René R. W. J. van der Hulst

The increase of metopic synostosis: A pan-European observation

Metopic synostosis is thought to have an incidence of about 1 in 15,000 births. Traditionally, this makes it the third most frequent single-suture craniosynostosis, after scaphocephaly (1 in 4200-8500) and plagiocephaly (1 in 11,000). Our units have, independently from each other, noted a marked increase in the number of metopic synostosis over the recent years. This is a pan-European, retrospective epidemiological study on the number of cases with metopic synostosis born between January 1, 1997, and January 1, 2006. This number was compared to the prevalence of scaphocephaly, the most frequently seen craniosynostosis. In the 7 units, a total of 3240 craniosynostosis were seen from 1997 until 2006. Forty-one percent (n = 1344) of those were sagittal synostosis, and 23% (n = 756) were metopic synostosis. There was a significant increase of the absolute number as well as of the percentage of metopic synostosis over these years (regression analysis, P = 0.017, R2 = 0.578) as opposed to a nonsignificant increase in the percentage of sagittal synostosis (P > 0.05, R2 = 0.368). The most remarkable increase occurred around 2000-2001, with the average of metopics being 20.1% from 1997 to 2000 and 25.5% from 2001 to 2005 (independent t-test, P = 0.002). The sagittal synostosis showed a smaller and nonsignificant increase in the same years: from 39.9% in 1997-2000 leading up to 42.5% in 2001-2005 (independent t-test, P > 0.05). The number of metopic synostosis has significantly increased over the reviewed period in all of our units, both in absolute numbers as in comparison to the total number of craniosynostosis.

The effect of triclosan-coated sutures in wound healing. A double blind randomised prospective pilot study

BACKGROUND Wound infection and dehiscence are both major contributors to postoperative morbidity. One potential cause or co-factor is the use of suture material. A recently introduced subcutaneous suture is coated with triclosan (TC), an antiseptic drug. It is suggested to reduce wound complications. METHODS To investigate the effect of TC on wound healing a double blind prospective pilot study in women undergoing a breast reduction was performed. Each patient was her own control. After randomisation the TC-coated sutures were used either on the left or right side. The contralateral side was used as the control. The incidence of dehiscence was studied. RESULTS Twenty-six patients were included. In the TC breasts there was a wound dehiscence in 16 cases, whereas in the control breasts in seven cases a dehiscence was observed (P=0.023). CONCLUSION These results suggest that TC-coated sutures should be used with caution. These sutures have already been introduced on to the market without good clinical studies and might have potential adverse effects as shown by these data.

Open Window Thoracostomy Treatment of Empyema Is Accelerated by Vacuum-Assisted Closure

BACKGROUND Recurrent thoracic empyema in the presence of residual lung tissue can be treated with an open window thoracostomy (OWT). Vacuum-assisted closure (VAC) of these large thoracic defects is a novel option. METHODS Nineteen patients with residual lung tissue received an OWT for treatment of recurrent thoracic empyema. In this retrospective case series, 8 patients (aged 58 +/- 20 years, all male) were treated conventionally, and 11 patients (aged 53 +/- 17 years, 8 male) were treated with VAC. RESULTS The application of the VAC system resulted in rapid debridement of the thoracic cavity and reexpansion of the residual lung tissue. The duration of OWT and VAC therapy was 39 +/- 17 and 31 +/- 19 days, respectively. All 11 patients were amenable for subsequent closure using pedicled muscular flaps. In 2 patients, VAC therapy alone resulted in complete closure of the OWT. The average duration of follow-up was 46 +/- 19 months. All patients, except 1, have recovered well. One patient died of nonpulmonary causes. In the non-VAC group (n = 8), the OWT was managed conventionally by application of saline-soaked gauzes. In 2 patients, the OWT was eventually closed using pedicled muscular flaps (after 75 and 440 days, respectively). Four patients died of OWT-related complications (1 bleeding, 3 recurrent infections) during follow-up; 1 patient died of a cause unrelated to OWT. The average duration of OWT was 933 +/- 1,422 days. CONCLUSIONS When compared with conventional management of OWT, VAC therapy accelerates wound healing and improves reexpansion of residual lung tissue in patients with OWT after empyema, allowing rapid surgical closure.

Review: ischaemia–reperfusion injury in flap surgery

Ischaemia-reperfusion injury is the mechanism underlying (partial) flap loss. This is not only a traumatic event for the patient, it also causes increased patient morbidity [Kerrigan CL, Stotland MA. Ischemia reperfusion injury: a review. Microsurgery 1993;14:165-75] as well as prolonged hospitalisation, increasing medical consumption and costs. For surgeons who perform flap surgery, it is important to have knowledge of ischaemia-reperfusion injury in order to prevent it. In this article, an update on the recent research on ischaemia-reperfusion is given. The production of reactive oxygen species, neutrophil influx, depletion of NO and apoptosis are discussed as well.

Quality of life after breast reduction.

The purpose of this study is to compare health-related quality of life in women with symptomatic macromastia before and after breast reduction. Two comparable groups of women were enrolled in the study, those waiting for breast reduction (group 1) and those who underwent surgery approximately 2 years before (group 2). To evaluate the specific beneficial effects of breast reduction, we used a unique combination of general and specific questionnaires: the Short Form 36 Health Survey Questionnaire (SF-36), the European Quality of Life-5 Dimensions (EQ-5D), the Rosenberg Self-Esteem Scale (RSE), the Self-Consciousness Scale (SCS), and the Derriford Appearance Scale 59 (DAS-59). The esthetic appearance of the breast was also evaluated using a visual analog scale (VAS). In both groups, preoperative back pain was present in more than 50% of patients. Complaints were significantly reduced after surgery. SF-36 showed significant higher quality of life in group 2 with regard to 7 of 8 investigated domains. Increased self-esteem after surgery, increased personal and public self-consciousness were observed. Moreover, the condition-specific DAS-59 showed that insecurity, pain, shame, and unattractiveness were significantly scored higher in the nonoperated group. Subjective esthetic score was significantly higher in the operated group (2.5 vs. 7.1). The data of this study provide further evidence that women who have been operated for breast hypertrophy have a significant improvement in quality of life compared with those who are not yet operated. These data are further evidence that breast hypertrophy is not solely an esthetic problem.

Wound administration of M2-polarized macrophages does not improve murine cutaneous healing responses.

Macrophages play a crucial role in all stages of cutaneous wound healing responses and dysregulation of macrophage function can result in derailed wound repair. The phenotype of macrophages is influenced by the wound microenvironment and evolves during healing from a more pro-inflammatory (M1) profile in early stages, to a less inflammatory pro-healing (M2) phenotype in later stages of repair. The aim of the current study was to investigate the potential of exogenous administration of M2 macrophages to promote wound healing in an experimental mouse model of cutaneous injury. Bone marrow derived macrophages were stimulated in-vitro with IL-4 or IL-10 to obtain two different subsets of M2-polarized cells, M2a or M2c respectively. Polarized macrophages were injected into full-thickness excisional skin wounds of either C57BL/6 or diabetic db/db mice. Control groups were injected with non-polarized (M0) macrophages or saline. Our data indicate that despite M2 macrophages exhibit an anti-inflammatory phenotype in-vitro, they do not improve wound closure in wild type mice while they delay healing in diabetic mice. Examination of wounds on day 15 post-injury indicated delayed re-epithelialization and persistence of neutrophils in M2 macrophage treated diabetic wounds. Therefore, topical application of ex-vivo generated M2 macrophages is not beneficial and contraindicated for cell therapy of skin wounds.

Is the treatment of keloid scars still a challenge in 2006

Background:Several options are described to treat keloid scars, none of them being 100% successful. Radiotherapy is suggested to have the most significant effect on recurrence rate. Objectives:The aim of the study is to confirm the effectiveness of iridium brachytherapy combined with surgery and to evaluate patient satisfaction. Patients and Methods:We retrospectively enrolled 24 patients with 30 keloids, treated by surgical excision and iridium 192 high-dose-rate (HDR) brachytherapy. Results:We observed a significant difference in scar thickness before and after the treatment (P < 0.001). With regard to patient satisfaction and complaints, 79.1% of them had no pain and irritation after treatment, 79.2% of patients would recommend this treatment to other patients, and 87.5% would undergo this treatment again if necessary. Conclusions:Our results confirm the effectiveness of surgical keloid excision followed by HDR brachytherapy in primary treatment or if other alternative methods have failed.

Risk factors and blood flow in the free transverse rectus abdominis (TRAM) flap: smoking and high flap weight impair the free TRAM flap microcirculation.

Mastectomy patients may have significant psychologic-related problems. Breast reconstruction provides in these cases substantial benefits in restoring body image and health-related quality of live. Autologous free tissue transfer is the treatment of choice due to excellent outcome. The purpose of this study was to elucidate the effect of the risk factors on the microcirculation and clinical outcome. In this prospective study, 21 patients with a free transverse rectus abdominis (TRAM) flap breast reconstruction were included. Patient demographics and flap characteristics were recorded. Blood flow was recorded in the central part (zone I) and the distal part (zone IV) of the flap with the laser Doppler flowmetry (LDF; Perimed). In this study, increased flap complications were seen in smokers when compared with nonsmokers (P < 0.000). LDF was higher in the older patient population (P = 0.008) in zone IV. Smoking, especially in combination with a high flap weight (HFW), revealed lower blood-flow values (P = 0.020) in zone IV. Other possible influencing risk factors such as a HFW and history of radio- and chemotherapy did not alter the microcirculation. Patients with smoking and a HFW did also show decreased blood flow but also more severe flap complications. Smoking, especially in patients with a HFW, impairs the free TRAM flap microcirculation in zone IV. In our opinion, these patients can still be included for reconstruction. However, extra care has to be taken during flap design to minimize disturbed wound healing.

Pulmonary glutamine production: effects of sepsis and pulmonary infiltrates

ObjectiveTo define the role of the lung in the production of glutamine in the critically ill and to determine the effects of the presence of pulmonary infiltrates and the presence and severity of sepsis.Design and settingProspective clinical study in a single center; interdisciplinary intensive care unit at a university hospital.PatientsEleven critically ill patients were compared to ten patients prior to cardiac bypass surgery.Measurements and resultsFluxes of glutamine and other amino acids were measured. Chest radiography was performed, and APACHE II and multiple-organ failure scores were calculated. Septic patients showed significantly higher glutamine efflux from the lungs than controls. At least one-half of this glutamine is estimated to result from protein breakdown. Severity of illness had no impact on glutamine fluxes. In the presence of pulmonary infiltrates on chest radiographs glutamine efflux did not differ from zero.ConclusionsThe lungs produce significant amounts of glutamine in septic patients. Pulmonary infiltrates decrease the glutamine efflux from the lung in septic patients. We suggest that this is caused by uptake of glutamine by white cells in the lung exerting immunological functions.

Breast Implants and the Risk of Anaplastic Large-Cell Lymphoma in the Breast

Importance Breast implants are among the most commonly used medical devices. Since 2008, the number of women with breast implants diagnosed with anaplastic large-cell lymphoma in the breast (breast-ALCL) has increased, and several reports have suggested an association between breast implants and risk of breast-ALCL. However, relative and absolute risks of breast-ALCL in women with implants are still unknown, precluding evidence-based counseling about implants. Objective To determine relative and absolute risks of breast-ALCL in women with breast implants. Design, Setting, and Participants Through the population-based nationwide Dutch pathology registry we identified all patients diagnosed with primary non-Hodgkin lymphoma in the breast between 1990 and 2016 and retrieved clinical data, including breast implant status, from the treating physicians. We estimated the odds ratio (OR) of ALCL associated with breast implants in a case-control design, comparing implant prevalence between women with breast-ALCL and women with other types of breast lymphoma. Cumulative risk of breast-ALCL was derived from the age-specific prevalence of breast implants in Dutch women, estimated from an examination of 3000 chest x-rays and time trends from implant sales. Main Outcomes and Measures Relative and absolute risks of breast-ALCL in women with breast implants. Results Among 43 patients with breast-ALCL (median age, 59 years), 32 had ipsilateral breast implants, compared with 1 among 146 women with other primary breast lymphomas (OR, 421.8; 95% CI, 52.6-3385.2). Implants among breast-ALCL cases were more often macrotextured (23 macrotextured of 28 total implants of known type, 82%) than expected (49 193 sold macrotextured implants of total sold 109 449 between 2010 and 2015, 45%) based on sales data (P < .001). The estimated prevalence of breast implants in women aged 20 to 70 years was 3.3%. Cumulative risks of breast-ALCL in women with implants were 29 per million at 50 years and 82 per million at 70 years. The number of women with implants needed to cause 1 breast-ALCL case before age 75 years was 6920. Conclusions and Relevance Breast implants are associated with increased risk of breast-ALCL, but the absolute risk remains small. Our results emphasize the need for increased awareness among the public, medical professionals, and regulatory bodies, promotion of alternative cosmetic procedures, and alertness to signs and symptoms of breast-ALCL in women with implants.