Lawrence J. Gottlieb

Glutamine administration reduces Gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control.

Objective To determine the effect of intravenous glutamine supplementation vs. an isonitrogenous control on infectious morbidity in severely burned patients. Previous clinical studies in seriously ill patients suggest a beneficial effect of glutamine on infectious morbidity, but no trials have examined possible clinical benefits in severely burned patients. Design Prospective, double-blind, randomized trial. Setting Burn intensive care unit of a university hospital. Patients Twenty-six severe burn patients with total burn surface area of 25% to 90% and presence of full-thickness burns. Patients were evaluated for occurrence of bacteremia and antibiotic use during the first 30 days of their burn unit admission. Nutritional status and overall inflammation were also measured. Intervention Either intravenous glutamine or an isonitrogenous control amino acid solution was administered as a continuous infusion during burn intensive care unit stay. Measurements and Main Results The incidence of Gram-negative bacteremia was significantly reduced in the glutamine-supplemented group (8%) vs. control (43%;p < .04). No difference was seen in the incidence of Gram-positive bacteremia or fungemia. Average number of positive blood cultures, antibiotic usage, and mortality rates also were reduced but did not reach statistical significance. Significant improvements in serum transferrin and prealbumin were observed in glutamine-supplemented patients at 14 days after burn injury (p < .01 and .04, respectively). C-reactive protein was also significantly reduced at 14 days after burn injury in the glutamine group (p < .01). Conclusions Significantly fewer bacteremic episodes with Gram-negative organisms occurred in the glutamine-supplemented patients. Glutamine supplementation improved measures of nutrition and decreased measures of overall inflammation. In addition, a trend toward lower mortality rate, decreased overall bacteremia incidence, and antibiotic usage in the glutamine group was observed. Glutamine’s beneficial effects may be a result of improved gut integrity or immune function, but the precise mechanism of glutamine’s protection is unknown.

Vacuum assisted closure for the treatment of sternal wounds: the bridge between débridement and definitive closure.

&NA; A method to refine the treatment of sternal wounds using Vacuum Assisted Closure (V.A.C.) therapy as the bridge between débridement and delayed definitive closure is described. A retrospective review of 35 consecutive patients with sternal wound complications over a 2‐year period (March of 1999 to March of 2001) was performed. The treatment of sternal wounds with traditional twice‐a‐day dressing changes was compared with the treatment with the wound V.A.C. device. An analysis of the number of days between initial débridement and closure, number of dressing changes, number and types of flaps needed for reconstruction, and complications was performed. Eighteen patients were treated with traditional twice‐a‐day dressing changes and 17 patients were treated with V.A.C. therapy alone. The two groups were similar regarding age, sex, type of cardiac procedure, and type of sternal wound. The V.A.C. therapy group had a trend toward a shorter interval between débridement and closure, with a mean of 6.2 days, whereas the dressing change group had mean of 8.5 days. The V.A.C. therapy group had a significantly lower number of dressing changes, with a mean of three, whereas the twice‐a‐day dressing change group had a mean of 17 (p < 0.05). Reconstruction required an average of 1.5 soft‐tissue flaps per patient treated with traditional dressing changes versus 0.9 soft‐tissue flaps per patient for those treated with V.A.C. therapy (p < 0.05). Before closure, there was one death among patients undergoing dressing changes and three in the V.A.C. therapy group, all of which were unrelated to the management of the sternal wound. Patients with sternal wounds who have benefited from V.A.C. therapy alone have a significant decrease in the number of dressing changes and number of soft‐tissue flaps needed for closure. Finally, the V.A.C. therapy group had a trend toward a decreased number of days between débridement and closure. (Plast. Reconstr. Surg. 111: 92, 2003.)

Hyperbaric oxygen therapy in plastic surgery: a review article.

The most important effects of hyperbaric oxygen (HBO), for the surgeon, are the stimulation of leukocyte microbial killing, the enhancement of fibroblast replication, and increased collagen formation and neovascularization of ischemic tissue. Preoperative hyperbaric oxygen induces neovascularization in tissue with radionecrosis. Refractory osteomyelitis and necrotizing fasciitis appear to respond to adjunctive hyperbaric oxygen. Crush injury and compartment syndrome appear to benefit through preservation of ATP in cell membranes, which limits edema. Hyperbaric oxygen in burn injury permits shorter hospital stays, a reduced number of surgeries, and less fluid replacement. Skin grafts and flaps are reported to take more completely and more rapidly. The same mechanisms may apply in ischemic problem wounds such as infected diabetic extremities. Contraindications and side effects are described. Hyperbaric oxygen will not heal normal wounds more rapidly but may, under certain circumstances, induce problem wounds to heal more like normal ones.

Medial Gastrocnemius Transposition Flap for the Treatment of Disruption of the Extensor Mechanism after Total Knee Arthroplasty

We describe a modified technique for the salvage of a total knee arthroplasty after disruption of the extensor mechanism. Between January and December 1992, seven patients had reconstruction of the extensor mechanism with use of a medial or an extended medial gastrocnemius flap. Six of the seven patients were followed for a mean of thirty-three months (range, twenty-six to forty-one months) and were evaluated both preoperatively and postoperatively with regard to the knee and functional scores of The Knee Society as well as the range of motion, extensor lag, walking status, and patellar height. The seventh patient was lost to follow-up six months postoperatively and was excluded from the analysis of the results. Preoperatively, the knee and functional scores were 16 ± 12.3 points and 12 ± 12.1 points (mean and standard deviation), respectively; the mean range of motion was 70 ± 44.0 degrees; and the mean extensor lag was 53 ± 33.4 degrees. Postoperatively, the mean knee and functional scores improved to 82 ± 12.4 points and 51 ± 23.0 points, respectively; the mean range of motion improved to 100 ± 21.8 degrees; and the mean extensor lag decreased to 24 ± 18.8 degrees. After the procedure, all patients who previously had been dependent on a walker were able to walk about the community with or without a cane, and those who had been dependent on a wheelchair were able to walk with the assistance of a walker. Patellar height was measured according to the method of Insall and Salvati for the four patients who had a patella. Preoperatively, the patellar heights were grossly abnormal; postoperatively, they more closely approached accepted normal values for three of the four patients. Reconstruction of a complicated rupture of the extensor mechanism with use of a medial gastrocnemius transposition flap after total knee arthroplasty is a reliable option for treatment.

Microsurgical replantation of the lip: a multi-institutional experience.

&NA; Traumatic amputation of the lip is a rare yet devastating event affecting both form and function. Considering the available methods for reconstruction, replantation may offer a reasonable solution. We sought to characterize the variables associated with lip replantation and to assess the outcome in a retrospective review of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. Lip replantation was successful in all 13 patients; partial flap loss occurred in one patient owing to iatrogenic injury. Follow‐up averaged 3.1 years. Average patient age at the time of injury was 21.1 years. There were six male and seven female patients. Injuries in two patients were the result of a human bite, the remaining injuries resulted from dog bites. One patient had significant associated injuries. Average length of hospital stay was 11.9 days. Ten patients suffered amputations of the upper lip, and three suffered amputations of the lower lip. Average defect size was 10.6 cm2. Operative time averaged 5.7 hours (range 2.5 to 12 hours). Warm ischemia time averaged 2.9 hours, and cold ischemia time averaged 2.7 hours. Donor and recipient veins were often scarce; all patients had at least one arterial anastomosis, whereas no vein was available in 7 of 13 patients; vein grafts were required in one patient. Leech therapy was employed in 11 of 13 patients. Anticoagulant therapy was administered in the majority of patients. Systemic heparin was utilized in 10 of 13 patients, low molecular weight dextran was used in 7 of 13 patients, and aspirin was given to 7 of 13 patients. One bleeding complication was incurred. An average of 6.2 units of packed red blood cells was administered to 12 of 13 patients (adjusted to 250 cc/unit). Antispasmodic therapy was employed in six of eight patients intraoperatively and in two of eight patients postoperatively. Intraoperative complications included difficulty identifying veins in 7 of 13 patients, arterial spasm in 1 of 13 patients, and vessel diameter <0.5 mm in 4 patients. Postoperatively, one patient suffered vein thrombosis requiring anastomotic revision. Broad spectrum antibiotics were administered to all patients, and there were no infections. Nearly onethird (4 of 13) patients suffered prolonged edema lasting >4 months. Color match of the replanted lip segment was rated excellent in all cases. Hypertrophic scarring occurred in 6 of 13 patients. A total of 12 revision procedures was performed in six patients. Interestingly, leech therapy resulted in permanent visible scarring as a result of the leech bite in 6 of 11 patients treated. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Stomal continence was present in all lips. Sensibility return in the replanted lip segment was quite good with 12 of 13 patients demonstrating at least protective moving two‐point sensibility (≥10 mm). Partial replant necrosis in one patient resulted in significant scar and contraction that compromised the aesthetic appearance. Overall, however, all patients were uniformly pleased with their final results. This clinical study is one of the largest of its kind on lip replantation. Although this represents a multi‐institutional experience, the data are remarkably consistent. Re‐establishment of venous outflow seems to be the most problematic technical challenge. By incorporating the adjuncts of anticoagulation, leech therapy, and antispasmodics, a successful outcome can be expected despite the paucity of vessels and small vessel size. The risks of blood transfusion, lengthy operative time, and hospital stay must be weighed against the functional benefits. (Plast. Reconstr. Surg. 102: 358, 1998.)

Preventing Unintentional Scald Burns: Moving Beyond Tap Water

OBJECTIVE. The goal was to examine in detail the mechanisms of significant scald burns among children <5 years of age, to discover insights into prevention. METHODS. Medical records for children <5 years of age who were admitted with scald burns between January 1, 2002, and December 31, 2004, were identified through the University of Chicago Burn Center database. Demographic data and details of the circumstances and mechanisms of injury were extracted from the medical records. RESULTS. Of 640 admissions to the University of Chicago Burn Center during the 3-year study period, 140 (22%) involved children <5 years of age with scald burns. Of the 137 available charts reviewed, 118 involved unintentional injuries. Of those unintentional injuries, 14 were tap water scalds and 104 were non–tap water scalds. Of the non–tap water scalds, 94 scalds (90.4%) were related to hot cooking or drinking liquids. Two unexpected patterns of injury were discovered. Nine children (8.7%) between the ages of 18 months and 4 years were scalded after opening a microwave oven and removing the hot substance themselves. Seventeen children (16.3%) were scalded while an older child, 7 to 14 years of age, was cooking or carrying the scalding substance or supervising the younger child. CONCLUSIONS. Current prevention strategies and messages do not adequately address the most common mechanisms of scald injury requiring hospitalization. Easy access to a microwave oven poses a significant scald risk to children as young as 18 months of age, who can open the door and remove the hot contents. An engineering fix for microwave ovens could help protect young children from this mechanism of scalding. Involvement of older children in a subset of scald injuries is a new finding that may have prevention implications.

A prospective randomized trial comparing subatmospheric wound therapy with a sealed gauze dressing and the standard vacuum-assisted closure device

ObjectiveTwo methods of subatmospheric pressure wound therapy—wall suction applied to a sealed gauze dressing (GSUC) and the vacuum-assisted closure device (VAC)—were compared in hospitalized patients at University of Chicago Medical Center. Summary of Background DataVAC therapy is widely used, but can be expensive and difficult to apply; it also fails in some patients. MethodsA randomized prospective study of 87 patients (N = 45 in the GSUC arm and N = 42 in the VAC arm) was undertaken between October 2006 and May 2008. The study comprised patients with acute wounds resulting from trauma, dehiscence, or surgery. ResultsDemographics and wound characteristics were similar in both groups. There were significant reductions in wound surface area and volume in each group. In the GSUC group, the reductions in wound surface area and volume were 4.5%/day and 8.4%/day, respectively (P < 0.001 for both), and in the VAC group, this was 4.9%/day and 9.8%/day, respectively (P < 0.001 for both). The reductions in wound surface area and volume were similar in both groups (P = 0.60 and 0.19, respectively, for the group-by-time interaction). The estimated difference (VAC − GSUC) was 0.4% (95% confidence interval: −1.0, 1.7) for wound surface area and 1.4% (95% confidence interval: −0.7, 3.5) for volume. The mean cost per day for GSUC therapy was

A new design for the radial forearm free-flap phallic construction.

4.22 versus

Pseudomonas aeruginosa virulence expression is directly activated by morphine and is capable of causing lethal gut-derived sepsis in mice during chronic morphine administration.

96.51 for VAC therapy (P < 0.01) and the average time required for a GSUC dressing change was 19 minutes versus 31 minutes for a VAC dressing change (P < 0.01). The sum of pain intensity differences was 0.50 in the GSUC group compared with 1.73 for the VAC group (P = 0.02). ConclusionsGSUC is noninferior to VAC with respect to changes in wound volume and surface area in an acute care setting. In addition, GSUC dressings were easier to apply, less expensive, and less painful.

Prosthesis placement after total phallic reconstruction.

One-stage phallic construction using the radial forearm free flap was originally reported in 1984. This potentially sensate, thin, minimally hair-bearing flap, whose design incorporated a vascularized urethra, provided significant advantages over previously described multistaged insensate phallic reconstructions. The original design, as described by Chang and Hwang, is limited in size and has the propensity to develop meatal stenosis. This article describes a new design of the radial forearm flap for phallic construction performed on four patients. The technique described incorporates a centrally located neourethra in continuity with a neoglans. It eliminates the circumferential meatal suture line and, therefore, meatal stenosis without sacrificing phallic length.