Integra™ in burns reconstruction: Our experience and report of an unusual immunological reaction.

Limited availability of autologous donor sites poses significant challenges for soft-tissue reconstruction in severe and complex burns. Integra™ is a bi-layered dermal regeneration template (DRT) which has played a significant role in soft tissue reconstruction since its initial use for full-thickness burn defects. The purpose of this study is to report our institutional experience of Integra™ in burns management over a 4-year period and highlight an unusual reaction to its second application. Twenty-four cases underwent Integra™ resurfacing for burn management from September 2007 to August 2011. Data on patient demographics, including co-morbidities, indications, operative data, complications, secondary reconstruction and outcomes were recorded. Integra™ was used in 24 patients on 37 anatomical sites. One patient died 3 weeks after injury and first stage of Integra™ application, and was therefore excluded from the study. Split-thickness skin grafting was performed within an average of 23 days (with a range of 7-55 days) and mean graft take was 87% (with a range of 75-100%). Five cases of local infection at the graft site were recorded. The average length of hospital stay was 47 days (with a range of 1-162 days). The mean follow-up time was 17 months (with a range of 9-34 months). Overall, our experience with DRT was mixed, that is to say we found it satisfactory with acute burns resurfacing but very good with secondary reconstruction. The main advantage of Integra™ is its immediate availability in unlimited quantities for soft-tissue reconstruction in major and complex burns. The main drawbacks are financial implications, twostage procedure, complex wound care and risk of infection. We believe that Integra™ can be considered as a promising modality in burns management.

La disponibilité limitée des sites donneurs autologues pose des défis importants pour la reconstruction des tissus mous des brûlures graves et complexes. Integra™ est un modèle de régénération dermique à double-couche qui a joué un rôle important dans la reconstruction des tissus mous depuis sa première utilisation pour des défauts des brûlures de pleine épaisseur. L'objectif de cette étude est de rapporter notre expérience institutionnelle d'Integra™ dans la gestion des brûlures, pendant une période de 4 ans et mettre en évidence une réaction inhabituelle à sa deuxième application. De Septembre 2007 à Août 2011 l'Integra™ a été utilisé dans la gestion des brûlures dans vingt-quatre cas. Les données sur les caractéristiques démographiques des patients, y compris les co-morbidités, les données opératoires, les complications, la reconstruction secondaire et les résultats ont été enregistrés. Integra™ a été utilisée chez 24 patients dans 37 sites anatomiques. Un patient qui est décédé 3 semaines après la blessure et le premier stade de l'application Integra™ a été exclus de l'étude. La greffe de peau mince a été réalisée dans un délai moyen de 23 jours (avec une gamme de 7-55 jours) et la moyenne prise de greffon était de 87 % (avec une gamme de 75-100%) Cinq cas d'infection locale au site de la greffe ont été enregistrées. La durée moyenne d'hospitalisation était de 47 jours (extrêmes: 1-162 jours). Le temps moyen de suivi était de 17 mois (extrêmes: 9-34 mois). Dans l'ensemble, notre expérience avec Integra™ a été mélangé : c'est satisfaisant avec le resurfaçage des brûlures graves mais très bon avec la reconstruction secondaire. Le principal avantage d'Integra™ est sa disponibilité immédiate en quantités illimitées pour la reconstruction des tissus mous des brûlures importantes et complexes. Les principaux inconvénients sont les incidences financières, la procédure en deux étapes, les soins de plaies complexes et les risques d'infection. Nous croyons qu'Integra™ peut être considéré comme une modalité prometteuse pour la gestion des brûlures.

Environmental decontamination of a hospital isolation room using high-intensity narrow-spectrum light.

The performance of a new decontamination technology, referred to as 'high-intensity narrow-spectrum light environmental decontamination system' (HINS-light EDS) was evaluated by a series of three studies carried out in a hospital isolation room used to treat burns patients. The ceiling-mounted HINS-light EDS emits high-intensity 405nm light which, although bactericidal, is harmless to patients and staff thereby permitting continuous environmental disinfection throughout the day. Performance efficacy was assessed by contact agar plate sampling and enumeration of staphylococcal bacteria on environmental surfaces within the room before, during and after HINS-light EDS treatment. When the room was unoccupied, use of HINS-light EDS resulted in ∼90% reduction of surface bacterial levels and when the room was occupied by an MRSA-infected burns patient, reductions between 56% and 86% were achieved, with the highest reduction (86%) measured following an extended period of HINS-light EDS operation. In an on/off intervention study, surface bacterial levels were reduced by 62% by HINS-light EDS treatment and returned to normal contamination levels two days after the system was switched off. These reductions of staphylococci, including Staphylococcus aureus and meticillin-resistant S. aureus, by HINS-light EDS treatment were greater than the reductions achieved by normal infection control and cleaning activities alone. The findings provide strong evidence that HINS-light EDS, used as a supplementary procedure, can make a significant contribution to bacterial decontamination in clinical environments.

Keratoderma hereditarium mutilans (Vohwinkel syndrome).

Keratoderma hereditarium mutilans, or Vohwinkel syndrome, is a very rare genetic skin condition which causes palmoplantar hyperkeratosis and constricting rings of the fingers and toes. Approximately 50 cases have been reported in the literature with only three having been managed surgically. All three had a high rate of recurrence and unfavourable results in the long term. We report two more cases managed surgically with a follow up of 5 and 8 years respectively. Our experience suggests that the use of full thickness grafts to line the released contractures does not work in the long term as the grafts become raised and painful, requiring multiple revisions. Surgical correction was easy to achieve but difficult to maintain and achieved poor outcomes in general. We therefore feel that the indication for surgical treatment should be a neurovascular compromise.

Prelaminated free radial forearm flap for a total nasal reconstruction.

A prelaminated osteocutaneous radial forearm flap has previously been described for total nasal reconstruction, but achieving good aesthetics at the dorsum and tip tends to be difficult with a flap that can be too bulky. We present a case of total nasal reconstruction in a burns patient where a tight adherent scar at the forehead precluded the use of a forehead flap, ideal for such reconstructions. We successfully used a prelaminated free radial forearm flap, with a non-vascularised bone graft. The existing scarred skin at the dorsum was turned down as pedicled flaps for the lining. We were able to achieve a successful total nasal reconstruction which was aesthetically pleasing and made a tremendous impact on the quality of life of the patient.

Assessment of burn depth: a prospective, blinded comparison of laser Doppler imaging and videomicroscopy.

INTRODUCTION AND AIMS: There is a need, both in clinical and research settings, for an affordable, objective method of assessing burn depth. This study compares burn depth assessment by videomicroscopy with laser Doppler imaging (LDI) in patients with dermal burns. The videomicroscope is inexpensive compared to LDI, and can visualise the dermal capillary structure, therefore potentially allowing objective assessment of dermal burn injuries. METHODS: Patients admitted <72 h post-injury were included in the trial. Blinded LDI and videomicroscopy assessments were carried out. The patients were then followed up to one of three end-points: primary healing without surgery; early surgery; delayed healing and subsequent split skin grafting. The incidence of infection was also noted. RESULTS: Twenty-seven burn wounds were examined. In superficial partial thickness injuries, the videomicroscope reliably demonstrated an intact or nearly intact dermal vascular structure, progressing through to large amounts of capillary destruction and haemoglobin deposition in deep partial thickness injuries and complete destruction in full thickness injuries. The videomicroscope findings correlated strongly with both those of the LDI (p<0.001) and with clinical outcome (p<0.001). DISCUSSION: The videomicroscope is capable of accurately and objectively assessing burn depth. The results correlated well with both the clinical outcome and the laser Doppler findings. In addition, videomicroscopy is significantly cheaper than LDI and avoids several of the disadvantages of LDI.

Off flavours in large waterbodies: physics, chemistry and biology in synchrony.

The Laurentian Great Lakes of North America are a drinking water source for millions of Canadian and US consumers. These waterbodies have undergone extensive change over the past century as a result of widespread degradation and remediation. Many of the Lakes are prone to taste and odour (T&O), and although these outbreaks have been poorly monitored, evidence suggests that they are increasing in frequency. Tracing and controlling T&O in such large systems presents a challenging task, due to their physical size and complexity. This paper presents an overview of recent investigative and management approaches to T&O in Lake Ontario and its outflow, the St. Lawrence River. We have identified three distinct patterns of T&O in these source-waters, caused by geosmin and 2-methylisoborneol and differing in their planktonic and benthic sources, and temporal and spatial dynamics. Each pattern has required a different approach by scientists and management, in partnership with the water industry. We have shown these T&O outbreaks are caused and moderated by physical, chemical and biological mechanisms over a spectrum of spatial and temporal scales. Canadian municipalities affected by these outbreaks have been key to the investigation of the links between T&O and ecosystem processes with the aim to develop more proactive water treatment and long-term management.

A comparison of biofilms from macrophytes and rocks for taste and odour producers in the St. Lawrence river.

Given their widespread and prolific annual development in the St. Lawrence River (SLR), macrophytes (i.e. submerged aquatic plants) represent large surface areas for biofilm growth and potentially important sites for associated production of taste and odour (T&O) compounds. We therefore evaluated the importance of submerged macrophytes and their associated biofilms for production of T&O compounds, 2-methylisoborneol (MIB) and geosmin (GM), compared with biofilms from adjacent rocks. We also tested the hypothesis that production of these compounds would differ between macrophyte species, based on the premise that they are not inert substrates but directly influence the communities that colonise their surfaces. Samples collected from transects across the SLR between Kingston and Cornwall, ON were dominated by the flat-bladed Vallisneria spp., and the leafed Myriophyllum spicatum, Elodea canadensis, Chara spp., Potamgeton spp., and Ceratophyllum spp. Overall, MIB and GM levels in biofilms ranged widely between samples. Expressed per g dry weight of biofilm, median levels from macrophyte were 50 (range 1-5000) ng MIB g(-1) and 10 (<1 to 580) ng GM g(-1) compared with 50 (range 5-970) ng MIB g(-1) and 160 (1-1600) ng GM g(-1) from rocks. Based on non-parametric statistical analysis, levels of GM were higher on a g dry weight basis in biofilms from rocks than macrophytes (P = 0.02), but MIB levels were similar (P = 0.94). However, when normalised for differences in substrate surface area (i.e. ng cm(-2)), levels of both MIB and GM were higher in biofilms from rocks than from macrophytes (P < 0.01). There were no discernable differences in MIB and GM concentrations from biofilms of different macrophytes based on either g dry weight sample or surface area (P > 0.05). Overlying water (OLW) concentrations ranged between 2-45 ng L(-1) for MIB and 5-30 ng L(-1) for GM and were not correlated with levels in adjacent biofilms. However, OLW concentrations peaked in shallow, low energy embayments consistent with enhanced production and release of MIB and GM in nearshore areas. The results support our previous work showing the importance of biofilms on various surfaces (rocks, macrophytes and zebra mussels) for MIB and GM production in the SLR, but suggest that inert surfaces like rocks are more productive sites per unit surface area than macrophytes.

Daphnia behavioural responses to taste and odour compounds: ecological significance and application as an inline treatment plant monitoring tool.

Continuous monitoring of volatile organic compounds (VOC) in raw water is highly desirable for taste and odour management, but in most treatment plants this capacity is lacking. We used a bbe Daphnia toximeter installed in the Zurich water treatment plant to determine if Daphnia magna could be used to monitor odour compounds in source-water. Trace levels of two widely distributed biogenic VOCs in freshwater: P-cyclocitral and 2(E),4(E),7(Z)-decatrienal were added to the raw water inflow to chambers containing test animals and their behaviour was recorded using a high resolution camera. We observed that each compound elicited a marked short-term increase in Daphnia swimming velocity, but the effect was brief and an acclimation to the compounds was observed after a time period or with repeated additions. The results demonstrate that the toximeter has considerable potential as a tool to monitor certain VOCs in water, and that Daphnia perceive and react to 2(E),4(E),7(Z)-decatrienal and P-cyclocitral at concentrations between 2.5 and 25 microM.

Odourous algal-derived alkenes: differences in stability and treatment responses in drinking water.

Drinking water supplies are often impacted by taste and odour (T/O) episodes caused by algal volatile organic compounds (AVOCs) from algal blooms. Treatment and control of these events is important to utility operators, as customer confidence in the safety of public drinking water supplies is based primarily on their palatability and odour. To manage T/O outbreaks successfully, knowledge about treatment responses of AVOCs and anticipation of their outbreaks are thus of major importance to the water industry. The Glenmore Reservoir and water treatment plant (GWTP) supplies drinking water to over 50% of the ca. 1 million consumers in Calgary (Alberta). Despite low nutrients and high raw water quality, the reservoir experiences periodic outbreaks of fishy/floral T/O, caused by chrysophytes and diatoms (Uroglena americana, Dinobryon spp., Synura petersenii, Asterionella formosa). These odours are produced by the unsaturated C7-C10 alkenes 2,4-heptadienal, 2,4,7-octatriene, 2,4-decadienal and 2,4,7-decatrienal, generated during from the enzymatic breakdown of algal polyunsaturated fatty acids (PUFAs). The formation, persistence and stability of these compounds in both the raw water and treatment plant is not well understood.

The Ontario Water Works Consortium: a functional model of source water management and understanding.

With an historical onus on reactive water treatment in North America, most taste and odour (T&O) outbreaks and other water quality issues have been unanticipated and difficult to control. Recent severe outbreaks of these drinking water issues have prompted wider advocacy of a more proactive "source-to-tap" approach, with greater focus on multidisciplinary partnerships among utilities, scientists and management/policy-makers. However, the practical application of this management model is faced with fragmented drainage basins, waterbodies and jurisdictions, and often requires a common issue such as T&O to initiate its development. This paper presents an example of a successful cooperative approach to drinking water management, the Ontario Water Works Research Consortium (OWWRC), consisting of the six major water utilities drawing water from Western Lake Ontario, scientists from the Canadian and Ontario governments and universities, and several other agencies. Established in 1999 following severe T&O outbreaks, the OWWRC has since operated as a highly effective model, employing a science-based approach to T&O management, supporting research on source-water and treatment issues, public outreach and utility surveys. The paper describes this partnership and summarises the results of an OWWRC T&O survey as one of the significant steps towards source-water characterisation undertaken by this cooperative.

Functional gracilis flap in thenar reconstruction.

UNLABELLED: Restoration of lost opposition in the context of significant thenar soft tissue defects represents a tremendous reconstructive challenge. Free functioning muscle transfer has been described in this context and has the advantage of providing both a functioning muscle unit as well as soft tissue coverage in a single reconstructive procedure. It adds to the injured limb, and by sparing donor tendons avoids the need for re-education of motor function. We describe the use of a free innervated gracilis muscle flap for functional thenar reconstruction in two unique cases following extensive traumatic loss of thenar skin and musculature. Crucially, in each case, the recurrent motor branch of the median nerve had been destroyed at its point of insertion into the thenar muscle remnants. AIM: To date, the main reported disadvantages of free functioning muscle transfer in thenar reconstruction include difficult flap dissections, donor site morbidity, inadequate strength and excursion of the transplanted muscle and excessively bulky flaps. Our aim was, as far as possible, to address these issues. SURGICAL PROCEDURE: Each thenar defect was measured and a corresponding segment of gracilis muscle, measured in situ, was raised on the proximal neurovascular pedicle. End-side microvascular anastomosis was performed between the medial circumflex femoral artery and the radial artery. The venae comitantes of the pedicle were anastomosed end-end with those of the radial artery and also with the cephalic vein. Epineural anastomosis was performed between the motor branch of the obturator nerve and the recurrent motor branch of the median nerve. Each flap was covered with a split thickness skin graft. RESULTS: Both flaps survived without any complication. Both patients regained excellent voluntary thumb opposition, sufficient to allow return to full-time employment, and had restoration of sufficient thenar bulk. This was achieved with minimal donor site morbidity. CONCLUSIONS: Restoration of lost opposition, in the context of significant thenar soft tissue defects, can be achieved using a free functional gracilis flap. This produces clinically excellent functional results and can be carried out as a single stage reconstructive procedure. This is a novel application of a tremendously versatile donor muscle in functioning free muscle transfer.

Pollicisation of the index metacarpal based on the first dorsal metacarpal artery.

We present our experience of two cases in which we carried out pollicisation of the index metacarpal based on the first dorsal metacarpal artery and venae comitans. Both cases were complex severe hand injuries where the initial injury was the result of a firework exploding while held in the hand. In both cases the radial side of the superficial palmar arch was destroyed by the injury. In both cases there was virtually complete loss of the thumb ray and amputation of the index through the base of the proximal phalanx. A useful opposition post has been created from vascularised index metacarpal with free flap soft tissue reconstruction.

Periphyton: a primary source of widespread and severe taste and odour.

In the last decade, a late summer-fall taste and odour problem has been a prolonged and annual event in the St Lawrence River (SLR). Earlier work identified the earthy/musty compounds geosmin and particularly, 2-methylisoborneol (GM-MIB), and ruled out Lake Ontario as a major source, but did not identify the biological origins. In 2000, we investigated the source(s) and underlying causes. We sampled littoral sites in the SLR near Cornwall, ON, and found that macrophytes (or associated biofilms) may be primary GM sources. Zebra mussel homogenate yielded low GM-MIB levels, but several associated actinomycetes generated high in vitro amounts. Periphyton from rocks showed significant yields, with cell-bound GM-MIB up to one hundred times the levels in overlying water. In 2001, we followed seasonal changes at some of these sites. Periphyton GM-MIB showed intriguing spatial and temporal patterns. Several cyanobacteria in these biofilms were identified as potential odour sources, notably Oscillatoriales. We conclude: i) periphyton is a major odour source in the SLR; ii) other biota such as macrophytes and mussels may also contribute; iii) seasonality in GM-MIB production and ratios indicate changes in cell production and/or taxa in response to environment. These results may account for the recent onset of the problematic odour events, which represent chemical signals of the increased water transparency and littoral surface area following the widespread dreissenid mussel invasion to the Great Lakes. Our data raise key questions about the processes that trigger the tremendous variability in biota and GM-MIB production in the SLR, the subject of our continued research.

Successful free flap transfer following venous thrombectomy in recipient vessel.

We report the case of a 53-year-old male patient who suffered a high velocity multiple trauma with bilateral open tibial fractures. At definitive orthopaedic and plastic surgical reconstruction 5 days post initial trauma, he was found peroperatively to have an existing deep venous thrombosis in his popliteal vein on one side. He underwent venous thrombectomy and had subsequent successful latissimus dorsi flap transfer using the unblocked popliteal vein as a recipient vessel.

Development and preliminary validation of a brief broad-spectrum measure of trauma exposure: the Traumatic Life Events Questionnaire.

This article describes the development and preliminary validation of a brief questionnaire that assesses exposure to a broad range of potentially traumatic events. Items were generated from multiple sources of information. Events were described in behaviorally descriptive terms, consistent with Diagnostic and Statistical Manual of Mental Disorders IV posttraumatic stress disorder stressor criterion A1. When events were endorsed, respondents were asked if they experienced intense fear, helplessness, or horror (stressor criterion A2). In separate studies with college students, Vietnam veterans, battered women, and residents of a substance abuse program, most items possessed adequate to excellent temporal stability. In a study comparing questionnaire and structured-interview inquiries of trauma history, the 2 formats yielded similar rates of disclosure. Preliminary data on positive predictive power are also presented.

Successful partial ear replantation after prolonged ischaemia time.

We present the case of a 34-year-old male patient who had successful replantation of upper pole of pinna 33 h after amputation. As no vein was anastomosed, systemic heparinisation and subcutaneous injection of heparin to the replanted ear were used to encourage outflow. Complications included arterial spasm and bleeding. Management of similar cases as planned urgent cases rather than emergency cases is discussed.

Severe upper limb injuries in four passengers of a 'People Carrier'; the contribution of design faults.

Four passengers of a 'People Carrier' in a single vehicle motor accident sustained severe left upper limb trauma, when the vehicle rolled onto the near side. These injuries were directly attributable to the large glass interface between patient and road. The glass windows shattered on contact, providing no protection and in effect created a secondary injury mechanism. We advocate both the use of laminated side windows and mandatory testing of 'roll-over' characteristics for these 'People Carriers' to reduce the incidence of such injuries.

Outcome after flap cover for exposed total knee arthroplasties. A report of 25 cases.

The long-term functional result of exposed total knee arthroplasty, treated by flap cover, is presented and the results compared with those of a randomly selected control group. The wound was successfully covered and the prosthesis was preserved in 76% of cases, but the final functional score was not as good as in those with primary wound healing.

Optimizing skin graft take in children's hand burns--the use of silastic foam dressings.

The use of silastic foam as a surgical dressing in 15 children with full thickness burns to the hand is described. Silastic foam is a safe, easy and effective means of dressing the hand following surgery. It is rigid enough to act as a splint, and at the same time is deformable and accommodates postoperative swelling.