Mary T. Rieman
Shriners Hospitals for Children
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Annals of Surgery | 1995
Steven T. Boyce; Michael J. Goretsky; David G. Greenhalgh; Richard J. Kagan; Mary T. Rieman; Glenn D. Warden
ObjectiveComparison of cultured skin substitutes (CSSs) and split-thickness autograft (STAG) was performed to assess whether the requirement for autologous skin grafts may be reduced in the treatment of massive bums. Summary Background DataCultured skiasubstitutes consisting of collagen-glycosaminoglycan substrates populated with autologous fibroblasts and keratinocytes have been demonstrated to close full-thickness skin wounds in athymic mice and to express normal skin antigens after closure of excised wounds in burn patients. MethodsData were collected from 17 patients between days 2 and 14 to determine incidence of exudate, incidence of regrafting, coloration, keratinization, and percentage of site covered by graft (n = 17). Outcome was evaluated on an ordinal scale (0 = worst; 10 = best) beginning at day 14, with primary analyses at 28 days (n = 10) and 1 year (n = 4) for erythema, pigmentation, epithelial blistering, surface roughness, skin suppleness, and raised scar. ResultsSites treated with CSSs had increased incidence of exudate (p = 0.06) and decreased percentage of engraftment (p < 0.05) compared with STAG. Outcome parameters during the first year showed no differences in erythema, blistering, or suppleness. Pigmentation was greater, scar was less raised, but regrafting was more frequent in CSS sites than STAG. No differences in qualtative outcomes were found after 1 year, and antibodes to bovine collagen were not detected in patientsera. ConclusionsThese results suggest that outcome of engrafted CSSs is not different from STAG and that increased incidence is related to decreased percentage of initial engraftment. Increased rates of CSSs may lead to improved outcome for closure of burn wounds, allow greater availability of materials for grafting, and reduce requirements for donor skin autogratt.
Annals of Surgery | 2002
Steven T. Boyce; Richard J. Kagan; Kevin P. Yakuboff; Nicholas A. Meyer; Mary T. Rieman; David G. Greenhalgh; Glenn D. Warden
ObjectiveComparison of cultured skin substitutes (CSS) and split-thickness skin autograft (AG) was performed to assess whether donor-site harvesting can be reduced quantitatively and whether functional and cosmetic outcome is similar qualitatively in the treatment of patients with massive cutaneous burns. Summary Background DataCultured skin substitutes consisting of collagen-glycosaminoglycan substrates populated with autologous fibroblasts and keratinocytes have been shown to close full-thickness skin wounds in preclinical and clinical studies with acceptable functional and cosmetic results. MethodsQualitative outcome was compared between CSS and AG in 45 patients on an ordinal scale (0, worst; 10, best) with primary analyses at postoperative day 28 and after about 1 year for erythema, pigmentation, pliability, raised scar, epithelial blistering, and surface texture. In the latest 12 of the 45 patients, tracings were performed of donor skin biopsies and wounds treated with CSS at postoperative days 14 and 28 to calculate percentage engraftment, the ratio of closed wound:donor skin areas, and the percentage of total body surface area closed with CSS. ResultsMeasures of qualitative outcome of CSS or AG were not different statistically at 1 year after grafting. Engraftment at postoperative day 14 exceeded 75% in the 12 patients evaluated. The ratio of closed wound:donor skin areas for CSS at postoperative day 28 was significantly greater than for conventional 4:1 meshed autografts. The percentage of total body surface area closed with CSS at postoperative day 28 was significantly less than with AG. ConclusionsThe requirement for harvesting of donor skin for CSS was less than for conventional skin autografts. These results suggest that acute-phase recovery of patients with extensive burns is facilitated and that complications are reduced by the use of CSS together with conventional skin grafting.
Plastic and Reconstructive Surgery | 1993
Steven T. Boyce; David G. Greenhalgh; Richard J. Kagan; T. Housinger; Sorrell Jm; Childress Cp; Mary T. Rieman; Glenn D. Warden
Closure of large skin wounds (i.e., burns, congenital giant nevus, reconstruction of traumatic injury) with split-thickness skin grafts requires extensive harvesting of autologous skin. Composite grafts consisting of collagen-glycosaminoglycan (GAG) substrates populated with cultured dermal fibroblasts and epidermal keratinocytes were tested in a pilot study on full-thickness burn wounds of three patients as an alternative to split-thickness skin. Light microscopy and transmission electron microscopy showed regeneration of epidermal and dermal tissue by 2 weeks, with degradation of the collagen-GAG implant associated with low numbers of leukocytes, and deposition of new collagen by fibroblasts. Complete basement membrane, including anchoring fibrils and anchoring plaques, is formed by 2 weeks, is mature by 3 months, and accounts for the absence of blistering of healed epidermis. All skin antigens tested (involucrin, filaggrin, laminin, collagens IV and VII, fibronectin, and chondroitin-sulfate) were expressed by 16 days after grafting. This cultured skin analogue provides an experimental alternative to split-thickness skin graft that develops histiotypic markers of skin anatomy and antigen expression after wound closure.
Wound Repair and Regeneration | 1994
David G. Greenhalgh; Mary T. Rieman
A phase I/II clinical study was performed to evaluate the safety and potential efficacy of topical recombinant human basic fibroblast growth factor on the healing of partial‐thickness skin graft donor sites in burned children. Each child served as his or her own control. In a blinded and random fashion, one donor site was sprayed with basic fibroblast growth factor (5 µg/cm2) on days 0 to 4 after harvest, whereas the other site was treated with vehicle. Twelve patients were entered in the study but one patient died of sepsis that was unrelated to growth factor treatment. Of the remaining 11 patients, no adverse events related to basic fibroblast growth factor occurred. Serum basic fibroblast growth factor levels were never detected and antibody levels remained unchanged. No differences in the rate of epithelialization or days until complete closure were noted (basic fibroblast growth factor = 12.9 ± 3.9 days, placebo = 12.2 ± 5.5 days; mean ± standard error of the mean). No differences in pain, itching, wound fragility, erythema, scarring, or pigmentation were noted. All of the scars matured within 1 year with good to excellent results. Investigators, patients, or families could not distinguish between the two wounds. Although basic fibroblast growth factor proved safe, no enhancement of donor site healing was seen in this small study. Because the time for donor site healing limits subsequent autograft use in patients with sizeable burns, studies should focus on accelerating healing in patients with larger burns where donor site healing is delayed and reharvest is required.
Journal of Burn Care & Research | 2017
Steven T. Boyce; Peggy Simpson; Mary T. Rieman; Petra Warner; Kevin P. Yakuboff; J. Kevin Bailey; Judith K. Nelson; Laura A. Fowler; Richard J. Kagan
Stable closure of full-thickness burn wounds remains a limitation to recovery from burns of greater than 50% of the total body surface area (TBSA). Hypothetically, engineered skin substitutes (ESS) consisting of autologous keratinocytes and fibroblasts attached to collagen-based scaffolds may reduce requirements for donor skin, and decrease mortality. ESS were prepared from split-thickness skin biopsies collected after enrollment of 16 pediatric burn patients into an approved study protocol. ESS and split-thickness autograft (AG) were applied to 15 subjects with full-thickness burns involving a mean of 76.9% TBSA. Data consisted of photographs, tracings of donor skin and healed wounds, comparison of mortality with the National Burn Repository, correlation of TBSA closed wounds with TBSA full-thickness burn, frequencies of regrafting, and immunoreactivity to the biopolymer scaffold. One subject expired before ESS application, and 15 subjects received 2056 ESS grafts. The ratio of closed wound to donor areas was 108.7 ± 9.7 for ESS compared with a maximum of 4.0 ± 0.0 for AG. Mortality for enrolled subjects was 6.25%, and 30.3% for a comparable population from the National Burn Repository (P < .05). Engraftment was 83.5 ± 2.0% for ESS and 96.5 ± 0.9% for AG. Percentage TBSA closed was 29.9 ± 3.3% for ESS, and 47.0 ± 2.0% for AG. These values were significantly different between the graft types. Correlation of % TBSA closed with ESS with % TBSA full-thickness burn generated an R 2 value of 0.65 (P < .001). These results indicate that autologous ESS reduce mortality and requirements for donor skin harvesting, for grafting of full-thickness burns of greater than 50% TBSA.
Journal of Burn Care & Research | 2011
Daniel P. Healy; Amy D. Sombun; Jason Gardner; Kathy Good; Paula Durkee; Lucy Toner; Mary T. Rieman; Alice N. Neely; Richard J. Kagan
Multidrug resistance in Gram-negative bacteria has led to a resurgence in colistin use. No pharmacokinetic data exist for burn patients. A 17-year-old boy suffered a 71% TBSA full-thickness burn with deep necrosis and compartment syndrome. He developed multidrug-resistant Acinetobacter baumannii burn wound sepsis/septic shock with acute renal failure requiring dialysis. The organism was resistant to all tested antibiotics except colistin. He received colistin 2.5 mg/kg every 24 hours. Peak and trough serum concentrations, area under the concentration-time curve, and elimination half-lives of colistin were 3.6 ± 1.0 μg/ml, 0.9 ± 0.5 μg/ml, 47.1 ± 14.4 mg · hr/L, and 12.3 ± 9.4 hours (mean ± SD), respectively. Serum levels were at or above the minimum inhibitory concentration for >90% of therapy. Nevertheless, salvage therapy with colistin proved futile as the patient developed acidosis, coagulopathy, and was vasopressor-dependent without any wound healing. He died on hospital day 52. Microbiologically, the serum levels of colistin were seemingly adequate, as repeat cultures were negative. Given the peak and trough levels of colistin relative to the minimum inhibitory concentration for the organism (0.5 μg/ml), it would seem that the dosage of 2.5 mg/kg administered every 24 hours for this patient on dialysis was appropriate. Patients on dialysis infected with an organism possessing a higher inhibitory concentration (≥1 μg/ml) should probably receive the same dosage every 12 hours to avoid subtherapeutic concentrations. Large-scale study of the pharmacokinetics of colistin in patients with burn injury is urgently needed.
Journal of Burn Care & Research | 2008
Mary T. Rieman; Melissa Hunley; Lori Woeste; Richard J. Kagan
The purpose of this study was to examine the incidence, causes, and demographics of burn injuries in Amish children, treated at a pediatric burn center located in close proximity to the Midwestern Amish country. After Institutional Review Board approval, we used our TRACS Burn Registry to identify burn injuries in Amish and non-Amish children. We then compared the groups formed by gender and culture. We identified 37 Amish children (1.25%) among the 2972 acute burn patients admitted over the 12-year period of review. Importantly, Amish girls sustained significantly more extensive and deeper burns than Amish boys or non-Amish children of either gender (P < .05). Ventilator days were also greater for Amish girls than for the non-Amish groups (P < .05). A greater length of hospital stay for the Amish girls was likely because of their significantly larger burn size. There were also overall significant differences in burn causes among Amish and non-Amish children (P = .002). Amish patients had a higher incidence of burns, by hot liquids not related to cooking, ignition of clothing, or ignition of flammable materials, than non-Amish children. Of note, Amish girls had a relatively shorter delay in admission to our burn center than did Amish boys and non-Amish children. Burn injuries to Amish children requiring inpatient treatment seem to be quite uncommon. When they do occur, burns in Amish children tend to be more extensive than similar injuries in non-Amish children. The data suggest that there may be significant and specific educational opportunities for burn prevention in Amish children in our burn center’s referral area.
Journal of Burn Care & Research | 2014
Richard J. Kagan; Alice N. Neely; Mary T. Rieman; Angela R. Hardy; Petra Warner; J. Kevin Bailey; Kevin P. Yakuboff
Existing practice guidelines designed to minimize invasive catheter infections and insertion-related complications in general intensive care unit patients are difficult to apply to the burn population. Burn-specific guidelines for optimal frequency for catheter exchange do not exist, and great variation exists among institutions. Previously, the authors’ practice was to follow a new site insertion at 48 hours by an exchange over a guidewire, which was followed 48 hours later by a second guidewire exchange (48h group). As a performance improvement initiative, the authors attempted to determine whether there would be any advantage or disadvantage to extending these intervals to 72 hours (72h). All patients with centrally placed intravascular catheters from October 2007 to August 2008 were included in the 48h group, and all patients with catheters placed from September 2008 to December 2009 comprised the 72h group. Catheter infection rates were determined using the National Healthcare Safety Network definition for central line–associated bloodstream infections (CLABSIs) and calculated as CLABSIs/1000 catheter days. The two groups were not significantly different for age, sex, burn etiology, total burn size, or percent third-degree burn. There were 3.1 CLABSIs/1000 catheter days for the 48h group and 2.8 CLABSIs/1000 catheter days for the 72h group (NS). The authors conclude that increasing the central catheter change interval from 48 to 72 hours did not result in any increase in their CLABSI rate. Implementation of this change in practice is expected to decrease supply costs by
Journal of Burn Care & Research | 2006
Jefferson M. Lyons; Christopher S. Davis; Mary T. Rieman; Robert Kopcha; Ho H. Phan; David G. Greenhalgh; Tina L. Palmieri; Richard J. Kagan
28,000 annually in addition to reducing clinical support services needed to perform these procedures.
Journal of Burn Care & Research | 2012
Mary T. Rieman; Richard J. Kagan
After burn shock resuscitation, serum gamma globulin levels decrease well below normal before slowly recovering over the course of 1 to 2 months. During this period, patients are vulnerable to further insult as a result of this immunocompromise. We hypothesized that intravenous immune globulin and subtherapeutic polymixin B (IVIG-B) could decrease the incidence and/or severity of sepsis after major thermal injury. A retrospective chart review from 1997 through 2003 at two hospitals compared patients who received IVIG-B (Hospital A) with those who did not (Hospital B). Patients with burns 40% or greater TBSA were included, whereas patients with nonsurvivable injuries were excluded from data analysis. A total of 152 patients were included in the study. One hundred two patients received IVIG-B, and 50 did not. Total burn size was 63.4% TBSA at Hospital A and 63.1% TBSA at Hospital B, with full-thickness burns of 54.4 and 61.7% TBSA, respectively (P < .05). Patients treated at Hospital A had a 51.9% incidence of inhalation injury compared with 28% of the patients at Hospital B (P < .05). There was an average of 1.2 and 1.9 septic episodes for patients treated at Hospital A and Hospital B, respectively (P < .05). Length of hospital stay was 77.1 days at Hospital A compared with 103.8 days at Hospital B (P < .05). Mortality was 17.6% and 18% at Hospitals A and B, respectively, and was not significantly different. Our data suggest that prophylactic IVIG-B is associated with a reduction in the incidence of septic episodes and decreased hospital length of stay following major thermal injury.