Management of stage 0 medication-related osteonecrosis of the jaw with hyperbaric oxygen therapy: a case report and review of the literature.

The definition of medication-related osteonecrosis of the jaw (MRONJ) includes a stage 0 presentation where exposed bone, the hallmark of this condition, is absent. Numerous management strategies have been recommended for MRONJ including hyperbaric oxygen (HBO2) therapy. This report describes a 64-year-old woman with stage 0 MRONJ of the bilateral mandible, refractory to clindamycin and local debridement, who was subsequently managed successfully with amoxicillin/clavulanate and HBO2 therapy. The authors also explore the current literature on the pathophysiology of MRONJ and the potential role of hyperbaric oxygen in its treatment.

A Descriptive Revenue Analysis of a Wound-Center IR Collaboration to Treat Lower Extremity Venous Ulcers.

PURPOSE: To describe the revenue from a collaboration between a dedicated wound care center and an interventional radiology (IR) practice for venous leg ulcer (VLU) management at a tertiary care center. MATERIALS AND METHODS: This retrospective study included 36 patients with VLU referred from a wound care center to an IR division during the 10-month active study period (April 2017 to January 2018) with a 6-month surveillance period (January 2018 to June 2018). A total of 15 patients underwent endovascular therapy (intervention group), whereas 21 patients did not (nonintervention group). Work relative value units (wRVUs) and dollar revenue were calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule. RESULTS: Three sources of revenue were identified: evaluation and management (E&M), diagnostic imaging, and procedures. The pathway generated 518.15 wRVUs, translating to $37,522. Procedures contributed the most revenue (342.27 wRVUs, $18,042), followed by E&M (124.23 wRVUs, $8,881), and diagnostic imaging (51.65 wRVUs, $10,599). Intervention patients accounted for 86.7% of wRVUs (449.48) and 80.0% of the revenue ($30,010). An average of 33 minutes (38.3 hours total) and 2.06 hours (36.8 hours total) were spent on E&M visits and procedures, respectively. CONCLUSIONS: In this collaboration between the wound center and IR undertaken to treat VLU, IR and E&M visits generated revenue and enabled procedural and downstream imaging revenue.

Refractory Ulcerated Necrobiosis Lipoidica: Closure of a Difficult Wound with Topical Tacrolimus.

OBJECTIVE: To report a case of refractory ulcerated necrobiosis lipoidica (NL) with significant response to treatment with topical tacrolimus. SUBJECT: A 55-year-old woman without diabetes and with a previous history of NL presented to the Helen L. and Martin S. Kimmel Hyperbaric and Advanced Wound Healing Center of NYU Langone Medical Center, New York, with bilateral lower-leg ulcerations resistant to wound healing techniques at other institutions. MATERIALS AND METHODS: Repeat biopsy performed at the author's institution confirmed the diagnosis of NL. Initial therapy was based on reports of other successful treatment methods, which included collagen wound grafts and collagen-based dressings coupled with compression. These methods initially showed promising results; however, the wounds reulcerated, and any gains in wound healing were lost. Alternative options were initiated, including topical clobetasol and narrowband ultraviolet B; however, no significant improvement was observed. The patient's lower-extremity wounds began to deteriorate. The patient also refused systemic therapy. Treatment was changed to topical 0.1% tacrolimus ointment and was applied daily for 10 months with multilayer compression wraps. RESULTS: Both lower-extremity ulcerations began to show significant improvement, with the ulcers progressing toward closure except for 1 very small area on the left lower extremity. CONCLUSIONS: Topical tacrolimus seems to be an effective treatment option for patients with refractory chronic ulcerated NL who do not want systemic oral therapy. The authors found that successful wound closure may require a multimodal approach, which promotes wound healing, but also concurrently addresses the underlying disease process.

Nonhealing Ulcers in Patients with Tophaceous Gout: A Systematic Review.

GENERAL PURPOSE: To provide information from a review of the literature about chronic ulcers associated with tophaceous gout. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify the pathophysiology of tophaceous gout, its presentation, phases, and common comorbidities.2. Evaluate the findings in this review regarding effectiveness of interventions for chronic tophaceous ulcers. ABSTRACT: OBJECTIVE: Treating chronic ulcers associated with tophaceous gout is an uncommon but important clinical challenge. However, treatments vary greatly from topical therapies, to debridements, to free flap wound coverage. To the authors' knowledge, this is the first study to assemble and compare these different approaches in order to guide effective treatment. DATA SOURCES: An electronic search of MEDLINE (PubMed) was conducted. Search terms included (gout and ulcer) not "peptic ulcer," and (gout, chronic wound) or (gout, nonhealing wound). STUDY SELECTION: Studies that discussed the presentation, characterization, or treatment of gout-associated wounds were included. The literature search yielded 9 case reports and case series; there were no randomized controlled studies or reviews. DATA EXTRACTION: Patient and wound characteristics, treatment approaches, and outcomes were noted. DATA SYNTHESIS: The 82% of 22 patients were male, aged 36 to 95 years. Three patients had not been previously diagnosed with gout, whereas others had received a diagnosis 2 to 35 years prior to presentation with an ulcer. Many patients had comorbidities including diabetes and peripheral vascular disease. Most of the 43 total ulcers occurred on the feet. Treatments included topical 3% citric acid in petroleum jelly, allogeneic culture dermal substitute, silver-containing dressing and heterologous lyophilized collagen, debridements, and free flap coverage. CONCLUSIONS: Chronic tophaceous wounds are a worldwide problem. Although physicians report some successes with different treatments, controlled studies are needed to determine the most effective approach and to identify risk factors and preventive strategies.

Hyperbaric Oxygen Therapy: Exploring the Clinical Evidence.

GENERAL PURPOSE: To provide information about hyperbaric oxygen therapy (HBOT), its mechanisms, indications and safe applications based on clinical evidence. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Recall the physiology of wound healing and the mechanisms of action of HBOT.2. Identify current applications of HBOT based on clinical evidence as well as its risks and contraindications. ABSTRACT: Treating chronic wounds and infections are challenging medical problems worldwide. Hyperbaric oxygen therapy (HBOT), the administration of 100% oxygen at pressures greater than 1.4 atmosphere absolute in a series of treatments, can be used as an adjunctive therapy in many wound care settings because it improves oxygenation and neovascularization and decreases inflammation in chronic wounds. A growing number of studies support the benefits of HBOT for enhancing wound healing and decreasing the likelihood of negative events such as amputation. However, many practitioners are unfamiliar with HBOT. This article provides a general introduction to HBOT, reviews the physiology and mechanisms of behind HBOT, discusses all the indications for HBOT, and explores in-depth the clinical evidence for HBOT in the treatment of arterial insufficiencies, diabetic ulcers, delayed radiation injury, and chronic refractory osteomyelitis.

Wounds in patients with HIV.

Highly active antiretroviral therapy has dramatically reduced morbidity and mortality among patients who are HIV-positive. A retrospective review of the authors' data separated subjects into cohorts based on HIV status and matched them for age and gender. The authors' data reveal a higher fraction of venous ulcers compared with a lower fraction of pressure ulcers in the seropositive population.

Pediatric "off-road vehicle" trauma: determinants of injury severity and type.

OBJECTIVES: This study aimed to describe the determinants of the severity and type of injuries sustained by children hurt in off-road vehicle (ORV) accidents. METHODS: This was a retrospective clinical study for which data were obtained from the trauma database at the Children's Hospital at Westmead covering the 10-year period between January 1, 1998, and December 31, 2007. Data points collected included age, sex, Injury Severity Score (ISS), body region injured, type of vehicle, accident setting, mechanism of injury, estimated speed, position of the rider, use of a helmet and/or protective clothing, and hospital length of stay. The study end points were determinants of injury severity and type. Statistical analysis of the collected data was done with the standard statistical software package, SPSS. RESULTS: A total of 288 children (242 male [84%] and 46 female [16%] patients) presented for ORV-related trauma. Helmets significantly diminished the chance of sustaining a head injury occasioning a skull fracture. Jumping was associated with increased ISS and a higher chance of sustaining an abdominal and/or thoracic injury. Older children were more likely to sustain pelvic and spinal injures, be injured while traveling at high speed, and be injured while going over a jump. Mean ISS was significantly lower if trauma was sustained while riding a mini motorcyle in any setting and any ORV at home. CONCLUSIONS: Further research (prospective, federal, and multi-institutional) is needed with a view to optimizing training schedules, rules, regulations, and licensing requirements for pediatric ORV riders.

A multidisciplinary team approach to hydroxyurea-associated chronic wound with squamous cell carcinoma.

Hydroxyurea (HU) has been shown to induce a variety of cutaneous adverse reactions, including severe leg ulcers. This report shows a successful treatment of a HU-induced chronic wound associated with squamous cell carcinomas (SCC). A 62-year-old patient affected with polycythemia vera and treated with HU for 10 years, presented with a non healing ulcer on a left heel. The patient gave a history of suffering from the wound for over 2 years. Biopsy showed evidence of invasive SCC. The patient underwent Mohs surgery and a greater saphenous vein ablation for polycythemia vera-associated vascular complications. The wound consistently decreased in size following successive debridements and coverage with human skin equivalent. The wound healed completely after a 6-month period. A multidisciplinary team approach to the treatment proved to be effective resulting in healing of this multifactorial chronic ulcer.

A phase 2B randomised trial of hyperbaric oxygen therapy for ulcerative colitis patients hospitalised for moderate to severe flares.

BACKGROUND: Hyperbaric oxygen has been reported to improve disease activity in hospitalised ulcerative colitis (UC) patients. AIM: To evaluate dosing strategies with hyperbaric oxygen for hospitalised UC patients. METHODS: We enrolled UC patients hospitalised for acute flares (Mayo score 6-12). Initially, all patients received 3 days of hyperbaric oxygen at 2.4 atmospheres (90 minutes with two air breaks) in addition to intravenous steroids. Day 3 responders (reduction of partial Mayo score ≥ 2 points and rectal bleeding score ≥ 1 point) were randomised to receive a total of 5 days vs 3 days of hyperbaric oxygen. RESULTS: We treated 20 patients with hyperbaric oxygen (75% prior biologic failure). Day 3 response was achieved in 55% (n = 11/20), with significant reductions in stool frequency, rectal bleeding and CRP (P < 0.01). A more significant reduction in disease activity was observed with 5 days vs 3 days of hyperbaric oxygen (P = 0.03). Infliximab or colectomy was required in only three patients (15%) despite a predicted probability of 80% for second-line therapy. Day 3 hyperbaric oxygen responders were less likely to require re-hospitalisation or colectomy by 3 months vs non-responders (0% vs 66%, P = 0.002). No treatment-related adverse events were observed. CONCLUSION: Hyperbaric oxygen appears to be effective for optimising response to intravenous steroids in UC patients hospitalised for acute flares, with low rates of re-hospitalisation or colectomy at 3 months. An optimal clinical response is achieved with 5 days of hyperbaric oxygen. Larger phase 3 trials are needed to confirm efficacy and obtain labelled approval.

Neurocognitive outcomes in children following immersion: a long-term study.

OBJECTIVE: To investigate long-term neurocognitive outcomes after a near-drowning incident in children who were deemed neurologically intact on discharge from hospital. DESIGN: A prospective cohort study of near-drowning children. SETTING: 95 drowning and near-drowning admissions, 0-16 years of age, from January 2009 to December 2013, to The Children's Hospital at Westmead, Sydney, NSW, Australia. PARTICIPANTS: 23 children both met the criteria and had parental consent for the study. MAIN OUTCOME MEASURES: Identification of the long-term deficits in behaviour, executive function, motor skills, communicative skills and well-being over a 5-year period. Assessment was undertaken at 3-6 months, 1 year, 3 years and 5 years after near-drowning at clinic visits. Physical developmental screening and executive function screening were done using Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P) and BRIEF. RESULT: 95 drowning and near-drowning episodes occurred during the study period. 10 (11%) children died, 28 were admitted to the paediatric intensive care unit and 64 directly to a ward. 3 children died in emergency department, 7 children had severe neurological deficit on discharge from the hospital. 23 were subsequently recruited into the study; 5 (22%) of these children had abnormalities in behaviour and/or executive function at some during their follow-up. CONCLUSION: Children admitted to hospital following a near-drowning event warrant long-term follow-up to identify any subtle sequelae which might be amenable to intervention to ensure optimal patient outcome.

A histopathologic basis for surgical debridement to promote healing of venous ulcers.

BACKGROUND: Pathologic analysis of deep tissue obtained during debridement of venous ulcers is often unnoticed in its importance. We previously reported pathologic findings on 139 patients with venous ulcers. The objective of this study was to correlate the pathologic findings in venous ulcers with wound healing to establish a negative margin for debridement. STUDY DESIGN: Consecutive patients with a lower extremity venous ulcer present for at least 4 weeks, presenting to a single wound healing center, were included. Wounds underwent aggressive surgical debridement beyond the subcutaneous level until judged to have a viable base. Specimens were scored based on cellularity, vascularity, collagen composition, inflammation, and dense fibrosis, with a highest possible score of 13. Healing was the primary outcome for analysis. RESULTS: Of the 26 patients who met inclusion criteria, only 50% of them (13 patients) with a total of 18 venous ulcers underwent surgical debridement available for pathologic analysis. Mean ulcer area was 34.7 cm(2) at initial presentation, and 89% of patients had a continuous positive healing curve as measured by decreasing wound area (from 34.7 cm(2) to 14.3 cm(2)). However, specimens with dense fibrosis, decreased cellularity, mature collagen, and pathology score less than 10 were predominantly nonhealing ulcers. CONCLUSIONS: Presence of dense fibrosis and high levels of mature collagen in deep tissue specimens are significant correlative factors in nonhealing of venous ulcers. We recommend deep debridement on all venous ulcers that are refractory to healing until the level of absence of dense fibrosis and mature collagen is reached to promote venous ulcer healing.