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Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Friday, March 8, 2019

The NPUAP 2019 annual conference took place Friday, March 1 and Saturday, March 2 at the St. Louis Union Station Hotel in St. Louis, Missouri. The conference, titled Innovative Research & Practice Across Populations: Connecting Science to Practice, featured nationally and internationally recognized experts focusing on pressure injury prevention and treatment across the spectrum of special populations. The NPUAP also annouced the 2019 International Guideline for Prevention and Treatment of Pressure Injury, scheduled to be launched November 15-16, 2019 in Los Angeles, California. Advances in Skin & Wound Care would like to extend our most enthusiastic congratulations to the conference's award winners:

Barbara Braden, PhD, FAAN, winner of the JoAnn Maklebust Lifetime Achievement Award


Joyce Black, PhD, RN, FAAN, winner of the Kosiak Award


William Padula, PhD, MS, MSc, winner of the Thomas Stewart Founder's Award


Michelle Deppisch, PT, CWS, FACCWS, winner of the President's Recognition Award 


Thursday, February 14, 2019

​Recently we asked you whether you think there is a reliable and objective way to evaluate dry skin. Clinical evaluation of the hydration status of the superficial skin is indirect, based upon visual and tactile evaluation of clinical observable signs. For example, the Overall Dry Skin Score according to the European Group on Efficacy Measurement of Cosmetics and other Topical Products for dry skin assessment categorizes clinical signs of dryness from 0 (absent) to 4 (large scales, roughness, redness, cracks/fissures). However, the highly subjective nature of visual assessment and unstandardized taxonomy to describe skin dryness often yields inconsistencies, poor reproducibility, and miscommunication. What seems to be dry skin to one clinician may not be consistent with another clinician's assessment. Evaluation is more challenging with darker skin, eczematous conditions, and aging frail skin.  

With recent advances in computer science and artificial intelligence, computerized metrics to discriminate and calibrate skin pathology are gaining popularity, and numerous computerized diagnostic systems have been reported in the literature for the evaluation for melanoma with satisfactory accuracy. Wound care researchers are working on a specific tool for the evaluation of dry skin. These coomputerized algorithms are created by many layers of artificial neurons to automatically extract clinical features of dry skin from data including scales, crack/fissures, redness, skin thickness, and eczematous changes. In other words, the computer program is trained to figure out a problem rather than having the answers programmed into it. The algorithm can be made more or less sensitive, allowing the researchers to tune its response depending on what they want it to assess. We hope to see the results soon! 

Friday, December 21, 2018

Noncommunicable diseases (NCDs) are responsible for 41 million deaths each year, or 71% of all deaths globally. Over 85% of "premature" deaths due to NCDs occur in low- and middle-income countries. Of those, 15 million are individuals between the ages of 30 and 69 years. 

The number of people with diabetes has doubled over the past 20 years, making this condition one of the largest global health emergencies. According to International Diabetic Federation:

  • 1 out of every 11 adults worldwide has diabetes
  • Diabetes is ranked ninth on the global list of causes of death in 2010 
  • It associated with a 67% increased risk of disability 
  • It accounts for 54% of years lost due to illness, disability, or early death in low- and middle-income countries.

To address important concerns like these, the third high-level meeting on NCDs was held on September 27 at the United Nations Headquarters in New York. This meeting was recognized as the most important political meeting on diabetes and other NCDs of the last four years. The theme of the meeting was "Scaling up multi-stakeholder and multisectoral responses for the prevention and control of non-communicable diseases in the context of the 2030 Agenda for Sustainable Development." The goal was to heighten focus on prevention to achieve a 0% increase in diabetes prevalence by 2025 and to achieve a 30% reduction in diabetes-related premature mortality by 2030. There is a recognized need to boost investment to ensure 80% access to essential medicines and devices by 2025 and Universal Health Coverage by 2030. Some of the suggestions to emerge from the meeting include:

  • Encouraging fiscal policies and other public health measures to promote healthier diets, especially among children;
  • Considering the use of cost-effective medication strategies, alongside lifestyle changes;
  • Establishing adequate education programs for healthcare professionals and people with diabetes about how to prevent, recognize, and treat diabetes to avoid serious complications that can ultimately lead to death;
  • Establishing an increased and stable government budget to improve or create reimbursement systems;
  • Improving multisectoral collaboration to regulate prices and to enhance the supply chain; and
  • Eliminating all types of discrimination against people with diabetes through the adoption of regulations that defend their rights as well as the development education campaigns aiming to eliminate misconceptions among the general population. 

Monday, October 22, 2018

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A 72-year-old woman with a history of colon cancer underwent a surgical procedure to remove part of her bowel. The remaining portion of the functioning intestine was brought through her abdominal wall, creating an ileostomy. She was managing her ostomy care without any problem, but she has gained a significant amount of weight in the last 6 months, and she presents to your clinic complaining about increased pouch leakage and pain in the peristomal skin. What could be causing the patient's pain?

Peristomal skin complications are common; the incidence is estimated to be as high as 72%. Even after a year or more living with a stoma, many patients continue to experience an array of skin complications, highest among people with ileostomy (57%), followed by urostomy (48%), and colostomy (35%). 

On examination, you notice an erythematous area and skin erosion (partial-thickness skin loss) in the immediate skin surrounding the stoma consistent with irritant dermatitis. You know that the exposure of skin to effluent from an ileostomy that contains a high concentration of digestive enzymes causes skin erosion. The severity and extent of dermatitis is more noticeable in the lower inferior aspect of the stoma, suggesting fecal pooling. This would explain why the patient experienced intense burning and pain. Skin erosion and weeping lesions in the peristomal area create a challenge for the appliance to stick to the skin, creating a vicious cycle of skin irritation, appliance failure, leakage, and more skin irritation. So what precipitated the leakage?

You also notice a change in the abdominal contour, including an out-pouching protuberance around the stoma suggesting peristomal herniation. You know older adults are at risk for herniation, because the rectus abdominus muscle becomes thinner and weaker with age, affecting stoma support. Now, the patient's appliance does not conform to the contour of the herniation. Stretching and relaxing of the peristomal skin with changes in position make it challenging to maintain a good pouching seal. Another possible other reason for increased leakage is related to stoma retraction, because the stoma sits below skin level. 

What can be done to reduce leakage? You ask yourself. Several interventions should considered: 

  • Use soft-convex flange to enable the stoma to protrude more.
  • Consider abdominal support belts or girdles to keep the appliance in place.
  • Avoid heavy lifting and heavy work to prevent further herniation.
  • Recommend exercise to strengthen abdominal muscles.
  • Educate the patient about weight reduction to achieve a body mass index of 20–25.
  • Evaluate the pouching system for the size and fit of the barrier to the stoma to minimize skin exposure to effluent and irritant dermatitis.
  • Trial a two-piece system so the pouch can be changed without removing the skin barrier.
  • Use skin barrier paste or strips to fill or level skin creases/folds or at the areas that are concave under the pouching system.
  • Consider skin barrier paste to caulk the edge of the skin barrier to slow the process of erosion.
  • Consider a cyanoacrylate-based liquid skin protectant to form a protective layer over the damaged skin. Sprinkle skin barrier powder onto the denuded area and apply a liquid polymer acrylate to seal the powder.

Thursday, October 18, 2018

Evaluate use of negative pressure wound therapy in obese and diabetic patients

Patients with higher body mass indices have an increased risk of developing surgical site infections in the abdomen because the majority of these incisions are extensive and deep in order for surgeons to access the treatment areas.  Healing can be complicated by diabetes and excessive skin folds/penus could damage the incision due to unwanted pressure, moisture, and bacteria. Researchers in the University of Illinois at Chicago Epicenter for Prevention of Healthcare Associated Infections received funding from Centers for Disease Control and Prevention to explore whether negative pressure wound therapy can help reduce the incidents of surgical site infections in obese and/or diabetic patients at five university-associated hospitals who have undergone C-sections, abdominal hysterectomy and colon procedures -- three procedures that have elevated rates of incision site infection.  Negative pressure helps increase blood flow to the area, keeps the edges of the incision intact, and draws out excess fluid. The efficacy of negative pressure wound therapy has been evaluated in several small trials, including for promoting healing in cesarean-section incisions, but results have been mixed as to its benefits. This new study will include 3,300 participants in collaboration with the University of Utah, the University of Maryland, Emory University and the University of Iowa.

3D structure of toxic proteins used by Pseudomonas aeruginosa to trigger infection

Pseudomonas aeruginosa infections are a common problem in hospitals. Researchers at Karolinska Institutet, Umeå University and Yale University have mapped the three-dimensional structure of two toxic proteins, called ExoS and ExoT, that the bacteria use to trigger the infection process.  The team found a large, hydrophobic contact interface on the bacterial toxins that is protected by the human protein called 14-3-3.  Otherwise, the toxins form inactive clusters in the cell's water-soluble environment. This newly identified contact interface presents a possible target for drug molecules.

Acelity to buy wound care firm Crawford Healthcare

US-based Acelity has signed an agreement to buy British advanced wound care firm Crawford Healthcare and its assets.  Crawford develops and commercialises treatments for skin care and repair. Its portfolio consists of KerraMax Care foam line, and KerraFoam and KerraCel antimicrobial gelling fibre brands for AWD. The move is intended to expand Acelity's advanced wound dressings (AWD) portfolio and bolster its footprint in the advanced wound healing market.

Smart bandage monitors and treats chronic wounds

Tufts University in the US has led a team of engineers in developing a prototype bandage that can actively monitor the condition of chronic wounds and deliver appropriate drug treatments to improve healing outcomes.  The bandages are designed with microprocessor that tracks data from the sensor and releases drugs on demand from its thermoresponsive drug carriers.  This device allows the delivery of tailored treatments in response to wound pH and temperature sensors that monitor signs of infection.  The entire product is attached to a transparent medical tape, forming a flexible bandage that is less than 3mm thick.  In the future, oxygen levels and inflammatory biomarkers could also be under surveillance.


Kent Imaging collaborates with SerenaGroup to improve wound care

Canadian medical technology company Kent Imaging has partnered with US-based wound healing research firm SerenaGroup to enhance wound tissue analysis by using near infrared imaging technology on its non-invasive KD203 device. A hand-held, portable device is designed to provide timely and accurate assessment of oxygen saturation (StO2), relative oxyhemoglobin (HbO2) and deoxyhemoglobin (Hb) levels in superficial tissue. The imaging technology delivers 2D colour-coded images that offer the information necessary for clinicians to identify at-risk tissue and aid in making treatment decisions.

CellerateJV to distribute activated collagen adjuvant in the US

Wound Management Technologies operating under WNDM Medical, has entered into a new joint venture with The Catalyst Group to produce its CellerateRX activated collagen assets. The newly formed Cellerate JV will maintain an exclusive sublicense to distribute the CellerateRX activated collagen adjuvant into the wound care markets in the US, Canada and Mexico, according to an SEC filing.

MolecuLight obtains FDA de novo clearance for handheld fluorescence wound imager

Last December, Smith & Nephew launched the MolecuLight i:X handheld imaging device in Europe. The Toronto-based company MolecuLight obtained FDA de novo clearance for its MolecuLight i:X a handheld imaging tool that is designed to assess wound surface area and help visualize harmful bacteria within the wounds at the point of care. The system also allows for the viewing and digital recording of wounds traditionally and through fluorescence emitted images of wounds exposed to an excitation light.