Faculty Bibliography

Chronic wounds remain a significant clinical challenge despite advances in dressings, biologics, and adjunctive therapies. Patients referred to advanced wound centers following unsuccessful treatment often demonstrate recurring and potentially correctable factors that contribute to delayed healing. Drawing upon observations from a quaternary referral wound center, this article focuses on recurring and potentially correctable factors encountered during evaluation of wounds that have failed to progress despite prior care. Although these patterns are neither novel nor unexpected, they continue to recur despite well-established wound care principles and treatment guidelines. This article highlights common pitfalls identified in patients referred for advanced wound care evaluation. Commonly encountered issues include inadequate implementation of compression therapy and lower extremity elevation, ineffective offloading in diabetic foot ulcers, limited attention to patient adherence and behavioral factors, and incomplete evaluation of underlying contributors to wound chronicity. Additional patterns include continued use of outdated or nonevidence-based topical agents, misapplication of debridement principles (particularly removal of stable eschar), and incomplete evaluation of underlying pathophysiology such as vascular insufficiency. Patients are frequently referred after undergoing advanced interventions, including hyperbaric oxygen therapy and grafting procedures, before optimization of fundamental wound care principles. In these settings, suboptimal patient selection and sequencing of therapy, particularly in the presence of uncontrolled edema or inadequate offloading, may contribute to prolonged treatment without clinical benefit. These observations highlight recurring gaps between recommended care and real-world execution. Recognition of these recurring pitfalls may improve wound healing outcomes, promote more effective use of advanced therapies, and reduce the need for escalation of care.

Cutaneous angiosarcoma is a rare and aggressive malignancy that may arise in chronic lymphoedema. Its presentation as a non-healing ulcer can lead to delayed diagnosis. We describe an atypical case of angiosarcoma presenting as a chronic lower extremity ulcer in the setting of chronic lymphoedema and to highlight the importance of early biopsy. We report on the clinical course, diagnostic evaluation, treatment, and outcome of a patient with chronic lymphoedema who developed a persistent ulcer. A 74-year-old woman with longstanding lower extremity lymphoedema developed a non-healing ulcer initially managed as cellulitis and venous ulceration. Due to failure of conservative therapy, biopsy was performed and revealed angiosarcoma. The patient underwent surgical resection and adjuvant radiotherapy, remaining disease-free for over 4 years before recurrence and eventual death. Malignancy should be considered in chronic non-healing ulcers, especially in the setting of longstanding lymphoedema. Early biopsy is essential to avoid delayed diagnosis and improve outcomes.

The loss of Royal Mail Ship (RMS) Titanic has been examined extensively through the lenses of engineering failure, maritime law, and social history, yet little attention has been paid to the conduct and professional identity of her medical officers. This surgical history examines the lives and final hours of the ship's 2 surgeons, Dr. William Francis Norman O'Loughlin and Dr. John Edward "Jack" Simpson, situating their actions within the evolving practice of maritime medicine in the early 20th century. Drawing on contemporary newspaper accounts, official inquiries, archival records, personal correspondence, and genealogical sources, this article reconstructs their careers, responsibilities, and conduct during the disaster. O'Loughlin, a senior surgeon with decades of maritime experience, and Simpson, a younger assistant surgeon at the outset of his career, represented 2 generations united by a shared professional ethic. Both remained at their posts, assisting passengers and crew, maintaining calm, and declining opportunities for self-preservation. Their actions exemplify the unwritten code of the surgeon: composure under pressure, disciplined and methodical judgment, and a steadfast respect for the dignity of every human life. Beyond documenting individual bravery, this article demonstrates that their conduct reflects enduring principles of surgical professionalism that transcend era, technology, and setting. In a tragedy remembered primarily for its scale, the surgeons' story highlights how judgment, humanity, and moral responsibility remain central to the identity of the surgeon, whether practiced in a modern operating room or a rolling hospital at sea.

OBJECTIVE:This study reports patient outcomes and predictors of outcomes after total contact casting (TCC) for diabetic stump ulceration in patients with partial-foot amputations. METHODS:Retrospective review of patients treated with TCC for diabetic stump ulcerations with ipsilateral partial-foot amputation at a tertiary center from 2015 to 2022 was performed. Patients lost to follow-up, those unable to tolerate TCC, and those with partial amputations of digits 2 to 5 were excluded. Patient demographics, outcomes, and complication rates of TCC were collected and compared. Multivariable linear regression was performed to identify demographic predictors of time to ulcer closure. RESULTS:Forty-three patients were included in this study, with a 93.5% rate of primary ulcer closure, 46.5% rate of re-ulceration, and 9.3% rate of re-amputation. Patients without re-ulceration were significantly more likely to be nonsmokers. Regression analysis also found that smoking history trended toward a longer delay to ulcer closure (P=.097). Age, body mass index, presence of contralateral amputation, and type of amputation did not affect patient outcomes or complication rates. CONCLUSIONS:TCC effectively promotes ulcer closure in diabetic patients with high comorbidity burden and partial-foot amputation, although smoking history increases re-ulceration rates.

We report a case of malignant transformation in a young woman with pilonidal disease-a rare manifestation of 'Marjolin's ulcer'. The patient initially presented to an outside hospital emergency department with an ulcer of the left buttock. Her family reported a longstanding mass present at this site prior to rupture. The patient had two ED visits and a surgical referral that did not result in biopsy, contributing to delayed diagnosis. She eventually presented to our wound clinic with a full-thickness, friable, frond-like ulcer with probable sacral extension. Immediate biopsy was performed and confirmed squamous cell carcinoma (SCC). Imaging revealed a buttock mass with lymphadenopathy. Fine-needle aspiration confirmed metastatic SCC in the inguinal lymph nodes. The disease was deemed unresectable and systemic therapy was begun. This case emphasizes the importance of biopsy in nonhealing ulcers, underscores the need for system-level processes to ensure follow-up, and demonstrates the enduring relevance of Marjolin's original 19th-century observations.

OBJECTIVE/UNASSIGNED:To determine the outcomes of patients receiving hyperbaric oxygen therapy for sudden sensorineural hearing loss and the impact of patient comorbidities on outcomes. STUDY DESIGN/UNASSIGNED:Retrospective chart review. SETTING/UNASSIGNED:Tertiary referral center. METHODS/UNASSIGNED:All patients over 18 diagnosed with sudden sensorineural hearing loss between 2018 and 2021 who were treated with hyperbaric oxygen therapy were included. Demographic information, treatment regimens and duration, and audiometric and speech perception outcomes were recorded and analyzed. RESULTS/UNASSIGNED:19 patients were included. The median age was 45 years. 53% were female and 21% had pre- existing rheumatologic disorders. The mean duration between hearing loss onset and physician visits was 9.6 days. All patients received an oral steroid course, while 95% also received a median of 3 intratympanic steroid injections. Patients began hyperbaric oxygen therapy an average of 34.2 days after the hearing loss onset for an average of 13 sessions. No significant relationships were found between patient comorbidities and outcomes. Of those who reported clinical improvement, 57% demonstrated complete recovery per Siegel's criteria. There was significant improvement after hyperbaric oxygen therapy for pure tone averages (50.3dB vs. 36.0dB, p<0.01) and word discrimination scores (73% vs 79%, p<0.05) for all patients regardless of reported clinical improvement. CONCLUSION/UNASSIGNED:Hyperbaric oxygen therapy, as an adjunct to steroids, significantly improves recovery from sudden sensorineural hearing loss. The Charlson comorbidity index was not significantly associated with patient outcome, but patients with rheumatologic disorders were less likely to respond. Differentiating the natural history of the disease from hyperbaric oxygen therapy-associated improvements remains a challenge.

OBJECTIVES/OBJECTIVE:Total contact casting (TCC) is used to promote wound closure in diabetic foot ulcers (DFUs); however, this technique is underused today. This study aims to further evaluate the efficacy of TCC in a large cohort, including patients with peripheral artery disease (PAD). METHODS:This was a retrospective analysis of patients with DFUs who underwent TCC from 2017 to 2021. PAD was defined as absence of pedal pulse or ABI <0.9. Demographic data, DFU characteristics, and peripheral arterial intervention were evaluated. Outcomes included complete healing, healing time, and rate of major amputation. Subgroup analysis was performed on patients undergoing peripheral intervention. RESULTS:= .0008) compared to patients without intervention. CONCLUSIONS:TCC remains an effective option for treatment of DFUs, as most were completely healed. Patients with PAD may benefit from TCC and revascularization, however, healing rates are lower in this cohort, necessitating the need for close observation.

Chopart's amputation is a limb length-preserving amputation that retains function but often suffers from stump ulcerations. We report a case of a 68-year-old male patient with poorly controlled type 2 diabetes mellitus and peripheral arterial disease who underwent left Chopart's amputation, presenting subsequently with nonhealing ulcers at the Chopart stump and heel for >1 year. Total contact casting was initiated, resulting in rapid wound healing without further interventions. This case highlights total contact casting's effectiveness in managing ulcerations post-Chopart's amputation, potentially preventing revision amputations, and extending its usefulness to complex foot anatomy in patients with diabetes and peripheral arterial disease.

BACKGROUND:Hyperbaric oxygen has been reported to improve disease activity in hospitalised ulcerative colitis (UC) patients. AIM/OBJECTIVE:To evaluate dosing strategies with hyperbaric oxygen for hospitalised UC patients. METHODS:We enrolled UC patients hospitalised for acute flares (Mayo score 6-12). Initially, all patients received 3 days of hyperbaric oxygen at 2.4 atmospheres (90 minutes with two air breaks) in addition to intravenous steroids. Day 3 responders (reduction of partial Mayo score ≥ 2 points and rectal bleeding score ≥ 1 point) were randomised to receive a total of 5 days vs 3 days of hyperbaric oxygen. RESULTS:We treated 20 patients with hyperbaric oxygen (75% prior biologic failure). Day 3 response was achieved in 55% (n = 11/20), with significant reductions in stool frequency, rectal bleeding and CRP (P < 0.01). A more significant reduction in disease activity was observed with 5 days vs 3 days of hyperbaric oxygen (P = 0.03). Infliximab or colectomy was required in only three patients (15%) despite a predicted probability of 80% for second-line therapy. Day 3 hyperbaric oxygen responders were less likely to require re-hospitalisation or colectomy by 3 months vs non-responders (0% vs 66%, P = 0.002). No treatment-related adverse events were observed. CONCLUSION/CONCLUSIONS:Hyperbaric oxygen appears to be effective for optimising response to intravenous steroids in UC patients hospitalised for acute flares, with low rates of re-hospitalisation or colectomy at 3 months. An optimal clinical response is achieved with 5 days of hyperbaric oxygen. Larger phase 3 trials are needed to confirm efficacy and obtain labelled approval.