Alcohol and drug abuse in burn injuries

A national analysis of burn injuries among homeless persons presenting to emergency departments

INTRODUCTION

Burn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs).

METHODS

Burn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling.

RESULTS

Of 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021).

CONCLUSION

Homeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients' unique presentation and triage to burn centers accordingly.

Fire deaths in Cape Town, South Africa: A retrospective review of medico-legal and toxicological findings (2006 - 2018)

BACKGROUND

In South Africa, fire-related deaths are common, particularly within dense informal housing settlements. Published data on deaths from fire incidents in Cape Town is sparse. Additionally, little emphasis has been placed on the role of toxicological investigations in these deaths, despite the known risk of alcohol and drug impairment to burn injury.

METHODS

A retrospective, descriptive analysis of post-mortem case reports from Salt River Mortuary was conducted to investigate all deaths in which fires were involved in the west metropole of Cape Town, between 2006 to 2018. Demographic, circumstantial, and toxicological data were analyzed using R software.

RESULTS

In total 1370 fire deaths occurred over 13 years, with a mean of 106 (SD ± 18) cases per annum (≈3% of the annual caseload and a mortality rate of 5.5 per 100,000). Males (70.4%), adults (mean=30.7 years), and toddlers (1-4 years old) were notably at risk. Deaths typically occurred in the early morning (00h00 - 06h00) (45.7%), during winter (32.1%), and in lower socioeconomic areas with highly dense informal settlements (65.6%), with 29% of deaths occurring in multi-fatality incidents. Ethanol was detected (≥0.01 g/100 mL) in 55.1% of cases submitted for analysis (71.5%), with a mean of 0.18 g/100 mL, and with 93.8% of positive cases > 0.05 g/100 mL. Carboxyhaemoglobin (COHb) analysis was requested in 76.4% of cases, with 57% of cases having a %COHb of ≥ 20%. Toxicology results (for drugs other than ethanol) from the national laboratory were outstanding in 34.4% of the cases at the conclusion of the study. BAC and %COHb were significantly higher in deaths from burns and smoke inhalation (usually accidents) than deaths from combined trauma and burns (typically homicides). Fire deaths with high COHb levels were more likely to display cherry-red discoloration (OR=3.1) and soot in the airways (OR=2.7) at autopsy.

CONCLUSION

This article provides an updated description of fire deaths in the west metropole of Cape Town. The importance of BAC and COHb testing in these cases was noted, and the authors call for an investigation of the role of drug impairment (specifically frequently misused drugs methamphetamine and methaqualone) as a risk factor in these deaths. Areas of high-density informal settlements, where open flames are used to heat, light, and cook, were noted as high risk.

Psychiatric Illness and Substance Abuse: Unaddressed Factors in Burn Injury

Patients with psychiatric illness and substance use comorbidities have high rates of burn injuries and experience prolonged hospital admissions. This retrospective chart review characterizes this marginalized population's inpatient burn care and examines post-discharge outcomes compared to burn patients without psychiatric or substance use comorbidities treated at our center. Patients admitted to a single burn center from January 1, 2018 to June 1, 2022 were included. Patient demographics, history of psychiatric disorders, treatment course, and post-discharge outcomes were collected. A total of 1660 patients were included in this study, of which 91 (6%) patients were diagnosed for psychiatric comorbidity and/or substance use comorbidity on admission for burn care. In this cohort of 91 patients with psychiatric and/or substance use comorbidities, the majority of patients were undomiciled (66%) and male (67%). In this cohort, 66 (72%) patients reported recent history or had positive urine toxicology results for illicit substances on admission. In this cohort, a total of 25 (28%) patients had psychiatric comorbidity at the time of burn injury or admission and 69 (76%) patients received inpatient psychiatric care, with 31 (46%) patients requiring psychiatric holds. After discharge, the readmission rate within 1 year of patients with psychiatric and/or substance use comorbidity was over four times greater than that of patients without psychiatric and/or substance use comorbidity. The most common causes of readmission were subsequent mental health crisis (40%) and inability to perform burn care (32%). Our study presents strategies to improve burn care for this marginalized and high-risk population.

Burn Injuries in People Who Used Drug, 2009-2017: A Case-Control Study in Shiraz, Southern Iran

BACKGROUND

Burn injury is a critical health issue, which is associated with several morbidities and mortalities. Substance abuse, which is an important public health problem in Iran, can affect burn injury outcomes and etiologies in victims. This study was aimed to evaluate different aspects of burn injuries in people who used drug (PWUD) in two referral centers in the south of Iran.

METHODS

This Case-Control Study was conducted on burn victims referred to Amir-al Momenin Hospital and Ghotb-al-din Hospital from 2009 to 2017. Patients with a history of drug consumption were selected from the database and compared to randomly selected burn victims with no history of drug use. Demographics, burn etiology, underlying disease, total body surface area, hospitalization duration, and also the outcomes were collected and recorded in both groups. Data analysis was done by SPSS software.

RESULTS

A total of 5,912 inpatients were included in this study, which 2,397 of them (40.54%) were female. The mean age of the patients was 26.12 ± 19.18. Drug history was positive in 659 patients (11.15%). Familial issues and mental disorders were significantly higher in the PWUD group compared to the control group (P<0.001). Explosion etiology was significantly higher in the PWUD group (P<0.001). Psychiatric disorders (P<0.001), total body surface area (P=0.023), and hospital stay (P<0.001) were significantly higher in PWUD; however, the mortality rate had no statistically significant differences between the groups (P=0.583).

CONCLUSION

Substance abuse is a risk factor in burn victims, which can affect burn etiology and burn-related morbidities.

Association Between Alcohol, Substance Use, and Inpatient Burn Outcomes

The use of alcohol and illicit substances has been associated with impaired judgment and health, but the effect on inpatient outcomes after burn injury remains unsettled. Our objective was to evaluate the effect of alcohol and illicit substance use on our inpatient burn outcomes. Adult patients admitted with burn injury-including inhalation injury only-between January 1, 2014 and June 30, 2019 were eligible for inclusion. Alcohol use and illicit drug use were identified on admission. Outcomes of interest included requiring mechanical ventilation, admission to the intensive care unit, length of stay, and inpatient mortality. Multivariable linear and logistic regression models were used to estimate the effects of use on inpatient outcomes. A total of 3476 patients were included in our analyses; 8% (n = 284) tested positive for alcohol, 10% (n = 364) tested positive for cocaine, and 27% (n = 930) tested positive for marijuana and at admission. Two hundred and eighty adults (18% of all positive patients) tested positive for at least two substances. Patients who tested positive for alcohol had longer lengths of stay and were more likely to be admitted to the intensive care unit. Patients who tested positive for cocaine had longer overall and intensive care unit lengths of stay. No differences in inpatient outcomes were seen among patients who tested positive for marijuana. Neither alcohol nor illicit substance use appears to affect inpatient mortality after burns. Alcohol and cocaine use significantly increased overall length of stay. Marijuana use had no impact on inpatient outcomes.

Protective effects of PX478 on gut barrier in a mouse model of ethanol and burn injury

Ethanol remains a confounder in postburn pathology, which is associated with an impaired intestinal barrier. Previously, we demonstrated that ethanol and burn injury reduce intestinal oxygen delivery (hypoxia) and alters microRNA (miR) expression in small intestinal epithelial cells. Hypoxia has been shown to influence expression of miRs and miR biogenesis components. Therefore, we examined whether hypoxia influences expression of miR biogenesis components (drosha, dicer, and argonaute-2 [ago-2]) and miRs (-7a and -150) and whether these changes impacted other parameters following ethanol and burn injury. Mice were gavaged with ethanol (∼2.9 g/kg) 4 h before receiving a ∼12.5% total body surface full thickness burn. Mice were resuscitated at the time of injury with normal saline with or without 5 mg/kg PX-478, a hypoxia-inducible factor-1α inhibitor. One day following injury mice were euthanized, and the expression of miRs and their biogenesis components as well as bacterial growth, tight junction proteins, intestinal transit, and permeability were assessed. Ethanol combined with burn injury significantly reduced expression of drosha, ago-2, miRs (-7a and -150), occludin, zonula occludens-1, claudin-4, zonula occludens-1, mucins-2 and -4, and intestinal transit compared to shams. Furthermore, there was an increase in intestinal permeability, total bacteria, and Enterobacteriaceae populations following the combined injury compared to shams. PX-478 treatment improved expression of drosha, ago-2, miRs (-7a and -150), occludin, claudin-4, zonula occludens-1, and mucin-2. PX-478 treatment also improved intestinal transit and reduced dysbiosis and permeability. These data suggest that PX-478 improves miR biogenesis and miR expression, and restores barrier integrity while reducing bacterial dysbiosis following ethanol and burn injury.

Examining the Impact of Psychological Factors on Hospital Length of Stay for Burn Survivors: A Systematic Review

Recovery of burn patients may be impeded by mental health problems. By gaining a better understanding of the impact that psychological factors may have on hospital length of stay, providers may be better informed to address the complex needs of burn survivors through effective and efficient practices. This systematic review summarizes existing data on the adverse psychological factors for the length of burn patients' hospitalization, and assesses the methodological quality of the extant literature on mental health conditions of burn survivors. A literature search was conducted in four electronic databases: PubMed, PsychINFO, Science Direct, and the Cumulative Index to Nursing and Allied Health Literature. Results yielded reports published between 1980 and 2016. Methodological quality was assessed by using an 11-item methodological quality score system. Seventy-four studies were identified by search; 19 articles were eligible for analysis. Findings demonstrate paucity of evidence in the area. Reports indicate longer hospital stay among burn patients with mental health problems. Substance use was the most consistent mental-health predictor of longer hospital stay. Heterogeneity in data on mental health conditions rendered impossible estimation of effect sizes of individual psychological factors on length of hospitalization. Many studies over-relied on retrospective designs, and crude indicators of psychological factors. Findings indicate that mental health problems do have an impact on the trajectory of burn recovery by increasing the length of hospital stay for burn survivors. Inpatient mental health services for burn patients are critically needed. Prospective designs, and more sensitive psychological indicators are needed for future studies.

The role of concomitant alcohol and drug use in increased risk for burn mortality outcomes

BACKGROUND

Burn injuries are a major cause of mortality and morbidity in low- and middle-income countries, with high rates in Sub-Saharan Africa. The risks may be heightened for persons who present with concomitant use of alcohol and illicit substances, which increase the risk for injury and severely compromise prognosis following injury.

METHODS

This study utilised a national dataset on hospitalised burns in South Africa to explore the risk for mortality relative to morbidity. To assess the influence of alcohol and drugs in mortality outcomes, the analysis was restricted to adult cases, 18 years and older (N = 918). The primary statistical procedures used in the analysis were logistic regression models.

FINDINGS

The results indicate that burn victims with full thickness and partial thickness burn degree and more than 30% TBSA had a significantly increased risk of mortality. In addition, the risk for mortality was increased ten times when concomitant alcohol and drugs were indicated compared to cases where these were absent. The length of stay in hospital diminished the risk for mortality by about 10%.

INTERPRETATION

The findings may be explained by the role of skin as the main barrier against infections and the concurrent increase in risk of infection based on the degree and extent of any damage. The combined presence of both alcohol and drugs may predispose towards more severe burns and greatly compromise liver function with heightened risk for sepsis and death.

Comparison of the characteristics of hot tap water scalds and other scalds in Germany

BACKGROUND/AIM

Mortality associated with hot tap water scalds remains significant, owing to a lack of up-to-date regulations on tap water temperature. We aimed to evaluate the effect of hot tap water scalds on patients admitted to our adult burn intensive care unit (BICU), and compare them to those with other scald types.

METHODS

We enrolled patients treated for scalds at the BICU of Cologne-Merheim Medical Center from 1989 to 2014, and retrospectively analyzed their age, sex-specific differences, characteristics, length of hospital stay, number of operations, and mortality. Patients were categorized into two groups: patients with hot tap water scalds and those with all other types of scalds.

RESULTS

A total of 333 patients were enrolled. In 23.4% (n=78) of the cases, the scalds were associated with hot tap water. Such injuries were more commonly observed in older men than women. Hot tap water scalds involved a significantly higher total burned surface area (TBSA) than other scalds, with TBSA values of 24.0% and 15.9% for men, and 21.8% and 10.9% for women, respectively. Hot tap water scald patients had a greater number of surgeries and longer BICU stays (27.8 days vs 9.1 days), and significantly higher mortality values (30.8% (n=24) vs 4.7% (n=12)) than those with the other scald types.

CONCLUSIONS

Hot water scalds are associated with large TBSAs, long stays in the BICU, and worse outcomes compared to the other scald types.

Acid attacks: Broadening the multidisciplinary team to improve outcomes

A rise in the current trend of corrosive substance attacks have been reported in the UK, causing devastating effects on victims. The optimal management of these patients requires the specialist skills of the burn multidisciplinary team (MDT) to address the resulting physical and psychological trauma experienced. However, burn care must commence in the pre-hospital setting. The public and first responders are invaluable resources in helping to limit the adverse effects of burns. Challenges of burn care outside the Burns Unit are not limited to the treatment of the injured patient and the rehabilitation of survivors. These challenges also encompass better education of the public and allied health professionals, as well as planning strategies to reduce the incidence of acid attacks. Prevention is always better than cure. This paper discusses the broadening of the MDT to improve outcomes in acid attacks by exploring the wider roles of the public, media, emergency services, police, legislation and better education.

Substance use and inhalation injury in adult burn patients: retrospective study of the impact on outcomes

Background

Substance use, alcohol use, and smoking use have all been associated with burn injury. Few studies have investigated associations with substances, alcohol, smoking, inhalational only burns, and patient outcomes. The purpose of the study was to identify risk factors for pulmonary failure in patients suffering inhalation injury, focusing on the impact of substance, alcohol, and cigarette use.

Methods

This is a single-center retrospective analysis of 115 patients admitted to the Johns Hopkins Bayview Burn Center with inhalational injury from January 1, 2010, through September 30, 2018. Patients were excluded if they were under the age of 18 years or had burn involvement of the skin > 5%. Primary outcome variables measured were if patients were intubated, length of total time intubated, substance use, alcohol use, and smoking use. Secondary outcome variables measured were types of substances used (amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, methadone, codeine/morphine), total number of substances used, intensive care unit (ICU) length of stay (LOS), hospital LOS, secondary complications, and patient mortality. Analysis was performed with Fisher’s exact test and the Mann-Whitney U test. A sub-group analysis for each substance, alcohol, smoking, and control sub-group was compared to its respective sub-group without substance, alcohol, smoking, and control within the no intubation and intubation group. A sub-group analysis of substance use, alcohol use, smoking use, and control was further analyzed with binomial logistic regression within the intubation group.

Results

Following inhalation injury, 50/115 (43%) patients required intubation. Forty-two of the 50 (84%) patients intubated had substance use (p < 0.001). Thirty-one of the 50 (62%) patients intubated had history of smoking (p = 0.038). Among the specific substances used, 26/50 (52%) patients intubated were using benzodiazepines (p < 0.001) and 7/50 (14%) patients were using cocaine (p = 0.022). The lengths of intubation, ICU LOS, and hospital LOS with no substance use were shorter than with substance use (p < 0.001). Following the adjusted sub-group analysis, patients with substance use (odds ratio (OR) 6.4, 95% confidence interval (CI) [2.5–16.3]; p < 0.001) and smoking use (OR 2.5, 95% CI [1.2–5.1]; p = 0.013) were more likely to be intubated on admission than those without substance or smoking use.

Conclusions

In patients admitted with an inhalational injury with less than or equal to 5% external burns, the presence of a substance and smoking use on admission provides a further risk of intubation and respiratory compromise. Substance use on admission poses a greater risk of longer intubation, ICU LOS, and hospital LOS. A higher potential for substance use should be suspected in this patient population with prompt treatment.

Enhanced Platelet-Activating Factor Synthesis Facilitates Acute and Delayed Effects of Ethanol-Intoxicated Thermal Burn Injury

Thermal burn injuries in patients who are alcohol-intoxicated result in greater morbidity and mortality. Murine models combining ethanol and localized thermal burn injury reproduce the systemic toxicity seen in human subjects, which consists of both acute systemic cytokine production with multiple organ dysfunction, as well as a delayed systemic immunosuppression. However, the exact mechanisms for these acute and delayed effects are unclear. These studies sought to define the role of the lipid mediator platelet-activating factor in the acute and delayed effects of intoxicated burn injury. Combining ethanol and thermal burn injury resulted in increased enzymatic platelet-activating factor generation in a keratinocyte cell line in vitro, human skin explants ex vivo, as well as in murine skin in vivo. Further, the acute increase in inflammatory cytokines, such as IL-6, and the systemic immunosuppressive effects of intoxicated thermal burn injury were suppressed in mice lacking platelet-activating factor receptors. Together, these studies provide a potential mechanism and treatment strategies for the augmented toxicity and immunosuppressive effects of thermal burn injury in the setting of acute ethanol exposure, which involves the pleotropic lipid mediator platelet-activating factor.

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models

In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units.

The Effect of Illicit Drug Use on Outcomes Following Burn Injury

Illicit drug use is common among patients admitted following burn injury. The authors sought to evaluate whether drug abuse results in worse outcomes. The National Burn Repository (NBR) was queried for data on all patients with drug testing results available. Outcomes included mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, and duration of ventilator support. Propensity score weighting was performed to control for age, alcohol use, burn size, gender, and etiology of burn. A total of 20,989 patients had drug screen data available; 11,642 (55.5%) tested positive for at least one drug of abuse. Illicit drug use was associated with a higher proportion of patients with flame burn (53.2 vs 48.4%) and larger average burn size (11.2 vs 9.5% TBSA, P < .001). Attempted suicide was more likely if the patient had used drugs (2.8 vs 1.7%, P < .001). Drug use resulted in longer hospital and ICU LOS (14.2 vs 11.4 and 8.5 vs 5.6 days, P < .001), but did not increase the risk of mortality (5.7 vs 5.2, P = .08). After propensity score weighting, drug use did not affect mortality, hospital LOS, or duration of ventilator support, but did increase the average ICU LOS by 1.2 days (P = .001). Drug use does not affect mortality, hospital LOS, or duration of ventilator support among burned patients. After controlling for burn size, age, mechanism of injury, and gender, patients with a positive drug screen had an average increase in ICU LOS by 1 day.

The influence of substance misuse on clinical outcomes following burn

INTRODUCTION

Ongoing increases in the prevalence of substance misuse among burn-injured patients necessitate a contemporary analysis of the association between substance misuse and clinical outcomes in burn-injured adults.

METHODS

We conducted a retrospective cohort study of 1199 patients admitted to a regional burn center. History of substance misuse was derived from a prospective clinical registry and categorized as alcohol, illicit drug, or both. The primary outcome was hospital length of stay; association of substance misuse and inpatient complications were secondary outcomes. Multivariable logistic regression was used to model the association between categories of substance misuse and each outcome, adjusting for patient and injury characteristics.

RESULTS

The incidence of substance misuse was 34% overall. After adjustment for patient and injury characteristics, drug misuse was associated with a significantly longer length of stay (RR 1.12; 95% CI 1.00-1.25), as was alcohol misuse (RR 1.32; 95% CI 1.14-1.52), and drug/alcohol misuse (RR 1.34; 95% CI 1.16-1.56). Drug/alcohol misuse was associated with significantly higher rates of bacteremia (OR 3.84; 95% CI 1.83-8.04) and sepsis (OR 2.50; CI 1.13-5.53).

CONCLUSIONS

A history of substance misuse is associated with an increased risk of inpatient complications and longer hospital stay. Providers should be cognizant of increased complications in this cohort with a view to improving outcomes.

Dysregulation of microRNA biogenesis in the small intestine after ethanol and burn injury

Ethanol exposure at the time of burn injury is a major contributor to post-burn pathogenesis. Many of the adverse effects associated with ethanol and burn injury are linked to an impaired intestinal barrier. The combined insult causes intestinal inflammation, resulting in tissue damage, altered tight junction expression, and increased intestinal permeability. MicroRNAs play a critical role in maintaining intestinal homeostasis including intestinal inflammation and barrier function. Specifically, miR-150 regulates inflammatory mediators which can contribute to gut barrier disruption. The present study examined whether ethanol and burn injury alter expression of microRNA processing enzymes (Drosha, Dicer, and Argonaute-2) and miR-150 in the small intestine. Male mice were gavaged with ethanol (~2.9g/kg) 4h prior to receiving a ~12.5% total body surface area full thickness burn. One or three days after injury, mice were euthanized and small intestinal epithelial cells (IECs) were isolated and analyzed for expression of microRNA biogenesis components and miR-150. Dicer mRNA and protein levels were not changed following the combined insult. Drosha and Argonaute-2 mRNA and protein levels were significantly reduced in IECs one day after injury; which accompanied reduced miR-150 expression. To further determine the role of miR-150 in intestinal inflammation, young adult mouse colonocytes were transfected with a miR-150 plasmid and stimulated with LPS (100ng/ml). miR-150 overexpression significantly reduced IL-6 and KC protein levels compared to vector control cells challenged with LPS. These results suggest that altered microRNA biogenesis and associated decrease in miR-150 likely contribute to increased intestinal inflammation following ethanol and burn injury.

A 365-day view of the difficult patients treated in an Australian adult burn center

Although the effect of burns on mental health has been well examined, the aims of this study were to determine the prevalence of pre-existing mental health, drug and alcohol, and forensic problems in an Australian burn patient population; examine differences between these groups in terms of burns characteristics and healing; and also establish any patterns of presentation amongst these groups. Retrospective case notes of all the acute burn admissions, 273 patients, into a busy tertiary adults burn center in a full year were reviewed. Almost half of the patients admitted had underlying complex issues. Those with psychotic, forensic, and/or drug and alcohol problems tended to stay longer in hospital and required more procedures, despite burn sizes comparable with those in the general population. These patients also tended to sustain their burn injuries, and present to hospital, on a Saturday, Sunday, or Monday, rarely coming later in the week. Those with depression/anxiety had similar lengths of stay, number of procedures and random temporal presentations to the general burns population. Burn centers should be well staffed and educated in how to deal with patients with complex needs; this staffing should be actively structured to deal with a clear pattern of presentation over the weekend and Monday.

The rapidly increasing trend of cannabis use in burn injury

The use of cannabis is currently increasing according to U.S. Department of Health and Human Services (HHS). Surprisingly, cannabis use among burn patients is poorly reported in literature. In this study, rates of cannabis use in burn patients are compared with general population. Data from the National Burn Repository (NBR) were used to investigate incidence, demographics, and outcomes in relation to use of cannabis as evidenced by urine drug screen (UDS). Thousands of patients from the NBR from 2002 to 2011 were included in this retrospective study. Inclusion criteria were patients older than 12 years of age who received a drug screen. Data points analyzed were patients' age, sex, UDS status, mechanism of burn injury, total body surface area, length of stay, ICU days, and insurance characteristics. Incidence of cannabis use in burn patients from the NBR was compared against national general population rates (gathered by Health and Human Services) using chi-square tests. Additionally, the burn patient population was analyzed using bivariate analysis and t-tests to find differences in the characteristics of these patients as well as differences in outcomes. Seventeen thousand eighty out of over 112,000 patients from NBR had information available for UDS. The incidence of cannabis use is increasing among the general population, but the rate is increasing more quickly among patients in the burn patient population (P = .0022). In 2002, 6.0% of patients in burn units had cannabis+ UDS, which was comparable with national incidence of 6.2%. By 2011, 27.0% of burn patients tested cannabis+ while national incidence of cannabis use was 7.0%. Patients who test cannabis+ are generally men (80.1%, P < .0001) and are younger on average (35 years old vs 42, P < .0001). The most common mechanisms of injury among patients who test cannabis+ or cannabis- are similar. Flame injury makes up >60% of injuries, followed by scalds that are >15%. In comparing cannabis+/- patients, cannabis+ patients are more likely to be uninsured (25.2% vs 17.26%, P < .0001). Finally, patients who test cannabis+ have larger burns (TBSA% of 12.94 vs 10.98, P < .0001), have a longer length of stay (13.31 days vs 12.6, P = .16), spend more days in the ICU (7.84 vs 6.39, P = .0006), and have more operations (2.78 vs 2.05, P < .0001). The rate patients testing positive for cannabis in burn units is growing quickly. These patients are younger and are less likely to be insured. These patients also have larger burns, spend more time in ICUs, and have a greater number of operations. The increasing use of cannabis, as expected from legalization of cannabis in multiple states, among burn patient population may lead to increased burden on already tenuous health care resources.

Regional variation in expression of pro-inflammatory mediators in the intestine following a combined insult of alcohol and burn injury

The intestine is segmented into functionally discrete compartments (duodenum, jejunum, ileum, and colon). The present study examined whether alcohol combined with burn injury differently influences cytokine levels in different parts of the intestine. Male mice were gavaged with alcohol (∼2.9 g/kg) 4 h prior to receiving a ∼12.5% total body surface area full thickness burn. Mice were sacrificed 1, 3, and 7 days after injury. The intestine segments (duodenum, jejunum, ileum, and colon) were harvested, homogenized, and analyzed for inflammatory mediators (IL-6, IL-18, and KC) using their respective ELISAs. KC levels were significantly increased in the jejunum, ileum, and colon following alcohol and burn injury as compared to shams. The increase in KC was ∼28-fold higher in the colon as compared to the levels observed in duodenum following alcohol and burn injury. Both IL-6 and IL-18 levels were significantly elevated in both the ileum and colon following the combined insult. There was a ∼7-fold increase in IL-6 levels in the colon as compared with the duodenum after the combined insult. Levels of IL-18 were increased by ∼1.5-fold in the colon as compared to the ileum following alcohol and burn injury. The data suggest that pro-inflammatory mediators are differentially expressed in the intestine following alcohol and burn injury.

Implications of alcohol intoxication at the time of burn and smoke inhalation injury: an epidemiologic and clinical analysis

Up to 50% of burn patient fatalities have a history of alcohol use, and for those surviving to hospitalization, alcohol intoxication may increase the risk of infection and mortality. Yet, the effect of binge drinking on burn patients, specifically those with inhalation injuries, is not well described. We aimed to investigate the epidemiology and outcomes of this select patient population. In a prospective study, 53 patients with an inhalation injury and a documented blood alcohol content (BAC) were grouped as BAC negative (n = 37), BAC = 1 to 79 mg/dl (n = 4), and BAC ≥ 80 mg/dl (n = 12). Those in the last group were designated as binge drinkers according to National Institute on Alcohol Abuse and Alcoholism criteria. Binge drinkers with an inhalation injury had considerably smaller %TBSA burns than did their nondrinking counterparts (mean %TBSA 10.6 vs 24.9; P = .065) and significantly lower revised Baux scores (mean 75.9 vs 94.9; P = .030). Despite binge drinkers having smaller injuries, the groups did not differ in terms of outcomes and resource utilization. Finally, those in the binge-drinking group had considerably higher carboxyhemoglobin levels (median 5.2 vs 23.0; P = .026) than did nondrinkers. Binge drinkers with inhalation injuries surviving to hospitalization had less severe injuries than did nondrinkers, although their outcomes and burden to the healthcare infrastructure were similar to the nondrinking patients. Our findings affirm the effect of alcohol intoxication at the time of burn and smoke inhalation injury, placing renewed emphasis on injury prevention and alcohol abuse education.

Activation of toll-like receptor 2 prevents suppression of T-cell interferon γ production by modulating p38/extracellular signal-regulated kinase pathways following alcohol and burn injury

Recent studies indicate that toll-like receptors (TLRs) are expressed on T cells and that these receptors directly or indirectly activate the adaptive immune system. We have shown previously that acute alcohol/ethanol (EtOH) intoxication combined with burn injury suppresses mesenteric lymph node (MLN) T-cell interleukin-2 (IL-2) and interferon γ (IFN-γ) production. We examined whether direct stimulation of T cells with TLR2, 4, 5 and 7 agonists modulates CD3-mediated T-cell IL-2/IFN-γ release following EtOH and burn injury. Male mice were gavaged with EtOH (2.9 gm/kg) 4 h prior to receiving an ~12.5% total body surface area sham or full-thickness burn injury. Animals were killed on d 1 after injury and T cells were purified from MLN and spleens. T cells were cultured with plate-bound anti-CD3 in the presence or absence of various TLR ligands. Although TLR2, 4 and 5 agonists potentiate anti-CD3-dependent IFN-γ by T cells, the TLR2 agonist alone induced IFN-γ production independent of CD3 stimulation. Furthermore, T cells were treated with inhibitors of myeloid differentiation primary response protein 88 (MyD88), TIR domain-containing adaptor protein (TIRAP), p38 and/or extracellular signal-regulated kinase (ERK) to determine the mechanism by which TLR2 mediates IL-2/IFN-γ production. IL-2 was not influenced by TLR agonists. MyD88 and TIRAP inhibitory peptides dose-dependently diminished the ability of T cells to release IFN-γ. p38 and ERK inhibitors also abolished TLR2-mediated T-cell IFN-γ. Together, our findings suggest that TLR2 directly modulates T-cell IFN-γ production following EtOH and burn injury, independent of antigen-presenting cells. Furthermore, we demonstrated that MyD88/TIRAP-dependent p38/ERK activation is critical to TLR2-mediated T-cell IFN-γ release following EtOH and burn injury.

Inflammatory response in multiple organs in a mouse model of acute alcohol intoxication and burn injury

This study characterized the inflammatory response after burn injury and determined whether ethanol (EtOH) intoxication at the time of burn injury influences this response. To accomplish this, male mice were gavaged with EtOH (2.9 g/kg) 4 hours before 12 to 15% TBSA sham or burn injury. Mice were killed on day 1 after injury; blood, small intestine, lung, and liver were collected to measure interleukin (IL)-6, IL-10, IL-18, and Monocyte chemotactic protein-1 (MCP-1) levels. In addition, neutrophil infiltration, myeloperoxidase activity, and edema formation were also measured in the small intestine, lung, and liver. There was no difference in the inflammatory markers in the small intestine, lung, and liver in mice receiving either sham or burn injury alone except IL-6 that was increased in all four tissue compartments after burn injury alone. However, when compared with EtOH or burn injury alone, EtOH combined with burn injury resulted in a significant increase in cytokines, neutrophil infiltration, myeloperoxidase activity, and edema in the small intestine, liver, and lung tissue. Furthermore, a significant increase in IL-6 and MCP-1 was observed in circulation after EtOH intoxication and burn injury compared with either EtOH intoxication or burn injury alone; no other cytokines were detected in circulation. These findings suggest that acute EtOH intoxication exacerbates the inflammatory response after burn injury.

Alteration in intestine tight junction protein phosphorylation and apoptosis is associated with increase in IL-18 levels following alcohol intoxication and burn injury

Intestinal mucosal barrier is the first line of defense against bacteria and their products originating from the intestinal lumen. We have shown a role for IL-18 in impaired gut barrier function following acute alcohol (EtOH) intoxication combined with burn injury. To further delineate the mechanism, this study examined whether IL-18 alters intestine tight junction proteins or induces mucosal apoptosis under these conditions. To accomplish this, rats were gavaged with EtOH (3.2g/kg) prior to ~12.5% total body surface area burn or sham injury. One day after injury, EtOH combined with burn injury resulted in a significant decrease in total occludin protein and its phosphorylation in small intestine compared to either EtOH or burn injury alone. There was no change in claudin-1 protein content but its phosphorylation on tyrosine was decreased following EtOH and burn injury. This was accompanied with an increase in mucosal apoptosis (p<0.05). The treatment of rats with anti-IL-18 antibody at the time of burn injury prevented intestine apoptosis and normalized tight junction proteins following EtOH and burn injury. Altogether, these findings suggest that IL-18 modulates tight junction proteins and cause apoptosis leading to impaired intestinal mucosal integrity following EtOH intoxication combined with burn injury.

Alcohol, burn injury, and the intestine

A significant number of burn and other traumatic injuries are reported to occur under the influence of alcohol (EtOH) intoxication. Despite this overwhelming association between EtOH intoxication and injury, relatively little attention has been paid to determining the role of EtOH in post-injury pathogenesis. This article reviews studies which have evaluated the impact of EtOH on post-burn intestinal immunity and barrier functions. The findings from these studies suggest that while a smaller burn injury by itself may not have an adverse effect on host defense, when combined with prior EtOH intoxication it may become detrimental. Experimental data from our laboratory further supports the notion that EtOH intoxication before burn injury suppresses intestinal immune defense, impairs gut barrier functions, and increases bacterial growth. This results in increased bacterial translocation which may contribute to post injury pathogenesis. Altogether, the studies reviewed in this article suggest that EtOH intoxication at the time of injury is a risk factor, and therefore blood EtOH should be checked in burn/trauma patients at the time of hospital admission.

Mental disorders among acute burn patients

OBJECTIVE

To investigate mental disorders among acute hospitalized burn patients.

METHOD

Consecutive acute adult burn patients (n=107) admitted to Helsinki Burn Centre were interviewed by an experienced psychiatrist with the Structured Clinical Interview for DSM-IV-TR for Axis I and II mental disorders assessed in three time frames (lifetime, the month prior to burn, and in acute care). Information on clinical features, psychiatric symptoms, personality traits, and burn severity (total body surface area, TBSA) was gathered.

RESULTS

The mean TBSA was 9%. Most (61%) acute burn patients had at least one lifetime Axis I or II mental disorder. Prevalences of lifetime substance-related disorders (47%), psychotic disorders (10%), and Axis II personality disorders (23%) were high. The overall prevalence of Axis I mental disorders increased significantly (Q=6.40, df=1, p=0.011) from the month prior to burn (40%) to acute care (48%). The prevalence of delirium for this period was significantly higher (0.9% vs. 13%; Q=13.00, df=1, p<0.001) in acute care.

CONCLUSIONS

Mental disorders, particularly substance use disorders, psychotic disorders, and personality disorders are common among acute burn patients before injury. These disorders may predispose to burns. Burn itself may also predispose to mental disorders, particularly delirium.

Elevated Blood Alcohol Level May be Protective of Trauma Patient Mortality

To determine whether a positive blood alcohol level (BAL) affects morbidity and mortality at a Level I trauma center, a retrospective review of trauma patients 18 years of age and older was performed. There were 7985 trauma patients and 8 per cent (645) had a positive BAL. BAL(+) patients had lower Injury Severity Score (ISS) (8 vs 11, P < 0.01), lower rate of penetrating injury (9 vs 25%, P < 0.01), and were older (38 vs 32 years, P = 0.01). Overall there were 559 deaths (7%); (1% mortality in BAL(+) patients and 7% in BAL(-) patients; P < 0.0001). There were 352 (4.4%) complications with similar rates among BAL(-) and (+) patients. On univariate analysis, a positive BAL was inversely associated with death (OR, 0.17) as was blunt trauma (OR, 0.29), whereas older age (OR 1.009) and increased ISS (OR 1.13) were associated with death. On multivariable analysis, after adjusting for age, ISS, and mechanism of injury, a positive BAL remained protective against death (OR 0.35) as did blunt trauma (OR 0.2). Age (OR 1.04) and increased ISS (OR 1.19) were associated with mortality. In conclusion, a positive BAL was associated with a decreased mortality risk in trauma patients, which persisted after adjusting for multiple confounding variables.

Inhalation injury associated with smoking, alcohol and drug abuse: an increasing problem

This study investigated the association of inhalation injury (IHI) with smoking, alcohol and drug abuse in patients admitted to the Welsh Centre for Burns between 1995 and 2006. Common characteristics of these individuals were identified and contrasted with inhalation injury not associated with these social factors. Two hundred and fourteen patients were identified with inhalation injury. Ninety-two of these were associated with smoking, alcohol abuse and/or drug abuse. The proportion of IHI cases associated with smoking remained stable but IHI associated with alcohol and drug abuse increased dramatically over the course of the study and if current trends continue will increase further in future years. This study also showed that IHI associated with smoking alcohol and drug abuse were found to be largely caused by housefires and deliberate self-harm, and occurred between 22:00 and 05:59 h. These results were in sharp contrast with IHI not associated with these factors.

Adverse clinical outcomes associated with elevated blood alcohol levels at the time of burn injury

Elevated blood alcohol content (BAC) on admission is associated with poorer outcomes, larger burns and more inhalation injury. This study's purpose was to examine the effects of alcohol through a matched case-controlled study, measuring early and extended markers of clinical outcomes. The hypothesis was that patients with an elevated admission BAC would require more resuscitation and have a longer hospital stay. Admissions 16 to 75 years of age with 15 to 75% TBSA and admission BACs were identified. Patients with BAC >30 mg/dl (BAC+, cases) were matched with patients with undetectable BAC (BAC-, controls), according to age, sex, TBSA, inhalation injury and mechanism. Screening identified 258 patients, 146 with admission BACs. Twenty-seven had a BAC > or = 30 mg/dl. There were 24 matched pairs. At 24 hours, BAC+ group had larger acute physiology and chronic health evaluation II scores (23.33 vs 18.75, P < .05), fluid requirements (5.25 vs 3.82 L (cc/kg/TBSA), P < .05), and base deficit (11.15 vs 7.15, P < .05). The duration of mechanical ventilation (14.85 vs 4.23 days, P < .05), intensive care unit length of stay (22.85 vs 9.38, P < .05), hospital length of stay (28.95 vs 15.68, P < .05), and mean hospital charges ($239,507 vs $144,598, P < .05) were increased in the BAC+ patients. Despite matched baseline injury characteristics, elevated BAC was associated with poorer short term and extended clinical outcomes, illustrating the impact of alcohol intoxication on physiologic derangement after burn injury.

Effects of ethanol on pulmonary inflammation in postburn intratracheal infection

Infectious complications are a major cause of mortality in trauma patients. Burn patients with prior ethanol exposure have a worse prognosis than those who sustain injury but had not been drinking. We examined pulmonary infection and lung pathology in mice given ethanol (1.2 g/kg) 30 minutes before being subjected to 13 to 15% total body surface area scald burn followed by intratracheal inoculation with Pseudomonas aeruginosa (1-2 x 10(3) colony-forming units [CFUs]). Survival was monitored for up to 48 hours. Sham control groups had 100% survival after intratracheal infection regardless of ethanol exposure. Infected burned animals had 55% survival; however, survival of infected mice exposed to ethanol and burn injury was significantly lower (27%, P < .0001). When pulmonary infection was evaluated, the lungs of sham groups were negative for bacterial colonies. In addition, at 24 hours there were no significant differences in lung CFUs from infected burned animals regardless of ethanol exposure (3.0 x 10(4)). However, pulmonary bacterial content significantly decreased (1.2 x 10, P < .02) at 48 hours in mice given burn injury alone, where CFUs from the lungs of mice exposed to ethanol prior to burn did not decline (5.4 x 10(5)). At the same time point, lungs from animals given ethanol and burn injury had about a 2-fold (P < .02) increase in leukocyte infiltration and vascular congestion, as well as decreased pulmonary oxygen saturation (82.8%, P < .02), when compared with other treatment groups. In summary, ethanol exposure in postburn intratracheal infection results in the inability to clear pulmonary infection marked by a prolonged pulmonary leukocyte accumulation and a decrease in pulmonary function.

Organ-specific inflammation following acute ethanol and burn injury

Clinical and experimental evidence demonstrates that ethanol exposure prior to injury alters local and systemic inflammatory responses, increasing morbidity and mortality. Moreover, the aberrant inflammatory responses can directly and indirectly lead to the poor prognosis after injury by altering leukocyte infiltration into the wound site and remote organs and by suppressing immunity leading to increased susceptibility to opportunistic infections. Recent studies from our laboratory have focused on inflammatory responses at the wound site and in other distal organs after exposure to acute ethanol and burn injury. This combined insult leads to increased mortality after dermal or intratracheal pseudomonas infection, relative to infected mice given ethanol or burn injury alone. The increased mortality in mice given ethanol and burn injury parallels elevated serum levels of proinflammatory cytokines, IL-6 and TNF-alpha, marked infiltration of leukocytes into the lung and gut, as well as immunosuppression at the sites of infection. Bacterial translocation from the gut is likely to be responsible, in part, for the aberrant accumulation of leukocytes in the lungs of ethanol-exposed, burn-injured mice. Additionally, other factors, such as expression of adhesion molecules, increased chemokine production, and leakiness of the vascular endothelium, may also be involved.

Use of the Beck Depression Inventory for assessing depression in patients hospitalized with severe burn Disentangling symptoms of depression from injury and treatment factors

The objective of this study was to assess whether scores on the Beck Depression Inventory (BDI) are biased by injury severity among hospitalized survivors of burn (N=262). A confirmatory factor analysis (CFA) model was developed with a general depression factor that loaded on all items and somatic and cognitive factors that were orthogonal to the general factor and to each other. The model fit the data well and substantially better than an alternative three-factor model with correlated factors. Percent total body surface area burned (TBSA) was significantly associated with the general depression factor (p=.04), but also with the orthogonal somatic factor (p<.001), suggesting biased measurement due to overlap between somatic symptoms of depression and the severity of the burn injury. Analysis of item communalities, however, suggested that only approximately 2% of total predicted item variance was associated with bias related to injury severity. It was concluded that, despite a small amount of bias, the BDI is a reasonably accurate clinical tool even in the context of severe burn. Appropriate adjustments for bias, however, should be made in research with the BDI among patients with acute burn.

The effects of preexisting medical comorbidities on mortality and length of hospital stay in acute burn injury: evidence from a national sample of 31,338 adult patients

OBJECTIVE

To determine whether and to what extent preexisting medical comorbidities influence mortality risk and length of hospitalization in patients with acute burn injury.

SUMMARY BACKGROUND DATA

The effects on mortality and length of stay of a number of important medical comorbidities have not been examined in acute burn injury. Existing studies that have investigated the effects of medical comorbidities on outcomes in acute burn injury have produced inconsistent results, chiefly due to the use of relatively small samples from single burn centers.

METHODS

Records of 31,338 adults who were admitted with acute burn injury to 70 burn centers from the American Burn Association National Burn Repository, were reviewed. A burn-specific list of medical comorbidities was derived from diagnoses included in the Charlson Index of Comorbidities and the Elixhauser method of comorbidity measurement. Logistic regression was used to assess the effects of preexisting medical conditions on mortality, controlling for demographic and burn injury characteristics. Ordinal least squares regression with a logarithmic transformation of the dependent variable was used to assess the relationship of comorbidities with length of stay.

RESULTS

In-hospital mortality was significantly predicted by HIV/AIDS (odds ratio [OR] = 10.2), renal disease (OR = 5.1), liver disease (OR = 4.8), metastatic cancer (OR = 4.6), pulmonary circulation disorders (OR = 2.9), congestive heart failure (OR = 2.4), obesity (OR = 2.1), non-metastatic malignancies (OR = 2.1), peripheral vascular disorders (OR = 1.8), alcohol abuse (OR = 1.8), neurological disorders (OR = 1.6), and cardiac arrhythmias (OR = 1.5). Increased length of hospital stay among survivors was significantly predicted by paralysis (90% increase), dementia (60%), peptic ulcer disease (53%), other neurological disorders (52%), HIV/AIDS (49%), renal disease (44%), a psychiatric diagnosis (42%), cerebrovascular disease (41%), cardiac arrhythmias (40%), peripheral vascular disorders (39%), alcohol abuse (36%), valvular disease (32%), liver disease (30%), diabetes (26%), congestive heart failure (23%), drug abuse (20%), and hypertension (17%).

CONCLUSIONS

A number of preexisting medical conditions influence outcomes in acute burn injury. Patients with preburn HIV/AIDS, metastatic cancer, liver disease, and renal disease have particularly poor prognoses.

Acute alcohol intoxication increases interleukin-18-mediated neutrophil infiltration and lung inflammation following burn injury in rats

In this study, we examined whether IL-18 plays a role in lung inflammation following alcohol (EtOH) and burn injury. Male rats (∼250 g) were gavaged with EtOH to achieve a blood EtOH level of ∼100 mg/dl before burn or sham injury (∼12.5% total body surface area). Immediately after injury, rats were treated with vehicle, caspase-1 inhibitor AC-YVAD-CHO to block IL-18 production or with IL-18 neutralizing anti-IL-18 antibodies. In another group, rats were treated with anti-neutrophil antiserum ∼16 h before injury to deplete neutrophils. On day 1 after injury, lung tissue IL-18, neutrophil chemokines (CINC-1/CINC-3), ICAM-1, neutrophil infiltration, MPO activity, and water content (i.e., edema) were significantly increased in rats receiving a combined insult of EtOH and burn injury compared with rats receiving either EtOH intoxication or burn injury alone. Treatment of rats with caspase-1 inhibitor prevented the increase in lung tissue IL-18, CINC-1, CINC-3, ICAM-1, MPO activity, and edema following EtOH and burn injury. The increase in lung IL-18, MPO, and edema was also prevented in rats treated with anti-IL-18 antibodies. Furthermore, administration of anti-neutrophil antiserum also attenuated the increase in lung MPO activity and edema, but did not prevent the increase in IL-18 levels following EtOH and burn injury. These findings suggest that acute EtOH intoxication before burn injury upregulates IL-18, which in turn contributes to increased neutrophil infiltration. Furthermore, the presence of neutrophils appears to be critical for IL-18-meditaed increased lung tissue edema following a combined insult of EtOH and burn injury.

Depression in survivors of burn injury: a systematic review

BACKGROUND

The objective of this study was to systematically review the prevalence, persistence, and risk factors for depression postburn injury.

METHODS

A search of the MEDLINE, CINAHL, and PsycINFO databases was conducted in June 2006 to identify studies that used a standardized interview or validated questionnaire to assess depression. The search was augmented by hand searching of selected journals and references of identified articles and reviews.

RESULTS

Major depression was identified in 4% to 10% of adult patients using structured interviews in hospital and in the year following discharge. The prevalence of significant depressive symptoms in studies that used the depression subscale of the Hospital Anxiety and Depression Scale post discharge was 4% to 13%, whereas studies that used the Beck Depression Inventory generally produced substantially higher rates: between 13% and 26% for "moderate to severe" symptoms and between 22% and 54% for at least "mild" symptoms.

CONCLUSIONS

The general low quality of studies reviewed suggests the need for future studies using larger sample sizes to adequately assess prevalence rates and risk factors. No existing studies have addressed the persistence of depression in burn survivors; there are no treatment studies; and there are no recent studies of children.

Effect of acute alcohol ingestion prior to burn injury on intestinal bacterial growth and barrier function

Previous studies from our laboratory have shown that acute alcohol (EtOH) ingestion prior to burn injury enhances intestinal bacterial translocation. This study tested if increased intestinal bacterial translocation in alcohol and burn injured rats is due to an overgrowth in intestinal bacteria. We determined if the translocation was accompanied with alterations in intestinal permeability and immune cell population. Rats (225-250 g) were gavaged with alcohol to achieve a blood EtOH level in the range of 100 mg/dl prior to burn or sham injury (25% total body surface area). Two days after injury, we found that acute alcohol ingestions prior to burn injury results in a significant increase in bacterial counts in small intestine. The increase in intestinal bacterial counts accompanied a significant increase in intestinal permeability. Finally, immunohistochemical analysis revealed a substantial (p<0.05) loss of both T cell and dendritic cells in intestine of alcohol and burn injured rats compared with intestine of rats receiving either burn or sham injury. Altogether, results presented in this manuscript suggest that increase in intestinal bacterial growth along with alterations in intestinal permeability and immune status contribute to the increase in bacterial translocation observed in alcohol and burn injured rats.

Ethanol and burn injury: estrogen modulation of immunity

A good deal of clinical evidence supports the idea that ethanol exposure is a causative factor in the occurrence of burn or other traumatic injury. In addition, more recent evidence reveals that individuals who sustain injury while under the influence of ethanol suffer from increased morbidity and mortality compared with those with comparable injuries who did not consume ethanol. Many of the complications seen in ethanol-exposed, burn-injured subjects result from depressed immune responses, which render the host unable to fight off infectious organisms. Both injury and ethanol exposure independently affect cellular immune responses, including delayed-type hypersensitivity and splenocyte proliferative responses, and the combined insult of ethanol exposure and injury acts in conjunction to increase further the magnitude and duration of immunosuppression. It is interesting that these immune responses can be restored experimentally in male, but not in female, mice by administration of low, proestrous levels of estrogen. The complexity of the responses after injury in ethanol-exposed subjects is multiplied when the sex of the subjects is added to the equation. This is due, in part, to the effect of the combined insult of injury and ethanol on the production of gonadal steroid hormones in males and females and the direct effects of those hormones on cytokine gene expression in sensitive cell types such as the macrophage. Evidence seems to indicate that cellular immune responses after ethanol exposure and burn injury differ in kinetics and magnitude for male and female subjects, and, hence, the therapeutic interventions to treat burn-injured patients should take into account both sex and ethanol exposure.

Alcohol, injury, and cellular immunity

It is widely accepted that alcohol exposure is a causative factor in the occurrence of burn or other traumatic injury. It is less well known that individuals who have consumed alcohol before sustaining an injury suffer from increased morbidity and mortality compared with the morbidity and mortality of non-alcohol-consuming subjects with similar injuries. Complications due to bacterial infection are the most common burn sequelae in injured patients and are frequently associated with depressed immunity. Independently, alcohol exposure and injury have been shown to influence cellular immunity negatively. These changes in immunity are closely linked to injury- or alcohol-induced alterations in the cytokine milieu in both clinical studies and animal models. Not surprisingly, the combination of insult of alcohol exposure and burn injury results in immune suppression that is greater in magnitude and duration compared with either insult alone. The combined effects of alcohol and injury on immunity have been examined in a limited number of studies. However, results of these studies support the suggestion that altered cytokine production is an integral part of the immune dysregulation and increased mortality that is observed. In particular, the increased presence of macrophage-derived mediators observed after burn or alcohol exposure alone seems to be synergistically increased in a combined injury model. Although more research is needed, it is likely that therapeutic modalities that include manipulation of cytokine networks to boost cellular immunity may improve outcome for patients who sustain injuries subsequent to consuming alcohol.

Psychiatry of the medically ill in the burn unit

Clinical experience and burn survivor testimony show that the experience of being burned can be associated with catastrophic stress and lead to drastic permanent body image changes from scarring and limb-function loss. Close relatives, if not killed in the fire, often also experience clinically significant bystander stress. Closeness of relationships may be lost, and self-image may suffer. Property damage and loss of crucial resources may be associated with fires. Although many burns result from accidents, most result from preventable causes associated with psychiatric disorders, which include mood disorders, psychoses, cognitive disorders, and substance-use disorders. Burns then result from: Deliberate self-harm Impaired judgment and poor coordination associated with substance intoxication Risk-taking behavior Poor supervision of children and impaired elderly persons Careless handling of flammable materials. Many clinical syndromes, such as delirium, ASD, acute psychosis, suicidality, and pain need to be addressed by the consulting psychiatrist to facilitate surgical treatment of the burn injury. Other psychiatric disorders, such as PTSD, major depression, and adjustment disorder, need to be treated to expedite long-term adjustment. Hospital length of stay and RTW/RTS are major outcome variables. The psychiatry consultant can positively affect both variables substantially using both pharmacologic and psychosocial measures. The important role of psychiatric issues both before and after burn injury support the need for more consistent and comprehensive medical insurance coverage for psychiatric consultation to burn units and clinics. Burn Support Groups are an invaluable asset.

David R. Boyd lecture in trauma care and emergency medical systems: "The surgical complications of toxins."

Toxins have had major roles in our societies for thousands of years. Interactions between surgeons, both generalists and subspecialists, and those caring for poisoned patients have been extensive throughout history. The advancement of the science of toxicology, the development of regional poison control centers, the development of emergency medicine, and the development of the subspecialty of medical toxicology have led to more appropriate and creative interactions between medical toxicologists, emergency physicians, and surgeons. This article will review the diverse interfaces between the medical toxicologist and the surgeon.