Benefits of Aerosolized, Point-of-care, Autologous Skin Cell Suspension (ASCS) for the Closure of full Thickness Wounds from Thermal and Non-Thermal Causes: Learning Curves from the first 50 Consecutive cases at an Urban, Level 1 Trauma Center.

OBJECTIVE: To determine the utility of Autologous Skin Cell Suspension (ASCS) in closing full-thickness (FT) defects from injury and infection. SUMMARY BACKGROUND DATA: Although ASCS has documented success in closing partial-thickness burns, far less is known about the efficacy of ASCS in FT defects. METHODS: Fifty consecutive patients with FT defects (burn 17, necrotizing infection 13, crush 7, degloving 5, other 8) underwent closure with the bilayer technique of 3:1 widely-meshed, thin, split-thickness skin graft and 80:1 expanded ASCS. End points were limb salvage rate, donor site reduction, operative and hospital throughput, incidence of complications, and re-epithelialization by 4, 8, and 12 weeks. RESULTS: Definitive wound closure was achieved in 76%, 94%, and 98% of patients, at 4, 8, and 12 weeks, respectively. Limb salvage occurred in 42/43 patients (10 upper, 33 lower extremities). Mean area grafted was 435 cm2; donor site size was 212 cm2, representing a potential reduction of 50%. Mean surgical time was 71 minutes; total OR time was 124 minutes. Mean length-of-stay was 26.4 days; time from grafting to discharge was 11.2 days. 4/50 patients (8%) required 6 reoperations for bleeding (1), breakdown (4), and amputation (1). 4/50 patients (8%) developed hypertrophic scarring, which responded to silicone sheeting (2) and laser resurfacing (2). Mean follow-up was 92.7 days. CONCLUSION: When used for closure of FT wounds, point-of-care ASCS is effective and safe. Benefits include rapid re-epithelialization, high rate of limb salvage, reduction of donor site size and morbidity, and low incidence of hypertrophic scarring.

Fulminant intracranial hypertension secondary to oxytetracycline requiring urgent ventriculo-peritoneal shunt insertion.

Idiopathic intracranial hypertension is a syndrome that presents with headaches and visual loss. Its pathogenesis is unknown. Treatment options include acetazolamide, therapeutic lumbar punctures or permanent CSF diversion. We present the only reported case of acute drug-induced intracranial hypertension secondary to oxytetracycline requiring urgent cerebrospinal fluid diversion. The patient's rapid visual failure progressed daily despite discontinuation of the drug and required an urgent ventriculo-peritoneal (VP) shunt insertion. Patients should be counselled about the rare potential risk of developing intracranial hypertension when commencing oxytetracycline. Rapid visual failure in IIH is a neurosurgical emergency necessitating urgent ventriculoperitoneal shunt insertion.

Functional abilities and cognitive decline in adult and aging intellectual disabilities. Psychometric validation of an Italian version of the Alzheimer's Functional Assessment Tool (AFAST): analysis of its clinical significance with linear statistics and artificial neural networks.

PURPOSE: (a) A psychometric validation of an Italian version of the Alzheimer's Functional Assessment Tool scale (AFAST-I), designed for informant-based assessment of the degree of impairment and of assistance required in seven basic daily activities in adult/elderly people with intellectual disabilities (ID) and (suspected) dementia; (b) a pilot analysis of its clinical significance with traditional statistical procedures and with an artificial neural network. METHODS: AFAST-I was administered to the professional caregivers of 61 adults/seniors with ID with a mean age (± SD) of 53.4 (± 7.7) years (36% with Down syndrome). Internal consistency (Cronbach's α coefficient), inter/intra-rater reliabilities (intra-class coefficients, ICC) and concurrent, convergent and discriminant validity (Pearson's r coefficients) were computed. Clinical significance was probed by analysing the relationships among AFAST-I scores and the Sum of Cognitive Scores (SCS) and the Sum of Social Scores (SOS) of the Dementia Questionnaire for Persons with Intellectual Disabilities (DMR-I) after standardisation of their raw scores in equivalent scores (ES). An adaptive artificial system (AutoContractive Maps, AutoCM) was applied to all the variables recorded in the study sample, aimed at uncovering which variable occupies a central position and supports the entire network made up of the remaining variables interconnected among themselves with different weights. RESULTS: AFAST-I shows a high level of internal homogeneity with a Cronbach's α coefficient of 0.92. Inter-rater and intra-rater reliabilities were also excellent with ICC correlations of 0.96 and 0.93, respectively. The results of the analyses of the different AFAST-I validities all go in the expected direction: concurrent validity (r=-0.87 with ADL); convergent validity (r=0.63 with SCS; r=0.61 with SOS); discriminant validity (r=0.21 with the frequency of occurrence of dementia-related Behavioral Excesses of the Assessment for Adults with Developmental Disabilities, AADS-I). In our sample age and gender do not correlate with the scale and comparing the distribution of the AFAST-I and DMR-SCS and DMR-SOS expressed as ES, it appears that memory disorders and temporal and spatial disorientation (SCS) precede the loss of functional abilities, whereas changes in social behaviour (SOS) are less specific in detecting cognitive deterioration sufficient to provoke functional disability and vice versa. The results of AutoCM analysis reveal that the hub (core) of the entire network is represented by the functional domain 'personal/oral hygiene' in the entire study sample and 'use of toilet' in a subgroup of subjects who obtained an ES equal to 0 at DMR-SCS. CONCLUSIONS: These results confirm the reliability and validity of AFAST-I and emphasise the complexity of the relationship among functional status, cognitive functioning and behaviour also in adults/seniors with ID.

Amnion-derived cellular cytokine solution promotes macrophage activity.

Activated macrophages play a significant role in wound healing and infected tissue repair. In this study, we investigate the recruitment of macrophages into the wound, and the effects on the bactericidal/phagocyte activity after exposure to amnion-derived cellular cytokine solution (ACCS). To evaluate the influence of ACCS on the migratory behavior of macrophages, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of macrophages through the membrane determined the influence of ACCS. In the presence of ACCS, macrophages demonstrated a statistically significant (P < 0.05) increase in migration as compared with controls. Subsequently, groups of macrophages were exposed to different concentrations of ACCS solution. The killing and phagocytic activity of each group was compared with the control after exposure to Escherichia coli. Macrophage activity following activation by higher concentrations of ACCS demonstrated significantly increased phagocytosis as well as a trend correlation between percentage ACCS concentration and bactericidal activity. These cell types, critical to normal wound healing, may be influenced by ACCS to accelerate migration and enhance bactericidal/phagocytic activity in wounds.

Individualized, targeted wound treatment based on the tissue bacterial level as a biological marker.

BACKGROUND: The use of biologic markers to aid in individualizing wound treatment may help improve outcomes. A biologic marker that has been demonstrated to be predictive of healing in both chronic and acute wounds is wound tissue bacterial level. The objective of this study was to determine whether tissue bacterial level can be used to individualize wound treatment regimens with a stem-like cell-derived product. METHODS: Amnion-derived cellular cytokine solution (ACCS) was topically applied to rat chronic wounds, and healing rates were measured. RESULTS: Experimental wounds treated with ACCS demonstrated accelerated healing regardless of the tissue level of bacteria, compared with saline. As the level of tissue bacteria increased, the frequency of ACCS application required to obtain optimal results increased. CONCLUSIONS: It appears that the biologic characteristic of tissue bacterial level can serve as a marker to predict the response of open granulating wounds treated with ACCS.

Primary breast lymphoma after mastectomy with reconstruction.

Primary breast lymphoma accounts for only 0.05%-1.1% of all breast malignancies, and less than 1% of all cases of non-Hodgkin lymphoma. Although primary breast lymphoma may present clinical similarities to breast carcinoma, the majority of cases lack the typical features of breast malignancy or lymphoma. We describe a case of primary breast lymphoma in a reconstructed breast, 8 years after a mastectomy for breast cancer. To the best of our knowledge, this is the first reported case in the worldwide literature of primary breast lymphoma in a reconstructed breast. We will discuss the diagnostic and treatment strategies involved in the management of primary breast lymphoma, and the effect of breast reconstruction on the detection of recurrent breast cancer.

Amnion-derived cellular cytokine solution (ACCS) promotes migration of keratinocytes and fibroblasts.

Amnion-derived Multipotent Progenitor cells appear to be useful as adjuvants in wound healing. Amnion-derived multipotent progenitor cells secrete a unique combination of cytokines and growth factors, known as amnion-derived cellular cytokine solution (ACCS). In the skin, a cytokine communication network between mesenchymal and epithelial cells tightly controls keratinocyte and fibroblast migration, proliferation and differentiation-key determinants of wound healing. To evaluate the influence of ACCS on the migratory behavior of keratinocytes and fibroblasts, cell migration was assayed quantitatively using a Boyden chamber. Chemotactic migration activity of fibroblasts or keratinocytes through the membrane determined the influence of ACCS. In the presence of ACCS, fibroblasts and keratinocytes demonstrated a statistically significant (P < 0.05) increase in migration when compared with controls. These cell types, critical to normal wound healing, may be influenced to accelerate migration in wounds, thus accelerating wound repair/healing.

An algorithmic approach to breast reconstruction using latissimus dorsi myocutaneous flaps.

BACKGROUND: Innovative surgical techniques developed by surgical oncologists have changed the landscape of mastectomy defects. Latissimus dorsi myocutaneous flap-based breast reconstruction provides a reliable foundation for breast reconstruction. The purpose of this study was to evaluate differential skin island designs with latissimus dorsi myocutaneous flap breast reconstruction, and to develop an algorithmic approach to breast reconstruction that is applicable to a broad spectrum of mastectomy defects. METHODS: In this study, the authors retrospectively reviewed data of patients who underwent latissimus dorsi myocutaneous flap reconstruction following unilateral or bilateral mastectomies between February of 2001 and April of 2005. Patients were selected to undergo reconstruction under the following circumstances: (1) previously irradiated tissue, (2) body mass index greater than 30, (3) current tobacco use, (4) previous abdominopelvic surgery, and (5) patient preference. Patients were divided into three groups based on defect present: intact inframammary fold with skin deficit, intact inframammary fold without skin deficit, and absent inframammary fold with or without skin deficit. Differential skin island design was customized to the presenting mastectomy defect to optimize results and minimize donor-site scaring. RESULTS: Fifty-four patients underwent 64 latissimus dorsi myocutaneous flap reconstructions. Aesthetic outcomes and donor-site scar placement differed between groups. CONCLUSIONS: The authors have developed an algorithmic approach to latissimus dorsi myocutaneous flap breast reconstruction. Through critical evaluation of mastectomy defects, reconstructive breast surgeons can tailor skin island orientation, minimize donor-site scarring, enhance cosmetic outcomes, and provide a durable and natural aesthetic outcome in breast reconstruction with the latissimus dorsi myocutaneous flap.

Effect of amnion-derived cellular cytokine solution on healing of experimental partial-thickness burns.

BACKGROUND: Amnion-derived multipotent progenitor (AMP) cells, unlike most stem cells, have been demonstrated to be nontumorigenic and nonimmunogenic. Amnion-derived cellular cytokine solution (ACCS), a secreted product of AMP cells, is a cocktail of cytokines existing at physiological levels and has been used to accelerate epithelialization of experimental partial-thickness burns. METHODS: Using modifications of Zawacki's guinea pig partial-thickness scald burn model, a total of 65 animals were treated with ACCS, ACCS + AMP cells, unconditioned medium (UCM) + AMP cells, or either UCM alone or saline as controls. Dosage times ranged from every other day to once a week. Percent epithelialization was serially determined from acetate wound tracings. Histology was performed on wound biopsies. RESULTS: ACCS, UCM + AMP cells, and ACCS + AMP cells improved epithelialization compared with the two control groups (P < 0.05). When ACCS was delivered more frequently, statistically significant more rapid epithelialization occurred (P < 0.05). By day 7, all groups treated with ACCS had reached at least 90% epithelialization, whereas control groups were only 20-40% epithelialized (P < 0.05). Histology showed excellent regeneration of the epidermis with rete ridge formation. Hair growth occurred in ACCS-treated animals but not in the control group. CONCLUSIONS: Amnion-derived cellular cytokine solution accelerates the healing of experimental partial-thickness burns. Based on these findings, a multicenter clinical trial is underway.

The use of amnion-derived cellular cytokine solution (ACCS) in accelerating closure of interstices in explanted meshed human skin grafts.

UNLABELLED: Meshed, split-thickness skin grafts, especially when required to be widely spread, do not obtain immediate biologic closure. In patients with burns that cover a large percentage of the body surface area, this leaves the patient at risk for metabolic problems and life-threatening infection. OBJECTIVE: The purpose of this study was to determine whether amnion-derived cellular cytokine solution could improve epithelialization kinetics and accelerate closure of meshed skin graft interstices. METHODS: Human meshed, split-thickness skin grafts were explanted to athymic "nude" rats and treated with 3 different regimens of amnion-derived cellular cytokine solution (groups I, II, and III) or normal saline (group IV) as a control. Serial wound tracings of unepithelialized interstitial wound areas were compared over time. Two different preparations of amnion-derived cellular cytokine solution were also compared with one another, one containing animal components and the other free of animal components. RESULTS: Only 67.03% of interstices in control animals closed by day 9. This compared with 92.2% closure for group I, 83.72% for group II, and 90.64% for group III. Interstices in all 3 groups treated with amnion-derived cellular cytokine solution (with or without animal-derived components) closed faster statistically than in the control animals (P < .05). There were no statistical differences among the 3 amnion-derived cellular cytokine solution-treated groups. CONCLUSIONS: These data suggest that epithelialization kinetics and interstitial closure of meshed skin grafts can be accelerated with the use of amnion-derived cellular cytokine solution, a physiologic cocktail of cytokines, and provide support for a future clinical trial.

Statin and stromal cell-derived factor-1 additively promote angiogenesis by enhancement of progenitor cells incorporation into new vessels.

Angiogenesis requires the mobilization of progenitor cells from the bone marrow and homing of progenitor cells to ischemic tissue. Statins facilitate the former, and the chemokine stromal cell-derived factor-1 (SDF-1) enhances the latter. Their combined influence on angiogenesis was studied in vivo in the ischemic hindlimb C57BL/6 mouse model. The ischemic to non-ischemic perfusion ratio increased from 0.29 +/- 0.02 immediately after femoral excision to 0.51 +/- 0.10 three weeks after the surgery in the mice treated with either fluvastatin or SDF-1 alone, which is significantly better than the control (0.38 +/- 0.05, p < .05, n = 6). The combined use of fluvastatin and SDF-1 further improved the reperfusion ratio (0.62 +/- 0.08, p < .05). More cell proliferation, less apoptosis, enhanced bone marrow-derived endothelial progenitor cell (EPC) incorporation and higher capillary density were observed in ischemic tissue treated with both statin and SDF-1. In vitro mono-treatment with either fluvastatin (100 nM) or SDF-1 (100 ng/ml) facilitated EPC proliferation and migration, inhibited EPC apoptosis, enhanced expression of matrix metalloproteinase-2 (MMP-2) and -9 (MMP-9), and increased Akt phosphorylation and nitric oxide production. These effects were significantly augmented by the two agents together and ablated by inhibitors of either Akt or nitric oxide synthase (NOS). In conclusion, statin and SDF-1 additively enhance progenitor cell migration and proliferation and down-regulate EPC apoptosis, resulting in improved reperfusion via activation of the Akt/NOS pathway and up-regulation of MMP-2 and MMP-9 expression.

Coregistration of quantitative proton magnetic resonance spectroscopic imaging with neuropathological and neurophysiological analyses defines the extent of neuronal impairments in murine human immunodeficiency virus type-1 encephalitis.

Relatively few immune-activated and virus-infected mononuclear phagocytes (MP; perivascular macrophages and microglia) may affect widespread neuronal dysfunction during human immunodeficiency virus type 1 (HIV-1)-associated dementia (HAD). Indeed, histopathological evidence of neuronal dropout often belies the extent of cognitive impairment. To define relationships between neuronal function and histopathology, proton magnetic resonance spectroscopic imaging (1H MRSI) and hippocampal long-term potentiation (LTP) were compared with neuronal and glial immunohistology in a murine model of HIV-1 encephalitis (HIVE). HIV-1(ADA)-infected human monocyte-derived macrophages (MDM) were stereotactically injected into the subcortex of severe combined immunodeficient (SCID) mice. Sham-operated and unmanipulated mice served as controls. Seven days after cell injection, brain histological analyses revealed a focal giant cell encephalitis, with reactive astrocytes, microgliosis, and neuronal dropout. Strikingly, significant reductions in N-acetyl aspartate concentration ([NAA]) and LTP levels in HIVE mice were in both injected and contralateral hemispheres and in brain subregions, including the hippocampus, where neuropathology was limited or absent. The data support the importance of 1H MRSI as a tool for assessing neuronal function for HAD. The data also demonstrate that a highly focal encephalitis can produce global deficits for neuronal function and metabolism.

Mycoplasma pneumoniae non-pulmonary infection presenting with pharyngitis, polyarthritis and localized exanthem.

We report a case of pharyngitis, polyarthritis and localized exanthem in acute Mycoplasma pneumoniae infection not involving the lower respiratory tract. Diagnosis was made by means of a particle agglutination test and IgM/IgG indirect immunofluorescence assay. This case describes a clinical complex never reported before and suggests the need for a high index of suspicion in cases of atypical presentation of M. pneumoniae infection.

Extent of human immunodeficiency virus type 1 drug resistance as a predictor of virological failure after genotype-guided treatment switch.

Little is known about factors involved in virological response to treatment changes guided by genotyping in patients whose highly active antiretroviral therapy (HAART) fails. A 12-month observational study was conducted of 45 patients infected with human immunodeficiency virus (HIV)-1, who underwent a new genotype-guided HAART regimen following virological treatment failure. Logistic regression models were used to define factors predictive of virological response to genotype-assisted treatment switches. Virological response was defined as achievement of a level of plasma HIV-1 RNA <1000 copies/mL at the end of the follow-up. Drug-resistance mutations were detected at baseline in 30 patients (66.7%). A sustained virological response to new treatment occurred in 13 (43.3%) of these, as opposed to 11 (73.3%) of the 15 patients harboring drug-susceptible virus at baseline (P=.07). In multivariate logistic regression analysis, the number of drug classes where there was resistance at baseline was the only independent predictor of virological failure (P=.0313). Lack of virological response to genotype-guided treatment changes is primarily due to complex baseline resistance patterns. Benefits of antiretroviral resistance testing may be seriously limited by the lack of subsequent treatment options for heavily pretreated patients.

Encephalitis caused directly by Mycoplasma pneumoniae.

A case of non-fatal encephalitis in a 21-y-old immunocompetent woman is described. High titre serum antibodies against Mycoplasma pneumoniae were found. In addition, Mycoplasma pneumoniae DNA was detected in the cerebrospinal fluid by polymerase chain reaction. Neuroimaging findings by magnetic resonance and computed tomographic scanning of the brain, and laboratory investigations, including a search for serum antibodies to gangliosides, did not support an immune-mediated mechanism. No other pathogens were found. These results strongly suggest that the encephalitis was caused directly by Mycoplasma pneumoniae invasion of the central nervous system. They also indicate that such pathogenetic mechanism may sometimes be sufficient to explain neurological manifestations occurring during the course of Mycoplasma pneumoniae infection. The consequences for therapy are discussed.

Patterns of cyclic AMP-dependent protein kinase gene expression during ontogeny of the murine palate.

Normal growth and differentiation of embryonic palatal tissue depends on regulated levels of intracellular cAMP. Cyclic AMP-dependent protein kinases (PKA) act to mediate the biological activities of cAMP. PKA isozyme protein profiles demonstrate a clear pattern of temporal alterations in embryonic palatal tissue during its development. In order to ascertain the molecular basis for changing PKA isozyme profiles during palatal ontogeny, the spatial and temporal expression of mRNAs for regulatory (RI alpha, RII alpha, and RII beta) and catalytic (C alpha) subunits of PKA was examined. RNA extracted from murine embryonic palatal tissue (days 12-14 of gestation) was examined by Northern blot analysis. Significant levels of constitutively expressed RI alpha and C alpha mRNA were seen on all days of gestation examined. RI alpha transcripts were substantially less abundant in palate mesenchymal cells in vitro than in palatal tissue in vivo. Levels of RII alpha and RII beta mRNA were highest on gestational day (GD) 12, a period characterized by pronounced palatal tissue growth. In addition, patterns of tissue distribution of RII beta, not previously described, were examined in the developing embryonic palate. A dramatic developmental shift in tissue distribution of RII beta was seen. The isozyme was evenly distributed between palatal epithelial and mesenchymal cells on GD 12 but by GD 14, RII beta was predominantly localized to palatal epithelial cells. Direct activation of adenylate cyclase with forskolin in murine embryonic palate mesenchymal (MEPM) cells resulted in an increase in RII alpha mRNA levels but had no effect on steady state levels of RII beta or C alpha mRNA. In addition, elevation of intracellular levels of cAMP resulted in a shift in the transcriptional profile of RI alpha mRNAs. Results of this study document specific patterns of expression for the genes encoding the various cAMP-dependent protein kinase regulatory and C alpha subunits in murine embryonic palatal tissue. In addition, we have demonstrated adaptational changes of this kinase in MEPM cells in response to conditions of increased intracellular levels of cAMP.

[Roseola infantum. Some epidemiologic, clinical and diagnostic aspects revisited. Personal experience]. / Esantema critico. Revisione su alcuni aspetti epidemiologici, clinici e diagnostici. Esperienza personale.

Seventy-five children aged less than 3 yrs, affected by Roseola infantum (maculopapular rash following an acute onset illness characterized by high fever for 2-5 days) were included in this study, 40% of them were admitted with urgency to our clinic for febrile convulsions. Several bacterial or viral agents other than HHV6 were isolated from more than 10% of the children; the role of HHV6 was studied with an immunofluorescence test (IFA) for specific antibodies (seroconversion); 25 single serum samples of the acute phase and 30 acute and convalescent paired sera were available; high positivity was shown in three preexanthematous samples; a serological evidence of HHV6 infection was obtained in only 9 of the 30 paired sera; a coinfection was shown in two subjects belonging to the last group; viral or bacterial agents other than HHV6, were demonstrated in 4 seronegative children. In our experience, the etiologic role of HHV6 in exanthema subitum is not always confirmed; we cannot explain the controversy of our results compared with those of Japanese literature.

Ethanol effects on embryonic craniofacial growth and development: implications for study of the fetal alcohol syndrome.

Fetal alcohol syndrome (FAS), which is brought about by maternal consumption of ethanol during pregnancy, is a major public health problem. To gain understanding of the etiology of this condition, a number of teratological studies have been performed in different animal systems to develop an animal model for FAS. The C57BL/6J mouse strain has been described as susceptible to the teratogenic effects of ethanol, whereas the ICR (CD-1) strain is considered relatively insensitive. We have compared the effects of ethanol on DNA and protein synthesis in cultured embryonic palate mesenchymal cells from both strains to determine if the reported differential sensitivity to ethanol is reflected in differences in ethanol's effects on cell behavior. Chronic exposure to 200 mM ethanol for 48 hr had a strong inhibitory effect on DNA synthesis in palate cells derived from both the C57BL/6J and ICR strains and a significant effect on protein synthesis in C57BL/6J palate cells. When we attempted to verify strain differences in susceptibility to ethanol teratogenesis, we were not able to observe an increased incidence of birth defects due to ethanol in either strain. High doses of ethanol (5.8 g/kg, administered by intraperitoneal injection on gestational day 8) resulted in death in both C57BL/6J and ICR mice. A lower dose (4.8 g/kg) caused decreased fetal weight and increased resorption in both strains, but did not bring about FAS-like craniofacial dysmorphology in either strain. It appears, therefore, that whereas ethanol can significantly affect the behavior of cells derived from craniofacial tissue, these effects cannot be correlated with sensitivity to ethanol teratogenesis in the mouse system.