Editor-in-Chief: Richard "Sal" Salcido, MD
ISSN: 1527-7941
Online ISSN: 1538-8654
Frequency: 12 issues per year
Impact Factor: 1.337

Current Issue Highlights

Wound CSI: Can You Solve the Case?

Welcome to Wound Clinical Solutions Investigation (CSI). See if you can make the diagnosis.

Q.  A female patient developed a heel ulcer after hip surgery.  It was covered with eschar tissue and described as an unstageable pressure injury (photo A).  The eschar tissue was removed by sharp debridement.  After a few days, the wound was re-assessed with evidence of some pink and yellow tissues (photo B).  What is the yellow tissue? What treatment should be considered for the management of yellow tissue?

 9-6-16 CSI photos.jpg


A. In general, necrotic tissues have been described in the form of eschar and slough.  Although eschar is often depicted as the dark, desiccated, hard, and leathery tissue, it could also appear wet, soft, and spongy; this depends on the amount of fluid intake and hydration. Slough, on the other hand, tends to be yellow in color and takes on a stringy, mucinous, and slimy consistency.  Slough is a devitalized tissue that may contain proteinaceous tissue, biofilm/bacterial, and fibrin.  During the wound healing process, soluble fibrinogen is converted into strands of fibrin monomers that are organized into insoluble fibrin polymers and a network of fibrin fibers. These scaffolds of fibrin provide stability to the fibrin clot and provide a provisional matrix that allows keratinocytes and other cells to adhere, proliferate, organize, and perform specialized functions required for the inflammatory response and for tissue repair at the site of damage.

The fibrinous matrix of a wound contains other plasma proteins, including fibronectin and vitronectin, which anchor cells to the extracellular matrix components, such as collagen and proteoglycans. Hyaluronic acid is another critical component of the wound extracellular matrix and may have a regulatory role in the control of fibrin degradation and polymerization, thus altering the structure of the fibrin matrix. There is evidence that outcomes of wound healing can be affected by the fibrin structure in terms of its thickness of the fibers, the number of branch points, the porosity, and the permeability.  A buildup of fibrinous material in a wound may trigger and perpetuate an excessive and prolonged inflammatory response.  The fibrin matrix may also harbor bacterial and biofilm.  Vigorous cleansing and debridement is an important step in wound management to remove excessive yellow fibrin.  However, other structures or materials could assume a similar yellow appearance on a wound bed, including tendon, bony structure, adipose or fatty tissue, thick viscous pus, dried up exudate or crust, and even wound dressing fabrics.  Careful evaluation is prudent to correctly identify yellow-colored tissue.







In the News

Antioxidant Bandage Delivers Healing Protein

A research team from Northwestern University has developed a "regenerative bandage" for diabetic foot ulcers.  This bandage is made of a thermoresponsive material with intrinsic antioxidant properties to counter inflammation. The novel material also has the ability to slowly release a protein into the wound that hastens the body's ability to repair itself by recruiting stem cells to the wound and creating new blood vessels to increase blood circulation. The thermoresponsive material is applied to the wound bed as a liquid and solidifies into a gel when exposed to body temperature.  Early research findings suggest the bandage can promote healing of diabetic wounds 4 times faster than a standard bandage and has the added benefit of promoting healing without side effects.

New Treatment to Prevent Biofilm

Biofilm is ubiquitous in chronic wounds.  Researchers at the University of Sheffield in collaboration with AGE UK have used proteins called tetraspanins from human cells to prevent bacteria from attaching to the wound surface, leading to biofilm formation.  As a result, the bacteria can easily be removed with cleansing to prevent infection.  The research has shown that these proteins prevent bacterial infections in a model of 3D tissue-engineered skin, which also allows the researchers to analyze the penetration of peptides and bacteria. Unlike conventional antibiotics, the tetraspanin proteins do not directly kill bacteria nor encourage the evolution of resistance.  The therapy could potentially be applied to wound bed as a gel or cream and impregnated in a dressing.

Medicare Coverage Expanded for Wound Products

Organogenesis Inc announced that its PuraPly and PuraPly Antimicrobial wound management products are now eligible for Medicare coverage and reimbursement in 10 additional states, providing coverage for an additional 7.5 million Medicare beneficiaries, following the decision by National Government Services to retire its local coverage determination for cellular and tissue-based products effective September 1, 2016. The 2 products are FDA 510(k)-cleared Class II medical devices indicated for acute and chronic wound management across a wide variety of wound types, including partial- and full-thickness wounds, pressure ulcers, surgical wounds, trauma wounds, and venous and diabetic ulcers.

Biomarkers to Predict Sepsis in Burn Victims

Major burn injuries result in a systemic inflammatory response syndrome and reduced immune function, putting patients at risk for infection.  Birmingham researchers from Healing Foundation Birmingham Centre for Burns Research identified peripheral blood neutrophil function and biomarkers of the neutrophil extracellular traps production on the day of injury to determine the risk of sepsis in patients with major burn injuries.   Three potentially novel biomarkers of sepsis in burn injury were tracked—immature granulocyte count, neutrophil phagocytosis, and plasma cell free DNA—with the combination of measurements displaying good discriminatory power to predict later development of sepsis, especially at day one after injury. The data highlights burn-induced neutrophil dysfunction as a potential therapeutic target to reduce susceptibility to bacterial infections and sepsis.

Negative Pressure Wound Therapy Combined with Hydrofiber

ConvaTec has launched in the United Kingdom the first system to combine negative pressure wound therapy with the benefits of Aquacel Technology to minimize periwound maceration. The Avelle NPWT System can be used on a broad range of low to moderately exuding wound types, including chronic, acute, traumatic, subacute and dehisced wounds, skin grafts, and surgically closed incisions. The new system received CE mark approval and commercial launch process commenced in the UK with clinical evaluations with key customers. 

Digital Surveillance System for Pressure Ulcers

Bruin Biometrics, based in Manchester, United Kingdom, and Los Angeles, California, announced it is linking its SEM Scanner, a wireless point-of-care device for pressure ulcer (PrU) detection, to a digital registry for PrUs known as ''PUNT'' (Pressure Ulcer Notification Tool). The company has licensed PUNT, which has been used within United Lincolnshire Hospitals NHS Trust (ULHT) to facilitate real-time recording of inpatient pressure injury. The ULHT is one of the largest acute hospital trusts in England, and PUNT directly links with the Trusts' patient management system to standardize and facilitate intervention and treatment. Since incorporating PUNT into PrU prevention protocols in 2011, the Trust has reduced the incidence of hospital-acquired pressure ulcers by nearly 40% to 0.9%, compared with England's national reported incidence rate of 4% to 6%. Currently, the SEM Scanner is CE Mark approved and is currently in commercial launch in the European Union and Canada. It is not yet available for sale in the United States.

New Biosorb Gelling Fiber Wound Dressing

Acelity has introduced the new Biosorb Gelling Fiber Dressing in the United States. The dressing features carboxymethylcellulose that forms a gel when it comes into contact with wound exudate. The dressing is able to absorb many times its own weight in fluid to protect the wound edge and surrounding skin. It is now available in the United States and has the CE Mark in Europe, where it will be available in the coming months.

Wound Healing and Methamphetamine Use

Wound care cost in methamphetamine users in the United States is nearly $20 million annually. These wounds are recalcitrant to healing because of the persistence of bacteria, drug-related immune deficiency, and behaviors by users, including constant scratching related to the sensation of crawling skin caused by drug. The National Institutes of Health is supporting a study to evaluate methamphetamine's effects on the underlying biological mechanisms that cause inflammation and impair wound healing. The research team has been studying the impact of meth on leukocytes, including neutrophils and macrophages, both of which play a key role in wound healing.

Preliminary studies show that meth causes an overproduction of IL-6, which delays the body's inflammatory response and ability to heal.  The study will address whether the use of antibodies that work against the IL-6 overproduction will promote wound healing.

The Impact of Diabetes on Electric Fields and Wound Healing

There is an electrical potential across living tissue creating an electric field. Scientists at the University of California Davis, Department of Dermatology demonstrate in a mouse model that electric currents are generated at the edges of the wound after removing a small piece of cornea in the eye.  Cells migrate along the electric currents, closing the damaged area in 48 hours.  However, these electric currents are much weaker in the eyes of diabetic mice than in healthy mice. Delayed wound healing is correlated with weak electric currents.  The researchers also discover that human corneal cells expose to high levels of glucose exhibit less response to an electric field.

















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The Official Journal of the APWCA


Words on Wounds
Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA
A forum to discuss the latest news and ideas in skin and wound care.

Latest Entry: 2/9/2016 What Are Wound Care Specialists?

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Frank L. Ross, MD, FACS
A forum to discuss interesting aspects of hyperbaric medicine.

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Quick Poll
Are there any clinical signs and symptoms that can help us to differentiate infection from inflammation?

Are there any clinical signs and symptoms that can help us to differentiate infection from inflammation?
Are there any clinical signs and symptoms that can help us to differentiate infection from inflammation?
WANTED: Online Exclusive Content!

Advances in Skin & Wound Care is going to offer authors the opportunity to have their article posted online only with free access to all readers. We are seeking a specific scope of article for this special section. Under the heading of “Wound Care around the World,” we’d like to invite articles that detail innovative and resourceful ways that clinicians are helping to heal patients’ wounds in all corners of the globe. Articles should have a “this is how we do it” approach, not present a research study. For example, an article might illustrate how clinicians fashion wound dressings in a remote region where current products and technology may be sparse or unavailable. Send your manuscript ideas to Kathleen Greaves, Senior Managing Editor, at Kathleen.Greaves@wolterskluwer.com. Articles invited for submission will go through the standard peer review and acceptance process. We hope to hear from you!