Islam Abdelrahman

Improvement in mortality at a National Burn Centre since 2000: Was it the result of increased resources?

Abstract The aim of this study was to find out whether the charging costs (calculated using interventional burn score) increased as mortality decreased. During the last 2 decades, mortality has declined significantly in the Linköping Burn Centre. The burn score that we use has been validated as a measure of workload and is used to calculate the charging costs of each burned patient. We compared the charging costs and mortality in 2 time periods (2000–2007 and 2008–2015). A total of 1363 admissions were included. We investigated the change in the burn score, as a surrogate for total costs per patient. Multivariable regression was used to analyze risk-adjusted mortality and burn score. The median total body surface area % (TBSA%) was 6.5% (10–90 centile 1.0–31.0), age 33 years (1.3–72.2), duration of stay/ TBSA% was 1.4 days (0.3–5.3), and 960 (70%) were males. Crude mortality declined from 7.5% in 2000–2007 to 3.4% in 2008–2015, whereas the cumulative burn score was not increased (P  =  .08). Regression analysis showed that risk-adjusted mortality decreased (odds ratio 0.42, P  =  .02), whereas the adjusted burn score did not change (P  =  .14, model R2 0.86). Mortality decreased but there was no increase in the daily use of resources as measured by the interventional burn score. The data suggest that the improvements in quality obtained have been achieved within present routines for care of patients (multidisciplinary/orientated to patients’ safety).

Changes in patterns of treatment of burned children at the Linkoping Burn Centre, Sweden, 2009–2014

INTRODUCTION Children are a relatively large group among patients with burns in Sweden. We changed the management of childrens burns to a flexible, outpatient-based plan. The aim was to follow up the outpatient management for childrens burns during the period 2009-2014, and track it, to find out to what extent the patients had been treated flexibly as outpatients, and to clarify the reasons behind those who did not fit in the plan. METHODS Descriptive retrospective analysis dividing the patients into three groups: inpatients only, flexible management, and outpatients. Other variables recorded included: age, sex, percentage total body surface area burned (TBSA%), percentage full thickness burn (FTB%), cause of burn, county of residence, operations required, number of visits to the outpatient department, costs, and duration of overnight stay in the hospital. RESULTS The study group included 620 children: nine were managed strictly as inpatients, 204 as flexible outpatients, and 407 strictly as outpatients. Among the total there were 269 children who came from remote areas (43%), and of these 260 were treated as outpatients and flexible outpatients. Median TBSA% in the whole group was 1 (10th-90th centile 0-9) with the biggest median TBSA% 12 (5-38) in the inpatient group. The most common cause of injury was scalds (332/620, 54%). Costs/patient (US

Treatment of Children With Scalds by Xenografts: Report From a Swedish Burn Centre

) was lower in the flexible outpatient group than in the inpatient group (median 10 557 (3213-35802) and 35343 (7344-66554), respectively). CONCLUSION Based on the results, we expect that the flexible outpatient treatment plan for children with minor to moderate burns can be expanded in the future. The results encourage us to continue the service and to further reduce duration of stay in hospital below the level already achieved (25% of the whole period of care).

Microbial cellulose dressing compared with silver sulphadiazine for the treatment of partial thickness burns: A prospective, randomised, clinical trial

Scalds are the most common type of burn in children, and one way to treat them is with xenografts with no topical antimicrobials in line with the recommendations of a recent review. However, this treatment has not been examined in detail. Our aim was to describe the treatment of such children when biological dressings (xenografts) were used without local antimicrobials. We reviewed the medical records of all children admitted to a Swedish National Burn Centre during the period 2010–2012 with scalds who were treated with xenografts. Percentage TBSA injured, age, length of hospital stay, number of operations, antibiotics given, duration of antibiotic treatment, and pain score during the first 3 days, application of xenografts, and clinical notes of wound infection were recorded. We studied 67 children, (43 of whom were boys), with a median (interquartile range [IQR]) age of 1 (1–2) year and median (IQR) TBSA% 6.2 (4–11). Twenty children (30%) required operation. Twelve (18%) developed a wound infection, 29 (43%) had other infections, and 26 (39%) were free from infection. The median (IQR) duration of systemic antibiotics was 10 (6–13) days. On the day that the xenografts were applied 10 of the children had a Face, Legs, Activity, Cry, and Consolability (FLACC) score between 3 and 7, and during the following 2 days, only four children scored in this range. The remaining 57 children had scores < 3 on the day that xenografts were applied and on the following 2 days. Median (IQR) length of stay/TBSA% was 0.7 (0.4–1.0). Treatment with xenografts was associated with median length of stay/TBSA% <1 and low pain scores. Despite a high rate of prescription of systemic antibiotics, most were for reasons other than wound infection.

Male Breast Glandular Liposculpturing, Response on Commentary

BACKGROUND The current treatment for partial thickness burns at the trial site is silver sulphadiazine, as it minimises bacterial colonisation of wounds. Its deleterious effect on wound healing, together with the need for repeated, often painful, procedures, has brought about the search for a better treatment. Microbial cellulose has shown promising results that avoid these disadvantages. The aim of this study was therefore to compare microbial cellulose with silver sulphadiazine as a dressing for partial thickness burns. METHOD All patients who presented with partial thickness (superficial and deep dermal) burns from October 2014 to October 2016 were screened for this randomised clinical trial. Twenty patients were included in each group: the cellulose group was treated with microbial cellulose sheets and the control group with silver sulphadiazine cream 10mg/g. The wound was evaluated every third day. Pain was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) scale during and after each procedure. Other variables recorded were age, sex, percentage total body surface area burned (TBSA%), clinical signs of infection, time for epithelialisation and hospital stay. Linear multivariable regression was used to analyse the significance of differences between the treatment groups by adjusting for the size and depth of the burn, and the patients age. RESULTS Median TBSA% was 9% (IQR 5.5-12.5). The median number of dressing changes was 1 (IQR 1-2) in the cellulose group, which was lower than that in the control group (median 9.5, IQR 6-16) (p<0.001). Multivariable regression analysis showed that the group treated with microbial cellulose spent 6.3 (95% CI 0.2-12.5) fewer days in hospital (p=0.04), had a mean score that was 3.4 (95% CI 2.5-4.3) points lower during wound care (p<0.001), and 2.2 (95% CI 1.6-2.7) afterwards (p<0.001). Epithelialisation was quicker, but not significantly so. CONCLUSION These results suggest that the microbial cellulose dressing is a better first choice for treatment of partial thickness burns than silver sulphadiazine cream. Fewer dressings of the wound were done and, combined with the low pain scores, this is good for both the patients and the health care system. The differences in randomisation of the area of burns is, however, a concern that needs to be included in the interpretation of the results.

Male Breast Glandular Liposculpture Challenges

Dear Sir, We have followed with interest the recent comments [1] on our recent publication [2] in your prestigious journal and we would like to clarify some of the points raised. The patients who attend our clinic are young males \ 50 years old, coming for body contouring mainly for the anterior chest wall and abdomen. As mentioned in many text books of plastic surgery, exclusion of secondary gynecomastia is a must which is our clinical praxis. In addition, radiological examination of the male breast when there is diffuse enlargement with no related clinical findings is not indicated [3]. We think that ultrasound or MRI examination is beneficial, but it’s an extra economic burden on the patients and we can use them when indicated. We acknowledge that the proportion of two dissatisfied patients out of a total number of 18 (11%) is considered high. However, one of the two dissatisfied patients had minor irregularities and asked for the revision at the 6-month follow-up visit, but he changed his mind at the 9-month follow-up, which was after the publication of the article. Therefore, it is clear that the 6-month follow-up period was a disadvantage for us as we could have lowered the percentage of dissatisfied patients to 5.5% if we had chosen a longer follow-up. Regarding the issue of breast cancer finding, it has been suggested that patients with a hard, irregular or asymmetrical mass, nipple discharge, axillary adenopathy, or a mass fixed to the skin or the chest wall must have a biopsy, which none of the study patients had [4]. Such an issue could deserve a future study to determine the odds of incidence after liposuction treatment of gynecomastia. As scarring is an important concern for most of our patients, we place the skin access incisions in a relatively hidden area, the upper one is placed behind the anterior axillary line in the hairy axilla, while the second one is 10 cm inferior and more posterior. The usual skin incision is a blade 11 stab around 3–5 mm which we think is more aesthetically appealing for our patients who, most of them, have dark skin that could increase the risk of developing hypertrophic or keloid scars, which would not be acceptable if unfortunately, it happened in a circum-areolar incision. Liposuction combined with surgical excision of residual breast tissue through periareolar incisions has several other drawbacks. The periareolar incision is adjacent to the main mound of breast tissue and too close to the area that needs to be liposuctioned, therefore providing less control when performing liposuction [5]. It also combines the morbidity of two separate procedures, namely liposuction and open excision, which explains the relatively high rate of complications in some studies [6]. Furthermore, radical resection of the gland with a subcutaneous & Islam Abdelrahman islam.abdelrahman@liu.se; islammohamedy@yahoo.com

Response to comments on: A prospective randomized cost billing comparison of local fasciocutaneous perforator versus free Gracilis flap reconstruction for lower limb in a developing economy

Dear Sir, We appreciate the positive comments on our paper [1] raised by Dr Shirol in his letter to the Editor, and we acknowledge that he agrees with us on the importance and relevance of the study. It is important to do accurate follow-up in the field of innovative plastic surgery [2], and we think that it is a successful strategy to combine clinical follow-up with research. We agree that keeping the incisions away from the breast aesthetic unit and NAC would result in a better appearance of the front chest wall and will reduce the incidence NAC retraction, hypopigmentation, or shape distortion due to scarring. In our publication, 92% of the patients who had the surgery using combined liposuction and liposculpture technique were highly satisfied with the results, which confirms the efficacy of the technique. It is worth mentioning that no patients developed a hematoma during the whole study; additionally, a minority of patients had complained of diminished sensation in the NAC, which was eventually improving during the 6-month period following the operation. Thus, we would like to clarify that the used cannulas (Mercedes and Fat Disruptor) did not result in any hematomas nor higher rates of diminished NAC sensation. We also agree that postoperative pressure garments should be used to prevent later complications. However, we think that applying the garment for continuous 10 days could carry a possible risk of missing early hematoma diagnosis and evacuation. Furthermore, it is hard to convince patients who reside in relatively hot weather (Egypt) not to take a shower for 10 days. Finally, we acknowledge the authors’ ability to use the tumescent anesthesia; unfortunately, it was not successful in our hands, as the patients were irritated and most of them were converted to general anesthesia during the procedure.

Evaluation of Glandular Liposculpture as a Single Treatment for Grades I and II Gynaecomastia

Response to comments on : A prospective randomized cost billing comparison of local fasciocutaneous perforator versus free Gracilis flap reconstruction for lower limb in a developing economy