Inhalation injury is known to be an important factor in predicting mortality in burns patients. However, the diagnosis is complicated by the heterogeneous presentation and inability to determine the severity of inhalation injury. The purpose of this study was to identify clinical features of inhalation injury that affect mortality and the values that could predict the outcome more precisely in burns patients with inhalation injury. This retrospective observational study included 676 burns patients who were over 18 years of age and hospitalized in the Burns Intensive Care Unit between January 2012 and December 2015. We analyzed variables that are already known to be prognostic factors (age, percentage of total body surface area (%TBSA) burned, and inhalation injury) and factors associated with inhalation injury (carboxyhemoglobin and PaO2/FiO2 [PF] ratio) by univariate and multivariate logistic regression. Age group (odds ratio [OR] 1.069, p<0.001), %TBSA burned (OR 1.100, p<0.001), and mechanical ventilation (OR 3.774, p<0.001) were identified to be significant predictive factors. The findings for presence of inhalation injury, PF ratio, and carboxyhemoglobin were not statistically significant in multivariate logistic regression. Being in the upper inhalation group, the lower inhalation group, and having a PF ratio <100 were identified to be significant predictors only in univariate logistic regression analysis (OR 4.438, p<0.001; OR 2.379, p<0.001; and OR 2.765, p<0.001, respectively). History and physical findings are not appropriate for diagnosis of inhalation injury and do not predict mortality. Mechanical ventilation should be recognized as a risk factor for mortality in burns patients with inhalation injury.
Hexachloroethane (HC)/zinc chloride (ZnCl, smoke bomb) exposure in the military setting results in lung injury which is uncommon and has been rarely described in previous studies. The aim of this study is to investigate the correlation between the serum zinc in patients with HC/ZnCl smoke inhalation lung injury and disease severity. A total of 15 patients with HC/ZnCl-related conditions were recruited in this study. The serum zinc level and the pulmonary function tests and liver function tests including total lung capacity (TLC), forced vital capacity (FVC), forced expiratory pressure in 1 second (FEV1), alanine aminotransferase (ALT), and aspartate transaminase (AST) were analyzed. Eleven cases had mild clinical manifestations. Four cases rapidly developed features typical of severe adult respiratory distress syndrome. The level of serum zinc was increased, but FVC, FEV1, and TLC was decreased significantly in the moderate and severe cases. In addition, the serum zinc level correlated well with the TLC, FVC, and FEV1 (r = -0.587, -0.626, -0.617, respectively; P = .027, .017, .019, respectively). The 4 cases in moderate and severe group had delayed impairment of liver functions after the accident. This study suggested that the serum zinc level may be associated with the severity of lung and liver injuries after HC/ZnCl smoke inhalation.
Lung Injury (3), Adult Respiratory Distress Syndrome (1), more mentions
BACKGROUND: The double capsule is a complication mostly described in aggressive macrotextured implants. Mechanical shear stress applied onto an immature periprosthetic capsule has been linked to their formation. The authors aim to demonstrate the role of bacterial phenotype and biofilm in the development of the double capsule.
METHODS: Seven double capsules formed at the interface of macrotextured breast expander implants were studied using scanning electron microscopy. Two samples for each surface of the inner capsule layer (the prosthesis interface and the intercapsular space) were analyzed for bacteria cell size, bacterial density, and biofilm deposition.
RESULTS: Although all routine bacterial cultures were negative, the prosthesis interface had both higher bacteria load and biofilm deposition compared with the intercapsular space (Mann-Whitney U test, p = 0.004 and p = 0.008, respectively). Moreover, bacteria cell sizes were significantly smaller at the prosthesis interface in six of seven samples. Comparison of bacteria density and biofilm dispersion showed an increase of biofilm extracellular matrix deposition over 2000 cells/mm (linear regression, p = 0.0025). These results indicate a common trend among bacteria species.
CONCLUSIONS: Bacterial expression between the different surfaces of the double capsule displays significant differences; bacteria at the prosthesis interface are mostly in a biofilm state, whereas they demonstrate a planktonic phenotype at the intercapsular space. When a sufficient amount of bacteria are present at a specific location, quorum sensing may trigger a biofilm phenotypic switch in planktonic bacteria cells. Biofilm formation may alter capsule formation through immune response, thereby weakening capsule strength and facilitating extracellular matrix delamination and double-capsule formation.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
Prosthetic reconstruction utilizing a 2-stage saline tissue expander-to-implant procedure is the most common technique for breast reconstruction in the United States. For nearly the past 50 years, 2-stage breast reconstruction using saline tissue expanders has been the standard of care. However, in December 2016, a carbon dioxide-filled, remote-controlled tissue expander received U.S. Food and Drug Administration clearance. This tissue expander, known as the AeroForm Tissue Expander System (AirXpanders, Inc., Palo Alto, Calif.), is a novel, patient-controlled, needle-free expander operated by a wireless remote control device, which allows patients the comfort and convenience of home expansion, precluding the need for percutaneous saline injections. A multicenter, randomized, prospective clinical trial has revealed statistically significant shorter times to full expansion as well as shorter overall reconstructive times. It is the first tissue expander device designed successfully with an alternative filling medium to saline, namely carbon dioxide. This CO2-filled expander thus provides several potential advantages over previous expander designs, including patient-controlled expansion, obviation of saline injections, and shorter expansion times.
BACKGROUND: Implant-based breast reconstruction is the most common type of reconstruction after postmastectomy radiation therapy (PMRT). The impact of the timing of PMRT to a tissue expander or permanent implant is not well understood. The purpose of this systematic review was to evaluate outcomes in implant-based reconstruction and the timing of PMRT.
METHODS: A review of the English literature in the PubMed/MEDLINE database (2000-2016) was performed to identify all articles on implant-based breast reconstruction and PMRT. Cases from each study were grouped by PMRT to a tissue expander or PMRT to a permanent implant. Outcomes of interest included reconstructive failure and capsular contracture as overall rates and associations were pooled. Effect sizes (z values), risk ratios (RRs), and heterogeneity scores (I(2)) were calculated on meta-analysis.
RESULTS: There were 20 studies meeting inclusion criteria with 2348 patients identified. Pooled analysis revealed an overall rate of reconstructive failure of 17.6% and Baker grade III/IV capsular contracture of 37.5%. PMRT applied to tissue expanders resulted in higher rates of reconstructive failure compared with PMRT applied to permanent silicone implants (20% versus 13.4%, RR = 2.33, P = 0.0083, 95% confidence interval 1.24-4.35), but lower rates of capsular contracture (24.5% versus 49.4%, RR = 0.53, P = 0.083, 95% confidence interval 0.26-1.09).
CONCLUSIONS: Regardless of timing, PMRT applied to implant-based breast reconstruction was associated with high risk of reconstructive failure and capsular contracture. Surgeons should consider alternative strategies, such as autologous tissue reconstructions, in patients requiring PMRT.
... AbstractText: N/A AbstractText: Individuals 18 and over who underwent burn-related surgery and met one of the following criteria: (1) > 10% total ... to 64 years of age; (3) electrical high voltage/lightning injury; or (4) burninjury to the hands, face, or feet... average and got progressively worse over time AbstractText: SWL after burninjury can be described by two different trajectories with substantially different ...
Abstract: Fatigue is a commonly reported but not well-documented symptom following burninjury. This study's objective was to determine the frequency and severity of fatigue over time and to identify predictors of fatigue in the adult burn population. Data from the Burn Model System National Database (April 1997 to January 2006) were analyzed.
BACKGROUND: Direct-to-implant breast reconstruction offers time-saving advantages over two-stage techniques. However, use of direct-to-implant reconstruction remains limited, in part, because of concerns over complication rates., The authors' aim was to compare 2-year complications and patient-reported outcomes for direct-to-implant versus tissue expander/implant reconstruction.
METHODS: Patients undergoing immediate direct-to-implant or tissue expander/implant reconstruction were enrolled in the Mastectomy Reconstruction Outcomes Consortium, an 11-center prospective cohort study. Complications and patient-reported outcomes (using the BREAST-Q questionnaire) were evaluated. Outcomes were compared using mixed-effects regression models, adjusting for demographic and clinical characteristics.
RESULTS: Of 1427 patients, 99 underwent direct-to-implant reconstruction and 1328 underwent tissue expander/implant reconstruction. Two years after reconstruction and controlling for covariates, direct-to-implant and tissue expander/implant reconstruction patients did not show statistically significant differences in any complications, including infection. Multivariable analyses found no significant differences between the two groups in patient-reported outcomes, with the exception of sexual well-being, where direct-to-implant patients fared better than the tissue expander/implant cohort (p = 0.047).
CONCLUSIONS: This prospective, multi-institutional study showed no statistically significant differences between direct-to-implant and tissue expander/implant reconstruction, in either complication rates or most patient-reported outcomes at 2 years postoperatively. Direct-to-implant reconstruction appears to be a viable alternative to expander/implant reconstruction. This analysis provides new evidence on which to base reconstructive decisions.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
AbstractText: The choice between local flap designs for burnreconstruction is largely shaped by aesthetic, vascularity, procedural complexity, and wound ... addressed by this study of patients who underwent local flap surgery to release post-burn scar contractures AbstractText: The flap type, its original size, and ... which flap design is optimal for the individual patient Keyword: Burnreconstruction.
Inclusion criterion was a principal diagnosis of burninjury... days, p=0.04), but total charges and costs were similar for both groups (amDiff: $16,268 ($-5093-$37,629), p=0.13 and $3275 ($-2337-$8888), p=0.25).Weekend admission is associated with increased mortality among patients with burninjury >65years old.
... United States, and diabetic patients are at increased risk for burninjury... Weighted Kaplan-Meier survival curves - adjusting for patient demographics, burn mechanism, presence of inhalation injury, total body surface area, additional comorbidities, and differential lengths of ... increases the risk of developing an HAI in patients following burninjury, but does not significantly impact the risk of inpatient mortality ...
Endocrine Disorders (2) Infections (3), Diabetes Mellitus (2), more mentions
Hypermetabolic and catabolic states in large TBSA burns lead to higher basal body temperature and tachycardia. These metabolic changes complicate the diagnosis of bacteremia and sepsis. Current indications for obtaining blood cultures (BCs) in this population are poorly described and nonstandardized. Fever, leukocytosis, and lactic acidosis are common during sepsis. This study aims to identify limits of these parameters with the highest rates of bacteremia. A retrospective review was performed for burn patients with > 20% TBSA between January 2009 and June 2011. BCs were collected with corresponding body temperature, white blood cell (WBC) count, and serum lactate levels. Positive culture rates were analyzed with univariate and multivariate analysis. Seventy-one patients met inclusion criteria and 360 BCs were included in data analysis. Cultures taken with temperature > 38.9C were significantly more positive (P = .01) than temperatures between 38 and 38.9C. There were significantly more positive cultures when the WBC count was < 4.5 compared with those ≥ 4.5 × 10/µl (P = .04). Lactate was an independent predictor of bacteremia (OR, 1.81; 95% CI, 1.21-12.71). Cultures were significantly more positive when the lactate level was ≥ 2.5 compared with < 2.5 mg/dL (P = .02). A temperature ≥ 38.5C and a lactate ≥ 2.5 mg/dL corresponded to a 28.6% positive culture rate compared with 4.8% for all other scenarios (P = .001). This study demonstrates that body temperature > 38.9C, WBC < 4.5 × 10/µl, and serum lactate ≥ 2.5 mg/dL have the highest rate for positive BCs in severe burn patients. A combination of leukopenia and pyrexia as well as lactic acidosis and pyrexia represent even higher specificity for positive BC in these patients.
... aimed to evaluate the hip fracture risk for patients with burninjury. A total of 16,430 patients with burninjury had an adjusted hazard ratio of 1.54 to encounter a ... future studies focusing on mechanisms leading to fracture associated with burninjury AbstractText: The relationship between burninjury and hip fracture risk is unclear ...
Muscular and Skeletal Diseases (12), Endocrine Disorders (2) Osteoporosis (3), Diabetes Mellitus (2), more mentions
... relationship persisted after adjustment for ISS, HR, temperature, presence of burninjury, TBI, and AKI. Burninjury was associated with mortality in the full multivariate analysis... MAP decile appears to be limited to casualties with associated burninjury, even after adjustment for TBI, AKI, and ISS, which takes into account the severity of the burninjury ...
... there remains a paucity of evidence to guide perioperative practice in burnsurgery... between hypothermia and operative time on post-operative complications in acute burnsurgery AbstractText: A historical cohort study from January 1, 2006 to October ... 1111 consecutive patients undergoing acute burnsurgery were included, and 2171 surgeries were analyzed.
Of the nearly 90,000 implant-based breast reconstructions performed in the United States, the majority use internal soft-tissue support. Aesthetically, these constructs may allow for better positioning of prosthesis, improve lower pole expansion, and increase projection. They may have particular utility in direct-to-implant, nipple-sparing mastectomies, and prepectoral reconstructions. In recent years, new permutations of acellular dermal matrices have evolved with diverse shapes, sizes, form-factor innovations, and processing characteristics. The literature is largely limited to retrospective studies (and meta-analyses thereof), making robust comparisons of 1 iteration vis-à-vis another difficult. Although synthetic mesh may provide a cost-effective alternative in primary and secondary reconstruction, comparative studies with acellular dermal matrix are lacking. This review aims to provide a balanced overview of recent biologic and synthetic mesh innovation. As this technology (and concomitant techniques) evolve, the reconstructive surgeon is afforded more-and better-choices to improve care for patients.
BACKGROUND: The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.
MATERIALS AND METHODS: Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality.
RESULTS: Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort.
CONCLUSIONS: Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.
BACKGROUND: Evidence regarding the effectiveness of arthroscopic débridement for a triangular fibrocartilage complex tear is uncertain. The purpose of this study was to conduct a systematic review of outcomes to evaluate the effectiveness of débridement for triangular fibrocartilage complex tears.
METHODS: The authors searched all available literature in the PubMed, Embase, and MEDLINE (Ovid) databases for articles reporting on triangular fibrocartilage complex tear débridement. Data collection included arc of motion, grip strength, patient-reported outcomes, and complications.
RESULTS: A total of 1723 unique studies were identified, of which 18 studies met the authors' criteria. The mean before and after arc of wrist extension/flexion motion values were 120 and 146 degrees (six studies). The mean before and after grip strength values were 65 percent and 91 percent of the contralateral side (10 studies). Disabilities of the Arm, Shoulder, and Hand scores (six studies) and pain visual analogue scale scores (seven studies) improved from 39 to 18, and from 7 to 3, respectively. The mean pain visual analogue scale score after débridement was 1.9 in the ulnar-positive group and 2.4 in the ulnar-neutral and ulnar-negative groups. Eighty-seven percent of patients returned to their original work.
CONCLUSIONS: Patients reported reduced pain and improved functional and patient-reported outcomes after débridement of triangular fibrocartilage complex tears. Most patients after débridement returned to previous work, with few complications. Although some of these cases may require secondary procedures, simple débridement can be performed with suitable satisfactory outcomes for cases with any type of ulnar variance.
Treating thoracic infective spondylodiscitis with anterior surgical approaches carry a relatively high risk of perioperative and postoperative complications. Posterior approaches have been reported to result in lower complication rates than anterior procedures, but more evidence is needed to demonstrate the safety and efficacy of 1-stage posterior approaches for treating infectious thoracic spondylodiscitis.Preoperative and postoperative clinical data, of 18 patients who underwent 2 types of 1-stage posterior procedures, costotransversectomy and transforaminal thoracic interbody debridement and fusion and 7 patients who underwent anterior debridement and reconstruction with posterior instrumentation, were retrospectively assessed.The clinical outcomes of patients treated with 1-stage posterior approaches were generally good, with good infection control, back pain relief, kyphotic angle correction, and either partial or solid union for fusion status. Furthermore, they achieved shorter surgical time, fewer postoperative complications, and shorter hospital stay than the patients underwent anterior debridement with posterior instrumentation.The results suggested that treating thoracic spondylodiscitis with a single-stage posterior approach might prevent postoperative complications and avoid respiratory problems associated with anterior approaches. Single-stage posterior approaches would be recommended for thoracic spine infection, especially for patients with medical comorbidities.
Discitis (4), Infections (3), Central Nervous System Infections (1), more mentions