Gerrolt N. Jukema

The effects of varying degrees of pressure delivered by negative-pressure wound therapy on skin perfusion.

Vacuum-assisted closure (V.A.C. Therapy) uses 2 distinct types of foams, with different physical characteristics: the black polyurethane (PU) foam and the white polyvinyl alcohol (PVA) foam. This prospective, randomized study evaluates the response of cutaneous blood flow (CBF) in healthy intact forearm skin to varying V.A.C. Therapy negative pressures and both foam types. Continuous negative pressure was used in the range of 25–500 mm Hg. Skin blood flow was measured with noninvasive laser Doppler probes incorporated into the foam. Significant increase in CBF was found with both foams up to negative pressure of 300 mm Hg, with over 5-fold increase (mean: 5.57; SD: 3.32) with the PU foam and nearly 3-fold increase (mean: 2.87; SD: 1.29) with the PVA foam. Comparison of blood flow at baseline and at a negative pressure of 300 mm Hg showed a statistically significant difference (P < 0.001). No decrease in blood flow below baseline was observed during the experiments.

Negative pressure wound treatment with polyvinyl alcohol foam and polyhexanide antiseptic solution instillation in posttraumatic osteomyelitis

In a retrospective, case–control cohort study an assessment was made of the clinical outcome of patients with osteomyelitis treated with a new modality of negative pressure wound therapy, so called negative pressure instillation therapy. In this approach, after surgical debridement, a site of osteomyelitis is treated with negative pressure of at least 300 mmHg applied through polyvinyl alcohol dressing. The polyvinyl alcohol foam is irrigated through the tubes three times a day with a polyhexanide antiseptic solution. In 30 patients (14 males; mean age 52 [range, 26–81]) admitted between 1999 and 2003 with osteomyelitis of the pelvis or lower extremity, we assessed time to wound closure, number of surgical procedures and rate of recurrence of infection as well as need for rehospitalizations. For comparison, a control group of 94 patients (males, 58; mean age 47 [range, 9–85]), matched for site and severity of osteomyelitis, was identified in hospital records between 1982 and 2002. These patients underwent standard surgical debridement, implantation of gentamicin polymethylmethacrylate beads and long‐term intravenous antibiotics. In the Instillation group the rate of recurrence of infection was 3/30 (10%), whereas 55/93 (58.5%) of the controls had a recurrence (p<0.0001). Moreover, in those treated with instillation the total duration of hospital stay was shorter and number of surgical procedures smaller as compared with the controls (all p<0.0001). We conclude that in posttraumatic osteomyelitis negative pressure instillation therapy reduces the need for repeated surgical interventions in comparison with the present standard approach.

Do maggots have an influence on bacterial growth? A study on the susceptibility of strains of six different bacterial species to maggots of Lucilia sericata and their excretions/secretions.

PURPOSE The maggots of Lucilia sericata are successfully used as a treatment for infected wounds. Many articles are published about possible direct antibacterial properties of maggots and their excretions/secretions (ES), but with different results. The present study reinvestigates the susceptibility of six bacterial strains to maggots and their ES. METHODS Live maggots were added to a bacterial suspension. After incubation for 16 h, the bacterial growth in this suspension was compared with the growth in a suspension without maggots. We tested Instar-1 and Instar-3 maggots and compared nutrient broths. A turbidimetric assay investigated the antibacterial activity of ES. Finally, we compared the bacterial growth of Gram-positive and Gram-negative bacteria. RESULTS The test with live maggots showed an increase of bacterial growth. Instar-1 maggots stimulated more bacterial growth than Instar-3 maggots, as well as the use of a more nutritious broth. The turbidimetric assay showed no inhibition of bacterial growth. For all bacteria, except Pseudomonas aeruginosa, an increase in bacterial growth was shown. CONCLUSION There is no direct antibacterial effect of maggots and/or ES in vitro, however in clinical observations maggot therapy is successful. More research is needed to focus on possible indirect antibacterial activity, such as an immune-related effect.

Complement Activation and Inhibition in Wound Healing

Complement activation is needed to restore tissue injury; however, inappropriate activation of complement, as seen in chronic wounds can cause cell death and enhance inflammation, thus contributing to further injury and impaired wound healing. Therefore, attenuation of complement activation by specific inhibitors is considered as an innovative wound care strategy. Currently, the effects of several complement inhibitors, for example, the C3 inhibitor compstatin and several C1 and C5 inhibitors, are under investigation in patients with complement-mediated diseases. Although (pre)clinical research into the effects of these complement inhibitors on wound healing is limited, available data indicate that reduction of complement activation can improve wound healing. Moreover, medicine may take advantage of safe and effective agents that are produced by various microorganisms, symbionts, for example, medicinal maggots, and plants to attenuate complement activation. To conclude, for the development of new wound care strategies, (pre)clinical studies into the roles of complement and the effects of application of complement inhibitors in wound healing are required.

Prehospital triage and survival of major trauma patients in a Dutch regional trauma system: relevance of trauma registry

Background and aimsSince 1999, the Dutch trauma care has been regionalized into ten trauma systems. This study is the first to review such a trauma system. The aim was to examine the sensitivity of prehospital triage criteria [triage revised trauma score (T-RTS)] in identifying major trauma patients and to evaluate the current level of trauma care of a regionalized Dutch trauma system for major trauma patients.Patients and methodsMajor trauma patients (n=511) (June 2001–December 2003) were selected from a regional trauma registry database. The prehospital T-RTS was computed and standardized W scores (Ws) were generated to compare observed vs expected survival based on contemporary US- and UK-norm databases.ResultsThe T-RTS showed low sensitivity for the prehospital identification of major trauma patients [34.1% (T-RTS≤10)]. Nevertheless, 78.0% of all major trauma patients were directly managed by the trauma center. These patients were more severely injured than their counterparts at non-trauma-center hospitals (p<0.001). No significant difference emerged between the mortality rates of both groups. The Ws {−0.46 calculated on the US model [95% confidence interval (CI) ranging from −1.99 to 1.07]} [0.60 calculated on the UK model (95% CI ranging from −1.25 to 2.44)] did not differ significantly from zero.ConclusionThe trauma center managed most of the major trauma patients in the trauma system but the triage criteria need to be reconsidered. The level of care of the regional trauma system was shown to measure up to US and UK benchmarks.

Synergism between maggot excretions and antibiotics

Maggots are successfully used to treat severe, infected wounds. This study investigated whether maggot excretions/secretions influence the antibacterial activity of different antibiotics. Minimal inhibitory concentrations and minimal bactericidal concentrations (MBC) were determined of gentamicin and flucloxacillin for Staphylococcus aureus, of penicillin for Streptococcus pyogenes, of amoxicillin and vancomycin for Enterococcus faecalis, of gentamicin for Enterobacter cloacae, and of gentamicin, tobramycin, and ciprofloxacin for Pseudomonas aeruginosa by checkerboard titration. A range of concentrations of antibiotics in combination with excretions/secretions was examined to investigate the potential of maggot excretions/secretions to affect antibacterial activity. The results showed a dose‐dependent increase of the antibacterial effect of gentamicin in the presence of excretions/secretions on S. aureus. Minimal concentrations and MBC of gentamicin decreased, respectively, 64‐ and 32‐fold. The MBC of flucloxacillin and excretions/secretions against S. aureus were also decreased. The other antibiotic and excretions/secretions combinations exerted an indifferent effect. Excretions/secretions alone did not have any antibacterial effect. The synergism between gentamicin and maggot excretions/secretions could be of direct importance in clinical practice, because it could allow the use of lower doses of gentamicin and thus minimize the risk of gentamicin‐related side effects.

Pediatric Splenic Injury: Nonoperative Management First!

Background and Purpose:In the past splenectomy was the standard procedure for traumatic blunt splenic injury, when bleeding of the spleen occurred. Since the spleen performs important immunological functions the advantage of a spleen-saving approach is preservation of immunological functions. Especially in the pediatric population splenic preservation is an important objective. Spleen-saving treatment, in particular selective nonoperative management, has gained ground in the past 20 years. An 18-year retrospective review was performed to evaluate our cumulative experience with nonoperative management. Endpoints: hemodynamical instability and splenectomy.Methods:Forty-six patients were identified. Demographics, methods of management, mechanism of injury, injury grade, associated injuries, hemodynamical parameters, bloodtransfusion, complications, ICU and hospital stay were documented and analyzed to determine statistical significance between modes of management.Results:Initially, 34 patients were managed nonoperatively, while 12 patients underwent laparotomy – with 7 (58.3% of the operative group) of these having splenectomy performed. Three patients (out of 34) failed nonoperative management and required delayed splenorraphy or splenectomy, a 91.2% (3 out of 34 failed) success rate for intended nonoperative management versus 85.7% for intended splenorraphy (1 out of 7 failed). Thus, overall rates of 67.4% nonoperative management and 82.6% splenic conservation were achieved. Analysis of parameters between treatments showed significant differences between nonoperative management and splenorraphy for splenic injury grade II and IV.Conclusion:We recommend based on our data on children with splenic injury grades II and IV that the standard treatment for children aged 0 to 18 years due to blunt abdominal trauma should be nonoperative management. However management of blunt splenic injury remains a clinical decision, for this reason does not preclude on CT-scan grade V for nonoperative management.

Posttraumatische Osteomyelitis: bessere Behandlungsergebnisse durch innovative Vakuumversiege‑lungstechnik mit Instillationstherapie

Posttraumatic Osteomyelitis: Improvement in Outcome by Negative Pressure Wound Therapy with Instillation Technique Abstract. Surgical treatment of post-traumatic (fistula) osteomyelitis can be difficult and is associated with an increased risk of later recurrence. Very often osteomyelitis is accompanied by a soft tissue (defective) wound. After surgical debridement, the use of the vacuum sealing technique can stimulate wound healing and improve local blood circulation. In particular, the introduction of the innovative instillation technique for wound sponges can increase the effectiveness of the treatment of the infection. By regularly rinsing the sponges with an antiseptic polyhexanide solution, the duration of treatment, the number of operations, the in-patient stay and the recurrence rate in this patient group can be statistically significantly reduced.

Ernsthafte Infektionen: „chirurgische“ Madenbehandlung in der Traumatologie

Ist die adjuvante Behandlung mit sterilen Larven (Lucilia Sericata) im Falle einer ernsthaften Infektion der Weichteile oder des Knochens (Osteomyelitis) sinnvoll? Zur Beantwortung dieser Frage wurde dazu ein Patientenkollektiv von 16 Patienten mit Fliegenlarven in Kombination mit chirurgischem Debridement behandelt.