Are Genetic Therapies for Epilepsy Ready for the Clinic?

In recent years, there has been a significant increase in preclinical studies to test genetic therapies for epilepsy. Some of these therapies have advanced to clinical trials and are being tested in patients with monogenetic or focal refractory epilepsy. This article provides an overview of the current state of preclinical studies that show potential for clinical translation. Specifically, we focus on genetic therapies that have demonstrated a clear effect on seizures in animal models and have the potential to be translated to clinical settings. Both therapies targeting the cause of the disease and those that treat symptoms are discussed. We believe that the next few years will be crucial in determining the potential of genetic therapies for treating patients with epilepsy.

Predicting vasospasm risk using first presentation aneurysmal subarachnoid hemorrhage volume: A semi-automated CT image segmentation analysis using ITK-SNAP.

PURPOSE: Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) is a significant complication associated with poor neurological outcomes. We present a novel, semi-automated pipeline, implemented in the open-source medical imaging analysis software ITK-SNAP, to segment subarachnoid blood volume from initial CT head (CTH) scans and use this to predict future radiological vasospasm. METHODS: 42 patients were admitted between February 2020 and December 2021 to our tertiary neurosciences center, and whose initial referral CTH scan was used for this retrospective cohort study. Blood load was segmented using a semi-automated random forest classifier and active contour evolution implemented in ITK-SNAP. Clinical data were extracted from electronic healthcare records in order to fit models aimed at predicting radiological vasospasm risk. RESULTS: Semi-automated segmentations demonstrated excellent agreement with manual, expert-derived volumes (mean Dice coefficient = 0.92). Total normalized blood volume, extracted from CTH images at first presentation, was significantly associated with greater odds of later radiological vasospasm, increasing by approximately 7% for each additional cm3 of blood (OR = 1.069, 95% CI: 1.021-1.120; p < .005). Greater blood volume was also significantly associated with vasospasm of a higher Lindegaard ratio, of longer duration, and a greater number of discrete episodes. Total blood volume predicted radiological vasospasm with a greater accuracy as compared to the modified Fisher scale (AUC = 0.86 vs 0.70), and was of independent predictive value. CONCLUSION: Semi-automated methods provide a plausible pipeline for the segmentation of blood from CT head images in aSAH, and total blood volume is a robust, extendable predictor of radiological vasospasm, outperforming the modified Fisher scale. Greater subarachnoid blood volume significantly increases the odds of subsequent vasospasm, its time course and its severity.

Phase 3 Study of OnabotulinumtoxinA Distributed Between Frontalis, Glabellar Complex, and Lateral Canthal Areas for Treatment of Upper Facial Lines.

BACKGROUND: Although commonly practiced, simultaneous onabotulinumtoxinA injections to multiple facial areas have not been investigated in prospective studies. OBJECTIVE: Evaluate safety and efficacy of onabotulinumtoxinA for treatment of forehead lines (FHL) distributed between the frontalis (20 U) and glabellar complex (20 U), with or without simultaneous lateral canthal areas (crow's feet lines [CFL], 24 U) treatment. METHODS: Subjects with moderate to severe FHL were randomized (2:2:1) to onabotulinumtoxinA 40 U, onabotulinumtoxinA 64 U, or placebo. After 180 days, subjects could receive up to 2 additional open-label onabotulinumtoxinA 64 U treatments. RESULTS: The intent-to-treat (ITT) population comprised 787 subjects, and the modified ITT (mITT) population (subjects with psychological impact) comprised 568. After 30 days, onabotulinumtoxinA 40 U and 64 U significantly improved investigator- and subject-assessed FHL severity by at least 2 Facial Wrinkle Scale (FWS) grades in 45.6% and 53.0% of ITT subjects, respectively, versus 0.6% receiving placebo (both, p < .0001). Significantly more mITT subjects receiving onabotulinumtoxinA achieved investigator- and subject-assessed FWS ratings of none/mild versus placebo (p < .0001). OnabotulinumtoxinA was well tolerated. CONCLUSION: OnabotulinumtoxinA distributed between the frontalis and glabellar complex, with or without additional CFL injections, was safe and effective for treatment of moderate to severe FHL.

Retrosplenial and postsubicular head direction cells compared during visual landmark discrimination.

BACKGROUND: Visual landmarks are used by head direction (HD) cells to establish and help update the animal's representation of head direction, for use in orientation and navigation. Two cortical regions that are connected to primary visual areas, postsubiculum (PoS) and retrosplenial cortex (RSC), possess HD cells: we investigated whether they differ in how they process visual landmarks. METHODS: We compared PoS and RSC HD cell activity from tetrode-implanted rats exploring an arena in which correct HD orientation required discrimination of two opposing landmarks having high, moderate or low discriminability. RESULTS: RSC HD cells had higher firing rates than PoS HD cells and slightly lower modulation by angular head velocity, and anticipated actual head direction by ~48 ms, indicating that RSC spiking leads PoS spiking. Otherwise, we saw no differences in landmark processing, in that HD cells in both regions showed equal responsiveness to and discrimination of the cues, with cells in both regions having unipolar directional tuning curves and showing better discrimination of the highly discriminable cues. There was a small spatial component to the signal in some cells, consistent with their role in interacting with the place cell navigation system, and there was also slight modulation by running speed. Neither region showed theta modulation of HD cell spiking. CONCLUSIONS: That the cells can immediately respond to subtle differences in spatial landmarks is consistent with rapid processing of visual snapshots or scenes; similarities in PoS and RSC responding may be due either to similar computations being performed on the visual inputs, or to rapid sharing of information between these regions. More generally, this two-cue HD cell paradigm may be a useful method for testing rapid spontaneous visual discrimination capabilities in other experimental settings.

Forehead Line Treatment With OnabotulinumtoxinA in Subjects With Forehead and Glabellar Facial Rhytids: A Phase 3 Study.

BACKGROUND: Effacement of horizontal forehead lines (FHL) with onabotulinumtoxinA has not been investigated in prospective Phase 3 studies. OBJECTIVE: To evaluate safety and efficacy of onabotulinumtoxinA treatment of FHL together with glabellar lines (GL). MATERIALS AND METHODS: A 12-month, Phase 3 study randomized subjects with moderate-to-severe FHL and GL to onabotulinumtoxinA 40 U or placebo, distributed between the frontalis (20 U) and glabellar complex (20 U). After Day 180, subjects could receive up to 2 additional open-label onabotulinumtoxinA treatments. Efficacy was assessed using the Facial Wrinkle Scale (FWS) and Facial Line Outcomes questionnaire. RESULTS: The intent-to-treat (ITT) population included 391 subjects, and the modified ITT (mITT) population (subjects with psychological impact) included 254 subjects. After 30 days, onabotulinumtoxinA significantly improved the investigator- and subject-assessed appearance of FHL severity by at least 2 FWS grades in 61.4% of ITT subjects versus 0% of placebo subjects (p < .0001). In the mITT population, 94.8% of onabotulinumtoxinA subjects and 1.7% of placebo subjects achieved investigator- and subject-assessed FWS ratings of none/mild (p = .0003). Patient-reported outcomes were consistent with FWS ratings. OnabotulinumtoxinA was well tolerated. CONCLUSION: OnabotulinumtoxinA 40 U distributed between the frontalis and glabellar complex was safe and effective for treatment of moderate-to-severe FHL.

Evolution of Facial Aesthetic Treatment Over Five or More Years: A Retrospective Cross-sectional Analysis of Continuous OnabotulinumtoxinA Treatment.

BACKGROUND: Little information exists on how facial aesthetic treatments are incorporated into aesthetic regimens. OBJECTIVE: Assess the evolution of facial aesthetic treatments in patients receiving long-term continuous onabotulinumtoxinA treatment. METHODS: This international retrospective chart review included patients with ≥5 years of continuous onabotulinumtoxinA treatments including ≥1 glabellar lines treatment/year. Charts were reviewed for facial areas treated, number of treatments, doses/treatment visit, concomitant aesthetic procedures, and onabotulinumtoxinA-related adverse events. RESULTS: Data were collected from 5,112 onabotulinumtoxinA treatment sessions for 194 patients over an average of 9.1 years. Dosing was relatively stable over time; however, interinjection intervals increased. Glabellar lines' treatment temporally preceded crow's feet lines and forehead lines' treatment. A majority of patients (85%) also received treatment with fillers. Cumulative increases in onabotulinumtoxinA treatments occurred over time and by facial area corresponding with increases in treatments with injectable fillers, energy-based devices, and prescription topical creams. The longer the patients were treated, the younger they perceived themselves to look. Rates of adverse events were low. CONCLUSION: OnabotulinumtoxinA treatment evolved over time, coinciding with growth of the facial aesthetics market. Additional treatment modalities were added as complements to onabotulinumtoxinA. Long-term continuous onabotulinumtoxinA injections are an important component of contemporary facial aesthetic treatment regimens.

Effects of OnabotulinumtoxinA treatment for crow's feet lines on patient-reported outcomes.

BACKGROUND: Although millions of aesthetic procedures are performed annually, few patient-reported outcome (PRO) measures have been used in this setting. OBJECTIVE: To evaluate the impact of onabotulinumtoxinA treatment for crow's feet lines (CFL) on relevant psychological variables and self-perception of age/appearance in subgroup populations. MATERIALS AND METHODS: Facial Lines Outcomes (FLO-11) Questionnaire, Self-Perception of Age (SPA), and Subject Global Assessment of Change in CFL (SGA-CFL) were PRO measures administered in 2 Phase 3, double-blind placebo-controlled trials for the treatment of CFL alone or CFL/glabellar lines (GL). Patient-reported outcome measures were analyzed by subgroups (age, gender, and baseline CFL severity). Subject satisfaction with appearance was also analyzed. RESULTS: Most subgroups receiving onabotulinumtoxinA demonstrated significant improvements in psychological impact (FLO-11 Items 2, 5, and 8) versus placebo at Day 30 (p ≤ .05). OnabotulinumtoxinA-treated subjects consistently rated themselves as looking younger on SPA versus placebo in all subgroups at Day 30 (p ≤ .05) and showed significant improvements in CFL appearance versus placebo at all time points on SGA-CFL. Overall, subjects were satisfied with their appearance. CONCLUSION: OnabotulinumtoxinA-treated subjects experienced significant improvements in perceived appearance, attractiveness, tiredness, age, and satisfaction versus placebo. Subjects treated for CFL and GL experienced even greater effects.

Novel Approaches to Examine Passage, Student, and Question Effects on Reading Comprehension.

Reading comprehension is influenced by sources of variance associated with the reader and the task. To gain insight into the complex interplay of multiple sources of influence, we employed crossed random-effects item response models. These models allowed us to simultaneously examine the degree to which variables related to the type of passage and student characteristics influenced students' (n = 94; mean age = 11.97 years) performance on two indicators of reading comprehension: different types of comprehension questions and passage fluency. We found that variables related to word recognition, language, and executive function were influential across various types of passages and comprehension questions and also predicted a reader's passage fluency. Further, an exploratory analysis of two-way interaction effects was conducted. Results suggest that understanding the relative influence of passage, question, and student variables has implications for identifying struggling readers and designing interventions to address their individual needs.

Sensitivity of computed tomography in detection of perirectal abscess.

Most patients with anorectal abscess are diagnosed clinically based on pain, erythema, warmth, and fluctuance. Some patients, however, present with subtle or atypical signs. CT is easily accessible and is commonly used for diagnosis and delineation of anorectal abscess. The purpose of this study is to determine the sensitivity of CT scan in detecting perirectal abscesses and to see if immune status impacts the accuracy of CT. A retrospective study was conducted to identify patients from 2000 to 2009 with International Classification of Diseases, 9th Revision code 566 (anal or rectal abscess). Patients included had a CT scan less than 48 hours before drainage. Patients with CT-positive abscess were compared with patients with CT-negative abscess. Patients were categorized as either immunocompetent or immunosuppressed based on documentation of diabetes mellitus, cancer, human immunodeficiency virus, or end-stage renal disease. One hundred thirteen patients were included in this study. Seventy-four (65.5%) were male and the average age was 47 years. Eighty-seven of 113 (77%) patients were positive on CT for anorectal abscess. Sixty of 113 (53%) patients included in this study were immunocompromised. CT missed 26 of 113 (23%) patients with confirmed perirectal abscess. Eighteen (69%) of these patients were immunocompromised compared with CT-positive patients (42 [48%], P = 0.05). The overall sensitivity of CT in identifying abscess was 77 per cent. CT lacks sensitivity in detecting perirectal abscess, particularly in the immunocompromised patient.

Evaluation of risk factors predictive of nausea and vomiting with current standard-of-care antiemetic treatment: analysis of phase 3 trial of aprepitant in patients receiving adriamycin-cyclophosphamide-based chemotherapy.

GOALS OF WORK: A number of prognostic factors have been identified as risk factors for chemotherapy-induced emesis. This post-hoc analysis addressed whether: (1) these prognostic factors can identify a low-risk group for whom ondansetron plus dexamethasone alone provide a high level of protection (≥80% no emesis); (2) the NK1 receptor antagonist aprepitant improves antiemetic outcome regardless of emetic risk. PATIENTS AND METHODS: Breast cancer patients in a phase III double-blind, placebo-controlled trial were randomized to antiemetic regimens including ondansetron and dexamethasone, or aprepitant, ondansetron, and dexamethasone. Multivariate logistic regression models were used to assess the impact on emesis (but not nausea) of the regimen with aprepitant, and previously reported risk factors, including age (<55 and ≥55 years), ethanol use (0-4 or ≥5 drinks/week), history of pregnancy-related morning sickness, and history of motion sickness, using a modified intent-to-treat approach. RESULTS: Treatment with aprepitant (P < 0.0001), older age (P = 0.006), ethanol use (P = 0.0048), and no history of morning sickness (P = 0.0007) were all significantly associated with reduced likelihood of emesis. The proportion of patients with one, two, or three risk factors who remained emesis free was significantly higher with the aprepitant-containing regimen than with the active control (70.2-82.8% vs. 38.6-66.4%, respectively). CONCLUSIONS: Aprepitant markedly improved control of emesis in patients with one or more risk factors. This analysis did not support using risk factors for modifying the antiemetic approach. A low-risk group with zero risk factors for whom aprepitant provided little benefit was of questionable clinical utility, since they comprised less than 3% of patients.

Differential time course of action of 5-HT3 and NK1 receptor antagonists when used with highly and moderately emetogenic chemotherapy (HEC and MEC).

BACKGROUND: Cisplatin-based highly emetogenic chemotherapy (HEC) displays a biphasic pattern of emesis with both an early and delayed period. In contrast, moderately emetogenic chemotherapy (MEC) has a monophasic pattern. The objective of this analysis was to further investigate the impact of the NK1-receptor antagonist aprepitant on these patterns. METHODS: Three phase III HEC (patients scheduled to receive cisplatin-based chemotherapy) and one phase III MEC (breast cancer patients scheduled to receive anthracycline plus cyclophosphamide (AC)) trials of aprepitant were included. In all studies, patients were randomized in a 1:1 ratio to an aprepitant regimen (aprepitant plus ondansetron plus dexamethasone) or the standard regimen (ondansetron plus dexamethasone). The exact dosing regimen for ondansetron and dexamethasone was different in each study. In a post hoc analysis, multivariate logistic regression models were used to assess the impact on first emesis at different time intervals after chemotherapy. RESULTS: One thousand five hundred twenty-seven patients and 856 patients were randomized and assessed for efficacy in the HEC and MEC trials, respectively. For HEC, aprepitant reduced the risk of first emesis by 38-77% vs. standard regimen, beginning 15-18 h after cisplatin and extending to 60 h. For MEC, aprepitant reduced the risk of first emesis by 38-61% vs. active control, beginning 3 h after AC and for up to 12 h. CONCLUSIONS: Time of onset and duration of enhanced control of emesis with the addition of aprepitant differed between HEC and MEC. This suggests that the pattern of NK1-sensitive mechanisms may vary for different chemotherapy regimens.

Trans fats in America: a review of their use, consumption, health implications, and regulation.

Trans fatty acids have long been used in food manufacturing due in part to their melting point at room temperature between saturated and unsaturated fats. However, increasing epidemiologic and biochemical evidence suggest that excessive trans fats in the diet are a significant risk factor for cardiovascular events. A 2% absolute increase in energy intake from trans fat has been associated with a 23% increase in cardiovascular risk. Although Denmark has shown it is possible to all but eliminate commercial sources of trans fats from the diet, total elimination is not possible in a balanced diet due to their natural presence in dairy and meat products. Thus, the American Heart Association recommends limiting trans fats to <1% energy, and the American Dietetic Association, the Institute of Medicine, US Dietary Guidelines, and the National Cholesterol Education Project all recommend limiting dietary trans-fat intake from industrial sources as much as possible. The presence of small amounts of trans fat in hydrogenated or partially hydrogenated oils/food products will likely cause many Americans to exceed their recommended maximum. This likelihood is exacerbated by the Food and Drug Administration labeling rules, which allow products containing <0.5 g trans fat per serving to claim 0 g trans fat. Many products with almost 0.5 g trans fat, if consumed over the course of a day, may approximate or exceed the 2 g maximum as recommended by American Heart Association, all while claiming to be trans-fat free. Accordingly, greater transparency in labeling and/or active consumer education is needed to reduce the cardiovascular risks associated with trans fats.

Evaluation of risk factors predictive of nausea and vomiting with current standard-of-care antiemetic treatment: analysis of two phase III trials of aprepitant in patients receiving cisplatin-based chemotherapy.

GOALS OF WORK: Certain patient and treatment characteristics are predictive of chemotherapy-induced nausea and vomiting (CINV). Objectives of this analysis were: (1) confirm the importance of several previously reported adverse risk factors for CINV in patients receiving chemotherapy, (2) assess the impact of the NK(1) receptor antagonist aprepitant according to these risk factors, and (3) assess the impact of age on antiemetic outcome. PATIENTS AND METHODS: Patients from two double-blind, placebo-controlled trials were randomized to an active-control group (ondansetron 32 mg IV, dexamethasone 20 mg PO day 1; dexamethasone 8 mg bid days 2-4) or an aprepitant group (aprepitant 125 mg PO, ondansetron 32 mg IV, dexamethasone 12 mg day 1; aprepitant 80 mg days 2-3; dexamethasone 8 mg qd days 2-4). The primary endpoint was complete response (no emesis or rescue therapy use). In a post-hoc analysis, multivariate logistic regression models were used to assess the impact of treatment with aprepitant and previously reported risk factors, using a modified intent-to-treat approach. MAIN RESULTS: Treatment with aprepitant (p < 0.0001), male gender (p = 0.023), cisplatin dose <80 mg/m(2) (p = 0.001), age >or=65 years (p = 0.021), and five or more alcoholic drinks per week (p = 0.027) were all significantly associated with improved complete response. Aprepitant improved complete response regardless of risk for all factors and neutralized the risk associated with female gender. CONCLUSIONS: This analysis confirmed the relevance of several previously reported risk factors for CINV in patients receiving chemotherapy. Aprepitant improved complete response regardless of risk and eliminated the increased risk of CINV associated with the female gender.

July--as good a time as any to be injured.

BACKGROUND: Recent studies have suggested worse outcomes for patients hospitalized during the beginning of the academic calendar, though these findings have not been reproduced among trauma patients. This study compares outcomes of patients during the beginning of the academic year with those at the end of the academic year. METHODS: Retrospective trauma registry analysis of a large urban level I trauma center. Patients admitted during April/May (ENDYEAR group) or July/August (FRESH group) between 1998 and 2007 were included. Demographic and injury parameters were recorded, and outcomes compared including crude mortality, complication rate, length of stay (LOS), and intensive care unit LOS (ICU-LOS). TRISS methodology was used to evaluate risk-adjusted performance. RESULTS: Three thousand sixty-seven patients were included in the FRESH group and 3626 in the ENDYEAR group. Groups were similar in age (36 +/- 17 years and 36 +/- 17 years, p = 0.39) and mean Injury Severity Score (8 +/- 11 and 8 +/- 10, p = 0.85). There was no difference in LOS (4.6 +/- 0.2 days versus 4.5 +/- 0.2 days, p = 0.92) or ICU-LOS (5.6 +/- 0.2 days versus 5.3 +/- 0.2 days, p = 0.96). Per patient complication rates for the FRESH and ENDYEAR groups were 6% and 6% (p = 0.8), total complication rates were 12% and 13% (p = 0.07), and crude mortality was 7% and 6% (p = 0.11), respectively. FRESH and ENDYEAR groups had similar W-Statistics (1.0 and 1.2) and z scores (3.5 and 4.4). CONCLUSION: Outcomes were similar between patients injured at the beginning of the academic year compared with the end of the academic year. Our data does not support the concept of a July effect in level I trauma centers.

Secondary overtriage: a consequence of an immature trauma system.

BACKGROUND: Trauma systems are designed to bring the injured patient to definitive care in the shortest practical time. This depends on prehospital destination criteria (primary triage) and interfacility transfer guidelines (secondary triage). Although primary undertriage is associated with increased costs and worse outcomes for selected injuries, secondary overtriage can overwhelm system resources and delay definitive care. The purpose of this study was to determine the incidence of secondary overtriage in a region without a formal trauma system. STUDY DESIGN: Retrospective cohort study of trauma registry data at an American College of Surgeons Committee on Trauma-verified Level I trauma center and regional referral center. Secondary overtriage was defined as patients transferred from another hospital emergency department to our trauma receiving unit who had an injury severity score < 10, did not require an operation, and who were discharged to home within 48 hours of admission. RESULTS: Data on 9,064 patients were reviewed; 6,875 (76%) arrived directly from the scene and 2,189 (24%) were transferred. Although the transferred group was more severely injured, the majority (64%) had minor injuries and 824 (39%) met secondary overtriage criteria. The degree of secondary overtriage and injury pattern varied with respect to referring facility. Peak admission day and times for overtriage patients coincided with scene admissions trauma receiving unit closure events. Patient payor mix and facility cost and reimbursement profiles did not differ between scene and transfer overtriage patients. CONCLUSIONS: A substantial proportion of transferred trauma patients require only brief diagnostic or observational care. Excessive overtriage calls for development of a regional inclusive trauma system with established primary and secondary triage guidelines to improve access to care and trauma system efficiency.

Is informed consent in trauma a lost cause? A prospective evaluation of acutely injured patients' ability to give consent.

BACKGROUND: Obtaining informed consent in acute trauma patients is often impossible, forcing investigators to abandon important projects. To better understand the likelihood of -- and barriers to -- informed consent in trauma patients, we evaluated when and how consent is possible in acutely injured patients. STUDY DESIGN: Over a 7-month period, at a large, urban, adult Level I trauma center, we prospectively assessed each patient's ability to give hypothetical informed consent. Patients were considered consentable when they were alert, unintoxicated, and stable, with no prohibitive language barrier, or when a proxy (first-degree relative) was available. When consent was not feasible on arrival, we documented the reason and the time at which consent became possible, either by the patient or proxy. RESULTS: Of 1,328 consecutive trauma patients, 1,020 (77%) were candidates for consent (personal or proxy) within 30 minutes of arrival. Twenty-five percent of patients with hypotension in the resuscitation area were consentable, as were 31% of severely injured (Injury Severity Score>24) patients. Eight hours after injury, 88% of all patients were consentable, as were 60% of severely injured patients and 36% of patients with initial hypotension. Primary barriers to consent included brain injury or unspecified alteration in awareness (41%), intoxication (28%), shock (26%), language barrier (2%), or medication (3%). CONCLUSIONS: Although an overall majority of trauma patients are candidates for early informed consent, the likelihood of early consent is substantially lower in patients with severe injury or shock. Alternatives to individual informed consent may be necessary to advance the early care of acutely, severely injured patients.

Seven years' experience with Integra as a reconstructive tool.

The bilayered dermal substitute Integra (Integra Life Sciences Corp., Plainsboro, NJ) was developed and has been widely used as primary coverage for excised acute burns. Our take has been slightly different, finding it most useful in the management of complex soft-tissue loss and threatened extremities as the result of tendon, joint, or bone exposure. Often tasked to fill significant volume loss, we have become adept at stacked multiple-layer applications. Creative use of this material has resulted in unexpected successes with distal limb salvage; the technique takes its place beside adjacent tissue transfer, composite flaps, and vascular pedicle flaps in our burn reconstructive practice. A prospective registry (44 patients) has been kept during the past 7 years that catalogs wounds with complex soft-tissue loss treated with Integra grafts. Many of these patients were at risk of extremity loss because of exposed tendons, joints, or bone. Integra was applied after 1:1 meshing. With profound soft-tissue defects, multiple layers of Integra were serially applied 1 to 2 weeks apart for reconstitution of soft-tissue contours. Local Integra graft infections were managed by silicone unroofing followed by topical sulfamylon liquid dressings. Wounds addressed included fourth-degree burns, necrotizing fasciitis, pit-viper envenomations, and total abdominal wall avulsion in one patient after being run over by a bus. Patients generally were free of pain from their wounds during the maturation phase of the Integra neodermis. Restoration of tissue contour was significantly better when using multiple layers for deep defects. Second and third layers of Integra were successfully applied after an abbreviated first graft maturation period of 7 days. Epithelial autografts on multilayer Integra applications frequently "ghosted"; they would auto-digest to dispersed cells followed subsequently by the reappearance of a confluent epithelial layer. Final grafted skin morphology over palmar and plantar surfaces assumed the type and fingerprint pattern of the original tissues. Infections were readily visible. Early recognition kept them to easily treated circumscribed areas, which did not jeopardize the entire wound. Lengths of stay were long (range, 2-246 days) but not significantly greater than with traditional techniques. The specific reconstructive use of Integra permitted unexpected salvage of several threatened extremities by protecting exposed tendons, bones and joints. Long-term histologic examination revealed unexpected persistence of Integra collagen. Large volume loss wounds benefited from the ability to fill voids with multilayered applications.