The Use of EZ Derm® in Partial-Thickness Burns: An Institutional Review of 157 Patients

OBJECTIVES

To evaluate the use of EZ Derm® (Molnlycke Health Care, US, LLC, Norcross, GA) on partial-thickness burns.

METHODS

A retrospective review of medical records from patients presenting to the Tampa General Regional Burn Center from January 1, 2008, through January 1, 2012, was conducted. A hospitalwide list of patients was generated on the basis of the presence of charge codes for EZ Derm®. All encounters that did not pass through the Burn Unit were excluded. Applicable charts were reviewed for basic patient characteristics, burn characteristics, outcomes, and complications. Complications were defined as premature separation of EZ Derm®, deviation from a flat fully epithelized wound at the time of final EZ Derm® separation and hypertrophic/keloid scaring.

RESULTS

A total of 157 patients were identified and met the study criteria. Eighteen complications were reported from 16 of the 157 patients. Complications were attributed to positioning (2/133 = 1.5%), infection (4/133 = 3.0%), incomplete epithelialization at time of separation (3/133 = 2.2%), need for additional excision and grafting (6/133 = 4.5%), hypertrophic scaring (2/60 = 3.3), and cryptogenic (1/133 = 0.75).

CONCLUSIONS

EZ Derm® has proven to be a robust wound dressing that provides cost-effective, consistent durable wound coverage with minimal complications that resolve without long-term sequela.

Successful use of ultrasound-guided compression for a princeps pollicis artery pseudoaneurysm: case report

A 73-year-old man receiving heparin developed a large hematoma in the first web after a routine blood draw. Color Doppler ultrasound demonstrated a pseudoaneurysm of the princeps pollicis artery. Ultrasound-guided compression resulted in successful thrombosis of the pseudoaneurysm.

A novel adjuvant to the resident selection process: the hartman value profile

OBJECTIVES

The goal of resident selection is twofold: (1) select candidates who will be successful residents and eventually successful practitioners and (2) avoid selecting candidates who will be unsuccessful residents and/or eventually unsuccessful practitioners. Traditional tools used to select residents have well-known limitations. The Hartman Value Profile (HVP) is a proven adjuvant tool to predicting future performance in candidates for advanced positions in the corporate setting.

METHODS

No literature exists to indicate use of the HVP for resident selection.

RESULTS

The HVP evaluates the structure and the dynamics of an individual value system. Given the potential impact, we implemented its use beginning in 2007 as an adjuvant tool to the traditional selection process.

CONCLUSIONS

Experience gained from incorporating the HVP into the residency selection process suggests that it may add objectivity and refinement in predicting resident performance. Further evaluation is warranted with longer follow-up times.

The use of growth factors and other humoral agents to accelerate and enhance burn wound healing

OBJECTIVE

Certain cytokines, especially those known as growth factors, have been demonstrated to mediate or modulate burn wound healing. Experimental and clinical evidence suggests that there are therapeutic advantages to the wound healing process when these agents are utilized. Positive effects have been reported for 4 types of wounds seen in the burn patient: partial-thickness wounds, full-thickness wounds, interstices of meshed skin grafts, and skin graft donor sites.

METHODS

A comprehensive literature search was performed using the MEDLINE, Ovid, and Web of Science databases to identify pertinent articles regarding growth factors and other cytokines in burns and wound healing.

RESULTS

The current knowledge about cytokine growth factors and their potential therapeutic applications in burn wound healing are discussed and reviewed.

CONCLUSIONS

Platelet-derived growth factor, fibroblast growth factors, epidermal growth factors, transforming growth factor alpha, vascular endothelial growth factor, insulin-like growth factor I, nerve growth factor, transforming growth factor beta, granulocyte-macrophage colony-stimulating factor, and amnion-derived cellular cytokine solution have all been suggested to enhance the rate and quality of healing in 1 or more of these wounds encountered in burn care.

Formulated collagen gel accelerates healing rate immediately after application in patients with diabetic neuropathic foot ulcers

We assessed the safety and efficacy of Formulated Collagen Gel (FCG) alone and with Ad5PDGF-B (GAM501) compared with Standard of Care (SOC) in patients with 1.5-10.0 cm(2) chronic diabetic neuropathic foot ulcers that healed <30% during Run-in. Wound size was assessed by planimetry of acetate tracings and photographs in 124 patients. Comparison of data sets revealed that acetate tracings frequently overestimated areas at some sites. For per-protocol analysis, 113 patients qualified using acetate tracings but only 82 qualified using photographs. Prior animal studies suggested that collagen alone would have little effect on healing and would serve as a negative control. Surprisingly trends for increased incidence of complete closure were observed for both GAM501 (41%) and FCG (45%) vs. Standard of Care (31%). By photographic data, Standard of Care had no significant effect on change in wound radius (mm/week) from during Run-in to Week 1 (-0.06 ± 0.32 to 0.78 ± 1.53, p=ns) but both FCG (-0.08 ± 0.61 to 1.97 ± 1.77, p<0.002) and GAM501 (-0.02 ± 0.58 to 1.46 ± 1.37, p<0.002) significantly increased healing rates that gradually declined over subsequent weeks. Both GAM501 and FCG appeared to be safe and well tolerated, and alternate dosing schedules hold promise to improve overall complete wound closure in adequately powered trials.

Clinical challenge: cutaneous Kaposi's sarcoma of the lower extremity

Kaposi's sarcoma (KS) typically presents as multiple bilateral cutaneous patches or plaques of the lower extremities. This malignancy, however, can evolve with atypical presentation masquerading as a chronic wound. Lesions can mimic venous stasis ulcers, arterial insufficiency, vascular ulcers or chronic-infected wounds. With acquired immune deficiency syndrome (AIDS)-associated KS, lesions are even more widespread, and can affect the respiratory tract, lymph nodes, gastrointestinal tract, spleen, liver and, rarely, bone. As the initial diagnosis of KS is generally determined clinically, a high index of suspicion is necessary for all patients with a known or suspected history of HIV/AIDS. Tissue biopsy with histological analysis is essential for all wound types in this patient subset, regardless of wound presentation. The purpose of this report is to review the pathogenesis as well as the typical and atypical presentations of KS with an example of a diagnostic dilemma.

Wound healing trajectories to determine pressure ulcer treatment efficacy

BACKGROUND

Wound healing trajectories (percent healing vs time) provide a dynamic picture of the decrease in wound burden over the entire continuum of the healing process. Trajectories can be robustly compared using survival statistics methodology. Improvement in healing can be determined by shifting the curve from "impaired" healing toward "ideal" healing. Although this concept of shifting the curve "to the left" has been demonstrated in acute incisional healing depicted by the gain in tensile strength, and in other chronic wounds, it has not been utilized for chronic pressure ulcers.

METHODS

Wound healing trajectories were constructed for 211 patients enrolled in 8 separate randomized clinical trials for grade III and IV pressure ulcers. Trajectories were constructed for patients achieving ≥90% or more healing within 112 days and those who achieved less than <90% wound closure. Kaplan-Meier curves were constructed for all patients receiving an experimental treatment and for those receiving placebo vehicles.

RESULTS

Different trajectories were achieved for the faster healing patients. Eighty-one percent of patients reached 90% healing within 112 days; 80% of those in treatment groups and 85% of those in placebo groups. Linear regression suggested that all patients entered into the clinical trials would achieve 90% healing by 18 weeks. Only 17% of the patients achieved total healing (100% wound closure) within the 112-day study period. Linear regression suggested that it would take 110 weeks to achieve total healing in all patients.

CONCLUSION

Wound healing trajectories provide a more complete description of treatment efficacy than do fixed endpoints, such as the number of patients achieving 100% closure at one defined time point. Since more successful healers have different trajectories than less successful healers, shifting the trajectory to the left from "impaired" toward "ideal" healing may provide a better endpoint to determine treatment efficacy.

Primary breast lymphoma after mastectomy with reconstruction

Primary breast lymphoma accounts for only 0.05%-1.1% of all breast malignancies, and less than 1% of all cases of non-Hodgkin lymphoma. Although primary breast lymphoma may present clinical similarities to breast carcinoma, the majority of cases lack the typical features of breast malignancy or lymphoma. We describe a case of primary breast lymphoma in a reconstructed breast, 8 years after a mastectomy for breast cancer. To the best of our knowledge, this is the first reported case in the worldwide literature of primary breast lymphoma in a reconstructed breast. We will discuss the diagnostic and treatment strategies involved in the management of primary breast lymphoma, and the effect of breast reconstruction on the detection of recurrent breast cancer.

A prospective, randomized clinical trial to assess the cost-effectiveness of a modern foam dressing versus a traditional saline gauze dressing in the treatment of stage II pressure ulcers

Modern dressings such as hydrocolloids, gels, and foams are typically more expensive than traditional dressings such as gauze. However, if modern dressings require fewer changes, the overall cost of treatment may be lower despite the higher initial purchase price. If healing rates are comparable or better, modern dressings also may be cost-effective. A 4-week, prospective, randomized clinical trial to assess differences in treatment costs and cost-effectiveness between a modern foam dressing and saline-soaked gauze was conducted among 36 patients (22 men, 14 women, mean age 72.8 years) with a Stage II pressure ulcer (mean duration 35 weeks) at five centers in the United States. Participants were randomized to treatment with a self-adhesive polyurethane foam (n = 20) or saline-soaked gauze dressing (n = 16). No difference in time to wound closure was observed (P = 0.817). Patients in the foam group had less frequent dressing changes (P <0.001). Total cost over the study period was lower by $466 per patient (P = 0.055) and spending on dressings was lower by $92 per patient in the foam group (P = 0.025). Cost per ulcer healed was lower by $1,517 and cost per ulcer-free day was lower by $80 for patients in the foam group. On the evidence of this study, the foam dressing is a more cost-effective treatment than saline-soaked gauze for the treatment of Stage II pressure ulcers.

Nail-gun injuries to the hand

BACKGROUND

The nail gun is a commonly utilized tool in carpentry and construction. When used properly with appropriate safety precautions, it can facilitate production and boost efficiency; however, this powerful tool also has the potential to cause serious injury. The most common site of nail-gun injuries in both industrial and nonoccupational settings is the hand.

MATERIALS AND METHODS

We report on two patients with nail-gun injuries to the hand. A review of the literature and discussion of clinical evaluation and treatment of nail-gun injuries to the hand are presented.

RESULTS

Two patients present with soft tissue injuries to the hand with the nail embedded and intact at the injury site. Operative removal of the nail and wound care resulted in successful treatment in both cases. Nail-gun injuries to the hand vary in severity on the basis of the extent of structural damage. Treatment is based on the severity of injury and the presence and location of barbs on the penetrating nail.

CONCLUSION

Healthcare providers must understand and educate patients on the prevention mechanics of nail-gun injuries. Nail-gun injuries to the hand necessitate appropriate evaluation techniques, understanding of surgical management versus nonsurgical management, and awareness of potential pitfalls in treatment.

Osteomyelitis of the mandibular symphysis caused by brown recluse spider bite

BACKGROUND

Brown recluse spider bites cause significant trauma via their tissue toxic venom. Diagnosis of these injuries and envenomation is difficult and many times presumptive. Treatment is varied and dependent upon presentation and course of injury.

MATERIALS AND METHODS

We present a case of a previously unreported incidence of osteomyelitis of the mandible as a result of a brown recluse spider bite. A review of the literature and discussion of diagnosis and treatment of brown recluse spider bites are presented.

RESULTS

Osteomyelitis of the mandible causing a chronic wound was the presenting finding of a patient with a history of spider bite and exposure to brown recluse spiders. Operative debridement and wound closure resulted in successful treatment. Brown recluse spider envenomation varies in its presentation and treatment is based on the presenting clinical picture.

CONCLUSION

Treatment regimens for brown recluse spider bite envenomation should include the basics of wound care. Systemic antibiotics, topical antimicrobials, dapsone, and surgical debridement are valuable adjuncts of treatment, as indicated, based on the clinical course.

The use of amnion-derived cellular cytokine solution to improve healing in acute and chronic wound models

OBJECTIVE

Growth factors demonstrate mixed results improving wound healing. Amnion-derived multipotent cells release physiologic levels of growth factors and tissue inhibitors of metalloproteinases. This solution was tested in models of acute and chronic wound healing.

METHODS

Acute model: Sprague-Dawley rats underwent laparotomy incisions. The midline fascia was primed with phosphate-buffered saline, unconditioned media, or amnion-derived cellular cytokine suspension prior to incision. Breaking strength of laparotomy wounds was tested with an Instron tensiometer. Incisional hernia formation was measured after 28 days. Chronic model: Chronic, infected granulating wounds were produced in rats by excising full thickness burn eschars inoculated with Escherica coli. Granulating wounds were treated with unconditioned media or amnion-derived cellular cytokine suspension. Treatments were applied either on day 0 and day 7 or day 0 and then every other day. Wounds were traced every 72 hours and biopsied for quantitative bacteriology.

RESULTS

Acute model: Priming with amnion-derived cellular cytokine suspension increased the breaking strength of laparotomy incisions in comparison with phosphate-buffered saline or unconditioned media (P < .05). Acute wound failure and incisional hernia formation was 100% in the phosphate-buffered saline and unconditioned media groups and 18% in the amnion-derived cellular cytokine suspension-treated group (P <.05). Chronic model: The rate of wound closure was accelerated in amnion-derived cellular cytokine suspension-treated chronic wounds (P < .05). Multidosing improved the effect.

CONCLUSIONS

A physiologic solution of cytokines and tissue inhibitors of metalloproteinases improves healing in models of acute and chronic wounds. Such a cocktail can be produced from amnion-derived multipotent progenitor cells.

Enzymatic debriding agents are safe in wounds with high bacterial bioburdens and stimulate healing

BACKGROUND

Debridement is essential for successful wound management. Enzymatic debridement is commonly utilized in wound care but has been reported to be unsafe in wounds with significant bacterial bioburden, unless used in conjunction with topical antimicrobials. We examine this hypothesis with 2 commercially available, commonly used preparations of enzymatic debriding agents.

MATERIALS AND METHODS

Using a standard rodent model of a chronically infected granulating wound with bacterial levels greater than 1 x 10(5) Colony Forming Units per gram of tissue, commercially available preparations of collagenase and papain-urea were utilized to investigate the response of infected wounds to these preparations, and to evaluate their ability to overcome the inhibition of infection on wound healing. Quantitative bacteriology of tissue biopsies and wound healing trajectories were used to compare the preparations to saline-treated negative controls.

RESULTS

Collagenase- and papain-urea-treated wounds demonstrated a reduction in bacterial burden of wounds to < 10(5) colony forming units/gram of tissue (P < .05). This decrease in bacterial bioburden occurred rapidly, allowing wounds to achieve bacterial balance in a short period of time. Wounds treated with enzymatic debriding agents healed significantly faster and to greater extent than saline-treated controls (P < .01); a direct reflection of the decreasing bacterial load of the wound.

CONCLUSIONS

Collagenase and papain-urea appear beneficial and safe even in wounds with high bacterial loads, and appear to significantly aid extent and rate of healing, probably by lowering bacterial burden through their positive enzymatic actions on bacteria and necrotic tissue.

Nonvenomous Bite Injuries of the Foot: Case Reports and Review of the Literature

Animal bite injuries to humans are relatively common, however, bite injuries to the lower extremity and more specifically the foot are relatively uncommon. Foot injuries, once infected, may lead to further complications, such as soft tissue loss, bone loss, and the need for amputation. Patients with preexisting medical conditions, such as peripheral vascular disease and diabetes, are especially at risk for such complications. In this article, 2 recent cases are detailed and the literature to examine these injuries of the foot is reviewed.

Wound healing in patients with cancer

OBJECTIVE

The treatment of patients with cancer has advanced into a complex, multimodal approach incorporating surgery, radiation, and chemotherapy. Managing wounds in this population is complicated by tumor biology, the patient's disease state, and additional comorbidities, some of which may be iatrogenic. Radiation therapy, frequently employed for local-regional control of disease following surgical resection, has quantifiable negative healing effects due to local tissue fibrosis and vascular effects. Chemotherapeutic agents, either administered alone or as combination therapy with surgery and radiation, may have detrimental effects on the rapidly dividing tissues of healing wounds. Overall nutritional status, often diminished in patients with cancer, is an important aspect to the ability of patients to heal after surgical procedures and/or treatment regimens.

METHODS

An extensive literature search was performed to gather pertinent information on the topic of wound healing in patients with cancer. The effects that surgical procedures, radiation therapy, chemotherapy, and nutritional deficits play in wound healing in these patients were reviewed and collated.

RESULTS

The current knowledge and treatment of these aspects of wound healing in cancer patients are discussed, and observations and recommendations for optimal wound healing results are considered.

CONCLUSION

Although wound healing may proceed in a relatively unimpeded manner for many patients with cancer, there is a potential for wound failure due to the nature and effects of the oncologic disease process and its treatments.

Comparative evaluation of silver-containing antimicrobial dressings and drugs

Wound dressings containing silver as antimicrobial agents are available in various forms and formulations; however, little is understood concerning their comparative efficacy as antimicrobial agents. Eight commercially available silver-containing dressings, Acticoat 7, Acticoat Moisture Control, Acticoat Absorbent, Silvercel, Aquacel Ag, Contreet F, Urgotol SSD and Actisorb, were tested to determine their comparative antimicrobial effectiveness in vitro and compared against three commercially available topical antimicrobial creams, a non treatment control, and a topical silver-containing antimicrobial gel, Silvasorb. Zone of inhibition and quantitative testing was performed by standard methods using Escherichia coli, Pseudomonas aeruginosa, Streptococcus faecalis and Staphylococcus aureus. Results showed all silver dressings and topical antimicrobials displayed antimicrobial activity. Silver-containing dressings with the highest concentrations of silver exhibited the strongest bacterial inhibitive properties. Concreet F and the Acticoat dressings tended to have greater antimicrobial activity than did the others. Topical antimicrobial creams, including silver sulfadiazine, Sulfamylon and gentamicin sulfate, and the topical antimicrobial gel Silvasorb exhibited superior bacterial inhibition and bactericidal properties, essentially eliminating all bacterial growth at 24 hours. Silver-containing dressings are likely to provide a barrier to and treatment for infection; however, their bactericidal and bacteriostatic properties are inferior to commonly used topical antimicrobial agents.

Hypochlorous Acid as a Potential Wound Care Agent: Part II. Stabilized Hypochlorous Acid: Its Role in Decreasing Tissue Bacterial Bioburden and Overcoming the Inhibition of Infection on Wound Healing

Background: A topical antimicrobial that can decrease the bacterial bioburden of chronic wounds without impairing the wound's ability to heal is a therapeutic imperative. A stabilized form of hypochlorous acid (NVC-101) has been demonstrated in vitro and in standard toxicity testing to possess properties that could fulfill these criteria. Materials and Methods: Using a standard rodent model of a chronically infected granulating wound, various preparations of NVC-101 and multiple treatment regimens were investigated to evaluate the role of NVC-101 in decreasing tissue bacterial bioburden and overcoming the inhibition of infection on wound healing. Quantitative bacteriology of tissue biopsies and wound healing trajectories were used to compare the various NVC-101 preparations and regimens to saline-treated negative controls and silver sulfadiazine-treated positive controls. Results: NVC-101 at 0.01% hypochlorous acid with a pH of 3.5 to 4.0 proved to be an effective topical antimicrobial. It was most effective when used for a brief period (15-30 minutes), and followed with another application. Possibly this was due to its rapid neutralization in the wound bed environment. Although not as effective at decreasing the tissue bacterial bioburden as silver sulfadiazine, NVC-101 was associated with improved wound closure. Conclusions: This stabilized form of hypochlorous acid (NVC-101) could have potential application as an antimicrobial wound irrigation and treatment solution if its effective pH range can be maintained in the clinical situation. NVC-101 solution was equally effective at pH 3.5 or 4.0 and more efficient soon after its application. As opposed to other antimicrobials investigated in this animal model, NVC-101 controls the tissue bacterial bioburden without inhibiting the wound healing process.

Down-regulating causes of fibrosis with tamoxifen: a possible cellular/molecular approach to treat rhinophyma

Fibrosis and proliferative scarring are prominent features of the severe forms of rhinophyma. Up-regulation of growth and fibroblast kinetics are hallmarks of fibrosis. Persistent overexpression or dysregulated activation of the fibrogenic isoforms of transforming growth factor beta (TGF-beta) is associated with the increased fibroblast function leading to fibrotic conditions such as rhinophyma. Tamoxifen, a synthetic nonsteroidal antiestrogen, can neutralize or down-regulate TGF-beta. Fibroblast-populated collagen lattices (FPCLs) were constructed from fibroblasts cultured from rhinophyma or normal nasal skin. One-half of each set of FPCLs was treated with Tamoxifen. Lattice contraction was serially measured over 5 days, and the supernatants of the cultures were analyzed for TGF-beta-2 by immunoassay. Tamoxifen significantly decreased fibroblast activity by decreasing contraction of the treated lattices (P < 0.05) and significantly decreased the production/secretion of TGF-beta-2 by rhinophyma fibroblasts (P < 0.001). These results suggest a possible new cellular/molecular approach to the treatment of the fibrotic varieties of rhinophyma.

Wound-healing trajectories as outcome measures of venous stasis ulcer treatment

Outcome measures of venous ulcer healing are not uniformly accepted. Stringent criteria of 100% closure fail to provide information of healing over the entire span of repair. Wound-healing trajectories (plot of percentage of wound closure versus time of wound treatment) were constructed for 232 patients treated in eight clinical trials at two independent wound care/research centres. Trajectories were constructed for ulcers that totally healed (100% closure) and those that did not (<100% closure) over a 20-week period. Kaplan-Meier survival plots determined the percentage of patients achieving total healing versus time of treatment. The wound-healing trajectories were almost identical for patients achieving complete ulcer healing, as were the trajectories for patients with less than 100% closure. The trajectories for the ulcers healing completely were significantly different from those with <100% closure. Only 60% of all patients achieved 100% closure by 20 weeks. Using linear regression, it was predicted that it would take 31 weeks for all patients to achieve total healing. Total healing is an inadequate outcome measure for healing of venous stasis ulcers. Clinical trials using this measure would require excessive time periods. As wound-healing trajectories for patients treated at two centres mimic one another, shifting the wound-healing trajectory from one of impaired healing to one of a more ideal healing course may be considered a better outcome measure for determining healing of venous stasis ulcers.

Cultured pressure ulcer fibroblasts show replicative senescence with elevated production of plasmin, plasminogen activator inhibitor-1, and transforming growth factor-beta1

In a 16-patient study, cultured fibroblast populations from normal skin were able to replicate an average of 14.8 +/- 2.2 times before becoming senescent, while fibroblast populations from the ulcer bed reached the end of their replicative life span after 7.2 +/- 1.9 population doublings (p= 0.001). Fibroblast populations from 10 of 16 pressure ulcers became senescent after fewer than five population doublings, whereas when populations of fibroblasts from adjacent normal skin were studied, only 2 of 16 became senescent within this same time period. In addition, only an occasional fibroblast from normal skin stained positively for senescence-associated beta-galactosidase compared to approximately 50% of equally aged ulcer bed fibroblasts (p = 0.0060). Senescent ulcer bed fibroblasts secreted significantly more plasmin than early passage ulcer bed fibroblasts (p= 0.0237), nearly six times as much plasmin as early passage normal skin fibroblasts (p < 0.0001), three and a half times the level of normal skin fibroblasts of the same age (11.52 +/- 4.58 microg/mg protein; p= 0.0003), and more than one and a half times the level of senescent normal skin fibroblasts (p= 0.0525). Senescent pressure ulcer fibroblasts generated significantly more plasminogen activator inhibitor-1 (1179.27 +/- 25.37 ng/mg protein) than normal skin fibroblasts of the same age (132.16 +/- 16.20 ng/mg protein; p = 0.0357). Also, senescent ulcer bed fibroblasts produced higher levels of transforming growth factor-beta1, but these were not significantly different from senescent normal skin fibroblasts. Although senescent ulcer fibroblasts produce elevated levels of plasminogen activator inhibitor-1 and transforming growth factor-beta1, the ratio of these factors to plasmin levels suggests that this may have little influence on extracellular matrix synthesis or maintenance in the chronic wound. These data show that cultured fibroblasts from most patient pressure ulcers profile a wound environment that is associated with an increasing population of senescent fibroblasts; however, factors within the chronic wound environment that promote cellular senescence remain unclear. We have proposed that a prolonged inflammatory response may be a contributing factor to the chronic wound condition.

Radiated Groin Wounds: Pitfalls in Reconstruction

Reconstruction procedures of soft tissue defects created after tumor excision in the ilioinguinal region which have received prior radiation therapy are associated with serious morbidities. Despite the availability of muscle or myocutaneous flaps, wound infection, wound breakdown, and necrosis occur with relative frequency. Changes in tissues secondary to radiation therapy are chronic and permanent and adversely affect wound healing. Tumors in this region should be considered for primary excision and reconstruction, followed by radiation, if necessary.

Radiated groin wounds: pitfalls in reconstruction

Reconstruction procedures of soft tissue defects created after tumor excision in the ilioinguinal region which have received prior radiation therapy are associated with serious morbidities. Despite the availability of muscle or myocutaneous flaps, wound infection, wound breakdown, and necrosis occur with relative frequency. Changes in tissues secondary to radiation therapy are chronic and permanent and adversely affect wound healing. Tumors in this region should be considered for primary excision and reconstruction, followed by radiation, if necessary.

Prophylactic antibiotics in plastic surgery: trends of use over 25 years of an evolving specialty

BACKGROUND

Infection complicating a plastic-surgery procedure can be a catastrophic event, both for the patient and the surgeon. Surveys published in 1975 and 1985 demonstrated the "usual and customary" practices of plastic surgeons with regard to the use of prophylactic antibiotics.

OBJECTIVE

The objective of this study was to determine plastic surgeons' current use of prophylactic antibiotics, to compare these data with similar data from 1975 and 1985, and to gain relevant information regarding newer aesthetic procedures.

METHODS

We conducted a survey of members of the American Society of Plastic Surgeons to elicit information on the frequency and timing of and modifying influences on their use of prophylactic antibiotics for plastic surgery procedures. The data we compiled were compared with the 1985 and 1975 data.

RESULTS

Respondents returned 1804 questionnaires, for a 35% response rate. Antibiotic usage increased by 100% in nearly half of the operative categories surveyed since 1985 (P = .001). Aesthetic procedures were most common in this group. In 7 procedures, usage increased by 200% (P = 0.001). These categories included rhinoplasty, blepharoplasty, rhytidectomy, and arm contouring.

CONCLUSIONS

The use of prophylactic antibiotics by plastic surgeons is increasing, especially in aesthetic procedures. A review of the literature indicates that this increase in use is not based on scientific evidence of increased incidence of infection or on increased evidence of efficacy. The necessary data to provide scientific guidelines for antibiotic usage in plastic surgery do not exist. (Aesthetic Surg J 2003;23:177-183.).

Significance of cell cycle for wound stratification in clinical trials: analysis of a pressure ulcer clinical trial utilizing cyclin D/cdk4

During the past 5 years, progress in the treatment of pressure ulcers appears to have reached a plateau. Several factors in the design of recent clinical studies may have contributed to this situation. These factors include the criteria chosen for patient selection, small sample size, and lack of a concisely defined final clinical outcome. Hunt noted that wound stratification according to a patient's physiological characteristics may be a key to quantifying differences among clinical treatments. To address this issue, we examined the expression of cyclin D/cdk4 in pressure ulcer fibroblasts taken from tissues during a recent clinical trial. The treatment groups included patients treated with the following regimens: placebo, granulocyte macrophage-colony stimulating factor alone, basic fibroblast growth factor alone, or granulocyte macrophage-colony stimulating factor and basic fibroblast growth factor given in sequence. Immunocytochemical colocalization of cyclin D and cdk4 showed that, before the initial treatment began, patients were distributed disproportionately among treatment subgroups in regards to the initial expression of these markers. For example, we found that compared with other subgroups, ulcer fibroblasts in the basic fibroblast growth factor treatment group showed a much lower expression of cyclin D/cdk4 at day 0. However, this group exhibited higher levels of expression of this complex after 35 days of treatment. This study shows that measurement of cyclin D/cdk4 expression permits more accurate stratification of patients within treatment subgroups, measurement of a cell's ability to detect the presence of functional cytokines, identification of area(s) of failure within the G1 of the cell cycle, and a basis for critical evaluation of various treatments.

Decreasing amputation rates in patients with diabetes mellitus. An outcome study

The lower-extremity amputation rate in people with diabetes mellitus is high, and the wound failure rate at the time of amputation is as high as 28%. Even with successful healing of the primary amputation site, amputation of part of the contralateral limb occurs in 50% of patients within 2 to 5 years. The purpose of this study was to provide valid outcome data before (control period) and 18 months after (test period) implementation of a multidisciplinary team approach using verified methods to improve the institutional care of wounds. Retrospective medical chart review was performed for 118 control patients and 116 test patients. The amputation rate was significantly decreased during the test period, and the amputations that were required were at a significantly more distal level. No above-the-knee amputations were required in 45 patients during the test period, compared with 14 of 76 patients during the control period. These outcome data suggest that unified care is an effective approach for the patient with diabetic foot problems.

Mycobacterium kansasii causing carpal tunnel syndrome with concomitant pulmonary Mycobacterium tuberculosis infection

Mycobacterium kansasii is an uncommon cause of infection of the hand. Other atypical mycobacteria that cause hand infections are M marinium, M avium, M intracellularis, and M chelonei. Such infections usually occur around aquatic areas, though sometimes the source of infection is elusive. Inoculation of the atypical mycobacterium into the host occurs usually from a traumatic break in the skin. Patients commonly report a history of fish tank cleaning, oyster shucking, swinuning, or other aquatic activities. Several drug regimenshave been suggested and used successfully. Surgical intervention is occasionally required for unresponsive or symptomatic cases. Concomitant hand infection and pulmonary tuberculosis is extremely rare. We present a case report of M kansasii infection of the hand and forearm, with carpal tunnel syndrome complicated by concomitant pulmonary M tuberculosis.

Further evidence for the role of fibrosis in the pathobiology of rhinophyma

Recent evidence suggests that fibrosis may play an important role in the pathobiology of rhinophyma. The fibrogenic cytokine transforming growth factor (TGF)-beta2 has been reported to be up-regulated in rhinophyma tissue. Of the three common isoforms of TGF-beta, TGF-beta1 and TGF-beta2 are considered fibrogenic, whereas TGF-beta3 has antiscarring properties. To provide further evidence for the role of fibrosis in the pathobiology of rhinophyma, specimens from 8 patients with rhinophyma were compared with nine specimens of normal nasal skin. Immunohistochemistry was used to compare intensity levels of TGFbeta1 and TGFbeta3 proteins, and quantitative reverse transcription-polymerase chain reaction was used to determine messenger ribonucleic acid (mRNA) expression levels of TGFbeta1 and TGFbeta3. TGF-beta1 was elevated significantly in rhinophyma tissue (p < 0.001), whereas TGF-beta3 was no different in the rhinophyma specimens compared with normal nasal skin (p = 0.06). TGFbeta1 mRNA expression was five-fold higher in rhinophyma tissue compared with normal skin (p < 0.001). The mRNA expression of TGF-beta3 was the same for both pathological and normal tissue (p < 0.09). These data, together with previously published observations, present further evidence that fibrosis mediated by the fibrogenic cytokines TGFbeta1 and TGFbeta2 play a role in the pathobiology of rhinophyma and suggest a means of treatment by neutralizing or down-regulating these cytokines.

Tamoxifen decreases fibroblast function and downregulates TGF(beta2) in dupuytren's affected palmar fascia

BACKGROUND

Dupuytren's contracture is a fibroproliferative disorder that is associated with increased collagen deposition. Isoforms of transforming growth factor beta (TGF(beta)), normally TGF(beta1) and TGF(beta2), are involved in the progressive fibrosis of Dupuytren's disease. It has been suggested that downregulation of TGF(beta) may be useful in the treatment of the condition. Tamoxifen, a synthetic nonsteroidal antiestrogen, is known to modulate the production of TGF(beta). This study examined the role of tamoxifen in decreasing fibroblast function and downregulating TGF(beta2).

METHODS

Primary cultures of fibroblasts were obtained from Dupuytren's affected fascia and carpal tunnel affected fascia as a control. Collagen lattices were prepared and populated with the fibroblasts. The fibroblast-populated collagen lattices (FPCL) were then measured for contraction every 24 h for 5 days. Supernatant was obtained from the culture medium following completion of the FPCL portion of the experiment and used for a TGF(beta2) immunoassay.

RESULTS

Dupuytren's affected fibroblasts contracted the FPCLs significantly more than carpal tunnel control fibroblasts. Treating the fibroblasts with tamoxifen caused a decreased contraction rate in both Dupuytren's affected fibroblasts and carpal tunnel controls. There was increased TGF(beta2) expression in the Dupuytren's affected fascia group compared to the carpal tunnel control group. Tamoxifen decreased TGF(beta2) expression in Dupuytren's affected fascia group but not in the carpal tunnel control group.

CONCLUSION

TGF(beta) appears to be the key cytokine in the fibrogenic nature of Dupuytren's disease. Tamoxifen treatment has been demonstrated to decrease the function of fibroblasts derived from Dupuytren's affected fascia and downregulated TGF(beta2) production in these same fibroblasts. These data suggest a method to manipulate and control Dupuytren's contracture in the clinical setting.

Desmoplastic Melanoma

Desmoplastic melanoma is an uncommonly encountered variant of malignant melanoma. Three histological subtypes exist: desmoplastic, neurotropic, and neural transforming. Desmoplastic melanoma commonly presents in conjunction with existing melanocytic lesions or as an amelanotic firm nodule. Local recurrences are common. Thirty patients over a 6-year period were treated at our institution for desmoplastic melanoma. All lesions were treated with local excision. Local recurrence occurred in seven patients (23%) and was treated by aggressive re-excision in each instance. Clinical regional metastasis (lymph nodal basins) were detected in two patients (6%). Distant metastasis (lung) developed in two patients (6%). Twenty-three patients (76%) were found to have desmoplastic subtype, whereas five (17%) had neurotropic subtype. Six patients (20%) had associated pigmented melanotic lesions. Average length of follow-up has been 18 months. Overall survival is 96 per cent. Presentations and histologic diagnosis can sometimes be difficult and misleading. Treatment is aggressive local excision with follow-up necessary to detect resectable recurrent lesions.

Desmoplastic melanoma

Desmoplastic melanoma is an uncommonly encountered variant of malignant melanoma. Three histological subtypes exist: desmoplastic, neurotropic, and neural transforming. Desmoplastic melanoma commonly presents in conjunction with existing melanocytic lesions or as an amelanotic firm nodule. Local recurrences are common. Thirty patients over a 6-year period were treated at our institution for desmoplastic melanoma. All lesions were treated with local excision. Local recurrence occurred in seven patients (23%) and was treated by aggressive re-excision in each instance. Clinical regional metastasis (lymph nodal basins) were detected in two patients (6%). Distant metastasis (lung) developed in two patients (6%). Twenty-three patients (76%) were found to have desmoplastic subtype, whereas five (17%) had neurotropic subtype. Six patients (20%) had associated pigmented melanotic lesions. Average length of follow-up has been 18 months. Overall survival is 96 per cent. Presentations and histologic diagnosis can sometimes be difficult and misleading. Treatment is aggressive local excision with follow-up necessary to detect resectable recurrent lesions.

Biotransformation, excretion kinetics, and tissue distribution of an N-pyrrolo[1,2-c]imidazolylphenyl sulfonamide herbicide in rats

TY029, an N-pyrrolo[1,2-c]imidazolylphenyl sulfonamide herbicide, controls economically important weeds through inhibition of protoporphyrinogen oxygenase. Due to the potential for exposure to this compound in food and animal feed items, a rat metabolism study was required to define the biotransformation of this compound. Animals were exposed to single 50- and 2-mg/kg doses of TY029 [hydantoin-5-(14)C] by oral gavage. About 90% of the administered dose was excreted within 96 h after oral administration. Excretion plateaued after 48 h, and the cumulative sum of urinary or fecal excretion after 48 h was less than 5% of the orally administered dose. TY029 yielded seven major metabolites. While some metabolites were formed by epimerization around chiral centers, others were generated through hydrolytic bond cleavage and hydroxylations and subsequent oxidation of hydroxyl groups to carboxylic acids. One metabolite, about 6.1% of the dose, was observed only in the urine from low-dose female rats. This metabolite was characterized as a glutamate conjugate of an extensively oxidized analog of TY029. With the exception of the glutamate conjugate, the same metabolites were observed in the excreta of all dose groups. However, the relative ratios of the metabolites were different between various dose groups.

Cytokine manipulation of explanted Dupuytren's affected human palmar fascia

INTRODUCTION

Dupuytren's disease plagues human hands and digits producing fibrotic nodules and fascial cords with resultant debilitating flexion contracture deformities. Interest in this condition is great but because the disease is specific to humans and study has been hampered by the lack of an in vivo model. By utilizing an in vivo "nude" rat model it is possible to maintain and study explanted Dupuytren's contracted palmar fascia for prolonged periods of time.

MATERIALS AND METHODS

Human specimens were divided into four, one for in vitro analysis, and three for model explantation. The explanted tissue was perfused with either transforming growth factor beta-2 (TGFbeta2), its antibody, or a control vehicle. Explant biopsies were obtained at 30 and 60 days and compared to tissue prior to explantation. Immunohistochemistry of collagen I and III, DNA synthesis, protein production, and fibroblast kinetics were serially determined.

RESULTS

Perfusion of explanted Dupuytren's tissue by TGFbeta2 upregulated collagen I and III from biopsies obtained from the explants at 30 days when compared to vehicle control (P < 0.001). Perfusion with antibody prevented this upregulation when compared to vehicle control (P < 0.001). Cell cultures derived from fibroblasts obtained from biopsies of the explants perfused with TGFbeta2 increased DNA synthesis, protein production and fibroblast kinetics.

CONCLUSION

These findings paralleled those from other fibroproliferative disorders suggesting a role for TGFbeta2 in the pathogenesis of Dupuytren's contracture as well as possible novel treatment approaches.

Long-term outcome study of growth factor-treated pressure ulcers

BACKGROUND

Exogenous application of growth factors have been reported in an attempt to accelerate healing of chronic wounds. Most of the trials were of brief duration with short to no follow-up periods. Long-term outcome studies are sparse for pressure ulcer therapies with success rates around 30% for both operative and nonoperative treatments.

METHODS

Follow-up evaluations were performed serially up to 12 months for patients completing a 35 day blinded, placebo-controlled cytokine clinical trial of pressure ulcers.

RESULTS

Fifty-four of 61 patients completed the follow-up period with 68.5% of the patients (37 of 54) being healed after 1 year. Of patients healing > or =85% during the active treatment phase, 84.6% were healed after 1 year compared with 61% of those that healed <85% during treatment (P <0.05).

CONCLUSION

Long-term outcome was better in this growth factor trial than with surgical or standard nonoperative treatment of pressure ulcers. Since only patients receiving exogenously applied cytokines achieved >85% closure during the treatment phase of the trial, the excellent long-term outcome appears attributable to the cytokine therapy.

Overexpression of transforming growth factor beta-2 and its receptor in rhinophyma: an alternative mechanism of pathobiology

Proliferative scarring is one of the clinical features of rhinophyma. The following study was undertaken to test the authors' hypothesis that fibrosis might also play an important role in the pathobiology of rhinophyma. The rhinophyma specimens were obtained from 5 white men (mean age, 67.8 years). Normal skin biopsies near benign facial lesions from 5 additional white men of similar age were obtained to serve as controls. Peroxidase-labeled immunohistochemical staining was performed in the rhinophyma and normal skin specimens for the presence of transforming growth factor (TGF) beta-2 and/or TGF-beta II receptor. Histological slides were then measured for the intensity of staining for TGF-beta2 and TGF-beta II receptor using a computer-aided imaging system. The dermis of the rhinophyma tissue displayed stronger immunoreactivity of TGF-beta2 (p = 0.014) and TGF-beta II receptor (p = 0.006) compared with the normal skin. The results of this study demonstrate the overexpression of the fibrogenic protein TGF-beta 2 and TGF-beta II receptor in rhinophyma tissues. These findings support the authors' hypothesis that fibrosis may also play an important role in the pathobiology of rhinophyma.

Sequential cytokine therapy for pressure ulcers: clinical and mechanistic response

OBJECTIVE

To compare the healing response of sequential topically applied cytokines to that of each cytokine alone and to a placebo in pressure ulcers, and to evaluate the molecular and cellular responses.

SUMMARY BACKGROUND DATA

Because of a deficiency of cytokine growth factors in chronic wounds and the reversal of impaired healing in animal models, pressure ulcer trials have been performed with several exogenously applied growth factors. Because single-factor therapy has not been uniformly successful, combination or sequential cytokine therapy has been proposed. Laboratory data have suggested that sequential treatment with granulocyte-macrophage/colony-stimulating factor (GM-CSF)/basic fibroblast growth factor (bFGF) might augment the previously reported effect of bFGF alone.

METHODS

A masked, randomized pressure ulcer trial was performed comparing sequential GM-CSF/bFGF therapy with that of each cytokine alone and with placebo during a 35-day period. The primary measure was wound volume decrease over time. Cytokine wound levels and mRNA levels were serially determined. Fibroblast-populated collagen lattices (FPCLs) were constructed from serial fibroblast biopsies. Cellular ultrastructure was evaluated by electron microscopy. Changes in ease of surgical closure and its relative cost were determined.

RESULTS

Ulcers treated with cytokines had greater closure than those in placebo-treated patients. Patients treated with bFGF alone did the best, followed by the GM-CSF/bFGF group. Patients treated with GM-CSF or bFGF had higher levels of their respective cytokine after treatment. Patients with the greatest amount of healing showed higher levels of platelet-derived growth factor (PDGF) on day 10 and transforming growth factor beta (TGFbeta1) on day 36. Message for the bFGF gene was upregulated after treatment with exogenous bFGF, suggesting autoinduction of the cytokine. FPCLs did not mimic the wound responses. Ultrastructure of wound biopsies showed response to bFGF. Treatment with any of the cytokines improved the wound by allowing easier wound closure. This was most marked for the bFGF-alone treatment, with a cost savings of $9,000 to $9,200.

CONCLUSIONS

Treatment with bFGF resulted in significantly greater healing than the other treatments in this trial. The clinical response appeared to be related to upregulation of the bFGF message and to increased levels of PDGF-AB, bFGF, and TGFbeta1 in the wounds and changes in ultrastructure. The resultant improvements could be correlated with cost savings.

Maintenance of wound bacterial balance

BACKGROUND

There is a critical number of bacteria above which tissue responds with infection. This balance of 10(5) or fewer bacteria/g tissue is also required for wound healing to proceed normally. This study evaluated whether a chronic wound once in bacterial balance can maintain that balance over time.

METHODS

Serial biopsies for bacterial analyses were obtained weekly during a blinded, placebo-controlled cytokine clinical trial of pressure ulcers. To enter the trial ulcers had to be debrided and have a bacterial count of 10(5) or fewer bacteria/g tissue with no beta-hemolytic streptococci.

RESULTS

In all, 96% of cultures (350/363) remained at <10(2) bacteria/g tissue over the 5-week trial; 3% had 10(2) to 10(5), and only 1% had >10(5) bacteria/g tissue.

CONCLUSION

Chronic pressure ulcers, once debrided and brought into bacterial balance, will remain in bacterial balance if cared for and kept free of necrotic tissue.