A Strategic Core Role Perspective on Team Coordination: Benefits of Centralized Leadership for Managing Task Complexity in the Operating Room.

OBJECTIVE: We examine whether surgical teams can handle changes in task requirements better when their formal leader and strategic core role holder-that is, the main surgeon-is central to team coordination. BACKGROUND: Evidence regarding the benefits of shared leadership for managing complex tasks is divided. We tested whether a strategic core role holder's centrality in team coordination helps teams to handle different types of task complexity. METHOD: We observed coordination as specific leadership behavior in 30 surgical teams during real-life operations. To assess the strategic core role holder's coordination centrality, we conducted social network analyses. Task complexity (i.e., surgical difficulty and unexpected events) and surgical goal attainment were rated in a questionnaire. RESULTS: In the critical operation phase, surgical difficulty impaired goal attainment when the strategic core role holder's coordination centrality was low, while this effect was nonsignificant when his/her coordination centrality was high. Unexpected events had a negative effect on surgical goal attainment. However, coordination centrality of the strategic core role holder could not help manage unexpected events. CONCLUSION: The results indicate that shared leadership is not beneficial when teams face surgical difficulty during the critical operation phase. In this situation, team coordination should rather be centralized around the strategic core role holder. Contrarily, when unexpected events occur, centralizing team coordination around a single leader does not seem to be beneficial for goal attainment. APPLICATION: Leaders and team members should be aware of the importance of distributing leadership differently when it comes to managing different types of task complexity.

Autologous lipotransfer for bone defects secondary to osteomyelitis: A report of a novel method and systematic review of the literature.

Autologous bone grafting is the gold standard in patients with bone defects but is associated with significant pain and donor site morbidity. Autologous lipotransfer (fat grafting or lipofilling) has become very popular in the therapy of chronic wounds. Mesenchymal stem cells from adipose tissue are known for their regenerative, reparative, and immunomodulatory effects. This case study and review evaluates the use of autologous lipotransfer for chronic osteomyelitis in a 26-year-old patient. A 26-year-old female suffering from chronic tibial osteomyelitis was initially treated with surgical debridement and antibiotics followed by lipoharvest and autologous lipofilling. MRI and computed tomography scans were performed at 2 and 6 weeks and 6 months postoperatively. A formal systematic review of clinical trials investigating autologous lipotransfer for osteomyelitis was conducted. The patient remained asymptomatic without recurrence, and the bone defect cavity showed vascularised adipose tissue after 6 weeks, with early signs of osteogenesis. The highest foot and ankle disability index was 100. The systematic review identified 266 studies after duplicates were removed. After screening for eligibility, seven manuscripts were further assessed, with none meeting the inclusion criteria. This is the first study to report the successful use of autologous lipotransfer with early signs of osteogenesis in a patient suffering from chronic osteomyelitis. Autologous lipotransfer is relatively simple, safe, and minimally invasive, making it a potential alternative to current treatments. Further research is required to assess the safety, feasibility, and efficacy of autologous fat grafting and the mechanism of osteogenesis.

Occurrence of Occult Malignancies in Reduction Mammoplasties.

OBJECTIVES: Patients undergoing reduction mammoplasty (RM) bear the risk of having occult breast cancer nests. The detection rate of malignant neoplasms in the resected specimens, varies greatly in the literature. The aim of our present study was to analyze risk factors and evaluate histopathological findings in our cohort of patients who underwent RM towards our center. MATERIAL AND METHODS: In this retrospective single center study we analyzed 559 female patients [median age 35.99 (±13.34)] who underwent RM between 2000 and 2010. The presence of carcinoma and ductal- (DCIS) or lobular carcinoma in situ (LCIS) were considered as pathological findings. Body mass index (BMI), age, surgical technique and mass of resected tissue were included into the analysis. RESULTS: There were 6 cases of occult neoplasia (1.08 %) including 2 cases of breast cancer, one multicentric DCIS and 3 cases of LCIS (0.54 %) in 559 patients. Patients with breast cancer showed a significant increased median age: 49y median (IQR ± 18) vs. 35y (IQR ± 21) (p = 0.004) and a trend towards increased BMI: 25.88 median (IQR ± 7.3) vs. 24.50 (IQR ± 4.09) (p = 0.219), compared to patients without pathological results. One patient with occult carcinoma had a negative preoperative mammography, a patient with LCIS a negative preoperative breast ultrasound. CONCLUSIONS: In our study the occurrence of occult neoplasia was associated with increased age and showed a trend towards increased BMI when compared to patients without pathological findings. The study demonstrates the necessity of thorough medical history, preoperative diagnostic screening and histopathological analysis of all resected specimens.

Nikolaus Rüdinger (1832-1896), His Description of Joint Innervation in 1857, and the History of Surgical Joint Denervation.

BACKGROUND: Selective joint denervation has become a reliable palliative treatment, especially for painful joints in the upper and lower extremity. METHODS: This article highlights the life and work of Nikolaus Rüdinger (1832-1896) who first described joint innervation which became the basis of later techniques of surgical joint denervation. The historical evolution of this method is outlined. RESULTS: Rüdinger made a unique career from apprentice barber to military surgeon and anatomy professor in Munich, Germany. His first description of articular innervation of temporomandibular, shoulder, elbow, wrist, finger, sacroiliac, hip, knee, ankle, foot, and toe joints in 1857 stimulated the subsequent history of surgical joint denervation. Comparing his investigations with modern joint denervation methods, developed by pioneers like Albrecht Wilhelm or A. Lee Dellon, shows his great exactitude and anatomical correspondence despite different current terminology. Clinical series of modern surgical joint denervations reveal success rates of up to 80% with reliable long-term results. CONCLUSION: The history of joint denervation with Rüdinger as its important protagonist offers inspiring insights into the evolution of surgical techniques and exemplifies the value of descriptive functional anatomy, even if surgical application may not have been realized until a century later.

Dupuytren Disease: Is There Enough Comprehensive Patient Information on the Internet?

BACKGROUND: Dupuytren disease is a chronic nonmalign fibroproliferative disorder that causes finger contractures via proliferation of new tissue under the glabrous skin of the hand, resulting in multiple functional limitations for the patient. As many surgical therapy options exist, patients suffering from this condition actively search for information in their environment before consulting a health professional. OBJECTIVE: As little is known about the quality of Web-based patient information, the aim of this study was to conduct its systematic evaluation using a validated tool. METHODS: A total of 118 websites were included, and qualitative and quantitative assessment was performed using the modified Ensuring Quality Information for Patients (EQIP) tool. This standardized and reproducible tool consists of 36 items to assess available information in three categories: contents, identification, and structure data. Scientific data with restricted access, duplicates, and irrelevant websites were not included. RESULTS: Only 32 websites addressed more than 19 items, and the scores did not significantly differ among the website developers. The median number of items from the EQIP tool was 16, with the top websites addressing 28 out of 36 items. The quality of the newly developed websites did not increase with passing time. CONCLUSIONS: This study revealed several shortcomings in the quality of Web-based information available for patients suffering from Dupuytren disease. In the world of continuously growing and instantly available Web-based information, it is the health providers' negligence of the last two decades that there are very few good quality, informative, and educative websites that could be recommended to patients.

Systematic Review of Quality of Patient Information on Liposuction in the Internet.

BACKGROUND: A large number of patients who are interested in esthetic surgery actively search the Internet, which represents nowadays the first source of information. However, the quality of information available in the Internet on liposuction is currently unknown. The aim of this study was to assess the quality of patient information on liposuction available in the Internet. METHODS: The quantitative and qualitative assessment of Web sites was based on a modified Ensuring Quality Information for Patients tool (36 items). Five hundred Web sites were identified by the most popular web search engines. RESULTS: Two hundred forty-five Web sites were assessed after duplicates and irrelevant sources were excluded. Only 72 (29%) Web sites addressed >16 items, and scores tended to be higher for professional societies, portals, patient groups, health departments, and academic centers than for Web sites developed by physicians, respectively. The Ensuring Quality Information for Patients score achieved by Web sites ranged between 8 and 29 of total 36 points, with a median value of 16 points (interquartile range, 14-18). The top 10 Web sites with the highest scores were identified. CONCLUSIONS: The quality of patient information on liposuction available in the Internet is poor, and existing Web sites show substantial shortcomings. There is an urgent need for improvement in offering superior quality information on liposuction for patients intending to undergo this procedure.

Microbiological findings in burn patients treated in a general versus a designated intensive care unit: Effect on length of stay.

BACKGROUND: Infection is one of the most common causes of mortality and morbidity in burn patients. The incidence and frequency of microbiological micro-organisms are known to vary across different models of intensive care units. To date, no study has attempted to describe the different findings in burn patients treated in an open, general intensive care unit (GICU) versus a dedicated burns intensive care unit (BICU). Only limited data is available on the effect of these microbiological micro-organisms on patients' length of stay. AIM: To characterize and compare the microbiological flora and antibiotic resistance patterns encountered in two different models of burn intensive care and to determine the effect of specific microbiological types on length of intensive care unit (ICU) and overall stay. METHODS: A retrospective case-control study of 209 burn patients treated in two highly specialized, Western burn referral centres between September 2009 and March 2014. RESULTS: 9710 culture results were analysed, of which 2590 (26.7%) yielded positive results (1537 in the GICU and 1050 in the BICU). Gram-positive cultures were more frequently found in the GICU, whereas Gram-negative and yeast cultures were more prevalent in the BICU. The most frequently encountered micro-organisms in both units were similar and included Staphylococcus aureus, Pseudomonas aeruginosa, coagulase-negative staphylococci (CoNS) and Candida albicans. Significantly more resistant bacteria were detected in the BICU. Testing positive across all types of microbiological isolates, as well as for both Gram-positive and -negative bacteria significantly prolonged patient length of stay. This effect was even more pronounced if the micro-organisms were resistant to antimicrobial therapy. CONCLUSION: There are notable differences in the microbiological isolate and antibiotic resistance patterns between burn patients treated in a GICU compared to a designated BICU. In both units, testing positive for resistant microbiological micro-organisms is significantly associated with longer hospital stay.

Quality of information for women seeking breast augmentation in the Internet.

Background Recently published data show that many women interested in breast augmentation (BA) actively search the Internet for information. The Internet is currently the main source of information on this topic. Objectives Little is known about the quality of available information on the Internet concerning BA. The goal was to evaluate this in a systematic manner using a validated and reproducible tool. Methods Women (n = 96) unrelated to medicine were asked which keywords they would use to search the Internet if they were interested in BA. Five keywords were used. Qualitative and quantitative assessment was performed with the modified Ensuring Quality Information for Patients (EQIP) tool. A total of 2500 websites containing information on BA were identified using Google, Bing, Yahoo, Ask, and AOL. Results Out of 623 eligible websites, only 153 (25%) addressed more than 20 EQIP items. Scores were higher for encyclopaedias and academic websites compared to hospital and practitioner websites. The median EQIP score was only 15 (IQR = 12-20), and quantitative postoperative morbidity and mortality risk estimates were available in only 38% and 25% of the websites, respectively. Major complications (e.g. capsular contraction, implant safety) were mentioned in only 156 (25%) of the websites. Conclusions This is the first assessment of online patient information on BA using the EQIP tool. This analysis demonstrated several shortcomings in the quality of information provided to BA candidates. There is an immediate need for better informative and educational websites regarding BA procedures that are compatible with international quality standards for plastic surgery.

Adaptive coordination in surgical teams: an interview study.

BACKGROUND: Effective teamwork has been recognised as a major contributor to safe patient care in surgery. Previous research has highlighted the importance of adaptive coordination for effective performance in acute care settings. Expanding this line of research this study explores the coordination behaviours and adaptive coordination strategies employed by surgical teams and identifies relevant situational characteristics influencing those coordination processes. METHOD: We conducted a qualitative content analysis of semi-structured interviews with 33 surgical team members (nurses and physicians) from different specialties and hospitals. RESULTS: We identified coordination behaviours (i.e. task management, information management, teaching and leadership) and adaptive coordination strategies triggered by varying requirements due to non-routine events, intraoperative complications and differing level of experience among operating room staff. Interviewees highlighted the importance of effectively managing challenging moments and the supporting effect of positive climate on teamwork. CONCLUSIONS: This study complements previous research on the non-technical skills underpinning safe performance in surgical teams. It highlights the central role of coordination and points out the ways in which situational variability requires the team to behave adaptively.

Otfrid Foerster (1873-1941)--self-taught neurosurgeon and innovator of reconstructive peripheral nerve surgery.

Otfrid Foerster (1873-1941) became a self-taught neurosurgeon during and after WW I, playing a critical role in the development of peripheral nerve reconstruction. Although best known for describing dermatomes, he published over 300 articles on the nervous system. Confronted by thousands of nerve injuries during WW I, as well as poor results and disinterest from his surgical colleagues, Foerster began performing neurolysis and tension-free nerve repairs himself under emergency conditions. He pioneered grafting motor nerve defects by expendable cutaneous nerves (e.g., sural) and performed intraplexal neurotizations and various nerve transfers, such as the pectoral, subscapular, long thoracic, and thoracodorsal nerves in brachial plexus injuries. Foerster championed rehabilitation, recognizing the potential of electrostimulation and physiotherapy to influence cortical reorganization (brain plasticity) and improve recovery after nerve injury. Foerster died from tuberculosis in 1941, leaving a rich reconstructive peripheral nerve legacy; his innovative and visionary spirit serves as a role model.

Attempted suicide by self-immolation is a powerful predictive variable for survival of burn injuries.

Up to 9% of all burn victims in western countries are reported to have been caused by self-immolation with suicidal intent and usually involve extensive injuries. The authors sought to identify differences between suicide burn victims as opposed to those who sustained their injuries accidentally with regard to injury severity and mortality and determine the possible impact of suicide as a prognostic variable in the context of a scoring system such as the Abbreviated Burns Severity Index (ABSI). The data of all burns patients treated at the Specialist Burns Intensive Care Unit, University Hospital Zürich, between 1968 and 2008 were analyzed retrospectively. Of the 2813 patients included in the study, 191 were identified as attempted suicides, most commonly involving the use of accelerants. Thirty percent of all suicide victims had preexisting psychiatric diagnoses. Suicide victims presented with significantly more extensive burns (53.7%, ±0.98 SEM vs 21.4 %, ±0.36 SEM, P < .0001), had higher total ABSI scores (8.4, ±0.23 SEM vs 6.6, ±0.05 SEM, P < .0001), and had higher mortality rates (42.9% [83/191] vs 16.3% [426/2622]) than accident victims. Furthermore, logistic regression revealed suicide to be a significant predictor of mortality as inhalation injury (odds ratio 2.2, 95% confidence interval 1.4-3.5, P < .0003 and odds ratio 2.4, 95% confidence interval 1.4-4.0, P < .0009, respectively). The odds of dying from an attempted suicide are twice as high compared with those of accident patients in the same ABSI category, making suicide a powerful predictor of mortality. The authors therefore suggest including it as a fixed variable in scoring systems for estimating a patient's mortality after burn injuries such as the widely used ABSI.

Validation of the Zürich burn-biofilm model.

BACKGROUND: Despite advances in the use of topical and parenteral antimicrobial therapy and the practice of early tangential burn-wound excision, bacterial infection remains a major problem in the management of burn victims today. The purpose of this study was to design and evaluate a polyspecies biofilm model with bacteria known to cause severe infections in burn patients. The model is simple to prepare, maintain and analyse, and allows for short-term exposure to antimicrobials. RESULTS: Initial experiments showed that it was impossible to establish balanced polyspecies biofilms with an inoculum of Gram-positive and -negative bacteria. After 64.5 h of incubation, the Gram-negative bacteria (Escherichia coli and Pseudomonas aeruginosa) had suppressed the Gram-positives (Enterococcus faecalis, Staphylococcus aureus and Streptococcus intermedius). However, adding the Gram-negative bacteria after 41.5 h to an established biofilm of Gram-positives resulted in a balanced microbial consortium. After 64.5 h, all species were present in high numbers (10(7) to 10(8) colony forming units (CFU) per biofilm). Multiple repetitions showed high reproducibility of biofilm formation without significant differences between and within experiments. Combined fluorescence in situ hybridisation/confocal laser scanning microscopy (FISH/CLSM) analyses, for which biofilms had to be grown on a different non-flexible substrate (hydroxy apatite), revealed that, by 41.5 h, the biofilm consisted of an almost confluent layer of bacteria firmly adherent to the substratum. After 64.5 h (22 h after the addition of the Gram negatives), the biofilm consisted of a confluent mixture of single cells, an abundance of galaxies of bacteria with small lacunae and large amounts of extracellular matrix polysaccharides. CONCLUSIONS: The polyspecies biofilm model contains the most prevalent burn-associated Gram-positive and Gram-negative bacterial pathogens and mimics the Gram-negative shift observed in vivo. It shows excellent reproducibility. It should allow adaptation to the bacterial spectrum prevalent in different burn centres and lead to a much more reliable investigation of the efficiency of topical antimicrobial agents than models operating with planktonic bacteria. The experiments further open up the perspective to create an in vivo model using these biofilms as infectious agents.

30 years later--does the ABSI need revision?

In light of changes in patient demographics together with constant developments in burn care, the predictive accuracy of the Abbreviated Burns Severity Index (ABSI) - first described in 1982 - for estimating the mortality of present day burns patients, may be questionable. We reviewed the records of 2813 burns patients treated between January 1968 and December 2008 in the intensive care unit at our institution, aiming to identify emerging discrepancies between the estimated and calculated outcome, based on each of the ABSI variables and the total burn score. The predictive value of each of the defined ABSI variables was confirmed to be highly significant. Univariable and multivariable analysis revealed an exponential increase in odds ratio (OR) for mortality for patients older than 60 years and more than 30% TBSA burned and showed OR values over 10 times higher than other significant variables like inhalation injury. Nevertheless, the ABSI for the estimation of mortality in our entire patient collective was highly accurate and could not be optimised by adapting the point distribution to the increase in OR. Our data indicates that despite significant changes in patient demographics and medical advances over the past 30 years, the ABSI scoring system is still an accurate and valuable tool in the prediction of burn patient mortality.

Spider silk constructs enhance axonal regeneration and remyelination in long nerve defects in sheep.

BACKGROUND: Surgical reapposition of peripheral nerve results in some axonal regeneration and functional recovery, but the clinical outcome in long distance nerve defects is disappointing and research continues to utilize further interventional approaches to optimize functional recovery. We describe the use of nerve constructs consisting of decellularized vein grafts filled with spider silk fibers as a guiding material to bridge a 6.0 cm tibial nerve defect in adult sheep. METHODOLOGY/PRINCIPAL FINDINGS: The nerve constructs were compared to autologous nerve grafts. Regeneration was evaluated for clinical, electrophysiological and histological outcome. Electrophysiological recordings were obtained at 6 months and 10 months post surgery in each group. Ten months later, the nerves were removed and prepared for immunostaining, electrophysiological and electron microscopy. Immunostaining for sodium channel (NaV 1.6) was used to define nodes of Ranvier on regenerated axons in combination with anti-S100 and neurofilament. Anti-S100 was used to identify Schwann cells. Axons regenerated through the constructs and were myelinated indicating migration of Schwann cells into the constructs. Nodes of Ranvier between myelin segments were observed and identified by intense sodium channel (NaV 1.6) staining on the regenerated axons. There was no significant difference in electrophysiological results between control autologous experimental and construct implantation indicating that our construct are an effective alternative to autologous nerve transplantation. CONCLUSIONS/SIGNIFICANCE: This study demonstrates that spider silk enhances Schwann cell migration, axonal regrowth and remyelination including electrophysiological recovery in a long-distance peripheral nerve gap model resulting in functional recovery. This improvement in nerve regeneration could have significant clinical implications for reconstructive nerve surgery.

Local burn versus local cold induced acute effects on in vivo microcirculation and histomorphology of the human skin.

BACKGROUND: The impact of burns and colds on human skin microcirculation and histomorphology has not been compared as yet. Reflectance confocal microscopy (RCM) enables in vivo insight in human skin on cellular and subcellular levels. We evaluated analogies and differences of thermal injuries on microcirculation and histomorphology in vivo using RCM. METHODS: Local superficial burn (6 female, 4 male; aged 28.4 ± 2.9 years, burn group) versus superficial cold (4 female, 6 male; aged 30.4 ± 5.2 years, cold group) was induced on the dorsum of the hand in an experimental immersion hand model. In vivo RCM was performed prior (control), immediately (t1) and 15 minutes (t2) following thermal injury to evaluate: Individual blood cell flow (IBCF), functional capillary density (FCD), epidermal thickness (ET), and granular cell size (GCS). RESULTS: In the burn group, IBCF was increased at t1 (78.02 ± 2.60/min) and remained elevated at t2 (84.16 ± 3.04/min). In the cold group, IBCF decreased at t1 (12.62 ± 2.12 min) and increased at t2 (74.24 ± 3.14/min, P < 0.05) compared to the controls (58.23 ± 3.21/min). FCD was 6.74 ± 0.52/mm(2) in controls and increased at both t1 (7.82 ± 0.72/mm(2)) and t2 (8.02 ± 0.81/mm(2)) in the burn group. In the cold group, FCD decreased at t1 (2.60 ± 0.42/mm(2)) and increased at t2 (7.92 ± 0.44/mm(2), P < 0.05). ET increased at both t1 (43.12 ± 4.08 µm, P > 0.05) and t2 (47.26 ± 4.72 µm, P < 0.05) in the burn group. In the cold group, ET decreased at t1 (39.92 ± 3.14 µm, P > 0.05) and increased at t2 (44.72 ± 4.06 µm, P < 0.05) compared to the controls (41.26 ± 3.82 µm). Control GCS was 726.9 ± 59.4 µm(2) and increased at both t1 (739.8 ± 69.8 µm(2), P > 0.05) and t2 (762.6 ± 71.4 µm(2), P < 0.05) in the burn group. In the cold group, GCS decreased at t1 (712.4 ± 53.8 µm(2), P > 0.05) and increased at t2 (742.6 ± 64.8 µm(2), P < 0.05). CONCLUSIONS: Superficial burn induces more cellular destruction and cold leads to huge fluctuation in tissue perfusion, however, with moderate impact on histomorphology. The effect on dermal capillaries suggests a selective neural control and cold injuries might down-regulate this system, much more than burns can activate it.

Interactions between spider silk and cells--NIH/3T3 fibroblasts seeded on miniature weaving frames.

BACKGROUND: Several materials have been used for tissue engineering purposes, since the ideal matrix depends on the desired tissue. Silk biomaterials have come to focus due to their great mechanical properties. As untreated silkworm silk has been found to be quite immunogenic, an alternative could be spider silk. Not only does it own unique mechanical properties, its biocompatibility has been shown already in vivo. In our study, we used native spider dragline silk which is known as the strongest fibre in nature. METHODOLOGY/PRINCIPAL FINDINGS: Steel frames were originally designed and manufactured and woven with spider silk, harvesting dragline silk directly out of the animal. After sterilization, scaffolds were seeded with fibroblasts to analyse cell proliferation and adhesion. Analysis of cell morphology and actin filament alignment clearly revealed adherence. Proliferation was measured by cell count as well as determination of relative fluorescence each after 1, 2, 3, and 5 days. Cell counts for native spider silk were also compared with those for trypsin-digested spider silk. Spider silk specimens displayed less proliferation than collagen- and fibronectin-coated cover slips, enzymatic treatment reduced adhesion and proliferation rates tendentially though not significantly. Nevertheless, proliferation could be proven with high significance (p<0.01). CONCLUSION/SIGNIFICANCE: Native spider silk does not require any modification to its application as a biomaterial that can rival any artificial material in terms of cell growth promoting properties. We could show adhesion mechanics on intracellular level. Additionally, proliferation kinetics were higher than in enzymatically digested controls, indicating that spider silk does not require modification. Recent findings concerning reduction of cell proliferation after exposure could not be met. As biotechnological production of the hierarchical composition of native spider silk fibres is still a challenge, our study has a pioneer role in researching cellular mechanics on native spider silk fibres.

Early fluid resuscitation with hyperoncotic hydroxyethyl starch 200/0.5 (10%) in severe burn injury.

INTRODUCTION: Despite large experience in the management of severe burn injury, there are still controversies regarding the best type of fluid resuscitation, especially during the first 24 hours after the trauma. Therefore, our study addressed the question whether hyperoncotic hydroxyethyl starch (HES) 200/0.5 (10%) administered in combination with crystalloids within the first 24 hours after injury is as effective as 'crystalloids only' in severe burn injury patients. METHODS: 30 consecutive patients were enrolled to this prospective interventional open label study and assigned either to a traditional 'crystalloids only' or to a 'HES 200/0.5 (10%)' volume resuscitation protocol. Total amount of fluid administration, complications such as pulmonary failure, abdominal compartment syndrome, sepsis, renal failure and overall mortality were assessed. Cox proportional hazard regression analysis was performed for binary outcomes and adjustment for potential confounders was done in the multivariate regression models. For continuous outcome parameters multiple linear regression analysis was used. RESULTS: Group differences between patients receiving crystalloids only or HES 200/0.5 (10%) were not statistically significant. However, a large effect towards increased overall mortality (adjusted hazard ratio 7.12; P = 0.16) in the HES 200/0.5 (10%) group as compared to the crystalloids only group (43.8% versus 14.3%) was present. Similarly, the incidence of renal failure was 25.0% in the HES 200/0.5 (10%) group versus 7.1% in the crystalloid only group (adjusted hazard ratio 6.16; P = 0.42). CONCLUSIONS: This small study indicates that the application of hyperoncotic HES 200/0.5 (10%) within the first 24 hours after severe burn injury may be associated with fatal outcome and should therefore be used with caution. TRIAL REGISTRATION: NCT01120730.

Management of microstomia in adult burn patients revisited.

OBJECTIVE: This study aims to review our experience in the surgical management of microstomia following facial burns. PATIENTS AND METHODS: For this retrospective study, we searched our burn patients' database for oral commissuroplasties with local mucosal flaps and reviewed the 18 patients suffering from microstomia after facial burns who had been operatively treated between 1995 and March 2007. Fifteen of the patients were primarily treated for severe facial burns in our burns unit, three were referred to our outpatients clinic for secondary reconstruction. Reconstruction of the oral commissures was performed according to one of the following methods: (1) triangular scar excision and mucosal Y-V advancement (n=10), (2) scar excision and wound closure with full-thickness or split-skin graft (n=4) and (3) division of the contracture and closure of the resulting defect with two rhomboid mucosal flaps per side (n=4). RESULTS: All patients showed acceptable aesthetic results and a good functional outcome. Apart from minor wound-healing disturbances, which neither required surgery nor worsened the result, no complications were observed. Patient satisfaction was high. CONCLUSION: Commissuroplasty is an early functional post-burn corrective procedure that often must be performed prior to completion of scar maturation. Mucosal advancement flaps are a viable procedure for the treatment of microstomia after facial burns, resulting in good aesthetic and functional outcome. Direct scar excision and skin grafting, although unavoidable in cases of extensive perioral scarring, frequently produces inferior results.