Multi-resistant organisms in burn patients: an end or a new beginning.

Infections are a major cause of morbidity and mortality in burn patients, and the rise of multidrug-resistant organisms (MDROs) has made it more challenging to manage and prevent infections. This review examines the available treatment options for MDROs in burn patients and anticipates the future challenges posed by their increasing prevalence. The review covers new antibiotics, such as Eravacycline and Plazomicin, as well as non-antibiotic therapies, such as bacteriophages and nanoparticles. Future research should focus on examining the long-term efficacy, cost-effectiveness, and in vivo efficacy of different treatment modalities. The potential of alternative therapies, such as probiotics and low-frequency magnetic fields, should also be explored. Accurate and rapid diagnostic and monitoring tools for detecting MDROs in burn patients should be developed. The emergence of MDROs in burn care is a challenge and a new beginning in infection innovation and novel treatments.

Transcatheter arterial embolisation for the relief of shoulder and elbow chronic joint pain refractory to conventional treatment: Systematic review.

Angiogenesis and accompanying nerve fibres might cause unsettling joint pain. Studies have suggested that transcatheter arterial embolisation (TAE) of these abnormal neovessels could relieve pain and symptoms in patients with upper limb joint pain refractory to conventional treatment. This study aims to investigate the efficacy and safety of TAE in treating chronic pain of shoulder and elbow joints that have been resistant to other treatments. Using six databases, a systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The primary outcome involved changes in the visual analogue scale (VAS) after TAE; while secondary outcomes involved comparing other parameters where relevant. Average VAS decreased from baseline, then at 1 day, 1 week, 1 month, 3 months, 4 months, 6 months, 1 year, 2 years and 44 months (7.5 at baseline vs. 4.7, 4.3, 3.4, 2.1, 2.5, 1.2, 0.7, 1.1 and 0.1, respectively). Average Quick-DASH scores decreased from baseline, then at 1, 3 and 6 months (61.3 at baseline vs. 30.6, 19.3 and 6.9, respectively). Minor adverse events were reported in 27/143 (18.9%) patients, where they resolved spontaneously or with oral analgesia. TAE is a possible treatment option for refractory shoulder and elbow joint pain; however, randomised controlled trials are still required.

Targeted muscle reinnervation in managing post-amputation related pain: A systematic review and meta-analysis.

INTRODUCTION: Limb amputation can cause residual limb pain (RLP) and/or phantom limb pain (PLP). Although targeted muscle reinnervation (TMR) was initially introduced to facilitate the control of prosthetic limbs, it has been noted that these patients experience less pain and improved prosthetic functional outcomes. As a result, the use of TMR in managing neuroma-related RLP is increasing. The aim of this review is to assess the quality and strength of the evidence supporting the effectiveness of TMR in managing amputation-related pain. METHODS: Five different databases, including MEDLINE (PubMed), Scopus, Web of Science, Cochrane Library, and Embase, were searched from inception to March 2022. The protocol for this systematic review has been registered in the PROSPERO database (CRD42020218242). To be included, studies needed to compare pre- and postoperative pain outcomes or different techniques for adult patients who underwent TMR following amputation. Eligible studies also needed to use patient-reported outcome measures (PROMS) and be clinical trials or observational studies published in English. Excluded studies were case reports, case series, reviews, proof of concept studies, and conference proceedings. A meta-analysis was performed on studies that had similar intervention and control groups to examine treatment effects using a random-effects model. Studies were weighted using the inverse variance method, and a statistically significant p-value was considered to be less than or equal to 0.05. RESULTS: This review included five studies for qualitative analysis and four studies for quantitative analysis. Reviewed studies enrolled a total of 127 patients. The TMR group was compared with standard treatment at 12 months follow-up. The TMR group showed significantly better PLP as assessed by the numerical rating score RLP, and PLP assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) also showed significantly lower pain intensity in the TMR group. CONCLUSION: There is limited evidence of good quality favoring TMR in reducing postamputation PLP and RLP pain compared with standard care. Randomized clinical trials are encouraged to compare the efficacy of different surgical techniques.

Thrombophilia and Preoperative Deep Venous Thrombosis and Their Effect on Free Flap Survival: A Scoping Review.

Background: A proper preoperative planning is essential to prevent flap failure. However, venous workup for flaps has not been commonly performed or utilized as a preoperative screening tool. A scoping review was conducted to explore preoperative venous system screening, including deep vein thrombosis diagnosis, and its effect on flap survival rate. This review identified existing gaps of knowledge and emphasized potential research areas for future studies. Methods: Two independent reviewers searched 3 electronic databases from inception to September 2020. Retrieved appropriate articles were selected systematically by title, abstract, and full review of the article. Studies were included if they enrolled patients who had thrombophilia or deep venous thrombosis (DVT) preoperatively and had undergone a free flap reconstruction. For eligible studies, the following information was extracted: basic demographics (sex, age, comorbidities), preoperative scans type, free flap type, clotting mode (causes), wound type, and flap survival. Results: Seventeen articles were found eligible for this review. Traumatic aetiology was found in 63 (33.6%) patients, while 124 (66.3%) patients had a non-traumatic aetiology. Preoperative screening for patients with non-traumatic aetiology was reported in 119 patients. In these patients, the flap survived in 107 (89.91%) patients. Four studies investigating patients with traumatic DVT aetiology, 60 patients (out of 63) had a preoperative computed tomography angiography or duplex. Those patients had 100% flap survival rates. Conclusion: Further investigations are required to identify venous thrombosis incidence in patients with non-traumatic thrombosis aetiology as this cohort of patients is at high risk of flap failure. Finally, the prognostic validity of available preoperative screening tools to identify high-risk patients should be assessed, such as imaging techniques, which would include venous duplex scanning, may prevent failure in free flap surgery.

Historique: Il est essentiel de procéder à une planification préopératoire appropriée pour prévenir l'échec du lambeau. Cependant, il n'est pas fréquent que le bilan veineux des lambeaux soit effectué ou utilisé comme outil de dépistage préopératoire. Les chercheurs ont réalisé une analyse exploratoire pour évaluer le dépistage du système veineux préopératoire, y compris un diagnostic de thrombose veineuse profonde et son effet sur le taux de survie des lambeaux. Cette analyse a permis de repérer les lacunes et de faire ressortir des domaines de recherche potentiels. Méthodologie: Deux analystes indépendants ont fait des recherches dans trois bases de données électroniques entre leur création et septembre 2020. Ils ont extrait systématiquement les articles appropriés en fonction de leur titre, de leur résumé et de leur analyse complète. Ils les ont conservés s'ils comprenaient des patients qui présentaient une thrombophilie ou une thrombose veineuse profonde avant l'opération et qui avaient subi une reconstruction par lambeau libre. Ils ont tiré l'information suivante des études admissibles: caractéristiques démographiques de base (sexe, âge, maladies associées), type d'imagerie préopératoire, type de lambeau libre, mode de coagulation (causes), type de plaie et survie du lambeau. Résultats: Les chercheurs ont trouvé 17 articles admissibles à l'analyse. Ils ont constaté une étiologie traumatique chez 63 patients (33,6 %), et une étiologie non traumatique chez 124 patients (66,3 %). Au total, 119 patients présentant une étiologie non traumatique ont été soumis à un dépistage préopératoire. Le lambeau a survécu chez 107 d'entre eux (89,91 %). Dans les quatre études sur les patients ayant une étiologie de thrombose veineuse profonde traumatique, 60 (sur 63) ont subi une angiographie tomographique ou un échodoppler duplex. Le taux de survie des lambeaux atteignait 100 % chez ces patients. Conclusion: D'autres explorations s'imposent pour déterminer l'incidence de thrombose veineuse chez les patients présentant une étiologie de thrombose non traumatique, car cette cohorte de patients est très vulnérable à un échec du lambeau. Enfin, il faudra évaluer la validité pronostique des outils de dépistage préopératoire visant à détecter les patients à haut risque, tels que les technologies d'imagerie, qui incluraient un échodoppler duplex, pour prévenir l'échec d'une opération à lambeau libre.

Internal mammary vein diameter - Is the left side really smaller? A study of 105 bilateral free flap breast reconstruction patients.

INTRODUCTION: Autologous free flap breast reconstruction is currently considered as the gold standard in breast reconstruction as it provides a durable, natural result. The internal mammary vessels are the most commonly used recipient vessels in free flap breast reconstruction, and anecdotally we have often observed that the left internal mammary vein (IMV) appears smaller than the right IMV. The aim of this study is to compare the diameters of the right and left IMVs by recording the size of the venous coupler used on each side in a large series of bilateral free flap breast reconstructions. METHODS: We searched our free flap database for patients who had breast reconstruction between October 2018 and August 2021. Inclusion criteria for this study were bilateral breast reconstruction patients, where the internal mammary vessels were used. We used a paired t-test for statistical analysis of the data. RESULTS: A total of 105 patients who had bilateral breast reconstruction were included in this study. Their mean age was 48.4 years. The mean venous coupler size used on the right was 2.64 mm (SD 0.35), whilst the mean left IMV coupler size was 2.48 (SD 0.32). Using a paired t-test, the p value for the comparison of the right and left IMV size in the cohort was 0.00032, demonstrating a statistically significant difference. CONCLUSION: We have confirmed that the right IMV is larger in diameter than the left side, and demonstrated that this translates into a recordable practical difference in the coupler size used. Despite this, we experienced no venous congestion or flap failures in our left-sided flaps, indicating that the IMVs remain a safe choice of recipient vein.

Use of free flaps in aesthetic breast surgery: a single centre experience and literature review.

BACKGROUND: Implant-based breast augmentation is one of the most performed procedures in aesthetic surgery, whereas autologous tissue application is confined to fat grafting as adjuvant procedure. The use of free flaps in cosmetic mammoplasties is not popular, but the number of reports in the literature is increasing. We believe that autologous tissue transfer for cosmetic purposes could be a valuable alternative for volume enhancement in selected conditions, especially following weight loss. In this paper, we provide a systematic literature review of the current literature of using autologous free flaps for breast augmentation in non-cancer patients, and we also report our experience on this topic to identify possible indications and criteria for the patients' selection. METHODS: PRISMA's guidelines have been followed for the literature review. In order to demonstrate the feasibility, safety and patient satisfaction with breast volume enhancement with autologous tissue, a retrospective single-centre study was conducted on women who underwent breast volume enhancement with autologous tissue. Patient's satisfaction was assessed with a visual analogue scale (VAS) creating an ad-hoc outcome scale, and the data were summarised with a descriptive statistic. RESULTS: Twelve patients were enrolled in the study. Weight loss was the main indication for surgery. The average length of procedure was 5.1 h, and the hospitalization was 2.3 days. After 12 month, the patient outcome was excellent in 2 cases, good in 9 cases and moderate in 1 case. CONCLUSIONS: Although further research is needed, the literature review and our case series show that the use of free flaps for breast volume enhancement is safe and gives a satisfactory outcome.

The impact of pre-existing venous pathology on lower limb free flap reconstruction and the role of preoperative screening: a systematic review.

Lower limb reconstruction is performed to replace like with like and achieve tissue durability. Free flaps are a method of reconstruction commonly used to manage cases of lower limb deficits. However, the failure rate is 8.5%, with venous thrombosis and congestion playing a significant role. Despite this, preoperative venous mapping of recipient site before free flap reconstruction is not routinely practiced, often resulting in pathologies remaining unidentified until the intraoperative stage. The aim of the review was to evaluate the existing literature on the topic of lower limb preoperative venous assessment, screening, and its effect on lower limb free flap survival. Five different databases were searched from their inception to August 2021. The search terms and included studies were independently reviewed by two investigators for their eligibility. Eleven articles were eligible for inclusion, with a combined patient population of 99, and 107 flaps were identified to have lower limb pathology at the donor or recipient vein. Venous pathology was detected preoperatively in 69 veins using ultrasound duplex scanning and computed tomography angiography; of them, 3 (4.34%) resulted in failure. In comparison, 38 veins were diagnosed with venous pathology intraoperatively; of them, 5 (13.85%) failed. The studies evaluated in this review demonstrated that preoperative screening for venous pathology showed a higher flap survival rate. It can therefore be inferred that developing a standardized preoperative process for identifying venous issues in lower limb free flap reconstruction may improve outcomes. This can be explored in future research, with a focus on assessing the validity and efficacy of such screening tools, and their role in the management of patients identified with venous pathology.

Trapeziectomy with Abductor Pollicis Longus Tendon Interposition Arthroplasty for First Carpometacarpal Joint Osteoarthritis: A Systematic Review.

Background: The prevalence of osteoarthritis (OA) of the first carpometacarpal (CMC) joint and subsequent thumb disability is rising. Abductor pollicis longus tendon interposition arthroplasty (APLTIA) has gained popularity as a procedure to alleviate pain and restore thumb function. Methods: A systematic review was performed to assess the current reported outcomes of APLTIA. Inclusion criteria involved clinical studies with case-series as the minimal accepted level of evidence. Our primary outcome focussed on PROMs data, whilst secondary outcomes focussed on objective measures of function and complications. Papers investigating pathologies other than CMC OA or procedures other than APLTIA were excluded. Results: Twelve studies were included (485 thumbs), all of which were observational in study design. APLTIA appears to be associated with a reduction in pain and functional improvement. APLTIA was not found to complicate further surgery. Conclusion: APLTIA may be associated with improvement in short-term pain relief and functional status. Further research is required to evaluate the benefits, duration of relief and long-term outcomes of APLTIA.

Breast reconstruction with autologous abdomen-based free flap with prior abdominal liposuction - a case-based review.

BACKGROUND: Over recent years, liposuction has become the most commonly used surgical procedure used to refine male and female body contours. In the last four decades, the incidence of breast cancer has increased. Of these patients, there are more women requiring breast reconstruction who have undergone liposuction in the past. There is little in the literature that discusses harvesting perforator flaps from previously liposuctioned donor sites. The authors report on their experience and review the current literature on the autologous abdominal-based free flap for breast reconstruction after previous liposuction of the abdominal wall. METHODS: Five electronic databases were searched (Medline (PubMed), Scopus, Web of Science, Cochrane) from inception to March 2021. Also, we searched our patients records and included our experience. RESULTS: We included three cases who had previous liposuction prior to their breast reconstruction procedure. We report no flap loss in our cases. Moreover, the database search showed 30 patients (83.33%) underwent deep inferior epigastric perforator (DIEP) reconstruction. The age ranged from 32 to 73 years (mean of 51.7 years). The mean length of reconstruction after liposuction is 8.9 years, ranging from 1.5 years to 23 years reported in 23 patients. Seven patients (19.4%) had partial loss of the flap. Twenty patients (55.55%) had CT angiography pre-operatively for the assessment of the perforators. CONCLUSION: A careful combination of preoperative scanning, handheld Doppler and clinical examination reduce the chance of an unsuccessful outcome.

Functional and Aesthetic Outcomes of the Anterolateral Thigh Flap in Reconstruction of Upper Limb Defects: A Systematic Review.

Background: Soft tissue coverage in the upper limb after trauma, burn injury, or tumour removal is a commonly addressed problem by the plastic surgeon. The anterolateral thigh flap (ALT) is recognized as a popular free flap option for covering various types of soft tissue defects due to its versatility. We aimed to assess the functional and aesthetic outcomes of the ALT flap for reconstruction of upper limb defects. Methods: Four electronic databases were searched (MEDLINE (PubMed), Scopus, Web of Science, and Cochrane) from inception to Feb 2021. Two reviewers independently extracted the data and performed risk assessment using the modified Downs and Black (MDB) quality assessment tool and the modified Newcastle Ottawa Scale for case series. Results: This review included seven studies for quantitative assessment. The eligible studies had 67 patients. Included studies had used a varied number of validated upper extremity functional scoring systems; the most commonly used score was QuickDASH with mean of 21.24, DASH score was 15.5. In regard to aesthetic outcome, an overall satisfactory result was reported. A secondary debulking procedure was performed in 7 patients. Conclusion: Further studies are recommended to ascertain the functional and aesthetic outcomes of the ALT free flap for upper limb defects, especially using standardized outcome scoring systems. This may be supplemented with a questionnaire that addresses common patient concerns (such as colour, contour, textile and hair growth) for the aesthetic outcome. Nevertheless, based on our review, the ALT flap may be a good reliable reconstructive option for upper limb defects with good functional outcome and satisfactory aesthetic results.

Atypical Presentation of Cutaneous Squamous Cell Carcinoma of the Head and Neck: A Case Report.

Tumors of the head and neck can spread by direct extension, hematogenous spread, or lymphatic dissemination. However, a process known as perineural invasion (PNI) allows nerves to act as a direct conduit for tumor growth away from the primary site. Perineural invasion is a rare, atypical presentation of cutaneous squamous cell carcinoma of the head and neck that affects about 2.5%-14% of the population. It is known to be associated with an increased risk of local recurrent and distant metastasis, thus adversely affecting the patient's prognosis. The majority of PNI cases are asymptomatic, often discovered during pathological evaluation. We report the case of a patient who presented with a 1-year history of right-sided face pain and symptoms suggestive of trigeminal facial neuralgia. A skin biopsy taken from a lesion on his right cheek showed PNI secondary to cutaneous squamous cell carcinoma of the head and neck. We treated the patient with radiotherapy and chemotherapy and his clinical condition improved significantly. We are publishing this case report to increase awareness of practicing physicians and nurses to PNI as an atypical presentation of squamous cell carcinoma that may affect selection of treatment modality and the patient's prognosis.

Monitoring Breast Reconstruction Flaps Using Near-Infrared Spectroscopy Tissue Oximetry.

Free flap reconstruction is a common procedure with success rates greater than 99%. However, vascular complications may occur, resulting in flap failure. For this reason, early detection of vascular compromise is crucial for flap salvage. Vascular complications may be detected early by monitoring tissue oximetry parameter changes using near-infrared spectroscopy (NIRS). This method of noninvasive monitoring can evaluate changes in flap oxygenation levels caused by arterial and venous thrombosis before surgical reexploration. The goal of this study was to assess the validity of using NIRS oximetry for monitoring free flaps. We conducted a prospective cohort observational study of 10 patients undergoing breast reconstruction. We used the INVOS 7100 cerebral oximetry monitoring system (Medtronic, Dublin, Ireland) to provide 24-hr continuous postoperative monitoring of flap perfusion and compared the data with clinical assessment findings. The median patient age was 57 years (range = 41-61 years). Patients underwent immediate breast reconstruction with deep inferior epigastric perforator (DIEP) flap surgery (n = 4), delayed reconstruction with DIEP flap surgery (n = 4), transverse upper gracilis flap surgery (n = 1), and latissimus dorsi flap with lipofilling (n = 1). We successfully monitored all 10 flaps for 24 hr postoperatively. The overall flap survival rate was 100%. Findings of clinical examination, Doppler studies, and surgical outcome were consistent with NIRS monitoring. In conclusion, NIRS tissue oximetry could potentially provide a noninvasive method for effective postoperative monitoring of free flaps.

Urethral involvement in granulomatosis with polyangiitis: a case-based review.

Granulomatosis with polyangiitis (GPA) commonly presents with glomerulonephritis and inflammation of upper and lower respiratory tracts. It can also involve other organs including those of the urinary tract. The involvement of the urethra is very rarely reported. We present a case of GPA in a patient who had recurrent urinary tract infections and an acute bladder outlet obstruction due to a urethral thickening by GPA. In this report, we discuss urethral involvement with GPA. The incidence of such involvement, as with other urinary tract organs, might be underestimated. It can affect both sexes, with male predominance, and can occur at any age. It responds to standard GPA medical treatment but may require surgical intervention. Rheumatologists should be aware of this limited form of GPA as early recognition and treatment can decrease the risk of complications.