Faculty Bibliography

Agnathia-otocephaly complex (AOC) is characterized by mandibular hypo- or aplasia, ear abnormalities, microstomia, and microglossia. Though rare and often fatal, this is the first report detailing various reconstructive strategies beyond infancy as well as longitudinal follow-up into adulthood.All patients with AOC treated at our institution over a 30 year period were reviewed. Four patients were identified, one with agnathia, one with micrognathia. Two males with nanognathia (defined as a symphyseal remnant without body nor ramus) were also included. The mean follow-up was 17 years. All four underwent perinatal tracheostomy and gastrostomy-tube placement. Commissuroplasties were typically performed before 3 years of age and repeated as necessary to allow for oral hygiene. Mandibular reconstruction was most successful with rib between ages 3 and 8, after which time, free fibula transfer was utilized. Due to some resoprtion or extrusion, all patients underwent repeated bone grafting procedures. Tissue expansion of the neck was used to restore the lower third of the face, but was most successful in the teenage years. At last follow-up of the eldest patients, one was in college while another was pursuing graduate education.AOC need not be a fatal nor untreatable condition; a reasonable quality of life can be achieved. Although the lower-facial contour may be improved, and a stoma created, the lack of musculature make deglutition virtually impossible with current therapies. Just as transplantation has emerged as a modality for facial restoration following severe trauma, so too may it be a future option for congenital deformities.

PURPOSE: The purpose of this learning activity is to provide information regarding the differentiation between pressure ulcers and acute skin failure (ASF) in critically ill patients. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Describe the purpose, methodology and impact of this research.2. Differentiate the pathophysiology of pressure ulcers and ASF.3. Identify risk factors and diagnostic criteria for ASF. ABSTRACT: To develop a statistical model to predict the development of acute skin failure in patients admitted to the intensive care unit (ICU) and to validate this model.Retrospective case-control, logistic regression modeling552 ICU patientsIntensive care unit patients with and without pressure ulcers (PrUs) were studied and compared on key variables sorted into the following categories: (1) disease status, (2) physical conditions, and (3) conditions of hospitalization.The variables, peripheral arterial disease (odds ratio [OR], 3.8; P = .002), mechanical ventilation greater than 72 hours (OR, 3.0; P < .001), respiratory failure (OR, 3.2; P < .001), liver failure (OR, 2.9; P = .04), and severe sepsis/septic shock (OR, 1.9; P = .02), were found to be statistically significant and independent predictors of acute skin failure in ICU patients. These variables created a predictor model for acute skin failure in the ICU.Lack of objective criteria to define acute skin failure presents a clinical conundrum for practitioners-the acknowledgment that skin failure exists, but no clear-cut diagnostic criteria in which to support its existence as a result of a paucity of empirical evidence. In certain populations, such as the critically ill patient, the phenomenon of acute skin failure may be occurring, and with the current level of evidence, these ulcers may be incorrectly identified as PrUs. Accurately distinguishing risk factors that lead to a PrU from factors that result in a lesion due to acute skin failure is crucial in the quest to provide evidence-based practice to patients.

PURPOSE/OBJECTIVES: To assess the effects of high blood sugar at the levels of diabetic or prediabetic states during cancer treatment because patients undergoing chemotherapy (CTX) experience multiple symptoms that vary among individuals and may be affected by glucose levels. DESIGN: Descriptive, cross-sectional. SETTING: Two comprehensive cancer centers, one Veterans Affairs hospital, and four community-based oncology programs. SAMPLE: 244 outpatients with breast, gastrointestinal, gynecologic, and lung cancers. METHODS: Patients completed demographic and symptom questionnaires. Glycosylated hemoglobin A1c (HbA1c) was evaluated to determine diabetic state. Descriptive statistics and one-way analyses of variance were used in the analyses. MAIN RESEARCH VARIABLES: HbA1c, symptom severity scores, patient and clinical characteristics (e.g., age, gender, comorbidities, sociodemographic information, body mass index [BMI], lifestyle factors). FINDINGS: HbA1c results showed 9% of the sample in the diabetic and 26% in the prediabetic state. Patients in the diabetic state reported a higher number of comorbid conditions and were more likely to be African American. Patients in the prediabetic state were older aged. Patients in the diabetic and prediabetic states had a higher BMI compared to nondiabetic patients. No differences in symptom severity or quality-of-life (QOL) scores were found among the three diabetic states. CONCLUSIONS: This study is the first to evaluate for associations between diabetic states and symptom severity and QOL scores in patients receiving CTX. This study confirmed that older age, as well as having higher BMI and having multiple comorbidities, were associated with increased mean glycemic levels. IMPLICATIONS FOR NURSING: Clinicians should assess and identify patients with diabetes or prediabetes undergoing treatment for cancer. Patients who are older aged, those with a high BMI, and those with multiple comorbid conditions may be at increased risk for higher glycemic states.

RATIONALE AND OBJECTIVES: Cellulitis is a common cause for emergency department (ED) presentation and subsequent hospital admission. Underlying fracture, osteomyelitis, or foreign body is often considered in the clinical evaluation of these patients. Accordingly, plain radiographs (XRs) of the affected extremity are often ordered during the initial work-up. The utility of these imaging studies in the treatment of uncomplicated lower-extremity cellulitis, however, remains unclear. In an effort to treat this common problem more efficiently, we evaluated our imaging practices and results in a cohort of consecutive patients admitted to a large public city hospital for treatment of uncomplicated lower-extremity cellulitis. MATERIALS AND METHODS: Retrospective cohort study of 288 consecutive ED admissions for treatment of uncomplicated cellulitis, of which 214 met the inclusion criteria for this study. Patient demographics, history, vitals, laboratory values, and test results were evaluated with univariate and multivariate statistical analyses. RESULTS: XRs of the affected lower extremity were obtained in 158 patients (73.8%). Positive XR findings were present in 19 patients (12.0%) and positively correlated with a history of acute trauma to the extremity (P < .001) or the presence of a chronic wound (P < .01). Multivariable logistic regression analysis revealed a history of trauma (P < .001) or the presence of a chronic wound (P < .05) to be independent predictors of positive XR findings with relative risks of 6.24 and 2.98, respectively. CONCLUSIONS: The establishment of evidence-based guidelines for the treatment of lower-extremity cellulitis has potential to significantly improve clinical efficiency and reduce cost by eliminating unnecessary testing. Based on our results, patients without a recent history of trauma to the affected extremity or the presence of a chronic wound do not appear to warrant XRs. When applied to our cohort, only 48 of 158 patients had a history of trauma or chronic wound. This means that 110 patients unnecessarily had plain films taken as part of their initial work-up. In a largely uninsured inner city patient population such as this cohort, that extra cost falls on the public hospital system.

BACKGROUND: Acellular dermal matrices are used in implant-based breast reconstruction. The introduction of contour fenestrated AlloDerm (Life-Cell, Branchburg, N.J.) offers sterile processing, a crescent shape, and prefabricated fenestrations. However, any evidence comparing reconstructive outcomes between this newer generation acellular dermal matrices and earlier versions is lacking. METHODS: Patients undergoing implant-based breast reconstruction from 2010 to 2014 were identified. Reconstructive outcomes were stratified by 4 types of implant coverage: aseptic AlloDerm, sterile "ready-to-use" AlloDerm, contour fenestrated AlloDerm, or total submuscular coverage. Outcomes were compared with significance set at P < 0.05. RESULTS: A total of 620 patients (1019 reconstructions) underwent immediate, implant-based breast reconstruction; patients with contour fenestrated AlloDerm were more likely to have nipple-sparing mastectomy (P = 0.0001, 0.0004, and 0.0001) and immediate permanent implant reconstructions (P = 0.0001). Those with contour fenestrated AlloDerm coverage had lower infection rates requiring oral (P = 0.0016) and intravenous antibiotics (P = 0.0012) compared with aseptic AlloDerm coverage. Compared with sterile "ready-to-use" AlloDerm coverage, those with contour fenestrated AlloDerm had similar infection outcomes but significantly more minor mastectomy flap necrosis (P = 0.0023). Compared with total submuscular coverage, those with contour fenestrated AlloDerm coverage had similar infection outcomes but significantly more explantations (P = 0.0001), major (P = 0.0130) and minor mastectomy flap necrosis (P = 0.0001). Significant independent risk factors for increased infection were also identified. CONCLUSIONS: Contour fenestrated AlloDerm reduces infections compared with aseptic AlloDerm, but infection rates are similar to those of sterile, ready-to-use AlloDerm and total submuscular coverage.

We present a case of rapidly ascending left ventricular assist device driveline and tunnel infection in a patient with a long length of driveline buried beyond the distal velour coating. Device salvage with radical debridement, exit site relocation, and local tissue advancement is described. The findings in this case suggest that the interface between nonvelour covered driveline and subcutaneous tissue can become the nidus of a virulent ascending infection because of poor tissue ingrowth.

Microvascular reconstruction offers patients with facial deformities excellent composite tissue restoration and improves functional outcomes. However, such techniques require facial skin incisions, leaving the patient with unsightly scarring. Implementing an intraoral microvascular anastomosis can obviate the need for facial skin incisions, yielding aesthetically favorable results. We present the case of a 29-year-old, cosmetically conscientious woman who underwent a free iliac osteomuscular flap with intraoral microvascular anastomosis for reconstruction of a right maxillary defect secondary to fibrous dysplasia. Endosseous dental implants were successfully placed using computer-aided design and manufacturing to effectively restore the dentition. Intraoral microvascular reconstruction provided the patient with an aesthetically pleasing result, effectively achieving functional restoration with patient satisfaction.

PURPOSE: To develop and validate a method of predicting whether patients will develop a heel pressure ulcer during their hospital stay. DESIGN: This retrospective case-control study used 2 separate data sets, one for an initial analysis followed by a second data set for validation analysis. SUBJECTS AND SETTING: From 2009 to 2011, medical records of discharged patients with a DRG code for heel pressure ulcers in our urban, tertiary medical center were retrospectively reviewed. Using age as the matching criterion, we then reviewed cases of patients without heel pressure ulcers. The initial analysis comprised 37 patients with hospital-acquired heel pressure ulcers and 300 without. The validation analysis included 12 patients with heel pressure ulcers and 68 without. METHOD: In order to develop this method of identifying patients with heel pressure ulcers, logistic regression modeling was used to select a set of patient characteristics and hospital conditions that, independently and in combination, predicted heel pressure ulcers. Logistic modeling produced adjusted and unadjusted odds ratios for each of the significant predictor variables. The validation analysis was employed to test the predictive accuracy of the final model. RESULTS: Initial analysis revealed 4 significant and independent predictors for heel pressure ulcer formation during hospitalization: diabetes mellitus, vascular disease, immobility, and an admission Braden Scale score of 18 or less. These findings were also supported in the validation analysis. CONCLUSION: Beyond a risk assessment scale, staff should consider other factors that can predispose a patient to heel pressure ulcer development during their hospital stay, such as comorbid conditions (diabetes mellitus and vascular disease) and immobility.

BACKGROUND: Interest in and acceptance of autologous fat grafting for use in contour abnormalities, breast reconstruction, and cosmetic procedures have increased. However, there are many procedural variations that alter the effectiveness of the procedure and may account for the unpredictable resorption rates observed. METHODS: The authors highlighted studies investigating the effects of harvesting procedures, processing techniques, and reinjection methods on the survival of fat grafts. This review focused on the impact different techniques have on outcomes observed in the following: in vitro analyses, in vivo animal experiments, and human studies. RESULTS: This systemic review revealed the current state of the literature. There was no significant difference in the outcomes of grafted fat obtained from different donor sites, different donor-site preparations, harvest technique, fat harvesting cannula size, or centrifugation speed, when tumescent solution was used. Gauze rolling was found to enhance the volume of grafted fat, and no significant difference in retention was observed following centrifugation, filtration, or sedimentation in animal experiments. In contrast, clinical studies in patients found more favorable outcomes with fat processed by centrifugation compared with sedimentation. In addition, higher retention was observed with slower reinjection speed and when introduced into less mobile areas. CONCLUSIONS: There has been a substantial increase in research interest to identify methodologies for optimizing fat graft survival. Despite some differences in harvest and implantation technique in the laboratory, these findings have not translated into a universal protocol for fat grafting. Therefore, additional human studies are necessary to aid in the development of a universal protocol for clinical practice.