Sudden Cardiac Arrest in the Postpartum Period Due to Long QT Syndrome and Dilated Cardiomyopathy

We describe the case of a previously healthy patient presenting with sudden cardiac arrest in the postpartum period as a result of concomitant congenital type 1 long QT syndrome and BAG3 dilated cardiomyopathy. This case highlights the increased rate of cardiac events for patients with long QT syndrome in the postpartum period. (Level of Difficulty: Advanced.).

Analgesic effects of posthypnotic suggestions and virtual reality distraction on thermal pain

The individual and combined effects of posthypnotic suggestion (PHS) and virtual reality distraction (VRD) on experimentally induced thermal pain were examined using a 2 x 2, between-groups design. After receiving baseline thermal pain, each participant received hypnosis or no hypnosis, followed by VRD or no VRD during another pain stimulus. Consistent with the hypothesis that hypnosis and VRD work via different mechanisms, results show that posthypnotic analgesia was moderated by hypnotizability but VRD analgesia was not. The impact of PHSs for analgesia was specific to high hypnotizables, whereas VRD was effective independent of hypnotizability. Results also show a nonsignificant but predicted pattern for high hypnotizables: Audio hypnosis combined with VRD reduced worst pain 22% more and pain unpleasantness 25% more than did VRD alone. Theoretical and clinical implications are discussed.

Impairment after burns: a two-center, prospective report

Impairment rating is regularly reported for trauma and other conditions but rarely for burns. The purposes of this study were: (1) to report impairment collected prospectively at our burn center, (2) to relate this impairment to measures of psychosocial and functional outcome, and (3) to compare these data to similar data from another burn center to verify that rating impairment is standardized and that the impairments are similar. We studied 139 patients from the University of Washington (UW) Burn Center and 100 patients from the University of Texas (UT) Southwestern Burn Center. The average whole person impairment (WPI) ratings at the University of Washington were 17% and this correlated with total body surface area burned and days off work. It did not correlate with Brief Symptom Inventory (BSI), Functional Independence Measure (FIM), Short-Form 36-Item Health Survey (SF-36), Satisfaction With Life Scale (SWLS), and the Community Integration Questionnaire (CIQ). Average whole person impairment ratings at UT Southwestern were similar at 19%. Several components of the impairment rating, however, differed at the two institutions. To minimize this variation, we recommend: (1) use the skin impairment definitions of the fifth edition of the Guides to the Evaluation of Permanent Impairment (or the most recent published versions of the Guide), and (2) include sensory impairment in healed burns and skin grafts in the skin impairment.

The 2002 Lindberg Award. PRN vs regularly scheduled opioid analgesics in pediatric burn patients

Very little has been published on treating acute pain in children younger than the age of 3 for burns or any other trauma etiology. This study prospectively monitored the pain behavior and opioid analgesic intake of 31 pediatric burn patients (mean age = 23.71 months; SD = 15.75). Twelve of those children were randomized to conditions in which they either received opioid analgesics pro re nata (ie, as needed, pain contingent) or on a regular basis. The two groups did not show differences in demonstrable pain but, interestingly, they received equivalent does of opioid analgesics. As such, the pro re nata group was likely medicated largely on a regularly scheduled basis. For most of the remaining (nonrandomized) subjects, physicians ordered regularly scheduled opioid analgesics, suggesting that this practice has become largely institutionalized in the study setting. Information on pediatric opioid analgesic dosing and pain measurement strategies for nonverbal subjects can be derived from the findings.

Sleep disturbance after burn injury

This study describes sleep disturbance and related factors in a group of 74 patients at 1 week after discharge using a sleep problems questionnaire developed by the authors. Results indicated that a significant proportion of patients reported a problem with their sleep (73%). Several items were identified as highly prevalent, including frequent nighttime awakenings (87%), napping during the daytime (65%), sleeping alone (64%), experiencing pain during the night (62%), and difficulties with sleep onset (62%). Results suggest numerous possible interventions to improve patients' sleep quality. The usefulness of a more extensive questionnaire was also indicated.

Effects of methylprednisolone on intracellular bacterial growth

Clinical studies have shown positive associations among sustained and intense inflammatory responses and the incidence of bacterial infections. Patients presenting with acute respiratory distress syndrome (ARDS) and high levels of proinflammatory cytokines, such as tumor necrosis factor alpha (TNF-alpha), interleukin 1 beta (IL-1 beta), and IL-6, have increased risk for developing nosocomial infections attributable to organisms such as Staphylococcus aureus, Pseudomonas aeruginosa, and Acinetobacter spp., compared to those patients with lower levels. Our previous in vitro studies have demonstrated that these bacterial strains exhibit enhanced growth extracellularly when supplemented with high concentrations of pure recombinant TNF-alpha, IL-1 beta, or IL-6. In addition, we have shown that the intracellular milieu of phagocytic cells that are exposed to supraoptimal concentrations of TNF-alpha, IL-1 beta, and IL-6 or lipopolysaccharide (LPS) favors survival and replication of ingested bacteria. Therefore, we hypothesized that under conditions of intense inflammation the host's micromilieu favors bacterial infections by exposing phagocytic cells to protracted high levels of inflammatory cytokines. Our clinical studies have shown that methylprednisolone is capable of reducing the levels of TNF-alpha, IL-1 beta, and IL-6 in ARDS patients. Hence, we designed a series of in vitro experiments to test whether human monocytic cells (U937 cells) that are activated with high concentrations of LPS, which upregulate the release of proinflammatory cytokines from these phagocytic cells, would effectively kill or restrict bacterial survival and replication after exposure to methylprednisolone. Fresh isolates of S. aureus, P. aeruginosa, and Acinetobacter were used in our studies. Our results indicate that, compared with the control, stimulation of U937 cells with 100-ng/ml, 1.0-microg/ml, 5.0-microg/ml, or 10.0-microg/ml concentrations of LPS enhanced the intracellular survival and replication of all three species of bacteria significantly (for all, P = 0.0001). Stimulation with < or =10.0 ng of LPS generally resulted in efficient killing of the ingested bacteria. Interestingly, when exposed to graded concentrations of methylprednisolone, U937 cells that had been stimulated with 10.0 microg of LPS were able to suppress bacterial replication efficiently in a concentration-dependent manner. Significant reduction in numbers of CFU was observed at > or =150 microg of methylprednisolone per ml (P values were 0.032, 0.008, and 0.009 for S. aureus, P. aeruginosa, and Acinetobacter, respectively). We have also shown that steady-state mRNA levels of TNF-alpha, IL-1 beta, and IL-6 in LPS-activated cells were reduced by treatment of such cells with methylprednisolone, in a concentration-dependent manner. The effective dose of methylprednisolone was 175 mg, a value that appeared to be independent of priming level of LPS and type of mRNA. We therefore postulate that a U-shaped relationship exists between the level of expression of TNF-alpha, IL-1 beta, and IL-6 within the phagocytic cells and their abilities to suppress active survival and replication of phagocytized bacteria.

Rates, trends, and severity of depression after burn injuries

It is commonly assumed that patients hospitalized for burn treatment will experience some level of depression. However, little is known about the trends in severity of depression over time. The purpose of this study was to determine the rates and severity of depression over a 2-year period. The Beck Depression Inventory was administered at 1 month (N = 151), 1 year (N = 130), and 2 years (N = 125) after discharge. At 1 month, 54% of patients showed symptoms of moderate to severe depression, and at 2 years, 43% of the patients responding still reported moderate to severe depression. The average correlation between scores over time was high. Women had higher depression scores than men at each time period. An interaction between gender and having a head or neck injury was also observed at 1 month and 1 year after discharge. Results suggest that routine outpatient screening for depression is warranted.

Effectiveness of virtual reality-based pain control with multiple treatments

OBJECTIVE

The current study explored whether immersive virtual reality continues to reduce pain (via distraction) with repeated use.

SETTING

The study was conducted in a burn care unit at a regional trauma center.

PATIENTS

Seven patients aged 9-32 years (mean age of 21.9 years; average of 23.7% total body surface area burned [range, 3-60%]) performed range-of-motion exercises of their injured extremity under an occupational therapist's direction on at least 3 separate days each.

INTERVENTION

For each physical therapy session, each patient spent equal amounts of time in virtual reality and in the control condition (no distraction). The mean duration of physical therapy in virtual reality was 3.5, 4.9, and 6.4 minutes for the first, second, and third session, respectively. Condition order was randomized and counter-balanced.

OUTCOME MEASURES

For each of the three physical therapy sessions, five visual analog pain scores for each treatment condition served as the dependent variables.

RESULTS

Pain ratings were statistically lower when patients were in virtual reality, and the magnitude of pain reduction did not diminish with repeated use of virtual reality. The results of this study may be examined in more detail at www.vrpain.com.

CONCLUSIONS

Although the small sample size limits generalizability. results provide converging preliminary evidence that virtual reality can function as a strong nonpharmacological pain reduction technique for burn patients during physical therapy. Results suggest that virtual reality does not diminish in analgesic effectiveness with three (and possibly more) uses. Virtual reality may also have analgesic potential for other painful procedures or pain populations. Practical implications are discussed.

The effectiveness of virtual reality for dental pain control: a case study

The present study explored whether immersive virtual reality can serve as an effective non-pharmacologic analgesic for dental pain. Two patients (aged 51 and 56 years old) with adult periodontitis, a chronic, progressive inflammatory disease that affects gums, ligaments, and bones around the teeth, were studied in the treatment room of a periodontist. Each patient received periodontal scaling and root planing (scraping off/removing plaque deposits below the gum line, hereafter referred to as scaling) under three treatment conditions: (1) virtual reality distraction, (2) movie distraction, and (3) a no-distraction control condition. Condition order was randomized and counterbalanced. For each of the three treatment conditions, five visual analog pain scores for each treatment condition served as the dependent variables. On 0-10 labeled scales, both patients provided sensory and affective pain ratings, and subjective estimates of time spent thinking about his pain during the procedure. For patient 1, mean pain ratings were in the severe range while watching a movie (7.2), or no distraction (7.2) but in the mild pain range (1.2) during the VR condition. Patient 2 reported mild to moderate pain with no distraction (mean = 4.4), mild pain while watching the movie (3.3), and essentially no pain while in VR (0.6) during his periodontal scaling. Although the small sample size limits generalizability, we contend that virtual reality is a uniquely attention-grabbing medium capable of maximizing the amount of attention drawn away from the "real world," allowing patients to tolerate painful dental procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable adjunctive nonpharmacologic analgesia for procedural dental/periodontal pain. Virtual reality may also have analgesic potential for other painful procedures or pain populations. Practical implications are discussed.

The utility of a burn specific measure of pain anxiety to prospectively predict pain and function: a comparative analysis

Patients treated for burn injuries commonly experience high levels of acute pain and anxiety during hospitalization, particularly as it relates to their dressing changes and other medical procedures. A new instrument, the burn specific pain anxiety scale (BSPAS), was designed to characterize patient's anxiety in this setting, but its predictive validity in relation to other measures of anxiety has yet to be demonstrated. In this study, 27 patients with acute burn injuries completed three measures of anxiety upon admission to a major medical burn trauma center. Scores on the anxiety measures were compared with regard to their ability to predict subsequent ratings of procedural and background pain levels, pain medication usage, and physical and emotional functioning upon discharge. In support of criterion-related validity, the BSPAS was the best predictor of procedural pain levels as rated later the same day relative to the other global anxiety measures; moreover, the BSPAS did not predict later-day background pain levels as hypothesized. Both the BSPAS and the global anxiety measures were found to significantly predict total number of pain medications over a 24-h period. Finally, the BSPAS was the only significant predictor of decreased physical role functioning at discharge whereas the other more global measures of anxiety were better predictors of emotional functioning. These results provide preliminary evidence that the BSPAS is a unique and valid indicator of pain-related anxiety surrounding burn care in hospitalized patients and may be useful in identifying those patients at risk for decreased functional capacity at the time of discharge.

Factor structure of the Eyberg Child Behavior Inventory: a parent rating scale of Oppositional Defiant Behavior Toward Adults, Inattentive Behavior, and Conduct Problem Behavior

Used the Eyberg Child Behavior Inventory (ECBI) to measure disruptive behavior problems in children and adolescents. A controversy exists, however, on the dimensional structure of the ECBI. To evaluate this issue, an exploratory factor analysis was first performed on a sample of 1,263 children and adolescents. This analysis identified 3 meaningful factors (i.e., Oppositional Defiant Behavior Toward Adults, Inattentive Behavior and Conduct Problem Behavior) and a fourth, poorly defined factor. A confirmatory factor analysis (CFA) evaluated the fit of the 3 meaningful factors in a second sample of 1,264 children and adolescents. The 3-factor model with 2 correlated errors provided a excellent fit. This 3-factor model also provided a significantly better fit than 2- and 1-factor models. Multiple group CFA indicated that the factor pattern, item-factor loadings, factor correlations, and correlated errors were equivalent across the samples. The CFA on sex yielded similar results. Initial normative information is presented for boys (n = 1,322) and girls (n = 1,205) within 4 age ranges (i.e., 2-5, 6-9, 10-13, 14-17) for the 3 factors. The use of these 3 factors, especially Oppositional Defiant Behavior and Conduct Problem Behavior, should make the ECBI more useful as a screening and outcome measure.

The 2000 Clinical Research Award. Describing and predicting distress and satisfaction with life for burn survivors

We investigated ratings of emotional distress and satisfaction with life at discharge from the hospital and at a 6-month follow-up in a multisite sample of 295 adults hospitalized for the care of a major burn injury. Several psychosocial variables (history of alcohol abuse, marital status, and previous mental health) and some medical variables (days of intensive care, pulmonary complications, and hand burns) accounted for significant variance in the prediction of outcomes. Brief Symptom Inventory (distress) scores were higher and Satisfaction With Life Scale scores were significantly lower than those of a normative population at both measurement points. The results show the utility of biosocial models in which psychological and physical variables interact to influence adjustment and quality of life.

Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study

OBJECTIVE

The pain experienced by burn patients during physical therapy range of motion exercises can be extreme and can discourage patients from complying with their physical therapy. We explored the novel use of immersive virtual reality (VR) to distract patients from pain during physical therapy.

SETTING

This study was conducted at the burn care unit of a regional trauma center.

PATIENTS

Twelve patients aged 19 to 47 years (average of 21% total body surface area burned) performed range of motion exercises of their injured extremity under an occupational therapist's direction.

INTERVENTION

Each patient spent 3 minutes of physical therapy with no distraction and 3 minutes of physical therapy in VR (condition order randomized and counter-balanced).

OUTCOME MEASURES

Five visual analogue scale pain scores for each treatment condition served as the dependent variables.

RESULTS

All patients reported less pain when distracted with VR, and the magnitude of pain reduction by VR was statistically significant (e.g., time spent thinking about pain during physical therapy dropped from 60 to 14 mm on a 100-mm scale). The results of this study may be examined in more detail at www.hitL.washington.edu/projects/burn/.

CONCLUSIONS

Results provided preliminary evidence that VR can function as a strong nonpharmacologic pain reduction technique for adult burn patients during physical therapy and potentially for other painful procedures or pain populations.

Psychological principles of burn wound pain in children. II: Treatment applications

The pain involved in acute burn care can be excruciating and intractable. Even the best pharmacologic pain control efforts often fail to adequately control pain, especially procedure-related pain, in pediatric patients with burn injuries. Nonpharmacologic interventions have been found to be effective in reducing pain in both children and adults and can be extremely important adjuvants to standard pharmacologic analgesia in the burn care setting. In the first article in this series, we outlined psychological factors that influence the emotions, cognitions, and behaviors of children during wound care. Building on this theoretical framework, we now present a detailed discussion of the implementation of nonpharmacologic intervention strategies in the burn care setting. Because accurate measurement of discomfort is imperative for the development of interventions and for the evaluation of their efficacy, we begin with a brief review of pain measurement techniques. We follow this with suggestions for tailoring interventions to meet specific patient needs and conclude with a detailed and practical discussion of specific intervention techniques and the implementation of those techniques.

Describing and predicting the nature of procedural pain after thermal injuries: implications for research

A prerequisite for studying and treating burn-related pain is the establishment of a good understanding of the nature of burn-related pain. However, in most investigations of pain, researchers have failed to examine pain over time or to create summary scores that capture differences in the nature of the pain experiences of individual patients. For 10 consecutive days, 47 patients treated for burn injuries reported on three aspects of procedural pain: worst pain, sensory pain, and affective pain. Three summary pain scores were constructed for each pain dimension: average pain, variability in pain, and linear change in pain. The authors found considerable variability in pain reports from the same patient and from different patients. Analyses indicated that pain reports decreased over time and that patients who had more trait anxiety reported more pain. Patients with larger burn injuries tended to report more affective pain and tended to have a pattern of high and low pain reports that differed from patients with less severe burn injuries. These findings suggest that adequate assessment of burn pain must occur frequently over the course of a single day, as well as for the duration of each patient's care.

The management of self-inflicted burn injuries and disruptive behavior for patients with borderline personality disorder

One of the greatest behavioral and ethical challenges faced by a burn team is the treatment of a patient whose burn injury is the result of parasuicidal behavior. Parasuicidal behavior is defined as intentional self-injurious behavior that, although not fatal, may result in tissue damage or risk of death. There are a number of reasons, usually psychiatric, that patients engage in parasuicidal behavior; however, our contention is that the majority of these patients have a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis II diagnosis of borderline personality disorder. We describe the nature of borderline personality disorder and how it leads to disruptive behavior, including self-harm behavior, on the burn unit, We also argue that if staff members fail to recognize the borderline personality disorder diagnosis, it will lead to responses from staff that can heighten disruptive behavior. We present a series of recommendations for treating such patients with burns and an illustrative case report.

Psychological principles of burn wound pain in children. I: theoretical framework

Burn injuries and the care of burn injuries are punishing experiences for hospitalized children. Pain, novelty, and altered reinforcement schedules elicit instinctive escape and avoidance behaviors that complicate wound care. An understanding of the psychological principles that underlie these complex, complicating behaviors paves the way for effective cognitive and behavioral interventions. In this first article of a two-part series, we use the principles of classical conditioning, operant conditioning, and control coping to describe the developmentally normal emergence of avoidance behaviors that are incompatible with burn wound care. Then, using brief case examples, we outline how classical conditioning transforms neutral stimuli into anxiety-producing, fearful stimuli, how operant behaviors are intentionally or unintentionally reinforced, and how the umbrella of reduced control in the novel hospital environment makes coping difficult for children. We conclude by discussing obstacles to effective application of cognitive and behavioral strategies for the enhancement of control and of compliance with wound care.

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.

Post-traumatic stress symptoms and distress 1 year after burn injury

The occurrence and predictors of post-traumatic stress symptoms 1 year after a burn injury were assessed in a large prospective sample (N = 172). Participants completed a self-report post-traumatic stress symptom checklist at 3 time points: within 24 hours of admission to a burn center, 1 month after the injury, and 1 year after the injury. A notable number of participants had a range of post-traumatic stress symptoms both at 1 month and at 1 year after the burn injury. More than half of the sample reported recurrent intrusive recollections of the burn injury at 1 month and at 1 year. Other commonly endorsed symptoms were sleep disturbance, avoidance of thoughts or feelings associated with the burn, and distress at reminders of the burn. The number of post-traumatic stress symptoms endorsed at 1 month was the only significant predictor of post-traumatic stress symptoms at 1 year. These results suggest that it is common for patients to have some post-traumatic symptoms 1 year after a burn injury and that early experiences of post-traumatic stress symptoms may be associated with the development or maintenance of post-traumatic stress disorder. We recommend that burn care professionals identify and intervene with patients who have clinically significant distress as a result of their burn injuries.

Post-traumatic stress symptoms and distress following acute burn injury

The occurrence and predictors of acute post-traumatic stress symptoms were assessed in a large, prospective sample of persons with new burn injuries (N = 172). Participants completed a self-report post-traumatic stress symptom checklist, pain ratings, and a premorbid mental health inventory within 24 h of admission to a burn center (Day 1). Over half of the sample reported sleep disturbance and recurrent, intrusive recollections of the burn injury on Day 1. Other commonly endorsed symptoms were difficulties concentrating, avoidance of thoughts/feelings associated with the burn, flashbacks, and exaggerated startle response. Persons with less favorable premorbid mental health and larger burns reported a greater number of stress symptoms on Day 1. These results suggest that experiencing some post-traumatic stress symptoms immediately following a burn trauma is normal. It is recommended that burn care professionals identify and intervene with patients who are suffering clinically significant distress early in the hospitalization.

Effects of cytokines and endotoxin on the intracellular growth of bacteria

Patients with unresolving acute respiratory distress syndrome (ARDS) have persistently elevated levels of proinflammatory cytokines in the lungs and circulation and increased rates of bacterial infections. Phagocytic cells hyperactivated with lipopolysaccharide (LPS), which induces high levels of proinflammatory cytokines in monocytic cells, are inefficient in killing ingested bacteria despite having intact phagocytic activity. On the other hand, phagocytic cells that are activated with an analogue of LPS that does not induce the expression of proinflammatory cytokines effectively ingest and kill bacteria. We hypothesized that in the presence of high concentrations of proinflammatory cytokines, bacteria may adapt and utilize cytokines to their growth advantage. To test our hypothesis, we primed a human monocytic cell line (U937) with escalating concentrations of the proinflammatory cytokines tumor necrosis factor alpha, interleukin-1beta (IL-1beta), and IL-6 and with LPS. These cells were then exposed to fresh isolates of three common nosocomial pathogens: Staphylococcus aureus, Pseudomonas aeruginosa, and an Acinetobacter sp. In human monocytes primed with lower concentrations of proinflammatory cytokines (10 to 250 pg) or LPS (1 and 10 ng), intracellular bacterial growth decreased. However, when human monocytes were primed with higher concentrations of proinflammatory cytokines (1 to 10 ng) or LPS (1 to 10 micrograms), intracellular growth of the tested bacteria increased significantly (P <0.0001). These results were reproduced with peripheral blood monocytes obtained from normal healthy volunteers. The specificity of the cytokine activity was demonstrated by neutralizing the cytokines with specific antibodies. Our findings provide a possible mechanism to explain the frequent development of bacterial infections in patients with an intense and protracted inflammatory response.

The quota system in burn rehabilitation

This article describes the quota system as a treatment for the helplessness behaviors and depressive symptoms that develop in some patients with burn injuries. With an A-B single-case design, the quota system was implemented for a patient who had sustained a particularly severe burn injury. A series of baseline behaviors were measured for 3 days, and then 80% of the patient's average performance on each of the targeted behaviors was computed and used as the initial quota value. The behavioral quotas were increased systematically and gradually by approximately 5% to 10% every day. The results suggest that the quota system may have been effective in decreasing an overall trend toward passivity, in increasing 3 of 4 targeted rehabilitation behaviors, and in reducing depressive symptoms in a patient with a particularly devastating injury.

Rates of dysfunction in parents of pediatric patients with burns

The purpose of the current study was to examine the rates of family and child dysfunction in a prospectively, consecutively admitted sample of children. One hundred eleven parents of children consecutively admitted for burn treatment were interviewed using a demographic questionnaire during their child's stay. Results of the questionnaire indicated that in 36% of the families, at least one parent reported significant dysfunction (history of substance abuse, involvement with Child Protective Services, incarceration, or psychiatric history). Results also indicated that 29% of the children over the age of 4 years had significant dysfunction (physical or sexual abuse, or both, psychiatric disorder, behavior problems, or learning disability. It was concluded that (1) parents of children with burns had a substantially high rate of dysfunction, (2) psychologic and preventive interventions should be focused on parents as well as children, and (3) burn injuries often should be regarded as a symptom rather than a cause of psychosocial problems in the family.

Hypnosis after an adverse response to opioids in an ICU burn patient

OBJECTIVE

Burn injuries produce severe wound care pain that is ideally controlled on intensive burn care units with high-dosage intravenous opioid medications. We report a case illustrating the use of hypnosis for pain management when one opioid medication was ineffective.

SETTING

Intensive burn care unit at a regional trauma center.

PATIENT

A 55-year-old man with an extensive burn suffered from significant respiratory depression from a low dosage of opioid during wound care and also experienced uncontrolled pain.

INTERVENTION

Rapid induction hypnotic analgesia.

OUTCOME MEASURES

Verbal numeric pain scale, and pain and anxiolytic medication usage.

RESULTS

The introduction of hypnosis, supplemented by little or no opioids, resulted in excellent pain control, absence of need for supplemental anxiolytic medication, shortened length of wound care, and a positive staff response over a 14-day period.

CONCLUSIONS

This case illustrates that hypnosis can not only be used easily and quite appropriately in a busy medical intensive care unit environment, but that sometimes this treatment may be a very useful alternative when opioid pain medication proves to be dangerous and ineffective. This case also illustrates possible clinical implications both pain relief and side-effect profiles for opioid receptor specificity. Although this report does not provide data regarding hypnotic mechanisms, it is clear that with some patients nonopioid inhibitory mechanisms can be activated in a highly effective manner, that clinical context may be important for the activation of those pathways, and that those mechanisms may be accessed more easily than opioid mechanisms.

Opiate-induced respiratory depression in young pediatric burn patients

Three children younger than 5 with minor burns (< 5% total body surface area) experienced opiate-induced respiratory depression early in hospitalization. This prompted a decrease in the recommended opiate analgesic-dose ranges on our pediatric worksheet. In reviewing 57 admissions, 31 pre- and 26 post-dose change, the amount of opioid equivalents/kg received on admission day did not differ significantly. However, the incidence of respiratory depressive events decreased. Lower opiate-dose guidelines might improve the safe administration of these medications to young children. Other factors- such as concomitant sedative medications, previously administered opiate analgesics, and underlying medical conditions-also must be considered when giving initial doses of opiate analgesics in the burn center.

The 1997 Clinical Research Award. Health outcome for burn survivors

Little is known concerning health outcome for patients who survive burn injuries, and how their health outcome compares with that of other medical populations. Such information is important given that the current direction of health care policy decision making is toward outcomes-driven decision models. We compared the health status of 91 patients 1 month after severe burn injury with the published reports of the health status of 39 medical comparison samples, and two reports of health status for the general population. Additionally, we collected longitudinal data on a subsample of our surviving patients with burn injuries at 1 year. Our findings suggest that people who survive a severe burn experience a stable and relatively good health status after their injury compared with other medical samples. However, their health status remains worse than that of the general population over time. Further, people who survive a major burn indicate that the areas of vocational and psychosocial functioning are often the most troublesome for them.

Comparison of pain control medication in three age groups of elderly patients

There are no published reports of burn pain management in the elderly population. To assess the range of requirement and use of opioids among elderly patients with burns of different age categories, a retrospective review of 89 consecutive admissions of patients over 55 years of age (January 1995 through July 1996) was conducted. Complete data were available on 44 patients with a burn mean total body surface area of 17.2%. Patient ages ranged from 55 to 92 years. Individuals were divided into three age categories: Group I (55 to 65) n = 20; Group II (66 to 75) n = 14; and Group III (76 to 92) n = 10. Use of commonly prescribed opioids for procedural pain and breakthrough pain were evaluated. We compared the opioid equivalents of medications prescribed versus the actual amount administered. Paired t tests comparing minimum amount of medication ordered with that given revealed Group I patients received significantly more procedural medication than the minimum prescribed (t = 3.88, p = 0.001), and that Group III patients were given significantly less as needed medication than the minimum prescribed (t = 2.58, p < 0.05).

Factors predicting hypnotic analgesia in clinical burn pain

The use of hypnosis for treating pain from severe burn injuries has received strong anecdotal support from case reports. Controlled studies provide less dramatic but empirically sound support for the use of hypnosis with this problem. The mechanisms behind hypnotic analgesia for burn pain are poorly understood with this patient population, as they are with pain in general. It is likely that, whatever the mechanisms are behind hypnotic pain analgesia, patients with burn injuries are more receptive to hypnosis than the general population. This article postulates some variables that may account for this enhanced receptivity, including motivation, hypnotizability, dissociation, and regression.

Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain

Benzodiazepines are commonly used to supplement opioid analgesics in treating procedural pain during the treatment of major burn injuries. To date, no study has investigated whether benzodiazepines actually have an analgesic or anxiolytic effect in such circumstances. Seventy-nine patients admitted to a major regional burn center were randomly assigned to groups that received 1 mg of lorazepam or a placebo in addition to their standard opioid analgesics. A strong analgesic effect of lorazepam was not observed when treatment groups were compared independent of their baseline pain ratings. However when patients who had high baseline pain were compared, lorazepam resulted in a significant reduction in pain ratings (adjusted post-treatment VAS mean score = 54.28; adjusted control VAS mean score = 69.06). Trait anxiety did not predict those patients who had an analgesic effect with lorazepam, but state anxiety did prove to be a covariate with visual analogue score decreases in pain reports.

Internal validity of the disruptive behavior disorder symptoms: implications from parent ratings for a dimensional approach to symptom validity

A dimensional approach was used to evaluate the internal validity of the DSM-III-R ADHD-inattention, ADHD-hyperactivity/impulsivity, oppositional defiant disorder (ODD), and conduct disorder (CD) symptoms (i.e., whether a symptom has a stronger correlation with its own dimension that the other three). Parents rated 4,019 children between the ages of 2 and 19 on these symptoms. The results showed that 5 of the 6 inattention symptoms, 3 of the 4 hyperactivity symptoms, 1 of the 4 impulsivity symptoms, 6 of the 9 oppositional defiant disorder symptoms, and 8 of the 11 CD symptoms had significant internal validity. Confirmatory factor analysis (CFA) found support for inattention, hyperactivity/impulsivity, oppositional defiant, and conduct disorder dimensions. Multiple-group CFA also found support for factor pattern and loading invariance across gender. The implications of these results as well as the merits of the dimensional approach to symptom validity are discussed in the context of the DSM-IV changes in ADHD, ODD, and CD.

Baseline pain as a moderator of hypnotic analgesia for burn injury treatment

Sixty-one patients hospitalized for severe burns were randomly assigned to conditions in which they received either hypnosis or a control condition in which they received attention, information, and brief relaxation instructions from a psychologist. The posttreatment pain scores of the 2 groups did not differ significantly when all patients were considered. However, when a subset of patients who reported high levels of baseline pain were examined, it was found that patients in the hypnosis group reported less posttreatment pain than did patients in the control group. The findings are used to replicate earlier studies of burn pain hypnoanalgesia, explain discrepancies in the literature, and highlight the potential importance of motivation with this population.

Baseline pain as a moderator of hypnotic analgesia for burn injury treatment

Sixty-one patients hospitalized for severe burns were randomly assigned to conditions in which they received either hypnosis or a control condition in which they received attention, information, and brief relaxation instructions from a psychologist. The posttreatment pain scores of the 2 groups did not differ significantly when all patients were considered. However, when a subset of patients who reported high levels of baseline pain were examined, it was found that patients in the hypnosis group reported less posttreatment pain than did patients in the control group. The findings are used to replicate earlier studies of burn pain hypnoanalgesia, explain discrepancies in the literature, and highlight the potential importance of motivation with this population.

Hypnosis as an adjunct to medical care in the management of Burger's disease: a case report

Burger's disease is a peripheral vascular disorder characterized by constricted blood flow, ischemic pain, and necrotizing tissue processes. This report describes the application of a brief hypnosis intervention in conjunction with standard medical procedures to increase peripheral blood flow in a patient with advanced Burger's disease. Using suggestions for foot warming and increased blood flow, substantial increases in surface foot temperature were obtained prior to and following an epidural sympathectomy. As a result, the procedure contributed to keeping necrotic tissue loss to a minimum, decreasing ischemic pain, and hopefully preventing the need for amputation. Treatment gains were maintained through discharge and at two month follow up. The results suggest that hypnosis may serve as a parsimonious, yet efficacious adjunct to standard medical care in the management of reduced peripheral blood flow in patients with Burger's disease. Further, it illustrates the feasibility of hypnosis as an adjunct treatment in busy, inpatient hospital settings.

Hypnosis in the treatment of patients with severe burns

Burn injuries are a frequent form of trauma, the care for which typically involves repeated, intrusive procedures and acute, excruciating levels of pain. Although research in the use of hypnosis with burn patients is largely anecdotal there is emerging evidence that the burn unit may be one of the most useful arenas for the clinical application of this technique. The acute, identifiable nature of burn care procedures and the emotional state of patients in trauma care both provide an often receptive setting for the use of this intervention.

Undifferentiated somatoform idiopathic anaphylaxis: nonorganic symptoms mimicking idiopathic anaphylaxis

BACKGROUND

Northwestern University's Division of Allergy and Immunology has had experience with the diagnosis and treatment of more than 350 patients with idiopathic anaphylaxis (IA). In 1992 we reported a group of patients with IA whose presentations mimicked IA, but IA and other organic causes were later excluded. Psychologic factors were suspected as the underlying problem. These patients were classified as IA-variant. Management of these cases was extremely difficult. There was significant morbidity and high and unnecessary costs.

OBJECTIVE

We aim to distinguish the nature of this disease and to highlight the evaluation and treatment of this group of patients.

METHODS

Their cases are reviewed and reported.

RESULTS

Common features included (1) presenting symptoms mimicking IA, (2) no objective findings that correlated with 1, (3) no response to the therapeutic regimen for IA, (4) meeting the Diagnostic and Statistical Manual of Mental Disorders criteria for undifferentiated somatoform disorder, and (5) significant wasted health care expenditure.

CONCLUSIONS

This group of patients were better defined as having undifferentiated somatoform-IA. An algorithm was proposed to expedite the diagnosis of the disease so that with early recognition of the disease, unwarranted repetitive consultations, tests, and inappropriate therapy can be avoided.

Pain, coping, and adjustment in patients with burns: preliminary findings from a prospective study

We prospectively examined the associations between procedural pain during hospitalization and coping and adjustment 1 month postdischarge in 43 patients treated at a major regional burn center for burns extensive enough to require at least 5 days of daily wound debridement procedures. Both patients and nurses provided ratings of patient pain, which were summarized and aggregated across a 5-day period. Results indicated that those subjects with higher pain scores also reported poorer adjustment as measured by scores on the Brief Symptoms Inventory and the Sickness Impact Profile. Moreover, these associations remained significant after partialling out the effects of preburn adjustment. Hierarchical regression analyses revealed evidence that seeking social support had a moderating effect on the association between pain and scores on a measure of posttraumatic stress disorder.

Non-opioid-based approaches to burn pain

Burn pain is almost always acute, and treatment strategies are often on the opposite end of the spectrum from chronic pain. However, many of the techniques developed for chronic pain can be useful for burn pain, particularly when the problem involves characteristics of both. The cognitive styles that patients bring to burn care and the manner in which they interpret nociception provide a rich source of intervention strategies. Learning theory can be extremely useful in pain control, particularly if such principles are structured into the overall manner in which care is provided (e.g., medication schedules and therapy approaches). Because patients in the burn unit often undergo significant distress, less conventional approaches such as hypnosis may assume a legitimate role. Finally, the needs of children have been neglected in the burn pain literature, and efforts on adjunctive techniques should also consider this population.

Coping and emotional attributions following spinal cord injury

Ways of Coping Checklist-Revised protocols gathered from 35 persons with spinal cord injuries on admission to an in-patient rehabilitation unit were cluster analysed using Ward's method. A two-cluster solution was produced reflecting patterns of coping similar to Lazarus und Folkman's (1984) emotion- and problem-focused dichotomy. These patterns of coping were validated against sets of demographic/medical and emotional adjustment/attribution variables gathered on discharge. Results showed that a group of subjects using emotion-focused coping styles reported greater ratings of depression. These subjects focused less on physical and therapy progress to promote positive feelings and focused more on thoughts about the accident. There was also a trend for physical setbacks to contribute to negative mood in these patients. This pattern was associated with having been readmitted to hospital. The clinical and research implications of the study are discussed.

Pain assessment from patients with burns and their nurses

We investigated pain experienced during burn wound debridement. Forty-nine adult patients with burns and 27 nurses submitted 123 pairs of visual analog scale pain ratings for burn wound debridements. While patients' overall visual analog scale pain scores were found to be evenly distributed, worst pain scores yielded a bimodal distribution with groups centered around means of 2.0 (low pain group) and 7.0 (high pain group). Low and high pain groups did not differ in age, sex, or total body surface area burned. Patient and nurse pain ratings were found to be highly correlated. According to one researcher's criteria, 53% of nurse pain ratings were accurate. Accuracy of nurses' ratings was unrelated to nursing experience or educational level. Future strategies are presented for comparing high and low pain groups and increasing nurse pain rating accuracy.

Fluid shifts induced by the administration of 7.5% sodium chloride in 6% dextran 70 (HSD) in dehydrated swine

This study determined the effects of HSD administration on fluid distribution, following dehydration in Female Yucatan micro pigs. Dehydration at 33 degrees C resulted in: significantly increased core temperature (37.2 +/- 0.2 (mean +/- SE) to 39.0 +/- 0.1 degrees C), and decreased (4.4 +/- 0.4%) body weight and plasma volume (PV, 43 +/- 2 to 37 +/- 1 ml/kg). HSD but not saline administration resulted in significant increases (over postdehydration levels) in PV (46 +/- 3 ml/kg), sodium concentration (141 +/- 1 to 150 +/- 2 mEq/L), and osmolality (291 +/- 2 to 307 +/- 11 mOsm). Following return of water to the animals, these values returned to baseline levels. Since insensible (respiratory and transdermal) water loss for the 24 hr at 23 degrees C was 714 +/- 64 ml, and for the 24 hr at 33 degrees C was 653 +/- 64 ml, increasing the ambient temperature did not result in increased dehydration in swine. HSD administration restored PV to baseline levels despite prior water loss dehydration.

Adjunctive interventions for burn pain control: comparison of hypnosis and ativan: the 1993 Clinical Research Award

Thirty-two patients hospitalized for the care of major burns were randomly assigned to groups that received hypnosis, lorazepam, hypnosis with lorazepam, or placebo controls as adjuncts to opioids for the control of pain during dressing changes. Analysis of scores on the Visual Analogue Scale indicated that although pain during dressing changes decreased over consecutive days, assignment to the various treatment groups did not have a differential effect. This finding was in contrast to those of earlier studies and is likely attributable to the low baseline pain scores of subjects who participated. A larger number of subjects with low baseline pain ratings will likely be necessary to replicate earlier findings. The results are argued to support the analgesic advantages of early, aggressive opioid use via PCA or through careful staff monitoring and titration of pain drugs.

Overview of the tolerability profile of clarithromycin in preclinical and clinical trials

Results of studies conducted to characterise local, systemic, reproductive, and mutagenic effects indicate that the new macrolide antimicrobial clarithromycin is well tolerated within reasonable multiples of the intended clinical dose. No adverse effects of clarithyromycin on male or female fertility, perinatal, or postnatal reproduction were indicated by data from rabbits, mice, rats and macaques. No evidence of mutagenic potential was revealed from various in vitro and in vivo study methodologies. Evidence of low potential for ototoxicity, oculotoxicity, hepatotoxicity and nephrotoxicity was provided in studies involving rats, dogs and primates. In agreement with studies with other macrolides, venous irritation potential for the intravenous lactobionate salt formulation was substantial in rabbit studies. In addition, the safety profile of this agent has been evaluated on the basis of adverse reactions and abnormal laboratory values seen in phase I, II and III international clinical trials conducted in adults. The most frequently reported adverse reactions occurring in 3768 patients receiving clarithromycin in phase II and III trials were nausea (3.8%), diarrhoea (3.0%), abdominal pain (1.9%) and headache (1.7%). Adverse reactions were not serious and were usually rapidly reversible. The incidence of adverse reactions did not vary with gender, race or age. Adverse reaction rates were comparable to or less than those of comparator beta-lactams and macrolides. Overall, clarithromycin appears to be a safe and well-tolerated macrolide antimicrobial agent.

Psychological effects of severe burn injuries

Severe burn injuries provide researchers with an opportunity to study the effects of painful but usually transient trauma on psychological functioning. To that end, this article presents a review of the 3 main areas of this body of literature: (a) premorbid characteristics of people who sustain severe burn injuries, (b) psychological reactions during hospitalization, and (c) long-term adjustment. The general implications of these studies are discussed and then used to illuminate the circumstances under which individuals suffer the most from this type of trauma, the effects of such injuries on personality function, and how meaningful units of measurements can be defined. Potential clinical applications are also described.

Buflomedil: one-year oral safety evaluation in rats

Buflomedil was given as a dietary mix to Sprague-Dawley Rats for one year at dosages of 0, 25, 75, and 400 mg/kg/day. Each group contained thirty rats of each sex, of which 10/sex/group were preassigned to a withdrawal period of 3 months following the 1-year drug administration period. There were no treatment-related deaths or clinical signs. Dosage-related decreases in body weight gain occurred during the 1-year treatment period. Food consumption was comparable to controls, except for a 10% decrease in high-dosage males during the first week of treatment. During the withdrawal period, body weight gain was higher than controls in all drug-treated groups. Hematocrit (PCV) and hemoglobin were slightly decreased during week 52 in high-dosage males; hematology values were comparable to controls during weeks 13 and 26 and at the end of the withdrawal period. There were no treatment-related changes in blood biochemistry. Urine pH was decreased in females at 75 mg/kg/day and in both sexes at 400 mg/kg/day. Discolored urine was observed in males at 75 mg/kg/day and in both sexes at 400 mg/kg/day. Urine pH and color were comparable to controls after the 3-month withdrawal period. There were slight decreases compared to controls in urine volume at all dosages in females during week 52; these changes were still evident in the mid- and high-dosage groups at the end of the withdrawal period. The only possibly treatment-related observation at necropsy was dirty tails at the end of the treatment period in the high-dosage group which may have been related to the discolored urine. Liver and kidney weights were slightly increased in males at 400 mg/kg/day at the end of the 1-year treatment period; these changes were not evident after the 3-month withdrawal period. There were no treatment-related histopathological changes. The changes observed were thought to result from either pharmacologic activity or physiological adaptation to compound administration or were marginal in severity. None were considered toxicologically significant. Therefore, the no-toxic-effect dosage was 400 mg/kg/day which is 40 times the maximum clinical dosage.

Hypnosis for the treatment of burn pain

The clinical utility of hypnosis for controlling pain during burn wound debridement was investigated. Thirty hospitalized burn patients and their nurses submitted visual analog scales (VAS) for pain during 2 consecutive daily wound debridements. On the 1st day, patients and nurses submitted baseline VAS ratings. Before the next day's would debridement, Ss received hypnosis, attention and information, or no treatment. Only hypnotized Ss reported significant pain reductions relative to pretreatment baseline. This result was corroborated by nurse VAS ratings. Findings indicate that hypnosis is a viable adjunct treatment for burn pain. Theoretical and practical implications and future research directions are discussed.

The treatment of agitation during initial hospitalization after traumatic brain injury

Agitation after traumatic brain injury is disruptive for patient care, distressing, and difficult to treat. The use of propranolol has been advocated to control agitation after brain injury. It reportedly lacks some of the deleterious cognitive and emotional effects of other medications and physical restraints. This study was designed to test if propranolol is effective in reducing agitated behavior. Subjects had traumatic closed-head injury treated at a combined Level I Trauma Center and Rehabilitation Center. Twenty-one subjects met the criteria of agitation and were treated with propranolol or placebo in a double-blind fashion. The intensity of agitation was significantly lower in the treatment group although the number of episodes were similar. The use of restraints was also significantly lower in the treatment group. The results support the effectiveness of propranolol in reducing the intensity of agitation during the initial hospitalization after closed-head injury.

Effects of a GnRH agonist on fertility following administration to prepubertal male and female rats

Leuprolide, a GnRH agonist, was administered daily to male and female rats for 90 days. Animals were sexually immature (25 days old) at the outset. Dosages were 20 and 200 micrograms/kg/day. Five males and five females were euthanized on Day 91. Sex organs were weighed and evaluated for histopathologic changes. These procedures were repeated 140 days later. Following a recovery period lasting 45 days (onset of normal-appearing estrous cycles) in females and 140 days (two spermatogenic cycles) in males, the fertility of these rats was assessed by mating with untreated animals. Treated males gained less weight while treated females gained more weight than controls. Weights of primary and secondary sex organs were reduced below control, but returned to normal following 140 days of recovery. Treated males were fertile and produced normal litters. Reproductive performance of low-dosage (20 micrograms/kg/day) females was normal 45 days after treatment cessation, but half of the high-dosage (200 micrograms/kg/day) females failed to become pregnant. However, reproductive performance of this group compared well with control performance after an additional 6 weeks of recovery. Atrophic changes were noted in male and female sex organs. Following 140 days of recovery, ovaries, uterus, vagina, prostate, and seminal vesicle were normal. Although testes and epididymides showed partial recovery at this time, multifocal or segmental atrophy and mineralization were noted in portions of some seminiferous tubules.