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Photographs of wounds often appear to decrease or increase in size due to the distance of the film plane from the wound. These variations in size tend to confuse and confound the observer. To accurately depict the healing progress of a wound, comparative imaging must be utilized; that is, the "image" of the wound must be the same size on the film plane for each exposure. This can only be accomplished if the plane of focus and the distance from the wound are constant for each exposure.

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The South Texas Physicians Outreach (STPO) organization makes at least one annual mission to Santa Rosa de Copan, Honduras to provide much needed medical and surgical care to the residents of western Honduras. The author was named the team photographer for both a trip in 1998 and a subsequent visit in 1999. In preparing for the 1999 trip, a plan to reduce the expenditure by STPO for photography support was put into motion. It was decided that digital photography would eliminate most of the cost for documentation of the team's activities in clinics, surgery, and human interest activities. This article provides a short history of the organization, a brief overview of the 1998 trip, and a discussion of the photographic aspects of the 1999 trip.

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Hyperbaric oxygen (HBO2) is used as an adjunct in the treatment of radiation injury at many sites, including the mandible, larynx, chest wall, bladder, and rectum. In these disorders, HBO2 is effective in stimulating neovascularization and reducing fibrosis. No previous publications report the application of HBO2 to radiation injuries of the extremities. From 1979 until 1997, 17 patients were treated at the Southwest Texas Methodist and Nix Hospitals for nonhealing necrotic wounds of the extremities within previously irradiated fields. All but one wound involved a lower extremity. Most of the patients had been irradiated for soft tissue sarcomas or skin cancers. The rest were irradiated for a variety of malignancies. HBO2 was delivered in a multiplace chamber at 2.4 atm abs daily for 90 min of 100% oxygen at pressure. This report is a retrospective, uncontrolled review of these patients. Eleven patients (65%) healed completely whereas five (29%) failed to heal and one (6%) was lost to follow-up. Three (60%) of those who failed were found to have local or distant recurrence of their tumor early in their course of hyperbaric treatment and were discontinued from therapy at that time. When last seen in the clinic, the wound of the patient who was lost to follow-up was improved but not completely healed. Four of those who failed (including the two with local tumor recurrence) required amputation. If we exclude those with active cancer and the patient lost to follow-up, the success rate was 11 of 13 or 85%. HBO2 was applied successfully with complete wound healing and the avoidance of amputation in a majority of these patients. The consequences of failure in patients suffering from radiation necrosis of the extremities (some complicated by the presence of tumor) are significant, with 80% of the five failures requiring amputation. In radiation injuries of the extremities as in delayed radiation injury at other sites, HBO2 is a useful adjunct and should be part of the overall management.

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In a previous publication (Feldmeier et al., Radiother Oncol 1995; 35:138-144) we reported our success in preventing delayed radiation enteropathy in a murine model by the application of hyperbaric oxygen (HBO2). In this study we introduce a histologic morphometric technique for assessing fibrosis in the submucosa of these same animal specimens and relate this assay to the previous results. The histologic morphometry, like the previous gross morphometry and compliance assays, demonstrates a significant protective effect for HBO2. The present assay is related to the previous assays in a statistically significant fashion. The predictive value for the histologic morphometric assay demonstrates a sensitivity of 75% and a specificity of 62.5%. The applicability of this assay to other organ systems and its potential superiority to the compliance assay are discussed.

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Radiation therapy is often utilized as adjunctive or primary treatment for malignancies of the abdomen and pelvis. Radiation complications are infrequent, but can be life threatening or significantly diminish the quality of life. Radiation necrosis is an approved indication for hyperbaric oxygen (HBO2). Previous publications have reported results in treating delayed radiation injuries involving many sites. This paper reports the experience of a single physician group in treating delayed injuries of the abdomen and/or pelvis. Forty-four such patients have been treated since 1979. Of the 41 patients available for follow up, 26 have healed; 6 failed to heal; and 9 patients had an inadequate course of therapy (fewer than 20 treatments). Especially encouraging was the resolution of fistulae in six of eight patients with only three requiring surgery for closure. Overall, the success rate in patients receiving at least 20 HBO2 treatments was 81%. Hyperbaric oxygen is a useful adjunct in treatment of delayed radiation injuries of the pelvis and abdomen.

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Since 1979, 23 cases of radiation-induced chest wall necrosis have been treated in the Hyperbaric Medicine Departments of Southwest Texas Methodist Hospital and the Nix Hospital, San Antonio, Texas. Eight cases involved soft tissue only. Six of eight (75%) patients with soft tissue involvement healed without requiring surgical debridement, although four patients (50%) did have flaps or grafts. Fifteen patients had bony and soft tissue necrosis. Eight of these patients (53%) resolved with adjunctive hyperbaric oxygen (HBO), but all required aggressive surgical debridement including skeletal resection. Four (27%) had reconstructive flaps as well. Six patients (40%) with bony necrosis who had either no or incomplete debridement failed to heal. Three patients (13%)(two soft tissue and one bony) were found to have residual tumor during HBO and were discontinued from treatment. HBO is an effective adjunctive therapy for soft tissue chest-wall, radiation-induced necrosis, but must be coupled with appropriate debridement to include surgical removal of all necrotic bone to ensure a successful outcome of bony plus soft tissue necrosis.

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This trial was accomplished in C3H mice to determine whether hyperbaric oxygen (HBO) could be administered to prevent delayed radiation enteropathy. Fifty mice randomized into two equal groups received 30 Gy abdominopelvic irradiation in 10 fractions. The study group received a course of 30 HBO treatments beginning 7 weeks after the radiation exposure. The control group received only housing and nutritional support after irradiation. A third group of three animals had no radiation or HBO. All animals were sacrificed 7 months after radiation. Animals were inspected grossly for signs of enteropathy. In addition, a special stretch apparatus was used to quantify narrowing and rigidity of ileum just proximal to the ileocecal junction. Those animals who received HBO had fewer gross signs of enteropathy and had less narrowing and less rigidity in their harvested bowel segments. These differences were highly statistically significant. Treatment with HBO drastically reduces signs of radiation enteropathy. Further study including clinical trials are recommended.

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We reviewed all known published reports or studies related to a possible cancer-causing or growth-enhancing effect by hyperbaric oxygen. Published articles were retrieved using Medline searches for the period 1960-1993. Additional references were obtained from bibliographies included in those articles discovered in the computer search. Also, hyperbaric medicine text books and the published proceedings of international hyperbaric conferences were visually searched. Studies and reports discovered in this fashion and related to the topic were included in the review. Twenty-four references were found: 12 were clinical reports, 11 were animal studies, and 1 reported both an animal study and a clinical report. Three clinical reports suggested a positive cancer growth enhancement, whereas 10 clinical reports showed no cancer growth enhancement. Two animal studies suggested a positive cancer-enhancing effect, and 10 animal studies showed no such effect. (The report that included both animals and humans is counted in both groups). The vast majority of published reports show no cancer growth enhancement by HBO exposure. Those studies that do show growth enhancement are refuted by larger subsequent studies, are mixed studies, or are highly anecdotal. A review of published information fails to support a cancer-causing or growth-enhancing effect by HBO.

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Laryngeal necrosis is a rare complication of therapeutic radiation, but when it does occur there is no established, definitive treatment and laryngectomy is frequently required. This report is a retrospective review of all patients referred for hyperbaric oxygen (HBO) therapy to a single hyperbaric medicine unit for treatment of their laryngeal necrosis between 1980 and 1985. Nine patients were in this series. One patient had had a vertical hemilaryngectomy and another a supraglottic laryngectomy before referral. Eight of the nine patients had a Chandler grade IV necrosis and the ninth had a Chandler grade III necrosis. All nine patients were able to maintain their voice until death or last follow up. Seven of the nine patients maintained good voice quality while two exhibited some hoarseness. All patients with tracheostomies were able to be decannulated, and all patients with fistulae had these closed. No untoward reactions to HBO occurred. Based on this review, HBO is recommended as a therapeutic option whenever laryngeal necrosis occurs and there is a chance to save the larynx.

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A questionnaire was sent to 179 clinical hyperbaric medicine facilities to survey treatment policies and referral patterns for patients with a history of malignancy. Eighty-five surveys were returned. Most respondents indicated that they would accept patients with a history of malignancy for either adjuvant or emergent hyperbaric oxygen (HBO). Depending on specific circumstances, from about one third to one half of respondents believed that such patients should be informed of a theoretical potential for tumor acceleration or reactivation. An overwhelming majority had not personally attended nor had they been told by colleagues of cases of patients whose malignancy had been activated or accelerated by HBO. A large majority felt that referring physicians did not believe that HBO was carcinogenic, and that referrals were not prevented by such concerns. Seven percent believed that HBO is potentially carcinogenic. Forty-two percent of respondents felt that they might be at risk for malpractice litigation if a patient had reactivation or acceleration of a malignancy. Among respondents to the questionnaire, there is a consensus that HBO does not have cancer-promoting or accelerating properties.

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