Effect of Negative Pressure Wound Therapy With Instillation on Bioburden in Chronically Infected Wounds.

INTRODUCTION: Standard negative pressure wound therapy (NPWT) has been shown to help close wounds despite increasing planktonic bioburden. Both planktonic and biofilm critical colonization are associated with delayed wound healing; therefore, reducing microbial colonization is thought to aid wound healing. The use of NPWT with topical antimicrobial irrigation solution has previously shown reduction in quantitative planktonic bioburden when combined with sharp debridement in chronic wounds. OBJECTIVE: The goal of this study was to evaluate the effectiveness of NPWT with instillation (NPWTi) on biofilm of chronic wounds. MATERIALS AND METHODS: A prospective, randomized trial was conducted. Following sharp debridement, 20 patients with chronic wounds were randomized to 1 week of either NPWTi with 0.125% sodium hypochlorite solution (n = 10) or NPWT without instillation (n = 10). Serial wound biopsy was performed predebridement, postdebridement, and after 1 week of study therapy to test for quantitative nonplanktonic or biofilm-protected bacteria. RESULTS: As expected, there was no difference in change in wound size between the 2 groups at 1 week. The NPWTi group had a mean reduction in quantitative biofilm-protected bacteria of 48%, while the NPWT without instillation group had a mean increase of 14% (P < .05). DISCUSSION: Consistent with previous studies, this trial demonstrates that NPWTi with dilute sodium hypochlorite solution is effective at reducing nonplanktonic bioburden of chronically, critically colonized wounds. CONCLUSION: Therefore, based on this and previously published work, this therapy provides both planktonic and nonplanktonic bioburden reduction as well as NPWT benefits and may be a tool for the preparation of infected wound beds prior to definitive closure.

Non-Operative Management of Paget-Schroetter Syndrome: A Single-Center Experience.

OBJECTIVE: The preponderance of existing literature for the treatment of Paget-Schroetter syndrome (PSS) advocates clot lysis followed by thoracic outlet decompression (TOD). We postulate that long-term anticoagulation has equal outcomes to more invasive and costly surgical intervention, and review our experience with non-operative management of PSS. METHODS: A retrospective review was conducted, examining patients between 1994-2014. Forty patients were identified with PSS, and 27 of these patients had sufficient follow-up for this analysis. Charts were reviewed for details of clinical presentation, disease course, interventions, duration of oral anticoagulation, ultrasound reports, and symptoms at long-term follow-up. RESULTS: With a mean follow-up of 54.3 months, 23/27 patients (85%) were asymptomatic after non-operative therapy. In this cohort, 16/27 patients (59%) underwent catheter-directed thrombolysis. Average treatment course with oral anticoagulation was 8.6 months. Four patients (15%) remained symptomatic at follow-up. Two patients (7%) underwent thoracic outlet decompression at another institution, with good results. At least partial recanalization of vessels was documented in 25/27 patients (93%), although recanalization did not correlate with symptoms at long-term follow-up. CONCLUSIONS: Based upon equivalent functional results, non-operative management appears to offer similar outcomes for some patients with PSS. We propose a patient-tailored approach to the treatment of PSS, in which patients presenting acutely undergo catheter-directed thrombolysis, followed by a 6-12 month course of oral anticoagulation. Persistent symptoms, recurrent disease, lengthy duration of symptoms prior to diagnosis, and identifiable structural abnormalities may be factors predictive of poor outcomes after non-operative intervention.

Cost analysis of negative-pressure wound therapy with instillation for wound bed preparation preceding split-thickness skin grafts for massive (>100 cm(2)) chronic venous leg ulcers.

OBJECTIVE: Massive (≥100 cm(2)) venous leg ulcers (VLUs) demonstrate very low closure rates with standard compression therapy and are costly to manage. Negative-pressure wound therapy (NPWT), followed by a split-thickness skin graft (STSG), can be a cost-effective alternative to this standard care. We performed a cost analysis of these two treatments. METHODS: A retrospective review was performed of 10 ulcers treated with surgical debridement, 7 days of inpatient NPWT with topical antiseptic instillation (NPWTi), and STSG, with 4 additional days of inpatient NPWT bolster over the graft. Independent medical cost estimators were used to compare the cost of this treatment protocol with standard outpatient compression therapy. RESULTS: The average length of time ulcers were present before patients entered the study was 38 months (range, 3-120 months). Eight of 10 patients had complete VLU closure by 6 months after NPWTi with STSG. The 6-month costs of the proposed treatment protocol and standard twice-weekly compression therapy were estimated to be $27,000 and $28,000, respectively. CONCLUSIONS: NPWTi with STSG treatment is more effective for closure of massive VLUs at 6 months than that reported for standard compression therapy. Further, the cost of the proposed treatment protocol is comparable with standard compression therapy.

The evidence for nonoperative management of visceral artery dissections: a single-center experience.

BACKGROUND: Spontaneous isolated visceral artery dissection is an uncommon condition encountered by clinicians. Presentation may vary from asymptomatic to acute intestinal ischemia, although a clear natural history has yet to be elucidated. No consensus exists on how best to manage these patients in the absence of true intestinal ischemia; however, much of the literature suggests that intervention is required. We present our institution's experience with 10 patients, both symptomatic and asymptomatic, all but 1 of whom was managed medically. METHODS: From September 2009 to August 2013, 10 patients presented to our institution with celiac or mesenteric artery dissection. We retrospectively reviewed these patients' clinical presentation, treatment, and follow-up. RESULTS: The mean age of the patients was 61.5 ± 10.3 (standard deviation [SD]) years (range, 41-77 years), and the mean follow-up period was 14.7 ± 11.6 (SD) months (range, 1-31 months). Four (40%) patients had abdominal pain and no ischemic changes of the bowel. There were 1 type I, 6 type II, 2 type III, and 1 type IV dissections according to Sakamoto classification. Treatments included observation without anticoagulation treatment in 8 patients (80%), anticoagulation treatment in 1 patient (10%), and endovascular stenting in 1 patient (10%) with unremitting abdominal pain. Anticoagulation was used in the 1 symptomatic patient with radiographic evidence of associated thrombus. The disease stabilized in all patients during follow-up. CONCLUSIONS: Most authors tend to advocate an endovascular or even operative repair for these processes. In our experience, most of these patients have a self-limited course of symptoms or their dissections are found incidentally. We believe that the results of conservative management in our cohort of patients support the conservative approach over the once recommended operative repair.

Office based therapies for complex lower extremity epithelial defects.

The chronic wound environment and the ideal way in which to regenerate healthy tissue remain enigmas in the field of wound healing. There are multiple modalities that have been evaluated in an attempt to discern the most clinically beneficial and cost-effective treatment strategies for the millions of individuals who suffer from chronic wounds and their associated morbidity. Engineered skin substitutes represent one of the novel and continuously evolving approaches to providing wound coverage and regenerating functional skin. Herein we describe a number of the products available and the literature to date on their use and efficacy. We will close with a discussion of the cost-reimbursement structure for these products, which is currently undergoing an important shift.

Outcomes of combined somatosensory evoked potential, motor evoked potential, and electroencephalography monitoring during carotid endarterectomy.

BACKGROUND: While much has been written about multiple methods of neuromonitoring during carotid endarterectomy (CEA), there has been relatively little discussion of the use of triple monitoring via somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) in conjunction with electroencephalography (EEG). Our objective was to evaluate the rate of detection and prevention of neurologic events by multinerve SEP, MEP, and EEG in patients undergoing CEA while under general anesthesia. METHODS: A prospective study of 181 consecutive patients undergoing CEA between June 2005 and September 2010 was reviewed. Intraoperative changes, including a 50% reduction in the amplitude of SEP waveforms, loss of MEP, and/or a 50% change in EEG frequency were noted as indications for shunting. This was correlated with the actual use of intraoperative shunting and postoperative neurologic sequelae at both 24 hours and 30 days. Median and tibial nerve SEPs and MEPs were also correlated. RESULTS: Eleven patients (6%) experienced intraoperative monitoring changes (SEP: 11/11; MEP: 6/11). Five of 11 patients with MEP/SEP changes underwent shunting, while the other 6 had normalization with the elevation of their blood pressure. Of the 11 patients that had neurophysiologic changes, 54% (6/11) were patients with symptomatic disease. No patients had significant EEG changes. The total shunt rate was 2.7% (5/181). No postoperative neurologic sequelae were noted. CONCLUSION: The ratio of shunting at 2.7% is equal to the lowest rates reported in the awake patient literature. Interestingly, the predicted synergy of multimodality monitoring cannot be directly attributed to an increased specificity resulting from the addition of SEP and MEP to EEG, because no patients had EEG changes. In addition, in today's cost-conscious world of health care, our results do not justify implementing this particular technique of neuromonitoring across the board-but it is apparent that the combination of these 3 modalities is both safe and effective with potential applications in symptomatic patients.