Wounds

Nanotechnology may help control the fungal infections that can lead to mortality in burn patients, early research suggests.

Nanoparticle encapsulated amphotericin b reduced fungal activity by 80%-95% compared with controls in a burn wound model. The findings were published online June 12 in Nanomedicine: Nanotechnology, Biology, and Medicine (doi:10.1016/j.nano.2013.06.002).

Courtesy Dr. Adam Friedman

"Infection and sepsis persist as frequent causes of morbidity and mortality for burn victims due to extensive compromise of the skin and contiguous tissue that serve as a protective barrier against microbial invasion," wrote David A. Sanchez and his colleagues at the Albert Einstein College of Medicine, New York.

Currently available antifungals such as amphotericin b (AmB) are associated with liver toxicity at high doses, but the researchers proposed that encapsulating the drug would allow for topical use.

In this study, nanoparticle encapsulated AmB (AmB-np) significantly reduced fungal biofilm activity in a burn tissue model compared with untreated control areas over an exposure period of 24 hours, and a significant reduction in fungal activity compared with controls remained evident after 15 days of treatment. Fungal activity was measured via CFU assay to test for Candida spp strains including C. albicans, C. glabrata, and C. parapsilosis.

The researchers also compared AmB-np to solubilized AmB (AmB-sol) and found similar antifungal efficacy. The data substantiate the hypothesis "that encapsulated AmB is actively being liberated from the nanoparticles," they noted.

The burn tissue was assessed at 7 and 11 days from baseline wounding. AmB-np and AmB-sol were similarly effective and were associated with "decreased peripheral wound erythema, tissue induration and edema, and necrotic crusting in comparison to infected controls," the researchers said. However, histology data showed "more advanced re-epithelialization, organized dermal proliferation and appropriate/expected dermal remodeling as compared to the AmB-sol and untreated infected control," they added.

Toxicity concerns remain a controversy associated with nanoparticle application, the researchers noted. However, AmB-np showed no significant difference compared with nontreated and solubilized groups in an animal model. "Moreover, our histological studies show enhanced tissue healing in the AmB-np animals compared to the other groups," the researchers noted.

The findings were limited by the differences between a murine model and human skin, and by the absence of blank nanoparticles as controls. But the results suggest that AmB-np has clinical potential as a topical antifungal because of its "uncompromised antimycotic action" against multiple fungal strains, and its successful delivery in an in vivo burn wound model, the researchers said.

Mr. Sanchez and his colleagues had no financial conflicts to disclose.

[email protected]

On Twitter: @hsplete

Nanotechnology may help control the fungal infections that can lead to mortality in burn patients, early research suggests.

Nanoparticle encapsulated amphotericin b reduced fungal activity by 80%-95% compared with controls in a burn wound model. The findings were published online June 12 in Nanomedicine: Nanotechnology, Biology, and Medicine (doi:10.1016/j.nano.2013.06.002).

Courtesy Dr. Adam Friedman

"Infection and sepsis persist as frequent causes of morbidity and mortality for burn victims due to extensive compromise of the skin and contiguous tissue that serve as a protective barrier against microbial invasion," wrote David A. Sanchez and his colleagues at the Albert Einstein College of Medicine, New York.

Currently available antifungals such as amphotericin b (AmB) are associated with liver toxicity at high doses, but the researchers proposed that encapsulating the drug would allow for topical use.

In this study, nanoparticle encapsulated AmB (AmB-np) significantly reduced fungal biofilm activity in a burn tissue model compared with untreated control areas over an exposure period of 24 hours, and a significant reduction in fungal activity compared with controls remained evident after 15 days of treatment. Fungal activity was measured via CFU assay to test for Candida spp strains including C. albicans, C. glabrata, and C. parapsilosis.

The researchers also compared AmB-np to solubilized AmB (AmB-sol) and found similar antifungal efficacy. The data substantiate the hypothesis "that encapsulated AmB is actively being liberated from the nanoparticles," they noted.

The burn tissue was assessed at 7 and 11 days from baseline wounding. AmB-np and AmB-sol were similarly effective and were associated with "decreased peripheral wound erythema, tissue induration and edema, and necrotic crusting in comparison to infected controls," the researchers said. However, histology data showed "more advanced re-epithelialization, organized dermal proliferation and appropriate/expected dermal remodeling as compared to the AmB-sol and untreated infected control," they added.

Toxicity concerns remain a controversy associated with nanoparticle application, the researchers noted. However, AmB-np showed no significant difference compared with nontreated and solubilized groups in an animal model. "Moreover, our histological studies show enhanced tissue healing in the AmB-np animals compared to the other groups," the researchers noted.

The findings were limited by the differences between a murine model and human skin, and by the absence of blank nanoparticles as controls. But the results suggest that AmB-np has clinical potential as a topical antifungal because of its "uncompromised antimycotic action" against multiple fungal strains, and its successful delivery in an in vivo burn wound model, the researchers said.

Mr. Sanchez and his colleagues had no financial conflicts to disclose.

[email protected]

On Twitter: @hsplete

Nanotechnology may help control the fungal infections that can lead to mortality in burn patients, early research suggests.

Nanoparticle encapsulated amphotericin b reduced fungal activity by 80%-95% compared with controls in a burn wound model. The findings were published online June 12 in Nanomedicine: Nanotechnology, Biology, and Medicine (doi:10.1016/j.nano.2013.06.002).

Courtesy Dr. Adam Friedman

"Infection and sepsis persist as frequent causes of morbidity and mortality for burn victims due to extensive compromise of the skin and contiguous tissue that serve as a protective barrier against microbial invasion," wrote David A. Sanchez and his colleagues at the Albert Einstein College of Medicine, New York.

Currently available antifungals such as amphotericin b (AmB) are associated with liver toxicity at high doses, but the researchers proposed that encapsulating the drug would allow for topical use.

In this study, nanoparticle encapsulated AmB (AmB-np) significantly reduced fungal biofilm activity in a burn tissue model compared with untreated control areas over an exposure period of 24 hours, and a significant reduction in fungal activity compared with controls remained evident after 15 days of treatment. Fungal activity was measured via CFU assay to test for Candida spp strains including C. albicans, C. glabrata, and C. parapsilosis.

The researchers also compared AmB-np to solubilized AmB (AmB-sol) and found similar antifungal efficacy. The data substantiate the hypothesis "that encapsulated AmB is actively being liberated from the nanoparticles," they noted.

The burn tissue was assessed at 7 and 11 days from baseline wounding. AmB-np and AmB-sol were similarly effective and were associated with "decreased peripheral wound erythema, tissue induration and edema, and necrotic crusting in comparison to infected controls," the researchers said. However, histology data showed "more advanced re-epithelialization, organized dermal proliferation and appropriate/expected dermal remodeling as compared to the AmB-sol and untreated infected control," they added.

Toxicity concerns remain a controversy associated with nanoparticle application, the researchers noted. However, AmB-np showed no significant difference compared with nontreated and solubilized groups in an animal model. "Moreover, our histological studies show enhanced tissue healing in the AmB-np animals compared to the other groups," the researchers noted.

The findings were limited by the differences between a murine model and human skin, and by the absence of blank nanoparticles as controls. But the results suggest that AmB-np has clinical potential as a topical antifungal because of its "uncompromised antimycotic action" against multiple fungal strains, and its successful delivery in an in vivo burn wound model, the researchers said.

Mr. Sanchez and his colleagues had no financial conflicts to disclose.

[email protected]

On Twitter: @hsplete

MIAMI BEACH – The extent of vascular disease, not the presence of diabetes or the cause of the ulceration, should drive the decision to intervene in a patient with a "diabetic foot," according to Dr. Joshua Beckman.

"When do I intervene on a diabetic foot? When I intervene on all feet: when there’s inadequate blood flow to heal the lesion," he said at the International Symposium on Endovascular Therapy 2013.

When lesions are detected in diabetic patients with PAD, assess for ankle pressures and determine ankle brachial index regardless of whether the lesion is neuropathic, he advised, explaining that, "even if you have a neuropathic initiation for your ulcer, if you have a low perfusion pressure, particularly under 50 mmHg, you’re not going to heal that lesion no matter how it was started."

"I always assess patients, whether I think the lesion is a neuropathic one or not, for the ankle pressures and do ankle brachial index and, assuming it’s low, I refer for revascularization based on the same criteria I would everybody else," said Dr. Beckman of Harvard Medical School, Boston.

That said, up to one-third of patients with diabetes have peripheral artery disease, and its presence is an independent predictor of adverse outcomes. "In fact, the combination of PAD and diabetes represents the group of people in the United States that has the most amputations, and their risk may be 20-fold that of people without both PAD and diabetes," he noted.

Indeed, the risk of amputation is much greater in diabetic patients, regardless of the care they receive, Dr. Beckman said, citing a study of 136 lower-extremity angiograms in patients with PAD. The odds ratios for amputation and death at 4.5 years’ follow-up were 5.4 for those with diabetes and 3.1 for those without diabetes (Diabetes Care 2001;24:1433-7).

Additionally, in a study of 1,244 men with claudication, the risk of ischemic ulceration was 4-fold higher in diabetic patients than in nondiabetic patients. Ankle brachial indices ranged from 0.9 to 0.1, and there was no point at which a diabetic patient was not worse off than a nondiabetic patient, he said. The risk in a diabetic patient with an ankle brachial index of 0.9 was equal to the risk in a nondiabetic patient with an ankle brachial index of 0.1 (J. Vasc. Surg. 2001;34:962-70).

Diabetic patients also can have a number of other initiators of diabetic foot ulceration, including neuropathy, bone deformity, callus, penetrating injury, and ill-fitting shoes. In combination, these factors can be especially problematic, he said.

Also, the extensor muscle abnormality that can result from motor neuropathy can change foot morphology, thereby increasing pressure on areas such as the ball of the foot, where ulcers are common.

Furthermore, a patient with neuropathy can walk around for a long time without recognizing a problem that an individual with normal nerve function wouldn’t tolerate. "A diabetic patient can have a bad shoe that rubs all day and not appreciate it," Dr. Beckman said.

With PAD, there are a "whole host of issues we never deal with in the nondiabetic patient that really accelerate the pathway toward ischemic ulceration and critical limb ischemia," he said. "Diabetes is a risk multiplier. It makes things worse, and it’s far more involved in the initiation [of ulceration] than in the decision whether to fix somebody."

Further underscoring the importance of such follow-up is a study of 533 diabetic patients hospitalized for critical limb ischemia. Nearly 50% of them developed critical limb ischemia in the contralateral limb at 6-year follow-up (Diabetes Res. Clin. Prac. 2007;77:445-50).

"So this is a group of people who need not only exquisite care, but exquisite surveillance, because it is very likely that, over time, they will come back to your office with the same problem in the other foot. I’m not recommending intervention or surgery in the asymptomatic foot, but I am suggesting you should probably never let them go, and have routine follow-ups where you look at their feet every time," he said.

Dr. Beckman reported having no disclosures relevant to his talk.

[email protected]

MIAMI BEACH – The extent of vascular disease, not the presence of diabetes or the cause of the ulceration, should drive the decision to intervene in a patient with a "diabetic foot," according to Dr. Joshua Beckman.

"When do I intervene on a diabetic foot? When I intervene on all feet: when there’s inadequate blood flow to heal the lesion," he said at the International Symposium on Endovascular Therapy 2013.

When lesions are detected in diabetic patients with PAD, assess for ankle pressures and determine ankle brachial index regardless of whether the lesion is neuropathic, he advised, explaining that, "even if you have a neuropathic initiation for your ulcer, if you have a low perfusion pressure, particularly under 50 mmHg, you’re not going to heal that lesion no matter how it was started."

"I always assess patients, whether I think the lesion is a neuropathic one or not, for the ankle pressures and do ankle brachial index and, assuming it’s low, I refer for revascularization based on the same criteria I would everybody else," said Dr. Beckman of Harvard Medical School, Boston.

That said, up to one-third of patients with diabetes have peripheral artery disease, and its presence is an independent predictor of adverse outcomes. "In fact, the combination of PAD and diabetes represents the group of people in the United States that has the most amputations, and their risk may be 20-fold that of people without both PAD and diabetes," he noted.

Indeed, the risk of amputation is much greater in diabetic patients, regardless of the care they receive, Dr. Beckman said, citing a study of 136 lower-extremity angiograms in patients with PAD. The odds ratios for amputation and death at 4.5 years’ follow-up were 5.4 for those with diabetes and 3.1 for those without diabetes (Diabetes Care 2001;24:1433-7).

Additionally, in a study of 1,244 men with claudication, the risk of ischemic ulceration was 4-fold higher in diabetic patients than in nondiabetic patients. Ankle brachial indices ranged from 0.9 to 0.1, and there was no point at which a diabetic patient was not worse off than a nondiabetic patient, he said. The risk in a diabetic patient with an ankle brachial index of 0.9 was equal to the risk in a nondiabetic patient with an ankle brachial index of 0.1 (J. Vasc. Surg. 2001;34:962-70).

Diabetic patients also can have a number of other initiators of diabetic foot ulceration, including neuropathy, bone deformity, callus, penetrating injury, and ill-fitting shoes. In combination, these factors can be especially problematic, he said.

Also, the extensor muscle abnormality that can result from motor neuropathy can change foot morphology, thereby increasing pressure on areas such as the ball of the foot, where ulcers are common.

Furthermore, a patient with neuropathy can walk around for a long time without recognizing a problem that an individual with normal nerve function wouldn’t tolerate. "A diabetic patient can have a bad shoe that rubs all day and not appreciate it," Dr. Beckman said.

With PAD, there are a "whole host of issues we never deal with in the nondiabetic patient that really accelerate the pathway toward ischemic ulceration and critical limb ischemia," he said. "Diabetes is a risk multiplier. It makes things worse, and it’s far more involved in the initiation [of ulceration] than in the decision whether to fix somebody."

Further underscoring the importance of such follow-up is a study of 533 diabetic patients hospitalized for critical limb ischemia. Nearly 50% of them developed critical limb ischemia in the contralateral limb at 6-year follow-up (Diabetes Res. Clin. Prac. 2007;77:445-50).

"So this is a group of people who need not only exquisite care, but exquisite surveillance, because it is very likely that, over time, they will come back to your office with the same problem in the other foot. I’m not recommending intervention or surgery in the asymptomatic foot, but I am suggesting you should probably never let them go, and have routine follow-ups where you look at their feet every time," he said.

Dr. Beckman reported having no disclosures relevant to his talk.

[email protected]

MIAMI BEACH – The extent of vascular disease, not the presence of diabetes or the cause of the ulceration, should drive the decision to intervene in a patient with a "diabetic foot," according to Dr. Joshua Beckman.

"When do I intervene on a diabetic foot? When I intervene on all feet: when there’s inadequate blood flow to heal the lesion," he said at the International Symposium on Endovascular Therapy 2013.

When lesions are detected in diabetic patients with PAD, assess for ankle pressures and determine ankle brachial index regardless of whether the lesion is neuropathic, he advised, explaining that, "even if you have a neuropathic initiation for your ulcer, if you have a low perfusion pressure, particularly under 50 mmHg, you’re not going to heal that lesion no matter how it was started."

"I always assess patients, whether I think the lesion is a neuropathic one or not, for the ankle pressures and do ankle brachial index and, assuming it’s low, I refer for revascularization based on the same criteria I would everybody else," said Dr. Beckman of Harvard Medical School, Boston.

That said, up to one-third of patients with diabetes have peripheral artery disease, and its presence is an independent predictor of adverse outcomes. "In fact, the combination of PAD and diabetes represents the group of people in the United States that has the most amputations, and their risk may be 20-fold that of people without both PAD and diabetes," he noted.

Indeed, the risk of amputation is much greater in diabetic patients, regardless of the care they receive, Dr. Beckman said, citing a study of 136 lower-extremity angiograms in patients with PAD. The odds ratios for amputation and death at 4.5 years’ follow-up were 5.4 for those with diabetes and 3.1 for those without diabetes (Diabetes Care 2001;24:1433-7).

Additionally, in a study of 1,244 men with claudication, the risk of ischemic ulceration was 4-fold higher in diabetic patients than in nondiabetic patients. Ankle brachial indices ranged from 0.9 to 0.1, and there was no point at which a diabetic patient was not worse off than a nondiabetic patient, he said. The risk in a diabetic patient with an ankle brachial index of 0.9 was equal to the risk in a nondiabetic patient with an ankle brachial index of 0.1 (J. Vasc. Surg. 2001;34:962-70).

Diabetic patients also can have a number of other initiators of diabetic foot ulceration, including neuropathy, bone deformity, callus, penetrating injury, and ill-fitting shoes. In combination, these factors can be especially problematic, he said.

Also, the extensor muscle abnormality that can result from motor neuropathy can change foot morphology, thereby increasing pressure on areas such as the ball of the foot, where ulcers are common.

Furthermore, a patient with neuropathy can walk around for a long time without recognizing a problem that an individual with normal nerve function wouldn’t tolerate. "A diabetic patient can have a bad shoe that rubs all day and not appreciate it," Dr. Beckman said.

With PAD, there are a "whole host of issues we never deal with in the nondiabetic patient that really accelerate the pathway toward ischemic ulceration and critical limb ischemia," he said. "Diabetes is a risk multiplier. It makes things worse, and it’s far more involved in the initiation [of ulceration] than in the decision whether to fix somebody."

Further underscoring the importance of such follow-up is a study of 533 diabetic patients hospitalized for critical limb ischemia. Nearly 50% of them developed critical limb ischemia in the contralateral limb at 6-year follow-up (Diabetes Res. Clin. Prac. 2007;77:445-50).

"So this is a group of people who need not only exquisite care, but exquisite surveillance, because it is very likely that, over time, they will come back to your office with the same problem in the other foot. I’m not recommending intervention or surgery in the asymptomatic foot, but I am suggesting you should probably never let them go, and have routine follow-ups where you look at their feet every time," he said.

Dr. Beckman reported having no disclosures relevant to his talk.

[email protected]

SCOTTSDALE, ARIZ. – Despite thromboprophylaxis, burn patients become hypercoagulable during recovery, putting them at increased risk of venous thromboembolism, a small, prospective study has shown.

"The hypercoagulable state is likely multifactorial, and we believe that additional prophylaxis and monitoring may be needed," Dr. Robert Van Haren said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Patrice Wendling/IMNG Medical Media

Hypercoagulability has long been known to contribute to venous thromboembolism (VTE), but it’s only more recently that the increased incidence of thromboembolic complications in burn patients has been appreciated.

A study using duplex ultrasound screening reported that 23% of burn patients developed deep venous thrombosis at an average of 6.7 days after admission (J. Burn Care Rehabil. 2002;23:439-43).

More recent work reports that such in-hospital risk factors as number of operations, pneumonia, and central venous access are significantly associated with VTE after thermal injury (J. Burn Care Res. 2012;33:84-8).

Dr. Van Haren and his colleagues at the University of Miami used thromboelastography (TEG) and coagulation tests to analyze blood samples drawn from indwelling catheters upon admission and at 1 week in 24 patients. All patients were placed on unfractionated or low-molecular-weight heparin at admission.

Their median age was 49 years, 88% were male, and the median total body surface area burned was 29%. Inhalation injuries also were present in 17%.

TEG values were within normal limits at admission for clotting time (R = 11.5 minutes), initial clot formation (K = 2.8 minutes), clot kinetics (alpha angle = 54.6 degrees), and clot strength (maximum amplitude = 62.5 mm).

Repeat TEG at 1 week in 16 patients who remained hospitalized revealed significantly decreased R (8.3 minutes) and K (2.0 minutes) times, and elevated alpha angle (65.5 degrees) and maximum amplitude (73.1 mm; all statistically significant, P less than .05).

"All of these changes demonstrate that these patients became more hypercoagulable at week 1," said Dr. Van Haren, a 4th-year general surgery resident.

Coagulation tests were generally supportive of TEG findings. From admission to week 1, significant decreases were observed in median prothrombin time (17.4 seconds vs. 15.7 seconds; P = .013) and international normalized ratio (1.47 vs. 1.28; P = .013). At the same time, significant elevations occurred in protein C activity (75% vs. 93%; P = .017), protein S activity (69% vs. 76%; P = .030), antithrombin III (62% vs. 88%; P = .005), and fibrinogen (524 mg/dL vs. 676 mg/dL; P = .047).

The changes suggest a procoagulant state, and cannot be attributed to hemoconcentration, as fluid balance was more positive and hematocrit was lower on repeat samples, Dr. Van Haren reported.

The only in-hospital risk factor significant for hypercoagulability at 1 week was a pre-TEG operation, he said. Men, however, were more likely to be hypercoagulable than women.

Two patients, both male, developed a deep venous thrombosis. Contrary to previous studies, the only predictive markers of VTE were decreased partial thromboplastin time and fibrinogen and elevated prothrombin fragment 1 + 2.

During the discussion period after Dr. Van Haren’s presentation, audience members asked why hypercoagulability was evaluated at 1 week, since hypercoagulability has been shown to develop quite rapidly in trauma patients. Other questions addressed whether clinicians should use the data to increase thromboprophylaxis or begin dosing based on body mass index in burn patients.

Dr. Van Haren said the 1-week time point was somewhat arbitrary, and plans to look at earlier time periods in another cohort to determine exactly when the transition to hypercoagulability occurs. "I think the most interesting thing would be to see if you can guide your thromboprophylaxis based on TEG, and use it to titrate your dose to see if it will result in decreases in VTE rates."

The study was funded in part by grants from the Office of Naval Research and U.S. Army. Dr. Van Haren and his coauthors reported no relevant financial conflicts.

[email protected]

SCOTTSDALE, ARIZ. – Despite thromboprophylaxis, burn patients become hypercoagulable during recovery, putting them at increased risk of venous thromboembolism, a small, prospective study has shown.

"The hypercoagulable state is likely multifactorial, and we believe that additional prophylaxis and monitoring may be needed," Dr. Robert Van Haren said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Patrice Wendling/IMNG Medical Media

Hypercoagulability has long been known to contribute to venous thromboembolism (VTE), but it’s only more recently that the increased incidence of thromboembolic complications in burn patients has been appreciated.

A study using duplex ultrasound screening reported that 23% of burn patients developed deep venous thrombosis at an average of 6.7 days after admission (J. Burn Care Rehabil. 2002;23:439-43).

More recent work reports that such in-hospital risk factors as number of operations, pneumonia, and central venous access are significantly associated with VTE after thermal injury (J. Burn Care Res. 2012;33:84-8).

Dr. Van Haren and his colleagues at the University of Miami used thromboelastography (TEG) and coagulation tests to analyze blood samples drawn from indwelling catheters upon admission and at 1 week in 24 patients. All patients were placed on unfractionated or low-molecular-weight heparin at admission.

Their median age was 49 years, 88% were male, and the median total body surface area burned was 29%. Inhalation injuries also were present in 17%.

TEG values were within normal limits at admission for clotting time (R = 11.5 minutes), initial clot formation (K = 2.8 minutes), clot kinetics (alpha angle = 54.6 degrees), and clot strength (maximum amplitude = 62.5 mm).

Repeat TEG at 1 week in 16 patients who remained hospitalized revealed significantly decreased R (8.3 minutes) and K (2.0 minutes) times, and elevated alpha angle (65.5 degrees) and maximum amplitude (73.1 mm; all statistically significant, P less than .05).

"All of these changes demonstrate that these patients became more hypercoagulable at week 1," said Dr. Van Haren, a 4th-year general surgery resident.

Coagulation tests were generally supportive of TEG findings. From admission to week 1, significant decreases were observed in median prothrombin time (17.4 seconds vs. 15.7 seconds; P = .013) and international normalized ratio (1.47 vs. 1.28; P = .013). At the same time, significant elevations occurred in protein C activity (75% vs. 93%; P = .017), protein S activity (69% vs. 76%; P = .030), antithrombin III (62% vs. 88%; P = .005), and fibrinogen (524 mg/dL vs. 676 mg/dL; P = .047).

The changes suggest a procoagulant state, and cannot be attributed to hemoconcentration, as fluid balance was more positive and hematocrit was lower on repeat samples, Dr. Van Haren reported.

The only in-hospital risk factor significant for hypercoagulability at 1 week was a pre-TEG operation, he said. Men, however, were more likely to be hypercoagulable than women.

Two patients, both male, developed a deep venous thrombosis. Contrary to previous studies, the only predictive markers of VTE were decreased partial thromboplastin time and fibrinogen and elevated prothrombin fragment 1 + 2.

During the discussion period after Dr. Van Haren’s presentation, audience members asked why hypercoagulability was evaluated at 1 week, since hypercoagulability has been shown to develop quite rapidly in trauma patients. Other questions addressed whether clinicians should use the data to increase thromboprophylaxis or begin dosing based on body mass index in burn patients.

Dr. Van Haren said the 1-week time point was somewhat arbitrary, and plans to look at earlier time periods in another cohort to determine exactly when the transition to hypercoagulability occurs. "I think the most interesting thing would be to see if you can guide your thromboprophylaxis based on TEG, and use it to titrate your dose to see if it will result in decreases in VTE rates."

The study was funded in part by grants from the Office of Naval Research and U.S. Army. Dr. Van Haren and his coauthors reported no relevant financial conflicts.

[email protected]

SCOTTSDALE, ARIZ. – Despite thromboprophylaxis, burn patients become hypercoagulable during recovery, putting them at increased risk of venous thromboembolism, a small, prospective study has shown.

"The hypercoagulable state is likely multifactorial, and we believe that additional prophylaxis and monitoring may be needed," Dr. Robert Van Haren said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

Patrice Wendling/IMNG Medical Media

Hypercoagulability has long been known to contribute to venous thromboembolism (VTE), but it’s only more recently that the increased incidence of thromboembolic complications in burn patients has been appreciated.

A study using duplex ultrasound screening reported that 23% of burn patients developed deep venous thrombosis at an average of 6.7 days after admission (J. Burn Care Rehabil. 2002;23:439-43).

More recent work reports that such in-hospital risk factors as number of operations, pneumonia, and central venous access are significantly associated with VTE after thermal injury (J. Burn Care Res. 2012;33:84-8).

Dr. Van Haren and his colleagues at the University of Miami used thromboelastography (TEG) and coagulation tests to analyze blood samples drawn from indwelling catheters upon admission and at 1 week in 24 patients. All patients were placed on unfractionated or low-molecular-weight heparin at admission.

Their median age was 49 years, 88% were male, and the median total body surface area burned was 29%. Inhalation injuries also were present in 17%.

TEG values were within normal limits at admission for clotting time (R = 11.5 minutes), initial clot formation (K = 2.8 minutes), clot kinetics (alpha angle = 54.6 degrees), and clot strength (maximum amplitude = 62.5 mm).

Repeat TEG at 1 week in 16 patients who remained hospitalized revealed significantly decreased R (8.3 minutes) and K (2.0 minutes) times, and elevated alpha angle (65.5 degrees) and maximum amplitude (73.1 mm; all statistically significant, P less than .05).

"All of these changes demonstrate that these patients became more hypercoagulable at week 1," said Dr. Van Haren, a 4th-year general surgery resident.

Coagulation tests were generally supportive of TEG findings. From admission to week 1, significant decreases were observed in median prothrombin time (17.4 seconds vs. 15.7 seconds; P = .013) and international normalized ratio (1.47 vs. 1.28; P = .013). At the same time, significant elevations occurred in protein C activity (75% vs. 93%; P = .017), protein S activity (69% vs. 76%; P = .030), antithrombin III (62% vs. 88%; P = .005), and fibrinogen (524 mg/dL vs. 676 mg/dL; P = .047).

The changes suggest a procoagulant state, and cannot be attributed to hemoconcentration, as fluid balance was more positive and hematocrit was lower on repeat samples, Dr. Van Haren reported.

The only in-hospital risk factor significant for hypercoagulability at 1 week was a pre-TEG operation, he said. Men, however, were more likely to be hypercoagulable than women.

Two patients, both male, developed a deep venous thrombosis. Contrary to previous studies, the only predictive markers of VTE were decreased partial thromboplastin time and fibrinogen and elevated prothrombin fragment 1 + 2.

During the discussion period after Dr. Van Haren’s presentation, audience members asked why hypercoagulability was evaluated at 1 week, since hypercoagulability has been shown to develop quite rapidly in trauma patients. Other questions addressed whether clinicians should use the data to increase thromboprophylaxis or begin dosing based on body mass index in burn patients.

Dr. Van Haren said the 1-week time point was somewhat arbitrary, and plans to look at earlier time periods in another cohort to determine exactly when the transition to hypercoagulability occurs. "I think the most interesting thing would be to see if you can guide your thromboprophylaxis based on TEG, and use it to titrate your dose to see if it will result in decreases in VTE rates."

The study was funded in part by grants from the Office of Naval Research and U.S. Army. Dr. Van Haren and his coauthors reported no relevant financial conflicts.

[email protected]

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

[email protected]

*This story was updated March 1, 2013.

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

[email protected]

*This story was updated March 1, 2013.

Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.

The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

A sample checklist that he shared included the following items:

• Referring physician.

• Who did the biopsy?

• Sign consent.

• Circle surgery site with patient verification.

• Verify and record pacemaker/defibrillator or other electronic implants.

• Review allergies to any anesthesia/antibiotics/latex/bandages.

• Check and record anticoagulants.

• Prophylactic antibiotics needed? If so, why?

• Record blood pressure and pulse – notify provider if elevated or too low.

• Check for special health concerns such as diabetes, etc.

• Buffered and unbuffered anesthesia on the field.

• Mapping card.

• Verify pathology report.

• Photo.

• Miscellaneous patient concerns.

Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.

Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.

This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.

Dr. Ceilley covered several other topics:

• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.

The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.

• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.

He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.

• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.

• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.

• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.

• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.

"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.

Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.

• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.

"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.

Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.

[email protected]

*This story was updated March 1, 2013.

Wide variation exists in the local treatment of donor site wounds after split-skin grafting, ranging from classic gauze dressings to modern silicone dressings.

In a multicenter randomized trial of 289 patients, hydrocolloid dressings led to a shorter healing time than other commonly used dressing materials for donor site wounds (DSWs) after split-skin grafting. Standard gauze dressings were found to increase the risk of infection, Dr. Fleur E. Brölmann said in presenting the study results at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

A 14-center, six-armed, randomized clinical trial (stratified per center) compared six wound dressing materials in adults with DSWs larger than 10 cm² for any indication. Primary outcomes were complete re-epithelialization and pain using a visual analog scale (VAS; 4 weeks). Secondary outcomes included itching (VAS; 4 weeks), adverse events, and scarring after 12 weeks as measured using the Patient and Observer Scar Assessment Scale (POSAS), said Dr. Brölmann, who is a Ph.D. candidate at the Academic Medical Center in Amsterdam.

Between October 2009 and December 2011, patients were randomized to either alginate (45 patients), film (49), gauze (50), hydrocolloid (47), hydrofiber (47), or silicone (48).

Time to complete re-epithelialization using hydrocolloid dressings (median 16 days) was 7 days shorter than with any other dressing, a significant difference, she said in her presentation titled "How To Treat Donor Site Wounds: An Evidence Based Approach."

Overall pain scores were low and slightly but significantly lower using film dressings. The infection rate among patients treated with gauzes was twice as high as in those receiving other dressings (18% vs. 9%; relative risk, 2.39; 95% confidence interval, 1.14-5.01). Patients receiving films were least satisfied with overall scar quality.

"This trial shows that hydrocolloid dressings led to the shortest healing time of DSWs among the dressings investigated, while gauzes should be avoided due to increased risk of infection," Dr. Brölmann said. Based on these results, hydrocolloid is the first-choice dressing for DSWs, and should be the standard of care, she added.

Wide variation exists in the local treatment of donor site wounds after split-skin grafting, ranging from classic gauze dressings to modern silicone dressings.

In a multicenter randomized trial of 289 patients, hydrocolloid dressings led to a shorter healing time than other commonly used dressing materials for donor site wounds (DSWs) after split-skin grafting. Standard gauze dressings were found to increase the risk of infection, Dr. Fleur E. Brölmann said in presenting the study results at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

A 14-center, six-armed, randomized clinical trial (stratified per center) compared six wound dressing materials in adults with DSWs larger than 10 cm² for any indication. Primary outcomes were complete re-epithelialization and pain using a visual analog scale (VAS; 4 weeks). Secondary outcomes included itching (VAS; 4 weeks), adverse events, and scarring after 12 weeks as measured using the Patient and Observer Scar Assessment Scale (POSAS), said Dr. Brölmann, who is a Ph.D. candidate at the Academic Medical Center in Amsterdam.

Between October 2009 and December 2011, patients were randomized to either alginate (45 patients), film (49), gauze (50), hydrocolloid (47), hydrofiber (47), or silicone (48).

Time to complete re-epithelialization using hydrocolloid dressings (median 16 days) was 7 days shorter than with any other dressing, a significant difference, she said in her presentation titled "How To Treat Donor Site Wounds: An Evidence Based Approach."

Overall pain scores were low and slightly but significantly lower using film dressings. The infection rate among patients treated with gauzes was twice as high as in those receiving other dressings (18% vs. 9%; relative risk, 2.39; 95% confidence interval, 1.14-5.01). Patients receiving films were least satisfied with overall scar quality.

"This trial shows that hydrocolloid dressings led to the shortest healing time of DSWs among the dressings investigated, while gauzes should be avoided due to increased risk of infection," Dr. Brölmann said. Based on these results, hydrocolloid is the first-choice dressing for DSWs, and should be the standard of care, she added.

Wide variation exists in the local treatment of donor site wounds after split-skin grafting, ranging from classic gauze dressings to modern silicone dressings.

In a multicenter randomized trial of 289 patients, hydrocolloid dressings led to a shorter healing time than other commonly used dressing materials for donor site wounds (DSWs) after split-skin grafting. Standard gauze dressings were found to increase the risk of infection, Dr. Fleur E. Brölmann said in presenting the study results at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

A 14-center, six-armed, randomized clinical trial (stratified per center) compared six wound dressing materials in adults with DSWs larger than 10 cm² for any indication. Primary outcomes were complete re-epithelialization and pain using a visual analog scale (VAS; 4 weeks). Secondary outcomes included itching (VAS; 4 weeks), adverse events, and scarring after 12 weeks as measured using the Patient and Observer Scar Assessment Scale (POSAS), said Dr. Brölmann, who is a Ph.D. candidate at the Academic Medical Center in Amsterdam.

Between October 2009 and December 2011, patients were randomized to either alginate (45 patients), film (49), gauze (50), hydrocolloid (47), hydrofiber (47), or silicone (48).

Time to complete re-epithelialization using hydrocolloid dressings (median 16 days) was 7 days shorter than with any other dressing, a significant difference, she said in her presentation titled "How To Treat Donor Site Wounds: An Evidence Based Approach."

Overall pain scores were low and slightly but significantly lower using film dressings. The infection rate among patients treated with gauzes was twice as high as in those receiving other dressings (18% vs. 9%; relative risk, 2.39; 95% confidence interval, 1.14-5.01). Patients receiving films were least satisfied with overall scar quality.

"This trial shows that hydrocolloid dressings led to the shortest healing time of DSWs among the dressings investigated, while gauzes should be avoided due to increased risk of infection," Dr. Brölmann said. Based on these results, hydrocolloid is the first-choice dressing for DSWs, and should be the standard of care, she added.

PRAGUE – Maggot debridement of wounds proved significantly faster, less painful, and less labor intensive than surgical debridement and conventional dressings in a randomized, multicenter clinical trial.

"There was quite an amazing debridement after 7 days of maggot therapy," Dr. Kristina Opletalova said of the phase III study findings presented at the annual congress of the European Academy of Dermatology and Venereology.

Courtesy National Institutes of Health

She reported on 119 patients hospitalized for 2 weeks for treatment of nonhealing sloughy wounds, most of which were venous ulcers on the lower limbs. Participants were randomized to maggot therapy or to thrice-weekly surgical debridement with topical anesthesia and conventional dressings.

The maggot therapy was administered via a novel delivery system: 80 maggots of Lucilia sericata were bagged in a special two-layer dressing, known as a Vitapad (BioMonde Laboratories), which allowed the critters to move and feed on the wound surface and kept them from escaping. The dressing was changed twice weekly.

Patients were blindfolded for all dressing changes so they didn’t know which study arm they were in. Wound sloughing was analyzed using computerized planimetry software, and other end points were assessed by an investigator blinded to treatment arm.

After 7 days of therapy, the wound status was significantly better in the maggot debridement group. The mean percentage of slough in wounds was 54.5%, compared with 66.5% in controls, but the significantly faster debridement didn’t boost the final healing rate. The day 15 percentage of slough in the wounds didn’t differ significantly between the two groups: 55.4% with maggot therapy and 53.8% in controls.

"So we think maggot debridement therapy should be stopped after 1 week and other types of dressings should then be used," said Dr. Opletalova, a dermatologist at the University of Caen (France).

Pain scores, which were assessed on a weekly basis, were similarly low in the two groups, but it must be noted that the control group received topical anesthetic and the maggot therapy group did not. Nursing time was four-fold greater in the control group. The study didn’t include a formal cost analysis, but the markedly reduced nursing time in the maggot therapy group is likely to spell cost savings, she said.

Maggot therapy was well tolerated. Patients expressed no reticence about it. A similar number of patients in both study arms reported a crawling sensation on their wounds.

Dr. Opletalova said that maggot therapy is likely to be particularly useful in patients with wounds that need rapid debridement, such as those with diabetes, or to prepare a wound for skin grafting or when there is an increased risk for infection.

Further details of the recently published randomized trial can be found in the Archives of Dermatology (2012;148:432-8).

The study was supported by university hospital research funding and by a grant from the French Society of Dermatology. Dr. Opletalova reported having no financial conflicts.

PRAGUE – Maggot debridement of wounds proved significantly faster, less painful, and less labor intensive than surgical debridement and conventional dressings in a randomized, multicenter clinical trial.

"There was quite an amazing debridement after 7 days of maggot therapy," Dr. Kristina Opletalova said of the phase III study findings presented at the annual congress of the European Academy of Dermatology and Venereology.

Courtesy National Institutes of Health

She reported on 119 patients hospitalized for 2 weeks for treatment of nonhealing sloughy wounds, most of which were venous ulcers on the lower limbs. Participants were randomized to maggot therapy or to thrice-weekly surgical debridement with topical anesthesia and conventional dressings.

The maggot therapy was administered via a novel delivery system: 80 maggots of Lucilia sericata were bagged in a special two-layer dressing, known as a Vitapad (BioMonde Laboratories), which allowed the critters to move and feed on the wound surface and kept them from escaping. The dressing was changed twice weekly.

Patients were blindfolded for all dressing changes so they didn’t know which study arm they were in. Wound sloughing was analyzed using computerized planimetry software, and other end points were assessed by an investigator blinded to treatment arm.

After 7 days of therapy, the wound status was significantly better in the maggot debridement group. The mean percentage of slough in wounds was 54.5%, compared with 66.5% in controls, but the significantly faster debridement didn’t boost the final healing rate. The day 15 percentage of slough in the wounds didn’t differ significantly between the two groups: 55.4% with maggot therapy and 53.8% in controls.

"So we think maggot debridement therapy should be stopped after 1 week and other types of dressings should then be used," said Dr. Opletalova, a dermatologist at the University of Caen (France).

Pain scores, which were assessed on a weekly basis, were similarly low in the two groups, but it must be noted that the control group received topical anesthetic and the maggot therapy group did not. Nursing time was four-fold greater in the control group. The study didn’t include a formal cost analysis, but the markedly reduced nursing time in the maggot therapy group is likely to spell cost savings, she said.

Maggot therapy was well tolerated. Patients expressed no reticence about it. A similar number of patients in both study arms reported a crawling sensation on their wounds.

Dr. Opletalova said that maggot therapy is likely to be particularly useful in patients with wounds that need rapid debridement, such as those with diabetes, or to prepare a wound for skin grafting or when there is an increased risk for infection.

Further details of the recently published randomized trial can be found in the Archives of Dermatology (2012;148:432-8).

The study was supported by university hospital research funding and by a grant from the French Society of Dermatology. Dr. Opletalova reported having no financial conflicts.

PRAGUE – Maggot debridement of wounds proved significantly faster, less painful, and less labor intensive than surgical debridement and conventional dressings in a randomized, multicenter clinical trial.

"There was quite an amazing debridement after 7 days of maggot therapy," Dr. Kristina Opletalova said of the phase III study findings presented at the annual congress of the European Academy of Dermatology and Venereology.

Courtesy National Institutes of Health

She reported on 119 patients hospitalized for 2 weeks for treatment of nonhealing sloughy wounds, most of which were venous ulcers on the lower limbs. Participants were randomized to maggot therapy or to thrice-weekly surgical debridement with topical anesthesia and conventional dressings.

The maggot therapy was administered via a novel delivery system: 80 maggots of Lucilia sericata were bagged in a special two-layer dressing, known as a Vitapad (BioMonde Laboratories), which allowed the critters to move and feed on the wound surface and kept them from escaping. The dressing was changed twice weekly.

Patients were blindfolded for all dressing changes so they didn’t know which study arm they were in. Wound sloughing was analyzed using computerized planimetry software, and other end points were assessed by an investigator blinded to treatment arm.

After 7 days of therapy, the wound status was significantly better in the maggot debridement group. The mean percentage of slough in wounds was 54.5%, compared with 66.5% in controls, but the significantly faster debridement didn’t boost the final healing rate. The day 15 percentage of slough in the wounds didn’t differ significantly between the two groups: 55.4% with maggot therapy and 53.8% in controls.

"So we think maggot debridement therapy should be stopped after 1 week and other types of dressings should then be used," said Dr. Opletalova, a dermatologist at the University of Caen (France).

Pain scores, which were assessed on a weekly basis, were similarly low in the two groups, but it must be noted that the control group received topical anesthetic and the maggot therapy group did not. Nursing time was four-fold greater in the control group. The study didn’t include a formal cost analysis, but the markedly reduced nursing time in the maggot therapy group is likely to spell cost savings, she said.

Maggot therapy was well tolerated. Patients expressed no reticence about it. A similar number of patients in both study arms reported a crawling sensation on their wounds.

Dr. Opletalova said that maggot therapy is likely to be particularly useful in patients with wounds that need rapid debridement, such as those with diabetes, or to prepare a wound for skin grafting or when there is an increased risk for infection.

Further details of the recently published randomized trial can be found in the Archives of Dermatology (2012;148:432-8).

The study was supported by university hospital research funding and by a grant from the French Society of Dermatology. Dr. Opletalova reported having no financial conflicts.