Implant-associated anaplastic large cell lymphoma: beyond breast prostheses.

OBJECTIVE: Anaplastic large cell lymphoma (ALCL) is a rare form of non-Hodgkin T-cell lymphoma potentially associated with silicone-shelled breast implants. The low incidence of ALCL has prevented establishment of causality. Many implantable devices are constructed with biomaterials similar to those used in breast prostheses. The purpose of this paper is to identify reports of ALCL in association with other types of implantable devices. METHODS: A literature review was conducted using PubMed to identify reports of non-Hodgkin lymphoma in association with various implantable devices. RESULTS: One case of ALCL was identified in association with a stainless steel internal fixation plate. Diffuse large B-cell lymphoma was widely reported in association with various implantable biomaterials and chronic inflammation. CONCLUSION: The neoplastic response associated with breast prostheses appears substantively different from other implantable devices. Physicians caring for patients with silicone elastomer-containing implants should have increased suspicion for implant-associated ALCL and report all pertinent cases in the literature.

A prospective, non comparative, multicenter study to investigate the effect of cadexomer iodine on bioburden load and other wound characteristics in diabetic foot ulcers.

Few studies regarding wound treatment with topical antimicrobials evaluate change in the bacterial bioburden of the wound with treatment. This study sought out to determine the in vivo effect of cadexomer iodine antibacterial dressing on diabetic foot ulcers (DFUs) that were infected or achieved a critical level of colonisation, looking specifically at wound progression in relation to bioburden. Fifteen patients corresponding to 16 total DFUs met criteria of displaying clinical signs of infection or critical colonisation and were suitable for a topical antibacterial dressing. They underwent weekly treatment for 6 weeks. Cultures were taken at week 0, 3 and 6 as appropriate. At week 6 median log10 bacterial count reduction of 1.0 was observed from baseline (p = 0·025). At week 3- a median log10 bacterial count reduction of 0.3 was observed from baseline (p = 0·049). Over the study period there was a 53.6% median reduction of the wound surface area. There were no patients that completely healed their ulcer over the 6 week study period. There was a statistically significant median reduction in the bacterial load over the 6 week period (p = 0·025) as well as 3 weeks (p = 0·049). This was accompanied by a median reduction of 53.6% in ulcer surface area and 50% in ulcer depth from baseline to final.

Review of Statutory Obligations for Reporting Ballistic Injuries.

Traumatic ballistic injury is an unfortunate and commonly encountered problem seen by surgeons. An estimated 85,694 nonfatal ballistic injuries occur annually, and in 2020 there were 45,222 firearm-related deaths in the United States. Surgeons of all subspecialties may provide necessary care. Acute care injuries are generally reported to authorities immediately; however, delayed presentation of ballistic injuries may go unreported despite regulations to do so. We present a case of a delayed ballistic injury and a comparative review of individual states' reporting requirements to highlight statutory obligations and penalties as an educational reference for surgeons treating ballistic injuries. Methods: Google and PubMed searches were performed utilizing keywords "ballistic," "gunshot," "physician," and "reporting" as terms. Inclusion criteria included the English language, official state statute sites, legal and scientific articles, and websites. Exclusion criteria included nongovernmental sites and information sources. Data collected were analyzed to include statute numbers, time to report, infraction consequences, and monetary fines. The resultant data are reported by state and region. Results: All but two state jurisdictions mandate healthcare providers to report knowledge and/or treatment of ballistic injuries, regardless of the timeline of injury. Violations of mandatory reporting may lead to fines or imprisonment, depending on the specific state. The timeline for reporting, fines, and subsequent legal action varies by state and region. Conclusions: Requirements for reporting injuries exist in 48 of 50 states. The treating physician/surgeon should thoughtfully question patients with a chronic ballistic injury history and provide reports to local law enforcement.

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.

Chemical characterization and biological properties of NVC-422, a novel, stable N-chlorotaurine analog.

During oxidative burst, neutrophils selectively generate HOCl to destroy invading microbial pathogens. Excess HOCl reacts with taurine, a semi-essential amino acid, resulting in the formation of the longer-lived biogenerated broad-spectrum antimicrobial agent, N-chlorotaurine (NCT). In the presence of an excess of HOCl or under moderately acidic conditions, NCT can be further chlorinated, or it can disproportionate to produce N,N-dichlorotaurine (NNDCT). In the present study, 2,2-dimethyltaurine was used to prepare a more stable N-chlorotaurine, namely, N,N-dichloro-2,2-dimethyltaurine (NVC-422). In addition, we report on the chemical characterization, in vitro antimicrobial properties, and cytotoxicity of this compound. NVC-422 was shown effectively to kill all 17 microbial strains tested, including antibiotic-resistant Staphylococcus aureus and Enterococcus faecium. The minimum bactericidal concentration of NVC-422 against Gram-negative and Gram-positive bacteria ranged from 0.12 to 4 µg/ml. The minimum fungicidal concentrations against Candida albicans and Candida glabrata were 32 and 16 µg/ml, respectively. NVC-422 has an in vitro cytotoxicity (50% cytotoxicity = 1,440 µg/ml) similar to that of NNDCT. Moreover, our data showed that this agent possesses rapid, pH-dependent antimicrobial activity. At pH 4, NVC-422 completely killed both Escherichia coli and S. aureus within 5 min at a concentration of 32 µg/ml. Finally, the effect of NVC-422 in the treatment of an E. coli-infected granulating wound rat model was evaluated. Treatment of the infected granulating wound with NVC-422 resulted in significant reduction of the bacterial tissue burden and faster wound healing compared to a saline-treated control. These findings suggest that NVC-422 could have potential application as a topical antimicrobial.

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.

Amnion-derived cellular cytokine solution promotes macrophage activity.

Activated macrophages play a significant role in wound healing and infected tissue repair. In this study, we investigate the recruitment of macrophages into the wound, and the effects on the bactericidal/phagocyte activity after exposure to amnion-derived cellular cytokine solution (ACCS). To evaluate the influence of ACCS on the migratory behavior of macrophages, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of macrophages through the membrane determined the influence of ACCS. In the presence of ACCS, macrophages demonstrated a statistically significant (P < 0.05) increase in migration as compared with controls. Subsequently, groups of macrophages were exposed to different concentrations of ACCS solution. The killing and phagocytic activity of each group was compared with the control after exposure to Escherichia coli. Macrophage activity following activation by higher concentrations of ACCS demonstrated significantly increased phagocytosis as well as a trend correlation between percentage ACCS concentration and bactericidal activity. These cell types, critical to normal wound healing, may be influenced by ACCS to accelerate migration and enhance bactericidal/phagocytic activity in wounds.

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.

Effect of amnion-derived cellular cytokine solution on healing of experimental partial-thickness burns.

BACKGROUND: Amnion-derived multipotent progenitor (AMP) cells, unlike most stem cells, have been demonstrated to be nontumorigenic and nonimmunogenic. Amnion-derived cellular cytokine solution (ACCS), a secreted product of AMP cells, is a cocktail of cytokines existing at physiological levels and has been used to accelerate epithelialization of experimental partial-thickness burns. METHODS: Using modifications of Zawacki's guinea pig partial-thickness scald burn model, a total of 65 animals were treated with ACCS, ACCS + AMP cells, unconditioned medium (UCM) + AMP cells, or either UCM alone or saline as controls. Dosage times ranged from every other day to once a week. Percent epithelialization was serially determined from acetate wound tracings. Histology was performed on wound biopsies. RESULTS: ACCS, UCM + AMP cells, and ACCS + AMP cells improved epithelialization compared with the two control groups (P < 0.05). When ACCS was delivered more frequently, statistically significant more rapid epithelialization occurred (P < 0.05). By day 7, all groups treated with ACCS had reached at least 90% epithelialization, whereas control groups were only 20-40% epithelialized (P < 0.05). Histology showed excellent regeneration of the epidermis with rete ridge formation. Hair growth occurred in ACCS-treated animals but not in the control group. CONCLUSIONS: Amnion-derived cellular cytokine solution accelerates the healing of experimental partial-thickness burns. Based on these findings, a multicenter clinical trial is underway.

Amnion-derived cellular cytokine solution (ACCS) promotes migration of keratinocytes and fibroblasts.

Amnion-derived Multipotent Progenitor cells appear to be useful as adjuvants in wound healing. Amnion-derived multipotent progenitor cells secrete a unique combination of cytokines and growth factors, known as amnion-derived cellular cytokine solution (ACCS). In the skin, a cytokine communication network between mesenchymal and epithelial cells tightly controls keratinocyte and fibroblast migration, proliferation and differentiation-key determinants of wound healing. To evaluate the influence of ACCS on the migratory behavior of keratinocytes and fibroblasts, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of fibroblasts or keratinocytes through the membrane determined the influence of ACCS. In the presence of ACCS, fibroblasts and keratinocytes demonstrated a statistically significant (P < 0.05) increase in migration when compared with controls. These cell types, critical to normal wound healing, may be influenced to accelerate migration in wounds, thus accelerating wound repair/healing.

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.

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.

An Analysis of Inhalation Injury Diagnostic Methods and Patient Outcomes.

The purpose of this study was to compare patient outcomes according to the method of diagnosing burn inhalation injury. After approval from the American Burn Association, the National Burn Repository Dataset Version 8.0 was queried for patients with a diagnosis of burn inhalation injury. Subgroups were analyzed by diagnostic method as defined by the National Burn Repository. All diagnostic methods listed for each patient were included, comparing mortality, hospital days, intensive care unit (ICU) days, and ventilator days (VDs). Z-tests, t-tests, and linear regression were used with a statistical significance of P value of less than .05. The database query yielded 9775 patients diagnosed with inhalation injury. The greatest increase in mortality was associated with diagnosis by bronchoscopy or carbon monoxide poisoning. A relative increase in hospital days was noted with diagnosis by bronchoscopy (9 days) or history (2 days). A relative increase in ICU days was associated with diagnosis according to bronchoscopy (8 days), clinical findings (2 days), or history (2 days). A relative increase in VDs was associated with diagnosis by bronchoscopy (6 days) or carbon monoxide poisoning (3 days). The combination of diagnosis by bronchoscopy and clinical findings increased the relative difference across all comparison measures. The combination of diagnosis by bronchoscopy and carbon monoxide poisoning exhibited decreased relative differences when compared with bronchoscopy alone. Diagnosis by laryngoscopy showed no mortality or association with poor outcomes. Bronchoscopic evidence of inhalation injury proved most useful, predicting increased mortality, hospital, ICU, and VDs. A combined diagnosis determined by clinical findings and bronchoscopy should be considered for clinical practice.

Upper extremity deep vein thrombosis with tourniquet use.

INTRODUCTION: Upper extremity deep vein thrombosis is an increasingly important clinical finding with significant morbidity and mortality. The condition may be under-diagnosed in trauma and surgery settings. PRESENTATION OF CASE: We present a case of upper extremity thrombosis with venous congestive symptoms secondary to the use of an operative tourniquet. A literature review and discussion of the causes of upper extremity deep vein thrombosis and the pathophysiological disturbances seen with tourniquet use are presented. DISCUSSION: Upper extremity deep venous thrombosis is uncommon. In this case the likely cause was operative tourniquet use. CONCLUSION: Operative tourniquet may be a risk factor in upper extremity deep vein thrombosis.

The evaluation of physical exam findings in patients assessed for suspected burn inhalation injury.

The purpose of this investigation was to evaluate the utility of singed nasal hair (SN), carbonaceous sputum (CS), and facial burns (FB) as indicators of burn inhalation injury, when compared to the accepted standard of bronchoscopic diagnosis of inhalation injury. An institutional review board approved, retrospective review was conducted. All patients were suspected to have burn inhalation injury and subsequently underwent bronchoscopic evaluation. Data collected included: percent burn TBSA, burn injury mechanism, admission physical exam findings (SN, CS, FB), and bronchoscopy findings. Thirty-five males and twelve females met inclusion criteria (n = 47). Bronchoscopy was normal in 31 patients (66%). Data were analyzed as all patients and in subgroups according to burn TBSA and an enclosed space mechanism of injury. Physical exam findings (SN, CS, FB) were evaluated individually and in combination. Overall, the sensitivities, specificities, positive predictive values, and negative predictive values calculated were poor and inconsistent, and they did not improve within subgroup analysis or when physical findings were combined. Further statistical analysis suggested the physical findings, whether in isolation or in combination, have poor discrimination between patients that have and do not have inhalation injury (AUC < 0.7, P > .05) and poor agreement with the diagnosis made by bronchoscopy (κ < 0.4, P > .05). This remained true in the subgroup analysis as well. Our data demonstrated the findings of SN, CS, and FB are unreliable evidence for inhalation injury, even in the context of an enclosed space mechanism of injury. Thus, these physical findings are not absolute indicators for intubation and should be interpreted as one component of the history and physical.

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.

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.

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.).