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Panayi AC, Knoedler L, Matar DY, Rühl J, Friedrich S, Haug V, Palackic A, Thomas B, Kneser U, Orgill DP, Hundeshagen G. The combined risk predictive power of frailty and hypoalbuminemia in free tissue flap reconstruction: A cohort study of 34,571 patients from the NSQIP database. Microsurgery 2024; 44:e31156. [PMID: 38549404 DOI: 10.1002/micr.31156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/19/2023] [Accepted: 02/01/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR). METHODS We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period. RESULTS A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001). CONCLUSION In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.
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Affiliation(s)
- Adriana C Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leonard Knoedler
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Dany Y Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of of Plastic Surgery, Department of Surgery, Baltimore, Maryland, USA
| | - Jasmin Rühl
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, Augsburg University, Augsburg, Germany
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, Augsburg University, Augsburg, Germany
- Centre for Advanced Analytics and Predictive Sciences (CAAPS), Augsburg University, Augsburg, Germany
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alen Palackic
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Benjamin Thomas
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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Tapking C, Panayi A, Haug V, Palackic A, Houschyar KS, Claes KEY, Kuepper S, Vollbach F, Kneser U, Hundeshagen G. Use of the modified meek technique for the coverage of extensive burn wounds. Burns 2024; 50:1003-1010. [PMID: 38383170 DOI: 10.1016/j.burns.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 12/26/2023] [Accepted: 01/10/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Autologous split thickness skin grafting using meshing technique remains the preferred option for the management of deep dermal and full thickness burns. The limited donor site availability seen in patients with extensive burns, however, restricts use of the mesh grafting technique for skin expansion. Meek micrografting was developed to allow for greater expansion, and, therefore, more reliable treatment of extensive burns. This study aimed to present our outcomes using the Meek micrografting technique and identify risk factors for graft failure. METHODS A retrospective review of patients admitted to our large academic hospital who were treated with the Meek micrografting technique from 2013 to 2022 was conducted. Patient demographics, surgical characteristics and outcomes were reported. Regression analyses were performed to identify factors that influence graft take and reoperation rate. RESULTS A total of 73 patients with a mean age of 45.7 ± 19.9 years and mean burn size of 60.0 ± 17.8%TBSA, with 45.3 ± 14.9% TBSA being third degree burns, received Meek transplantation. The mean graft take after removal of the pre-folded polyamide gauze at the tenth post-operative day was 75.8 ± 14.7%. Pre-treatment with use of an allograft, longer waiting time between admission and Meek grafting and transplantation over a dermal matrix were identified as positive predictors for graft take, while age was established as a negative predictor. CONCLUSION By examining the outcomes of the Meek micrografting technique in extensive burn wounds we identified that preconditioning of the wound bed, through allograft or negative pressure wound therapy application, positively correlates with improved outcomes, including higher graft take. At the same time, older age was seen to negatively correlate with graft take. Overall, Meek transplantation displays a favorable safety profile with promising outcomes. Future prospective studies and clinical trials can optimize the procedure and help establish it as the golden standard for extensive and complex burns.
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Affiliation(s)
- C Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - A Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - V Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - A Palackic
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - K S Houschyar
- Department of Dermatology and Allergology, University Hospital Aachen, Germany
| | - K E Y Claes
- Burn Center, Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
| | - S Kuepper
- Burns Center and Plastic Surgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - F Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, Heidelberg University, Ludwigshafen, Germany
| | - G Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, Heidelberg University, Ludwigshafen, Germany.
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Hundeshagen G, Blears E, Mertin V, Day AG, Palackic A, Tapking C, Haug V, Kneser U, Bliesener B, Panayi AC, Aballay A, Depret F, Stoppe C, Heyland DK. Administration and effects of beta blockers and oxandrolone in severely burned adults: a post hoc analysis of the RE-ENERGIZE trial. Burns Trauma 2024; 12:tkad063. [PMID: 38650969 PMCID: PMC11033841 DOI: 10.1093/burnst/tkad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 10/15/2023] [Accepted: 12/13/2023] [Indexed: 04/25/2024]
Abstract
Background Prospective randomized trials in severely burned children have shown the positive effects of oxandrolone (OX), beta blockers (BB) and a combination of the two (BBOX) on hypermetabolism, catabolism and hyperinflammation short- and long-term post-burn. Although data on severely burned adults are lacking in comparison, BB, OX and BBOX appear to be commonly employed in this patient population. In this study, we perform a secondary analysis of an international prospective randomized trial dataset to provide descriptive evidence regarding the current utilization patterns and potential treatment effects of OX, BB and BBOX. Methods The RE-ENERGIZE (RandomizEd Trial of ENtERal Glutamine to minimIZE Thermal Injury, NCT00985205) trial included 1200 adult patients with severe burns. We stratified patients according to their receipt of OX, BB, BBOX or none of these drugs (None) during acute hospitalization. Descriptive statistics describe the details of drug therapy and unadjusted analyses identify predisposing factors for drug use per group. Association between OX, BB and BBOX and clinical outcomes such as time to discharge alive and 6-month mortality were modeled using adjusted multivariable Cox regressions. Results More than half of all patients in the trial received either OX (n = 138), BB (n = 293) or BBOX (n = 282), as opposed to None (n = 487, 40.6%). Per study site and geographical region, use of OX, BB and BBOX was highly variable. Predisposing factors for the use of OX, BB and BBOX included larger total body surface area (TBSA) burned, higher acute physiology and chronic health evaluation (APACHE) II scores on admission and younger patient age. After adjustment for multiple covariates, the use of OX was associated with a longer time to discharge alive [hazard ratio (HR) 0.62, confidence interval (CI) (0.47-0.82) per 100% increase, p = 0.001]. A higher proportion of days on BB was associated with lower in-hospital-mortality (HR: 0.5, CI 0.28-0.87, p = 0.015) and 6-month mortality (HR: 0.44, CI 0.24-0.82, p = 0.01). Conclusions The use of OX, BB and BBOX is common within the adult burn patient population, with its use varying considerably across sites worldwide. Our findings found mixed associations between outcomes and the use of BB and OX in adult burn patients, with lower acute and 6-month-mortality with BB and longer times to discharge with OX. Further research into these pharmacological modulators of the pathophysiological response to severe burn injury is indicated.
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Elisabeth Blears
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Viktoria Mertin
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Andrew G Day
- Kingston General Health Research Institute, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, K7L 2V7, Canada
| | - Alen Palackic
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Björn Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Adriana C Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Ariel Aballay
- Department of Plastic Surgery, Bayview Medical Center, Johns Hopkins University, 4940 Eastern Ave, Baltimore 21224, MD, USA
| | - Francois Depret
- Department of Anaesthesiology, Intensive Care Medicine and Burn center, Saint-Louis Hospital, 1 avenue Claude-Vellefaux, 75010, Asistance Publique Hôpitaux de Paris, Paris Cité University, France
| | - Christian Stoppe
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Schwanenweg 21, 24105 Kiel, Germany
- University Hospital, Würzburg, Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, Oberdürrbacher Str. 6, 97080 Würzburg, Germany
- Departments of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Augustenburger Platz 1 | 13353, Berlin, Germany
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen’s University, 76 Stuart Street, Kingston, K7L 2V7 Ontario, Canada
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Tapking C, Willkomm L, Stolle A, Harhaus L, Hundeshagen G, Bliesener B, Kneser U, Radu CA. Health-related quality of life after burn injury due to bioethanol-fueled fireplaces. Burns 2024; 50:685-690. [PMID: 38042627 DOI: 10.1016/j.burns.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/29/2023] [Accepted: 11/12/2023] [Indexed: 12/04/2023]
Abstract
OBJECTIVE Commercially available bioethanol-fueled fireplaces are a potential source of burns and are commonly used for home use. The present study aimed to evaluate the quality of life following burn injuries that were caused by bioethanol-related accidents. METHODS Burned patients who were admitted to our burn unit with burn injury due to bio-ethanol fueled fire places between January 2010 and December 2021 were contacted to ask for their willingness to participate in this study. They were asked to answer questions regarding the circumstances of the accident and three questionnaires to capture burn specific and general health related quality of life (Burn Specific Health Scale-Brief (BSHS-B), Short-Form Health Survey 36 (SF-36)) and general information about the accident. Patients were matched and compared to a group of patients suffering comparable burns from other burn mechanisms, which were also admitted to our burn unit at the same time. RESULTS Of 35 patients that met the inclusion criteria, 19 answered the questionnaire and were compared to 38 patients with other burn mechanisms. There were no statistical differences regarding age (bioethanol: 37.4 ± 14.7 years vs. control: 36.2 ± 14.3 years, p = 0.777), TBSA (9.9 ± 6.8% vs. 8.9 ± 10.4, p = 0.715), and sex (42.1% females vs. 36.8% females, p = 0.882). Most patients in the bioethanol-group reported that they did not follow the manual instructions (68.4%) and that the accident happened during the refilling process (52.6%). There was no significant difference in any subscale of the BSHS-B or the SF-36. DISCUSSION Burns related to bioethanol-fueled fireplaces are rare compared to other typical burn mechanisms. However, as they are used for personal pleasure and interior design, psychological impairment following burn may be even more critical. Detailed education on the use of these fireplaces needs to take place in order to reduce the risk of accidents.
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Affiliation(s)
- C Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - L Willkomm
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - A Stolle
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - L Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - G Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - B Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - C A Radu
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
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Bonaventura B, Panayi AC, Hummedah K, Palackic A, Tapking C, Haug V, Kilian K, Runkel A, Bliesener B, Kneser U, Hundeshagen G. Outcomes in patients with burns to the perineum, buttocks and genitalia: A retrospective cohort study. Burns 2024; 50:767-773. [PMID: 38036375 DOI: 10.1016/j.burns.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/26/2023] [Accepted: 10/09/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Burns that involve the perineum, buttocks and genitals (PBG) have been associated with more challenging therapeutic needs and worse clinical outcomes. We aimed to investigate whether PBG burns are an independent predictor for mortality, morbidity and complications in a large, heterogenous patient collective and in comparison to patients without PBG burns. PATIENTS AND METHODS Patients admitted to a level one burn center between August 2014 and July 2022 were included and stratified based on the presence of PBG burns on admission (PBG & control group = CTR). Demographic baseline data, burn aetiology, inhalation trauma (IHT), full-thickness burns (FT), number of operations (NOR), mortality, length of ICU stay (LOS-ICU), length of in-hospital stay (LOHS) and bacteraemia were assessed to compare key clinical characteristics and outcomes between the groups. Multivariate regression analyses and a 1:1 propensity score matching were conducted for key clinical outcomes. RESULTS A total of 1024 patients were included in the analysis (PBG: n = 227; CTR: n = 797). PBG burns were older (median (IQR) 54 (34-72) vs. 44, (30-61) years, p < 0.0001), more frequently female (35% vs. 23%, p = 0.002) presented with larger total body surface area (TBSA) burns overall (27 (32-39) vs. 10 (13-15) %, p < 0.0001) and sustained FT burns more frequently (69% vs. 26% p < 0.0001). Scald burns were more frequently the cause of PBG burns (45% vs. 15%, p < 0.0001), PBG patients needed twice as many surgical procedures (Mean (SD) 2 (2.84) vs. 1 (1.6), p < 0.0001) as CTR. In multivariate analyses, a significant correlation was identified between length of ICU stay and presence of PBG burns. Following strict cohort matching to account for sex, age, cause of burn, TBSA %, presence of FT burn, inhalation trauma and bacteraemia, PBG burns were an independent predictor for mortality (p = 0.0003). CONCLUSION PBG burns are at risk for prolonged intensive care, hospitalization and complications during treatment. Furthermore, the presence of PBG burns appears to be a risk factor for mortality, irrespective of patient age, TBSA affected and other relevant covariates.
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Affiliation(s)
- Bastian Bonaventura
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Adriana C Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Kamal Hummedah
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Alen Palackic
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Christian Tapking
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Katja Kilian
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Alexander Runkel
- Department of Plastic and Hand Surgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Bjoern Bliesener
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, Ludwigshafen, Germany.
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Panayi AC, Heyland DK, Stoppe C, Jeschke MG, Didzun O, Matar D, Tapking C, Palackic A, Bliesener B, Harhaus L, Knoedler S, Haug V, Bigdeli AK, Kneser U, Orgill DP, Hundeshagen G. The long-term intercorrelation between post-burn pain, anxiety, and depression: a post hoc analysis of the "RE-ENERGIZE" double-blind, randomized, multicenter placebo-controlled trial. Crit Care 2024; 28:95. [PMID: 38519972 PMCID: PMC10958907 DOI: 10.1186/s13054-024-04873-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 03/14/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Despite the growing prevalence of burn survivors, a gap persists in our understanding of the correlation between acute burn trauma and the long-term impact on psychosocial health. This study set out to investigate the prevalence of long-term pain and symptoms of anxiety and depression in survivors of extensive burns, comparing this to the general population, and identify injury and demographic-related factors predisposing individuals to psychosocial compromise. METHODS RE-ENERGIZE was an international, double-blinded, randomized-controlled trial that enrolled 1200 patients with partial- or full-thickness burns that required surgical treatment. For the post hoc analysis, we excluded participants who did not complete the Short Form Health Survey (SF-36) questionnaire. Normative data were taken from the 2021 National Health Interview Survey dataset. Propensity score matching was performed using the nearest-neighbor 1-to-1 method, and the two cohorts were compared in terms of chronic pain, and symptoms of anxiety and depression. A multivariable analysis was performed on the burns cohort to identify factors predicting post-discharge pain and symptoms of anxiety and depression. RESULTS A total of 600 burn patients and 26,666 general population adults were included in this study. Following propensity score matching, both groups comprised 478 participants each, who were predominately male, white, overweight and between 20 and 60 years old. Compared to the general population, burn patients were significantly more likely to report the presence of moderate and a lot of pain (p = 0.002). Symptoms of anxiety were significantly higher in the burn population in two of four levels (most of the time; some of the time; p < 0.0001 for both). Responders in the burn population were significantly less likely to report the absence of depressive symptoms (p < 0.0001). Burn patients were also significantly more likely to report that their mental health affects their social life. TBSA, history of depression, and female sex were identified as independently associated factors for pain, anxiety, and depressive symptoms. The presence of chronic pain and anxiety symptoms independently predicted for symptoms of depression. CONCLUSIONS Analyzing the largest multicenter cohort of patients with extensive burns, we find that burn injury is associated with chronic pain, and symptoms of anxiety and depression. In addition, TBSA-burned and history of depression directly correlate with the prevalence of chronic pain, and symptoms of anxiety and depression. Finally, pain, and symptoms of anxiety and depression are interrelated and may have interactive effects on the process of recovery following burn injury. Burn patients would, therefore, benefit from a multidisciplinary team approach with early mobilization of pain and mental health experts, in order to promptly prevent the development of psychosocial challenges and their consequences.
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Affiliation(s)
- Adriana C Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Würzburg, Würzburg, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Marc G Jeschke
- Hamilton Health Sciences Research, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Oliver Didzun
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Dany Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian Tapking
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Alen Palackic
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Björn Bliesener
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Leila Harhaus
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Amir K Bigdeli
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women'S Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Straße 13, 67071, Ludwigshafen/Rhine, Germany.
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Knoedler S, Kauke-Navarro M, Knoedler L, Friedrich S, Ayyala HS, Haug V, Didzun O, Hundeshagen G, Bigdeli A, Kneser U, Machens HG, Pomahac B, Orgill DP, Broer PN, Panayi AC. The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis. J Plast Reconstr Aesthet Surg 2024; 89:40-50. [PMID: 38134626 DOI: 10.1016/j.bjps.2023.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/26/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. METHODS We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications. RESULTS A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. CONCLUSION At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.
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Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Augsburg, Germany
| | - Haripriya S Ayyala
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Oliver Didzun
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Amir Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital Munich, Munich, Germany.
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
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8
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Panayi AC, Knoedler S, Knoedler L, Tapking C, Hundeshagen G, Diehm YF, Fischer S, Thamm OC, Kneser U, Haug V. Patient-reported Outcomes Utilizing the Breast-Q Questionnaire After Breast Conserving Surgery With and Without Oncoplastic Breast Surgery: A Systematic Review and Meta-analysis. Aesthet Surg J 2024:sjae002. [PMID: 38195101 DOI: 10.1093/asj/sjae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/11/2024] Open
Abstract
Oncoplastic breast surgery (OBS) arose to decrease the deformity following breast conserving surgery (BCS) for breast cancer. In this meta-analysis (MA), we pool Breast-Q™ questionnaire data to compare quality of life (QOL) in breast cancer patients who received BCS alone or in combination with Level I or II oncoplastic breast surgery (BCS+OBS). All relevant databases were searched following the PRISMA and QUOROM guidelines. All prospective or retrospective studies with a BCS or BCS+OBS cohort that reported QOL as assessed with the Breast-Q™ questionnaire were eligible. Fifty-five studies (75 distinct patient cohorts; 11,186 patients) were included in the MA, with 12 studies reporting both pre- and postoperative values and eligible for a pairwise MA. The pairwise MA showed a significant postoperative improvement in the overall satisfaction with the breast (MD +8.0%, p=0.003) and in the psychosocial well-being (MD +9.2%, 3.5-14.8, p=0.001) of the entire cohort (BCS and BCS+OBS). A subgroup MA of proportions highlighted a superiority of BCS+OBS to BCS in terms of overall satisfaction with the breast (72.0%, 68.0-76.1, versus 62.9%, 58.3-67.5; p=0.02) and psychosocial well-being (78.9%, 71.5-86.4, versus 73.3%, 67.3-76.5, p=0.0001). A leave-one-out sensitivity analysis confirmed the results of the pairwise MA and the MA of proportions. Oncoplastic breast surgery effectively improves QoL based on the patient-reported outcomes assessed using the Breast-Q™ questionnaire. The improvements were associated with acceptable complication rates, further supporting the use of BCS followed by OBS where mastectomy would otherwise be necessary.
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Affiliation(s)
- Adriana C Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Christian Tapking
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Yannick F Diehm
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Sebastian Fischer
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Oliver C Thamm
- Clinic for Plastic and Reconstructive Surgery, Helios Hospital Berlin-Buch, Berlin, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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Hundeshagen G, Palackic A, Knoedler L, Panayi A, Kneser U. An objective calculator for preoperative planning of Meek micrografting. J Plast Reconstr Aesthet Surg 2024; 88:314-315. [PMID: 38043400 DOI: 10.1016/j.bjps.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Alen Palackic
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Leonard Knoedler
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Adriana Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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10
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Knoedler S, Schliermann R, Knoedler L, Wu M, Hansen FJ, Matar DY, Obed D, Vervoort D, Haug V, Hundeshagen G, Paik A, Kauke-Navarro M, Kneser U, Pomahac B, Orgill DP, Panayi AC. Impact of sarcopenia on outcomes in surgical patients: a systematic review and meta-analysis. Int J Surg 2023; 109:4238-4262. [PMID: 37696253 PMCID: PMC10720826 DOI: 10.1097/js9.0000000000000688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Surgeons have historically used age as a preoperative predictor of postoperative outcomes. Sarcopenia, the loss of skeletal muscle mass due to disease or biological age, has been proposed as a more accurate risk predictor. The prognostic value of sarcopenia assessment in surgical patients remains poorly understood. Therefore, the authors aimed to synthesize the available literature and investigate the impact of sarcopenia on perioperative and postoperative outcomes across all surgical specialties. METHODS The authors systematically assessed the prognostic value of sarcopenia on postoperative outcomes by conducting a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching the PubMed/MEDLINE and EMBASE databases from inception to 1st October 2022. Their primary outcomes were complication occurrence, mortality, length of operation and hospital stay, discharge to home, and postdischarge survival rate at 1, 3, and 5 years. Subgroup analysis was performed by stratifying complications according to the Clavien-Dindo classification system. Sensitivity analysis was performed by focusing on studies with an oncological, cardiovascular, emergency, or transplant surgery population and on those of higher quality or prospective study design. RESULTS A total of 294 studies comprising 97 643 patients, of which 33 070 had sarcopenia, were included in our analysis. Sarcopenia was associated with significantly poorer postoperative outcomes, including greater mortality, complication occurrence, length of hospital stay, and lower rates of discharge to home (all P <0.00001). A significantly lower survival rate in patients with sarcopenia was noted at 1, 3, and 5 years (all P <0.00001) after surgery. Subgroup analysis confirmed higher rates of complications and mortality in oncological (both P <0.00001), cardiovascular (both P <0.00001), and emergency ( P =0.03 and P =0.04, respectively) patients with sarcopenia. In the transplant surgery cohort, mortality was significantly higher in patients with sarcopenia ( P <0.00001). Among all patients undergoing surgery for inflammatory bowel disease, the frequency of complications was significantly increased among sarcopenic patients ( P =0.007). Sensitivity analysis based on higher quality studies and prospective studies showed that sarcopenia remained a significant predictor of mortality and complication occurrence (all P <0.00001). CONCLUSION Sarcopenia is a significant predictor of poorer outcomes in surgical patients. Preoperative assessment of sarcopenia can help surgeons identify patients at risk, critically balance eligibility, and refine perioperative management. Large-scale studies are required to further validate the importance of sarcopenia as a prognostic indicator of perioperative risk, especially in surgical subspecialties.
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Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Rainer Schliermann
- Faculty of Social and Health Care Sciences, University of Applied Sciences Regensburg, Regensburg
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Mengfan Wu
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, People’s Republic of China
| | - Frederik J. Hansen
- Department of General and Visceral Surgery, Friedrich-Alexander University Erlangen, Erlangen
| | - Dany Y. Matar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Angie Paik
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, USA
| | - Dennis P. Orgill
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Adriana C. Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Surgery, Division of Plastic Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston
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11
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Knoedler S, Knoedler L, Kauke-Navarro M, Rinkevich Y, Hundeshagen G, Harhaus L, Kneser U, Pomahac B, Orgill DP, Panayi AC. Regulatory T cells in skin regeneration and wound healing. Mil Med Res 2023; 10:49. [PMID: 37867188 PMCID: PMC10591349 DOI: 10.1186/s40779-023-00484-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 10/04/2023] [Indexed: 10/24/2023] Open
Abstract
As the body's integumentary system, the skin is vulnerable to injuries. The subsequent wound healing processes aim to restore dermal and epidermal integrity and functionality. To this end, multiple tissue-resident cells and recruited immune cells cooperate to efficiently repair the injured tissue. Such temporally- and spatially-coordinated interplay necessitates tight regulation to prevent collateral damage such as overshooting immune responses and excessive inflammation. In this context, regulatory T cells (Tregs) hold a key role in balancing immune homeostasis and mediating cutaneous wound healing. A comprehensive understanding of Tregs' multifaceted field of activity may help decipher wound pathologies and, ultimately, establish new treatment modalities. Herein, we review the role of Tregs in orchestrating the regeneration of skin adnexa and catalyzing healthy wound repair. Further, we discuss how Tregs operate during fibrosis, keloidosis, and scarring.
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Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, 85764, Germany
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Yuval Rinkevich
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Munich, 85764, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, 67071, Germany.
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12
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Knoedler S, Matar DY, Friedrich S, Knoedler L, Haug V, Hundeshagen G, Kauke-Navarro M, Kneser U, Pomahac B, Orgill DP, Panayi AC. The surgical patient of yesterday, today, and tomorrow-a time-trend analysis based on a cohort of 8.7 million surgical patients. Int J Surg 2023; 109:2631-2640. [PMID: 37788019 PMCID: PMC10498871 DOI: 10.1097/js9.0000000000000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/14/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Global healthcare delivery is challenged by the aging population and the increase in obesity and type 2 diabetes. The extent to which such trends affect the cohort of patients the authors surgically operate on remains to be elucidated. Comprising of 8.7 million surgical patients, the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database can be analyzed to investigate the echo of general population dynamics and forecast future trends. MATERIAL AND METHODS The authors reviewed the ACS-NSQIP database (2008-2020) in its entirety, extracting patient age, BMI, and diabetes prevalence. Based on these data, the authors forecasted future trends up to 2030 using a drift model. RESULTS During the review period, median age increased by 3 years, and median BMI by 0.9 kg/m2. The proportion of patients with overweight, obesity class I, and class II rates increased. The prevalence of diabetes rose between 2008 (14.9%) and 2020 (15.3%). The authors forecast the median age in 2030 to reach 61.5 years and median BMI to climb to 29.8 kg/m2. Concerningly, in 2030, eight of ten surgical patients are projected to have a BMI above normal. Diabetes prevalence is projected to rise to 15.6% over the next decade. CONCLUSION General population trends echo in the field of surgery, with the surgical cohort aging at an alarmingly rapid rate and increasingly suffering from obesity and diabetes. These trends show no sign of abating without dedicated efforts and call for urgent measures and fundamental re-structuring for improved future surgical care.
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Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Dany Y. Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Sarah Friedrich
- Department of Mathematical Statistics and Artificial Intelligence in Medicine, University of Augsburg, Augsburg
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Dennis P. Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
| | - Adriana C. Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital
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Knoedler S, Knoedler L, Wu M, Haug V, Broer PN, Kauke-Navarro M, Hundeshagen G, Prantl L, Orgill DP, Panayi AC. Incidence and Risk Factors of Postoperative Complications After Rhinoplasty: A Multi-Institutional ACS-NSQIP Analysis. J Craniofac Surg 2023; 34:1722-1726. [PMID: 37487058 DOI: 10.1097/scs.0000000000009553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 05/24/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVE Despite the popularity of rhinoplasty, outcome research has been mainly limited to single-surgeon or single-institution reports. Therefore, we performed a multi-institutional analysis to present a broader portrait of the postoperative outcomes and risk factors for adverse events after rhinoplasty surgery. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2009-2019) to identify patients who underwent rhinoplasty. The postoperative outcomes of interest included 30-day mortality, reoperation, readmission, and surgical and medical complications. We also analyzed risk factors for complication occurrence, including patient comorbidities and preoperative laboratory values. RESULTS We identified 835 patients, 72% (n=602) of whom underwent a primary, 21% (n=175) a secondary, and 6.7% (n=58) a cleft nasal deformity procedure. The average patient age was 41±17 years, with most patients being female (n=472; 57%) and white (n=643; 77%). Complications rates were generally low, with reoperation (n=19; 2.3%) and superficial incisional infection (n=9; 1.1%) account for the most common general and surgical adverse event, respectively. Multivariable analysis revealed male sex ( P =0.04) and higher ASA scores ( P <0.0001) as risk factors for complications. Low serum albumin ( P =0.04) and hematocrit ( P =0.003) levels were associated with the occurrence of any complication, whereas low serum albumin ( P =0.02) also correlated with the incidence of surgical adverse events. CONCLUSION Complication rates after rhinoplasty were overall low and seemed to correlate with male sex and ASA scores. We identified preoperative albumin and hematocrit as predictive biomarkers of adverse events. Preoperative nutritional optimization and management of low hematocrit may improve postoperative outcomes.
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Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital Munich, Munich, Germany
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale New Haven Hospital, Yale School of Medicine; New Haven, CT
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen
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14
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Palackic A, Franco-Mesa C, Beck I, Nolte S, Tapking C, Panayi AC, Stolle A, Haug V, Hirche C, Kneser U, Hundeshagen G. The Impact of Facial Burns on Short- and Long-Term Quality of Life and Psychological Distress-A Prospective Matched Cohort Study. J Clin Med 2023; 12:5057. [PMID: 37568459 PMCID: PMC10419582 DOI: 10.3390/jcm12155057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/17/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Burn injuries are a major healthcare challenge worldwide, with up to 50% of all minor burns located on the head and neck. With this study, we sought to describe the effect of facial burns (FB) on health-related quality of life through a prospective and matched cohort study design. Patients completed the 36 Item Short Form (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Results were analyzed based on the distribution of datasets. In total, 55 patients with FB and 55 age-and sex-matched candidates were recruited. The most common mechanism of thermal injury was burns from flames. The FB group scored lower in physical and psychological dimensions than the control group, both acutely and one year after injury. An analysis of each domain showed that subjects in the FB group trended toward improvements in their score after one-year post-burn in physical functioning (acute: 71.0 ± 29.2; one-year: 83.7 ± 23.9; p = 0.02) and bodily pain (acute: 58.5 ± 30.3; one-year: 77.9 ± 30.5; p = 0.01) domains. Additionally, the FB group had significanlyt higher scores for anxiety (FB: 4.8 ± 3.2; control: 2.5 ± 2.8; p = <0.002) and depression (FB: 3.9 ± 3.5; control: 2.1 ± 2.7; p = 0.01) compared to the control. In conclusion, facial burns are associated with physical and psychosocial deficits, as well as elevated levels of psychological distress.
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Affiliation(s)
- Alen Palackic
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA;
| | - Camila Franco-Mesa
- Department of Surgery, University of Texas Medical Branch, Galveston, TX 77555, USA;
| | - Inessa Beck
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
- Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
| | - Adriana C. Panayi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
| | - Annette Stolle
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
- Department of Plastic, Hand and Reconstructive Microsurgery, Hand Trauma and Replantation Center (FESSH), BG Klinik Frankfurt am Main gGmbH, Academic Teaching Hospital of Goethe-University of Frankfurt, 60629 Frankfurt am Main, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany; (A.P.); (I.B.); (S.N.); (C.T.); (A.C.P.); (A.S.); (V.H.); (C.H.); (U.K.)
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15
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Tapking C, Rontoyanni VG, Diehm YF, Strübing F, Solimani F, Bigdeli AK, Hundeshagen G, Fischer S, Kneser U, Siegwart LC. Enzymatic Debridement in Geriatric Burn Patients—A Reliable Option for Selective Eschar Removal. J Clin Med 2023; 12:jcm12072633. [PMID: 37048716 PMCID: PMC10095072 DOI: 10.3390/jcm12072633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/20/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
The treatment of geriatric burn patients represents a major challenge in burn care. The objective of this study was to evaluate the efficacy of enzymatic debridement (ED) in geriatric burn patients. Adult patients who received ED for treatment of mixed pattern and full thickness burns (August 2017–October 2022) were included in this study and grouped in the younger (18–65 years) and geriatric (≥65 years) groups. Primary outcome was a necessity of surgery subsequent to ED. Both groups (patient characteristics, surgical and non-surgical treatment) were compared. Multiple logistic and linear regression models were used to identify the effect of age on the outcomes. A total of 169 patients were included (younger group: 135 patients, geriatric group: 34 patients). The burn size as indicated by %TBSA (24.2 ± 20.4% vs. 26.8 ± 17.1%, p = 0.499) was similar in both groups. The ASA (2.5 ± 1.1 vs. 3.4 ± 1.1, p < 0.001) and ABSI scores (6.1 ± 2.8 vs. 8.6 ± 2.3, p < 0.001) were significantly higher in the geriatric group. The %TBSA treated with ED (5.4 ± 5.0% vs. 4.4 ± 4.3%, p = 0.245) were similar in both groups. The necessity of additional surgical interventions (63.0 % vs. 58.8 %, p = 0.763) and the wound size debrided and grafted (2.9 ± 3.5% vs. 2.2 ± 2.1%; p = 0.301) were similar in both groups. Regression models yielded that age did not have an effect on efficacy of ED. We showed that ED is reliable and safe to use in geriatric patients. Age did not have a significant influence on the surgical outcomes of ED. In both groups, the size of the grafted area was reduced and, in many patients, surgery was avoided completely.
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Affiliation(s)
- Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | | | - Yannick F. Diehm
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Felix Strübing
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
- Berlin Institute of Health at Charité, Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, 10178 Berlin, Germany
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Laura C. Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
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16
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Wang AT, Panayi AC, Fischer S, Diehm YF, Tapking C, Hundeshagen G, Kneser U, Mastroianni M, Pomahac B, Haug V. Patient-Reported Outcomes After Reduction Mammoplasty Using BREAST-Q: A Systematic Review and Meta-Analysis. Aesthet Surg J 2023; 43:NP231-NP241. [PMID: 36411260 DOI: 10.1093/asj/sjac293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The BREAST-Q questionnaire reduction module is an established tool for outcomes after reduction mammoplasty. OBJECTIVES This systematic review and meta-analysis assess key parameters affecting pre- and postoperative scores, with specific foci on patient characteristics and tissue resection weights. METHODS This study was conducted per PRISMA guidelines. PUBMED (National Institutes of Health; Bethesda, MD), Google Scholar (Google; Mountain View, CA), and Web of Science (Clarivate Analytics; Philadelphia, PA) were searched. All studies published before August 1, 2021, were assessed for eligibility by 2 independent reviewers. Inclusion criteria were prospective or retrospective studies in 6 languages that reported quality of life after reduction mammoplasty employing the BREAST-Q questionnaire reduction module. Quality of included studies was assessed employing the Newcastle-Ottawa-Scale. Analysis was performed per Cochrane Collaboration and the Quality of Reporting of Meta-analyses guidelines. RESULTS A total of 28 papers were included in the systematic review, 13 for preoperative meta-analysis, and 17 for postoperative meta-analysis. Postoperative scores in all 3 quality of life domains (psychosocial, physical, and sexual well-being) and satisfaction with breasts increased significantly after reduction mammoplasty compared with preoperative scores. Satisfaction with breasts showed the greatest improvement, from 22.9 to 73.0. Preoperative scores were lower than normative data, with improvement to comparable scores as the healthy population postoperatively. Improvements in BREAST-Q scores did not correlate with patient comorbidities, complication rates, or amount of breast tissue resected. CONCLUSIONS Reduction mammoplasty provides marked improvement in BREAST-Q patient-reported quality of life as well established in literature. However, these improvements do not correlate with tissue resection weights, warranting further inquiry of insurance-defined resection requirements. LEVEL OF EVIDENCE: 3
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17
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Beck I, Tapking C, Haug V, Nolte S, Böcker A, Stoppe C, Kneser U, Hirche C, Hundeshagen G. Short- and long term hyposmia, hypogeusia, dysphagia and dysphonia after facial burn injury - A prospective matched cohort study. Burns 2023; 49:380-387. [PMID: 35525769 DOI: 10.1016/j.burns.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/03/2022] [Accepted: 04/15/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Facial burns frequently occur in occupational or household accidents. While dysphagia and dysphonia are known sequelae, little is known about impaired smell and taste after facial burns. METHODS In a prospective observational controlled study, we evaluated hyposmia via the Sniffin' Stick Test (SnS), hypogeusia via a taste strip test, and dysphonia and dysphagia via validated questionnaires acutely and one-year after burn, respectively. A matched control group consisting of a convenience sample of healthy volunteers underwent the same assessments. RESULTS Fifty-five facial burn patients (FB) and 55 healthy controls (CTR) were enrolled. Mean burn size was 11 (IQR: 29) % total body surface area (TBSA); CTR and FB were comparable regarding age, sex and smoking status. Acutely, hyposmia was present in 29% of the FB group (CTR: 9%, p = 0.014) and burn patients scored worse on the SnS than CTR (FB: 10; CTR: 11; IQR: 2; p = 0.013). Hyposmia per SnS correlated with subjective self-assessment. Hyposmia and SnS scores improved over time (FB acute: 10.5 IQR: 2; FB one year: 11; IQR: 2; p = 0.042) and returned to normal at one-year post burn in most patients who completed the study (lost to follow-up: 21 patients). Taste strip scores were comparable between FB and CTR, as was the acute prevalence of dysphagia and dysphonia. CONCLUSION Hyposmia acutely after facial thermal trauma appeared frequently in this study, especially when complicated by inhalation trauma or large TBSA involvement. Of all complete assessments, a fraction of burn patients retained hyposmia after one year while most improved over time to normal. Prevalence of dysphonia, dysphagia and hypogeusia was comparable to healthy controls in this study, perhaps due to overall minor burn severity.
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Affiliation(s)
- Inessa Beck
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, Ulm, Germany
| | - Arne Böcker
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christian Stoppe
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Plastic, Hand and Reconstructive Microsurgery, Hand Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
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18
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Nagel SS, Rauh A, Siegwart LC, Hundeshagen G, Kotsougiani-Fischer D, Kuepper S, Kneser U, Hirche C. From Esthetic Medicine to Optimizing Reconstructive Outcome: A Feasibility Trial on Secondary Refinement of Fasciocutaneous Anterolateral Thigh Flaps with Cryolipolysis. J Reconstr Microsurg 2023; 39:156-164. [PMID: 36150694 DOI: 10.1055/s-0042-1755259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Free adipocutaneous anterolateral thigh (ALT) flaps have evolved as workhorse flaps to reconstruct complex, multicompound defects. While coverage is safely achieved, flaps may remain bulky. As a standard of care, flaps are refined with liposuction, partial excision, or combination of both. Cryolipolysis is widely used for fat reduction in esthetic medicine. This pilot comparative study analyses whether cryolipolysis may serve as a safe alternative method to effectively reduce volume in fasciocutaneous flaps. Moreover, patients' satisfaction with the procedure is evaluated. METHODS In this single-center, retrospective, interventional comparative cohort study, 10 patients with free subfascial ALT flaps for distal extremity reconstruction underwent cryolipolysis (60 minutes, -9°C). Circumference of the extremities and subcutaneous fat thickness were determined before (T1) and 12 weeks (T2) after cryolipolysis. Patient satisfaction was evaluated with a questionnaire of Likert's scale questions. Duration of hospital stay, intervention time, costs, and possible complications were analyzed and compared with surgical flap contouring (n = 12). RESULTS All patients undergoing cryolipolysis were male, with a median age of 52 years without arterial disease-like state or deep vein thrombosis (DVT). At T2, a significant reduction of circumference of 1.8 ± 0.9 cm (p < 0.001) and subcutaneous fat layer of 7.7 ± 3.0 mm (p < 0.0001) was recorded. Overall, 90% of the patients were satisfied with the result. Cryolipolysis was well tolerated. One patient developed a second-degree frostbite which healed without further intervention. Cryolipolysis proofed to be as safe as surgical flap contouring. Hospital stay was significantly shorter (p < 0.01) and personal resources were spared when flap contouring was performed with cryolipolysis. CONCLUSION This is a novel application of evolving body-contouring cryolipolysis from esthetic medicine into optimizing outcomes in reconstructive surgery. Cryolipolysis has been shown to be relatively safe and effective to reduce ALT's volume with high patients' satisfaction. This successful pilot study encourages further investigation with a prospective randomized control trial.
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Affiliation(s)
- Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Annika Rauh
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Laura C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Simon Kuepper
- Department of Plastic Surgery and Burn Center, BG Hospital Berlin, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Klinik Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main GmbH, Goethe University of Frankfurt, Germany
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19
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Knoedler S, Matar DY, Knoedler L, Obed D, Haug V, Gorski SM, Kim BS, Kauke-Navarro M, Kneser U, Panayi AC, Orgill DP, Hundeshagen G. Association of age with perioperative morbidity among patients undergoing surgical management of minor burns. Front Surg 2023; 10:1131293. [PMID: 36923377 PMCID: PMC10008887 DOI: 10.3389/fsurg.2023.1131293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023] Open
Abstract
Introduction Burn injuries are associated with significant morbidity, often necessitating surgical management. Older patients are more prone to burns and more vulnerable to complications following major burns. While the relationship between senescence and major burns has already been thoroughly investigated, the role of age in minor burns remains unclear. To better understand differences between elderly and younger patients with predominantly minor burns, we analyzed a multi-institutional database. Methods We reviewed the 2008-2020 ACS-NSQIP database to identify patients who had suffered burns according to ICD coding and underwent initial burn surgery. Results We found 460 patients, of which 283 (62%) were male and 177 (38%) were female. The mean age of the study cohort was 46 ± 17 years, with nearly one-fourth (n = 108; 23%) of all patients being aged ≥60 years. While the majority (n = 293; 64%) suffered from third-degree burns, 22% (n = 99) and 15% (n = 68) were diagnosed with second-degree burns and unspecified burns, respectively. An average operation time of 46 min, a low mortality rate of 0.2% (n = 1), a short mean length of hospital stay (1 day), and an equal distribution of in- and outpatient care (51%, n = 234 and 49%, n = 226, respectively) indicated that the vast majority of patients suffered from minor burns. Patients aged ≥60 years showed a significantly prolonged length of hospital stay (p<0.0001) and were significantly more prone to non-home discharge (p<0.0001). In univariate analysis, advanced age was found to be a predictor of surgical complications (p = 0.001) and medical complications (p = 0.0007). Elevated levels of blood urea nitrogen (p>0.0001), creatinine (p>0.0001), white blood cell count (p=0.02), partial thromboplastin time (p = 0.004), and lower levels of albumin (p = 0.0009) and hematocrit (p>0.0001) were identified as risk factors for the occurrence of any complication. Further, complications were more frequent among patients with lower body burns. Discussion In conclusion, patients ≥60 years undergoing surgery for predominantly minor burns experienced significantly more complications. Minor lower body burns correlated with worse outcomes and a higher incidence of adverse events. Decreased levels of serum albumin and hematocrit and elevated values of blood urea nitrogen, creatinine, white blood count, and partial thromboplastin time were identified as predictive risk factors for complications.
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Affiliation(s)
- Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.,Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Dany Y Matar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany.,Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Doha Obed
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Sabina M Gorski
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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20
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Hundeshagen G, Mertin V, Busch M, Thiele P, Trogisch F, Heineke J, Egger M, Buerkert H, Van Linthout S, Fielitz J, Mayr M, Kneser U, Most P. Chronic heart failure as a sequel of severe burn injury: first insight into a novel pathological heart-skin axis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Research question
Our clinical research unveiled chronic heart failure with preserved ejection fraction (HFpEF) as a long-term sequel in survivors of severe pediatric burn injury due to a yet unknown molecular pathomechanism (1). Applying a standardized scald injury rat model, which is widely used in burn research, we systematically determined the pathophysiological impact of burn injury on cardiac performance to uncover systemic and molecular pathomechanisms that may cause post-burn injury HFpEF development.
Methods
Male adolescent SD-rats were subjected to a 60% total body surface area (TBSA) full-thickness burn- or sham-trauma and subsequently characterized by serial transthoracic echocardiography, bulk myocardial next-generation sequencing and proteomics as well as RT-PCR, immuno-blotting (IB), histology and plasma proteomics for cardiac performance and molecular alterations, for up to 90 days (3, 7, 30 and 90d).
Results
In comparison to the sham-group (SG, n=10), animals from the burn-group (BG, n=10; survival rate 100%) recapitulated typical post-burn clinical traits, such as significant loss in body weight (BG 27% less than SG at 30d, p<0.05) or skeletal muscle wasting (i.e., 27% less at 30d, p<0.05) in accord with elevated molecular atrophy markers throughout the observation period. Our focus on the heart revealed for the first-time post-burn cardiac muscle wasting (BG 22% less at 30d, p<0.05) and persistent markers of cardiac dysfunction in accord with significant histological cardiomyocyte hypotrophy (BG −8% at 30d, p<0.05) and significantly diminished left ventricular (LV) global longitudinal strain and isovolumic relaxation time in BGs, while LV-EF remained unchanged. Subsequent IB analysis uncovered diminished protein synthesis activity and diminished mTOR pathway activity in BG hearts. Weighted gene network correlation analysis i.e., from bulk myocardial NGS and clinical traits related activation of immunological and pro-fibrotic pathways in post-burn injury hearts to cardiac dysfunction in BGs. Subsequent RT-PCR and histology confirmed significant myocardial accumulation of cardio-depressive damage associated molecular patterns (i.e., S100A8 and A9) and infiltration by granulocytes (myeloperoxidase+) and monocytes (CD 68+) as well as significant LV fibrosis. Serial plasma proteomic analysis indicated elevated plasma levels i.e., of S100A8 and A9 and other heart failure markers that mirrored similar changes in human post-burn injury plasma samples.
Conclusion
Here we report for the first time the development of HFpEF as a novel systemic consequence of severe burn injury in a rodent model, which prepares the ground for further mechanistic and translational studies. The initial observation of cardiac inflammation and fibrosis, which are known to negatively impact cardiac performance, may be mechanistic key findings that will guide further therapeutic studies and subsequent validation of post-burn heart failure biomarkers.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Rolf-Schwiete Stiftung
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Affiliation(s)
| | - V Mertin
- University of Heidelberg , Heidelberg , Germany
| | - M Busch
- University of Heidelberg , Heidelberg , Germany
| | - P Thiele
- University of Heidelberg , Heidelberg , Germany
| | - F Trogisch
- University Medical Centre of Mannheim , Mannheim , Germany
| | - J Heineke
- University Medical Centre of Mannheim , Mannheim , Germany
| | - M Egger
- University of Heidelberg , Heidelberg , Germany
| | - H Buerkert
- University of Heidelberg , Heidelberg , Germany
| | | | - J Fielitz
- University Hospital of Greifswald , Greifswald , Germany
| | - M Mayr
- King's College London , London , United Kingdom
| | - U Kneser
- University of Heidelberg , Heidelberg , Germany
| | - P Most
- University of Heidelberg , Heidelberg , Germany
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Heyland DK, Wibbenmeyer L, Pollack J, Friedman B, Turgeon AF, Eshraghi N, Jeschke MG, Bélisle S, Grau D, Mandell S, Velamuri SR, Hundeshagen G, Moiemen N, Shokrollahi K, Foster K, Huss F, Collins D, Savetamal A, Gurney JM, Depetris N, Stoppe C, Ortiz-Reyes L, Garrel D, Day AG. A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries. N Engl J Med 2022; 387:1001-1010. [PMID: 36082909 DOI: 10.1056/nejmoa2203364] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation. METHODS In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk. RESULTS A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed. CONCLUSIONS In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).
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Affiliation(s)
- Daren K Heyland
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Lucy Wibbenmeyer
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Jonathan Pollack
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Bruce Friedman
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Alexis F Turgeon
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Niknam Eshraghi
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Marc G Jeschke
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Sylvain Bélisle
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Daisy Grau
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Samuel Mandell
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Sai R Velamuri
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Gabriel Hundeshagen
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Naiem Moiemen
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Kayvan Shokrollahi
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Kevin Foster
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Fredrik Huss
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Declan Collins
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Alisa Savetamal
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Jennifer M Gurney
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Nadia Depetris
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Christian Stoppe
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Luis Ortiz-Reyes
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Dominique Garrel
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
| | - Andrew G Day
- From the Clinical Evaluation Research Unit (D.K.H., L.O.-R.) and the Research Institute (A.G.D.), Kingston Health Sciences Centre, and the Departments of Critical Care Medicine (D.K.H., L.O.R.) and Public Health Sciences (D.K.H.), Queen's University, Kingston, ON, the Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, and the Population Health and Optimal Health Practices Unit (Trauma-Emergency-Critical Care Medicine) and the Canada Research Chair in Critical Care Neurology and Trauma, Centre Hospitalier Universitaire de Québec-Université Laval Research Center, Quebec, QC (A.F.T.), the Department of Surgery, Division of Plastic Surgery, Department of Immunology, and Institute of Medical Science, University of Toronto, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, and Sunnybrook Research Institute, Toronto (M.G.J.), and the Departments of Medicine and Anesthesiology (S.B.) and the Department of Nutrition, Faculty of Medicine (D. Garrel), University of Montreal, Montreal - all in Canada; the University of Iowa, Iowa City (L.W.); Mercy Hospital Burn Center, Mercy Hospital, St. Louis (J.A.P.); Joseph M. Still Research Foundation, Augusta, GA (B.F.); Legacy Oregon Burn Center and Oregon Health and Science University, Portland (N.E.); Internal Medicine, Centro Nacional de Quemaduras y Cirugía Reconstructiva, Asunción, Paraguay (D. Grau); UT Southwestern Medical Center, Dallas (S.M.), and Joint Base San Antonio-Fort Sam Houston, San Antonio (J.M.G.) - both in Texas; University of Tennessee Health Science Center and Firefighters Burn Center, Memphis (S.R.V.); the Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg (G.H.), and the Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Würzburg, Würzburg (C.S.) - both in Germany; Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham (N.M.), Mersey Regional Burn Centre, St. Helens and Knowesley NHS Trust, Whiston Hospital, Prescot (K.S.), Manchester Metropolitan University, Manchester (K.S.), and Plastic Surgery and Burns, Chelsea and Westminster Hospital London, London (D.C.) - all in the United Kingdom; Arizona Burn Center Valleywise Health, Maricopa Medical Center, Phoenix (K.F.); the Department of Surgical Sciences, Plastic Surgery, Uppsala University, and the Burn Center, Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden (F.H.); Connecticut Burn Center, Yale New Haven Health/Bridgeport Hospital, Bridgeport (A.S.); and Centro Traumatologico Ortopedico, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, Turin, Italy (N.D.)
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Hundeshagen G, Mertin V, Thiele P, Jungmann A, Trogisch FA, Drews O, Heineke J, Van Linthout S, Fielitz J, Mayr M, Busch M, Kneser U, Most P. Abstract P3020: Chronic Heart Failure As A Sequel After Severe Burn Injury - First Insight Into A Novel Pathological Heart-skin Axis. Circ Res 2022. [DOI: 10.1161/res.131.suppl_1.p3020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
We described chronic heart failure with preserved ejection fraction (HFpEF) as a long-term sequel in survivors of severe pediatric burn injury (BI) (Hundeshagen et al., Lancet Child & Adolescent Health, 2017). Applying a widely used standardized scald injury rat model in burn research, we sought to uncover systemic and molecular pathomechanisms that may cause post-BI HFpEF development.
Methods and Results:
Male adolescent SD-rats were subjected to a 60% total body surface area full-thickness BI (B; 100% survival) or sham (S) procedure (each n=10) and characterized them up to 90 days (3, 7, 30 and 90d) by serial echocardiography (E), bulk myocardial NGS and -proteomics, RT-PCR, IB, histology (H) and plasma proteomics for cardiac performance and molecular alterations, respectively. B rats mirrored typical post-burn clinical traits as significant loss in body (-27%*) or skeletal muscle weight (-30%*) e.g., with elevated atrophy markers as Murf1 (5-fold*) throughout the observation period vs S (30d, *P<0.05) Our focus on the heart revealed in vivo heart weight loss (-22%*), cardiomyocyte hypotrophy (-8%*) and diminished mTOR activity in B hearts (p/t-mTORC2 -43%*) vs S as well as significantly diminished left ventricular (LV) GLS with unchanged LV-EF. RT-PCR and H showed significant cardiac accumulation of cardiodepressive factors (i.e., S100A8 and A9) and e.g., granulocyte (MPO, >3-fold*) infiltration as well LV fibrosis (2.2-fold*). Cardiac proteomics yielded e.g., neutrophil degranulation as lead GO-term. Serial blood and plasma proteomic and ELISA analysis indicated elevated WBC (+26%*) and levels e.g., of IL6, S100A8/A9, CH3L1 and other HF markers alike changes in human post-BI plasma samples. WGCNA for bulk myocardial NGS and clinical traits related activated immunological and pro-fibrotic pathways in post-BI hearts to cardiac dysfunction in B.
Conclusion:
The first ever report of the development of HFpEF as a novel systemic consequence of severe burn injury in a rodent model prepares the ground for further mechanistic and translational studies. Cardiac inflammation and fibrosis that negatively impact cardiac performance may be mechanistic key findings guiding further therapeutic studies and validation of post-BI HF biomarkers.
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Affiliation(s)
- Gabriel Hundeshagen
- BGU Ludwigshafen, Dept of Hand, Plastic and Reconstructive Surgery, Ludwigshafen, Germany
| | - Victoria Mertin
- BGU Ludwigshafen, Dept of Hand, Plastic and Reconstructive Surgery, Heidelberg, Germany
| | - Philipp Thiele
- BGU Ludwigshafen, Dept of Hand, Plastic and Reconstructive Surgery, Ludwigshafen, Germany
| | | | | | - Oliver Drews
- Mannheim Univ, Institute of Clinical Chemistry, Mannheim, Germany
| | - Joerg Heineke
- Mannheim Univ, Dept of Cardiovascular Physiology, Mannheim, Germany
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charite, Experimental Immunocardiology, Berlin, Germany
| | | | - Manuel Mayr
- KINGS COLLEGE LONDON, London, United Kingdom
| | | | - Ulrich Kneser
- BGU Ludwigshafen, Dept of Hand, Plastic and Reconstructive Surgery, Ludwigshafen, Germany
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23
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Tapking C, Siegwart LC, Jost Y, Hundeshagen G, Kotsougiani-Fischer D, Gazyakan E, Bliesener B, Kneser U, Fischer S. Enzymatic debridement in scalds is not as effective as in flame burns regarding additional eschar excision: A retrospective matched-control study. Burns 2022; 48:1149-1154. [PMID: 34627661 DOI: 10.1016/j.burns.2021.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Enzymatic debridement of burn eschar became an accepted and widely used technique for burn wound treatment over the last years. However, this practice is not exempt from failure and recent experimental studies indicate that it may not be as efficient in scalds as in flame burns. METHODS Patients that were admitted to the burn intensive care unit between June 2017 and February 2021 and received enzymatic debridement within the first 72 h after scald and flame burn were included. Patients with scald burns were matched regarding age, sex and per cent total body surface area (%TBSA) burned in a 1:2 ratio with patients presenting with flame burns. RESULTS Eighteen patients with scald burns were matched with 36 with flame burns. After matching, both groups were similar in terms of age (flame burns 44.5 ± 21.1 years vs. scald 41.8 ± 22.6 years, p = 0.666), and %TBSA burned (11.0 ± 8.2% vs. 10.6 ± 9.6%, p = 0.851). Patients with scald burns significantly more often underwent further surgical eschar excision compared to controls (scald 16 (88.9%) vs. flame 19 (52.8%), p = 0.016). Length of stay per %TBSA was significantly longer in scald burns (scald 7.8 ± 9.2 days vs. flame 3.7 ± 3.8, p = 0.013). CONCLUSION This study indicates that enzymatic debridement may not be as effective in scalds as in flame burns. It was shown that patients with scalds and subsequent enzymatic debridement more frequently underwent additional surgical intervention and that the size of the transplanted area was larger compared to control. Moreover, those patients had a longer length of stay at the hospital per %TBSA burned.
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Affiliation(s)
- C Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - L C Siegwart
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Y Jost
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - G Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - D Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - E Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - B Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - S Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.
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Tapking C, Hundeshagen G, Kirchner M, Fischer S, Kneser U, Bliesener B. Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial. Burns 2022; 48:522-528. [PMID: 35339324 DOI: 10.1016/j.burns.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/15/2022] [Accepted: 03/12/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Early excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery. METHODS Patients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA. RESULTS Twenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542). DISCUSSION This study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.
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Affiliation(s)
- C Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - G Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - M Kirchner
- Institute of Medical Biometry, University Hospital Heidelberg, Heidelberg, Germany
| | - S Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - B Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Anesthesia, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.
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25
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Bigdeli AK, Falkner F, Thomas B, Hundeshagen G, Mayer SA, Risse EM, Harhaus L, Gazyakan E, Kneser U, Radu CA. The Free Myocutaneous Tensor Fasciae Latae Flap—A Workhorse Flap for Sternal Defect Reconstruction: A Single-Center Experience. J Pers Med 2022; 12:jpm12030427. [PMID: 35330425 PMCID: PMC8951458 DOI: 10.3390/jpm12030427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 01/14/2023] Open
Abstract
Introduction: Deep sternal wound infections (DSWI) after cardiac surgery pose a significant challenge in reconstructive surgery. In this context, free flaps represent well-established options. The objective of this study was to investigate the clinical outcome after free myocutaneous tensor fasciae latae (TFL) flap reconstruction of sternal defects, with a special focus on surgical complications and donor-site morbidity. Methods: A retrospective chart review focused on patient demographics, operative details, and postoperative complications. Follow-up reexaminations included assessments of the range of motion and muscle strength at the donor-site. Patients completed the Quality of Life 36-item Short Form Health Survey (SF-36) as well as the Lower Extremity Functional Scale (LEFS) questionnaire and evaluated aesthetic and functional outcomes on a 6-point Likert scale. The Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS) were used to rate scar appearance. Results: A total of 46 patients (mean age: 67 ± 11 years) underwent sternal defect reconstruction with free TFL flaps between January 2010 and March 2021. The mean defect size was 194 ± 43 cm2. The mean operation time was 387 ± 120 min with a flap ischemia time of 63 ± 16 min. Acute microvascular complications due to flap pedicle thromboses occurred in three patients (7%). All flaps could be salvaged without complete flap loss. Partial flap loss of the distal TFL portion was observed in three patients (7%). All three patients required additional reconstruction with pedicled or local flaps. Upon follow-up, the range of motion (hip joint extension/flexion (p = 0.73), abduction/adduction (p = 0.29), and internal/external rotation (p = 0.07)) and muscle strength at the donor-sites did not differ from the contralateral sides (p = 0.25). Patient assessments of aesthetic and functional outcomes, as well as the median SF-36 (physical component summary (44, range of 33 to 57)) and LEFS (54, range if 35 to 65), showed good results with respect to patient comorbidities. The median VSS (3, range of 2 to 7) and POSAS (24, range of 18 to 34) showed satisfactory scar quality and scar appearance. Conclusion: The free TFL flap is a reliable, effective, and, therefore, valuable option for the reconstruction of extensive sternal defects in critically ill patients suffering from DSWIs. In addition, the TFL flap shows satisfactory functional and aesthetic results at the donor-site.
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Mertin V, Most P, Busch M, Trojan S, Tapking C, Haug V, Kneser U, Hundeshagen G. Current understanding of thermo(dys)regulation in severe burn injury and the pathophysiological influence of hypermetabolism, adrenergic stress and hypothalamic regulation—a systematic review. Burns & Trauma 2022; 10:tkac031. [PMID: 36168403 PMCID: PMC9501704 DOI: 10.1093/burnst/tkac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/08/2022] [Indexed: 11/25/2022]
Abstract
Background In this systematic review, we summarize the aetiology as well as the current knowledge regarding thermo(dys)regulation and hypothermia after severe burn trauma and aim to present key concepts of pathophysiology and treatment options. Severe burn injuries with >20% total body surface area (TBSA) affected commonly leave the patient requiring several surgical procedures, prolonged hospital stays and cause substantial changes to body composition and metabolism in the acute and long-term phase. Particularly in severely burned patients, the loss of intact skin and the dysregulation of peripheral and central thermoregulatory processes may lead to substantial complications. Methods A systematic and protocol-based search for suitable publications was conducted following the PRISMA guidelines. Articles were screened and included if deemed eligible. This encompasses animal-based in vivo studies as well as clinical studies examining the control-loops of thermoregulation and metabolic stability within burn patients Results Both experimental animal studies and clinical studies examining thermoregulation and metabolic functions within burn patients have produced a general understanding of core concepts which are, nonetheless, lacking in detail. We describe the wide range of pathophysiological alterations observed after severe burn trauma and highlight the association between thermoregulation and hypermetabolism as well as the interactions between nearly all organ systems. Lastly, the current clinical standards of mitigating the negative effects of thermodysregulation and hypothermia are summarized, as a comprehensive understanding and implementation of the key concepts is critical for patient survival and long-term well-being. Conclusions The available in vivo animal models have provided many insights into the interwoven pathophysiology of severe burn injury, especially concerning thermoregulation. We offer an outlook on concepts of altered central thermoregulation from non-burn research as potential areas of future research interest and aim to provide an overview of the clinical implications of temperature management in burn patients.
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Affiliation(s)
- Viktoria Mertin
- University of Heidelberg Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, , 67071 Ludwigshafen am Rhein, Germany
| | - Patrick Most
- Department of Internal Medicine III University Hospital Heidelberg Division of Molecular and Translational Cardiology, , 69120 Heidelberg, Germany
- Deutsches Zentrum für Herz- und Kreislaufforschung (GCCR) , Partner site Heidelberg/Mannheim, Germany
| | - Martin Busch
- Department of Internal Medicine III University Hospital Heidelberg Division of Molecular and Translational Cardiology, , 69120 Heidelberg, Germany
- Deutsches Zentrum für Herz- und Kreislaufforschung (GCCR) , Partner site Heidelberg/Mannheim, Germany
| | - Stefan Trojan
- University of Witten/Herdecke Department of Anesthesiology and Intensive Care Medicine, Merheim Medical Center, Hospitals of Cologne, , 51109 Cologne, Germany
| | - Christian Tapking
- University of Heidelberg Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, , 67071 Ludwigshafen am Rhein, Germany
| | - Valentin Haug
- University of Heidelberg Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, , 67071 Ludwigshafen am Rhein, Germany
| | - Ulrich Kneser
- University of Heidelberg Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, , 67071 Ludwigshafen am Rhein, Germany
| | - Gabriel Hundeshagen
- University of Heidelberg Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, , 67071 Ludwigshafen am Rhein, Germany
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Haug V, Kadakia N, Wang A, Dorante MI, Panayi AC, Kauke-Navarro M, Hundeshagen G, Diehm Y, Fischer S, Hirche C, Kneser U, Pomahac B. “Racial disparities in short-term outcomes after breast reduction surgery - A National Surgical Quality Improvement Project Analysis with 23,268 patients using Propensity Score Matching”. J Plast Reconstr Aesthet Surg 2022; 75:1849-1857. [DOI: 10.1016/j.bjps.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 12/05/2021] [Accepted: 01/09/2022] [Indexed: 11/29/2022]
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Tapking C, Kilian K, Hundeshagen G, Haug V, Teufel A, Houschyar KS, Kneser U, Hirche C. Hepatic functional pathophysiology and morphological damage following severe burns: a systematic review and meta-analysis. J Burn Care Res 2021; 43:1074-1080. [PMID: 34894242 DOI: 10.1093/jbcr/irab239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Severe burns are devastating injuries affecting multiple organ systems. Little is known about the influence on the hepatic system and its physiology. This systematic review aimed to assess the current state of research on morphologic liver damage following severe burns. METHODS A search was conducted in Pubmed, Web of Science and Cochrane databases using PRISMA guidelines. Outcomes included serum levels of transaminases, fatty infiltration and necrosis. Weighted individual study estimates were used to calculate pooled transaminase levels and necrosis/fatty infiltration rates using a random-effects approach. Risk ratios (RRs) or Odds ratios (ORs) and 95% confidence intervals (CIs) were used to describe pooled estimates for risk factors. RESULTS The literature search retrieved 2548 hits, of which 59 studies were included into qualitative synthesis, and finally ten studies were included into meta-analysis. Studies were divided into those reporting autopsies and those reporting changes of serum transaminase levels. The majority of liver autopsies showed fatty infiltration 82% (95% CI39%-97%) or necrosis of the liver 18% (95% CI13%-24%). DISCUSSION Heterogeneity in studies on hepatic functional damage following severe burns was high. Only few were well-designed and published in recent years. Many studies could not be included because of insufficient numerical data. There is a high number of patients deceasing from burns that present with fatty infiltration or necrosis of hepatic tissue. Transaminases were elevated during the first days after burn. Further research on how severe burns affect the hepatic function and outcome, especially long-term, is necessary.
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Affiliation(s)
- C Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - K Kilian
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - G Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - V Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - A Teufel
- Department of Medicine II, Division of Hepatology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.,Clinical Cooperation Unit Health Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - K S Houschyar
- Department of Dermatology and Allergology, University Hospital of RWTH Aachen, Aachen, Germany
| | - U Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - C Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Unfallklinik Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic, Hand- and Reconstructive Microsurgery, Handtrauma- and Replantation Center BG Unfallklinik Frankfurt am Main gGmbH, Frankfurt/Main, Germany
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29
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Haug VF, Tapking C, Panayi AC, Thiele P, Wang AT, Obed D, Hirche C, Most P, Kneser U, Hundeshagen G. Long-term sequelae of critical illness in sepsis, trauma and burns: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:736-747. [PMID: 34252062 DOI: 10.1097/ta.0000000000003349] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sepsis, major trauma, and severe burn injury are life-threatening critical illnesses that remain significant contributors to worldwide morbidity and mortality. The three underlying etiologies share pathophysiological similarities: hyperinflammation, hypermetabolism, and acute immunomodulation. The aims of this study were to assess the current state of long-term outcome research and to identify key outcome parameters between the three forms of critical illness. METHODS This systematic review and meta-analysis (MA) were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed was searched from January 1, 1975, to December 31, 2019. Studies were assessed for eligibility by independent reviewers. Inclusion criteria were studies reporting at least a 6-month follow-up of health-related quality of life and organ-specific sequelae within the three etiologies: severe burn injury, sepsis, and major trauma. RESULTS In total, 125 articles could be included in the systematic review and 74 in the MA. The mean follow-up time was significantly longer in burn studies, compared with sepsis and trauma studies. The majority of patients were from the sepsis group, followed by burns, and major trauma studies. In the overall health-related quality of life, as assessed by Short Form 36 and European Quality-of-Life Index, the three different etiologies were comparable with one another. CONCLUSION The effects of critical illness on survivors persist for years after hospitalization. Well-reported and reliable data on the long-term outcomes are imperative, as they can be used to determine the treatment choice of physicians and to guide the expectations of patients, improving the overall quality of care of three significant patient cohorts. LEVEL OF EVIDENCE Systematic review and MA, level III.
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Affiliation(s)
- Valentin F Haug
- From the Department of Hand, Plastic and Reconstructive Surgery (V.F.H., C.T., P.T., C.H., U.K., G.H.), Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; Department of Plastic, Hand and Reconstructive Microsurgery (C.H.), Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany; German Center for Cardiovascular Research (DZHK) (P.M.), Partner site Heidelberg/Mannheim, Heidelberg; Division of Plastic Surgery, Department of Surgery (V.F.H., A.C.P., A.T.W., D.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Molecular and Translational Cardiology (P.T.), and Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany; and Division of Molecular and Translational Cardiology, Department of Internal Medicine III (P.M.), University Hospital, Heidelberg, Germany
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Muenzberg M, Kaeppler K, Hundeshagen G, Kenngott T, Ziegler B, Gruetzner PA, Kneser U, Hirche C. Thermo-mechanical combination injuries - A rare but life-threatening entity. J Burn Care Res 2021; 43:691-695. [PMID: 34537838 DOI: 10.1093/jbcr/irab176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Thermo-mechanical-combination-injuries (TMCI) are feared for their demanding preclinical and clinical management and bear the risk of high mortality compared to the single injury of a severe burn or multiple traumata. There remains a significant lack of standardized algorithms for diagnostics, and therapy of this rare entity. The aim of the present study was to profile TMCI aiming at standardized procedures. In this study, TMCI were extracted from our burn database of a level 1 burn and trauma centre. From 2004 to 2017, all patients with TMCI were retrospectively analyzed. Further inclusion criteria were multiple trauma accompanied by burn with ≥10% TBSA. Patient and injury characteristics including ISS and outcome parameter were analyzed. A total of 45 patients matched the selective inclusion criteria of TMCI comprising of 4% of all burn injuries during the period. Average age was 38 years (range: 14-86), with a mean TBSA of 43% (range: 10-97%). The mean recorded temperature at admission was 34.8°C (range: 29.6 - 37.1) with 2215 ml volume (range: 500 - 8000) administered preclinically in total. The mean ISS was 16. The overall mortality rate was 22%. TMCI are rare and life-threatening events which require highly qualified management in combined level 1 trauma and burn centres to adress both burn and trauma treatment. The multiple injury pattern is diverse, complicating standardized management in view of burn care specific measures, as normothermia and restrictive volume management. The present study reveals further profiles and underlines the need for addressing TMCI in ABLS®; ATLS® and PHTLS® programs.
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Affiliation(s)
- Matthias Muenzberg
- Department for Rescue- and Emergency Medicine, BG Trauma Centre, Ludwigshafen/Rhine, Germany.,Department for Trauma- and Orthopaedic Surgery, BG Trauma Centre, Department of Trauma, University of Heidelberg, Ludwigshafen/Rhine, Germany
| | - Kathrin Kaeppler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwigshafen/Rhine, Germany.,Department of Orthopaedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwigshafen/Rhine, Germany
| | - Theresa Kenngott
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwigshafen/Rhine, Germany
| | - Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwigshafen/Rhine, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Centre, BG Unfallklinik Frankfurt am Main gGmbH, Goethe-University Frankfurt, Frankfurt, Germany
| | - Paul Alfred Gruetzner
- Department for Trauma- and Orthopaedic Surgery, BG Trauma Centre, Department of Trauma, University of Heidelberg, Ludwigshafen/Rhine, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwigshafen/Rhine, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Centre, BG Trauma Centre Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University Heidelberg, Ludwigshafen/Rhine, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Centre, BG Unfallklinik Frankfurt am Main gGmbH, Goethe-University Frankfurt, Frankfurt, Germany
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Zhang Y, Gazyakan E, Hundeshagen G, Fischer S, Bigdeli AK, Marks PW, Kneser U, Hirche C. A meta-analysis evaluating risk factors for compound free flaps for upper extremity defect reconstruction comparing complications and functional outcomes of compound free flaps with and without bone components. Microsurgery 2021; 41:688-696. [PMID: 34357657 DOI: 10.1002/micr.30791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 07/06/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Compound flaps offer the advantage of one stage defect reconstruction respecting all relevant tissues and early functional recovery by optimal vascularity of all components. Due to its specific vascular anatomy and the three-dimensional donor site, compound flaps with bone components may result in higher complication rates compared to soft tissue compound flaps. The meta-analysis summarizes the available evidence and evaluates whether bone components are a risk factor for periprocedural complications in upper extremity multidimensional defect reconstruction. METHOD PubMed and Embase were searched for all publications addressing compound free flaps for upper extremity defect reconstruction with bone or soft tissue components published between January 1988 and May 2018. The methodological quality was assessed with the American Society of Plastic Surgeons Evidence Rating Scale for Therapeutic Studies. Flap loss, thrombosis rate, early infection, hematoma, seroma, as well as donor site complications were extracted and analyzed. RESULTS Twelve out of 1157 potentially eligible studies (evidence-III) comprising 159 patients were finally included with publication bias for all summarized complication rates. Complication rates for flaps with/ without bone components were: total flap loss 5%, 95% CI = 3%-10% (6%/5%); partial flap loss 8%, 95% CI = 5%-15%, (9%/8%); arterial/venous thrombosis 7%, 95% CI = 4%-12%, (8%/5%)/14%, 95% CI = 9%-21% (16%/6%, P < .05) with higher risk for flaps with bone components; infection 6%, 95% CI = 3%-12% (6%/6%); hematoma 6%, 95% CI = 3%-11% (6%/5%); seroma 5%, 95% CI = 3%-10% (5%/5%); dehiscence 10%, 95% CI = 6%-17% (11%/9%). CONCLUSION Compound flaps for upper extremity defect reconstruction including bone components have a higher venous thrombosis rate compared to compound soft-tissue flaps.
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Affiliation(s)
- Ying Zhang
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Burn, Plastic and Reconstructive Surgery, Beijing Jishuitan Hospital, Beijing, China
| | - Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany
| | - Patrick Will Marks
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital to the Goethe-University Frankfurt am Main, Germany
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32
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Glaser J, Ziegler B, Hirche C, Tapking C, Haug V, Bliesener B, Kilian K, Kneser U, Hundeshagen G. The status quo of early burn wound excision: Insights from the German burn registry. Burns 2021; 47:1259-1264. [PMID: 34330580 DOI: 10.1016/j.burns.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is a common, well-known and established recommendation to excise burn wounds within 24-72 h in order to mitigate the systemic inflammatory and immunomodulatory response, shorten length of hospitalization through early grafting and optimize patient survival. Despite this apparent consensus, surprisingly few systematic studies have evaluated the actual adherence to this practice and its implications on patient outcomes. In this registry study, we sought to objectify the current status of early burn wound excision, its influencing factors and impact on patient outcomes for all German burn centers. METHODS The German burn registry ('Deutsches Verbrennungsregister') was queried for 3 consecutive years for all patients, who received at least one surgical intervention. Patients were stratified based on whether the first surgical procedure was performed early (EE, within 72 h) or late (LE, after 72 h) post-burn. Descriptive statistics and univariate regressions were performed to quantify fraction of EE vs. LE and to evaluate factors which might favor one over the other (i.e. age, inhalation injury, burn severity by total body surface area (TBSA), scald vs. other burns, obesity, time of admission). Key patient outcomes were analyzed for each group (i.e. mortality, length of hospitalization, number of surgeries) and multifactorial regression analyses were carried out to model the impact of EE on mortality. Statistical significance was accepted at p < 0.05. RESULTS After initial screening, 1494 complete records were included for final analysis and were stratified into EE and LE. Only 670 (44%) underwent EE within 72 h. Increasing TBSA burned (i.e. [TBSA > 30%]: 53.8% EE, [TBSA < 30%]: 43.5% EE, p < 0.01) and admission on a weekday between Sunday and Wednesday were associated with higher probability of EE (51.5% EE) versus Thursday to Sunday (37.3%, p < 0.001). Age, inhalation injury, cause of burn, and obesity had no effect on EE vs. LE. Patients with EE had significantly shorter median lengths of hospitalization (EE: 18 d, LE: 21 d, p < 0.01). The median number of operations was comparable for both groups. Gross mortality appeared higher in the EE group, but turned out to be comparable to LE after correction for age, TBSA and sex in multifactorial regression analysis. CONCLUSION Despite apparent consensus among burn physicians, early excision of burn wounds is performed in less than 50% of cases in German burn centers. The relationship of EE to TBSA burned is expected and clinically sound, while a dependence on admission weekday raises administrative and infrastructural questions, especially when patients who receive EE have significantly shorter hospital stays. More analyses from other burn repositories are needed to compare and benchmark the international status quo of early burn wound excision.
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Affiliation(s)
- Julia Glaser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany; Department of Plastic, Hand and Reconstructive Microsurgery, Hand, Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Academic Teaching Hospital of Goethe-University of Frankfurt, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany; Department of Plastic, Hand and Reconstructive Microsurgery, Hand, Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Academic Teaching Hospital of Goethe-University of Frankfurt, Germany
| | - Christian Tapking
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Björn Bliesener
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Katja Kilian
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic- and Hand Surgery, University of Heidelberg, Germany.
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Roth S, Cao J, Singh V, Tiedt S, Hundeshagen G, Li T, Boehme JD, Chauhan D, Zhu J, Ricci A, Gorka O, Asare Y, Yang J, Lopez MS, Rehberg M, Bruder D, Zhang S, Groß O, Dichgans M, Hornung V, Liesz A. Post-injury immunosuppression and secondary infections are caused by an AIM2 inflammasome-driven signaling cascade. Immunity 2021; 54:648-659.e8. [PMID: 33667383 DOI: 10.1016/j.immuni.2021.02.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 12/16/2020] [Accepted: 02/08/2021] [Indexed: 01/01/2023]
Abstract
Loss of lymphocytes, particularly T cell apoptosis, is a central pathological event after severe tissue injury that is associated with increased susceptibility for life-threatening infections. The precise immunological mechanisms leading to T cell death after acute injury are largely unknown. Here, we identified a monocyte-T cell interaction driving bystander cell death of T cells in ischemic stroke and burn injury. Specifically, we found that stroke induced a FasL-expressing monocyte population, which led to extrinsic T cell apoptosis. This phenomenon was driven by AIM2 inflammasome-dependent interleukin-1β (IL-1β) secretion after sensing cell-free DNA. Pharmacological inhibition of this pathway improved T cell survival and reduced post-stroke bacterial infections. As such, this study describes inflammasome-dependent monocyte activation as a previously unstudied cause of T cell death after injury and challenges the current paradigms of post-injury lymphopenia.
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Affiliation(s)
- Stefan Roth
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Jiayu Cao
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Vikramjeet Singh
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ting Li
- Gansu Key Laboratory of Biomonitoring and Bioremediation for Environmental Pollution, School of Life Sciences, Lanzhou University, Lanzhou, China
| | - Julia D Boehme
- Immune Regulation, Helmholtz Centre for Infection Research, Braunschweig, Germany; Infection Immunology, Institute of Medical Microbiology, Infection Control and Prevention, Health Campus Immunology, Infectiology and Inflammation, Otto von-Guericke University, Magdeburg, Germany
| | - Dhruv Chauhan
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Jie Zhu
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Alessio Ricci
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Oliver Gorka
- Institute of Neuropathology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Yaw Asare
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Jun Yang
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Mary S Lopez
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Markus Rehberg
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Dunja Bruder
- Immune Regulation, Helmholtz Centre for Infection Research, Braunschweig, Germany; Infection Immunology, Institute of Medical Microbiology, Infection Control and Prevention, Health Campus Immunology, Infectiology and Inflammation, Otto von-Guericke University, Magdeburg, Germany
| | - Shengxiang Zhang
- Gansu Key Laboratory of Biomonitoring and Bioremediation for Environmental Pollution, School of Life Sciences, Lanzhou University, Lanzhou, China
| | - Olaf Groß
- Institute of Neuropathology, Medical Center, University of Freiburg, Freiburg, Germany; Signalling Research Centres BIOSS and CIBSS, Freiburg, Germany; Center for Basics in NeuroModulation (NeuroModulBasics), Freiburg, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Veit Hornung
- Gene Center and Department of Biochemistry, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Arthur Liesz
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany; Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.
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Diehm YF, Fischer S, Gazyakan E, Hundeshagen G, Kotsougiani-Fischer D, Falkner F, Kneser U, Hirche C. Negative pressure wound therapy as an accelerator and stabilizer for incorporation of artificial dermal skin substitutes – A retrospective, non-blinded, and non-randomized comparative study. J Plast Reconstr Aesthet Surg 2021; 74:357-363. [DOI: 10.1016/j.bjps.2020.08.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 05/29/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
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35
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Tapking C, Houschyar KS, Rontoyanni VG, Hundeshagen G, Kowalewski KF, Hirche C, Popp D, Wolf SE, Herndon DN, Branski LK. The Influence of Obesity on Treatment and Outcome of Severely Burned Patients. J Burn Care Res 2020; 40:996-1008. [PMID: 31294797 DOI: 10.1093/jbcr/irz115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Obesity and the related medical, social, and economic impacts are relevant multifactorial and chronic conditions that also have a meaningful impact on outcomes following a severe injury, including burns. In addition to burn-specific difficulties, such as adequate hypermetabolic response, fluid resuscitation, and early wound coverage, obese patients also present with common comorbidities, such as arterial hypertension, diabetes mellitus, or nonalcoholic fatty liver disease. In addition, the pathophysiologic response to severe burns can be enhanced. Besides the increased morbidity and mortality compared to burn patients with normal weight, obese patients present a challenge in fluid resuscitation, perioperative management, and difficulties in wound healing. The present work is an in-depth review of the current understanding of the influence of obesity on the management and outcome of severe burns.
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Affiliation(s)
- Christian Tapking
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Khosrow S Houschyar
- Department of Plastic Surgery, Hand Surgery, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
| | - Victoria G Rontoyanni
- Department of Surgery, University of Texas Medical Branch, Galveston.,Metabolism Unit, Shriners Hospitals for Children, Galveston, Texas
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | | | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Daniel Popp
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas.,Department of Urology, University Medical Center Mannheim, University of Heidelberg, Germany
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch, Galveston.,Shriners Hospitals for Children, Galveston, Texas.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
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Haug V, Kadakia N, Panayi AC, Kauke M, Hundeshagen G, Diehm Y, Fischer S, Hirche C, Kneser U, Pomahac B. Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients. J Plast Reconstr Aesthet Surg 2020; 74:1031-1040. [PMID: 33436337 DOI: 10.1016/j.bjps.2020.10.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/06/2020] [Accepted: 10/20/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage. METHODS By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort. RESULTS We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001). CONCLUSION Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.
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Affiliation(s)
- Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Nikita Kadakia
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA
| | - Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Yannick Diehm
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA; Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 45 Francis St, Boston, MA 02115, USA.
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Falkner F, Thomas B, Hundeshagen G, Wittenberg G, Bliesener B, Bigdeli AK, Kneser U. One-stage double free flap arteriovenous loop reconstruction of a massive abdominothoracic defect following necrotizing fasciitis: A case report. Microsurgery 2020; 40:911-915. [PMID: 33085145 DOI: 10.1002/micr.30673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/27/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022]
Abstract
We report the case of a 67-year old male with necrotizing fasciitis after injection of the glenohumeral joint. After extensive debridement a massive defect from the left hip joint to the left upper arm, exposing ribs, scapula, axillary vessels and brachial plexus (45 × 40 cm) was present. Reconstruction was performed with a conjoined right myocutaneous tensor fasciae lata/vastus lateralis flap and a left myocutaneous vastus lateralis flap in combination with an arteriovenous loop originating from the axillary vessels using the greater saphenous vein. Revisional surgeries were necessary including ribs resection and flap re-advancements. Due to multiorganic failure invasive ventilation, renal replacement- and extensive transfusion therapy was required. After 241 days the patient was discharged for rehabilitation. At the 12 months follow-up wounds were sufficiently closed without the need for further intervention. This case illustrates that immediate diagnosis followed by an aggressive multidisciplinary treatment approach is crucial for the patient survival.
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Affiliation(s)
- Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gerhard Wittenberg
- Department of Anesthesia, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Björn Bliesener
- Department of Anesthesia, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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38
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Stoppe C, Hill A, Day AG, Kristof AS, Hundeshagen G, Kneser U, Beier J, Lumenta D, Kim BS, Plock J, Collins DP, Gille J, Jiang X, Heyland DK. The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation. Burns 2020; 47:765-775. [PMID: 33288334 DOI: 10.1016/j.burns.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/25/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate "Persistent Organ Dysfunction" plus death as endpoint in burn patients and to demonstrate its statistical efficiency. METHODS This secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care. RESULTS In the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used. CONCLUSIONS POD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted. STUDY TYPE Prospective cohort study, level of evidence: II.
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Affiliation(s)
- Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH, Aachen, Germany; CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Aileen Hill
- Department of Intensive Care Medicine, University Hospital RWTH, Aachen, Germany; CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany
| | - Andrew G Day
- KGH Research Institute, Kingston Health Sciences Centre, Kingston, Ontario
| | - Arnold S Kristof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, Faculty of Medicine, Departments of Medicine and Critical Care, Montreal, Canada
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center. BG Trauma Center Ludwigshafen; University of Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center. BG Trauma Center Ludwigshafen; University of Heidelberg, Germany
| | - Justus Beier
- Department of Plastic, Hand and Burn Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - David Lumenta
- Research Unit for Tissue Regeneration, Repair and Reconstruction, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Jan Plock
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Declan P Collins
- Department of Burns and Plastic Surgery, Chelsea and Westminster Hospital, London, United Kingdom
| | - Jochen Gille
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy. Burn Unit. St. Georg Hospital GmbH Leipzig, 04129 Leipzig, Germany
| | - Xuran Jiang
- Department of Critical Care Medicine, Queen´s University, K7L 2V7 Kingston, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen´s University, K7L 2V7 Kingston, Canada.
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Bergmeister KD, Aman M, Kramer A, Schenck TL, Riedl O, Daeschler SC, Aszmann OC, Bergmeister H, Golriz M, Mehrabi A, Hundeshagen G, Enkhbaatar P, Kinsky MP, Podesser BK. Simulating Surgical Skills in Animals: Systematic Review, Costs & Acceptance Analyses. Front Vet Sci 2020; 7:570852. [PMID: 33195561 PMCID: PMC7554573 DOI: 10.3389/fvets.2020.570852] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Modern surgery demands high-quality and reproducibility. Due to new working directives, resident duty hours have been restricted and evidence exists that pure on-the-job training provides insufficient exposure. We hypothesize that supplemental simulations in animal models provide a realistic training to augment clinical experiences. This study reviews surgical training models, their costs and survey results illustrating academic acceptance. Methods: Animal models were identified by literature research. Costs were analyzed from multiple German and Austrian training programs. A survey on their acceptance was conducted among faculty and medical students. Results: 915 articles were analyzed, thereof 91 studies described in-vivo animal training models, predominantly for laparoscopy (30%) and microsurgery (24%). Cost-analysis revealed single-training costs between 307€ and 5,861€ depending on model and discipline. Survey results illustrated that 69% of the participants had no experience, but 66% would attend training under experienced supervision. Perceived public acceptance was rated intermediate by medical staff and students (4.26; 1–low, 10 high). Conclusion: Training in animals is well-established and was rated worth attending in a majority of a representative cohort to acquire key surgical skills, in light of reduced clinical exposure. Animal models may therefore supplement the training of tomorrow's surgeons to overcome limited hands-on experience until virtual simulations can provide such educational tools.
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Affiliation(s)
- Konstantin D Bergmeister
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Pölten, Krems, Austria
| | - Martin Aman
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Anne Kramer
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Karl Landsteiner University of Health Sciences, Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital St. Pölten, Krems, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Thilo L Schenck
- Hand Surgery, Plastic Surgery and Aesthetic Surgery, Ludwig-Maximilians-University, Munich, Germany
| | - Otto Riedl
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Simeon C Daeschler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Hospital Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Oskar C Aszmann
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Helga Bergmeister
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Hospital Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Perenlei Enkhbaatar
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States
| | - Michael P Kinsky
- Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, United States
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria.,Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
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40
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Tapking C, Popp D, Hundeshagen G, Houschyar KS, Haug V, Boson AL, Benedikt S, Branski LK. Evaluation of the Online-Presence of ABA-Verified Burn Centers. J Burn Care Res 2020; 41:1063-1068. [PMID: 32639010 DOI: 10.1093/jbcr/irz204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Currently, patients seek healthcare information online. An up-to-date online presence is vital for success among the competition amid hospitals. Hospital websites have become an important medium to communicate with patients, provide information about certain diseases/conditions, and advertise healthcare services. This study aims to evaluate burn centers websites verified by the American Burn Association (ABA). The online presence of the 73 ABA-verified burn centers was evaluated according to criteria previously published by Benedikt et al. This included general information on burns, first aid, treatment at the burn unit, research, and education. ABA-verified burn centers were then compared with 48 German-speaking burn centers evaluated by Benedikt et al. Online information about patient care including treatment options and techniques was more often present in ABA-verified burn centers. However, this information was still provided in only half of the websites. Furthermore, ABA-verified burn centers more often used multimedia-based elements and social media platforms. On the other hand, German-speaking burn centers more often provided translations, general information (eg, staff and ward) about the burn center, as well as research and education. This study demonstrates that although many burn centers have well-designed websites, relevant burn-related information on patient care, research, and education is often missing or sparse. Today, most patients look for healthcare information online. Also, applicants for residency or fellowship programs tend to get a first picture of their potential employer on websites or social media. Keeping websites and social media up-to-date and informative can improve recruitment of patients and employees.
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Affiliation(s)
- Christian Tapking
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston.,Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Daniel Popp
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston.,Division of Plastic, Aesthetic, and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Gabriel Hundeshagen
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | | | - Valentin Haug
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany.,Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexis L Boson
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston.,School of Medicine, University of Texas Medical Branch, Galveston
| | - Stefan Benedikt
- Division of Plastic, Aesthetic, and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria.,Department of Trauma Surgery, University Hospital Innsbruck, Austria
| | - Ludwik Krzysztof Branski
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston.,Division of Plastic, Aesthetic, and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
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Diehm YF, Loew J, Will PA, Fischer S, Hundeshagen G, Ziegler B, Gazyakan E, Kneser U, Hirche C. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) with V. A. C. VeraFlo in traumatic, surgical, and chronic wounds-A helpful tool for decontamination and to prepare successful reconstruction. Int Wound J 2020; 17:1740-1749. [PMID: 32716140 PMCID: PMC7948994 DOI: 10.1111/iwj.13462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/24/2020] [Accepted: 06/28/2020] [Indexed: 01/10/2023] Open
Abstract
For nearly two decades, Negative Pressure Wound Therapy (NPWT) has been used for temporary wound coverage as well as wound bed preparation. The addition of instillation and dwell time as an adjunct to NPWT (NPWTi‐d) enables wound bed cleaning and improved wound bed granulation. Thirty patients with different types of colonised wounds (traumatic, surgical, and chronic) were treated with NPWTi‐d using saline for instillation. Patient data, microbiological data and wound characteristics were collected and analysed. Endpoints were bacterial decontamination (count and type), effect on wound bed granulation, and successful reconstruction. Additionally, subgroup analyses for traumatic, surgical, and chronic wounds as well as patients pretreated with conventional NPWT or isolated gram‐positive or negative germs were performed. NPWTi‐d was applied on average for 13 days with a total hospitalisation time of 51 days. After NPWTi‐d, decontaminated wounds were detected in 23% of cases. The number of different bacteria as well as bacterial count could be significantly reduced from 2.38 to 1.16 and 3.9 to 1.3, respectively. This was similar for all subgroups except surgical wounds, in which NPWTi‐d did not lead to a significant reduction of the bacterial count. NPWTi‐d resulted in a significant stimulation of granulation tissue. Successful reconstruction was achieved in 90% of cases. NPWTi‐d enabled wound pre‐conditioning by powerfully reducing or decontaminating the bacterial load and spectrum in most of the wounds. The wound bed integrity was re‐established to prepare successful reconstruction.
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Affiliation(s)
- Yannick F Diehm
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julia Loew
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Patrick A Will
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.,Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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Haug V, Panayi AC, Kadakia N, Abdulrazzak O, Endo Y, Udeh K, Kollar B, Hundeshagen G, Pomahac B, Kneser U, Hirche C. Use of venous couplers in microsurgical lower extremity reconstruction: A systematic review and meta-analysis. Microsurgery 2020; 41:50-60. [PMID: 32227603 DOI: 10.1002/micr.30581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 01/14/2020] [Accepted: 03/13/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Free tissue transfer for lower limb reconstruction has become a workhorse procedure for limb-salvage. Compared with other recipient sites, the lower extremity has a higher risk of microvascular complications, in particular with venous anastomosis. The study's objective is to evaluate the evidence, safety, and efficacy of venous coupler use in microsurgical anastomosis in lower limb reconstruction to provide objective appraisal of the surgical techniques. METHODS A systematic review (SR) and meta-analysis (MA) were performed analyzing articles from PubMed, Cochrane, Embase, and Web of Science from January 1990, to August 2018. Abstracts and titles were screened and assessed for eligibility by independent reviewers. Following full-text review, articles were included in the SR and MA. Case reports were excluded. Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUOROM) guidelines were followed. RESULTS Out of 15 included studies that met the inclusion criteria for the SR, 9 were included in MA. Patients treated with venous couplers did not experience more surgical complications (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.48-1.33; p = .38), total failure (RR 0.61; 95% CI 0.22-1.70; p = .34), venous compromise (RR 0.72; 95% CI 0.23-2.27; p = .57), arterial compromise (RR 0.85; 95% CI 0.25-2.88; p = .80), partial failure (RR 0.77; 95% CI 0.33-1.77; p = .54), or reoperation (RR 11.79; 95% CI 0.49-286.55; p = .13) in comparison with hand-sewn anastomosis. CONCLUSIONS Outcomes of venous couplers in lower limb reconstruction are comparable to those of hand-sewn anastomosis. However, this study was limited by the quality of the available literature. Additional prospective studies should aim to directly compare both techniques and potential further benefits in clinical trials.
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Affiliation(s)
- Valentin Haug
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikita Kadakia
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Obada Abdulrazzak
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yori Endo
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kodi Udeh
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,The University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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Nagel SS, Radu CA, Kremer T, Meess D, Horter J, Ziegler B, Hirche C, Schmidt VJ, Kneser U, Hundeshagen G. Safety, Pharmacodynamics, and Efficacy of High- Versus Low-Dose Ascorbic Acid in Severely Burned Adults. J Burn Care Res 2020; 41:871-877. [PMID: 32141505 DOI: 10.1093/jbcr/iraa041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
In sepsis and burns, ascorbic acid (AA) is hypothesized advantageous during volume resuscitation. There is uncertainty regarding its safety and dosing. This study evaluated high dose AA (HDAA: 66 mg/kg/h for 24 hours) versus low dose AA (LDAA: 3.5 g/days) administration during the first 24 hours in severely burned adults. We conducted a retrospective study comparing fluid administration before and after switching from low dose to HDAA in severely burned adults. A total of 38 adults with burns >20% TBSA, who received either HDAA or LDAA were included in this retrospective study. AA serum concentrations were quantified at 0, 24, and 72 hours postburn. HDAA impact on hemodynamics, acid-base homeostasis, acute kidney injury, vasopressor use, resuscitation fluid requirement, urinary output, and the incidence of adverse effects was evaluated; secondary clinical outcomes were analyzed. AA plasma levels were 10-fold elevated in the LDAA and 150-fold elevated in the HDAA group at 24 hours and decreased in both groups afterwards. HDAA was not associated with a significantly increased risk of any complications. A significant reduction in colloid fluid requirements was noted (LDAA: 947 ± 1722 ml/24 hours vs HDAA: 278 ± 667 ml/24 hours, P = 0.029). Other hemodynamic and resuscitation measures, as well as secondary clinical outcomes were comparable between groups. HDAA was associated with higher AA levels and lower volumes of colloids in adults with severe burns. The rate of adverse events was not significantly higher in patients treated with HDAA. Future studies should consider prolonged administration of AA.
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Affiliation(s)
- Sarah Sophie Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Christian Andreas Radu
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Thomas Kremer
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic and Hand Surgery, Burn Center, Klinikum St. Georg Leipzig, Leipzig, Germany
| | - David Meess
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Johannes Horter
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Volker Juergen Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, University of Heidelberg, Ludwigshafen, Germany
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Hundeshagen G, Kneser U. RE: Large-defect Resurfacing: A Comparison of Skin Graft Results Following Sarcoma Resection and Traumatic Injury Repair. Wounds 2019; 31:297. [PMID: 31747368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We have read the article by Hanada et al1 from the July 2019 issue of Wounds with great interest and acknowledge that split-thickness skin grafting (STSG) following sarcoma resection is a feasible and noninvasive means of defect reconstruction. The comparison to traumatic defects certainly underpins the safety and efficacy of the method. However, regarding the given defect sizes and localizations, as well as associated defects in tissue volume, we propose free or pedicled flap reconstruction not only would have been feasible, but superior to STSG in most of their1 cases.
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Affiliation(s)
- Gabriel Hundeshagen
- Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany; University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany; University of Heidelberg, Heidelberg, Germany
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45
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Ziegler B, Hundeshagen G, Uhlmann L, Will Marks P, Horter J, Kneser U, Hirche C. Impact of diagnostic bronchoscopy in burned adults with suspected inhalation injury. Burns 2019; 45:1275-1282. [PMID: 31383606 DOI: 10.1016/j.burns.2019.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Inhalation injury is a common complication of thermal trauma. Fiberoptic bronchoscopy (FOB) is regarded as current standard practice in diagnosing and grading inhalation injury. Nonetheless, its predictive value in terms of therapeutic decision-making and clinical outcome is controversial. METHODS Adult burn patients with inhalation injury (InI) were selected from the National Burn Repository of the American Burn Association. Subjects were propensity score pair-matched based on injury severity and grouped based on whether or not FOB had been performed (FOB, CTR, respectively). Mortality, incidence of pneumonia, length of hospitalization, length of ICU stay and dependency on mechanical ventilation were compared between the two groups. RESULTS 3014 patients were matched in two groups with a mean TBSA of 22.4%. There was no significant difference in carboxyhemoglobin fraction at admission. Patients, who underwent FOB on admission had a significantly increased incidence of pneumonia (p < 0.001), mortality (p < 0.05), length of hospitalization (p = 0.002), ICU stay (p < 0.001) and duration of mechanical ventilation (p = 0.006). In a subgroup analysis of patients with TBSA of at least 20%, incidence of pneumonia was significantly higher in the FOB group (p < 0.001) and longer mechanical ventilation was required (p = 0.036). DISCUSSION Diagnosis and grading of InI through FOB is the current standard, although its predictive value regarding key outcome parameters and therapeutic decision-making, remains unclear. The potential procedural risk of FOB itself should be considered. This study demonstrates correlations of FOB with major clinical outcomes in both a general collective of burned adults as well as severely burned adults. Although these findings must be interpreted with caution, they may induce further research into potential harm of FOB and critical review of routine diagnostic FOB in suspected inhalation injury in thermally injured patients.
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Affiliation(s)
- Benjamin Ziegler
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University Heidelberg, Im Neuenheimer Feld 130.3, D-69120 Heidelberg, Germany
| | - Patrick Will Marks
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Johannes Horter
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center BG Trauma Center Ludwigshafen, Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-Guttmann-Str. 13, D-67071 Ludwigshafen, Germany.
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Ziegler B, Kenngott T, Fischer S, Hundeshagen G, Hartmann B, Horter J, Münzberg M, Kneser U, Hirche C. Early hypothermia as risk factor in severely burned patients: A retrospective outcome study. Burns 2019; 45:1895-1900. [PMID: 31378620 DOI: 10.1016/j.burns.2019.07.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/28/2019] [Accepted: 07/10/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Burn trauma-related hypothermia is a frequent observation but risk factors and impact on patient related outcome are ambiguously reported. It is expected that hypothermia is associated with increased mortality and reduced overall outcome in severely burned patients, but available evidence is limited. METHODS This retrospective single-center-study reviewed preclinical service protocols and medical records of patients sustaining a burn with a total body surface area (TBSA) ≥15% from 2008 to 2012. General patient and burn specific characteristics, outcome parameters as well as body temperature at admission measured via urine catheter or nasal temperature probe were recorded and statistically analyzed comparing normothermic (≥36 °C), mild hypothermic (<36 °C) and severely hypothermic (<34.5 °C) patients. Chi-square test was performed to demonstrate impact of hypothermia on primary outcome parameters and to reveal risk factors for developing hypothermia. To assess independent influences on mortality, a multivariate logistic regression analysis was performed. RESULTS Out of 300 patients matching inclusion criteria, a sufficient record of temperature was found in 144 patients (48%). Out of 141 eligible patients with an average burn extent (SD) of 33.38% (24.5%) TBSA, 31.9% (n = 45) suffered from severe hypothermia (<34.5 °C) and 28.4% (n = 40) showed mild hypothermia. Total burn extent, presence of full thickness burns, presence of inhalation injury, preclinical mechanical ventilation and administration of sedative drugs were risk factors for developing hypothermia. Patients' age, total burn extent and presence of full thickness burns could be identified as independent factor for mortality. Although a trend towards an independent positive influence of normothermia at admission on mortality was seen, it was not statistically significant. CONCLUSION Incidental hypothermia of burned patients is associated with an increased mortality and needs to be addressed by emergency health care providers and immediately at the burn center. Especially patients with extensive burns, full-thickness burns, inhalation injury or patients undergoing preclinical intubation are at risk for hypothermia and benefit from any measures for temperature preserving.
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Affiliation(s)
- Benjamin Ziegler
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Theresa Kenngott
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Sebastian Fischer
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Bernd Hartmann
- Burn Center and Plastic Surgery, Unfallkrankenhaus Berlin, Warenerstr. 7, 12683 Berlin, Germany
| | - Johannes Horter
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Matthias Münzberg
- Department of Orthopaedic and Trauma Surgery, BG Trauma Center Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen, Germany.
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Affiliation(s)
- G Hundeshagen
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; University of Texas Medical Branch, Galveston, TX
| | - C Tapking
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; University of Texas Medical Branch, Galveston, TX
| | - B Ziegler
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; University of Texas Medical Branch, Galveston, TX
| | - U Kneser
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; University of Texas Medical Branch, Galveston, TX
| | - C Hirche
- BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany; University of Texas Medical Branch, Galveston, TX
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Tapking C, Hundeshagen G, Popp D, Lee JO, Herndon DN, Zapata-Sirvent R, Branski LK. The Frequency and Reason For Amputations in Electrically Burned Pediatric Patients. J Burn Care Res 2019; 40:107-111. [PMID: 30371857 DOI: 10.1093/jbcr/iry056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Electrical injuries induce substantial morbidity and mortality. Amputations are often necessary to enable survival and based on tissue nonviability, development of life-threatening infection, or expected nonfunctional outcome. They analyzed occurrence and type of amputations in their institution for electrical and nonelectrical pediatric burns and the number of reconstructive operations. Patients who underwent any amputation between 1999 and 2017 were identified. Patients with electrical burns (EB) were matched regarding age, sex, and percent total body surface area (%TBSA) burned to patients with nonelectrical burns (NEB). Both groups (n = 35 EB, n = 70 NEB) were comparable regarding age (EB, 11.6 ± 4.5 years; NEB, 11.1 ± 4.5 years, P = .550) and %TBSA (36.7 ± 15.4% and 37.7 ± 12.9%, P = .738). Major amputations (above wrist or ankle) were performed in 77% of EB vs 31% of NEB (P < .001). Amputations above knee or elbow were performed in 13 (37.1%) vs two patients (2.9%, P < .001). Eight (22.9%) vs six patients (8.6%) underwent combination of two or more major amputations (P = .042). In both groups, most amputations were performed for functional reasons. Length of stay was shorter in EB group (33 ± 27 vs 47 ± 38 days, P = .040). EB patients underwent 9.9 ± 7.1 total operations compared with 14.4 ± 5.1 operations (P < .001). Of these, 6.5 ± 3.6 and 7.9 ± 3.3 (P = .023) were performed during acute stay and 3.3 ± 4.8 and 6.5 ± 3.5 after acute stay (P < .001), respectively. Mortality was comparable. EB were associated with larger extent of limb loss and more major amputations than NEB with amputations. They furthermore required a smaller number of reconstructive procedures. EB require extra attention of caregivers, because of their extensive tissue damage.
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Affiliation(s)
- Christian Tapking
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston® Galveston, Texas.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston® Galveston, Texas.,Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Daniel Popp
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston® Galveston, Texas.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston® Galveston, Texas
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston® Galveston, Texas
| | - Ramón Zapata-Sirvent
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston® Galveston, Texas
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children-Galveston® Galveston, Texas.,Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Herndon D, Capek KD, Ross E, Jay JW, Prasai A, Ayadi AE, Foncerrada-Ortega G, Blears E, Sommerhalder C, McMullen K, Amtmann D, Cox R, Hundeshagen G, Jennings K, Sousse LE, Suman OE, Meyer WJ, Finnerty CC. Reduced Postburn Hypertrophic Scarring and Improved Physical Recovery With Yearlong Administration of Oxandrolone and Propranolol. Ann Surg 2018; 268:431-441. [PMID: 30048322 PMCID: PMC6478032 DOI: 10.1097/sla.0000000000002926] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Massive burns induce a hypermetabolic response that leads to total body wasting and impaired physical and psychosocial recovery. The administration of propranolol or oxandrolone positively affects postburn metabolism and growth. The combined administration of oxandrolone and propranolol (OxProp) for 1 year restores growth in children with large burns. Here, we investigated whether the combined administration of OxProp for 1 year would reduce scarring and improve quality of life compared with control. STUDY DESIGN Children with large burns (n = 480) were enrolled into this institutional review board-approved study; patients were randomized to control (n = 226) or administration of OxProp (n = 126) for 1 year postburn. Assessments were conducted at discharge and 6, 12, and 24 months postburn. Scar biopsies were obtained for histology. Physical scar assessments and patient reported outcome measures of physical and psychosocial function were obtained. RESULTS Reductions in cellularity, vascular structures, inflammation, and abnormal collagen (P < 0.05) occurred in OxProp-treated scars. With OxProp, scar severity was attenuated and pliability increased (both P < 0.05). Analyses of patient-reported outcomes showed improved general and emotional health within the OxProp-treated group (P < 0.05). CONCLUSIONS Here, we have shown improvements in objective and subjective measures of scarring and an increase in overall patient-reported physical function. The combined administration of OxProp for up to a year after burn injury should be considered for the reduction of postburn scarring and improvement of long-term psychosocial outcomes in children with massive burns.
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Affiliation(s)
- David Herndon
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
| | - Karel D Capek
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Evan Ross
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Jayson W Jay
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
| | - Anesh Prasai
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Amina El Ayadi
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Guillermo Foncerrada-Ortega
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Elizabeth Blears
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
| | - Christian Sommerhalder
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Kara McMullen
- Department of Rehabilitation Medicine, The University of Washington, Seattle, WA
| | - Dagmar Amtmann
- Department of Rehabilitation Medicine, The University of Washington, Seattle, WA
| | - Robert Cox
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Department of Pathology, The University of Texas Medical Branch, Galveston, TX
| | - Gabriel Hundeshagen
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Kristofer Jennings
- Department of Preventative Medicine and Community Health, The University of Texas Medical Branch, Galveston, TX
| | - Linda E Sousse
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Oscar E Suman
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
| | - Walter J Meyer
- Department of Psychiatry and Behavioral Science, The University of Texas Medical Branch, Galveston, TX
| | - Celeste C Finnerty
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX
- Shriners Hospitals for Children - Galveston, Galveston, TX
- Institute for Translational Sciences, The University of Texas Medical Branch, Galveston, TX
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50
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Cambiaso-Daniel J, Rontoyanni VG, Foncerrada G, Nguyen A, Capek KD, Wurzer P, Lee JO, Hundeshagen G, Voigt CD, Branski LK, Finnerty CC, Herndon DN. Correlation between invasive and noninvasive blood pressure measurements in severely burned children. Burns 2018; 44:1787-1791. [PMID: 30153960 DOI: 10.1016/j.burns.2018.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/05/2018] [Accepted: 03/03/2018] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Accurate blood pressure monitoring is essential for burn management, with the intra-arterial line method being the gold standard. Here we evaluated agreement between cuff and intra-arterial line methods. METHODS Data from burned children admitted from 1997 to 2016 were retrospectively reviewed. Simultaneously collected intra-arterial and cuff measurements were cross-matched and linear regression performed to assess agreement for systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP). RESULTS We identified 9969 matches for SBP, DBP, and MAP in 872 patients (579 male) aged 8±5years with burns covering 52±20% of the total body surface area and a hospitalization lasting 33±31 days. Intra-arterial lines had a complication rate of 1%. The mean bias (95% CI) between methods was 1.3 (0.5, 2.1) mm Hg for SBP, -6.4 (-7.0, -5.7) mmHg for DBP, and -5.8 (-6.4, -5.3) mmHg for MAP. The standard deviation of the bias (95% limit of agreement) was 12.1 (-22.5, 25.1) mmHg for SBP, 9.9 (-25.8, 13.0) mmHg for DBP, and 8.7 (-22.8, 11.1) mmHg for MAP. CONCLUSIONS Cuff measurements vary widely from those of intra-arterial lines, which have a low complication rate. Intra-arterial lines are advisable when tight control of the hemodynamic response is essential.
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Affiliation(s)
- Janos Cambiaso-Daniel
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria.
| | - Victoria G Rontoyanni
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA; Metabolism Unit, Shriners Hospitals for Children, Galveston, TX, USA.
| | - Guillermo Foncerrada
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA.
| | - Anthony Nguyen
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA.
| | - Karel D Capek
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA.
| | - Paul Wurzer
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria.
| | - Jong O Lee
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA.
| | - Gabriel Hundeshagen
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA; Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Department of Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany.
| | - Charles D Voigt
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA.
| | - Ludwik K Branski
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria.
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX, USA.
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, TX USA.
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