Cooling of a Zero-Nuclear-Spin Molecular Ion to a Selected Rotational State.

We demonstrate rotational cooling of the silicon monoxide cation via optical pumping by a spectrally filtered broadband laser. Compared with diatomic hydrides, SiO^{+} is more challenging to cool because of its smaller rotational interval. However, the rotational level spacing and the large dipole moment of SiO^{+} allows for direct manipulation by microwaves, and the absence of hyperfine structure in its dominant isotopologue greatly reduces demands for pure quantum state preparation. These features make ^{28}Si^{16}O^{+} a good candidate for future applications such as quantum information processing. Cooling to the ground rotational state is achieved on a 100 ms timescale and attains a population of 94(3)%, with an equivalent temperature T=0.53(6) K. We also describe a novel spectral-filtering approach to cool into arbitrary rotational states and use it to demonstrate a narrow rotational population distribution (N±1) around a selected state.

Protocol for optically pumping AlH+ to a pure quantum state.

We propose an optical pumping scheme to prepare trapped AlH+ molecules in a pure state, the stretched hyperfine state of the rovibronic ground manifold |X2Σ+, v = 0, N = 0 . Our scheme utilizes linearly-polarized and circularly-polarized fields of a broadband pulsed laser to cool the rotational degree of freedom and drive the population to the hyperfine state, respectively. We simulate the population dynamics by solving a representative system of rate equations that accounts for the laser fields, blackbody radiation, and spontaneous emission. In order to model the hyperfine structure, new hyperfine constants of the A2Π excited state were computed using a RASSCF wavefunction. We find that adding an infrared laser to drive the 1-0 vibrational transition within the X2Σ+ manifold accelerates the cooling process. The results show that, under optimal conditions, the population in the target state of the rovibronic ground manifold can reach 63% after 68 µs (330 ms) and 95% after 25 ms (1.2 s) with (without) the infrared laser.

Examining Factors That Contribute to Delayed Wound Healing in Children with Tracheostomy Wounds.

OBJECTIVE: To identify variables that may contribute to delayed wound healing times in pediatric patients with tracheostomy wounds. DESIGN: Researchers identified 134 charts spanning January 2013 to June 2017; 95 charts met the inclusion criteria. The study examined Pressure Ulcer Scale for Healing (PUSH) scores, pressure injury staging, and albumin levels. SETTING: Arkansas Children's Hospital. PATIENTS: Patients (birth to 18 years) who developed or were admitted with a wound caused by a tracheostomy device. MAIN OUTCOME MEASURE: Time in days to wound closure. MAIN RESULTS: There was a moderate positive correlation between albumin and days to healing (r = 0.432, n = 22, P = .045) with higher albumin levels associated with shorter healing times. The PUSH scores and pressure injury stage were significant in explaining 14.1% of variance in days to healing (F77,2 = 7.458; P < .001). CONCLUSIONS: Wound healing appears to be multifactorial in nature in the pediatric population; albumin levels, pressure injury stage, and PUSH scores are all positively correlated with healing times. Further research is needed to investigate the contribution of race to healing time predication for the pediatric population.

Pediatric Tracheostomy Wound Healing: A Retrospective Cohort Study.

OBJECTIVE: To compare wound products by measuring time to granulation tissue and time to complete wound healing for tracheostomy wounds in the pediatric population. METHODS: Investigators identified 134 charts of patients treated January 2013 and June 2017; 93 charts met the inclusion criteria. This study compared the use of a foam dressing (n = 34) to the foam dressing plus a wound filler (n = 59) in patients who developed or were admitted with a wound caused by a tracheostomy device. PRIMARY OUTCOME MEASURES: Time in days to granulation tissue and to wound closure. RESULTS: The average time to complete wound closure for participants in this study was 14 days. There was no statistically significant difference in time to granulation tissue or wound closure formation between the wound care products (F2,34 = 1.11, P = .34). Cluster analysis (10 splits) revealed that pressure injury stage was the best predictor, accounting for 41% of the variance in the high treatment response group (those healing in <14 days). Patients who were African American with a stage 2 pressure injury, had a PUSH score of 5 or more, and were using a foam plus a wound filler dressing were 86% more likely to be in the high-response group. CONCLUSIONS: All wounds reviewed healed with current wound care practices without surgical intervention. Best practice for healing tracheostomy wounds in pediatric patients should include the wound filler in the first 14 days based on variable interaction.

Prostate cancer screening practices and diagnoses in patients age 50 and older, Southeastern Michigan, pre/post 2012.

INTRODUCTION: Studies investigating the regional impact of the 2012 U.S. Preventive Services Task Force (USPSTF) recommendation against the use of prostate specific antigen (PSA) screening for prostate cancer have been limited. METHODS: A retrospective cohort study was conducted on men age 50years and older in Southeastern Michigan pre (n=3647) and post (n=3618) USPSTF recommendation. PSA screening, transrectal ultrasound, and prostate biopsy rates were evaluated pre/post using a generalized piecewise linear model with a Poisson distribution, and log link. A knot was placed at year 2011 to estimate pre/post slope coefficients. Generalized estimating equations were used to estimate the marginal probability of a prostate diagnosis as a logistic function of pre and post-period, and comorbidities. RESULTS: PSA utilization significantly increased (ß=0.28; 95% CI: 0.25, 0.31) during the pre-period, but significantly decreased in the post-period (ß=-0.29; 95% CI: -0.34, -0.25). Prostate biopsies decreased pre (ß=-0.16; 95% CI: -0.25, -0.08) and did not change post (ß=0.01; 95% CI: -0.09, 0.12). Transrectal ultrasounds were stable pre (ß=0.16; 95% CI: -0.03, 0.35) and significantly decreased post (ß=-0.27; 95% CI: -0.50, -0.04). Patients in the post-period had a decreased probability of having a diagnosis of prostate cancer (OR: 0.81; 95% CI: 0.74-0.89) compared to the pre-period. CONCLUSION: Our study demonstrates how PSA tests are still being frequently used in Southeastern Michigan. Further research is needed to better understand regional variation in prostate cancer screening practices in the U.S.

Substitution urethroplasty is as successful as anastomotic urethroplasty for short bulbar strictures.

INTRODUCTION: To evaluate the efficacy of transecting anastomotic urethroplasty (AU) and buccal mucosa graft (BMG) ventral onlay substitution urethroplasty (SU) in treating short bulbar urethral strictures. MATERIALS AND METHODS: Sixty patients underwent either AU or SU for bulbar strictures of similar length with follow up of at least 12 months. Follow up included clinical history, uroflowmetry, and ultrasound post-void residuals (PVR) performed every 4 months for the first year and yearly thereafter. RESULTS: Out of 131 patients with short bulbar strictures, 40 were treated with BMG onlay SU and 20 had AU. Median follow up in the SU group was 57 months (IQR 27-76) and 120 months (IQR 109-130) in the AU group. The median stricture length was 3 cm (IQR 2.5-3.0) in the SU group and 1.3 cm (IQR 1-2) in the AU group (p < 0.001). The 3 year freedom from intervention was 93% in the SU group, and 85% in the AU group (p = 0.72). CONCLUSIONS: BMG onlay ventral urethroplasty has similar success rates to anastomotic urethroplasty for short bulbar urethral strictures. Due to the relatively fewer complications reported after substitution urethroplasty with BMG, it should be considered the treatment of choice for short bulbar urethral strictures.

Enhancing reactivity of SiO+ ions by controlled excitation to extreme rotational states.

Optical pumping of molecules provides unique opportunities for control of chemical reactions at a wide range of rotational energies. This work reports a chemical reaction with extreme rotational excitation of a reactant and its kinetic characterization. We investigate the chemical reactivity for the hydrogen abstraction reaction SiO+ + H2 → SiOH+ + H in an ion trap. The SiO+ cations are prepared in a narrow rotational state distribution, including super-rotor states with rotational quantum number (j) as high as 170, using a broad-band optical pumping method. We show that the super-rotor states of SiO+ substantially enhance the reaction rate, a trend reproduced by complementary theoretical studies. We reveal the mechanism for the rotational enhancement of the reactivity to be a strong coupling of the SiO+ rotational mode with the reaction coordinate at the transition state on the dominant dynamical pathway.

Optical pulse-shaping for internal cooling of molecules.

We consider the use of pulse-shaped broadband femtosecond lasers to optically cool rotational and vibrational degrees of freedom of molecules. Since this approach relies on cooling rotational and vibrational quanta by exciting an electronic transition, it is most easily applicable to molecules with similar ground and excited potential energy surfaces, such that the vibrational state is usually unchanged during electronic relaxation. Compared with schemes that cool rotations by exciting vibrations, this approach achieves internal cooling on the orders-of-magnitude faster electronic decay timescale and is potentially applicable to apolar molecules. For AlH(+), a candidate species, a rate-equation simulation indicates that rovibrational equilibrium should be achievable in 8 µs. In addition, we report laboratory demonstration of optical pulse shaping with sufficient resolution and power for rotational cooling of AlH(+).

Precisely spun super rotors.

Improved optical control of molecular quantum states promises new applications including chemistry in the quantum regime, precision tests of fundamental physics, and quantum information processing. While much work has sought to prepare ground state molecules, excited states are also of interest. Here, we demonstrate a broadband optical approach to pump trapped SiO+ molecules into pure super rotor ensembles maintained for many minutes. Super rotor ensembles pumped up to rotational state N = 67, corresponding to the peak of a 9400 K distribution, had a narrow N spread comparable to that of a few-kelvin sample, and were used for spectroscopy of the previously unobserved C2Π state. Significant centrifugal distortion of super rotors pumped up to N = 230 allowed probing electronic structure of SiO+ stretched far from its equilibrium bond length.

Reliability and Validity of the Patient-Specific Functional Scale in Community-Dwelling Older Adults.

BACKGROUND AND PURPOSE: Clinical measurement of physical function that is both specific to the individual and generates comparable outcome data is a fundamental need in physical therapy examination. The Patient-Specific Functional Scale (PSFS) has been found to be a reliable and valid measure of physical function in patients with musculoskeletal disorders and may have applications for other patient populations. However, the reliability and the validity of the PSFS have not been evaluated in older adults. The purpose of this study was to investigate the reliability and the validity of the PSFS in community-dwelling older adults. METHODS: Thirty-one community-dwelling older adults (11 males, 20 females), mean age = 81.1 (8.3) years, were included. Participants completed the PSFS, Lower Extremity Functional Scale (LEFS), Activity-specific Balance Confidence Scale (ABC), Short Physical Performance Battery (SPPB), Berg Balance Scale, and the Timed Up and Go on 2 separate days, 48 hours apart. Assessment scores were compared between testing days and reliability was analyzed using the intraclass correlation coefficient (ICC) and minimal detectable change (MDC). Validity of the PSFS was assessed by comparing initial scores with the other measures using the Pearson correlation coefficient, scatter plots, and Bland-Altman plots. RESULTS: The ICC and the MDC for the PSFS were 0.82 (95% confidence interval = 0.67-0.91) and 2.8, respectively. Significant correlations (P < .05) were found when the PSFS was compared with the ABC (r = 0.68), LEFS (r = 0.81), and SPPB (r = 0.37). Bland-Altman plots and 95% limits of agreement (LOA) using z scores indicated considerable agreement between the PSFS versus the ABC (LOA =-1.6 to 1.6), LEFS (LOA =-1.2 to 1.2), and SPPB (LOA =-2.1 to 2.1). CONCLUSION: The PSFS is a reliable and valid measure of physical function in community-dwelling older adults. A change of 2.8 or greater on the PSFS suggests a true change in physical function in this population.

Peripheral Infiltration and Extravasation Injury Methodology: A Retrospective Study.

Peripheral infiltration is defined as the inadvertent delivery of nonvesicant fluid or medication into surrounding tissue that has the potential to harm the patient. Vesicant fluid that has leaked into the tissue space is called extravasation. At present, there is no agreement in the literature on the best practice for managing these injuries in pediatric patients. The purpose of this study was to identify occurrences of peripheral infiltration injuries and examine treatment modalities used to treat pediatric patients who suffered such an injury.

Acquired von Willebrand Disease Secondary to Clear Cell Renal Cell Carcinoma.

Background: Acquired von Willebrand disease (AvWD) is a rare and often underdiagnosed disease that typically is associated with lymphoproliferative, cardiovascular disease, and myeloproliferative disease. It is challenging to diagnose as it requires a hemostatic challenge to present itself. Case Presentation: This is a 46-year-old male with a history of multiple sclerosis complicated by neurogenic bladder who presented with intermittent gross painless hematuria. He underwent a gross hematuria workup. Cystoscopy demonstrated active bleeding from the right ureteral orifice. CT Urogram showed a filling defect in the right renal pelvis and endophytic 3 cm solid, enhancing left kidney mass. The patient underwent diagnostic cystourethroscopy, bilateral retrograde pyelogram demonstrating no filling defects bilaterally. Right ureteropyeloscopy demonstrated diffuse patchy erythema of the infrarenal collecting system with biopsies obtained. His postoperative course was complicated by gross hematuria requiring cystoscopy which demonstrated no upper tract bleeding and small pulsatile bleeding vessel in the bladder requiring cauterization. Hematology was consulted to rule out bleeding diathesis with workup demonstrating a von Willebrand deficiency (vWD). He had no family history of vWD and an AvWD was suspected. Hematologic workup was consistent with AvWD, type 2B vWD also known as a platelet-type von Willebrand disease. Renal pelvis biopsies were negative for pathology. Further investigation of the left renal mass confirmed a biopsy-proven clear cell renal cell carcinoma (ccRCC). He underwent a laparoscopic left radical nephrectomy with final pathology demonstrating pT1 ccRCC with negative margins. Postoperatively his repeat laboratories demonstrated normal factor VIII activity, ristocetin cofactor, and vWF antigen with normalized activated partial thromboplastin time. Follow-up imaging demonstrated no further evidence of disease supporting the hypothesis of a paraneoplastic syndrome from his ccRCC that caused an AvWD. Conclusion: This is the first case report to our knowledge of a paraneoplastic AvWD secondary to ccRCC. This should be on your differential when there is abnormal bleeding in the setting of renal masses.

Pudendal Neuromodulation as a Treatment for Persistent Genital Arousal Disorder-A Case Series.

BACKGROUND: Persistent genital arousal disorder (PGAD) is a rare life-altering condition characterized by unwanted, uncomfortable genital sensations or spontaneous orgasms without physical or emotional stimulation. Its etiology remains unclear, and a variety of treatments have been attempted with incomplete resolution. We propose that chronic pudendal neuromodulation (CPN) may be a useful treatment for PGAD symptoms. METHODS: A retrospective chart review was performed for women older than 18 years with a diagnosis of PGAD that had staged neuromodulation with placement of a tined lead at the pudendal nerve. Demographic, operative, and postoperative data were collected. A survey was then sent to these women to assess additional demographic data, preoperative and postoperative symptoms, and patient satisfaction. Descriptive statistics were performed. RESULTS: Six women underwent CPN for PGAD. Mean age was 52 (SD, 9) years. Five (83%) of 6 were still implanted at time of survey, at a mean of 38 months after implantation; 1 device was removed for nonuse. Four of 6 completed surveys and were still using their device. Three of 4 had met their treatment goals and were satisfied with CPN; 3 of 4 felt CPN was the most useful treatment modality they had used overall. Chronic pudendal neuromodulation also improved chronic pelvic pain (4/4), bowel function (3/4), and bladder function (3/4). CONCLUSIONS: Chronic pudendal neuromodulation can be an effective treatment for decreasing frequency of PGAD symptoms and providing symptom relief.

Trapped ion chain thermometry and mass spectrometry through imaging.

We demonstrate a spatial-imaging thermometry technique for ions in a one-dimensional Coulomb crystal by relating their imaged spatial extent along the linear radiofrequency ion trap axis to normal modes of vibration of coupled oscillators in a harmonic potential. We also use the thermal spatial spread of "bright" ions in the case of a two-species mixed chain to measure the center-of-mass resonance frequency of the entire chain and infer the molecular composition of the co-trapped "dark" ions. These non-destructive techniques create new possibilities for better understanding of sympathetic cooling in mixed-ion chains, improving few-ion mass spectrometry, and trapped-ion thermometry without requiring a scan of Doppler cooling parameters.

Noise reduction of a Libbrecht-Hall style current driver.

The Libbrecht-Hall circuit is a well-known, low-noise current driver for narrow-linewidth diode lasers. An important feature of the circuit is a current limit to protect the laser diode. As the current approaches the maximum limit, however, the noise in the laser current increases dramatically. This paper documents this behavior and explores simple circuit modifications to alleviate this issue.

Clinical Comparison of 2 Trial-of-Void Methods After Outpatient Midurethral Sling Placement.

OBJECTIVES: This study aimed to assess the efficacy, efficiency, and costs of 2 methods of trial of void (TOV) after midurethral sling (MUS) placement. METHODS: A retrospective chart review was performed on women who underwent outpatient MUS between January 2013 and April 2014 by 3 urologists. Patients were excluded if they had a concomitant prolapse repair, hysterectomy, bladder/urethral injury, or any procedure that may prolong recovery room (RR) stay. Trial of void was performed by either (1) bladder instillation, catheter removal in the operating room (OR) fill with attempted void in RR, or (2) bladder instillation and catheter removal with immediate attempted void in the RR fill. Intraoperative, postoperative, and cost data were analyzed. RESULTS: Ninety-one of 183 women (mean age, 55.9 ± 12 years; mean body mass index, 28.8 ± 5.8 kg/m) met inclusion criteria. Eighty-three had a transobturator sling. Forty-nine (54%) had an OR fill and 42 (46%) had an RR fill; age and body mass index were similar between groups. The OR fill group had shorter median operative time (15 vs 22 minutes; P = 0.003) and median RR time (138 vs 161, P = 0.033). The OR fill and RR fill groups did not differ in TOV failure rate (3/49 vs 6/42; P = 0.29), overall mean LOS (4.96 vs 5.51 hours; P = 0.055), and median RR costs ($627 vs $678; P = 0.065). No patient had urinary retention after successful TOV. CONCLUSIONS: After MUS placement, both OR fill and RR fill TOV methods are effective and efficient with similar TOV failure rates.

Surgical management of genitoperineal hidradenitis suppurativa in men.

OBJECTIVE: To report our successful experience in treating genital and perineal hidradenitis suppurativa (HS) and its sequelae including localized chronic lymphedema. We describe our method of diseased tissue resection and wound defect coverage with local flaps and split-thickness skin grafts (STSG). METHODS: From 2004 to 2012, we treated 6 patients with genital and perineal HS with radical resection of diseased tissue. Wound coverage was performed with skin flaps and/or STSGs. RESULTS: Two patients had enough normal neighboring skin for local flap coverage of their wound defect. Four others had more extensive disease requiring STSG coverage. Two patients with secondary penile skin lymphedema required STSG for penile shaft reconstruction. All patients achieved excellent cosmetic results. There was one recurrence that required repeat resection and wound coverage. No wound complications occurred at the STSG donor site. Successful STSG "take" on the scrotum and penis ranged from 90% to 100% (mean 98%). Wound complications from local flap closure were clinically insignificant and include small (≤2 cm) areas of wound breakdown with no evidence of infection in 3 patients (50%). CONCLUSION: Genitoperineal HS is a debilitating and disfiguring disease that results in the need for repeated abscess drainage operations, chronically painful skin boils, and chronic foul-smelling infectious discharge. It can be associated with lymphedema of surrounding tissues, requiring removal of tissues not originally affected by the disease. The use of complete resection and reconstruction with skin flaps and grafts provides a viable treatment option for these patients.

Body mass index predicts outcome of ureteroscopy-assisted retrograde nephrostomy for percutaneous nephrolithotomy.

INTRODUCTION: Several clinical series of retrograde nephrostomy for percutaneous nephrolithotomy (PCNL) have been published over the past 30 years demonstrating good outcomes and safety. We previously reported our adaptation of the Lawson technique, wherein we deploy the puncture wire through a flexible ureteroscope. We herein aim to clarify the performance characteristics of this nephrostomy creation technique. MATERIALS AND METHODS: Institutional Review Board approval and informed consent were obtained. A ureteroscopy-assisted retrograde nephrostomy (UARN) procedure was performed as described previously. Data were collected prospectively. Multiple patient and operative factors were evaluated for association with UARN success and nephrostomy creation time: body mass index (BMI), skin-to-stone distance, Guy's score, Clinical Research of the Endourological Society nephrolithometric score, hydronephrosis, stone burden, location of nephrostomy, exit from a stone-bearing calix, and use of holmium laser to access calix. RESULTS: Nephrostomy was successful in 49/52 UARN procedures (94%). Only single access was placed: upper-18, mid-27, and lower-7. Median BMI was 29 kg/m(2) and median time for nephrostomy creation was 39 minutes. Fluoroscopy time for the entire PCNL including nephrostomy creation was 84 and 16 seconds for case numbers 1-25 and 26-52, respectively. By stepwise linear regression, variables correlating with nephrostomy creation time were BMI (r(2)=0.219), stone burden (r(2)=0.094), use of holmium laser to access calix (r(2)=0.104), and total r(2) linear=0.416. CONCLUSIONS: UARN is an intuitive safe procedure that offers dramatic reductions in fluoroscopy times. UARN is best suited to cases requiring only one nephrostomy tract. Upper pole access is commonly performed with a subcostal technique to navigate the puncture wire below the ribs. Increasing BMI best predicts longer nephrostomy creation times; procedure failure was associated with BMI exceeding 40 kg/m(2). UARN is a robust technique for nephrostomy creation in appropriately selected patients.

Active surveillance for low-risk prostate cancer in African American men: a multi-institutional experience.

OBJECTIVE: To compare the outcomes of active surveillance (AS) series between African American men (AAM) and non-AAM diagnosed with low-risk prostate cancer at 3 medical centers. METHODS: Between 2005 and 2012, 214 men accepted AS on the basis of favorable clinical features and parameters after initial and repeat biopsy. Failure was defined as increase in Gleason score >6, total positive cores >33%, maximum cancer volume in any core >50%, or a prostate-specific antigen >10 ng/mL. Disease progression and overall AS failure were compared between the 2 groups. RESULTS: Of 214 men, 75 were excluded, leaving 67 AAM and 72 non-AAM on AS. Median age at diagnosis was 64 and 67 years for AAM and non-AAM, respectively, and median follow-up was 34 and 46 months, respectively. During this time, 44 AAM (66%) remained on AS, and 23 (34%) underwent treatment, of whom 6 (26%) were treated by patient choice and 17 (74%) because of disease progression. In the non-AAM group, 59 (82%) men remained on AS, and 13 (18%) underwent treatment, 8 (62%) were treated by patient choice and 5 (38%) because of disease progression. The 3-year freedom from overall treatment was 74% and did not differ by race (P = .06). The 3-year freedom from disease progression was 85%, where AAM were at significantly higher risk of disease progression (hazard ratio = 3.8; 95% confidence interval: 1.4-10.4; P = .01). CONCLUSION: Our study suggests a higher disease progression rate in AAM who choose AS for low-risk prostate cancer compared with non-AAM, signifying a potential need for closer follow-up and more stringent enrollment criteria in AAM.

Enhanced tracheostomy wound healing using maltodextrin and silver alginate compounds in pediatrics: a pilot study.

BACKGROUND: Tracheostomy wounds are commonly encountered in children but rarely reported. Relatively few treatments are available or have been investigated to manage this problem. Healing times for pediatric tracheostomy wounds are often unpredictable and protracted. Recent use of maltodextrin gel (MD) and a silver alginate sponge (AG) at our institution has demonstrated expedited healing and interest in this novel treatment for tracheostomy wounds. METHODS: We conducted an 11-month retrospective review of children with wound complications following tracheostomy placement at a tertiary care facility. Wounds were evaluated and rated based upon the National Pressure Ulcer Advisory Panel staging system. Subjects identified with stage 2 or greater tracheostomy-related ulcers treated with MD and/or AG were included. Subject characteristics and wound healing rates were tabulated in a database that included age, wound site, initial and final wound stage, type of treatment, length of treatment, and complications. Tracheostomy wounds treated as an out-patient were excluded from the study. RESULTS: Eighteen subjects, which included both in-patients and out-patients, were treated with AG and/or MD during the study period for tracheostomy-related wounds. Of the 26 subjects with tracheostomies performed during the study period, 10 (38.5%) were treated for postoperative wounds. A total of 11 subjects completed their in-patient wound treatment and were thus included in the study. Average subject age was 5.3 y (range 0.25-15.6 y). Wound locations were as follows: infrastomal region (n = 8), stoma (n = 2), and lateral neck (n = 1). Six subjects had stage 2 wounds, 4 had stage 3 wounds, and 1 had a stage 4 ulcer. All wounds achieved complete epithelialization following treatment with MD and/or AG. The average length of treatment was 12.8 d (range 6-28 d). No adverse effects were identified. CONCLUSIONS: Postoperative tracheostomy wounds are common. The use of MD and AG provides an effective and safe treatment for tracheostomy-related ulcers.