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Background: Oftentimes, obese dialysis patients develop a viable dialysis access but the access is too deep for cannulation and needs a superficialization procedure. Methods: We present our 14-patient cohort in whom we performed liposuction to superficialize viable but deep vascular accesses. Out of 14 patients, 12 had arteriovenous fistulas and 2 arteriovenous grafts. The primary end points were the ability to superficialize a completely unusable access and to remove the hemodialysis catheter (3patients), or to significantly extend the useful length of a deep access in which only a very short segment was used and to continue to use the access post-surgery without the need to place a dialysis catheter (11 patients). Results: The study goal was met in 13 out of 14 patients. In two of three patients, the catheters were removed and their access usable length was 14 and 13 cm, respectively. The accesses could be used immediately after liposuction in all patients in which this applied—11 patients. The usable access length increased from a mean of 5 to 12.7 cm. The access mean depth decreased from 10.8 mm pre-surgery to 7 mm post-surgery and 5.3 mm 4 weeks after surgery. The mean volume of fat removed was 43.8 cc. We had only one surgical complication: bleeding that was readily controlled with manual pressure. All patients were discharged to home the same day. Postoperative pain was mild. Conclusion: Liposuction is effective, safe, and seems to be the least invasive technique of superficialization.

Biofilms of multidrug-resistant bacteria in chronic wounds pose a great challenge in wound care. Herein, we report the topical delivery of molecularly engineered antimicrobial peptides using electrospun nanofiber dressings as a carrier for the treatment of biofilms of multidrug-resistant bacteria in diabetic wounds. Molecularly engineered human cathelicidin peptide 17BIPHE2 was successfully encapsulated in the core of pluronic F127/17BIPHE2-PCL core-shell nanofibers. The in vitro release profiles of 17BIPHE2 showed an in initial burst followed by a sustained release over 4 weeks. The peptide nanofiber formulations effectively killed methicillin-resistant Staphylococcus aureus (MRSA) USA300. Similarly, the 17BIPHE2 peptide containing nanofibers could also effectively kill other bacteria including Klebsiella pneumoniae (104 to 106 CFU) and Acinetobacter baumannii (104 to 107 CFU) clinical strains in vitro without showing evident cytotoxicity to skin cells and monocytes. Importantly, 17BIPHE2-containing nanofiber dressings without debridement caused five-magnitude decreases of the MRSA USA300 CFU in a biofilm-containing chronic wound model based on type II diabetic mice. In combination with debridement, 17BIPHE2-containing nanofiber dressings could completely eliminate the biofilms, providing one possible solution to chronic wound treatment. Taken together, the biodegradable nanofiber-based wound dressings developed in this study can be utilized to effectively deliver molecularly engineered peptides to treat biofilm-containing chronic wounds.

The demand for car seat heaters is on the rise due to the added comfort they offer passengers. However, such luxury is not without risk and prolonged exposure to high surface temperatures of the seat may result in severe burns. We present a unique case of an 18-year-old paraplegic patient who sustained severe full-thickness burns requiring operative intervention after prolonged exposure to a car seat heater. We then tested 10 car seat heaters manufactured after 2014 to establish maximum temperature settings and safety features. We also examine the importance of raising awareness to this issue and share the concerns of previous publications regarding the lack of manufacturer standards in car seat heaters.

Aim: The aim of this study was to develop a nanofiber-based dressing capable of local sustained delivery of 1α,25-dihydroxyvitamin D3 (1,25(OH)2D3) and augmenting human CAMP induction. Materials & methods: Nanofibrous wound dressings containing 1,25(OH)2D3 were successfully prepared by electrospinning, which were examined in vitro, in vivo and ex vivo. Results: 1,25(OH)2D3 was successfully loaded into nanofibers with encapsulation efficiency larger than 90%. 1,25(OH)2D3 showed a sustained release from nanofibers over 4 weeks. Treatment of U937 and HaCaT cells with 1,25(OH)2D3-loaded poly(ϵ-caprolactone) nanofibers significantly induced hCAP18/LL37 expression in monocytes and keratinocytes, skin wounds of humanized transgenic mice and artificial wounds of human skin explants. Conclusion: 1,25(OH)2D3 containing nanofibrous dressings could enhance innate immunity by inducing antimicrobial peptide production.

Aim: The aim of this study was to develop nanofiber-based sutures capable of inducing endogenous antimicrobial peptide production. Methods: We used co-axial electrospinning deposition and rolling to fabricate sutures containing pam3CSK4 peptide and 25-hydroxyvitamin D3 (25D3). Results: The diameters and mechanical properties of the sutures were adjustable to meet the criteria of United States Pharmacopeia designation. 25D3 exhibited a sustained release from nanofiber sutures over 4 weeks. Pam3CSK4 peptide also showed an initial burst followed by a sustained release over 4 weeks. The co-delivery of 25D3 and pam3CSK4 peptide enhanced cathelicidin antimicrobial peptide production from U937 cells and keratinocytes compared with 25D3 delivery alone. In addition, the 25D3/pam3CSK4 peptide co-loaded nanofiber sutures did not significantly influence proliferation of keratinocytes, fibroblasts, or the monocytic cell lines U937 and HL-60. Conclusion: The use of 25D3/pam3CSK4 peptide co-loaded nanofiber sutures could potentially induce endogenous antimicrobial peptide production and reduce surgical site infections.

Three-dimensional (3D) scaffolds composed of poly(e-caprolactone) and gelatin nanofibers were fabricated by a combination of electrospinning and modified gas-foaming. Arrayed holes throughout the scaffold were created using a punch under cryo conditions. The crosslinking with glutaraldehyde vapor improved the water stability of the scaffolds. Cell spheroids of green fluorescent protein-labeled human dermal fibroblasts were prepared and seeded into the holes. It was found that the fibroblasts adhered well on the surface of nanofibers and migrated into the scaffolds due to the porous structures. The 3D nanofiber scaffolds may hold great potential for engineering tissue constructs for various applications.

Introduction Today it is estimated that approximately 30–40% of the cars in U.S have seat warmers, with the demand increasing. Unfortunately, these seat warmers do not have any established guideline of safety, leading some warmers to stay on for extended periods of time and reach temperatures that far exceed the human skin tolerance levels. Magunia et al. first described a patient with full-thickness burns in 2003, however in the time since this publishing, minimal factory standards have been instituted. We report a unique case of a neurologically impaired patient who suffered posterior thigh full-thickness burns secondary to a car seat heater. A delay in her treatment led to the need for surgical intervention. We also tested car models 2014 and newer to establish whether modern cars still present a danger to vulnerable populations. Methods Testing of 10 cars, models 2014 or newer, with a contact surface temperature thermometer independently calibrated. Testing in 21°C ambient air. Four tests, average and highest temperature both recorded. Results Maximum seat temperatures range from 35°C - 53°C. Average seat temperatures range from 34°C - 49°C. Conclusions This case illustrates the dangers and risks presented with car seat heaters. Cases such as this, still happening after the voluntary NHTSA mandate, emphasize the need for heightened physician awareness and mandatory factory standards. In agreement with the National Highway Traffic Safety Administration (NHTSA) statement, under no circumstances should a seat heater top 43°C. We tested 10 cars and found 7 of these cars exceeded the 43°C. In addition, all seat heaters should include self-timers. In our unique case, the patient had no awareness the seat heater was on, suggesting the need for a clearer alert on the dashboard. Health-care providers should also help educate patients about the potential dangers of seat warmers, especially in vulnerable populations. Applicability of Research to Practice This research highlights the potential dangers car seat heaters present to consumers. Mounting evidence, including lawsuit and case reports, show car seat heaters far exceed voluntary standards set by NHTSA. These temperatures put patrons at increased risk of life-altering burns. Furthermore, these are not “faulty” heaters, these heaters are functioning as the manufacturers fabricated them. We also report seat heaters have not followed suggestions outlined by Manguina et al in 2003, such as dash alerts, automatic turn off timer, and other safety features. The first step is raising awareness to healthcare workers so proper warnings can be made to patients, especially those who are neurologically impaired.

AIM: The aim of this study was to develop a nanofiber-based dressing capable of local sustained delivery of 1α,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) and augmenting human CAMP induction. MATERIALS & METHODS: Nanofibrous wound dressings containing 1,25(OH)(2)D(3) were successfully prepared by electrospinning, which were examined in vitro, in vivo and ex vivo. RESULTS: 1,25(OH)(2)D(3) was successfully loaded into nanofibers with encapsulation efficiency larger than 90%. 1,25(OH)(2)D(3) showed a sustained release from nanofibers over 4 weeks. Treatment of U937 and HaCaT cells with 1,25(OH)(2)D(3)-loaded poly(ϵ-caprolactone) nanofibers significantly induced hCAP18/LL37 expression in monocytes and keratinocytes, skin wounds of humanized transgenic mice and artificial wounds of human skin explants. CONCLUSION: 1,25(OH)(2)D(3) containing nanofibrous dressings could enhance innate immunity by inducing antimicrobial peptide production.

Channeling feelings into the written word rather than the scalpel was at the heart of the creative writing challenge that the first author (DR) accepted when she joined the Seven Doctors Project at the University of Nebraska Medical Center in 2008. Burnout has become recognized as a factor undermining physicians' quality of life, and the practice of creative writing helps mitigate stress and sustain a successful practice. When physicians partner with and are mentored by a seasoned creative writer, creative writing can serve as an exercise in ethical reflection, which is particularly valuable at mid-career; this is the subject of the following dialogue between one physician writer and the facilitator of the Seven Doctors Project creative writing class.

The unfavorable result in plastic surgery , The unfavorable result in plastic surgery , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

Glass fronted gas fireplaces (GFGFs) have exterior surfaces that can reach extremely high temperatures. Burn injuries from contact with the glass front can be severe with long-term sequelae. The Consumer Product Safety Commission reported that these injuries are uncommon, whereas single-center studies indicate a much higher frequency. The purpose of this multi-institutional study was to determine the magnitude and severity of GFGF injuries in North America. Seventeen burn centers elected to participate in this retrospective chart review. Chart review identified 402 children ≤10 years of age who sustained contact burns from contact with GFGF, who were seen or admitted to the study hospitals from January 2006 to December 2010. Demographic, burn, treatment, and financial data were collected. The mean age of the study group was 16.8 ± 13.3 months. The majority suffered burns to their hands (396, 98.5%), with burns to the face being the second, much less common site (14, 3.5%). Two hundred and sixty-nine required rehabilitation therapy (66.9%). The number of GFGF injuries reported was 20 times greater than the approximately 30 injuries estimated by the Consumer Product Safety Commission's 10-year review. For the affected children, these injuries are painful, often costly and occasionally can lead to long-term sequelae. Given that less than a quarter of burn centers contributed data, the injury numbers reported herein support a need for broader safety guidelines for gas fireplaces in order to have a significant impact on future injuries.

Management of head and neck burns involves acute and intermediate phases. Acutely, the goals are establish a secure airway and treat life-threatening injuries. Then, optimize nutrition, assess extent of the burn, perform local wound care, and provide eye protection. Management depends on the degree of the head and neck burn. Postinjury splinting and rehabilitation are vital to healing. After the acute inflammation has resolved and the scars have matured, reconstruction begins with the goals of restoring both function and aesthetics. Reconstruction ranges from simple scar release, to skin grafting, and possibly free flap reconstruction.

Electrospun nanofibers represent a novel class of materials that show great potential in many biomedical applications including biosensing, regenerative medicine, tissue engineering, drug delivery and wound healing. In this work, we review recent advances in electrospun nanofibers for wound healing. This article begins with a brief introduction on the wound, and then discusses the unique features of electrospun nanofibers critical for wound healing. It further highlights recent studies that have used electrospun nanofibers for wound healing applications and devices, including sutures, multifunctional dressings, dermal substitutes, engineered epidermis and full-thickness skin regeneration. Finally, we finish with conclusions and future perspective in this field.

Amniotic membrane is immunologically privileged and is a reservoir of growth factors and cytokines known to modulate inflammation and enhance the healing process, while also possessing antimicrobial, antifibrosis, and antiscarring properties. These properties establish a strong argument for using amniotic membrane derived products as a treatment for burns. The purpose of this article is to describe the use of commercially available dehydrated human amnion/chorion membrane allografts in patients with partial-thickness and full-thickness burns.

Development of metrics for burn care, including healing of skin wounds during the acute phase of treatment, is essential in an environment of decreasing resources and increasing interest in quality and accuracy of medical information. Advantages of consensus metrics include: tracking of trends in care; consistency of care; and correlation of treatment with medical outcomes. For cutaneous burn wounds, these advantages are confounded by factors that contribute to the heterogeneity of burn wounds, including but not limited to: TBSA of injury, depth of injury (partial or full thickness), cause, patient-dependent factors such as age, sex, and comorbidities, anatomic site, and time between injury and treatment. Similar factors contribute to complex injuries from trauma, depth, debridement or excision of devitalized tissue, dressing or grafting of the prepared wound bed, and assessment to determine wound closure. In the absence of confounding factors or comorbidities, wound closure is one of the key criteria for discharge from acute care whether in hospital, or ambulatory care. Not surprisingly, these metrics for wound healing have been used repeatedly in the assessment of developing therapies for wound care. In response, review by the FDA of novel therapies has led to Guidance for Industry: chronic cutaneous ulcer and burn wounds developing products for treatment. and allow for risk adjustment of individuals in the population, who otherwise may be outliers to the statistical mean of the entire population.

SUMMARY Chemical burns are interesting and challenging to treat. When the practitioner is comfortable with the pathophysiology of chemical injury and treatment based on these principles, most patients can be treated effectively with good outcome (Fig. 2). Early treatment with water irrigation, followed by diligent wound care, will allow our patients to benefit to the maximum from our medical skills.

Background: Epinephrine administration for hemostasis during burn wound excision may produce potential anesthetic risks. Two patient groups were studied to determine the absorption of either topical concentrated epinephrine or exogenously injected dilute epinephrine. Methods: For the topical group (10 patients, 10 procedures), excision of wounds under tourniquet was performed, followed by epinephrine ( 1 mg/10 mL) gauze with pressure wrapping. For the clysis group (9 patients, 12 procedures), donor sites were injected with 0.5 mg epinephrine/1,000 mL lactated Ringer's solution before harvest. Nine intraoperative serum samples were collected and frozen during each procedure for epinephrine and norepinephrine assay. Results: Concentrated epinephrine (67 mL) was topically applied to excise 1,362 cm 2 . Dilute epinephrine (1,350 mL) was clysed to obtain 1,950 cm 2 autograft. No significant increases in the serum catecholamines or changes in the cardiovascular profiles occurred. Conclusion: The administration of either topical or clysed epinephrine during acute burn excision does not cause any side effects for safe anesthetic management; there were no detectable increased plasma levels of epinephrine or norepinephrine. Epinephrine provides the burn surgeon with two safe methods for controlling intraoperative blood loss.

Burn scar contractures of the foot cause significant morbidity. We reviewed 68 children in regard to number and rates of burn scar contracture recurrence, surgical techniques, and functional and aesthetic results. Two surgical techniques of foot burn scar contracture release have been used. Originally, an incision over the metatarsal heads perpendicular to the line of the metatarsals, which releases the longitudinal arch of the foot was used. More recently, additional releasing incisions parallel to the plane of the metatarsals to release the transverse metatarsal arch have been used. The time between burn injury and primary burn scar contracture release was 4.18 +/- 0.76 years, and the time until the first recurrence was 3.44 +/- 0.46 years. With release of only the longitudinal arch, recurrence of burn scar contractures occurred in 3.5 +/- 0.41 years and in 4.29 +/- 1.27 years in six patients who also received release of the transverse arch. Wound closure at the time of acute burn with split-thickness skin graft expansion ratios of 1:2 and 1:4 had burn scar contractures that required release in 4.21 +/- 0.70 and 2.29 +/- 0.52 years, respectively.

Twenty-nine patients with necrotizing fasciitis who were treated with 5% mafenide acetate solution (MAS) as an adjunct after grafting were compared with 45 patients treated without MAS. Statistical analysis of differences was obtained through P values by chi2 testing. The MAS+ (M) and MAS- (C) groups were similar in percent skin deficit (M = 7.5%; C = 9.8%), with the extremity being the most common area of infection. Streptococcus was the most common single organism but polymicrobial infections were the most prevalent (M = 48%; C = 58%). Patients with necrotizing fasciitis treated with MAS had fewer debridements per patient (M = 3.7; C = 5.4), fewer closure procedures (average per patient: M = 1.2; C = 1.73) and a higher percent of first-time closures (83 vs 59%; chi2 = 4.26; P = 0.039). There is a trend toward a lower mortality rate (3.4 vs 13%; chi2 = 2.00; P = 0.158). We conclude that MAS is a useful adjunct in necrotizing fasciitis wound care protocols.

A 42-year-old black man presented with an extensive keloid on the anterior section of his chest wall. He had acne as a child and developed a number of significant keloids, the most symptomatic being the keloid on his chest wall. This keloid had been treated with excision approximately 10 years previously in another city, followed by placement of a number of mesh split-thickness skin grafts (STSGs) obtained from his thighs. According to the patient, the superior edge of the keloid had also been irradiated some time after surgery. The entire keloid located on his chest wall had regrown significantly, causing the patient problems with bending at the waist and with full range of motion in his shoulders. The recurrence had been treated with intralesional corticosteroids and cryotherapy (separately and combined), as well as silicone gel and flurandrenolide (Cordran tape, Lilly, Eli and Co, Indianapolis, Ind) without significant improvement. In addition, a smaller keloid had been excised on his back and the epidermis removed from the keloid and replaced over the wound, with significant regrowth of that keloid as well. On physical examination the patient had an extensive keloid encompassing the surface area extending from the clavicle to the inframammary crease (Figure 1). The inferior portion of the keloid, which was the thickest portion, had curled under itself and had completely encased the patient’s areolae, which were not visible. In addition, the patient had a number of keloids located on his back and upper extremities. He had hypertrophic, but not keloidal, scars on his thighs at the donor sites from his previous STSGs.

Seventeen sweeteners varying widely in chemical structure were arranged in a three-dimensional space by two multidimensional scaling procedures, INDSCAL and ALSCAL. Fructose, glucose, sorbose, xylitol and xylose tended to fall near one another. Two sweeteners with a syrupy component, maltose and sorbitol, fell further away. Ca cyclamate and the dipeptide aspartame were the two artificial sweeteners which fell closest to and thus tasted most like the sugars. The proteins monellin and thaumatin, as well as the chalcone glycoside, neohesperidin dihydrochalcone, all have long aftertastes and thus tended to fall proximate to one another. Stimuli with the highest metallic and bitter ratings (acetosulfam, sodium saccharin, rebaudioside and stevioside) tended to fall near one another with the amino acid d-tryptophan located a little farther away. Adjective scales were related to the spatial arrangement. Wide variability in the patterns of intensity ratings over subjects suggests that the sweet taste may be mediated by several peripheral receptor mechanisms.

Taste detection thresholds for 19 L-amino acids and four monohydrochloride derivatives were determined for young and elderly subjects. Although the ranges of the thresholds were extensive, the elderly were found to have significantly diminished sensitivity. On the average, thresholds were 2 1/2 times higher in the elderly than in young subjects. Relationships between the taste detection thresholds of amino acids, their chemical structures, and suprathreshold taste qualities were found. Amino acids with aliphatic side chains and those containing hydroxyl groups and having sweet tastes at suprathreshold concentrations tended to have the highest thresholds. Amino acids containing sulfur, as well as those with acidic or basic groups, tended to have the lowest thresholds.