Wound Bed Preparation 2024: Delphi Consensus on Foot Ulcer Management in Resource-Limited Settings.

GENERAL PURPOSE: To review a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Summarize issues related to wound assessment.2. Identify a class of drugs for the treatment of type II diabetes mellitus that has been shown to improve glycemia, nephroprotection, and cardiovascular outcomes.3. Synthesize strategies for wound management, including treatment in resource-limited settings.4. Specify the target time for edge advancement in chronic, healable wounds.

Chronic wound management in low-resource settings deserves special attention. Rural or underresourced settings (ie, those with limited basic needs/healthcare supplies and inconsistent availability of interprofessional team members) may not have the capacity to apply or duplicate best practices from urban or abundantly-resourced settings. The authors linked world expertise to develop a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. A group of 41 wound experts from 15 countries reached a consensus on wound bed preparation in resource-limited settings. Each statement of 10 key concepts (32 substatements) reached more than 88% consensus. The consensus statements and rationales can guide clinical practice and research for practitioners in low-resource settings. These concepts should prompt ongoing innovation to improve patient outcomes and healthcare system efficiency for all persons with foot ulcers, especially persons with diabetes.

A comparison of duplex ultrasound findings after cyanoacrylate embolization versus endovenous laser ablation of the great saphenous vein.

BACKGROUND: Whereas numerous studies have demonstrated noninferiority of cyanoacrylate embolization (CAE) relative to endovenous laser ablation (EVLA), little is known about the natural history of the vein or the glue that is implanted. This study provides the first description of duplex ultrasound changes of the great saphenous vein (GSV) after CAE relative to EVLA as well as a pragmatic view of outcomes in clinical practice. METHODS: Patients treated with CAE and EVLA at our institution were matched by time of procedure and vein size. GSV diameter was measured at the saphenofemoral junction, midthigh, and knee. Duplex ultrasound imaging was repeated after treatment in the same noninvasive laboratory with an identical protocol. Clinical data were collected by retrospective chart review. RESULTS: Of 481 eligible patients, 119 underwent postoperative duplex ultrasound imaging. Although there was a trend toward decreased vein diameter over time in CAE patients relative to their preoperative vein diameter, this failed to reach statistical significance at the midthigh (P = .32) or at the knee (P = .511). In EVLA patients, as follow-up interval increased, the vein was less frequently visualized on ultrasound at the midthigh (P = .046) and knee (P = .038). At >2 years of follow-up, >80% of EVLA patients had no visible vein segment. Anatomic recurrence was observed in 10.5% of CAE patients and 8.2% of EVLA patients, which was not statistically significantly different (P = .60). The majority of recurrence was observed in the presence of incompetent tributaries. CONCLUSIONS: After CAE of the GSV, our results indicate that the glue cast remains for at least 3 years. Although our results suggest that the glue is broken down over time, this process is much slower than expected. In contrast, after EVLA, the vein tissue is remodeled and is no longer visible with time. In our study, which represents a pragmatic clinical population with a large (median, 9.2 mm) vein diameter, we again demonstrate no statistically significant difference in recurrence rates. Whereas CAE offers an attractive treatment option for GSV incompetence, the glue cast remains for a prolonged time, and longer follow-up studies than those currently available are indicated.

Laparoscopic Colorectal Surgery in the Emergency Setting: Trends in the Province of Ontario.

BACKGROUND: The purpose of this study was to examine the adoption trends of emergency laparoscopic colorectal surgery in the province of Ontario. STUDY DESIGN: We conducted a retrospective time-series analysis examining rates of emergency colorectal surgery among 10.5 million adults in Ontario, Canada from April 1, 2002 to December 31, 2009. We linked administrative claims databases and the Ontario Cancer Registry to assess procedure rates over time. Procedure trends were assessed using time-series analysis. RESULTS: Over the 8-year period, 29,676 emergency colorectal procedures were identified. A total of 2582 (8.7%) were performed laparoscopically and 27,094 (91.3%) were open. Open and laparoscopic patients were similar with respect age, sex, and Charlson Comorbidity Index. The proportion of surgery for benign (63.8% of open cases vs. 65.6% laparoscopic, standardized difference=0.04) and malignant disease (36.2% open vs. 34.4% laparoscopic, standardized difference=0.04) was equal between groups. The percentage of emergency colorectal surgery performed laparoscopically increased from 5.7% in 2002 to 12.0% in 2009 (P<0.01). The use of laparoscopy increased for both benign and malignant disease. Statistically significant upward trends in laparoscopic surgery were seen for inflammatory bowel disease (P<0.01), obstruction (P<0.01), and colon cancer (P<0.01). From 2002 to 2009, annual procedure rates increased at a greater rate in nonacademic centers (P<0.01). CONCLUSIONS: Laparoscopic emergency colorectal surgery has increased significantly between 2002 and 2009 for both benign and malignant disease and for a wide range of diagnoses. This was driven in part by steadily rising usage of laparoscopy in nonacademic centers.

Cardiac tamponade caused by incarcerated small bowel in the pericardium after coronary bypass grafting using the right gastroepiploic artery.

Although rare, herniation of the gastrointestinal contents into the pericardium after coronary artery bypass grafting using the right gastroepiploic artery has been previously described. The associated clinical symptoms vary from gastrointestinal obstruction to cardiac tamponade. We report a patient who presented with cardiac tamponade secondary to incarceration of the small bowel in the pericardium 1 year after coronary artery bypass grafting utilizing the right gastroepiploic artery.

Resident training in minimally invasive surgery: a survey of Canadian department and division chairs.

BACKGROUND: This study aimed to seek the opinions of academic surgical chairs on minimally invasive surgery (MIS) education for general surgery residents and to identify perceived gaps and trends in educational strategies. METHODS: A national survey on attitudes toward MIS was sent to the chairs of departments of surgery and divisions of general surgery across the 16 Canadian academic centers. The survey contained 34 questions consisting of Likert scales, single answers, and multiple-choice questions. Nonresponders were contacted directly. At the time of the survey, two department chair positions were vacant. RESULTS: The response rate was 87% (26/30). The majority of the centers used early operating room exposure to basic MIS cases (92%) and animal labs (85%). Two-thirds of the institutions used early operating room exposure to advanced MIS cases (69%) and didactic lectures (65%). Half of the academic centers used MIS video (54%) and the laparoscopic virtual reality simulator (54%). The least used method was computer software (19%). The surgical division and department chairs believed the most effective teaching method was early operating room exposure to basic MIS cases (100%), followed by the laparoscopic virtual reality simulator (91%) and animal labs (88%). Computer software was considered 42% useful, and the least useful method was didactic lectures (16%). In the next 5 years, 62% of academic centers plan to add laparoscopic virtual reality simulators to their MIS curriculum. CONCLUSION: The chairs' opinion on the most effective MIS teaching method for residents is basic MIS cases followed by laparoscopic virtual reality simulators. The majority of academic institutions plan to add laparoscopic virtual reality simulators to the curriculum in the next 5 years.

Expression of circadian rhythm genes in gonadotropin-releasing hormone-secreting GT1-7 neurons.

The center for circadian rhythms in mammals is the suprachiasmatic nucleus (SCN) of the hypothalamus, composed of single cell circadian oscillators driven by a transcriptional/translational feedback loop where clock proteins drive clock gene expression. These genes are expressed in peripheral tissues and several brain areas outside the SCN. It is likely that some peripheral oscillators are synchronized by the SCN. The pineal hormone melatonin plays an important role in the entrainment of circadian rhythms through feedback to the SCN. Melatonin also plays a role in reproduction, including direct effects on GnRH-secreting GT1-7 neurons. The intrinsic rhythmicity of GnRH neurons suggests that these neurons may express the components of the circadian oscillator. Using the GT1-7 cell line, we demonstrate expression of the circadian rhythm genes, clock, BMAL1,timeless (tim), period1,period2, cryptochrome1, andcryptochrome2. Furthermore, semiquantitative RT-PCR demonstrates that BMAL1, period1, andperiod2 as well as GnRH mRNAs are expressed with a circadian-like rhythm after synchronization over 54 h. With available antibodies, we demonstrated CLOCK, BMAL1, and PERIOD1 protein expression in these cells, with BMAL1 protein levels showing a rhythmic expression pattern. In addition, receptors for melatonin, mt1 and MT2, also show a circadian expression pattern in the GT1-7 cells, and their expression is down-regulated by melatonin treatment. These findings suggest that the components of the clock machinery in mammals may play a role in GnRH neuronal function.