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Oxygen Therapy For Diabetes

Hyperbaric Oxygen Therapy For The Treatment Of Diabetic Foot Ulcers: A Health Technology Assessment

Hyperbaric Oxygen Therapy For The Treatment Of Diabetic Foot Ulcers: A Health Technology Assessment

Hyperbaric Oxygen Therapy for the Treatment of Diabetic Foot Ulcers: A Health Technology Assessment 130 Bloor Street West, 10th Floor, Toronto, Ontario, M5S 1N5, Tel: 416-323-6868, Toll Free: 1-866-623-6868, Fax: 416-323-9261, Email: [email protected] , www.hqontario.ca Copyright Queen's Printer for Ontario, 2017 About 15% to 25% of people with diabetes will develop a foot ulcer. These wounds are often resistant to healing; therefore, people with diabetes experience lower limb amputation at about 20 times the rate of people without diabetes. If an ulcer does not heal with standard wound care, other therapeutic interventions are offered, one of which is hyperbaric oxygen therapy (HBOT). However, the effectiveness of this therapy is not clearly known. The objectives of this health technology assessment were to assess the safety, clinical effectiveness, and cost-effectiveness of standard wound care plus HBOT versus standard wound care alone for the treatment of diabetic foot ulcers. We also investigated the preferences and perspectives of people with diabetic foot ulcers through lived experience. We performed a review of the clinical and economic literature for the effectiveness and cost-effectiveness of hyperbaric oxygen therapy, as well as the budget impact of HBOT from the perspective of the Ministry of Health and Long-Term Care. We assessed the quality of the body of clinical evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. To better understand the preferences, perspectives, and values of patients with diabetic foot ulcers and their experience with HBOT, we conducted interviews and administered an online survey. Seven randomized controlled trials and one nonrandomized controlled trial met the Continue reading >>

Oxygen Therapy Could Help In Diabetes Treatment

Oxygen Therapy Could Help In Diabetes Treatment

Oxygen therapy could help in diabetes treatment A new study from the United States has found that hyperbaric oxygen therapy , which allows more oxygen to get into the bloodstream than usual, can help to prevent or slow down the development of type 1 diabetes in laboratory mice, although the researchers do not know if such treatment will be effective in humans. The research, which was published in Diabetes , showed that the hyperbaric treatment involving a pressurised chamber could alter the response of the immune system to the development of diabetes , with it decreasing the risk of diabetes by around 20 to 40 per cent, as well as slowing the progression of the condition in mice that did develop diabetes. It is hoped that a combination of oxygen therapy , which is used to help scuba divers suffering from the bends after rising to the surface too fast as the pressure inside the chamber is around two and half times greater than that of normal, along with a drug treatment could enhance the effectiveness of both. Senior author of the study, Antonello Pileggi, from the Diabetes Research Institute at the University of Miami Miller School of Medicine, said "Hyperbaric oxygen therapy is a relatively non-harmful way of enhancing oxygen delivery to the tissues." He added "We were able to suppress the transfer of the disease (in mice) before the onset of the disease. After diabetes had occurred, the efficacy [of hyperbaric therapy] was much less." Continue reading >>

Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

“One must always hope when one is desperate, and doubt when one hopes.” Gustave Flaubert. Hyperbaric oxygen therapy (HBOT) has been promoted as an effective treatment for diabetic foot wounds, and the first controlled trial for this indication was reported (in Diabetes Care) over 20 years ago (1). Advocates have suggested that the experimentally demonstrated effects of HBOT on improving wound tissue hypoxia, enhancing perfusion, reducing edema, downregulating inflammatory cytokines, promoting fibroblast proliferation, collagen production, and angiogenesis make it a useful adjunct in clinical practice for “problem wounds,” such as diabetic foot ulcers (2,3). HBOT is also touted for eradicating difficult to treat soft tissue and bone infections by mechanisms that include killing microorganisms, improving leukocyte and macrophage function, and enhancing the effect of antimicrobials (4). If realized clinically, these beneficial effects, although requiring expensive technology, might powerfully reduce the risk of lower-extremity amputation in diabetic patients with foot wounds. Thus, rigorously assessing the clinical effectiveness of HBOT in diabetic foot ulceration is an important enterprise. But, because both patients and clinicians are strongly motivated to avoid the devastating outcome of amputation, there is a high potential for bias in poorly designed trials. Proof of benefit requires properly conducted clinical trials that minimize the possibility that preexisting prejudices will influence the allocation of patients, diligence of foot care, or other key management decisions. Most of the published reports on the effect of HBOT for treating diabetic foot wounds have been case series or nonrandomized trials with major methodological limitations. Although these ar Continue reading >>

Oxygen Therapy As An Alternative Treatment For Diabetes

Oxygen Therapy As An Alternative Treatment For Diabetes

Oxygen Therapy As An Alternative Treatment For Diabetes Oxygen Therapy As An Alternative Treatment For Diabetes With Obesity reaching epidemic proportions in Western society, the number of people suffering from Diabetes has become grossly excessive and is on the increase. The treatment of Diabetes demands that the diabetic make drastic lifestyle changes. These changes can include: weight loss, rigid exercise programs and a complete restructuring of ones diet. Unfortunately, a great many diabetics struggle to initiate and maintain these changes and find themselves being gradually and increasingly affected by damaging symptoms of the disease. Outside of these changes, the prevention and treatment of the symptoms is often limited. While more and more people are turning to alternative and natural remedies as treatment for a variety of ailments, the use of Oxygen Therapy as a method of controlling and preventing the symptoms of Diabetes, is still largely neglected. Oxygenating the cells in your body adequately will have many positive health benefits, and it has been found that it can aid in the prevention of several diabetic symptoms. Diabetes is the leading cause of amputation of the lower legs, with amputations in Diabetes sufferers occurring 15 times more regularly than other people. Foot ulcers and a lack of circulation in the extremities is what makes these amputations necessary. Regular intake of oxygen supplements which increase cellular oxygenation, can help in preventing these symptoms. Oxygen aids the body in healing, and the infusion of life-giving Oxygen Therapy can prove to be the difference between suffering permanent debilitation and continuing to live a normal life. Hyperbaric Oxygen Therapy can even help to heal foot ulcers after theyve already formed. Doct Continue reading >>

Oxygen Could Be The Key To A Cure For Diabetes

Oxygen Could Be The Key To A Cure For Diabetes

Oxygen could be the key to a cure for diabetes Oxygen could be the key to a cure for diabetes With Obesity steadily increasing in the Western world, the number of people suffering from Diabetes has become grossly excessive and is on the increase. The treatment of Diabetes demands that the diabetic make drastic lifestyle changes. These changes can include: weight loss, rigid exercise programs and a complete restructuring of a persons diet. Unfortunately many patients struggle to initiate and maintain these changes and find themselves being gradually and increasingly affected by damaging symptoms of the disease. Type 1 diabetes is caused by the immune system attacking itself and destroying cells in the pancreas. The pancreas produces insulin and so it results in the body not producing enough. It can be caused by an infection, toxins or an autoimmune reaction. Type 2 diabetes can be caused by multiple risk factors including obesity, increasing age, poor diet, pregnancy and illness. When there isnt enough insulin or the insulin is not used as it should be, glucose (sugar) cant get into the bodys cells and builds up in the bloodstream. Since the cells arent getting the glucose they need, they cant function properly and the build up causes damage in multiple areas of the body, leading to many various diabetes-related diseases and conditions. A new bio-material has been designed which has the capacity to spontaneously generate oxygen when it is exposed to water. This material allows oxygen to be released in the bloodstream in targeted or generalised areas increasing oxygen levels within the body and not relying on lung function. A major potential use of this material is that it can be used in transplantation and skin grafts. Normally when new cells are surgically placed it ta Continue reading >>

Counterpoint: Hyperbaric Oxygen For Diabetic Foot Wounds Is Not Effective

Counterpoint: Hyperbaric Oxygen For Diabetic Foot Wounds Is Not Effective

Counterpoint: Hyperbaric Oxygen for Diabetic Foot Wounds Is Not Effective Bone Infection Unit, Nuffield Orthopaedic Centre NHS Trust Reprints or correspondence: Dr. Anthony R. Berendt, Bone Infection Unit, Nuffield Orthopaedic Centre NHS Trust, Windmill Rd., Headington, Oxford, OX3 7LD, United Kingdom ( [email protected] ). Search for other works by this author on: Clinical Infectious Diseases, Volume 43, Issue 2, 15 July 2006, Pages 193198, A. R. Berendt; Counterpoint: Hyperbaric Oxygen for Diabetic Foot Wounds Is Not Effective, Clinical Infectious Diseases, Volume 43, Issue 2, 15 July 2006, Pages 193198, Background. Diabetic foot ulceration is common, affecting 1.0%4.1% of diabetic persons per year and up to 25% in a lifetime. Diabetic foot ulcers are multifactorial in origin, and many are slow to heal and/or are complicated by infection, frequently leading to amputation. Hyperbaric oxygen therapy has been suggested for numerous indications, and it is recognized by funding agencies for a smaller number including diabetic foot wounds. Methods. I reviewed the literature about the history and practice of hyperbaric oxygen therapy and key issues relevant to efficacy, effectiveness, and cost-effectiveness. Results. Although recognized for reimbursement by Medicare and major insurers, the evidence base for hyperbaric oxygen therapy for diabetic foot care remains weak. A systematic review for the Cochrane Collaboration concluded that hyperbaric oxygen therapy may have value in treating diabetic wounds, but the studies reviewed all had methodological weaknesses, and the positive effect of treatment was not seen in the single reviewed randomized trial to include a sham treatment arm. Hyperbaric oxygen therapy consumes very substantial resourcesand has the potenti Continue reading >>

Efficacy Of Hyperbaric Oxygen Therapy In Diabetic Foot Ulcers

Efficacy Of Hyperbaric Oxygen Therapy In Diabetic Foot Ulcers

Efficacy of Hyperbaric Oxygen Therapy in Diabetic Foot Ulcers Efficacy of Hyperbaric Oxygen Therapy in Diabetic Foot Ulcers Researchers evaluated the efficacy and safety profile of using hyperbaric oxygen therapy for the treatment of diabetic foot ulcers. The use of hyperbaric oxygen therapy (HBOT) in the treatment of diabetic foot ulcers may not result in a difference in outcomes when compared with standard therapy (ST), according to a study published by Clinical Therapeutics. Researchers performed a meta-analysis of 9 randomized controlled trials including 526 patients to determine the efficacy and safety profile of using HBOT as a treatment modality in patients with diabetic foot ulcers, with a focus on the incidence of healed ulcers, major amputations, minor amputations and reduction in the ulcer wound area. There were no differences identified between patients treated with HBOT compared with ST with regard to the incidence of healed ulcers (risk ratio [RR] = 2.22, 95% CI, 0.87-5.62; P =.32; I2 = 81%), minor amputations (RR = .95; 95% CI, 0.39-2.29; P =.91; I2 = 74%), major amputations (RR = .47; 95% CI, 0.17-1.28; P =.14; I2 = 61%), and adverse events (RR = 1.00; 95% CI, 0.64-1.56; P =.99; I2 = 26%). However, it was found that HBOT resulted in a statistically significant greater reduction in ulcer wound area when compared with ST (standard mean difference = 1.12; 95% CI, 0.20-2.04; P =.04; I2 = 70%). Continue reading >>

Adult Onset Diabetes - Oxygenated Blood Can Help

Adult Onset Diabetes - Oxygenated Blood Can Help

Introductory Ozone Therapy Articles Ozone Therapy Basics A Review of Ozone Therapy Applications Knee, Back, and Shoulder Pain Cured with Prolozone Amazing Ozone Healing Miracles from Cuba Ozone-Oxygen Therapies Ozone Therapy: New Breakthrough for Back Treatment The Politics of AIDS and Ozone What is Ozone? Medical Ozone and Cancer Why Use Ozone Therapy? Advanced Ozone Therapy Articles Adult Onset Diabetes - Ozone Can Help Healing Ozone AIDS and Cancer Cured Ozone - A Wide Spectrum Healer Ozone - The Breath of Life Ozone Studies Coming Soon! As many Ozone Therapy Articles that we can find, in English. If you have any official Ozone Studies you would like to send us so we can post them on this site, please email them to us! Thank you! Adult Onset Diabetes - Oxygenated Blood can Help From: Alternative Medicine Magazine, Issue 26, November 1998, Pages 26 - 28 (Please Read the related Article: 552 Million People could have Diabetes by 2030) YOU DON'T normally think of oxygen as a treatment for diabetes, but according to Frank Shallenberger, M.D., H.M.D., director of the Nevada Center of Alternative and Anti-Aging Medicine in Carson City, Nevada, ozone (a less stable, more reactive form of oxygen) can produce remarkable improvements in both the major and secondary symptoms of adult- onset diabetes. The connection between the ozone and diabetes is the blood circulation, Dr. Shallenberger says, as demonstrated in the following cases. Virginia, 51, had been diabetic for five years and was taking Glucotrol, an oral medication for controlling blood sugar levels. However, Virginia came to Dr. Shallenberger seeking treatment for recurrent breast cancer, a tumor that periodically grew then diminished. Dr. Shallenberger decided to ozonate her blood as ozone is often used as a healing Continue reading >>

The Connection Between Oxygen And Diabetes

The Connection Between Oxygen And Diabetes

A lack of O2 in fat cells triggers inflammation and insulin resistance in obesity Researchers at the University of California, San Diego School of Medicine have, for the first time, described the sequence of early cellular responses to a high-fat diet, one that can result in obesity-induced insulin resistance and diabetes. The findings, published in the June 5 issue of Cell, also suggest potential molecular targets for preventing or reversing the process. “We’ve described the etiology of obesity-related diabetes. We’ve pinpointed the steps, the way the whole thing happens,” said Jerrold M. Olefsky, MD, associate dean for Scientific Affairs and Distinguished Professor of Medicine at UC San Diego. “The research is in mice, but the evidence suggests that the processes are comparable in humans and these findings are important to not just understanding how diabetes begins, but how better to treat and prevent it.” More than 25 million Americans have diabetes – 8.3 percent of the population – with another 79 million Americans estimated to be pre-diabetic, according to the American Diabetes Association. Diabetes is characterized by high blood sugar levels poorly regulated by either inadequate insulin production or because cells to not respond properly to the regulating hormone. Diabetes is the seventh leading cause of death in the United States and a major risk factor for other life-threatening conditions, including heart disease and stroke. Past research by Olefsky and others has shown that obesity is characterized by low-grade inflammation in adipose or fat tissues and that this inflammatory state can become chronic and result in systemic insulin resistance and diabetes. In today’s Cell paper, the scientists describe the earliest stages of the process, which Continue reading >>

Treating Diabetic Foot Ulcers With Hbot And Topical Oxygen

Treating Diabetic Foot Ulcers With Hbot And Topical Oxygen

Treating Diabetic Foot Ulcers With HBOT And Topical Oxygen Sarah Mohamed, DPM, and Khurram Khan, DPM Diabetes mellitus continues to be a global health threat. The Centers for Disease Control and Prevention (CDC) estimates that 9.3 percent of the United States population has diabetes.1 The CDC estimates that by 2030, diabetes will affect more than 360 million people worldwide.1 With uncontrolled diabetes comes the increased risk of the development of diabetic foot ulcers (DFUs). An estimated 15 percent of patients affected by diabetes will suffer from a DFU in their lifetime.2 It is important to note that about 20 percent of patients with diabetes admitted in the hospital are admitted for DFUs. The presence of DFUs increases the risks of infection, gangrene, amputation and even loss of life. Patients with diabetes are 15 times more likely to sustain an amputation in comparison to people without diabetes.2 Based on these statistics and the patients we see every day in practice, it is essential that we have a thorough understanding of the various treatment options available for DFUs. There are various risk factors associated with the development of DFUs. These include diabetic neuropathy, peripheral vascular disease, foot deformities, previous diabetic foot ulceration or lower extremity amputation, and increased plantar pressures to an insensate foot. Researchers have reported that the most common causes of a DFU are minor trauma, neuropathy and foot deformity.2,3 It is our goal as practitioners to determine the cause of the ulceration and design a treatment plan that will heal the wound. There are various treatment modalities that we utilize for DFUs. Initially, conservative therapy includes debridement and offloading. It is important to debride the wound, essentially re Continue reading >>

Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

Hyperbaric Oxygen Therapy for Diabetic Foot Wounds Benjamin A. Lipsky , MD, FACP, FIDSA, FRCP1 and Anthony R. Berendt , BM, BCH, FRCP2 1University of Washington, VA Puget Sound, Seattle, Washington; 2Bone Infection Unit, Nuffield Orthopaedic Centre NHS Trust, Oxford, U.K. Corresponding author: Benjamin A. Lipsky, [email protected] . Author information Copyright and License information Disclaimer Copyright 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See for details. This article has been cited by other articles in PMC. One must always hope when one is desperate, and doubt when one hopes. Gustave Flaubert. Hyperbaric oxygen therapy (HBOT) has been promoted as an effective treatment for diabetic foot wounds, and the first controlled trial for this indication was reported (in Diabetes Care) over 20 years ago ( 1 ). Advocates have suggested that the experimentally demonstrated effects of HBOT on improving wound tissue hypoxia, enhancing perfusion, reducing edema, downregulating inflammatory cytokines, promoting fibroblast proliferation, collagen production, and angiogenesis make it a useful adjunct in clinical practice for problem wounds, such as diabetic foot ulcers ( 2 , 3 ). HBOT is also touted for eradicating difficult to treat soft tissue and bone infections by mechanisms that include killing microorganisms, improving leukocyte and macrophage function, and enhancing the effect of antimicrobials ( 4 ). If realized clinically, these beneficial effects, although requiring expensive technology, might powerfully reduce the risk of lower-extremity amputation in diabetic patients with foot wounds. Thus, rigorously assessing the clinical Continue reading >>

Hyperbaric Therapy Could Help Diabetics.

Hyperbaric Therapy Could Help Diabetics.

Nov. 7, 2001 -- Last year, a surgeon told Thelma Bell that wounds on her right foot had progressed to gangrene and she was facing amputation . She'd already lost two toes because of nerve and circulatory damage caused by diabetes . But within a few weeks, Bell's wounds were nearly healed, and the tissue on her foot appeared pink and healthy. Her foot and leg were saved, and doctors predicted that once she was fitted with a special shoe, she should be able to walk normally. Bell escaped the fate of the estimated 86,000 people each year who have lower limb amputations because of complications of diabetes ; they account for half of all leg and foot removals performed annually in the U.S. Her outcome was different because of wound care aided by hyperbaric oxygen therapy, says Jeffrey Stone, DO, MPH. Stone, director of the hyperbaric medicine unit at the Institute for Exercise and Environmental Medicine (IEEM), is studying whether use of the therapy can reduce diabetic amputations. "One of my questions has been the role of hyperbarics in diabetic wounds," he tells WebMD. Patients are put in a large, submarine-like chamber and don a clear plastic hood into which 100% oxygen is pumped. This increases the amount of oxygen in their blood , which in turn helps generate growth of vessels, says Stone. Vessel growth is crucial for diabetics because they have circulatory problems due to blocked arteries and capillaries. They also have nerve problems, called sensory neuropathy , so they often can't feel cuts on their feet. "I've had patients come in with a nail in a foot and not know it," Stone says. Once an injury occurs, it may not heal if there's not enough oxygen-enriched blood reaching the area. Often, as in Bell's case, the wound may fester until the only option is amputation. Continue reading >>

Alternative Treatment - Hyperbaric Oxygen Therapy For Diabetes And Non Healing Wounds

Alternative Treatment - Hyperbaric Oxygen Therapy For Diabetes And Non Healing Wounds

Alternative Treatment to Heal Diabetes and Non-Healing Wounds As of this moment, there are 23.6 million children and adults who are suffering from diabetes or roughly 7.8% of the American population. In Canada, there is an estimated 25% Canadians with diabetes who develop foot complications and 1 in 15 end up having a limb amputation during their lifetime. In B.C., someone is diagnosed with diabetes every 20 minutes, according to Donna Van Walleghem of the Canadian Diabetes Association. So is diabetes a uncurable disease? No, Diabetes is curable and OXYGEN is the key for diabetes and wound healing. Oxygen is one of the most powerful and versatile agents available to the modern medical practitioner today. The therapeutic use of oxygen under pressure has been used to assist in the healing of wounds for almost 40 years. This therapeutic use of oxygen under pressure is called hyperbaric oxygen therapy (HBOT) and in the following paragraphs are its specific biological actions which can enhance diabetes and wound healing. HBOT can be used successfully in hypoxic or ischemic wounds such as diabetic wounds,venous static ulcers, failing flaps and grafts, refractory osteomylitis and necrotising soft tissue infections. In wound healing, hypoxia delivers an insufficient supply of oxygen which prevents normal healing processes. Continue reading >>

A Guide To Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

A Guide To Hyperbaric Oxygen Therapy For Diabetic Foot Wounds

Author(s): Hyperbaric oxygen (HBO) chambers are currently located in over 750 facilities in the United States. New wound care centers are opening monthly across the country and most incorporate HBO chambers. Which foot and ankle conditions benefit from HBO treatment? Does clinical evidence support HBO treatments? Patients undergoing HBO therapy enter a chamber filled with 100 percent oxygen atmosphere pressurized to 2.0 to 2.5 ATA (atmospheric pressure absolute), which is equivalent to the pressure 33 to 48 feet below sea level. Hyperbaric oxygen therapy treatment “force feeds” oxygen through the lungs to the rest of the body. A 90-minute treatment in this hyperbaric environment induces “hyperoxygenation” with oxygen levels over 10 times the normal amount in the bloodstream.1 Driven by a systemic effect, HBO therapy requires high pressure, sturdy chambers made of metal and acrylic materials. “Portable” or “collapsible” or chambers made of plastic and vinyl materials (often sold as non-medical, over-the-counter devices) are not built to withstand such high pressures over 2.0 ATA. These devices are no more therapeutic than administering oxygen via nasal canula or face mask. “Topical” oxygen therapy that encloses a body part (e.g. a lower extremity with wounds) lacks strong clinical evidence at this time. Medicare does not reimburse either “portable” or “topical” HBO therapy Oxygen is a metabolite in respiration and an essential component of human physiology. Of the same token, wound repair mechanisms require oxygen to build skin, granulation tissues and new blood vessels. Interestingly, oxygen under hyperbaric conditions “behaves as drugs” and hyper-oxygenation causes: • a decrease in leg edema and excessive inflammation; • an increase Continue reading >>

Hyperbaric Oxygen For The Treatment Of Diabetic Foot Ulcers: A Systematic Review - Sciencedirect

Hyperbaric Oxygen For The Treatment Of Diabetic Foot Ulcers: A Systematic Review - Sciencedirect

Volume 47, Issue 6 , June 2014, Pages 647-655 Hyperbaric Oxygen for the Treatment of Diabetic Foot Ulcers: A Systematic Review Author links open overlay panel R.M.Stoekenbroeka A systematic review of randomized clinical trials (RCTs) to assess the additional value of hyperbaric oxygen therapy (HBOT) in promoting the healing of diabetic foot ulcers and preventing amputations was performed. MEDLINE, Embase, and the Cochrane Library were searched to identify RCTs in patients with diabetic foot ulcers published up to August 2013. Eligible studies reported the effectiveness of adjunctive HBOT with regard to wound healing, amputations, and additional interventions. Seven of the 669 identified articles met the inclusion criteria, comprising 376 patients. Three trials included 182 patients with ischaemic ulcers, two trials studied 64 patients with non-ischaemic ulcers, and two trials comprising 130 patients did not specify ulcer type. Two trials were of good methodological quality. Pooling of data was deemed inappropriate because of heterogeneity. Two RCTs in patients with ischaemic ulcers found increased rates of complete healing at 1-year follow-up (number needed to treat (NNT) 1.8 (95% CI: 1.1 to 4.6) and 4.1 (95% CI: 2.3 to 19)), but found no difference in amputation rates. A third trial in ischaemic ulcers found significantly lower major amputation rates in patients with HBOT (NNT 4.2, 95% CI: 2.4 to 17), but did not report on wound healing. None of the RCTs in non-ischaemic ulcers reported differences in wound healing or amputation rates. Two trials with unknown ulcer types reported beneficial effects on amputation rates, although the largest trial used a different definition for both outcomes. HBOT did not influence the need for additional interventions. Current evidenc Continue reading >>

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