Prolonged Healing Research Articles

Sydenham's Chorea; Clinical and Magnetic Resonance Imaging Findings, a Retrospective Observational Study in Children

AbstractThe purpose of this study was to evaluate the correlation between magnetic resonance imaging (MRI) findings and demographic and clinical characteristics, response to treatment times, and recurrence rates of Sydenham's chorea (SC), the most common of the acquired pediatric choreas. The clinical and radiological findings of 12 patients presenting to the pediatric neurology clinic in the previous 4 years and diagnosed with SC on the basis of the modified Jones criteria were investigated retrospectively from the hospital files. In addition, we measured the maximum prefrontal cortex and basal ganglia (globus pallidus, putamen, and caudate nucleus) thicknesses in the axial plane from patients' cerebral MRIs and compared these values with prefrontal cortex and basal ganglia thicknesses of a healthy control group measured using the same technique. Patient and control groups' cranial and basal ganglia MRIs were found to be normal. However, patients' globus pallidus thicknesses were significantly lower than those of the healthy control group. Additionally, the globus pallidus values of patients with recurrent SC and a prolonged healing time were lower than average. However, we determined no significant difference in terms of prefrontal motor cortex, caudate nucleus, or putamen thicknesses between the patient and control groups. Low globus pallidus thicknesses in patients with SC may indicate atrophy associated with globus pallidus involvement. Further experimental and prospective and long-term studies are needed for a better understanding of the factors affecting the pathophysiology, recurrence, and healing time of SC.

Evaluation of the Intraoperative Blood Flow of Pedicled Perforator Flaps Using Indocyanine Green-fluorescence Angiography.

Background:Although indocyanine-green fluorescence angiography (ICG-FA) has been established as a useful tool to assess perfusion in free tissue transfer, only few studies have applied this modality to pedicled perforator flaps. As both volume and reach of pedicled perforator flaps are limited and tip necrosis often equals complete flap failure, ICG-FA may help to detect hypoperfusion in pedicled flaps.Methods:In 5 patients, soft tissue reconstruction was achieved with pedicled perforator flaps. ICG-FA was utilized intraoperatively to visualize flap perfusion.Results:Three pedicled anterolateral thigh flap flaps and 2 propeller flaps were transferred. ICG-FA detected hypoperfusion in 2 flaps. No flap loss occurred; in 2 cases, prolonged wound healing was encountered.Conclusions:ICG-FA confirmed clinical findings and reliably detected tissue areas with hypoperfusion. A clear cut-off point between nonvital tissue and such that stabilized in the following clinical course could not be found. ICG-FA is a promising technology which could also be used in pedicled perforator flaps.

Small Incision in Lower Posterior Axillary Wall Combining Multihole Drainage Technique for the Treatment of Axillary Bromhidrosis

Surgical excision of apocrine glands is an effective method for the treatment of bromhidrosis. However, common postoperative complications such as skin necrosis can result in prolonged healing and unsightly scars, which are mainly caused by surgical injuries and seroma or hematoma formation. We have improved the traditional surgical methods, in the hope that the new method can not only ensure the surgical effect, but also minimize the surgical trauma and postoperative complications. Forty-four patients with bromhidrosis were included. A 1-cm incision was made in the posterior wall of the lower axilla. Tissue scissors completely separated the skin from the subcutaneous tissue of glandular distribution. Iris scissors were used to trim subcutaneous glandular tissue, until there was only full-thickness skin left. Residual glandular tissue was removed with serrated edge curettage. After adequate irrigation and hemostasis, a drainage strip was placed in the incision. Then, we evenly divided the surgical area into 8 sections. In the center of each section, a draining hole was made. Of the 88 axillae, malodor was eradicated in 84 and considerably reduced in 4. Although 6 arms had temporary edema, and 10 axillae experienced superficial epidermal necrosis, no full-thickness skin necrosis was observed. Complications like hematoma, seroma, and infection were not present in all cases. All the scars of the incision and drainage holes were inconspicuous. The use of small incisions in the posterior axillary wall could accomplish sweat gland elimination and simultaneously provide excellent drainage. Combining this with porous drainage can effectively prevent hematoma, skin necrosis, and scar formation.

The management of herpes labialis, oral thrush and angular cheilitis in cases of oral diabetes

Background: As reported in several studies, prolonged or uncontrolled cases of diabetes mellitus (DM) may induce a more extreme inflammatory response. Mucosal lesions can be observed in patients who present this systemic condition. Purpose: The purpose of this study was to elaborate the management of herpes labialis, oral thrush and angular cheilitis as oral manifestations of diabetes. Case: A 49-year-old male complained of having experienced painful lip ulceration for the preceding seven days. The anamnesis of the patient revealed that, prior to lip ulceration, he had experienced high fever and malaise in addition to frequent urination at night and a tingling sensation in the toes and fingertips on waking. Case management: The patient was referred to undergo blood count, fasting blood glucose and oral glucose tolerance tests. The blood test result confirmed the patient to be suffering from DM and anemia. The immunocompromised condition of the patient prompted the occurrence of herpes labialis, oral thrush and angular cheilitis. Conclusion: Multidisciplinary treatment for herpes labialis resulting in oral candidiasis in DM patients is indispensable. Concurrent infection with HSV and candidiasis necessitates a more prolonged healing process. Consequently, it is a essential to treat the hyperglycemia which induces an immunocompromised state in diabetic patients.

Surgical drainage of lactational breast abscess with ultrasound-guided Encor vacuum-assisted breast biopsy system.

Lactational breast abscess is a serious complication of mastitis and commonly diagnosed in breast‐feeding women. The traditional drainage of breast abscess was often performed with incisive technique which may result in prolonged healing time, regular dressings, dressing pain, interfering with breastfeeding and unsatisfactory cosmetic outcome. As minimal invasive alternatives to incisive drainage, needle aspiration or percutaneous catheter placement cannot completely replace incisive drainage for the inability to treat large, multiloculated or chronic abscess. Vacuum‐assisted breast biopsy system (VABB) has been successfully applied in the treatment of benign breast diseases with satisfactory cosmetic outcomes. Among VABB devices, EnCor system has some distinctive features that make it an appropriate candidate for the treatment of lactational breast abscesses. In this study, for the first time, we investigated the feasibility, efficacy, and cosmetic results of surgical drainage of lactational breast abscess with US‐guided Encor VABB system. Our data suggests this procedure could serve as a promising alternative for women with lactational breast abscess who require incisive intervention with high cure rate, relatively short healing time, low recurrence rate, few complications, satisfactory cosmetics outcome and without interfering with breastfeeding.

Plasma Bleomycin Concentrations during Electrochemotherapeutic Treatment of Fibropapillomas in Green Turtles Chelonia mydas.

Fibropapillomatosis of sea turtles is traditionally treated with surgical debulking techniques that are often associated with prolonged healing and tumor recurrence. Electrochemotherapy was recently described for green turtles Chelonia mydas and can be an alternative to surgery and even general anesthesia. The objectives of this study were to replicate an electrochemotherapy protocol from a previous report and add plasma bleomycin analysis to the treatment. After bleomycin injection into similarly sized tumors of two green turtles and immediate electroporation at two time points, plasma bleomycin reached detectable concentrations that were considerably lower than those found in human studies. At 3months posttherapy, no healing complications or recurrences were encountered and only scar tissue remained. This study adds further support that electrochemotherapy with bleomycin has the potential to be used as an effective alternative treatment for this complex disease.

Clinical Outcomes of Total Ankle Arthroplasty With Total Talar Prosthesis.

Total ankle arthroplasty (TAA) has been developed to treat patients with end-stage ankle osteoarthritis (OA). However, there is often difficulty in treating complicated pathologies such as ankle OA with subtalar joint OA and severe talar collapse. Therefore, this study aimed to explore the short-term results and complications of TAA with total talar prosthesis, known as combined TAA, as the new techniques to treat such complicated pathology. We examined postoperative results including ankle range of motion, Japanese Society for Surgery of the Foot (JSSF) scale, and complications. There were 22 patients (15 women), with mean follow-up of 34.9 (range, 24-53 months), and the mean age was 72 (range, 62-80) years. The main indications for combined TAA included osteoarthritis (18 patients), rheumatoid arthritis (3 patients), and talar osteonecrosis with osteoarthritis (one patient). The mean range of motion improved from 4.0 to 14.4 degrees in dorsiflexion and from 23.8 to 32.0 degrees in plantarflexion. The JSSF scale improved from 50.5 to 91.5 points. Prolonged wound healing occurred in 3 patients, and medial malleolus fracture occurred in 4 patients. Combined TAA was a reliable procedure for the treatment of not only ankle OA following avascular necrosis of talus but also of degeneration of both ankle and subtalar joints. Level IV, case series.

Nipple Reconstruction: A Novel Triple Flap Design.

Restoring the nipple-areola complex completes the breast reconstructive process. Local flaps are often used for the nipple reconstruction; however, the number of techniques indicates the lack of a superior design. The aims of this study were to test the feasibility of a new triple flap design for nipple reconstruction and to evaluate complication rate and nipple projection. From November 2015 to November 2018, we performed the triple flap nipple reconstruction guided by a template for preoperative mark-up. Patients were followed up postoperatively to evaluate healing and signs of complications including wound dehiscence, infection, and flap necrosis, and nipple projection. The areola was tattooed 3 months postoperatively. Twenty-six nipple reconstructions were successfully performed in 22 women. Four nipple reconstructions (15%) were performed in irradiated tissue. One reconstruction had a superficial infection, while there were no cases of wound dehiscence or flap necrosis. Three nipple reconstructions (12%) experienced prolonged healing that did not require intervention. None of these reconstructions had received radiation therapy. The nipple projection was 7.3 mm (range 6-9 mm) at the time of surgery and 3.1 mm (range 0-6 mm), 2.5 mm (range 2-3 mm), and 1.6 mm (range 0-3 mm) at follow-up of 3, 6, and 12 months, respectively. We present the new triple flap design for nipple reconstruction guided by a template for mark-up. The preliminary results indicate a low complication rate in both irradiated and nonirradiated patients while sustaining the projection over time remains to be a challenge.

Comparison of IL-6 and CRP Concentration Between Quadratus Lumborum and Epidural Blockade Among Living Kidney Donors: A Randomized Controlled Trial

BackgroundAn adequate anesthesia technique generates appropriate postoperative analgesic properties and decreases the patient’s stress response. This will lead to decreased morbidity and mortality associated with immunology disturbances, such as infection, prolonged wound healing, and sepsis.ObjectivesThe aim of this study was to compare interleukin-6 (IL-6) and C-reactive protein (CRP) concentrations, as the markers of the stress response, between continuous epidural and quadratus lumborum (QL) block as postoperative analgesia techniques among living kidney donors.MethodsSixty-two patients were randomly divided into two equal groups: continuous epidural and QL block. A group received bilateral QL block with 20 mL of bupivacaine 0.25% and the other received 6 mL/hour of bupivacaine 0.25% continuously via an epidural catheter. Prior to extubation, the QL block group received bilateral QL block with the same dose and the continuous epidural group was administered with 6 mL/hour of bupivacaine 0.125%. Blood samples were drawn to compare IL-6 and CRP concentrations after intubation (preoperatively), directly after surgery, 24 hours postoperatively, and 48 hours postoperatively. Postoperative pain was measured with the numerical rating scale (NRS). Morphine requirement and duration of catheter usage were also measured postoperatively. Side effects within 24 hours postoperatively were noted. Data were analyzed with independent t-test or Mann-Whitney test.ResultsNo difference was observed between the groups in the plasma concentration of IL-6 either after surgery or 24 hours postoperatively (P = 0.785 and P = 0.361, respectively) although the mean IL-6 concentration 24 hours postoperatively was lower in the QL block group than in the continuous epidural group. CRP concentration was not significantly different between the groups either after surgery or 48 hours postoperatively (P = 0.805 and P = 0.636, respectively).ConclusionsThere was no significant difference in IL-6 and CRP concentrations between continuous epidural and QL block among living kidney donors. Both continuous epidural and QL block techniques showed comparable postoperative analgesic properties among living kidney donors undergoing laparoscopic nephrectomy.

Requirements and Interaction Patterns for a Novel Interaction Device for Patients in Intensive Care

Abstract Intensive care patients that are weaned from mechanical ventilation are facing substantial physical and psychical stress. Due to the breathing tube, they often cannot voice their basic needs adequately. Possible consequences, amongst other complications, are a prolonged healing process and a delirium. To address this issue and support patient communication in intensive care, we provide a solution tailored to patients that are dealing with limited cognitive and physiological abilities, hindering them to use traditional devices efficiently. For this purpose, we develop a novel interaction device tailored to the special situation of in-bed interaction. In this paper, we present key requirements for the device, which are relevant to the interaction itself as well as possible interaction gestures that may be performed with the device. The basis for this is a human-centered design process consisting of a comprehensive user and context analysis, as well as a requirements analysis. As a result, we identified three categories relevant for the interaction, namely look and feel, sensors, and actuators. The results of the requirement analysis were precise enough to start the actual development process of the device.

Intrawound vancomycin powder increases post-operative wound complications and does not decrease periprosthetic joint infection in primary total and unicompartmental knee arthroplasties.

A frequent reason for revision surgery after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is periprosthetic joint infection (PJI). The efficacy of intrawound VP in preventing PJI after primary TKA or UKA is rarely reported. The purpose of this study was to investigate the efficacy and side effects of local high-dose VP application to the joint to prevent PJI in TKA and UKA. From 2010 to 2017, 166 consecutive patients that underwent primary TKA or UKA were enrolled. Seventy-five patients (92 knees) did not receive VP (control group), while 90 patients (110 knees, VP group) received VP (intrawound, 1g) before capsule closure during TKA and UKA. Aseptic wound complications, such as skin erosion, wound dehiscence, and prolonged wound healing, were evaluated within 3months post-operatively. PJI was assessed within a year post-operatively. Seven patients (7.6%) in the control group and five patients (4.5%) in the VP group had PJI. No significant differences existed in the PJI rates between the groups. Aseptic operative wound complications occurred in 4 patients (4.3%) and 13 patients (11.8%), whereas prolonged operative wound healing occurred in 3 patients (3.3%) and 14 patients (12.7%) of patients in the control and VP group, respectively. Operative wound complications were significantly frequent in the VP group. Intrawound VP administration does not decrease PJI occurrence in primary TKA and significantly causes aseptic wound complications. The use of intrawound VP for the prevention of PJI after primary TKA and UKA is not recommended. Level II.

Increased opioid consumption in diabetics with operative ankle fractures: a retrospective case-control study.

Opioids are commonly used for post-operative pain control. It is known that diabetic patients with ankle fractures will experience prolonged healing, higher risk of hardware failure, and an increased risk of infection. However, the opioid requirements amongst this patient cohort have not been previously evaluated. Thus, the purpose of this study is to retrospectively compare opioid utilization amongst ankle fracture patients with and without diabetes mellitus (DM). An IRB approval was obtained for the retrospective review of patients who presented with an ankle fracture and underwent surgery between November 2013 and January 2017. A total of 180 patients (144 without DM, 36 with DM) with a mean age of 50years (± 18years) were included. Opioid consumption was quantified utilizing a morphine-milliequivalent conversion algorithm. A repeated measures ANOVA was conducted to compare opioid consumption. A two-tailed p value of 0.05 was set as the threshold for statistical significance. Repeated measures ANOVA revealed a statistically significant decrease in total opioid consumption during the 4-month duration (p < 0.001). The model demonstrated a mean difference in opioid consumption of - 214.3 morphine meq between the patients without and with DM (p = 0.022). Post hoc pair-wise comparison revealed less opioid consumption amongst non-diabetic patients at 2 (- 418.5 Meq; p = 0.009), 3months (- 355.6 Meq; p = 0.021), and 4months (- 152.6 Meq; p = 0.006) after surgery. Our study revealed increased opioid consumption amongst diabetic patients who are treated surgically for ankle fractures. With increasing efforts aimed at reducing opioid administration, orthopaedic surgeons should be aware of higher opioid consumption amongst this patient cohort. Further studies are needed to verify the results of this study.

Oxidative Stress and Inflammation in Wound Repair: Molecular and Cellular Mechanisms

Oxidative stress and inflammation are the critical factors attributed with delay in wound repairing process. Experimental studies established the dogma that inflammation is essential to the establishment of cutaneous homeostasis following injury, and in recent years information about specific subsets of inflammatory cell lineages and the cytokine network orchestrating inflammation associated with tissue repair has increased. Recently, this dogma has been challenged, and reports have raised questions on the validity of the essential prerequisite of inflammation for efficient tissue repair. Indeed, in experimental models of repair, inflammation has been shown to delay healing and to result in increased scarring. The main focus of present study was to explore the effect of oxidative stress and inflammation in the wound healing in patients with pressure injuries. The study was performed in patients in the medical clinic, from a general hospital, located in Espirito Santo‐Brazil. Weekly swab collection was performed in order to follow the healing process and therapeutic response. Molecular biology analyzes were performed to measure the presence increase, or time‐dependent reduction related to oxidative stress and inflammatory process. Our data show that pressure injuries in stages 2 and 3 of difficult healing present reduced of antioxidant enzymes, such as SOD and Catalase, as well as an increase in oxidant and inflammatory enzymes. We also evaluated the changes in inducible nitric oxide synthase (iNOS) and other inflammatory enzymes using western blot. Our results showed that, in pressure injuries, there is higher level of iNOS, inflammatory and oxidants enzymes. iNOS is linked to increased inflammation, leading to prolonged wound healing. Our results suggest that treatments that aim to reduce the local inflammatory process and consequently the oxidative stress can improve the healing process, as well as make the tissue repair process easier.Support or Funding InformationThis research was supported by a CNPq research grant. This study was funded by Fundação de Amparo a Pesquisa do Espirito Santo (FAPES‐Brazil) and Conselho Nacional de Desenvolvimento Científico e Tecnológico.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Survival Impact of Time to Initiation of Adjuvant Radiation for Merkel Cell Carcinoma: An Analysis of the National Cancer Database

PurposeThis study aimed to determine the impact of time to initiation (TTI) of adjuvant radiation therapy (RT) on overall survival (OS) for patients with stage I or II Merkel cell carcinoma (MCC). Methods and materialsThe National Cancer Database was queried for patients with MCC of the head and neck, trunk, or extremities diagnosed between 2006 and 2014. Patients who did not undergo resection or receive adjuvant RT within 180 days of surgery were excluded. TTI was defined as the time from resection to first RT fraction. Linear regression was used to define factors associated with TTI. Recursive partitioning analysis modeling was performed to determine an optimal threshold for TTI. Cox proportional hazards modeling was performed to define covariates associated with OS. ResultsA total of 2293 patients were included in this study. The median TTI for the cohort was 62 days (interquartile range, 43-86 days). TTI was not associated with OS for the overall cohort by multivariable Cox modeling (P = .19). Age, treatment facility type, lymph node examination, anatomic subsite, and surgical margin were associated with TTI (P < .05). Age, sex, insurance status, Charlson-Deyo comorbidity score, lymph node examination status, tumor size, and surgical margin were associated with OS (all P < .05). ConclusionsIncreased TTI of adjuvant RT was not associated with OS for patients with early stage MCC in this analysis of the National Cancer Database. The median TTI of 62 days from resection to adjuvant RT initiation for our study cohort contextualizes TTI on a national level and may offer reassurance for patients with prolonged postoperative wound healing or intercurrent illness delaying immediate RT initiation. Despite the lack of a clear detriment to survival with increased TTI up to 180 days from surgery, unnecessary delays in initiating adjuvant therapy should continue to be minimized while ensuring optimal recovery from resection.

The impact of stress on epidermal barrier function: an evidence-based review.

The epidermal barrier functions to limit skin infection and inflammation by inhibiting irritant and immunogen invasion. Abundant evidence suggests that psychological stress stemming from crowding, isolation, nicotine smoking, insomnia, mental arithmetic tasks, physical pain, real-life stressors (examinations and marital strain) and lack of positive personality traits may impart both acute and chronic epidermal dysfunction. To review the relationship between stress and epidermal barrier dysfunction. A review of the PubMed and Embase databases was conducted to identify all English-language case-control, cross-sectional and randomized control trials that have reported the effect of stress on epidermal barrier function. The authors' conclusions are based on the available evidence from 21 studies that met the inclusion and exclusion criteria. Psychological stressors upregulate the hypothalamic-pituitary-adrenal axis to stimulate local and systemic stress hormone production. This ultimately leads to aberrant barrier dysfunction, characterized by decreased epidermal lipid and structural protein production, decreased stratum corneum hydration and increased transepidermal water loss. This evidence-based review explores the adverse effects of psychological stressors on epidermal barrier function. Future investigations using more real-life stressors are needed to elucidate further their impact on skin physiology and identify practical stress-relieving therapies that minimize and restore epidermal barrier dysfunction, particularly in at-risk populations. What's already known about this topic? The literature reports the negative effect of stress on prolonged wound healing. Less is known about the relationship between stress and epidermal barrier dysfunction, a chronic, superficial wound involving the upper epidermal layers. What does this study add? Psychological stressors impact epidermal barrier function by activating the hypothalamic-pituitary-adrenal axis to stimulate local and systemic stress hormone production. Stress hormones negatively affect the epidermal barrier by decreasing epidermal lipids and structural proteins, decreasing stratum corneum hydration and increasing transepidermal water loss. Identification of such stressors can promote stress-avoidance and stress-reduction behaviours that protect epidermal barrier function and prevent certain dermatological conditions.

Evaluation of the Effects of Adipose Derived Mesenchymal Stem Cells Cultured on Decellularized Amniotic Membrane in Wound Healing of Distal Part of the Limbs in Horse

Background: Equine wounds, particularly those involving the distal portion of the limbs, often undergo prolonged complex healing and may enter a non-healing state with obvious financial and welfare implications. Poor blood supply and lower levels of oxygen to the lower limbs lead to imbalance of growth factors related to wound healing. Decellular amniotic membrane has been widely used in soft tissue engineering especially skin regeneration due to its biological and mechanical properties. It is used as a scaffold for treatment of partial full thickness wound dressing. OBJECTIVES: Evaluation of the effects adipose derived mesenchymal cells (ADMSCs) cultured on decellularized amniotic membrane (DAM) in wound healing of distal part of equine limb. METHODS: Stem cells were isolated from adipose tissue in the base of the tail and then cultured and seeded on bovine decellular amniotic membrane. Full thickness excision wounds (2x3 cm) were created on the mid-lateral of all metatarsus of each horse aseptically. The wounds were classified into four groups: the first one covered by DAM seeded by ADMSCs, the second one dressed with only DAM, the third one treated with1% silver sulfadiazine, and the last one as control with no treatment. Digital photographs of wounds were obtained at each bandage change while biopsy samples were obtained for histopathology at days 5, 15 and 30 after treatment. RESULTS:Wounds treated with DAM/ADMSCs significantly demonstrated promotion of wound healing in geometric analysis of total wound area, epithelialization and wound contraction compared with the other groups (P<0.05). Microscopically, re-epithelization of wounds covered by DAM/ADMSCs and DAM at day 5 was significantly more than Control group (P<0.05). Fibroplasia in wounds treated with DAM/ADMSCs and DAM was higher than the group that received sulfadiazine (P<0.05). CONCLUSIONS: These results indicate positive effects of using DAM to improve the quality and speed of wound healing. Use of DAM as a scaffold for ADMSCs shows better results.

Ciprofloxacin HCl and quercetin functionalized electrospun nanofiber membrane: fabrication and its evaluation in full thickness wound healing

Microbial infection and oxidative damage of the fibroblast often results in prolonged and incomplete wound healing. Therefore, there is an increasing demand for a scaffold being effective to prevent any possible infection and neutralize excessively released free radicals. Herein, we designed a PCL-based nanofiber loaded with ciprofloxacin hydrochloride (CHL) and quercetin. Developed nanofiber showed the formation of smooth and continuous nanofiber with 101.59 ± 29.18 nm average diameter and entrapping the drugs in amorphous form without any possible physico-chemical interaction between drugs and excipient. High entrapment efficiency (CHL: 92.04% and Que: 94.32%) and prolonged in-vitro release (for 7 days) demonstrated the capability of scaffold to suppress any probable infection and oxidative damage, which was further confirmed by in-vitro antibacterial and antioxidant activity. The biocompatibility of scaffold for direct application to wound site was evaluated through hemocompatibility and cytocompatibility assay. The wound healing efficacies of nanofiber were assessed using full thickness wound model in rats, which displayed accelerated wound healing with complete re-epithelialization and improved collagen deposition within 16 days. In-vivo wound healing finding was further corroborated by SOD, catalase, and hydroxyproline assay. The current study validates the application of ciprofloxacin HCl and quercetin functionalized nanofiber as a potential wound dressing material.

A randomised controlled feasibility trial to evaluate local heat preconditioning on wound healing after reconstructive breast surgery: the preHEAT trial

ObjectivepreHEAT was a randomised controlled feasibility trial to determine how best to measure skin necrosis in breast reconstruction to inform the design of a larger multicentre trial.BackgroundMastectomy skin flap necrosis (MSFN) is a serious complication resulting in prolonged wound healing. Local heat preconditioning of the MSF before surgery has been shown to reduce skin necrosis in immediate breast reconstruction patients (IBR).MethodpreHEAT was a single-centre, randomised control two-arm single-blind parallel arm feasibility trial of local heat preconditioning in breast cancer patients undergoing SSM and NSM at Guy’s and St Thomas’ Hospital, London, UK. All patients undergoing IBR above the age of 18 were included. Intervention patients heated breast skin to 43 °C in three, 30-min cycles interrupted by spontaneous cooling using hot water bottles. The primary aim was to compare measurement of skin necrosis using binary ‘yes/no’ assessment, the SKIN score, and wound area.ResultsOne hundred forty-one patients were randomised over a 2-year period (71 heated group, 70 controls). There was near perfect agreement between assessors using the “yes/no” measurement of necrosis. The proportion of patients experiencing necrosis in controls was 35% (n = 23/66) in the heated 26% (n = 18/68]). In the control group, 17% (n = 4/23) patients experiencing necrosis required surgical intervention for necrosis compared to 11% (n = 2/18) in the heated group.ConclusionThe binary outcome of MSFN “yes/no” is a suitable and reliable primary outcome measure of necrosis and was superior to the SKIN Score or necrosis area. The trial study design is feasible for a larger definitive trial.Trial registrationISRCTN15744669. Date of registration: 25/02/2018

Two case of neurofibromatosis elephantiasis with prolonged healing after surgery

Two case of neurofibromatosis elephantiasis with prolonged healing after surgery

Quantifying the costs and profitability of care for diabetic foot ulcers treated in a multidisciplinary setting

ObjectiveIncreasing Wound, Ischemia, and foot Infection (WIfI) stage has previously been shown to be associated with prolonged wound healing time, higher number of surgical procedures, and increased cost of care in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. However, the profitability of this care model is unknown. We aimed to quantify the hospital costs and net margins associated with multidisciplinary DFU care. MethodsAll patients presenting to our multidisciplinary diabetic limb preservation service (January 2012-June 2016) were enrolled in a prospective database. Inpatient and outpatient costs and net margin (U.S. dollars) were calculated for each wound episode (initial visit until complete wound healing) overall and per day of care according to WIfI classification. ResultsA total of 319 wound episodes in 248 patients were captured. Patients required an average of 2.6 ± 0.2 inpatient admissions and 0.9 ± 0.1 outpatient procedures to achieve complete healing. Limb salvage at 1 year was 95.0% ± 2.4%. The overall mean cost of care per wound episode was $24,226 ± $2176, including $41,420 ± $3318 for inpatient admissions and $11,265 ± $1038 for outpatient procedures. The mean net margin was $2412 ± $375 per wound episode, including $5128 ± $622 for inpatient admissions and a net loss ($−3730 ± $596) for outpatient procedures. Mean time to wound healing was 136.3 ± 7.9 days, ranging from 106.5 ± 13.1 days for WIfI stage 1 wounds to 229.5 ± 20.0 days for WIfI stage 4 wounds (P < .001). When adjusted for days of care, the net margin ranged from $2.6 ± $1.3 per day (WIfI stage 1) to $23.6 ± $18.8 (WIfI stage 4). ConclusionsThe costs associated with multidisciplinary DFU care are substantial, especially with advanced-stage wounds. Whereas hospitals can operate at a profit overall, the net margins associated with outpatient procedures performed in a hospital-based facility are prohibitive, and the overall net margins are relatively low, given the labor required to achieve good outcomes. Thus, reimbursement for the multidisciplinary care of DFUs should be re-examined.