Stress disorder and PTSD after burn injuries: a prospective study of predictors of PTSD at Sina Burn Center, Iran

Therapeutic approach to emotional reactions accompanied with thermal skin injury - from basic to epidemiological research

In this editorial, we discuss the status of a therapeutic approach to emotional reactions accompanying thermal skin injuries. Burns are considered a major health problem, as well as an economic and social problem, with potentially devastating and life-changing consequences. They affect a wide range of patients with different damage mechanisms, varied depths, and localizations of the burns. The most common are thermal burns, with more than 11 million occurrences annually according to the World Health Organization data. Thermal skin injuries are among the most tragic and catastrophic injuries, almost unsurpassed in terms of severity, morbidity, and mortality, as well as functional, aesthetic, social, economic, and psychological consequences. Burn survivors face stress, anxiety, depression, low self-esteem, body deformity, social isolation, unemployment, financial burden, and family problems. The advances in acute burn care have allowed researchers and physicians to pay more attention to other effects of burns, focusing on psychological consequences in particular. Apart from the significant improvements in routine protocols, it seems useful to take care of psychological disturbances that occur simultaneously but may emerge as the most lasting outcome of those injuries. In that sense, various standards and additional approaches may be involved to achieve overall recovery.

Patterns of Injuries Among Children Diagnosed With Attention Deficit Hyperactivity Disorder in Aseer Region, Southwestern Saudi Arabia

Background

Globally, attention deficit hyperactivity disorder (ADHD) is the most common neurobehavioral disorder that affects children. In 2011, there was an ADHD diagnosis prevalence of around 8% among children (4-17 years) in the US. ADHD-affected children are more prone to physical injuries such as physical trauma, accidental poisoning, burns, etc. This study was aimed to evaluate the association of ADHD with severe injuries, the influence of age and gender on this association, and the impact of ADHD medications on the frequency of such injuries.

Methodology

This study was conducted in three governmental and three private settings in Aseer region. The files of children who were diagnosed with ADHD in the study settings were reviewed for a 12-month time period. Data were extracted from the medical files using a pre-structured data extraction sheet to avoid errors and inter-rater bias. The extracted data included child gender, age, duration of disease, and injury-related data. A brief questionnaire had been applied to mothers regarding mothers' attitudes towards injuries among their children, adherence to medications, as well as the reasons for non-adherence to medications and clinical visits in a non-adherent group during the clinic visit.

Results

One hundred and sixty-three children with a diagnosis of ADHD completed the study. The affected children were aged between two and 15 years (mean: 7.8 ± 2.9 years). An exact of 116 (71.2%) children were males. An exact of 70 (42.9%) affected children had trauma. The most-reported traumas were superficial injuries (84.3%), burns (48.6%), fractures (37.1%), deep injuries (31.4%), and broken or lost teeth (28.6%). About 52% of the children were adherent to medications and their clinical visits. Among the non-adherent group, the most reported reasons were parents’ care and attention (20.5%), followed by the COVID-19 pandemic and delay in visits times (16.7%). Regarding mothers' attitudes towards injuries among children with ADHD, 49.1% of the mothers agreed that there is an association between a child with ADHD and being traumatized while 22.7% said there was no relation.

Conclusions

In our cohort, the majority of the children with ADHD were boys at primary school age. Association of the history of the disease with trauma was not uncommon, and most injuries were not severe, but burns and deep injuries were reported among considered portions.

Evaluation the Healing Potential of Oleuropein on ‎Second-Degree Burn Wounds in a Rat Model

Background: Skin burn is one of the most common complications throughout the world. Olive derivatives have been used for the treatment of skin lesions in Iran. Oleuropein is one of the main constituents of olive leaves. Objectives: The aim of the present study was to evaluate the healing effects of oleuropein cream on second-degree burns wounds in a rat model. Methods: This experimental study was performed on 72 male Wistar rats. Superficial second-degree burns were induced in the hairless back of the animals. Then, they were randomly divided into six equal groups. The burnt area in the first group was covered twice a day with normal saline, in the second group with eucerin, in the third group with 1% silver sulfadiazine and in the fourth-sixth groups, oleuropein cream was applied topically. To evaluate the efficacy of treatment, four rats in each group were euthanized on days 4, 9, and 14, and their skin was processed for wound contraction, glutathione (GSH) level, malondialdehyde (MDA) level, hydroxyproline (HP) content, inflammatory factors (transforming growth factor beta [TGF-β] and interleukin 6 [IL-6]), and histological examination. Results: In comparison with untreated control rats, the daily application of 5% oleuropein cream significantly increased wound contraction, HP content, and GSH level over time. Moreover, it caused a significant reduction in inflammatory factors and MDA level. Histological examination confirmed the results. Conclusions: This study indicated that oleuropein has therapeutic value in treating burn wounds and thus supports its traditional use.

The Epidemiology of Burn and Lethal Area of Fifty Percentage (LA50) in Children in Shiraz, Southern Iran

BACKGROUND

This study was conducted to assess the epidemiology of burn and lethal area of fifty percentage (LA50) in children in Shiraz, Southern Iran.

METHODS

In this case series study, 619 hospitalized burn children from burn centers affiliated to Shiraz University of Medical Sciences, Shiraz, Iran from 2012 to 2016 were enrolled. Demographic characteristics of patients such as age, gender, place and cause of burn, and morality rate were evaluated. LA50 was measured using Probit analysis.

RESULTS

The mean age of patients was 4.4±3.4 years. The mortality rate in burn patients was 8.7% and LA50 of total body surface area (TBSA%) ranged from 40.1% in 2012 to 68.3% in 2016. Although the number of male burn patients (65%) was more than females (35%), the mortality rate in females was more than males (11.4% vs. 7.2%). Scald and flame were the most common causes of burn.

CONCLUSION

The findings in our burn center comparing burn patients to developed countries showed that LA50 and survival rate were lower denoting to an urgent necessity to promote current policies in burn care and prevention and to decrease the mortality rate too.

Post-Traumatic Stress Disorder (Ptsd) Following Burn Injuries: A Comprehensive Clinical Review

Burns are a global public health problem with a large number of psychosocial and psychological problems that may ensue after burn injuries. One of the commonest psychological problems seen after burn injuries is depression, anxiety and post-traumatic stress disorder (PTSD). The following paper reviews the existing literature on PTSD following burn injuries. The concept of PTSD is explained for the non-psychiatrist involved in burn rehabilitation. The various psychosocial factors that determine the causation and course of PTSD following burn injuries are discussed. PTSD following burn injuries in special populations like women, children and adolescents, intentional burns and self immolation are also discussed. The role of cultural factors in the development of PTSD are elucidated and future research needs are laid out. PTSD is a very common occurrence after burn injuries and needs a multidisciplinary team evaluation for its management.

Prevalence of post-traumatic stress disorder during the COVID-19 pandemic in Saudi Arabia

Background

The coronavirus diseases of 2019 (COVID-19) pandemic was classified as one of the worst pandemics in the 21st century. Its rapid transmission, unpredicted mortality rate, and the uncertainty surrounding its transmission method have evoked additional fear and anxiety. Nonetheless, to the best of our knowledge, no prior study has explored PTSD prevalence three months after the start of the quarantine procedures in Saudi Arabia nor has examined PTSD prevalence by three different methods.

Objective

This observational cross-sectional study aimed to identify the prevalence, severity, and influencing factors of PTSD in different regions of Saudi Arabia three months after the onset of the quarantine procedures related to the COVID-19 pandemic.

Methods

Through the month of June 2020, 1374 people (49.05% men and 50.95% women) completed a 35-item, 10-minute online. The prevalence of PTSD was measured using PCL-S (specific for COVID-19) that assesses the 17 symptoms of PTSD. Resilience was measured using 2-items Arabic version of the Connor-Davidson Resilience Scale 2 (CD-RISC 2).

Results

We calculated the prevalence by three methods, namely, PTSD cut-off score, criteria, and combined, and the prevalence was 22.63%, 24.8%, and 19.6%, respectively. Female participants showed higher prevalence than male. As well, participants who were either tested positive or suspected of having been infected with COVID-19 showed higher PTSD prevalence. Higher resilience was associated with lower PTSD prevalence.

Conclusions

This was the first study to report PTSD prevalence by three differential methods three months after the onset of the quarantine procedures related to the COVID-19 pandemic in Saudi Arabia. We observed a significant impact of the COVID-19 pandemic in the Saudi population; therefore, great attention should be performed in implementing new procedures that deal with the highlighted risk factors, especially in vulnerable groups, to overcome the psychological impact of the COVID-19 pandemic.

Comparison of the effects of Lactobacillus plantarum versus imipenem on infected burn wound healing

Background: Infection of burn wounds is one of the most important problems in the world. Lactobacillus plantarum is known for burn wound healing because of the immunomodulatory and anti-microbial roles. This study was performed to compare the effects of L. plantarum and imipenem - alone and in combination - on infected burn wound healing. Methods: Burn wounds were experimentally induced on 50 rats in three test groups (germ and supernatant of L. plantarum ) and two control groups (n=10 each) and were inoculated with Pseudomonas aeruginosa. During a 14-day period, wounds in all groups were daily treated topically. The data were analyzed using one-way analysis of variance followed by Tukey-Kramer and LSD. A p-value of < 0.05 was considered as statistically significant. Results: The mean size of the wound on day 14 after the treatment in the probiotic group was significantly lower than the control and the supernatant treated groups (p<0.05). The percentage of wound healing was significantly higher in the probiotic pellet treated group compared to the imipenem and the supernatant groups (by Anova test: 69.58%, p=0.022). The mean leukocyte count in the probiotic pellet group (12110) and supernatant group (13650) was significantly higher than the imipenem group (7670) (p=0.002 and 0.001, respectively). Wound cultures revealed that the percentage of cases where the pathogens had no growth was significantly different among the comparison groups. In all three test groups, P. aeruginosa was completely eliminated in comparison to the positive control group (p<0.05). Conclusion: The results of our study showed that L. plantarum and its by-products promote wound healing and can be used as an alternative to antibiotics to treat ulcer infections caused by resistant bacteria.

Road Crashes in Adults with Attention Deficit Hyperactivity Disorder and Risky Driving Behavior

Objective: Attention deficit hyperactivity disorder (ADHD) is one of the most common problems in adolescents. Risky behaviors in patients with ADHD are due to impaired impulse control resulting from problems with inhibition of proponent responses, controlling interference, and stopping ongoing responses after feedback on errors. The present study investigated the relationship between ADHD and risky driving behavior and the likelihood of car accident in Arak, Iran, in 2015-16. Method : This case-control study was conducted in the Emergency Department of Vali-Asr hospital in Arak (Iran) on drivers who met the inclusion criteria. The data gathering tools included the Demographic Questionnaire, Manchester Driving Behavior Questionnaire (MDBQ), and Wender Utah Rating Scale (WURS). Statistical analyses were performed using SPSS version 20 software. Results: The mean of ADHD (±SD) was higher among cases (81.64 [26.78]) than in controls (64 [24.28], P = 0.000). The mean of risky driving behaviors (±SD) was higher among cases (66.41[26.78]) than in controls (36.79 [25.42]). There was a significant relationship between ADHD, risky behavior, lapse errors, slips, deliberate ‎violation, and unintentional violation and car accident (P = 0.000). Conclusion: This study showed that ADHD increases the risk of road crashes and motor vehicle injuries. These drivers tend to drive at unauthorized speed, have less control over the vehicle, drive more carelessly, and are more likely to have an accident.

Challenges Facing Women Survivors of Self-Immolation in the Kurdish Regions of Iran: A Qualitative Study

OBJECTIVES

Women confront many problems after self-immolation, so the purpose of this study was to explore the challenges facing women survivors of self-immolation in the Kurdish Regions of Iran.

METHOD

This study used a qualitative approach and conventional content analysis. Data were collected through semi-structured interviews with 19 Kurdish women who attempted self-immolation in Iran. They were sampled through purposeful sampling and snowball sampling. The Lincoln and Guba criteria were used to strengthen the research.

RESULTS

The results of data analysis were categorized into five main categories: 1-psychological problems, 2-lack of social and legal supportive structures, 3-incomplete treatment, 4-poor self-care, and 5-social problems. These categories consist of 19 subcategories.

CONCLUSION

Having been rescued from self-immolation, the women confront many challenges returning to normal life. Reducing these women's problems and paving the way for their return to life requires multi-dimensional and community-based interventions. Therefore, all social organizations and institutes can cooperate and each of them paves part of the way.

Epidemiology and the survival rate of burn-related injuries in Iran: a registry-based study

Burns are considered an important preventable fraction of injuries in low and middle-income countries, and are still a leading cause of death in Iran. This study investigates features of burns in Sina Hospital's Burn Centre in East Azerbaijan Province in order to calculate survival and mortality rates as well as factors affecting mortality in this centre. In this cross-sectional study, demographic characteristics of patients such as age, sex, cause of burns, type of burns, length of stay (LOS) in the hospital, total body surface area (TBSA), anatomic distribution of burn, mortality rate and final status of patients at the time of discharge from hospital (recovery, death) were investigated. The total mortality rate was 6.84%. Hot liquid burns and gas cylinder explosion burns were among the most common. Burns on multiple regions of the body (45.9%) and pelvic and lower limb burns (22%) constituted the next most common injury. In the TBSA index, compared to reference categories (extent of burn less than 50 percent), the categories of 50-59, 60-69, 70-79, 80-89 and over 90 percent indicated lowest survival based on the Log-Rank test. Hazard ratio for burns greater than 10% was 15.33 fold. Total body surface area burned of over 10% constantly increases the instantaneous risk of mortality therefore there is a need to enhance the quality of care provided to burn victims.

Increased risk of chronic fatigue syndrome following burn injuries

Background

The overlapping symptoms and pathophysiological similarities between burn injury and chronic fatigue syndrome (CFS) are noteworthy. Thus, this study explores the possible association between burn injury and the subsequent risk of CFS.

Method

We used data from the Taiwan National Health Insurance system to address the research topic. The exposure cohort comprised of 17,204 patients with new diagnoses of burn injury. Each patient was frequency matched according to age, sex, index year, and comorbidities with four participants from the general population who did not have a history of CFS (control cohort). Cox proportional hazards regression analysis was conducted to estimate the relationship between burn injury and the risk of subsequent CFS.

Result

The incidence of CFS in the exposure and control cohorts was 1.61 and 0.86 per 1000 person-years, respectively. The exposure cohort had a significantly higher overall risk of subsequent CFS than did the control cohort (adjusted hazard ratio [HR] = 1.48, 95% confidence interval [CI] = 1.41–1.56). The risk of CFS in patients with burn injury in whichever stratification (including sex, age, and comorbidity) was also higher than that of the control cohort.

Conclusion

The findings from this population-based retrospective cohort study suggest that thermal injury is associated with an increased risk of subsequent CFS and provided a point of view suggesting burn injuries in sun- exposed areas such as the face and limbs had greater impact on subsequent development of CFS compared with trunk areas. In addition, extensively burned areas and visible scars were predictors of greater physiological and psychosocial that are needed to follow-up in the long run.

Exploring Symptoms of Post-traumatic Stress Disorders and Perceived Social Support among Patients with Burn Injury

Introduction

Burns are a serious public health problem globally, causing an estimated 265,000 deaths per year. Although the association of burn injuries with mortality and morbidity rates has been well established, data on their psychological consequences are scarce. The present study explores the frequency of post-traumatic stress disorder (PTSD) and perceived social support among patients with burn injuries in Pakistan.

Methods

This cross-sectional study was conducted at two teaching hospitals in Lahore, Pakistan from May 2015 to July 2015. Eighty patients with burn injuries were included by convenience sampling and interviewed with a specifically designed questionnaire with items on demographics, and the Impact of Events Scale-Revised (IES-R) and Multidimensional Scale of Perceived Social Support (MSPSS) instruments.

Results

Data were analyzed for a total of 80 participants: 56 women (70.0%) and 24 men (30.0%). Mean age was 35.74 (11.15) years. A high proportion of participants perceived highest social support from friends, reported high ego resiliency levels, had more severe symptoms of avoidance and intrusion, and had high overall PTSD scores. There were no differences between groups in the proportions of respondents who reported high perceived social support from significant others or family, overall social support or symptoms of hyperarousal.

Conclusion

The findings reflect a high frequency of PTSD symptomatology and poor social support among Pakistani patients with burn injuries in our sample. These factors can exacerbate the patient’s physical injury, delaying both their physical and mental rehabilitation.

Long-term outcome in 324 polytrauma patients: what factors are associated with posttraumatic stress disorder and depressive disorder symptoms?

Background

Physical impairment is well-known to last for many years after a severe injury, and there is a high impact on the quality of the survivor’s life. The purpose of this study was to examine if this is also true for psychological impairment with symptoms of posttraumatic stress disorder or depression after polytrauma.

Design

Retrospective cohort outcome study.

Setting

Level I trauma centre.

Population

637 polytrauma trauma patients who were treated at our Level I trauma centre between 1973 and 1990. Minimum follow-up was 10 years after the injury.

Methods

Patients were asked to fill in a questionnaire, including parts of the Posttraumatic Stress Diagnostic Scale, the Impact of Event Scale-Revised and the German Hospital Anxiety and Depression Scale, to evaluate mental health. Clinical outcome was assessed before by standardised scores.

Results

Three hundred and twenty-four questionnaires were evaluated. One hundred and forty-nine (45.9%) patients presented with symptoms of mental impairment. Quality of life was significantly higher in the mentally healthy group, while the impaired group achieved a lower rehabilitation status.

Conclusions

Mental impairment can be found in multiple trauma victims, even after 10 years or more. Treating physicians should not only focus on early physical rehabilitation but also focus on early mental rehabilitation to prevent long-term problems in both physical and mental disability.

Psycho-social and Mental Variables and Post-Traumatic Stress Disorder in Traffic Accident Survivors in Northern Iran

OBJECTIVE

To assess the psycho-social and mental variables associated with post-traumatic stress disorder (PTSD) in a series of Iranian patients.

METHODS

A total of 528 eligible accident survivors in pre-sampling of a randomized controlled trial targeting PTSD were included in this cross-sectional study. Psycho-social characteristics associated to PTSD were explored in these survivors in an outpatient clinic. They completed the questionnaires via interview between six weeks to six months after accident. Data collection tools were PSS (DSM-V version) for PTSD and BDI-II for depression and a researcher-made questionnaire for psycho-social variables.

RESULTS

There was a significant association between PTSD and the following variables; family communication, current depression, return to work, history of death of relatives, witnessed the death, length of amnesia, hospitalization, injured situation, and accident severity. Multivariate logistic regression indicated that some variables were associated with PTSD such as accident severity, (p<0.001), injured situation, (p<0.001), current depression, (p<0.001), RTW (p<0.001), and family communication (p=0.01).

CONCLUSION

Psychiatric nursing prevention efforts is best directed toward motorcycle depressed drivers with severe accident and poor family communication who do not return to work. Thus, routine assessment of PTSD, depression and psycho-social variables after traffic accidents must be taken into account.

Attention deficit/hyperactivity disorder and risk of injuries: A systematic review and meta-analysis

Background:

This study systematically reviewed the literature in order to determine the effect of Attention-Deficit Hyperactivity Disorder (ADHD) on injuries and assessed the magnitude of the potential association.

Methods:

A systematic review of the studies examining the association of ADHD and injuries was carried out across multiple databases. Odds ratios and standardized mean differences were pooled.

Results:

A total of 35 studies were selected for quantitative analysis. The association of ADHD and injuries was confirmed over the meta-analysis of eligible studies. The odds ratio pooled over all comparative studies was 1.96(95% CI: 1.6-2.4) using random effects model. Pooled odds ratio of 2.1 and 2.17 were calculated respectively when cohort and case-control studies or just cohort studies were included. The pooled odds ratio reduced to 1.8(CI:1.45-2.3) when studies on specific injuries were removed. For studies comparing scores of rating scales, the pooled standardized mean difference was 0.61(95% CI: 0.03-1.2).

Conclusions:

Those with ADHD are nearly two times more likely to be injured.

Adult attention-deficit hyperactivity disorder, risky behaviors, and motorcycle injuries: a case-control study

BACKGROUND

The aim of this study was to assess the association of motorcycle traffic injuries with motorcycle riding behavior and subtypes of attention-deficit hyperactivity disorder (ADHD) while controlling for individual correlates of motorcycle traffic injuries.

METHODS

A case-control study was carried out in 298 patients with motorcycle trauma along with 151 control patients admitted to the Shohada and Imam Reza university hospitals as the two referral specialty centers in the East Azarbyjan Province of Iran in 2013. The Persian version of the Motorcycle Riding Behavior Questionnaire and the Persian version of Conner's Adult ADHD Rating Scales (the self-report short version) were used to assess riding behavior and screen for adult ADHD, respectively. The scale has four subscales, comprising subscale A (inattention), subscale B (hyperactivity, impulsivity), subscale C (A + C), and subscale D (ADHD index). The statistical analysis was done using Stata version 11.

RESULTS

All subjects were male and aged 13-79 years. Approximately 54% of the participants were married and 13% had academic education. Approximately 18% of the motorcycle riders stated that their motorcycle riding was only for fun purposes. More than two thirds of the participants did not have a motorcycle riding license. Variables found to be significantly associated with motorcycle injuries in bivariate analysis included age, marital status, educational level, having a motorcycle riding license, using a helmet while riding, daily amount of riding, riding just for fun, riding behavior score, and ADHD scale scores. It was found in multivariate analysis that if the ADHD index (subscale D) score was used to assess the association of ADHD with motorcycle injuries, a protective role for ADHD was observed. However, the two other subscales showed a different predictive pattern for subscale A versus subscale B, with only subscale B increasing the likelihood of motorcycle traffic injuries. The score based on motorcycle rider behavior was found to be associated with motorcycle injuries. Other variables that were significant in multivariate models were the purpose of riding, educational level, economic status, and marital status.

CONCLUSION

ADHD and riding behavior scores affect the likelihood of motorcycle traffic injuries among motorcycle riders independent of other injury indicators, and include education, purpose of riding, and economic status.