Joshua D. Fox

Healing Refractory Venous Ulcers: New Treatments Offer Hope

Non-healing wounds are associated with an inflammatory and proteolytic wound environment, and recent therapeutic strategies have been focused on reversing these changes. Connexins, as members of gap junctions, are important in intercellular signaling and wound repair. Connexin 43 (Cx43) downregulation is associated with normal wound healing, and it has been found to be upregulated in non-healing venous leg ulcers (VLUs). Ghatnekar et al. (2014) report findings of a small phase II trial performed in Indian patients with chronic VLUs, reporting that ACT1, a mimetic peptide of Cx43, accelerates healing in the treatment group. Despite standard care with compression therapy and adjuvant therapy for refractory wounds, at present in clinical practice a significant number of patients remain unhealed. The potential for ACT1 exists to help heal refractory VLUs, but it faces additional regulatory hurdles.

A Review of Cellular and Acellular Matrix Products: Indications, Techniques, and Outcomes

Background: Wound healing is a dynamic process whereby cells, growth factors (GFs), and the extracellular matrix (ECM) interact to restore the architecture of damaged tissue. Chronic wounds can be difficult to treat due to the increased presence of inflammatory cells that degrade the ECM, GF, and cells necessary for wound healing to occur. Cellular and acellular matrix products can be used in the management of a variety of chronic wounds including venous, diabetic, and pressure ulcers and other conditions such as burns, epidermolysis bullosa, pyoderma gangrenosum, and surgical wounds. These matrices provide cells, GF, and other key elements that act as a scaffold and promote reepithelialization and revascularization of the wound bed. Methods: This article focuses on cellular and acellular matrix products that have been well-studied clinically with positive results in randomized clinical trials and widely available matrices for chronic nonhealing wounds. We present trial results as well as their indications, techniques, and outcomes. Results: There are a variety of matrix products available on the market. Some of these products are used to treat chronic wounds, for example, diabetic foot ulcers, venous leg ulcers, pyoderma gangrenosum, and pressure ulcers. In this review, we found that wounds of different etiologies have been treated with a variety of matrices, with successful outcomes compared with standard wound care. Conclusions: Both cellular and acellular matrix products are useful in the management of a variety of chronic wounds. These matrices provide cells, GF, and other key elements that promote reepithelialization and revascularization of the wound bed while preventing degradation of the ECM. The treatment of chronic wounds with matrix products in combination with standard wound care has been proven to aid in wound healing when added to standard of care.

Development of a Flipped Medical School Dermatology Module.

Objectives The flipped classroom module incorporates independent study in advance of in-class instructional sessions. It is unproven whether this methodology is effective within a medical school second-year organ system module. We report the development, implementation, and effectiveness of the flipped classroom methodology in a second-year medical student dermatology module at the University of Miami Leonard M. Miller School of Medicine. Methods In a retrospective cohort analysis, we compared attitudinal survey data and mean scores for a 50-item multiple-choice final examination of the second-year medical students who participated in this 1-week flipped course with those of the previous year’s traditional, lecture-based course. Results Each group comprised nearly 200 students. Students’ age, sex, Medical College Admission Test scores, and undergraduate grade point averages were comparable between the flipped and traditional classroom students. The flipped module students’ mean final examination score of 92.71% ± 5.03% was greater than that of the traditional module students’ 90.92% ± 5.51% (P < 0.001) score. Three of the five most commonly missed questions were identical between the two cohorts. The majority of students preferred the flipped methodology to attending live lectures or watching previously recorded lectures. Conclusions The flipped classroom can be an effective instructional methodology for a medical school second-year organ system module.

Chronic Wounds: The Need for Greater Emphasis in Medical Schools, Post-graduate Training and Public Health Discussions.

C hronic cutaneous ulcers (CCUs) are wounds that fail to heal in a timely fashion and include diabetic foot ulcers (DFU), pressure ulcers (PU), and venous leg ulcers (VLU). CCUs affect over 6 million Americans annually, cost well over

Statins may be associated with six‐week diabetic foot ulcer healing

25 billion in direct treatment costs (with newer estimates suggesting even higher costs) and have greater mortality than many cancers (Table 1). Patients with CCUs are complicated medically, suffering from many comorbidities. CCUs are painful, malodorous, leak fluid, and decrease mobility, and cause anger, resentment, fear, social isolation, and depression. Medical education pertaining to CCUs is limited, and a defined wound care specialty does not exist. Additionally, the federal research budget fails to match the public health-care cost of the disease, and the US Food and Drug Administration (FDA) has approved few drugs to treat CCUs. CCUs are prevalent, lethal, and costly; however, public awareness, research funding, stimulus for innovation, and patient and physician education is lacking.

Ankle Range of Motion, Leg Pain, and Leg Edema Improvement in Patients With Venous Leg Ulcers

Diabetic foot ulcers (DFUs) affect 1.5 million Americans annually, of which only a minority heal with standard care, and they commonly lead to amputation. To improve care, investigations are underway to better understand DFU pathogenesis and develop more effective therapies. Some currently used medications may improve healing. One small, randomized clinical trial found statins improve DFU healing. In this secondary analysis of a large multisite prospective observational cohort of 139 patients with DFUs receiving standard care, we investigated whether there was an association between 6‐week DFU wound size reduction and use of a variety of medications including alpha‐blockers, beta‐blockers, angiotensin converting enzyme inhibitors (ACEi) and statins. We found no significant (p < 0.05) association between six‐week wound reduction and use of any of the evaluated drugs; however, statins did trend toward an association (p = 0.057). This suggests a potential benefit of statins on DFU healing, and larger, targeted studies are warranted.

Adalimumab treatment leads to reduction of tissue tumor necrosis factor-alpha correlated with venous leg ulcer improvement: a pilot study.

Disclaimer: The content of this publication does not necessarily reflect the views or policies of the US Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. This article reflects the views of the authors and should not be construed to represent FDA’s views or policies. The mention of commercial products, their sources, or their use in connection with material reported herein is not to be construed as either an actual or implied endorsement of such products by the US Department of Health and Human Services.

Comparison of sun safety knowledge and behavior of Hispanic and non-Hispanic mothers in Miami: A cross-sectional survey

Venous leg ulcers (VLUs) have higher tumor necrosis factor‐α (TNF‐α) levels compared with normal skin. Refractory VLUs of long duration have higher TNF‐α levels compared with VLUs of shorter duration. As up to 75% of VLUs fail to heal with standard care, we sought to evaluate the role of anti‐TNF‐α therapy for patients with refractory VLUs. Evaluable data were obtained in four of five subjects with recalcitrant VLUs treated with 80 mg of subcutaneous adalimumab at week 0 and with 40 mg at week 2 along with compression therapy and were followed‐up for 6 weeks. Wound biopsies taken at weeks 0 and 4 were stained with anti‐TNF‐α antibodies. Average 4‐week percent wound size reduction was 20.5% ± 6.4%. Two patients had wound size reduction more than 25%, and their percent wound size reduction correlated to percent TNF‐α staining score reductions (P = 0.02, R2 = 0.999). VLU TNF‐α level decrease 4 weeks post‐adalimumab treatment correlated with wound healing.

Comment on Yang et al. Association of statin use and reduced risk of lower-extremity amputation among patients with diabetes: A nationwide population-based cohort observation. Diabetes Care 2016;39:e54-e55

We describe a distinctive clinical presentation of pigmented macules in individuals with red hair localized on bony prominences. This clinical presentation is distinct from the usual presentation of ephelides. Repeated frictions in individuals with predisposed genetic background is suspected to be the causative factor, but further investigations are now required to better understand the pathophysiology and the potential prognostic value of such lesions.

Paraspinal morphea (paraspinal fibrosing plaque): differentiation from other paraspinal entities.

It is estimated that 2 million Americans, two-thirds of whom have diabetes mellitus (DM), are currently living with a limb amputation (1). Patients with DM are at significant risk for limb amputation, as one in four will develop a diabetic foot ulcer (DFU) over their lifetime and nearly one in six will require amputation (2). In 2009, U.S. hospital costs due to amputation exceeded