M.A. Altintas

Changes in bacterial isolates from burn wounds and their antibiograms: a 20-year study (1986-2005).

BACKGROUND Our aim is to elucidate shifts in the bacterial spectrum colonising burn wounds and corresponding antibiotic susceptibilities during a 20-year study period. METHODS Microbiological results from burn patients collected between 1986 and 2005 were analysed retrospectively. RESULTS Staphylococcus aureus was isolated most frequently (20.8%), followed by Escherichia coli (13.9%), Pseudomonas aeruginosa (11.8%), coagulase-negative staphylococci (CNS) (10.9%), Enterococcus sp. (9.7%), Enterobacter cloacae (5.6%), Klebsiella pneumoniae (5%), Acinetobacter sp. (3.2%), Proteus mirabilis (2%) and Stenotrophomonas maltophilia (1.4%). Susceptibility of S. aureus to broad-spectrum substances such as ciprofloxacin or penicillinase-stable penicillins has waned, others such as cotrimoxazole or netilmicin remained effective. Not a single resistance against vancomycin was recorded. Increases in methicillin-resistant S. aureus (MRSA) were pronounced (3% in 1986-1997 (the first of the three study periods) to 16% in 1998-2001 and 13% in 2002-2005). Results for methicillin-resistant CNS (MRCNS) show an even greater increase. P. aeruginosa has shown increasing susceptibility against netilmicin (1986-1989: 84%, 2002-2005: 95%). Susceptibility of P. aeruginosa to ceftazidime has decreased markedly. S. maltophilia has shown clinically relevant susceptibility mainly against ciprofloxacin. Acinetobacter sp. have shown little susceptibility to most antibiotics. Imipenem or meropenem have been very reliable reserve antibiotics throughout the study period for the fermenting Enterobacteriaceae (E. coli, K. pneumoniae, E. cloacae and P. mirabilis), with susceptibilities of or near 100%. CONCLUSION In-depth knowledge of the bacteria causing infectious complications and of their antibiotic susceptibilities is a prerequisite for treating burn patients. Our study shows shifts in the microbial spectrum and their antibiogram, which mandate frequent reassessments.

Percutaneous collagen induction–regeneration in place of cicatrisation?

BACKGROUND Ablative procedures that are used for the improvement of a degenerative process that leads to a loss of skin elasticity and integrity, injure or destroy the epidermis and its basement membrane and lead to fibrosis of the papillary dermis. It was recently shown in clinical and laboratory trials that percutaneous collagen induction (PCI) by multiple needle application is a method for safely treating wrinkles and scars and smoothening the skin without the risk of dyspigmentation. In our study, we describe the effect of PCI on epidermal thickness and the induction of genes relevant for regenerative processes in the skin in a small animal model. METHODS The purpose of this study in a rat model was to determine the effects of PCI on the skin both qualitatively and quantitatively. The epidermal and dermal changes were observed by histology and immunofluorescence. The changes in gene expression were measured by array analysis for cytokines, such as vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF)-7, epidermal growth factor (EGF) and extracellular matrix molecules such as collagen type I and type III. RESULTS The present study showed that PCI with topical vitamins resulted in a 140% increase in epidermal thickness; an increase in gene and protein expression of collagen I, glycosaminoglycans (GAGs) and growth factors such as VEGF, EGF and FGF7. The collagen fibre bundles were increased, thickened, and more loosely woven in both the papillary and reticular dermis. CONCLUSION We were able to show that PCI modulates gene expression in skin of those genes that are relevant for extracellular matrix remodelling.

Differentiation of superficial-partial vs. deep-partial thickness burn injuries in vivo by confocal-laser-scanning microscopy

OBJECTIVE The current determination of burn depth is based both on a visual and clinical assessment. Confocal-laser-scanning microscopy (CLSM) enables in vivo histomorphological images. We hypothesized that CLSM can differentiate superficial-partial vs. deep-partial thickness burns on a histomorphological level. METHODS Thirty-eight burn wounds in 14 patients were clinically divided in three groups from superficial (group 1), superficial-partial (group 2) to deep-partial (group 3) thickness burns. CLSM was performed with the Vivascope 1500 (Lucid Inc., Rochester, NY, USA) 24h after burn. The following parameters were assessed: cell size of the granular-layer, thickness of the basal-layer, minimal thickness of the epidermis and number of perfused dermal papillae. RESULTS Superficial burns resulted in a significant increase of the cell size of the granular-layer and a higher increase of the minimal thickness of the epidermis as in superficial-partial thickness burns. The granular-layer in partial thickness burns was destroyed. Superficial burns had an increased thickness of the basal-layer; in superficial-partial thickness burns the basal-layer was partly destroyed with complete destruction in deep-partial thickness burns. In superficial burns the perfused dermal papillae were increased significantly, while decreased in superficial-partial thickness, and completely destroyed in deep-partial thickness burns up to a depth of 350 microm. CONCLUSIONS In vivo confocal-laser-scanning microscopy can differentiate superficial-partial vs. deep-partial thickness burns on a histomorphological level.

Burn-induced organ dysfunction: Vagus nerve stimulation attenuates organ and serum cytokine levels

INTRODUCTION The interaction of the CNS and the immune system is well known. A parasympathetic anti-inflammatory pathway has recently been described. Both electrical and pharmacological parasympathetic stimulation attenuate proinflammatory mediator generation. Burn induces abacterial cytokine generation and we sought to evaluate whether parasympathetic stimulation after experimental burn decreases cardiodepressive mediator generation. MATERIAL AND METHODS A 30% TBSA full-thickness rat burn model was used. After microsurgical preparation of the cervical portion of the vagus nerve, we performed electric vagus nerve stimulation. Serum was harvested and organ samples of heart and liver were homogenized. Samples were subjected to sandwich-ELISA specific for TNF-alpha, IL-1beta and IL-6. Heart rate measurements were done using left ventricular microcatheterization. Statistical analysis was done using Students t-tests and analysis of variance (ANOVA). RESULTS Burn induced a significant rise of TNF-alpha, IL-1beta and IL-6 in organ homogenates and serum. After cervical vagal electrostimulation, serum and organ homogenate levels of proinflammatory cytokines were markedly reduced compared to burn controls. Left ventricular microcatheter assessment demonstrated no cardiodepressive effect of the vagal stimulation itself. CONCLUSION Our results encourage further research regarding the neuroimmunologic background of burn, possibly leading to the development of a novel therapeutic approach to burn-induced organ dysfunction and immunodysregulation.

Insight in microcirculation and histomorphology during burn shock treatment using in vivo confocal-laser-scanning microscopy ☆,☆☆

PURPOSE Microcirculatory disturbances are well known during shock; however, the accompanied histomorphological alterations are widely unknown. We used high resolution confocal-laser-scanning microscopy for the evaluation of microcirculation and histomorphology during Burn Shock treatment. METHODS Confocal-laser-scanning microscopy was performed in 10 burn shock patients (4 women, 6 men; aged 40.6 +/- 11.4 years, burn extent >20% body surface area) initially and 24 hours after shock resuscitation. Ten matched hemodynamic stable burn intensive care unit patients served as controls. The following parameters were evaluated: quantitative blood cell flow, cell size of the granular layer, basal layer thickness, and epidermal thickness. RESULTS Quantitative blood cell flow in controls was 62.45 +/- 3.39 cells per minute. Burn shock significantly reduced blood cell flow to 37.27 +/- 3.64 cells per minute; fluid resuscitation effectively restored baseline blood flow (65.18 +/- 3.76 cells per minute) after 24 hours. Granular cell size was 793.61 +/- 41.58 microm(2) in controls vs 644.27 +/- 42.96 microm(2) during burn shock. Post resuscitation granular cell size measured 932.74 +/- 38.83 microm(2). Basal layer thickness was 14.84 +/- 0.59 microm in controls, 13.26 +/- 0.54 microm in burn patients at admission and before resuscitation, and 17.50 +/- 0.46 microm after resuscitation. Epidermal thickness in control patients was 49.60 +/- 2.36 microm, 37.83 +/- 2.47 microm in burn patients at admission and 69.50 +/- 3.18 microm after resuscitation. CONCLUSIONS Confocal-laser-scanning microscopy provides a noninvasive tool for simultaneous evaluation of microcirculation and tissue histomorphology. It may help to assess the adequacy of and response to resuscitation of burn patients early after trauma.

In vivo evaluation of histomorphological alterations in first-degree burn injuries by means of confocal-laser-scanning microscopy-more than "virtual histology?".

There are various approaches to the treatment of superficial burns. No modality exists to date for determining treatment efficiency on morphological features. We review the first application of high-resolution in vivo confocal-laser-scanning microscopy (CLSM) to the evaluation of superficial burns on a histomorphological level. Sixteen patients (6 women, 10 men; 34.5 ± 16.2 years) with first-degree thermal contact injuries to a maximum extent of 1% of the body surface were enrolled into the study. CLSM was performed with the Vivascope 1500 (Lucid Inc., Rochester, NY) 24 hours after injury. The following parameters were assessed: cell size of the granular layer, thickness of the basal layer, minimal thickness of the epidermis, and diameter of capillary loops. Compared with the control sites 24 hours postburn, the minimal thickness of the epidermis increased on average by approximately 11% (P = .01; t-test); the thickness of the basal layer increased about 7% (P = .008; t-test); the diameter of capillary loops increased approximately by 17% (P = 0.003; t-test); and the cell size of the granular layer increased about 8% (P = .009; Wilcoxon’s test). In vivo CLSM allows characterizing and quantifying histomorphological alterations in superficial burns. CLSM could be helpful in assessing the effects of various treatment approaches for superficial burns on a histomorphological level.

Reflectance confocal-laser-scanning microscopy in vivo assessments of cigarette-induced dynamic alterations of cutaneous microcirculation on histomorphological level.

Objective: Until now, high resolution reflectance confocal‐laser‐scanning microscopy (CLSM) was used for observation of cutaneous morphology in vivo and in real time. We hypothesized that CLSM also allows observation of dynamic processes of cutaneous microcirculation. Methods: Reflectance CLSM (Vivascope1500; Lucid, Rochester, NY) was performed in 24 young male habitual smokers (23 years, range: 19–26, body mass index 23.9 ± 4.04) with relatively limited cigarette exposure (mean: 3.1 ± 2.4 pack‐years). Eight matched nonsmokers served as controls. The quantitative blood cell flow and the diameter of capillary loops were determined prior (baseline), during, as well as 5 and 10 min after smoking. Results: Baseline value for blood cell flow was 55.50 ± 2.33 cells/min, and decreased over 45% during smoking (30.43 ± 3.76/min; P = 0.02). They were still 22% lower (43.33 ± 2.45/min; P = 0.01) 5 min after smoking and exceeded baseline values 10 min after smoking by 13% (63.00 ± 3.10/min; P > 0.05). The baseline values for capillary loop diameter (9.03 ± 0.22 μm) decreased by 21% (7.18 ± 0.28 μm; P = 0.03) during smoking, remained about 9% (8.23 ± 0.18 μm; P = 0.01) lower 5 min after smoking and exceeded baseline values insignificantly by 4% (9.38 ± 0.28 μm; P > 0.05) 10 min after smoking. There were no significant differences to the controls. Conclusion: Reflectance CLSM enables qualitative and quantitative observation of dynamic processes of cutaneous microcirculation on histomorphological level. Microsc. Res. Tech., 2009.

To heal or not to heal: predictive value of in vivo reflectance-mode confocal microscopy in assessing healing course of human burn wounds.

The purpose of this study was to assess if the healing course of burn wounds of indeterminate depth can be predicted based on serial in vivo reflectance-mode confocal microscopy (RMCM) analysis. Twenty-four patients (mean age, 33.1 ± 11.4 years; mean burn size: 6% TBSA) were investigated at 12, 36, and 72 hours after burn of indeterminate depth and retrospectively grouped into healing group (HG: 16 patients) and nonhealing group (NHG: eight patients). Noninjured skin served as controls. The following parameters were assessed: quantitative blood cell flow (BCF), basal layer thickness (BLT), and inflammatory cells. At 12 hours postburn, BCF increased to 101.67 ± 7.64 cells/min in HG vs 85 ± 50 cells/min in NHG compared with controls (56.5 ± 2.3 cells/min). At 36 and 72 hours, BCF increased to 115 ± 10 cells/min and 125 ± 50 cells/min in HG vs decreased to 80 ± 5 cell/min and 75 ± 5 cells/min in NHG (P < .05). At 12 hours postburn, BLT increased to 19.43 ± 0.93 &mgr;m in HG vs 29 ± 1 &mgr;m in NHG compared with controls (15.40 ± 0.60 &mgr;m, P < .05). In HG, further gradual increase of BLT to 20 ± 1 &mgr;m (36 hours) and 21 ± 1 &mgr;m (72 hours) was observed, whereas BLT was destroyed after 36 hours in NHG. Qualitative assessment found insignificant amount of IC in controls and low amount in HG until 72 hours postburn, whereas progressive increase in IC from low amount (12 hours) to numerous (36 hours) and massive (72 hours) was observed in NHG. RMCM enables simultaneous evaluation of microcirculation, histomorphology, and inflammatory cell trafficking in burn wounds. RMCM may help to predict whether burns of indeterminate depth have the potential to heal and can be a valuable tool to clinicians to guide early therapeutic decision-making process in burn patients.

Acute effects of splint immobilization of the forearm on in vivo microcirculation and histomorphology of the human skin

BACKGROUND: Splint immobilization of the forearm is often performed in clinical practice. Previous studies investigated the effect of immobilization on bone, cartilage, muscle, and tendon, however, the acute effects on human skin microcirculation and histomorphology remains elusive. METHODS: In 12 healthy, nonsmoking individuals (aged 29.7 ± 9.1 years) a randomly selected forearm was immobilized by splinting for 72 h, whereas the other forearm served as control. In vivo Reflectance‐Mode Confocal‐Microscopy (RMCM) was performed prior (baseline value) and postimmobilization to evaluate: quantitative blood cell flow; density of functional dermal capillaries; epidermal thickness; and granular cell size. RESULTS: At 72h forearm immobilization, quantitative blood cell flow was significantly reduced (42.86 ± 3.68 cells/min) compared to the control blood flow (53.11 ± 3.68 cells/min, P < 0.05) and dermal capillaries indicates less functional density (5.73 ± 0.63 capillaries/mm2) compared to the controls (7.04 ± 0.81 capillaries/mm2, P < 0.05). Histometric assessment reveals significantly thinner epidermis following immobilization compared to the control site (40.02 ± 2.91 vs. 46.64±3.09 µm, P < 0.05). Granular cell size was significantly altered at 72 h splinting (730.1 ± 42.53 µm2) compared to the control cell size at 770.2 ± 38.21 µm2. Comparison of baseline values of both forearms indicate statistically insignificance (P > 0.05) for each parameter. CONCLUSION: At 72 h splint immobilization, for the first time, significant adaptive mechanisms were evaluated on human skin microcirculation and histomorphology using in vivo RMCM. These adaptations may be considered as an incipient atrophy of the human skin. Long‐term effects of immobilization including the regenerative potential should be evaluated in further RMCM studies. Microsc. Res. Tech. 77:99–103, 2014.

Postbariatrische plastische Chirurgie

ZusammenfassungDie postbariatrische plastische Chirurgie kann nach massiver Gewichtsreduktion durch funktionelle Rekonstruktion und Wiederherstellung der Körpersilhouette die Lebensqualität steigern. Unter Beachtung von resorptionsbedingten Ernährungsdefiziten oder Nebenerkrankungen bedarf es einer exakten präoperativen Planung insbesondere zur ästhetisch günstigsten Platzierung der Narben. So lassen sich die Komplikationsraten niedrig halten und ein für den Patienten ästhetisch befriedigendes Ergebnis erzielen. Plastisch-chirurgische Maßnahmen zur Körperkonturierung stellen anspruchsvolle Operationen dar und erfordern spezielle plastisch-chirurgische Fachkenntnisse. Es stehen zahlreiche Verfahren zur Verfügung, die sich nach den individuellen Gegebenheiten des Patienten richten. Die postbariatrische Körperkonturierung stellt den letzten Schritt in der Behandlungskette des neuen Gebietes der Adipositaschirurgie dar. In diesem Beitrag werden die facettenreichen Möglichkeiten und Grenzen der modernen postbariatrischen plastischen Chirurgie geschildert.AbstractPostbariatric plastic surgery after major weight loss can improve quality of life through functional reconstruction and restoration of a normal body contour. Comorbidities associated with obesity necessitate individual indications and precise preoperative planning in order to reduce the rate of postoperative complications. Postbariatric plastic surgery includes a variety of sophisticated surgical techniques and therefore requires profound knowledge and experience in this special field. Satisfactory results can be achieved by complying with basic principles and through the use of established methods. The present article provides an overview of current concepts and trends in postbariatric plastic surgery.Postbariatric plastic surgery after major weight loss can improve quality of life through functional reconstruction and restoration of a normal body contour. Comorbidities associated with obesity necessitate individual indications and precise preoperative planning in order to reduce the rate of postoperative complications. Postbariatric plastic surgery includes a variety of sophisticated surgical techniques and therefore requires profound knowledge and experience in this special field. Satisfactory results can be achieved by complying with basic principles and through the use of established methods. The present article provides an overview of current concepts and trends in postbariatric plastic surgery.