Cultured epithelial autografts: three years of clinical experience with eighteen patients.

Eighteen patients with major burns (mean total body surface area burned was 49% and mean total body surface area with full-thickness burns was 38%) had cultured epithelial autografts applied to 2% to 35% of the body surface area. In six patients successful "take" of greater than 65% occurred, and in 12 patients less than 40% "take" occurred. Most wounds underwent early excision to subcutaneous fat or fascia, and the wounds of 16 patients had been treated previously with homograft. Cultured epithelial autografts were covered with either single or multilayered dressings. Perioperative wound cultures showed that all patients had microorganisms, and appropriate perioperative antibiotic coverage of Staphylococcus epidermidis and Pseudomonas aeruginosa was noted less frequently in the poor take group, which may have influenced subsequent cultured epithelial allograft take. Adherence and stability of cultured epithelial allografts lag behind adherence and stability of meshed split-thickness autograft. The anterior trunk and thighs are the best recipient sites. The number of autograft harvests that were required to close wounds and the length of hospital stay were not significantly decreased by the use of cultured epithelial allografts as compared with comparable full-thickness burns that were treated previously without cultured epithelial allografts. Presently, grafting with cultured epithelial allografts is an adjunct but not an alternative to conventional burn-wound coverage with split-thickness autograft, because engraftment is inconsistent.

Comparison of silver sulfadiazine 1% with chlorhexidine digluconate 0.2% to silver sulfadiazine 1% alone in the prophylactic topical antibacterial treatment of burns.

Wound bacterial colonization in 118 patients treated with chlorhexidine digluconate 0.2% in silver sulfadiazine 1% applied daily to the burn wounds was compared to that of 135 comparable patients similarly treated with silver sulfadiazine 1%. With chlorhexidine digluconate 0.2% in silver sulfadiazine 1%, colonization by Staphylococcus aureus was less frequent (38%) than with silver sulfadiazine (54%, p = 0.016). No statistical difference was found for colonization by Enterococcus faecalis, Pseudomonas aeruginosa, or Enterobacter cloacae. Washing of the wounds of 65 patients with chlorhexidine gluconate 4% during daily dressing changes was associated with reduced wound colonization by S. aureus (35% versus 51%, p = 0.03) and P. aeruginosa (8% versus 16%, p = 0.08) when compared to the 188 washed with nonantibacterial soap. Chlorhexidine, whether added to the topical agent silver sulfadiazine (chlorhexidine digluconate 0.2%) or in the bath soap (chlorhexidine gluconate 4%), decreased colonization by S. aureus.

Carotid artery thrombosis after elective mandibular and maxillary osteotomies.

This is believed to be the first reported case of carotid artery thrombosis after elective maxillary or mandibular osteotomy. The most likely cause was a sudden, sharp blow to the right carotid artery region either when the mandibular split was completed or when the maxillary tuberosity was separated. The blow was associated with neck hyperextension and some lateral flexion. In a patient with tight, underdeveloped soft tissue, the resultant intimal tear caused thrombosis of the artery. Although this event is associated with a 40% mortality and further 52% serious morbidity, our patient has regained nearly full neurological function--probably thanks to a competent circle of Willis that allowed adequate collateral flow to the brain.

Eminectomy for chronic recurring subluxation of the temporomandibular joint.

Numerous treatment modalities have been employed for chronic recurrent subluxation of the temporomandibular joint. Most conservative and surgical approaches have had mediocre results. In 1951 Hilmar Myrhaug reported on a new surgical technique wherein the articular eminence is removed. This procedure, it appears, has not been widely accepted. Our experience with 15 patients treated by this means has been excellent. The series is presented to recommend it as a useful surgical technique for this often perplexing problem.

Vitamin A assay in burned patients.

A study of serum vitamin A levels in burned patients at the Vancouver General Hospital (1972-1973) is reported in an attempt to relate hypovitaminosis A to acute stress erosions in the gastrointestinal tract. Thirty-one patients were studied, of whom 10 had moderate to severe burns. Vitamin A levels of normal males and females at the Vancouver General Hospital averaged at 35 mug/100 ml. Patients with burn indices of less than 12 did not show any significant fall in serum vitamin A levels. The fall of vitamin A levels was greater as the burn index increased, and the fall of vitamin A level was noticed within 48 hours postburn and returned to normal by the second week postburn. In patients with severe burns and gastrointestinal bleeding with stress ulcers, the serum vitamin A levels fell more profoundly (e.g., 18 mug/100 ml). Four patients with gastrointestinal bleeding were detected, of whom three had acute gastric erosions with low serum vitamin A levels. The possibility that hypovitaminosis A is a contributing factor in acute gastric erosions of the gastric mucosa in severely burned patients is suggested.

Submucous cleft palate and the general practitioner.

Submucous cleft palate refers to a situation where the soft palate is largely composed of mucosa with little or no muscle. The defect is often not obvious on inspection of the mouth and pharynx. There is considerable clinical variation, with speech ranging from normal or minimal nasality to severe nasality and defective articulation. Many patients who have latent submucous cleft palate have the condition unmasked by an adenoidectomy because the adenoid pad had served as a compensatory factor in effecting palatopharyngeal closure. All physicians who perform tonsillectomy and adenoidectomy should be aware of the signs and symptoms which may suggest the diagnosis.