Publications by authors named "James A Fauerbach"

55 Publications

Exploratory analysis of long-term physical and mental health morbidity and mortality: A comparison of individuals with self-inflicted versus non-self-inflicted burn injuries.

Burns 2020 05 20;46(3):531-538. Epub 2019 Oct 20.

Department of Psychiatry, UT Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Introduction: Self-inflicted burn (SIB) injuries are relatively rare, but patients may experience complex biopsychosocial challenges. This study aimed to compare long-term physical and psychological outcomes for individuals with SIB and non-SIB injuries.

Methods: Records of adult SIB (n = 125) and non-SIB (n = 3604) injuries were collected from U.S. burn centers within the Burn Model System between 1993 and 2018. Assessments were administered at discharge, 6 months, 24 months, 5 years, and 10 years.

Results: SIB patients were more often younger, unmarried, unemployed, male, struggling with pre-morbid psychiatric issues, and injured by fire/flame (all p < 0.001). SIB injury predicted prolonged mechanical ventilation, hospitalization, and rehabilitation (all p < 0.001). After injury, SIB patients had increased anxiety at 24 months (p = 0.0294), increased suicidal ideation at 5 years (p = 0.004), and clinically worse depression at 10 years (p = 0.0695). SIB patients had increased mortality across 24 months compared to non-SIB patients (OR = 4.706, p = 0.010).

Conclusion: SIB injuries are associated with worse physical and psychological outcomes compared to non-SIB injuries including complicated hospitalizations and chronic problems with anxiety, depression, suicidality, and mortality, even when controlling for common indicators of severity such as burn size. This underscores the importance of multidisciplinary treatment, including mental healthcare, and long-term follow-up for SIB patients. Identified pre-morbid risk factors indicate the need for targeted injury prevention.
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http://dx.doi.org/10.1016/j.burns.2019.09.003DOI Listing
May 2020

Cognitive Behavioral Treatment for Acute Posttrauma Distress: A Randomized, Controlled Proof-of-Concept Study Among Hospitalized Adults With Burns.

Arch Phys Med Rehabil 2020 01 15;101(1S):S16-S25. Epub 2019 Feb 15.

Johns Hopkins Burn Center, Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Department of Surgery, Division of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Objective: (1) To evaluate the feasibility of conducting a randomized controlled trial (RCT) of the Safety, Meaning, Activation and Resilience Training (SMART) intervention vs nondirective supportive psychotherapy (NDSP) in an acutely hospitalized adult survivor of burn injury sample; and (2) to assess the preliminary effect of SMART on acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD) symptom reduction as secondary prevention.

Design: Proof-of-concept, parallel group RCT design.

Setting: Regional burn center.

Participants: Acutely injured, hospitalized adult survivors of burn injury (N=50) were randomly assigned to SMART (n=28) or nondirective supportive psychotherapy (n=22). Due to dropout and missing data, final sample size was 40, SMART (n=21) and nondirective supportive psychotherapy (n=19).

Interventions: SMART is a manualized, 4-session cognitive behavioral therapy-based psychological intervention targeting ASD, PTSD, and MDD symptoms. NDSP is a manualized, 4-session protocol.

Main Outcome Measures: Davidson Trauma Scale ([DTS]; diagnostic proxy for ASD and PTSD; clinical cutoff=40, with higher score=higher severity) and the Patient Health Questionnaire-9 ([PHQ-9]; diagnostic proxy for MDD; clinical cutoff=10, with higher score=higher severity) at pretreatment, immediate posttreatment, and 1 month posttreatment.

Results: At baseline, median DTS scores and PHQ-9 scores were above clinical cutoffs and did not differ across groups. At 1 week and 1 month posttreatment, median DTS and PHQ-9 scores were beneath clinical cutoffs in the SMART group; scores remained above clinical cutoffs in the NDSP group at these time points.

Conclusions: It is feasible to conduct an RCT of SMART in hospitalized adult survivors of burn injury. SMART has the potential to yield clinically significant outcomes. Additional studies are needed to replicate and extend these findings.
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http://dx.doi.org/10.1016/j.apmr.2018.11.027DOI Listing
January 2020

National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System: Review of Program and Database.

Arch Phys Med Rehabil 2020 01 5;101(1S):S5-S15. Epub 2017 Oct 5.

Administration on Community Living, U.S. Department of Health and Human Services, National Institute on Disability, Independent Living, and Rehabilitation Research, Washington, DC.

The Burn Model System (BMS) centers program was created in 1994 to evaluate the long-term outcomes of burn injuries. As part of this multicenter program, a comprehensive longitudinal database was developed to facilitate the study of a number of functional and psychosocial outcomes after burn injury. In this article, we provide an overview of the data collection procedures, measures selection process, and an overview of the participant data collected between 1994 and 2016. Surveys were administered during hospitalization and at 6, 12, and 24 months after discharge, and in the most recent funding cycle, data collection at every 5 years postinjury was added. More than 7200 people with burn injury were eligible to participate in the BMS National Longitudinal Database. Of these, >5900 (82%) were alive at discharge and consented to follow-up data collection. The BMS National Longitudinal Database represents a large sample of people with burn injury, including information on demographic characteristics, injury characteristics, and health outcomes. The database is publicly available and can be used to examine the effect of burn injury on long-term outcomes.
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http://dx.doi.org/10.1016/j.apmr.2017.09.109DOI Listing
January 2020

Fatigue Following Burn Injury: A Burn Model System National Database Study.

J Burn Care Res 2018 04;39(3):450-456

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA.

Fatigue is a commonly reported but not well-documented symptom following burn injury. This study's objective was to determine the frequency and severity of fatigue over time and to identify predictors of fatigue in the adult burn population. Data from the Burn Model System National Database (April 1997 to January 2006) were analyzed. Individuals over 18 years of age who were alive at discharge were included. The vitality subscale of the Short-Form 36 Item Health Survey was examined at preinjury and discharge and at 6, 12, and 24 months postinjury. Mean and number of low vitality scores were calculated at each time interval. Descriptive statistics were generated for demographic and medical data. Cross-sectional regression models analyzed predictors of vitality at 6, 12, and 24 months postinjury. The study included 945 subjects. The population was 72.5% male and had a mean age of 40.6 years and mean burn size of 17.4%. Fatigue symptoms were present in a majority of the population (74.6%) and were most commonly reported at discharge. Although fewer burn survivors reported fatigue symptoms at each subsequent follow-up (P < .001), approximately one-half (49%) of the population continued to report fatigue symptoms at 24 months postinjury. Larger burn size was the only variable that was significant or approaching significance at all follow-up time points (P < .0167). Fatigue symptoms are common after burns and many burn survivors continue to report symptoms at 2 years postinjury. Burn survivors did not return to preinjury fatigue levels, highlighting the importance of understanding and monitoring fatigue.
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http://dx.doi.org/10.1097/BCR.0000000000000625DOI Listing
April 2018

Psychological Outcomes Following Burn Injuries.

J Burn Care Res 2017 May/Jun;38(3):e629-e631

From the *Department of Rehabilitation Medicine, University of Washington, Seattle; †Department of Child and Adolesent Psychiatry, New York University, New York; and ‡Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.1097/BCR.0000000000000549DOI Listing
May 2019

Cody.

Eplasty 2015 6;15:e35. Epub 2015 Aug 6.

Johns Hopkins Burn Center, Johns Hopkins University School of Medicine, Baltimore MD.

Advances in burn management over the past 2 decades have resulted in improved survival and reduced morbidity. The treatment of a single patient following a 90% total body surface area injury illustrates the intensity of labour and coordinated hospital care required for such catastrophically injured patients. Data were extracted from the medical records and from personal recollections of the individual members of the multidisciplinary team as well as from the patient. The clinical course and management of complications are described chronologically as a series of overlapping phases from admission to discharge.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4532175PMC
August 2015

Validation of the Community Integration Questionnaire in the adult burn injury population.

Qual Life Res 2015 Nov 19;24(11):2651-5. Epub 2015 May 19.

Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, 300 1st Avenue, Boston, MA, 02114, USA.

Purpose: With improved survival, long-term effects of burn injuries on quality of life, particularly community integration, are important outcomes. This study aims to assess the Community Integration Questionnaire's psychometric properties in the adult burn population.

Methods: Data were obtained from a multicenter longitudinal data set of burn survivors. The psychometric properties of the Community Integration Questionnaire (n = 492) were examined. The questionnaire items were evaluated for clinical and substantive relevance; validation procedures were conducted on different samples of the population; construct validity was assessed using exploratory factor analysis; internal consistency reliability was examined using Cronbach's α statistics; and item response theory was applied to the final models.

Results: The CIQ-15 was reduced by two questions to form the CIQ-13, with a two-factor structure, interpreted as self/family care and social integration. Item response theory testing suggests that Factor 2 captures a wider range of community integration levels. Cronbach's α was 0.80 for Factor 1, 0.77 for Factor 2, and 0.79 for the test as a whole.

Conclusions: The CIQ-13 demonstrates validity and reliability in the adult burn survivor population addressing issues of self/family care and social integration. This instrument is useful in future research of community reintegration outcomes in the burn population.
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http://dx.doi.org/10.1007/s11136-015-0997-4DOI Listing
November 2015

Clinical and psychiatric characteristics of self-inflicted burn patients in the United States: comparison with a nonintentional burn group.

J Burn Care Res 2015 May-Jun;36(3):381-6

From the Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Medicine, Baltimore, Maryland.

The main objective of the present study was to examine whether self-inflicted burn patients would differ from nonintentional, nonwork related burn patients on psychiatric and personality characteristics. Sociodemographic and injury related factors were also compared. Self-inflicted (N = 15) and nonintentional (N = 178) burn patient samples were drawn from a larger study examining physical and psychosocial outcomes following major burn. Psychiatric/personality factors included self-reported psychiatric treatment history, alcohol/drug use, preburn mental health (Short Form Health Survey-12 MCS) and neuroticism (NEO five factor inventory). Sociodemographic factors and injury related factors were obtained through medical records. Comparisons between the self-inflicted and the nonintentional groups were made using Fisher's exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. The self-inflicted group was 11.5 times more likely to report prior psychiatric treatment relative to the nonintentional burn group (P < .001) and 4.3 times more likely to have previously abused alcohol (P = .02). Compared to nonintentional burn patients, self-inflicted burn patients reported worse preburn mental health (P < .001). There were no differences on TBSA (P = .52) or sociodemographic characteristics (P values > .08). Relative to survivors of nonintentional burns, self-inflicted burn patients in the United States demonstrate high psychiatric comorbidity. Standards of care must be developed to optimize treatment procedures and recovery outcomes in this subgroup.
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http://dx.doi.org/10.1097/BCR.0000000000000100DOI Listing
March 2016

Pruritus in adult burn survivors: postburn prevalence and risk factors associated with increased intensity.

J Burn Care Res 2013 Jan-Feb;34(1):94-101

Department of Surgery, University of Washington, Seattle, WA, USA.

Pruritus (itching) is a common and distressing complaint after injury. The purpose of this study was to investigate self-reported postburn pruritus in a large, multisite cohort study of adult burn survivors. Descriptive statistics, general linear regression, and mixed model repeated measures analyses were employed to test statistical significance. Two cohorts of adult burn survivors were studied. Group 1 participants (n = 637) were injured from 2006 to 2010 and were followed up prospectively for 2 years from the time of injury. Prevalence and severity of pruritus were compared across multiple subgroups. Prevalence of pruritus at discharge, 6, 12, and 24 months following injury were 93, 86, 83, and 73%, respectively. Regression results established that %TBSA-burn and %TBSA-grafted were correlated to itch intensity values. Group 2 participants (n = 336) were injured 4 to 10 years before an assessment using the validated 5-D Itch Scale. Many patients (44.4%) reported itching in the area of the burn, graft, or donor site. Within this group, 76% reported itching for <6 hours/day, and 52 and 29% considered itch intensity to be mild or moderate, respectively. This study confirms that the prevalence of burn pruritus is high, initially affecting >90% and persisting for >40% of long-term burn survivors. New predictors for postburn itch were identified to include younger age, dry skin, and raised/thick scars. Characterization of the impact of postburn pruritus on leisure, vocation, and sleep are quantified for those long-term survivors suffering from postburn pruritus.
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http://dx.doi.org/10.1097/BCR.0b013e3182644c25DOI Listing
June 2013

Measuring coping behavior in patients with major burn injuries: a psychometric evaluation of the BCOPE.

J Burn Care Res 2011 May-Jun;32(3):392-8

Department of Psychiatry and Behavioral Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Burn injuries involve significant physiological, psychological, and social challenges with which individuals must cope. Although the brief COPE (BCOPE) is frequently used, knowledge of its factor structure and construct validity is limited, thus limiting confidence with interpreting results. This study assessed psychometric properties of the BCOPE in hospitalized patients with burn injury. Participants had a major burn injury (n = 362). Measures assessed coping behavior and physical, psychological, and social functioning. Exploratory factorial analysis was conducted to evaluate patterns of coping strategies. To assess construct validity, the BCOPE scale scores were correlated with the distress measures across time points. Exploratory factorial analysis revealed seven factors accounting for 51% of total variance. The pattern matrix indicated four items loaded onto factor 1 (active coping = 0.47-0.80) and four onto factor 2 (avoidant coping = 0.59-0.73). The remaining factors were consistent with original scale assignments reported by Carver (Int J Behav Med 1997;4:92-100). Construct validity of BCOPE scales (active and avoidant) was demonstrated by their association with the Davidson trauma scale, short form-12, and satisfaction with appearance scale. The results indicate that the BCOPE is valid, reliable, and can be meaningfully interpreted. Research using these factors may improve knowledge about interrelationships among stress, coping, and outcome, thus building the evidence base for managing distress in this population.
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http://dx.doi.org/10.1097/BCR.0b013e318217f97aDOI Listing
September 2011

Perceived stigmatization and social comfort: validating the constructs and their measurement among pediatric burn survivors.

Rehabil Psychol 2010 Nov;55(4):360-71

Department of Psychology, College of Staten Island, City University of New York, 2800 Victory Blvd., Staten Island, NY 10314, USA.

Objective: The current study implemented a four-step process to evaluate the measurement properties of the Perceived Stigmatization Questionnaire (PSQ) and the Social Comfort Questionnaire (SCQ) among long-term pediatric burn survivors.

Methods: First, a series of confirmatory factor analyses (CFAs) compared the hypothesized four-factor model--3 perceived stigmatization factors (absence of friendly behavior, confused and staring behavior, and hostile behavior)--and one social comfort factor to three other models. Second, we tested the measurement invariance of the instruments between pediatric and adult burn survivor samples. Third, possible differences in structural parameters across groups were tested. Fourth, we tested whether the three perceived stigmatization factors and the social comfort factor loaded on one second-order factor. Participants included 369 pediatric and 347 adult burn survivors.

Results: The four-factor model was superior to the comparison models. The PSQ and SCQ demonstrated measurement invariance. Factor variance, factor covariance, and the latent means of the PSQ did not vary across groups. The adult group had a significantly lower latent mean on the SCQ than the pediatric group. The three factors of the PSQ and the one-factor SCQ loaded on one second-order factor.

Conclusion: The results of this study lend support to both the construct validity of perceived stigmatization and social comfort and the potential value of the PSQ and SCQ for studying the social experience of people with visible differences.
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http://dx.doi.org/10.1037/a0021674DOI Listing
November 2010

Comparing parent and child perceptions of stigmatizing behavior experienced by children with burn scars.

Body Image 2011 Jan 11;8(1):70-3. Epub 2010 Nov 11.

Department of Psychology, The College of Staten Island, City University of New York, 2800 Victory Boulevard, Staten Island, NY 10314, USA.

This study examined perceptions of stigmatization in a sample of 85 pediatric burn survivors and their parents. Survivors and a parent independently completed the Perceived Stigmatization Questionnaire (PSQ) rating the frequency that the child experienced three types of stigmatizing behaviors: absence of friendly behavior, confused and staring behavior, and hostile behavior. The sample was divided into a high (top 25%) and low (bottom 75%) perceived stigmatization groups. The mean ratings of parents did not significantly differ from that of children reporting low stigmatization. The mean PSQ parent ratings were significantly lower than those of children reporting high stigmatization. Additionally, the concordance on PSQ subscale scores within child-parent dyads was significantly lower in children reporting high stigmatization relative to child-parent dyads of children reporting low stigmatization. Children surviving burns may experience stigmatization that is under-perceived by their parents. Clinicians should be alert to this potential discrepancy.
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http://dx.doi.org/10.1016/j.bodyim.2010.09.004DOI Listing
January 2011

Peritraumatic heart rate and posttraumatic stress disorder in patients with severe burns.

J Clin Psychiatry 2011 Apr 19;72(4):539-47. Epub 2010 Oct 19.

Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, 4940 Eastern Ave, Asthma and Allergy Center, 5B.71B, Baltimore, MD 21224, USA.

Objective: Previous studies have suggested a link between heart rate (HR) following trauma and the development of posttraumatic stress disorder (PTSD). This study expands on previous work by evaluating HR in burn patients followed longitudinally for symptoms of acute stress disorder (ASD) and PTSD.

Method: Data were collected from consecutive patients admitted to the Johns Hopkins Burn Center, Baltimore, Maryland, between 1997 and 2002. Patients completed the Stanford Acute Stress Reaction Questionnaire (n = 157) to assess symptoms of ASD. The Davidson Trauma Scale was completed at 1 (n = 145), 6 (n = 106), 12 (n = 94), and 24 (n = 66) months postdischarge to assess symptoms of PTSD. Heart rate in the ambulance, emergency room, and burn unit were obtained by retrospective medical chart review.

Results: Pearson correlations revealed a significant relationship between HR in the ambulance (r = 0.32, P = .016) and burn unit (r = 0.30, P = .001) and ASD scores at baseline. Heart rate in the ambulance was related to PTSD avoidance cluster scores at 1, 6, 12, and 24 months. In women, HR in the ambulance was correlated with PTSD scores at 6 (r = 0.65, P = .005) and 12 (r = 0.78, P = .005) months. When covariates (gender, β-blockers, Brief Symptom Inventory Global Severity Index score) were included in multivariate linear regression analyses, ambulance HR was associated with ASD and PTSD scores at baseline and 1 month, and the interaction of ambulance HR and gender was associated with PTSD scores at 6 and 12 months. Multivariate logistic regression results were similar at baseline and 12 months, which included an HR association yet no interaction at 6 months and a marginal interaction at 1 month.

Conclusions: While peritraumatic HR is most robustly associated with PTSD symptom severity, HR on admission to burn unit also predicts the development of ASD. Gender and avoidance symptoms appear particularly salient in this relationship, and these factors may aid in the identification of subgroups for which HR serves as a biomarker for PTSD. Future work may identify endophenotypic measures of increased risk for PTSD, targeting subgroups for early intervention.
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http://dx.doi.org/10.4088/JCP.09m05405bluDOI Listing
April 2011

Self-assessed physical health predicts 10-year mortality after myocardial infarction.

J Cardiopulm Rehabil Prev 2010 Jan-Feb;30(1):35-9

Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224, USA.

Purpose: In spite of their widespread use in other fields, global measures of health are not commonly used in determining the prognosis of patients with myocardial infarction (MI). The objective of the present study was to ascertain the relationship between self-assessed physical health at the time of the MI and long-term mortality.

Methods: This was a prospective cohort study of 284 patients with MI admitted to an academic community hospital between July 1995 and December 1996 who completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). The physical component scale from the SF-36 was used as a self-assessment of physical health. All-cause mortality was assessed 10 years later by using the Social Security Death Index.

Results: Patients with lower self-reported physical health were significantly more likely to be women; older; depressed; have a history of coronary artery disease; have a family history of MI; have a non-Q wave MI; have a Killip class 3 or 4 MI; have hypertension, diabetes mellitus, renal insufficiency, and chronic obstructive pulmonary disease; and have a longer hospitalization period. Patients with higher physical component scores had significantly lower mortality in the 10 years after MI and this persisted after adjusting for confounders (hazard ratio = 0.97 [95% CI 0.96-0.99], P = .001).

Conclusions: These data suggest that self-assessed physical health provides information on the long-term prognosis of patients with MI above and beyond that provided by traditional risk predictors.
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http://dx.doi.org/10.1097/HCR.0b013e3181c85a11DOI Listing
March 2010

Growth curve trajectories of distress in burn patients.

J Burn Care Res 2010 Jan-Feb;31(1):64-72

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA.

Psychological adjustment after a major burn injury is a significant concern to providers and patients alike. Although efforts have been made to identify associated risk factors, little is known about heterogeneity in the levels or trajectories of adjustment in this population. This study used a novel application of Growth Mixture Modeling to identify subgroups of patients based on their longitudinal self-reported distress using the Brief Symptom Inventory (BSI). Data were drawn from the database of the Burn Model Systems project, a prospective, multisite, cohort study of major burn injury survivors. The BSI was used to assess symptoms in-hospital and at 6, 12, and 24 months postburn. Participants' T scores on the BSIs Global Severity Index provided a continuous measure of psychological distress. Analyses were conducted using participants' Global Severity Index T scores to discern distinct classes of respondents with similar trajectories across the 2-year follow-up. Results from the Growth Mixture Modeling analysis produced an ordered four-class model of psychological recovery from a major burn. Groups represented the equivalent of high, subthreshold, mild, and minimal symptom severity. Covariates significantly affected the intercept and slope of each class, as well as prediction of group assignment. These analyses demonstrate differences between individual recoveries after a major burn. Psychological distress symptoms remain largely stable over time and highlight the psychological vulnerability of this patient population.
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http://dx.doi.org/10.1097/BCR.0b013e3181cb8ee6DOI Listing
May 2010

Posttraumatic stress disorder and pain impact functioning and disability after major burn injury.

J Burn Care Res 2010 Jan-Feb;31(1):13-25

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA.

This study sought to clarify the prospective and concurrent associations of posttraumatic stress disorder (PTSD) and pain with functioning and disability after burn injury. The sample was composed of consecutive patients admitted to a regional burn center with major burn injuries (N = 171) who were followed at 1, 6, 12, and 24 months postdischarge. The predictor measures were the McGill Pain Questionnaire and Davidson Trauma Scale, and the outcome measures were Short Form-36 Health Survey subscales administered at 6, 12, and 24 months after discharge. Linear mixed-effects analyses were conducted to evaluate pain and PTSD as predictors of functional outcomes. Higher PTSD symptom severity soon after hospital discharge was prospectively related to poorer physical and social functioning and greater psychosocial disability (P < .001). However, significant PTSD-by-time interactions also predicted future physical functioning and disability, indicating that the deleterious effects of early PTSD were ameliorated by time. In addition, at each follow-up, PTSD symptoms were concurrently related to greater physical and psychosocial disability, poorer social functioning, and less vitality (P < .001). More severe pain at each follow-up, but not PTSD, was correlated with poorer concurrent physical functioning (P < .002). Significant interaction terms indicated that the concurrent effect of PTSD on psychosocial disability, social functioning, and vitality attenuated during the 24-month recovery period. These findings suggest that assessing PTSD and pain following burn injury may aid in predicting future functioning. Future work should confirm this and evaluate whether aggressively treating both PTSD and pain helps improve functioning after major burn injury.
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http://dx.doi.org/10.1097/BCR.0b013e3181cb8cc8DOI Listing
May 2010

Relation of anxiety and adherence to risk-reducing recommendations following myocardial infarction.

Am J Cardiol 2009 Jun 16;103(12):1629-34. Epub 2009 Apr 16.

Division of Research and American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia, USA.

Unlike depression, the relation between anxiety and the adherence to risk-reducing recommendations after myocardial infarction (MI) has not been well studied. The aim of this study was to explore the effect of anxiety on adherence after MI. Patients (n = 278) hospitalized for MI were assessed for anxiety using the Beck Anxiety Inventory during the hospitalization (baseline) and at 4 months of follow-up. The measures of adherence included following a low-sodium, low-fat diet, exercising regularly, taking medications, decreasing stress, carrying medical supplies, increasing socialization, following a diabetic diet, measuring blood glucose levels, and smoking cessation (where applicable). Baseline anxiety was associated with younger age, female gender, hypertension, tobacco use, depression, and current mood disorder. At 4 months of follow-up, anxiety was also associated with living alone, a history of coronary artery disease, and Killip class >1. An anxiety summary score was calculated to assess anxiety across both points. Summary anxiety was associated with worse adherence to exercise, reducing stress, increasing socialization, and smoking cessation but with better adherence to carrying supplies (all p <0.05). After controlling for demographic, cardiovascular, and psychological factors, summary anxiety predicted worse adherence to reducing stress (p = 0.004) and increasing socialization (p = 0.033) and was the only significant predictor of worse adherence to smoking cessation (p = 0.001) and better adherence to carrying supplies (p = 0.04). Anxiety during the initial hospitalization and 4 months later was associated with lower adherence to many important risk-reducing recommendations after MI. In conclusion, additional research is needed to evaluate whether treating anxiety can improve adherence in this setting.
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http://dx.doi.org/10.1016/j.amjcard.2009.02.014DOI Listing
June 2009

Approach-avoidance coping conflict in a sample of burn patients at risk for posttraumatic stress disorder.

Depress Anxiety 2009 ;26(9):838-50

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: Following an acute burn injury, higher distress is consistently observed among individuals exhibiting a conflict between approach coping (e.g., processing) and avoidance coping (e.g., suppression) relative to those individuals who use only one of these methods. Study objectives were to determine if contradictory coping messages would lead to such approach-avoidance coping conflict and to determine if experiment-induced coping conflict is also associated with higher distress.

Methods: Participants (n=59 adults hospitalized with acute burn injuries) were assigned randomly to experimental conditions differing in the order in which training was provided in two ways of coping with posttrauma re-experiencing symptoms (i.e., process-then-suppress versus suppress-then-process). The primary dependent variable was coping behavior during the 24-hr posttraining period. Coping behavior was categorized as approach coping (processing), avoidance coping (suppressing), or approach-avoidance coping conflict (both) on the basis of median splits on subscales assessing these behaviors. Secondary analyses examined the relationship between this experiment-induced coping conflict and re-experiencing symptoms.

Results: Results indicated that participants in the process-then-suppress condition, relative to the suppress-then-process condition, were significantly more likely to exhibit approach-avoidance coping conflict (i.e., above median split on both processing and suppressing) during the next 24 hr. Furthermore, approach-avoidance coping conflict was associated with greater re-experiencing symptoms assessed via self-report and by blinded coding of recorded speech.

Conclusions: It is concluded that the order of coping skill training can influence treatment outcome, success of coping methods, and overall levels of distress. therefore, training in stabilizing and calming methods should precede training in active processing following stressful life events.
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http://dx.doi.org/10.1002/da.20439DOI Listing
December 2009

Confirmatory factor analysis of the Short Form McGill Pain Questionnaire with burn patients.

Eplasty 2008 1;8:e54. Epub 2008 Dec 1.

Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

The Short Form McGill Pain Questionnaire (SF-MPQ) is an abbreviated version of McGill Pain Questionnaire (MPQ) developed for pragmatic reasons to improve the clinical utility of the MPQ. Although the SF-MPQ has been used in more than 250 published studies, few studies have examined the core constructs it measures. The objective of this study was to evaluate in a sample with burn injuries whether the factor structure of the SF-MPQ is consistent with the theoretic pain constructs it purports to measure. Participants (n = 338) met American Burn Association's criteria for major burn injury and had a mean total body surface area burned of 14%. They were mostly male (70.1%) and Caucasian (63.4%) with an average age of 41.25 years. There were 2 primary findings. First, confirmatory factor analysis yielded fit index values demonstrating viability of a 2-factor, oblique, solution composed of sensory and affective latent constructs. These findings were consistent with previous work and the theoretic constructs. Second, results from a relatively new model consisting of 8 SF-MPQ items demonstrated potential viability for measuring similar constructs.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2596340PMC
June 2010

Long-term significance of Killip class and left ventricular systolic dysfunction.

Am J Med 2008 Nov;121(11):1015-8

Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224-2780, USA.

Background: Killip classification is an independent predictor of early mortality after myocardial infarction, and the presence of left ventricular systolic dysfunction (left ventricular ejection fraction <50%) and high Killip class predicts poor short-term prognosis. The long-term prognostic significance of Killip class and left ventricular systolic dysfunction, however, is unknown.

Methods: We studied the impact of Killip class and left ventricular systolic dysfunction on all-cause mortality (assessed in May 2007 using the Social Security Death Index) in myocardial infarction patients admitted from July 1995 to December 1996.

Results: Of 282 patients, 60% (n=168) were Killip class 1, 23% (n=64) were Killip class 2, and 17% (n=50) were Killip class 3 or 4. Patients with higher Killip class were older and more likely to have diabetes, a non-Q-wave myocardial infarction, renal insufficiency, chronic obstructive pulmonary disease, and left ventricular systolic dysfunction. There were 152 deaths at 10 years after myocardial infarction, and patients with Killip class 2, 3, or 4 had higher mortality compared with Killip class 1 in unadjusted analyses. Patients with left ventricular systolic dysfunction and Killip class of 2 or more had significantly higher 10-year mortality (70 deaths or 76.9%) compared with Killip class 1 patients without left ventricular systolic dysfunction (29 deaths or 34.5%, P <.001). This risk persisted after adjusting for demographics, cardiovascular risk factors, and co-morbidities. Much of the risk was explained by deaths in the first 5 years after myocardial infarction.

Conclusions: Killip class is a strong predictor of long-term mortality, and patients with high Killip class and left ventricular systolic dysfunction are at highest risk.
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http://dx.doi.org/10.1016/j.amjmed.2008.06.020DOI Listing
November 2008

Sleep onset insomnia symptoms during hospitalization for major burn injury predict chronic pain.

Pain 2008 Sep 24;138(3):497-506. Epub 2008 Mar 24.

Johns Hopkins University School of Medicine, Department of Psychiatry, USA Johns Hopkins University School of Nursing, USA University of Texas - Southwestern Medical Center, USA University of Washington, Harborview Burn Center, USA University of Texas, Medical Branch, USA University of Colorado, Health Sciences Center, USA.

Both cross-sectional studies of chronic pain and sleep deprivation experiments suggest a bi-directional relationship between sleep and pain. Few longitudinal studies, however, have assessed whether acute insomnia following traumatic injury predicts the development of persistent pain. We sought to evaluate (1) whether in-hospital insomnia independently predicts long-term pain after burn injury and (2) whether in-hospital pain predicts future insomnia symptoms. We analyzed data on 333 subjects hospitalized for major burn injury (72.7% male; mean age=41.1+/-14.5years) who were participating in the multi-site, Burn Model System project. Subjects completed measures of health, function (SF-36), and psychological distress (Brief Symptom Inventory) while in hospital, at 6, 12, and 24months after discharge. Participants were categorized as either having or not having sleep onset insomnia at discharge. Linear mixed effects analyses revealed that persons reporting insomnia at discharge (40.5%) had significantly decreased improvement in pain and increased pain severity during long-term follow-up (p<0.001). More severe pain during the week preceding hospital discharge, time from injury, lack of college education and older age also contributed independent effects on chronic pain (p<0.05). In a reciprocal model (N=299), more severe pain during the week preceding discharge predicted increased rates of long-term sleep onset insomnia. In-hospital insomnia and pre-burn mental health symptoms were also highly significant predictors of insomnia. This study provides support for a long-term, prospective and reciprocal interaction between insomnia and pain. Future work should ascertain whether treatment of insomnia and pain during acute injury can prevent or minimize chronic pain.
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http://dx.doi.org/10.1016/j.pain.2008.01.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791087PMC
September 2008

Effect of depression on late (8 years) mortality after myocardial infarction.

Am J Cardiol 2008 Mar 14;101(5):602-6. Epub 2008 Jan 14.

Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.

Depression during hospitalization for myocardial infarction (MI) is associated with subsequent mortality, but whether this risk persisted long term is not well studied. This study was performed to determine whether depression during hospitalization for MI, which predicted mortality at 4 months, predicted mortality 8 years later. This was a prospective observational study of 284 hospitalized patients with MI. Major depression and dysthymia were assessed using structured interview for Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, and depressive symptoms, using the Beck Depression Inventory. Mortality was determined using the Social Security Death Index. Mean age during MI hospitalization was 64.8 years, 43.0% of patients were women, 66.7% had hypertension, and 35.7% had diabetes mellitus. Any depression (major depression, dysthymia, and/or Beck Depression Inventory score > or =10) was present in 76 patients (26.8%). The 8-year mortality rate was 47.9% (136 deaths). Any depression at the time of MI was not associated with mortality at 8 years in unadjusted (hazard ratio 1.25, 95% confidence interval 0.87 to 1.81, p = 0.22) or multivariate models (hazard ratio 0.76, 95% confidence interval 0.47 to 1.24, p = 0.27). In conclusion, depression after MI was associated with increased short-term mortality, but its relation with mortality over time appeared to wane, at least in a group of older patients who had multiple co-morbidities.
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http://dx.doi.org/10.1016/j.amjcard.2007.10.021DOI Listing
March 2008

From survival to socialization: a longitudinal study of body image in survivors of severe burn injury.

J Psychosom Res 2008 Feb;64(2):205-12

Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: Little is known about the course of body image dissatisfaction following disfiguring injury or illness. The objective of this study was to test a proposed framework for understanding the trajectory of body image dissatisfaction among burn survivors and to longitudinally investigate the role of body image in overall psychosocial functioning.

Methods: A sample of 79 survivors of severe burn injuries completed the Satisfaction with Appearance Scale (SWAP), the Importance of Appearance subscale of the Multidimensional Body-Self Relations Questionnaire, and the SF-36 in the hospital and at 6 and 12 months postdischarge (SWAP and SF-36). A repeated-measures analysis of covariance model was used to assess the course of body image dissatisfaction over time, and a path analysis model tested the role of body image dissatisfaction in mediating the relationship between preburn and postburn psychosocial functioning.

Results: Female sex (P<.05), total body surface area burned (P<.01), and importance of appearance (P<.01) predicted body image dissatisfaction. From hospitalization to 12 months postdischarge, body image dissatisfaction increased for women (P<.01) and individuals with larger burns (P<.01) compared, respectively, to men and individuals with smaller burns. In the path analysis, body image dissatisfaction was the most salient predictor of psychosocial function at 12 months (beta=.53, P<.01) and mediated the relationship between preburn and 12-month psychosocial function.

Conclusion: Findings from this study suggest the importance of routine psychological screening for body image distress during hospitalization and after discharge.
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http://dx.doi.org/10.1016/j.jpsychores.2007.09.003DOI Listing
February 2008

Acute stress disorder and posttraumatic stress disorder: a prospective study of prevalence, course, and predictors in a sample with major burn injuries.

J Burn Care Res 2008 Jan-Feb;29(1):22-35

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

This is one of the largest prospective studies of patients with major burn injuries to use psychometrically sound methods to track and predict posttraumatic stress disorder (PTSD) across 2 years after burn. The principal objectives were to investigate the utility of self-report measures in detecting acute stress disorder (ASD) and PTSD, and in tracking and predicting PTSD. Participants were adult patients admitted for treatment of a major burn injury. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was used to assess ASD symptomatology at discharge (n = 178), and the Davidson Trauma Scale was used to assess PTSD symptoms at scheduled follow-ups at 1 (n = 151), 6 (n = 111), 12 (n = 105), and 24 (n = 71) months after burn. The prevalence of in-hospital ASD was 23.6%, and 35.1, 33.3, 28.6, and 25.4% of the participants met PTSD criteria at 1, 6, 12, and 24 months, respectively. Clinically significant and reliable change in PTSD symptomatology during the 24 months was uncommon. SASRQ diagnostic cutoff and total scores each robustly predicted PTSD at the first three follow-ups and all four follow-ups, respectively. A SASRQ empirically derived cutoff score (> or =40) yielded moderate-high sensitivities (0.67-0.71) and specificities (0.75-0.80), and predicted PTSD at each follow-up. In conclusion, ASD and PTSD are prevalent following major burn injuries, ASD symptomatology can reliably predict PTSD up to 24 months later, and, once established, PTSD usually persists. Research is needed to determine whether early recognition and treatment of persons with in-hospital ASD can improve long-term outcomes.
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http://dx.doi.org/10.1097/BCR.0b013e31815f59c4DOI Listing
March 2008

A test of the moderating role of importance of appearance in the relationship between perceived scar severity and body-esteem among adult burn survivors.

Body Image 2006 Jun 29;3(2):101-11. Epub 2006 Mar 29.

The College of Staten Island, The City University of New York, Department of Psychology, Building 4S-108, 2800 Victory Boulevard, Staten Island, NY 10314, United States.

This study tested the hypothesis that the relationship between subjective burn scar severity and body-esteem is moderated by importance of appearance. Three hundred and forty-six adult burn survivors completed a mailed or online survey. The three subscales of the Body-Esteem Scale for Adolescents and Adults (BE-Appearance [satisfaction with general appearance], BE-Weight [weight satisfaction], BE-Others [others' evaluations of one's body and appearance]) were regressed onto sex, subjective burn scar severity, importance of appearance and their two- and three-way interactions. With one exception, the hypothesized main effects were significant in each of the regression equations. As hypothesized, importance of appearance moderated the relationship between subjective burn scar severity and body-esteem for BE-Appearance and BE-Other but not BE-Weight. The results of this study are consistent with the cognitive model of body-esteem. Clinical implications are discussed.
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http://dx.doi.org/10.1016/j.bodyim.2006.01.003DOI Listing
June 2006

Assets and liabilities of the Burn Model System data model: a comparison with the National Burn Registry.

Arch Phys Med Rehabil 2007 Dec;88(12 Suppl 2):S7-17

Department of Preventive Medicine and Biometrics, University of Colorado and Health Sciences Center, Denver, CO 80262, USA.

Objectives: To determine whether the Burn Model System (BMS) population is representative of the larger burn population and to investigate threats to internal and external validity in a multicenter longitudinal database of severe burns.

Design: Cohort data for the BMS project have been collected since 1994. Follow-up data have been collected at 6, 12, and 24 months postburn. The demographic and burn characteristics of the BMS population were compared with those of patients in the National Burn Registry (NBR).

Setting: The BMS, which collected data for these analyses from 5 regional burn centers in the United States, and the NBR dataset, which is a registry of information collected through the Trauma Registry of the American College of Surgeons and includes data from 70 hospitals in the United States and Canada.

Participants: BMS study participants were severely burned patients treated at 1 of the 5 participating burn centers. We compared the BMS population with that of the NBR both in total and filtered to include only patients with comparable injuries.

Interventions: Not applicable.

Main Outcome Measures: Comparable demographic and burn characteristics contained in both the NBR and the 5-center BMS longitudinal database and baseline and follow-up distributions of demographic variables and burn characteristics in the BMS database.

Results: Although minor deviations in demographic distributions were found between the BMS and NBR and between discharge and follow-up populations, our results show that the BMS population sample is internally and externally valid and is adequate for answering research questions.

Conclusions: Cohort studies examining long-term outcomes have the potential flaw of using a nonrepresentative study population. The BMS population was found to be sufficiently representative, but future analyses will require cautious and purposeful application of statistical adjustment strategies.
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http://dx.doi.org/10.1016/j.apmr.2007.09.011DOI Listing
December 2007

Barriers to return to work after burn injuries.

Arch Phys Med Rehabil 2007 Dec;88(12 Suppl 2):S50-6

Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

Objective: To identify barriers to return to work after burn injury as identified by the patient.

Design: A cohort study with telephone interview up to 1 year.

Setting: Hospital-based burn centers at 3 national sites.

Participants: Hospitalized patients (N=154) meeting the American Burn Association criteria for major burn injury, employed at least 20 hours a week at the time of injury, and with access to a telephone after discharge.

Intervention: Patients were contacted via telephone every 2 weeks up to 4 months, then monthly up to 1 year after discharge.

Main Outcome Measures: A return to work survey was used to identify barriers that prevented patients from returning to work. A graphic rating scale determined the impact of each barrier.

Results: By 1 year, 79.7% of patients returned to work. Physical and wound issues were barriers early after discharge. Although physical abilities continued to be a significant barrier up to 1 year, working conditions (temperature, humidity, safety) and psychosocial factors (nightmares, flashbacks, appearance concerns) became important issues in those with long-term disability.

Conclusions: The majority of patients return to work after a burn injury. Although physical and work conditions are important barriers, psychosocial issues need to be evaluated and treated to optimize return to work.
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http://dx.doi.org/10.1016/j.apmr.2007.09.009DOI Listing
December 2007

Barriers to return to work after burn injuries.

Arch Phys Med Rehabil 2007 Dec;88(12 Suppl 2):S50-6

Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

Objective: To identify barriers to return to work after burn injury as identified by the patient.

Design: A cohort study with telephone interview up to 1 year.

Setting: Hospital-based burn centers at 3 national sites.

Participants: Hospitalized patients (N=154) meeting the American Burn Association criteria for major burn injury, employed at least 20 hours a week at the time of injury, and with access to a telephone after discharge.

Intervention: Patients were contacted via telephone every 2 weeks up to 4 months, then monthly up to 1 year after discharge.

Main Outcome Measures: A return to work survey was used to identify barriers that prevented patients from returning to work. A graphic rating scale determined the impact of each barrier.

Results: By 1 year, 79.7% of patients returned to work. Physical and wound issues were barriers early after discharge. Although physical abilities continued to be a significant barrier up to 1 year, working conditions (temperature, humidity, safety) and psychosocial factors (nightmares, flashbacks, appearance concerns) became important issues in those with long-term disability.

Conclusions: The majority of patients return to work after a burn injury. Although physical and work conditions are important barriers, psychosocial issues need to be evaluated and treated to optimize return to work.
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http://dx.doi.org/10.1016/j.apmr.2007.09.009DOI Listing
December 2007

Augmented exercise in the treatment of deconditioning from major burn injury.

Arch Phys Med Rehabil 2007 Dec;88(12 Suppl 2):S18-23

Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: To investigate the efficacy of a 12-week exercise program in producing greater improvement in aerobic capacity in adult burn survivors, relative to usual care.

Design: Randomized, controlled, double-blinded trial.

Setting: Burn center.

Participants: A population-based sample of 35 adult patients admitted to a burn center for treatment of a serious burn injury.

Intervention: A 12-week, 36-session, aerobic treadmill exercise program where work to quota (WTQ) participants intensified their exercise according to preset quotas and work to tolerance (WTT) participants continued to their tolerance. Participants completed a maximal stress test at baseline and 12 weeks to measure physical fitness.

Main Outcome Measure: Maximal aerobic capacity.

Results: The WTT and the WTQ exercise groups both made significant improvements in aerobic capacity from baseline to 12 weeks (t=-3.60, P< or =.01; t=-3.17, P< or =.01, respectively). The control group did not (t=-1.39, P=.19). WTT and WTQ participants demonstrated significantly greater improvements in aerobic capacity in comparison to the control group members (F=4.6, P< or =.05). The WTT and WTQ groups did not differ significantly from each other with regard to their respective improvements in aerobic capacity (F=.014, P=.907).

Conclusions: The aerobic capacity of adult burn survivors can be improved with participation in a structured, 12-week exercise program after injury.
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http://dx.doi.org/10.1016/j.apmr.2007.09.003DOI Listing
December 2007