The Health Economic Impact of Living Cell Tissue Products in the Treatment of Chronic Wounds: A Retrospective Analysis of Medicare Claims Data OBJECTIVE To investigate differences in wound-related costs; product waste; lower-extremity amputations; and number of applications, hospitalizations, and emergency room visits among patients treated with three cellular and/or tissue-based products. METHODS This retrospective intent-to-treat matched-cohort study analyzed the full Medicare claims dataset from 2010 to 2014. Patients who received either a bilayer cellular construct (BLCC), dermal skin substitute (DSS), or cryopreserved human skin allograft (CHSA) were concurrently matched for Charlson Comorbidity Index, age, sex, and region. Key variables were reported at 60, 90, and 180 days after the first product application. RESULTS There were no statistically significant differences in the distribution of Charlson Comorbidity Index, age, sex, and region among cohorts (n = 14,546). Wound-related costs and product wastage were lower for CHSA patients relative to both BLCC and DSS patients at all time intervals, and those treated with CHSA received fewer product applications than DSS at 90 and 180 days (P < .05). Amputations were significantly higher among patients treated with DSS than either CHSA or BLCC (P < .0001). CONCLUSIONS The data demonstrate that wound-related costs, product waste, amputations, and frequency of applications are lower for CHSA than DSS. Wound-related costs and product waste are lower for CHSA compared with BLCC. Further claims analysis and prospective clinical trials are needed. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Refining Heel Pressure Injury Risk Factors in the Hospitalized Patient OBJECTIVE To replicate previous research that found four independent and significant predictors of heel pressure injuries (HPIs) in hospitalized patients using a larger and more diverse patient population. METHODS Researchers conducted a retrospective, case-control study with a main and a validation analysis (N = 1,937). The main analysis had 1,697 patients: 323 patients who had HPIs and 1,374 who did not. The validation analysis had 240 patients: 80 patients who developed HPIs and 160 who did not. Researchers used a series of diagnosis codes to define variables associated with an HPI. Data were extracted from the New York Statewide Planning and Research Cooperative System for January 2014 to June 2015. Study authors conducted a series of forward stepwise logistic regression analyses for both samples to select the variables that were significantly and independently associated with the development of an HPI in a multivariable setting. Researchers generated a receiver operating characteristic curve using the final model to assess the regression model's ability to predict HPI development. RESULTS Seven variables were significant and independent predictors associated with HPIs: diabetes mellitus, vascular disease, perfusion issues, impaired nutrition, age, mechanical ventilation, and surgery. The receiver operating characteristic curve demonstrated predictive accuracy of the model. CONCLUSIONS Beyond a risk assessment scale, providers should consider other factors, such as comorbidities, which can predispose patients to HPI development. Acknowledgments: The study was funded by Sage Products, LLC. The funding source was not involved in study design, monitoring, data collection, statistical analyses, interpretation of results, or manuscript writing. The authors have disclosed no other financial relationships related to this article. Submitted January 29, 2019; accepted in revised form April 3, 2019. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Rare Presentation of Postsurgical Pyoderma Gangrenosum Presenting as Necrotizing Soft Tissue Infection Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis believed to be mediated by an autoimmune reaction. Typical treatment includes autolytic debridement, management of exudate, protection from trauma, and steroid therapy. A diagnosis of exclusion, PG is frequently mistaken for a wound infection, but antibiotics do not alleviate the condition. Incision and debridement has been observed to cause further spread of the lesions because of pathergy resulting from the additional trauma. This case report describes a patient who was misdiagnosed with necrotic soft tissue infection that was actually postsurgical PG. The authors have disclosed no financial relationships related to this article. Submitted February 11, 2019; accepted in revised form April 17, 2019. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Is Negative-Pressure Wound Therapy a “Bridge to Reconstruction” for Poststernotomy Mediastinitis? A Systematic Review OBJECTIVE: To assess the efficacy of negative-pressure wound therapy (NPWT) in preparing sternal wounds for flap reconstruction. METHODS: Investigators searched standard research databases with terms including “post-sternotomy mediastinitis,” “deep sternal wound infection,” “negative pressure wound therapy,” “vacuum assisted closure,” and “VAC.” Of 434 reports, 14 studies described patients diagnosed with poststernotomy mediastinitis who underwent NPWT followed by flap reconstruction. Eligible studies were assessed for length of stay, mortality, manufacturer involvement, and methodological rigor. MAIN RESULTS: Among a total 429 patients, median length of stay was 29 (±16) days. There were 41 deaths in this inpatient group (10%). Seventy-one percent of the reports were nonrandomized, and 36% of the studies accurately accounted for baseline differences in severity, whereas 14% failed to report diagnostic criteria. Only one study reported follow-up results. Nine studies (64%) failed to make a statement regarding conflicts of interest. In this analysis of quality, 48% (n = 8) of the studies were of very low to low quality. One study was of high quality. CONCLUSIONS: Investigators failed to find ample support for routine use of NPWT as a “bridge to reconstruction.” Serious complications related to the use of NPWT including right ventricular rupture, atrial fibrillation, respiratory arrest, recurrent infection, and a retained sponge were reported in this group of studies. Rigorous evaluative studies that assess the true effectiveness of NPWT as a “bridge to reconstruction” must precede its adoption. The authors have disclosed no financial relationships related to this article. Submitted September 1, 2018; accepted October 9, 2018. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.