Unique combination of hyaluronic acid and amino acids in the management of patients with a wide range of moderate-to-severe chronic wounds: Evidence from international clinical practice.

The availability of new products and strategies to manage wounds has taken a quantum leap in recent years. Healthcare professionals now have an extensive range of products to choose from, but while positive this also raises dilemmas in real-world clinical practice to decide on the most appropriate treatment for a given patient. Clinical trials confirm the effectiveness of the unique combination of hyaluronic acid and amino acids (Vulnamin®) in a range of wounds, but are these results replicated in real-world clinical practice? International experts presented their clinical experience with the use of the combination in difficult-to-treat wounds. The objective was to reach a consensus on how and when to use the unique combination products to provide a cost-effective, convenient option, in all healthcare settings that improves QoL for patients and their carers.

Intralesional epidermal growth factor therapy in recalcitrant diabetic foot ulcers.

OBJECTIVES: Diabetic foot ulcers (DFUs) cause high morbidity and mortality despite best treatment. Thus, new products are urgently needed to treat DFUs. Intralesional epidermal growth factor (EGF) (Heberprot-p) is considered to be an adjuvant therapy to standard of care (SOC) in DFUs. In the present study, the effect of Heberprot-p treatment on wound healing is compared to standard treatment. METHODS: The data of patients with DFUs were retrospectively analysed. The patients who had had DFUs of at least four weeks' duration and who had been treated in the wound clinic between January 2014 and 2017 were included in the study. The patients were divided into study and control groups. The study group consisted of patients in whom intralesional recombinant human EGF, Heberprot-p 75µg, was applied; the control group consisted of the remaining patients in whom EGF was not applied. The efficacy of Heberprot-p treatment in Wagner 2 and 3 DFUs were retrospectively investigated. RESULTS: The study group (n=29 patients) who received Heberprot-p treatment was found to have shorter treatment times and higher rates of wound healing than the control group (n=22 patients). Although the amputation rate in the study group was less than the control group, the difference was not statistically significant. CONCLUSION: Heberprot-p therapy is a promising treatment in DFUs, which can be routinely used as an adjunct to standard care.

Effectiveness of negative-pressure wound therapy compared to wet-dry dressing in pressure injuries.

This study aims to compare the effects of Negative-Pressure Wound Therapy (NPWT) and wet-to-dry dressing on Stages 3 and 4 pressure injuries (PI), This study is a randomized controlled trial. A total of 30 patients with Stages 3 and 4 pressure injuries were included in the study. The patients were divided into two groups: NPWT group and the wet-to-dry dressing group. All patients received 3 rounds of treatment. Data were collected with a Patient Identification Form, Pressure Ulcer Scale for Healing (PUSH) Tool and the findings of the Three-Dimensional Wound Measurement (3DWM) device. We found that granulation tissue formation was more significant in the experimental group (p < .05), and that there was more significant wound shrinkage (p < .05) with a more significant decrease in the PUSH Tool scores (p < .05). The wounds were assessed with the tool and the 3DWM system. Device measurements were found to be correlated with PUSH Tool findings (p < .05). There was a significant correlation between device-measured granulation findings and PUSH Tool score results of the experimental group's third measurements (p < .05). We conclude that NPWT is an effective treatment method for pressure injuries, and 3DWM device is a useable wound assessment tool.

A case of elephantiasis nostras verrucosa treated successfully by a new type of compressive garment.

Elephantiasis nostras verrucosa (ENV) is a clinical manifestation composed of hyperkeratotic, verrucous, and papillomatous lesions and dermal fibrosis, which complicate chronic lymphedema. There is currently no cure for ENV, however, several measures have been used to reduce lymphedema and the resultant pseudoepidermal hyperplasia. Supportive dressings and compression therapy still constitute an important part of the treatment. In this report, we present a 69-year-old male patient with ENV developed due to chronic lymphedema caused by venous insufficiency. After failure of healing with conventional two- and three-layered bandages, and elastic stockings, he was successfully treated by a new type of compression garment. We recommend this user friendly garment for prevention of frictional trauma, contact dermatitis, and secondary infection, which all may complicate compression treatments.

Successful treatment of thoracic aortic graft infection by omental flap following vacuum-assisted closure therapy.

BACKGROUND: Postoperative thoracic aortic graft infection (TAGI) is a serious and potentially fatal complication. The classical approach is to replace the infected graft. However, this approach has a high mortality rate. Alternatively, treatment of TAGI without graft replacement can be performed METHOD: Herein, we present a 72-year-old case with mediastinitis and graft infection after type A aortic dissection operation and successful treatment using omental flap coverage following vacuum-assisted wound closure therapy without graft replacement. CONCLUSION: The patient had an uneventful postoperative course and remains infection-free to date.

Successful anesthetic management in axillo-axillary bypass surgery.

Axillo-axillary bypass grafting is considered the operation of choice for patients with subclavian steal syndrome. Anesthetic management of high-risk patients with coronary-subclavian steal syndrome presents safety and technical challenges. Presently described is case of chronic obstructive lung disease and coronary artery disease in a 52-year-old man who required axillo-axillary bypass surgery to treat stenosis at the origin of left subclavian artery. Successful anesthetic management was achieved for patient undergoing axillary-axillary bypass surgery using a cervical epidural technique.

Treating a Patient of Dysfibrinogenemia with Acute Thromboembolism by Rivaroxaban and Cilostazol.

Congenital dysfibrinogenemia is a rare autosomal recessive bleeding disorder, which is characterized by the absence of functional fibrinogen. Patients may have bleeding and paradoxical arterial and venous thrombotic problems from early childhood. The optimal antithrombotic therapy in these patients hasn't been determined yet. In this report we present a dysfibrogenemic patient, who has suffered recurrent arterial thrombosis under aspirin treatment. Intravenous fibrinogen concentrates (fc) along with reduced doses of rivaroxaban (10 mg daily), cilostazol (50 mg bid) and aspirin (100 mg daily) were given as antithrombotic treatment. The pain and the cyanosis clinically recovered within 6 weeks. This is, to our knowledge, the first time in which a new oral anticoagulant, rivaroxaban and cilostazol combination was used in a dysfibrinogenemic patient with thrombotic episodes. We determined the type, the dosage and the duration of antithrombotic treatment according to the clinical progress of the symptoms. Rivaroxaban, cilostazol and fibrinogen concentrate replacement; combination may represent a useful alternative for the antithrombotic treatment in dysfibrinogenemic patients.

The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting.

STUDY OF OBJECTIVE: To compare the effects of oral tramadol+paracetamol combination on morphine consumption following coronary artery bypass grafting (CABG) in the patient-controlled analgesia (PCA) protocol. DESIGN: A prospective, double-blind, randomized, clinical study. SETTING: Single-institution, tertiary hospital. PATIENTS: Fifty cardiac surgical patients undergoing primary CABG surgery. INTERVENTIONS: After surgery, the patients were allocated to 1 of 2 groups. Both groups received morphine according to the PCA protocol after arrival to the coronary intensive care unit (bolus 1 mg, lockout time 15 minutes). In addition to morphine administration 2 hours before operation and postoperative 2nd, 6th, 12th, 18th, 24th, 30th, 36th, 42th, and 48th hours, group T received tramadol+paracetamol (Zaldiar; 325 mg paracetamol, 37.5 mg tramadol) and group P received placebo. Sedation levels were measured with the Ramsay Sedation Scale, whereas pain was assessed with the Pain Intensity Score during mechanical ventilation and with the Numeric Rating Scale after extubation. If the Numeric Rating Scale score was ≥3 and Pain Intensity Score was ≥3, 0.05 mg/kg morphine was administered additionally. MEASUREMENTS: Preoperative patient characteristics, risk assessment, and intraoperative data were similar between the groups. MAIN RESULTS: Cumulative morphine consumption, number of PCA demand, and boluses were higher in group P (P<.01). The amount of total morphine (in mg) used as a rescue analgesia was also higher in group P (5.06±1.0), compared with group T (2.37±0.52; P<.001). The patients who received rescue doses of morphine were 8 (32%) in group T and 18 (72%) in group P (P<.001). Duration of mechanical ventilation in group P was longer than group T (P<.01). CONCLUSION: Tramadol+paracetamol combination along with PCA morphine improves analgesia and reduces morphine requirement up to 50% after CABG, compared with morphine PCA alone.

An Extraordinary Manifestation of Nodular Cystic Fat Necrosis.

Nodular cystic fat necrosis (NCFN) is characterized by mobile subcutaneous nodules composed of necrotic adipocytes encapsulated by fibrous tissue. The classical presentation of NCFN is solitary or multiple, up to 40, discrete nodules scattered usually on the extremities or trunk. Here, the authors present an elderly woman who developed an unusual and striking clinical picture of NCFN, two months after a fall. The patient had a large indurated plaque and subcutaneous nodule with superposing necrotic ulcers. During debridement of the ulcers, nearly 100 small nodules popped up freely along with a brownish discharge. Deep in the ulcer, the authors discovered a dislocated nail that belongs to an old hip prosthesis. Histopathological findings of the nodules were compatible with NCFN.

Acral melanoma with satellitosis, disguised as a longstanding diabetic ulcer: a great mimicry.

Acral lentiginous melanoma affects the palms, soles, and nail apparatus. Around 3-15% of all cutaneous melanomas are located on the foot and have a poorer prognosis than melanoma elsewhere. Possible reasons for this prognostic difference may be omitting this area during routine skin check by both the patient and the physicians, in addition to misdiagnosis of melanoma as other benign skin lesions. We describe here an elderly female patient treated for a non-healing foot ulcer interpreted as a diabetic ulcer, which after 2 years was diagnosed as acral melanoma with satellitosis. Histopathological examination of the amputated distal phalanx revealed an advanced stage melanoma with 1·2 cm Breslow thickness and of Clark level 5. Dermoscopy of the bluish papulonodules scattered on the dorsal foot showed characteristic findings described for metastasis of skin melanoma. This case underlines the importance of considering skin malignancies in case of chronic, non-healing ulcers in diabetic patients. Furthermore, we point out the critical significance of skin examination as a whole, and dermoscopy being an important tool in the diagnosis of melanoma and/or cutaneous melanoma metastasis.

The effects of different ventilator modes on cerebral tissue oxygen saturation in patients with bidirectional superior cavopulmonary connection.

AIMS AND OBJECTIVES: We used near-infrared spectroscopy to document changes in cerebral tissue oxygen saturation (SctO2) in response to ventilation mode alterations after bidirectional Glenn (BDG; superior cavopulmonary connection) procedure. We also determined whether spontaneous ventilation have a beneficial effect on hemodynamic status, lactate and SctO2 when compared with other ventilation modes. MATERIALS AND METHODS: 20 consecutive patients undergoing BDG were included. We measured SctO 2 during three ventilator modes (intermittent positive-pressure ventilation [IPPV]; synchronized intermittent mandatory ventilation [SIMV]; and continuous positive airway pressure + pressure support ventilation [CPAP + PSV]). We, also, measured mean airway pressure (AWP), arterial blood gases, lactate and systolic arterial pressures (SAP). RESULTS: There was no change in SctO2 in IPPV and SIMV modes; the SctO2 measured during CPAP + PSV and after extubation increased significantly (60.5 ± 11, 61 ± 10, 65 ± 10, 66 ± 11 respectively) (P < 0.05). The differences in the SAP measured during IPPV and SIMV modes was insignificant; the SAP increased significantly during CPAP + PSV mode and after extubation compared with IPPV and SIMV (109 ± 11, 110 ± 12, 95 ± 17, 99 ± 13 mmHg, respectively) (P < 0.05). Mean AWP did not change during IPPV and SIMV modes, mean AWP decreased significantly during CPAP + PSV mode (14 ± 4, 14 ± 3, 10 ± 1 mmHg, respectively) (P < 0.01). CONCLUSIONS: The SctO2 was higher during CPAP + PSV ventilation and after extubation compared to IPPV and SIMV modes of ventilation. The mean AWP was lower during CPAP + PSV ventilation compared to IPPV and SIMV modes of ventilation.

Anesthesia management with single injection paravertebral block for aorta coarctation in infant.

BACKGROUND: Thoracotomy causes severe pain in the postoperative period. Perioperative thoracic paravertebral block reduces pain score and may improve outcome after pediatric cardiac surgery. This prospective study was designed for the efficacy and duration of a single level, single injection ultrasound-guided thoracic paravertebral block (TPVB) for fifteen infants undergoing aortic coarctation repair. METHODS: After approval of the ethical committee and the relatives of the patients, 15 infants who had undergone thoracotomy were enrolled in the study. The patients received 0.5 ml·kg(-1) a bolus 0.25% bupivacaine with epinephrine 1 : 200 000 at T5-6 level after standard general anesthesia induction. Anesthesia depth with Index of Consciousness (IOC) and tissue oxygen saturation with cerebral (rSO2-C) and somatic thoracodorsal (rSO2-S) were monitored. Intraoperative hemodynamic and postoperative hemodynamic and pain scores were evaluated for 24 h after surgery. Face, Legs, Activity, Cry, Consolability (FLACC) score was utilized to measure postoperative pain in the intensive care unit. Rescue 0.05 mg·kg(-1) IV morphine was applied to patients in whom FLACC was >3. RESULTS: The median age of the patients was 4.5 (1-11) months, and the median intraoperative endtidal isoflurane concentration was 0.6% (0.3-0.8). The amount of remifentanil used intraoperatively was 4.5 (2.5-14) µg·kg(-) (1) ·h(-1). Intraoperative heart rate and blood pressure values significantly decreased compared with values detected at 5th, 10th, and 15th min after TPVB application, after incision prior and after cross-clamp (P < 0.01). The median time of first dose of morphine application after block was 320 (185-430) min. The median morphine consumption in 24 h was 0.16 (0.09-0.4) mg·kg(-1). The median length of postoperative intensive care unit and in-hospital stay times was 23 (1-67) h and 4 (1-10) days, respectively. CONCLUSION: We believe that TPVB, as part of a balanced anesthetic and analgesic regime, provides effective pain relief in patients undergoing aortic coarctation repair.

Coronary artery fistula between left coronary artery and coronary sinus in newborn.

Aneurysmal circumflex coronary artery fistula connected to the coronary sinus is a rare clinical entity that usually remains asymptomatic until later in life. The timing of surgical treatment for asymptomatic patients is crucial. The decision to leave or exclude the aneurysmatic coronary artery following ligation of the fistula is controversial. Herein, we report the successful management of a coronary fistula between the circumflex artery and the coronary sinus without using cardiopulmonary bypass during the newborn period.

Early initiation of peritoneal dialysis after arterial switch operations in newborn patients.

BACKGROUND AND AIM: We investigated the clinical outcome of early initiated peritoneal dialysis (PD) use in our newborn patients who underwent arterial switch operation (ASO) for transposition of the great arteries (TGA) and had routine intraoperative PD catheter implantation. We determined the risk factors for PD, factors associated with prolonged PD, morbidity, and mortality. The aim of the present study was to describe our experience of using PD in this patient cohort. MATERIALS AND METHODS: Eighty two patients who were diagnosed with TGA and TGA-ventricular septal defect (VSD) and who had undergone TGA correction operation in Baskent University, Istanbul Medical Research and Training Hospital between 2007 and 2012 were retrospectively investigated. All the patients were under 30 days old. PD catheters were routinely implanted intraoperatively at the end of the operation. PD was initiated in transient renal insufficiency. In the absence of oliguria and increased creatinine level, PD was established in the presence of one of the following: clinical signs of fluid overload, hyperkalemia (>5 mEq/L), persistent metabolic acidosis, lactate level above 8 mmol/L or low cardiac output syndrome. The patients were divided into two groups according to the need for postoperative PD (PD group and non-PD group). PD was initiated in 32 (39%) patients after the operation, whereas 50 (61%) patients did not need dialysis. The clinical outcomes and perioperative data of the two groups were compared. RESULTS: The demographics in the two groups were similar. Cardiopulmonary bypass time was longer in the PD group [non-PD group, 175.24 ± 32.39 min; PD group, 196.22 ± 44.04 min (p < 0.05)]. Coronary anomaly was found to be higher in the PD group [non-PD group, n = 2 patients (4.0%); PD group, n = 7 patients (21.9%); p < 0.05]. There was more need for PD in TGA + VSD patients [simple TGA patients, n = 14; TGA + VSD patients, n = 18 (p < 0.05)]. PD rate was higher in patients whose sterna were left open at the end of the operation (p < 0.05). The ventilator time [non-PD group, 4.04 ± 1.51 days; PD group, 8.12 ± 5.21 days (p < 0.01)], intensive care unit stay time [non-PD group, 7.98 ± 5.80 days; PD group, 15.93 ± 18.31 days (p < 0.01)], and hospital stay time were significantly longer in the PD group [non-PD group, 14.98 ± 10.14 days; PD group, 22.84 ± 20.87 days (p < 0.01)]. CONCLUSION: We advocate routine implantation of PD catheters to patients with TGA-VSD, coronary artery anomaly, and open sternum in which we have determined high rate of postoperative PD need.

Delayed sternal closure after pediatric cardiac operations; single center experience: a retrospective study.

BACKGROUND: Delayed sternal closure (DSC) after cardiac surgery is a therapeutic option in the treatment of the severely impaired heart in pediatric cardiac surgery. The results with the technique of DSC over a 4-year period are examined with regard to mortality and morbidity. METHODS: We retrospectively reviewed records of 38 patients who had undergone DSC among 1100 congenital cardiac operations. Indication of DSC, time to sternal closure, pre and post closure cardiopulmonary and metabolic status, mortality, rate of wound and bloodstream infections were recorded. RESULTS: The mean sternal closure time was 2.9 days. The mortality rate was 34.2% (n = 13). Twenty (52.6%) patients required prolonged antibiotic use due to postoperative infection. There was gram negative microorganism predominance. There were 4 (10.5%) patients with postoperative mediastinitis. Postoperative infection rate statistically increased with cardiopulmonary bypass time (CPBT), sternal closure time (SCT) and intensive care unit (ICU) stay time (p = 0.039;p = 0.01;p = 0.012). On the other hand, the mortality rate significantly increased with increased cross clamp time (CCT), SCT, and extracorporeal membrane oxygenation (ECMO) use (p = 0.017; p = 0.026; p = 0.03). Single ventricular physiology was found to be risk factor for mortality in delayed sternal closure (p < 0.007). CONCLUSIONS: Elective DSC does not reduce the morbidity. The prolonged sternal closure time is associated with increased rate of postoperative infection rate; therefore early closure is strongly advocated.

Valve-sparing replacement of the ascending aorta and aortic arch in a child with Loeys-Dietz syndrome.

We describe a successful surgical treatment in a 2.5-year old boy with Loeys-Dietz syndrome, in whom we performed aortic arch and ascending aorta replacement with a valve-sparing operation (VSO) of the aortic root because of significant aortic insufficiency and dilation of the aortic root. We believe that VSO is ideal for treating young patients with aortic root aneurysm with normal or minimally diseased aortic cusps to avoid the disadvantages of prosthetic valve replacements.

Treatment of subaortic stenosis in hearts with single-ventricle physiology.

BACKGROUND: We evaluated the patients who had had a Damus-Kaye-Stansel (DKS) operation for single-ventricular physiology with the aorta originating from a hypoplastic ventricle and the pulmonary artery from the systemic ventricle. METHODS: Seven patients who were operated on between May 2007 and November 2010 were evaluated retrospectively. The patients had been diagnosed with a transposed double-inlet left ventricle and triscuspid atresia, and had been waiting for a Fontan operation. Systemic outflow stenosis was defined echocardiographically as those with a gradient greater than 20 mmHg, and angiographically those with greater than 5 mmHg in the subaortic region. RESULTS: The mean age and weight of the patients was 15 ± 9.7 months and 8 ± 3.3 kg, respectively. The mean gradient between the systemic ventricle and the aorta was 35 ± 25 mmHg. This gradient decreased to 14.3 ± 4 mmHg postoperatively. The early hospital mortality was 14% (one patient). The mean extubation time and mean time in the intensive care unit (ICU) were 13 ± 7.3 hours and 2.2 ± 0.5 days, respectively. The mean follow-up time was 11 ± 2 months. No mortality and semi-lunar valve insufficiency were observed after discharge. CONCLUSIONS: One of the major problems that occur while waiting for a Fontan operation is systemic ventricular hypertrophy and deterioration in the compliance of the ventricle due to systemic ventricular outflow stenosis. When the disadvantages of outflow resection are encountered, a DKS proves to be a good alternative.