Wound Graft Research Articles

Negative pressure dressings for severe hidradenitis suppurativa (acne inversa): a case report

Hidradenitis suppurativa (HS) is a frustrating disease to treat for both the patient and the practitioner. In severe cases, aggressive management will often have a more tolerable outcome. We present the case of a 46-year-old gentleman with a long-standing history of severe HS, who was treated successfully with wide surgical excision, followed by a full-thickness skin graft and negative pressure wound therapy (both pre- and post-operatively). A review of the literature revealed few reports of HS treatment using these sequential steps.

Pelvic Organ Prolapse Management in Female Kidney Transplant Recipients

Pelvic organ prolapse in female postmenopausal kidney transplant recipients may be complicated by adverse events affecting graft function. We describe our experience with pelvic reconstructive surgery in renal transplant recipients. Pelvic reconstructive surgery was done in 16 female renal transplant recipients with pelvic organ prolapse with or without stress urinary incontinence. Intraoperative and postoperative data were recorded prospectively, including medical and surgical history, pelvic organ prolapse quantification measurement, 24-hour pad count, quality of life measurements and graft outcome. Patients were followed up to 12 months. Mean +/- SD age at surgery was 58.3 +/- 7.7 years (range 50 to 66). Mean time to renal transplantation was 54.2 +/- 15.1 months (range 38 to 123). A total of 12 anterior and 4 combined anterior/posterior colporrhaphies were done. A concomitant suburethral single incision transobturator sling procedure was performed in 8 women. We noted no bladder or rectal injury, bleeding necessitating transfusion or infection. Pelvic floor testing at 12-month followup showed stage I vaginal wall prolapse in only 4 patients (25%). No patient had evidence of de novo incontinence, synthetic sling infection, erosion or rejection. All women reported improved quality of life on the SF-36 questionnaire. Renal graft function remained stable in all patients. Pelvic reconstructive surgery is feasible for pelvic organ prolapse in patients with a kidney allograft on immunosuppression. However, concern about impaired graft function, infection and wound healing remains important.

Management of localized prostate cancer by retropubic radical prostatectomy in patients after renal transplantation

The study aimed to report our experience with retropubic radical prostatectomy (RRP) for treatment of localized prostate cancer in renal transplant recipients (RTR). Data of 16 RTR who had an RRP between 2001 and 2007 were retrospectively analysed and compared to the data of 294 non-transplanted patients who were operated for RRP during the same period. Diagnostic work-up consisted of digital rectal examination, serum prostate specific antigene levels, as well as Transrectal Ultrasonography (TRUS)-guided prostate biopsy. Follow-up was obtained in all patients with a mean follow-up time of 2.1 years in RTR. Mean time distance to the renal transplantation at the time of RRP was 81.2 ± 19.1 months. RRP was successfully performed and tolerated in all RTR without pelvic lymph node dissection. No major complications occurred during or after the operation. There were two minor complications in transplant group (prolonged haematuria and urinary leakage). Mean operative time was 108.3 ± 3.9 min in transplant group, which was significantly longer as in non-transplanted group (89.1 ± 4.1, P < 0.05). Mean estimated intra-operative blood loss was significantly lower in transplant group (P < 0.05). In RTR, one case of positive surgical margins was present (R(1): 6.2 vs. 12.3% in non-transplanted group, P < 0.05). None of the RTR had impairment of graft function. At follow-up, no case of biochemical recurrence was observed in RTR. RRP is safe and feasible for management of localized prostate cancer in patients with kidney allograft being under immunosuppression. However, concern about impairment of graft function, infection and wound healing remains important.

DETECTION AND IMPLICATION OF EARLY AGROBACTERIUM TUMEFACIENS INFECTION OF PARADOX SEEDS AND SEEDLINGS

Paradox (Juglans hindsii × J. regia), the dominant rootstock used in California, USA walnut production, has many desirable horticultural characteristics, but is highly susceptible to crown gall. Crown gall, caused by the bacterium Agrobacterium tumefaciens, is not consistently controlled with soil fumigation. This observation, in conjunction with observations of galls occurring in above ground grafting wounds, led to the hypothesis that A. tumefaciens inoculum may be endophytic in walnut seedlings. Paradox seeds collected directly from commercial Paradox mother trees (i.e., Juglans hindsii) were free of A. tumefaciens. Sampling conducted at multiple times during seed production revealed that seed-borne A. tumefaciens populations increased as a function of contact time with the orchard floor. In greenhouse experiments, seeds inoculated with A. tumefaciens produce seedlings with galls at the crown and/or roots in the absence of artificial wounding. Endophytic populations of A. tumefaciens were also found in shoot and root tissue. These data suggest that A. tumefaciens inoculum may exist as a resident endophyte and that timely seed collection, limiting contact with the orchard floor, may be an important first step in preventing crown gall disease of walnut.

A Novel Technique Combining Platelet Gel, Skin Graft, and Fibrin Glue for Healing Recalcitrant Lower Extremity Ulcers

There is no ideal procedure for the treatment of chronic skin ulcers. The use of platelet gel (PG) in this indication is raising interest. To evaluate the safety and efficacy of a new procedure combining allogeneic single-donor PG and fibrin glue (FG) to enhance skin graft take for treating recalcitrant ulcers. Fifteen patients with 17 ulcers of various etiologies were enrolled. Skin ulcers were débrided, and the wounds covered with moist saline dressing. Three to 14 days later, the wound bed was sprayed with PG, a thin split-thickness skin graft with multiple slits was put on the wound bed, and FG was sprayed on the skin graft. A short leg polypropylene splint was used to immobilize the skin graft. Most skin grafts took well. The interval between skin graft and complete wound healing ranged from 3 weeks to 2 months. No recurrence of ulcers was noted during the 3- to 18-month follow-up period. No adverse reactions were observed. The procedure provides advantages in skin grafting for recalcitrant ulcers because PG functions as a delivery system of powerful mitogenic and chemostatic factors and FG as a hemostatic tissue sealant that avoids the use of staples or sutures.

Traumatic Wound Dehiscence After Deep Anterior Lamellar Keratoplasty: Protective Role of Intact Descemet Membrane After Big-Bubble Technique

To describe a case of traumatic wound dehiscence after deep anterior lamellar keratoplasty. Observational case report. A 31-year-old man who had undergone deep anterior lamellar keratoplasty using big-bubble technique for keratoconus 3 months earlier presented to emergency room after blunt trauma.On examination, visual acuity was counting fingers at 2 m. The corneal graft wound dehisced from 12 to 3 o'clock (90 degrees) with localized suture ruptures, but the anterior chamber was deep and the Seidel test was negative. Surprisingly, there was intact Descemet membrane prolapsed through the corneal wound gap. This case indicates that intact Descemet membrane remaining after big-bubble technique might reduce the severity of ocular injury after traumatic wound dehiscence.

Development of a Tubing-grafting Robotic System for Fruit-bearing Vegetable Seedlings

This research aims to develop an automatic tubing-grafting robotic system using soft rubber tubes as the grafting material that is suitable for the rootstock and scion of fruit-bearing vegetables having similar stem diameter, such as tomato, bitter melon and sweet pepper. Compared with grafting using grafting clips, the soft rubber tube approach is low-cost and minimizes water loss from the grafting wounds. Moreover, as the grafted seedlings grow, the soft rubber tubes automatically peel off from seedlings due to embrittlement and this saves recycling. The tubing-grafting robotic system is made up of six major units, namely the rootstock gripping, the rootstock cutting, the scion gripping, the scion cutting, the tube supplying, and the guiding units. A pneumatic mechanism with a programmable logic controller is used to process the sequential events needed. In the guiding unit, a pair of guiding sleeves ensures that the rootstock and scion are able to be inserted into the rubber tube smoothly even if the stem of either the rootstock or scion is deflective. The experimental results indicated that the average grafting success rate is over 93.8% and the system has a working capability of 327 seedlings per hour; the overall adhesion rate for the grafted seedlings kept in an acclimatization chamber is over 84.4%. Demonstrations were held and farmers were highly satisfied with the system performance.

Traumatic Wound Dehiscence and Lens Extrusion After Penetrating Keratoplasty

The purpose of this study was to investigate risk factors for and results of treatments in patients with traumatic wound dehiscence and lens extrusion after penetrating keratoplasty. In this retrospective case series, 7 eyes (4 right eyes and 3 left eyes) of 7 patients who had traumatic wound dehiscence and lens extrusion were studied at Rassoul Akram Hospital. Six patients were male and one patient was female. After emergency treatment for the trauma, the wound was checked under general anesthesia, and anterior vitrectomy was performed. The iris was repositioned as needed and the dehiscence site was sutured in all patients using 10-0 nylon thread. Follow up was similar to that after keratoplasty. All recorded data were statistically analyzed using SPSS software (version 15; SPSS Inc., Chicago, IL). Mean age at trauma was 21 years (range, 10-30 years), and the mean interval between keratoplasty and trauma was 15.6 months (range, 2.5-26.5 months). Mean best-corrected visual acuity of patients before blunt trauma and after final treatment was 20/80 and 20/160, respectively. In one case, visual acuity decreased to light perception after final treatment. The dehiscence site was superior to the graft in 4 patients. Hitting by a hand was the cause of most cases of blunt trauma. No cases of endophthalmitis were seen. Patients who undergo penetrating keratoplasty are susceptible to graft wound dehiscence resulting from trauma, especially during the first year after keratoplasty. This type of dehiscence is more prevalent in young people, who engage in more social activities and are more exposed to trauma that may lead to blindness. Patient education about the effects of trauma, use of protective eye shields by patients, and performance of lamellar keratoplasty instead of penetrating keratoplasty can decrease trauma and its effects in these patients.

The noninvasive, quantitative, in vivo assessment of adenoviral-mediated gene delivery in skin wound biomaterials

Because there are few reports using gene delivery in clinically-approved synthetic matrices, we examined the feasibility of using a noninvasive imaging system to study the kinetics of luciferase gene expression when delivered in an adenoviral vector. Using a mouse model of full thickness injury, we quantified the kinetics of gene expression, determined the optimal dose of particle delivery, and established the temporal importance of drug delivery in obtaining optimal gene expression. Specifically, we found that the ideal time to deliver adenovirus to a graft is during the early phase of graft wound closure (days 0–3 post-operatively) for a peak of gene expression to occur 7 days after delivery. Under these conditions, there is a saturating dose of 6 × 10 8 adenoviral particles per graft. In light of these findings, we examined whether the efficacy of delivery could be increased by modulating the composition of the grafts. When a collagen gene-activated matrix (GAM) containing basic fibroblast growth factor (FGF2) was compared to matrix alone, a significant increase in gene expression is observed when identical amounts of vector are delivered ( p < 0.05). Taken together, these results show how a noninvasive and quantitative assessment of gene expression can be used to optimize gene delivery and that the composition of matrices can dramatically influence gene expression in the wound bed.

Multicentric outcome analysis of sirolimus-based immunosuppression in 252 liver transplant recipients

The use of sirolimus (SRL) in orthotopic liver transplantation (OLT) has been controversial after experimental data suggested an increased risk of hepatic artery thrombosis (HAT). To assess the safety and efficacy of SRL as de novo immunosuppression in OLT recipients. Outcomes of 252 OLT patients who received SRL were compared with outcomes of 291 OLT recipients who received calcineurin inhibitor in a retrospective study. Primary outcomes of this study were: patient- and graft survivals, vascular, biliary, wound complications and rejection rates. Secondary outcomes were: postoperative infection rate, bone marrow and renal function and changes of lipid levels. Patient- and graft survivals, rejection and infection rates were similar. In the SRL group, HAT occurred in 1.2%, biliary complications in 19.4%, and incisional hernias in 9.1%. In the control group the incidence of HAT was 5.8% (P = 0.004), biliary complications 18.5% (P = NS) and incisional hernias 7.2% (P = NS). Patients on SRL experienced significantly higher levels of serum triglycerides but fewer acute cellular rejections. Bone marrow and renal functions were similar in both the groups. Our findings would suggest that SRL is safe and effective for very selected OLT recipients. Randomized controlled trials are necessary to confirm our results.

Incidence of Delayed Graft Function and Wound Healing Complications After Deceased-Donor Kidney Transplantation Is not Affected by De Novo Everolimus

Concerns about delayed graft function (DGF) and wound healing complications with sirolimus has led to suggestions that everolimus introduction could be delayed after transplantation. In a prospective, multicenter, open-label study, deceased-donor kidney transplant recipients at protocol-specified risk of DGF (defined as > or =1 dialysis session during the first week posttransplant excluding day 1) were randomized to start everolimus therapy on day 1 posttransplant (immediate everolimus [IE]), or from week 5 (delayed everolimus [DE]) with mycophenolic acid until everolimus was initiated. All patients received anti-interleukin-2 receptor antibodies, cyclosporine A, and corticosteroids. A planned 3-month analysis from this 12-month study is presented here. One hundred and thirty-nine patients were randomized (IE 65, DE 74). The primary composite endpoint: biopsy-proven acute rejection, graft loss, death, DGF, wound healing events, or lost to follow-up at month 3, occurred in 36 IE patients (55.4%) and 47 DE patients (63.5%, P=0.387). The incidence of DGF was similar between groups (IE 24.6%, DE 24.3%; n.s.). Wound healing events of any type occurred in 40.0% and 41.9% of IE and DE patients (n.s.); events relating to initial transplant surgery occurred in 36.9% IE patients and 37.8% DE patients (n.s.), most of which were fluid collections. Study drug was discontinued due to adverse events or graft loss in 13 IE (20.0%) and 17 DE patients (23.0%). Findings from this randomized, multicenter trial indicate that kidney function recovery, wound healing, efficacy, and tolerance are similar at 3 months posttransplant with immediate or DE in patients at protocol-specified risk of DGF.

A structural investigation of corneal graft failure in suspected recurrent keratoconus

Penetrating keratoplasty was performed on the right eye of a 51-year-old patient diagnosed with advanced bilateral keratoconus. Thirteen years later, an 8.5 mm regraft was required as a result of gross vascularisation, a poor epithelium, and suspected recurrent keratoconus. To learn more about the structural basis for graft failure, we examined the removed tissue for the presence of abnormalities in the stroma and limiting membranes. X-ray scattering and electron microscopy were used to study the failed-graft tissue to provide information on the integrity of the limiting membranes and the diameter, dominant orientation, and distribution of collagen within the corneal stroma. The findings were compared with similar structural data from normal and keratoconus corneas. In contrast to the keratoconus cornea, a normal orientation and distribution of collagen was seen throughout most of the failed-graft tissue, although abnormalities were observed in the infero-nasal quadrant at the original graft/host junction. The average diameter of collagen fibrils in the failed-graft button did not differ from that of normal corneas. The structural abnormalities identified in this case of graft failure were not consistent with those typically seen in keratoconus. The clear demarcation of the graft/host boundary 13 years after surgery suggests that a normal stromal collagen arrangement may never be fully achieved in corneal graft wounds.

Kourokhitin, a potential drug containing two active substances

The currently used drugs usually contain one active substance. Note that it is difficult to use water-insoluble substances, which, even displaying useful pharmacological properties, as a rule, have comparatively low bioaccessibility. Consequently, a high concentration of such substances in the corresponding drugs is required; this is disadvantageous from both the economical standpoint and due to potential toxicity of some substances under these conditions. The aromatic alkaloid tryptanthrin (kouropitin), isolated from several plants, yeast-like fungi, and marine bacteria, displays a wide range of biomedical activities [1‐6]. It is an antiinflammatory agent specifically inhibiting the cyclooxygenase (COX-2) and 5-lipoxygenase (5-LOX) activities, decreases the macrophage production of the proinflammatory agents nitric oxide (NO) and prostaglandin E 2 [1], inhibits some pathogenic fungi, and displays antituberculous and antiprotozoal properties [2, 3]. In addition, tryptanthrin inhibits induction of the growth factors involved in malignant transformation of normal cells and tumor growth, invasion, and metastasizing [4]; causes an in vitro apoptosis of human leukemic cells [5]; and considerably reduces the rate of the azoxymethane-induced intestinal cancer in rats [6]. As this alkaloid is practically insoluble in water and biological fluids, it is necessary to increase its bioaccessibility. A combined use of this alkaloid produced by a single-stage synthesis [7] with another pharmacologically active agent, chitosan, can enhance its bioaccessibility and, moreover, widen the range of its useful pharmacological effects. Chitosan, produced from the natural polysaccharide chitin, displays an absorbing ability towards hydrophobic substances and provides for a prolongation of their effect [8]. It is also important that chitosan is nontoxic, compatible with the human body, and itself displays a wide range of activities, including those compatible with the main pharmacological effects of tryptanthrin [9]. Using these two substances, we have designed a gel form comprising chitosan nanoparticles coated with tryptanthrin; this preparation was named Kourokhitin and is intended for both external and oral administrations. A wider medicinal range of this composition as compared with its individual components as well as possible use of lower tryptanthrin doses was confirmed by the below briefed experiments. The wound-healing activity of Kourokhitin was assessed using the experimental model of thermal and graft wounds [10]. The experimental results are listed in Tables 1 and 2. The main wound healing activity of this preparation is observed in phase II of the wound process in both the burn and stratified graft wounds. After applications of the Kourokhitin gel, the scabs were considerably faster (as early as day 4) formed on animal wounds as compared with the animals treated with methyluracil ointment. Later, we also recorded accelerated epithelization of the wound surface and skin restoration induced by Kourokhitin. The anti-inflammatory properties of Kourokhitin were assessed in the model of nonspecific local inflammation induced with δ -carrageenan injection into the hind paw pad. As is evident from figure, Kourokhitin

Influence of polyester gauze on evaporation capacity and healing of the surface of microskin graft wound after escharectomy

To investigate the influence of polyester gauze on evaporation capacity and its clinical effect after escharectomy of deep burn wound and micro-skin grafting. Twenty patients with deep burn admitted within 24 hours after injury underwent escharectomy and Meek skin grafting. Two surfaces of wound with the area of about 1% as the whole wound surface were used, one covered by Meek skin graft and polyester gauze as inner dressing (polyester gauze group), and the other covered by split-thickness skin sheet 0.3 mm x 0.3 mm in size and vaseline oil gauze as inner dressing (vaseline oil gauze group). Five days after skin grafting, the evaporation capacities of the surface of inner dressing, wound surface without dressing (nude wound), and normal skin near the wound were tested by evaporation test equipment. The complete healing time and survival rate of skin sheet in both groups were observed. The degree of pain during dressing change was evaluated with visual analog scale. The evaporation capacity of the inner dressing surface of polyester gauze group was (24.8 +/- 5.2) ml x h(-1) x m(-2), significantly lower than those of the vaseline oil gauze group [(35.4 +/- 5.0) ml x h(-1) x m(-2), P < 0.01] and nude wound [(41.3 +/- 4.5) ml x h(-1) x m(-2), P < 0.01], and similar to that of the normal skin near the wound [(21.1 +/- 5.1) ml x h(-1) x m(-2), P > 0.05]. The evaporation capacity of the inner dressing surface of vaseline oil gauze group was significantly lower than nude wound [(40.7 +/- 3.6) ml x h(-1) x m(-2), P < 0.01], but significantly higher than the normal skin near the wound [(21.2 +/- 3.8) ml x h(-1) x m(-2), P < 0.01]. The survival rate of skin sheets of the polyester gauze group was 98% +/- 3%, not significantly different from that of the vaseline oil gauze group (98% +/- 2% , P > 0.05). The wound healing rates on days 10, 15, and 20 of the polyester gauze group were 80% +/- 20%, 96% +/- 7%, and 100% respectively, all significantly higher than those of the vaseline oil gauze group (70% +/- 33%, 81% +/- 21%, and 97% +/- 11% respectively, all P < 0.01). The complete healing time of the polyester gauze group was (13.6 +/- 1.9) days, significantly shorter than that of the vaseline oil gauze group [(16.7 +/- 2.6) days, P < 0.01]. The pain scores during dressing change 5 and 10 days after grafting of the polyester gauze group were (3.2 +/- 0.8) and (4.9 +/- 0.4) respectively, both significantly lower than those of the vaseline oil gauze group [(5.1 +/- 0.6) and (8.2 +/- 0.5) respectively, both P < 0.01]. Polyester gauze has quite good abilities to retain moisture and can promote the migration and proliferation of epithelial cells, relieves the pain caused by tearing of dressings off the wound, thus raising its acceptability. It is a relatively ideal carrier of skin grafting, as well as a new type of inner cover for the wound.

Avoiding Secondary Skin Graft Donor Site Morbidity in the Fibula Free Flap Harvest

To compare donor site morbidity in patients who have undergone fibula free flap reconstruction in which the skin graft was taken from the expected cutaneous paddle of the fibula with the known complications of the popular technique of obtaining a split-thickness skin graft (STSG) from a secondary donor site. Cohort study. The tertiary care centers at Loma Linda University Medical Center and University of California, Los Angeles, Medical Center. From September 1, 2006, to March 30, 2007, 30 patients underwent fibula free flap harvest by 2 surgeons at separate tertiary care centers. Twenty-one of those procedures took place at the University of California, Los Angeles, and 9 at Loma Linda University. Patients included 15 men (50%) and 15 women (50%), with a mean age of 58 (range, 19-88) years. All 30 patients underwent fibula free flap harvest with a split-thickness skin graft (graft thickness, 0.04 cm), obtained from osteocutaneous paddle using a 5.1-cm-wide dermatome, as well as oral cavity and oropharyngeal reconstruction with the de-epithelialized skin paddle. Measures of donor site morbidity, including graft failure and wound breakdown, and measures of recipient site morbidity, including flap failure, hardware complications, intraoral complications, and the need for additional surgery. Of the 30 patients who underwent this procedure, 4 had partial skin graft failures, for a complete skin graft survival of 87%. There were no complete skin graft losses. Regarding the fibula osteocutaneous free flap, there were no complete flap losses, 1 skin paddle necrosis that required debridement, 2 postoperative orocutaneous fistulas, 1 case of infected/extruded hardware, and 1 adhesion formation that required additional surgery for lysis of adhesion and placement of the split-thickness skin graft. The outlined novel technique has similar rates of free flap survival and skin graft take compared with previously described methods. Harvesting the skin graft over the expected osteocutaneous paddle results in decreased lower extremity morbidity by providing equivalent graft tissue for donor site closure and eliminating the morbidity of a secondary donor site. As long as there will not be 2 large opposing grafted surfaces, this technique should be considered when harvesting fibula free flaps for reconstruction of oromandibular resection defects, especially in cancers of the alveolar ridge and floor of the mouth.

Five Years' Experience of Transverse Groin Incision for Femoral Artery Access in Arterial Reconstructive Surgery: Parallel Observational Longitudinal Group Comparison Study

Vertical groin incisions (VGIs) have been used to access femoral vessels, but reports allude to wound complications. Our aim was to compare VGI with transverse groin incision (TGI) for femoral artery exposure. Over a 5-year interval, 196 patients with 284 femoral artery exposures for supra- and infrainguinal procedures were studied. Primary endpoints were surgical skin site wound infection, seroma, haematoma formation, and major lower limb amputation. Secondary endpoints were graft patency, wound paresthesias, and length of hospital stay. There were 160 TGIs and 124 VGIs. The demographics and risk factor profile were not statistically different between groups. Seroma developed in 4.4% of TGIs and 13.7% of VGIs (p= .005). The complicated skin and soft tissue infection rate was five times greater with VGI (p= .001). The VGI group had a significantly higher rate of major amputation (p= .0005). Significantly higher graft failure rates were observed in the VGI group (p= .011). No paresthesia was reported in any TGI wound. The mean hospital stay was also significantly shorter in the TGI group (p= .006). The study data support and expound on the theory that an alternative incision to VGI offers lower short- and long-term morbidity. Our findings sustain the selection of the TGI in femoral artery surgery for both supra- and infrainguinal procedures without compromise of vessel exposure.

A non-surgical device for faecal diversion in the management of perineal burns

Background Burns to the perineal, buttock and upper thigh areas are frequently exposed to continual faecal contamination which results in sepsis, graft loss, delayed wound healing and shrinkage of scars. A temporary diverting colostomy may be required. Two specifically designed intrarectal catheters were evaluated for their safety and ability to divert faeces away from the burn and allow wound healing. Methods A prospective study was conducted involving patients at the burns centre. Either the Zassi Bowel Management System or the Flexi-Seal Fecal Management System were used. These differed only in the presence of a specific intraluminal balloon in the Zassi system to facilitate retention of infused irrigates. Data regarding skin graft success, wound contamination and adverse events were collected. Results The study included eight participants, five of whom were treated successfully without colostomy. Four participants experienced complications, comprising one bowel occlusion, one anal ulceration and two reversible cases of anal atony. Conclusion A specifically designed intrarectal catheter can divert faeces to allow wound healing, and may avert colostomy. More studies are necessary to evaluate safety.

P-160 Management of post cardiac surgical patients with Type 2 diabetes using telecare

Diabetes mellitus is one of the major causes of coronary artery disease in Singapore. Apart from life-style modification and medical therapy, coronary artery bypass graft (CABG) is an alternative modality of treatment for patients with diabetes. Although tight glycemic controls are advocated to patients during their stay in hospital, post discharged glycemic control is often overlooked. Patients either do not monitor their glycemic control or if they do perform self-monitoring blood glucose (SMBG) they are unsure on how to correlate the results with their diabetes care routine. Studies have shown that the risk of sternal and saphenous vein graft wound infection are higher when glycemic control is not optimised peri operatively. This would not only lead to prolonged hospitalisation but also readmission for wound infection. In order to ensure the continuity of tight glycemic control for the post-cardiac surgical patients, four post CABG and 1 post heart transplanted discharged patients participated in the “Telecare” project for a duration of ranges from 8-12 months. Through this system, patients conveyed their SMBG results to nurse clinicians through the telecare application software (Sirius) via the web. The aim was to optimise their glycemic control by attaining premeal blood glucose reading of <8mmol and 2hrs post meal of <10 mmol. In addition to this, reduction of HbA1c 1-2% from their preoperative phase was used as an indicator of optimal diabetes control. Apart from tracking patient’s glycemic control post discharged, the nurse clinician would still be able to empower patients with on going diabetes self-management education in relation to the patients SMBG results. As this technology also allows the clinician to be alerted of grossly abnormal results, early intervention could be rendered before the outpatient follow-up, thus minimising hospital readmission for wound infection.

Delayed skin allograft rejection following matrix membrane pretreatment

No solution has been offered to induce long-term skin allograft survival in burn patients. We investigated whether transplant acceptance could be improved by a nonsystemic pretreatment of the graft and recipient wound surfaces with a bioengineered interface consisting of an acellular matrix membrane. Group 1 (n=30): Crosstransplants of untreated skin grafts between BALB/c and C57BL/6 mice. Group 2 (n=30): Crosstransplants of matrix-treated skin grafts between BALB/c and C57BL/6 mice. Group 3 (n=30): Retransplantation of skin grafts from the original donor on to the sensitised recipients. Sensitisation was accomplished by prior transplantation of an untreated skin allograft from the same donor (Group 1 mice). Two skin grafts were transplanted: one treated and one untreated. Rejection occurred in the untreated group after a mean of 6.8 days (+/-1.5 days). In contrast, treatment with the bioengineered matrix membrane was found to substantially prolong allograft survival with a mean of 28 days (+/-3.8 days). Graft survival between the two groups reached statistical significance (P<0.05). In the sensitised mice, the untreated skin regrafts were all rejected in an accelerated fashion with an onset of less than 4 days (mean+/-1 days). However, the matrix membrane-treated skin regrafts were maintained for a mean of 18 days (+/-3 days). These results show that treatment with the bioengineered matrix membrane greatly delays the onset of acute allograft rejection. The described topical application to the wound surfaces of both the graft and the recipient may offer a new and readily available source of wound coverage in patients with extensive burns.

Calcineurin inhibitor‐sparing regimens in solid organ transplantation: focus on improving renal function and nephrotoxicity

The calcineurin inhibitors (CNIs), cyclosporine and tacrolimus, have had a revolutionary effect on the overall success of renal transplantation through reduction in early immunologic injury and acute rejection rates. However, the CNIs have a significant adverse impact on renal function and cardiovascular disease, and extended long-term graft survival has not been achieved. The recognition of these effects sparked interest in CNI-sparing strategies. Strategies to limit CNI exposure include CNI minimization, avoidance, and withdrawal. We sought to review the impact of CNI-sparing strategies in kidney, liver, and heart transplantation. A PubMed search 1966 to August 2006 was conducted to identify relevant research articles, and the references of these articles as well as the authors' personal files were reviewed. Calcineurin inhibitor minimization using mycophenolate mofetil or sirolimus may be associated with a modest increase in creatinine clearance (CrCl) and a decrease in serum creatinine (SCr) in the short term. Despite improvement in CrCl or SCr, CNI nephrotoxicity and chronic allograft nephrotoxicity are progressive over time when CNI exposure is maintained. In kidney transplantation, the tubulo-interstitial and glomerular damage are irreversible. Mycophenolate mofetil may improve renal outcomes during CNI minimization more than sirolimus, and antibody induction may be effective to limit CNI exposure, but longer-term follow-up data are required. Use of sirolimus with mycophenolate mofetil or azathioprine to avoid CNI exposure de novo has improved glomerular filtration rate for at least two yr in most studies in kidney transplantation; however, experience is limited in liver and heart transplantation, and reports of delayed graft function and wound healing with sirolimus may have dampened enthusiasm for de novo use. Late CNI withdrawal has achieved variable results, possibly because withdrawal was attempted after the kidney damage was too extensive. Early CNI withdrawal, prior to significant graft damage, has generally improved CrCl and markers of fibrosis and decreased chronic allograft lesions, a finding also observed with sirolimus in most CNI avoidance studies. Successful withdrawal appears to be more effective than CNI minimization. Calcineurin inhibitors are associated with significant nephrotoxicity and chronic kidney damage. Minimization is associated with a modest increase in renal function, but persistent damage is observed on biopsies as long as the CNIs are continued. Avoidance is hampered by lack of experience and possible sirolimus-induced side effects. CNI withdrawal may be the best option by delivering CNIs during the early period of immunologic graft injury and then converting them to less nephrotoxic agents before significant renal damage occurs.