Complex lower extremity wounds treated with skin grafts and NPWT: a retrospective review.

OBJECTIVE: To evaluate a single centre experience with the use of NPWT for securing split-thickness skin grafts in the management of specifically lower extremity chronic wounds, including revascularised arterial wounds, amputations, diabetic and venous leg ulcers. METHOD: A seven-year retrospective review of a prospectively maintained database of all the patients who underwent primary split-thickness skin grafts (STSGs) with immediate postoperative NPWT for at least 96 hours was carried out. The percentage graft take after removal of NPWT device and clinical follow-up date were reviewed. RESULTS: A total of 59 skin grafts procedures had adequate follow up to be reviewed. This included 39% post-debridement/ amputation wounds in patients who presented with diabetic foot infection/gangrene, 31% venous leg ulcers, and 31% other post-surgical wounds (arterial ulcers that had undergone revascularisation). The mean percentage graft survival after removal of V.A.C. was 94%; 63% of cases had complete graft survival, 25% had 90-99% survival, and 8.5% had 80-89% survival. Outpatient follow up ranged from 2 weeks to 5 years (mean of 10 months). Fifteen per cent of patients were lost to follow up, and, of the remaining patients, 76% remained completely healed, 10% remained partially healed, and 14% lost the entire STSG. CONCLUSION: Patients with STSGs secured with NPWT required fewer repeated grafting procedures, had very high initial graft survival with complete recipient bed coverage, and had good long-term wound closure rates compared with historical controls. While retrospective reviews, such as this, support NPWT as a good method of STSG affixation, the paucity of reviews with other study designs does not allow for good historic comparison, so a well-enrolled prospective trial would be of use. DECLARATION OF INTEREST: Dr J.C. Lantis is a member of the speakers' bureau, has been a site principal investigator of four multicentre trials and has been a consultant for KCI Inc. The same author has no equity in the company and has no financial benefit from positive results for the company's product(s). No external funding was sought nor obtained for this study.

Endoscopic carpal tunnel release surgery: report of patient satisfaction.

Recently, a trend has developed to use an endoscope to achieve carpal tunnel release. Proponents of the endoscopic technique believe it has benefits to patients that include minimal incision, minimal pain and scarring, a shortened recovery period and a high level of patient satisfaction. To test these beliefs, a retrospective analysis of the first 42 cases that were done between May 1997 and June 1998 was completed. Endoscopic carpal tunnel release surgery was performed on patients with the classical clinical and neurophysiological findings of carpal tunnel syndrome. The procedure was performed in an outpatient surgery center under primarily local anesthesia and by the same neurosurgeon (RG), who was blind to data analysis. The biportal technique (Instratek Inc., Houston, TX, USA) was used as described by Brown. The first 42 patients (n = 35, seven patients had bilateral surgeries) were sent a survey (modified Health Outcomes Carpal Tunnel Questionnaire, Health Outcomes, Bloomington, MN, USA) that measured a wide spectrum of variables, with a year follow-up. Patient demography indicated wide patient selection. All subjects (100%) had claimed work-related injury. Patient satisfaction was reported in 86%. No or mild incisional pain, night pain, absent tingling, and improved grip strengthening were reported in 100%, 95%, 81%, and 85% respectively. The mean for return to daily activity and work was 14 and 25 days respectively. No recurrent hematoma, infection, or structure injury was reported. Endoscopic carpal tunnel release can be done safely and effectively with excellent self-reports of patient satisfaction. Reduced recovery period and hospitalization with minimal tissue violation and incisional pain can be expected.

Transfusion management of an IgA deficient patient with anti-IgA and incidental correction of IgA deficiency after allogeneic bone marrow transplantation.

A patient with multiple myeloma was noted to have an IgA deficiency during investigation of a possible transfusion reaction due to IgA deficiency and anti-IgA. Because of the patient's age, otherwise good health, and early stage of disease, he was enrolled in a research treatment protocol that involved an allogeneic bone marrow transplant (BMT). The BMT successfully put the patient in complete remission from his multiple myeloma and corrected his IgA deficiency. Class-specific IgG anti-IgA antibody that had been identified prior to BMT was no longer detectable in his plasma. Anaphylactic transfusion reactions were successfully avoided by using a combination of IgA-deficient and washed blood components including the marrow graft, and IgA-reduced intravenous immunoglobulin.

The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity.

OBJECTIVES: To determine the presentation, course and duration of delirium in hospitalized older people. DESIGN: Observational cohort study. SETTING: Inpatient surgical and medical wards at a university hospital. PARTICIPANTS: 432 people over the age of 65. MEASUREMENTS: All participants were screened daily for confusion and, in those who were confused, delirium was ascertained using the Diagnostic and Statistical Manual of Mental Disorders (DSM) III-R criteria. Those who were found to be delirious were followed daily while in hospital for evidence of delirium. The Delirium Rating Scale (DRS) was used to describe the clinical characteristics of delirium. RESULTS: About 15% of subjects had delirium. Sixty-nine percent of delirious subjects had delirium on a single day. The DRS total was higher on the first day of delirium for those with delirium on multiple days than those with delirium on a single day (P = 0.03). Among those with delirium on multiple days, there were no patterns of change over time in specific DRS items. CONCLUSIONS: Delirium in hospitalized older people is common and has a varied presentation and time course. Clinicians and researchers need to consider this great heterogeneity when caring for patients and when studying delirium.

Predictive factors for the rate of engraftment of neuroblastoma patients autotransplanted with purged marrow.

Predictive values for patient engraftment in neuroblastoma have not been defined. By analyzing the parameters available to us at the time of harvest and post-harvest, we found that the MNC/kg after purging demonstrated significant correlation with patient engraftment as measured by the patient's time to reach a WBC count of 1,000/microL and an ANC count of 500/microL. Platelet and red cell independence was difficult to measure as some of these patients remain platelet- and red cell-dependent for extended periods of time. Platelet refractoriness, alloimmunization, infection and many other factors can delay platelet and red cell recovery following transplantation. A larger number of patients is needed to assess a correlation between the parameters analyzed and platelet and red cell recovery, as well as to validate our observation with myeloid recovery.

A uniform labeling system for bone marrow and peripheral blood stem cells.

The separation of bone marrow (BM) constituents, BM cell purging, and cryopreservation of BM and peripheral blood stem cells (PBSC) are frequently performed in the clinical laboratories. In 1991, recognizing the increasing involvement of transfusion services in BM and PBSC processing, the American Association of Blood Banks (AABB) established standards that, in general, held BM and PBSC processing to the same standards as applied to blood components. In 1993, the AABB defined the information that was required on the container label, but did not establish a uniform system of labeling for BM/PBSC preparations. We present a system of labeling for definitive identification of allogeneic BM and autologous BM/PBSC collections that identifies all components derived from the original product from the time of collection to final infusion or disposal. This system avoids the risk of component misidentification, particularly when multiple collections are processed simultaneously. Our transfusion service computer system was adapted with BM/PBSC component names and abbreviated codes to provide a singular validated mechanism for labeling, tracking, and final disposition of these products. We propose the adaptation of a "universal system" for BM/PBSC labeling for AABB accredited transfusion services utilizing the existing guidelines for labeling of blood and blood components.

A study of binding-solubilization of some glycolytic enzymes in striated muscle in situ.

The solubilization of lactate dehydrogenase (LDH), glyceraldehyde-3-phosphate dehydrogenase (GAPDH), and alpha-glycerophosphate dehydrogenase (GAPDH) was studied in pressed muscle as a function of ionic strength and NADH concentration. The results indicate that these factors affect the binding-solubilization of LDH and GAPDH in a similar way to their effect in dilute homogenized tissue. Alpha-glycerophosphate dehydrogenase was included as a typical soluble enzyme, since we have been unable to demonstrate its binding to subcellular fractions under any conditions. As with homogenized tissue, LDH was less susceptible to solubilization by ionic strength than GAPDH. It was demonstrated that LDH isozymes richer in heart-type subunits were more easily removed from muscle by centrifugation-imbibition than isozymes richer in the muscle-type subunits. This was interpreted as indicating that binding of the enzyme to subcellular structures was a major factor in the restricted removal of these enzymes from muscle, since only the muscle-type subunit is capable of binding to subcellular particles. It was further demonstrated that LDH could be taken up into muscle tissue, depleted in the enzyme, against an apparent concentration gradient. This was also interpreted as binding of the enzyme to the particulate structure of the muscle. Furthermore, this uptake of LDH occurred under conditions of ionic strength (0.25) and pH (7.5) that would prevent binding of the enzyme to the particulate fraction of a dilute suspension of homogenized muscle tissue. Thus, physiological conditions of pH and ionic strength do not necessarily induce solubilization of chicken breast muscle LDH in situ. Data obtained with dilute tissue homogenates, therefore, may not necessarily be easily and safely extrapolated to conditions in situ.