Large Body Surface Area Research Articles

Outcomes of Current-Generation Transfemoral Balloon-Expandable Versus Self-Expandable Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) continues to gain momentum with current-generation balloon-expandable (BE) Edwards SAPIEN 3 (Edwards Lifesciences, Irvine, CA) and self-expandable (SE) Medtronic Evolut valves (Medtronic, Minneapolis, MN). Safety and efficacy of each device has been studied independently but head-to-head comparisons remain limited. The institutional database was used to identify patients undergoing TAVR with BE and SE systems through transfemoral access between 2015 and 2018. Patients with an alternative access were excluded. Multivariable logistic and Cox proportional hazards regression was used to compare baseline risk-adjusted 30-day Valve Academic Research Consortium-2 variables and midterm outcomes, including survival, stroke, and readmission rates. A total of 294 BE (52.2%) and 269 SE (47.8%) valves were implanted. BE cohort was predominantly male (59.9% vs 33.1%, P < .001), with a larger body surface area (1.9 m2 vs 1.8 m2, P < .001), fewer prior aortic valve replacements (3.7% vs 10.0%, P= .003), and a lower Society of Thoracic Surgeons predicted risk of mortality score (4.9% vs 6.7%, P < .001). After risk adjustment, SE patients had a higher propensity of ischemic stroke at 30 days (6.0% vs 1.4%, P= .015) but were comparable in other Valve Academic Research Consortium-2 variables, including mortality (1.7% vs 3.4%, P= .474), pacemaker (12.7% vs 15.2%, P= .162), and moderate paravalvular leak (1.8% vs 3.2%, P= .165). Over the midterm, SE and BE were comparable in mortality (adjusted hazard ratio [aHR], 1.24; P= .269), all-cause readmission (aHR, 0.92; P= .576), and stroke rate (aHR, 1.97; P= .061). Midterm outcomes of both valve types were comparable despite a higher risk of short-term stroke for the SE cohort. Select patients may benefit from one valve type over another based on clinical and anatomic risk factors.

Performance and Durability of Cryopreserved Allograft Aortic Valve Replacements

The value of allografts for aortic root replacement is controversial, with recent concern about limited durability. Currently, we prefer allografts for invasive infective endocarditis. Purposes of this study were to assess allograft performance and durability in our cumulative experience with aortic allografts. From January 1987 to January 2017, 2042 adults received 2110 aortic allograft root replacements at our institution: 986 (47%) for infective endocarditis (669 [68%] for prosthetic valve endocarditis) and 1124 (53%) for other indications. Mean recipient age was 54 ± 15 years, and mean allograft donor age was 35 ± 13 years. Follow-up was 85% complete and comprised 17,253 patient-years of data. Longitudinal allograft performance was extracted from 6339 available echocardiographic studies. Durability was assessed by explant for allograft structural failure. Allograft mean gradient at hospital discharge was 6 mm Hg and 9, 13, and 15 mm Hg at 5, 10, and 15 years post-implant, respectively. Severe aortic regurgitation was 0% at hospital discharge, but 14%, 25%, and 35% at 5, 10, and 15 years, respectively. A total of 405 allografts were explanted for structural failure, actuarially 2%, 14%, 34%, and 51% at 5, 10, 15, and 20 years, respectively. Risk factors for structural failure were younger recipient age, larger body surface area, hypertension, and thoracic aorta disease; donor factors were older age and larger allograft size. Implant for infective endocarditis was not associated with accelerated structural failure. This study affirms allografts' long-term acceptable hemodynamic performance and durability. Concern about structural failure should not limit allograft use. Recipient hypertension, allograft size, and donor age are modifiable risk factors.

Nanotechnology-based Drug Delivery Systems as Potential for Skin Application: A Review

Administration of substances through the skin represents a promising alternative, in relation to other drug administration routes, due to its large body surface area, in order to offer ideal and multiple sites for drug administration. In addition, the administration of drugs through the skin avoids the first-pass metabolism, allowing an increase in the bioavailability of drugs, as well as reducing their side effects. However, the stratum corneum (SC) comprises the main barrier of protection against external agents, mainly due to its structure, composition and physicochemical properties, becoming the main limitation for the administration of substances through the skin. In view of the above, pharmaceutical technology has allowed the development of multiple drug delivery systems (DDS), which include liquid crystals (LC), cubosomes, liposomes, polymeric nanoparticles (PNP), nanoemulsions (NE), as well as cyclodextrins (CD) and dendrimers (DND). It appears that the DDS circumvents the problems of drug absorption through the SC layer of the skin, ensuring the release of the drug, as well as optimizing the therapeutic effect locally. This review aims to highlight the DDS that include LC, cubosomes, lipid systems, PNP, as well as CD and DND, to optimize topical skin therapies.

Diameter and growth rate of the thoracic aorta-analysis based on serial computed tomography scans.

BackgroundAlthough there are studies on the growth of thoracic aorta in the general population, research based on serial computed tomography scan is rare. We investigated the influence of patient age and anthropometric variables on the size and growth rate of the thoracic aorta in the general hospital population.MethodsData on 2,353 adults [2003–2014] who underwent ≥2 serial computed tomography examinations with at least a 6-year interval were analyzed. There were 1,444 men (61%), and the mean age was 58±12 years (range, 17–92 years). Thoracic aortic diameters were measured at 5 levels (the sinus of Valsalva, ascending aorta, aortic arch, and proximal and distal descending thoracic aorta) in the first and last computed tomography scans taken at a median interval of 7.0 years (interquartile range: 6.4–8.0).ResultsThe mean aorta diameters were 34.9±4.7, 34.1±4.6, 28.0±3.8, 24.8±3.4, and 23.8±3.3 mm in the sinus of Valsalva, ascending aorta, arch, and proximal and distal descending thoracic aorta, respectively. The initial aorta diameter was larger in older subjects and in those with a larger body surface area (BSA). Female subjects had a significantly larger indexed diameter (diameter/BSA) than male subjects (P<0.001 at all five levels). In all thoracic aorta levels, the growth rate was the highest in subjects in their 40s, and the growth rate negatively correlated with the initial indexed diameter (P<0.001 at all five levels). In 40–50% of the subjects, thoracic aorta size remained stable during the interval.ConclusionsThe thoracic aorta dilated with aging and was larger in subjects with a larger body size. Sex differences in the gross aortic diameter might be related to differences in body size. The growth of the thoracic aorta was faster in younger subjects with a smaller indexed diameter.

Multidrug Resistant Organism Burden in Critically-Ill Burn Patients

<h3>Background</h3> The National Burn Repository 2019 reports burn-related data from July 2017- June 2018 of 1,101 hospitals and 221,519 patients. Large total body surface area (TBSA) burns and inhalational lung injury (ILI) are major risks for a complicated course requiring critical care support and infections are the most serious and most common complications of burns. The aim of this study is to evaluate the burden of multidrug resistant organisms (MDRO) in critically-ill burn patients. <h3>Methods</h3> Our burn center receives 3,000 visits and provides treatment for around 1300 patients annually. In 2018, 225 patients were admitted to the hospital's 9-bed critical-care burn unit. Patients who had burns more than 10% TBSA and/or ILI were included in the study if they survived more than 48 hours. The records were reviewed for length of stay (LOS), mortality, as well as MDRO clinical as well surveillance cultures. <h3>Results</h3> 55 patients were included in the study with 39 (71%) male and with an average LOS of 11 days. Inhalational lung injury was found to be present in 58% of patients. 8 patients died who had an average TBSA burn of 60%. While patients who were discharged alive had average TBSA burns of 29% and average LOS of 26 days. 22% of discharged patients were found to have MDRO acquisition detected by clinical cultures and 14% of patients had MRSA detected by follow-up nasal screening. <h3>Conclusions</h3> MDRO colonization is common in severely-ill burn patients. This highlights the importance of more aggressive MDRO surveillance in this population for early detection and prevention of hospital-associated infections and outbreaks.

Stentless Pericarbon Freedom Versus Stented Perimount Aortic Bioprosthesis: Propensity-Matched Long-Term Follow-Up.

Stentless aortic valves have shown superior hemodynamic performance and faster left ventricular mass regression compared to stented bioprostheses. Yet, controversies exist concerning the durability of stentless valves. This case-matched study compared short- and long-term clinical outcomes of stentless LivaNova-Sorin Pericarbon Freedom™ (SPF) and stented Carpentier-Edwards Perimount (CEP) aortic prostheses. From 2003 through 2006, 134 consecutive patients received aortic valve replacement with SPF at our institution. This cohort was matched, according to 20 preoperative clinical parameters, with a control group of 390 patients who received CEP prosthesis during the same time. The resulting 55 + 55 matched patients were analyzed for perioperative results and long-term clinical outcomes. Early mortality was 0% for both groups. Lower transvalvular gradients were found in the SPF group (10.6 ± 2.9 versus 15.7 ± 3.1 mmHg, P < 0.001). Overall late mortality (mean follow-up: 10.03 years) was similar for both groups (50.1% versus 42.8%, P = 0.96). Freedom from structural valve degeneration (SVD) at 13 years was similar for both groups (SPF = 92.3%, CEP = 73.9%, P = 0.06). Freedom from aortic valve reinterventions did not differ (SPF = 92.3%, CEP = 93.5%, P = 0.55). Gradients at 13-year follow-up remained significantly lower in SPF group (10.0 ± 4.5 versus 16.2 ± 9.5 mmHg, P < 0.001). Incidence of acute bacterial endocarditis (ABE) and major adverse cardiovascular and cerebrovascular events (MACCE) was similar. SPF and CEP demonstrated comparable long-term outcomes related to late mortality, SVD, aortic valve reinterventions, and incidence of ABE and MACCE. Superior hemodynamic performance of SPF over time can make this valve a suitable choice in patients with small aortic root and large body surface area.

Incidence, predictors, and outcome of prosthesis-patient mismatch after transcatheter aortic valve replacement: A meta-analysis.

Prosthesis-patient mismatch (PPM) following transcatheter aortic valve replacement (TAVR) is common, but the incidence, predictors and outcome of PPM are still controversial. A total of 18 articles incorporating 72,016 patients were identified form PubMed and Embase online database. The pooled incidences of overall, and severe PPM following TAVR were 32.0% and 10.0% separately. Comparing to surgical aortic valve replacement (SAVR), TAVR had lower incidence of overall (OR, 0.31, 95% CI, 0.20-0.50) and severe PPM (OR, 0.38, 95% CI, 0.28-0.52). PPM was associated with a larger body surface area (BSA), larger body mass index (BMI) and previous myocardial infarction in comparison with those patients without PPM. Although PPM was not rare after TAVR, no significant differences were observed both in short- and mid-term all-cause mortality (30 day: OR: 1.51, 95% CI, 0.79-2.87, 1 year: OR: 1.02, 95% CI, 0.96-1.08, and 2 years: OR: 0.99, 95% CI, 0.79-1.24) between patients with PPM and those without PPM. Despite the fact that the incidence of PPM was lower than that of SAVR, PPM was not seen to have an impact on short- and mid-term survival.

A Novel Approach to Maintaining Normothermia in Major Spinal Deformity Surgery with an Esophageal Warming Device

Maintenance of normothermia is a priority during major spinal deformity surgery. However, this is difficult due to the large body surface area exposed to ambient temperatures. We report the novel use of an esophageal warming device, added to standard care, to maintain normothermia in three patients. We conclude that esophageal warming is feasible in major spine surgery with no apparent complications. Safety and efficacy, as compared to standard warming devices, will need to be determined in future prospective trials.

Early Newborn Bath and Associated Factors among Parturient Women Who Gave Birth in the Last Month in Harar Region, Eastern Ethiopia, 2017.

Background: Neonatal thermal care is a vital intervention as newborns are susceptible to hypothermia than adults for certain reasons such as having a large body surface area, thin skin, little insulating fat, and overwhelmed thermoregulation mechanisms. Many newborn complications develop because of hypothermia due to thermal care malpractices. The leading thermal practice by women of developing countries is early bathing which predisposes newborns for life-threatening situations, such as low blood sugar levels, respiratory distress, abnormal clotting, jaundice, pulmonary hemorrhage and increased risk of developing infections. Hence, this research is aimed to provide substantial evidence regarding the women’s practices of newborn bath and the factors that determine early (&lt;24hr) bathing. Objective: The study aimed to assess the early newborn bath and its associated factors among parturient women who gave birth in the last month in the Harar region, Eastern Ethiopia, 2017. Methods: The study applied an institutional-based cross-sectional study design by recruiting 433 women. The data collectors interviewed study participants face to face at the baby immunization ward from two hospitals and four health centers. The author calculated the sample size using a double population proportion formula. A systematic sampling technique from the women’s medical registration frame was used to select the final study participants. The data collectors gathered the data using a structured questionnaire adapted from different literature, checking its consistency, reliability and validity by a pretest. Results: The response rate of this study was 99.8%. The early newborn bathing practice was found in 153 (35.4% with 95% (CI): (30.3%, 40.3%) women. Uneducated (AOR=3.12 95% CI: (2.12-5.3), no knowledge of hypothermia (AOR=4.95 95% CI: (3.10-12.2), being Primi para (AOR=3.5 95% CI: (2.5-5.6) and no utilization of newborn bed net (AOR=6.2 95% CI: (3.3-45) were statistically significant factors determining early newborn bathing practice. Conclusion: The study revealed that although the ministry implemented a good deal of awareness promotion activities, women still practice early newborn bathing. Maternal illiteracy, giving birth for the first time, knowledge deficiency related to hypothermia and newborn bed net application were among the factors which demand improvement to solve the problem.

The association between Body Surface Area (BSA) and vitamin D level among obese adolescent patients in Denpasar, Bali, Indonesia

Background: Prevalence of obesity in adolescent in Indonesia is still high. An obese adolescent is likely to stay obese into adulthood and tends to develop into cardiovascular and metabolic diseases. Obese subjects have larger body surface area and should be able to produce more vitamin D from cutaneous synthesis. This study aims to determine the prevalence of obesity in adolescent in Denpasar, determine vitamin D status among obese adolescents and obtained an association between body surface area and vitamin D levels.Methods: A descriptive observational study using a cross-sectional approach has been conducted among 51 obese adolescents in Denpasar during May to December 2018. Several variables assessed in this study were age, sex, weight, height, Body Mass Index (BMI), Body Surface Area (BSA), and vitamin D levels. Factors associated with vitamin D levels in obese adolescence were analyzed with appropriate statistical analysis. Data were analyzed using SPSS version 17 for Windows. Results: From 51 subjects, 32 (62.74%) male and 19 (37.26%) female subjects were enrolled in this study. The mean weight and height of respondents were 89.4±9.8 kg and 158.6±7.3 cm. In addition, the average Body Mass Index (BMI) and Body Surface Area (BSA) were 33.6±3.4 kg/m2 and 2.1±0.2 m2. The mean Vitamin D levels was 18.9±4.9 ng/mL with 40 subjects (78,4%) were known in a vitamin D deficiency state. There was a significant weak positive association between BSA and vitamin D levels (r=0.32; p=0,002).Conclusion: Most obese adolescents were in vitamin D deficiency with a significant weak positive association between BSA and vitamin D levels.Â

538 Successful Wound Closure in Patients with Large Total Body Surface Area (TBSA) Calciphylaxis with Aggressive Medical and Surgical Therapy

Abstract Introduction Calcific Uremic Arteriolopathy (CUA), commonly known as Calciphylaxis, is a rare disorder characterized by ischemic necrosis of the skin and histologically by arteriolar calcification. CUA is most commonly seen in patients with end-stage renal disease (ESRD), but can be seen in other patients as well. CUA is an extremely morbid condition and carries a high mortality rate, up to 80% in some studies, even in patients with limited disease. In light of this, many surgeons have adopted a “do-not-touch” approach. Over the past five years, our institution has seen an increase in the referrals of patients with large total-body-surface-area (TBSA) CUA. Methods Retrospective review of all patients with biopsy-proven (by dermatopathology) large, &amp;gt;5% TBSA CUA admitted to a Verified Adult and Pediatric Burn Center from 2015 to present. Demographics, laboratory data, treatment modalities, infectious complications and outcomes, including mortality and wound closure were recorded. Secondary observations included exposure to anticoagulants and recent significant weight loss. Results A total of eight patients with large TBSA CUA were admitted after being transferred from outside hospitals. Average TBSA affected was 13.76% (range 5–27%). Six of these patients (75%) were noted to have non-uremic calciphylaxis. One patient (12.5%) had elevated parathyroid hormone (PTH) levels and hyperphosphatemia while one patient each had isolated hypercalcemia and hyperphosphatemia. All patients had positive wound cultures on admission, and one patient (12.5%) developed a bacteremia in hospital. There were no central line associated bloodstream infections, catheter associated urinary tract infections or ventilator associated infections. All patients underwent surgical debridement (average 4.125, range 2–5), and 5 patients (62.5%) underwent grafting, (average 1.6, range 2–5) and subsequently proceeded to wound closure. In-hospital mortality was 25% and another patient was referred to a hospice facility after being readmitted with medical complications related to her calciphylaxis. Secondary findings included 50% of the patients recently experienced significant weight loss (&amp;gt;100 lbs) and 25% of the patients were taking warfarin within 6 months of presentation. Percent TBSA involvement did not correlate with mortality. Conclusions Utilizing a multi-modal management strategy that includes surgical debridement and skin grafting, patients with large total body surface area calciphylaxis can progress to wound closure. Applicability of Research to Practice Findings may influence surgeons to be aggressive surgically with patients with calciphylaxis leading to improved morbidity and mortality. Improved medical multi-modal therapy has been shown to influence outcomes as well.

636 Case Report on Continuous Passive Motion (CPM) Therapy on Hand Burns in a Patient with a Large Total Body Surface Area (TBSA) Burn

Abstract Introduction Methods Results Expectations: To lose ROM as healing progressed due to the extent of the injuries (based on prior experience) &amp; because some contracture was assessed as early as 1 week. Outcomes Conclusions Applicability of Research to Practice That other therapists might consider this therapy and experience similar outcomes when treating deeply burned hands.

Percent atheroma volume: Optimal variable to report whole-heart atherosclerotic plaque burden with coronary CTA, the PARADIGM study

Background and aimsDifferent methodologies to report whole-heart atherosclerotic plaque on coronary computed tomography angiography (CCTA) have been utilized. We examined which of the three commonly used plaque burden definitions was least affected by differences in body surface area (BSA) and sex. MethodsThe PARADIGM study includes symptomatic patients with suspected coronary atherosclerosis who underwent serial CCTA >2 years apart. Coronary lumen, vessel, and plaque were quantified from the coronary tree on a 0.5 mm cross-sectional basis by a core-lab, and summed to per-patient. Three quantitative methods of plaque burden were employed: (1) total plaque volume (PV) in mm3, (2) percent atheroma volume (PAV) in % [which equaled: PV/vessel volume * 100%], and (3) normalized total atheroma volume (TAVnorm) in mm3 [which equaled: PV/vessel length * mean population vessel length]. Only data from the baseline CCTA were used. PV, PAV, and TAVnorm were compared between patients in the top quartile of BSA vs the remaining, and between sexes. Associations between vessel volume, BSA, and the three plaque burden methodologies were assessed. ResultsThe study population comprised 1479 patients (age 60.7 ± 9.3 years, 58.4% male) who underwent CCTA. A total of 17,649 coronary artery segments were evaluated with a median of 12 (IQR 11–13) segments per-patient (from a 16-segment coronary tree). Patients with a large BSA (top quartile), compared with the remaining patients, had a larger PV and TAVnorm, but similar PAV. The relation between larger BSA and larger absolute plaque volume (PV and TAVnorm) was mediated by the coronary vessel volume. Independent from the atherosclerotic cardiovascular disease risk (ASCVD) score, vessel volume correlated with PV (P < 0.001), and TAVnorm (P = 0.003), but not with PAV (P = 0.201). The three plaque burden methods were equally affected by sex. ConclusionsPAV was less affected by patient's body surface area then PV and TAVnorm and may be the preferred method to report coronary atherosclerotic burden.

A077 Incidence, Predictors and Prognostic Impact of Patient-Prosthesis Mismatch Following Transcatheter Aortic Valve Implantation

Patient-prosthesis mismatch (PPM) describes a state where the effective orifice area (EOA) of a valve prosthesis is too small relative to the patient's body surface area (BSA). We reviewed the incidence and prognostic impact of PPM following transcatheter aortic valve implantation (TAVI). A retrospective review of patients undergoing TAVI in the Auckland Region between October 2011 and December 2018 was performed. PPM was classified as severe (<0.65 cm2/m2), moderate (0.65-0.85 cm2/m2), or none (>0.85 cm2/m2) on post-TAVI echocardiography. Multivariable logistic regression analysis was used to determine independent predictors of PPM. One-year clinical outcomes were analysed. A total of 294 patients were included in this study (median age 81 years, interquartile range [IQR] 76 to 85 years], BSA 1.87m2, IQR 1.69 to 2.05m2). SAPIEN XT or S3 valves were used in 239 patients (81.3%) and 24 (8.2%) had valve-in-valve TAVI. Moderate and severe PPM were observed following TAVI in 42 (14.3%) and 26 (8.8%) patients respectively. In our multivariate analysis, larger BSA, smaller left ventricular outflow tract (LVOT) diameter and valve-in-valve procedures were identified as independent predictors of severe PPM. There was no significant difference in 30 day or 1-year mortality between PPM groups. Larger BSA, smaller LVOT diameter and valve-in-valve TAVI were predictors of moderate or severe PPM. PPM did not have a significant prognostic impact on mortality following TAVI, consistent with larger international registries.

Sorafenib Population Pharmacokinetics and Skin Toxicities in Children and Adolescents with Refractory/Relapsed Leukemia or Solid Tumor Malignancies

To determine the pharmacokinetics and skin toxicity profile of sorafenib in children with refractory/relapsed malignancies. Sorafenib was administered concurrently or sequentially with clofarabine and cytarabine to patients with leukemia or with bevacizumab and cyclophosphamide to patients with solid tumor malignancies. The population pharmacokinetics (PPK) of sorafenib and its metabolites and skin toxicities were evaluated. In PPK analysis, older age, bevacizumab and cyclophosphamide regimen, and higher creatinine were associated with decreased sorafenib apparent clearance (CL/f; P < 0.0001 for all), and concurrent clofarabine and cytarabine administration was associated with decreased sorafenib N-oxide CL/f (P = 7e-4). Higher bilirubin was associated with decreased sorafenib N-oxide and glucuronide CL/f (P = 1e-4). Concurrent use of organic anion-transporting polypeptide 1B1 inhibitors was associated with increased sorafenib and decreased sorafenib glucuronide CL/f (P < 0.003). In exposure-toxicity analysis, a shorter time to development of grade 2-3 hand-foot skin reaction (HFSR) was associated with concurrent (P = 0.0015) but not with sequential (P = 0.59) clofarabine and cytarabine administration, compared with bevacizumab and cyclophosphamide, and with higher steady-state concentrations of sorafenib (P = 0.0004) and sorafenib N-oxide (P = 0.0275). In the Bayes information criterion model selection, concurrent clofarabine and cytarabine administration, higher sorafenib steady-state concentrations, larger body surface area, and previous occurrence of rash appeared in the four best two-predictor models of HFSR. Pharmacokinetic simulations showed that once-daily and every-other-day sorafenib schedules would minimize exposure to sorafenib steady-state concentrations associated with HFSR. Sorafenib skin toxicities can be affected by concurrent medications and sorafenib steady-state concentrations. The described PPK model can be used to refine exposure-response relations for alternative dosing strategies to minimize skin toxicity.

Sprayable and biodegradable, intrinsically adhesive wound dressing with antimicrobial properties.

Conventional wound dressings are difficult to apply to large total body surface area (TBSA) wounds, as they typically are prefabricated, require a layer of adhesive coating for fixation, and need frequent replacement for entrapped exudate. Large TBSA wounds as well as orthopedic trauma and low‐resource surgery also have a high risk of infection. In this report, a sprayable and intrinsically adhesive wound dressing loaded with antimicrobial silver is investigated that provides personalized fabrication with minimal patient contact. The dressing is composed of adhesive and biodegradable poly(lactic‐co‐glycolic acid) and poly(ethylene glycol) (PLGA/PEG) blend fibers with or without silver salt (AgNO3). in vitro studies demonstrate that the PLGA/PEG/Ag dressing has antimicrobial properties and low cytotoxicity, with antimicrobial silver controllably released over 7–14 days. In a porcine partial‐thickness wound model, the wounds treated with both antimicrobial and nonantimicrobial PLGA/PEG dressings heal at rates similar to those of the clinical, thin film polyurethane wound dressing, with similar scarring. However, PLGA/PEG adds a number of features beneficial for wound healing: greater exudate absorption, integration into the wound, a 25% reduction in dressing changes, and tissue regeneration with greater vascularization. There is also modest improvement in epidermis thickness compared to the control wound dressing.

Clinical significance of postoperative atrial arrhythmias in patients who underwent lung transplantation.

Background/AimsAtrial arrhythmia (AA) occasionally occurs after lung transplantation (LT); however, risk factors for AA and their impact on clinical outcomes are inconsistent. We aimed to investigate the incidence, predisposing factors, and clinical outcomes of AA after LT.MethodsWe retrospectively evaluated 153 consecutive patients who underwent LT between January 2010 and August 2016. An AA episode was defined as a documented atrial fibrillation (AF), atrial flutter, or atrial tachycardia on 12-lead electrocardiography or episodes lasting ≥ 30 seconds on telemetry monitoring.ResultsThe mean follow-up time was 22.0 ± 19.1 months. Postoperative AA occurred in 46 patients (30.1%) after LT. Patients with postoperative AA were older, had larger body surface area, and had an increased incidence of paroxysmal AF prior to transplantation, idiopathic pulmonary fibrosis, and postoperative tracheostomy than patients without AA. Preoperative right atrial pressure (RAP) (odds ratio [OR], 1.19; p = 0.005) and longer periods of mechanical ventilation (OR, 1.03; p = 0.008) were found to be independent risk factors for AA after surgery. Development of AA was a significant predictor of long-term overall mortality (hazard ratio, 2.75; p = 0.017).ConclusionsPatients with elevated preoperative RAP and long-term ventilator care had a higher risk of AA after LT. Further, AA after LT was associated with poor long-term survival.

A case of diquat poisoning in pigs

Diquat is a bipyridyl compound which belongs to the group of herbicides. Its activity is based on the liberation of the superoxide anion radical and, subsequently, hydrogen peroxide, leading to tissue destruction by oxidative stress. Acute poisoning is associated with high mortality within several hours to a few days. The reported case of poisoning occurred on a commercial farm. The fattening pigs of the Landrace and Large White breeds were affected. The pigs were kept on a deep litter. Reglone (active ingredient diquat dibromide, 200 g/l) was used on the farm fields to desiccate the clover crop. The dry clover straw was harvested and stored for approximately a month and then used as a litter. In total, 50 pigs were affected. The onset of the poisoning was very fast. Within eight hours after the litter administration, 20 animals died. The only clinical sign seen was severe haemorrhagic dermatitis. The pathological examination revealed acute superficial haemorrhagic dermatitis on the belly, the snout and the ears of the affected pigs. Hyperaemia of the tonsils, pharynx and oesophagus was diagnosed, as well as a pronounced hyperaemia of the stomach fundus. In the distal part of the trachea, there was a dense, white foam. The lungs were congested, with focal emphysema. The liver was slightly hyperaemic. The histological examination revealed a massive haemostasis in liver and diffuse acute polymorphonuclear hepatitis. The other organs were without changes. The examination revealed acute poisoning caused by the large body surface areas contacting with a toxic substance. The pigs that survived were immediately removed to a non-contaminated area. The changes on their skin were not so extensive compared to the dead ones. Within 5–7 days after the exposure to diquat, the skin lesions healed.

Role of dual energy X-ray absorptiometry scan for assessing bone mineral density in patients with chronic plaque psoriasis: a cross-sectional study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Psoriasis is a T cell mediated chronic inflammatory disorder of skin, joints and immune system. Data regarding possible association between psoriasis and reduced bone mineral density are limited and hence association is not fully conclusive. Systemic inflammatory cytokines in the psoriasis have been identified in the pathogenesis of reduced bone mineral density. Among various available methods, Dual X-ray absorptiometry (DXA), found to be gold standard for assessing bone mineral density.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; An observation study of 30 patients with chronic plaque psoriasis aged between 18 years to 50 years fulfilling the criteria were enrolled and studied. Dual energy X-ray absorptiometry scan (DEXA) of left forearm radius (non-dominant hand) was done. T score was calculated and bone mineral density assessed based on WHO criteria. Using software SPSS version 24, Pearson’s correlation and linear regression analysis applied.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Out of 30 patients, there were 18 males and 12 females. Mean age of patients 37.93 years. Majority of the psoriatic patient showed osteopenia on DEXA scan and significant positive correlation was found between duration of psoriasis disease (r=0.34, p=0.03), body surface area percentage (r=0.36, p=0.04) and body mass index (r=0.32, p=0.02).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Early identification of reduced bone mineral density in patients with psoriasis particularly in those with longer duration of the disease, involving large body surface area (more than 10) and with higher body mass index by DEXA scan helps to reduce osteoporotic fracture and other associated comorbidities.&lt;/p&gt;

First aid is associated with improved outcomes in large body surface area burns

BackgroundAnimal studies indicate treating burn injuries with running water (first aid) for 20 min up to 3 h after burn reduces healing time and scarring. We have previously demonstrated the benefits of first aid in minor burn injuries with respect to a reduction in wound depth, faster healing, and decreased skin grafting utilisation. The purpose of this cohort study was to assess the effect of first aid on clinical outcomes in large body surface area burn injuries (≥20%). MethodsData was prospectively collected for patients with ≥20% TBSA burns from 2004– 2018. Multivariate regression analysis was used to determine the association of adequate first aid with 8 outcomes – mortality, total length of stay, total body surface area (TBSA), percentage/proportion of TBSA that was full thickness [PFTI], TBSA grafted, number of re-grafting sessions, intensive care admission, and intensive care length of stay. Adequate first aid was defined as the application of 20 min of cool, running tap water up to 3 h following the burn injury. Findings390 patients were identified. Adequate first aid was received in 35.6% (139) of patients. There was a trend towards a reduction in mortality (OR 0.37; 95% CI 0.12–1.13; P = 0.08). Patients who received adequate first aid had a statistically significant 9.8% reduction in TBSA (95% CI −13.6% to −6.1%; P < 0.0001) as well as a 12% lower PTFI compared to patients who received inadequate first aid (95% CI −19% to −4%; P < 0.01). Whilst there was no significant effect of adequate first aid on the TBSA grafted (P = 0.37), adequate first aid was associated with a significantly less number of re-grafting sessions (95% CI −-0.29 to −0.08; P < 0.001). InterpretationAdequate first aid with 20 min of running water is associated with improved outcomes in large burn injuries. Significant benefits are seen in a reduction in TBSA, proportion of the burn wound that is full thickness, as well as decreased re-grafting. This has significant patient and health system benefits and adds to the body of evidence supporting 20 min of cooling in burns care.