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Background The field of consultation-liaison psychiatry has generated a relatively small number of rigorous clinical trials that guide clinical care. Consequently, there is a need for a consensus-building process to inform best practices for common clinical dilemmas in consultation-liaison psychiatry. Objective We review several consensus-building approaches in academic medicine and describe a novel educational process called a “conseminar,” which is intended to minimize the variability in teaching and practice on a service staffed by multiple faculty members. Methods The conseminar is an iterative group exercise among faculty who attend on a consultation-liaison service. Faculty members generate a list of candidate topics and then prioritize those topics for a focused and critical literature review, aided by a librarian. In the absence of definitive clinical trial data or established practice guidelines, the faculty articulates a consensus “best-practice” approach and creates a brief document that summarizes specific recommendations for learners on the service. Conclusions The conseminar process can minimize variability among consultation-liaison faculty within a single institution with respect to the diagnostic and treatment recommendations conveyed to trainees. Furthermore, conseminar documents can be shared across institutions to promote more consistent teaching and practice within consultation-liaison psychiatry.

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.

Alcohol and illicit drug use are common among burn-injured patients. Urine toxicology and alcohol screens are a part of our admission order sets and automatically ordered for all adult patients. Our objective was to determine the impact of bias in screening compliance and compare those results to patients who test positive. All adult patients admitted between January 1(st), 2014 and December 31(st), 2018 were eligible for inclusion. Multivariable logistic regression was used to identify potential predictors for compliance in obtaining samples for screens, and patient characteristics associated with testing positive. Four thousand nine hundred ninety-eight patients were included in the study. The biggest predictors for compliance in obtaining samples for screens were inhalation injury, intensive care unit stay, length of stay, burn size, and current smoking status. No differences in compliance with screens were seen across age, race, or ethnicity. Current smokers and patients with a history of major psychiatric illness were more likely to test positive for alcohol and illicit drugs. Non-Hispanic Black patients were more likely to test positive for illicit drugs. Male sex and pre-existing psychiatric conditions were significant predictors for compliance for alcohol screens, and, positive tests. Implicit bias based on age, race, or ethnicity played no predictive role in compliance for either screen, however, non-Hispanic Blacks were more likely to test positive for illicit drugs. More studies are needed to understand the effect of selection bias related to sample collection, and the significance of positive test results.

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.

Introduction In recent years, burn centers are managing more patients with exfoliative skin disorders including Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), and SJS/TEN overlap. While it is well known that burn patients have higher rates of co-morbid psychiatric disorders than the general population, the incidence of pre-existing psychiatric disorders among patients who develop SJS, SJS/TEN overlap, and TEN is unknown. This study aimed to characterize a cohort of patients with pre-existing psychiatric disorders admitted to a tertiary burn center for treatment of SJS, SJS/TEN overlap, and TEN with specific focus on those who received the offending agent for a psychiatric indication. Methods A retrospective descriptive case series using an institutional burn center registry was performed. All patients admitted to a single verified burn center between January 1, 2009 and December 31, 2018 with biopsy-proven SJS, SJS/TEN overlap, or TEN and the presence of a co-morbid psychiatric disorder were identified. Demographic, hospital, and clinical information were extracted from the burn registry and verified through review of the electronic medical record. Results Among 168 patients with biopsy-proven SJS, SJS/TEN overlap, or TEN, 18% (30/168) had a pre-existing psychiatric disorder, with the offending agent being prescribed for a psychiatric indication in 30% (10/30) of patients. Lamotrigine was the offending agent in 80% of cases and prescribed 100% of the time for a psychiatric indication. Of those who received lamotrigine, patients were 100% female, 63% black, and had an average age of 38 years. The mean length of stay was 24 days and 88% received a psychiatric consultation. While 75% of patients were started on lamotrigine for a diagnosis of bipolar disorder, none of these patients met criteria for bipolar disorder. Conclusions Pre-existing psychiatric comorbidity is less common among patients that develop SJS, SJS/TEN overlap, and TEN than in burn-injured patients. For patients with pre-existing psychiatric disorders who develop these potentially fatal skin diseases from an offending agent that was prescribed for a psychiatric indication, early involvement of psychiatry colleagues is recommended to ensure proper psychiatric diagnosis and management moving forward. Applicability of Research to Practice This study highlights the importance of accurate assessment for and diagnosis of bipolar disorder prior to determining treatment approach. For the burn surgeon treating these patients, early involvement of psychiatric consultants is recommended and extremely important.

Introduction Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a rare, severe mucocutaneous eruption caused by medications and resulting in diffuse epidermal detachment. Patients are often referred to burn units for specialized care. This study assesses trends in precipitating medications over 10 years at our Burn Center. Methods We performed a single-site, retrospective review at our burn center using the institutional burn registry and patient charts. Patients admitted from January 1, 2009 to December 31, 2018 identified as having SJS/TEN were eligible for inclusion. Demographics, comorbidities, diagnosis, treatment, inciting agents, and severity-of-illness score for TEN (SCORTEN) were evaluated. Statistical analysis was performed using the Mann Whitney U test using SAS version 9.4 (SAS Inc., Cary, NC). Results Biopsy-proven SJS, SJS/TEN overlap, or TEN was confirmed in 168 patients. Of these, 103 had a single identified offending drug. Of these patients, 36% had been exposed to sulfamethoxazole-trimethoprim (SMX-TMP), 11% to allopurinol, and 10% to lamotrigine. Trends in culprit drug by year are shown in Figure 1. The majority of SMX-TMP and penicillin cases occurred early in the period of study; lamotrigine and pembrolizumab cases occurred more recently. Patients exposed to allopurinol presented with higher SCORTENs than patients exposed to SMX-TMP, 2.9 vs 1.9, respectively (p< 0.035). Conclusions SMX-TMP once accounted for a large portion of SJS and TEN cases at our center. In recent years, lamotrigine has become a more common offending drug, prescribed in our cohort for psychiatric indications. Also notable, in the past year we have treated three patients with TEN due to immunotherapy (pembrolizumab) for metastatic or unresectable cancer. Paralleling the increasing use of immunotherapy has been a rise of immune-related adverse events, including severe skin toxicities. Further study is warranted to determine what can be done to prevent SJS/TEN from occurring in patients treated with these drugs. Applicability of Research to Practice Understanding emerging trends in causative agents of SJS/TEN will allow the burn community to focus education efforts for providers who prescribe these medications frequently. The psychiatric and oncology communities may benefit from increased awareness of the risk of SJS/TEN in patients receiving lamotrigine and immunotherapy, respectively.

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.

Introduction Stevens-Johnson syndrome (SJS) and Toxic epidermal necrolysis (TEN) are a spectrum of rare, life-threatening drug reactions characterized by diffuse skin detachment and mucositis. Our objective was to describe and analyze mortality trends at our institution for patients with biopsy-proven SJS and TEN over the last decade. Methods Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted with biopsy proven SJS, SJS/TEN overlap, and TEN between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay (LOS), co-morbid conditions and mortality were evaluated. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test. Results One hundred sixty-eight patients had biopsy-proven SJS, SJS/TEN overlap, or TEN. The average age was 48 years. Sixty-one percent of patients were female. The average length of stay was 30 days. Fifty-six percent of patients were Black. Twenty-seven percent of patients died. Increased mortality risk was significantly associated with female gender, age, underrepresented minorities, Human Immunodeficiency Virus, and chronic obstructive pulmonary disease. The presence or absence of malignancy or chronic kidney disease was not evaluated. Conclusions Biopsy proven SJS, SJS/TEN overlap, and TEN are associated with increased mortality for females, underrepresented minority populations, and patients with comorbidities. Black patients represent 28% of our state’s population, but 56% of patients with biopsy proven SJS, SJS/TEN overlap, and TEN at our institution. Further study is warranted to investigate and mitigate these outcome disparities in these patient populations. Applicability of Research to Practice This study highlights the importance of acknowledging that these at-risk patient populations must be protected with higher vigilance during evaluation, assessment of the offending agent, and resuscitation.

Introduction Female gender is associated with poorer outcomes in burns, not necessarily related to co-morbid conditions. Our objective was to analyze the effect of gender in biopsy proven Stevens-Johnson syndrome (SJS) and Toxic epidermal necrolysis (TEN) spectrum disorders at our institution. Methods Patients were identified using Institutional Burn Center registry, and linked to the clinical and administrative data. All patients admitted with biopsy proven SJS, SJS/TEN overlap, and TEN between January 1, 2009 and December 31, 2018 were eligible for inclusion. Demographics, length of stay, and mortality were evaluated. Statistical analysis was performed with Students’ t-test, chi-squared, and Fischer’s exact test. Results One hundred and sixty-eight patients had biopsy proven SJS, SJS/TEN overlap, or TEN. Sixty-one percent of patients were female. The average age of female patients was 51 years while the average age of male patients was 44 years, p< 0.05. Fifty-sex percent of female patients were black. All American Indian patients were female. Female patients had significantly longer lengths of stay, 34 days versus 22 days, p< 0.05. Female patients had an average SCORTEN (a severity of illness score of TEN) compared to male patients. Thirty-three percent of female patients died compared to 18% of male patients, p< 0.05. Two out of three American Indian patients in this cohort died. Conclusions Female gender is associated with increased mortality in burn patients, as well as in our cohort of patients with SJS/TEN. Females represent 51% of our state’s population, but 61% of patients with biopsy proven SJS, SJS/TEN overlap, and TEN at our institution. Compared to male patients, female patients presented with more severe disease (higher SCORTEN at presentation). Genomic, and proteomic studies looking at sex-based differences may be helpful in elucidating the origin of these differences. Applicability of Research to Practice This study demonstrates sex-based differences related to skin desquamating disorders, and these outcomes, coupled with known disparities in burns, may indicate a need for hypervigilance in inpatient management for women, and a re-evaluation of prognostic scoring tools to include a variable for gender.

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.