Multidisciplinary Application of an External Tissue Expander Device to Improve Patient Outcomes: A Critical Review.

Significance: Continuous external tissue expansion (CETE) is a versatile tool in soft tissue injury management, and could be an addition to the traditional reconstructive ladder. Recent Advances: This critical review discusses the principles and application of CETE, covering a company-sponsored consensus meeting on this emerging technology and highlighting the DermaClose® (Synovis Micro Companies Alliance, Inc., Birmingham, AL) device's unique approach to soft tissue injury management. There is clinical evidence to support the use of CETE in the management of a number of wound types, including fasciotomy, trauma, amputation, and flap donor sites. The device can be applied to open wounds, potentially avoiding the need for a skin graft or other more complex or invasive reconstruction options. DermaClose applies constant tension without restricting blood flow and does not require repeated tightening. Critical Issues: CETE is becoming more widely used by surgeons of different specialties, and numerous reports describing its efficacy and safety in wound management have been published. Surgeons using CETE must follow the correct technique and select patients carefully to achieve optimal outcomes. However, there is no single source of information or consensus recommendations regarding CETE application. Future Directions: Prospective evidence on the efficacy and safety of CETE in clinical practice is required to communicate the best techniques and share important experiences. This will help to solidify its place in the reconstructive ladder as a valuable additional option for surgeons.

Beneficial Effects of Amnion-Chorion Stem Cell Grafting in the Long Term Management of Nonuremic Calciphylaxis Wounds.

Calciphylaxis is a poorly understood disease with high morbidity and mortality. The current primary literature on treatment is lacking; however, disease management often involves a multifaceted approach with a primary focus on consistent wound care. This report describes a case outlining the long-term management of nonuremic calciphylaxis wounds in a patient with severe malnutrition with the use of human amniotic membrane grafts, aggressive surgical debridement, nutritional therapy, and advanced wound healing techniques. A 38-year-old African American female with a history of non-uremic calciphylaxis presented from a transitional facility with numerous non-healing wounds in the setting of severe malnutrition secondary to bariatric surgery. Biweekly wound debridement was initiated utilizing an amniotic stem cell skin graft, dry applicable absorbent dressing, high-frequency ultrasonic ablation, and wound vacuum-assisted closure (VAC) over the course of approximately nine months. Nutritional supplementation was given in the form of jejunostomy tube feed due to a gastric bypass and a perforated viscus. At the current date, the patient demonstrates significant improvement in pain and wound healing. The patient is also able to ambulate with care and has begun steps towards independent management of wounds. Future goals of care include independent bedside wound management, placement of allograft, and discharge to a long-term care facility. Most patients with refractory pain, widespread necrotic wounds, and dangerous comorbidities will inevitably be referred to palliative care. This case creates a framework for the long term management of medically complex patients with nonuremic calciphylaxis using human amniotic membrane stem cell grafts and appropriate advanced wound care techniques.

Comparison of resident operative case logs during a surgical oncology rotation in the United States and an international rotation in India.

This study compared the operative case log experience between rotations during General Surgery residency in the United States and an international rotation in India. A resident from the General Surgery residency program at University of Nebraska Medical Center participated in an international rotation in Surgical Oncology at Mehdi Nawaz Jung Institute of Oncology in Hyderabad, India for 3 months in 2009. The operative case log of this resident (INT) was compared to those of another resident (US) on a rotation in surgical oncology at the parent institution during the same time period. Both institutions were tertiary care centers. We noted that the INT resident performed a greater number of cases (132) when compared to the US resident (61). The INT resident also performed cases in a wider variety of disease categories such as: head and neck (26 %), gynecology (19 %), breast (14 %) and urology (4 %). In contrast, abdominal cases accounted for 68 % of the cases performed by the US resident with fewer cases in the other categories. The INT resident performed 98 % of the cases by the open approach, whereas the US resident performed only 81 % of cases by the open approach, with the remaining 19 % of cases performed by the laparoscopic approach. The results demonstrate that the INT resident performed a greater number of operative cases when compared to a resident (US) at the parent institution, and performed cases in more diverse disease categories with an emphasis on the open operative approach.

Inhibition of plaque neovascularization reduces macrophage accumulation and progression of advanced atherosclerosis.

Plaque angiogenesis promotes the growth of atheromas, but the functions of plaque capillaries are not fully determined. Neovascularization may act as a conduit for the entry of leukocytes into sites of chronic inflammation. We observe vasa vasorum density correlates highly with the extent of inflammatory cells, not the size of atheromas in apolipoprotein E-deficient mice. We show atherosclerotic aortas contain activities that promote angiogenesis. The angiogenesis inhibitor angiostatin reduces plaque angiogenesis and inhibits atherosclerosis. Macrophages in the plaque and around vasa vasorum are reduced, but we detect no direct effect of angiostatin on monocytes. After angiogenesis blockade in vivo, the angiogenic potential of atherosclerotic tissue is suppressed. Activated macrophages stimulate angiogenesis that can further recruit inflammatory cells and more angiogenesis. Our findings demonstrate that late-stage inhibition of angiogenesis can interrupt this positive feedback cycle. Inhibition of plaque angiogenesis and the secondary reduction of macrophages may have beneficial effects on plaque stability.