Patent foramen ovale closure in ischemic stroke patients with and without thrombophilia: a systematic review and meta-analyses.

Ischemic stroke patients with thrombophilia and patient foramen ovale (PFO) may have an increased risk of recurrent stroke and transient ischemic attack (TIA), and may benefit from PFO closure. However, screening for thrombophilia is not routinely performed and the impact of thrombophilia on prognosis after PFO closure is uncertain. We aim to compare the risk of recurrent stroke and TIA after PFO closure in patients with thrombophilia versus those without. We performed a systematic review and meta-analyses of the literature, with a comprehensive literature search performed on 12 January 2023. Studies comparing the outcomes of patients with and without thrombophilia after PFO closure were included. The primary outcome evaluated was a recurrence of acute cerebrovascular event (ACE), a composite of recurrent ischemic stroke and recurrent TIA. The secondary outcomes included recurrent ischemic stroke only or TIA only. A total of 8 cohort studies were included, with a total of 3514 patients. There was an increased risk of stroke/TIA in patients with thrombophilia compared to those without thrombophilia after PFO (OR: 1.42, 95% CI: 1.01-1.99, I2 = 50%). The association between risk of TIA only (OR: 1.36, 95% CI: 0.77-2.41, I2 = 0%) and stroke only (OR: 1.09, 95% CI: 0.54-2.21, I2 = 0%) with thrombophilia did not reach statistical significance. There is an increased risk of recurrent cerebral ischemia event in patients with thrombophilia compared to those without thrombophilia after PFO closure. Future large prospective studies are necessary to characterise the risk and benefits of PFO closure, as well as the appropriate medical treatment to reduce the risk of recurrent stroke and TIA in this high-risk population.

A prospective study comparing the FLIR ONE with laser Doppler imaging in the assessment of burn depth by a tertiary burns unit in the United Kingdom.

INTRODUCTION: Laser Doppler imaging (LDI) is the 'gold standard' tool for the assessment of burn depth. However, it is costly. The FLIR ONE is a novel, mobile-attached, thermal imaging camera used to assess burn wound temperature. This study compares the FLIR ONE and LDI in assessing burn depth and predicting healing times. METHODS: Forty-five adult patients with burn wounds, presenting at 1-5 days, were imaged with the FLIR ONE and LDI. Infected, chemical and electrical burns were excluded. Healing potential was determined by comparing wound and normal skin temperature for the FLIR ONE and blood flow changes with the LDI. Healing potential was categorised into wounds healing in less than and over 21 days. Pearson's test was used to determine the correlation between changes in wound temperature and healing potential. RESULTS: Percent total body surface area (%TBSA) was in the range of 0.5-45. FLIR demonstrated a sensitivity of 66.67% and specificity of 76.67% in predicting healing within 21 days, while LDI demonstrated a sensitivity of 93.33% and specificity of 40%. The FLIR ONE showed a significant difference in the mean temperature changes between burns that healed in less than (0.1933 ± 0.3554) and over 21 days (-1 ± 0.4329) (P = 0.04904). Pearson's test showed a significant correlation between the difference in wound and normal skin temperature with healing times (P = 0.04517). CONCLUSION: The inexpensive FLIR ONE shows a significant correlation between changes in wound temperature and healing times. It is useful in predicting healing within 21 days. However, evaporative cooling at the wound surface can lead to overprediction of healing times and overtreatment. LAY SUMMARY: Background Laser Doppler imaging is currently the main tool for burn depth assessment. It works by analysing the blood flow in a burn wound. Based on these findings, it can predict the depth of the burn injury and predict if it will heal in less than or over 21 days. The main problem is that it is costly. The FLIR ONE is a novel, mobile-attached, thermal imaging camera. It can be used to assess burn depth by comparing the temperature of the burn wound to the surrounding normal skin. This information can then be used to predict healing times into less than and over 21 days. The issue being explored The usefulness of the FLIR ONE in assessing burn depth and predicting healing time when compared to the LDI. How was the work conducted? Forty-five adult patients who sustained a burn injury within the last five days were imaged with both the FLIR ONE and LDI. Those with infected, electrical or chemical burns were excluded. Healing potential was determined by comparing the temperature of the burn wound with normal skin for the FLIR ONE and by changes in wound blood flow with the LDI. Healing potential was categorised into wounds healing in less than and over 21 days. The correlation between the temperature changes of the burn wound and healing time was evaluated for the FLIR ONE. What we learned from the study This study was able to demonstrate that the FLIR ONE showed a significant correlation between the temperature difference between the burn wound and normal skin with healing times. When compared with the LDI, the FLIR ONE was useful in predicting if a burn wound will heal in less than 21 days. The FLIR ONE has advantages over the LDI, it is low cost, portable and produces instantaneous images. Ultimately, this developing technology may increase access to higher standard burn care in centres where LDI is not affordable.

Venous Congestion in Pedicled Frontal Branch Superficial Temporal Artery Flaps Reconstructions for Head and Neck Defects: A Review.

The superficial temporal artery (STA) flap is a versatile flap for head and neck defect reconstruction. It can be based on the frontal branch of the STA and an islanded 360-degree rotation arc for various defects on the scalp, cheek, and auricular region. It provides a nonmicrosurgical option for reconstructing such defects, which is itself relatively easy to perform. However, venous congestion is a problem than often can cause worry to the clinician and hence preclude its use. In this review, we revisit this flap in head and neck reconstruction, with case examples used for reconstruction of defects on the scalp, maxilla, lip, ear, and retroauricular area. The STA flap in our review can be used either as a fasciocutaneous flap or with its fascia alone. The main issue with the STA flap is that it is generally a high-inflow flap with variable outflow. Venous congestion is frequently encountered in our practice, and adequate management of the venous drainage in the postoperative period is crucial in ensuring its success as a versatile and viable option for head and neck reconstruction.

A useful alternative surgical technique to reconstructing large defects following excision of recurrent pilonidal sinus disease in the intergluteal region: An operative approach for the transverse lumbar artery perforator flap.

The reconstruction of defects in the intergluteal region following pilonidal sinus excision is challenging due to its anatomical location, close proximity to the anus, and being a high-tension area prone to wound-healing problems. Excision and primary closure is known to carry a higher risk of recurrence and subsequent complications compared with using nearby local healthy tissue, such as a flap, to reconstruct defect. Extra due diligence should be given to patient selection and flap choice when deciding the reconstruction of a defect. The senior author, who has briefly reviewed complication rates in previous published literature, prefers the transverse lumbar artery perforator (TLAP) flap for reconstruction following pilonidal sinus excision in the intergluteal region. This paper illustrates the operative approach used by the senior author when raising a TLAP flap.

A challenging case of calcific myonecrosis of tibialis anterior and hallucis longus muscles with a chronic discharging wound.

The occurrence of calcific myonecrosis of the anterior compartment of the leg is rare. Common risk factors include a history of trauma, although little is known about the exact pathophysiology, latency period or triggering factors resulting in disease progression. Macroscopically, it begins with a single muscle being replaced by a fusiform calcified mass, which progresses peripherally. We present a rare case of a 7-year history of chronic discharging sinus overlying the site with protruding calcified muscle and discuss the senior author's wound management strategy and surgical considerations. The initial approach used dressing applications to reduce wound exudate while obtaining repeated imaging for disease progression comparison. Repeated CT scans showed significant disease progression from a single solitary amorphous soft tissue calcification to disseminated scattered calcified myonecrosis. In planning such surgeries, extensive debridement and temporary wound coverage is the first stage. Subsequent definitive coverage includes skin grafting of the remaining defect.

Cold burn injuries in the UK: the 11-year experience of a tertiary burns centre.

BACKGROUND: Guidance for the management of thermal injuries has evolved with improved understanding of burn pathophysiology. Guidance for the management of cold burn injuries is not widely available. The management of these burns differs from the standard management of thermal injuries. This study aimed to review the etiology and management of all cold burns presenting to a large regional burn centre in the UK and to provide a simplified management pathway for cold burns. METHODS: An 11-year retrospective  analysis (1 January 2003-31 December 2014)  of all cold injuries presenting to a regional burns centre in the UK was conducted. Patient case notes were reviewed for injury mechanism, first aid administered, treatment outcomes and time to healing. An anonymized nationwide survey on aspects of management of cold burns was disseminated between 13 July 2015-5 October 2015 to British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and Plastic Surgery Trainees Association (PLASTA) members in the UK. Electronic searches of MEDLINE, EMBASE and the Cochrane Library were performed to identify relevant literature to provide evidence for a management pathway for cold burn injuries. RESULTS: Twenty-three patients were identified. Age range was 8 months-69 years. Total body surface area (TBSA) burn ranged from 0.25 to 5 %. Twenty cases involved peripheral limbs. Seventeen (73.9 %)cases were accidental, with the remaining six (26.1 %) cases being deliberate self-inflicted injuries. Only eight patients received first aid. All except one patient were managed conservatively. One case required skin graft application due to delayed healing. We received 52 responses from a total of 200 questionaires. Ninety percent of responders think clearer guidelines should exist. We present a simplified management pathway based on evidence identified in our literature search. CONCLUSIONS: Cold burns are uncommon in comparison to other types of burn injuries. In the UK, a disproportionate number of cold burn injuries are deliberately self-inflicted, especially in the younger patient population. Our findings reflect a gap in clinical knowledge and experience. We proposed a simplified management pathway for managing cold burn injuries, consisting of adequate first aid using warm water, oral prostaglandin inhibitors, deroofing of blisters and topical antithromboxane therapy.

Bubble bath burns: an unusual case.

We present an unusual case of flash burn injury in an adolescent following accidental combination of foaming bath bubbles and tea light candle flame. There has not been any reported similar case described before. This serves as a learning point for public prevention and clinicians managing burn injuries.

Smoke inhalation increases intensive care requirements and morbidity in paediatric burns.

Burn survival has improved with advancements in fluid resuscitation, surgical wound management, wound dressings, access to antibiotics and nutritional support for burn patients. Despite these advancements, the presence of smoke inhalation injury in addition to a cutaneous burn still significantly increases morbidity and mortality. The pathophysiology of smoke inhalation has been well studied in animal models. Translation of this knowledge into effectiveness of clinical management and correlation with patient outcomes including the paediatric population, is still limited. We retrospectively reviewed our experience of 13 years of paediatric burns admitted to a regional burn's intensive care unit. We compared critical care requirements and patient outcomes between those with cutaneous burns only and those with concurrent smoke inhalation injury. Smoke inhalation increases critical care requirements and mortality in the paediatric burn population. Therefore, early critical care input in the management of these patients is advised.

A pilot study of a hand-held camera in a busy burn centre: Prediction of patient length of recuperation with wound temperature.

AIM: The aim of our study was to evaluate temperature differences of burns looking at their prognostic ability to predict healing at the 21 day mark. MATERIALS AND METHOD: Thirty two burns in 26 patients aged 1-71 years old were photographed with a FLIR T650 camera. Environment, reflected, and body core temperature of the patients were measured. Skin emissivity was constant 0.98. Pictures were analyzed with R&D FLIR Software. Minimal and average burn temperatures and skin temperature in 255 pixel squares were measured. Patients were divided into healed and not healed groups. Statistical analysis was performed with SPSS 20 (IBM Armonk, USA) and p<0.05 was significant. RESULTS: There were 25 healed and 7 non-healed burns at 21 days. Healed burns were significantly warmer than non-healed burns (p<0.05). There was a statistically significant strong, negative correlation between the difference of minimal burns temperatures and healthy skin temperatures with days needed to heal the burns (p=0.001; rho=-0.564). CONCLUSION: Infrared camera seems to be useful equipment in predicting burns' healing time. However further clinical studies need to be done.

Assaults from corrosive substances and medico legal considerations in a large regional burn centre in the United Kingdom: calls for increased vigilance and enforced legislation.

Burn injuries from corrosive substances have been recognised as a common method of assault in low and middle income countries (LMICs) motivated by various factors. Such injuries often leave survivors with severely debilitating physical and psychological injuries and scars. The number of reported cases of acid assaults within the United Kingdom (UK) appears to be on the rise. As one of the largest regional burn centres in the UK, we have reviewed our experience of chemical burns from assault. This study aims to: (1) review the demographics, incidence and patient outcomes; (2) evaluate the long-term psychosocial support provided; and (3) review current criminal litigation proceedings and preventative legislations in the UK specific to assault by corrosive substances. A 15-year retrospective review of 21 burn injuries from assault with corrosive substances presenting to a regional burn unit was conducted. Victims were mostly young men; male perpetrators were more common. The most common motive cited was assault. The most common anatomical region affected was the face and neck. The number of victims who pursue litigation is disproportionately lower than the number of total cases at presentation. In an effort to better understand the legal considerations surrounding such assaults, we also collaborated with lawyers experienced in this particular field. We hope that our work will help educate healthcare professionals regarding the legal assistance and existing laws available to protect these patients.

Flaming alcoholic drinks: flirting with danger.

Alcohol-related burn injuries carry significant mortality and morbidity rates. Flaming alcoholic beverages served in trendy bars and clubs are becoming increasingly popular. The dangers associated with an ignited alcoholic drink are often underestimated by party goers whose risk assessment ability is already impaired by heavy alcohol consumption. The authors present two cases demonstrating the varied severity of burn injuries associated with flaming alcoholic drinks, and their clinical management. Consumption of flaming alcoholic drinks poses potential risks for burn injuries. Further support is required to enable national and local agencies to implement effective interventions in drinking environments.