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The aim of this study was to describe the prevalence, characteristics and outcome of critically burn patients with pulmonary HSV reactivation.Retrospective, single-center cohort study in a burn critical care unit in a tertiary center, including all consecutive severely burn patients with bronchoalveolar lavage performed for pneumoniae suspicion and screened for HSV from January 2013 and April 2017. We used logistic regression to identify factors associated with HSV reactivation and outcomes.94 patients were included, mean age was 51 (39-64) years; median total body surface area burned was 36 (25-54)% and ICU mortality 38%. Fifty-five patients (59%) had pulmonary HSV reactivation and 30 (55%) were treated with acyclovir. Patients with HSV reactivation were more severely ill with higher SOFA score at admission compared to patient without HSV reactivation (6 [3-8] vs. 2 [1-4], p0.0001 respectively). In multivariate analysis, sex, SOFA score at admission and smoke inhalation were significantly associated with HSV reactivation. Only septic shock was associated with 90-day mortality when HSV reactivation was not.Pulmonary HSV reactivation is frequent among severely ill burn patients. Initial severity and smoke inhalation are risk factors. Antiviral treatment was not associated with outcome.

International audience; Background: Tumor molecular deciphering is crucial in clinical management. Pan-cancer next-generation sequencing panels have moved towards exhaustive molecular characterization. However, because of treatment resistance and the growing emergence of pharmacological targets, tumor-specific customized panels are needed to guide therapeutic strategies.Objective: The objective of this study was to present such a customized next-generation sequencing panel in melanoma.Methods: Melanoma patients with somatic molecular profiling performed as part of routine care were included. High-throughput sequencing was performed with a melanoma tailored next-generation sequencing panel of 64 genes involved in molecular classification, prognosis, theranostic, and therapeutic resistance. Single nucleotide variants and copy number variations were screened, and a comprehensive molecular analysis identified clinically relevant alterations.Results: Four hundred and twenty-one melanoma cases were analyzed (before any treatment initiation for 94.8% of patients). After bioinformatic prioritization, we uncovered 561 single nucleotide variants, 164 copy number variations, and four splice-site mutations. At least one alteration was detected in 368 (87.4%) lesions, with BRAF, NRAS, CDKN2A, CCND1, and MET as the most frequently altered genes. Among patients with BRAFV600 mutated melanoma, 44.5% (77 of 173) harbored at least one concurrent alteration driving potential resistance to mitogen-activated protein kinase inhibitors. In patients with RAS hotspot mutated lesions and in patients with neither BRAFV600 nor RAS hotspot mutations, alterations constituting potential pharmacological targets were found in 56.9% (66 of 116) and 47.7% (63 of 132) of cases, respectively.Conclusions: Our tailored next-generation sequencing assay coupled with a comprehensive analysis may improve therapeutic management in a significant number of patients with melanoma. Updating such a panel and implementing multi-omic approaches will further enhance patients' clinical management.

The development of BRAF and MEK inhibitors (BRAFi/MEKi) has led to major advances in melanoma treatment. However, the emergence of resistance mechanisms limits the benefit duration and a complete response occurs in less than 20% of patients receiving BRAFi ± MEKi. In this study, we evaluated the impact of an intermittent versus continuous dosing schedule of BRAF/MEK inhibition in a melanoma model mildly sensitive to a BRAF inhibitor. The combination of a BRAFi with three different MEKi was studied with a continuous or intermittent dosing schedule in vivo, in a xenografted melanoma model and ex vivo using histoculture drug response assays (HDRAs) of patient-derived xenografts (PDX). To further understand the underlying molecular mechanisms of therapeutic efficacy, a biomarker pharmacodynamic readout was evaluated. An equal impact on tumor growth was observed in monotherapy or bitherapy regimens whether we used continuous and intermittent dosing schedules, with no significant differences in biomarkers expression between the treatments. The antitumoral effect was mostly due to modulations of expression of cell cycle and apoptotic mediators. Moreover, ex vivo studies did not show significant differences between the dosing schedules. In this context, our preclinical and pharmacodynamic results converged to show the similarity between intermittent and continuous treatments with either BRAFi or MEKi alone or with the combination of both.

In light of the concerns regarding the occurrence of anaplastic large-cell lymphoma, seromas, and scar capsules, there appears to be merit in analysis and presentation of the results of our series of inflatable smooth implants filled with saline solution, for which the follow-up was more than 10 years. We carried out a retrospective study, including all of the patients who underwent a first breast implant for cosmetic reasons, between 2003 and 2006. A total of 383 patients with 766 smooth implants filled with saline solution were included in our study. No cases of lymphoma and seroma were diagnosed. Eleven patients exhibited a postoperative hematoma, and four went on to develop a capsule. Twenty-two patients (5.7%) developed a Baker Grade III or IV capsule that required revision surgery. Two patients (0.5%) opted for a bilateral prosthesis replacement due to visual rippling. In total, there were 26 (3.4%) early deflations of prostheses. There is not a statistically significant correlation between the occurrence of hematomas and the formation of a capsule. We found a lower shell rate with smooth-walled versus textured implants. The fact of having a decline of 10 years allows to be exhaustive. As for wrinkling and ripples, their occurrence has not been increased by the use of inflatable retropectoral implants. Smooth inflatable implants filled with saline solution have numerous advantages such as the possibility of a very small approach route and perioperative adaptability of the volume. In light of the lack of indication of anaplastic large-cell lymphoma with smooth implants, they are clearly an attractive alternative to textured implants filled with silicone gel. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

BACKGROUND Patients with extensive burns are at risk of developing candidemia. OBJECTIVES To identify potentially modifiable risk factors and outcomes of candidemia in critically ill burns patients. PATIENTS AND METHODS Retrospective matched cohort study including adult burns patients. Patients who developed candidemia were matched with burns patients with Candida spp colonisation and sepsis or septic shock without candidemia in a ratio of 1:3 (same severity scores and colonisation index). Univariate and multiple regression analyses were performed. RESULTS Of 130 severely burned patients with Candida spp colonisation and at least one episode of sepsis or septic shock, 14 were diagnosed with candidemia. In the candidemia group, patients had a median (IQR) total burns surface area (TBSA) of 57 (38-68)%, SAPSII of 43 (36-58) and ABSI of 11 (8-13). Multiple regression analysis showed that only duration of prior antibiotic therapy was independently associated with candidemia. ICU mortality was higher in the candidemia group (71% vs 35% [P = 0.02]). The log-rank test for 28-day mortality comparing patients with candidemia treated with an empirical strategy vs a curative strategy did not reach significance (P = 0.056). CONCLUSIONS Burns patients having received recent antibiotherapy have a higher risk of candidemia. Antifungal strategies did not influence outcome in this series.

Objective: There are few means to treat large keloid scars, as exeresis—even if partial—impedes direct closure without tension in the absence of a flap or a skin graft. This study evaluates the efficacy, indications for use and limitations of a new therapeutic protocol, combining an extralesional keloid excision left to heal by secondary intention with a paraffin dressing and glucocorticoid ointment, followed by monthly intrascar injections of corticosteroids upon full re-epithelialisation. Method: A retrospective study of patients treated for keloid scars by using the new therapeutic protocol. Scars were categorised as either healed or recurring. Their recurrence was scored according to the changes in functional signs and the scar volume. Results: A total of 36 scars were studied. The mean follow-up was 14.1 months. Healing occurred in a mean of 6.8 weeks. The mean surface area was 21.6cm2. Healing rate was 30.5%. Scar volume was improved in 60% of recurrent cases and functional signs in 56%. Based on adherence with the corticotherapy, two patient groups could be discerned. For patients in the ‘adherent’ group, the healing rate was 40%, and scar volume was improved in 75% of recurrent cases and the functional signs in 83% of cases. Conclusions: The healing rate in this study was close to that reported in the literature. Excision-healing by secondary intention could therefore be offered to patients for whom adherence is uncertain. The protocol in this study offers a straightforward, fast, accessible solution that does not appear to entail any risk of additional keloids. It could potentially offer a treatment option in case of failure of other treatments, large keloid scars or scalp keloids.

Summary Our retrospective study of burn patients presents a three-step treatment of heterotopic ossification: excision surgery, early rehabilitation, and analgesia. We included patients admitted to the department for treatment of postburn heterotopic ossification between January 1, 1979, and September 30, 2015. The mean age at the time of the burn was 43.3 years. Men accounted for the majority of burn patients who developed an osteoma (70.8%). The mean total skin area burned was 38.4%. No osteoma justifying surgery was found for any patient with a total burned skin area less than 19%. The burned zones were related to the osteoma development in 94.3% of cases. On average, the surgery took place 10.8 months after the burn. The osteotomy was accompanied by surgical treatment of a contracture in 37.1% of patients. Most of the osteomata were found at the elbows (30), followed by the shoulders (3), and finally the knees (2). Rehabilitation began on D0 after the surgery, except if a flap or a thin-skin graft was used. Regarding analgesia, opiates were prescribed systematically during the immediate postoperative period. Elbow range of motion on flexion improved by a mean of 84.1°. During the postoperative period, we found 2 recurrences of osteoma and 1 elbow hematoma in two separate patients. There were no postoperative infections or neurological sequelae. Our retrospective French study confirmed results found in the international literature. The three-step treatment – excision surgery, early rehabilitation, and antalgia – seems to be the best means of treating osteoma with satisfactory results. Surgery is indicated only in the case of functional impairment and not simply based on imaging.

Resume Introduction Les complications cicatricielles post-chirurgie abdominale ou pelvienne sont plus frequentes chez les patientes obeses. L’infection, les seromes et les retards de cicatrisation occasionnes peuvent dans ce cas etre extremement difficiles a traiter. L’objectif de cette note technique est de vous presenter un cas original d’une patiente de 48 ans obese, operee neuf ans auparavant d’une hysterectomie par laparotomie et presentant de maniere chronique une fistule chronique associee a une lymphorree septique non resolutive malgre de multiples interventions chirurgicales, dont la guerison a pu etre obtenue par un lambeau de grand epiploon. Technique chirurgicale L’ideal est de realiser cette intervention en double equipe avec un chirurgien digestif en cas de survenue de plaie viscerale ou vasculaire intra-abdominale durant la dissection. Le lambeau de grand epiploon etait leve de maniere classique sur l’artere gastro-epiploique droite. Un orifice suffisamment large doit etre laisse au niveau de l’aponevrose abdominale afin d’eviter toute compression du pedicule. Enfin, le lambeau doit etre etale sur toute la surface du decollement et fixe a l’aponevrose anterieure. Conclusion La fiabilite et la richesse a la fois vasculaire et lymphatique font du lambeau de grand epiploon une methode tres efficace dans les cas de plaies chroniques associees a une lymphorrhee majeure. La cicatrisation obtenue dans le cas clinique presente met ainsi en valeur les qualites specifiques de ce lambeau.

Rare and dreaded, necrosis of the nipple-areola complex (NAC) is one of the major complications of breast reduction surgery. Our objective was to establish a management algorithm summarizing the different possible treatments reported in the literature. The data extracted from the articles selected for this literature review covered surgical techniques, frequency of NAC necrosis, type of necrosis, and management proposed for women who have had this surgery for macromastia. In the 54 articles finally selected, the mean frequency of NAC necrosis was 5.1%. The risk factors for necrosis were the weight of the tissue resected, smoking, obesity, the surgical technique used, and stretch marks. The treatments proposed were listed according to four categories of issues: patient-specific susceptibility, type of breast, surgical technique, and its technical performance. No consensus exists about the management of NAC necrosis, which remains a complication feared by surgeons. We propose a management algorithm that simplifies the therapeutic indications. Level of Evidence: Not ratable

In cases involving small burns in patients without a comorbidity or associated pathology, a referral from a surgeon is necessary and sometimes it cannot be ascertained when the patient is not brought in by a specialized team. The purpose of this retrospective study was to evaluate the quality of our method for performing telemedicine. This retrospective study included the 323 patients who were initially treated using the telemedicine system implemented between 2011 and 2016. This procedure only involved patients burned over a small portion of their body's surface area (ie, ≤15%) who were between 15 and 75 years of age and who did not have a major comorbidity. The purpose of the procedure was to evaluate the need for surgery. The initial diagnosis regarding the need for a surgical procedure was accurate in 94.4% (305/323) of the cases. Eleven patients (3.4%) were transferred unnecessarily as they ultimately did not require surgery, and seven patients (2.2%) were ultimately transferred even though the need for surgery was not initially established at the time that the pictures were viewed. No initial errors in the photographic evaluation caused a worsening in the life-threatening, functional, or aesthetic prognoses. We have recently opted to use telemedicine for initial patient management. In 94.4% of cases, the opinion that was provided was accurate. Only 3.2% of the patients for whom outpatient treatment was recommended ultimately underwent surgery without subsequently experiencing the slightest injury due to any delay in therapy. Although it will never replace clinical examination, these results have encouraged us to develop telemedicine based on digital photography.

Introduction: Cancer-associated fibroblasts (CAFs), a component of tumor microenvironment, play a key role in oncogenesis and promote growth, invasion, metastasis and chemo-resistance of tumor cells. Our previous RNAseq results brought evidence of the contribution of dermal fibroblasts obtained from cutaneous T-cell lymphoma (CTCL) lesions to support tumor growth. Here, we further go on by analyzing the alteration of protein production by dermal fibroblasts obtained from CTCL lesions versus control fibroblasts. Materials and methods: Secretome and proteome was performed on fibroblast primary cultures skin biopsies of 6 cutaneous T-cell lymphoma (CTCL[GD1]) versus fibroblasts from healthy mammary skin controls (age-paired). The fibroblasts of the two groups were studied at the 3rd passage, after stimulation or not with 5 ng/ml TGF-β for 24 h. The supernatants and lysates collected underwent enzymatic digestion with trypsin before peptide analysis by HLPC/Mass spectrometry Results: The comparison of the secretomes from the CTCL groups (± TGF-s) and the control donors showed a global significant differential expression (fold >2, p-value 2, p-value Conclusion: The present data demonstrate the potent proteomic alteration of CTCL-associated dermal fibroblasts, confirming the involvement of mesenchymal cells on the behavior of CTCL.

We read the manuscript entitled “Closed-suction drains after subcutaneous mastectomy for gynecomastia: do they reduce complications? » published by Chao et al. (Aesthetic Plast Surg, 2017. https://doi.org/10.1007/s00266-017-0959-z ). They have concluded that drains may reduce rates of seromas requiring needle aspiration after surgical treatment, but also that there are several adverse effects of drains: patients’ discomfort, anxiety, cost and additional clinic visits. They also recalled several limitations: (1) bias in terms of surgeon decision to place a drain, (2) nuances in technique. Here we want to discuss our different technique of drainage. To prevent all the disadvantages, we have chosen to replace closed-suction drains with silicone blades and a wide scar opening at the level of the periareolar scar. We carried out a retrospective study in our department in 2016. This series consisted of 83 patients (153 breasts) aged 26.7 years of age (15–67), with an average BMI of 28.6 (19.5–39). All were followed during the 12 months postoperatively. We considered here only grade 1–2a gynecomastia with palpable fibrous glandular tissue. The surgical procedure consisted of initial liposuction, then open surgical excision via the periareolar approach. We did not notice any seroma or collection requiring intervention. However, 4 patients (4/153; 2.6%) had hematomas requiring intervention the day after surgery. Our technique presents a lot of advantages, reduced length of stay in the hospital, costs from drain site care and clinic visits, patients’ discomfort, and antibiotic prescriptions. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

We aimed at assessing the predictive value of plasmatic Neutrophil Gelatinase Associated Lipocalin (pNGAL) at admission and severity scores to predict major adverse kidney events (MAKE, defined as death and/or need for renal replacement therapy (RRT) and/or non-renal recovery at day 90) in critically ill burn patients.Single-center cohort study in a burn critical care unit in a tertiary center, including all consecutive severely burn patients (total burned body surface20%) from January 2012 until January 2015 with a pNGAL dosage at admission. Reclassification of patients was assessed by Integrated Discrimination Improvement (IDI).87 patients were included. Mean age was 47.7 (IQ 25-75: 33.4-65.2) years; total burn body surface area was 40 (IQ 25-75: 30-55) % and ICU mortality 36%. 39 (44.8%) patients presented a MAKE, 32 (88.9%) patients died at day 90. pNGAL was higher in the MAKE group (423 [IQ 25-75: 327-518]pg/mL vs 184 [IQ 25-75: 147-220]pg/mL, p0.001). In multivariate analysis, pNGAL and abbreviated burn severity index (ABSI) remained associated with MAKE (OR 1.005 [CI 95% 1.0005-1.009], p=0.03 and OR 1.682 [CI95%1.038-2.726], p=0.035 respectively). Adding pNGAL to abbreviated burn severity index, simplified organ failure assessment and the simplified acute physiology score 2 did outperform clinical scores for the prediction of MAKE and AKI and for most severe forms of AKI and allowed a statistically significant reclassification of patients compared to ABSI for MAKE, RRT, AKI at Day 7 and AKI during hospitalization with a number of patients needed to screen to detect one extra episode of MAKE was 44, 13 for severe AKI and 15 for AKI.pNGAL at admission is associated with the risk of MAKE in this population, and outperform severity scores when associated. Interventional studies are now needed to assess if impact of biomarkers-guided strategies would improve outcome.