[Hemochromatosis - too much iron]. / Hämochromatose ­ zu viel Eisen.

Hemochromatosis is a disorder of genetic origin which affects iron hemostasis, resulting in an increased transferrin saturation, hyperferritinemia and parenchymal iron overload.Recently, a new system for the classification of hemochromatosis has been proposed, wherein patients are separated into 4 groups, based on the disease affected iron regulatory genes. Excess iron and increased transferrin saturation results in the formation of non-transferrin bound iron which leads to tissue damage. Hemochromatosis is a common genetic disease, but screening of the general population is not routinely recommended. In order to provide ideal care for hemochromatosis patients, it is crucial to delineate hemochromatosis from other causes of hyperferritinemia, which is a common finding in patients with metabolic disorders. This article summarizes the diagnostic algorithm for hemochromatosis. Furthermore, recommendations for optimal care - including targets for phlebotomy - are discussed.

The use of accelerometers to assess upper limb function in patients with obstetric brachial plexus palsy.

For half a century, the Mallet Scale (MS) has been utilized to assess upper limb function in patients with obstetric brachial plexus palsy (OBPP). However, the correct use of the MS requires trained personnel and the MS does not measure compensatory movements. For this reason, new methods are needed to compensate for these weaknesses. This study introduces an innovative method for objective functional motion analysis using accelerometers to measure upper limb movements in thirty patients with obstetric brachial plexus lesions. Five triaxial accelerometers were positioned on the chest and each upper limb. They recorded acceleration signals during repetitive everyday tasks: hand-to-mouth (HM), hand-to-neck (HN), and hand-to-spine (HS). From these signals, 54 features were extracted and subjected to linear correlation tests to identify 5 suitable features. An algorithm was then developed to categorize patients into five groups and compute an individual movement performance score (iMPScore) assessing the patient's upper extremity function. By using the iMPScore more than 75% of all participants have been classified correctly with respect to their MS category. Identification of MS I category patients in general and assessing upper extremity function of MS I to III in HS tasks were most challenging. We conclude that the introduced approach is a valuable tool for gauging movement limitation of upper limbs in patients with obstetric brachial plexus palsy. Compared to other clinically established methods, it becomes possible to record and even quantify the extent of compensatory movements. In this way, an objective, user- and patient-friendly method is offered, which supports significantly physicians and therapists in their evaluation of OBPP.

Comparison of Pulmonary Outcome in Minimally Invasive (TCRAT) and Full Sternotomy CABG.

BACKGROUND: Pulmonary complications are among the main causes of increased mortality, and morbidity, as well as prolonged intensive care unit (ICU) and hospital stay after cardiac surgery. Recently, a sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced. A higher risk of pulmonary injury could be anticipated due to the thoracic incision and the longer duration of surgery. Pulmonary complications in TCRAT were compared to standard coronary artery bypass grafting (CABG) via full median sternotomy (FS). METHODS: Records of 151 consecutive TCRAT (from September 2021 to November 2022) and 229 consecutive FS patients (from January 2017 to December 2018) patients, who underwent elective or urgent CABG, were analyzed. Preoperative baseline characteristics (age, sex, body mass index, diabetes, hypertension, chronic obstructive pulmonary disease, smoking status, left ventricular ejection fraction, pulmonary hypertonus, and EuroScore II) were comparable between groups. RESULTS: Differences between examined groups examined were found for the pulmonary parameters: Horowitz index 6 hours after operation (TCRAT 270 ± 72 vs. FS 293 ± 73, p < 0.05), pneumothorax (TCRAT 0% vs. FS 2.6%, p < 0.05), bronchoscopies (TCRAT 5.9% vs. FS 1.7%, p < 0.05), and pleural effusion (TCRAT 8.6% vs. FS 3.5%, p < 0.05). Moreover, there were differences between groups with regard to mean ICU stay (TCRAT 2.4 ± 3.0 days vs. FS 1.8 ± 1.8 days, p < 0.05), stroke (TCRAT 0% vs. FS 1.3%, p < 0.05), and hospital stay (TCRAT 10.9 ± 8.5 days vs. FS 13.2 ± 9.3 days, p < 0.05). There were no differences regarding atelectasis, reintubations, tracheostomies, ventilation time, and mortality. CONCLUSION: Pulmonary complications in terms of pleural effusions were more common with TCRAT, however, without substantial impact on clinical outcome.

Artificial Intelligence-Powered Hand Surgery Consultation: GPT-4 as an Assistant in a Hand Surgery Outpatient Clinic.

PURPOSE: Exploring the integration of artificial intelligence in clinical settings, this study examined the feasibility of using Generative Pretrained Transformer 4 (GPT-4), a large language model, as a consultation assistant in a hand surgery outpatient clinic. METHODS: The study involved 10 simulated patient scenarios with common hand conditions, where GPT-4, enhanced through specific prompt engineering techniques, conducted medical history interviews, and assisted in diagnostic processes. A panel of expert hand surgeons, each board-certified in hand surgery, evaluated GPT-4's responses using a Likert Scale across five criteria with scores ranging from 1 (lowest) to 5 (highest). RESULTS: Generative Pretrained Transformer 4 achieved an average score of 4.6, reflecting good performance in documenting a medical history, as evaluated by the hand surgeons. CONCLUSIONS: These findings suggest that GPT-4 can effectively document medical histories to meet the standards of hand surgeons in a simulated environment. The findings indicate potential for future application in patient care, but the actual performance of GPT-4 in real clinical settings remains to be investigated. CLINICAL RELEVANCE: This study provides a preliminary indication that GPT-4 could be a useful consultation assistant in a hand surgery outpatient clinic, but further research is required to explore its reliability and practicality in actual practice.

Factors influencing surgical care and outcome of pediatric burn injuries and the use of synthetic skin substitutes.

Burn trauma is one of the most common causes of inpatient treatment in children and is associated with severe physical and psychological consequences. Synthetic skin substitutes are designed to reduce the risk of infection, minimize wound pain, and reduce the frequency of dressing changes. However, data regarding premature detachment of these materials is scarce. The aim of this study was to identify factors associated with early detachment and subsequent consequences for surgical treatment. A retrospective analysis of 392 children with superficial and deep partial thickness burns undergoing inpatient treatment with application of a skin substitute (Suprathel®) was performed. Patient age, wound localization and progression as well as burned total body surface area (TBSA %) were investigated as possible risk factors for early detachment of wound dressings and surgical intervention. Premature material detachement was significantly associated with burn localization (p < 0.001) and correlated with burn depth progression (r = 0.23, < 0.001) and patient age (r = 0.22, < 0.001). Surgical revision after material detachment were required in 13 % of patients. Patient age and burn localization seem to increase the risk of premature material detachement. In addition, we observed increased premature detachment of Suprathel®in areas which elicited higher wound progression rates. Identifying these areas might prove pivotal in the improvement of pediatric burn trauma management.

[Nerve Transfers in Children with Non-traumatic Amyoplasia] / Nerventransfers bei Kindern mit nicht traumatischer AmyoplasieNerve Transfers in Children with Non-traumatic Amyoplasia.

BACKGROUND: The treatment of obstetric brachial plexus palsy through primary reconstruction and nerve transfers has been established in the past decades. In the case of non-traumatic diseases that lead to flaccid paralysis and the inability to move the extremities, such as transverse myelitis (TM) or arthrogryposis multiplex congenita (AMC), which can have a wide variety of causes, the focus has been on rehabilitative therapy so far, while surgical interventions have been used to a lesser extent, e. g., in the form of osteotomies or muscle transfers. Our aim is to establish nerve transfers as a surgical option to improve mobility in non-traumatic amyoplasia. PATIENTS: This work presents the needs-adapted treatment of a total of 23 patients (aged 4 months to 64 months, 18 with AMC and 5 with TM) using nerve transfers on the upper extremity. RESULTS: We were able to show that early nerve transfers in the upper extremity enabled the reanimation of muscles in both AMC and TM. CONCLUSION: This work shows that the treatment of non-traumatic amyoplasia in children with selective nerve grafts is a successful method. Nerve transfers allow patients to gain or regain important functions for managing independent everyday life. The surgical methods have been established in the treatment of traumatic nerve injuries. They are well-known and can be carried out safely. We believe that this is an important treatment option for paediatric patients with paralysis associated with TM or AMC, which should also be known to the treating physicians.

[Contralateral C7 Nerve Transfer]. / Der kontralaterale C7 Transfer.

Complex brachial plexus injuries with multiple or complete root avulsions make intraplexic reconstruction impossible in some cases. Such cases necessitate the use of extraplexic nerve donors such as the spinal accessory nerve or intercostal nerves. The contralateral C7 root represents a donor with a high axon count and can be used as an axon source in such cases. We summarise current indications, surgical technique and functional results after a contralateral C7 transfer in cases of brachial plexus injury, describing some of our own cases and including a selective literature review.

Can AI Think Like a Plastic Surgeon? Evaluating GPT-4's Clinical Judgment in Reconstructive Procedures of the Upper Extremity.

This study delves into the potential application of OpenAI's Generative Pretrained Transformer 4 (GPT-4) in plastic surgery, with a particular focus on procedures involving the hand and arm. GPT-4, a cutting-edge artificial intelligence (AI) model known for its advanced chat interface, was tested on nine surgical scenarios of varying complexity. To optimize the performance of GPT-4, prompt engineering techniques were used to guide the model's responses and improve the relevance and accuracy of its output. A panel of expert plastic surgeons evaluated the responses using a Likert scale to assess the model's performance, based on five distinct criteria. Each criterion was scored on a scale of 1 to 5, with 5 representing the highest possible score. GPT-4 demonstrated a high level of performance, achieving an average score of 4.34 across all cases, consistent across different complexities. The study highlights the ability of GPT-4 to understand and respond to complicated surgical scenarios. However, the study also identifies potential areas for improvement. These include refining the prompts used to elicit responses from the model and providing targeted training with specialized, up-to-date sources. This study demonstrates a new approach to exploring large language models and highlights potential future applications of AI. These could improve patient care, refine surgical outcomes, and even change the way we approach complex clinical scenarios in plastic surgery. However, the intrinsic limitations of AI in its current state, together with the potential ethical considerations and the inherent uncertainty of unanticipated issues, serve to reiterate the indispensable role and unparalleled value of human plastic surgeons.

Three-Dimensional Bioprinting in Soft Tissue Engineering for Plastic and Reconstructive Surgery.

Skeletal muscle tissue engineering (TE) and adipose tissue engineering have undergone significant progress in recent years. This review focuses on the key findings in these areas, particularly highlighting the integration of 3D bioprinting techniques to overcome challenges and enhance tissue regeneration. In skeletal muscle TE, 3D bioprinting enables the precise replication of muscle architecture. This addresses the need for the parallel alignment of cells and proper innervation. Satellite cells (SCs) and mesenchymal stem cells (MSCs) have been utilized, along with co-cultivation strategies for vascularization and innervation. Therefore, various printing methods and materials, including decellularized extracellular matrix (dECM), have been explored. Similarly, in adipose tissue engineering, 3D bioprinting has been employed to overcome the challenge of vascularization; addressing this challenge is vital for graft survival. Decellularized adipose tissue and biomimetic scaffolds have been used as biological inks, along with adipose-derived stem cells (ADSCs), to enhance graft survival. The integration of dECM and alginate bioinks has demonstrated improved adipocyte maturation and differentiation. These findings highlight the potential of 3D bioprinting techniques in skeletal muscle and adipose tissue engineering. By integrating specific cell types, biomaterials, and printing methods, significant progress has been made in tissue regeneration. However, challenges such as fabricating larger constructs, translating findings to human models, and obtaining regulatory approvals for cellular therapies remain to be addressed. Nonetheless, these advancements underscore the transformative impact of 3D bioprinting in tissue engineering research and its potential for future clinical applications.

Nerve Transfers Using a Dedicated Microsurgical Robotic System.

Microsurgical demands in peripheral nerve surgery are increasing. Because of the development of multiple simultaneous selective nerve transfers, the transposition of very small nerves and even single fascicles has evolved. Coaptation of these increasingly smaller structures require high skills in microsurgical techniques. In addition, the surgical situs often has very limited access and is difficult to reach with conventional microsurgical options. Robot technology, the Symani Surgical System (Medical Microinstruments, S.p.A, Calci, Pisa, Italy), was used for epineural coaptation of three donor nerves (intercostal nerves 4-6) to the long thoracic nerve and the thoracodorsal nerve as recipient nerves in a patient with brachial plexus palsy. The coaptations could be carried out successfully with the microsurgical robot technology. In combination with a high-magnification (up to 26×) 3D-exoscope, the epineural sutures could be placed very precisely and accurately. Using this new microsurgical robotic system, successful coaptation of very small nerve structures is possible. This opens possibilities for the microsurgeon to carry out even finer, more targeted and more complex nerve transfers, including procedures in anatomical regions that are difficult to reach.

Outcome of Budd-Chiari Syndrome Patients Treated With Direct Oral Anticoagulants: An Austrian Multicenter Study.

BACKGROUND AND AIMS: Direct oral anticoagulants (DOACs) may simplify management of Budd-Chiari syndrome (BCS). Here, we report our experience with off-label use of DOACs for anticoagulation in BCS. METHODS: The safety of DOAC vs vitamin K antagonist treatment as well as associated clinical outcomes were retrospectively assessed in 47 BCS patients treated at 6 Austrian centers. RESULTS: Mean age at study inclusion was 37.9 ± 14.0 years and mean Model for End-Stage Liver Disease was 13.1 ± 5.1. Overall, 63.8% (n = 30) of patients had decompensated liver disease, and 87.2% (n = 41) showed clinical signs of portal hypertension. During a median follow-up of 82.5 (interquartile range, 43.1-121.8) months, 43 (91.5%) patients received anticoagulation alone or following interventional treatment, including 22 (46.8%) patients treated with DOACs (edoxaban: 10, apixaban: 4, rivaroxaban: 3, dabigatran: 3, more than one DOAC sequentially: 2) for a median of 24.4 (interquartile range, 5.7-35.1) months. While 72.7% (n = 16 of 22) of patients were switched from low-molecular-weight heparin (n = 12) or vitamin K antagonist (n = 4) to DOAC after disease stabilization or improvement, 27.3% (n = 6 of 22) of BCS patients were initially treated with DOAC. Complete response (European Association for the Study of the Liver criteria) was achieved or maintained in 14 (63.6%) of 22 patients, with ongoing response in 2 patients, while disease progressed in 6 patients (including 2 patients with hepatocellular carcinoma). Four major spontaneous bleedings (18.2%; incidence rate 8.8 per 100 patient-years; n = 2 upper gastrointestinal bleeding, n = 1 lower gastrointestinal bleeding, n = 1 hepatocellular carcinoma rupture), 7 minor bleedings, and 1 major procedure-related bleeding (4.5%; 2.2 per 100 patient-years) occurred during DOAC therapy. Overall transplant-free survival was 91.6% at 5 years. CONCLUSIONS: DOACs seem to be effective and safe for long-term anticoagulation in patients with BCS, but confirmation by larger prospective studies is needed.

Measures for Preventing Infection in Burn Surgery.

The skin is the largest human organ and an important barrier to protect against the environment. Burns damage the skin and thus destroy this anatomical barrier. This makes initially sterile wounds susceptible to colonization by pathogenic germs. In severely burned patients, immune competence decreases as part of the burn disease. Sepsis and multiple organ failure as a result of infection are the main causes of death in this cohort. Therefore, prevention and recognition of infections as well as surgical treatment and targeted anti-infective therapy are of great importance. In this article, we present up-to-date solutions for the treatment of burn wounds by means of plastic and reconstructive surgery to minimize the risk of infection. We demonstrate the principles of infection defense by the skin barrier. We outline the principles of burns and how to perform an appropriate diagnosis and therapy, from outpatient therapy to intensive care therapy, depending on the severity. We address the typical bacteria responsible for wound infections in severely burned patients and how to prevent and treat them. We also describe the hygiene measures that must be used in a severe burn unit to reduce the risk of complications such as infection and improve patient survival.

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.

Cervical Spine Injuries with Acute Traumatic Spinal Cord Injury: Spinal Surgery Adverse Events and Their Association with Neurological and Functional Outcome.

STUDY DESIGN: Monocenter case-control study. OBJECTIVE: Effects of spinal surgical adverse events (SSAE) on clinical and functional outcome, length of stay, and treatment costs after traumatic cervical spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: Traumatic SCI is a challenge for primary care centers because of the emergency setting and complex injury patterns. SSAE rates of up to 15% are reported for spine fractures without SCI. Little is known about SSAE after traumatic SCI and their outcome relevance. METHODS: Acute traumatic cervical SCI patients were enrolled from 2011 to 2017. Cases with and without SSAE were compared regarding neurological recovery, functional outcome, secondary complications, mortality, length of stay, and treatment costs. Adjusted logistic regression and generalized estimating equation models were calculated for the endpoints ASIA impairment scale (AIS)-conversion and dysphagia. All analyses were run in the total and in a propensity score matched sample. RESULTS: At least one SSAE occurred in 37 of 165 patients (22.4%). Mechanical instability and insufficient spinal decompression were the most frequent SSAE with 13 (7.9%) or 11 (6.7%) cases, respectively. The regression models adjusted for demographic, injury, and surgery characteristics demonstrated a reduced probability for AIS-conversion related to SSAE (OR [95% CI] 0.14 [0.03-0.74]) and additionally to single-sided ventral or dorsal surgical approach (0.12 [0.02-0.69]) in the matched sample. Furthermore, SSAE were associated with higher risk for dysphagia in the matched (4.77 [1.31-17.38]) and the total sample (5.96 [2.07-17.18]). Primary care costs were higher in cases with SSAE (median (interquartile range) 97,300 [78,200-112,300]) EUR compared with cases without SSAE (52,300 [26,700-91,200]) EUR. CONCLUSION: SSAE are an important risk factor after acute traumatic cervical SCI with impact on neurological recovery, functional outcome, and healthcare costs. Reducing SSAE is a viable means to protect the limited intrinsic capacity for recovery from SCI.Level of Evidence: 4.

Plastic Surgery Reconstruction of Chronic/Non-Healing Wounds.

In western countries, approximately 1 % of individuals are affected by chronic wounds during their lifetime. Due to changing demographics, this incidence will likely increase in the future. Additionally, the high prevalence is accompanied by substantial treatment expenditures. Therefore, it is of global interest to find effective treatment algorithms. In this article, we present up-to-date solutions for treating chronic / difficult to heal and complex wounds by means of plastic and reconstructive surgery. We outline the principles of chronic wounds and how to perform an appropriate diagnosis. Close cooperation and interdisciplinary exchange are important for optimizing treatment. We report the principles of wound debridement and the role of negative pressure wound therapy. Moreover, we discuss the state of the art of defect reconstruction by means of skin grafting, with or without acellular dermal matrices, local tissue transfers and free tissue transfers. In very complex cases, the local macrovascular blood flow is greatly reduced and there are few, if any, recipient vessels for free flap reconstruction. We discuss the role of arteriovenous loops to overcome this problem.

Warp-Knitted Spacer Fabrics: A Versatile Platform to Generate Fiber-Reinforced Hydrogels for 3D Tissue Engineering.

Mesenchymal stem cells (MSCs) possess huge potential for regenerative medicine. For tissue engineering approaches, scaffolds and hydrogels are routinely used as extracellular matrix (ECM) carriers. The present study investigated the feasibility of using textile-reinforced hydrogels with adjustable porosity and elasticity as a versatile platform for soft tissue engineering. A warp-knitted poly (ethylene terephthalate) (PET) scaffold was developed and characterized with respect to morphology, porosity, and mechanics. The textile carrier was infiltrated with hydrogels and cells resulting in a fiber-reinforced matrix with adjustable biological as well as mechanical cues. Finally, the potential of this platform technology for regenerative medicine was tested on the example of fat tissue engineering. MSCs were seeded on the construct and exposed to adipogenic differentiation medium. Cell invasion was detected by two-photon microscopy, proliferation was measured by the PrestoBlue assay. Successful adipogenesis was demonstrated using Oil Red O staining as well as measurement of secreted adipokines. In conclusion, the given microenvironment featured optimal mechanical as well as biological properties for proliferation and differentiation of MSCs. Besides fat tissue, the textile-reinforced hydrogel system with adjustable mechanics could be a promising platform for future fabrication of versatile soft tissues, such as cartilage, tendon, or muscle.

[Echocardiography in Acute Right Heart Insufficiency]. / Echokardiografie bei akuter Rechtsherzinsuffizienz.

The anesthetist is increasingly faced with more complex operations in combination with an aging patient population characterized by pre-existing conditions. Acute right heart failure is often not recognized as the cause of cardiopulmonary insufficiency. Echocardiography has emerged as an important diagnostic tool. Not only perioperatively and in the intensive care unit, transesophageal (TEE) and transthoracic echocardiography (TTE) allow the diagnosis of right heart failure at bedside, promptly and with low invasiveness. Possible causes of right heart insufficiency on the level of afterload, preload and contractility can be clarified. Life-saving immediate measures can be initiated and, in addition, the success of the therapy can be visualized virtually "live". If indicated, a peri-/intraoperative echocardiographic examination also has a direct influence on therapy control. With a focused cardiac examination crucial information can be gained and the outcome of the patient can be positively influenced by adapted therapy control. By using standard ultrasound views, right heart failure can be detected as the cause of hemodynamic instability.