Bromelain-based enzymatic debridement of chronic wounds: A preliminary report.

Sharp debridement is currently considered most effective for debridement of chronic wounds; however, some patients do not have access to or cannot be treated by surgical methods. This study was designed to provide a first impression of the safety and efficacy of bromelain-based enzymatic debridement of chronic wounds. Two consecutive single-arm studies assessing the enzymatic debridement efficacy of a concentrate of proteolytic enzymes enriched in bromelain in chronic wounds was conducted in 2 medical centres. Patients were treated with up to 11 consecutive 4-hour enzymatic debridement sessions and then treated until wound closure. Twenty-four patients with chronic wounds of different aetiologies were enrolled. All wounds achieved an average of 68% ± 30% debridement in an average of 3.5 ± 2.8 enzymatic debridement 4-hour sessions. Seventeen responding wounds (venous, diabetic, pressure, and post-traumatic aetiologies) achieved an average 85% ± 12% debridement in 3.2 ± 2.5 applications. Seven non-responding wounds (arterial and post-surgical aetiologies) achieved an average 26% ± 13% debridement in 4.3 ± 3.5 applications. No treatment-related serious adverse events were observed, and the only adverse event attributed to the enzymatic debridement was pain. These preliminary results indicate the potential safety and efficacy of bromelain-based enzymatic debridement in chronic wounds. Larger controlled studies are needed to further investigate this indication.

Long-term pediatric skin eruption-related hospitalizations in offspring conceived via fertility treatment.

BACKGROUND: Although concerns have been raised regarding the long-term health risks of offspring conceived following fertility treatments, limited information is available regarding their health status beyond the neonatal period. We aimed to evaluate the risk of long-term eruptive dermatological morbidity among children born following fertility treatments as compared to those conceived spontaneously. METHODS: A population-based cohort study was conducted, including all singleton deliveries occurring between the years 1991 and 2014 at a single tertiary medical center. Fetuses with congenital malformations and multiple gestations were excluded. Children delivered following fertility treatment pregnancies and spontaneous pregnancies were compared. Hospitalizations of the offspring up to the age of 18 years involving cutaneous eruptions were evaluated. A Kaplan-Meier survival curve was used to compare cumulative morbidity incidence and a Cox regression model to control for confounders. RESULTS: During the study period, 242,187 singleton deliveries met the inclusion criteria, 1.8% of which were following fertility treatments (n = 4324). Eruptive dermatological morbidity of the offspring up to the age of 18 years was significantly more common in the fertility treatment group (1.5%) as compared to spontaneous pregnancies (1.1%; P = 0.023). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of eruptive dermatological morbidity following fertility treatments (log-rank P = 0.007). Using the Cox regression model, while controlling for multiple confounders, fertility treatment was noted as an independent risk factor for long-term pediatric eruptive dermatological morbidity (adjusted HR = 1.43, CI 1.12-1.83, P = 0.004). CONCLUSION: Singletons conceived via fertility treatments appear to be at an increased risk for long-term eruptive dermatological morbidity.

Effect of Botulinum Toxin A on Muscle Healing and its Implications in Aesthetic and Reconstructive Surgery.

BACKGROUND: Muscle activity contributes to the enhancement of facial aging deformity, blepharospasm, cerebral palsy spasticity, trismus, torticollis, and other conditions. Myotomy of the involved muscles in order to reduce the deformity has variable success rates due to muscle healing and regeneration of activity. OBJECTIVES: The goal of this study was to investigate whether blocking striated muscle activity with Botulinum toxin (BtxA) during the healing time after myotomy alters the healing process and reduces long-term muscle activity. METHODS: Eighteen Sprague Dawley rats where divided into 3 groups: group A (n = 7) underwent myotomy of their Latisimus Dorsi muscle; group B (n = 7) underwent myotomy and injection of BtxA into their severed muscle; group C (n = 4) injection of BtxA only. Muscle strength was tested periodically using a grip test. RESULTS: Starting at week 16 and until the termination of study at week 22, group B (Myotomy + BtxA) showed significant reduction in muscle power compared to the two control groups. CONCLUSIONS: Addition of BtxA injection into a muscle immediately after myotomy may interfere with muscle healing and contribute to a more successful long-term result.

[REVIEW OF 30 YEARS OF RESEARCH AND DEVELOPMENT OF AN ENZYMATIC DEBRIDEMENT AGENT FOR BURNS].

INTRODUCTION: Early removal of burn eschar is a cornerstone of burn care. The most commonly practiced eschar removal technique for deep burns in modern burn care is surgical debridement but this technique is associated with surgical burden and leads to unnecessary excision of viable tissue. GOALS: To review 30 years of research and development of an enzymatic debridement agent for burns. METHODS: Studies performed during the last 30 years are reviewed in this manuscript. RESULTS: Patients who underwent enzymatic debridement had a significantly shorter time to complete debridement, the surgical burden was significantly lower, hand burns did not necessitate escharotomy, and the long term results were favorable. DISCUSSION: Early enzymatic debridement leads to an efficient debridement, preservation of viable tissue, a reduction in surgical burden and favorable long term results. CONCLUSION: We believe early enzymatic debridement will lead to better care for burn victims and perhaps, even to a paradigm shift in the treatment of burns.

Defensive Medicine Among Plastic and Aesthetic Surgeons in Israel.

BACKGROUND: Defensive medicine (DM) includes medical practices that are aimed at avoiding liability rather than benefitting the patient. DM has not been well characterized among plastic surgeons. OBJECTIVES: The authors examined the extents of intended and unintended DM among members of the Israeli Society of Plastic and Aesthetic Surgery (ISPAS) and identified risk factors for DM. METHODS: A total of 108 ISPAS members were asked to complete a questionnaire that addressed physician attitudes toward DM and intended or unintended DM practices. RESULTS: Seventy-eight surgeons (72.2% response rate) returned the questionnaire, although some questionnaires were returned incomplete. Forty respondents acknowledged practicing DM (ie, DM group), and 33 respondents did not (ie, non-DM group). There were no between-group differences in gender, years of practice, or number of previous litigations. Thirty-one percent of respondents in the DM group indicated that they avoid certain surgical procedures, compared with 6% of respondents in the non-DM group (P = .008). In private practice, 66.2% of respondents stated that they obtain written informed consent twice before surgery, and 100% request preoperative blood-coagulation testing. In contrast, 40% and 74% of respondents in public practice, respectively, acknowledged these behaviors (for consent, P = .027; for testing, P = .0059). Sixty-three percent of respondents prescribe antibiotics for more than 24 hours postoperatively, and this practice was slightly more common in the DM group (34 prescribe antibiotics vs 21 in the non-DM group; P = .079). CONCLUSIONS: DM is highly integrated into the daily medical practices of plastic surgeons in Israel.

Facial Reconstruction of a Mucormycosis Survivor by Free Rectus Abdominis Muscle Flap, Tissue Expansion, and Ocular Prosthesis.

Invasive sinonasal mucormycosis is a rare fungal infection that usually occurs in immunocompromised or diabetic patients, and it is often fatal. The authors present a case of a woman patient suffering from systemic lupus erythematosus and diabetes mellitus treated with prednisone, presenting with a rapidly progressive rhino-orbital-cerebral mucormycosis. She was successfully treated with combined intravenous antifungal therapy and radical debridement followed by complex defect reconstruction with a free vertical rectus abdominis myocutaneous flap, tissue expander, and ophthalmic prosthesis.

Lymph Node Metastasis in Cutaneous Head and Neck Squamous Cell Carcinoma.

BACKGROUND: Cutaneous squamous cell carcinoma (CSCC), the second most common cancer in whites, may result in nodal metastasis in 4% of patients. In the last decade, sentinel lymph node biopsy (SLNB) became the common practice for treating patients with invasive skin cancers such as melanoma, although its use in patients with CSCC is still under debate. OBJECTIVE: To find the rate of cervical lymph node metastasis in the series of patients with CSCC of the head and neck and to identify those who may need SLNB. MATERIALS AND METHODS: A retrospective data collection on all patients diagnosed with CSCC of head and neck during the years 1998 to 2005. RESULTS: A total of 572 patients with 725 head and neck CSCC were included in the study group. During the follow-up period, 10 (1.3%) patients developed lymph node metastases and no patient developed distant metastases. The probability of lymph node metastasis within 6 years for T1 and T2 tumors was 1.09% and 5.46%, respectively (p = .0387). CONCLUSION: Because of the relatively low incidence of cervical lymph node metastases in patients with CSCC of the head and neck, SLNB for clinically N0 patients is not justified.

Admission cell free DNA as a prognostic factor in burns: quantification by use of a direct rapid fluorometric technique.

BACKGROUND: Despite great advances in the treatment of burn patients, useful prognostic markers are sparse. During the past years there has been increasing interest in circulating plasma cell free DNA as a potential marker for tissue injury. We have developed a rapid direct fluorescent assay for cell free DNA quantification that allows obtaining accurate, fast, and inexpensive measurements. OBJECTIVE: To use this technique for measuring plasma cell free DNA levels in burn patients and to further explore the use of cell free DNA as a potential marker of patient outcome in burns. METHODS: Cell free DNA levels obtained from 14 burn victims within 6 hours of injury and 14 healthy controls were quantified by a direct rapid fluorometric assay. RESULTS: Patient admission cell free DNA levels were significantly elevated compared with that of controls (1797 ± 1523 ng/mL versus 374 ± 245 ng/mL, P = 0.004). There are statistically significant correlations between cell free DNA admission levels and burn degree (Spearman's correlation = 0.78, P = 0.001), total body surface area (Spearman's correlation = 0.61, P = 0.02), and total burn volume (Spearman's correlation = 0.64, P = 0.014). CONCLUSIONS: Admission cell free DNA levels can serve as a prognostic factor in burns and future routine use can be made possible by use of our direct rapid fluorometric assay.

Increasing the Efficacy of SLNB in Cases of Malignant Melanoma Located in Close Proximity to the Lymphatic Basin.

Background. Being predictive of the entire nodal bed, sentinel lymph node biopsy (SLNB) is invaluable in the surgical management of melanoma. Although the concept is simple, sentinel lymph node (SLN) identification and removal can be technically challenging. Methods. A total of 102 consecutive patients have undergone SLNB in the Division of Plastic and Reconstructive Surgery of Soroka University Medical Center from 2009 to 2012. Patients have undergone SLNB using a radioactive tracer and blue stain in order to identify the SLN. Although SLNB usually precedes the wide excision of melanoma, primary lesions in close proximity (<10 cm) to the lymph basin require wide excision before beginning the SLN quest. Results. All pathology reports confirmed the excision of lymph nodes. Conclusions. When treating MM in close proximity to the lymph basin, changing the sequence of the SLNB procedure seems to increase the efficacy of the method.

Total lip reconstruction with tendinofasciocutaneous radial forearm flap.

INTRODUCTION: Squamous cell carcinoma is a common tumour of lower lip. Small defects created by surgical resection may be readily reconstructed by linear closure or with local flaps. However, large tumours resection often results with microstomia and oral incompetence, drooling, and speech incomprehension. The goal of this study is to describe our experience with composite free radial forearm-palmaris longus tendon flap for total or near total lower lip reconstruction. PATIENTS AND METHODS: This procedure was used in 5 patients with 80-100% lip defect resulting from Squamous cell carcinoma. Patients' age ranged from 46 to 82 years. They are three male patients and two female. In 3 cases chin skin was reconstructed as well and in one case a 5 cm segment of mandible was reconstructed using radius bone. In one case where palmaris longus was missing hemi-flexor carpi radialis tendon was used instead. All patients tolerated the procedure well. RESULTS: All flaps totally survived. No patient suffered from drooling. All patients regained normal diet and normal speech. Cosmetic result was fair to good in all patients accept one. CONCLUSION: We conclude that tendino-fasciocutaneous radial forearm flap for total lower lip reconstruction is safe. Functional and aesthetic result approaches reconstructive goals.

Epidemiology of cleft lip and palate among Jews and Bedouins in the Negev.

BACKGROUND: Clefts of the lip and palate are the most common significant congenital birth anomaly of the orofacial region. The condition may vary from a minor easily correctable cleft to a significant functional and cosmetic incapacitation. This is the first epidemiological study of orofacial clefts in the Negev region in Israel. OBJECTIVES: To establish the frequency of cleft lip and palate in the population of the Negev, characterize the demographic features of affected individuals and find possible risk factors, compare the risk in two major population groups: Bedouin and Jewish in a well-defined geographic area, and determine whether there is a change overtime in the birth of babies with facial clefts. METHODS: We conducted a retrospective survey of the Soroka Medical Center archives. The sample population comprised all 131,218 babies born at Soroka during the 11 year period 1 January 1996 to 31 December 2006. Statistical tests used Pearson's chi-square test, Student's t-test and Spearman's correlation coefficient test according to the type of parameter tested. RESULTS: During the study period 140 babies were born with orofacial cleft. The overall incidence of cleft lip and palate was 1.067/1000. The incidence of facial clefts was 1.54/1000 among Bedouins and 0.48/1000 among Jews (P < 0.001). Cleft palate was significantly more frequent in female than male babies (P = 0.002). Over the study years we found a significant decrease in the incidence of facial clefts in the Bedouin population, with Spearman's correlation coefficient rank -0.9 (P < 0.01). CONCLUSIONS: A significant decrease occurred in the incidence of facial clefts among Bedouin. This change may be attributed to prenatal care in the Bedouin Negev population as part of social and health-related behavior changes. The reduction in rates of congenital malformations, however, does not mean a reduction in the number of cases in a growing population. Also, with a modern western lifestyle, the expectancy and demand for reconstructive facial surgery and comprehensive care for these children are on the rise.

Efficacy of enzymatic debridement of deeply burned hands.

BACKGROUND: The burned hand is a common and difficult to care-for entity in the field of burns. Due to the anatomy of the hand (important and delicate structures crowded in a small limited space without sub-dermal soft tissue), surgical debridement of the burned tissue is technically difficult and may cause considerable complications and, therefore, should be performed judiciously. Selective enzymatic debridement of the burn wound can preserve the spontaneous epithelialisation potential and reduce the added injury to the traumatised tissue added by a surgical debridement. OBJECTIVE: The aim of the study was to assess the implication of a selective enzymatic compound (Debrase(®) - Ds) in the special field of deep hand burns, by comparing the actual burn area that required surgical coverage after enzymatic debridement to the burn area clinically judged to require skin grafting prior to debridement. MATERIALS AND METHODS: This was a retrospective data collection and analysis from 154 complete files of prospective, open-label study in 275 hospitalised, Ds-treated burn patients. RESULTS: A total of 69 hand burns diagnosed as 'deep' was analysed; 36% of the wounds required surgical intervention after enzymatic debridement; 28.6% of the total burned area estimated initially as deep was covered by skin graft (statistically significant p<0.001). CONCLUSION: Debridement of deep-hand burns with a selective enzymatic agent decreased the perceived full-thickness wound area and skin-graft use.

[Description of differential optical spectropolarimetric imaging system (DOSI) for non-invasive detection of skin tumors].

BACKGROUND: Most physicians diagnose skin malignancy using theoretical criteria and clinical experience. Apart from dermatoscopy, noninvasive means for skin tumors' diagnosis are highly expensive and are not in daily use. We developed a simple, handy and relatively inexpensive tool for non-invasive diagnosis of skin tumors. The Differential Optical Spectropolarimetric Imaging system (DOSI) is based on collecting information from the surface and depth of skin tumors, using the advantage of liquid crystal devices (LCDs]. OBJECTIVE: DOSI feasibility study in order to diagnose skin tumors non-invasively. METHOD: Skin tumor optical data was collected in order to create image indicators for specific skin tumors. Spectral images of skin tumors are captured before the lesion that was scheduled for removal was surgically excised. Repeating features of images of each tumor type (which was histologically diagnosed) that characterize the specific tumor and show distinction from the features of other tumors are recorded. RESULTS: The feasibility of DOSI has been demonstrated for research, but it is not yet mature for clinical use. Specific images, indicating specific skin tumors could not yet be reliably concluded. One relatively obvious characteristic for malignancy seems to be crescent-like and finger-like growth patterns. In the non-malignant lesions: crescent and finger-like structures are of less pronounced orders of magnitude. Crescents are more open and radius of curvature are of larger orders of magnitude than in malignant specimen. DISCUSSION: The advantage of using LCD is the ability to manipulate light electronically, without any movable components. LCDs are the building blocks of optical filters and polarization controllers. Using optical filters and polarization controllers, we are able to electronically manipulate the polarization and wavelength of our light source without any movable components. The light source emits different wavelengths (colors) that penetrate the tissue at different depths. The camera (CCD) captures the diffused reflected light from a skin lesion as a sequence of images for each polarization stage. By applying our novel method for each polarization stage we are able to overcome the noise of the diffused reflection and emphasize the scattering areas. Emphasizing the scattering areas provided images that may indicate malignancy. CONCLUSIONS: The feasibility of DOSI has been demonstrated. In order to obtain reliable diagnostic image indicators for specific skin tumors, more clinical tests are necessary.

Expression of ligands to NKp46 in benign and malignant melanocytes.

Human melanoma cell lines were shown to express ligands for the natural cytotoxicity receptor, NKp46, expressed by natural killer (NK) cells. We aimed to examine the expression of ligands for NKp46 by various primary human melanocytic cells and melanocytic lesions. Sections from primary nevi and melanomas were tested for expression of NKp46 ligands employing chimeric NKp46-Fc for staining. The melanocytes present in the reticular dermis were negative for NKp46 ligands in common nevi; in malignant melanocytic lesions, the deeper melanocytes were focally positive. In dermoepidermal junction of all melanocytic lesions, the melanocytes showed enhanced expression of NKp46 ligands. Melanophages in all lesions were consistently positive for NKp46 ligands. These observations establish the expression of NKp46 ligands by primary-transformed melanocytes. Normal melanocytes did not express ligands to NKp46. Therefore, the results show (i) a correlation between the malignant potential of the lesion and the expression of NKp46 ligands in the reticular dermis, and (ii) enhanced expression of NKp46 ligands in the active proliferation zone (dermoepidermal junction) of nevi and melanomas. Ligands to NKp46 were expressed on the membrane and within the cells. The physiological role of NKp46 ligands in the progression of malignancy within melanocytic lesions should be explored further.

Accreditation of skin from a methanol-poisoned victim for banking and grafting.

BACKGROUND: Acute poisoning is a contraindication for organ and tissue donation. In this study the suitability of skin from a methanol-poisoned (MP) donor for future grafting and keratinocytes culturing was investigated. METHODS: A patient was admitted with a methanol blood level of 2.7 mg/mL, which became undetectable after 4 days of treatment with 4-methylpyrazole (fomepizole). Upon declared brain death and family consent, organs and skin were harvested. For approving MP skin for grafting, the following parameters were studied: viability and plating efficiency of MP keratinocytes, integrity of MP skin after cryopreservation, and its performance as xenografts on wounds in a pig model. Nonpoisoned (NP) controls included skin of matching age, cryopreservation period, and NP keratinocytes. RESULTS: No significant differences were observed for any parameter between NP and MP samples. Furthermore, in vitro exposure of NP keratinocytes and fibroblasts to <10 mg/mL methanol inhibited their growth by <20%, with an extrapolated LD50 of 100 mg/mL. A parallel exposure to formaldehyde, a spontaneous metabolite of methanol, yielded LD50 of 20 microg/mL and eradication of viability at 300 microg/mL. CONCLUSIONS: These results indicate that skin from a carefully monitored MP donor is suitable for banking toward massive burns and skin losses. This methodology may be applied to approve skin harvested from other types of poisoned donors for banking and future grafting.