Thursday, June 7, 2012

Diabetic Ulcers without Optimal Glycemic Control: New Study Concludes HBOT Should Not Be Delayed

Physicians treating wounds in patients with diabetes often delay hyperbaric oxygen therapy until the patient has attained optimal blood sugar levels. A new multicenter, prospective cohort study, presented 24 May 2012 in Philadelphia at the annual meeting of the American Association of Clinical Endocrinoligists, suggests that, in patients with diabetic ulcers of the lower extremities, the success of hyperbaric oxygen therapy is not affected by pretreatment glycemic control.

Here's the complete abstract from the AACE 2012 Abstract Book:

Owaise Mansuri, MD, Parkash Bakhtiani, MBBS, Abhijeet Yadav, Chima Osuoha, Patricia Knight, Robert McLafferty, Michael Jakoby, IV, MD

Objective: Diabetic lower extremity ulcers are a major cause of disability and mortality, accounting for approximately two-thirds of all non-traumatic amputations performed in the United States. Hyperbaric oxygen (HBO) is increasingly used as an adjunct to antibiotics, debridement, and revascularization for therapy of chronic, non-healing wounds associated with diabetes mellitus. We investigated whether glycemic control at time of HBO therapy measured by hemoglobin A1c (HbA1c) has a significant impact on diabetic wound healing. Methods: A multi-center, prospective cohort study assessing lower extremity wound healing rates among adult patients with diabetes mellitus treated with HBO was conducted at the Regional Wound Care Center in Springfield, IL and University Medical Center Hyperbaric Oxygen Center and Burn Care Unit in Las Vegas, NV. Patients underwent 20 sessions of HBO over the course of one month, and ulcer size (surface area and depth) and location were recorded at each visit. Transcutaneous oxygen pressures (TcPO2) were measured during each session. HbA1c was measured at first and last HBO treatments from capillary blood specimens using a Siemens DCA Vantage A1c Analyzer. Patient characteristics including age, gender, weight, type and duration of diabetes mellitus, current diabetes treatment regimen, hypertension, peripheral artery disease (PAD), tobacco use, ulcer duration, and additional wound care therapies (e.g. debridement, platelet derived growth factor) were determined. Results: Complete data were collected for 22 patients who were included in the study analysis and divided into two groups based on pre-HBO HbA1c. Patients in the “controlled diabetes” group had HbA1c < 7.5%, and patients in the “uncontrolled diabetes” group had HbA1c ≥ 7.5%. Mean HbA1c in the “controlled diabetes” group (6.5 ± 0.8%, N=12) was significantly lower (P < 0.001) than in the “uncontrolled diabetes” group (8.8 ± 1.4%, N=10). Both groups were well matched across all other recorded characteristics. Wound volume was reduced by 65 ± 29% in the “controlled diabetes” group and 71 ± 30% in the “uncontrolled diabetes” group (P = 0.60). Wound healing was also unaffected by presence or absence of PAD, hypertension, tobacco use, weight, duration of diabetes, or ulcer duration. Discussion: This study demonstrates that diabetic lower extremity wound response to HBO treatment is unaffected by pre-treatment glycemic control and several other clinical factors that may adversely impact wound healing. Conclusion: HBO treatment should not be delayed if glycemic control is suboptimal at time that therapy is prescribed.

Previous studies have shown that hyperglycemia inhibits wound healing. Here there was no significant difference between the controlled and uncontrolled groups. Why? Lead author Mansuri, in widespread press coverage of the findings, has said, "We suspect that the effect of hyperbaric oxygen therapy was potent enough to overcome the negative effect of hyperglycemia." We're eager to learn more from any wound care and hyperbaric medical experts who may wish to comment.

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