The impact of different co-morbidities on clinical outcomes and resource utilization in critically ill burn and surgical patients: A population-based analysis of social determinants of health.

BACKGROUND: This study aims to establish the significance of social determinants of health and prevalent co-morbidities on multiple indicators for quality of care in patients admitted to the Burn and Surgical Intensive Care Unit (ICU). METHODS: We performed a retrospective analysis of population group data for patients admitted at the Burn and Surgical ICU from January 1, 2016, to November 18, 2019. The primary outcomes were length of hospital stay (LOS), mortality, 30-day readmission, and hospital charges. Pearson's chi-square test for categorical variables and t-test for continuous variables were used to compare population health groups. RESULTS: We analyzed a total of 487 burn and 510 surgical patients. When comparing ICU patients, we observed significantly higher mean hospital charges and length of stay (LOS) in BICU v. SICU patients with a history of mental health ($93,259.40 v. $50,503.36, p = 0.013 and 16.28 v. 9.16 days, p = 0.0085), end-stage-renal-disease (ESRD) ($653,871.05 v. $75,746.35, p = 0.0047 and 96.15 v. 17.53 days, p = 0.0104), sepsis ($267,979.60 v. $99,154.41, p = <0.001 and 39.1 v. 18.42 days, p = 0.0043), and venous thromboembolism (VTE) ($757,740.50 v. $117,816.40, p = <0.001 and 93.11 v. 20.21 days, p = 0.002). Also, higher mortality was observed in burn patients with ESRD, ST-Elevation Myocardial Infarction (STEMI), sepsis, VTE, and diabetes mellitus. 30-day-readmissions were greater among burn patients with a history of mental health, drug dependence, heart failure, and diabetes mellitus. CONCLUSIONS: Our study provides new insights into the variability of outcomes between burn patients treated in different critical care settings, underlining the influence of comorbidities on these outcomes. By comparing burn patients in the BICU with those in the SICU, we aim to highlight how differences in patient backgrounds, including the quality of care received, contribute to these outcomes. This comparison underscores the need for tailored healthcare strategies that consider the unique challenges faced by each patient group, aiming to mitigate disparities in health outcomes and healthcare spending. Further research to develop relevant and timely interventions that can improve these outcomes.

Invasive Non-Candida Fungal Infections in Acute Burns-A 13-Year Review of a Single Institution and Review of the Literature.

The past decade has demonstrated increased burn wound infections with atypical invasive fungal organisms. The range of previously regiospecific organisms has expanded, and plant pathogens are increasingly represented. Our institution sought to examine changes in severe fungal non-Candida infections in our patients, via retrospective review of patients admitted to our burn center from 2008 to 2021. We identified 37 patients with atypical invasive fungal infections. Non-Candida genera included Aspergillus (23), Fusarium (8), Mucor (6), and 13 cases of 11 different species, including the second-ever human case of Petriella setifera. Three fungi were resistant to at least one antifungal. Concomitant infections included Candida (19), Staphylococcus and Streptococcus (14), Enterococcus and Enterobacter (13), Pseudomonas (9), and 14 additional genera. Complete data was available for 18 patients, who had a median of 3.0 (IQR 8.5, range 0-15) additional bacteria required a median of 1 (IQR 7, range 0-14) systemic antibacterials and 2 (IQR 2.5, range 0-4) systemic antifungals. One case of total-drug-resistant Pseudomonas aeruginosa required bacteriophage treatment. One case of Treponema pallidum was found in infected burn wound tissue. Every patient required Infectious Disease consultation. Eight patients became bacteremic and one developed Candida fermentatifungemia. There were five patient deaths (13.8%), all due to overwhelming polymicrobial infection. Burn patients with atypical invasive fungal infections can have severe concomitant polymicrobial infections and multidrug resistance with fatal results. Early Infectious Disease consultation and aggressive treatment is critical. Further characterization of these patients may provide better understanding of risk factors and ideal treatmentpatterns.

Target Receptors of Regenerating Nerves: Neuroma Formation and Current Treatment Options.

Neuromas form as a result of disorganized sensory axonal regeneration following nerve injury. Painful neuromas lead to poor quality of life for patients and place a burden on healthcare systems. Modern surgical interventions for neuromas entail guided regeneration of sensory nerve fibers into muscle tissue leading to muscle innervation and neuroma treatment or prevention. However, it is unclear how innervating denervated muscle targets prevents painful neuroma formation, as little is known about the fate of sensory fibers, and more specifically pain fiber, as they regenerate into muscle. Golgi tendon organs and muscle spindles have been proposed as possible receptor targets for the regenerating sensory fibers; however, these receptors are not typically innervated by pain fibers, as these free nerve endings do not synapse on receptors. The mechanisms by which pain fibers are signaled to cease regeneration therefore remain unknown. In this article, we review the physiology underlying nerve regeneration, the guiding molecular signals, and the target receptor specificity of regenerating sensory axons as it pertains to the development and prevention of painful neuroma formation while highlighting gaps in literature. We discuss management options for painful neuromas and the current supporting evidence for the various interventions.

Oncologic Safety of Autologous Fat Grafting in Breast Reconstruction.

Autologous fat grafting is a useful adjunct to breast reconstruction to address contour changes, volume loss, and deformity. More recent benefits observed include mitigation of pain and inflammation. Although there is no clinical evidence to suggest an increased risk in recurrence or new cancer development in fat grafting for breast reconstruction, the oncologic safety of grafting has come into question. Adipose tissue grafts contain progenitor cells and immunomodulatory cytokines, which may induce vasculogenesis or tumor progression or recurrence at the site. Although these are all theoretical concerns, there is a discrepancy between basic science research and clinical outcomes studies. In this review, the authors summarize available literature regarding three important controversies in fat grafting for oncologic breast reconstruction: the interaction of graft component cells, such as adipose-derived stem cells, with cancer cells; the concern of fat grafting interference with breast cancer screening and detection; and clinical evidence regarding the oncologic safety of fat grafting following breast cancer treatment.

The Evolving Trends in the Impact Factor of Plastic Surgery Journals: A 22-Year Analysis.

BACKGROUND: The journal impact factor (IF) is one of the most widely adopted metrics to assess journal value. We aimed to investigate the trends in the IF and ranking of plastic surgery journals (PSJs) over a 22-year period. METHODS: The Journal Citation Report 2018 was used to identify all journals within the field of plastic surgery from 1997 to 2018. We analyzed the IF of PSJs and that of the category surgery. RESULTS: A total of 34 PSJs were identified. The mean IF increased from 0.584 (median, 0.533) in 1997 to 1.58 (median, 1.399) in 2018 (P < 0.0001). Over the same time, the median IF of the journals in the category surgery increased from 0.914 to 1.883. The mean journal IF percentile of PSJs within surgery remained fairly stable (P = 0.999). A strong positive correlation was identified between the IF of PSJs and both the 5-year IF (r = 0.943, P < 0.0001) and the immediacy index (r = 0.736, P < 0.0001). The percentage of self-citations across the study period was fairly stable at a mean of 19.2%. A weak positive correlation was found between the IF and the percentage of self-citations (r = 0.171, P < 0.0001). CONCLUSIONS: The mean journal IF in PSJs has been trending upward over the last 22 years. Ranking of PSJs IF within the category surgery has remained unchanged. The self-citation rate has been fairly stable and correlated weakly with the IF. A strong positive correlation exists between the IF and both the immediacy index and the 5-year IF.

A retrospective cohort analysis of the effects of renin-angiotensin system inhibitors on spinal fusion in ACDF patients.

BACKGROUND CONTEXT: Recently, preclinical and clinical studies suggest an association between renin-angiotensin system (RAS) blockers and bone healing, particularly in the context of osteoporotic bone fractures. PURPOSE: To determine the correlation between the use of RAS inhibitors and fusion outcomes and neurologic status in anterior cervical discectomy and fusion (ACDF) surgery. STUDY DESIGN: Retrospective observational study. PATIENT SAMPLE: Patients who underwent ACDF for degenerative disorders. OUTCOME MEASURES: Spinal fusion status and neurologic function (modified Japanese Orthopedic Association [mJOA] and Nurick grading scales). METHODS: A retrospective chart review was performed, including 200 patients who underwent ACDF for degenerative disorders with 1-year minimum follow-up. Demographic data, comorbidities, antihypertensive medication, neurologic examination, and fusion status were collected. Spinal fusion was assessed via plain cervical x-ray, resorting to dynamic radiographs and/or computer tomography (CT) in cases of uncertainty. Preoperative mJOA and Nurick scores and recovery rates were calculated to determine neurologic status. RESULTS: Of the 200 patients (42.5% females, 57.5% males, median age of 53.7 years), 82 hypertensive patients were identified. Seventy-seven (93.9%) were taking antihypertensive medication as follows: 36.4% angiotensin-II receptor blockers (ARBs), 35.1% angiotensin-converting enzyme inhibitors (ACEIs), and the remaining patients were taking other medication. In the analysis of fusion rates, patients treated with ARBs exhibited a higher fusion rate, while those treated with ACEIs displayed a lower fusion rate compared to untreated nonhypertensive patients (p = .04 and .02, respectively). The difference in fusion rates between ARBs and ACEIs was also significant, with the former displaying higher rates (p < .001). Smoking exhibited a negative correlation with spinal fusion (p < .001). In the multivariate analysis, ARBs remained an independent factor for successful fusion (p = .02), while smoking remained a risk factor for failed fusion (p = .002). In the neurologic examination, ACEIs, hypertension status, and older age correlated with lower modified Japanese Orthopedic Association (mJOA) recovery rates (p = .001, <.001, and <.001, respectively) in the univariate analysis. CONCLUSIONS: In ACDF patients, we observed that ARBs were associated with higher fusion rates. Conversely, ACEIs and smoking were related to failed fusion. Prospective case-control studies are needed to confirm these RAS inhibitors effects on spinal fusion.

Polymorphisms of a Collagen-Like Adhesin Contributes to Legionella pneumophila Adhesion, Biofilm Formation Capacity and Clinical Prevalence.

Legionellosis is a severe respiratory illness caused by the inhalation of aerosolized water droplets contaminated with the opportunistic pathogen Legionella pneumophila. The ability of L. pneumophila to produce biofilms has been associated with its capacity to colonize and persist in human-made water reservoirs and distribution systems, which are the source of legionellosis outbreaks. Nevertheless, the factors that mediate L. pneumophila biofilm formation are largely unknown. In previous studies we reported that the adhesin Legionella collagen-like protein (Lcl), is required for auto-aggregation, attachment to multiple surfaces and the formation of biofilms. Lcl structure contains three distinguishable regions: An N-terminal region with a predicted signal sequence, a central region containing tandem collagen-like repeats (R-domain) and a C-terminal region (C-domain) with no significant homology to other known proteins. Lcl R-domain encodes tandem repeats of the collagenous tripeptide Gly-Xaa-Yaa (GXY), a motif that is key for the molecular organization of mammalian collagen and mediates the binding of collagenous proteins to different cellular and environmental ligands. Interestingly, Lcl is polymorphic in the number of GXY tandem repeats. In this study, we combined diverse biochemical, genetic, and cellular approaches to determine the role of Lcl domains and GXY repeats polymorphisms on the structural and functional properties of Lcl, as well as on bacterial attachment, aggregation and biofilm formation. Our results indicate that the R-domain is key for assembling Lcl collagenous triple-helices and has a more preponderate role over the C-domain in Lcl adhesin binding properties. We show that Lcl molecules oligomerize to form large supramolecular complexes to which both, R and C-domains are required. Furthermore, we found that the number of GXY tandem repeats encoded in Lcl R-domain correlates positively with the binding capabilities of Lcl and with the attachment and biofilm production capacity of L. pneumophila strains. Accordingly, the number of GXY tandem repeats in Lcl influences the clinical prevalence of L. pneumophila strains. Therefore, the number of Lcl tandem repeats could be considered as a potential predictor for virulence in L. pneumophila isolates.

Small Rho GTPases and the Effector VipA Mediate the Invasion of Epithelial Cells by Filamentous Legionella pneumophila.

Legionella pneumophila (Lp) exhibits different morphologies with varying degrees of virulence. Despite their detection in environmental sources of outbreaks and in respiratory tract secretions and lung autopsies from patients, the filamentous morphotype of Lp remains poorly studied. We previously demonstrated that filamentous Lp invades lung epithelial cells (LECs) and replicates intracellularly in a Legionella containing vacuole. Filamentous Lp activates ß1integrin and E-cadherin receptors at the surface of LECs leading to the formation of actin-rich cell membrane structures we termed hooks and membrane wraps. These structures entrap segments of an Lp filament on host cell surface and mediate bacterial internalization. Here we investigated the molecular mechanisms responsible for the actin rearrangements needed for the formation and elongation of these membrane wraps and bacterial internalization. We combined genetic and pharmacological approaches to assess the contribution of signaling downstream of ß1integrin and E-cadherin receptors, and Lp Dot/Icm secretion system- translocated effectors toward the invasion process. Our studies demonstrate a multi-stage mechanism of LEC invasion by filamentous Lp. Bacterial attachment to host cells depends on signaling downstream of ß1integrin and E-cadherin activation, leading to Rho GTPases-dependent activation of cellular actin nucleating proteins, Arp2/3 and mDia. This mediates the formation of primordial membrane wraps that entrap the filamentous bacteria on the cell surface. Following this, in a second phase of the invasion process the Dot/Icm translocated effector VipA mediates rapid membrane wrap elongation, leading to the engulfment of the filamentous bacteria by the LECs. Our findings provide the first description of Rho GTPases and a Dot/Icm effector VipA regulating the actin dynamics needed for the invasion of epithelial cells by Lp.