Risk factors and outcome associated with fungal infections in patients with severe burn injury: 10-year retrospective IFI-BURN study.

BACKGROUND: In burn patients, skin barrier disruption and immune dysfunctions increase susceptibility to invasive fungal diseases (IFDs) like invasive candidiasis (IC) and invasive mold infections (IMI). We provide an in-depth analysis of IFD-related factors and outcomes in a 10-year cohort of severe burn patients. METHOD: Retrospective cohort study including adult patients admitted to the Burn Intensive Care Unit (BICU) between April 2014 and May 2023 with Total Burn Surface Area (TBSA) ≥15%. Patients were classified as proven IFD according to EORTC/MSGERC criteria applicable for IC. Putative IMIs were defined with: ≥2 positive cultures from a skin biopsy/bronchoalveolar lavage OR ≥2 positive blood specific-qPCRs OR a combination of both. RESULTS: Among 1381 patients admitted, 276 consecutive patients with TBSA ≥15% were included. Eighty-seven (31.5%; IC n=30; IMI n=43; both n=14) patients fulfilled the criteria for probable/putative IFD. At Day 30 after the burn injury, the estimated cumulative incidence pr/pu IFD was 26.4% (95%CI 21.4-31.8%). Factors independently associated with IFDs were TBSA, severity scores and indoor burn injury (i.e., from confined space fire). Overall mortality was 15.3% and 36.8% in the no IFD, pr/pu IFD groups respectively (p<0.0001). IFD was independently associated with a risk of death (HR: 1.94 for pr/pu IFD; 95%CI, 1.12-3.36; p=0.019). DISCUSSION: This study describes 21st-century characteristics of IFDs in sever burn patients confirming known risk factors with thresholds and identifying the indoor injury as an independent factor associated to IFDs. This suggests a link to contamination caused by fire damage, which is highly susceptible to aerosolizing spores.

Evolution, control and success of combination therapy with Ampicilin-sulbactam/Ceftazidime-Avibactam during a Carbapenem-Resistant Acinetobacter baumannii outbreak in burn Intensive Care Unit.

We present our findings on interpatient transmission, epidemic control measures, and the outcomes of a series of ten critically ill burn patients who were either colonized or infected with carbapenem-resistant Acinetobacter baumannii (CRAB). None of the five infected patients achieved clinical cure, and all experienced relapses. Microbiological failure was observed in 40% of the infected patients. The isolated CRAB strains were found to carry blaOXA-23 and armA resistance genes. Despite the lack of clinical cure, all five infected patients survived and were discharged from the Burn Intensive Care Unit.

Interindividual and Intraindividual Variations of Breast Sensitivity Before and After Breast Reduction: A Prospective Study.

BACKGROUND: More than 300,0000 breast plastic surgery procedures are performed annually worldwide, of which more than 100,000 are reduction mammoplasties carried out in the United States. Although most patients tend to be satisfied with the immediate outcomes of this procedure, there is increasing concern among surgeons as well as patients with regard to breast sensibility and the postoperative recovery.The objectives of this study were to assess the variation in the sensibility in patients undergoing hypertrophic breast surgery by quantification of the impact of various variables and to evaluate its progression from before the surgery to between 3 and 6 months and 1 year postoperatively. METHODS: We carried out a nonrandomized, monocentric, prospective study. All of the patients were examined by the same evaluator using a set of 20 von Frey monofilaments on the day before the surgery and at 3 to 6 months and 1 year postoperatively. The breast skin, areola, and nipple sensibilities were tested. Age, body mass index, tobacco use, and the breast volume were recorded. RESULTS: We did not find any significant effect of the body mass index, tobacco use, or age on breast sensibility. The nipple and areola complex (NAC) sensibility was inversely correlated with the degree of hypertrophy before the surgery, but this difference disappeared in the postoperative evaluations. After the surgery, the NAC sensibility decreased at the first follow-up at 4.5 months and returned to normal after 1 year. CONCLUSIONS: The inverse relationship between breast volume and sensibility in the preoperative evaluation disappeared after mammaplasty reduction. In the early postoperative period, the sensibility decreased on the NAC but returned to normal after 1 year.

A new therapeutic protocol for the treatment of keloid scars: a retrospective study.

OBJECTIVE: There are few means to treat large keloid scars, as exeresis-even if partial-impedes direct closure without tension in the absence of a flap or a skin graft. This study evaluates the efficacy, indications for use and limitations of a new therapeutic protocol, combining an extralesional keloid excision left to heal by secondary intention with a paraffin dressing and glucocorticoid ointment, followed by monthly intrascar injections of corticosteroids upon full re-epithelialisation. METHOD: A retrospective study of patients treated for keloid scars by using the new therapeutic protocol. Scars were categorised as either healed or recurring. Their recurrence was scored according to the changes in functional signs and the scar volume. RESULTS: A total of 36 scars were studied. The mean follow-up was 14.1 months. Healing occurred in a mean of 6.8 weeks. The mean surface area was 21.6cm2. Healing rate was 30.5%. Scar volume was improved in 60% of recurrent cases and functional signs in 56%. Based on adherence with the corticotherapy, two patient groups could be discerned. For patients in the 'adherent' group, the healing rate was 40%, and scar volume was improved in 75% of recurrent cases and the functional signs in 83% of cases. CONCLUSIONS: The healing rate in this study was close to that reported in the literature. Excision-healing by secondary intention could therefore be offered to patients for whom adherence is uncertain. The protocol in this study offers a straightforward, fast, accessible solution that does not appear to entail any risk of additional keloids. It could potentially offer a treatment option in case of failure of other treatments, large keloid scars or scalp keloids.

Epidemiology and Prevention of Breast Prosthesis Capsular Contracture Recurrence.

INTRODUCTION: Baker grade III and IV breast prosthesis capsular contractures represent a major problem for patients undergoing mammoplasties. The risk factors involved in recurrence are debated, and the best surgical approach for their prevention is not established. The objective was to identify these. MATERIALS AND METHODS: We carried out a retrospective study of patients operated on for capsular contracture at the Saint-Louis Hospital in Paris from 2012 to 2014. The characteristics at inclusion were compared so as to determine the risk factors of recurrence. The surgical approaches were compared between the patients with recurrence and those without at 5 years. RESULTS: Of the 100 patients included, 24 had a recurrence. The minimal follow-up was 5 years. No risk factors of recurrence of capsular contracture were identified. The surgical approach associated with the lowest rate of recurrence was anterior capsulectomy [OR total capsulectomy = 2.36 (0.73; 8.037) OR capsulotomy = 4.33 (1.37; 14.81)] (p < 0.040) with alteration of the volume of the implant, whether greater or less than initially [OR greater volume = 0.30 (0.096; 0.83); OR smaller volume = 0.14 (0.008; 0.85)] (p < 0.018). CONCLUSION: The occurrence of capsular contracture is a major problem with prosthetic breast surgery. The main risk factors identified to date are essentially in regard to the occurrence of a first episode. No significant risk factors for recurrence were identified. The best prevention appears to be an anterior capsulectomy with reducing the volume of the implant. 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 . IV.

A 10-Year Follow-Up Experience of 383 Patients with Bilateral Smooth Inflatable Breast Implants Filled with Saline Solution.

INTRODUCTION: In light of the concerns regarding the occurrence of anaplastic large-cell lymphoma, seromas, and scar capsules, there appears to be merit in analysis and presentation of the results of our series of inflatable smooth implants filled with saline solution, for which the follow-up was more than 10 years. PATIENTS AND METHOD: We carried out a retrospective study, including all of the patients who underwent a first breast implant for cosmetic reasons, between 2003 and 2006. RESULTS: A total of 383 patients with 766 smooth implants filled with saline solution were included in our study. No cases of lymphoma and seroma were diagnosed. Eleven patients exhibited a postoperative hematoma, and four went on to develop a capsule. Twenty-two patients (5.7%) developed a Baker Grade III or IV capsule that required revision surgery. Two patients (0.5%) opted for a bilateral prosthesis replacement due to visual rippling. In total, there were 26 (3.4%) early deflations of prostheses. DISCUSSION: There is not a statistically significant correlation between the occurrence of hematomas and the formation of a capsule. We found a lower shell rate with smooth-walled versus textured implants. The fact of having a decline of 10 years allows to be exhaustive. As for wrinkling and ripples, their occurrence has not been increased by the use of inflatable retropectoral implants. CONCLUSION: Smooth inflatable implants filled with saline solution have numerous advantages such as the possibility of a very small approach route and perioperative adaptability of the volume. In light of the lack of indication of anaplastic large-cell lymphoma with smooth implants, they are clearly an attractive alternative to textured implants filled with silicone gel. 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.

Contributing factors and outcomes of burn-associated cholestasis.

BACKGROUND & AIMS: Cholestasis often occurs after burn injuries. However, the prevalence of cholestasis and its effect on outcomes in patients with severe burn injuries are unknown. The aim of this study was to describe the course and the burden of cholestasis in a cohort of severely burned adult patients. METHODS: We investigated the relationship between burn-associated cholestasis (BAC) and clinical outcomes in a retrospective cohort of patients admitted to our unit for severe burn injuries between 2012 and 2015. BAC was defined as an increased level of serum alkaline phosphatase (ALP) ≥1.5x the upper limit of normal (ULN) with an increased level of gamma-glutamyltransferase (GGT) ≥3x ULN, or as an increased level of total bilirubin ≥2x ULN. RESULTS: A total of 214 patients were included: 111 (52%) patients developed BAC after a median (IQR) stay of 9 (5-16) days. At 90 days, the mortality rate was 20%, including 34 and 9 patients with and without BAC (p <0.001), respectively, which corresponded to a 2.5-fold higher (95% CI 1.2-5.2, p = 0.012) risk of 90-day mortality for patients with BAC. After being adjusted for severity of illness, patients with BAC, hyperbilirubinemia and without elevated ALP and GGT levels had a hazard ratio of 4.51 (95% CI 1.87-10.87) for 90-day mortality. BAC was associated with the severity of the burn injury, shock and bacteraemia. BAC was present in 38 (51%) patients at discharge, and 7 (18%) patients had secondary sclerosing cholangitis. These patients maintained elevated levels of ALP and GGT that were 5.8x (1.7-15) the ULN and 11x the ULN (4.5-22), respectively, 20 months (3.5-35) after discharge. CONCLUSION: BAC is prevalent among patients with severe burn injuries and is associated with worse short-term outcomes, especially when total bilirubin levels were increased without elevated ALP and GGT levels. BAC survivors are at risk of developing sclerosing cholangitis. LAY SUMMARY: Cholestasis is common after burn injuries and is associated with burn severity, sepsis, organ failure and mortality. Patients with hyperbilirubinemia without elevated alkaline phosphatase and gamma-glutamyltransferase levels after the burn injury have a poor prognosis. Patients with burn-associated cholestasis may develop sclerosing cholangitis and secondary biliary cirrhosis.

Outcome and potentially modifiable risk factors for candidemia in critically ill burns patients: A matched cohort study.

BACKGROUND: Patients with extensive burns are at risk of developing candidemia. OBJECTIVES: To identify potentially modifiable risk factors and outcomes of candidemia in critically ill burns patients. PATIENTS AND METHODS: Retrospective matched cohort study including adult burns patients. Patients who developed candidemia were matched with burns patients with Candida spp colonisation and sepsis or septic shock without candidemia in a ratio of 1:3 (same severity scores and colonisation index). Univariate and multiple regression analyses were performed. RESULTS: Of 130 severely burned patients with Candida spp colonisation and at least one episode of sepsis or septic shock, 14 were diagnosed with candidemia. In the candidemia group, patients had a median (IQR) total burns surface area (TBSA) of 57 (38-68)%, SAPSII of 43 (36-58) and ABSI of 11 (8-13). Multiple regression analysis showed that only duration of prior antibiotic therapy was independently associated with candidemia. ICU mortality was higher in the candidemia group (71% vs 35% [P = 0.02]). The log-rank test for 28-day mortality comparing patients with candidemia treated with an empirical strategy vs a curative strategy did not reach significance (P = 0.056). CONCLUSIONS: Burns patients having received recent antibiotherapy have a higher risk of candidemia. Antifungal strategies did not influence outcome in this series.

[Adult thermal burn dressings in three acts]. / Les pansements de brûlés thermiques adultes en trois actes.

Dressings are a real challenge in the care of patients with thermal burns. They help to heal and prevent or treat possible skin infections. Paramedical teams must have a perfect strategy for organizing, managing pain and optimizing hygiene and asepsis rules. The purpose is to facilitate the understanding and implementation of this treatment by suggesting protocols that can be applied by all. It remains essential to mobilize specialized services to promote the evolution of burns.

Closed-Suction Drains After Subcutaneous Mastectomy for Gynecomastia: Do They Reduce Complications? A Different Approach.

INTRODUCTION: We read the manuscript entitled "Closed-suction drains after subcutaneous mastectomy for gynecomastia: do they reduce complications? ¼ published by Chao et al. (Aesthetic Plast Surg, 2017. https://doi.org/10.1007/s00266-017-0959-z ). They have concluded that drains may reduce rates of seromas requiring needle aspiration after surgical treatment, but also that there are several adverse effects of drains: patients' discomfort, anxiety, cost and additional clinic visits. They also recalled several limitations: (1) bias in terms of surgeon decision to place a drain, (2) nuances in technique. Here we want to discuss our different technique of drainage. To prevent all the disadvantages, we have chosen to replace closed-suction drains with silicone blades and a wide scar opening at the level of the periareolar scar. METHOD: We carried out a retrospective study in our department in 2016. RESULTS: This series consisted of 83 patients (153 breasts) aged 26.7 years of age (15-67), with an average BMI of 28.6 (19.5-39). All were followed during the 12 months postoperatively. We considered here only grade 1-2a gynecomastia with palpable fibrous glandular tissue. The surgical procedure consisted of initial liposuction, then open surgical excision via the periareolar approach. We did not notice any seroma or collection requiring intervention. However, 4 patients (4/153; 2.6%) had hematomas requiring intervention the day after surgery. CONCLUSION: Our technique presents a lot of advantages, reduced length of stay in the hospital, costs from drain site care and clinic visits, patients' discomfort, and antibiotic prescriptions. LEVEL OF EVIDENCE V: 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 M-Y Axilloplasty After Massive Weight Loss: Analysis of 159 Consecutive Patients.

BACKGROUND: Brachioplasties often culminate in unsightly scars that are a source of disappointment to patients. We aimed to evaluate the results of M-Y axilloplasty following massive weight loss. PATIENTS: We performed a retrospective assessment of our technique for brachioplasty with an M-Y axilloplasty in 159 female patients after massive weight loss. This retrospective study covered a study period of 10 years. METHOD: After substantial lipoaspiration, the incision is placed on the internal side of the arm, with an M-shaped axilloplasty. RESULTS: The satisfaction rate was 154/159 (97%) and 120/159 (75.5%) being happy with their esthetic results. Nineteen percent (30/159) of the patients had complications and 12/159 (7.5%) underwent a surgical revision. CONCLUSION: M-Y axilloplasty for brachioplasty is an effective procedure for treating women who are unhappy with their upper arms after massive weight loss. The satisfaction rate is high, and the result leaves no excess skin on the chest. 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 .

Undetectable haptoglobin is associated with major adverse kidney events in critically ill burn patients.

BACKGROUND: Intravascular haemolysis has been associated with acute kidney injury (AKI) in different clinical settings (cardiac surgery, sickle cell disease). Haemolysis occurs frequently in critically ill burn patients. The aim of this study was to assess the predictive value of haptoglobin at admission to predict major adverse kidney events (MAKE) and AKI in critically ill burn patients. METHODS: We conducted a retrospective, single-centre cohort study in a burn critical care unit in a tertiary centre, including all consecutive severely burned patients (total burned body surface > 20% and/or shock and/or mechanical ventilation at admission) from January 2012 to April 2017 with a plasmatic haptoglobin dosage at admission. RESULTS: A total of 130 patients were included in the analysis. Their mean age was 49 (34-62) years, their median total body surface area burned was 29% (15-51%) and the intensive care unit (ICU) mortality was 25%. Early haemolysis was defined as an undetectable plasmatic haptoglobin at admission. We used logistic regression to identify MAKE and AKI risk factors. In multivariate analysis, undetectable haptoglobin was associated with MAKE and AKI (respectively, OR 6.33, 95% CI 2.34-16.45, p < 0.001; OR 8.32, 95% CI 2.86-26.40, p < 0.001). CONCLUSIONS: Undetectable plasmatic haptoglobin at ICU admission is an independent risk factor for MAKE and AKI in critically ill burn patients. This study provides a rationale for biomarker-guided therapy using haptoglobin in critically ill burn patients.

A qualitative study of life events and psychological needs underlying the decision to have cosmetic surgery.

Objective A thorough psychological assessment of patients requesting cosmetic surgery can help to protect them from the risk of postoperative dissatisfaction and the onset and/or aggravation of psychiatric disorders. This study seeks to shed more light on why people desire cosmetic surgery and thus help surgeons, psychiatrists, and psychologists to conduct assessments before surgery. Methods In-depth interviews were conducted with 35 subjects who requested cosmetic surgery. The interviews were recorded and transcribed and then analyzed qualitatively with Grounded Theory. Themes and categories were identified and compared in logical order, to build a consistent theoretical model. Results In each interview, we identified one or more recent events that the subjects considered to be contributing factors in their decisions to have cosmetic surgery. We observed that 33 of 35 patients said they sought cosmetic surgery at a time when they were experiencing, or had just experienced, one or more major changes in their bodies or their relationships. Recent life events triggered or strengthened specific psychological needs in the subjects: to cope with the past and with change, attain a consistent identity, find or regain a positive self-image, alter others' perceptions, define themselves in relation to others, or please themselves or others. Patients said that they chose plastic surgery to fulfill one or more of these needs. Conclusions This study identifies the role of recent events in inciting individuals to resort to cosmetic surgery. This factor provides new perspectives for surgeons to understand those patients and opens new avenues for research.

Detection of Circulating Mucorales DNA in Critically Ill Burn Patients: Preliminary Report of a Screening Strategy for Early Diagnosis and Treatment.

BACKGROUND: Invasive wound mucormycosis (IWM) is associated with an extremely poor outcome among critically ill burn patients. We describe the detection of circulating Mucorales DNA (cmDNA) for the early diagnosis of IWM in those patients and report the potential value of detecting cmDNA for treatment guidance. METHODS: Severely ill burn patients admitted to our tertiary referral center between October 2013 and February 2016 were included. Retrospective plasma samples were tested for the presence of cmDNA by quantitative real-time polymerase chain reaction (qPCR). Patients were then prospectively screened twice a week, and liposomal amphotericin-B therapy initiated based on a positive qPCR. The primary endpoint was the time between cmDNA detection and standard diagnosis. Secondary endpoints were the time from cmDNA detection and treatment initiation and mortality. RESULTS: Seventy-seven patients (418 samples) were included. The average age was 46 (28-60) years, abbreviated burn severity index was 8 (7-10), and simplified acute physiology score was 33 (23-46). The total body surface area was 33% (22%-52%). cmDNA was detected 11 (4.5-15) days before standard diagnosis. The in-hospital mortality was 62% for patients with IWM and 24% for those without (P = .03). The mortality due to IWM was 80% during period A and 33% during period B (P = .46). CONCLUSIONS: This study suggests that the detection of cmDNA allows earlier diagnosis of IWM in severely ill burn patients and earlier initiation of treatment. Further studies are needed to confirm the impact of earlier treatment initiation on patient outcome.

Specificities of the Management of perineal burns.

There is a paucity of articles addressing the management strategy for perineal burns. Pelvic floor burns present a multitude of problems. These relate to the management of stool, urine, areas of maceration, significant strain, and the risk of infection. The objective of this study was to analyze a consecutive series of perineal burns by studying their characteristics, treatment, and the management of urine and feces. This was a retrospective study including 100 patients between January 2018 and December 2022. The patients had all been hospitalized after suffering burns to the perineum. In 28% of the patients, the perineal burn was complicated by infection. In 61% of cases, a cutaneous infection, in 32% of cases, a urinary tract infection, in 25% of cases, a respiratory tract infection, and in 7% of cases, an infection of the digestive tract. Superinfection is associated with an increased risk of poor engraftment. 100% of the patients with poor or average engraftment had an infection in the aftermath of the burn, compared with 20% of the patients with excellent engraftment and 61% of the patients with good engraftment. In our series, the analysis revealed that, in 95% of cases, no specific procedures were implemented for stool management. Perianal involvement was associated with a risk of sub-excellent engraftment. The results were statistically significant, with p=0.005 and an OR=8.72 after multivariate analysis. We favor the least invasive approach to stool management. Indications for a rectal catheter arise in patients with the following characteristics: the patient must be sedated, the burns must be deep and close to the anal opening, and the stools must be watery and abundant. In 95% of cases, we do not install a stool management device. Colostomies should remain exceptional.

Short- and long-term morbidity after Taylor flap (oblique rectus abdominis flap) for perineal reconstruction after abdominoperineal resection: A single-center series of 140 patients.

BACKGROUND: Abdominoperineal resection (APR) leads to a substantial loss of tissue and a high rate of complications. The Taylor flap is a musculocutaneous flap used in reconstruction after APR. OBJECTIVES: We aimed to analyze the short and long-term morbidity of reconstruction with a Taylor flap (oblique rectus abdominis flap) after APR and to identify the risk factors for postoperative complications. METHODS: We retrospectively included all patients who had undergone APR with immediate reconstruction with a Taylor flap in our department between July 2000 and June 2018. Demographics, oncological data, treatment, and short- and long-term morbidity were reviewed. RESULTS: Among the 140 patients included, we identified early minor complications in 42 patients (30%) and 14 early major complications (10%). Total necrosis of the flap requiring its removal occurred in four patients (2.8%). Eleven patients (7.9%) presented with a midline incision hernia, and seven (5%) presented with a subcostal incision hernia. No perineal hernia was found. No risk factors for the complications were identified. CONCLUSION: The Taylor flap is a safe procedure with few complications and limited donor site morbidity. Moreover, it prevents perineal hernias. These results confirm that the Taylor flap is a well-suited procedure for reconstruction after APR.

Glucocorticoid receptor activity discriminates between progesterone and medroxyprogesterone acetate effects in breast cells.

The purpose of this article is to determine the tumorigenic potential of estradiol treatment (E2) when combined with either progesterone (P4) or medroxyprogesterone acetate (MPA) in normal luminal human breast cells (HBE) and in human breast cancer cells (T47-D, MCF-7). Proliferation profiles were evaluated, along with the gene transactivation activity between the progesterone and glucocorticoid receptors (PR, GR) in HBE, T47-D, and MCF-7 cells treated by E2 + P4 or E2 + MPA. High throughput transcriptome analysis was performed on RNA from HBE cells treated by E2, E2 + MPA and E2 + P4. GR content was analyzed in normal breast cells as well. In HBE cells, E2 + P4 treatment was antiproliferative and promoted cellular differentiation. In contrast, E2 + MPA displayed mitogenic, antiapoptotic effects in HBE cells and did not influence cellular differentiation. The effect of P4 and MPA on cell proliferation was, however, variable in breast cancer cells. In cells containing GR or/and PR, MPA decreased proliferation whereas P4 antiproliferative effect needed the presence of PR. In HBE cells, the regulation of genes by E2 + P4, and E2 + MPA was significantly different, particularly in cell proliferation and cell death gene families. Further analysis revealed a modulation of the glucocorticoid receptor gene expression pathway by E2 + MPA. Predominant MPA glucocorticoid activity in normal and breast cancer cells was demonstrated using a glucocorticoid antagonist and the down-regulation of the GR by RNA interference. In normal luminal breast cells and in breast cancer cells, P4 and MPA combined with E2 treatment have opposing mitogenic effects due to GR. The consequences of MPA glucocorticoid potencies as well as the importance of GR in breast tissue merit a reappraisal.