Hyperbaric oxygen for the treatment of fournier's gangrene.

PURPOSE: Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. MATERIALS AND METHODS: The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. RESULTS: A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). CONCLUSIONS: These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.

The epidemiology and treatment of anogenital warts in Singapore: a retrospective evaluation.

INTRODUCTION: A retrospective study in the referral centre for sexually transmitted infections (STIs) in Singapore to describe the epidemiology and treatment outcome of patients with anogenital warts. SUBJECTS AND METHODS: We reviewed the case records of 301 patients with anogenital warts who were seen over a 1-year period (1999). We also attempted to interview every patient by telephone to find out if they had any clinical recurrences for which treatment was sought elsewhere. RESULTS: There were 255 males and 46 females with a mean age of 34 years. Two hundred and nineteen (72.8%) presented with symptoms lasting 12 weeks or less. In males, warts occurred most frequently in the preputial cavity (52.5%) and on the penile shaft (40.8%). In females, they occurred most frequently on the external genitalia (91.3%). Two hundred and thirty-five males were treated with cryotherapy and 69% (95% CI, 62.6% to 74.8%) achieved clinical resolution after a mean of 6 treatment cycles. Seven males were treated with podophyllin 0.25% in ethanol and 71% (95% CI, 29.0% to 96.3%) were clinically cured after a mean of 4 treatment cycles. Thirty-nine females were treated with cryotherapy and 67% (95% CI, 49.8% to 80.9%) achieved clinical cure after a mean of 4 treatment cycles. Of the 290 patients treated at the centre, 212 (73%; 95% CI, 67.3% to 77.8%) patients (184 males, 28 females) achieved clinical cure after a mean of 7 weeks (range, 1 to 34 weeks); 90% (95% CI, 86.0% to 93.2%) of them by 15 weeks. Seven-two patients defaulted follow-up and 6 responded partially to treatment. Of the 212 patients who achieved clinical cure, 195 were interviewed by telephone, on an average, 17.7 months after clinical resolution. Thirty-seven (19%; 95% CI, 13.7% to 25.2%), all males, relapsed clinically after a mean of 100 days (range, 5 to 329 days); 90% (95% CI, 84.6% to 93.6%) relapsed by 228 days. CONCLUSIONS: Podophyllin 0.25% in ethanol was the most cost-effective treatment for males. One in 5 patients had a recurrence of their warts and most had their recurrence within 8 months of initial resolution.

The cost of treating genital warts.

BACKGROUND: Genital warts is a common sexually transmitted disease treated by a variety of medical specialists. Standard therapies offer symptomatic relief but cannot ensure lasting remission. Using the clinical literature, claims databases, and a panel of experienced practitioners, the relative efficacy, cost, and cost effectiveness of five common treatments for genital warts were assessed in this study. METHODS: We reviewed the clinical literature for the following genital wart therapies: podofilox, podophyllin, trichloroacetic acid, cryotherapy, and laser therapy, focusing on their relative efficacy. Physicians experienced in treating genital warts defined standard treatment protocols for men and women patients with moderate wart burdens. Using national claims data and protocols developed by physicians, we derived three economic models based on provider charges, third-party payments, and a resource-based relative value scale, respectively. RESULTS: The literature review demonstrated highly variable success and recurrence rates among treatment methods and failed to show that one treatment provides consistently superior efficacy. In the economic models, treating women generally proved more costly than treating men per episode of care. This was due to the need for more extensive follow-up visits in the treatment of women. Total costs were highest for cryotherapy and lowest for a patient-applied therapy that reduced the need for follow-up visits. CONCLUSIONS: Clinicians should consider both clinical and cost issues when choosing the appropriate treatment for patients with genital warts.