New Name, Same Day and Time for Monthly Wound Wire Webcast

Episode 7 of the highly edutaining Wound Rounds LIVE webcast, newly renamed Wound Wire, airs tomorrow 27 June 2012 at 11 AM Central. Co-hosted by Dr Jeffrey A. Niezgoda and Sharon Baranoski, and powered by WebCME, the free webcast streams live on the last Wednesday of every month and covers new technologies, products, and devices, clinical insight, new procedures, and robust literature reviews covering every aspect of wound care.

Hyperbaric Oxygen for Autism: New Rossignol Literature Review Does Not Impress

In May we cheered Ahmad Ghanizadeh's new systematic review of the published clinical evidence on hyperbaric oxygen for autism. Ghanizadeh encouraged further study but found scant evidence to support practice. This month another paper, reviewing the same body of medical literature, and published in the same online open-source journal Medical Gas Research [doi:10.1186/2045-9912-2-16], arrives at a much more optimistic conclusion. The review and analysis was led by Dr Daniel A. Rossignol (pictured right). We are wholly unimpressed. To us this paper smells of wishful thinking and investigator bias. It's almost (but not quite) enough to make us ban Medical Gas Research from our journal club. Read the abstract or download the provisional PDF of the full article and decide for yourself. After exhaustive reading and reflecting, we have at long last completed our update to the HyperbaricLink autism page, now in press. Our writeup and commentary will fully reflect the weakness of the medical literature in this important area of research.

Full Program Now Available for Download: 45th UHMS Annual Scientific Meeting

The Undersea and Hyperbaric Medical Society (UHMS) is holding its 45th Annual Scientific Meeting this week, June 21-23, in Phoenix, Arizona. We sorely regret we are not able to attend again this year. Visit the UHMS website to download the Schedule Overview or a PDF of the Full Program including scientific abstracts. Always required reading for everyone interested in evidence-based hyperbaric medicine.

Freezer Malfunction at Harvard Tissue Bank a Setback for Autism and Other Brain Research

A freezer and alarm failure, causing severe damage to one-third of the frozen brain tissue specimens stored at one Harvard Brain Bank center at McLean Hospital in Belmont, Massachusetts, a collection owned by Autism Speaks, is a real setback to autism research and a wake-up call to other brain banks. The study of donated brains drives some of the most important research into autism, Alzheimer's, traumatic brain injury, and other neurological and psychiatric conditions. We have written before about the Center for the Study of Traumatic Encephalopathy (CSTE), a brain bank affiliated with the Boston University Medical Center and the Sports Legacy Institute at the Bedford Veterans Administration Medical Center in Bedford, Massachusetts. Several groups are investigating the Harvard incident. More in the excellent boston.com story.

[Image: Harvard Brain Tissue Resource Center]

Summer Reading List: Young Men and Fire, by Norman Maclean

Across the western US today thousands of firefighters battle 19 active wildfires, on the ground, from the air, under thankfully improving weather conditions. Our thoughts with them. And to our readers once more we recommend Young Men and Fire by Norman Maclean (University of Chicago Press, 1992). It's so much more than a gripping history of the 1949 Mann Gulch tragedy, in which a crew of elite smokejumpers got caught in a blowup. It's also a detailed explanation of how wildfires work, a fact-filled commentary on what the firefighting community learned and how it changed its approach to fighting wildfires in the last half century, and a personal memoir about living and dying. You won't find much better nonfiction prose anywhere. Maclean also wrote A River Runs Through It and Other Stories. We suggest Young Men and Fire as Further Reading on our smoke inhalation page. We recommend it again here for what's shaping up to be another memorable season of western fires.

Hyperbaric Oxygen for Inflammatory Bowel Disease (IBD): Systematic Review of the Medical Literature

We are loath to recommend the work of such a controversial figure as Dr Daniel Rossignol. But his new systematic review and analysis of the medical literature on hyperbaric oxygen therapy (HBOT) for inflammatory bowel disease is very helpful indeed.

Inflammatory bowel disease (IBD), the chronic inflammation of all or part of the digestive tract, includes Crohn's disease and ulcerative colitis. Rossignol's review includes both human and animal models, touches on some of the physiologic mechanisms that may (or may not) be involved, and finds the published clinical evidence for HBOT stronger for Crohn's than for ulcerative colitis:

In the studies of Crohn's disease, 78% of treated patients had an improvement with HBOT at a pressure ranging from 2.0 to 2.8 ATA. In the studies of ulcerative colitis, all treated patients showed improvements with a pressure delivered at 2.0 ATA. These studies suggest that a higher pressure may be needed to achieve these improvements. However, because none of these studies utilized a lower pressure of HBOT, it is not known if a lower pressure or oxygen level would be beneficial in IBD. However, some investigators have reported improvements in GI function in some children with autism using HBOT at 1.3 to 1.5 ATA [117,118]. Furthermore, previous studies have reported improvements in certain neurological conditions using hyperbaric treatment at lower pressures and/or oxygen levels [119-122]. Additional studies using HBOT at varying oxygen concentrations and atmospheric pressures would be helpful in determining optimal treatment protocols.

This self-serving argument and the mild HBOT studies cited, 117-122, including Rossignol's own widely discredited autism study, significantly weaken an otherwise fine review of the medical literature on this important topic.

[Image: findingDulcinea]

Diabetic Ulcers without Optimal Glycemic Control: New Study Concludes HBOT Should Not Be Delayed

Physicians treating wounds in patients with diabetes often delay hyperbaric oxygen therapy until the patient has attained optimal blood sugar levels. A new multicenter, prospective cohort study, presented 24 May 2012 in Philadelphia at the annual meeting of the American Association of Clinical Endocrinoligists, suggests that, in patients with diabetic ulcers of the lower extremities, the success of hyperbaric oxygen therapy is not affected by pretreatment glycemic control.

Here's the complete abstract from the AACE 2012 Abstract Book:

GLYCEMIC CONTROL AT INITIATION OF HYPERBARIC OXYGEN THERAPY DOES NOT AFFECT DIABETIC LOWER EXTREMITY WOUND HEALING
Owaise Mansuri, MD, Parkash Bakhtiani, MBBS, Abhijeet Yadav, Chima Osuoha, Patricia Knight, Robert McLafferty, Michael Jakoby, IV, MD
 
Objective: Diabetic lower extremity ulcers are a major cause of disability and mortality, accounting for approximately two-thirds of all non-traumatic amputations performed in the United States. Hyperbaric oxygen (HBO) is increasingly used as an adjunct to antibiotics, debridement, and revascularization for therapy of chronic, non-healing wounds associated with diabetes mellitus. We investigated whether glycemic control at time of HBO therapy measured by hemoglobin A1c (HbA1c) has a significant impact on diabetic wound healing. Methods: A multi-center, prospective cohort study assessing lower extremity wound healing rates among adult patients with diabetes mellitus treated with HBO was conducted at the Regional Wound Care Center in Springfield, IL and University Medical Center Hyperbaric Oxygen Center and Burn Care Unit in Las Vegas, NV. Patients underwent 20 sessions of HBO over the course of one month, and ulcer size (surface area and depth) and location were recorded at each visit. Transcutaneous oxygen pressures (TcPO2) were measured during each session. HbA1c was measured at first and last HBO treatments from capillary blood specimens using a Siemens DCA Vantage A1c Analyzer. Patient characteristics including age, gender, weight, type and duration of diabetes mellitus, current diabetes treatment regimen, hypertension, peripheral artery disease (PAD), tobacco use, ulcer duration, and additional wound care therapies (e.g. debridement, platelet derived growth factor) were determined. Results: Complete data were collected for 22 patients who were included in the study analysis and divided into two groups based on pre-HBO HbA1c. Patients in the “controlled diabetes” group had HbA1c < 7.5%, and patients in the “uncontrolled diabetes” group had HbA1c ≥ 7.5%. Mean HbA1c in the “controlled diabetes” group (6.5 ± 0.8%, N=12) was significantly lower (P < 0.001) than in the “uncontrolled diabetes” group (8.8 ± 1.4%, N=10). Both groups were well matched across all other recorded characteristics. Wound volume was reduced by 65 ± 29% in the “controlled diabetes” group and 71 ± 30% in the “uncontrolled diabetes” group (P = 0.60). Wound healing was also unaffected by presence or absence of PAD, hypertension, tobacco use, weight, duration of diabetes, or ulcer duration. Discussion: This study demonstrates that diabetic lower extremity wound response to HBO treatment is unaffected by pre-treatment glycemic control and several other clinical factors that may adversely impact wound healing. Conclusion: HBO treatment should not be delayed if glycemic control is suboptimal at time that therapy is prescribed.

Previous studies have shown that hyperglycemia inhibits wound healing. Here there was no significant difference between the controlled and uncontrolled groups. Why? Lead author Mansuri, in widespread press coverage of the findings, has said, "We suspect that the effect of hyperbaric oxygen therapy was potent enough to overcome the negative effect of hyperglycemia." We're eager to learn more from any wound care and hyperbaric medical experts who may wish to comment.

In the News: Hyperbaric Oxygen Therapy for Leber Hereditary Optic Neuropathy (LHON)?

Today the National Hyperbaric Centre of Dublin, Ireland, reports success in using hyperbaric oxygen therapy (HBOT) to save the eyesight of a young man with Leber hereditary optic neuropathy (LHON), a mitochondrial disease that usually causes a loss of central vision within two to eight weeks. Eric Lokko, pictured here, began losing his eyesight at age 12, started HBOT at 14, and can see well enough at 16 to qualify for a driver's license. More of this story on Independent.ie.

Cheers to Eric, his family, and his clinical team, and thanks for inspiring us to look into the medical literature on this subject. Hyperbaric oxygen is now indicated for the treatment of central retinal artery occlusion (CRAO), a kind of stroke of the eye, a vascular event requiring speedy attention. Proper treatment in the first 24 hours is critical. Until today's news we had not heard of any longer-term use of hyperbaric oxygen to preserve or restore eyesight or prevent blindness.

About HBOT for Leber hereditary optic neuropathy, the International Foundation for Optic Nerve Disease (IFOND) says:

The sparse negative anectodal evidence of Hyperbaric Oxygen Therapy [HBO] treatment specifically in LHON is not encouraging. This is not currently a line of active research in LHON. HBO has been suggested as a treatment by delivering increased levels of oxygen to the affected nerve cell during its "starvation" period, or period of onset of blindness. A counter argument is that too much oxygen may be toxic in the context of poor cell antioxidant functioning. Oxygen toxicity to the eye is a known problem in premature babies on oxygen. There has been some success, however, using HBO with with other nerve diseases.

This paragraph does not sound like the work of someone who has made a serious study of the hyperbaric medical literature. A quick search for "optic AND neuropathy AND hyperbaric" yields 8 entries in the Rubicon Research Repository and 33 papers on PubMed. We better get reading.

[Photo: Independent.ie]

Johns Hopkins Medicine: About as Good as Online HBOT Info Gets (and That's Not a Compliment)

Should you somehow manage to find the Hyperbaric Oxygen Therapy page, somewhere under Dermatology, in the Johns Hopkins online Health Library, you will be rewarded with a pretty okay overview. You will learn that HBOT helps wound healing, prevents "reperfusion injury" (nice), blocks harmful bacteria, strengthens the immune system, and encourages the formation of new connective tissue and skin cells. You will also get a quick history of hyperbaric medicine (why?) and blurbs about clinical indications, mechanisms, chamber types, precautions, and misuses. As one would expect, this august medical institution also takes a stand for hospital-based HBOT facilities staffed by trained and certified medical personnel.

Brilliant. Until the last paragraph, under "Misuses of HBOT":

In addition, some chiropractors and clinics use portable fabric HBOT chambers, the routine use of which, experts say, poses a serious fire and explosion hazard. Although no fire fatalities involving HBOT in a hospital setting have been reported since 1967, portable chambers have been implicated recently in several deaths after a unit caught on fire. 

Wrong. The doubly fatal 2009 fire at Lauderdale-by-the-Sea, Florida, involved a 40-year-old hard chamber. The other recent fatal incident, earlier this year in Ocala, Florida, involved a large chamber used to treat horses. Portable fabric bags—we won't call them hyperbaric chambers—raise all sorts of questions about therapeutic efficacy and medical fraud and quackery, but they do not pose a "serious fire and explosion hazard" if used as intended. We feel odd defending chiropractors and bag clinics. Those are just the facts.

Last month we wrote the Johns Hopkins webmaster to correct this misinformation but have not yet received a reply.

HyperbaricLink lists the wound healing center at the Johns Hopkins Bay View Medical Center, and from there, with just a click or two, to anywhere on our website, you will find more complete and more accurate information about hyperbaric oxygen therapy. That's why we're in business.

UHMS Accredits Hyperbaric Medicine at Eisenhower Army Medical Center, Fort Gordon, Georgia

The Hyperbaric Medicine Service at Dwight David Eisenhower Army Medical Center in Fort Gordon, Georgia, has received accreditation from the Undersea and Hyperbaric Medical Society (UHMS). Fort Gordon is home to the US Army Signal Corp. The military-only center is not open to the public. About UHMS accreditation, medical director Michael Madsen, MD, said it:

... signifies Eisenhower Army Medical Center’s commitment to patient safety and upholding the highest performance standards when treating patients with hyperbaric oxygen therapy.

Read the announcement in The Fort Gordon Signal. Learn more about facility accreditation in our UHMS profile and on the UHMS website.

[Photo: Eisenhower Army Medical Center website]