An outbreak of methicillin resistant Staphylococcus aureus on a burn unit: potential role of contaminated hydrotherapy equipment.

OBJECTIVE: To report a multi-institution outbreak caused by a single strain of methicillin-resistant Staphylococcus aureus (MRSA). OUTBREAK: Between September 19 and November 20, 1996 an index case and five secondary cases of nosocomial MRSA occurred on a 26 bed adult plastic surgery/burn unit (PSBU) at a tertiary care teaching hospital. Between November 11 and December 23, 1996, six additional cases were identified at a community hospital. One of the community hospital cases was transferred from the PSBU. All strains were identical by pulsed-field gel electrophoresis. MRSA may have contributed to skin graft breakdown in one case, and delayed wound healing in others. Patients required 2 to 226 isolation days. CONTROL MEASURES: A hand held shower and stretcher for showering in the hydrotherapy room of the PSBU were culture positive for the outbreak strain, and the presumed means of transmission. Replacement of stretcher showering with bedside sterile burn wound compresses terminated the outbreak. The PSBU was closed to new admissions and transfers out for 11 days during the investigation. Seven of 12 patients had effective decolonization therapy. CONCLUSION: Environmental contamination is a potential source of nosocomial MRSA transmission on a burn unit. Notification among institutions and community care providers of shared patients infected or colonized with an antimicrobial resistant microorganism is necessary.

A complication of submandibular intubation in a panfacial fracture patient.

We present the complication of a mucocele in the floor of the mouth caused by a submandibular intubation in a patient with a panfacial fracture.

Surgical treatment of pressure ulcers: 20-year experience.

OBJECTIVE: To review the outcomes of surgical management of spinal cord injury (SCI) patients with severe pressure ulcers and to examine likely risk factors for recurrence of pressure ulcers. DESIGN: A retrospective medical record review. SETTING: An SCI unit in a tertiary care facility. PATIENTS: All admissions to the SCI unit for grade 4 pressure ulcers from 1976 to 1996. INTERVENTION: Surgical repair of pressure ulcers. MAIN OUTCOME MEASURE: Complication and recurrence rates of pressure ulcers. RESULTS: Of 598 pressure ulcers, 468 were pelvic area ulcers, of which 431 (92%) were treated surgically. Fifty-three had split-thickness skin grafting, and 380 were treated with 421 surgical procedures (253 fasciocutaneous or cutaneous flaps, 93 muscle or musculocutaneous flaps, 75 primary closures). One hundred eight (26%) of these procedures required some bone work. Suture line dehiscence occurred in 130 (31%), with 45 (11%) requiring reconstruction and 8 (2%) requiring skin grafting to heal. At discharge, 38 (9%) of these pelvic ulcers had not healed. Recurrent admissions occurred in 90 (54%) of the patients. Recurrence of ulcers at the same site occurred in 31% of the total number of ulcers and at a different site in 21%. At the time of the 415 admissions, 336 (81%) of the patients were unemployed; 159 (38%) had grade 8 or lower level of education; and 226 (55%) lived alone or with family but were independent in self-care. Of the 168 patients studied, 45 (27%) were aboriginal (Canadian native), and 59 (35%) had a history of drug or alcohol abuse. CONCLUSIONS: The vast majority of severe pressure ulcers were surgically treated. Complication and recurrence rates are similar to previous reports. Psychosocial problems (unemployment, low level of education, drug or alcohol abuse, poverty in the native communities) appear to increase the risk for pressure ulcer development.

The anatomy of the accessory nerve and cervical lymph node biopsy.

Injury to the accessory nerve is the most frequent complication of surgical procedures in the posterior triangle of the neck. The symptoms produced by paralysis of the trapezius are disabling. The components of this disability are pain, limitation of abduction, and drooping of the affected shoulder. A detailed knowledge of the course of the nerve and its anatomic relations are essential in avoiding injury. Useful anatomic landmarks are the proximal internal jugular vein in the anterior triangle and Erb's point in the posterior triangle. Prevention of accessory nerve injury is the best management. The indications for lymph node biopsies in the neck should be sound. The use of a general anesthetic without paralysis is recommended if an excisional biopsy is necessary. Adequate exposure is essential. Whether the nerve needs to be identified in all cases has to be individualized and requires careful judgment. A divided or injured nerve is best managed with primary repair within 3 months of injury.

Infrared spectra of basal cell carcinomas are distinct from non-tumor-bearing skin components.

Infrared spectroscopy, by probing the molecular vibration of chemical bonds, directly indicates tissue biochemistry. An expanding body of literature suggests that infrared spectra distinguish diseased from normal tissue. The authors used infrared spectroscopy to examine basal cell carcinoma to explore distinctive characteristics of basal cell carcinoma versus normal skin samples and other skin neoplasms. Spectra of epidermis, tumor, follicle sheath, and dermis were acquired from unstained frozen sections, and analyzed qualitatively, by t-tests and by linear discriminant analyses. Dermal spectra were significantly different from the other skin components mainly due to absorptions from collagen in dermis. Spectra of normal epidermis and basal cell carcinoma were significantly different by virtue of subtle differences in protein structure and nucleic acid content. Linear discriminant analysis characterized spectra as arising from basal cell carcinoma, epidermis, or follicle sheath with 98.7% accuracy. Use of linear discriminant analysis accurately classified spectra as arising from epidermis overlying basal cell carcinoma versus epidermis overlying nontumor-bearing skin in 98.0% of cases. Spectra of basal cell carcinoma, squamous cell carcinoma, nevi, and malignant melanoma were qualitatively similar. Distinction of basal cell carcinoma, squamous cell carcinoma, and melanocytic lesions by linear discriminant analyses, however, was 93.5% accurate. Therefore, spectral separation of abnormal versus normal tissue was achieved with high sensitivity and specificity, which points to infrared spectroscopy as a potentially useful screening tool for cutaneous neoplasia.

Assessment of tissue viability using near-infrared spectroscopy.

Prolonged and severe tissue hypoxia results in tissue necrosis in pedicled flaps. We demonstrate the potential of near-infrared spectroscopy for monitoring of skin flaps. This approach clearly identifies tissue regions with low oxygen supply, and also the severity of this challenge, in a rapid and non-invasive manner with a high degree of reproducibility. Tissue haemoglobin oxygen saturation and water content of pre-selected dorsal sites were monitored for 72 h prior to, and 72 h following elevation of a reversed McFarlane rat dorsal skin flap (n = 9). Oxygen delivery to flap tissue dropped immediately upon flap elevation. This was most pronounced in the distal half of the flap and least pronounced in the region nearest its base. Haemoglobin oxygen saturation of tissue proximal to the vascular base of the flap recovered, exceeding pre-elevation saturation values, within 6 h of raising the flap. Typically, this higher haemoglobin oxygen saturation persisted for the full 72 h post-elevation observation period. At a distance greater than 2 cm from the vascular pedicle, the tissue remained hypoxic over the post-elevation monitoring period. Tissues remaining below a certain haemoglobin oxygen saturation threshold (oxygen saturation index < 1) for prolonged periods (> 6 h) became increasingly dehydrated, eventually becoming visibly necrotic. Tissues above this threshold (oxygen saturation index > 1), despite being significantly hypoxic, relative to the pre-elevation saturation values, remained viable over the 72 h post-elevation monitoring period.

Tissue viability by multispectral near infrared imaging: a fuzzy C-means clustering analysis.

Clinically, skin color, temperature, and capillary perfusion are used to assess tissue viability following microvascular tissue transfer. However, clinical signs that arise as a consequence of poor perfusion become evident only after several hours of compromised perfusion. This study demonstrates the potential usefulness of optical/infrared multispectral imaging in the prognosis of tissue viability immediately post-surgery. Multispectral images of a skin flap model acquired within 1 h of surgical elevation are analyzed in comparison to the final 72-h clinical outcome with a high degree of correlation. Regional changes in tissue perfusion and oxygenation present immediately following surgery are differentiated using fuzzy clustering and image processing algorithms. These methodologies reduce the intersubject variability inherent in infrared imaging methods such that the changes in perfusion are reproducible and clearly distinguishable across all subjects. Clinically, an early prognostic indicator of viability such as this would allow for a more timely intervention following surgery in the event of compromised microvasculature.

Setting up an Nd:YAG laser training course.

We report our experience in developing a two-day training course for the Nd:YAG (Neodymium: Yttrium-Aluminium-Garnet) laser and describe the curriculum. This project arose from an attempt to modify an existing course on the CO2 laser for a newly-acquired Nd:YAG laser in such a way as to adequately demonstrate the properties of the latter and to highlight dissimilarities with the CO2 laser. The course, which is taught on a 1:1 student to instructor basis, uses both videotapes and a series of locally developed exercises to appraise the trainee of the potential of this tool. Both inanimate objects and live subjects (anaesthetized rats) are used in the exercises. Examples of the exercises developed and the principles they demonstrate are given, as well as specific problems that were overcome in order to produce a course that adequately covered the subject whilst containing costs at a reasonable level. The need for extensive hands-on use of the laser is emphasised.

Effect of Nd:YAG laser on wound contraction and epithelial regeneration in rabbits.

This study was undertaken to objectively compare healing rates in wounds produced by the Nd:YAG (Neodymium:Yttrium-Aluminium-Garnet) laser to those caused by steel scalpel, in rabbits. Rates of contraction and epithelialisation in standard wounds were determined by daily measurement of the wound area from the time of wounding until epithelialisation was complete. The wounds were of three types: superficial to the panniculus carnosus, deep to it and ear wounds. Significant delays in both wound contraction (p < 0.0001) and epithelialisation (p < 0.0001) were demonstrated in all Nd:YAG laser wounds. Normal epithelial regenerative capacities were observed. The final appearance of the healed areas was comparable across the laser and scalpel groups.

Nail gun injuries of the fingers: a safer method of nail removal.

In nail gun injuries of the fingers, removal of the nail in the antegrade fashion (in the same direction as its introduction) prevents soft tissue entrapment by the hooked barbs of the nail. This concept is illustrated in a case report.

Wound sterilisation: cautery vs CO2 laser.

Al-Qattan et al. (1989) demonstrated that for difficult infected surgical wounds the CO2 laser was a much more effective sterilising agent than a standard surgical scrub (P < 0.005). This study compares the effectiveness of a standard electrocautery unit against that of the CO2 laser for wound sterilisation. Cautery sterilisation of infected wounds was found to be significantly superior to that of the CO2 laser (P < 0.05). Infection was noted in 4% of the cautery sterilised wounds and 12% of the wounds treated with CO2 laser. Case reports are also presented to demonstrate the clinical applications and effectiveness of this technique.

Video assessment of surgical technique.

The surgical technique of nine trainee surgeons, as recorded on videotape, was evaluated under five headings using a scoring system and the results were discussed with them. Six of the trainees were assessed on more than one occasion during their training. All trainees felt that they had benefited from the assessment.

Healing of infected wounds following iodine scrub or CO2 laser treatment.

This study compares CO2 laser sterilization with iodine surgical scrub in infected pseudomonas wounds in the rabbit, and on frequency of wound breakdown secondary to sepsis. Thirty-three New Zealand rabbits underwent bilateral flank incisions and infection with a standard solution of pseudomonas aeruginosa. After 4 days of incubation, the wounds were randomized to receive laser sterilization and routine iodine surgical scrub respectively. Following sterilization, excision of the wound, and suturing was carried out. After 12 days, the wounds were assessed for evidence of residual infection as well as wound breakdown in a double blind fashion. Clinical observation, qualitative microbiology, and in some cases histology, were used to document the presence of infection. Statistical analysis of wound breakdown secondary to infection revealed a significant difference in breakdown rates. Three laser and 12 iodine treated wounds displayed breakdown secondary to sepsis. We conclude that the CO2 laser sterilization technique is more effective than routine iodine surgical scrub.

The effect of carbon dioxide laser on wound contraction and epithelial regeneration in rabbits.

This study was undertaken to compare objectively healing rates (in rabbits) of wounds caused by CO2 laser with those caused by scalpel. The rates of contraction and epithelialisation of standard wounds were determined with daily measurement of wound area from the time of wounding until the wound had healed. Our results demonstrate significant delays in both wound contraction (p = 0.0001) and epithelialisation (p = 0.0001) for CO2 laser-created wounds when compared to those seen in scalpel-created wounds. Normal epithelial regenerative capacities were demonstrated in the laser group despite the slow onset of epithelial migration. The appearance of the healed areas appeared comparable for both modalities.

Wound sterilization: CO2 laser versus iodine.

Control of infection in a surgical wound remains a challenge, especially if further surgery in the area is needed. This study was designed to compare the effectiveness of sterilization of a standard experimental infected wound by surgical skin preparation (Betadine) as compared to treatment with the CO2 laser. Standard wounds (5 x 6 cm) were created superficial to the panniculus carnosus on each flank of 37 adult male New Zealand rabbits. Each wound was infected with a standard dose of Pseudomonas aeruginosa. All wounds became grossly infected. On the third day one flank wound was treated with the CO2 laser, the other with the Betadine solution, and a punch biopsy (4 mm) was taken from each wound for quantitative bacterial counts. Less than 10% of the laser-treated wounds grew Pseudomonas, whereas nearly 40% of the iodine-treated wounds remained infected (P less than 0.005). Our early clinical experience using the CO2 laser for the sterilization of infected wounds is also reported.

Accidental reinnervation as a complication of latissimus dorsi free flap to the face and scalp.

Although direct nerve neurotization is well known, accidental full reinnervation of a major muscle following microvascular transfer has not previously been reported. Our patient, who presented with total scalp loss, was initially treated with simple skin grafts. Repeated breakdowns over the years necessitated the use of more durable cover. A free latissimus dorsi muscle flap achieved this objective. Two years post-transfer it became evident that the whole of the latissimus dorsi had become innervated, producing facial and scalp distortion when the patient smiled. Formal exploration and section of both neural trunks to the latissimus dorsi was necessary to abolish this bizarre grimace.