Tissue Sloughing Research Articles

Wound Characteristics Among Patients Exposed to Xylazine

ImportanceThe alpha-2 agonist xylazine is increasingly detected as an adulterant in illicitly manufactured fentanyl. There is concern that xylazine may be responsible for an emerging pattern of necrotizing wounds among people who use drugs, but the clinical features of wounds associated with xylazine remain poorly characterized.ObjectiveTo systematically characterize the location, wound bed surface, and chronicity of wounds among persons with confirmed xylazine exposure.Design, Setting, and ParticipantsThis case series at 3 academic medical hospitals in Philadelphia, Pennsylvania, included patients with emergency department or inpatient encounters from April 2022 to February 2023 who had a wound-related chief complaint and xylazine detected with urine gas chromatography–mass spectroscopy.ExposureXylazine.Main Outcomes and MeasuresThe location, size, wound bed, and chronicity of wounds associated with xylazine using electronic medical record abstraction and Fisher exact tests.ResultsOf 59 wounds from 29 unique patients with confirmed xylazine exposure (mean [SD] age, 39.4 [8.8] years; 15 [52%] male; all using fentanyl, and 23 [79%] routinely injecting opioids), 53 wounds (90%) were located on extremities, and 41 (69%) involved extensor surfaces. Five wounds (9%) involved exposed deep structures such as bone or tendon. Of 57 wounds with photographs, 34 (60%) had wound beds of predominantly devitalized tissue (eschar or slough). Based on patient report, 28 wounds (48%) were acute (<1 month old), 12 (20%) were subacute (present for 1-3 months), and 17 (29%) were chronic (developed ≥3 months prior). Subacute and chronic wounds were more often medium or large in size (odds ratio, 48.5; 95% CI, 8.2-1274.8; P < .001) and more frequently had devitalized wound beds (odds ratio, 9.5; 95% CI, 2.9-37.0; P < .001).Conclusions and RelevanceIn this case series of hospitalized patients with confirmed xylazine exposure, wounds were commonly located on extensor surfaces of the extremities, frequently had devitalized tissue or exposed deep structures, and were more likely to have larger and necrotic wound beds the longer they had persisted. This systematic characterization of xylazine-associated wounds may inform identification, management, and research to address this emerging public health threat.

Pythium aphanidermatum causing seedling damping-off of Hylocereus megalanthus in China.

Hylocereus megalanthus (family Cactaceae), commonly known as bird's nest fruit (Yanwo fruit), was a new tropical plant cultivated commercially in south China because of its high nutritional content and sweet taste. In August 2023, damping-off disease of approximately 60% of seedlings was observed at a nursery in Zhanjiang, Guangdong Province (E110°17'46″ N21°9'2″). Stems of infected seedlings exhibited symptoms of water-soaked tissue which caused collapse at the base of the stem and sloughing of necrotic root cortex tissue was observed (Figure 1). White aerial mycelia were visible on the surface of the stem and soil at a high relative humidity. Diseased tissues about 0.5 cm2 were taken from the infected roots and stems, surface disinfected with 75% ethanol and 3% hydrogen peroxide solution, each for 1 min, subsequently rinsed in sterile water, and placed on potato dextrose agar (PDA). Plates were incubated at 25 to 28℃ in the dark for 3 days. Coenocytic hyphae grew from all infected roots and stems. Hyphal tip transfers were completed twice, and twelve isolates with the same morphological characteristics were obtained. The colony growth on PDA was ample. Main hyphae are up to 9.5 µm wide. Sporangia were terminal, inflated, branched or unbranched. Encysted zoospores were 7.5 µm in diameter. Oogonia were terminal, globose, smooth and of 16.8 to 27.4 µm (average 21.5 µm) diameter. Oospores were typically spherical, thick-walled, yellowish, 19.7 to 26.3 µm (average 21.1 µm) diameter, wall 1 to 2 µm thick. Antheridia were mostly intercalary, sometimes terminal, broadly sac-shaped, 15.0×19.0 µm (Figure 2). The morphological features were very similar to those of Pythium spp. (Toporek and Keinath 2021). For further identification, the LSU and ITS regions of isolate CCAS-YWGCD (stored in Agricultural Culture Collection of China, ACCC 35633) were amplified and sequenced with using primer pairs LROR/LR7 and ITS1/ITS4, respectively (Gao et al. 2017; White et al. 1990). The resulting sequences were deposited in GenBank (ITS: OR775664; LSU: OR775667). BLASTn results showed 100% sequence similarity with reference sequences of Pythium aphanidermatum (AY598622 for ITS and HQ665084 for LSU). Phylogenetic tree generated from maximum likelihood analysis based on combined LSU and ITS sequence data with MEGA 10.1.8, clustered the oomycete in P. aphanidermatum clade with 100% bootstrap support (Figure 3). Therefore, the oomycete was identified as P. aphanidermatum. To confirm Koch's postulates, six three-month-old seedlings of H. megalanthus (height about 15 cm) were transplanted to 15 cm pots. Six-mm-diameter mycelial plugs obtained from 7-day-old cultures at 25℃ in the dark were buried adjacent to the stem of three unwounded healthy seedlings. Another three seedlings inoculated with PDA agar served as controls. The plants were covered with plastic bags, kept at about 30℃, and watered regularly to keep the soil moisture content high. All inoculated seedlings exhibited symptoms of stems rot and damping-off, Symptoms did not develop on the control seedlings. P. aphanidermatum by morphological and molecular analysis was reisolated from the stems. P. aphanidermatum had been reported worldwide causing disease in many agricultural crops (Qi et al. 2021; Kim et al. 2020), but this is the first report causing damping-off of H. megalanthus seedling in China as well as worldwide, and this disease should be monitored in nursery seedlings.

AN AYURVEDIC APPROACH IN THE MANAGEMENT OF OSTEOMYELITIS TOES

Background – Osteomyelitis toe is commonly seen in patients who have peripheral neuropathy associated with diabetic mellitus. In Ayurveda, osteomyelitis can be correlated with Asthimajja Vidradhi1 or Dusta Vrana. Dusta vrana (infected wound) can cause loss of physical activity and it can produce a significant impact on the quality of life. This study mainly concentrates on Vrana Shodhan karma (surgical debridement) of dusta vrana (infected wound) and followed by application of Karanjadi Ghrita with Shaman Chikitsa which is performed to restore the function of toe and achieve adequate wound healing. Material and method- A Fifty-eight-year-old male pa-tient came to Shalya tantra OPD of our institute (GAC Raipur) with complaints of non-healing wounds on his great and second toe of left foot along with pain, swelling and discoloration of skin. Routine blood investigation and foot x-ray was taken and was diagnosed as osteomyelitis toe. Under all aseptic manner surgical debridement of necrotic tissue(slough) of wound was done by following classical guideline of Sushruta Samhita. Simultane-ously, wounds cleaned by lukewarm water and alcohol then after wounds was dressed in use of Karanjadi Ghri-ta and following internal medicine were given to the patient for three months like Triphala Guggulu, Kaishora Guggulu, Lakshadi Guggulu, Varunadi Kashayam. Result- Significant output were observed like pain, oedema is subsided, and wound was completely healed within 3 months. Conclusion- Multidisciplinary Ayurvedic ap-proach can play a good supportive role in managing critical conditions such as diabetic osteomyelitis toe and cosmetically preserve the body part and amputation can be avoided.

Acute and chronic toxicity of manganese to tropical adult coral (Acropora millepora) to support the derivation of marine manganese water quality guideline values

Adult corals are among the most sensitive marine organisms to dissolved manganese and experience tissue sloughing without bleaching (i.e., no loss of Symbiodinium spp.) but there are no chronic toxicity data for this sensitive endpoint. We exposed adult Acropora millepora to manganese in 2-d acute and 14-d chronic experiments using tissue sloughing as the toxicity endpoint. The acute tissue sloughing median effect concentration (EC50) was 2560 μg Mn/L. There was no chronic toxicity to A. millepora at concentrations up to and including the highest concentration of 1090 μg Mn/L i.e., the chronic no observed effect concentration (NOEC). A coral-specific acute-to-chronic ratio (ACR) (EC50/NOEC) of 2.3 was derived. These data were combined with chronic toxicity data for other marine organisms in a species sensitivity distribution (SSD). Marine manganese guidelines were 190, 300, 390 and 570 μg Mn/L to provide long-term protection of 99, 95, 90, and 80 % of marine species, respectively.

Adult corals are uniquely more sensitive to manganese than coral early-life stages.

Manganese is an essential element and generally considered to be one of the least toxic metals to aquatic organisms, with chronic effects rarely seen at concentrations below 1000 µg/L. Anthropogenic activities lead to elevated concentrations of manganese in tropical marine waters. Limited data suggests that manganese is more acutely toxic to adult than to early life-stages of scleractinian corals in static renewal tests. However, to enable the inclusion of sufficient sensitive coral data in species sensitivity distributions to derive water quality guideline values (GVs) for manganese, we determined the acute toxicity of manganese to the adult scleractinian coral, Acropora muricata, in flow-through exposures. The 48-h EC50 was 824 µg Mn/L (based on time-weighted average, measured, dissolved manganese). The endpoint was tissue sloughing, a lethal process by which coral tissue detaches from the coral skeleton. Tissue sloughing was unrelated to superoxidase dismutase activity in coral tissue, and occurred in the absence of bleaching, i.e., toxic effects were observed for the coral host, but not for algal symbionts. We confirm that adult scleractinian corals are uniquely sensitive to manganese in acute exposures at concentrations 10 to 340 times lower than those reported to cause acute or chronic toxicity to coral early life stages, challenging the traditional notion that early life stages are more sensitive than mature organisms. This article is protected by copyright. All rights reserved. Environ Toxicol Chem 2023;00:0-0. © 2023 SETAC.

Potential Utility of Hand Acceleration Time in Quantifying the Degree of Malperfusion in Patients With Suspected Hemodialysis Access–Induced Distal Ischemia

Steal phenomenon after upper extremity hemodialysis access is a clinical diagnosis and consists of signs and symptoms ranging from pain during dialysis to tissue loss. Duplex ultrasonography of the access site and limb arterial perfusion often serves as an adjunct to the diagnosis but can have limitations and there is no specific duplex measurement that indicates that an intervention will be a success. We have used hand acceleration time (HAT) to assess perfusion in a number of trauma and shock cases and hypothesized that this approach could also be beneficial in assessing patients with hemodialysis access–induced distal ischemia (HAIDI), both for identifying patients who are candidates for intervention and to measure whether the intervention will be successful. Specifically, we hypothesized that a HAT <100 ms is associated with normal hand perfusion. We performed a retrospective review of 4 patients with upper extremity arteriovenous fistulas who presented with pain and tissue loss involving the ipsilateral hand. In 2 cases, the tissue loss was not primarily due to steal (one due to skin slough from antibiotic reaction and the other due to focal calciphylaxis), and 2 patients had diffuse calcific disease of the forearm arteries. All 4 patients had antegrade flow in the forearm arteries and HAT >100 ms. One patient with soft tissue sloughing was managed with banding of the proximal fistula, and 3 had proximalization of the fistula. All 4 achieved HAT <100 ms and had resolution of symptoms. Hand acceleration time may be a valuable adjunct to determine whether intervention in the setting of hemodialysis access–induced distal ischemia HAIDI may assist with wound healing.

Abstract CT107: Phase Ib Study of Pembrolizumab in Combination with Intratumoral Injection of Clostridium novyi-NT in Patients with Advanced Solid Tumors

Abstract BACKGROUND: Intra-tumoral Clostridium novyi-NT (non-toxic) is an attenuated strain of C. novyi lacking alpha toxin replication within hypoxic tumor regions, causing tumor cell lysis and inflammation. Immunotherapy (IO) augments anticancer activity with intratumoral agents in prior preclinical and clinical studies. This phase 1b dose escalation study assessed safety and potential synergistic effects of pembrolizumab and C. novyi-NT in advanced solid tumors. METHODS: We enrolled patients with percutaneous injectable, solid tumors to receive single intratumoral injection of C. novyi-NT administered on Day 8 across 4 dose cohorts (3 × 10^4 to 100 × 10^4 spores, 3+3 design) with pembrolizumab 200mg IV Q3weekly starting on Day 0 up to 24 months. Primary objectives: Safety, tolerability and maximum tolerated dose (MTD) of combination. Secondary objectives: anti-tumor activity of combination in the injected tumor lesion and overall response by iRECIST 1.1. RESULTS: At data cutoff on October 24, 2022, 16 patients were enrolled and evaluable for toxicity and efficacy. It was well tolerated across all cohorts without dose limiting toxicities with median number of 5 cycles administered (1-34). 10 patients (63%) experienced progression; 1 withdrew consent; 1 completed therapy; 1 came off trial due to toxicity (immune related dermatitis) and 3 patients remain on trial. Median age was 62.5 years (40-71) while all patients (100%) had performance status of 1. 8 (50%) received prior IO and 7 (44%) had > 4 lines of prior therapies. Confirmed overall objective response rate (ORR) was 25% in 4 patients [non-keratinizing undifferentiated nasopharyngeal squamous carcinoma (NPC), human papilloma virus positive squamous cell carcinoma of base of tongue, vulvar melanoma and chordoma] with 3 partial responses (PR) and 1 complete response (CR). Among responders, median duration of response was 8.18 months and 1/4 (25%) had prior IO. NPC patient completed 24 months on trial to completion with best response at PR (-87%) while vulvar melanoma patient remains on trial with best response at CR (-100%). Median injected tumor size was 2.65cm (1-11) with confirmed ORR in injected lesions at 19% with 2 PRs and 1 CR. Most prevalent grade 1 and 2 adverse events were injection site reaction (25%), pyrexia (19%), pruritus (13%), leukopenia (13%) and anemia (13%). No grade 3 or 4 treatment related adverse events noted. Signs and symptoms of C. novyi-NT germination (infection) including fever, injection site pain, erythema, swelling, tenderness, and in some cases, ulceration, spontaneous drainage, tissue sloughing, bleeding, and malodor were observed in 5 patients. CONCLUSIONS: Intratumoral C. novyi-NT with pembrolizumab demonstrates clinical activity with favorable tolerability in patients regardless of tumor histology. This study is ongoing to define the recommended phase 2 dose (NCT03435952). Citation Format: Blessie Elizabeth Nelson, Filip Janku, Siqing Fu, Ecaterina I. Dumbrava, David S. Hong, Daniel Karp, Aung Naing, Jordi Rodon, Apostolia Tsimberidou, Rodabe N. Amaria, Anthony Conley, Senthil Damodaran, Kanwal P. Raghav, Brent L. Kreider, David Tung, Mary Varterasian, Khashayarsha Khazaie, Sarina Piha-Paul. Phase Ib Study of Pembrolizumab in Combination with Intratumoral Injection of Clostridium novyi-NT in Patients with Advanced Solid Tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr CT107.

Diplosoma simile (Ascidiacea: Didemnidae) distribution and its photosynthetic thermal stress responses from Mauritius: Implications for invasive or opportunistic behavior

Abstract. Fai ALY, Kaullysing D, Jeetun S, Soondur M, Bhagooli R. 2023. Diplosoma simile (Ascidiacea: Didemnidae) distribution and its photosynthetic thermal stress responses from Mauritius: Implications for invasive or opportunistic behavior. Indo Pac J Ocean Life 7: 16-26. This study aimed to investigate the morphological identity of the ascidian Diplosoma, its distribution, experimental thermal stress responses, and its characteristics of being potentially invasive or opportunistic in Mauritian waters. The Diplosoma species were anesthetized in menthol, fixed, and preserved in a formalin-seawater solution. Isolated zooids and embryos were examined under a microscope for distinct morphological characteristics, which revealed their identity as D. simile (Sluiter, 1909). The D. simile percentage cover studied at seven sites in 2019 around Mauritius tended to be high at the near-reef zone, with a high percentage of dead coral cover per 0.5 m2. At Flic en Flac, long-term observations in 2008, 2010, 2016, and 2019 indicated a significant decrease and increased from 61.25±3.31 to 6.15±0.60 % and 0.08±0.05 to 2.50±090% for the percentage covers of live coral and D. simile, respectively. The D. simile was recorded on five coral species, and its percentage occurrence increased from 2008 to 2019 in Acropora muricata, A. cytherea, Pocillopora damicornis, and Montipora aequituberculata with the highest levels occurring in Acropora while Porites lutea was not found to be covered by D. simile during the study. Visual observations from the thermal exposures at 27ºC, 30ºC, and 33ºC during 19 hrs revealed that D. simile was more affected by increasing temperature and exposure time. Using four observed conditions of normal, bleached/paled, tissue sloughing, and mortality, D. simile suffered from only bleaching/paling at 33ºC at 19 hrs exposure. Variable visual responses were noted for corals, with P. lutea appearing normal at all trials while A. cytherea was suffering from mortality both at 30ºC and 33ºC at 19 hrs exposure. The effective quantum yield (?PSII), measured using a Diving-PAM, declined significantly at 33ºC treatments at 6 and 19 hrs of exposure. D. simile generally tended to be more thermally tolerant than corals like P. lutea, P. damicornis, M. aequituberculata, A. muricata, A, cytherea, though the ?PSII thermal responses were variable among the tested corals. When considering the reported behavioral characteristics of D. simile, namely the lack of broad dispersal range and wide environmental tolerance, it is tempting to deduce that the species is potentially invasive. However, in this study, D. simile’s significant distribution on dead corals, its presence in zones of high anthropogenic activities, and its relatively more robust thermal stress responses than corals colonized suggest an opportunistic behavior.

THE ROLE OF JAVA CABE (Piper retrofractum vahl.) ON TRAUMATIC ULCER TREATMENT

Introduction: Dental and oral diseases in Indonesia still need attention. Theoral cavity is a place for microorganisms that cause infection that can affectthe general state of health in which the oral mucosa serves as a protector ordefense to protect the oral cavity from disease. One of the most common oral mucosal diseases is traumatic ulcer. Review: Traumatic ulcer is an oraldisease that often found in the community and often underestimated.Traumatic ulcer is a pathological condition characterized by loss of epithelial tissue due to sloughing of necrotic and widespread inflammatory tissue in thelamina propria, which caused by trauma, for example is when wearingdenture wings too sharp, causing ulcers. The etiology of traumatic ulcers arethermal, chemical, and mechanical trauma. The common location oftraumatic ulcers occurs in the labial/buccal mucosa, palate, and tongue.Needed for appropriate treatment for treat traumatic ulcers. Discussion: Fortreat traumatic ulcer, parts that can be used from the Javanese chili plant arethe fruit, leaves, and roots for treating bad breath, as antipyretic, antioxidant,antibacterial, and etc. Javanese chili (Piper Retrofractum Vahl.) hascompounds that act as antioxidants and antibacterial, namely flavonoid whichtrigger the growth of epithelial tissue in wound tissue, and piperine whichinhibits cyclooxygenase which has an effect on reducing leukocytes thatoccurs in traumatic ulcers. Conclusion: Javanese chili herbs contain activecompounds such as flavonoid and piperine which can heal traumatic ulcers.

RECURRENT RESPIRATORY PAPILLOMATOSIS TREATED WITH RADICAL PHOTODYNAMIC THERAPY

RECURRENT RESPIRATORY PAPILLOMATOSIS TREATED WITH RADICAL PHOTODYNAMIC THERAPY

Fulminant Orbital Myiasis - A Rare Case Report from Central India

A 42 year old male farmer presented to eye OPD with a history of painful, foul smelling discharging wound over the lower lid along the inferior orbital margin since two weeks and crawling sensation over the wound with diminution of vision right eye since three days. He gave history of trauma to right eye after falling on sharp edge of stone one month back when he was in a drunken state due to which he had a lacerated wound of about 5cm x 2 cm x 2cm along inferior orbital margin.
 The wound was cleaned and dressed only once at a local hospital, however, he neglected the wound and didn’t open the dressing for about next 15 days until he noticed a crawling sensation and maggots teeming from the wound. He denied a history of diabetes mellitus, hypertension or any other chronic systemic disease or any prolonged use of medications, progressive loss of weight or appetite. However, he was a chronic alcoholic. He belonged to low socioeconomic strata with poor personal hygiene and was residing in a rural area.
 On presentation, the patient was in agony due to pain. On examination of the right eye, the eyelids were severely oedematous and indurated with severe mechanical ptosis. The lower lid along the inferior orbital rim had a deep open, macerated wound of size about 5cm x 2cm x 2cm, filled with necrotic tissue (slough), discharge and around 5-6 maggots were seen teeming from the wound [Fig. 1]. The skin around the wound was red and friable. On separating the lids gently and mechanically, the conjunctiva was severely congested and chemosed. Unaided visual acuity was 3/60; best-corrected visual acuity could not be assessed as the patient was in agony due to pain. The cornea, anterior chamber and iris were normal. The pupil was normal-sized reacting to light. The eyeball had deviated inwards and ocular movements were painful and restricted in all directions. Lens had immature senile cataract. Intraocular pressure and nasolacrimal passage could not be assessed because of gross lid oedema. Fundus examination of the right eye was within normal limits. On examination of the left eye, unaided visual acuity was 6/18 and best-corrected visual acuity was 6/9. Anterior segment was within normal limits with pupil normally reacting to light and fundus examination was normal.
 Five to six superficially lying maggots were removed with the help of turpentine oil and forceps after adequate local anaesthesia. Many more deep-seated maggots were seen but were difficult to remove.

A Case Report on Fournier’s Gangrene and its Management

Fournier’s gangrene is an eruptive form of necrotizing fasciitis of the perineal & genital regions. General burden in population is 1.6 cases per 1,00,000 men per year. It is a flesh-eating infection where the bacteria kill the soft tissues, often quickly including muscles, nerves and blood vessels. It presents with scrotum pain & redness, tenderness or swollen perineal region along with rapid progression to gangrene and sloughing of tissues. Along with high fever spikes and leukocytosis which deteriorates to sepsis. The Route of infection is identifiable in 95% of cases which arises from anorectal, genito-urinary and cutaneous sources. The other risk factors include diabetes mellitus, morbid obesity, immune compromised, alcohol abuse, unprotected sex, masturbation, genital piercing, abscess and malignant neoplasms. However, in Healthy adults, the exact cause is unknown. Fournier’s Gangrene Severity Index (FGSI) is used to predict mortality risk. The basic treatment for Fournier’s gangrene includes an emergency surgical debridement with higher antibiotics therapy and ICU care. In this case report, we discussed a case of a young male of 24 years with necrotizing fasciitis of the perineal and genital regions, who was reconstructed and surgically managed in a two staged procedure with good outcome.

THE CORRELATION OF TWO MONTHS FULL OF BREASTFEEDING ON EARLY INITIATED BREASTFEEDING GROUP WITH PUERPERIUM BLEEDING

Background: Postpartum bleeding is one of the main causes of mortality in mothers in 2017. Based on Profil Kesehatan Provinsi Jawa Timur's data in 2017, about 28,26% of mothers' mortality percentage is because of postpartum bleeding. Some of the factors affecting the duration of puerperium bleeding are the initiation of early breastfeeding and exclusive breastfeeding. Early breastfeeding initiation can stimulate the oxytocin hormone to contract the uterine and help complete the extrusion of the placental site and sloughing of decidua tissue (lochia). Objective: This study aims to know the correlation of 2 months full of breastfeeding on early initiated breastfeeding group with puerperium bleeding. Method: This study is an observational analytical study where the design is cohort retrospective, and the 60 samples used in this research are taken with simple random technique sampling. This research was carried out by collecting information from secondary data, and the whole process was done in Gotong Royong Hospital Surabaya from July to September 2020. This research used the Mann-Whitney U test to analyze and find the correlation of both variables. Results: Based on the statistic test, there is no correlation between both variables, resulting in p = 0,211. Conclusion: there is no significant correlation between 2 months full of breastfeeding on the early initiated breastfeeding group with puerperium bleeding.

Pre-exposure to a variable temperature treatment improves the response of Acropora cervicornis to acute thermal stress

Given that global warming is the greatest threat to coral reefs, coral restoration projects have expanded worldwide with the goal of replenishing habitats whose reef-building corals succumbed to various stressors. In many cases, however, these efforts will be futile if outplanted corals are unable to withstand warmer oceans and an increased frequency of extreme temperature events. Stress-hardening is one approach proposed to increase the thermal tolerance of coral genotypes currently grown for restoration. Previous studies have shown that corals from environments with natural temperature variability experience less bleaching when exposed to thermal stress, though it remains unclear if this localized acclimatization or adaptation to variable temperatures can be operationalized for enhancing restoration efforts. To evaluate this approach, fragments from six source colonies of nursery-raised Caribbean staghorn coral (Acropora cervicornis) were treated with a variable temperature regime (oscillating twice per day from 28 to 31 °C) or static temperatures (28 °C) in the laboratory for 89 d. Following this, fragments were subjected to a heat-stress assay (32 °C) for 2 weeks. Corals treated with variable temperatures manifested signs of severe thermal stress later than static temperature laboratory controls as well as untreated field controls collected from the nursery. Furthermore, there was a stark contrast in the physiological response to heat stress, whereby the laboratory and field control groups had a significantly higher incidence of rapid tissue sloughing and necrosis, while the variable temperature-treated corals succumbed to bleaching more gradually. Overall, our data show that pre-acclimation to a variable temperature regime improves acroporid thermotolerance. As corals continue to be outplanted back onto Florida’s changing reef scape, understanding the molecular mechanisms underlying this enhanced thermal tolerance and its endurance in situ will be critical for future research and restoration applications.

A novel mechanism of macular holes in patients with Behçet's uveitis

To describe two cases of Behçet's retinitis lesions in the macula causing sloughing of retinal tissue forming a full-thickness macular hole. This was a case series study. Case 1 was a 26-year-old presented, known case of Behçet's disease, presented with a large area of retinitis involving the center of the macula with overlying vitritis. One day after the initiation of treatment, vitritis improved, but the retinitis patch sloughed and created a full-thickness macular hole. Case 2 was a 31-year-old male, known case of Behçet's uveitis, who presented vitritis and multiple retinitis patches involving the macula of the left eye. Two weeks after infliximab infusion, the inflammation resolved with medical management, however, the retinitis patch was complicated by a full-thickness macular hole with an inferior rhegmatogenous retinal detachment. Retinitis at the macula can be complicated by a full-thickness macular hole.

189 Anterior Ankle Surface Pressures in Lower Extremity Splints: Minimizing Insult After Injury

Though ubiquitously utilized in lower extremity orthopaedic trauma, lower extremity splints are not without their associated iatrogenic risk of morbidity. In fact, improper splinting not only necessitates replacement, but splint- related soft tissue complications are the second most common iatrogenic cause for referral to plastic surgery. Pressure ulcers result from perpendicular forces that compress the soft tissues between body mass, bony prominences, and the support surfaces below. Within those soft tissues are vessels that run parallel to the surface of the site of skin collapse and may collapse easily from pressure loads. As such, prolonged pressure above the threshold for capillary tolerance results in occluded blood flow, interstitial fluid flow, ischemia, pain, necrosis, and sloughing of dead tissue. While clinicians commonly pad bony prominences to minimize the skin pressure, the effect of joint position on skin pressure and, more specifically, changing joint position, is real but has not been well studied or described. The purpose of this biomechanical study is to identify problems with anterior ankle skin pressure secondary to joint position change during splinting and ultimately to determine the optimal position of the ankle during application of the splint as well as the padding technique required over the anterior ankle to minimize iatrogenic skin pressure ulcers. Following ethics approval by our institutional review board, various constructs of lower extremity, short-leg splints were applied to two healthy subjects (two limbs total in this preliminary data set) with an underlying pressure transducer (Tekscan® I-Scan® system, (Tekscan Inc, South Boston, MA, USA) on the skin surface centered on the anterior ankle on the tibialis anterior tendon. All subjects underwent anterior ankle surface pressure assessment when padding was applied in maximum plantar flexion and neutral position for conventional short leg splints application. Percent change from initial contact pressure centered on the tibialis anterior with either Webril© (Covidien/Medtronic, Dublin, Ireland), or Specialist© Cotton Blend Cast Padding (BSN Medical, Charlotte, NC, USA) were calculated. Neutral position of the foot/ankle will be confirmed with a goniometer. There were two limbs total that were analyzed for presentation of pilot data for this study. The percent change in anterior ankle contact pressure when padding was applied in maximum plantar flexion (PF) and then placed in neutral was increased at least two-fold without the addition of plaster and subsequently with the addition of plaster in lower extremity short leg splints (Figure 1). In this pilot data, we report significant increases in anterior ankle contact pressures when splint padding is applied in plantar-flexion and re-positioned into neutral during splint application which may precipitate iatrogenic pressure ulcers. This data, though preliminary, underscores the importance of proper splinting techniques for all clinicians that manage lower extremity trauma (eg, orthopaedic surgery, emergency medicine, urgent care, etc).

Stony Coral Tissue Loss Disease in Florida Is Associated With Disruption of Host–Zooxanthellae Physiology

Samples from eight species of corals (Colpophyllia natans, Dendrogyra cylindrus, Diploria labyrinthiformis, Meandrina meandrites, Montastraea cavernosa, Orbicella faveolata, Pseudodiploria strigosa, and Siderastrea siderea) that exhibited gross clinical signs of acute, subacute, or chronic tissue loss attributed to stony coral tissue loss disease (SCTLD) were collected from the Florida Reef Tract during 2016–2018 and examined histopathologically. The hallmark microscopic lesion seen in all eight species was focal to multifocal lytic necrosis (LN) originating in the gastrodermis of the basal body wall (BBW) and extending to the calicodermis, with more advanced lesions involving the surface body wall. This was accompanied by other degenerative changes in host cells such as mucocyte hypertrophy, degradation and fragmentation of gastrodermal architecture, and disintegration of the mesoglea. Zooxanthellae manifested various changes including necrosis (cytoplasmic hypereosinophilia, pyknosis); peripheral nuclear chromatin condensation; cytoplasmic vacuolation accompanied by deformation, swelling, or atrophy; swollen accumulation bodies; prominent pyrenoids; and degraded chloroplasts. Polyhedral intracytoplasmic eosinophilic periodic acid–Schiff-positive crystalline inclusion bodies (∼1–10 μm in length) were seen only in M. cavernosa and P. strigosa BBW gastrodermis in or adjacent to active lesions and some unaffected areas (without surface lesions) of diseased colonies. Coccoidlike or coccobacilloidlike structures (Gram-neutral) reminiscent of microorganisms were occasionally associated with LN lesions or seen in apparently healthy tissue of diseased colonies along with various parasites and other bacteria all considered likely secondary colonizers. Of the 82 samples showing gross lesions of SCTLD, 71 (87%) were confirmed histologically to have LN. Collectively, pathology indicates that SCTLD is the result of a disruption of host–symbiont physiology with lesions originating in the BBW leading to detachment and sloughing of tissues from the skeleton. Future investigations could focus on identifying the cause and pathogenesis of this process.

Management of Grade IV Pressure Ulcers With a Novel Negative Pressure Device in Traumatic Paraplegia Subjects.

IntroductionPressure ulcers (PUs) are a major health problem for bedridden patients or persons with reduced mobility; individuals with spinal cord injury (SCI) are more prone to developing pressure ulcers. The purpose of this study was to determine the efficacy of a novel negative pressure wound therapy (NPWT) system for the treatment of Grade IV PUs.MethodsA total of 34 SCI patients with Grade IV PUs were divided into two groups: 17 cases were managed by our bellows-powered negative pressure device (NPD) and 17 received wet-to-moist gauze dressing as standard wound care.ResultsWound healing outcome measures were recorded every week (at seven days) and compared at weeks 3, 6, and 9. There were no significant changes in the length and width of PUs between the groups till week 3. Significantly reduced length and width of NPD-treated PUs were found at week 6 (p=0.04) that further reduced at week 9 (p=0.001) as compared to standard wound care. Similarly, significant reduction in the depth of PUs was found in the NPD-treated group at week 9 (p<0.05). Exudate levels were significantly (p=0.001) lower in the NPD-treated group as compared to the standard wound care group from week 3 (2.96±0.21 vs 2.62±0.49); this difference continued through week 9 (1.35±0.75 vs 0.14±0.35). Disappearance of slough and formation of healthy granulation tissue was significantly higher in the NPD-treated PUs after week 6 (p=0.001).ConclusionNPWT may be the future of wound healing. As an alternative to the existing electrically powered NPWT systems, our NPD is safe, easy to apply, and efficacious in treating the PUs.

Giant Eyelid Hemangioma With Ulceration.

Two-month-old male baby presented with history of rapidly growing mass right eye of 6 weeks duration, was treated with oral steroids, intravenous antibiotics, and oral propranolol before presenting to us. On examination, large hemangioma measuring 7 × 6 cm involving both upper and lower eyelids with extensions into frontal, maxillary, and preauricular area with complete mechanical ptosis, areas of necrosis was noted (Fig. 1). The right globe was not visualized. Left eye was normal. Direct and indirect pupillary reactions were normal. CT scan done elsewhere confirmed the diagnosis and ruled out orbital involvement. The child was advised surgical debulking with maternal skin graft under general anesthesia. While awaiting surgery, the child was continued on oral propranolol in a maximum dose of 2 mg/kg/day in 2 divided doses, topical broad spectrum antibiotics, and daily saline dressing. Topical timolol gel (2%) was added twice daily. At 2 weeks review, gradual sloughing of necrotic tissue was noted (Fig. 2). At 6 weeks follow up, near total regression of hemangioma was noted. The child could open the eyelids and visual axis was clear (Fig. 3). There was ectropion of both upper and lower eyelids with minimal lagophthalmos. Eyelid can be a rare site for giant capillary hemangioma. Management of ulcerated giant hemangioma poses a therapeutic challenge. B blockers will help in the fast resolution of ulcerated hemangiomas by decreasing the production of vascular endothelial growth factor and fibroblast growth factor leading to prevention of functional and cosmetic deficits.The other differential diagnosis of thrombosed varix is very unlikely considering the age and the near-total resolution of the lesion.FIG. 1.: Clinical picture at presentation.FIG. 2.: Clinical picture at 2 weeks review-Gradual sloughing of necrotic tissue.FIG. 3.: Near total regression of the lesion at 6 weeks follow up.

Comparing the Efficacy of a Compound Topical Anesthetic Versus Benzocaine: A Pilot Study.

To compare the effectiveness of a combination of 10% lidocaine, 10% prilocaine, and 4% tetracaine versus 20% benzocaine for use as a topical anesthetic agent prior to dental injections. A double-blind randomized prospective clinical trial was conducted with 26 participants receiving a topical anesthetic of 20% benzocaine (control) and 26 participants receiving a compound topical anesthetic mixture of 10% lidocaine, 10% prilocaine, and 4% tetracaine (experimental) prior to a maxillary infiltration injection. The procedure was conducted by 1 operator with the Wand® injection system. Pain was assessed directly with visual analog scale (VAS) scores and indirectly by measuring changes in heart rate at 4 different time points. Complications associated with the application of the topical anesthetics were also assessed. The experimental group had a significantly higher mean VAS score of 19.5 ± 19.7 mm versus 14.2 ± 14.6 mm for the control group (p < .001). No significant differences in heart rate at any of the 4 measured time points compared with baseline were noted for either group. The experimental group had a significantly higher incidence of complications, including tissue sloughing, when compared with the control group (p < .001). Participants in the control group reported significantly lower VAS scores than those in the experimental group. Both types of topical anesthetic showed similar impacts on alterations to heart rate. No benefits were seen with the use of 10% lidocaine, 10% prilocaine, and 4% tetracaine as a topical anesthetic prior to a maxillary infiltration of local anesthetic when compared with 20% benzocaine.