December 2017 - Volume 30 - Issue 12

  • Richard "Sal" Salcido, MD
  • 1527-7941
  • 1538-8654
  • 12 issues per year
  • 1.088

Current Issue Highlights


Editorial


Payment Strategies


Practice Points



Clinical Management Extra


Original Investigation


Case Series



New Products


Association News


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

Q.  A 50-year-old female patient presents to the wound clinic with an ulcer on the dorsum of her foot that has persisted for 3 months. The ulcer is extremely painful and has been increasing in size and depth, exposing tendon. What's the diagnosis?

 PAD 9-9-17.jpg

A. On examination, the skin is cool to touch and it appears atrophic and bluish without any lower limb hair. Together with abnormal capillary refill time (more than 2 seconds) and dependent rubor that disappears with elevation, findings suggest an arterial leg ulcer as a result of peripheral artery disease (PAD).   

What causes PAD?  

PAD is a common and disabling health condition affecting about 4% of North Americans over the age of 40 and 20% over age 75. PAD is a complex health condition associated with atherosclerotic occlusive lesions in the arteries, limiting normal blood flow mostly involving the lower extremities (also known as lower extremity arterial disease [LEAD]). While patients with LEAD may experience a wide range of clinical symptoms, the predominant concern is leg pain, with about one third of patients reporting classic claudication and half reporting atypical leg pain during the early stages of the disease. Claudication is pain in a lower extremity that is elicited by walking, when the metabolic demand in the muscle outstrips oxygen supply, and is relieved within a few minutes of rest. 

For people with advanced critical limb ischemia, the lack of perfusion precipitates further tissue injury. These changes often result in persistent pain at rest that may be accompanied with deep non-healing wounds and gangrene, affecting physical functioning and threatening limb viability. A recent study found that over a quarter of venous leg ulcer patients had evidence of LEAD. Many LEAD patients restrict physical activity as a natural strategy to avoid exertional pain, although this can limit social engagement and participation in meaningful activities. ​

How should this condition be treated?

At the moment, revascularization procedures are considered the cornerstone of therapy for ischemic pain to improve blood flow to the lower extremities. They are not always appropriate or safe for frail older adults because of the severity or location of LEAD, multimorbidities, patient preferences, and surgical risks. Medications do not always work; LEAD patients may continue to experience persistent rest pain despite high doses of opiate analgesia. Emerging evidence suggests that the use of intermittent pneumatic compression, electrical muscle stimulators, and exercise therapies may provide some pain relief to LEAD patients, but the findings warrant cautious interpretation because of small sample sizes and the exclusion of frail older adults. 

 

New changes to CMS Section M Skin Conditions MDS 3.0 Resident Assessment Instrument (RAI) Manual beginning October 1, 2017

This revision of the MDS 3.0 RAI Manual has important clarifications to existing coding and transmission policy as well as clarifications and scenarios concerning complex areas.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

Living in a stimulating environment has been shown to promote wound repair and fight cancer

Studies have found that depression, stress, and social isolation increase the risk of cancer progression. Researchers from the Huntsman Cancer Institute at the University of Utah revealed that cognitive stimulation, social interactions, and physical activity increase lifespan in mice with colon cancer by triggering the body's wound repair response. The team exposed mice with colon cancer to environmental enrichment by housing them in cages filled with many other mice, along with running wheels, tunnels, huts, igloos, and nesting materials. The researchers found that exposure to stimulating surroundings increased the lifespan of male and female mice with colon tumors (55 days and 82 days, respectively). Environmental enrichment reduced tumor size in females but decreased blood levels of inflammatory molecules in males. Researchers also found that environmental enrichment activated nuclear hormone receptor signaling pathways involved in wound repair and improved tumor vasculature that could help deliver chemotherapeutic or immunotherapeutic agents to the tumor. 

Regeneration of skin rather than scar tissue

Myofibroblasts are responsible for the final stage of wound healing, replacing wounded areas with scar tissues. Scar tissues are characterized by the absence of fat cells and hair follicles, giving it a different appearance than the rest of the skin. Researchers at the University of Pennsylvania have discovered ways to convert myofibroblasts into fat cells that gives the healed wound a natural look instead of leaving a scar. Researchers identified a factor called Bone Morphogenetic Protein (BMP) that signals the myofibroblasts to become fat. BMP has the potential to be revolutionary in the field of dermatology.

Special peptides hydrogel biomaterial for wound healing

Scientists from the University of Toronto have discovered a special peptide called QHREDGS, or Q-peptide, which promotes the survival of many different cell types, including stem cells, heart cells, and fibroblasts (the cells that make connective tissues). The multidisciplinary team worked with Covalon Technologies Ltd. to develop a peptide-hydrogel biomaterial that helps skin cells migrate toward one another, closing chronic, non-healing wounds. The peptide-hydrogel promotes healing 200% faster than no treatment, and 60% faster than treatment with a leading commercial collagen-based product. 

Mölnlycke to establish R&D innovation unit in AstraZeneca’s BioVentureHub 

Mölnlycke has announced the establishment of an R&D innovation unit in the BioVentureHub at AstraZeneca Gothenburg. The new unit will build on Mölnlycke’s cell biology and analytical chemistry capabilities, and develop innovative advanced wound care and surgical solutions along the entire continuum of care, from prevention to post-acute settings.

ConvaTec launches Natura™ Convex Accordion Flange™, to make ostomy pouch application easier 

ConvaTec Group Plc (“ConvaTec”) announced the global launch of the Natura™ Convex Cut-to-Fit Accordion Flange™ designed to make 2-piece ostomy pouch application easier and more comfortable for people with a stoma. The new convex product completes the company’s Accordion Flange™ range alongside the earlier roll out of Flat Cut-to-Fit and ConvaTec Moldable Technology™ products. It also complements the recently launched Esteem™+ Flex Convex 1-piece system, offering more options for convexity, a fast-growing segment of the ostomy market, and providing consumers and nurses with a wide choice of 1- and 2-piece ostomy solutions to suit their individual needs and preferences. The Accordion Flange™ is a component of a 2-piece system that adheres to the skin around the stoma (and can also be referred to as a wafer, skin barrier, or baseplate). To attach a pouch to the wafer, the accordion-like flange lifts up, away from the body, allowing the user to snap the pouch onto the flange ring without pressing onto the abdomen. An audible click tells the user that the pouch attachment is secure. The pouch can then be gently lowered back into place against the body, giving the user a discreet low profile during wear.

Handheld robotics-assisted total knee arthroplasty (TKA) application

Smith & Nephew (NYSE:SNN; LSE:SN) announced the launch of NAVIO handheld robotics-assisted total knee arthroplasty (TKA) application. The NAVIO Surgical System is a next-generation handheld robotics platform designed to aid surgeons with implant alignment, ligament balancing, and bone preparation. The NAVIO robotics-assisted system does not require preoperative imaging. This allows patients to receive the benefits of robotics assistance without the extra steps, costs, and radiation associated with additional preoperative imaging.

Accurate measurement of intra-abdominal pressure in critical care patients

The prevalence of intra-abdominal hypertension (IAH) in the critically ill is reported to be as high as 50% and is a significant cause of abdominal compartment syndrome (ACS), morbidity, and mortality. Diagnosis requires an accurate, reliable, and consistent standardized methodology for measuring intra-abdominal pressure (IAP). The accuracy of the intra-vesical pressure (IVP) method, the current standard-of-care measurement method, is performed manually and introduces non-standardized construction, clinical technique, and quality control challenges. It is often time-consuming, leads to errors, and can put patients at risk for infection. A recent study demonstrates a new method for automatically measuring IAP, the Accuryn Monitoring System (produced by Potrero Medical), which gives the same precision of accuracy as commercially-available methods. The IAP measurement is taken directly from the catheter tip with just a push of a button, helping to reduce setup time, potential errors, and infection risk. Medline, a leading global medical supplies company, has partnered with Potrero Medical to bring the device to market and advance real-time monitoring for critically ill patients.