Critical care polyneuropathy in burn injuries: An integrative review.

Polyneuropathy is a debilitating condition which may be associated with large burns. The aim of this integrative review is to identify factors that contribute to the development of critical care polyneuropathy in patients admitted to an intensive care unit with a severe burn injury. PubMed, Scopus, CINHAL and EMBASE were searched up until July 2016. Studies/case reports focusing on critical care polyneuropathy for burn injured patients were included. The ten studies, included a total of 2755 burns subjects and identified 128 critical care polyneuropathy patients with an incidence of 4.4%. Three case reports identified prolonged ventilation and development of critical care neuropathy. Overall, factors identified as contributing to the development of critical care polyneuropathy in burn injured patients included prolonged ventilation (>7 days), large and deep total body surface area burns (mean TBSA 40%), and sepsis. Critical care polyneuropathy in burn patients remains challenging to diagnose and treat. To date, there is a lack of long term studies describing the impact of critical care polyneuropathy on functional performance or participation in activities of daily living in the burns population and this is consistent with the general literature addressing the lack of follow up assessments and long term consequences of persistent muscle weakness.

Burns in Israel, comparative study: Demographic, etiologic and clinical trends 1997-2003 vs. 2004-2010.

OBJECTIVES: To review hospitalised burn patients from 2004 to 2010 admitted to Israeli burn units and compare these result with data from 1997 to 2003. METHODS: Retrospectively, data was collected from the Israeli Trauma Registry (ITR) encompassing all burn admissions to Israeli burn units from 2004-2010 and compared to 1997-2003. RESULTS: Of the 5269 burn patients admitted from 2004 to 2010, 39.8% were non-Jewish. Infants under two years were the prominent age group (24.1%). Second to third degree burns 1-9% TBSA/first degree burns were 71%, second to third degree burns 10-19% TBSA were 16% and those 20%>TBSA consisted of 13%. Only 2.7% involved an inhalation injury. The average length of stay was 11.67 days and mortality rate 3.72%. All data was compared to the previous year's 1997-2003 and trends were identified. CONCLUSIONS: Within Israel, high risk populations remain infants under two years of age, males and those from non-Jewish populations. National prevention strategies and campaigns are warranted to inform and educated parents of young children and those at risk of burns. Of note, advances in burn care and procedures might have contributed to a decrease in the length of hospital stay (LOS).

Hypoglossal nerve paralysis in a burn patient following mechanical ventilation.

Traumatic injury resulting in isolated dysfunction of the hypoglossal nerve is relatively rare and described in few case reports. We present a patient with isolated unilateral palsy of the twelfth cranial nerve (CN XII) resulting from recurrent airway intervention following extensive burn injuries. The differential diagnosis for paralysis of the CN XII is also discussed herein. This case illustrates the significance of comprehensive diagnostic evaluation and the need for refined airway manipulation in patients that require multiple endotracheal intubations.

Une blessure traumatique résultant en un dysfonctionnement isolé du nerf hypoglosse est relativement rare et décrit dans quelques rapports de cas. Nous présentons un patient atteint de paralysie hypoglossal unilatérale isolée à la suite de l'intervention des voies respiratoires récurrentes après de brûlures extensives. Le diagnostic différentiel de la paralysie du nerf crânien (NC XII) est également discuté ici. Ce cas illustre l'importance de l'évaluation diagnostique complète et la nécessité pour la manipulation délicate des voies respiratoires chez les patients qui nécessitent de multiples intubations trachéales.

AlloDerm Sling for Correction of Synmastia After Immediate, Tissue Expander, Breast Reconstruction in Thin Women.

INTRODUCTION: Synmastia is a condition in which the breasts are conjoint and the natural intermammary sulcus is obliterated. It is the rarest type of breast implant malpositioning during breast augmentation; however, it is the most difficult one to correct. AlloDerm is an acellular dermal matrix that is assuming a major role in immediate breast reconstruction in recent years. METHODS: In the past 2 years, we have treated 3 thin women, a total of 6 breasts, for correction of synmastia after bilateral immediate breast reconstruction, using tissue expanders and skin sparing mastectomy. All of them suffered from synmastia, which manifested immediately after the mastectomy and accelerated during tissue expander inflation. We exchanged the expander into silicone implants, and during the same procedure we corrected the synmastia, using an AlloDerm sling. A thick sheet of AlloDerm (Life-Cell Corp, Branchbung, NJ) is used and the AlloDerm sheet is designed into a long narrow sling. Then, the sling is sutured into place. RESULTS: This technique successfully resolved the synmastia. CONCLUSION: The use of an AlloDerm sling to reinforce the capsule and the AlloDerm incorporation into it ensures a sound solution with a low recurrence rate.

Patient and observer scar assessment scale: how good is it?

This is the only scar assessment tool to include a component for patients to fill in. The few studies that investigated the effectiveness of this scale have found that it is a reliable, valid and feasible tool that is well suited for everyday practice.

Treatment of postdermabrasion facial hypertrophic and keloid scars with intralesional 5-Fluorouracil injections.

Hypertrophic and keloid scarring is a known complication of dermabrasion facial resurfacing, although only a very small fraction of patients experience it. Treatment with intralesional corticosteroid injections and flashed pumped vascular dye laser is recommended in the literature. The treatment of keloid and hypertrophic scars using intralesional 5-fluorouracil (5-FU) injections has been well described, but there is no literature regarding use of the same treatment for postdermabrasion hypertrophic and keloid scars. In this case report, we describe a 67-year-old woman with persistent postdermabrasion facial hypertrophic and keloid scars that were treated at our scar clinic using intralesional 5-FU injections.

Burn care standards in Israel: lack of consensus.

UNLABELLED: In recent years, the need for a national burn center based on ABA guidelines has emerged in Israel. The formation of such a center is now underway in the Chaim Sheba Medical Center. As a first step in the standardization of burn care in Israel, we have conducted a nation-wide survey among burn care personnel (physicians, nurses and other burn team members), regarding different aspects of the treatment of burn patients. METHODS: A questionnaire comprised of 30 questions regarding the severity of burns admitted, the site of initial management, wound care (both burn/skin-graft sites and donor sites), dressing changes protocols, sterility precautions, hydrotherapy, and pressure dressings was presented to 70 health-care professionals involved in the treatment of burns. RESULTS AND DISCUSSION: Seventy-seven percent of interviewed personnel participated in the survey. Consensus was found regarding most local (topical) wound care, (SSD for clean non-facial burns, Sulfamylon (mafenide-acetate) for contaminated non-facial burns, Threolone (chloramphenicol 3% and prednisolone 0.5%) or Bacitracin for facial burns, Paraffin gauzes with or without Sulfamylon for donor and graft sites). Dressing changes regimes were also agreed upon generally. However, there was no consensus regarding the ideal time for the removal of donor site dressings and this issue will need to be resolved. Other important findings are that both Edinborough University Solution of Lime (EUSOL), which has been deemed unsuitable for burn treatment due to toxic effects, and hydrotherapy, which has been proposed as a source of infection and contamination, are still widely used. We anticipate that these issues will be settled in our unified national burn care protocols (which are currently under development and revision).

Myiasis with Lund's fly (Cordylobia rodhaini) in travelers.

Myiasis is an infestation of human tissue by the larvae of certain flies. There are many forms of myiasis, including localized furuncular myiasis, creeping dermal myiasis and wound and body cavity myiasis.1 Cordylobia anthropophaga (the Tumbu fly) and Dermatobia hominis (the human botfly) are the most common causes of myiasis in Africa and tropical America respectively. The genus Cordylobia also contains two less common species, C. ruandae and C. rodhaini. The usual hosts of C. rodhaini are various mammals (particularly rodents), and and humans are accidentally infested. Figure 1 shows the life cycle of C. rodhaini, which occurs over 55 to -67 days.3 The female fly deposits her eggs on dry sand polluted with the excrement of animals or on human clothing. In about 3 days, the larva is activated by the warm body of the host, hatches and invades the skin. As the larva matures, it induces a furuncular swelling. In 12 to -15 days, the larva reaches a length of about 23 mm, exits the skin and falls to the ground to pupate. The adult fly emerges in 23 to -26 days, and the life cycle resumes. In humans, the skin lesion starts as a red papule that gradually enlarges and develops into a furuncle. In the center of the lesion an opening forms, through which the larva breaths and discharges its serosanguinous feces. The lesion is associated with increasing pain until the larva exits the skin. The disease is usually uncomplicated and self-limiting.

Treatment of rhinophyma with Er:YAG laser.

BACKGROUND AND OBJECTIVE: Rhinophyma is a benign, disfiguring disorder of the nose which presents the end stage of acne rosacea, and can also occasionally result in nasal airway obstruction. We describe the first series of patients treated with Erbium laser. STUDY DESIGN/MATERIALS AND METHODS: Severe-to-moderate rhinophyma in six patients were treated at our institution between 1995 and 1996, using the Erbium:YAG (Erb:YAG) laser. RESULTS: All patients achieved marked cosmetic improvement, with no complications. Post-operative healing time was seven to fourteen days-significantly shorter than similar other modalities. CONCLUSIONS: The Erbium laser provides very accurate tissue ablation and allows the sculpturing of the hypertrophied areas, offering good cosmetic results, with a very short healing period as shown in our study.

Breast augmentation with fresh-frozen homologous fat grafts.

The purpose of this report is to present a patient who underwent breast augmentation with fresh-frozen fat homografts in Russia 10 years ago, despite the publication of major complications following this procedure.

Total lower lip reconstruction with innervated muscle-bearing flaps: a modification of the Webster flap.

BACKGROUND: Mohs surgery and other surgical techniques are used for the removal of squamous cell carcinoma of the lower lip and may leave a large defect in the vermilion and underlying tissue. When nearly the entire lower lip is excised, reconstruction of this defect is a challenge. Repair requires the matching of vermilion color, maintenance of oral sphincter function and mouth opening size, and retention of sensation. Several techniques have been suggested. We present a modification of the Webster flap for total lower lip reconstruction using innervated muscle-bearing flaps. OBJECTIVE: To present a surgical technique for the reconstruction of total lower lip defects after excision of squamous cell carcinoma. METHODS: Innervated muscle-bearing flaps are used and demonstrated in one case. The surgical technique is discussed in detail. RESULTS: The reconstructive results were excellent. There were no postoperative complications. CONCLUSION: The use of innervated muscle-bearing flaps is a useful and effective option for the reconstruction of total lower lip defects.

The versatility of the nasolabial flap enhanced by the delay procedure.

BACKGROUND: The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall following Mohs surgery. However, both extirpation of a tumor in the region of the base of the flap or previous use of the flap often destroy the proximal axial blood supply to the flap, excluding its immediate utilization. We describe a different use of the nasolabial flap and a technique for preserving its capacity in the case of reutilization OBJECTIVE: To describe the versatility of the nasolabial flap and a delay procedure that enables its exploitation despite prior disruption of the proximal blood supply. METHODS: Three different uses of the same nasolabial flap are demonstrated in one patient. The surgical techniques are discussed in detail. RESULTS: The reconstructive results were excellent. There were no postoperative complications. CONCLUSION: The nasolabial flap is a versatile and effective option for the closure of nasal defects of the cheek and nasal sidewall. When the nasolabial flap has been used before, or its blood supply compromised, the delay procedure can reestablish its applicability.

Photodynamic therapy of cutaneous lymphoma using 5-aminolevulinic acid topical application.

BACKGROUND: Photodynamic therapy (PDT) with topical application of 5-aminolevulinic acid (ALA) is a new and effective modality for treatment of superficial basal and squamous cell carcinomas. OBJECTIVE: We present the kinetics of ALA-induced protoporphyrin IX (PP) accumulation and the results of ALA PDT treatment on two patients with different stages (stage I and stage III) of mycosis fungoides (MF)-type cutaneous T-cell lymphoma (CTCL). METHODS: ALA-Decoderm cream was applied to the lesions for 16 hours. Spectrofluorescence measurements of PP accumulation were carried out before, during, and 1 hour after photoirradiation (580-720 nm) using the VersaLight system. RESULTS: Different patterns of PP fluorescence kinetics were observed in patients with early and advanced stages of the disease. During photoirradiation the intensity of fluorescence decreased depending on the lesion thickness. One hour after the photoirradiation procedure no PP fluorescence was observed in the stage I MF lesion, while in the thick stage III MF lesions, PP fluorescence reappeared; after an additional 10-15 minutes of irradiation PP fluorescence disappeared. Complete response with excellent cosmetic results was observed in the stage I lesion after a single irradiation with a light dose of 170 J/cm2; in five stage III lesions, complete response was achieved after fractionated irradiation with a total light dose of 380 J/cm2 (follow-up at 27 and 24 months, respectively). CONCLUSION: The results showed a high response of both stage I and stage III MF lesions to ALA PDT. This modality appears to be very effective and can be used successfully for MF treatment.

Osteomyelitis of the clavicle after subclavian vein catheterization.

Osteomyelitis of the clavicle or the sternoclavicular joint is a rare complication of subclavian vein catheterization. Soft tissue infections around the puncture site occur frequently and respond well to topical and antibiotic treatment. If symptoms persist for several weeks, osteomyelitis or sternoclavicular pyo-arthrosis should be considered. Bone and gallium scintigraphy scans and computerized tomography scans are helpful diagnostic measures.

Posterolateral approach. An alternative strategy in laparoscopic splenectomy.

Laparoscopic splenectomy (LS) is effective and technically feasible for treating various hematological diseases, especially idiopathic thrombocytopenic purpura (ITP). An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is often difficult. A total of 13 patients with ITP underwent elective laparoscopic splenectomy. We utilized a laparoscopic posterolateral approach involving dissection of the suspensory ligaments at the lower pole, then dissection and division of the posterolateral attachments, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. This procedure was completed in 11 of our 13 patients and converted to open surgery in the other two patients. Mean operative time was 3 h; mean postoperative stay was 3 days. No blood transfusion was required, and no complications were noted in the postoperative period. The posterolateral approach provides better visualization and control of branches of the splenic vein and artery in the splenic hilum. It also permits visualization and control of surgical hemorrhage through the operating ports.

[Surgical approach to benign cecal ulcer].

Benign cecal ulcer is a rare lesion, usually diagnosed during operation for suspected acute appendicitis or peritonitis of unknown origin. In the past, right hemicolectomy was recommended as the treatment of choice because of the difficulty in differentiating malignant lesions from benign cecal ulcers. However, in recent reports a more conservative approach has been suggested, consisting of selective colectomy followed by frozen section biopsy. This approach is aimed at preventing unnecessary excision of the colon and conserving the ileocecal valve. We present a 47-year-old woman operated for right lower quadrant peritonitis, believed to be due to acute appendicitis. On exploration, a biopsy-proven benign cecal ulcer was found and resected.