Fungal wound infection (not colonization) is independently associated with mortality in burn patients.

OBJECTIVE: To analyze the occurrence of fungal wound infection (FWI) after thermal injury and its relationship to mortality. BACKGROUND: FWI is an uncommon but potentially lethal complication of severe thermal injury. METHODS: The records of patients with thermal burns admitted to a single burn center (1991-2002) were reviewed. Analyses accounted for total burn size (TBS, percentage body surface area), full-thickness burn size (FTBS, percentage body surface area), age, inhalation injury, sex, and fungal-status category. Fungal colonization and infection were determined histopathologically. RESULTS: Criteria for inclusion were met by 2651 patients. Each patient's fungal-status category was defined according to the deepest level of fungal involvement observed during the hospital course: no fungus (2476 patients), fungal wound colonization (FWC, 121 patients), or fungal wound infection (FWI, 54 patients). Median TBS (9%, 47%, 64%, respectively) and mortality (5%, 27%, 76%, respectively) varied significantly among fungal-status groups. Logistic regression was used to detect significant independent associations. FWI was associated with higher TBS. Mortality was associated with TBS, FTBS, inhalation injury, FWI, and age. Unlike FWI, FWC was not independently related to mortality, the greater observed mortality in FWC being explained by other variables such as TBS. The odds ratio for FWI (8.16) suggested about the same mortality impact as augmenting TBS by 33%. A midrange TBS of 30% to 60% was required for most of the detectable association of FWI with mortality. CONCLUSIONS: FWI accompanies larger burns and is associated with mortality in burn patients, particularly in those with TBS 30% to 60%. This association is independent of burn size, inhalation injury, and age.

One hundred ninety-five cases of high-voltage electric injury.

High-voltage electric injury (HVEI) is associated with a high incidence of extremity compartment syndrome and of major amputation. The purpose of this study was to review our experience with HVEI and to attempt to develop predictors of the need for fasciotomy and amputation in patients with HVEI. The records of the 195 patients with HVEI who were admitted to a single burn center during a 19-year period were reviewed. Evidence for muscle necrosis, to include myoglobinuria and elevated creatine phosphokinase (CPK) levels, was noted. A total 187 patients (95.9%) survived to hospital discharge. A total of 56 underwent fasciotomy within 24 h of injury; 80 patients underwent an amputation during the hospitalization. Fasciotomy was predicted by presence of myoglobinuria with an overall accuracy of 72.8%. Amputation was predicted by a logistic model incorporating myoglobinuria, undergoing a previous fasciotomy, and age, with an overall accuracy of 73.3%. HVEI was associated with high amputation risk and a low rate of mortality in patients admitted to our burn center. Patients with gross myoglobinuria are at higher risk of requiring fasciotomy and/or amputation.

The link between the insecticide heptachlor epoxide, estradiol, and breast cancer.

Given the suspected effects of estrogens on breast cancer, xenoestrogenic insecticides may be a risk factor. Studies of the weak xenoestrogen, 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDE), have failed to demonstrate a causal relationship, though another estrogenic organochlorine insecticide, dieldrin, belonging to the cyclodiene family, has recently been linked to breast cancer. Other cyclodienes such as heptachlor epoxide (HE) and oxychlordane (OC) present in breast tissue have not been evaluated as rigorously, presumably due to their lower concentration and lower recovery using solvent extraction procedures. We used sparging extraction coupled with gas chromatography to determine the levels of HE, OC, and DDE in adipose tissue within breast biopsies in a series of 34 women evaluated for breast abnormality. Of the three insecticides tested, only HE (p=0.007) was positively associated with prevalence of breast cancer in the biopsies. In rapid, non-genomic studies using isolated human leukocytes, flow cytometric methods were used to measure HE-induced oxidants and DNA damage. These studies indicated that HE, at concentrations similar to those in breast biopsies, induced an inverted-U increase in intracellular oxidants and DNA strand breaks [both blocked by specific nitric oxide- (NO-) synthesis blockade withL: -NMMA] in human polymorphonuclear leukocytes (PMNs). HE-treated PMNs also induced damage to surrounding lymphocytes in mixed-leukocyte incubations (also inhibited by NO blockade). The HE-induced changes in NO were inhibited by 17beta-estradiol-(17beta-E2) receptor antagonists and were mimicked by similar concentrations of 17beta-E2. The addition of tumor necrosis factor-alpha (TNF-alpha) increased intracellular oxidants and DNA damage and shifted the responses to lower HE concentrations. This study, along with others, suggests that HE-induced NO production may contribute to initiation, promotion, and progression of cancer.

Xenoestrogens: do they lower survival after thermal injury?

The effect of hormone disruptors on human health is an area of recent concern. The authors measured heptachlor epoxide and oxychlordane--the body storage forms of estrogenic insecticides-in the sera of patients with major burns (i.e., 7 survivors and 10 age- and burn-size-matched nonsurvivors) on days 1, 3, 5, 7, and 11 after they had been burned, as well as in 12 age-matched normal controls. During the hypermetabolic phase, serum concentrations of heptachlor epoxide and oxychlordane were greater in nonsurvivors than in controls, and heptachlor epoxide concentrations in nonsurvivors exceeded those in survivors on postburn day 5. The postburn alterations in heptachlor epoxide and oxychlordane concentrations could not be accounted for by changes in concentrations of circulating lipid. These findings, which indicate that xenoestrogens are released from fat depots after thermal injury, suggest a possible contribution to mortality, especially in older patients.