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

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Wound CSI: Can You Solve the Case?

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

Q.  A 64-year-old resident in a long-term care facility presented with the following discoloration on the gluteal area.  What is the correct diagnosis?

 CSI DTI 11-30-16.jpg

 

A. The male resident is incontinent of stool and urine, and is totally immobile.  He is unable to swallow and is reliant on enteral feeding to maintain adequate nutritional and fluid intake.  He is placed in an upright position for most of the day to prevent aspiration.  Given the resident's history and risks for pressure injury, one would presume that deep tissue injury (DTI) is the most likely diagnosis.

According to the most recent National Pressure Ulcer Advisory Panel guidelines, DTI refers to an area that exhibits persistent, nonblanchable, deep red, maroon, or purple discoloration.  A DTI may also manifest itself as a darkened wound bed or blood filled blister.  There are 2 possible outcomes; a DTI may evolve rapidly to a wound revealing the actual extent of tissue injury, or it may resolve without tissue loss.  This purple discoloration on the skin has existed for more than 12 months. Would this injury fit into the definition of DTI?

There are other differential diagnoses that should be considered.  Since there is no consensus on the direct and accurate determination of DTI, it is important to rule out other conditions that may mimic this condition.  The person is incontinent; thus, moisture-associated skin damage, incontinent dermatitis, or contact irritant dermatitis should be considered as an alternative diagnosis.  In the literature, people who are immobile may also develop venous congestion in the sacral area.  Venous congestion may promote local inflammation and skin changes similar to those documented for venous leg disease.  Other conditions may include post-inflammatory pigmentation, scarring, ecchymosis, infection, and inflammatory skin diseases, such as psoriasis.  

As the name DTI implies, what is evident on the skin surface or wound bed indicates that the injury has likely occurred from the inside out—from deep tissue. When a darkened wound bed is caused by dressing material, it is confusing whether DTI is the appropriate diagnosis.  If the injury is caused from the "outside-in," it may only involve superficial tissue.  There is a need to clarify this important concept that is evidence based.  Further dialogue will help move this issue forward to achieve a better consensus.

 

 

 

 

 

 

In the News

Impaired Insulin Metabolism in Periwound Skin Can Affect Healing

Wound healing is impaired in people with diabetes because high levels of glucose in the blood can affect blood vessels, nerves, and the immune system. In Cologne, Germany, researchers demonstrated in a study, using the skin of larvae of the fruit fly Drosophila melanogaster, that slowed insulin metabolism at the wound site can directly affect neighboring cells involved in wound healing. After a skin injury, the periwound cells respond by forming an actomyosin cable around the wound. The ring gradually contracts to seal off the gap until complete healing is achieved. When insulin metabolism is impaired, the formation of actomyosin cable ring is delayed and weak. This results in incomplete or slow wound healing.

Wireless Electroceutical Dressing to Promote Wound Healing

A team of researchers at Ohio State University has created a portable adhesive patch that delivers a continuous, small electrical current. The wireless electroceutical dressing mimics the natural physiological process and harnesses the body's innate response to injury to help wounds heal and destroy biofilm. The new prototype is made of a combination of silk and silver and includes a flexible, portable, and self-contained battery that delivers a continuous, safe, low-level electrical current to the injury. Preliminary data indicated that infected wounds covered by the experimental bioelectric dressing healed better and more quickly than those covered with a plain dressing that is commonly used in the care of wounds. Researchers hypothesize that the electrical currents may disrupt bacteria in 2 ways: by interrupting the production of chemical messages that instruct bacteria to develop biofilms and by weakening the molecular structure of existing biofilms, potentially making them more susceptible to antibiotics or the body's natural immune response.

Fungus Promote Biofilm Formation

Researchers in Pennsylvania and Iowa have discovered that fungal communities found in chronic wounds can form mixed bacterial-fungal biofilms leading to poor healing outcomes. The team followed 100 patients with diabetic foot ulcers over 26 weeks. Eighty percent of the wounds harbored fungi including Cladosporium herbarum that was found in 41% of the samples and Candida albicans found more than one-fifth of the samples. High levels of ascomycetes, or sac fungi, were associated with wounds that took longer than 8 weeks to heal. Although no single species of fungi was associated with poor outcomes, mixed communities were associated with slow healing or complications, such as bone infection and amputation.

Development of Atmospheric Plasma Wound Treatment Device

Advanced Plasma Products and its partners from the Montana State University and the University Of Tennessee are working on the development and testing of the Atmospheric Plasma Wound Applicator device to treat chronic wounds that are difficult to treat. Plasma forms when certain amounts of energy, like heat or more commonly some kind of electricity, passes through a gas.

The collection of free electrons and ionized gas, called plasma, can support wound healing by its antiseptic effects, by stimulation of proliferation and migration of wound relating skin cells, by activation or inhibition of integrin receptors on the cell surface or by its proangiogenic effect.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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The Official Journal of the APWCA

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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: 11/1/2016 World Union of Wound Healing Societies Congress

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

Latest Entry: 1/15/2016 HBO Nugget 16

Quick Poll
Do we have a consensus for the diagnosis of deep tissue injury?
Do we have a consensus for the diagnosis of deep tissue injury?
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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!