two utility instruments, the EQ-5D and the 15D, in the critical care setting. Intensive Care Med 2010;36(December (12)):2090-3.