Evolution, control and success of combination therapy with Ampicilin-sulbactam/Ceftazidime-Avibactam during a Carbapenem-Resistant Acinetobacter baumannii outbreak in burn Intensive Care Unit

We present our findings on interpatient transmission, epidemic control measures, and the outcomes of a series of ten critically ill burn patients who were either colonized or infected with carbapenem-resistant Acinetobacter baumannii (CRAB). None of the five infected patients achieved clinical cure, and all experienced relapses. Microbiological failure was observed in 40% of the infected patients. The isolated CRAB strains were found to carry blaOXA-23 and armA resistance genes. Despite the lack of clinical cure, all five infected patients survived and were discharged from the Burn Intensive Care Unit.

Short- and long-term morbidity after Taylor flap (oblique rectus abdominis flap) for perineal reconstruction after abdominoperineal resection: A single-center series of 140 patients

BACKGROUND

Abdominoperineal resection (APR) leads to a substantial loss of tissue and a high rate of complications. The Taylor flap is a musculocutaneous flap used in reconstruction after APR.

OBJECTIVES

We aimed to analyze the short and long-term morbidity of reconstruction with a Taylor flap (oblique rectus abdominis flap) after APR and to identify the risk factors for postoperative complications.

METHODS

We retrospectively included all patients who had undergone APR with immediate reconstruction with a Taylor flap in our department between July 2000 and June 2018. Demographics, oncological data, treatment, and short- and long-term morbidity were reviewed.

RESULTS

Among the 140 patients included, we identified early minor complications in 42 patients (30%) and 14 early major complications (10%). Total necrosis of the flap requiring its removal occurred in four patients (2.8%). Eleven patients (7.9%) presented with a midline incision hernia, and seven (5%) presented with a subcostal incision hernia. No perineal hernia was found. No risk factors for the complications were identified.

CONCLUSION

The Taylor flap is a safe procedure with few complications and limited donor site morbidity. Moreover, it prevents perineal hernias. These results confirm that the Taylor flap is a well-suited procedure for reconstruction after APR.

Specificities of the Management of perineal burns

There is a paucity of articles addressing the management strategy for perineal burns. Pelvic floor burns present a multitude of problems. These relate to the management of stool, urine, areas of maceration, significant strain, and the risk of infection. The objective of this study was to analyze a consecutive series of perineal burns by studying their characteristics, treatment, and the management of urine and feces. This was a retrospective study including 100 patients between January 2018 and December 2022. The patients had all been hospitalized after suffering burns to the perineum. In 28% of the patients, the perineal burn was complicated by infection. In 61% of cases, a cutaneous infection, in 32% of cases, a urinary tract infection, in 25% of cases, a respiratory tract infection, and in 7% of cases, an infection of the digestive tract. Superinfection is associated with an increased risk of poor engraftment. 100% of the patients with poor or average engraftment had an infection in the aftermath of the burn, compared with 20% of the patients with excellent engraftment and 61% of the patients with good engraftment. In our series, the analysis revealed that, in 95% of cases, no specific procedures were implemented for stool management. Perianal involvement was associated with a risk of sub-excellent engraftment. The results were statistically significant, with p=0.005 and an OR=8.72 after multivariate analysis. We favor the least invasive approach to stool management. Indications for a rectal catheter arise in patients with the following characteristics: the patient must be sedated, the burns must be deep and close to the anal opening, and the stools must be watery and abundant. In 95% of cases, we do not install a stool management device. Colostomies should remain exceptional.

Evidence of inter- and intra-keloid heterogeneity through analysis of dermal fibroblasts: A new insight in deciphering keloid physiopathology

Keloid scars are hypertrophic and proliferating pathological scars extending beyond the initial lesion and without tendency to regression. Usually, keloids are considered and treated as a single entity but clinical observations suggest heterogeneity in keloid morphologies with distinction of superficial/extensive and nodular entities. Within a keloid, heterogeneity could also be detected between superficial and deep dermis or centre and periphery. Focusing on fibroblasts as main actors of keloid formation, we aimed at evaluating intra- and inter-keloid fibroblast heterogeneity by analysing their gene expression and functional capacities (proliferation, migration, traction forces), in order to improve our understanding of keloid pathogenesis. Fibroblasts were obtained from centre, periphery, papillary and reticular dermis from extensive or nodular keloids and were compared to control fibroblasts from healthy skin. Transcriptional profiling of fibroblasts identified a total of 834 differentially expressed genes between nodular and extensive keloids. Quantification of ECM-associated gene expression by RT-qPCR brought evidence that central reticular fibroblasts of nodular keloids are the population which synthesize higher levels of mature collagens, TGFβ, HIF1α and αSMA as compared to control skin, suggesting that this central deep region is the nucleus of ECM production with a centrifuge extension in keloids. Although no significant variations were found for basal proliferation, migration of peripheral fibroblasts from extensive keloids was higher than that of central ones and from nodular cells. Moreover, these peripheral fibroblasts from extensive keloids exhibited higher traction forces than central cells, control fibroblasts and nodular ones. Altogether, studying fibroblast features demonstrate keloid heterogeneity, leading to a better understanding of keloid pathophysiology and treatment adaptation.

Modulation of NK cell activation by exogenous calcium from alginate dressings in vitro

Natural Killer (NK) cells participate in the defense against infection by killing pathogens and infected cells and secreting immuno-modulatory cytokines. Defects in NK cell activity have been reported in obese, diabetic, and elderly patients that are at high risk of developing infected chronic wounds. Calcium alginate dressings are indicated for the debridement during the inflammatory phase of healing. Since calcium ions are major activators of NK cells, we hypothesized that these dressings could enhance NK functions, as investigated in vitro herein. Primary human blood NK cells were freshly-isolated from healthy volunteers and exposed to conditioned media (CM) from two alginate dressings, Algosteril® (ALG, pure Ca2+ alginate) and Biatain® Alginate (BIA, Ca2+ alginate with CMC), in comparison with an exogenous 3mM calcium solution. Our results demonstrated that exogenous calcium and ALG-CM, but not BIA-CM, induced NK cell activation and enhanced their capacity to kill their targets as a result of increased degranulation. NK cell stimulation by ALG depended on the influx of extracellular Ca2+via the SOCE Ca2+ permeable plasma membrane channels. ALG-CM also activated NK cell cytokine production of IFN-γ and TNF-α through a partly Ca2+-independent mechanism. This work highlights the non-equivalence between alginate dressings for NK cell stimulation and shows that the pure calcium alginate dressing Algosteril® enhances NK cell cytotoxic and immuno-modulatory activities. Altogether, these results underline a specific property of this medical device in innate defense that is key for the cutaneous wound healing process.

Dermal substitute: a safe and effective way in surgical management of adults post-burn dorsal foot contractures

OBJECTIVE

Neglected dorsal foοt burns may result in typical fοrefοοt defοrmities characterised by cοntractures leading tο hyperextensiοn οf the tοes and gait disturbance. These defοrmities usually cause a significant impairment in daily activities and difficulty in wearing shοes. This article presents a recοnstructiοn series οf severe fοrefοοt defοrmities by means of dermal regeneratiοn templates (also known as dermal substitutes) and split thickness skin grafts.

PATIENTS AND METHODS

We retrοspectively reviewed οur institutiοnal burn database from 2010 to 2020 focusing on all those dοrsal fοοt cοntractures treated with the use οf a dermal regeneratiοn template. The patients' demοgraphics, burn injury mechanisms, depth, lοcalizatiοn, surface, treatments and fοllοw-up were described.

RESULTS

Twelve patients underwent this prοcedure and the mean affected area was 75 cm2. The mean time between the dermal regeneratiοn template applicatiοn and the split thickness skin graft was 19.6 days. Just fοr one patient, an additiοnal skin grafting prοcedure was required. The mean fοllοw-up was 4.6 years. We did not register specific cοmplicatiοns at bοth the recipient (forefoot) and dοnοr sites (scalp). All patients were able tο wear shοes and walk after the procedure. Nο recurrence οf cοntractures were οbserved. All patients were satisfied with cοsmetic results, and they did not request any additiοnal prοcedure οf cοsmetic imprοvement.

CONCLUSIONS

The use οf the dermal regeneratiοn template can be cοnsidered as an extremely safe and efficient treatment οf severe post-burn fοrefοοt defοrmities.

[Buried chipped skin grafts for patients in failure of treatment]

Local conditions can lead to a failure of traditional skin grafts. We propose here our technique about the realization of autologous skin graft using it buried chipped grafts, for wounds in failure of treatments or at risk of failure. The protocol includes cutting the skin graft within little squared pieces of a few millimeters of length, that are then buried directly deep into the wound. We can then obtain little islands of epidermisation on the random places of the wound that will heal by confluence of those epidermal islands.

Brûlures Profondes Des Membres Inférieurs Chez Les Patients Diabétiques: À Propos De 30 Cas

We checked the files of 30 inpatients with diabetes and deep burns to the lower limbs. We looked for a diabetes-related neuropathy (60% had one), the context of the accident, the topography of burns, any delays before the first and possible subsequent surgeries, the length of stay, and return to walking, if achieved. Burns mostly involved distal parts of the lower limbs, were thermal in 90% with an intentional action in 43%, and frequently occurred in a bathing room (48%) during a footbath (54%). Mean time to the first surgery was day 3,35 and, when needed, the second one was performed 6,54 days later. Mean LOS was 14,6 days, eleven patients were walking again by this time. We found a significant (p<0.001) association between the time to the 1st surgery and time elapsed between the burn and hospitalization. The existence of a diabetes-related neuropathy is a risk factor of lower limb burns, provided it suppresses the alarm of pain. Early surgery seems to reduce the LOS.

Repair Of Palm Burns Of The Hand: A Contralateral Inner Arm Bag-Shaped Flap

Hands are one of the most often burnt parts of the body. Deep palmar burns are often the result of an electrical burn or a thermal burn from grasping a hot item. With a deep burn, joints, vasculo-nervous pedicles, tendons or bones can become exposed and lead to amputation. Different surgical repair methods are used depending on the area of the hand that is burnt. Most of the publications to date have described surgical techniques for dorsal hand burns. The abdominal bag-shaped flap is one of the main surgical techniques to cover dorsal deep tissue exposure. Bag-shaped flaps need time to achieve the vascular autonomy of the flap without any movement. Abdominal bagshaped flaps are particularly suitable for dorsal soft-tissue defects, while for palmar defects, it is an uncomfortable position to maintain for three weeks. A contralateral arm bag-shaped flap for palmar burns allows a comfortable position to be achieved as the upper burnt limb is positioned as if the patient has their arms crossed. Furthermore, as stated above, the contralateral arm bag-shaped flap has the advantage of allowing a flap to be used that is thinner than an abdominal bag-shaped flap. At the Saint Louis Burns Center, we recently treated two patients with deep palmar burns and deep tissue exposure. We performed a contralateral arm bag-shaped flap for both of these patients. In our experience, the use of the contralateral arm bag-shaped flap technique to cover palmar lesions resulted in favorable postoperative progression, with complete closure of the lesions, good functional outcomes, as well as other advantages such as a hidden scar at the donor site. This technique allows amputation of fingers to be avoided when pedicles, joints, or tendons are exposed and when the burnt area of the palm is extensive and no other flaps can be used.

A new therapeutic protocol for the treatment of keloid scars: a retrospective study

OBJECTIVE

There are few means to treat large keloid scars, as exeresis-even if partial-impedes direct closure without tension in the absence of a flap or a skin graft. This study evaluates the efficacy, indications for use and limitations of a new therapeutic protocol, combining an extralesional keloid excision left to heal by secondary intention with a paraffin dressing and glucocorticoid ointment, followed by monthly intrascar injections of corticosteroids upon full re-epithelialisation.

METHOD

A retrospective study of patients treated for keloid scars by using the new therapeutic protocol. Scars were categorised as either healed or recurring. Their recurrence was scored according to the changes in functional signs and the scar volume.

RESULTS

A total of 36 scars were studied. The mean follow-up was 14.1 months. Healing occurred in a mean of 6.8 weeks. The mean surface area was 21.6cm². Healing rate was 30.5%. Scar volume was improved in 60% of recurrent cases and functional signs in 56%. Based on adherence with the corticotherapy, two patient groups could be discerned. For patients in the 'adherent' group, the healing rate was 40%, and scar volume was improved in 75% of recurrent cases and the functional signs in 83% of cases.

CONCLUSIONS

The healing rate in this study was close to that reported in the literature. Excision-healing by secondary intention could therefore be offered to patients for whom adherence is uncertain. The protocol in this study offers a straightforward, fast, accessible solution that does not appear to entail any risk of additional keloids. It could potentially offer a treatment option in case of failure of other treatments, large keloid scars or scalp keloids.

Interindividual and Intraindividual Variations of Breast Sensitivity Before and After Breast Reduction: A Prospective Study

BACKGROUND

More than 300,0000 breast plastic surgery procedures are performed annually worldwide, of which more than 100,000 are reduction mammoplasties carried out in the United States. Although most patients tend to be satisfied with the immediate outcomes of this procedure, there is increasing concern among surgeons as well as patients with regard to breast sensibility and the postoperative recovery.The objectives of this study were to assess the variation in the sensibility in patients undergoing hypertrophic breast surgery by quantification of the impact of various variables and to evaluate its progression from before the surgery to between 3 and 6 months and 1 year postoperatively.

METHODS

We carried out a nonrandomized, monocentric, prospective study. All of the patients were examined by the same evaluator using a set of 20 von Frey monofilaments on the day before the surgery and at 3 to 6 months and 1 year postoperatively. The breast skin, areola, and nipple sensibilities were tested. Age, body mass index, tobacco use, and the breast volume were recorded.

RESULTS

We did not find any significant effect of the body mass index, tobacco use, or age on breast sensibility. The nipple and areola complex (NAC) sensibility was inversely correlated with the degree of hypertrophy before the surgery, but this difference disappeared in the postoperative evaluations. After the surgery, the NAC sensibility decreased at the first follow-up at 4.5 months and returned to normal after 1 year.

CONCLUSIONS

The inverse relationship between breast volume and sensibility in the preoperative evaluation disappeared after mammaplasty reduction. In the early postoperative period, the sensibility decreased on the NAC but returned to normal after 1 year.

Epidemiology and Prevention of Breast Prosthesis Capsular Contracture Recurrence

INTRODUCTION

Baker grade III and IV breast prosthesis capsular contractures represent a major problem for patients undergoing mammoplasties. The risk factors involved in recurrence are debated, and the best surgical approach for their prevention is not established. The objective was to identify these.

MATERIALS AND METHODS

We carried out a retrospective study of patients operated on for capsular contracture at the Saint-Louis Hospital in Paris from 2012 to 2014. The characteristics at inclusion were compared so as to determine the risk factors of recurrence. The surgical approaches were compared between the patients with recurrence and those without at 5 years.

RESULTS

Of the 100 patients included, 24 had a recurrence. The minimal follow-up was 5 years. No risk factors of recurrence of capsular contracture were identified. The surgical approach associated with the lowest rate of recurrence was anterior capsulectomy [OR total capsulectomy = 2.36 (0.73; 8.037) OR capsulotomy = 4.33 (1.37; 14.81)] (p < 0.040) with alteration of the volume of the implant, whether greater or less than initially [OR greater volume = 0.30 (0.096; 0.83); OR smaller volume = 0.14 (0.008; 0.85)] (p < 0.018).

CONCLUSION

The occurrence of capsular contracture is a major problem with prosthetic breast surgery. The main risk factors identified to date are essentially in regard to the occurrence of a first episode. No significant risk factors for recurrence were identified. The best prevention appears to be an anterior capsulectomy with reducing the volume of the implant.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . IV.

Increased expression of PD1 and CD39 on CD3+ CD4+ skin T cells in the elderly

Normal ageing is associated with an impaired systemic immune response contributing to an increased susceptibility to infectious diseases. The aim of this study was to compare the lymphocyte phenotype in human skin from old and young healthy subjects. Skin samples from donors were used for explant cultures before flow cytometric analysis. Our results depicted a higher proportion of CD4⁺ and a lower proportion of CD8⁺ among CD3⁺ T cells, a decreased proportion of CD45RA⁺ naive T cells (3.5 ± 1.9% vs 22.9 ± 11.1%, P ≤ 0.007) and an upregulation of the expression of CD39 and PD1 on CD3⁺ CD4⁺ T cells (25.1 ± 8.5% vs 12.5 ± 8.5%, P ≤ 0.003, 68.8 ± 11.6% vs 50.0 ± 11.3%, P ≤ 0.01, respectively) in the skin of old subjects. These findings could explain a reduced generation of long-lived memory T cells and an impaired antitumoral response in the skin of the elderly.

External Fixation During the Acute Phase of Deep Burned Hands: Description of Saint Louis' Burn Center Technique

Restoration of a good hand function and limitation of the sequelae are the main concerns in burns treatment. The intrinsic plus position is known as the safe position for hand splinting. This article aims at describing the technique of external fixation that have been developed in Saint Louis' Burn Center in management of burned hands during the acute phase. Since 2013, a technique of external fixation has been developed in our burn center using Hoffmann II External Fixation System from Stryker® and pins from Medicalex®. External fixation of a deep burned hand is an efficient and safe way to immobilize the hand in a correct intrinsic plus position, to secure the skin grafts to improve graft take and to permit changes of the dressings without removing the immobilization device.

A 10-Year Follow-Up Experience of 383 Patients with Bilateral Smooth Inflatable Breast Implants Filled with Saline Solution

INTRODUCTION

In light of the concerns regarding the occurrence of anaplastic large-cell lymphoma, seromas, and scar capsules, there appears to be merit in analysis and presentation of the results of our series of inflatable smooth implants filled with saline solution, for which the follow-up was more than 10 years.

PATIENTS AND METHOD

We carried out a retrospective study, including all of the patients who underwent a first breast implant for cosmetic reasons, between 2003 and 2006.

RESULTS

A total of 383 patients with 766 smooth implants filled with saline solution were included in our study. No cases of lymphoma and seroma were diagnosed. Eleven patients exhibited a postoperative hematoma, and four went on to develop a capsule. Twenty-two patients (5.7%) developed a Baker Grade III or IV capsule that required revision surgery. Two patients (0.5%) opted for a bilateral prosthesis replacement due to visual rippling. In total, there were 26 (3.4%) early deflations of prostheses.

DISCUSSION

There is not a statistically significant correlation between the occurrence of hematomas and the formation of a capsule. We found a lower shell rate with smooth-walled versus textured implants. The fact of having a decline of 10 years allows to be exhaustive. As for wrinkling and ripples, their occurrence has not been increased by the use of inflatable retropectoral implants.

CONCLUSION

Smooth inflatable implants filled with saline solution have numerous advantages such as the possibility of a very small approach route and perioperative adaptability of the volume. In light of the lack of indication of anaplastic large-cell lymphoma with smooth implants, they are clearly an attractive alternative to textured implants filled with silicone gel.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Head and neck skin expansion: assessment of efficiency for the treatment of lesions in the lower half of the face

The treatment of sequelae for burns or other loss of perioral tissues is complex due to the site where they occur, its functional importance, and social and esthetic aspects. Functional consequences of burns to this area are cutaneous retraction and a lack of skin that can lead to an inability to close the oral aperture, compromising the provision of dental hygiene and intubation procedures. The aim of the present publication was to evaluate the efficacy of chin, labial and jugal cutaneous expansions for the treatment of perioral lesions and lesions of the lower half of the face in our retrospective series of patients. We collected data and photography from digital files for each patient. Proportion of scarred skin that could be treated by one or several expansion procedures was evaluated. The main outcome was the resection of 50% or more initial lesions. Side effects were assessed. Out of a total of 33 expanders, 28 were at the jugal level, 5 were chin expanders, and none were labial expanders. This equated to the inclusion of fourteen patients. The average percentage of the lesion that was removed after the perioral expansion protocol was 68.9% (40%-100%). 85% of patients had a positive outcome. 12% of procedures were complicated by hematoma, infection or prosthesis exposure. Each time that the lesional area could be fully (i.e. 100%) treated, only a single expansion was used. Head and neck expansion is the technique of choice for reconstruction of the lower half of the face and the horizontal part of the neck in terms of efficiency and safety.

[Quick screening for Body Dysmorphic Disorder in a plastic surgery population in France]

INTRODUCTION

All plastic surgeons are frequently faced with patients with Body Dysmorphic Disorder (BDD). However, no screening test exists in French to help the plastic surgeons to diagnose this disease. The Body Dysmorphic Disorder Questionnaire (BDDQ) is the Gold Standard to easily detect BDD in consultation with any non-psychiatric physician. The aim of this study was to translate and validate the BDDQ into French to help plastic surgeons to detect BDD before the surgery. This way, plastic surgeons will be able to provide an optimal medical care and to reduce the risk of psychiatric collapse.

METHODS

We asked Katherine Philipps for her approval to use her BDDQ for our study, and thereafter we translated it respecting the criteria of the World Health Organization. We first evaluated the psychometric qualities of the BDDQ in French and then its reproducibility and its sensitivity to change.

RESULTS

A French version of the BDDQ appeared to be reliable and comprehensible. The questionnaire has been tested on a sample of patients in plastic surgery consultation, at a T moment and a T plus one month to certify its reproducibility and its sensitivity to change.

CONCLUSION

These results permit to claim that the French version of the BDDQ is now validated to detect patients with a BDD in a plastic surgery consultation.

Utility of anaerobic bottles for the diagnosis of bloodstream infections

BACKGROUND

Obligate anaerobes usually account for less than 10% of bacteria recovered from blood cultures (BC). The relevance of routine use of the anaerobic bottle is under debate. The aim of this study was to evaluate the utility of anaerobic bottles for the diagnosis of bloodstream infections (BSI).

METHODS

We conducted a 6-month, retrospective, monocentric study in a tertiary hospital. All positive BC were grouped into a single episode of bacteremia when drawn within 7 consecutive days. Bacteremia were classified into contaminants and BSI. Charts of patients with BSI due to obligate anaerobes were studied.

RESULTS

A total of 19,739 blood cultures were collected, 2341 of which (11.9%) were positive. Anaerobic bottles were positive in 1528 (65.3%) of all positive BC but were positive alone (aerobic bottles negative) in 369 (15.8%). Overall 1081 episodes of bacteremia were identified, of which 209 (19.3%) had positive anaerobic bottles alone. The majority 126/209 (60.3%) were contaminants and 83 (39.7%) were BSI. BSI due to facultative anaerobes, obligate aerobes and obligate anaerobes were identified in 67 (80.7%), 3 (3.6%) and 13 (15.7%) of these 83 episodes, respectively. BSI due to obligate anaerobic bacteria were reported in 9 patients with gastro-intestinal disease, in 3 with febrile neutropenia and in 1 burned patient.

CONCLUSIONS

Anaerobic bottles contributed to the diagnosis of a significant number of episodes of bacteremia. Isolated bacteria were mostly contaminants and non-obligate anaerobic pathogens. Rare BSI due to obligate anaerobes were reported mainly in patients with gastro-intestinal disorders and during febrile neutropenia.

Stepwise Management of Severe Thoracogenic Scoliosis in Burned Child

BACKGROUND

Skin and soft tissue retraction secondary to burns of the trunk may induce severe and progressive thoracogenic spinal deformities in children. Its management is rarely described.

CASE DESCRIPTION

Our study reports a case of severe thoracic scoliosis in a 13-year-old adolescent, secondary to soft tissue retraction due to trunk burn in early childhood. The Cobb angle of the scoliosis was 100 degrees. The 3-stage surgical strategy consisted of scar excision and skin graft in the first stage, halo gravity traction in the second stage, and posterior correction and fusion of the spine in the third and final stage. The postoperative course was satisfactory, and late follow-up at 1 year showed stable correction of the spine, with satisfactory coronal and sagittal balance and good healing of skin and soft tissues.

DISCUSSION

While spinal deformities secondary to burns are rare, they require specific, sequential, and multidisciplinary medical and surgical management. Our surgical strategy was to treat skin and soft tissues retractions first and then address spinal deformity. We used halo-gravity traction between the 2 surgical stages to help improve the spine deformity correction while reducing the risk of neurologic complications.

Ongoing Development and Evaluation of a Method of Telemedicine: Burn Care Management With a Smartphone

In cases involving small burns in patients without a comorbidity or associated pathology, a referral from a surgeon is necessary and sometimes it cannot be ascertained when the patient is not brought in by a specialized team. The purpose of this retrospective study was to evaluate the quality of our method for performing telemedicine. This retrospective study included the 323 patients who were initially treated using the telemedicine system implemented between 2011 and 2016. This procedure only involved patients burned over a small portion of their body's surface area (ie, ≤15%) who were between 15 and 75 years of age and who did not have a major comorbidity. The purpose of the procedure was to evaluate the need for surgery. The initial diagnosis regarding the need for a surgical procedure was accurate in 94.4% (305/323) of the cases. Eleven patients (3.4%) were transferred unnecessarily as they ultimately did not require surgery, and seven patients (2.2%) were ultimately transferred even though the need for surgery was not initially established at the time that the pictures were viewed. No initial errors in the photographic evaluation caused a worsening in the life-threatening, functional, or aesthetic prognoses. We have recently opted to use telemedicine for initial patient management. In 94.4% of cases, the opinion that was provided was accurate. Only 3.2% of the patients for whom outpatient treatment was recommended ultimately underwent surgery without subsequently experiencing the slightest injury due to any delay in therapy. Although it will never replace clinical examination, these results have encouraged us to develop telemedicine based on digital photography.

Early hypoalbuminemia is associated with 28-day mortality in severely burned patients: A retrospective cohort study

BACKGROUND

Hypoalbuminemia is a frequent condition in the first 24 h after a severe burn injury and is associated with worse outcomes.

METHODOLOGY

We investigated the relation between very early hypoalbuminemia (<6 h after admission) and clinical outcome in a retrospective cohort admitted to our unit for severe burn injuries between 2012 and 2017.

RESULTS

73 severely burned patients were included, with a delay of admission of 3 (2-4) h. In a context of early exogenous supply of albumin, admission and 4H Albuminemia (Alb4 h) were significantly lower in deceased patients (respectively, 34 (29-37) vs 27 (23-30) g/l; p = 0.009 and 27 (24-32) vs 21 (17-27) g/l; p = 0.022) whereas albuminemia ≥6 h were not. The best threshold value of Alb4 h to discriminate 28-day mortality was 23 g/l. Patients with an Alb4 h < 23 g/l had a higher 28-day mortality than patients with an Alb4 h ≥ 23 g/l (42% vs 11%; p = 0.003); adjusted OR = 4.47 (95% CI 1.15-17.36); p = 0.03.

CONCLUSION

In severely burned patients receiving early albumin supply, early hypoalbuminemia is associated with higher mortality whereas later albuminemia (≥6 h) is not. Exploration of whether early albumin infusion (8-12 h post injury) may alter clinical outcome is warranted.

Contributing factors and outcomes of burn-associated cholestasis

BACKGROUND & AIMS

Cholestasis often occurs after burn injuries. However, the prevalence of cholestasis and its effect on outcomes in patients with severe burn injuries are unknown. The aim of this study was to describe the course and the burden of cholestasis in a cohort of severely burned adult patients.

METHODS

We investigated the relationship between burn-associated cholestasis (BAC) and clinical outcomes in a retrospective cohort of patients admitted to our unit for severe burn injuries between 2012 and 2015. BAC was defined as an increased level of serum alkaline phosphatase (ALP) ≥1.5x the upper limit of normal (ULN) with an increased level of gamma-glutamyltransferase (GGT) ≥3x ULN, or as an increased level of total bilirubin ≥2x ULN.

RESULTS

A total of 214 patients were included: 111 (52%) patients developed BAC after a median (IQR) stay of 9 (5-16) days. At 90 days, the mortality rate was 20%, including 34 and 9 patients with and without BAC (p <0.001), respectively, which corresponded to a 2.5-fold higher (95% CI 1.2-5.2, p = 0.012) risk of 90-day mortality for patients with BAC. After being adjusted for severity of illness, patients with BAC, hyperbilirubinemia and without elevated ALP and GGT levels had a hazard ratio of 4.51 (95% CI 1.87-10.87) for 90-day mortality. BAC was associated with the severity of the burn injury, shock and bacteraemia. BAC was present in 38 (51%) patients at discharge, and 7 (18%) patients had secondary sclerosing cholangitis. These patients maintained elevated levels of ALP and GGT that were 5.8x (1.7-15) the ULN and 11x the ULN (4.5-22), respectively, 20 months (3.5-35) after discharge.

CONCLUSION

BAC is prevalent among patients with severe burn injuries and is associated with worse short-term outcomes, especially when total bilirubin levels were increased without elevated ALP and GGT levels. BAC survivors are at risk of developing sclerosing cholangitis.

LAY SUMMARY

Cholestasis is common after burn injuries and is associated with burn severity, sepsis, organ failure and mortality. Patients with hyperbilirubinemia without elevated alkaline phosphatase and gamma-glutamyltransferase levels after the burn injury have a poor prognosis. Patients with burn-associated cholestasis may develop sclerosing cholangitis and secondary biliary cirrhosis.

Reconstruction Of The Burnt Nose Using A Carved Flap In Four Cases

Techniques for reconstructing nasal defects in burns are very limited because the surrounding scar tissue makes it difficult to use local flaps. The authors report their experience using the Converse scalping flap harvested from scarred skin, placed as a mass on the nasal area, then secondarily carved to shape the nose and covered by a skin graft. This is a retrospective study of 4 patients, 3 men and 1 woman, with an average age of 45 years, who were operated on between 1994 and 2013 using this technique for postburn nasal reconstruction. Patients had 45% burns on average. The flap was weaned from its donor site at the third week and the frontalis donor area grafted. Several months later, the flap was sculpted from the outside to the inside in the three dimensions, removing the scarred epidermal areas to restore the aesthetic units of the nose, which were grafted using a full thickness skin graft. The final aesthetic result of the nasal reconstruction was evaluated by the patient and the surgical team. The four nasal reconstructions were carried out to completion. Three were rated as 'very good' (75%) and one was rated as 'good' (25%). The Converse flap modification, referred to as the "carved flap", to reconstruct the burned nose is a reliable technique, possible on a scarred forehead with no additional donor site morbidity.

Improving Safety after Abdominoplasty: A Retrospective Review of 1128 Cases

BACKGROUND

Over the course of several decades, abdominoplasty has undergone numerous improvements, thereby improving patient safety. The choice of the site of the incision and the extent of the detachment directly influence the occurrence of the main complications.

METHODS

A retrospective study was carried out involving 1128 patients who underwent abdominoplasty between January of 1990 and June of 2014. The main postoperative complications were analyzed.

RESULTS

The hematoma rate was 5.7 percent; in addition, infections (4.5 percent), cutaneous necrosis (2.7 percent), seromas (2.7 percent), disunions (1.3 percent), and deep venous thrombosis (0.2 percent) were observed. Three main risk factors for complications were highlighted: age older than 40 years, obesity, and smoking. The authors noted a significant variation in the rate of complications depending on the technique used, with a substantial rate of necrosis in case of inverted-T abdominoplasty. Liposuction was not a source of complications, regardless of the patient's background or the type of intervention.

CONCLUSIONS

Abdominoplasty is currently a reliable technique that allows the abdomen to be repaired and quality of life to be restored. Other means remain to be explored to improve the overall treatment and to move toward a maximal reduction of the risks.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Electrical Burns and Late Spontaneous Artery Ruptures: About Three Cases

Electrical burns are responsible for arterial and venous thrombosis, as well as weakening of the arteries. Immediate or delayed arterial occlusions, secondary to the aggression of the intima, or aneurysms, secondary to the aggression of the media, sometimes lead to artery ruptures without any warning signs. Such ruptures may trigger a hemorrhagic shock whose period of onset is variable and unpredictable. We are presenting here three cases treated in our department for electrical burns, whose complications were marked by hemorrhagic shock, secondary to late artery ruptures, sometimes occurring several months following the event. These case reports required performance of emergency hemostasis in order to control sudden bleeding, with first approach being placement of a tourniquet at the base of the limb and/or a compression point. Through these cases, we thought it is crucial to closely monitor for a few weeks all patients who were victims of electrical injury, even more so if it was associated with a compartment syndrome of one or more limbs and high rhabdomyolysis, which seem to be predictive factors of late artery ruptures in our case reports.

Outcome and potentially modifiable risk factors for candidemia in critically ill burns patients: A matched cohort study

BACKGROUND

Patients with extensive burns are at risk of developing candidemia.

OBJECTIVES

To identify potentially modifiable risk factors and outcomes of candidemia in critically ill burns patients.

PATIENTS AND METHODS

Retrospective matched cohort study including adult burns patients. Patients who developed candidemia were matched with burns patients with Candida spp colonisation and sepsis or septic shock without candidemia in a ratio of 1:3 (same severity scores and colonisation index). Univariate and multiple regression analyses were performed.

RESULTS

Of 130 severely burned patients with Candida spp colonisation and at least one episode of sepsis or septic shock, 14 were diagnosed with candidemia. In the candidemia group, patients had a median (IQR) total burns surface area (TBSA) of 57 (38-68)%, SAPSII of 43 (36-58) and ABSI of 11 (8-13). Multiple regression analysis showed that only duration of prior antibiotic therapy was independently associated with candidemia. ICU mortality was higher in the candidemia group (71% vs 35% [P = 0.02]). The log-rank test for 28-day mortality comparing patients with candidemia treated with an empirical strategy vs a curative strategy did not reach significance (P = 0.056).

CONCLUSIONS

Burns patients having received recent antibiotherapy have a higher risk of candidemia. Antifungal strategies did not influence outcome in this series.

Incidence, risk factors and outcome of multi-drug resistant Acinetobacter baumannii nosocomial infections during an outbreak in a burn unit

BACKGROUND

Multidrug-Resistant Acinetobacter baumannii (MR-AB) can cause outbreaks in burn units. We aimed to study the incidence, risk factors and outcome of MR-AB infections in a burn unit (BU).

METHODS

A prospective study was conducted from April to November, 2014 during an outbreak in a BU in Paris. Weekly surveillance cultures were performed to determine MR-AB colonization. MR-AB nosocomial infections, discharge or death without MR-AB infection were considered as competing events. To identify risk factors for MR-AB infection, baseline characteristics and time-dependent variables were investigated in univariate analyses using Cox models.

RESULTS

Eighty-six patients admissions were analyzed during the study period. Among them, 15 (17%) acquired MR-AB nosocomial infection. Median time to infection was 22days (interquartile range: 10-26 days). Cumulative incidence of MR-AB infections was 15% at 28days (95% CI=8-24). Risk factors for MR-AB infection in univariate analysis were SAPS II (Hazard Ratio (HR):1.08; 95% CI:1.05-1.12; P<0.0001) and ABSI (Abbreviated Burn Severity Index) scores (HR:1.32; 95% CI:1.12-1.56; P=0.001), MR-AB colonization (HR:10.2; 95%CI:2.05-50.3; P=0.004), invasive procedures (ventilation, arterial and/or venous catheter) (P=0.0001) and ≥2 skin grafts (HR:10.2; 95% CI:1.76-59.6; P=0.010). MR-AB infection was associated with an increased risk of death (HR: 7.11; 95%CI: 1.52-33.2; P=0.013) and longer hospital stay with a median estimated increase of 10days (IQR: 6; 14).

CONCLUSIONS

Incidence of MR-AB nosocomial infection was high during this outbreak, and was associated with prolonged hospitalization and increased risk of death. High patient severity scores, prior MR-AB colonization, invasive procedures and repeated skin grafts were associated with an increased risk of nosocomial infection.

Free-style puzzle flap as a cross-leg pedicled flap: the concept of re-using a flap in acute burns, a case report

Background

In well-selected cases, flaps can play a pivotal role in optimizing outcomes in the acute phase of burns. A previous redundant flap could be reused or recycled as a donor site from which a new flap could be raised.

Case presentation

We report the case of a patient with full thickness burns on both legs, leading to the exposure of joints of the right ankle and the right foot and left patellar tendon. The right lower extremity was covered with a free musculo-cutaneous latissimus dorsi flap. Then, a musculo-cutaneous cross-leg flap pedicled on the anterior branch and centered on a perforator was harvested from the previous redundant flap to cover the controlateral knee.

Conclusion

Sequential flap coverage can be considered in cases of extensive soft tissue defects and particularly in burns. This case illustrates that re-using a redundant part of a previous flap to cover another defect is a safe and interesting alternative in the event of a lack of donor sites or to save donor sites for later reconstruction of contracted burn scars.

[Complications with surgical treatment of basal cell carcinomas in individuals over 75 years of age: A retrospective study of prognostic factors in 158 cases]

INTRODUCTION

Basal cell carcinoma (BCC) is a pathology that evolves locally and it is common in elderly subjects whose frailty could restrict the indications for the reference treatment, which is based on surgery. The aim of this study was to investigate the morbidity and the mortality associated with surgical treatment of BCC in patients over 75 years of age, so as to identify possible prognostic factors for postoperative complications.

MATERIALS AND METHODS

This was a retrospective study carried out with patients over 75 years of age who were treated surgically for one or several BCC between 2010 and 2015 in the reconstructive and cosmetic plastic surgery unit of the Saint-Louis Hospital in Paris (France). We collated the demographic characteristics, the characteristics of the treatment, as well as the rate of major postoperative complications. We performed a univariate and then a multivariate analysis of the various risk factors that were identified.

RESULTS

A total of 158 patients were analyzed and they exhibited a rate of major complications of 12%. The statistical analysis identified five significant risk factors: being over 85 years of age (P=0.006), long-term use of anticoagulant treatment (P=0.02), the presence of at least one comorbidity (P=0.018), a conventional hospitalization (P=0.002), and the use of general anesthesia (P=1.2e^-10).

CONCLUSION

Five risk factors for major postoperative complications with the surgical treatment of BCC in patients over 75 years of age were identified. These factors may provide direction to medico-surgical teams in regard to the optimal treatment of BCC in elderly patients.

Interleukin-32 promotes detachment and activation of human Langerhans cells in a human skin explant model

BACKGROUND

Cross-talk between skin keratinocytes (KCs) and Langerhans cells (LCs) plays a fundamental role in the body's first line of immunological defences. However, the mechanism behind the interaction between these two major epidermal cells is unknown. Interleukin (IL)-32 is produced in inflammatory skin disorders. We questioned the role of IL-32 in the epidermis.

OBJECTIVES

We aimed to determine the role of IL-32 produced by KCs on surrounding LCs.

METHODS

We used an ex vivo human explant model from healthy donors and investigated the role of IL-32 on LC activation using imaging, flow cytometry, reverse transcriptase quantitative polymerase chain reaction and small interfering (si)RNA treatment.

RESULTS

Modified vaccinia virus ankara (MVA) infection induced KC death alongside the early production of the proinflammatory cytokine IL-32. We demonstrated that IL-32 produced by MVA-infected KCs induced modest but significant morphological changes in LCs and downregulation of adhesion molecules, such as epithelial cell adhesion molecule and very late antigen-4, and CXCL10 production. The treatment of KCs with IL-32-specific siRNA, and anti-IL-32 blocking antibody significantly inhibited LC activation, demonstrating the role of IL-32 in LC activation. We also found that some Toll-like receptor ligands induced a very high level of IL-32 production by KCs, which initiated LC activation.

CONCLUSIONS

We propose, for the first time, that IL-32 is a molecular link between KCs and LCs in healthy skin, provoking LC migration from the epidermis to the dermis prior to their migration to the draining lymph nodes.