Faculty Bibliography

Telemedicine use in the field of wound care had been increasing in popularity when the novel coronavirus 2019 paralyzed the globe in early 2020. To combat the constraints of healthcare delivery during this time, the use of telemedicine has been further expanded. Although many limitations of telemedicine are still being untangled, the benefits of virtual care are being realized in both inpatient and outpatient settings. In this article, the advantages and disadvantages of telemedicine are discussed through two case examples that highlight the promise of implementation during and beyond the pandemic.

The definition of medication-related osteonecrosis of the jaw (MRONJ) includes a stage 0 presentation where exposed bone, the hallmark of this condition, is absent. Numerous management strategies have been recommended for MRONJ including hyperbaric oxygen (HBO2) therapy. This report describes a 64-year-old woman with stage 0 MRONJ of the bilateral mandible, refractory to clindamycin and local debridement, who was subsequently managed successfully with amoxicillin/clavulanate and HBO2 therapy. The authors also explore the current literature on the pathophysiology of MRONJ and the potential role of hyperbaric oxygen in its treatment.

Introduction: There has been a growing interest in hyperbaric oxygen therapy (HBOT) in recent years across multiple disciplines. In the field of ophthalmology, the implications of increased HBOT use may include expanded applications in treating ocular vascular pathologies as well as a greater incidence of HBOT-induced visual complications. Areas covered: The authors review recent studies on HBOT usage in the treatment of ocular conditions. In addition to providing updates on the ophthalmic indications of HBOT, adverse visual effects of HBOT are also investigated. Expert opinion: Further evidence substantiating HBOT as an effective treatment modality for ocular vascular pathologies, such as central retinal artery occlusion and diabetic retinopathy, have been published in recent years. With the identification of more prognostic factors, increased success in HBOT has been reported. However, studies also show that adverse ocular effects associated with hyperbaric oxygen exposure include myopia and cataracts. It is important to recognize the risks of iatrogenic changes in visual acuity when considering patients for HBOT.

PURPOSE/OBJECTIVE:To describe the revenue from a collaboration between a dedicated wound care center and an interventional radiology (IR) practice for venous leg ulcer (VLU) management at a tertiary care center. MATERIALS AND METHODS/METHODS:This retrospective study included 36 patients with VLU referred from a wound care center to an IR division during the 10-month active study period (April 2017 to January 2018) with a 6-month surveillance period (January 2018 to June 2018). A total of 15 patients underwent endovascular therapy (intervention group), whereas 21 patients did not (nonintervention group). Work relative value units (wRVUs) and dollar revenue were calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule. RESULTS:Three sources of revenue were identified: evaluation and management (E&M), diagnostic imaging, and procedures. The pathway generated 518.15 wRVUs, translating to $37,522. Procedures contributed the most revenue (342.27 wRVUs, $18,042), followed by E&M (124.23 wRVUs, $8,881), and diagnostic imaging (51.65 wRVUs, $10,599). Intervention patients accounted for 86.7% of wRVUs (449.48) and 80.0% of the revenue ($30,010). An average of 33 minutes (38.3 hours total) and 2.06 hours (36.8 hours total) were spent on E&M visits and procedures, respectively. CONCLUSIONS:In this collaboration between the wound center and IR undertaken to treat VLU, IR and E&M visits generated revenue and enabled procedural and downstream imaging revenue.

BACKGROUND:Development of diabetic foot ulcers is a common complication of diabetes. Standard-of-care (SOC) therapy alone is often not sufficient to heal these wounds, resulting in application of adjuvant wound therapies including biologic skin substitutes. Although a variety of products exist, it has been difficult to formulate conclusions on their clinical efficacy. We therefore performed a systematic review and meta-analysis on the efficacy of healing diabetic foot ulcers with biologic skin substitutes. METHODS:A systematic review was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Four electronic databases (PubMed/MEDLINE, EMBASE [Ovid], Cochrane CENTRAL [Ovid], and Web of Science) were searched from inception through February 27, 2019. Searches included keywords and subject headings pertaining to 3 main concepts: biologic skin substitutes, wound healing, and diabetic foot ulcers. Cochrane randomized controlled trial filters were used to narrow results. Data were extracted from 54 included articles, and risk-of-bias assessments were conducted by 2 independent reviewers. The primary objective was to calculate a pooled risk ratio for the proportion of wounds completely closed by 12 weeks. Secondary objectives included a pooled risk ratio for the proportion of wounds completely closed by 6 weeks and mean time to healing. RESULTS:Twenty-five studies were identified that assessed the proportion of complete wound closure by 12 weeks. We found that wounds treated with biologic dressings were 1.67 times more likely to heal by 12 weeks than those treated with SOC dressings (P < 0.00001). Five studies assessed the proportion of complete wound closure by 6 weeks. Wounds treated with biologic dressings were 2.81 times more likely to heal by 6 weeks than those treated with SOC dressings (P = 0.0001). Descriptively, 29 of 31 studies that assessed time to healing favored biologic dressings over SOC dressings. CONCLUSIONS:This systematic review provides supporting evidence that biologic skin substitutes are more effective than SOC dressings at healing diabetic foot ulcers by 12 weeks. Future studies must address the relative benefits of different skin substitutes as well as the long-term implications of these products and their financial considerations.

Innovative surgery is defined as a novel procedure, a significant modification of a standard technique, or a new application of an established technique. Although innovation is a crucial part of improving patient care in plastic surgery, there are various ethical considerations and dilemmas in performing unvalidated techniques and procedures, especially for non-life-threatening indications. The aim of this study was to gain a better understanding regarding the motivations and ethical considerations of plastic surgeons in their decision to perform innovative operations. An anonymous, institutional review board-approved, online survey was sent to members of the American Society of Plastic Surgeons and other international plastic surgeons worldwide. The survey asked respondents to rank various factors that influence their decisions to perform innovative plastic surgery, both reconstructive and aesthetic, on a five-point Likert scale. Seven hundred thirty-three of 26,028 plastic surgeons (response rate, 2.9 percent) responded to the survey. Although similar factors were considered to be important for both reconstructive and aesthetic operations, only approximately 50 percent of respondents considered institutional review board approval to be an important factor when considering innovation in both reconstructive (50 percent) and aesthetic surgery (51 percent), suggesting that respondents do not consider innovation a form of research that ought be subject to standard research protections. Overall, the authors' survey suggests that more effort must be extended to ethical training in plastic surgery to create a stronger professional atmosphere regarding innovation and, possibly, to the creation of a more formal group charged with oversight of innovation.