Hyperbaric Oxygen Therapy in Management of Diabetic Foot Ulcers: Indocyanine Green Angiography May Be Used as a Biomarker to Analyze Perfusion and Predict Response to Treatment.

SUMMARY: The authors present indocyanine green angiography to assess the effects of hyperbaric oxygen therapy and as a potential biomarker to predict healing of chronic wounds. They hypothesize that favorable initial response to hyperbaric oxygen therapy (improved perfusion) would be an early indicator of eventual response to the treatment (wound healing). Two groups were recruited: patients with chronic wounds and unwounded healthy controls. Inclusion criteria included adults with only one active wound of Wagner grade III diabetic foot ulcer or caused by soft-tissue radionecrosis. Patients with chronic wounds underwent 30 to 40 consecutive hyperbaric oxygen therapy sessions, once per day, 5 days per week; controls underwent two consecutive sessions. Indocyanine green angiography was performed before and after the sessions, and perfusion patterns were analyzed. Healing was determined clinically and defined as full skin epithelialization with no clinical evidence of wound drainage. Fourteen chronic-wound patients and 10 controls were enrolled. Unlike unwounded healthy volunteers, a significant increase in indocyanine green angiography perfusion was found in chronic-wound patients immediately after therapy (p < 0.03). Moreover, the authors found that 100 percent of the wounds that demonstrated improved perfusion from session 1 to session 2 went on to heal within 30 days of hyperbaric oxygen therapy completion, compared with none in the subgroup that did not demonstrate improved perfusion (p < 0.01). This study demonstrates a beneficial impact of hyperbaric oxygen therapy on perfusion in chronic wounds by ameliorating hypoxia and improving angiogenesis, and also proposes a potential role for indocyanine green angiography in early identification of those who would benefit the most from hyperbaric oxygen therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Er:YAG laser vs. sharp debridement in management of chronic wounds: Effects on pain and bacterial load.

Chronic wounds affect roughly 6.5 million patients in the US annually. Current standard of therapy entails weekly sharp debridement. However, the sharp technique is associated with significant pain, while having minimal impact on the bioburden. Our study proposes the Er:YAG laser as an alternative method of debridement that may decrease procedural pain, reduce bioburden, and potentially improve overall healing. This pilot study was performed as a prospective, randomized, controlled, crossover clinical trial, containing two groups: (1) one group underwent single laser debridement session first, followed by single sharp debridement session one week later; and (2) the other group underwent single sharp debridement session first, followed by single laser debridement session one week later. Variables analyzed included pain during debridement, pre- and post-debridement wound sizes, pre- and post-debridement bacterial loads and patient preference. Twenty-two patients were enrolled (12 patients in Group 1, plus 10 patients in Group 2). The mean pain score for patients undergoing laser debridement was 3.0 ± 1.7 vs. 4.8 ± 2.6 for those undergoing sharp debridement (p = 0.003). The mean percent change in wound size 1-week post-laser debridement was -20.8% ± 80.1%, as compared with -36.7% ± 54.3% 1-week post-sharp debridement (p = 0.6). The percentage of patients who had a bacterial load in the low/negative category increased from 27.3% to 59.1% immediately after laser debridement (p = 0.04), vs. 54.5% to 68.2% immediately after sharp debridement (p = 0.38). Moreover, there was a sustained decrease in bacterial load 1-week post-laser debridement, as compared with no sustained decrease 1-week post-sharp debridement (p < 0.02). Overall, 52.9% of patients preferred laser debridement vs. 35.3% for sharp debridement. We believe that Er:YAG laser serves as a promising technology in chronic wounds, functioning as a potentially superior alternative to sharp debridement, the current standard of therapy.

Refinements and secondary surgery after flap reconstruction of the traumatized hand.

The traumatized hand often has soft tissue loss requiring flap reconstruction. Before proceeding with flap selection, the need for future refinement and secondary surgery should be taken into consideration. Although muscle flaps may offer better contour, fasciocutaneous flaps allow easier secondary flap elevation. After the initial flap reconstruction, indications for secondary procedures may be managed according to tissue type: bone, joint, tendon, nerve, and soft tissue.

Magnetic resonance imaging for detection of brain abnormalities in fetuses with cleft lip and/or cleft palate.

OBJECTIVE: To determine the prevalence of brain abnormalities identified by prenatal imaging of fetuses with cleft lip with or without cleft palate (CL/P) or cleft palate only (CP) and to compare with postnatal imaging and neurologic evaluation. DESIGN: This was a retrospective review of radiologic images (magnetic resonance imaging [MRI] and sonography) of fetuses diagnosed with CL/P or CP at the Advanced Fetal Care Center at Children's Hospital Boston between 2002 and 2008. Images were reviewed for possible brain abnormalities by a pediatric radiologist who specializes in this field. Postnatal imaging was also assessed whenever available and correlated with clinical findings. SETTING: A large, tertiary-care, academic pediatric hospital. POPULATION: One hundred twenty-six fetuses and 105 corresponding infants. RESULTS: Brain abnormalities were found in 8 of 126 fetuses (6.3%) by prenatal MRI. The malformations were corpus callosal dysgenesis (n = 3), encephalocele (n = 1), hypoplasia of the cerebellar hemispheres or vermis (n = 3), and white matter neuronal migration anomaly (n = 1). An additional 2 patients were diagnosed with brain abnormalities postnatally that had not been detected on prenatal imaging. CONCLUSIONS: The possibility of brain anomalies should be assessed in a fetus found to have CL/P or CP by sonography and/or MRI. Central nervous system imaging and careful neurodevelopmental follow-up is indicated in these infants.

Two routine blood tests-mean corpuscular volume and aspartate aminotransferase-as predictors of delirium tremens in trauma patients.

BACKGROUND: Delirium tremens (DT) in trauma patients is associated with significant morbidity and mortality. Short interview tools have been used to determine the risk of DT but require an alert, compliant patient and a motivated physician. The mean corpuscular volume (MCV) and aspartate aminotransferase (AST) levels are parts of routine laboratory testing, influenced by excessive alcohol consumption, and may serve as predictors of DT. This study examines the predictive ability of these two readily available biological markers. METHODS: The records of 423 consecutive trauma patients who presented to a Level I trauma center with a positive toxicology screen for alcohol were reviewed. The outcome variable was DT, as defined by the presence of tremor, diaphoresis, autonomic instability, and hallucinations. The positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR) of the admission MCV and AST values were calculated for the prediction of DT. RESULTS: Of the 336 patients who met the criteria for study participation, 110 were diagnosed with DT due to alcohol withdrawal. When the admission MCV and AST were normal, only 3 patients (3.8%) developed DT. The NPV, PPV, and LR with two normal values together were 58.2%, 3.8%, and 0.080, respectively. When both were abnormal, 72 patients (64.3%) developed DT. The NPV, PPV, and LR with two abnormal values together were 83%, 64.3%, and 3.698, respectively. CONCLUSION: Normal admission MCV and AST values in intoxicated trauma patients nearly exclude the development of DT.