Butane Hash Oil Burns: A 7-Year Perspective on a Growing Problem.

With the legalization of marijuana in four states, and decriminalization in many others, marijuana is becoming easier to obtain. The authors have experienced an increase in burn injuries related to the production of butane hash oil (BHO; a concentrated tetrahydrocannabinol product produced by the distillation of marijuana plant products with pressurized butane). This article updates our experience and highlights the increasing public health problem associated with these burns. Charts of patients who presented to the burn center with suspicion of BHO-related injuries between January 2007 and December 2014 were examined. Data collected included demographics, injury characteristics, treatment utilized, and outcomes. Charts of 101 patients were identified as having BHO-related burn injury. The mean age of these patients was 30.5 ± 10.6 years (mean ± standard deviation, range: 2-55 years) and 93.1% were male. Patients sustained a mean of 26.8 ± 24.1% TBSA burn with 14.3 ± 25.1% third degree burns. Three patients died as the result of their injuries. Patients required a mean of 12 ± 48.4 ventilator days, and 27.1 ± 59.4 days in the hospital. The number of patients presenting with these burns increased over the past 7 years. BHO burns occur most commonly in February (12 patients), on Wednesday (19 patients), and between 18:00 and 06:00 (58 patients). There has been a sharp increase in the number of patients presenting with burn-associated BHO production in the region over the past 7 years. The authors as burn care providers need to increase public awareness of this issue and aid in the development of legislation to help prevent these burns before it becomes a public health crisis.

Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications.

BACKGROUND: Little information exists on the incidence of complications after acellular human dermis implantation in two-stage tissue expander breast reconstruction. The purpose of this study was to evaluate the incidence of postoperative adverse events and identify significant predictors of complications in acellular human dermis tissue expander breast reconstruction. METHODS: This study accrued all patients from January of 2004 through April of 2008 undergoing two-stage immediate tissue expander breast reconstruction using acellular human dermis. A total of 153 expanders were placed. Complications were assessed. Univariate and multivariate logistic regression modeling was performed. Comparison of complication rates using the traditional (non-acellular human dermis) technique from concurrent (2004 to 2008) and consecutive time periods (2001 to 2003) for 2910 and 1170 expanders, respectively, is provided. RESULTS: A total of 153 expanders were implanted in 96 women: 39 unilateral and 57 bilateral. Eleven (7.2 percent) were removed due to infection (n = 5, 3.3 percent), exposure (n = 4, 2.6 percent), or patient preference (n = 2, 1.3 percent). Other complications included cellulitis (3.9 percent), seroma (7.2 percent), hematoma (2.0 percent), mastectomy flap necrosis (4.6 percent), and leak/failed expansion (0.0 percent); 92.8 percent were successfully expanded and exchanged for a permanent implant. Eleven seromas (7.2 percent) were identified; nine underwent aspiration. None of these resulted in infection or reconstructive failure. Univariate analysis revealed age, body mass index, axillary dissection, and postoperative chemotherapy to be associated with reconstructive failure (p < 0.05). Multivariate analysis revealed that age, body mass index, and axillary dissection are independent risk factors for developing complications (p < 0.05). CONCLUSION: Acellular human dermis is a useful adjunct for intraoperative pocket development in immediate tissue expander reconstruction but can result in an increased risk of complications, in particular, seroma and reconstructive failure.

The absorbable dermal staple device: a faster, more cost-effective method for incisional closure.

BACKGROUND: Closure with dermal sutures is time consuming, may increase the risks of inflammation and infection secondary to foreign body reaction, exposes the surgeon to possible needlestick injuries, and has variable cosmetic outcomes depending on each surgeon's technique. The absorbable INSORB dermal stapler is hypothesized to be faster and more cost effective than sutures for dermal layer closures and provides a safer and more consistent result. METHODS: This is a prospective, randomized, controlled study. Patients undergoing bilateral breast reconstruction with tissue expanders had one incision randomized to dermal closure with absorbable dermal staples. The contralateral side was closed with dermal sutures. During the expansion period, wounds were assessed by a blinded plastic surgeon using the 13-point Vancouver Scar Scale. At the time of implant exchange, both scars were excised and examined for histologic signs of inflammation. RESULTS: Eleven patients (22 incisions) were enrolled in the study. The dermal stapler was four times faster than standard suture closure, reducing closure time by 10.5 minutes (p

Gene therapy in skin: choosing the optimal viral vector.

Skin is an ideal gene therapy target because it is readily accessible and is involved in many pathologic processes. Viruses are the most common gene vectors, however, few comparative studies exist examining their efficacy in skin. This study evaluates adenovirus serotype 5, adeno-associated virus type 2 and 5, MMLV-derived retrovirus, and human immunodeficiency virus-1 derived lentivirus for gene vector activity in human dermal fibroblasts and other skin cell lines. Human immunodeficiency virus-1-based lentiviral vector resulted in over 90% transduction in all cell lines tested. Transduced cells maintained reporter expression over several passages after a single exposure. In contrast, gene activity fell rapidly over cell divisions with adenoviral and adeno-associated vectors. Therefore, lentiviral vectors are the delivery mechanism of choice for long-term therapeutic gene expression in dermal fibroblasts and other skin cell lines, whereas adenoviral or adeno-associated vectors may be preferred for short-term therapy.

A novel method for targeted gene therapy in ischemic tissues through viral transfection of an expression cassette containing multiple repetitions of hypoxia response element.

BACKGROUND: Increased levels of the transcription factor hypoxia inducible factor (HIF)-1 occur only in hypoxic tissue. The authors propose a therapeutic strategy that relies on HIF-1, the enhancer hypoxia response element (HRE), and the delivery vector adeno-associated virus-2 (AAV2) to direct ischemia specific gene therapy to skin. METHODS: An expression cassette containing the CMV promoter driving the reporter gene green fluorescent protein (GFP) was used to assess cutaneous tropism of AAV2. Transfection of dermal fibroblasts and immortalized keratinocytes (HaCat) was assessed with flow cytometry. Human embryonic kidney 293 (HEK) cells were used to produce vector stocks and test the authors' therapeutic strategy in quadruplicate. An expression cassette with nine repeats of HRE linked to beta-galactosidase (LacZ) within the AAV2 vector was constructed. HEK cells were transfected and exposed to normoxic (21% oxygen) and hypoxic (1% oxygen) conditions. LacZ activity was measured by conversion of galactoside red-beta-D-galactopyranoside. RESULTS: Approximately 50 percent of dermal fibroblasts and HaCat cells were transfected when treated with 1 x 10(4) genome copies/cell of AAV2-CMV-GFP. Using the same titration of AAV2-9HRE-LacZ, transfected HEK cells demonstrated LacZ activity of 0.496 +/- 0.068 U/microg in normoxia and 2.9 +/- 0.58 U/microg in hypoxia. Transfected cells exposed to 24 hours of hypoxia show greater than an 11-fold increase in LacZ activity (p < 0.05) compared with baseline normoxic controls. CONCLUSIONS: The authors' results confirm that AAV2 has in vitro tropism for skin-derived cell lines. Furthermore, HRE will drive gene expression in ischemia but not normoxia. This is the first step toward the authors' goal of HIF-1-regulated gene therapy to prevent ischemia related skin injury.