Resident Rounds: Part III - Case Report: A Non-Syndromic Case of Multiple Unilateral Nodular and Pigmented Basal Cell Carcinomas.

Although basal cell carcinomas (BCC) are relatively common, particularly in older individuals, the development of multiple BCCs at a young age can indicate an associated genetic disorder. Several cases of unilateral or segmental BCCs have been described in the literature. Some cases have demonstrated concomitant syndromic findings while others had unilateral BCCs as the only finding. Herein we present a non-syndromic case of multiple unilateral nodular and pigmented BCCs in a 61-year-old Hispanic man.

Wound research funding from alternative sources of federal funds in 2012.

Chronic wounds represent a major healthcare burden, costing $25 billion annually, and are associated with high mortality. We previously reported that cutaneous wound healing represented only 0.1% ($29.8 million) of the National Institutes of Health budget. This current study focuses on quantifying the contribution by federal agencies other than the National Institutes of Health for fiscal year 2012. Federal databases including USA Spending, Veterans Affairs, Tracking Accountability in Government Grants Systems, Health Services Research Projects in Progress, and Patient-Centered Outcomes Research Institute, were searched for individual projects addressing wound healing. Twenty-seven projects were identified, totaling funding of $16,588,623 (median: $349,856). Four sponsor institutions accounted for 74% of awarded funds: Department of the Army, National Science Foundation, Department of Veterans Affairs, and Agency for Healthcare Research & Quality. Research projects and cooperative agreements comprised 44% and 37% of awarded grants. New applications and continuing projects represented 52% and 37%. Wound healing represented 0.15% of total medical research funded by the non-National Institutes of Health federal sector. Compared with potential impact on US public health, federal investment in wound research is exiguous. This analysis will draw attention to a disproportionately low investment in wound research and its perils to American public health.

The effect of ankle range of motion on venous ulcer healing rates.

Limitation of ankle movement may contribute to calf muscle pump failure, which is thought to contribute to venous leg ulcer formation, which affects nearly 1 million Americans. We therefore wished to study ankle movement in patients with venous leg ulcers and its effect on healing. Using goniometry, we measured baseline ankle range of motion in venous leg ulcer patients from a Phase 2 dose-finding study of an allogeneic living cell bioformulation. Two hundred twenty-seven patients were enrolled in four active treatment groups and one standard-care control group, all receiving compression therapy. Goniometry data from a control group of 49 patients without venous disease, from a previous study, was used for comparison. We found patients with active venous leg ulcers had significantly reduced ankle range of motion compared with the control group (p = 0.001). After 12 weeks of therapy, baseline ankle range of motion was not associated with healing, as there was no significant difference between healed and nonhealed groups, suggesting that ankle range of motion is not important in venous leg ulcer healing or, more likely, is overcome by compression. However, patients with venous ulcers located on the leg (as opposed to the ankle) had significantly higher ankle range of motion for plantar flexion and inversion (p = 0.021 and p = 0.034, respectively) and improved healing with both cell bioformulation and standard care (p = 0.011), suggesting that wound location is an important variable for ankle range of motion as well as for healing outcomes.

Optimizing Skin Grafting Using Hair-derived Skin Grafts: The Healing Potential of Hair Follicle Pluripotent Stem Cells.

BACKGROUND: A man in his 60s with recurrent venous leg ulcers (VLUs) presented with an 18-month history of a VLU on his medial left leg measuring 59.3 cm(2). He had been treated with multi- component compression bandages without significant decrease in ulcer size. Given the ulcer's size, refractory nature, and history of recurrence, the authors sought to optimize the patient's healing. METHODS: Approximately 23% of the total wound was treated using punch grafts (PGs) harvested from different locations on the body based on hair density using the "stick and place" method. RESULTS: One month later, a 56% reduction in ulcer size was observed, especially in the area that received hair-bearing skin. CONCLUSION: Punch grafts from hair-bearing skin are a viable source of follicular stem cells and may be superior to PG from nonhair-bearing skin for the treatment of chronic wounds.

Current Management of Pediatric Vitiligo.

Vitiligo is a common inflammatory disorder with worldwide prevalence of 0.4-2 % of the population, with half of cases beginning in childhood. The management of childhood vitiligo should be tailored to avoid negative effects on the overall growth and psychological development of the patient. Therapy of vitiligo in childhood is chosen based on the location of the lesions, lesion age, and extent of lesions in the context of the child's age and the developmental status of the child. There are four age categories in childhood vitiligo: [1] infantile and toddler (rare) (ages 0-3 years), [2] ages 4-8 years, [3] ages 9-12 years, and [4] 13+ years of age, based on developmental stage, psychological maturation, and ability to comply or participate in therapy. These categories are also differentiated psychologically by susceptibility to bullying, self-image development, and personal concern with lesion appearance, which increases with time. Intervention is advisable in cases with facial and leg involvement due to prominence of lesions and cosmetic defect. Medical interventions are largely the usage of topical therapies including corticosteroids and calcineurin inhibitors, some vitamin therapy (oral and topical vitamin D), and judicious introduction of phototherapy sources based on age and severity. Screening and appropriate subspecialist referral for co-morbidities (e.g., thyroid disease, celiac disease, psychological distress, and vitamin D deficiency) may enhance overall health. Cosmesis and camouflage are generally safe in childhood and have been noted to improve overall quality of life in this grouping. Genetic transmission of vitiligo is minimal at 5-6 % in first-degree relatives. This article reviews the therapeutics of pediatric vitiligo from the perspective of developmental stages and response to therapy.

Factors Influencing Efficacy of Bilayered Cell Therapy.

Objective: Diabetic foot ulcers (DFUs) that fail to heal with standard care should be treated with advanced wound care products. Efficacy of advanced therapies is dependent on many factors. A secondary analysis of pivotal trial data for a bilayered cellular construct used in the treatment of DFU was undertaken to determine if glycemic control and other factors had an effect on time to healing. Approach: We analyzed the effect of age, gender, diabetes type, insulin usage, body mass index, smoking, initial and ending glycohemoglobin (HgbA1c), Charcot deformity, and wound area, duration, and location on likelihood of healing for wounds treated with bilayered cellular construct (BLCC). Results: In those treated with BLCC, initial wound area (cm2), age, and history of Charcot deformity were found to significantly affect healing. Neither initial HgbA1c nor change in HgbA1c was associated with healing. The bilayered product was found to be equally effective regardless of initial or change in HgbA1c levels (p-values 0.94 and 0.44, respectively). In the control group, initial HgbA1c, insulin usage, female gender, and wound location at the toes significantly influenced healing. Innovation: BLCC subgroup analysis to elucidate selection criteria allowing for targeted use of advanced products on those more likely to respond as well as direct further research into prognostic indicators for BLCC-treated patients. Conclusion: The bilayered cellular construct product remains equally effective regardless of initial or change in HgbA1c levels. Further specific research into the effect of glucose control and other factors on the effectiveness of different advanced DFU treatment products is recommended.