Abrazo Arrowhead Campus

Background. HOCl (eg, pHAp) preserved solutions have antimicrobial properties and are considered safe and effective for wound management. NPWTi-d (or NPWTi) is an established adjunctive wound modality for a variety of wound etiologies in various anatomic locations in which an instillate solution dwells on the surface of the wound to assist in wound bed preparation. A variety of solutions have been used, including 0.9% normal saline wound cleansers and antiseptics. pHAp is growing in popularity as the solution of choice for NPWTi-d. Objective. To evaluate consensus statements on the use of NPWTi-d with pHAp. Methods. A 15-member multidisciplinary panel of expert clinicians in the United States, Canada, and France convened in person in April 2023 in Washington, D.C. and/or corresponded later to discuss 10 statements on the use of pHAp with NPWTi-d. The panelists then replied "agree" or "disagree" to each statement and had the option to provide comments. Results. Ten consensus statements are presented, along with the proportion of agreement or disagreement and summary comments. Although agreement with the statements on NPWTi-d with pHAp varied, the statements appear to reflect individual preferences for use rather than concerns about safety or efficacy. Conclusion. The consensus indicates that NPWTi-d with pHAp can have a beneficial effect in wound care.

BACKGROUND Subclinical atrial fibrillation is short-lasting and asymptomatic and can usually be detected only by long-term continuous monitoring with pacemakers or defibrillators. Subclinical atrial fibrillation is associated with an increased risk of stroke by a factor of 2.5; however, treatment with oral anticoagulation is of uncertain benefit. METHODS We conducted a trial involving patients with subclinical atrial fibrillation lasting 6 minutes to 24 hours. Patients were randomly assigned in a double-blind, double-dummy design to receive apixaban at a dose of 5 mg twice daily (2.5 mg twice daily when indicated) or aspirin at a dose of 81 mg daily. The trial medication was discontinued and anticoagulation started if subclinical atrial fibrillation lasting more than 24 hours or clinical atrial fibrillation developed. The primary efficacy outcome, stroke or systemic embolism, was assessed in the intention-to-treat population (all the patients who had undergone randomization); the primary safety outcome, major bleeding, was assessed in the on-treatment population (all the patients who had undergone randomization and received at least one dose of the assigned trial drug, with follow-up censored 5 days after permanent discontinuation of trial medication for any reason). RESULTS We included 4012 patients with a mean (±SD) age of 76.8±7.6 years and a mean CHA2DS2-VASc score of 3.9±1.1 (scores range from 0 to 9, with higher scores indicating a higher risk of stroke); 36.1% of the patients were women. After a mean follow-up of 3.5±1.8 years, stroke or systemic embolism occurred in 55 patients in the apixaban group (0.78% per patient-year) and in 86 patients in the aspirin group (1.24% per patient-year) (hazard ratio, 0.63; 95% confidence interval [CI], 0.45 to 0.88; P = 0.007). In the on-treatment population, the rate of major bleeding was 1.71% per patient-year in the apixaban group and 0.94% per patient-year in the aspirin group (hazard ratio, 1.80; 95% CI, 1.26 to 2.57; P = 0.001). Fatal bleeding occurred in 5 patients in the apixaban group and 8 patients in the aspirin group. CONCLUSIONS Among patients with subclinical atrial fibrillation, apixaban resulted in a lower risk of stroke or systemic embolism than aspirin but a higher risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; ARTESIA ClinicalTrials.gov number, NCT01938248.).

Chronic soft tissue defects are notoriously difficult to heal. Surgical reconstruction of chronic defects using tissue flaps is a routine approach for closure of challenging chronic defects. Due to the poor tissue quality of chronic defects and associated inflammation, infection and impaired blood supply the success of flap closure is marred by reported complication rates of 25–58%. Extracellular matrix (ECM)-based graft materials are commonly used for resolving chronic wounds and in plastic and reconstructive procedures to create a scaffold for tissue regeneration. We hypothesized combination use of ECM grafts with tissue flaps in a single-stage surgical procedure would reduce complications and improve outcomes in the closure of chronic soft tissue defects. We report a case series ( n = 9) of chronic soft tissue defect reconstruction using this modified procedure of ECM graft augmented flap closure. Defects included pressure injuries and surgical dehiscence and ranged in wound age from 5 months to 7 years. Successful uncomplicated healing was achieved in six defects. Post-operative complications (dehiscence) occurred in two defects, however, these healed via secondary intention without additional surgical intervention. All healed defects exhibited acceptable cosmesis and “normal” function, with 100% patient satisfaction. Augmentation of tissue flaps with ECM graft materials in this modified single-stage procedure may improve outcomes and minimize typical complications encountered in flap closure of chronic defects attributed to inflammation, infection, hypoperfusion, and dead space.

West Nile Virus (WNV) is the most common mosquito-borne virus in the United States and North America. Although WNV disease occurs on a spectrum ranging from a relatively benign febrile illness to life-threatening neuroinvasive disease, the clinical presentations can vary widely and thus necessitates a high degree of suspicion. Here we describe three such cases where each individual presented with a unique constellation of symptoms that made the diagnosis challenging. It is essential for physicians to be well informed on the differing symptomology so early diagnosis and supportive management can mitigate poor prognosis.