Factors Associated With Mortality Following Burns Complicated by Necrotizing Skin and Soft Tissue Infections: A Systematic Review and Meta-Analysis of Individual Participant Data.

We reviewed studies with individual participant data of patients who sustained burn injury and subsequently developed necrotizing skin and soft tissue infections (NSTI). Characteristics and managements were compared between patients who lived and patients who died to determine factors associated with mortality. Six databases (PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL) were searched. PRISMA-IPD guidelines were followed throughout the review. Eligible patients sustained a burn injury, treated in any setting, and diagnosed with a NSTI following burn injury. Comparisons were made between burned patients who lived "non-mortality" and burned patients who died "mortality" following NSTI using non-parametric univariate analyses. Fifty-eight studies with 78 patients were published from 1970 through 2019. Non-mortality resulted in 58 patients and mortality resulted in 20 patients. Patients with mortality had significantly greater median %TBSA burned (45%[IQR:44-64%] vs 35%[IQR:11-59%], P = .033), more intubations (79% vs 43%, P = .013), less debridements (83% vs 98%, P = .039), less skin excisions (83% vs 98%, P = .039), more complications (100% vs 50%, P < .001), management at a burn center (100% vs 71%, P = .008), underwent less flap surgeries (5% vs 35%, P = .014), less graft survival (25% vs 86%, P < .001), and less healed wounds (5% vs 95%, P < .001), compared to patients with non-mortality, respectively. Non-mortality patients had more debridements, skin excised, systemic antimicrobials, skin graft survival, flaps, improvement following surgery, and healed wounds compared to mortality patients. Mortality patients had greater %TBSA burned, intubations, management at a burn center and complications compared to non-mortality patients.

Treatment approach to isolated common peroneal nerve palsy by mechanism of injury: Systematic review and meta-analysis of individual participants' data.

BACKGROUND: We reviewed the individual participant data of patients who sustained isolated common peroneal nerve (CPN) injuries resulting in foot drop. Functional results were compared between eight interventions for CPN palsies to determine step-wise treatment approaches for the underlying mechanisms of nerve injury. METHODS: PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were searched. PRISMA-IPD and Cochrane guidelines were followed in the data search. Eligible patients sustained isolated CPN injuries resulting in their foot drop. Patients were stratified by mechanisms of nerve injury, ages, duration of motor symptoms, and nerve defect/zone of injury sizes, and were compared by functional results (poor = 0, fair = 1, good = 2, excellent = 3), using meta-regression between interventions. Interventions evaluated were primary neurorrhaphy, neurolysis, nerve grafts, partial nerve transfer, neuromusculotendinous transfer, tendon transfer, ankle-foot orthosis (AFO), and arthrodesis. RESULTS: One hundred and forty-four studies included 1284 patients published from 1985 through 2020. Transection/Cut: Excellent functional results following tendon transfer (OR: 126, 95%CI: 6.9, 2279.7, p=0.001), compared to AFO. Rupture/Avulsion: Excellent functional results following tendon transfer (OR: 73985359, 95%CI: 73985359, 73985359, p<0.001), nerve graft (OR: 4465917, 95%CI: 1288542, 15478276, p<0.001), and neuromusculotendinous transfer (OR: 42277348, 95%CI: 3001397, 595514030, p<0.001), compared to AFO. Traction/Stretch: Good functional results following tendon transfer (OR: 4.1, 95%CI: 1.17, 14.38, p=0.028), compared to AFO. Entrapment: Excellent functional results following neurolysis (OR: 4.6, 95%CI: 1.3, 16.6, p=0.019), compared to AFO. CONCLUSIONS: Functional results may be optimized for treatments by the mechanism of nerve injury. Transection/Cut and Traction/Stretch had the best functional results following tendon transfer. Rupture/Avulsion had the best functional results following tendon transfer, nerve graft, or neuromusculotendinous transfer. Entrapment had the best functional results following neurolysis.

Comparison of arterial and venous implantable Doppler postoperative monitoring of free flaps: Systematic review and meta-analysis of diagnostic test accuracy.

BACKGROUND: Early detection of vascular compromise following free flap microsurgical reconstruction is essential. This can lead to timely reoperations and flap salvage. Both arteries and veins are monitored postoperatively with implantable ultrasound Dopplers based on surgeon preference with no consensus as to which method is best. This systematic review and meta-analysis compared arterial to venous implantable Dopplers for postoperative monitoring of microsurgical free flap reconstruction. METHODS: Five databases (MEDLINE via PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus) were systematically and independently searched. PRISMA and Cochrane guidelines were strictly followed. Clinical characteristics, donor and recipient sites, specific arterial or venous vessels, diagnostic data, outcomes, and complications were recorded. RESULTS: The seven studies included in the meta-analysis were published from 1994 to 2018, with results from 38 of the possible 64 outcomes and complications queried. A total of 763 flaps with implantable Doppler probes on 527 arteries and 388 veins were included in the study. Compared to patients monitored with venous implantable Dopplers, arterial monitoring was associated with a risk of false-positives reduced by 74% (RR:0.26, 95% CI:0.12, 0.55, I2 = 40%, p = .0004) and risk of signal loss reduced by 63% (RR:0.37, 95% CI:0.24, 0.59, I2 = 26%, p < .0001). Patients being monitored with a venous implantable Doppler did not show significantly different sensitivities, specificities, true-positives, false-negatives, true-negatives, positive predictive values, negative predictive values, time to signal loss, take-backs, salvage rates, flap failures, flap failure rates, arterial, venous, vascular, and hematoma compromise compared to an arterial implantable Doppler. CONCLUSION: These findings suggest arteries may be the best vessels to monitor when using an implantable Doppler following free flap microsurgical reconstruction. Caution is advised when interpreting these findings for clinical significance due to no significant differences in take-backs, SR, flap failures, and FFR.

Impact of nicotine/smoking, alcohol, and illicit substance use on outcomes and complications of burn patients requiring hospital admission: systematic review and meta-analysis.

Burn patients admitted to the hospital with concurrent intoxication are believed to be at an increased risk of poor outcomes and the development of complications, however data varies within the literature and remains controversial. This systematic review and meta-analysis compared outcomes and complications between nicotine/smoking, alcohol, and/or substance use in 26,512 burn patients admitted to the hospital to 299,543 burn patients admitted without these characteristics. The PubMed, EMBASE, Cochrane Library, and Web of Science databases were systematically and independently searched. PRISMA and Cochrane guidelines were strictly followed. Clinical characteristics, nicotine/smoking use, alcohol use, substance use, outcomes and complications were recorded. Seventeen of the 27 studies included in the study, were eligible for meta-analysis, with results from 39 of the possible 84 outcomes and complications. In conclusion, this systematic review and meta-analysis found that compared to non-nicotine/smoking, non-alcohol, non-substance use burn patients, patients using nicotine/smoking, alcohol, and/or substances were associated with more burn related operations, higher rates of graft loss/failure, longer hospital LOS (length of stay), higher rates of intubation, longer ICU (intensive care unit) LOS, increased mortality, and increased wound/local skin infections. Patients using nicotine/smoking were associated with higher rates of intubation and wound/local skin infections. Patients consuming alcohol were associated with more days on a ventilator, had higher rates of intubation, higher rates of inhalation injury, longer ICU LOS, and increased mortality. Patients taking substances were associated with higher %TBSA (percent total body surface area) of burns, longer hospital LOS, higher rates of intubation, higher rates of inhalation injury, longer ICU LOS, and increased wound/local skin infections.

Pre-, intra-, and/or postoperative arterial and venous thromboembolism prophylaxis for breast surgery: Systematic review and meta-analysis.

Both thromboembolism and excessive bleeding following breast surgery could result in multiple surgical procedures, breast reconstruction failure, or even mortality. This systematic review and meta-analysis of 5617 female breast surgery patients compared pharmacological prophylaxis to nonpharmacological prophylaxis interventions during the pre-, intra-, and/or postoperative time points and evaluated associated outcomes and complications. The PubMed, EMBASE, Cochrane Library, Web of Science, and Google Scholar databases were systematically and independently searched. Patient and clinical characteristics, surgical and medical interventions, outcomes, and complications were recorded. Eleven of the 344 studies queried were eligible for systematic review and meta-analysis, with results from 26 of the possible 117 outcomes and complications using strict PRISMA and Cochrane guidelines. Patients receiving intraoperative pharmacological prophylaxis for breast surgery were found to have more reoperations and more occurrences of any bleeding, while patients receiving postoperative pharmacological prophylaxis were found to have more occurrences of any bleeding than patients receiving nonpharmacological prophylaxis. Patients were more likely to receive preoperative pharmacological prophylaxis if they had diabetes mellitus and postoperative chemoprophylaxis if they had higher BMIs. Patients administered pharmacological prophylaxis during the pre-, intra-, and/or postoperative time periods did not show a significant decrease in deep vein thrombosis and/or pulmonary embolism or increase in hematomas compared to those administered nonpharmacological prophylaxis.

Surgical outcomes in adults with purpura fulminans: a systematic review and patient-level meta-synthesis.

BACKGROUND: Cutaneous manifestations of purpura fulminans (PF) present many challenges for clinicians and surgeons. In a state of septic shock complicated by limb ischemia, surgical interventions are necessary to control the pathological cascade and improve patient outcomes. The objective of this article was to report etiologies and surgical outcomes associated with cutaneous manifestations in adults. METHODS: This systematic review and meta-analysis compared 190 adult patients with etiologies, signs and symptoms, and surgical outcomes associated with cutaneous manifestations of PF. The PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical interventions, outcomes, and complications were recorded. RESULTS: Seventy-nine studies were eligible for the systematic review, and 77 were eligible for meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. A total of 71/190 (38%) cases reported surgical debridement. Fasciotomies were reported in 12/190 (6%) cases and 20 procedures. Amputations were reported in 154/190 (81%) cases. Reconstruction was reported in 45 cases. Skin grafts were applied in 31 cases. Flaps were used for reconstruction in 28 cases. Median (IQR) surgical procedures per patient were 4 (4, 5) procedures. Infectious organisms causing PF were 32% Neisseria meningitidis (n = 55) and 32% Streptococcus pneumonia (n = 55). Coagulase-negative Staphylococcus (95% confidence interval (CI)(8.2-177.9), p = 0.032), Haemophilus influenza (95%CI (7.2-133), p = 0.029), Streptococcus pneumonia (95% CI (13.3-75.9), p = 0.006), and West Nile Virus (95%CI (8.2-177.9), p = 0.032) were associated with significantly more extensive amputations compared to other organisms. CONCLUSION: This systematic review and patient-level meta-analysis found the most common presentation of PF was septic shock from an infectious organism. Neisseria meningitidis and Streptococcus pneumonia were equally the most common organisms associated with PF. The majority of cases were not treated in a burn center. The most common surgeries were amputations, with below-the-knee-amputations being the most common procedure. Skin grafting was the most commonly performed reconstructive procedure. The most common complications were secondary infections. Organisms with significantly more extensive amputations were coagulase-negative Staphylococcus, Haemophilus influenza, Streptococcus pneumonia, and West Nile Virus. Interpretation of findings should be cautioned due to limited sample data.

Acute surgical vs non-surgical management for ocular and peri-ocular burns: a systematic review and meta-analysis.

BACKGROUND: Burn-related injury to the face involving the structures of the eyes, eyelids, eyelashes, and/or eyebrows could result in multiple reconstructive procedures to improve functional and cosmetic outcomes, and correct complications following poor acute phase management. The objective of this article was to evaluate if non-surgical or surgical interventions are best for acute management of ocular and/or peri-ocular burns. METHODS: This systematic review and meta-analysis compared 272 surgical to 535 non-surgical interventions within 1 month of patients suffering burn-related injuries to 465 eyes, 253 eyelids, 90 eyelashes, and 0 eyebrows and evaluated associated outcomes and complications. The PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched. Patient and clinical characteristics, surgical and medical interventions, outcomes, and complications were recorded. RESULTS: Eight of the 14,927 studies queried for this study were eligible for the systematic review and meta-analysis, with results from 33 of the possible 58 outcomes and complications using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines. Surgery was associated with standard mean differences (SMD) 0.44 greater visual acuity on follow-up, SMD 1.63 mm shorter epithelial defect diameters on follow-up, SMD 1.55 mm greater changes in epithelial diameters from baseline, SMD 1.17 mm2 smaller epithelial defect areas on follow-up, SMD 1.37 mm2 greater changes in epithelial defect areas from baseline, risk ratios (RR) 1.22 greater numbers of healed epithelial defects, RR 11.17 more keratitis infections, and a 2.2 greater reduction in limbal ischemia compared to no surgical intervention. CONCLUSIONS: This systematic review and meta-analysis found that compared to non-surgical interventions, acute surgical interventions for ocular, eyelid, and/or eyelash burns were found to have greater visual acuity on follow-up, shorter epithelial defect diameters on follow-up, greater changes in epithelial diameters from baseline, smaller epithelial defect areas on follow-up, greater changes in epithelial defect areas from baseline, greater numbers of healed epithelial defects, more keratitis infections, and a greater reduction in limbal ischemia, possibility preventing the need of a future limbal stem cell transplantation.