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.

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.

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.

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.

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.

Attenuated cardiovascular response to sympathetic system activation during exercise in patients with dialysis-induced hypotension.

BACKGROUND: We wished to investigate potential causes of dialysis-induced hypotension (DIH), including the attenuated cardiovascular response to sympathetic system activation during exercise and myocardial dysfunction. METHODS: This study included 26 end-stage renal disease (ESRD) patients with DIH, 30 ESRD patients without DIH (Non-DIH), and 30 control subjects. Each patient was evaluated with echocardiography and a symptom-limited treadmill stress test. The chronotropic index (CRI), heart rate recovery (HRR), systolic blood pressure response to exercise (SBP response), and tissue Doppler systolic myocardial velocities were calculated. RESULTS: The HRR and velocities were reduced in dialysis patients compared to controls; however, they were similar in patients with and without DIH. Patients with DIH had the lowest CRI compared to the Non-DIH group (0.62 ± 0.15 vs. 0.73 ± 0.17, p = 0.020) and controls (0.62 ± 0.15 vs. 0.86 ± 0.11, p < 0.001). Similarly, patients with DIH had the lowest SBP response values compared to the Non-DIH (34.88 ± 15.01 vs. 55.67 ± 25.42, p = 0.002) and controls (34.88 ± 15.01 vs. 59.70 ± 23.04, p < 0.001). CONCLUSION: Patients with DIH have inadequate sympathetic activity of the cardiovascular system during exercise and impaired left ventricular systolic function. Both factors could contribute to the development of hypotension during hemodialysis.

A new technique to avoid the intraoperative complications of septal myectomy in patients with obstructive hypertrophic cardiomyopathy.

Although transaortic septal myectomy in obstructive hypertrophic cardiomyopathy (OHC) is accepted as a safe procedure, it may end up with serious peroperative complications. We developed a practical method to avoid this unfavorable outcome by using a 20-cc syringe body. We believe this apparatus will provide safe and effective septal myectomy procedures without additional cost.

Posterior pericardial annuloplasty in ischemic mitral regurgitation.

BACKGROUND: Ischemic mitral regurgitation (IMR) is an important risk factor in coronary artery bypass grafting (CABG) operations. The decision to perform concomitant mitral annuloplasty along with the CABG depends on the surgeon's choice. The aim of this study was to evaluate the results of posterior annuloplasty procedures with autologous pericardium performed in patients with midadvanced and advanced functional ischemic mitral regurgitation. METHODS: Study participants were 36 patients with IMR (mean age 59 +/- 10 years) who underwent posterior pericardial annuloplasty and CABG operations between 2002 and 2007. Preoperative and postoperative (mean follow-up 18 +/- 1 months) MR grade, left atrium diameter, left ventricle end systolic diameter, left ventricle end diastolic diameter, left ventricle ejection fraction, and mitral valve gradients were measured with transthoracic echocardiography. RESULTS: There was one late mortality (2, 8%) but none of the patients required reoperation for residual MR. We did not observe thromboembolism, bleeding, or infective endocarditis. The mean MR grade decreased from 3.4 +/- 0.5 to 0.5 +/- 0.6 (P < .01), left atrium diameter decreased from 45.3 +/- 5.5 mm to 43.2 +/- 3.8 mm (P < .01), left ventricle end diastolic diameter decreased from 53.2 +/- 5.6 mm to 50.9 +/- 5.5 mm (P < .01), and left ventricle end systolic diameter decreased from 39.7 +/- 5.8 mm to 34.6 +/- 6.5 mm (P < .01), whereas mean left ventricle ejection fraction increased from 37.9% +/- 6.1% to 43.7% +/- 7.3% (P < .01). In the late postoperative term, the functional capacity of the patients increased from mean New York Heart Association class 2.6 +/- 0.9 to 1.1 +/- 0.5. We did not observe any gradient in the mitral valve preoperatively in any patient, but in the follow-up, the mean gradient increased to 1.3 +/- 2.1 mmHg (P < .01). CONCLUSION: Posterior pericardial annuloplasty with CABG in the treatment of IMR provides efficient mitral repair and significant decrease in the left atrium and left ventricle diameters, and provides a significant increase in left ventricular function. These results show IMR to be as effective as the other annuloplasty techniques. IMR is performed with autologous material and therefore does not entail any risk of complications from prosthetic material and is highly cost-effective.

Revascularization of left anterior descending (LAD) artery with in situ left internal thoracic artery (LITA) and coronary-coronary free LITA grafts: 12-year patency.

BACKGROUND: We aim to present a patient with coronary-coronary bypass grafting (CCBG), left anterior descending-left anterior descending (LAD-LAD) coronary artery bypass with left internal thoracic artery (LITA), and provide the 12-year follow-up angiogram to confirm the longest reported patency. METHODS AND RESULTS: A 57-year-old man with three vessel disease where LAD had multiple lesions was operated on. LITA with pedicle was grafted in situ onto the proximal LAD, and the distal residual segment was used as a free LITA graft to bypass the distal stenosis. The postoperative course was uneventful. The patient has been recently readmitted to our clinic with atypical chest pain. In angiography, all of the bypasses, including the free LITA graft, were patent. CONCLUSIONS: We used free LITA graft to bypass the distal lesions of LAD in selected patients as a valid alternative to sequential bypass grafting. To the best of our knowledge, this is the only angiographic view of a CCBG in LAD with LITA graft confirming the long-term patency.

Inflammatory aneurysm of arcus aorta with massive hemoptysis.

A 72-year-old woman was admitted to the intensive care unit with a diagnosis of acute coronary syndrome. An aneurysm in the aortic arch was detected in the radiologic investigations. The aortic arch was replaced with a Dacron graft with the patient under total circulatory arrest. A pathology evaluation revealed an inflammatory aneurysm. To date, a few cases of inflammatory aneurysms of the aortic arch have been reported. Unlike the previously reported cases, the aneurysm in our case unexpectedly presented with massive hemoptysis.

An alternative reinforced closure technique with external Kirschner wires in sternal dehiscence.

OBJECTIVE: We present an alternative closure technique that is effective in length stabilization of the dehisced sternum, technically easy, and less time consuming. METHODS: Between June 2000 and June 2003, 850 patients underwent open heart surgery in the participating clinics. In all of the patients, the sternotomies were primarily closed with No. 5 steel wires in a figure 8 manner or with single sutures. Eleven patients with sterile sternal dehiscence underwent operations with Kirschner wires. RESULTS: During the postoperative period, no complications related to the implants were observed in any of the patients in the early and late follow-ups. CONCLUSION: With this technique, the fragile sternum is easily and effectively stabilized by reinforcing with suprasternal Kirschner wires without applying complicated manipulations.

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.

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.

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.