Barriers to employment among working-aged patients with major burn injury

The purpose of this study was to examine the prevalence of preexisting and burn-related impairments and to describe their association with preburn employment status. Data gathered during the acute hospitalization were analyzed on a consecutive series of burn patients aged 16 to 64 years (N = 770) enrolled in a prospective, longitudinal, multicenter study. Patients who were unemployed before the injury were more likely than those who were employed to report being alcohol-dependent (36 vs 18%), abusing other drugs (22 vs 10%), having received psychiatric treatment in the past year (21 vs 6%), and having preexisting physical disability (23 vs 3%); all were significant at P < .001). Of the unemployed patients who received toxicologic screening at admission, 49% tested positive for alcohol and 39% positive for other drugs, percentages that were significantly higher than 26 and 31%, respectively, for the employed. With adjustment for age, sex, race, and education, variables that were most predictive of preinjury unemployment status were preexisting physical disability (odds ratio, 51.0; 95% confidence interval, 7.7-336.9) and being alcohol-positive at admission (odds ratio, 2.8; 95% confidence interval, 1.2-6.8). Unemployed and employed patients also differed significantly in injury patterns and clinical outcomes, with inhalation injury and psychiatric distress being more prevalent among the unemployed and both hand burns and hand surgery among the employed. The greater prevalence of preexisting impairments among survivors who were unemployed before the injury helps explain why preburn employment status is such a powerful determinant of postburn work outcomes, and suggests the need to include psychosocial services in a program of comprehensive rehabilitation.

Drug-induced linear immunoglobulin A bullous disease that clinically mimics toxic epidermal necrolysis

Drug-induced linear immunoglobulin A bullous disease is a subepidermal blistering disorder that most commonly occurs after exposure to vancomycin. It can clinically mimic toxic epidermolytic necrolysis. We describe an 87-year-old white woman in whom linear immunoglobulin A bullous disease developed while she was taking vancomycin and phenytoin. A few days after the linear immunoglobulin A bullous disease developed, both medications were discontinued. No new bullae developed, and the eruption completely resolved within 2 weeks. The patient was treated with only topical therapy.

American Burn Association/Shriners Hospitals for Children burn outcomes questionnaire: construction and psychometric properties

To develop a standardized, practical, self-administered questionnaire to monitor pediatric patients with burns and to evaluate the effectiveness of comprehensive pediatric burn management treatments, a group of experts generated a set of items to measure relevant burn outcomes. Children between the ages of 5 and 18 years were assessed in a cross-sectional study. Both parent and adolescent responses were obtained from children 11 to 18 years old. The internal reliability of final scales ranged from 0.82 to 0.93 among parents and from 0.75 to 0.92 among adolescents. Mean differences between parent and adolescent were small; the greatest difference occurred in the appearance subscale. Parental scales showed evidence of validity and potential for sensitivity to change. In an effort to support the construct validity of the new scales, they were compared with the Child Health Questionnaire and related to each other in clinically sensible ways. These burn outcomes scales reliably and validly assess function in patients with burns, and the scales have been developed in such a way that they are likely to be sensitive to change over time.

The 1998 Clinical Research Award. Sleep disturbance after burn injury: a frequent yet understudied complication

This study investigated the frequency of sleep disturbance of burn survivors at 3 time points: during hospitalization (time 1: n = 237), 1 week after discharge (time 2: n = 149), and 2 months after discharge (time 3: n = 91). Predictors of sleep disturbance and its relationship to quality of life are explored. Measures of sleep, post-traumatic stress disorder, depression, anxiety, pain, and quality of life were administered at each time point. Fifty percent of participants had sleep disturbance while in the hospital and 1 week after discharge. Forty percent of participants continued to have sleep disturbance 2 months after discharge. In regression equations, emotional distress was a better predictor of sleep disturbance than pain and total body surface area burned at each time point. Sleep disturbance was significantly negatively correlated with all aspects of quality of life represented on the SF-36 Health Survey. Sleep disturbance is a common and often chronic postburn complication that warrants further research.

Toxic epidermal necrolysis syndrome: mortality rate reduced with early referral to regional burn center

Toxic epidermal necrolysis syndrome is an uncommon, acute, life-threatening disorder that involves sloughing of skin at the dermal-epidermal junction with associated mucositis. Between 1985 and 1995, 36 patients were treated for toxic epidermal necrolysis syndrome, at the Baltimore Regional Burn Center. A retrospective chart analysis was performed to discover significant determinants of mortality. Ninety-seven percent of the patients (35 of 36) were referred from outside institutions after an average of 6.3 +/- 0.8 days. Analysis of the data shows that patients who survived had been referred 7.5 days earlier than nonsurvivors (4.0 +/- 0.5 days versus 11.5 +/- 1.4 days, p < 0.001). When the patients were separated into two groups on the basis of time of referral, those referred "early" (< or = 7 days) had a mortality rate of 4 percent (1 of 24) versus 83 percent (10 of 12) for those referred "late" (> 7 days) (p < 0.001). Data were available from transferring institutions for 21 of the 36 patients. Analysis of the microbiologic data from these 21 patients revealed bacteremia, and subsequent death occurred in 100 percent (6 of 6) of the patients referred with positive cultures, whereas bacteremia developed in only 33 percent (5 of 15) of the patients referred with negative cultures, for a mortality rate of 7 percent (1 of 15). In addition, 86 percent (6 of 7) of the patients who were referred late (> 7 days) had positive cultures on referral. The current trend toward prolonged treatment in outside facilities before referral to a burn center is detrimental to the care of patients with toxic epidermal necrolysis syndrome. The overall rate of bacteremia, septicemia, and mortality is significantly reduced with early (< or = 7 days) referral to a regional burn center.

Efficacy of fiberoptic laryngoscopy in the diagnosis of inhalation injuries

BACKGROUND

A significant proportion of burn patients with inhalation injuries incur difficulties with airway protection, dysphagia, and aspiration. In assessing the need for intubation in burn patients, the efficacy of fiberoptic laryngoscopy was compared with clinical findings and the findings of diagnostic tests, such as arterial blood gas analysis, measurement of carboxyhemoglobin levels, pulmonary function tests, and radiography of the lateral aspect of the neck.

OBJECTIVE

To determine if these patients were at risk for aspiration or dysphagia, barium-enhanced fluoroscopic swallowing studies were performed.

DESIGN

Prospective study.

SETTINGS

Burn intensive care unit in an academic tertiary referral center.

MAIN OUTCOME MEASURES

Need for endotracheal intubation and potential for aspiration.

RESULTS

Six (55%) of 11 patients had clinical findings and symptoms that indicated, under traditional criteria, endotracheal intubation for airway protection. Visualization of the upper airway with fiberoptic laryngoscopy obviated the need for endotracheal intubation in all 11 patients. These patients also failed to evidence an increased risk of aspiration or other swallowing dysfunction.

CONCLUSIONS

In comparison with other diagnostic criteria, fiberoptic laryngoscopy allows differentiation of those patients with inhalation injuries who, while at risk for upper airway obstruction, do not require intubation. These patients may be safely observed in a monitored setting with serial fiberoptic examinations, thus avoiding the possible complications associated with intubation of an airway with a compromised mucosalized surface. In these patients, swallowing abnormalities do not manifest.

Work status and attrition from longitudinal studies are influenced by psychiatric disorder

Participants (n=95) were assessed at the time of discharge and at 4 and 12 months after discharge in regard to work status and psychiatric history both before and after the burn injury. Complex psychiatric comorbidity and substance abuse disorders that occurred before the burn injury each significantly raised the risk of unemployment before the burn injury; preburn substance abuse also affected unemployment at 4 months after the burn injury. Trends for higher unemployment rates at 12 months after discharge also were noted among those with a preburn history of complex psychiatric comorbidity and alcohol use, anxiety, or mood disorder. Preburn substance-use disorder raised the risk of attrition from the 12-month study; whereas, those diagnosed at the time of discharge with post-traumatic stress disorder or with two or more current psychiatric disorders after the burn injury dropped out less often. The greater risk for unemployment and attrition observed among subjects with psychiatric disorders before the burn injury suggests the need for routine screening, tracking, and assistance in accessing supportive or rehabilitative services to remove barriers to employment.

Preburn psychiatric history affects posttrauma morbidity

A sample of inpatient, burn-injured adults (N = 95) were assessed upon discharge, and 4 and 12 months later with a structured interview and DSM-III-R criteria. The prevalence of disorder in this sample was contrasted with published data on a representative national community-dwelling comparison group in the National Comorbidity Study. The prevalence of lifetime affective, alcohol, and substance use disorders was significantly higher, and lifetime anxiety disorders significantly lower, in the burn-injured sample. The 12-month postburn prevalences of alcohol, and substance use disorders were significantly greater in the burn-injured sample. The risk of postburn disorder was significantly greater for the subjects who had a preburn history of affective, alcohol, or substance use disorder. The risk for developing posttraumatic stress disorder (PTSD) was elevated in the subjects with a preburn affective disorder but not preburn anxiety disorder. Finally, postburn PTSD was associated with a greater length of stay, and greater preburn comorbidity predicted preburn employment status and tended to lengthen hospitalization.

Interactions of ACTH and TGF beta on monocyte proliferation: implications for trauma and burn patients

The purpose of this study was to try to elucidate a possible biobehavioral mechanism associated with decreased immune function in trauma patients by determining whether there is an interaction between the effects of ACTH, a stress hormone, and TGF beta, a cytokine, on peripheral blood lymphocyte proliferation. Peripheral mononuclear lymphocytes (PMLs) from healthy donors were preincubated with varying concentrations of ACTH for 24 hr, stimulated with concanavalin A and increasing concentrations of TGF beta, and incubated for 72 hr. Proliferation was assayed by tritiated thymidine incorporation. A parallel aliquot of PMLs were incubated in the presence of ACTH to determine the direct effect of ACTH on mononuclear cell TGF beta production. While harvested supernatant from cells incubated in the presence of ACTH did not contain any detectable TGF beta, ACTH as well as TGF beta were found to significantly decrease cellular proliferation independent of one another. An even greater decrease in cellular proliferation was found when both ACTH and TGF beta were used, compared to either ACTH or TGF beta alone. These results suggest a biobehavioral interaction between ACTH and TGF beta at the cellular level and that interactions to relieve stress may assist in improving function and recovery from trauma.

Preinjury psychiatric illness and postinjury adjustment in adult burn survivors

The impact of preinjury DSM-III-R anxiety, mood, and alcohol and substance abuse disorders, determined by using the Structured Clinical Interview for DSM-III-R, nonpatient version (SCID-NP), on postinjury adjustment was examined prospectively in a consecutive series of 98 adult patients admitted to a regional burn center and followed for 1 year. The subjects were grouped according to SCID diagnoses: 1) any preburn mood and/or anxiety diagnosis; 2) preburn alcohol abuse or dependence diagnosis; or 3) any preburn diagnosis (i.e., any of the above diagnoses). These groups showed greater impairment in many functional domains at discharge than the subjects who had no preburn disorder. By 4 months postinjury, the "no diagnosis" and the preburn diagnosis groups had comparable levels of adjustment, and this comparability was maintained at the 1-year follow-up. Similarly, trait neuroticism had an early negative impact on adjustment, while trait extroversion had both an early and late positive effect on adjustment.

Early avoidance of traumatic stimuli predicts chronicity of intrusive thoughts following burn injury

The role of avoidance behavior in perpetuating the experience of intrusive thoughts among burn survivors was investigated. The Impact of Events Scale (IES), which has subscales that measure the frequency of intrusive thoughts and avoidance behavior, was administered to burn survivors (n = 23) upon discharge and four months later. Both avoidance behavior and intrusive thoughts at discharge were significantly related to experiencing intrusive thoughts at four months (r = 0.59, P < 0.003, r = 0.45, P < 0.03, respectively). In a hierarchical regression analysis controlling for intrusive thoughts at discharge, avoidance behavior continued to significantly predict intrusive thoughts at four months [B = 0.43, t(20) = 2.9, P < 0.009]. Limitations of the study and implications for treatment are discussed.

Increased production of TGF-beta and Il-6 by aged spleen cells

Aging is accompanied by a progressive decline in immunity in every species that has been studied. Despite its ubiquity, the causes of immunosenescence are unknown. Transforming growth factor beta (TGF-beta) is a cytokine with potent immunosuppressive properties. Cells from aged mice produce increased levels of TGF-beta in vitro along with similar increases in interleukin 6 (Il-6), a cytokine which is immunosuppressive at elevated concentrations. Il-6 does not upregulate TGF-beta production, but high concentrations of Il-6 increase the percentage of cells expressing the TGF-beta receptor. Increased TGF-beta production and Il-6-induced upregulation of the TGF-beta receptor may be factors contributing to age-associated immunosuppression.

Pathologic concentrations of interleukin 6 inhibit T cell responses via induction of activation of TGF-beta

Interleukin 6 levels are increased in a variety of clinical conditions including bacterial and viral infections, HIV infection, autoimmune diseases, certain neoplasias, and traumatic injury. In general, all these conditions are characterized by suppression of one or more manifestations of the immune response. Concentrations of IL 6 comparable to those found in the sera of immunosuppressed, thermally injured patients selectively inhibit T cell proliferative responses. This suppression is independent of IL 2-mediated responses, is dependent on macrophage activity, and is reversed by antisera specific for transforming growth factor-beta (TGF-beta).

Altered expression of lymphocyte Il-2 receptors in burned patients

Impairment of T-cell function is a consistent observation in burned patients. Concomitant with this impairment is an increase in serum factors which inhibit interleukin-2-mediated T-cell functions. These factors are heat labile and do not behave like endotoxins. Nonetheless, treatment of burned patients with endotoxin-neutralizing regimens of polymyxin B reduces the levels of these factors, suggesting that they are generated in response to endotoxin exposure. In addition to factors which inhibit Il-2 responses burn serum contains increases of circulating soluble, cell-free Il-2 receptors. However, the level of Il-2R is not altered by polymyxin B treatment and does not appear to be a direct result of endotoxin exposure. These observations suggest that multiple causes contribute to T-cell impairment in burned patients.

A statewide targeted burn prevention program

The statewide Burn Prevention Program has demonstrated a significant improvement in testable knowledge of burn prevention and fire safety among children and senior citizens as a result of an effective educational program. Formal evaluation using written examinations was done with the children. The statistical significance of the results of these evaluations was analyzed using chi square tests and two sample t tests. Significant improvements were seen in both mean test scores and the percentage of children answering all the test questions correctly. A much less formal type of evaluation was done with the elderly group. Senior citizens were assisted with a pre-program questionnaire. The results of this questionnaire were compared to the results of "BURN-GO" (copyright 1986), a bingotype game, played immediately after the educational session. Again, the post-implementation results of the program were significantly higher than those achieved prior to the intervention.

The isolation and characterization of bacteriophages infecting obligately thermophilic strains of Bacillus

Twenty-four thermophilic bacteriophages have been isolated from diverse sources such as compost, soil, silage and rotting straw. Although considerable individual host specificity was observed, the phages were able to infect most of the major taxonomic groups of Bacillus thermophiles. The phages varied considerably in morphology and size; the phage heads were either cylindrical or polyhedral with tails varying in length between 15 and 500 nm. Most of the phages were stable at 50 degrees C for 4-5 h but at 70 degrees C the plaque-forming units decreased by between 10(2)- and 10(7)-fold in 2 h. The DNA of morphologically similar phages was examined by restriction enzyme analysis, and some differences in the DNA fragment patterns were found. Efficiency of plating data indicated that 'B. caldotenax' has a restriction and modification system. These phages may be valuable for the study of the genetics of thermophilic bacilli: transduction of 'B. caldotenax' and 'B. caldovelox' by phage JS017 has been observed.

Ecthyma gangrenosum in a kidney transplant recipient with Pseudomonas septicemia

This report describes a renal transplant recipient in whom Pseudomonas septicemia and ecthyma gangrenosum developed within days of renal transplantation. Microscopic skin sections showed perivascular bacillary invasion. Pseudomonas organisms were cultured and microscopically visualized in sections from the transplanted kidney. Although cultures from the donor kidney preservation perfusate fluid showed no growth, Pseudomonas aeruginosa was found in the recipient's urine, blood, and peritoneal fluid. The recipient's course was complicated by septic shock, cardiopulmonary arrest, coma, and extensive skin lesions; but his condition improved with appropriate antibiotic therapy, wound debridement, and an aggressive rehabilitative program. He is now a candidate for retransplantation. This is the first known case of ecthyma gangrenosum in a renal transplant recipient.