Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multi-centre randomised clinical trial.

INTRODUCTION: Hyperbaric oxygen treatment (HBOT) is sometimes used in the management of open fractures and severe soft tissue crush injury, aiming to reduce complications and improve outcomes. METHODS: Patients with open tibial fractures were randomly assigned within 48 hours of injury to receive standard trauma care or standard care plus 12 sessions of HBOT. The primary outcome was the incidence of necrosis or infection or both occurring within 14 days of injury. RESULTS: One-hundred and twenty patients were enrolled. Intention to treat primary outcome occurred in 25/58 HBOT assigned patients and 34/59 controls (43% vs 58%, odds ratio (OR) 0.55, 95% confidence interval (CI) 0.25 to 1.18, P = 0.12). Tissue necrosis occurred in 29% of HBOT patients and 53% of controls (OR 0.35, 95% CI 0.16 to 0.78, P = 0.01). There were fewer late complications in patients receiving HBOT (6/53 vs 18/52, OR 0.22, 95% CI 0.08 to 0.64, P = 0.007) including delayed fracture union (5/53 vs 13/52, OR 0.31, 95% CI 0.10 to 0.95, P = 0.04). Quality of life measures at one and two years were superior in HBOT patients. The mean score difference in short form 36 was 2.90, 95% CI 1.03 to 4.77, P = 0.002, in the short musculoskeletal function assessment (SMFA) was 2.54, 95% CI 0.62 to 4.46, P = 0.01; and in SMFA daily activities was 19.51, 95% CI 0.06 to 21.08, P = 0.05. CONCLUSIONS: In severe lower limb trauma, early HBOT reduces tissue necrosis and the likelihood of long-term complications, and improves functional outcomes. Future research should focus on optimal dosage and whether HBOT has benefits for other injury types.

Assessing adolescent tobacco use in a substance use treatment program with self-report and biological measures.

Tobacco use in adolescents can alter their lifetime health outcomes. Despite the importance of early identification and treatment, adolescent tobacco use, including that of electronic vapor products (e.g., e-cigarettes), is often missed. In a state-funded substance use treatment program, we added biological measures, including urinary cotinine and exhaled carbon monoxide to self-report measures to assess recent and lifetime tobacco use. We conducted a retrospective review of the de-identified charts to examine the feasibility of screening for self-report and biological measures of tobacco use. Self-report, urinary cotinine, and exhaled carbon monoxide samples were obtained at every visit, including intake and follow-up. There were 52 adolescents with a total of 400 clinic visits to the program. Of those 400 visits, 258 included self-reported tobacco use and 142 included a denial of using any form of tobacco. However, of those 142 visits with a negative self-report of tobacco, 31 tested positive for cotinine and 6 had positive exhaled carbon monoxide. Although 111 of the 142 had negative cotinine, 5 had positive carbon monoxide, but all of those self-reported recent cannabis use. Despite using a sensitive measure of self-report of tobacco use, almost 22% of visits had a discordant self-report with a biological measure that indicated tobacco use. Considering the lifelong impact of adolescent tobacco use, clinicians should consider augmenting self-report with biological measures of tobacco use. Identification of tobacco use in adolescents with substance use can assist clinicians in providing education about tobacco use, such as electronic vapor products, and individualizing treatments.