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.  The patient is a 61-year old woman with a history of advanced multiple sclerosis and a recent episode of pneumonia that was treated with appropriate antibiotics.  She presented to the wound clinic with skin lesions in the perianal area.  The lesions looked like fluid-filled blisters and they were described as Stage 2 pressure injuries.  The patient was immobile, incontinent of urine and stool, and slightly malnourished as evidenced by recent weight loss. The unusual aspect of these lesions was the excruciating pain the patient experienced even when the area was not manipulated or touched.   Although the patient may be at risk for pressure injury, she was turned on regular basis and the skin was cleaned meticulously. 

The location of the skin lesions were not really prone to pressure and shear problem, what is the correct diagnosis?

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A. On examination, there were clusters of small, tense vesicles appearing on an erythematous base.  A viral culture fluid from the blister was taken and material was obtained from the base of a vesicle for viral culture.  The diagnosis was herpes simplex virus

Herpes simplex virus (HSV), HSV-1 and HSV-2, can cause recurrent infection affecting the skin, mouth, lips, eyes, and genitals. Genital and perianal lesions of herpes are usually caused by herpes simplex type II.    After the initial infection, HSV infects the skin and remains dormant in nerve ganglia.  It can periodically emerge, causing lifelong latent infection or eruptions precipitated by physical or emotional stress, immunosuppression, and other unknown stimuli.

An HSV infection may be accompanied by prodromal period (typically < 6 h) of tingling discomfort or itching. The skin lesions often appear in clusters varying in size from 0.5 to 1.5 cm, but may coalesce.  Lesions usually heal completely within 5 to 10 days, however; recurrent lesions at the same site may cause scarring and secondary bacterial infection.   Herpes simplex virus should be distinguished from herpes zoster, which rarely recurs and usually causes more severe pain and larger groups of lesions that are distributed along a dermatome. There is little evidence indicating benefit from treatment of recurrent orolabial herpes, which tends to be mild and infrequent.

 

 

 

 

 

 

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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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?

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

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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!