How to evaluate scar colour after burn injuries - A clinical comparison of the Mexameter® and the subjective scar assessment (POSAS/VSS).

INTRODUCTION: Scarring after burn injuries remains one of the major challenges in burn medicine and is the subject of current research. Accurate and high-quality assessment of scars is needed to enable exact outcome evaluation of different treatments. Our aim was to evaluate the most common subjective scar evaluation scores-the POSAS (Patient and Observer Scar Assessment Scale) and VSS (Vancouver Scar Scale)-in comparison with the objective device Mexameter® for colour evaluation. METHODS: A prospective monocentre study was performed, which included 120 examined scar areas of 60 patients with third degree burns who had received skin grafts between 1975 and 2018 with a total burned surface area (TBSA) > 2%. Two different scar areas in comparison with one healthy skin area concerning 'colour', 'pigmentation', and 'vascularization' were evaluated by the Mexameter® MX 18, the OSAS, and the VSS by the same examiner, as well as the PSAS by the patient. RESULTS: The mean TBSA of the 60 patients was 24.3%. In the OSAS, 61% of the scars were evaluated as 'hyper-', 19% as 'hypo-', and 19% as 'mix-pigmented'. Furthermore, 65% of the scars were estimated as highly vascularized. In the Mexameter®, the melanin index values of the scar areas compared to the healthy skin areas showed a small difference of 12 (p < 0.05). The mean difference of erythema between the scar and the healthy skin areas was 84 (p < 0.001). For the Mexameter®, moderate correlations were found when comparing 'erythema' with the OSAS category 'vascularization' (r = 0.33, p < 0.05) and 'melanin' with the OSAS parameter 'pigmentation' (r = 0.28, p < 0.05). When comparing the Mexameter® measurements to the OSAS questionnaire, 27% of the scars were wrongly evaluated as 'hyperpigmented' by the observer and 21% as 'hypervascularized', while showing low measurements in the device. Additionally, a novel Mexameter® ordinal scare scale was calculated. CONCLUSION: In this study, we were able to show on a relatively large patient population that with the Mexameter®, the subjectivity of the scar colour assessment by examiner/patient can be overcome, but precise differentiation can still be ensured with subjective evaluation tools. We further introduced a novel Mexameter® Scar Scale. It is necessary to further investigate the vast range of objective devices and develop scar panels for with an incorporation of objective and subjective devices to further improve reliability with reduced bias in terms of scar assessment.

Contamination of burn wounds by Achromobacter Xylosoxidans followed by severe infection: 10-year analysis of a burn unit population.

Gram-negative infections predominate in burn surgery. Until recently, Achromobacter species were described as sepsis-causing bacteria in immunocompromised patients only. Severe infections associated with Achromobacter species in burn patients have been rarely reported. We retrospectively analyzed all burn patients in our database, who were treated at the Intensive Care Burn Unit (ICBU) of the Cologne Merheim Burn Centre from January 2006 to December 2015, focusing on contamination and infection by Achromobacter species.We identified 20 patients with burns contaminated by Achromobacter species within the 10-year study period. Four of these patients showed signs of infection concomitant with detection of Achromobacter species. Despite receiving complex antibiotic therapy based on antibiogram and resistogram typing, 3 of these patients, who had extensive burns, developed severe sepsis. Two patients ultimately died of multiple organ failure. In 1 case, Achromobacter xylosoxidans was the only isolate detected from the swabs and blood samples taken during the last stage of sepsis. Achromobacter xylosoxidans contamination of wounds of severely burned immunocompromised patients can lead to systemic lethal infection. Close monitoring of burn wounds for contamination by Achromobacter xylosoxidans is essential, and appropriate therapy must be administered as soon as possible.

Les infections à Gram négatif prédominent chez les brûlés. Jusqu'à une période récente, Achromobacter xylosoxidans (Ax) n'était décrit comme pathogène que chez les patients immunodéprimés. Les infections sévères à Achromobacter n'ont été que rarement décrites chez les brûlés. Nous avons rétrospectivement revu tous les patients hospitalisés dans l'unité de réanimation du centre de traitement des brûlés Merheim de Cologne entre janvier 2006 et décembre 2015, à la recherche d'une infection ou d'une contamination à Achromobacter et avons trouvé 20 patients. Quatre d'entre eux présentaient des signes de sepsis dont trois, sévèrement brûlés, un sepsis sévère malgré une antibiothérapie adaptée à l'antibiogramme, deux en étant décédés dans un tableau de défaillance multiviscérale. Dans un cas, Ax était la seule bactérie isolée de prélèvements cutané et sanguins, prélevés en phase tardive du sepsis. La contamination cutanée par Ax, chez des patients immuodéprimés car sévèrement brûlés, peut conduire à un sepsis létal. La surveillance rapprochée de l'écologie de la brûlure et une antibiothérapie adaptée précoce sont donc essentielles.

Liver fibrogenesis due to cholestasis is associated with increased Smad7 expression and Smad3 signaling.

BACKGROUND/AIMS: Profibrogenic TGF-beta signaling in hepatic stellate cells is modulated during transdifferentiation. Strategies to abrogate TGF-beta effects provide promising antifibrotic results, however, in vivo data regarding Smad activation during fibrogenesis are scarce. METHODS: Here, liver fibrosis was assessed subsequent to bile duct ligation by determining liver enzymes in serum and collagen deposition in liver tissue. Activated hepatic stellate cells were identified by immunohistochemistry and immunoblots for alpha smooth muscle actin. Cellular localization of Smad3 and Smad7 proteins was demonstrated by immunohistochemistry. RTPCR for Smad4 and Smad7 was conducted with total RNA and Northern blot analysis for Smad7 with mRNA. Whole liver lysates were prepared to detect Smad2/3/4 and phospho- Smad2/3 by Western blotting. RESULTS: Cholestasis induces TGF-beta signaling via Smad3 in vivo, whereas Smad2 phosphorylation was only marginally increased. Smad4 expression levels were unchanged. Smad7 expression was continuously increasing with duration of cholestasis. Hepatocytes of fibrotic lesions exhibited nuclear staining Smad3. In contrast to this, Smad7 expression was localized to activated hepatic stellate cells. CONCLUSIONS: Hepatocytes of damaged liver tissue display increased TGF-beta signaling via Smad3. Further, negative feedback regulation of TGF-beta signaling by increased Smad7 expression in activated hepatic stellate cells occurs, however does not interfere with fibrogenesis.

[De Quervain's stenosing tendovaginitis--one of the most common conditions affecting the hand]. / Erkennen Sie auf Anhieb die Tendovaginitis stenosans de Quervain?

De Quervain's stenosing tendovaginitis is an inflammation of the first dorsal compartment. It is considered to be one of the most common forms of inflammation of the tendon sheaths. The diagnosis is based on the case history and the clinical examination. Finkelstein's test is pathognomonic. Should conservative treatment not prove successful, the condition is readily amenable to surgical treatment.

[Vacuum-assisted closure as temporary coverage in the "problem zone hand"]. / Die Vakuumtherapie als temporäre Deckung an der "Problemzone Hand".

INTRODUCTION: Vacuum therapy of hand defect problematic due to the interdigital folds and in particular due to the small surface. As a temporary cover in staged procedures, e. g. following excision of tumor-suspicious skin alterations at the hand, and/or at the fingers, the application of vacuum therapy results not only in a sterile, temporary cover of the wound, furthermore it promotes wound conditioning and reduction of the wound area as well as lymph and edema reduction. PATIENTS AND METHODS: A 75 year old female patient presented herself with a skin alteration at the right dorsal ring finger and the tentative diagnosis of a Morbus Bowen like lesion was raised. Due to the unclear histological status, a staged procedure with excision of the tumour and temporary defect coverage by means of vacuum therapy until final histological evaluation was indicated. We accomplished the radical excision of the unclear skin tumour at the proximal phalanx under preservation of the synovial sheath of the tendon. Subsequently, the wound was temporarily closed with vacuum therapy. Histological examination revealed the complete removal of a solar keratosis. Finally, after 7 days of vacuum therapy as a sterile dressing, with obvious reduction of wound area and simultaneous decrease of edema, the defect was finally covered with a reversed cross finger flap from the adjacent middle finger. The donor site was covered with a full thickness skin graft harvested from the right forearm. The further course was without complication after flap dissection and complete healing. DISCUSSION: Vacuum therapy represents a usefull procedure for temporary wound coverage. Especially at hand defects, when nerves, tendons or bones following trauma or staged procedures are exposed, vacuum therapy can be successfully applied utilizing the special surgical "hand glove" technique.

[Use of vacuum therapy during defect coverage of the upper extremity with microsurgically grafted arterialized venous flaps]. / Der Einsatz der Vakuumtherapie bei der Defektdeckung an der oberen Extremität mit freien mikrochirurgischen arterialisierten venösen Lappen.

Arterialized venous soft tissue flaps are defined as tissue portions usually harvested from the anterior and distal third of the forearm over a venous pathway to be transplanted to another recipient area. Basically, they are composed of skin, subcutaneous tissue, and subdermal venous plexus. At the recipient site flaps are perfused by a nourishing artery while the other veins are connected to one or more regional veins. The retrograde blood perfusion often results in edema, temporary epidermolysis, or even some degree of skin necrosis that disappear during subsequent treatment. To circumvent these drawbacks grafting of arterialized flaps was combined with local application of vacuum to overcome the venous initial stasis, resulting in improved healing and survival of these flaps.