Psychosocial care of persons with severe burns.

Treatment of people with burn injuries includes recovery of optimal function for survivors to fully participate in society, psychologically and physically. Increased likelihood of physical survival has led to greater concern for potential psychological morbidity for the burn survivor. Based on research and on many years of clinical experience in providing psychosocial care to burned children and adults, the authors outline their approach to assisting burn survivors and their families through the arduous process of recovery from admission through critical care, inpatient recuperation and reintegration upon hospital discharge. A philosophy of rehabilitation, a process that may occur for many months or years after patients' discharge from their acute hospitalization, is presented in the form of seven guidelines for working with burn survivors.

Coping style, personality and adolescent adjustment 10 years post-burn.

An assessment carried out on adolescents aged 11-18 who had suffered severe burns in early childhood 10-11 years previously indicated that the levels of problem behavior were similar and the levels of depression lower than those reported by adolescents in comparable reference populations. Adolescents' self-reports revealed higher levels of the personality traits emotional stability, agreeableness and extraversion. Self-reports further revealed lower levels of passive coping than are found in a normative reference population. Regression analyses showed that less emotional stability, less agreeableness and more passive coping styles were related to increased behavioral problems and symptoms of depression. The authors argue that future studies should focus on resilience and within-group differences.

Non-pharmacological nursing interventions for procedural pain relief in adults with burns: a systematic literature review.

Adult burn patients experience pain during wound care despite pharmacological interventions. Additional nursing interventions are needed to improve pain management. A systematic review was undertaken in order to examine the implications of previous research for evidence based decisions concerning the use of non-pharmacological nursing interventions and for future research. Twenty-six studies met the inclusion criteria and were discussed. The majority of the included studies concerned behavioural nursing interventions and focussed on promotion of psychological comfort. Although 17 studies showed that the intervention had a positive effect on pain outcomes and no adverse effects of the reviewed interventions were reported, the best available evidence was found for active hypnosis, rapid induction analgesia and distraction relaxation. However, in order to reduce methodological limitations, further research is needed before well-founded evidence based decisions for nursing practice can be made. Aspects that seem important for future research, like the type of the intervention, theoretical framework, manner of giving instruction and guidance, cost, outcomes, measurement instruments and data collection points are considered.

All three functional domains of the large ribosomal subunit protein L25 are required for both early and late pre-rRNA processing steps in Saccharomyces cerevisiae.

Mutational analysis has shown that the integrity of the region in domain III of 25S rRNA that is involved in binding of ribosomal protein L25 is essential for the production of mature 25S rRNA in the yeast Saccharomyces cerevisiae. However, even structural alterations that do not noticeably affect recognition by L25, as measured by an in vitro assay, strongly reduced 25S rRNA formation by inhibiting the removal of ITS2 from the 27S(B) precursor. In order to analyze the role of L25 in yeast pre-rRNA processing further we studied the effect of genetic depletion of the protein or mutation of each of its three previously identified functional domains, involved in nuclear import (N-terminal), RNA binding (central) and 60S subunit assembly (C-terminal), respectively. Depletion of L25 or mutating its (pre-)rRNA-binding domain blocked conversion of the 27S(B) precursor to 5.8S/25S rRNA, confirming that assembly of L25 is essential for ITS2 processing. However, mutations in either the N- or the C-terminal domain of L25, which only marginally affect its ability to bind to (pre-)rRNA, also resulted in defective ITS2 processing. Furthermore, in all cases there was a notable reduction in the efficiency of processing at the early cleavage sites A0, A1 and A2. We conclude that the assembly of L25 is necessary but not sufficient for removal of ITS2, as well as for fully efficient cleavage at the early sites. Additional elements located in the N- as well as C-terminal domains of L25 are required for both aspects of pre-rRNA processing.

Reliability and validity of the Health Outcomes Burn Questionnaire for infants and children in The Netherlands.

The Health Outcomes Burn Questionnaire (HOBQ) is a self-administered questionnaire to monitor outcome after burns in young children. This study aimed to assess feasibility, reliability and validity of the Dutch version of the HOBQ. The HOBQ was adapted into Dutch and tested in a population of children aged 0-4 years with a primary admission to a Dutch burn centre in March 2001-February 2004. Parents of 413 children were sent a questionnaire. To assess validity, a generic outcome instrument was included, the Infant Toddler Quality of Life Questionnaire (ITQOL). The response rate was 50.0% (n=196). Mean self-reported completion time was 16.7 min. The internal consistency of all the HOBQ-scales was good (Cronbach's alpha's>0.69). Test-retest results showed no differences in 7 out of 10 scales. High correlations between HOBQ-scales and conceptually equivalent ITQOL and scales were found in 5 out of 7 comparisons. The majority of the HOBQ-scales (7 out of 10) showed significant differences in the expected direction between children with a long versus short length of stay. Our data support the reliability and validity of the Dutch HOBQ. The HOBQ can be used as a research tool, to monitor functional outcome after burns in young children. Further research in other samples is recommend to fully establish the reliability and validity of the HOBQ.

Reliability and validity of the pain observation scale for young children and the visual analogue scale in children with burns.

The aim of this study was to assess if the pain observation scale for young children (POCIS) and the visual analogue scale (VAS) are reliable and valid instruments to measure procedural and background pain in burned children aged 0-4 years. Burn care nurses (n=73) rated pain from 24 fragments of videotaped children during wound care procedures and during periods of rest using the POCIS and the VAS. Intraclass correlations were used to assess inter-rater and intra-rater reliability for the POCIS and the VAS. Internal consistency for POCIS was assessed by Cronbach's alpha. The POCIS has shown poor to moderate inter-rater reliability, moderate to good intra-rater reliability and an acceptable internal consistency. The VAS turned out to have poor inter-rater reliability and poor to moderate intra-rater reliability. Due to poor results of inter-rater reliability in both scales, construct validation is left undone until more acceptable results are obtained. Factors explaining the results are the large number of raters, the manner they were trained and a lack of variation between pain classes in video fragments. Although not all results were satisfying, an easy to use scale as POCIS has promising qualities and deserves further reliability research.

The burn specific pain anxiety scale: introduction of a reliable and valid measure.

The burn specific pain anxiety scale (BSPAS) is a nine-item self-report scale for the assessment of pain-related and anticipatory anxiety in burned patients. This paper describes a study designed to explore the psychometric properties of the scale. The study used 35 burned patients hospitalized in Rotterdam and Groningen, The Netherlands, to confirm the internal consistency of the instrument and provide an assessment of its validity. The alpha coefficient was high: 0.94. The BSPAS correlated statistically significantly with the STAI-S, procedural pain, non-procedural pain, and nurses' visual analog observation ratings of tension.

Burn injuries, pain and distress: exploring the role of stress symptomatology.

Forty-three consecutive patients were assessed for post-traumatic stress 7 days after admission to hospital. Patients were asked to complete the Impact-of-Event Scale. Findings indicated that among the 43 patients 52.1 per cent experienced serious levels of stress symptomatology. A Visual Analog Thermometer was employed to measure the pain experienced at rest and during therapeutic procedures. High levels of post-traumatic stress were associated with higher pain scores during therapeutic procedures and more pain when at rest.

Posttraumatic stress and maladjustment among adult burn survivors 1-2 years postburn.

Burn patients were assessed 14-24 months following their injury to estimate the prevalence of chronic posttraumatic stress in the adult burn population in The Netherlands. Among 428 patients, 33 per cent suffered severe posttraumatic stress symptomatology. Burn related health problems and shame were strongly associated with posttraumatic stress. Bootstrapping was used to estimate standardized regression weights in a structural equation model.

Posttraumatic stress and maladjustment among adult burn survivors 1 to 2 years postburn. Part II: the interview data.

The purpose of this study was to assess the reaction to burn trauma, the hospitalisation characteristics and psychosocial adjustment in 174 burn victims who agreed to participate in a structured interview. It was postulated that once patients sustain a burn, the level of loneliness feelings and feelings of shame is a function of the visibility of the scars. Contrary to expectation, the visibility of the burn scars was not a predictor of pathological feelings of shame. By contrast, social introversion was a factor significantly associated with the development of burn related pathological feelings of shame.

Dissociation as a predictor of psychopathology following burns injury.

Forty-six burned adults were seen, on average 7 days after admission to hospital. Eighty per cent suffered from one or more dissociative symptoms during trauma and three or more dissociative phenomena were experienced by 19.5 per cent. Blunting or absence of emotion was the symptom most frequently reported. The number of dissociative phenomena during trauma was statistically significant and associated with extreme anxiety. The intensity of the dissociation-anxiety reaction during trauma was a predictor for psychopathology measured at the moment of discharge.

Post-traumatic stress, pain and anxiety in adult burn victims.

This article describes the relationship between post-traumatic morbidity, anxious anticipation of pain and pain perception in 33 adult burn patients. Burn patients were assessed, on average, 7 days after admission to the hospital. Five times a day nurses asked the patients to provide pain ratings. The more patients suffered from post-traumatic stress, the more their anxiety state was elevated. The association between post-traumatic stress and pain perception was, controlling for the effects of anxious anticipation, spurious.

Do burn patients need burn specific multidisciplinary outpatient aftercare: research results.

In a cross-sectional study of patients 12-24 months after a burn injury, the need for a multidisciplinary burn specific outpatient clinic was examined in relation to aftercare consumption, physical and psychological problems. Four hundred and twenty nine patients were assessed by means of three self-report questionnaires: IES, SCL(PTSD-SL) and BSHS-SV-S. Results indicated that the current aftercare providers are almost exclusively medical doctors and that a quarter of the patients are dissatisfied with received aftercare. However, dissatisfaction about current aftercare was not the only criterion to determine whether patients wanted burn-specific aftercare. The severity of psychological and physical problems predicted interest in a multi-disciplinary outpatient clinic. Self-reported psychological and physical problems were found to be related to one another. Univariate logistic regression outcomes suggested that patients with serious psychological and physical problems are more likely to express interest in a burn-specific outpatient clinic, but that, in a multivariate regression analysis, physical problems and psychological problems measured on the SCL(PTSD-SLEEP) do not contribute to the prediction of the interest in a burn-specific outpatient clinic anymore once symptoms of PTSD are taken care of. Results suggest that psychological aftercare for burn patients needs to be improved. Possible steps to improve aftercare to meet patients' needs are discussed.

A European hospital survey to determine the extent of psychological services offered to patients with severe burns.

Analogous to a hospital survey in North America (the US and Canada) a survey in Europe was performed to determine the extent of psychological services offered in burn units. The questionnaire used to acquire this information was exactly the same in both continents. One hundred and seventy questionnaires and self-addressed stamped envelopes were sent to the medical manager of the European burn units with the request to pass the questionnaire to the person who provides psychological care to patients in the burn units. The questionnaire was translated into four other languages. Response was 103 (62.8%). The questions posed inquired after what percentage of patients received psychological testing, psychological therapy, displayed symptoms of depression and post-traumatic stress, what percentage is given referral and if emotional follow-up is arranged. Also questions about whether staff members of the burn unit displayed symptoms of depression and post-traumatic stress were enclosed. Results indicated that few burn units in Europe provide formal psychological testing for their patients and in half of the European hospitals, less than 20% of the patients receive psychological therapy or counselling during their stay in the hospital. Aftercare services are also capable of improvement. Compared with North America, Europe provided less psychological services. No statistical differences were found between countries within Europe.

The abbreviated burn specific pain anxiety scale: a multicenter study.

The authors examined ratings on a scale of pain-related anxiety in 173 burn patients in three groups: patients with small burns, patients with moderate burns and patients with extensive burns. The data suggest a greater degree of anxiety during procedures and before procedures in the burn patients with extensive burns than in burn patients with small and moderate burns. This study introduces a novel measure of pain-related anxiety in clinical burn patients, the abbreviated Burn Specific Pain Anxiety Scale (BSPAS), which showed a high degree of reliability. The alpha coefficients were high for the BSPAS subscales.

Psychological and social problems in burn patients after discharge. A follow-up study.

Approximately 18 months after discharge we were able to screen 42 burned adult patients for psychological and social problems. Using independent semi-standardized interviews, validated psychological questionnaires and standardized self-reports of the patients, we obtained three separate evaluations. The interreliability between the three different 'judges' varied from poor to moderate. Research suggests that 40% of burned adult patients have psychological problems. The cycle of recovery is dynamic. Only 21% need psychological help 18 months after discharge, but half of these are in danger of becoming 'drop-outs' because they do not receive the necessary treatment. A follow-up consisting of psychological questionnaires six months post-discharge appears to be a good and efficient instrument in limiting the drop-out risk.

Itching following burns: epidemiology and predictors.

BACKGROUND: Itching (pruritus) following burns is a well-known clinical problem. However, there are no long-term prospective studies that document the course and the extent of the problem. Studies on risk factors are anecdotal. OBJECTIVES: To study self-reported itching in a multicentre cohort among adults with burns at 3, 12 and 24 months postburn. Further, to examine psychological and injury characteristics in relation to itching at these three points in time. METHODS: Itching was assessed as part of a self-report scar complaint list in a prospective longitudinal cohort study. Injury characteristics, demographics and self-reported post-traumatic stress symptoms were examined as possible risk factors in three linear regression models. RESULTS: A total of 510 persons participated. The reported prevalence rates of mild to severe itching were as high as 87%, 70% and 67% at the three respective points in time. Significant predictors of itching at all three points in time were deep dermal injury and early post-traumatic stress symptoms. Along with these, total burned surface area and female gender were predictors at 3 months postburn. CONCLUSIONS: Itching remains a significant problem over a 2-year period. Individuals having undergone surgical procedures and experiencing early post-traumatic distress are more likely to suffer from long-term and persistent itching. Implications regarding practice and research are discussed.

Development and application of an in vivo system to study yeast ribosomal RNA biogenesis and function.

We have developed a system for mutational analysis of Saccharomyces cerevisiae ribosomal RNA in vivo in which yeast cells can be made completely dependent on mutant rRNA and ribosomes by a simple switch in carbon source. The system is based on a yeast strain defective in RNA polymerase I (Pol I) transcription [Nogi et al. (1991) Proc. Natl. Acad. Sci. USA 88, 3962-3966]. This normally inviable strain was rescued by integration of multiple copies of the complete 37S pre-rRNA operon under control of the inducible, Pol II-transcribed GAL7 promoter into the rDNA repeat on chromosome XII. The resulting YJV100 strain can only grow on medium containing galactose as the carbon source. A second, episomal vector was constructed in which the rDNA unit was placed under control of the constitutive PGK1 promoter. YJV100 cells transformed with this vector are now also able to grow on glucose-based medium making the cells completely dependent on plasmid-encoded rRNA. We show that the Pol II-transcribed pre-rRNA is processed and assembled similarly to authentic Pol I-synthesised pre-rRNA, making this 'in vivo Pol II system' suitable for the detailed analysis of rRNA mutations, even highly deleterious ones, affecting ribosome biogenesis or function. A clear demonstration of this is our finding that an insertion into variable region V8 in 17S rRNA, previously judged to be neutral with respect to processing of 17S rRNA, its assembly into 40S subunits and the polysomal distribution of these subunits [Musters et al. (1989), Mol. Cell. Biol. 9, 551-559], is in fact a lethal mutation.

Yeast Rrp9p is an evolutionarily conserved U3 snoRNP protein essential for early pre-rRNA processing cleavages and requires box C for its association.

Pre-rRNA processing in eukaryotic cells requires participation of several snoRNPs. These include the highly conserved and abundant U3 snoRNP, which is essential for synthesis of 18S rRNA. Here we report the characterization of Rrp9p, a novel yeast U3 protein, identified via its homology to the human U3-55k protein. Epitope-tagged Rrp9p specifically precipitates U3 snoRNA, but Rrp9p is not required for the stable accumulation of this snoRNA. Genetic depletion of Rrp9p inhibits the early cleavages of the primary pre-rRNA transcript at A0, A1, and A2 and, consequently, production of 18S, but not 25S and 5.8S, rRNA. The hU3-55k protein can partially complement a yeast rrp9 null mutant, indicating that the function of this protein has been conserved. Immunoprecipitation of extracts from cells that coexpress epitope-tagged Rrp9p and various mutant forms of U3 snoRNA limits the region required for association of Rrp9p to the U3-specific box B/C motif. Box C is essential, whereas box B plays a supportive role.