Impact of diabetes on clinical outcome in severely burned patients.

INTRODUCTION: According to the International Diabetes Federation, approximately 425 million people worldwide suffer from diabetes mellitus, a figure that will double in the next 20 years. Data on the ratio of treated diabetics in burn intensive care units remain scarce and the effects on the mortality rate are poorly defined. METHODS: Our retrospective, single-centre study aimed to evaluate differences in the risk factors due to diabetes mellitus, the clinical outcome and the patient population of diabetic patients after severe burn injuries over a time period of 21 years. RESULTS: Despite increasing numbers of diabetic patients, the ratio of burn patients suffering from diabetes remained stable during the study period. The risk factors for mortality were higher age (OR 1.03, 95% confidence interval (CI), 1.02-1.04, p < 0.0001), female sex (OR 1.56, 95% CI, 1.06-2.29, p = 0.025), higher % total body surface area (TBSA) (OR 3.88, 95% CI, 2.81-5.46, p < 0.0001), full thickness burns (OR 8.58, 95% CI, 3.84 - 23.60, p < 0.0001) and the presence of inhalation injuries (OR 4.68, 95% CI, 3.15-7.02, p < 0.0001) Patients with diabetes had a smaller extent of burned areas with a median TBSA of 30% (quartiles: 22-50%, p = 0.036) compared to non-diabetic patients (35% (25-55%)) but had a similar length of stay with a median of 29 (quartiles: 13-44) days vs. 23 (10-48) days. Outcome analysis showed an overall mortality of 35.6%. Diabetes was not associated with higher mortality rate after burn injury in a univariate model (OR 1.80, 95% CI 0.92-3.51). After correction for %TBSA, the effect of diabetes on mortality was significant (OR 2.80, 95% CI, 1.33-5.90). CONCLUSION: Our data indicate higher mortality rates (50-100%) of diabetic patients with TBSA greater than 40% in severely burned patients compared to non-diabetic patients without a significant outcome due to the low number of cases in the subgroup analyses.

BMI Specific Complications Following Implant-Based Breast Reconstruction after Mastectomy.

BACKGROUND: Breast reconstruction has a positive impact on body image and quality of life for women after experiencing the physically and psychologically demanding process of mastectomy. Previous studies have presented body mass index (BMI) as a predictor for postoperative complications after breast reconstruction, however, study results vary. This retrospective study aimed to investigate the impact of patients' BMI on postoperative complications following implant-based breast reconstruction. METHODS: All implant-based breast reconstructions performed at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Vienna from January 2001 to March 2018 were evaluated. A total of 196 reconstructed breasts among 134 patients met eligibility criteria. Demographic data, surgical techniques, as well as major and minor complications within a one-year follow-up period were analyzed. RESULTS: Patients' BMI did not show a significant impact on complication rates. The overall incidence of postoperative complications was 30.5% (40/131) of which 17.6% required reoperation. Impaired wound healing (18.3%), seroma (6.1%), hematoma (4.6%), capsular contraction (4.6%) and infection (3.8%) were the most common complications. CONCLUSION: In our study cohort, BMI was not associated with a significantly higher risk of complications. However, postoperative complications significantly increased with a longer operative time and resulted in an extended length of hospital stay.

The secretome of stressed peripheral blood mononuclear cells increases tissue survival in a rodent epigastric flap model.

Reconstructive surgery transfers viable tissue to cover defects and to restore aesthetic and functional properties. Failure rates after free flap surgery range from 3 to 7%. Co-morbidities such as diabetes mellitus or peripheral vascular disease increase the risk of flap failure up to 4.5-fold. Experimental therapeutic concepts commonly use a monocausal approach by applying single growth factors. The secretome of γ-irradiated, stressed peripheral blood mononuclear cells (PBMCsec) resembles the physiological environment necessary for tissue regeneration. Its application led to improved wound healing rates and a two-fold increase in blood vessel counts in previous animal models. We hypothesized that PBMCsec has beneficial effects on the survival of compromised flap tissue by reducing the necrosis rate and increasing angiogenesis. Surgery was performed on 39 male Sprague-Dawley rats (control, N = 13; fibrin sealant, N = 14; PBMCsec, N = 12). PBMCsec was produced according to good manufacturing practices (GMP) guidelines and 2 ml were administered intraoperatively at a concentration of 2.5 × 107 cells/ml using fibrin sealant as carrier substance. Flap perfusion and necrosis (as percentage of the total flap area) were analyzed using Laser Doppler Imaging and digital image planimetry on postoperative days 3 and 7. Immunohistochemical stainings for von Willebrand factor (vWF) and Vascular Endothelial Growth Factor-receptor-3 (Flt-4) were performed on postoperative day 7 to evaluate formation of blood vessels and lymphatic vessels. Seroma formation was quantified using a syringe and flap adhesion and tissue edema were evaluated clinically through a cranial incision by a blinded observer according to previously described criteria on postoperative day 7. We found a significantly reduced tissue necrosis rate (control: 27.8% ± 8.6; fibrin: 22.0% ± 6.2; 20.9% reduction, p = .053 vs. control; PBMCsec: 19.1% ± 7.2; 31.1% reduction, p = .012 vs. control; 12.9% reduction, 0.293 vs. fibrin) together with increased vWF+ vessel counts (control: 70.3 ± 16.3 vessels/4 fields at 200× magnification; fibrin: 67.8 ± 12.1; 3.6% reduction, p = .651, vs. control; PBMCsec: 85.9 ± 20.4; 22.2% increase, p = .045 vs. control; 26.7% increase, p = .010 vs. fibrin) on postoperative day 7 after treatment with PBMCsec. Seroma formation was decreased after treatment with fibrin sealant with or without the addition of PBMCsec. (control: 11.9 ± 9.7 ml; fibrin: 1.7 ± 5.3, 86.0% reduction, 0.004 vs. control; PBMCsec: 0.6 ± 2.0; 94.8% reduction, p = .001 vs. control; 62.8% reduction, p = .523 vs. fibrin). We describe the beneficial effects of a secretome derived from γ-irradiated PBMCs on tissue survival, angiogenesis, and clinical parameters after flap surgery in a rodent epigastric flap model.

Does obesity impact the outcome of severely burned patients?

Although obesity appears to be an important predictor of mortality and morbidity, little data about the impact of body mass index (BMI) on the outcome of severely burned patients are available. Patients admitted to the General Hospital Vienna between 1994 and 2014, who underwent surgery because of burn injuries, were enrolled in this study. BMI was used to divide patients into five groups: BMI 18.5 to 24.9, 25 to 29.9, 30 to 34.9, 35 to 39.9, and > 40. The groups were compared in terms of difference of mortality and morbidity. Of 460 patients, 34.3% (n = 158) died. Mortality rates were the lowest in patients with obesity class III and the highest in patients with BMI 35 to 39.9 (BMI 18.5-24.9: 30.5%, BMI 25-29.9: 31.5%, BMI 30-34.9: 41.3%, BMI 35-39.9: 55.5%, BMI > 40: 30%; P = .031). BMI was not found to be an independent risk factor when corrected with age, percent total body surface area burned, full-thickness burns, and inhalation injury. No significant differences in length of stay, inhalation trauma, pneumonia, wound infection, sepsis, and invasive ventilation were observed. BMI as an independent risk factor for severely burned patients could not be confirmed via multivariate analysis.

Feasibility of ultrasound measurement in a human model of acute compartment syndrome.

BACKGROUND: Early diagnosis of acute compartment syndrome (ACS) of the leg is essential to improve the outcome. Direct invasive measurement is currently recommended to measure intracompartmental pressure. A non-invasive and reproducible means of making the diagnosis would be a step forward. The purpose of this exploratory study was to investigate the feasibility of non-invasive ultrasound-guided angle measurement as a surrogate of increased pressure in a model of ACS. METHODS: A model of ACS was generated by infusion of saline into the anterior compartment of the leg of human cadavers to incrementally increase the intracompartmental pressure from 10 to 100 mmHg. In 40 legs (20 cadavers), the angle (TFA, tibia-fascia angle) between the anterolateral cortex of the tibia and the fascia of the anterior compartment was measured at each 10 mmHg pressure increase using ultrasound in a standardized transversal plane. A multilevel linear regression model was used to estimate intracompartmental pressure from delta TFA (ΔTFA). RESULTS: TFA (mean [± SD]) increased from 61.0° (± 12.0°) at 10 mmHg up to 81.1° (± 11.1°) at 100 mmHg compartment pressure. Each increase ΔTFA by one degree was associated with an increase in pressure by 3.9 mmHg (95% CI, 3.8-4.0, p < 0.001). CONCLUSIONS: We found that intracompartmental pressure of the anterior compartment of the calf can be well estimated by ultrasound-based ΔTFA in this post mortem experiment. Our findings indicate that non-invasive TFA measurement is feasible and it is reasonable that this will hold true in real life, but the findings are too preliminary to be used in clinical practice now.

Gender has no influence on mortality after burn injuries: A 20-year single center study with 839 patients.

BACKGROUND: According to the ABSI - Abbreviated Burn Severity Index - women exhibit an increased risk of succumbing to burn injuries. In contrast, following non-thermal trauma, increased mortality has been shown for the male gender. Therefore, the purpose of this study was to evaluate gender-specific differences among burn patients with special regard to burn mortality. METHODS: We retrospectively studied 839 patients who were admitted to the Burn Intensive Care Unit (BICU) and underwent surgical treatment between June 1994 and December 2014. In-hospital mortality was the main clinical endpoint. Odds ratios (ORs) were calculated using univariate and multivariate logistic regression models for the association between sex and mortality. RESULTS: In total, we included 530 male and 309 female burn patients. All patients had at least partial-thickness burns and underwent one or more operative procedures. Women were significantly older than men (mean 60.0 years vs 46.2 years; p<0.001). Despite having smaller injuries (24.6% vs 30.3% total body surface area (TBSA); p<0.001), burn mortality among women significantly differed from that of men (27.8% vs 21.7%; OR 1.39, p=0.045, 95% CI 1.01-1.92). This association, however, did not persist after adjusting for age, %TBSA, inhalation injury and full-thickness burns (OR 1.07, p=0.77, 95% CI 0.68-1.70). CONCLUSIONS: Despite increasing research directed at women's health, the assoziation between gender and burn mortality has yielded conflicting results. This study does not support a gender-specific difference in burn mortality in our study population.

The supraorbital region revisited: An anatomic exploration of the neuro-vascular bundle with regard to frontal migraine headache.

BACKGROUND: Recent findings on the pathogenesis of frontal migraine headache support, besides a central vasogenic cause, an alternative peripheral mechanism involving compressed craniofacial nerves. This is further supported by the efficiency of botulinum toxin injections as a new treatment option in frontal migraine headache patients. METHODS: The supraorbital regions of 22 alcohol-glycerine-embalmed facial halves of both sexes were dissected. Both the supratrochlear and supraorbital nerves (STN and SON, respectively) were identified, and their relationship with the corrugator supercilii muscle (CSM) was investigated by dissection and ultrasound. The course of both nerves was defined, and the interaction between the supraorbital artery (SOA) and SON was determined. RESULTS: We discovered a new possible compression point of the STN passing through the orbital septum and verified previously described compression points of both STN and SON. Osteofibrous channels used by the STN and SON were found constantly. We described the varying topography of the STN and CSM, the SON and CSM, and the SON and SOA. Further, we provide an algorithm for the ultrasound visualization of the supraorbital neurovascular bundle. CONCLUSION: Our data support the hypothesis of a peripheral mechanism for frontal migraine headache because of following potential irritation points: first, the CSM is constantly perforated by the SON and frequently by the STN; second, the topographic proximity between SOA and SON and the osteofibrous channels is used by the SON and STN; and third, the STN passes through the orbital septum.

A small 'lick' will sink a great ship: fulminant septicaemia after dog saliva wound treatment in an asplenic patient.

Capnocytophaga canimorsus is a bacterium transmitted through the saliva of dogs. An infection can cause severe sepsis with acral necrosis and is potentially fatal. Here, we report the case of a 41-year-old man who was infected through a wound that was licked by his dog. He went into septic shock with disseminated intravascular coagulation and subsequently lost both lower legs, his nose and all the fingers on both hands.

Reduction mammaplasty: outcome analysis based on bodyweight.

UNLABELLED: This retrospective study aimed to evaluate how reduction mammaplasty influences the bodyweight of patients 5 years after the procedure. The literature shows controversy regarding the effect of breast reduction on the progression of bodyweight. Between 1 January 2006 and 31 July 2007, 249 reduction mammaplasties were performed in the Department of Plastic, Reconstructive, and Aesthetic Surgery at the University Hospital Innsbruck. The exclusion criteria ruled out patients with oncoplastic breast reduction plasties, unilateral reduction mammaplasty, no documented preoperative weight, and bariatric procedures. The study finally included 50 women with a mean age of 44 ± 12 years. Of these 50 women, 26 (52 %) gained weight, 18 (36 %) lost weight, and 6 (12 %) remained stable during a 5-year follow-up period after the procedure. The mean weight gain was 4.50 ± 3.5 kg, and the mean weight loss was 3.44 ± 2.20 kg. The results of the study suggest that reduction mammaplasty is not a stimulus for weight loss. Although a tendency to gain weight was discovered, the weight gain compared with that of the standard population did not reach statistical significance. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The internal mammary artery perforator (IMAP) breast-flap harvested from an asymmetric hyperplastic breast for correction of a mild funnel chest deformity.

Pectus excavatum deformity is the most frequent congenital anomaly of the thoracic wall. If the invasive surgical procedures of thoracoplasty are not indicated or the patient refuses them, alternative treatment options should be considered. In such cases, local or distant transposition of autologous tissue could be appropriate. This report presents a selected case of funnel chest deformity and concomitant unilateral breast hyperplasia. Both deformities were corrected simultaneously using a pedicled internal mammary artery perforator (IMAP) flap dissected from the hyperplastic breast. This is a safe, reliable, low-morbidity, one-stage option for adult women that uses an easy-to-harvest flap for simultaneous correction of mild funnel chest deformity and concomitant breast hyperplasia with a single resulting scar.

Hypertonic saline up-regulates A3 adenosine receptor expression of activated neutrophils and increases acute lung injury after sepsis.

OBJECTIVE: Hypertonic saline resuscitation reduces tissue damage by inhibiting polymorphonuclear neutrophils. Hypertonic saline triggers polymorphonuclear neutrophils to release adenosine triphosphate that is converted to adenosine, inhibiting polymorphonuclear neutrophils through A2a adenosine receptors. Polymorphonuclear neutrophils also express A3 adenosine receptors that enhance polymorphonuclear neutrophil functions. Here we investigated whether A3 receptors may diminish the efficacy of hypertonic saline in a mouse model of acute lung injury. DESIGN: Randomized animal study and laboratory investigation. SETTING: University research laboratory. INTERVENTIONS: The effect of A3 receptors on the efficacy of hypertonic saline resuscitation was assessed in A3 receptor knockout and wild-type mice. Animals were treated with hypertonic saline (7.5% NaCl, 4 mL/kg) before or after cecal ligation and puncture, and acute lung injury and mortality were determined. The effect of timing of hypertonic saline exposure on A3 receptor expression and degranulation was studied in vitro with isolated human polymorphonuclear neutrophils. MEASUREMENTS AND MAIN RESULTS: Treatment of human polymorphonuclear neutrophils with hypertonic saline before stimulation with formyl methionyl-leucyl-phenylalanine inhibited A3 receptor expression and degranulation, whereas hypertonic saline-treatment after formyl methionyl-leucyl-phenylalanine-stimulation augmented A3 receptor expression and degranulation. Acute lung injury in wild-type mice treated with hypertonic saline after cecal ligation and puncture was significantly greater than in wild-type mice pretreated with hypertonic saline. This aggravating effect of delayed hypertonic saline-treatment was absent in A3 receptor knockout mice. Similarly, mortality in wild-type mice with delayed hypertonic saline-treatment was significantly higher (88%) than in animals treated with hypertonic saline before cecal ligation and puncture (50%). Mortality in A3 receptor knockout mice remained only 50% regardless of timing of hypertonic saline administration. CONCLUSIONS: Polymorphonuclear neutrophil A3 receptors expression determines whether hypertonic saline resuscitation inhibits or aggravates polymorphonuclear neutrophil-induced acute lung injury. These findings suggest that A3 antagonists could improve the efficacy of hypertonic saline resuscitation by reducing side effects in patients whose polymorphonuclear neutrophils are activated before hypertonic saline treatment.