A comparison of interactive immersive virtual reality and still nature pictures as distraction-based analgesia in burn wound care.

PURPOSE: Non-pharmacologic adjuncts to opioid analgesics for burn wound debridement enhance safety and cost effectiveness in care. The current study explored the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults, and tested whether interactive VR would reduce pain more effectively than nature stimuli viewed in the same VR goggles. METHODS: Forty-eight patients with severe burn injuries (44 adults and 4 children) had their burn injuries debrided and dressed in a wet wound care environment on Study Day 1, and 13 also participated in Study Day 2. INTERVENTION: The study used a within-subject design to test two hypotheses (one hypothesis per study day) with the condition order randomized. On Study Day 1, each individual (n = 44 participants) spent 5 min of wound care in an interactive immersive VR environment designed for burn care, and 5 min looking at still nature photos and sounds of nature in the same VR goggles. On Study Day 2 (n = 12 adult participants and one adolescent from Day 1), each participant spent 5 min of burn wound care with no distraction and 5 min of wound care in VR, using a new water-friendly VR system. On both days, during a post-wound care assessment, participants rated and compared the pain they had experienced in each condition. OUTCOME MEASURES ON STUDY DAYS 1 AND 2: Worst pain during burn wound care was the primary dependent variable. Secondary measures were ratings of time spent thinking about pain during wound care, pain unpleasantness, and positive affect during wound care. RESULTS: On Study Day 1, no significant differences in worst pain ratings during wound care were found between the computer-generated world (Mean = 71.06, SD = 26.86) vs. Nature pictures conditions (Mean = 68.19, SD = 29.26; t < 1, NS). On secondary measures, positive affect (fun) was higher, and realism was lower during computer-generated VR. No significant differences in pain unpleasantness or "presence in VR" between the two conditions were found, however. VR VS. NO VR. (STUDY DAY 2): Participants reported significantly less worst pain when distracted with adjunctive computer generated VR than during standard wound care without distraction (Mean = 54.23, SD = 26.13 vs 63.85, SD = 31.50, t(11) = 1.91, p < .05, SD = 17.38). In addition, on Study Day 2, "time spent thinking about pain during wound care" was significantly less during the VR condition, and positive affect was significantly greater during VR, compared to the No VR condition. CONCLUSION: The current study is innovative in that it is the first to show the feasibility of using a custom portable water-friendly immersive VR hardware during burn debridement in adults. However, contrary to predictions, interactive VR did not reduce pain more effectively than nature stimuli viewed in the same VR goggles.

Adolescents with and without head and neck burns: comparison of long-term outcomes in the burn model system national database.

INTRODUCTION: Facial burns account for persistent differences in psychosocial functioning in adult burn survivors. Although adolescent burn survivors experience myriad chronic sequelae, little is known about the effect of facial injuries. This study examines differences in long-term outcomes with and without head and neck involvement. METHODS: Data collected for 392 burn survivors between 14-17.9 years of age from the Burn Model System National Database (2006-2015) were analyzed. Comparisons were made between two groups based on presence of a head and neck burn (H&N) using the following patient reported outcome measures: Satisfaction with Appearance Scale, Satisfaction with Life Scale, Community Integration Questionnaire, and Short Form-12 Health Survey at 6, 12, and 24 months after injury. Regression analyses were used to assess association between outcome measures and H&N group at 12-months. RESULTS: The H&N group had more extensive burns, had longer hospital stays, were more likely to be burned by fire/flame and were more likely to be Hispanic compared to the non-H&N group. Regression analysis found that H&N burn status was associated with worse SWAP scores. No significant associations were found between H&N burn status and other outcome measures. CONCLUSIONS: Adolescents with H&N burn status showed significantly worse satisfaction with appearance at 12-months after injury. Future research should examine interventions to help improve body image and coping for adolescent burn survivors with head and neck burns.

Measuring the impact of burn injury on the parent-reported health outcomes of children 1-to-5 years: Item pool development for the Preschool1-5 Life Impact Burn Recovery Evaluation (LIBRE) Profile.

Modern, reliable, and valid outcome measures are essential to understanding the health needs of young children with burn injuries. Burn-specific and age-appropriate legacy assessment tools exist for this population but are hindered by the limitations of existing paper-based instruments. The purpose of this study was to develop item pools comprised of questions appropriate for children aged 1-5 with burn injuries. Item development was based on a framework provided by previous work to develop the Preschool Life Impact Burn Recovery Evaluation (LIBRE) Conceptual Model. The Preschool LIBRE Conceptual Model work established four sub-domains of functioning for children with burns aged 1-5. Item development involved a systematic literature review, a qualitative item review process with clinical experts, and parent cognitive interviews. Four item pools were established: (1) communication and language development; (2) physical functioning; (3) psychological functioning and (4) social functioning for preschool-aged children with burn injuries. We selected and refined candidate items, recall periods, survey instructions, and response option choices through clinical and parental feedback during the qualitative review and cognitive interview processes. Item pools are currently being field-tested as part of the process to calibrate and validate the Preschool1-5 LIBRE Computer Adaptive Test (CAT) Profile.

Virtual reality hand therapy: A new tool for nonopioid analgesia for acute procedural pain, hand rehabilitation, and VR embodiment therapy for phantom limb pain.

INTRODUCTION: Affordable virtual reality (VR) technology is now widely available. Billions of dollars are currently being invested into improving and mass producing VR and augmented reality products. PURPOSE OF THE STUDY: The purpose of the present study is to explore the potential of immersive VR to make physical therapy/occupational therapy less painful, more fun, and to help motivate patients to cooperate with their hand therapist. DISCUSSION: The following topics are covered: a) psychological influences on pain perception, b) the logic of how VR analgesia works, c) evidence for reduction of acute procedural pain during hand therapy, d) recent major advances in VR technology, and e) future directions-immersive VR embodiment therapy for phantom limb (chronic) pain. CONCLUSION: VR hand therapy has potential for a wide range of patient populations needing hand therapy, including acute pain and potentially chronic pain patients. Being in VR helps reduce the patients' pain, making it less painful for patients to move their hand/fingers during hand therapy, and gamified VR can help motivate the patient to perform therapeutic hand exercises, and make hand therapy more fun. In addition, VR camera-based hand tracking technology may be used to help therapists monitor how well patients are doing their hand therapy exercises, and to quantify whether adherence to treatment increases long-term functionality. Additional research and development into using VR as a tool for hand therapist is recommended for both acute pain and persistent pain patient populations.

Virtual Reality Analgesia for Children With Large Severe Burn Wounds During Burn Wound Debridement.

The objective of this study was to compare the effect of adjunctive virtual reality vs. standard analgesic pain medications during burn wound cleaning/debridement. Participants were predominantly Hispanic children aged 6-17 years of age, with large severe burn injuries (TBSA = 44%) reporting moderate or higher baseline pain during burn wound care. Using a randomized between-groups design, participants were randomly assigned to one of two groups, (a) the Control Group = pain medications only or (b) the VR Group = pain medications + virtual reality. A total of 50 children (88% Hispanic) with large severe burns (mean TBSA > 10%) received severe burn wound cleaning sessions. For the primary outcome measure of worst pain (intensity) on Study Day 1, using a between groups ANOVA, burn injured children in the group that received virtual reality during wound care showed significantly less pain intensity than the No VR control group, [mean worst pain ratings for the No VR group = 7.46 (SD = 2.93) vs. 5.54 (SD = 3.56), F (1,48) = 4.29, <0.05, MSE = 46.00]. Similarly, one of the secondary pain measures, "lowest pain during wound care" was significantly lower in the VR group, No VR = 4.29 (SD = 3.75) vs. 1.68 (2.04) for the VR group, F(147) = 9.29, < 0.005, MSE = 83.52 for Study Day 1. The other secondary pain measures showed the predicted pattern on Study Day 1, but were non-significant. Regarding whether VR reduced pain beyond Study Day 1, absolute change in pain intensity (analgesia = baseline pain minus the mean of the worst pain scores on Study days 1-10) was significantly greater for the VR group, F (148) = 4.88, p < 0.05, MSE = 34.26, partial eta squared = 0.09, but contrary to predictions, absolute change scores were non-significant for all secondary measures.

Measuring the Impact of Burn Injury on the Parent-Reported Health Outcomes of Children 1 to 5 Years: A Conceptual Framework for Development of the Preschool Life Impact Burn Recovery Evaluation Profile CAT.

Due to the rapid developmental growth in preschool-aged children, more precise measurement of the effects of burns on child health outcomes is needed. Expanding upon the Shriners Hospitals for Children/American Burn Association Burn Outcome Questionnaire 0 to 5 (BOQ0-5), we developed a conceptual framework describing domains important in assessing recovery from burn injury among preschool-aged children (1-5 years). We developed a working conceptual framework based on the BOQ0-5, the National Research Council and Institute of Medicine's Model of Child Health, and the World Health Organization's International Classification of Functioning, Disability, and Health for Children and Youth. We iteratively refined our framework based on a literature review, focus groups, interviews, and expert consensus meetings. Data were qualitatively analyzed using methods informed by grounded theory. We reviewed 95 pediatric assessments, conducted two clinician focus groups and six parent interviews, and consulted with 23 clinician experts. Three child health outcome domains emerged from our analysis: symptoms, functioning, and family. The symptoms domain describes parents' perceptions of their child's pain, skin-related discomfort, and fatigue. The functioning domain describes children's physical functioning (gross and fine motor function), psychological functioning (internalizing, externalizing, and dysregulation behavior; trauma; toileting; resilience), communication and language development (receiving and producing meaning), and social functioning (connecting with family/peers, friendships, and play). The family domain describes family psychological and routine functioning outcomes.

One-Year Comparison of a Community-Based Exercise Program Versus a Day Hospital-Based Exercise Program on Quality of Life and Mental Health in Severely Burned Children.

OBJECTIVE: To compare the effects of long-term psychosocial functioning and mental health of a "day hospital"-based exercise program (DAYEX) versus a community-based exercise program (COMBEX). DESIGN: A prospective design that consisted of 2 groups (DAYEX and COMBEX). SETTING: A children's hospital specialized in burn care. PARTICIPANTS: Patients (N=18; DAYEX [n=9], COMBEX [n=9]) were assessed at intensive care unit discharge and up to 1 year postburn. INTERVENTIONS: The Child Health Questionnaires (CHQ-Child Form [CHQ-CF87] and CHQ-Parent Form [CHQ-PF28]) were used to assess changes in quality of life from discharge to 1 year postburn. MAIN OUTCOME MEASURES: CHQ-PF28 and CHQ-CF87. RESULTS: Demographic characteristics and total body surface area burned were similar in both groups. Length of hospital stay was significant in the COMBEX group. CHQ-CF87 and CHQ-PF28 documented significant improvements in both groups between discharge and 1 year. Significance was evident in Physical Functioning, Bodily Pain, Self-Esteem, Change in Health, and Family Activities. CHQ-CF87 showed improvement in Family Cohesion in COMBEX more than DAYEX. CHQ-PF28 showed improvement in Role/Social Limitations-Emotional, Bodily Pain, and Family Activities in COMBEX more than DAYEX. CONCLUSIONS: The proposed COMBEX program is feasible and beneficial physically, psychosocially, and mentally. The results show some improvements in the COMBEX group in optimizing function and health in severely burned children. The COMBEX group performed at least as well as the DAYEX group. Larger-scale studies are needed to validate current findings.

Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study.

Background/Aim: Using a within-subjects, within-wound care design, this pilot study tested for the first time, whether immersive virtual reality (VR) can serve as an adjunctive non-opioid analgesic for children with large severe burn wounds during burn wound cleaning in the ICU, in a regional burn center in the United States, between 2014-2016. Methods: Participants included 48 children from 6 years old to 17 years of age with >10% TBSA burn injuries reporting moderate or higher worst pain during no VR on Day 1. Forty-four of the 48 children were from developing Latin American countries. Patients played adjunctive SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the same wound care session (initial treatment condition randomized). Using Graphic Rating scales, children's worst pain ratings during "No VR" (treatment as usual pain medications) vs. their worst pain during "Yes VR" was measured during at least 1 day of wound care, and was measured for up to 10 study days the patient used VR. Results: VR significantly reduced children's "worst pain" ratings during burn wound cleaning procedures in the ICU on Day 1. Worst pain during No VR = 8.52 (SD = 1.75) vs. during Yes VR = 5.10 (SD = 3.27), t (47) = 7.11, p < 0.001, SD = 3.33, CI = 2.45-4.38, Cohen's d = 1.03 (indicating large effect size). Patients continued to report the predicted pattern of lower pain and more fun during VR, during multiple sessions. Conclusion: Immersive virtual reality can help reduce the pain of children with large severe burn wounds during burn wound cleaning in the Intensive Care Unit. Additional research and development is recommended.

Postacute Care Setting Is Associated With Employment After Burn Injury.

OBJECTIVE: To examine differences in long-term employment outcomes in the postacute care setting. DESIGN: Retrospective review of the prospectively collected Burn Model System National Database. SETTING AND PARTICIPANTS: A total of 695 adult survivors of burn injury enrolled between May 1994 and June 2016 who required postacute care at a Burn Model System center following acute care discharge were included. Participants were divided into 2 groups based on acute care discharge disposition. Those who received postacute care at an inpatient rehabilitation facility (IRF) following acute care were included in the IRF group (N=447), and those who were treated at a skilled nursing facility, long-term care hospital, or other extended-care facility following acute care were included in the Other Rehab group (N=248). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status at 12 months postinjury. Propensity score matching and logistic regression were utilized to determine the effect of postacute care setting on employment status. RESULTS: Individuals in the IRF group had larger burns and were more likely to have an inhalation injury and to undergo amputation. At 12 months postinjury, the IRF group had over 9 times increased odds of being employed compared to the Other Rehab group, using propensity score matching (P=.046). CONCLUSIONS: While admitting patients with more severe injuries, IRFs provided a long-term benefit for survivors of burn injury in terms of regaining employment. Given the current lack of evidence-based guidelines on postacute care decisions, the results of this study shed light on the potential benefits of the intensive services provided at IRFs in this population.

The Presence of Scarring and Associated Morbidity in the Burn Model System National Database.

INTRODUCTION: Postburn scarring is common, but the risk factors, natural history, and consequences of such scars are still poorly understood. This study aims to describe the frequency of scar-related morbidity for up to 2 years after injury and to analyze the impact of burn scars on long-term functional, psychosocial, and reintegration outcomes. METHODS: Analysis was conducted on data collected between January 2006 and May 2014 from 960 patients (2440 anatomic burn sites) using the Burn Model System (BMS) database. Study population demographics were analyzed and odds ratios for the development of raised or thick scarring were determined. Regression analyses were used to evaluate the impact of hypertrophic scarring (HTS) on psychosocial outcomes, including the Community Integration Questionnaire, Satisfaction with Life Scale, Distress, and the Short Form 12. Symptoms associated with scarring were analyzed at discharge and 6, 12, and 24 months after burn using a set of questions on scarring developed by the BMS. Mixed-effect modeling was used to determine linear change over time and the significance of symptoms. RESULTS: The study population was primarily white (65.0%) and male (71.8%), with a mean (SD) age of 44.0 (15.2) years and mean total body surface area burned of 19.6% (17.9%). The incidence of raised or thick scars increased from 65% to 80% (P < 0.0001) for the 2-year follow-up period. The presence of scarring was not associated with Community Integration Questionnaire, Satisfaction with Life Scale, or Short Form 12 scores. Most patients reported symptoms associated with scarring at 2 years after burn, including dry or fragile skin, scars that restrict range of motion at a joint, issues with hand function, and scar pain and itch. CONCLUSIONS: In this large, longitudinal, multicenter cohort of burn survivors, nearly all patients noted the presence of scarring, and a majority noted additional symptoms and morbidity related to their scars even at 2 years after injury. This study demonstrates a need for the continued support of burn survivors to address scar-related morbidity. Furthermore, future studies examining the impact of novel treatments for scarring should use similar scar problem questionnaires and distress scores.

Virtual Reality Analgesia With Interactive Eye Tracking During Brief Thermal Pain Stimuli: A Randomized Controlled Trial (Crossover Design).

In light of growing concerns about opioid analgesics, developing new non-pharmacologic pain control techniques has become a high priority. Adjunctive virtual reality can help reduce acute pain during painful medical procedures. However, for some especially painful medical procedures such as burn wound cleaning, clinical researchers recommend that more distracting versions of virtual reality are needed, to further amplify the potency of virtual reality analgesia. The current study with healthy volunteers explores for the first time whether interacting with virtual objects in Virtual Reality (VR) via "hands free" eye-tracking technology integrated into the VR helmet makes VR more effective/powerful than non-interactive/passive VR (no eye-tracking) for reducing pain during brief thermal pain stimuli. METHOD: Forty eight healthy volunteers participated in the main study. Using a within-subject design, each participant received one brief thermal pain stimulus during interactive eye tracked virtual reality, and each participant received another thermal pain stimulus during non-interactive VR (treatment order randomized). After each pain stimulus, participants provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and rated the amount of fun they had during the pain stimulus. RESULTS: As predicted, interactive eye tracking increased the analgesic effectiveness of immersive virtual reality. Compared to the passive non-interactive VR condition, during the interactive eye tracked VR condition, participants reported significant reductions in worst pain (p < 0.001) and pain unpleasantness (p < 0.001). Participants reported a significantly stronger illusion of presence (p < 0.001), and significantly more fun in VR (p < 0.001) during the interactive condition compared to during passive VR. In summary, as predicted by our primary hypothesis, in the current laboratory acute pain analog study with healthy volunteers, increasing the immersiveness of the VR system via interactive eye tracking significantly increased how effectively VR reduced worst pain during a brief thermal pain stimulus. Although attention was not directly measured, the pattern of pain ratings, presence ratings, and fun ratings are consistent with an attentional mechanism for how VR reduces pain. Whether the current results generalize to clinical patient populations is another important topic for future research. Additional research and development is recommended.

Reduced Postburn Hypertrophic Scarring and Improved Physical Recovery With Yearlong Administration of Oxandrolone and Propranolol.

BACKGROUND: Massive burns induce a hypermetabolic response that leads to total body wasting and impaired physical and psychosocial recovery. The administration of propranolol or oxandrolone positively affects postburn metabolism and growth. The combined administration of oxandrolone and propranolol (OxProp) for 1 year restores growth in children with large burns. Here, we investigated whether the combined administration of OxProp for 1 year would reduce scarring and improve quality of life compared with control. STUDY DESIGN: Children with large burns (n = 480) were enrolled into this institutional review board-approved study; patients were randomized to control (n = 226) or administration of OxProp (n = 126) for 1 year postburn. Assessments were conducted at discharge and 6, 12, and 24 months postburn. Scar biopsies were obtained for histology. Physical scar assessments and patient reported outcome measures of physical and psychosocial function were obtained. RESULTS: Reductions in cellularity, vascular structures, inflammation, and abnormal collagen (P < 0.05) occurred in OxProp-treated scars. With OxProp, scar severity was attenuated and pliability increased (both P < 0.05). Analyses of patient-reported outcomes showed improved general and emotional health within the OxProp-treated group (P < 0.05). CONCLUSIONS: Here, we have shown improvements in objective and subjective measures of scarring and an increase in overall patient-reported physical function. The combined administration of OxProp for up to a year after burn injury should be considered for the reduction of postburn scarring and improvement of long-term psychosocial outcomes in children with massive burns.

The Effect of Facial Burns on Long-Term Outcomes in Young Adults: A 5-Year Study.

Long-term functional outcomes in young adults with facial burns remain poorly studied. This 5-year (2003-2008) prospective multicenter study includes burn survivors (age 19-30 years) who completed the Young Adult Burn Outcome Questionnaire (YABOQ) from 0 to 36 months after baseline survey administration. A composite canonical score was developed from 15 YABOQ domains using discriminant analysis, maximizing the difference at the baseline between burn-injured patients with face involved and not involved. A generalized linear model with the generalized estimation equation technique was used to track the changing pattern of the composite score over time. Individual domain scores with high correlation to the canonical score were used to evaluate recovery patterns in facial burns. A total of 153 burned (31% with face burns) and 112 nonburned subjects completed 620 questionnaires. Canonical analysis showed that early postburn, facial burns were associated with a difference in outcome, but this overall difference diminished over time. Regression analysis showed that for survivors with facial injury, Emotion and Sexual Function scores were persistently lower (worse), while Religion scores were persistently higher. Satisfaction with Role was initially better than the nonface burned group, but over time got worse, while Perceived Appearance was initially worse in the face burned group but this difference diminished over time. Social Function Limited by Appearance was initially similar between the groups, but over time the group with face burns scored lower. The overall difference in recovery between survivors with and without facial burns diminished over time while the individual domains had various patterns of recovery.

The Safety and Efficacy of Propranolol in Reducing the Hypermetabolic Response in the Pediatric Burn Population.

Pediatric burn patients often have hypertension and tachycardia for several years post-injury. Propranolol has shown to be effective in treating the hypermetabolic state secondary to a major burn injury. This study was conducted to document a safe and effective dosing regimen for three different age groups. One hundred four burn-injured children with a 30% to 92% total body surface area burn were treated for 1 to 2 years with propranolol in the outpatient setting. Guardians of the patients were instructed on how to take and monitor the systolic blood pressure and heart rate, and document their vital signs several times a day. The documentation was reviewed with the guardian and patient, and based on age-specific vital sign parameters, propranolol dosing adjustment was done to measure at least 15% to 20% reduction in admission heart rate. Mean doses for the age groups were as follows: 0 to 3 years 5.2 ± 2.8 mg/kg/day, 4 to 10 years 4.2 ± 1.8 mg/kg/day, and 11 to 18 years 2.9 ± 1.4 mg/kg/day. The propranolol dose decreased as time post-burn increased. On selected patients, propranolol was stopped due to changes in the heart rate, but at all times, it was safe and effective. No adverse effects were noted. The dosing regimen was not affected by burn size or gender. Propranolol can be safely stopped abruptly with no rebound hypertension. Individuals older than 10 years required a lower dose per kilogram following the burn injury than prepubertal burn survivors. Propranolol proved to be both safe and effective in the management of cardiovascular changes occurring in the hypermetabolic state.

Poverty, population density, and the epidemiology of burns in young children from Mexico treated at a U.S. pediatric burn facility.

INTRODUCTION: Children 5 and younger are at risk for sustaining serious burn injuries. The causes of burns vary depending on demographic, cultural and socioeconomic variables. At this pediatric burn center we provided medical care to children from Mexico with severe injuries. The purpose of this study was to understand the impact of demographic distribution and modifiable risk factors of burns in young children to help guide prevention. METHODS: A retrospective chart review was performed with children 5 and younger from Mexico who were injured from 2000-2013. The medical records of 447 acute patients were reviewed. Frequency counts and percentages were used to identify geographic distribution and calculate incidence of burns. Microsoft Powermap software was used to create a geographical map of Mexico based on types of burns. A binomial logistic regression was used to model the incidence of flame burns as opposed to scald burns in each state with relation to population density and poverty percentage. In all statistical tests, alpha=0.05 for a 95% level of confidence. RESULTS: Burns were primarily caused by flame and scald injuries. Admissions from flame injuries were mainly from explosions of propane tanks and gas lines and house fires. Flame injuries were predominantly from the states of Jalisco, Chihuahua, and Distrito Federal. Scalds were attributed to falling in large containers of hot water or food on the ground, and spills of hot liquids. Scald injuries were largely from the states of Oaxaca, Distrito Federal, and Hidalgo. The odds of a patient having flame burns were significantly associated with poverty percentage (p<0.0001) and population density (p=0.0085). Increasing levels of poverty led to decrease in odds of a flame burn, but an increase in the odds of scald burns. Similarly, we found that increasing population density led to a decrease in the odds of a flame burn, but an increase in the odds of a scald burn. CONCLUSIONS: Burns in young children from Mexico who received medical care at this pediatric burn center were attributed to flame and scalds. Potential demographic associations have been identified. Different states in Mexico have diverse cultural and socioeconomic variables that may influence the etiology of burns in young children and this information may help efficiently tailor burn prevention campaigns for burn prevention efforts in each region. APPLICABILITY OF RESEARCH TO PRACTICE: This information will be used to develop and help modify existing prevention campaigns.

Use of gabapentin and pregabalin for pruritus and neuropathic pain associated with major burn injury: A retrospective chart review.

INTRODUCTION: Pruritis after burn is one of the most common chronic complaints in burn survivors. Pruritus is often indistinguishable from neuropathic pain. There is a paucity of studies reporting the use of gabapentin and pregabalin to treat both pruritus and neuropathic pain. The purpose of this current study is to explore and document the effect of gabapentin and pregabalin in children and adolescent burn survivors. METHODS: A retrospective review of charts and pharmacy records of gabapentin and pregabalin dispensed to control pruritus and/or pain was conducted for burn survivors up to 20 years of age. Data collected included medication doses, age and weight of patients, presence of neuropathic pain and pruritus, reported response to medication, and side effects of these medications. 136 individuals who received gabapentin, pregabalin, or both medications are included in the study. 112 received only gabapentin, none received only pregabalin, and 24 received both. All results are documented in mean±standard deviation (s.d.) dose/kg/day. 104 individuals experienced pruritus exclusively, two experienced neuropathic pain exclusively, and 30 experienced both. Use of medications was considered effective if the individuals reported pruritus or pain relief from the medication. The medication was considered safe if the individuals did not experience adverse side effects warranting discontinuation of the drugs. Medications were continued with dose adjustments if an individual reported minor side effects such as sedation or hyperactivity. RESULTS: The average effective dose mg/kg/day for gabapentin and pregabalin was calculated for each of the three age groups (≤5years, 6-12 years, and >12years). The average effective dose of gabapentin was 23.9±10.3mg/kg/day for children ≤5years, 27.0±15.3mg/kg/day for children 6-12 years, and 34.1±15.7mg/kg/day for children >12years. The average effective dose of pregabalin was 6.5±3.5mg/kg/day for children 6-12 years and 4.7±1.6mg/kg/day for children >12years. One 5-year-old child received 3.7mg/kg/day of pregabalin. Note that for all patients in this study, pregabalin was added after an inadequate response to gabapentin. For individuals receiving both gabapentin and pregabalin, the maximum gabapentin failure dose for pruritus was 32.8±18.0mg/kg/day and for both pain and pruritus was 28.1±18.3mg/kg/day. For individuals treated with only gabapentin, 91.4% had an adequate response for pruritus, 100% for neuropathic pain, and 43.3% for both pruritus and pain. 100% of individuals treated with both gabapentin and pregabalin had an adequate response for pruritus and 88.2% had an adequate response for both pruritus and pain. Gabapentin was associated with hyperactivity in two individuals, and sedation in one individual. One individual reported nausea, vomiting, and headaches when taking both medications; this resolved when gabapentin was discontinued. One individual reported sedation while taking both medications. CONCLUSION: Gabapentin and pregabalin are effective in relieving pruritus and neuropathic pain in most burn survivors. In some instances, these medications can be given together. Few individuals reported side effects.

Does Acute Propranolol Treatment Prevent Posttraumatic Stress Disorder, Anxiety, and Depression in Children with Burns?

OBJECTIVE: This study examined whether acute propranolol treatment prevented posttraumatic stress disorder (PTSD), anxiety, and depression in children hospitalized in the pediatric intensive care unit for large burns. We hypothesized that the prevalence of PTSD, anxiety, and depression would be significantly less in the propranolol than nonpropranolol groups. METHODS: Children who had previously participated in a randomized controlled clinical trial of acute propranolol and nonpropranolol controls were invited to participate in long-term follow-up interviews. Eligible participants from 1997 to 2008 were identified from the electronic medical records, and data were collected in 2010-2011. Measures included the Missouri Assessment of Genetics Interview for Children to assess lifetime PTSD, Revised Children's Manifest Anxiety Scale to assess anxiety, and two depression inventories Children's Depression Inventory and Beck Depression Inventory-II. RESULTS: Of 202 participants, 89 were in the propranolol group and 113 were nonpropranolol controls. Children were an average of 7 years postburn. The average total body surface area burned was 56.4 + 15.1% (range = 24%-99%). The mean dose of propranolol was 3.64 ± 3.19 mg/kg per day (range = 0.36-12.12). The duration of propranolol inpatient treatment days varied, mean days 26.5 ± 19.8. The prevalence of lifetime PTSD in the propranolol group was 3.5% and controls 7.2%, but this difference was not statistically significant. We controlled for administration of pain medications, anxiolytics, and antidepressants overall and no significant differences were detected in the rates of PTSD, anxiety, or depression. CONCLUSIONS: The prevalence of PTSD, anxiety, and depression was similar in children who received propranolol acutely and those who did not. This may be influenced by the standard of care that all children received timely pharmacotherapy for pain and anxiety management and psychotherapy beginning in their acute phase of treatment.

The Use of Virtual Reality Facilitates Dialectical Behavior Therapy® "Observing Sounds and Visuals" Mindfulness Skills Training Exercises for a Latino Patient with Severe Burns: A Case Study.

Sustaining a burn injury increases an individual's risk of developing psychological problems such as generalized anxiety, negative emotions, depression, acute stress disorder, or post-traumatic stress disorder. Despite the growing use of Dialectical Behavioral Therapy® (DBT®) by clinical psychologists, to date, there are no published studies using standard DBT® or DBT® skills learning for severe burn patients. The current study explored the feasibility and clinical potential of using Immersive Virtual Reality (VR) enhanced DBT® mindfulness skills training to reduce negative emotions and increase positive emotions of a patient with severe burn injuries. The participant was a hospitalized (in house) 21-year-old Spanish speaking Latino male patient being treated for a large (>35% TBSA) severe flame burn injury. Methods: The patient looked into a pair of Oculus Rift DK2 virtual reality goggles to perceive the computer-generated virtual reality illusion of floating down a river, with rocks, boulders, trees, mountains, and clouds, while listening to DBT® mindfulness training audios during 4 VR sessions over a 1 month period. Study measures were administered before and after each VR session. Results: As predicted, the patient reported increased positive emotions and decreased negative emotions. The patient also accepted the VR mindfulness treatment technique. He reported the sessions helped him become more comfortable with his emotions and he wanted to keep using mindfulness after returning home. Conclusions: Dialectical Behavioral Therapy is an empirically validated treatment approach that has proved effective with non-burn patient populations for treating many of the psychological problems experienced by severe burn patients. The current case study explored for the first time, the use of immersive virtual reality enhanced DBT® mindfulness skills training with a burn patient. The patient reported reductions in negative emotions and increases in positive emotions, after VR DBT® mindfulness skills training. Immersive Virtual Reality is becoming widely available to mainstream consumers, and thus has the potential to make this treatment available to a much wider number of patient populations, including severe burn patients. Additional development, and controlled studies are needed.

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.

Objective: To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. Participants: The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. Consensus Process: Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. Conclusion: Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.