Women do Worse than Men after Burn Injury: A Systematic Review of the Literature

Burn injuries are a public health problem that although decreasing in incidence in the United States (US), can be devastating with lifelong health, social and economic ramifications. Studies have shown that extremes of age, greater percent total body surface area (%TBSA), and inhalation injury, are all associated with greater morbidity and mortality after burn injury. Unlike other forms of trauma, women appear to do worse after burn injury as compared to men, but little research has been done to understand why this is the case. We thus aimed to do a systematic review of studies designed to specifically assess the effect of sex on outcomes after burn injury in adult patients. We searched PubMed, Medline, Embase, Clinical Key, CINAHL for studies that looked at the relationship between burn or thermal injury, sex, gender and outcome. Our search criteria resulted in a total of 939 articles. After review of the articles, a total of ten articles were identified for final review. All of the identified articles were retrospective in nature and relied on large single or multicenter registry sources of data for analysis. While the studies were heterogeneous in nature, the majority of articles showed that women had greater mortality after burn injury as compared to men. Given the retrospective nature of all of the studies, none were able to offer causality for why women do worse. Many studies speculated that sex hormones, i.e. estrogen, likely cause dysregulation of the immune system leading to worse outcomes. There may also be an interplay between sex hormones and the differential distribution of adipose tissue, in men and women, which may contribute to the differences seen in mortality between the sexes. In addition to physiologic and immunologic mechanisms, there may be social, economic and psychological/psychiatric factors that may prime women for longer lengths of stay, slower recovery and worse long term outcomes after burns as compared to men. Many studies found that women who are burned tend to be older, have lower socioeconomic status, have greater co-morbidities, and tend to have lower social capital as compared to men who are burned. Although no definitive answers were provided in the papers, it is clear that there is a complex interaction between physiologic and social factors that increase women’s risk for worse outcomes and greater mortality after burns. The results of this systematic review highlight the need for prospective, translational studies designed to explore why women do worse than men after burns. In addition, there are many opportunities for the public health community to engage in interdisciplinary burn research to improve burn prevention efforts and to help better understand the interactions between behavior, social isolation and health, with respect to burn trauma.Master of Public Healt

The Employed Surgeon: A Changing Professional Paradigm

OBJECTIVE: To identify trends and characteristics of surgeon employment in the United States. Surgeons are increasingly choosing hospital or large group employment as their practice environment. DESIGN American Medical Association Physician Masterfile data were analyzed for the years 2001 to 2009. SETTING: Surgeons identified within the American Medical Association Masterfile. PARTICIPANTS: Surgeons were defined using definitions from the American Medical Association specialty data and the American Board of Medical Specialties certification data and included active, nonfederal, and nonresident physicians younger than 80 years of age. MAIN OUTCOME MEASURES: Employment status and trends. RESULTS: The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices. CONCLUSIONS: General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice. The trend is especially notable among younger surgeons and among female surgeons. The trend denotes a professional paradigm shift of major importance

Chest High-Frequency Oscillatory Treatment for Severe Atelectasis in a Patient With Toxic Epidermal Necrolysis:

Atelectasis is a significant risk factor for the development of pneumonia, especially in pediatric populations that are more prone to alveolar collapse or those who may have weakened muscular tone. The Metaneb® System is a pneumatic, non-invasive physiotherapy technique that delivers chest high frequency oscillations (CHFO). CHFO has been shown to enhance mucociliary clearance of secretions and help resolve patchy atelectasis. This report describes the case of a 17 year old female who developed significant left sided atelectasis after extubation and was effectively managed with complete resolution of her atelectasis with the Metaneb System, obviating the need for reintubation

Blood utilization in patients with burn injury and association with clinical outcomes (CME)

Uncontrolled bleeding is an important cause of increased transfusion in burn victims; however, description of blood utilization patterns in the burn population is lacking

Differential regulation of innate immune cytokine production through pharmacological activation of Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) in burn patient immune cells and monocytes

Burn patients suffer from immunological dysfunction for which there are currently no successful interventions. Similar to previous observations, we find that burn shock patients (≥15% Total Burn Surface Area (TBSA) injury) have elevated levels of the innate immune cytokines Interleukin-6 (IL-6) and Monocyte Chemoattractant Protein-1 (MCP-1)/CC-motif Chemokine Ligand 2(CCL2) early after hospital admission (0–48 Hours Post-hospital Admission (HPA). Functional immune assays with patient Peripheral Blood Mononuclear Cells (PBMCs) revealed that burn shock patients (≥15% TBSA) produced elevated levels of MCP-1/CCL2 after innate immune stimulation ex vivo relative to mild burn patients. Interestingly, treatment of patient PBMCs with the Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) agonist, CDDO-Me(bardoxolone methyl), reduced MCP-1 production but not IL-6 or Interleukin-10 (IL-10) secretion. In enriched monocytes from healthy donors, CDDO-Me(bardoxolone methyl) also reduced LPS-induced MCP1/CCL2 production but did not alter IL-6 or IL-10 secretion. Similar immunomodulatory effects were observed with Compound 7, which activates the NRF2 pathway through a different and non-covalent Mechanism Of Action (MOA). Hence, our findings with CDDO-Me(bardoxolone methyl) and Compound 7 are likely to reflect a generalizable aspect of NRF2 activation. These observed effects were not specific to LPS-induced immune responses, as NRF2 activation also reduced MCP-1/CCL2 production after stimulation with IL-6. Pharmacological NRF2 activation reduced Mcp-1/Ccl2 transcript accumulation without inhibiting either Il-6 or Il-10 transcript levels. Hence, we describe a novel aspect of NRF2 activation that may contribute to the beneficial effects of NRF2 agonists during disease. Our work also demonstrates that the NRF2 pathway is retained and can be modulated to regulate important immunomodulatory functions in burn patient immune cells

DNA and Inflammatory Mediators in Bronchoalveolar Lavage Fluid From Children With Acute Inhalational Injuries:

Assess the feasibility of using serial bronchoalveolar lavage fluids (BALF) to characterize the course of cell damage and inflammation in airways of pediatric patients with acute burn or inhalation injury

Visual findings in children exposed to Zika in utero in Nicaragua

Knowledge regarding the frequency of ocular abnormalities and abnormal visual function in children exposed to Zika virus (ZIKV) in utero but born without congenital Zika syndrome (CZS) is limited. We hypothesized that children exposed to ZIKV in utero born without CZS may have visual impairments in early childhood. We performed ophthalmic examination between 16 and 21 months of age and neurodevelopment assessment at 24 months of age with the Mullen Scales of Early Learning test (MSEL) on children enrolled in a cohort born to women pregnant during and shortly after the ZIKV epidemic in Nicaragua (2016–2017). ZIKV exposure status was defined based on maternal and infant serological testing. Visual impairment was defined as abnormal if the child had an abnormal ophthalmic exam and/or low visual reception score in the MSEL assessment. Of 124 children included in the analysis, 24 (19.4%) were classified as ZIKV-exposed and 100 (80.6%) unexposed according to maternal or cord blood serology. Ophthalmic examination showed that visual acuity did not differ significantly between groups, thus, 17.4% of ZIKV-exposed and 5.2% of unexposed had abnormal visual function (p = 0.07) and 12.5% of the ZIKV-exposed and 2% of the unexposed had abnormal contrast testing (p = 0.05). Low MSEL visual reception score was 3.2-fold higher in ZIKV-exposed than unexposed children, but not statistically significant (OR 3.2, CI: 0.8–14.0; p = 0.10). Visual impairment (a composite measure of visual function or low MESL visual reception score) was present in more ZIKV-exposed than in unexposed children (OR 3.7, CI: 1.2, 11.0; p = 0.02). However, the limited sample size warrants future investigations to fully assess the impact of in utero ZIKV exposure on ocular structures and visual function in early childhood, even in apparently healthy children

Correction: Differential regulation of innate immune cytokine production through pharmacological activation of Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) in burn patient immune cells and monocytes.

[This corrects the article DOI: 10.1371/journal.pone.0184164.]

Differential regulation of innate immune cytokine production through pharmacological activation of Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) in burn patient immune cells and monocytes.

Burn patients suffer from immunological dysfunction for which there are currently no successful interventions. Similar to previous observations, we find that burn shock patients (≥15% Total Burn Surface Area (TBSA) injury) have elevated levels of the innate immune cytokines Interleukin-6 (IL-6) and Monocyte Chemoattractant Protein-1 (MCP-1)/CC-motif Chemokine Ligand 2(CCL2) early after hospital admission (0-48 Hours Post-hospital Admission (HPA). Functional immune assays with patient Peripheral Blood Mononuclear Cells (PBMCs) revealed that burn shock patients (≥15% TBSA) produced elevated levels of MCP-1/CCL2 after innate immune stimulation ex vivo relative to mild burn patients. Interestingly, treatment of patient PBMCs with the Nuclear Factor-Erythroid-2-Related Factor 2 (NRF2) agonist, CDDO-Me(bardoxolone methyl), reduced MCP-1 production but not IL-6 or Interleukin-10 (IL-10) secretion. In enriched monocytes from healthy donors, CDDO-Me(bardoxolone methyl) also reduced LPS-induced MCP1/CCL2 production but did not alter IL-6 or IL-10 secretion. Similar immunomodulatory effects were observed with Compound 7, which activates the NRF2 pathway through a different and non-covalent Mechanism Of Action (MOA). Hence, our findings with CDDO-Me(bardoxolone methyl) and Compound 7 are likely to reflect a generalizable aspect of NRF2 activation. These observed effects were not specific to LPS-induced immune responses, as NRF2 activation also reduced MCP-1/CCL2 production after stimulation with IL-6. Pharmacological NRF2 activation reduced Mcp-1/Ccl2 transcript accumulation without inhibiting either Il-6 or Il-10 transcript levels. Hence, we describe a novel aspect of NRF2 activation that may contribute to the beneficial effects of NRF2 agonists during disease. Our work also demonstrates that the NRF2 pathway is retained and can be modulated to regulate important immunomodulatory functions in burn patient immune cells