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Objective: Low-frequency ultrasound debridement with irrigation is an effective method of wound bed preparation. A recent clinical study compared hypochlorous acid preserved wound cleanser (HAPWOC) to saline and found HAPWOC to be a more effective adjunct to low frequency ultrasound debridement. However, HAPWOC has an added cost. The primary objective of this study was to assess the cost-effectiveness of HAPWOC as an irrigation modality with low-frequency ultrasound debridement for the treatment of severely complex wounds that were destined to be closed primarily via a flap. The secondary objective of this study was to estimate the number needed to treat (NNT) to avoid a wound-related complication and its expected cost per NNT. Methods: A patient-level Monte-Carlo simulation model was used to conduct a cost-effectiveness analysis from the US health system perspective. All clinical data were obtained from a prospective clinical trial. Cost data were obtained from the publicly available data sources in 2021 US dollars. The effect measure was the avoidance of wound-related complications at 14-days post-debridement. The primary outcome was the incremental cost-effectiveness ratio (ICER), a measure of the additional cost per benefit. The secondary outcomes were the NNT and expected cost per NNT to avoid one complication (complementary to the ICER in assessing cost-effectiveness). Deterministic and probabilistic sensitivity analyses (PSA) were performed to gauge the robustness and reliability of the results. Results: The ICER for HAPWOC versus saline irrigation was US$90.85 per wound complication avoided. The expected incremental cost per patient in the study and effect was US$49.97 with 55% relative reduction in wound-related complications at day 14 post debridement procedure. The NNT and cost per NNT were 2 and US$99.94, respectively. Sensitivity analyses demonstrated that these results were robust to variation in model parameters. Conclusion: HAPWOC was a cost-effective strategy for the treatment of complex wounds during ultrasonic debridement. For every two patients treated with HAPWOC, one complication was avoided.

Introduction: Wound debridement is considered essential in chronic wound management. Hypochlorous acid has been shown to be an effective agent in reducing wound bacterial counts in open wounds. Ultrasound-enabled wound debridement is an effective and efficient method of debridement. This study compared ultrasound irrigation with hypochlorous acid versus saline irrigation for wound debridement on pre- and postoperative wounds and determined regrowth of bacteria over 1 week period of time. Finally, the outcome of definitive wound closure of the clinically clean-appearing wounds was recorded. Methods: Seventeen consenting adult patients with chronic open wounds were randomly selected for study. The patients were randomly divided into the hypochlorous acid irrigation or saline irrigation group. All patients provided pre- and postoperative tissue samples for qualitative and quantitative bacteriology. For the time (7 days) between the debridement procedure and the definitive closure procedure, the wounds were dressed with a silver-impregnated dressing and a hydroconductive dressing. Results : Both types of irrigation in the ultrasonic system initially lowered the bacterial counts by 4 to 6 logs. However, by the time of definitive closure, the saline-irrigated wounds had bacterial counts back up to 10 5 whereas the hypochlorous acid-irrigated wounds remained at 10 2 or fewer. More than 80% of patients in the saline group had postoperative closure failure compared with 25% of patients in the hypochlorous acid group. Conclusions: Hypochlorous acid irrigation with ultrasound debridement reduced bacterial growth in chronic open wounds more efficiently than saline alone. Postoperative wound closure outcomes suggest a remarkable reduction in wound complications after wound debridement using hypochlorous acid irrigation with ultrasound versus saline alone.

Sympathetic axons can form atypical pathways to denervated orbital targets in neonatal rats but not in rats aged 30 or more days. The objective of this study was to determine if connective tissue pathways that carry sympathetic nerves lose their ability to sustain axonal sprouting during the early postnatal period. Regions of periorbital sheath known to contain large numbers of sympathetic axons that travel to distal orbital targets were excised from rats (sympathectomized 3 days previously) on postnatal days 6-7, 14-15, 30-31, and 48-49 and placed in anterior chambers of adult host rats. Tissues were removed 3, 6, or 10 days post-transplant and sympathetic ingrowth was analyzed by catecholamine histofluorescence in whole-mount or cryosectioned specimens. Connective tissue transplants from 6-15-day-old donors showed significant fiber ingrowth by 3 days in oculo, and innervation was maximal by 6 days. In contrast, sprouting into 30-49-day-old tissue was significantly slower, with most transplants lacking fibers at 3 days, and with small numbers of short fibers present at 6 days. We conclude that maturational changes occur in periorbital connective tissue pathways in the early postnatal period which make them less receptive to ingrowth by sympathetic nerves. The findings that connective tissue pathways are better substrates for sympathetic sprouting in the neonatal rat supports the view that developmental changes in these tissues are likely to contribute to the impaired reinnervation of orbital targets by contralateral neurons in juvenile and adult rats.

This case report describes presurgical anxiety in a 13-year-old female with complete cleft lip and palate, treatment of the anxiety with cognitive-behavioral therapy and progressive relaxation with biofeedback prior to a septorhinoplasty, and the treatment outcome.

Argon beam coagulation (ABC) uses argon gas to evacuate blood in an operative field and simultaneously to transport a coagulating electric current to bleeding sites. This allows a 'no touch' method of coagulation which is faster, more precise, and less destructive than conventional electrocautery. The technique has been used to reduce blood loss in liver surgery, trauma surgery and neck dissections. In this study, the effect of ABC treatment of the recipient graft beds on the survival of split thickness skin grafts was assessed in pigs, testing the hypothesis that ABC treatment of the recipient bed would have no adverse effect on skin graft survival. Nine 20 kg mixed breed pigs had split thickness skin grafts raised on each side of the paraspinous area. The graft beds on one side were prepared using ABC and the contralateral side served as controls. The percentage of graft survival on the ABC treated sides was compared to control graft survival on the other side at 12 days postsurgery. Our results confirm the hypothesis that treatment of the recipient bed with ABC does not adversely affect the survival of split thickness skin grafts.

The purpose of this paper is to present the Facial Impairment Scales for Clefts. The Facial Impairment Scales for Clefts consist of four, 24-photograph, empirically derived scales of severity of cleft impairment. They were developed (1) to serve as research tools in single and multicenter studies of the surgical, psychosocial, and integrated treatment outcomes of facial clefts and (2) to assist in clinical assessment staging of the aesthetic severity of cleft impairment. Study 1 was conducted to extend the generalizability of the Facial Impairment Scales for Clefts to other groups of raters, including plastic surgeons. Reliability of scale ratings between children (n = 54) and plastic surgeons (n = 23) was examined. Rank orders of photographic subjects by severity of cleft impairment by children were highly correlated with ranks given by plastic surgeons. Study 2 in this series was conducted to assess if new photographs could be reliably fitted to scales. One-hundred and thirty-four medical student raters were able to scale new photographs reliably to the standard measures. These findings suggest that the Facial Impairment Scales for Clefts have sufficient reliability and validity for use in studies of severity of facial impairment.

The effect of rapid versus slow tissue expansion on random-pattern skin-flap survival lengths was evaluated in two groups of pigs. Each group (group 1--slow; group 2--rapid) was further evaluated for the effect that delay (A), delay plus expansion (B), expansion only (C), and acute flap elevation (D) had on flap length viability. Intergroup and intragroup comparisons were made. In the slowly expanded group, significantly greater flap length viabilities were demonstrated in the slow expansion flaps as compared with the delay plus expander flaps and the delayed flaps, respectively. In the rapidly expanded group, the flap length viabilities of flaps C, B, and A were statistically equal. However, the flap length viability of the rapidly expanded flaps was statistically equal to that of the slowly expanded flaps (C1 = C2). The effect tissue expansion has on improving flap length viability as compared with the delay phenomenon may be related to the combination of a delay effect plus increased nutrient flow density that slow expansion produces. This combined metabolic enhancement is preserved with rapid tissue expansion.

This article briefly reviewed the research literature on the psychosocial correlates of facial clefts and described a program of research to study the relationship between severity of cleft impairment and psychosocial adjustment. In the past 40 years, there has been increasing recognition and research literature on the psychologic implications of facial clefts to patients and their families. Advances in both the knowledge base and the science of the psychologic correlates of facial clefts have been made. Children with clefts are not at greater risk for psychopathology than are individuals without clefts; however, they are at significant risk for social competence problems relating to development of friendships, progress in school, and participation in organizations. Problems with social competence have a negative effect on development. The ability of all children to make friends and to be liked by others is considered by most parents, teachers, and child development specialists to be a major developmental milestone. Not having friends and social withdrawal can cause parents or teachers to refer noncleft children to mental health professionals and is a predictor of impaired adult social competence and mental health. Studies of adults with clefts are consistent with studies of adults without clefts. Adults with repaired clefts are less likely to marry than are their noncleft siblings, and they have more problems with social withdrawal. Because facial attractiveness is well-known to affect peer acceptance, we hypothesized that the severity of the cleft deformity may have a significant impact on social competence. Consequently, we undertook a program of research to examine this question.(ABSTRACT TRUNCATED AT 250 WORDS)

Recently, we evaluated a 27-month-old boy with congenital generalized nonspecific myopathy, Möbius sequence, Robin sequence, and failure to thrive. We think the child has the same entity described by Carey, Fineman, and Ziter in 1982 [J Pediatr 101:353-364] and as such represents only the third example of this unusual syndrome. Review of the large number of conditions in which the Robin sequence occurs supports heterogeneity. Our case strengthens the Möbius-Robin association and further defines the Carey-Fineman-Ziter syndrome as a viable entity. It is most likely inherited as an autosomal recessive trait.

Children and adolescents provided their impressions of stimulus faces that systematically varied in attractiveness and severity of cleft impairment. The results indicated that facial attractiveness is a consistent characteristic of cleft-impaired faces. However, facial attractiveness did not moderate the negative impact of cleft impairment on social perception. Reduced severity of impairment did moderate the negativity of social perception. The implications of these findings for our understanding of the effects of cleft impairment on social perceptions are discussed.

The reliability and validity of human judgments in rating the severity of cleft-related facial impairment were examined in this series of studies. The goal of the research was to develop scales for rating the severity of facial cleft impairment using psychophysical methods for measuring human judgment. The principle findings were: (1) Four photographic categorized scales with high inter-group reliability and satisfactory content and construct validity were developed; (2) Raters used objective stimulus characteristics of the face to scale impairment; (3) Ratings of facial attractiveness decreased as the severity of impairment increases; (4) Full face ratings of the severity of impairment correlated highly with ratings of the same photographs cropped below the eyes. The implications of these findings for clinical and research application are discussed.

An experimental approach to treatment, using a modified Schwartz appliance, is described. The patient died from unrelated causes, but sufficient progress was made to warrant further clinical evaluation of the treatment method.

Nearly 10 million patients with traumatic lacerations are treated annually in Emergency Departments in the United States. Since these wounds do not usually pose a threat to the patient's life, they assume a lower level of priority than emergent conditions. Consequently, treatment of patients with lacerations is often delayed until the emergent patient is resuscitated. In the event that wound care is inadvertently delayed, bacteria may proliferate to levels that result in infection. In selected patients, supervised wound care by an emergency nurse practitioner (ENP) can safely eliminate this delay in treatment. During their graduate training in the University of Virginia Nursing School, the ENPs are instructed to treat traumatic wounds with physician supervision. The criteria for patient selection and care are outlined in comprehensive guidelines reported herein. The bases for these treatment guidelines were clinical and experimental studies conducted at our medical center which examined the influence of various therapeutic decisions on the ultimate fate of the wound.

The extent to which the nutrient artery alone is capable of maintaining bone growth in the immature animal was studied by excision and reimplantation of the upper tibia in two groups of puppies. In one group the reimplant was totally devascularized, and in a second group attempts were made to preserve the nutrient vessels to the reimplant. Technetium-99m methylene diphosphonate (Tc-99m MDP) was used to assess the effectiveness with which the nutrient circulation was maintained. With one exception the Tc-99m MDP scans proved to be reliable in indicating the potential for continued growth after reimplantation. It was found that the nutrient artery alone is capable of maintaining longitudinal bone growth in metaphyseal reimplants in immature animals. Complete devascularization results in cessation of growth. The Tc-99m MDP bone scan should prove of critical importance in the assessment of free vascularized transplants of immature bone.

The key to successful fluid resuscitation of the thermally injured patient is close monitoring of the clinical response. Individualized resuscitation based on the parameters described allows for approximation of this goal. An eclectic approach used by the authors has been described with reference to clinical subsets that may require specialized resuscitative methods. Efforts should be made to use the smallest volume of fluid needed to optimize end organ perfusion. The goals of fluid resuscitation have been summarized and a variety of formulas have been described. We anticipate that our understanding of patient subsets outlined in this paper will undergo further evolution.

Studies were conducted to examine glucose and amino acid metabolism by skeletal muscle isolated from rhesus monkeys before and sequentially after an episode of resuscitated hemorrhagic shock. After shock and reinfusion, the tissue exhibited decreased effect of insulin on glucose utilization increased leucine oxidation, and a reduced rate of leucine incorporation into protein. These changes were observed 15 min after reinfusion and persisted in part for at least 3 days. All of the observed abnormalities were more pronounced 24 h after shock and reinfusion than 15 min after and returned to normal by 2-4 wk. The shock-induced metabolic abnormalities in skeletal muscle occurred in spite of prevention of shock-induced adrenal steroid and catecholamine secretion and of changes in blood insulin concentration using adrenalectomized-streptozotocin diabetic monkeys receiving replacement cortisol and insulin infusions. This study thus demonstrated that hemorrhagic shock in rhesus monkeys was followed by insulin resistance plus abnormalities of glucose and amino acid metabolism by skeletal muscle that were not dependent on the concurrent changes in plasma levels of adrenal steroids or catecholamines or on altered circulating insulin levels associated with shock.

Parents' ratings of conduct and school problems were evaluated in 79 subjects with palatal clefts. Subjects were divided into four groups consisting of: (1) unilateral complete clefts of the lip and palate (UC Group); (2) unilateral complete clefts of the lip and palate with associated congenital malformations (UC-C Group); (3) cleft palate only (CPO Group); and (4) cleft palate only with associated congenital malformations (CPO-C Group). Comparisons between groups suggested that subjects with associated congenital malformations, whether or not they had UC or CPO, tended to have more serious school and conduct problems when compared to children with clefts and no associated congenital malformations. The association of congenital malformations with a cleft lip and palate increased the risk of reported conduct problems at home and behavioral and learning problems at school.

Emergency department treatment, triage and transfer protocols for patients with major thermal injury have been devised by the three burn centers in Virginia. A burn nurse educator has presented these guidelines to the emergency departments of Virginia. The development of these protocols has considerably improved the immediate care of the victims of thermal injury who are transferred to the burn centers in the Commonwealth of Virginia.

The antimicrobial activity of cerium nitrate and silver sulfadiazine was assessed in vitro and in vivo using Pseudomonas aeruginosa. In vitro, the activity of silver sulfadiazine was significantly greater than that of cerium nitrate. Synergism between silver sulfadiazine and cerium nitrate was observed in water or saline solution suspensions, but not in broth. In vivo, cerium nitrate offered no therapeutic benefit in reducing wound infection in contaminated wounds. Treatment of similar wounds with silver sulfadiazine resulted in a significant decrease in wound infection and in the level of viable bacteria when compared with that for untreated controls. The addition of cerium nitrate to silver sulfadiazine in aqueous soultion reduced the therapeutic benefit of silver sulfadiazine.

The records of 51 patients with chemical burns were reviewed to identify demographics, mechanism and place of injury, cause, distribution, initial management, and outcome of treatment. Patients were classified as having received adequate (immediate dilution or neutralization of the chemical treatment--group A, or inadequate (delayed or inappropriate) treatment--group B. Inpatient mortality for chemical burns was 13% compared to 15% overall burn center mortality. Of the burns, 79% occurred in the 21-50 age group; 69% of burns were work-related in men and 17% in women. In group A, 19% required skin grafting (mortality 9.5%); in group B, 36% required grafting (mortality 21%). Alkali were the most frequent cause of burns, followed by sulfuric acid and, less often, gasoline, anhydrous ammonia, white phosphorus, and hydrofluoric acid.

The essential features of the major benign and malignant vascular tumors affecting infants, children and adults have been presented. Major emphasis has been placed upon the classification and treatment of hemangiomas, although malignant vascular tumors are discussed, and extensive and selected references are cited. The classification system of hemangiomas presented in this monograph is based upon the clinical prognosis of the angioma. The principles of treatment for hemangiomas based upon our clinical classification are discussed and may be summarized as follows: 1. The diagnostic features and prognosis vary with the variety of the angioma. 2. Spontaneous regression occurs only with juvenile hemangiomas, and the major involution occurs before age 5. 3. Patients with rapidly growing capillary cavernous hemangiomas should be treated with steroids. 4. Treatment modalities that increase scarring of the surface epithelium are contraindicated. 5. Intradermal and cirsoid angiomas do not spontaneously regress. 6. Congenital A-V fistulas require aggressive surgery. 7. The ultimate deformity resulting from angiomas may be greatly reduced by plastic surgical techniques. 8. Radiation therapy is never indicated for the treatment of hemangiomas. 9. The psychologic impact of the congenital deformity on patients is generally more detrimental than comparable postsurgical or traumatic deformities.

A standardized questionnaire was used to record parents' ratings of the frequency of conduct problems and their tolerance of the problems. According to parent report, children without facial clefts and children with facial clefts displayed conduct problems with about the same frequency. However, parents of children with facial clefts were significantly more tolerant of problems in their offspring. These data suggest that the social learning environments in the homes may be different for the two groups of children.

An analysis of 1,478 consecutive admissions to the University of Kansas Burnett Burn Center revealed 18 patients who developed heterotopic ossification (1.2% incidence). Seventeen patients developed this disease in the elbows; one patient had shoulder involvement. Two patients eventually developed bilateral elbow disease. All patients initially presented with pain and limitation of joint motion. The diagnosis was then confirmed radiographically. All patients suspected of heterotopic ossification received physical therapy consisting of active range of motion only. Ten patients responded to conservative treatment and regained functional range of motion, and eight patients developed refractory ankylosis requiring surgical management. All surgically managed patients achieved a functional range of motion with an average followup of 35.0 months.

The decision to seek secondary treatment for facial clefts is often the result of concerns about the esthetic acceptability of appearance. There are no standard techniques to assess cleft impairment for esthetic acceptability. Therefore, it is not possible to evaluate objectively either the need for or the benefits of treatment. If it could be shown that people agree closely on how they rate the esthetic appearance of cleft impairments that vary in severity, then esthetic measures of cleft impairment could be developed with human judgment as the yardstick. The goals of this study were: (1) to examine the reliability with which children express their preferences for cleft impairments that vary in severity, (2) to determine if other facial characteristics influence the reliability of children's preferences for cleft impairments, and (3) to evaluate if age and gender of children influence preferences for cleft impairments. Based on preratings, eight types of photographic slides were created that varied in severity of cleft impairment and global facial attractiveness. A second sample of subjects then rated the slides on the esthetic acceptability of appearance. Children ranked the photographic types consistently. They least preferred the photographic types depicting severe impairment or low facial attractiveness, or both, and most preferred faces with no impairment or moderate attractiveness, or both. There were also developmental effects in that younger children tended to have less consensus in their ratings of appearance than older children. Finally, boys displayed greater consensus than girls.

Insulin secretory rates (ISR) during intravenous glucose tolerance tests (IVGTT's) were measured in six dogs subjected to hemorrhagic shock and were compared to ISR's from five monkeys subjected to shock of comparable severity. ISR's also were measured in normotensive control dogs and monkeys subjected to the same blood sampling protocol. A sixfold increase in ISR occurred in shocked dogs after glucose loading; however, no ISR response occurred in monkeys subjected to hemorrhage. It is concluded that marked species differences exist in the insulin-glucose metabolic responses to shock. In addition, the dog would appear to be an inappropriate experimental animal as applied to trauma-insulin metabolism in man.

The effects of teaching patients strategies for coping with the pain of an acute burn injury and its treatment were investigated. Twenty patients with comparable burn injuries and admitted to a Burn Center were randomly assigned to either a control or experimental group. Experimental patients received systematic instruction on how to cope with the pain and stress of burn injury; control patients received standard information and social support only. Results showed that experimental patients reported less pain and greater sense of psychological well-being and control over the outcome of their injuries than did control patients. Moreover, experimental patients went home, on the average, more than 1 week sooner than did control patients. The implications of these findings for the improved care of patients with burn injuries and the economics of burn care are discussed.

In an effort to determine an optimal method of utilizing the gastrointestinal tract to meet the nutritional need of burn patients, a comparison was made between continuous and intermittent delivery of lactose-free tube-fed diets in similar groups of burn-injured patients. It was found that significantly less stool frequency and time required to achieve the nutritional goal occurred in patients treated with continuous pump tube feeding over those fed intermittently.