Jennifer C. Tang

Is surgical resection superior to transplantation in the treatment of hepatocellular carcinoma

Objective:To compare outcomes for patients with hepatocellular carcinoma (HCC) treated with either liver resection or transplantation. Methods:A retrospective, single-institution analysis of 413 HCC patients from 1999 to 2009. Results:A total of 413 patients with HCC underwent surgical resection (n = 106) and transplantation (n = 270) or were listed without receiving transplantation (n = 37). Excluding transplanted patients with incidental tumors (n = 50), 257 patients with suspected HCC were listed with the intent to transplant (ITT). The median diameter of the largest tumor by radiography was 6.0 cm in resected, 3.0 cm in transplanted, and 3.4 cm in the listed-but-not-transplanted patients. Median time to transplant was 48 days. Recurrence rates were 19.8% for resection and 12.1% for all ITT patients. Overall, patient survival for resection versus ITT patients was similar (5-year survival of 53.0% vs 52.0%, not significant). However, for HCC patients with model end-stage liver disease (MELD) scores less than 10 and who radiologically met Milan or UCSF (University of California, San Francisco) criteria, 1-year and 5-year survival rates were significantly improved in resected patients. For patients with MELD score less than 10 and who met Milan criteria, 1-year and 5-year survival were 92.0% and 63.0% for resection (n = 26) versus 83.0% and 41.0% for ITT (n = 73, P = 0.036). For those with MELD score less than 10 and met UCSF criteria, 1-year and 5-year survival was 94.0% and 62.0% for resection (n = 33) versus 81.0% and 40.0% for ITT (n = 78, P = 0.027). Conclusions:Among known HCC patients with preserved liver function, resection was associated with superior patient survival versus transplantation. These results suggest that surgical resection should remain the first line therapy for patients with HCC and compensated liver function who are candidates for resection.

State of the art in topical wound-healing products

Summary: Chronic wounds represent a significant medical burden. Such wounds fail to normally progress through the stages of healing, often complicated by a proinflammatory milieu caused by increased proteinases, hypoxia, and bacterial burden. As a result, several modalities, such as dressings, antimicrobials, growth factors, and human skin substitutes, have been devised in an attempt to correct the chronic wound environment. This review addresses these modalities with a focus on evidence and randomized controlled trials.

High mortality in patients with chronic wounds

To the Editor: Chronic wounds have become a major public health issue in the United States and abroad. Patients with chronic wounds are often elderly, have cardiovascular disease and other comorbid conditions, and are at additional risk for further complications. This results in additional health care expenditures; for example, the United States alone spends

Wound Healing Society (WHS) venous ulcer treatment guidelines: What's new in five years?

25 billion annually related to chronic wounds and the demand for wound care is increasing. Specifically, diabetic foot ulcer complications have 5-year mortality rates similar to common types of cancer. A recent study from the Netherlands reported patients with diabetes mellitus who had foot ulcers to be at an increased risk for mortality compared with diabetics without foot ulceration (49% mortality over 10 years compared with 35.2% mortality—R 1.49). However, little is known about mortality for patients with other chronic wounds. We evaluated mortality in patients with chronic wounds to understand this better. We performed a retrospective cohort study of patients with chronic wounds treated in wound care centers and patients not treated in wound centers (matched by age, gender, and state of residence) using Centers for Medicare and Medicaid Services (CMS) data. Wound etiologies included venous leg ulcers, diabetic foot ulcers, and pressure ulcers. Using administrative data patients were followed for a 2-year period. We examined the incidence of wound-related deaths over a 2-year period. One thousand eight hundred fifteen patients with diabetic foot ulcers (DFU), pressure ulcers (PU) and venous leg ulcers (VLU) were included, 854 were treated at outpatient wound centers and 961 were treated in community practices. Fiftythree (52.6%) percent were men and the mean age of the group was 78 years old. Pressure ulcers accounted for 44% of the wounds and 84% were lower limb ulcers (Table 1). Comorbidities were common as two-thirds had cardiovascular disease, over half of patients had diabetes mellitus (DM), over 40% had peripheral arterial disease (PAD), one-quarter had either renal disease or neuropathy, and 4% had suffered a hip fracture. A higher frequency of comorbidities existed in patients treated in wound centers (Table 2). Of 1,815 patients, 28% (504 patients) died during the 2-year follow-up. Forty-six (2.5%) died in the hospital from a wound-related diagnosis (Table 3). No difference in death rate was noted in the different sites (Table 3), nor differences in the frequency of comorbidities or wound infection between deceased and surviving patients but differences existed in gangrene (RR51.93 95%, CI51.56–2.39); amputation (RR5 1.74 95%, CI51.35–2.25); and hospitalization for a woundrelated condition (RR51.95 95%, CI51.52–2.50) (Table 4). In summary we found that over one-quarter (28%) of wounded patients seen as outpatients died during a 2-year period. Drawn from both outpatient wound centers and community-based practices, they likely represent outpatients with wounds that are seen in the United States. As subjects of this study were outpatients and the majority of wounds were on the lower extremity, inpatients might have a different or even higher mortality with a greater percentage of sacral or ischial wounds. The population’s mean age was 75 years old and compared with similarly aged patients, death rates were much higher than the reported death rate for 75–79 year olds (4%), suggesting a higher risk of death in the wounded population. As expected patients studied had a high frequency of diseases that impede normal healing or may contribute to the

Lasers in the treatment of nonmelanoma skin cancer.

Since the establishment of the guidelines for the treatment of venous ulcers by the Wound Healing Society in 2006, there has been an abundance of new literature, both in accord and discord with the guidelines. The goal of this update is to highlight new findings since the publication of these guidelines to assist practitioner and patient in appropriate health care decisions, as well as to drive future research endeavors.

Use of dermal fat graft for augmentation of the labia majora

BACKGROUND Nonmelanoma skin cancers (NMSCs) constitute the largest proportion of cancers worldwide, especially in the Western population, making it essential to develop methods to manage these cancers. Ultraviolet (UV) light being the most significant culprit in the development of NMSCs makes the sun‐exposed parts of the body, such as face and extremities, the most vulnerable to develop these tumors. Early diagnosis and emphasis on cosmesis are vital while treating them especially, in patients with multiple squamous and basal cell carcinomas. Lasers seem to be a useful therapeutic modality and are being explored to develop them as a tool for treating skin cancers. OBJECTIVE To review the use of lasers in the treatment of NMSCs. METHODS We reviewed articles that involved the use of lasers in the management of NMSCs and prepared a critical analysis of the same. RESULTS AND CONCLUSIONS Lasers as a single modality, as the coherent light source in photodynamic therapy (PDT), or as an adjunct to PDT or other treatment modalities are a potential method of NMSC eradication. Superficial NMSCs and most precancerous cutaneous lesions such as Bowens disease and actinic keratoses respond best, whereas deeper, more‐aggressive NMSCs show poor outcomes with laser treatments. The authors have indicated no significant interest with commercial supporters.

Wound healing society 2015 update on guidelines for venous ulcers

Dermal fat grafts have been utilized in plastic surgery for both reconstructive and aesthetic purposes of the face, breast, and body. There are multiple reports in the literature on the male phallus augmentation with the use of dermal fat grafts. Few reports describe female genitalia aesthetic surgery, in particular rejuvenation of the labia majora. In this report we describe an indication and use of autologous dermal fat graft for labia majora augmentation in a patient with loss of tone and volume in the labia majora. We found that this procedure is an option for labia majora augmentation and provides a stable result in volume-restoration.

Topical Timolol for a Refractory Wound

The Wound Healing Society (WHS) guidelines for the treatment of venous ulcers were originally published in 2006. These guidelines provided recommendations, along with their respective levels of evidence and strength on various categories. Over the past 7 years, a great deal of literature regarding these aspects of venous ulcer management has been published. An advisory panel comprised of academicians, clinicians, and researchers was chosen to update the 2006 guidelines. Members included vascular surgeons, internists, plastic surgeons, anesthesiologists, dermatologists, emergency medicine physicians, and registered nurses, all with expertise in wound healing. The goal of this article is to evaluate relevant new findings, on which an updated version of the guidelines will be based.

Postradiation Chronic Scalp Ulcer: A Challenge for Wound Healing Experts

A43-year-old woman presented with a large refractory wound on her left mid-back (Figure 1A). Her past medical history was significant for a heart transplant in 1994 because of postpartum cardiomyopathy. Chronic rejection and subsequent worsening congestive heart failure resulted in a second heart transplant in 2008. A prolonged hospital stay, including multiple thoracotomies and pulmonary window for empyema, along with placement of numerous chest tubes, had complicated her most recent transplant. As a result of these interventions, she had had a traumatic ulcer on her back for the previous 15 months. During that time, she failed to improve with conservative care comprising Aquacel (ConvaTec, Skillman, NJ), Adaptic (Johnson & Johnson, New Brunswick, NJ), and foam dressings and Negative Pressure Wound Therapy (V. A. C. Kinetics Concepts Incorporated, San Antonio, TX). She was not a candidate for surgical correction with a flap because of the location of the wound. Her medications include tacrolimus, mycophenolate mofetil, candesartan, atenolol, pravastatin, trimethoprim and sulfamethoxazole, aspirin, iron sulfate, magnesium, zinc sulfate, calcium, vitamin D, and folic acid. On examination, she had a 26-cm defect with a depth of 3.5 cm on her left mid-back. At the base was a 69 4-cm ulcer with pink–red granulation tissue overlying the wound base (Figure 1B). The wound base moved with respiration (Video). Other than a slight cough, she was systemically well. Daily application of topical recombinant human platelet-derived growth factor for 3 weeks (Regranex Systagenix, North Yorkshire, UK) failed to lead to reepithelialization.

Use of immediate dermal fat graft for scalp contour defect following resection of arteriovenous malformation.

For example, ionizing radiation, although beneficial for treating cancer, has negative effects on surrounding uninvolved tissues. Fragile and friable areas of damaged skin after radiation may lead to chronic, painful, and recalcitrant ulcers and, at times, bony changes. It may also result in more difficult healing after surgery and recurrence of the wound even with minor trauma. Despite improvements in radiation therapy techniques and equipment, chronic radiation ulcers are often resistant to conventional treatment modalities or advanced surgical options such as flap coverage or skin grafting and continue to be a therapeutic challenge. We present a case of a radiation ulcer treated using tissue engineered skin, discuss the pathophysiology of radiation-induced skin damage, and review the current management strategies.