Infections in Burn Patients: A Retrospective View over Seven Years.

Backgroundand objectives: Burn patients represent a challenging cohort because the injuries entail a vulnerability to colonisation by microorganisms. The ensuing infections can lead to serious complications and, in many cases, to the death of the burn patient. Surgical intervention and wound dressings, as well as antibiotic treatment, are crucial for optimising the treatment of the patient. Materialand Methods: In this retrospective analysis, we analysed the treatment course, antibiotic therapy, and general complications of 252 burn patients with second- or third-degree burns over a time span of 7 years. Results: Patients who developed infections tended to have, on average, a higher total body surface area (TBSA), higher abbreviated burn severity index (ABSI) scores, and longer hospital stays. Patients who were admitted to the burn unit after 2006 had significantly shorter stays in the burn unit. TBSA and ABSI scores were lower in the patient cohort admitted after 2006. Patients exhibiting a TBSA greater than 30% had significantly longer hospital stays and antibiotic treatment periods. TBSA and ABSI scores were significantly higher in patients who died. The results of binary logistic regression indicate that a higher ABSI score increases the odds ratio of developing an infection. Bacteria number had no significant effect on the odds of patient death but positively influenced the odds ratio of developing an infection. TBSA was negatively associated with the risk of developing an infection and was an insignificant predictor of mortality. Conclusions: To gauge the optimal treatment for a burn patient, it is crucial for practitioners to correctly select, dose, and time antibiotics for the patient. Monitoring bacterial colonisation is vital to nip rising infection in the bud and ensure the correct antibiotic selection. This will help prevent the development of multi-resistant bacteria.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a systematic review and meta-analysis.

OBJECTIVE: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare and severe skin and mucosal reactions that are associated with high mortality. Despite the severity, an evidence-based treatment protocol for SJS/TEN is still lacking. METHOD: In this systematic review and meta-analysis, the PubMed database was searched using the following terms: [Stevens-Johnson syndrome] OR [toxic epidermal necrolysis] AND [therapy] OR [treatment] over a 20-year period (1999-2019) in the German and English language. All clinical studies reporting on the treatment of SJS/TEN were included, and epidemiological and diagnostic aspects of treatment were analysed. A meta-analysis was conducted on all comparative clinical studies that met the inclusion criteria. RESULTS: A total of 88 studies met the inclusion criteria, reporting outcomes in 2647 patients. Treatment was either supportive or used systemic corticosteroid, intravenous immunoglobulin, plasmapheresis, cyclosporine, thalidomide or cyclophosphamide therapy. The meta-analysis included 16 (18%) studies, reporting outcomes in 976 (37%) patients. Systemic glucocorticoids showed a survival benefit for SJS/TEN patients in all analyses compared with other forms of treatment. Cyclosporine treatment also showed promising results, despite being used in a small cohort of patients. No beneficial effects on mortality could be demonstrated for intravenous immunoglobulins. CONCLUSION: Glucocorticoids and cyclosporine may be tentatively recommended as the most promising immunomodulatory therapies for SJS/TEN, but these results should be investigated in future prospective controlled trials.

Stevens-Johnson syndrome and toxic epidermal necrolysis: a 10-year experience in a burns unit.

OBJECTIVE: Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), are skin hypersensitivity reactions defined by epidermal blistering and necrosis. The exact pathophysiology of SJS/TEN is yet to be deciphered, but a number of risk factors have been identified including adverse drug reactions. The diagnosis of SJS/TEN is made on a clinical basis, and treatment consists of supportive care and occasionally immunosuppressants, such as cyclosporin, high-dose intravenous immunoglobulins and/or corticosteroids. Mortality rates can reach 20-25% in adults but are reduced with early intervention. To identify optimal treatment regimens, to better understand the patient cohort affected, and to help identify key risk factors for mortality, we report our experience with the treatment and management of SJS/TEN patients. METHODS: A retrospective review of consecutive patients with SJS and/or TEN admitted to a single burns centre in Germany, between 2008 and 2018, was conducted. The primary outcomes of demographics, clinical course, treatment and patient-reported outcomes were recorded and compared with a control group of patients with burns without a diagnosis of SJS/TEN. RESULTS: A total of 23 patients with SJS/TEN met the inclusion criteria: 17 (74%) with TEN; four (17%) with SJS/TEN overlap; and two (9%) with SJS. Of the patients, 14 (61%) were female and nine (39%) were male. Patient age ranged from 32-78 years (mean: 52 years). A matched cohort of 23 patients with burns served as the control group. All patients received standard of care with a multidisciplinary team. Compared with the control group, SJS/TEN patients had higher mortality rates (n=6, 26% versus n=8, 35%, respectively). The average age of death was 69 years in SJS/TEN patients versus 63 years in control group patients. Age and SCORTEN scores were significant predictors of mortality. CONCLUSIONS: SJS and TEN are rare but extreme reactions of the skin and mucosa, associated with high disease mortality rates. This 10-year single-centre retrospective review contributes to the bank of information for reviews evaluating the management of SJS/TEN patients.

[Perforator based flaps of lateral thoracic artery (LTAP) and thoracodorsal artery (TDAP) for axillary reconstruction in patients with hidradenitis suppurativa]. / Die Verwendung lokaler Perforatorlappenplastiken der Arteria thoracica lateralis (LTAP) und Arteria thoracodorsalis (TDAP) zur axillären Rekonstruktion bei Hidradenitis suppurativa.

Hidradenitis suppurativa is a chronic inflammatory disease of apocrine gland-bearing skin, especially in the axilla. The coverage of large defects in the region of the axilla after radical resection poses a challenge to reconstructive surgery. The lateral chest offers, among others, two options for perforator flaps: the thoracodorsal artery perforator flap and the lateral thoracic artery perforator flap. This article introduces the lateral thoracic artery flap as an additional option for defect restoration alongside the thoracodorsal artery perforator flap. A total of 13 flaps (10 lateral thoracic artery perforator flaps and 3 thoracodorsal artery perforator flaps) were used for defect reconstruction in 10 patients with axillary hidradenitis suppurativa stages II or III. All patients were assessed for surgical complications pursuant to the classification of Clavien-Dindo, subjective aesthetic results, recurrence rate, and maximum abduction angle evaluated by measuring the range of motion. All flaps healed without major or partial flap necrosis. In 12 out of 13 flaps, the aesthetic result was rated very good or good.Only one patient complained of a visible scar, but rated the overall result as satisfactory. The range of motion in the shoulder was unlimited in all cases with a maximum abduction angle of 178.8 ± 4.2°. Recurrence was not observed in any case during the postsurgical follow-up of 27.2 ± 14.4 months. The use of the two perforator-based fasciocutaneous flaps of the thoraco dorsal artery and the lateral thoracic artery offers a useful and reliable option for the reconstruction of large axillary defects while maintaining full shoulder movement and providing cosmetically satisfactory results.

[Hyperspectral imaging for postoperative flap monitoring of pedicled flaps]. / Hyperspektralimaging zum postoperativen Lappenmonitoring von lokoregionären Lappenplastiken.

BACKGROUND: Since pedicle flaps were first described by the Indian physician Sushruta Samhita in the 6th century B. C., they have become an integral part of reconstructive surgery. As more and more research has been conducted into the underlying physical principles, flap monitoring has developed steadily in the last few decades. Hyperspectral Imaging (HSI) is a new quantitative measuring method for assessing the perfusion of the underlying tissue. OBJECTIVE: This study aims to evaluate HSI as a monitoring method for pedicle flaps. PATIENTS AND METHODS: In 16 patients who had undergone reconstructive surgery, oxygen saturation, haemoglobin and water concentration of the locoregional flap, necrotic flap areas as well as intact skin were measured on postoperative days 1 to 7. Subsequently, the data were statistically described and graphically illustrated. RESULTS: HSI revealed increased haemoglobin concentration and decreased oxygen and water concentration in necrotic flap areas compared with the monitor island and healthy skin. The distribution of the values collected from the vital skin areas and the monitor island was almost identical. CONCLUSION: HSI allows for safe, immediate, non-contact measurement of tissue perfusion of transferred tissue areas in patients after pedicle flap surgery. The use of HSI may improve postoperative flap monitoring.

Molecular Mechanisms of Hair Growth and Regeneration: Current Understanding and Novel Paradigms.

Hair is a defining feature of mammals and has critical functions, including protection, production of sebum, apocrine sweat and pheromones, social and sexual interactions, thermoregulation, and provision of stem cells for skin homeostasis, regeneration, and repair. The hair follicle (HF) is considered a "mini-organ," consisting of intricate and well-organized structures which originate from HF stem and progenitor cells. Dermal papilla cells are the main components of the mesenchymal compartments in the hair bulb and are instrumental in generating signals to regulate the behavior of neighboring epithelial cells during the hair cycle. Mesenchymal-epithelial interactions within the dermal papilla niche drive HF embryonic development as well as the postnatal hair growth and regeneration cycle. This review summarizes the current understanding of HF development, repair, and regeneration, with special focus on cell signaling pathways governing these processes. In particular, we discuss emerging paradigms of molecular signaling governing the dermal papilla-epithelial cellular interactions during hair growth and maintenance and the recent progress made towards tissue engineering of human hair follicles.

Optimising management of self-inflicted burns: a retrospective review.

OBJECTIVE: Self-inflicted burns typically result in extensive injuries requiring intensive care and attention in a specialised burn unit. Burn units should be familiar with the optimal management of self-inflicted burns, including the psychological and psychiatric treatment. This paper describes the experiences of managing these challenging injuries in a German burn centre. METHODS: A retrospective review of patients with self-inflicted burns admitted to the burn centre between 2000 and 2017. Demographics, details of injury, presence of psychiatric disorder, clinical course, operative management and patient outcomes were recorded and compared with a control group without self-inflicted burns. Outcome measures included graft take rate, complications and need for further surgery. RESULTS: There were a total of 2055 burn patient admissions, with 17 cases (0.8%) of self-inflicted burns. The mean age was 36±11 years with an mean percentage total body surface area (%TBSA) burned of 43.5±22.5% which was not significantly different from the control group (p=0.184). Schizophrenia and personality disorder were the most common diagnoses in the self-inflicted burns patients (n=11; 65%). Of these, four had sustained previous self-inflicted burns. Length of hospital stay was significantly longer in the self-inflicted burn group than in the control group (49.0±16.7 days, respectively, p=0.002). CONCLUSION: Attempted suicide by self-inflicted burns represents <1% of burn admissions. This population demonstrates a high incidence of prior psychiatric disorders. Successful treatment includes multidisciplinary management of acute medical, surgical, and psychiatric care.

Carbon monoxide intoxication: What we know.

Carbon monoxide (CO) is a toxic, color-, taste- and odorless gas with fatal consequences if undetected. Intoxication caused by CO is frequent possibly leading to a high morbidity and mortality. The disease involves multiple organ systems without a typical clinical presentation. The clinical picture is furthermore unrelated to levels of carboxyhemoglobin - the routine biomarker. Therefore the diagnosis and treatment can be very demanding. This article in detail reviews epidemiology, symptoms, diagnosis and the therapy of this multidisciplinary challenge.

Wnt Pathway in Bone Repair and Regeneration - What Do We Know So Far.

Wnt signaling plays a central regulatory role across a remarkably diverse range of functions during embryonic development, including those involved in the formation of bone and cartilage. Wnt signaling continues to play a critical role in adult osteogenic differentiation of mesenchymal stem cells. Disruptions in this highly-conserved and complex system leads to various pathological conditions, including impaired bone healing, autoimmune diseases and malignant degeneration. For reconstructive surgeons, critically sized skeletal defects represent a major challenge. These are frequently associated with significant morbidity in both the recipient and donor sites. The Wnt pathway is an attractive therapeutic target with the potential to directly modulate stem cells responsible for skeletal tissue regeneration and promote bone growth, suggesting that Wnt factors could be used to promote bone healing after trauma. This review summarizes our current understanding of the essential role of the Wnt pathway in bone regeneration and repair.

Macrophage Migration Inhibitory Factor - A Favorable Marker in Inflammatory Diseases?

BACKGROUND: Macrophage migration inhibitory factor (MIF) was firstly described in the 1960s as a pleiotropic cytokine affecting a variety of immune cells. Different physiological functions mainly involving inflammatory reactions such as chemokine-like function and regulating systemic stress responses have been reported. OBJECTIVE: In several clinical studies the use of MIF as a biomarker has been investigated promising support for diseases with an inflammatory aspect such as sepsis, systemic infections and autoimmune diseases. This article in detail reviews clinical data and evaluates the function as biomarker focusing on inflammatory and autoimmune diseases. CONCLUSION: Recent studies suggest MIF to be a marker for different inflammatory diseases and might serve as therapeutic target in the future.