The journal of the American College of Certified Wound Specialists最新文献

Human calciphylaxis reflects a form of severe tissue compromise attributable to a unique microangiopathy that combines features of vascular thrombotic occlusion with endoluminal calcification. While most frequently described in patients with renal failure, it is seen in other settings, such as multiple myeloma; polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (POEMS) syndrome; cirrhosis; and rheumatoid arthritis. Although most commonly involving the skin, calciphylaxis can affect other organs including the heart and gastrointestinal tract, in which cases it falls under the appellation of systemic calciphylaxis. There are cases in which the main pathology is one of endovascular thrombosis of the vessels of the fat without discernible calcification or one manifesting a pseudoangiosarcomatous pattern, hence adding to the histomorphologic spectrum of calciphylaxis. A variety of factors contribute to this severe occlusive microangiopathy, including an underlying procoagulant state and ectopic neo-osteogenesis of the microvasculature through varied mechanisms, including increased osteopontin production by vascular smooth muscle or reduced synthesis of fetuin and GLA matrix protein, important inhibitors of ectopic neo-osteogenesis. Certain factors adversely affect outcome, including truncal and genital involvement and systemic forms of calciphylaxis. With a better understanding of its pathophysiology, more-effective therapies, such as sodium thiosulfate and biphosphanates to reduce reactive oxygen species and receptor activator of nuclear factor κβ-mediated nuclear factor κβ activity, respectively, are being developed.

Introduction

Skin fissures are a common dermatologic condition caused by excessive dry skin, numerous systemic diseases, and backless shoe gear. They are defects in skin that fall into the category of damaged, partial-thickness skin wounds, as opposed to full-thickness wounds. Patients with heel fissures are at an increased risk for developing infection, which could cause more severe issues, especially in patients with diabetes and peripheral vascular disease.

Methods

Five patients from Temple Foot and Ankle Institute, Philadelphia, PA, with a total of 8 heel fissures and 2 hallux fissures, were studied. Patients were dispensed 9 vials of a cyanoacrylate liquid skin protectant (Marathon^™, Medline Industries, Inc, Mundelein, IL) to be applied to the fissure every 3 days. Patients returned every 2 weeks for follow-up in clinic.

Results

The hallux fissures and 4 of the heel fissures went to complete closure after 2 weeks. There was an average decrease of 1.16 cm in length of the heel fissure dimensions after 2 weeks and an average decrease of 1.1 cm in length of the hallux fissures.

Conclusion

This novel skin protectant proved to be a comfortable, easy, and effective tool in aiding the resolution of pedal skin fissures.

Background

Nonhealing and stalled chronic wounds are often reported to reside within an alkaline environment. Consequently, a number of researchers have proposed that lowering the pH of a chronic wound environment will enable healing to progress. However, it is not known whether the efficacies of silver-impregnated wound dressings are affected by pH.

Objective

To investigate whether pH has an effect on the antimicrobial barrier efficacy of a silver alginate wound dressing on wound isolates.

Methods

Twenty-five bacteria and yeasts that had been routinely isolated from chronic wounds were separately exposed to a silver alginate wound dressing with the use of a standardized corrected zone of inhibition (CZOI) assay.

Results

The silver alginate dressing demonstrated a broad spectrum of antimicrobial barrier activity within the dressing against all wound isolates. However, at a pH of 5.5, compared with a pH of 7, the antimicrobial barrier activity of the silver alginate dressing significantly increased. For all yeasts the CZOI ranged from 6.25 to 11 mm at a pH of 7. At a pH of 5.5, the CZOI range increased from 8.5 to 12.25 mm. For the Gram-negative isolates, the CZOI ranged from 0.75 to 6.5 mm at a pH 7, compared with a CZOI range of 2.75 to 8 mm at pH 5.5. The CZOI for the Gram-positive isolates, including meticillin-resistant Staphylococcus aureus, ranged from 3 to 7.75 mm at pH 7 and from 4.5 to 11.75 mm at pH 5.5.

Conclusion

For all isolates tested, excluding one strain of Candida albicans and one vancomycin-resistant Enterococcus strain, lowering pH to 5.5 resulted in an improvement in the antimicrobial barrier activity within the silver alginate dressing. Based on these initial in vitro findings, it is possible to suggest that there may be benefits to maintaining an infected or recalcitrant wound in a slightly acid (pH 5.5) environment. In particular, doing so may lead to an enhanced antimicrobial barrier effect of silver, a quicker reduction in the wound microbial bioburden, and therefore a reduction in the need for prolonged antimicrobial use. However, more in vitro and in vivo studies would be warranted to further substantiate these claims.

A study involving 3 patients was performed to evaluate the efficacy of Matristem, an extracellular matrix scaffold derived from the porcine urinary bladder matrix (UBM), to promote natural healing in patients with severe, chronic wounds that did not respond well to standard wound management. In all cases, the wounds closed after only a few weeks of repeated treatments with UBM, with all patients showing complete epithelialization of the wound with limited formation of scar tissue by 13 weeks after first treatment. These initial results suggest that UBM warrants further investigation for treatment of chronic nonhealing ulcers that are recalcitrant to standard wound therapies.

Dr. Jayesh Shah will be publishing a quarterly column titled “ACE Your Certification Exam.” Every quarter, he will publish 5 questions with explanations to help you practice for your exam.

As the largest organ of the body, the human skin protects all subcutaneous tissues. Despite its many attributes, the skin is vulnerable to pressure ulcers. The number of pressure ulcers and venous leg ulcers is on the rise, but healing rates have not improved over the past decade. The reason may be a tendency to focus on one or two fundamentals of wound healing, but not on all 3 fundamentals equally. The 3 fundamentals of wound healing are (1) pressure relief and nursing care, (2) dressings, and (3) nutrition. Nutrition is the area that is most often overlooked, which commonly causes the care plan to be out of balance. In the United States, few clinicians would consider malnutrition to be an issue in the homecare and long-term care setting, yet nutritional status and risk for pressure ulcer formation are well documented and strongly correlated. Our aging population will continue to survive previously catastrophic events, only to present with pressure ulcers or the potential for developing pressure ulcers. Clinicians caring for residents with pressure ulcers must strike a balance between pressure relief, dressings, and nutrition. Functional gastrointestinal-tract impairments must be diagnosed and addressed. Wounds must be treated aggressively with high-protein calorically-balanced diets because wounds heal from the inside out.

Collagen, which is produced by fibroblasts, is the most abundant protein in the human body. A natural structural protein, collagen is involved in all 3 phases of the wound-healing cascade. It stimulates cellular migration and contributes to new tissue development. Because of their chemotactic properties on wound fibroblasts, collagen dressings encourage the deposition and organization of newly formed collagen, creating an environment that fosters healing. Collagen-based biomaterials stimulate and recruit specific cells, such as macrophages and fibroblasts, along the healing cascade to enhance and influence wound healing. These biomaterials can provide moisture or absorption, depending on the delivery system. Collagen dressings are easy to apply and remove and are conformable. Collagen dressings are usually formulated with bovine, avian, or porcine collagen. Oxidized regenerated cellulose, a plant-based material, has been combined with collagen to produce a dressing capable of binding to and protecting growth factors by binding and inactivating matrix metalloproteinases in the wound environment. The increased understanding of the biochemical processes involved in chronic wound healing allows the design of wound care products aimed at correcting imbalances in the wound microenvironment. Traditional advanced wound care products tend to address the wound’s macroenvironment, including moist wound environment control, fluid management, and controlled transpiration of wound fluids. The newer class of biomaterials and wound-healing agents, such as collagen and growth factors, targets specific defects in the chronic wound environment. In vitro laboratory data point to the possibility that these agents benefit the wound healing process at a biochemical level. Considerable evidence has indicated that collagen-based dressings may be capable of stimulating healing by manipulating wound biochemistry.

Elective surgeries account for millions of acquired scars annually. Many of these scars can be problematic, being aesthetically unpleasant and causing discomfort. Silicone gel sheeting has been shown to be efficacious for the prevention and treatment of problematic scars. By wound hydration, along with other factors, silicone dressings are thought to decrease scarring. However, we found the usual treatment was commonly started after epithelialization of the incision site. The current standard of care in wound healing is to promote a moist wound environment to ensure quick epithelialization and decrease excessive scar formation. With that standard in mind, after foot surgery was performed on 2 patients, silicone sheeting was applied immediately in order to compare its effects with those of standard moist wound healing (XEROFORM Petrolatum Gauze).