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Goodall RJ, Roberts J, Correia MD, Frew Q, Barnes D, Dziewulski P, Shelley O, El-Muttardi N. Management of purpura fulminans skin loss at a regional burns centre: Sixteen-year experience. J Plast Reconstr Aesthet Surg 2023; 79:23-29. [PMID: 36842284 DOI: 10.1016/j.bjps.2023.01.004] [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: 08/18/2022] [Accepted: 01/29/2023] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Purpura fulminans (PF) is a rare syndrome of cutaneous purpura which is the consequence of severe circulatory shock causing intravascular thrombosis, haemorrhagic necrosis, and consequent tissue loss. The aim of this study was to present our 16-year experience of managing PF in a regional burns centre. METHODS We performed a single-centre retrospective case series of all patients admitted to the St Andrews Burns Centre at Broomfield Hospital, Chelmsford, Essex, UK, between June 2006 and July 2022 with a diagnosis of PF. Data were extracted by retrospectively searching hospital case notes. RESULTS Thirteen individuals were identified [five children (mean age 5, range 1-14) and eight adults (mean age 39, range 24-54)]. The total body surface area of cutaneous necrosis ranged from 5% to 80%, with a mean of 27.2%. Patients were treated with an established surgical sequence of total wound debridement and immediate coverage with a cadaveric allograft, followed by staged wound autografting. The mean time from disease onset to wound autografting was 37.3 days (range 20-64 days). Eight individuals (61.6%) required major amputation of at least one limb (proximal to the ankle or wrist joint). Only one mortality (of 80% total body surface area skin loss) was observed in the identified cohort. CONCLUSIONS The large body surface areas often involved in PF cases make management of these wounds well suited for burns centres, wherein established facilities and multidisciplinary teams exist that are familiar with managing large cutaneous burns. We provide a suggested algorithm to aid the management of PF.
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Affiliation(s)
- R J Goodall
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK.
| | - J Roberts
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - M D Correia
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - Q Frew
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - D Barnes
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - P Dziewulski
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - O Shelley
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
| | - N El-Muttardi
- St Andrews Centre for Burns and Plastic Surgery, Broomfield Hospital, Chelmsford, Essex, UK
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Miranda B, Jica R, Pinto-Lopes R, Mopuri N, Sood M, Tare M, Shelley O, El-Muttardi N. 1164 St Andrew’s COVID Surgery Safety (StACS) Study: Skin Cancer. Br J Surg 2021. [DOI: 10.1093/bjs/znab258.058] [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: 11/14/2022]
Abstract
Abstract
Background
Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19.
Objective
This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-safety guidelines.
Method
A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). ‘Real-time’ 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively.
Results
Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups.
Conclusions
These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic.
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Affiliation(s)
- B Miranda
- Mid and South Essex Hospital, Chelmsford, United Kingdom
| | - R Jica
- Mid and South Essex Hospital, Chelmsford, United Kingdom
| | - R Pinto-Lopes
- Mid and South Essex Hospital, Chelmsford, United Kingdom
| | - N Mopuri
- Mid and South Essex Hospital, Chelmsford, United Kingdom
| | - M Sood
- Mid and South Essex Hospital, Chelmsford, United Kingdom
| | - M Tare
- Mid and South Essex Hospital, Chelmsford, United Kingdom
| | - O Shelley
- Mid and South Essex Hospital, Chelmsford, United Kingdom
| | - N El-Muttardi
- Mid and South Essex Hospital, Chelmsford, United Kingdom
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Miranda BH, Jica RCI, Pinto-Lopes R, Mopuri N, Sood MK, Tare M, Shelley O, El-Muttardi N. St Andrew's COVID-19 Surgery Safety (StACS) study: Skin cancer. J Plast Surg Hand Surg 2021; 55:315-321. [PMID: 33606568 DOI: 10.1080/2000656x.2021.1883633] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Skin cancer represents the most common malignancy worldwide and it is imperative that we develop strategies to ensure safe and sustained delivery of cancer care which are resilient to the ongoing impact of COVID-19. OBJECTIVE This study prospectively evaluates the COVID-19 related patient risk and skin cancer management at a single tertiary referral centre, which rapidly implemented national COVID-19 safety guidelines. METHOD A prospective cohort study was performed in all patients who underwent surgery for elective skin cancer service management, during the UK COVID-19 pandemic peak (April-May 2020). 'Real-time' 30-day hospital database deceased data were collected. Random selection was undertaken for patients who either underwent operative (surgery group) management or remained on the waiting list (control group); these groups were also prospectively followed-up within a controlled cohort study design and telephoned at the end of June 2020 for the control group or 30 days post-operatively. RESULTS Of the 767 patients who had operations, there were no COVID-19 related deaths. Both the surgery (n = 384) and control (n = 100) groups were matched for age, sex, ethnicity, BMI, presence of comorbidities, smoking and positive COVID-19 contact. There were no differences in post-operative versus any symptom development (1.3%, 5/384 vs. 4%, 4/100, p = 0.093), or proportion of positive tests (8.6%, 33/384 vs. 8%, 8/100; p = 0.849), between the surgery and control groups. CONCLUSION These data support continued and safe service provision, and no increased risk to skin cancer patients who require surgical management, which is vital for continuation of cancer treatment in the context of a pandemic. LEVEL OF EVIDENCE II.
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Affiliation(s)
- B H Miranda
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
| | - R C I Jica
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
| | - R Pinto-Lopes
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
| | - N Mopuri
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
| | - M K Sood
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
| | - M Tare
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
| | - O Shelley
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
| | - N El-Muttardi
- St Andrew's Centre for Plastic Surgery & Burns, Broomfield Hospital, Chelmsford, UK
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Concannon E, Kennedy S, Shelley O. Toxic epidermal necrolysis after acute burn injury. Ann Burns Fire Disasters 2018; 31:266-270. [PMID: 30983926 PMCID: PMC6441584] [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] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/28/2019] [Indexed: 06/09/2023]
Abstract
Toxic epidermal necrolysis is a rare, potentially fatal disorder that involves large areas of skin desquamation. Patients with toxic epidermal necrolysis are frequently referred to burn centres for expert wound management and early comprehensive critical care as this has been shown to improve patient outcome and mortality. The authors describe the first report of medication-induced toxic epidermal necrolysis occurring in a patient during acute burn management in a tertiary burn care facility. The patient sustained a 17% total body surface area flame burn to her face, chest, bilateral upper limbs and bilateral lower limbs while escaping from a wildfire. She required extensive debridement and allografting to manage burn injured areas and additional areas of epidermal loss from subsequent toxic epidermal necrolysis, amounting to a total body surface area of 90%. Definitive burn wound closure was achieved using autologous split-thickness skin grafting once donor sites healed and became suitable for harvest 3 weeks after the onset of toxic epidermal necrolysis. Grafts achieved complete take and the patient was discharged home following rehabilitation..
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Affiliation(s)
- E. Concannon
- Elizabeth Concannon E
MB BAO BCh, National Burns Unit, St. James’ HospitalJames’ Street North, Dublin 8, D03 VX82Republic of Ireland+353 1 4162326+353 1 4103716
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Tong E, Martin F, Shelley O. A novel approach to reconstruct a large full thickness abdominal wall defect: Successful treatment with Matriderm® and Split. J Wound Care 2014; 23:355-7. [DOI: 10.12968/jowc.2014.23.7.355] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- E. Tong
- Senior house officer, National Burns Unit Dept Plastic & Reconstructive Surgery St. James's Hospital Dublin, Ireland
| | - F. Martin
- Specialist registrar, consultant, National Burns Unit Dept Plastic & Reconstructive Surgery St. James's Hospital Dublin, Ireland
| | - O. Shelley
- Consultant, National Burns Unit Dept Plastic & Reconstructive Surgery St. James's Hospital Dublin, Ireland
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Masud D, Norton S, Smailes S, Shelley O, Philp B, Dziewulski P. The use of a frailty scoring system for burns in the elderly. Burns 2013; 39:30-6. [DOI: 10.1016/j.burns.2012.03.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Revised: 03/02/2012] [Accepted: 03/07/2012] [Indexed: 11/24/2022]
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Frew Q, Philp B, Shelley O, Myers S, Navsaria H, Dziewulski P. The use of Biobrane® as a delivery method for cultured epithelial autograft in burn patients. Burns 2013; 39:876-80. [PMID: 23352181 DOI: 10.1016/j.burns.2012.11.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Revised: 11/22/2012] [Accepted: 11/26/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cultured epithelial autografts (CEA) are well described in the literature and are advantageous when dealing with major burns. There have been many methods of CEA application described, however they all have their own difficulties. Here we describe a novel technique of culturing the keratinocytes in Biobrane(®). METHODS Skin samples were taken from three patients and cultured into pre-confluent keratinocytes. These were seeded in Biobrane(®) and applied directly to the patients' wounds. RESULTS Three patients had Biobrane(®) with seeded keratinocytes applied. The Biobrane was applied to both donor and burn wound sites, with healing times being similar to the keratinocyte sheets. CONCLUSION The experience of the authors shows that using Biobrane(®) seeded with keratinocytes was easier to handle and quicker to produce than confluent sheets of keratinocytes, with no perceived disadvantages to the patients.
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Affiliation(s)
- Q Frew
- St. Andrews Centre for Burns and Plastics, STAaR Research Unit, United Kingdom.
| | - B Philp
- St. Andrews Centre for Burns and Plastics, STAaR Research Unit, United Kingdom
| | - O Shelley
- St. Andrews Centre for Burns and Plastics, STAaR Research Unit, United Kingdom
| | - S Myers
- St. Andrews Centre for Burns and Plastics, STAaR Research Unit, United Kingdom
| | - H Navsaria
- St. Andrews Centre for Burns and Plastics, STAaR Research Unit, United Kingdom
| | - P Dziewulski
- St. Andrews Centre for Burns and Plastics, STAaR Research Unit, United Kingdom
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Horner C, Atkins J, Simpson L, Philp B, Shelley O, Dziewulski P. Estimating the usage of allograft in the treatment of major burns. Burns 2011; 37:590-3. [DOI: 10.1016/j.burns.2010.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 11/30/2010] [Accepted: 12/05/2010] [Indexed: 10/18/2022]
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Hemington-Gorse SJ, Clover AJP, Macdonald C, Harriott J, Richardson P, Philp B, Shelley O, Dziewulski P. Comfort care in burns: the Burn Modified Liverpool Care Pathway (BM-LCP). Burns 2011; 37:981-5. [PMID: 21493007 DOI: 10.1016/j.burns.2011.03.012] [Citation(s) in RCA: 19] [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: 08/25/2010] [Revised: 03/10/2011] [Accepted: 03/21/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Despite advances in burn care some injuries remain non survivable. Good end of life care for these patients is arguably as important as life prolonging care. The Liverpool Care Pathway is a useful tool for providing good quality end of life care. It has previously been modified for the acute setting. We modified it further specifically for use in burn care in 2007 and would like to share our experience of using it. METHODS A retrospective case series of deaths occurring between 01/01/08 and 31/12/09 is presented and adherence to the Burn Modified Liverpool Care Pathway (BM-LCP) is assessed. RESULTS There were 22 deaths over the study period with a mean TBSA of 55%. Mean Acute Burn Severity Index score (ABSI) 12.5. A decision of futility was made in 14 cases, 11 of these were started on the BM-LCP. 7 were started on the pathway at the time of admission. Mean time from decision to start the pathway to death 11 h (range 3-48). There were no variances from the pathway. CONCLUSION The BM-LCP appears to be an appropriate tool for assisting in end of life care in burns and when used appears to improve end of life care. We recommend its use and would encourage others to implement its use.
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Affiliation(s)
- S J Hemington-Gorse
- St Andrew's Centre for Burns, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom.
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Abstract
BACKGROUND Recent findings indicate that severe injury primes the immune system for an enhanced and lethal proinflammatory cytokine response against bacterial-derived superantigens. This study asked whether this response to injury involves the CD95 (Fas) signaling pathway. METHODS To assess superantigen-mediated mortality, wild-type (WT) C57BL/6 and Fas-deficient C57BL/6 lpr (-/-) (lpr) mice underwent burn or sham injury and were challenged 2 hours later with staphylococcal enterotoxin B (SEB). Spleen cells from sham and burn WT or lpr mice were stimulated in vitro with SEB to assess injury effects on IL-2, TNF-alpha, and IFN-gamma production. RESULTS Lpr burn mice survived the SEB challenge (100% survival), while WT burn mice showed a high mortality (17% survival, P < 001, analysis of variance [ANOVA]). Sham lpr or WT mice suffered no mortality to the SEB challenge. In vitro studies demonstrated that burn lpr mice produced significantly less TNF-alpha, IFN-gamma, IL-2 than burn WT mice (P <.01, ANOVA). Burn injury markedly enhanced SEB-stimulated IFN-gamma production by WT spleen cells and CD8+ T cells, while this did not occur in SEB-stimulated lpr spleen cells. CONCLUSIONS These findings support the hypothesis that the CD95 (Fas) signaling pathway plays an integral role in the injury-induced enhanced and lethal T-cell reactivity against bacterial superantigens.
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Affiliation(s)
- M R Kell
- Department of Surgery(Immunology), Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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