JBUR-4193; No. of Pages 4 burns xxx (2013) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Impact of necrotising fasciitis on quality of life: A qualitative analysis Jurga Pikturnaite *, Mark Soldin 1 Plastic and Reconstructive Surgery Department, St. George’s Hospital, Blackshaw Road, London SW17 0QT, UK
article info
abstract
Article history:
Mortality rates from severe necrotising soft tissue infections are improving progressively,
Received 28 July 2013
therefore more emphasis should be placed on assessing and improving the quality of life of
Received in revised form
surviving patients. We investigated the functional and psychological issues, ability to social
4 October 2013
integration and self-perception of appearance in such patients presenting to our unit over 4
Accepted 18 October 2013
years. To conduct the study, we used the Short Form-36 and the Derriford Appearance Scale-
Available online xxx
24, which were distributed to those willing to participate. Ten patients have returned fully
Keywords:
appearance were moderate (average SF-36 score of 65.8, DAS-24 score of 38). Statistical
Necrotising fasciitis
correlations between the scores and demographics were carried out using the Spearman
completed questionnaires. The overall quality of life and level of distress about the changed
Quality of life
rank correlation test. The capability of psychosocial adjustment was shown to improve with
Necrotising soft tissue infection
longer follow-up time and older age. However pain, physical limitations and energy levels were considerably more relevant in the older individuals and improved slower with time compared to psychological issues. Our results act as a good indicator of the quality of life in people dealing with the aftermath of necrotising soft tissue infections, but further, more extensive studies are required to achieve comprehensive and statistically significant results. # 2013 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
With treatment modalities progressively reducing mortality rates from severe and life threatening necrotising soft tissue infections (NSTIs), more emphasis should be made on assessing and improving the quality of life of the surviving patients. The aftermath of overcoming these conditions invariably involves patients and their families dealing with extensive scarring, functional limitations, changed and disfigured cosmetic appearance. These are important factors affecting successful social integration potentially leading to social isolation and profound psychological problems [1]. The impact of such factors has been well documented in patients surviving major burns [2–6,8]. However, except for a
comprehensive study assessing physical limitations [7] little is known about the life quality of patients surviving necrotising soft tissue infections. It is often assumed that a changed health status would affect the patient’s quality of life, which can be objectively measured using patient reported outcomes. These are stratified into patient reported health status level and health related quality of life report. The former is a quantity measured modality, while the latter is based on the reflection of how patients perceive their well-being and react to their health status. Using generic as well as specific problem orientated tools ensures more comprehensive results [9]. The aim of our study was to assess the quality of life of patients post necrotising fasciitis using the generic Short
* Corresponding author. Tel.: +44 020 8672 1255. E-mail addresses: [email protected] (J. Pikturnaite), [email protected] (M. Soldin). 1 Tel.: +44 020 8672 1255. 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.10.016
Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
JBUR-4193; No. of Pages 4
2
burns xxx (2013) xxx–xxx
Form-36 and the specific problem orientated Derriford Appearance Scale-24. We investigated the functional and psychological issues and limitations, ability to social integration and self-perception of appearance. Particular emphasis was paid to the assessment of how patients coped with their newly discovered incapacity, pain and changed appearance in their daily life and social environment after they were discharged from hospital.
2.
Materials and methods
Both the Short Form-36 (SF-36) and the Derriford Appearance Scale-24 (DAS-24) are scientifically sound assessment tools that have been rigorously developed via psychometric testing and statistical validation [10,11]. To conduct the generic quality of life assessment, the SF-36 was chosen for its well investigated and accredited suitability in the assessment of a person’s perception of changes to their health, functional limitations in performing simple daily living tasks and their ability of successfully integrating themselves into society [10]. It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. The DAS-24 was chosen as a tool targeting a specific problem: it determines a particular feature of appearance that the person is dissatisfied with and analyses the impact that it has on the individual’s perception of their appearance and ability to cope with it in social circumstances [11]. For the purposes of this study all patients treated for a necrotising soft tissue infection at the plastic surgery unit at St. George’s Hospital, London, within a four year period were identified from inpatient lists and theatre logbooks. Patients younger than 16 years of age and those lacking mental capacity (as identified from medical notes) were excluded. All patients with a necrotising soft tissue infection underwent surgical debridement of necrotic tissues, with the procedure repeated as necessary until wounds were healthy. The appropriate antimicrobial regimen was administered, based on the advice of the microbiologist. All wounds were closed using split skin grafting. Subsequent physiotherapy and psychological support was provided on an ad-hoc basis. Patients who survived were contacted by telephone in order to obtain a verbal consent to participate in the study. Those who agreed to participate were sent the SF-36 and DAS-24 by post together with a personalised letter and a stamped return envelope to yield a greater response rate. The non-responders were contacted via telephone and if willing to participate, were sent a further pack of questionnaires. Questionnaire analysis was conducted strictly adhering to the result scoring and outcome calculating rules as outlined by the questionnaire developers. Correlations between scores and demographics were carried out using the Spearman rank correlation test.
3.
Results
Thirty six patients were admitted to our unit with NSTIs or referred from other hospitals for reconstruction of soft tissue
defects following debridement over the four year period. The overall mortality rate was 36% (thirteen patients). Nineteen of the twenty three survivors were contactable and initially willing to participate in our study. The remaining four patients were non-contactable as their telephone numbers or addresses could not be traced. Ten of the nineteen patients have fully completed and returned both questionnaires. Eight of the respondents were male and two were female with the mean age of 56 years (range: 29–89 years). Nine patients have indicated their marital status with three of them living with their spouse and six being single. Five individuals were in full time employment at the time of filling out the questionnaires, two were retired and three were unemployed. The average follow-up time was 38.8 months (range: 7–98 months). The commonest affected body part was the lower limb in six cases, either isolated or combined with other areas. Less common sites included the perineum and trunk. Two patients had more than two anatomical areas affected. None of the survivors required limb amputations. The resulting defects following debridement were covered with split skin grafts. One of the two patients with the involvement of abdominal/flank area required a diverting colostomy.
3.1.
Results of the DAS-24
The DAS-24 score represents the degree of distress with regards to one’s appearance: the higher the score, the more distress the person is experiencing. The lowest DAS-24 score is 11 points and represents no distress at all, whereas the highest score representing extreme distress with regards to the appearance is 96 points. The average DAS-24 score in our group was 38 (range: 22– 64), representing a moderate level of distress overall. One person reported no particular concern with his appearance; however he had a moderately high score of 59 from the questionnaire and kept referring to a feature of appearance causing problems in his answers. The remaining nine patients clearly listed their reconstructed areas as causing the most distress. No significant correlation between the age of a participant and final DAS-24 score was noted (Spearman rank correlation coefficient r = 0.06). Those who had a longer period of time lapsed between hospitalisation and questionnaire completion were found to have lower DAS-24 scores, representing a lesser degree of distress (Spearman’s r = 0.335). DAS-24 also includes simple pain and limitations of physical activities scales, with the choices of none/never, sometimes, often and always. Seven patients reported experiencing pain sometimes, one patient complaining of pain often, one all the time and a single patient reported no pain at all. Physical limitations ranged from ‘none’ in three cases, ‘sometimes’ in three, ‘often’ in one and ‘always’ in three. Both pain and physical limitations had relevant positive correlations with age (r = 0.40 and 0.87, respectively). Longer duration between hospitalisation and completion of questionnaires seemed to have relevant negative correlation with physical limitations (r = 0.44), representing greater ability to adjust to the incapacity with time. However time did not have any meaningful impact on the severity of pain judged from the DAS-24 (r = 0.02). These results did not achieve statistical
Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
JBUR-4193; No. of Pages 4 burns xxx (2013) xxx–xxx
significance ( p > 0.1). Interestingly, those scoring overall higher on the DAS-24 have reported experiencing pain significantly more often (r = 0.75, p = 0.019).
3.2.
Results of the SF-36
The SF-36 is a multi-purpose, short-form health survey with 36 questions. It yields 8 domains including physical functioning, limitations due to physical health, limitations due to emotional problems, level of energy/fatigue, emotional well-being, social functioning, level of pain and self-assessment of general health. The higher score is achieved from the SF-36, the better is the quality of life of an individual (score range of 0–100 points). The average score across all eight domains was 65.8 (range: 54–80), representing a moderate quality of life among the participants. The lowest score was attributed to the lack of energy and level of fatigue (54 points), followed by physical functioning (58.5 points) and physical limitations (62.5 points). The psychological and social issues were scored better, ranging from 72.5 to 80 points. Limitations due to emotional problems seemed to be the least troublesome and were scored at 80 points. The pain scale was marked on average at 62.5 points among the group. A moderate negative correlation between the age and mean SF-36 scores was noted (Spearman coefficient r = 0.27), representing a worse overall adjustment to the normal daily life with increasing age. However a strong positive correlation (r = +0.384) was found of the SF-36 score with increasing time following discharge, demonstrating better adjustment to the issue after longer periods since hospitalisation. Looking at individual domains of the SF-36 and its correlations with age, physical functioning and pain levels were mainly responsible for reduced capability to adjust to normal social environment in older individuals: significant ( p < 0.05) negative correlations between age and the domains of physical functioning (r = 0.46) and pain levels (r = 0.69) were found. Both physical functioning and pain only had weak positive correlations with increasing time to follow up (r = +0.18 and +0.22, respectively), representing minimal improvement in these domains with time. However limitations due to poor physical health seemed to improve with time (r = +0.31). The emotional well-being had a strong positive correlation with both increasing age (r = +0.37, 0.1 > p > 0.05) and time to follow up, demonstrating a capability of better psychological adjustment improving with time and age. There was no significant correlation between the scores of emotional well-being and pain levels within the SF-36 (r = 0.07, p > 0.1). Both social functioning and energy levels seemed to be worse with increasing age (r = 0.27 and 0.29, respectively), but were improving with longer follow up (r = +0.26 and +0.27, respectively). Patients who were married seemed to have better scores from both DAS24 and SF-36 (r = 0.87 and r = 0.93, respectively). Returning to work did not seem to have any impact on the scores of either one of the questionnaires (weak correlations of r = +0.15 for DAS24 and r = 0.05 for SF-36).
4.
3
Discussion
The consequences of surviving a severe necrotising soft tissue infection can have a dramatic impact on the patient’s life. Body image is an important variable influencing the long-term quality of life in a range of clinical populations [12]. Thombs et al. [13] found that in the population showing symptoms of at least mild depression, the dissatisfaction with the body image was the single most important predictor of depression. People’s feelings about their appearance can have significant effects on their self-perceptions, well being and their adherence to treatment, therefore the health psychologists should emphasise appearance when assessing patients [1]. While most studies assessing quality of life of patients having suffered extensive soft tissue injuries have mainly focussed on patients with burns, there is little in the literature that has formally assessed the psychosocial aspects of the quality of life of patients surviving severe necrotising soft tissue infections. In the study by Pavoni et al. [5], burns involving over 40% of total body surface area (TBSA) were associated with long-term health problems with a variety of complications including physical limitations, psychological and social disturbance: one year after the injury 79% of patients still had difficulties carrying out everyday activities and suffered pain and anxiety. However in their series of patients with burns of less than 20% TBSA, Shakespeare et al. [6], reported little to a lot of pain in 47% of the patients at three months after discharge from treatment. In our study 90% of patients have reported still experiencing pain at 7–98 months following hospitalisation. Necrotising tissue infections affect deeper tissue layers compared to burns. Therefore debridement is more extensive and involves surgical division of larger sensory nerves with subsequent development of neuromata which could explain higher levels of pain persisting for longer periods of time. Salvador-Sanz et al. [4] found that burns did not significantly impede long term physical health relating to daily living activities such as physical work or self-care. However affected social relations, general activity and psychological health was found. Patients in our series complained more of pain and restricted physical function, but seemed to be better emotionally and socially. In burns patients the extent of injury has been shown to correlate with subsequent improvement in the quality of life with time. Although we were not able to assess the correlation of the extent of scarring with quality of life, we did observe more favourable scores with longer follow up times. Quality of life reports in burns show better adjustment to social life where the individuals return to their employment [3]; we did not note any such correlation in our series. Our findings of worse physical health but satisfactory social functioning are also in line with the results published by Moi et al. [14], who found that burns patients classify their overall quality of life similarly to that of the normal population, suggesting that they were able to feel satisfied with their new situation in life. Overall both questionnaires yielded average scores in our group. Older individuals had more problems recovering physically, but showed significantly better scores in terms of emotional well being as well as perception of their appearance:
Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
JBUR-4193; No. of Pages 4
4
burns xxx (2013) xxx–xxx
it seems that older people place less emphasis on their physical appearance altogether in both clinical and normal populations [11]. The scores in our group represented better quality of life where more time has lapsed since hospitalisation. We also observed a better ability to adjust to both physical and psychological issues in married people, which is in line with previously published work [17]. In the original validation study of the DAS-24 questionnaire by Carr et al. [11], the average score was 42.7 in their clinical population (patients with trauma, cancer treatment, congenital malformations were all included with a wide range of anatomical areas affected). The general population, which was randomly selected, exhibited an average score 30.5 points in the same study. In both populations worse scores were reported from younger patients and females. The DAS-24 score averaged 38 points in our study in spite of the presence of significant scarring, representing a more favourable self-perception of appearance compared to the clinical population from the Carr et al. study. Although we took steps to improve our response rate, i.e. enclosing a personalised letter and a stamped return envelope with the questionnaires, further prompting over the phone or by post [15], we only achieved a response rate of 52%. We were able to contact three of the non-responders, two of whom stated they were too distressed to talk about their experiences and the third felt it was a waste of their time. Such responses suggest that the population which has been affected the most has not been accounted for in our study and we do not know how it influenced our results. Limited number of available cases has inevitably affected the comprehensiveness of our results and caused difficulties drawing any statistical significance. Nonetheless, we feel the results from our study act as a good indicator of the quality of life assessment in people dealing with the aftermath of necrotising soft tissue infections.
5.
Conclusions
This study is the first of its kind in patients dealing with the psychosocial sequelae of necrotising soft tissue infections and further, more extensive studies are required to achieve more comprehensive, statistically significant results. Programmes of psychological support for burns victims have already been developed and are an integral part of their care [2,16]. The overall benefit of creating such programme for the survivors of NSTIs is currently uncertain. We suggest routinely involving a psychologist during the post-operative recovery period to help these patients to adjust mentally to their new lives. In order to stratify those in need of such support and to capture any changes in their psychological health, a quality of life questionnaire could be routinely administered at the follow up clinics. With NSTI being such a rare condition, this approach would aid the creation of a large and comprehensive database and make further qualitative research into the quality of life of these patients feasible.
Conflict of interest
Financial disclosures None.
references
[1] Rumsey N. The psychology of appearance: why health psychologists should ‘do looks’. Eur Health Psychol 2008;10. [2] Corry N, Pruzinsky T, Rumsey N. Quality of life and psychosocial adjustment to burn injury: social functioning, body image, and health policy perspectives. Int Rev Psychiatry 2009;21(6):539–48. [3] Dyster-Aas J, Kildal M, Willebrand M. Return to work and health-related quality of life after burn injury. J Rehabil Med 2007;39:49–55. [4] Salvador-Sanz JF, Sanchez-Paya J, Rodriguez-Marin J. Quality of life of the Spanish burn patient. Burns 1999;25:593–8. [5] Pavoni V, Gianesello L, Paparella L, Buoninsegni LT, Barboni E. Outcome predictors and quality of life of severe burn patients admitted to intensive care unit. Scand J Trauma Resusc Emerg Med 2010;18:24. [6] Shakespeare V. Effect of small burn injury on physical, social and psychological health at 3–4 months after discharge. Burns 1998;24:739–44. [7] Pham TN, Moore ML, Costa BA, Cuschieri J, Klein MB. Assessment of functional limitation after necrotizing soft tissue infection. J Burn Care Res 2009;30(2):301–6. [8] Patterson DR, Ptacek JT, Cromes F, Fauerbach LJ, Engra A. The 2000 clinic research award. Describing and predicting distress and satisfaction with life for burn survivors. J Burn Care Rehab 2000;21(6):490–8. [9] Davis Sears Erika, Chung Kevin C. A Guide to interpreting a study of patient-reported outcomes. Plast Reconstr Surg 2012;129(5):1200–7. [10] Brazier JE, Harper R, Jones NM, O’Cathain A, Thomas KJ, Usherwood T, et al. Validating the SF-36 health survey questionnaire: new outcome measure for primary care. BMJ 1992;305(6846):160–4. [11] Carr T, Moss T, Harris D. The DAS24. A short form of the Derriford Appearance Scale DAS59 to measure individual responses to living with problems of appearance. Br J Health Psychol 2005;10:285–98. [12] Pruzinsky T. Enhancing quality of life in medical populations: a vision for body image assessment and rehabilitation as standards of care. Body Image 2004;1(1):71–81. [13] Thombs BD, Haines JM, Bresnick MG, Magyar-Russell G, Fauerbauch JA, Spence RJ. Depression in burn reconstruction patients: symptom prevalence and association with body image dissatisfaction and physical function. Gen Hosp Psychiatry 2007;29(1):14–20. [14] Moi AL, Wentzel-Larsen T, Salemark L, Wahl AK, Hanestad BR. Impaired generic health status but perception of good quality of life in survivors of burn injury. J Trauma 2006;61(4):961–8. discussion 968-9. [15] Edwards P, Roberts I, Clarke M, DiGuiseppi C, Pratap C, Wentz R, Kwan I. Increasing response rates to postal questionnaires: a systematic review. BMJ 2002;324:1183–5. [16] National Burn Care Review: Committee Report 2001. Standards and Strategy for Burn Care. [17] Proulx CM, Snyder-Rivas LA. The longitudinal associations between marital happiness, problems, and self-rated health. J Fam Psychol 2013;27(2):194–202.
None. Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Impact of necrotising fasciitis on quality of life: A qualitative analysis Jurga Pikturnaite *, Mark Soldin 1 Plastic and Reconstructive Surgery Department, St. George’s Hospital, Blackshaw Road, London SW17 0QT, UK
article info
abstract
Article history:
Mortality rates from severe necrotising soft tissue infections are improving progressively,
Received 28 July 2013
therefore more emphasis should be placed on assessing and improving the quality of life of
Received in revised form
surviving patients. We investigated the functional and psychological issues, ability to social
4 October 2013
integration and self-perception of appearance in such patients presenting to our unit over 4
Accepted 18 October 2013
years. To conduct the study, we used the Short Form-36 and the Derriford Appearance Scale-
Available online xxx
24, which were distributed to those willing to participate. Ten patients have returned fully
Keywords:
appearance were moderate (average SF-36 score of 65.8, DAS-24 score of 38). Statistical
Necrotising fasciitis
correlations between the scores and demographics were carried out using the Spearman
completed questionnaires. The overall quality of life and level of distress about the changed
Quality of life
rank correlation test. The capability of psychosocial adjustment was shown to improve with
Necrotising soft tissue infection
longer follow-up time and older age. However pain, physical limitations and energy levels were considerably more relevant in the older individuals and improved slower with time compared to psychological issues. Our results act as a good indicator of the quality of life in people dealing with the aftermath of necrotising soft tissue infections, but further, more extensive studies are required to achieve comprehensive and statistically significant results. # 2013 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
With treatment modalities progressively reducing mortality rates from severe and life threatening necrotising soft tissue infections (NSTIs), more emphasis should be made on assessing and improving the quality of life of the surviving patients. The aftermath of overcoming these conditions invariably involves patients and their families dealing with extensive scarring, functional limitations, changed and disfigured cosmetic appearance. These are important factors affecting successful social integration potentially leading to social isolation and profound psychological problems [1]. The impact of such factors has been well documented in patients surviving major burns [2–6,8]. However, except for a
comprehensive study assessing physical limitations [7] little is known about the life quality of patients surviving necrotising soft tissue infections. It is often assumed that a changed health status would affect the patient’s quality of life, which can be objectively measured using patient reported outcomes. These are stratified into patient reported health status level and health related quality of life report. The former is a quantity measured modality, while the latter is based on the reflection of how patients perceive their well-being and react to their health status. Using generic as well as specific problem orientated tools ensures more comprehensive results [9]. The aim of our study was to assess the quality of life of patients post necrotising fasciitis using the generic Short
* Corresponding author. Tel.: +44 020 8672 1255. E-mail addresses: [email protected] (J. Pikturnaite), [email protected] (M. Soldin). 1 Tel.: +44 020 8672 1255. 0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.10.016
Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
JBUR-4193; No. of Pages 4
2
burns xxx (2013) xxx–xxx
Form-36 and the specific problem orientated Derriford Appearance Scale-24. We investigated the functional and psychological issues and limitations, ability to social integration and self-perception of appearance. Particular emphasis was paid to the assessment of how patients coped with their newly discovered incapacity, pain and changed appearance in their daily life and social environment after they were discharged from hospital.
2.
Materials and methods
Both the Short Form-36 (SF-36) and the Derriford Appearance Scale-24 (DAS-24) are scientifically sound assessment tools that have been rigorously developed via psychometric testing and statistical validation [10,11]. To conduct the generic quality of life assessment, the SF-36 was chosen for its well investigated and accredited suitability in the assessment of a person’s perception of changes to their health, functional limitations in performing simple daily living tasks and their ability of successfully integrating themselves into society [10]. It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. The DAS-24 was chosen as a tool targeting a specific problem: it determines a particular feature of appearance that the person is dissatisfied with and analyses the impact that it has on the individual’s perception of their appearance and ability to cope with it in social circumstances [11]. For the purposes of this study all patients treated for a necrotising soft tissue infection at the plastic surgery unit at St. George’s Hospital, London, within a four year period were identified from inpatient lists and theatre logbooks. Patients younger than 16 years of age and those lacking mental capacity (as identified from medical notes) were excluded. All patients with a necrotising soft tissue infection underwent surgical debridement of necrotic tissues, with the procedure repeated as necessary until wounds were healthy. The appropriate antimicrobial regimen was administered, based on the advice of the microbiologist. All wounds were closed using split skin grafting. Subsequent physiotherapy and psychological support was provided on an ad-hoc basis. Patients who survived were contacted by telephone in order to obtain a verbal consent to participate in the study. Those who agreed to participate were sent the SF-36 and DAS-24 by post together with a personalised letter and a stamped return envelope to yield a greater response rate. The non-responders were contacted via telephone and if willing to participate, were sent a further pack of questionnaires. Questionnaire analysis was conducted strictly adhering to the result scoring and outcome calculating rules as outlined by the questionnaire developers. Correlations between scores and demographics were carried out using the Spearman rank correlation test.
3.
Results
Thirty six patients were admitted to our unit with NSTIs or referred from other hospitals for reconstruction of soft tissue
defects following debridement over the four year period. The overall mortality rate was 36% (thirteen patients). Nineteen of the twenty three survivors were contactable and initially willing to participate in our study. The remaining four patients were non-contactable as their telephone numbers or addresses could not be traced. Ten of the nineteen patients have fully completed and returned both questionnaires. Eight of the respondents were male and two were female with the mean age of 56 years (range: 29–89 years). Nine patients have indicated their marital status with three of them living with their spouse and six being single. Five individuals were in full time employment at the time of filling out the questionnaires, two were retired and three were unemployed. The average follow-up time was 38.8 months (range: 7–98 months). The commonest affected body part was the lower limb in six cases, either isolated or combined with other areas. Less common sites included the perineum and trunk. Two patients had more than two anatomical areas affected. None of the survivors required limb amputations. The resulting defects following debridement were covered with split skin grafts. One of the two patients with the involvement of abdominal/flank area required a diverting colostomy.
3.1.
Results of the DAS-24
The DAS-24 score represents the degree of distress with regards to one’s appearance: the higher the score, the more distress the person is experiencing. The lowest DAS-24 score is 11 points and represents no distress at all, whereas the highest score representing extreme distress with regards to the appearance is 96 points. The average DAS-24 score in our group was 38 (range: 22– 64), representing a moderate level of distress overall. One person reported no particular concern with his appearance; however he had a moderately high score of 59 from the questionnaire and kept referring to a feature of appearance causing problems in his answers. The remaining nine patients clearly listed their reconstructed areas as causing the most distress. No significant correlation between the age of a participant and final DAS-24 score was noted (Spearman rank correlation coefficient r = 0.06). Those who had a longer period of time lapsed between hospitalisation and questionnaire completion were found to have lower DAS-24 scores, representing a lesser degree of distress (Spearman’s r = 0.335). DAS-24 also includes simple pain and limitations of physical activities scales, with the choices of none/never, sometimes, often and always. Seven patients reported experiencing pain sometimes, one patient complaining of pain often, one all the time and a single patient reported no pain at all. Physical limitations ranged from ‘none’ in three cases, ‘sometimes’ in three, ‘often’ in one and ‘always’ in three. Both pain and physical limitations had relevant positive correlations with age (r = 0.40 and 0.87, respectively). Longer duration between hospitalisation and completion of questionnaires seemed to have relevant negative correlation with physical limitations (r = 0.44), representing greater ability to adjust to the incapacity with time. However time did not have any meaningful impact on the severity of pain judged from the DAS-24 (r = 0.02). These results did not achieve statistical
Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
JBUR-4193; No. of Pages 4 burns xxx (2013) xxx–xxx
significance ( p > 0.1). Interestingly, those scoring overall higher on the DAS-24 have reported experiencing pain significantly more often (r = 0.75, p = 0.019).
3.2.
Results of the SF-36
The SF-36 is a multi-purpose, short-form health survey with 36 questions. It yields 8 domains including physical functioning, limitations due to physical health, limitations due to emotional problems, level of energy/fatigue, emotional well-being, social functioning, level of pain and self-assessment of general health. The higher score is achieved from the SF-36, the better is the quality of life of an individual (score range of 0–100 points). The average score across all eight domains was 65.8 (range: 54–80), representing a moderate quality of life among the participants. The lowest score was attributed to the lack of energy and level of fatigue (54 points), followed by physical functioning (58.5 points) and physical limitations (62.5 points). The psychological and social issues were scored better, ranging from 72.5 to 80 points. Limitations due to emotional problems seemed to be the least troublesome and were scored at 80 points. The pain scale was marked on average at 62.5 points among the group. A moderate negative correlation between the age and mean SF-36 scores was noted (Spearman coefficient r = 0.27), representing a worse overall adjustment to the normal daily life with increasing age. However a strong positive correlation (r = +0.384) was found of the SF-36 score with increasing time following discharge, demonstrating better adjustment to the issue after longer periods since hospitalisation. Looking at individual domains of the SF-36 and its correlations with age, physical functioning and pain levels were mainly responsible for reduced capability to adjust to normal social environment in older individuals: significant ( p < 0.05) negative correlations between age and the domains of physical functioning (r = 0.46) and pain levels (r = 0.69) were found. Both physical functioning and pain only had weak positive correlations with increasing time to follow up (r = +0.18 and +0.22, respectively), representing minimal improvement in these domains with time. However limitations due to poor physical health seemed to improve with time (r = +0.31). The emotional well-being had a strong positive correlation with both increasing age (r = +0.37, 0.1 > p > 0.05) and time to follow up, demonstrating a capability of better psychological adjustment improving with time and age. There was no significant correlation between the scores of emotional well-being and pain levels within the SF-36 (r = 0.07, p > 0.1). Both social functioning and energy levels seemed to be worse with increasing age (r = 0.27 and 0.29, respectively), but were improving with longer follow up (r = +0.26 and +0.27, respectively). Patients who were married seemed to have better scores from both DAS24 and SF-36 (r = 0.87 and r = 0.93, respectively). Returning to work did not seem to have any impact on the scores of either one of the questionnaires (weak correlations of r = +0.15 for DAS24 and r = 0.05 for SF-36).
4.
3
Discussion
The consequences of surviving a severe necrotising soft tissue infection can have a dramatic impact on the patient’s life. Body image is an important variable influencing the long-term quality of life in a range of clinical populations [12]. Thombs et al. [13] found that in the population showing symptoms of at least mild depression, the dissatisfaction with the body image was the single most important predictor of depression. People’s feelings about their appearance can have significant effects on their self-perceptions, well being and their adherence to treatment, therefore the health psychologists should emphasise appearance when assessing patients [1]. While most studies assessing quality of life of patients having suffered extensive soft tissue injuries have mainly focussed on patients with burns, there is little in the literature that has formally assessed the psychosocial aspects of the quality of life of patients surviving severe necrotising soft tissue infections. In the study by Pavoni et al. [5], burns involving over 40% of total body surface area (TBSA) were associated with long-term health problems with a variety of complications including physical limitations, psychological and social disturbance: one year after the injury 79% of patients still had difficulties carrying out everyday activities and suffered pain and anxiety. However in their series of patients with burns of less than 20% TBSA, Shakespeare et al. [6], reported little to a lot of pain in 47% of the patients at three months after discharge from treatment. In our study 90% of patients have reported still experiencing pain at 7–98 months following hospitalisation. Necrotising tissue infections affect deeper tissue layers compared to burns. Therefore debridement is more extensive and involves surgical division of larger sensory nerves with subsequent development of neuromata which could explain higher levels of pain persisting for longer periods of time. Salvador-Sanz et al. [4] found that burns did not significantly impede long term physical health relating to daily living activities such as physical work or self-care. However affected social relations, general activity and psychological health was found. Patients in our series complained more of pain and restricted physical function, but seemed to be better emotionally and socially. In burns patients the extent of injury has been shown to correlate with subsequent improvement in the quality of life with time. Although we were not able to assess the correlation of the extent of scarring with quality of life, we did observe more favourable scores with longer follow up times. Quality of life reports in burns show better adjustment to social life where the individuals return to their employment [3]; we did not note any such correlation in our series. Our findings of worse physical health but satisfactory social functioning are also in line with the results published by Moi et al. [14], who found that burns patients classify their overall quality of life similarly to that of the normal population, suggesting that they were able to feel satisfied with their new situation in life. Overall both questionnaires yielded average scores in our group. Older individuals had more problems recovering physically, but showed significantly better scores in terms of emotional well being as well as perception of their appearance:
Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
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it seems that older people place less emphasis on their physical appearance altogether in both clinical and normal populations [11]. The scores in our group represented better quality of life where more time has lapsed since hospitalisation. We also observed a better ability to adjust to both physical and psychological issues in married people, which is in line with previously published work [17]. In the original validation study of the DAS-24 questionnaire by Carr et al. [11], the average score was 42.7 in their clinical population (patients with trauma, cancer treatment, congenital malformations were all included with a wide range of anatomical areas affected). The general population, which was randomly selected, exhibited an average score 30.5 points in the same study. In both populations worse scores were reported from younger patients and females. The DAS-24 score averaged 38 points in our study in spite of the presence of significant scarring, representing a more favourable self-perception of appearance compared to the clinical population from the Carr et al. study. Although we took steps to improve our response rate, i.e. enclosing a personalised letter and a stamped return envelope with the questionnaires, further prompting over the phone or by post [15], we only achieved a response rate of 52%. We were able to contact three of the non-responders, two of whom stated they were too distressed to talk about their experiences and the third felt it was a waste of their time. Such responses suggest that the population which has been affected the most has not been accounted for in our study and we do not know how it influenced our results. Limited number of available cases has inevitably affected the comprehensiveness of our results and caused difficulties drawing any statistical significance. Nonetheless, we feel the results from our study act as a good indicator of the quality of life assessment in people dealing with the aftermath of necrotising soft tissue infections.
5.
Conclusions
This study is the first of its kind in patients dealing with the psychosocial sequelae of necrotising soft tissue infections and further, more extensive studies are required to achieve more comprehensive, statistically significant results. Programmes of psychological support for burns victims have already been developed and are an integral part of their care [2,16]. The overall benefit of creating such programme for the survivors of NSTIs is currently uncertain. We suggest routinely involving a psychologist during the post-operative recovery period to help these patients to adjust mentally to their new lives. In order to stratify those in need of such support and to capture any changes in their psychological health, a quality of life questionnaire could be routinely administered at the follow up clinics. With NSTI being such a rare condition, this approach would aid the creation of a large and comprehensive database and make further qualitative research into the quality of life of these patients feasible.
Conflict of interest
Financial disclosures None.
references
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None. Please cite this article in press as: Pikturnaite J, Soldin M. Impact of necrotising fasciitis on quality of life: A qualitative analysis. Burns (2013), http://dx.doi.org/10.1016/j.burns.2013.10.016
