Chronic Ciguatera Poisoning: A Case Report.

Ciguatera is a common marine, toxin-borne illness caused by the consumption of fish that contain toxins that activate voltage-sensitive sodium channels. The clinical manifestations of ciguatera are typically self-limited, but chronic symptoms may occur in a minority of patients. This report describes a case of ciguatera poisoning with chronic symptoms, including pruritus and paresthesias. A 40-y-old man was diagnosed with ciguatera poisoning after consuming amberjack while vacationing in the US Virgin Islands. His initial symptoms, including diarrhea, cold allodynia, and extremity paresthesias, evolved into chronic, fluctuating paresthesias and pruritus that became worse after the consumption of alcohol, fish, nuts, and chocolate. After a comprehensive neurologic evaluation failed to reveal another cause for his symptoms, he was diagnosed with chronic ciguatera poisoning. His neuropathic symptoms were treated with duloxetine and pregabalin, and he was counseled to avoid foods that triggered his symptoms. Chronic ciguatera is a clinical diagnosis. Signs and symptoms of chronic ciguatera can include fatigue, myalgias, headache, and pruritus. The pathophysiology of chronic ciguatera is incompletely understood but may involve genetic factors or immune dysregulation. Treatment involves supportive care and avoidance of foods and environmental conditions that may exacerbate symptoms.

The evolving use of hyperbaric oxygen therapy during the COVID-19 pandemic.

The Sars-CoV-2 (COVID-19) pandemic has resulted in significant and unprecedented shifts in the delivery of health care services in the United States. Although wound care remains an essential service during the COVID-19 pandemic, the financial consequences and infectious disease ramifications of the pandemic have resulted in closure or limitation of hours in many outpatient wound and hyperbaric oxygen therapy (HBOT) centers. As HBOT patients often require daily treatment sessions for a period of months, it is necessary for facilities providing HBOT services to adjust to the COVID-19 pandemic while still maintaining availability of this important service. Modification of HBOT session timing and chamber decontamination procedures, utilisation of telehealth services for initial patient evaluations, and acceptance of novel patient populations and diagnoses are mechanisms by which HBOT centers can adapt to the evolving model of health care delivery throughout a pandemic. While COVID-19 is not a currently accepted indication for HBOT, patients may be referred for HBOT consultation due to the post-infectious sequelae of the virus, and thus HBOT facilities must be aware of the potential uses of this treatment for post-viral complications. By redefining paradigms for health care delivery during the COVID-19 pandemic, HBOT and wound centers can continue to provide high-quality and uninterrupted care to vulnerable patient populations.

Use of hyperbaric oxygen therapy for tissue ischemia after breast reconstruction.

INTRODUCTION: Mastectomy skin flap necrosis represents a significant complication of breast reconstructive procedures and is reported to occur in 30%-52% of patients undergoing breast reconstruction. Early identification of ischemia and early initiation of hyperbaric oxygen (HBO2) therapy can mitigate the effects of ischemia and rescue otherwise non-viable breast flap tissue. METHODS: We retrospectively examined the outcomes of HBO2 therapy in eight breasts with compromised mastectomy skin flaps between September 2015 and January 2017. Indocyanine green angiography (ICGA) was used to assess perfusion intraoperatively and post-HBO2 administration. RESULTS: Seven patients were referred for HBO2 within 24 hours of mastectomy. One patient failed to improve despite starting hyperbaric treatment within 24 hours. All other patients manifested successful healing of their mastectomy skin flaps with acceptable cosmesis after 10 HBO2 treatments. The mean relative perfusion of the at-risk area was 13.8% (±3.7%) pre-HBO2 and 101.6% (±37.3%) post-HBO2. The average area at-risk pre-HBO2 was 17.1 cm2 and reduced to zero post-HBO2. Relative perfusion values after HBO2 were found to be 6.8 (±3.4) times greater than those measured prior to HBO2. CONCLUSIONS: A short course of HBO2 may be sufficient to successfully rescue at risk post-mastectomy breast flaps. ICGA is a useful adjunct for evaluating post-mastectomy breast flap perfusion before and after HBO2 therapy.

Building a Multidisciplinary Hospital-Based Wound Care Center: Nuts and Bolts.

BACKGROUND: A hospital-based wound care center provides an important platform for the multidisciplinary approach to wound care. The colocation of specialists is an ideal working environment for the efficient delivery of quality care of the complex wound through daily communication and shared resources. METHODS: We describe the critical components necessary in building a hospital-based wound care center. Furthermore, the experience at the authors' institution in developing the multidisciplinary approach is discussed. RESULTS: Readily available ancillary services, specially trained personnel, continuum of care from the outpatient clinic to admission to surgery, and inpatient and outpatient post operative care all contribute to a process that is especially amenable to the care of the complex wound. CONCLUSIONS: The final goal is to return the patient to the best quality of life achievable given his or her wound or disability. The aim of this study is to present the authors' experiences and provide insight for others who may want to build this model within their institutions.

A comparison of carbon monoxide exposures after snowstorms and power outages.

BACKGROUND: Unintentional carbon monoxide poisoning occurs frequently after natural disasters. Although the epidemiology of carbon monoxide exposures that occur after power loss storms has been reported, few publications detail the characteristics of carbon monoxide exposures after massive snowstorms. PURPOSE: To compare the differences in patient characteristics of carbon monoxide exposures after a snowstorm and power loss storm. METHODS: In 2013, a retrospective review was conducted of patient characteristics and exposure data from all carbon monoxide cases reported to the Connecticut Poison Control Center in the days following both a major snowstorm in 2013 and a winter storm that caused extensive power outages in 2011. RESULTS: Portable generators were the most common source of carbon monoxide exposure after a storm that resulted in power losses; car exhaust was the most frequent source of exposure after an extensive snowstorm. Most exposures occurred within the first day after the snowstorm, and on the second and third days after the power outage storm. There were no significant differences between the two storms in terms of patient age, gender, or median carboxyhemoglobin concentration. CONCLUSIONS: Future public health and medical education regarding the dangers of carbon monoxide in the aftermath of storms should include attention to the differences in the typical exposure sources and timing.

Linezolid penetration into wound tissue of two diabetic patients before and after hyperbaric oxygen therapy.

OBJECTIVE: We describe linezolid tissue penetration in two diabetic patients with lower-extremity ulcers, measured by in vivo microdialysis, before and after hyperbaric oxygen (HBO2) therapy. METHODS: Each diabetic patient received a single orally administered dose of linezolid 600 mg within one week of initiating an eight-week HBO2 course for treatment of his or her Wagner Grade 3 lower-extremity wound. A microdialysis catheter was placed at the margin of the wound for collection of extracellular tissue fluid. Blood and tissue samples were collected hourly over the following 12 hours. After completion of HBO2, each patient received a second dose of linezolid 600 mg, the microdialysis catheter was reinserted in same location, and blood/tissue samples were recollected for comparison. RESULTS: Patient 1 completed all eight weeks of HBO2, while Patient 2 completed only five of eight weeks. Based on the 12-hour area under the curve ratio between extracellular tissue fluid and blood, linezolid penetration was 0.474 and 0.479 for Patients 1 and 2, respectively, at the beginning of HBO2. After completing HBO2, penetration improved in both patients to 0.950 and 0.757, respectively. CONCLUSION: Tissue concentrations of linezolid at the site of lower extremity ulcers improved following a course of HBO2 in two patients with diabetes.