Quick Updates - Undersea and Hyperbaric Medicine Section Newsletter, September 2012
Bruce J. Derrick, MD
The ACEP Scientific Assembly is rapidly approaching.
First and foremost, don’t forget to plan your trip to Denver. Hotels are booking up fast!
Second, mark your calendar and plan on decompressing with us at the UHM section meeting:
Date: Wednesday, October 10, 2012
Time: 9:00 am – 11:00 am
Where: Colorado Convention Center
Room: Mile High Ballroom C
During the section meeting, elections for Chair-elect and Secretary/Newsletter Editor will be held. If you have an interest in serving as an officer for the UHM Section, please notify Margaret Montgomery, staff liaison or Norma Cooney, MD, FACEP, UHM Section Chair. Nominations from the floor will be accepted at the meeting.
Have you had an interesting case recently? Read a thought provoking paper? Thinking about making evidence-based protocol changes? Have an idea for a new treatment indication? Heard of any legislative updates? Have you been to other meetings recently? Do you know residents or medical students who are interested in sharing their perspective on HBO? If you answered “yes” to any of these questions, or if you have any other hyperbaric medicine related thoughts to share, then we need YOU to submit an article for the next UHM section newsletter!
Yes, it takes a little effort to sit down and write an article, but they don’t need to be long or overwhelmingly time consuming to create. Everyone from seasoned faculty and fellows to residents and medical students are encouraged to submit. Start typing and share your thoughts with the group. Who knows, you may spawn the ideas for the next groundbreaking research or treatment indication!
Please email Bruce J. Derrick with your submissions or questions.
Section Listserv – don’t forget me!
We went through a short burst of listserv postings earlier in the year and had some great discussions, but this great resource has gone largely underutilized as of late. Let’s get back on the wagon and start some collective thinking. The listserv is a great means to reach out to your friends and colleagues when you’re faced with an interesting clinical question or research dilemma. Someone out there might have the answer you’re looking for! It’s also a means of generating ideas on how to advance the field, inspire collaborative research projects, improve patient care, and enables those who can’t always make it to meetings to be active participants in current discussions. Section members can post to the listserv by emailing: firstname.lastname@example.org.
Past Chairwoman’s Column - Undersea and Hyperbaric Medicine Section Newsletter, September 2012
Tracy Leigh LeGros, MD, PhD, UHM, FACEP
What a year it has been! We had section elections and Norma Cooney, MD, FACEP, a great woman, is our new Chair. I am sure she will do an amazing job. I have a couple of things to discuss, so onward.
ACGME/RRC REVIEW REQUEST: Yes, it is that time again. The Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC) told us that they would be coming back in a couple of years to revisit our progress and see how things were going. Originally in 2010, they wrote to us having concerns about the growth of our specialty as it relates to fellowship development. Following that request, a committee was formed that included myself, Heather Murphy-Lavoie, Laurie Gesell, Enoch Huang, Bob Sanders, and Chris Logue. A forty-seven page document was generated, supplemented by over forty letters of support from institutions around the country, as well as the Presidents of the American Academy of Emergency Medicine (AAEM), the Undersea and Hyperbaric Medical Society (UHMS) and of course ACEP. Additionally, we obtained letters from THE Surgeon General of the United States, as well as from the Surgeon Generals' of the Army, Navy, and Air Force. It was a wonderful achievement. We submitted this document, entitled “In Advocacy of Undersea and Hyperbaric Medicine Fellowships: Report to the Accreditation Council for Graduate Medical Education (ACGME) and the Residency Review Committee (RRC).” Gesell L., LeGros T., Murphy-Lavoie H., Sander R., and Huang E. It was presented on September, 2010; Passed January, 2011. They agreed with our assessment that we do provide unique, invaluable and unduplicated expertise in what we do, and congratulated us on a job well done. Well now, they are back, and they want an update.
THE NEW REPORT TO THE ACGME/RRC: One of the Louisiana State University (LSU) Fellows, Dr. Aimee Kramer, graciously agreed to contact the original forty one institutions who submitted letters of support, as well as 20 other institutions we identified that had the capacity to begin a UHM Fellowship. An email and phone survey was conducted. The results were most pleasing. We have identified ELEVEN institutions ACTIVELY engaged in the development of UHM Fellowships. They are not just interested and supportive. They have fellowships in development. This is great news. Additionally, Dr. Kramer revisited the perceived barriers to fellowship development and found an interesting twist when comparing this surveys results with the last survey performed by a graduate of the LSU UHM Fellowship (Dr. Marina Wilder). These findings will form the basis of our new report to the ACGME/RRC. This new report will contain the survey results, as well as new letters of support from the aforementioned individuals, and will also provide new insight into the barriers to fellowship development that are actually quite concerning to all institutions that provide GME training for Residents and Fellows.
A NEW INDICATION FOR HYPERBARIC OXYGEN THERAPY - IDIOPATHIC SUDDEN SENSORINEURAL HEARING LOSS: For those of you who may not have been to UHMS last year, Dr. Steve Piper (one of our LSU Fellows), Dr. Heather Murphy-Lavoie, and myself brought forth a proposal for a new indication for HBO2 - ISSHL. Actually we brought forth two new indications for considerations, the other one was femoral head avascular necrosis (spearheaded by another LSU Fellow - Dr. Sarah Parks). For those of you that are unsure how an indication gets approved, please refer to the May/June 2012 issue of the UHM Journal. It contains the outline of how this process occurs. In a nutshell, we batted .500. ISSHL was approved and FAVN was not. That is pretty good for the majors! Because we won the battle, we were honored to write the definitive article. Please read it, it is a really comprehensive review that also spells out the treatment guidelines, patient management, follow up, and utilization review. Don't worry about FAVN though, LSU (and other institutions) are providing more studies. Our IRB is put through and we have been treating FAVN patients since last June. We will try again!
THE COMPREHENSIVE TEXTBOOK OF UNDERSEA AND HYPERBARIC MEDICINE: As some of you know, Drs. Robert Sanders, Heather Murphy-Lavoie, Laurie Gesell, and Chris Logue and myself are spearheading the development of this new text. We are very proud of it. It will contain a full and well rounded amount of Diving Medicine, Diving Math, Hypobaric Medicine, Indications, Contraindications, Side Effects, Complications, Fitness to Dive, and a whole bunch more. It will be accompanied by a second text of questions and answers. This companion text will be great for anyone that prefers question based learning, is studying for the UHM Boards, is in Fellowship training, or simply wants to a great set of texts for reference. We have been meeting ferociously and are excited about the author list. It contains a wide array of absolutely stunning authors. You should really get a lot out of this text.
UNDERSEA AND HYPERBARIC MEDICAL SOCIETY ELECTIONS: Well, the votes have been counted. Your New UHMS Officers are: James Holm (President-Elect); Ken LeDez (Vice President); Member at Large for BOD (Tracy Leigh LeGros (yea!!); Enrico Camporesis (Treasurer). Additionally, Dr. Heather Murphy-Lavoie was named the new Chairwoman of the Education Committee. Thanks to everyone for their support. Please let me know if I can ever bring up any concerns of yours with the Board of Directors. I would be glad to do so.
UNDERSEA AND HYPERBARIC MEDICAL SOCIETY COMMITTEE ASSIGNMENTS: Okay, just a bit more UHMS news. We have a bunch of committees to tell you about. I am Co-Chairing two committees with Laurie Gesell. These are the Fellowship Committee and the UHMS Text Committee. Please contact me if you have an interest in either one. Moreover, Enoch Huang is head of the Publications committee. Dr. Murphy-Lavoie, Dr. Norma Cooney, Dr. Derek Cooney, and myself are also on this committee and we always value new members and interest. And finally, there Dr. Murphy's education committee. It is a very important committee and is doing a lot of very important work with regard to hospital credentialing, proctorships, standards for educational conferences and much more. Current members include myself, Bob Sanders, Norma Cooney, Derek Cooney, Jeannie Le, and of course the big names like Ben Slade and Paul Sheffield and Laurie Gesell. You may contact Dr. Murphy about your interest in this committee. Dr. Kelly Matthews is the Chair of the Membership committee and would appreciate any input from you. You may find all of these contacts within your UHMS Directory. I will email you one if you need one.
UHMS CHAPTER MEETINGS: Please consider supporting one of your local UHMS Chapter Meetings. They are as follows:
|Canadian Chapter||Ottawa||November 17- 18, 2012|
|Gulf Coast Chapter||The Beau Rivage, Biloxi, MS||September 7-8, 2012|
|Midwest Chapter||The Sheraton, St. Louis, MO||August 24-26, 2012|
|Northeast Chapter||The Marriott, Springfield, MA||September 28-30, 2012|
|Pacific Chapter||The Benson, Portland, OR||October 18-20, 2012|
|Brazil Chapter||No Information|| |
Please look at the lineup of speakers and topics and consider joining us. Drs. Norma Cooney, Derek Cooney, Owen O'Neil, Heather Murphy-Lavoie and myself will be lecturing at the Pacific and Gulf Coast Chapter meetings and would love to see you!! These are great meetings that often have guest lecturers like Dr. Brett Hart (immediate past UHMS President), Dr. John Feldmeier (current President for UHMS), and Past Presidents (Dr. Laurie Gesell). They are really jam packed with great lectures and lecturers.
Well, that is all for me. I would like to thank Dr. Bruce Derrick, our new Editor for this Newsletter, for asking me to write this column. I can't wait to see all of you in Denver!!
Tracy Leigh LeGros
Articles You May Have Missed - Undersea and Hyperbaric Medicine Section Newsletter, September 2012
Bruce J. Derrick, MD
This is a short review of a recent article that you may have overlooked in that tall stack of medical journals sitting in the corner of your office. The goal is simply to give you an idea of what the publication offers and to stimulate interest in reading it for yourself. Any views expressed are that of myself and do not reflect the opinion of any particular institution or organization. Special thanks to the authors, Chai R. Soh, Ricardo Pietrobon, John J. Freiberger, Sophia T. Chew, Dimple Rajgor, Mihir Gandhi, Jatin Shah, and Richard E. Moon, for their hard work and dedication toward the advancement of the field of undersea and hyperbaric medicine.
Soh CR, Pietrobon R, Freiberger JJ, et al. Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample. Intensive Care Med. Jul 2012;38(7):1143-1151.
Necrotizing soft tissue infections (NSTI) continues to be a frightening disease that is difficult to treat and carries a high rate of morbidity and mortality. Hyperbaric oxygen therapy (HBOT) has been an adjunct therapy to surgical debridement and antibiotics for some time, but its use is far from universal. As with many approved indications for HBOT, debate exists as to the efficacy this treatment modality for NSTI. Given the low prevalence of this disease, the relative sparseness of hyperbaric facilities and a wide variety of other factors, the gold-standard “multicenter randomized control” remains elusive and is unlikely to ever be conducted. As the authors of this paper note, “…it is not uncommon to read about statements describing the lack of adequately powered or controlled trials in HBO2 therapy for NSTI.”1
Chai Soh and colleagues utilized the “United States Nationwide Inpatient Sample” (NIS) in an attempt to study what effect, if any, HBOT had in the treatment of NSTI. The NIS is a national database of de-identified patient information which now comes from 1,051 different hospitals in 45 states, and contains data from roughly 8 million hospital admissions annually.2 Through a search of ICD-9 codes for necrotizing fasciitis, Fournier’s and gas gangrene, the authors retrospectively identified 45,913 patients from 1988 through 2009; 405 of which were treated with HBOT.1 Patient oriented outcome data was compared for two groups; the 45,109 patients who did not receive HBOT vs. the 405 who did. The primary outcome was in-hospital mortality as the database does not capture outpatient or post-discharge information.1 A myriad of secondary outcomes were evaluated including amputation rates, length of stay (LOS), hospital charges, complications related to the disease, and complications related to HBOT.1 These were again searched for using ICD-9 codes.
The authors report the HBO and non-HBO groups were statistically dissimilar in some respects. The HBO group was more likely to be female, more likely to be in an urban hospital center, more likely to be diagnosed with non-clostridial myonecrosis, and had more comorbidities.1 After statistical analysis, the authors found that the group who received HBOT had a lower inpatient mortality rate and fewer complications, but had greater inflation adjusted cost and had longer inpatient hospital stays.1 Soh and colleagues also report that patients in the HBO group had lower rates of shock, lower rates of severe sepsis, and less acute organ dysfunction.1
This study has many inherent limitations which the authors discuss freely. The NIS database does not record all the information we would like to have. For example, we do not know what percent of surface area is affected by NSTI, nor does it reflect the number of surgical debridements or antibiotic use.1 The authors are also unable to comment on the number of HBO treatments the patients received or the profiles utilized.1 Despite the multiple limitations of conducting a retrospective database analysis, this paper does have an extremely large sample of patients, and appears to find in favor of the effectiveness of HBOT in treating necrotizing soft tissue infections.
From an evidence based medicine perspective, one could look at this data through the “number needed to treat” (NNT). Reporting on the NNT from this study needs to be taken in context; this is a retrospective database review, not a randomized control trial. Use it for what it’s worth, but based on the data in this study, it appears a physician would need to treat roughly 20 patients with NSTI with hyperbaric oxygen to save one life.
I encourage everyone to read the article for themselves to make your own informed decision about how to apply this information to your individual patients with NSTI. Special thanks again to Chai Soh and colleagues for their efforts in utilizing this publically available information to add to our base of knowledge regarding the use of HBOT in the context of necrotizing soft tissue infections.
1. Soh CR, Pietrobon R, Freiberger JJ, et al. Hyperbaric oxygen therapy in necrotising soft tissue infections: a study of patients in the United States Nationwide Inpatient Sample. Intensive Care Med. Jul 2012;38(7):1143-1151.
2. Healthcare Cost and Utilization Project (HCUP). HCUP Databases 2012; www.hcup-us.ahrq.gov/nisoverview.jsp. Accessed July 24, 2012, 2012.