Faculty Bibliography

BACKGROUND: Pathologic analysis of deep tissue obtained during debridement of venous ulcers is often unnoticed in its importance. We previously reported pathologic findings on 139 patients with venous ulcers. The objective of this study was to correlate the pathologic findings in venous ulcers with wound healing to establish a negative margin for debridement. STUDY DESIGN: Consecutive patients with a lower extremity venous ulcer present for at least 4 weeks, presenting to a single wound healing center, were included. Wounds underwent aggressive surgical debridement beyond the subcutaneous level until judged to have a viable base. Specimens were scored based on cellularity, vascularity, collagen composition, inflammation, and dense fibrosis, with a highest possible score of 13. Healing was the primary outcome for analysis. RESULTS: Of the 26 patients who met inclusion criteria, only 50% of them (13 patients) with a total of 18 venous ulcers underwent surgical debridement available for pathologic analysis. Mean ulcer area was 34.7 cm(2) at initial presentation, and 89% of patients had a continuous positive healing curve as measured by decreasing wound area (from 34.7 cm(2) to 14.3 cm(2)). However, specimens with dense fibrosis, decreased cellularity, mature collagen, and pathology score less than 10 were predominantly nonhealing ulcers. CONCLUSIONS: Presence of dense fibrosis and high levels of mature collagen in deep tissue specimens are significant correlative factors in nonhealing of venous ulcers. We recommend deep debridement on all venous ulcers that are refractory to healing until the level of absence of dense fibrosis and mature collagen is reached to promote venous ulcer healing.

Hydroxyurea (HU) has been shown to induce a variety of cutaneous adverse reactions, including severe leg ulcers. This report shows a successful treatment of a HU-induced chronic wound associated with squamous cell carcinomas (SCC). A 62-year-old patient affected with polycythemia vera and treated with HU for 10 years, presented with a non healing ulcer on a left heel. The patient gave a history of suffering from the wound for over 2 years. Biopsy showed evidence of invasive SCC. The patient underwent Mohs surgery and a greater saphenous vein ablation for polycythemia vera-associated vascular complications. The wound consistently decreased in size following successive debridements and coverage with human skin equivalent. The wound healed completely after a 6-month period. A multidisciplinary team approach to the treatment proved to be effective resulting in healing of this multifactorial chronic ulcer.

Diabetic foot ulcers (DFUs) are a significant and rapidly growing complication of diabetes and its effects on wound healing. Over half of diabetic patients who develop a single ulcer will subsequently develop another ulcer of which the majority will become chronic non-healing ulcers. One-third will progress to lower extremity amputation. Over the past decade, the outcomes for patients with DFUs ulcers have not improved, despite advances in wound care. Successful treatment of diabetic foot ulcers is hindered by the lack of targeted therapy that hones in on the healing processes dysregulated by diabetes. Stem cells are a promising treatment for DFUs as they are capable of targeting, as well as bypassing, the underlying abnormal healing mechanisms and deranged cell signaling in diabetic wounds and promote healing. This review will focus on existing stem cell technologies and their application in the treatment of DFUs.

Background: Healthcare disparities associated with insurance and socioeconomic status have been well characterized for several malignancies, such as lung cancer. To assess whether there are healthcare disparities in thyroid cancer, this study evaluated the stage on initial presentation of patients with differentiated thyroid cancer (DTC) in a public versus university teaching hospital. Methods: A retrospective chart review was performed to identify patients with a new diagnosis of DTC from January 1, 2007, to January 1, 2010, in a large public and adjoining university teaching hospital at a single academic medical center. Medical records were reviewed for demographics, pathology, and American Joint Committee on Cancer tumor-node-metastasis stage at initial presentation. Results: There were 49 cases of well-DTC (96% papillary and 4% Hurthle) in the public hospital and 370 cases (95% papillary, 2% Hurthle, and 3% follicular) in the university teaching hospital. Median age (years) at presentation was 50 in the public versus 48 in the university teaching hospital (p=0.39). Ninety-six percent of public hospital patients were from ethnic minorities compared with 16% of university teaching hospital patients (p<0.0001). Only 1 (2%) public hospital patient had private insurance compared with 85% of university teaching hospital patients. Tumor status (p=0.002) and stage (p=0.03) were more advanced and extrathyroidal extension (p=0.02) was more prevalent among public hospital patients compared with university teaching hospital patients. In a multivariable analysis, public hospital, male gender, increasing age, advanced tumor status, and the presence of lymphovascular invasion were the best predictors of more advanced disease stage. Public hospital patients were 3.4 times more likely to present with advanced DTC than university teaching hospital patients of the same age, gender, tumor status, and lymphovascular invasion status (95% confidence interval 1.29-8.95). Conclusions: In a public hospital, where the patient population is defined primarily by insurance status, patients were more likely to present with advanced-stage DTC than patients presenting to an adjacent university teaching hospital. These results suggest a disparity in the stage on initial presentation of DTC, possibly resulting in a delayed diagnosis of cancer.

OBJECTIVE: The objective of the study was to inform wound care practitioners of mesenchymal stem cell application for nonhealing wounds. Recent advances in delivery systems are also discussed in order to highlight potential improvements toward clinical application of stem cell therapy for chronic wounds. DATA SOURCES: MEDLINE and PubMed Central were searched for scientific studies regarding the use of mesenchymal stem cells and delivery systems in wound healing. STUDY SELECTION: Preclinical studies using stem cells as therapeutic modality for chronic wounds were selected for this review. DATA EXTRACTION: Information on study design, sample size and characteristics, stem cell source, type of delivery systems, and rate and time of wound closure was abstracted. DATA SYNTHESIS: Application of mesenchymal stem cells improved wound healing in experimental and clinical settings. Advances in stem cell therapy and delivery vehicles offer promising alternatives to current limited therapeutic modalities for chronic wounds. CONCLUSIONS: Stem cell therapy has recently emerged as a promising therapeutic strategy for nonhealing wounds. Further research is needed to evaluate the relationship between the various delivery systems and stem cells in order to maximize their therapeutic effects. Development of novel delivery vehicles for stem cells can open new opportunities for more effective cell therapy of chronic wounds

OBJECTIVE: To determine if final intraoperative parathyroid hormone (IOPTH) level predicts those at risk for recurrence after parathyroidectomy. Minimally invasive parathyroid exploration guided by preoperative imaging and IOPTH level is an accepted alternative to bilateral exploration for the treatment of primary hyperparathyroidism (HPT). However, additional enlarged, hypercellular parathyroid glands are present in some patients in whom IOPTH levels fall to normal after excision of a single adenoma. At least 15% of patients are normocalcemic with elevated PTH levels (PPTH) after parathyroidectomy. In these patients, a higher risk of recurrent HPT has been found. DESIGN: Retrospective review of medical records. SETTING: University teaching hospital. PATIENTS: The records of all 194 patients who underwent successful initial parathyroidectomy for nonfamilial HPT in 2007 and 2008 by 1 surgeon were reviewed. MAIN OUTCOME MEASURES: Intraoperative PTH level was measured prior to incision (baseline); at excision of the abnormal gland; at 5, 10, 15, and 20 minutes after excision; and at various additional times as needed. Of the patients, 71% underwent minimally invasive parathyroid exploration. Calcium, PTH, and 25-hydroxyvitamin D levels were measured during the first month after surgery in all patients and after 3 months or more in 80%. Patients were divided into 5 groups depending on the following final IOPTH levels: lower than 10 pg/mL (group l) (to convert PTH to nanograms per liter, multiply by 1.0); 10 to 19 pg/mL (group 2); 20 to 29 pg/mL (group 3); 30 to 39 pg/mL (group 4); and 40 pg/mL or higher (group 5). RESULTS: Of the patients, 82% had a single adenoma, 9% had double adenomas, and 9% had 3 or more abnormal glands. The final IOPTH/baseline IOPTH value in groups 1 to 5 was 7%, 11%, 16%, 23%, and 26%, respectively. There was no significant difference in the preoperative calcium among the groups. All 3 patients with persistent HPT and 5 patients with PPTH were in group 5. One of the 96 patients in groups 1 and 2 and 5 of the 72 patients in groups 3 and 4 had PPTH at the last evaluation. CONCLUSION: Patients with a final IOPTH level of 40 pg/mL or higher are at higher risk of having persistent HPT and should be followed up closely and indefinitely following parathyroidectomy