Successful treatment of radiation-induced vaginal soft tissue radionecrosis with HBO2.

Introduction: Radiation therapy to the pelvis can result in radiation-induced vaginal soft tissue necrosis. This significantly impacts quality of life. Studies evaluating the efficacy of HBO2 are limited. Methods: In this retrospective report, we reviewed the medical records of patients treated with once-daily HBO2 for radiation-induced vaginal soft tissue necrosis. We included females between the ages of 18 to 90 with history of pelvic cancer treated with radiotherapy and resultant soft tissue radionecrosis. Data collected included age, comorbid disease, cancer type, radiation dose, HBO2 treatment pressure, time, and total treatments. Primary outcome was improvement of radionecrosis; secondary outcomes were improvement of pelvic pain, reduction in need for analgesia, and improvement of vaginal bleeding. Results: Seven patients were identified, of which six received HBO2. One patient had a vaginal fistula. Four patients had documented improvement of radionecrosis. Four out of five patients with pelvic pain had resolution of their pain, with two patients no longer requiring opioid analgesia. Two patients who presented with vaginal bleeding showed improvement with one resolved and one significantly decreased requiring no further hospitalization or transfusion. One patient experienced no documented improvement in any of the measured outcomes. Conclusion: In this case series, five out of six (83%) patients treated with HBO2 for radiation-induced vaginal necrosis improved in at least one outcome measure. While the sample size is small, these results add to the data available that supports the use of HBO2 in suitable candidates without contraindications who have symptoms related to radiation-induced vaginal soft tissue necrosis.

Pilot study: Utility of long-wave infrared thermography as a correlate to transcutaneous oximetry for candidates of hyperbaric oxygen therapy.

Hyperbaric oxygen (HBO2 ) has been used as an adjunctive treatment for the care of advanced non-healing diabetic foot ulcers (DFUs). A patient's in-chamber transcutaneous oximetry measurement (TCOM) is currently the most effective predictor for response to HBO2 therapy but still excludes close to one in four patients who would benefit out of treatment groups when used for patient selection. Improving selection tools and criteria could potentially help better demonstrate HBO2 therapy's efficacy for such patients. We sought to identify if long-wave infrared thermography (LWIT) measurements held any correlation with a patient's TCOM measurements and if LWIT could be used in a response prediction role for adjunctive HBO2 therapy. To investigate, 24 patients already receiving TCOM measurements were enrolled to simultaneously be imaged with LWIT. LWIT measurements were taken throughout each patient's therapeutic course whether they underwent only standard wound care or adjunctive HBO2 treatments. A significant correlation was found between in-chamber TCOM and post-HBO2 LWIT. There was also a significant difference in the post-HBO2 LWIT measurement from 1st treatment to 6 weeks or the last treatment recorded. These initial findings are important as they indicate a possible clinical use for LWIT in the selection process for patients for HBO2 therapy. Larger studies should be carried out to further articulate the clinical use of LWIT in this capacity.

Use of in-chamber transcutaneous oxygen measurement to determine optimal treatment pressure in patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: Hyperbaric oxygen (HBO2) therapy is used to promote healing in select problem wounds. Transcutaneous oxygen measurement (TCOM) can be used to predict the response of these wounds to HBO2, with in-chamber TCOM values shown to be the most predictive. We evaluated the use of in-chamber TCOM values to determine optimal treatment pressure. METHODS: A retrospective review was completed of patients undergoing HBO2 therapy for a lower-extremity wound and who had in-chamber TCOM. Data collected included TCOM values, treatment profile, and patient outcome. RESULTS: A total of 142 patients were identified. The overall results demonstrated healing in 59%, minor amputation (below ankle) in 11.3%, and major amputation (above ankle) in 16.2% of patients. 79.3% of patients at 2 atmospheres absolute (ATA) and 86.6% of patients at 2.4 ATA had transcutaneous oxygen pressure (TcPO2) values ≥250 mmHg. Among those with TcPO2 ⟨250 mmHg at 2 ATA, 41% attained TcPO2 ⟩250 mmHg at 2.4 ATA. Among those treated at 2 ATA the healing rate was 70.6% if TcPO2 ⟩250 mmHg, and 11.8% if TcPO2 ⟨250 mmHg (P⟨0.001). Among those treated at 2.4 ATA the healing rate was 33.3% if TcPO2 ⟩250 mmHg and 14.3% if TcPO2 ⟨250 mmHg (P⟨0.001). DISCUSSION: Determining optimal therapeutic pressure for patients undergoing HBO2 is important to maximize benefit and minimize risk. This study indicates that in-chamber TCOM can be used to select an individualized optimal treatment pressure in patients undergoing HBO2 for lower-extremity wounds, including diabetic foot ulcers. This may result in better utilization of HBO2 and better outcomes.

Upfront Radiotherapy with Concurrent and Adjuvant Vismodegib Is Effective and Well-Tolerated in a Patient with Advanced, Multifocal Basal Cell Carcinoma.

We present a case report of a male with multifocal and extensive basal cell carcinoma. Due to extremely large size and deep tumor infiltration, he was not a surgical candidate. Combined modality treatment of fractionated radiation with concurrent vismodegib was chosen. Concurrent treatment was previously reported in the palliative and recurrent setting. This is the first case of concurrent vismodegib and radiation therapy for upfront definitive management. The patient experienced complete response in all treated lesions.

Hyperbaric Oxygen Therapy: Side Effects Defined and Quantified.

Significance: Hyperbaric oxygen therapy (HBOT) is an important advanced therapy in the treatment of problem wounds, including diabetic foot ulcers and late effect radiation injury. HBOT remains among the safest therapies used today. Nonetheless, there are side effects associated with HBOT. It is important for providers to be able to identify, understand, and quantify these side effects for prevention, management, and informed consent. Recent Advances: The past two decades have seen significant advancements in our understanding of the underlying mechanisms of HBOT. This has led to a better understanding of the underlying reason for clinical benefit. It has also led to a better understanding of its side effects. Moreover, more recent literature allows for better quantification of these side effects. This review will highlight these side effects. Critical Issues: Wound healing in the case of problem nonhealing wounds requires the use of various advanced treatment modalities, including HBOT. HBOT has been shown to significantly improve healing rates in certain problem wounds, including advanced diabetic foot ulcers and late effect radiation injury. It is provided in a variety of clinical settings by providers with varying levels of expertise. It is important for those providing this therapy to understand the potential side effects. Future Directions: Research in HBOT has led to significant advancements in the area of wound healing. At the same time, there remains a variety of treatment protocols used at different institutions. It is important to quantify risk and benefit at different treatment pressures and times to better standardize treatment and improve patient care.

Patient Outcomes and Factors Associated with Healing in Calciphylaxis Patients Undergoing Adjunctive Hyperbaric Oxygen Therapy.

Calcific uremic arteriolopathy, also known as calciphylaxis, is a rare syndrome of small vessel calcification of unknown etiology causing painful, violaceous skin lesions that progress to form chronic non-healing ulcers and gangrene. Hyperbaric oxygen therapy (HBOT) can be used as adjunctive therapy in the treatment of these ulcers. However, due to paucity of cases, there is limited data on the clinical benefit of HBOT and identifying factors associated with healing. The purpose of this study was to determine patient outcomes and factors associated with healing in patients with calciphylaxis undergoing HBOT. A retrospective chart review was completed on patients who were diagnosed with calciphylaxis and had hyperbaric medicine consultation between May 2012 and January 2016. Clinical outcomes, demographics, risk factors, laboratory values, wound distribution, and HBOT profiles were collected and analyzed. We identified 8 patients. Out of 8 patients consulted for calciphylaxis, five were consented and underwent HBOT (2 males and 3 females). All had coexisting ESRD and Diabetes. All males were able to tolerate being in the chamber and received therapeutic treatments (at least 20 HBOT) with complete resolution of ulcers. HBOT was discontinued in one female due to an inconsistent biopsy report and two others due to death secondary to septic shock or respiratory arrest and severe uremia. Calciphylaxis is a devastating disease with a high mortality rate. Our results demonstrated a positive response to HBOT especially when receiving at least 20 treatments. A majority of calciphylaxis cases are females and indeed female gender has been cited as a risk factor for this disease. However, current literature has not conferred a relationship between gender nor the number of HBOT received and outcomes. Our results showed that males had a more favorable outcome provided they received at least twenty HBOT. Further prospective studies are needed to elucidate these outcomes.

Hyperbaric oxygen for the treatment of nonhealing arterial insufficiency ulcers.

There is limited data regarding hyperbaric oxygen's effectiveness in the treatment of nonhealing arterial insufficiency ulcers. This study was designed to analyze healing rates and amputation rates in patients who underwent adjunctive hyperbaric oxygen for a nonhealing arterial insufficiency ulcer. A retrospective chart review was completed on patients who underwent hyperbaric oxygen for arterial insufficiency ulcers that failed to heal despite standard treatment. Information collected included complete ulcer healing, amputation, and patient characteristics. There were 82 patients identified. A majority did not have diabetes (84.1%). The overall rate of healing was 43.9%. The overall major amputation rate was 17.1%. The amputation rate among those who healed was 0% compared to 42.4% among those not healed (p < 0.0001). Dialysis was predictive of major amputation (p = 0.03). Our findings suggest hyperbaric oxygen can play a role in management of arterial insufficiency ulcers that have failed standard treatment. The overwhelming majority of these patients did not have diabetes, which allows this study to be translated to patients with a primary arterial insufficiency ulcer. These results support the use of hyperbaric oxygen for select nonhealing arterial insufficiency ulcers that have failed standard therapy and the need for a prospective pilot study.

CD34+/CD45-dim stem cell mobilization by hyperbaric oxygen - changes with oxygen dosage.

Because hyperbaric oxygen treatment mobilizes bone marrow derived-stem/progenitor cells by a free radical mediated mechanism, we hypothesized that there may be differences in mobilization efficiency based on exposure to different oxygen partial pressures. Blood from twenty consecutive patients was obtained before and after the 1st, 10th and 20th treatment at two clinical centers using protocols involving exposures to oxygen at either 2.0 or 2.5 atmospheres absolute (ATA). Post-treatment values of CD34+, CD45-dim leukocytes were always 2-fold greater than the pre-treatment values for both protocols. Values for those treated at 2.5 ATA were significantly greater than those treated at 2.0 ATA by factors of 1.9 to 3-fold after the 10th and before and after the 20th treatments. Intracellular content of hypoxia inducible factors -1, -2, and -3, thioredoxin-1 and poly-ADP-ribose polymerase assessed in permeabilized CD34+ cells with fluorophore-conjugated antibodies were twice as high in all post- versus pre-treatment samples with no significant differences between 2.0 and 2.5 ATA protocols. We conclude that putative progenitor cell mobilization is higher with 2.5 versus 2.0 ATA treatments, and all newly mobilized cells exhibit higher concentrations of an array of regulatory proteins.

Middle ear barotrauma in hyperbaric oxygen therapy.

INTRODUCTION: Middle ear barotrauma (MEB) is a common complication of hyperbaric oxygen (HBO2) therapy. The purpose of this study was to determine the overall incidence of MEB and evaluate for differences in the incidence of MEB at different rates of compression (ROC). The study also sought to identify other potential risk factors for MEB. METHODS: A retrospective chart review was performed on patients undergoing HBO2 at an academic regional level 1 trauma center. The MEB overall incidence as well as incidence at different ROC were determined. RESULTS: 236 patients representing 4,981 treatments were analyzed. The overall incidence of MEB was 43.2%. There was no statistically significant difference in the incidence of MEB at different ROC. There was a statistically significant higher incidence of TEED 4 MEB in intubated patients (p < 0.0001). The vast majority of MEB was minor when considering severity based on overall lower TEED scores of 1 or 2 (84%). DISCUSSION: The overall incidence of MEB in this study is consistent with those previously reported. It is important to note that a vast majority of MEB was minor. This supports HBO2 as a safe treatment modality with minimal overall risk. The current study supports standardization of most treatment protocols to a ROC of 2 psi/minute.

Seizure incidence by treatment pressure in patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: Hyperbaric oxygen (HBO2) therapy uses different maximum treatment pressures. A side effect of HBO2 is oxygen toxicity seizure. The purpose of this study was to determine the overall incidence of oxygen toxicity seizure and assess risk at different treatment pressures. METHOD: A retrospective chart review was performed on patients who underwent HBO2 at a university hospital and at an outpatient center. Statistical analysis was performed to determine overall incidence of seizure and identify risk factors including maximum treatment pressure. RESULTS: A total of 931 patients were identified representing a total of 23,328 treatments. The overall incidence of seizure was one in 2,121 treatments (five per 10,000). There were zero per 10,000 at 2.0 atmospheres absolute/atm abs (0/16,430), 15 per 10,000 at 2.4/2.5 atm abs (1/669) and 51 per 10,000 at 2.8 atm abs (1/197). There was a statistically significant difference for seizure between the different pressures (χ2 (2, 23,540) = 31.38, p < .001). DISCUSSION: The overall incidence of oxygen toxicity seizure in this study is consistent with recent reports. This study demonstrated a statistically significant increased risk of seizure with increasing treatment pressure. Treatment at higher pressure should be chosen based on demonstrable benefit with a clear understanding of increased risk with higher pressure.

Hyperbaric oxygen and dental extractions in irradiated patients: short- and long-term outcomes.

PURPOSE: Mandibular osteoradionecrosis (ORN) can occur in patients post-radiation therapy. This study assessed the incidence of ORN in the setting of adjunctive hyperbaric oxygen therapy (HBO2) and sought to identify risk factors that may predispose to its development. METHODS: A retrospective chart review was completed on patients with a history of radiation therapy to the head and neck who underwent HBO2 prior to and immediately following dental extractions between January 1, 1995, and December 31, 2005, in the hyperbaric medicine unit. RESULTS: The incidence of ORN in 40 patients immediately following completion of HBO was 0%. Available follow-up longer than six months after completion of HBO2 on 19 of these patients showed an incidence of ORN increased to 15.8%. None of the considered risk factors for development of ORN reach statistical significance. CONCLUSION: The incidence of ORN at the completion of HBO2 was less than previously reported incidences between 1.5%-4.2%. However, long-term follow-up indicated a much higher incidence of 15.8%. The difference in incidence of ORN immediately upon completion of HBO2 approximately two weeks after dental extractions compared to that at least six months later identifies a need for more long-term follow-up of these patients following their dental extractions.

Professional attitudes in regard to hyperbaric oxygen therapy for dental extractions in irradiated patients: a comparison of two specialties.

OBJECTIVES: Mandibular osteoradionecrosis (ORN) is a serious complication of radiation therapy. The current use of hyperbaric oxygen therapy (HBO2) to prevent ORN when dental extractions are performed has been called into question. We sought to determine the current acceptability and confidence in this treatment by practitioners from two different specialties. METHODS: We surveyed both hyperbaric medicine physicians and radiation oncologists regarding their views on the use of HBO2 for the prevention of ORN. Separate web-based anonymous surveys were sent via email invitation. These two groups were compared, including statistical analysis using the chi-square test when appropriate. RESULTS: 175 radiation oncologists and 118 hyperbaric medicine physicians participated. Among those not recommending HBO2, lack of evidence was cited by 52% of radiation oncologists and 38% of hyperbaric medicine physicians (chi2 = 5.0, p = 0.03, 95%, CI 1.9% to 25.6%). A majority of radiation oncologists (79%) and hyperbaric medicine physicians (85%) believe it is important that a new randomized controlled trial (RCT) is conducted (chi2 = 1.3, p = NS). CONCLUSIONS: While HBO2 has been used for decades, recent tissue-sparing radiation techniques and advanced surgical techniques are now calling into question the continued use of HBO2 for ORN prevention. Our results demonstrate that there is overwhelming support among responding practitioners for a new RCT.

The Use of Hyperbaric Oxygen Therapy in the Treatment of Non-healing Ulcers Secondary to Graft-versus-host Disease.

We present the case of a 69 year-old gentleman with non-healing ulcers of the bilateral medial malleoli as a result of graft-versus-host disease (GvHD). The patient discussed was diagnosed with stage IV mantle cell lymphoma. Over the course of 4 years the patient was treated with autologous stem cell transplant, later reduced-intensity allogeneic stem cell transplant, and finally donor lymphocyte infusion due to recurrence. Following these therapies, the patient developed extensive GvHD that resulted in bilateral non-healing ulcers of the medial malleoli. The patient was seen in the wound care center, and his ulcers were treated with standard care that included off-loading, minor outpatient debridement, macrovascular assessment, and local moist wound healing. Despite this care, the ulcers failed to heal over a 6 month period. The patient underwent adjunctive hyperbaric oxygen therapy (HBO). He healed both ulcers within a month of completing HBO. It is our goal to discuss the pathophysiologic mechanism of non-healing wounds in the setting of GvHD and discuss the potential role of HBO in their treatment.