Copyright 2007 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2007
Inappropriate Antibiotic Use in Soft Tissue Infections
Hypothesis: Many soft tissue infections treated with surgical drainage resolve even when treated with antibiotics not active against the organism isolated from the infection.
Setting: Integrated Soft Tissue Infection Services clinic.
Patients: All patients treated from July 19, 2000, to August 1, 2001, who underwent surgical drainage of a soft tissue infection and had microbiological culture results.
Main Outcome Measures: Documented resolution of the infection with drainage of the abscess and antibiotic therapy alone was deemed a cure. An infection resulting in death or other surgical therapy was deemed a failure. Therapy was appropriate when the organism was sensitive to prescribed antibiotics and was inappropriate when the organism was insensitive.
Results: The study included 376 patients with 450 infections. Staphylococcus aureus as the primary organism was isolated from 441 of the cultures. Methicillin sodium–sensitive S aureus and methicillin-resistant S aureus were found in 157 and 284 of these isolates, respectively. Appropriate antibiotics were prescribed in 153 infections with methicillin-sensitive S aureus and in 25 with methicillin-resistant S aureus. Of 441 episodes, 408 were clinically evaluated for cure. Three patients failed treatment, 2 in the appropriately treated group (resulting in death and amputation) and 1 patient with osteomyelitis in the inappropriately treated group. The cure rate for infections treated appropriately or inappropriately was the same.
Conclusions: Treatment of soft tissue infections after surgical drainage, even with inappropriate antibiotics, has a high cure rate. Further studies to evaluate the efficacy of treating these infections without antibiotics are needed.
Paydar KZ, Hansen SL, Charlebois ED, Harris HW, Young DM
Mucosal Wound Healing: The Roles of Age and Sex
Hypothesis: It remains unclear whether aging delays wound healing, as past human studies have not adequately controlled for confounding factors such as morbidity and medications. Furthermore, although dermal wounds heal more quickly in women than in men, clinical observations suggest that the opposite may be true for mucosal healing. We assessed age and sex differences in mucosal wound healing, and we hypothesized that aging delays healing and sex modulates healing independent of age.
Design and Setting: Clinical experimental study performed from June 2000 to August 2003 involving younger and older adult volunteers from the general community.
Participants: Two hundred twelve male and female volunteers aged 18 to 35 years (n = 119) or 50 to 88 years (n = 93).
Intervention: Standardized 3.5-mm circular wounds were placed on the oral hard palates of volunteers.
Main Outcome Measure: Wound videographs were taken daily for 7 days after wounding to assess wound closure.
Results: Wounds healed significantly more slowly in older adults compared with younger adults (P<.001) regardless of sex. This remained true even when individuals receiving medication and/or having a coexisting medical condition were excluded. Mucosal wounds healed more slowly in women than in men (P = .008) regardless of age. These effects were independent of demographic factors such as ethnicity, alcohol or nicotine use, or body mass index.
Conclusions: Wound closure in older individuals was clearly delayed even when eliminating potential age-related confounds, indicating that aging does slow wound healing. Wound closure in women was also delayed, suggesting that wound healing is modulated by different mechanisms depending on tissue type. These findings may help target patients with increased surgical risks and greater need for postsurgical care.
Engeland CG, Bosch JA, Cacioppo JT, Marucha PT
Aesthetic and Functional Efficacy of Subcuticular Running Epidermal Closures of the Trunk and Extremity: A Rater-Blinded Randomized Control Trial
Objective: To ascertain whether subcuticular epidermal closures of elliptical excisions of the trunk and extremities result in better functional and cosmetic outcomes than simple running epidermal closures of the same sites.
Design: Randomized controlled trial, with allocation of epidermal closure of elliptical excisions to 4 arms, including 1 control arm (simple running polypropylene sutures removed after 14 days) and 3 experimental arms (subcuticular running polypropylene sutures removed after 14 days, subcuticular running polypropylene sutures left in place, and subcuticular running polyglactin 910 sutures left in place). All experimental interventions were preceded by deep dermal closure with simple interrupted polyglactin 910 sutures. Interventions were delivered by 3 surgeons, who underwent 2 training sessions to minimize intersurgeon technique variability.
Setting: Institutional referral practice providing ambulatory care in an urban environment.
Patients: A consecutive sample of 36 adult patients (ages 18-65 years), each referred for concurrent elliptical excision of at least 2 clinically atypical nevi of the trunk and/or extremity, were included in the study.
Main Outcome Measures: Primary outcome measures obtained at 3 and 9 months included scar width in millimeters and blinded observer ordinal scale assessment of overall scar appearance. Secondary outcome measures included ratings on the standardized Vancouver Scar Scale and the Hollander Scar Scale; an additional nonstandard item was added to assess pruritus.
Results: No difference among groups was found in scar width at 3 or 9 months. Differences among groups were detected in overall scar appearance (3 months, P<.001; 9 months, P<.001), vascularity (3 months, P = .001; 9 months, P<.001), excessive distortion (3 months, P = .04; 9 months, P = .02), contour irregularity (3 months, P<.001), and edge inversion (3 months, P = .01). The best overall appearance was with a subcuticular running polyglactin 910 suture left in place, and the next best was with a subcuticular running polypropylene suture left in place; differences across groups persisted but decreased in intensity at 9 months. A secondary analysis that matched high-tension anatomic sites (back and lower leg), and high and moderate tension sites (also chest and shoulder) yielded the same main effects and mostly the same results in pairwise comparisons.
Conclusion: While scar width does not appear to vary significantly based on choice of epidermal closure, bilayered closures of the trunk and extremity have better overall appearance and less associated erythema at 3 and 9 months after surgery with the use of a subcuticular running polyglactin 910 suture left in place.
Alam M, Posten W, Martini MC, Wrone DA, Rademaker AW
The Relationship Between Melanoma Thickness and Time to Diagnosis in a Large Population-Based Study
Objective: To examine the relationship between melanoma thickness and reported time from first recognition and from first physician contact to the diagnosis of invasive melanoma.
Design: Telephone survey of patients recently diagnosed as having melanoma, combined with relevant pathological data (including melanoma thickness and morphologic structure) from the population-based Queensland Cancer Registry. A test-retest study (n = 176) was also conducted.
Setting: Population-based study in Queensland.
Participants: Residents of Queensland (n = 3772) who had been diagnosed as having invasive melanoma between January 1, 2000, and December 31, 2003.
Main Outcome Measures: Prepresentation time (time between first noticing a suspicious spot and the first physician visit), postpresentation time (time between the first physician visit and diagnosis), and total time to diagnosis (time from initial detection of the melanoma to diagnosis).
Results: With 1 exception, we found no significant association between melanoma thickness and reported time to diagnosis for all melanomas combined, superficial spreading melanomas, or nodular melanomas. The exception was a positive association between melanoma thickness and postpresentation delay of physician-detected nodular melanomas. The reliability study gave intraclass correlation coefficients of 0.85 to 0.90 for the measures of intervals.
Conclusions: This large study demonstrates no clear relationship between the melanoma thickness when diagnosed and the time from first recognition of changes or from first physician examination to diagnosis. This may be because of varying biological characteristics of melanomas, as well as methodological limitations of retrospective studies when trying to measure this complex association.
Baade PD, English DR, Youl PH, McPherson M, Elwood JM, Aitken JF
Abstracts: In Other Archives Journals. Arch Facial Plast Surg. 2007;9(2):147-148. doi: