Flow-through Instillation of Hypochlorous Acid in the Treatment of Necrotizing Fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is a rare and rapidly progressing bacterial infection of soft tissues. Bacterial toxins cause local tissue damage and necrosis, as well as blunt immune system responses. A self-propagating cycle of bacterial invasion, toxin release and tissue destruction can continue until substantial amounts of tissue become necrotic. Neutralization of bacterial toxins should improve the results. MATERIALS AND METHODS: Pure hypochlorous acid (HOCl) (0.01% w/v) with no sodium hypochlorite impurity in saline pH 4-5, which was recently shown to both eradicate bacteria and neutralize bacterial toxins in vitro, was administered via flowthrough instillation to 6 patients with NF 4-6 times daily as needed. Utilizing a vacuum-assisted closure, 5-10 mL of pure 0.01% HOCl with no sodium hypochlorite impurity was instilled and removed frequently to irrigate the wounds. RESULTS: Of the 6 patients, no deaths or limb amputations occurred. All infected areas healed completely without major complications. CONCLUSION: The toxicity and immune dysfunction caused by bacterial toxins and toxins released from damaged cells may be mitigated by flow-through instillation with saline containing pure 0.01% HOCl with no sodium hypochlorite impurity. Randomized controlled clinical trial research of this relatively simple and inexpensive instillation protocol is suggested for identified cases of NF.

Delay of adjuvant chemotherapy after elective mastectomy and immediate reconstruction in breast-conservation candidates: a matched-pair analysis.

OBJECTIVES: To analyze factors that influence the timing of adjuvant chemotherapy in patients who are candidates for breast-conservation therapy (BCT) but elect mastectomy with immediate reconstruction (M-IR). METHODS: We identified 35 consecutively treated patients with stage I or II breast cancer between 2004 and 2009 who underwent M-IR and adjuvant chemotherapy from the University of Louisville Cancer Registry. We matched these patients for age and AJCC stage to 35 controls who underwent BCT and adjuvant chemotherapy. We examined the timing and delay of initiation of chemotherapy using univariate logistic regression and McNemar test for matched pairs. RESULTS: For the 70 patients evaluated, the median age was 46 years (range, 30 to 65 y), and the distribution for stage I, IIA, and IIB was 22.9%, 65.7%, and 11.4%, respectively. The 2 groups were well balanced in terms of race, rural/urban status, smoking, diabetes, insurance coverage, and histology. For BCT and M-IR, the median time to chemotherapy initiation was 38 days (range, 25 to 103 d) and 55 days (range, 30 to 165 d), respectively. Patients undergoing M-IR were more likely to experience any delay (>45 d; 54.3% vs. 22.9%; P<0.001) and/or significant delay (>90 d; 20.0% vs. 2.9%; P<0.001). On univariate logistic regression analysis, surgery type had a major impact on delay of chemotherapy (odds ratio=8.35; 95% confidence interval, 2.86-24.4; P<0.001). CONCLUSIONS: The use of M-IR in breast-conservation candidates independently predicts for delay in initiation of adjuvant chemotherapy. Further study is needed to qualify the causes and clinical significance of these delays.

Treatment of Acute Necrotizing Fasciitis Using Negative Pressure Wound Therapy and Adjunctive NeutroPhase Irrigation Under the Foam.

Necrotizing fasciitis is a complication of a bacterial infection that activates the immune system in perifascial planes. This case report highlights initial diagnostic failures that delay early treatment, which causes profoundly negative consequences. Antimicrobial control with abolition of the inciting bacteria does not neutralize the subsequent endopathologic ravages. A new therapeutic technique, which combines negative pressure wound therapy (NPWT) and a pure hypochlorous acid solution 0.01% (NeutroPhase, NovaBay Pharmaceuticals Inc, Emeryville, CA) along with debridement and antibiotics is described in this study. It is believed that the combination of neutralization of the toxins produced by bacteria with NeutroPhase along with the NPWT action of removing exudates is effective in saving the patient.

NeutroPhase(®) in chronic non-healing wounds.

Chronic non-healing wounds, such as venous stasis ulcers, diabetic ulcers, and pressure ulcers are serious unmet medical needs that affect a patient's morbidity and mortality. Common pathogens observed in chronic non-healing wounds are Staphylococcus including MRSA, Pseudomonas, Enterobacter, Stenotrophomonas, and Serratia spp. Topical and systemically administered antibiotics do not adequately decrease the level of bacteria or the associated biofilm in chronic granulating wounds and the use of sub-lethal concentrations of antibiotics can lead to resistant phenotypes. Furthermore, topical antiseptics may not be fully effective and can actually impede wound healing. We show 5 representative examples from our more than 30 clinical case studies using NeutroPhase(®) as an irrigation solution with chronic non-healing wounds with and without the technique of negative pressure wound therapy (NPWT). NeutroPhase(®) is pure 0.01% hypochlorous acid (i.e. >97% relative molar distribution of active chlorine species as HOCl) in a 0.9% saline solution at pH 4-5 and is stored in glass containers. NovaBay has three FDA cleared 510(k)s. Patients showed a profound improvement and marked accelerated rates of wound healing using NeutroPhase(®) with and without NPWT. NeutroPhase(®) was non-toxic to living tissues.

One decade later: trends and disparities in the application of post-mastectomy radiotherapy since the release of the American Society of Clinical Oncology clinical practice guidelines.

PURPOSE: In 2001 ASCO published practice guidelines for post mastectomy radiotherapy (PMRT). We analyzed factors that influence the receipt of radiotherapy therapy and trends over time. METHODS AND MATERIALS: We analyzed 8889 women who underwent mastectomy as primary surgical treatment for stage II or III breast cancer between 1995 and 2008 using data from the Kentucky Cancer Registry. We categorized patients according to ASCO group: group 1, PMRT not routinely recommended (T2, N0); group 2, PMRT controversial/evidence insufficient (T1-2, N1); group 3, PMRT recommended or suggested (T3-4 or N2-3). Probability of receiving PMRT was assessed using logistic regression. RESULTS: Overall, 24.0% of women received PMRT over the study period. The rates of PMRT for group 1, 2, and 3 were 7.5%, 19.5%, and 47.3%, respectively. Since 2001, there was an increase in the use of PMRT (from 21.1%-26.5%, P<.0001), which occurred mainly among group 3 members (from 40.8%-51.2%, P<.0001). The average rate remained constant in group 1 (from 7.1%-7.4%, P=.266) and decreased in group 2 (from 20.0%-18.1%, P<.0001). On multivariate analysis, the rate of PMRT was significantly lower for women aged >70 years (vs. younger), rural Appalachia (vs. non-Appalachia) populations, and Medicaid (vs. privately insured) patients. CONCLUSIONS: ASCO guidelines have influenced practice in an underserved state; however PMRT remains underused, even for highest-risk patients. Barriers exist for elderly, rural and poor patients, which independently predict for lack of adequate care. Updated guidelines are needed to clarify the use of PMRT for patients with T1-2, N1 disease.

Interfraction accumulation of seroma during accelerated partial breast irradiation: preliminary results of a prospective study.

PURPOSE: To quantify and characterize the process of seroma accumulation during accelerated partial breast irradiation using multicatheter balloon brachytherapy. MATERIALS AND METHODS: Twenty-two patients were treated using the Contura Multilumen brachytherapy catheter to a dose of 34Gy in 10 fractions over 5 treatment days. Serial aspirations of the vacuum port of the catheter were performed at the time of CT simulation and before each treatment. Volume and characteristics of fluid drawn were recorded. Univariate analysis was performed to evaluate various factors predictive of seroma formation. RESULTS: Median patient age was 59.5 years, body mass index was 31, and volume of surgical specimen was 62.4cm(3). Median time from breast conservation surgery to placement of Contura catheter was 18.5 days. Pericatheter seroma, typically scant with a median volume of 0.75mL, was noted in 91% of patients at CT simulation. A total of 203 aspirations were performed with a median-aspirated seroma volume of 4.05mL. There was no significant correlation between the volume of seroma and histology (invasive vs. in situ), quadrant of location, body mass index, reexcision or reoperation, days from breast conservation surgery to balloon placement, or the volume of specimen removed. Radiation treatment factors, including balloon volume, balloon to skin distance, and planning target volume evaluation, also did not correlate with aspirated seroma. CONCLUSIONS: Interfraction seroma accumulation has a variable pattern of development with no discernible predictors of occurrence. Routine pretreatment aspirations via vacuum port may potentially improve dosimetric reproducibility for a minority of patients.

Columbia University/New York-Presbyterian Hospital: improving access to renal transplantation.

There continues to be an increasing disparity between organ supply and demand in kidney transplantation with over 87,000 patients currently on the waiting list. Prolonged waiting times on dialysis is associated with significant morbidity and mortality rates. At Columbia University Medical Center/New York-Presbyterian Hospital we have implemented several strategies to improve access to transplantation. Here we present these key steps that have resulted in a significant reduction in our median waiting times and successfully increased the rate of transplantation at our center.

Mycophenolate mofetil (MMF) vs placebo in patients with moderately advanced IgA nephropathy: a double-blind randomized controlled trial.

BACKGROUND: IgA nephropathy (IgAN) is the most common form of glomerulonephritis worldwide. Up to 40% progress to end-stage renal disease (ESRD) over 10-20 years. Currently, treatment is limited. We studied the use of mycophenolate mofetil (MMF) vs placebo in a group of North American IgAN patients at high risk for progressive disease. METHODS: Included were 32 patients aged 18-75 years from multiple centres who had their biopsies read at Columbia and who had at least 1 g of proteinuria per day plus at least two of the following risk factors: (i) male sex; (ii) hypertension >150/90 mmHg or requiring antihypertensive medications; (iii) creatinine clearance, measured by 24 h urine collection, <80 and >20 ml/min at time of enrolment; and (iv) presence of glomerulosclerosis or tubulointerstitial atrophy and fibrosis on renal biopsy. Patients were randomized to either 1 year of MMF, titrated up to a dose of 1000 mg bid, or placebo. Total follow-up was 2 years. All patients received angiotensin inhibition medication. The primary outcome was a 50% increase in baseline serum creatinine (SCr). Secondary outcomes were an increase of 0.5 mg/dl SCr, ESRD and a 50% reduction in proteinuria. RESULTS: The mean baseline SCr was 2.4 mg/dl. No statistically significant differences were observed for any outcome. Five of 17 who received MMF vs two of 15 patients in the placebo group reached a 50% increase in SCr (P = 0.4). In both groups, all patients who reached the primary outcome also reached ESRD. Ten who received MMF vs seven who received placebo had a 0.5 mg/dl increase in SCr (P = 0.7) Only three MMF and two placebo patients had a 50% reduction in 24 h proteinuria. No serious adverse events occurred in either group. CONCLUSION: No benefit was seen in patients who received MMF in this high risk group, probably reflecting the relatively advanced stage of disease of our population. We conclude that MMF is probably not effective in patients with IgAN who already have moderate renal insufficiency.

Chronic Wounds Yesterday's Challenges Healing Today.

Chronic, non-healing wounds have been a challenge to surgeons for years. Physicians get frustrated trying multiple modalities to heal the wounds with varying degrees of success. Patients and their families get impatient and depressed because the wounds will not heal. Hospitals in the US lose money on these patients because so many of them are in the Medicare population and require lengthy hospitalisations. Third party payors spend inordinate amounts of money on these patients since they require on-going care even though they are not healing. This scenario is a major challenge in health care today as we face caring for an aging population more prone to chronic wounds.

Transmyocardial Revascularisation by CO2 Laser.

Anatomical channels connecting the left ventricular chamber to the myocardial sinusoids supplying the left ventricle with oxygenated blood in the human heart were described by Dr Wearn in 1933. He microscopically confirmed these communicating vessels or tiny clusters of arteries by gelatin filling. The second type of these channels was located at the end of the vessels almost as though woven into the fabric of the muscular fibres. These irregular shaped blood vessels were called myocardial sinusoids. Three other early investigators described connecting channels. The first was Adrian Christian Thebesius, a Dutch physician in 1708 who described connections from the atrium the coronary veins which were called Thebesian veins. The second was the American physiologist F H Pratt who, in 1898, perfused blood though the ventricle alone in a cat, keeping it alive for more than an hour. Finally, the historical work of R T Grant who in 1926 reported that a congenitally deformed heart in a child had connecting cavities with the surrounding veins and arteries.