Attentional bias and symptoms of posttraumatic stress disorder one year after burn injury

Clinical therapeutic effects of platelet-rich plasma in patients with burn wound healing: A protocol for systematic review and meta-analysis

BACKGROUND

In clinical settings, burn wounds are frequently encountered. Since burn wounds are a form of physical injury, they can have long-term adverse effects on the human body. It has been a significant challenge to treat burn wounds completely. Since traditional treatment strategies have been unable to heal burn wounds completely, they lack the efficacy to cure the wounds without long-term effects, such as heavy scarring. Reportedly, platelet-rich plasma (PRP) has shown potential to accelerate wound healing. Yet, there are no conclusive reports on a methodological comparative study of research that has assessed the medical benefits of PRP for treating individuals carrying burn wounds. Thus, the present meta-analysis and systematic study aims to assess the medical benefits of PRP for treating patients carrying burn wounds.

METHODS

The authors will conduct a comprehensive search for randomized controlled trials that evaluate the safeness and efficiency of PRP to treat burn wounds. The search includes 3 Chinese language databases (WanFang database, Chinese BioMedical Literature database, and China National Knowledge Infrastructure) and 4 English language databases (Cochrane Library, EMBASE, Web of Science, and MEDLINE). These electronic databases will be searched from their establishment till May 2021. A pair of independent authors will be selecting eligible studies for extracting data. The same authors will employ the Cochrane risk of bias tool to evaluate the bias risk. We will make use of RevMan (version: 5.3) software to complete data synthesis.

RESULTS

The present protocol will establish practical and targeted results evaluating the efficacy and safeness of using PRP to treat burn wounds. The current study also provides a reference for clinical use of PRP.

CONCLUSION

Stronger evidence about the effectiveness and safety of using PRP to treat and heal burn wounds will be provided for clinicians to refer.

ETHICS AND DISSEMINATION

Ethics approval is unrequired.

REGISTRATION NUMBER

March 31, 2021.osf.io/whauj. (https://osf.io/whauj/).

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

Use of an estradiol-based combined oral contraceptives has no influence on attentional bias or depressive symptoms in healthy women

Combined oral contraceptive (COC) use is associated with small, albeit significant, increases in mental symptom scores, predominantly irritability, depressed mood, and anxiety. Yet, randomized prospective trials are needed to better characterize the women at risk for COC-induced negative mood change. Thus, the primary aim of this sub-study to a placebo-controlled randomized trial was to determine whether COC use influences emotional interference by negative and positive stimuli. Secondly, we wanted to evaluate what factors would predict depressive symptoms at the end of the trial, taking personality factors, history of mental disorders and other demographic factors into account. Sixty-nine women were included, randomized to three cycles of treatment with a COC (1.5 mg estradiol and 2.5 mg nomegestrolacetate) or placebo. An emotional verbal Stroop task was used to measure interference of emotional stimuli, in which participants were asked to only name the color of a presented word, while ignoring the meaning of the word. Four different word categories were used; neutral, positive, depression, and anxiety. For the second aim of the study, rating on the Montgomery-Åsberg Depression Rating Scale during the final days of the trial was used as outcome. We found no interaction between emotional verbal Stroop word category and treatment, indicating that COC treatment did not evoke any differences in emotional interference to the three word categories. Significant predictors for depressive symptoms at the end of the trial were trait anxiety at baseline and prior adverse mood effects by hormonal contraceptive use. Treatment (i.e. whether women had been treated with the COC or placebo) did not play a role in predicting depression scores at the end of the trial. In conclusion, we found no evidence that combined oral contraceptive use is associated with impaired cognitive-emotional processing. Instead, the main predictors of self-rated depression at the end of the trial were baseline trait anxiety and previous mental symptoms during hormonal contraceptive use.

Flaminal® versus Flamazine® in the treatment of partial thickness burns: A randomized controlled trial on clinical effectiveness and scar quality (FLAM study)

Although partial thickness burns are the most frequently reported burn injuries, there is no consensus on the optimal treatment. The objective of this study was to compare the clinical effectiveness and scar quality of Flaminal® Forte to silver sulfadiazine (Flamazine®) in the treatment of partial thickness burns. In this two-arm open label multicenter randomized controlled trial, adult patients with acute partial thickness burns and an affected total body surface area of less than 30% were randomized between Flaminal® Forte and Flamazine® and followed for 12 months. Dressing changes in the Flamazine® group were performed daily, and in the Flaminal® group during the first 3 days post burn and thereafter every other day until complete wound healing or surgery. Forty-one patients were randomly allocated to Flaminal® Forte and 48 patients to Flamazine®. The primary outcome was time to wound healing, which did not differ between the groups: median 18 days with Flaminal® Forte (range 8-49 days) versus 16 days with Flamazine® (range 7-48 days; p = 0.24). Regarding the secondary outcomes during hospital admission, there were no statistically significant differences between the groups concerning need for surgery, pain scores, pruritus, or pain-related and anticipatory anxiety. More patients in the Flaminal® group developed wound colonization (78% versus 32%, p < 0.001), but the treatment groups did not differ regarding the incidence of local infections and use of systemic antibiotics. In terms of scar quality, no statistically significant differences between both treatment groups were found regarding subjective scar assessment (Patient and Observer Scar Assessment Scale (POSAS)), scar melanin and pigmentation (DermaSpectrometer®), and scar elasticity and maximal extension (Cutometer®) during 12 month postburn. In conclusion, time to wound healing did not differ, but the use of Flaminal® Forte seemed favorable because less dressing changes are needed which lowers the burden of wound care.

Different patterns of attentional bias in antenatal and postpartum depression

BACKGROUND

Biased information processing in attention, memory, and interpretation is proposed to be central cognitive alterations in patients with major depressive disorder, but studies in women with peripartum depression are scarce. Because of the many similarities with depression in nonperipartum states as regards symptom profile and risk factors, we hypothesized that women with antenatal and postpartum depression would display attentional bias to negatively and positively valenced words.

METHODS

One hundred and seventy-seven pregnant and 157 postpartum women were included. Among these, 40 suffered from antenatal depressive disorder and 33 from postpartum depressive disorder. An emotional Stroop task with neutral, positive, negative, and negatively valenced obstetric words was used.

RESULTS

No significant difference in emotional interference scores was noted between women with antenatal depression and nondepressed pregnant women. In contrast, women with postpartum depression displayed shorter reaction times to both positive (p = .028) and negative (p = .022) stimuli, compared with neutral words. Pregnant women on antidepressant treatment displayed longer reaction times to negatively valenced obstetric words in comparison with untreated depressed women (p = .012), and a trend toward greater interference in comparison with controls (p = .061).

CONCLUSIONS

In contrast with the hypothesis, we found no evidence of attentional bias to emotionally valenced stimuli in women with untreated peripartum depression. However, the shorter reaction times to emotional stimuli in women with postpartum depression may indicate emotional numbing, which in turn, is a functional impairment that may have repercussions for child development and well-being. Our findings emphasize the need to identify and treat women with postpartum depression at the earliest possible time point to ensure swift recovery and support for the family.

Prevalence and Predictors of Posttraumatic Stress Symptomatology Among Burn Survivors: A Systematic Review and Meta-Analysis

Burns can be a traumatic and stressful experience, although each patient may respond in very different ways. The aim of this study was to explore the variability on posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) prevalence and evaluate the specific weight of different variables on PTSD development among adult burn patients. A systematic review was carried out to explore the prevalence of ASD and PTSD and identify their predictors. Meta-analytical methods were used to explore the strength of association between PTSD and the latter. From an initial pool of 190 studies, 24 were used in the systematic review, and only 19 studies could be used for the meta-analysis because of different methodological limitations. The prevalence of ASD at baseline ranged from 2 to 30% and prevalence of PTSD ranged from 3 to 35% at 1 month, 2 to 40% between 3 and 6 months, 9 to 45% in the year postinjury and ranged 7 to 25% more than 2 years later. Life threat perception was the strongest predictor for PTSD occurrence, followed by acute intrusive symptoms and pain associated with burn injuries. Predictive variables identified in this research may be useful in targeting burn patients who are at risk for developing posttraumatic stress symptoms and stress-related psychological symptoms.

Patient opinion of scarring is multidimensional: An investigation of the POSAS with confirmatory factor analysis

INTRODUCTION

Scarring is a significant consequence for patients following a burn. Understanding how patients perceive the physiological scar and define scar severity may provide valuable information regarding how the scar influences quality of life after burn. The Patient and Observer Scar Assessment Scale was the first scar assessment tool validated to include the patients' evaluation of the scars physical qualities, following a burn. Validation studies of this tool have previously been conducted for a discrete scar-site after burn. The aim of this study was to assess the structural validity of the POSAS to capture the patients' evaluation of the total area of burn scar(s).

METHOD

Statistical analysis was based on 508 completed POSAS forms from 358 patients. Exploratory factor analysis (EFA) was used initially to identify the number of factors within the tool, then confirmatory factor analysis (CFA) using structural equation modelling explored areas of misfit within each factor and whether the model provided a predicable structure to capture patient perception of scar severity.

RESULTS/DISCUSSION

The CFA analysis confirmed that a two dimensional model was superior to a unidimensional model when assessing the patient opinion of their total burn scar. The two dimensions were the physical scar (color, stiffness, thickness and irregularity) and the sensory scar (pain and itch). Further strain analysis of the two factor model identified additional domains. Independent factors influenced the perception of color forming a separate subdomain within the physical domain. Color is a visual characteristic, whereas the other three are predominantly tactile characteristics. A significant relationship between thickness and irregularity suggested they may form another subdomain, however further research is required to confirm this. Both pain and itch were recognized as independent, multidimensional latent variables, which require assessment tools with multidimensional structures.

CONCLUSIONS

When assessing the entire burn scar, three independent dimensions influence patient perception: (1) the physical scar, (2) pain and (3) itch. Within the physical domain, color formed a visual subdomain separate to a tactile subdomain. Further development of these domains within a high-order multi-dimensional structure is recommended.

Translational evidence for a role of endocannabinoids in the etiology and treatment of posttraumatic stress disorder

INTRODUCTION

Posttraumatic stress disorder (PTSD) is a prevalent, chronic, and disabling anxiety disorder that may develop following exposure to a traumatic event. Despite the public health significance of PTSD, relatively little is known about the etiology or pathophysiology of this disorder, and pharmacotherapy development to date has been largely opportunistic instead of mechanism-based. Recently, an accumulating body of evidence has implicated the endocannabinoid system in the etiology of PTSD, and targets within this system are believed to be suitable for treatment development.

METHODS

Herein, we describe evidence from translational studies arguing for the relevance of the endocannabinoid system in the etiology of PTSD. We also show mechanisms relevant for treatment development.

RESULTS

There is convincing evidence from multiple studies for reduced endocannabinoid availability in PTSD. Brain imaging studies show molecular adaptations with elevated cannabinoid type 1 (CB1) receptor availability in PTSD which is linked to abnormal threat processing and anxious arousal symptoms.

CONCLUSION

Of particular relevance is evidence showing reduced levels of the endocannabinoid anandamide and compensatory increase of CB1 receptor availability in PTSD, and an association between increased CB1 receptor availability in the amygdala and abnormal threat processing, as well as increased severity of hyperarousal, but not dysphoric symptomatology, in trauma survivors. Given that hyperarousal symptoms are the key drivers of more disabling aspects of PTSD such as emotional numbing or suicidality, novel, mechanism-based pharmacotherapies that target this particular symptom cluster in patients with PTSD may have utility in mitigating the chronicity and morbidity of the disorder.

Cannabinoid type 1 receptor availability in the amygdala mediates threat processing in trauma survivors

Attentional bias to threat is a key endophenotype that contributes to the chronicity of trauma-related psychopathology. However, little is known about the neurobiology of this endophenotype and no known in vivo molecular imaging study has been conducted to evaluate candidate receptor systems that may be implicated in this endophenotype or the phenotypic expression of trauma-related psychopathology that comprises threat (ie, re-experiencing, avoidance, and hyperarousal) and loss (ie, emotional numbing, depression/dysphoria, generalized anxiety) symptomatology. Using the radioligand [(11)C]OMAR and positron emission tomography (PET), we evaluated the relationship between in vivo cannabinoid receptor type 1 (CB1) receptor availability in the amygdala, and performance on a dot-probe measure of attentional bias to threat, and clinician interview-based measures of trauma-related psychopathology. The sample comprised adults presenting with a broad spectrum of trauma-related psychopathology, ranging from nontrauma-exposed, psychiatrically healthy adults to trauma-exposed adults with severe trauma-related psychopathology. Results revealed that increased CB1 receptor availability in the amygdala was associated with increased attentional bias to threat, as well as increased severity of threat, but not loss, symptomatology; greater peripheral anandamide levels were associated with decreased attentional bias to threat. A mediation analysis further suggested that attentional bias to threat mediated the relationship between CB1 receptor availability in the amygdala and severity of threat symptomatology. These data substantiate a key role for compromised endocannabinoid function in mediating both the endophenotypic and phenotypic expression of threat symptomatology in humans. They further suggest that novel pharmacotherapies that target the CB1 system may provide a more focused, mechanism-based approach to mitigating this core aspect of trauma-related psychopathology.

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

AIMS

The aims of this study were to assess the internal reliability (internal consistency), construct validity, sensitivity and ceiling and floor effects of the Brazilian-Portuguese version of the Impact of Event Scale (IES).

DESIGN

Methodological research design.

METHOD

The Brazilian-Portuguese version of the IES was applied to a group of 91 burned patients at three times: the first week after the burn injury (time one), between the fourth and the sixth months (time two) and between the ninth and the 12th months (time three). The internal consistency, construct validity (convergent and dimensionality), sensitivity and ceiling and floor effects were tested.

RESULTS

Cronbach's alpha coefficients showed high internal consistency for the total scale (0·87) and for the domains intrusive thoughts (0·87) and avoidance responses (0·76). During the hospitalisation (time one), the scale showed low and positive correlations with pain measures immediately before (r=0·22; p<0·05) and immediately after baths and dressings (r=0·21; p<0·05). After the discharge, we found strong and negative correlations with self-esteem (r=-0·52; p<0·01), strong and positive with depression (r=0·63; p<0·01) and low and negative with the Bodily pain (r=-0·24; p<0·05), Social functioning (r=-0·34; p<0·01) and Mental health (r=-0·27; p<0·05) domains of the SF-36 at time two. Regarding the sensitivity, no statistically significant differences were observed between mean scale scores according to burned body surface (p=0·21). The floor effect was observed in most of the IES items.

CONCLUSION

The adapted version of the scale showed to be reliable and valid to assess postburn reactions on the impact of the event in the group of patients under analysis.

RELEVANCE TO CLINICAL PRACTICE

The Impact of Event Scale can be used in research and clinical practice to assess nursing interventions aimed at decreasing stress during rehabilitation.