Pretibial hematomas - A real-world single-center study.

We analyzed treatment, outcome, and risk factors for skin necrosis of 60 patients aged ≥65 years treated for a pretibial hematoma in the province of Kymenlaakso, Finland, between 2015 and 2019. Reviewing patients' medical records revealed two cohorts with distinct trajectories in outcome. By comparing the cohorts, we were able to discover factors associated with the prognosis for generating skin necrosis and the need for operative treatment. Thirty-five (58.3%) patients healed without any management, and 25 (41.7%) patients were treated with hematoma evacuation, mostly for having generated skin necrosis (72%). Among operatively treated patients' descriptions, such as "parchment skin" and "poor skin quality" were observed frequently (80%) in the medical records. This pathology, dermatoporosis, was statistically significant (p<0.0001) among patients with a complicated outcome of a pretibial hematoma. In addition to dermatoporosis, patients with hematoma evacuation were more fragile having a higher Charlson comorbidity index (p = 0.005), a greater need for a walking aid (p = 0.0002), and overall compromised independency (p = 0.033). Hospitalization and rehabilitation were prolonged in the operatively treated cohort, 6.4 days vs. 2 days, respectively. We recorded a delay in the diagnosis and hematoma evacuation (mean 6, range 0-51 days). In addition, six (10%) patients were misdiagnosed for having erysipelas or deep vein thrombosis indicating that pretibial hematomas are not recognized. Skin quality should be documented, and prompt surgical hematoma evacuation should be executed in fragile patients with dermatoporosis. This could prevent skin necrosis and the further need of wound care or surgical care, long hospitalization, and rehabilitation periods.

Pretibial lacerations among elderly patients: A province-wide study from Kymenlaakso, Finland, 2015-2019.

In this retrospective cohort study, we analysed treatment and outcomes among ≥65-year-old patients who experienced a traumatic pretibial laceration in the province of Kymenlaakso, Finland, between 2015 and 2019. We reviewed computerised medical records for 116 patients with a pretibial laceration, 107 of whom we analysed in further detail. Patients were traced from injury to healing, including rehabilitation periods in health care centres. As expected, the majority of patients were elderly women (67%). Most lacerations were superficial and small, explaining why treatment was mostly conservative. Only 11 (9.48%) patients were treated operatively with surgical debridement or a split-thickness skin graft. The number of overall complications in wounds was high, with a complication rate of 30.2%. Most complications were local wound infections. We found that wound healing took more than 3 months in 32% of patients. Thorough patient tracing revealed numerous follow-up visits and long rehabilitative hospitalisation periods, indicating a significant decline in patient independence and the excessive use of resources. Successful wound healing was eventually observed in 89.66% patients. Furthermore, no terminology regarding pretibial lacerations was found in patient records. This study indicates that pretibial lacerations remain poorly recognised and understood in Finland.

Severe intimate partner violence affecting both young and elderly patients of both sexes.

BACKGROUND: Intimate partner violence (IPV) affects 25-35 % of women and men in Western countries. Despite the high prevalence of IPV among trauma patients, very little is known about the associated injuries. Most previous studies excluded male victims and IPV is often limited to violence against women. Few reports on IPV among elderly patients exist. METHODS: We examined self-reports of IPV among patients at two major trauma centers of the Helsinki Central Hospital in Finland. Based on previous studies, we hypothesized that we would find the most severe injuries among young and middle-aged women. RESULTS: We identified 29 patients with a total of 105 injuries; patients typically presented with multiple injuries. Half of all patients required hospitalization or surgery. Contrary to previous studies, 17 % of our cohort were male, while 17 % of patients were 65 years or older. We found that 40 % of male victims presented with a New Injury Severity Score (NISS) over 15, indicating severe trauma. Two elderly patients presented with an NISS of 27, the highest in our study. CONCLUSIONS: IPV leads to severe injury across all age groups among both male and female patients. The injury mechanism should be clearly defined for all trauma patients, keeping IPV in mind as a potential cause despite patient age or gender.

The Use of Blood Products in Adult Patients with Burns.

INTRODUCTION: Burn anemia represents a common complication following a burn injury. Burn anemia etiology carries distinct features occurring at each stage of the post-injury and treatment periods resulting from different causes. We aimed to analyze the use of blood components in Finnish burn victims and to identify patient- and injury-related factors influencing their use. METHODS: To study the use of blood products in burn patients, we used data collected from the Optimal Use of Blood registry, developed through co-operation between 10 major hospital districts and the Finnish Red Cross Blood Service. Burn patients ⩾18 years treated at the Helsinki University Hospital between 2005 and 2011 with an in-hospital stay ⩾1 day who received at least one transfusion during their hospital stay were included in this study. RESULTS: Among all 558 burn patients, 192 (34%) received blood products during their hospital stay. The transfused cohort comprised 192 burn patients. The study cohort received a total of 6087 units of blood components, 2422 units of leukoreduced red blood cells, 1728 units of leukoreduced platelets, and 420 units of single-donor fresh frozen plasma or, after 2007, 1517 units of Octaplas(®) frozen plasma. All three types of blood components were administered to 29% of patients, whereas 45% received only red blood cells and 6% received only Octaplas. Transfused patients were significantly older (p < 0.001), experienced fire-/flame-related accidents and burns to multiple locations (p < 0.001), and their in-hospital mortality exceeded that for non-transfused burn patients fivefold (p < 0.05). DISCUSSION: We show that Finnish adult burn patients received ample transfusions. The number of blood components transfused varied according to the anatomical location of the injury and patient survival. Whether the additional mortality is related directly to transfusions or is merely a manifestation of the more severe burn injury remains unknown.

Sensitization and desensitization of burn patients as potential candidates for vascularized composite allotransplantation.

Sensitization describes the acquired ability of the immune system to react to foreign human leukocyte antigens (HLA) by producing antibodies and developing memory cells. In the field of transplantation, recipient preformed HLA antibodies due to previous sensitization have been identified - beneath ABO incompatibility - as a major factor for acute graft rejection. Several reasons for sensitization have largely been studied, such as previous blood transfusions, pregnancies or former transplants. Recent studies indicate that the use of assist devices (e.g. ECMO) or cadaveric skin allotransplantation providing temporary coverage in burn patients may lead to additional sensitization. As vascularized composite allotransplantation (VCA) has become a rapidly advancing therapeutic option for reconstruction of complex tissue defects in burns, it seems even more important to become familiar with immunological principles and to be cautiously aware of both sources of sensitization and therapeutic concepts in burns avoiding sensitization. This may also include emergency VCAs in burn patients as potential strategy for early definitive reconstruction avoiding procedures triggering HLA antibody formation. We hereby provide an overview on current evidence in the field of pre- and peritransplant sensitization, followed by posttransplant strategies of desensitization and their potential impact on future treatments of burn patients.

Prokineticins and Merkel cell polyomavirus infection in Merkel cell carcinoma.

BACKGROUND: Prokineticin-1 (PROK1) and prokineticin-2 (PROK2) are chemokine-like proteins that may influence cancer growth by regulating host defence and angiogenesis. Their significance in viral infection-associated cancer is incompletely understood. We studied prokineticins in Merkel cell carcinoma (MCC), a skin cancer linked with Merkel cell polyomavirus (MCPyV) infection. METHODS: Carcinoma cell expression of PROK1 and PROK2 and their receptors (PROKR1 and PROKR2) was investigated with immunohistochemistry, and tumour PROK1 and PROK2 mRNA content with quantitative PCR from 98 MCCs. Subsets of tumour infiltrating leukocytes were identified using immunohistochemistry. RESULTS: Merkel cell polyomavirus-positive MCCs had higher than the median PROK2 mRNA content, whereas MCPyV-negative MCCs contained frequently PROK1 mRNA. Cancers with high tumour PROK2 mRNA content had high counts of tumour infiltrating macrophages (CD68+ and CD163+ cells). Patients with higher than the median PROK2 mRNA content had 44.9% 5-year survival compared with 23.5% among those with a smaller content (hazard ratio (HR): 0.53; 95% confidence interval (CI): 0.34-0.84; P=0.005), whereas the presence of PROK1 mRNA in tumour was associated with unfavourable survival (P=0.052). CONCLUSIONS: The results suggest that prokineticins are associated with MCPyV infection and participate in regulation of the immune response in MCC, and may influence outcome of MCC patients.

Lateral distribution of Merkel cell carcinoma in a nationwide cohort.

BACKGROUND: The asymmetric laterality of UV-linked skin cancer, including melanoma and non- melanoma skin cancers has been identified. However, there seems to be a paucity in the data correlating the laterality and presence of Merkel cell polyoma virus (MCPyV) DNA as an aetiological factor for this phenomenon. OBJECTIVE: To study the laterality in Finnish primary Merkel cell carcinoma (MCC) patients, and compare statistically clinicopathological variables with lateral distribution. METHODS: Data on 171 primary MCC patients and tumour characteristics; and the presence of MCPyV DNA or large T antigen in the tumour tissue, MCPyV copy number and MCC specific mortality were compared statistically against left, right or midline presentation. RESULTS: Fiftysix percentage of tumours presented on the left, 37% on the right and 7% in the midline. Excluding the latter category, the left-sided excess was 60%. The excess of left-sided tumours was noted in head and neck with left-right ratio 3.22, face 1.5, forearm and hand 4.0 and the leg and foot 2.4. On the trunk, tumours occurred equally on both sides. Statistically significant difference was noted for smaller midline tumours (P < 0.0065). Left-sided tumours associated with lower median Merkel cell polyoma virus copy number (P < 0.042) although the trend vanished when comparing the groups separately. CONCLUSION: We confirmed left-sided asymmetry in MCC distribution. In areas commonly hidden form solar exposure, the occurrence was symmetrical. Detailed aetiology of these findings remains unclear, plausible explanations include biology of viral associated tumours or alterations in Nodal transcription factor pathway.

Asymmetric laterality of Chiari type I malformation in patients with non-syndromic single-suture craniosynostosis.

BACKGROUND: Chiari type I malformation is a frequent incidental finding commonly associated with craniosynostosis. However, there seems to be a paucity of literature concerning the asymmetry of tonsillar herniation in patients with non-syndromic single-suture craniosynostosis. METHODS: To study the asymmetry in this cohort, measurements of the right and left tonsils were made from sagittal images from both pre-operative and post-operative images from 11 patients with non-syndromic single-suture craniosynostosis. RESULTS: Pre-operatively, the mean difference between the caudal descent of all tonsils ranged from 0 to 7 mm, with a mean difference between sides of 2.45 mm. In three cases, cerebellar tonsils were symmetrically herniated. Post-operatively, the mean difference between caudal descent of all tonsils ranged from 0 to 4 mm, with a mean difference between sides of 1.45 mm. Four were symmetrically herniated. In patients with non-syndromic single-suture craniosynostosis, the tonsillar herniation is asymmetric in the majority of cases. CONCLUSIONS: Asymmetry of cerebellar tonsil herniation is a frequent finding in this cohort. The right tonsil is more inferiorly located in majority of cases, with predominance to the synostotic suture side in asymmetric craniosynostosis cases.

Morphometric comparison of foramen magnum in non-syndromic craniosynostosis patients with or without Chiari I malformation.

BACKGROUND: In order to compare the morphometry of foramen magnum (FM) in a matched-pair study, in children with non-syndromic craniosynostosis with and without Chiari I malformation (CMI), both brain magnetic resonance (MRI) and multidetector computed tomography (MDCT) images were utilized. METHODS: Brain MR images were retrieved from the Helsinki University Hospital Picture Archiving and Communications System to identify patients with CMI during 1.1.2004 to 31.3.2009. Age-, gender-, and craniosynostosis-matched controls were retrieved from the same cohort. Morphometric analysis of FM was carried out. RESULTS: Seven patients with non-syndromic craniosynostosis with CMI were recorded. In CMI patients, the absolute anteroposterior length was 33.4 mm as compared to 36.7 mm in controls (p = 0.023). The mean width was 28.1 and 29.9 mm (p = 0.29), and the cross-sectional area was 654.1 and 764.9 mm(2) (p = 0.11) in CMI and controls, respectively. In CMI patients, the relative anteroposterior length of the FM was, on average, 91 % of the control's measurements. On average, the width was 95 % and the cross-sectional area was 88 % of the control's results. CONCLUSIONS: In pediatric non-syndromic craniosynostosis patients, a statistically significant reduced anteroposterior diameter of the FM is found in patients with an adjacent CMI as compared to their age-, gender-, and type-matched controls of craniosynostosis.

The evolution of cerebellar tonsillar herniation after cranial vault remodeling surgery.

PURPOSE: We sought to examine the pre- and postoperative changes of cerebellar tonsillar herniation by MR imaging in asymptomatic pediatric patients with nonsyndromic, single-suture craniosynostosis (N-SSSC), who underwent cranial vault remodeling surgery without suboccipital decompression. We required cerebellar tonsillar herniation through foramen magnum ≥3 mm for Chiari type I malformation (CMI). We hypothesized that the increase of intracranial volume by cranial vault remodeling would correct the asymptomatic CMI. METHODS: We identified 9 patients among 121 N-SSSC children undergoing craniofacial surgery from January 2004 to October 2010 with CMI. However, two of them were excluded from the study due to missing postoperative MR images. In the final study population, six were males, five were scaphocephalic, while two were diagnosed with coronal synostosis. RESULTS: In four of the cases, the CMI was decreased in postoperative MR imaging varying from 6 to 12 mm. In three cases, the herniation remained stable. The median change of cerebellar tonsillar herniation was -6.5 mm. CONCLUSIONS: We conclude that asymptomatic patients with existing CMI may benefit from cranial vault remodeling surgery alone increasing the intracranial volume.

Brain anomalies in 121 children with non-syndromic single suture craniosynostosis by MR imaging.

INTRODUCTION: The aim of this study was to evaluate prevalence of intracranial abnormalities in children with non-syndromic single suture craniosynostosis scheduled for cranial vault remodelling surgery using pre-operative magnetic resonance imaging. PATIENTS AND METHODS: A retrospective analysis of brain magnetic resonance imaging studies of 129 non-syndromic single suture craniosynostosis children undergoing craniofacial surgery between January, 2004-October, 2010 was conducted. Statistical analysis was performed for child, maternal and sibling related predisposing factors for abnormal brain magnetic resonance imaging findings. The mean age of these 121 patients at the time of imaging was 21.6 months. The majority, 78% were males and 74% of the patients were scaphocephalic. RESULTS: In 18 (15%) patients abnormal brain findings were noted. The most common finding was Chiari 1 malformation in 11 (9%). Chiari 1 malformation comprised over half (61%) of the brain anomalies identified. None of these findings required any additional surgical procedures. None of the statistical analysis reached statistical significance. CONCLUSIONS: Brain anomalies in connection with non-syndromic single suture craniosynostosis patients seem to be a coincidental event. We did not establish any specific craniosynostosis form to be regularly associated with abnormal brain magnetic resonance imaging findings. The routine use of pre-operative magnetic resonance imaging in non-syndromic single suture craniosynostosis patients seems to be of limited value in the search for associated intracranial malformations necessitating additional interventions.

[Tattoos and dermatological, plastic and visceral surgery]. / Les tatouages et la chirurgie dermatologique, plastique et viscérale.

The estimated prevalence of tattooed individuals in Europe and in France is around 10%. The current "tattooed generation" was born mainly between 1975 and 1986, and according to a recent German study, the "typical tattooed" individual is a 30-year-old male or female with a mean tattooed area of 300 cm(2) or over in 61% of cases and more than one tattoo in 65% of cases. As this population gradually ages, physicians will be increasingly called on to treat tattooed areas, either for surgical removal of the tattoo itself or for excision of a suspect lesion or skin tumour, or for incision of the skin in a setting of either elective or emergency visceral surgery. This review focuses on the surgical situations potentially arising in tattooed patients.

Specifically requesting surgical tattoo removal: are deep personal motivations involved?

BACKGROUND: Motivations for tattoo removal include employment reasons, stigmata, changes in lifestyles or partners, incompatibility with present attitudes and values and clothing problems. Most studies on the motivations for tattoo removal have focused on patients seeking laser therapy. We hypothesized that patients seeking surgical tattoo removal would present with different motivations. OBJECTIVE: We analysed the characteristics and motivations of patients specifically requesting surgical tattoo removal. METHODS: We retrospectively reviewed the medical records of 16 patients in Helsinki, Finland, from 2005 to 2011. Demographic, clinical data, number of tattoos, location and size, time elapsed since tattooing, reason(s) for wanting surgical tattoo removal and surgical operations were analysed and compared with the other literature on tattoo removal. RESULTS: Patients were mainly Caucasian females (ratio 3 : 1, median age of 26 years). Tattoos were all done by studio artists, most measured less than 30 cm², and were quite recent (median 5.3 years). Personal reasons accounted for 42.8% of all reasons, professional/social reasons for 37.5% and miscellaneous for 18.8%. Personal concerns were usually marital status changes, with few expressing dissatisfaction with the actual design of the tattoo. Tattoos were excised during a single procedure in 70% of the cases with only one case producing a hypertrophic scar. CONCLUSIONS: Patients seeking surgical removal were aware of the limits and risks of the technique. They expressed intense personal reasons for wanting radical surgical removal. The possibility of surgical tattoo removal should be accessible to patients if the tattoo is small and discussion reveals strong personal motivation.

[Recent update on tumour biology and treatment of Merkel Cell carcinoma]. / Aktuelles Update zur Tumorbiologie und Behandlung des Merkelzell-Karzinoms.

Merkel cell carcinoma (MCC) is a carcinoma arising from Merkel cells located in the basal layer of the epidermis. The skin of the head and neck is a common site for MCC, occurring generally in fair-skinned elderly patients. MCC is considered as the most lethal skin cancer. Radical surgical excision with pathological verification of complete removal of the tumour is the recommended treatment. Early MCC can be cured by surgery with or without postoperative radiation therapy, whereas advanced MCC is currently considered to be incurable. In the year 2008, a new polyoma virus was found in the tumour genome of the MCC tumours. MCPyV (Merkel cell polyoma virus) appears to be the first example of a human oncogenic polyoma virus. Specific mutations in the viral genome and its clonal integration to the tumour genome are strong evidence against MCPyV as being a passenger virus that secondarily infects MCC tumours. The purpose of this review article is to shed light on this rare skin cancer and introduce the latest advances in research on MCC.

Chronic lymphocytic leukaemia patients have a high risk of Merkel-cell polyomavirus DNA-positive Merkel-cell carcinoma.

BACKGROUND: Immunosuppression and Merkel-cell polyomavirus (MCPyV) infection may have a role in the pathogenesis of Merkel-cell carcinoma (MCC), a rare neuroendocrine carcinoma of the skin. METHODS: We studied incidence of chronic lymphocytic leukaemia (CLL) and MCC from the files of the Finnish Cancer Registry and the largest hospital of Finland, Helsinki University Central Hospital, from 1979 to 2006. Presence of MCPyV DNA in MCCs was investigated by quantitative PCR. RESULTS: We identified 4164 patients diagnosed with CLL and 172 diagnosed with MCC. Six patients diagnosed with both diseases were found; CLL was the first diagnosis in four cases and MCC in two. The standardised incidence ratio (SIR) for CLL after the diagnosis of MCC was highly elevated, 17.9 (95% confidence interval (CI), 2.2-64.6; P<0.001), and the SIR for MCC after the diagnosis of CLL was also elevated, 15.7 (3.2-46.0, P<0.01). Merkel-cell polyomavirus DNA was present in all five MCCs with tumour tissue available for analysis. CONCLUSIONS: We conclude that patients diagnosed with CLL have a substantially increased risk for MCC, and vice versa. Merkel-cell polyomavirus DNA is frequently present in MCCs that occur in CLL patients. Immunosuppression related with CLL and viral infection might explain the association between CLL and MCC.

Merkel cell carcinoma in a young pregnant woman.

SUMMARY: We present a 27-year-old pregnant woman with Merkel cell carcinoma on the forehead. In early pregnancy, the lesion was excised as an epidermal cyst. It was only after recurrence that a diagnosis of Merkel cell carcinoma was made. Sentinel-node biopsy, excision with 2 cm margins and reconstruction with free microvascular radial forearm flap was carried out, and the patient received postoperative radiotherapy. No evidence of recurrence or disease progression was found 24 months after surgery.

[Unusual and fatal type of burn injury: hot air sauna burn]. / Quemaduras por aire caliente en saunas: lesiones fatales y poco frecuentes.

Sauna bathing is a popular recreational activity in Finland and is generally considered safe even for pregnant women and patients suffering from heart problems; but mixing alcohol with sauna bathing can be hazardous. In the normal Finnish recreational sauna the temperature is usually between 80 and 90 degrees C. A wide variety of burn injuries, in all age groups, are related to sauna bathing; scalds and contact burns account for over 85% while hot air, steam and flame burns for only 15%. Dehydration in patients under the influence of alcohol heightens the risk of hypotension which impairs skin blood circulation. This increased warming of the skin is an effect that is more marked on the outer and upper parts of the body exposed to hot air. Such patients require intensive care on admission: fluid replacement according to the Parkland formula, forced diuresis and immediate correction of acidosis and myoglobinuria. These patients have significant rhabdomyolysis on admission. The best predictor of survival is the creatine kinase level on the second post-injury day. CT scans are necessary to diagnose the underlying conditions of unconsciousness. The necrotic area extends to subcutaneous fat tissue and even to the underlying muscles. The level of excision is typically fascial and, in some areas, layers of the muscle must be removed. Owing to the popularity of sauna bathing throughout the world, it is important to know the extent of damage in this type of injury, in order not to underestimate the severity of such lesions.