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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.

Catatonia is a neuropsychiatric syndrome that affects 1.5 - 2% of patients referred to psychiatry consultation-liaison (C-L) services. Catatonia is a manifestation of an underlying medical illness in approximately 20% of patients seen in the general medical hospital. Acute symptoms often respond to intravenous (IV) benzodiazepines or electroconvulsive therapy, but little is known about the course of catatonia after patients transition to the outpatient setting. We present a case of a 60-year-old man with history of atrial septal defect, coronary artery disease, heart failure, peripheral artery disease, hypertension, type II diabetes, gout, and no known psychiatric history who was admitted to a general medical unit for altered mental status. Our inpatient C-L service diagnosed him with catatonia, based on the presence of immobility, mutism, stereotypy, withdrawal, and automatic obedience. These symptoms initially responded well to lorazepam during hospitalization, but they had recurred when he presented to our outpatient psychiatry C-L clinic. His symptoms have persisted over the last two years despite numerous medication trials and extensive workup for underlying conditions. In this report, we highlight both the challenges we have faced and successful strategies employed in the longitudinal care of this patient with catatonia and comorbid complex medical issues.

Purpose of Review To describe the presentation, etiologies, and suggested management of post-acute COVID-19 neuropsychiatric symptoms. Recent Findings Over 30% of patients hospitalized with COVID-19 may exhibit cognitive impairment, depression, and anxiety that persist for months after discharge. These symptoms are even more common in patients who required intensive care for severe effects of the virus. In addition to the pandemic-related psychological stress, multiple biological mechanisms have been proposed to understand the neuropsychiatric symptoms observed with COVID-19. Given limited research regarding effective interventions, we recommend pharmacologic and behavioral strategies with established evidence in other medically-ill populations. Summary Long-term, neuropsychiatric complications of COVID-19 are common and consequential. Because these are likely to co-occur with other medical problems, patients recovering from COVID-19 are best managed in clinics with highly coordinated care across disciplines and medical specialties. Future research is needed to inform appropriate interventions.

BACKGROUND Central nervous system complications after transplantation occur in up to 40% of recipients and these complications are associated with increased length of hospital stay and mortality. Catatonia is a neuropsychiatric clinical syndrome which has been described in case reports and in a small case series as occurring in the immediate post-solid organ transplantation (SOT) period, and it has been attributed to calcineurin inhibitor neurotoxicity, psychological vulnerability, and depression. Among transplant recipients, the incidence of catatonia is unknown; it may be under diagnosed in part due to a broad differential diagnosis in the post-transplantation setting, which includes hypoactive delirium, non-convulsive status epilepticus, drug toxicity, conversion disorder, and volitional uncooperativeness. CASE REPORT We present 2 cases of catatonia diagnosed in liver allograft recipients. We also reviewed current literature for cases of catatonia among SOT recipients. We provide provisional evaluation and management strategies of recipients with clinical concern for catatonia. Catatonia generally occurs within the few first days after liver transplantation, and presents with staring, immobility, or mutism, but is also associated with other neurological and psychiatric symptoms. Catatonia can be successfully treated with intravenous lorazepam, and thus, modifying immunosuppressive regimens may be avoidable. Medications to treat catatonia are generally tapered over weeks to months, and psychiatric follow-up is indicated. The early post-liver transplantation period may be a state of relative deficiency in GABA (gamma-aminobutyric acid) signaling, predisposing liver transplant recipients in particular to post-transplantation catatonia. CONCLUSIONS Despite difficulties in establishing the diagnosis, catatonia after liver transplantation was rapidly responsive to intravenous lorazepam, indicating that changing immunosuppressants may be avoidable.

Background Psychiatric and substance use disorders are common among trauma and burn patients and are known risk factors for repeat episodes of trauma, known as trauma recidivism. The epidemiology of burn recidivism, specifically, has not been described. This study aimed to characterize cases of burn recidivism at a large US tertiary care burn center and compare burn recidivists (RCs) with non-recidivists (NRCs). Methods A 10-year retrospective descriptive cohort study of adult burn patients admitted to the North Carolina Jaycee Burn Center was conducted using data from an electronic burn registry and the medical record. Continuous variables were reported using medians and interquartile ranges (IQR). Chi-square and Wilcoxon-Mann-Whitney tests were used to compare demographic, burn, and hospitalization characteristics between NRCs and RCs. Results A total of 7134 burn patients were admitted, among which 51 (0.7%) were RCs and accounted for 129 (1.8%) admissions. Of the 51 RCs, 37 had two burn injuries each, totaling 74 admissions as a group, while the remaining 14 RCs had between three and eight burn injuries each, totaling 55 admissions as a group. Compared to NRCs, RCs were younger (median age 36 years vs. 42 years, p = 0.02) and more likely to be white (75% vs. 60%, p = 0.03), uninsured (45% vs. 30%, p = 0.02), have chemical burns (16% vs. 5%, p Conclusions Distinct from trauma recidivism, burn recidivism is not associated with more severe injury or increased mortality. Similar to trauma recidivists, but to a greater extent, burn RCs have high rates of comorbid psychiatric and medical conditions that contribute to increased health care utilization and costs. Studies involving larger samples from multiple centers can further clarify whether these findings are generalizable to national burn and trauma populations.

Background Traumatic brain injury (TBI) is an increasingly common cause of behavioral and emotional dysregulation among hospitalized patients. While consultation-liaison psychiatrists are often called to help manage these behaviors, acute pharmacological management guidelines are limited. Objective Conduct a systematic review to determine which pharmacological measures are supported by the literature for targeting agitation and aggression in the acute time period following a TBI. Methods In a systematic review of MEDLINE, Embase, PsycInfo, ClinicalTrials.gov and the Cochrane Library, we identified and then analyzed publications that investigated the pharmacological management of behavioral and emotional dysregulation following a TBI during the acute time period following injury. Results There were a limited number of high quality studies that met our inclusion criteria, including only five randomized controlled trials. The majority of the literature identified consisted of case reports or case series. Trends identified in the literature reviewed suggested that amantadine, propranolol, and anti-epileptics were the best supported medications to consider. For many medication classes, the time of medication initiation and duration of treatment, relative to the time of injury, may impact the effect observed. Conclusions The pharmacological management of agitated patients immediately following a TBI is still an area of much-needed research, as there is limited data-driven guidance in the literature.

Background Older adults comprise a growing proportion of the United States population that is at risk for burns. However, few studies have examined cognitive function in this patient population. Objective The purpose of this study was to measure the prevalence and incidence of dementia and delirium in older adults admitted for burn injuries. Methods This was an Institutional Review Board-approved, retrospective study of all patients 65 years and older admitted to the University of North Carolina Jaycee Burn Center from 2005–2015. Data extracted from the medical records included patient demographics, characteristics of the burn injury, incidence of delirium, incidence of psychiatric consultation, diagnosis of dementia, disposition, and mortality. The primary outcomes of interest were the prevalence and incidence of dementia and delirium. Secondary outcomes included length of stay and cost of hospitalization. Results A total of 392 patients were included. These patients had a median age of 74 years and a median total body surface area burn of 7%. On admission, 44 patients (11%) had a diagnosis of dementia. An additional 28 patients were diagnosed with dementia during hospitalization for a total of 72 patients (18%); 154 patients (39%) were diagnosed with delirium. After controlling for burn severity, dementia and delirium were significantly associated with length of stay, incidence of psychiatry consultation, and discharge to a skilled nursing facility. Conclusions Physicians should have high suspicion for dementia and delirium in older patients admitted for burn injuries. Dementia and delirium are associated with morbidity in older patients with burn injuries.