Hyalomatrix coverage in scalp wounds with exposed cranium and dura.

AIM: The armamentarium of options available for soft tissue reconstruction of the scalp spans the reconstructive ladder. The purpose of this paper is to describe a case series of patients with exposed cranium and dura who were successfully reconstructed using esterified hyalomatrix (eHAM, Hyalomatrix, Medline Industries Inc., US). METHODS: After obtaining Institutional Review Board approval, a retrospective review of the senior author's (ALF) patient database was completed. Patients who underwent scalp reconstruction using eHAM were identified. Each patient's chart was reviewed and data collected on demographics, days to skin graft, duration of follow-up, pathology, comorbidities and complications. RESULTS: This case series consisted of five patients aged ≥18 years, with scalp wounds exposing dura or cranium, who were treated with eHAM as a bridge to definitive coverage with a skin graft. Each wound successfully granulated the exposed critical structure with the use of the eHAM. The mean time to skin graft coverage was 41 days, with a range of 13-79 days. Of the series of five patients, four had a follow-up of ≥12 weeks. The mean defect size was 90.2cm2. CONCLUSION: Complex scalp reconstruction can be accomplished using healing by secondary intention, skin grafts, local flaps, tissue expansion and free tissue transfer. As shown in this case series, another option available in select patients is using a dermal substitute such as eHAM. This is one treatment option available to reconstructive surgeons in multiple specialties.

Histone Deacetylase Inhibitors Enhance Cytotoxicity Towards Breast Tumors While Preserving the Wound-Healing Function of Adipose-Derived Stem Cells.

INTRODUCTION: Paclitaxel improves the oncologic response of breast cancer resections; however, it may negatively affect the wound-healing potential of human adipose-derived stem cells (hASCs) for fat grafting and reconstructive surgery. Histone deacetylase inhibitors (HDACis) modify the epigenetic regulation of gene expression and stabilize microtubules similarly to paclitaxel, thus, creating a synergistic mechanism of cell cycle arrest. We aim to combine these drugs to enhance cytotoxicity towards breast cancer cells, while preserving the wound-healing function of hASCs for downstream reconstructive applications. METHODS: Triple negative breast cancer cells (MBA-MB-231) and hASCs (institutional review board-approved clinical isolates) were treated with a standard therapeutic dose of paclitaxel (1.0 µM) or with low-dose paclitaxel (0.1 µM) combined with the HDACi suberoylanilide hydroxamic acid or trichostatin A. Cell viability, gene expression, apoptosis, and wound-healing/migration were measured via methylthiazol tetrazolium assay, quantitative real-time polymerase chain reaction, annexin V assay, and fibroblast scratch assay, respectively. RESULTS: Combined HDACi and low-dose paclitaxel therapy maintained cytotoxicity towards breast cancer cells and preserved adipose-derived stem cell viability. Histone deacetylase inhibitor demonstrated selective anti-inflammatory effects on adipose-derived stem cell gene expression and decreased expression of the proapoptotic gene FAS. Furthermore, HDACi therapy did not increase relative apoptosis within hASCs. A scratch assay demonstrated enhanced wound healing among injured fibroblasts indirectly co-cultured with HDACi-treated hASCs. CONCLUSIONS: Combining HDACi with low-dose paclitaxel improved cytotoxicity towards breast cancer cells and preserved hASC viability. Furthermore, enhanced wound healing was observed by improved migration in a fibroblast scratch assay. These results suggest that the addition of HDACi to taxane chemotherapy regimens may improve oncologic results and wound-healing outcomes after reconstructive surgery.

Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit.

OBJECTIVE: To examine the impact of adherence to a ventilator-associated pneumonia (VAP) bundle on the incidence of VAP in our surgical intensive care units (SICUs). DESIGN: Prospectively collected data were retrospectively examined from our Infection Control Committee surveillance database of SICU patients over a 38-month period. Cost of VAP was estimated at $30,000 per patient stay. SETTING: Two SICUs at a tertiary care academic level I trauma center. PATIENTS: Ventilated patients admitted to a SICU. INTERVENTION: The Institute for Healthcare Improvement VAP bundle was instituted at the beginning of the study and included head-of-bed elevation, extubation assessment, sedation break, peptic ulcer prophylaxis, and deep vein thrombosis prophylaxis. A daily checklist was considered compliant if all 5 items were performed for each patient. MAIN OUTCOME MEASURES: Patients were assessed for VAP. Staff were assessed for compliance with the VAP bundle. RESULTS: Prior to initiation of the bundle, VAP was seen at a rate of 10.2 cases/1000 ventilator days. Compliance with the VAP bundle increased over the study period from 53% and 63% to 91% and 81% in each respective SICU. The rate of VAP decreased to 3.4 cases/1000 ventilator days. A cost savings of $1.08 million was estimated. CONCLUSIONS: Initiation of the VAP bundle is associated with a significantly reduced incidence of VAP in patients in the SICU and with cost savings. Initiation of a VAP bundle protocol is an effective method for VAP reduction when compliance is maintained.