Gastric Pseudomelanosis: An Uncommon Finding.

Gastric pseudomelanosis is a benign condition that has been characterized by pigment deposition within subepithelial macrophages inside the stomach wall. Occurrence of the condition is rare, with pseudomelanosis occurring more often within the duodenal mucosa. Few cases have reported pseudomelanosis within the gastric mucosa. We report a case of an 86-year-old female who presented with worsening iron deficiency anemia concerning for gastrointestinal bleeding. Her endoscopic evaluation was remarkable for a speckled pattern of dark pigmentation within the stomach, confirmed to be pseudomelanosis by histologic evaluation with pigment showing positive staining for iron.

Bacterial protease activity as a biomarker to assess the risk of non-healing in chronic wounds: Results from a multicentre randomised controlled clinical trial.

Millions worldwide suffer from chronic wounds challenging clinicians and burdening healthcare systems. Bacteria impede wound healing; however, the diagnosis of excessive bacterial burden or infection is elusive. Clinical signs and symptoms of infection are inaccurate and unreliable. This trial evaluated a novel, point-of-care, lateral flow diagnostic designed to detect virulence factors released by the most common bacteria found in chronic wounds. A multicentre prospective cohort clinical trial examined the efficacy of a diagnostic test in detecting bacterial proteases taken from swab samples of chronic venous, arterial, pressure and mixed aetiology chronic wounds. Two hundred and sixty six wounds were included in the analysis of the study. The wounds were tested at the start of the study after which investigators were permitted to use whatever dressings they desired for the next 12 weeks. Healing status at 12 weeks was assessed. The presence of elevated bacterial protease activity decreased the probability of wound healing at 12 weeks. In contrast, a greater proportion of wounds were healed at 12 weeks if they had little or no bacterial protease activity at study start. In addition, the presence of elevated bacterial protease activity increased the time it takes for a wound to heal and increased the risk that a wound would not heal, when compared to the absence of bacterial protease activity. The results of this clinical trial indicate that bacterial protease activity, as detected by this novel diagnostic test, is a valid clinical marker for chronicity in wounds. The diagnostic test offers a tool for clinicians to detect clinically significant bacteria in real time and manage bacteria load before the clinical signs and symptoms of infection are evident.

Adjuvant Lymphatic Osteopathic Manipulative Treatment in Patients With Lower-Extremity Ulcers: Effects on Wound Healing and Edema.

CONTEXT: In 2012, the US wound registry estimated that the cost of managing chronic wounds in the United States exceeded $50 billion. A large percentage of these wounds are venous stasis ulcers of the lower extremity. Evidence suggests that adjuvant osteopathic manipulative treatment (OMT) may provide a benefit by reducing edema and subsequent healing times in venous stasis ulcers of the lower extremity. OBJECTIVE: To determine whether a lymphatic OMT protocol improves wound healing rates among patients with lower-extremity edema. METHODS: This pilot study was a nonrandomized before-after community trial of lymphatic OMT in patients with lower-extremity wounds and edema. Wound surface area measurements for the preliminary phase were obtained retrospectively. During the intervention period, patients received 10 minutes of OMT twice per week. The OMT protocol, which aimed to improve lymphatic flow, included myofascial thoracic outlet release, doming of the diaphragm, pelvic diaphragm release, popliteal release, and pedal pump (2-3 minutes of continuous pump) performed in sequence. Rates of wound healing were compared between the preliminary (standard therapy), intervention (standard therapy plus OMT), and follow-up (standard therapy) phases. Rates of change in edema (measured using leg volume) were evaluated during the intervention phase. A custom-designed questionnaire was used to assess patients' satisfaction with their treatment and confidence that its effects on their health were good. RESULTS: Eight patients were included in the study. The wound surface area increased during the preliminary phase by a mean of 10 cm2/wk and decreased during the intervention phase by a mean of 4.9 cm 2/wk. Patients' mean leg volume decreased during the intervention phase. Six patients were "very satisfied" with their treatment. CONCLUSION: The adjunctive OMT protocol may have reduced edema and reversed the trend of wound growth in patients with venous stasis ulcers. Edema reduction is a mainstay of current wound therapy, and any modality that decreases edema may subsequently decrease healing times.

Defining a new diagnostic assessment parameter for wound care: Elevated protease activity, an indicator of nonhealing, for targeted protease-modulating treatment.

It is widely accepted that elevated protease activity (EPA) in chronic wounds impedes healing. However, little progress has occurred in quantifying the level of protease activity that is detrimental for healing. The aim of this study was to determine the relationship between inflammatory protease activity and wound healing status, and to establish the level of EPA above which human neutrophil-derived elastase (HNE) and matrix metalloproteases (MMP) activities correlate with nonhealing wounds. Chronic wound swab samples (n = 290) were collected from four wound centers across the USA to measure HNE and MMP activity. Healing status was determined according to percentage reduction in wound area over the previous 2-4 weeks; this was available for 211 wounds. Association between protease activity and nonhealing wounds was determined by receiver operating characteristic analysis (ROC), a statistical technique used for visualizing and analyzing the performance of diagnostic tests. ROC analysis showed that area under the curve (AUC) for HNE were 0.69 for all wounds and 0.78 for wounds with the most reliable wound trajectory information, respectively. For MMP, the corresponding AUC values were 0.70 and 0.82. Analysis suggested that chronic wounds having values of HNE >5 and/or MMP ≥13, should be considered wound healing impaired. EPA is indicative of nonhealing wounds. Use of a diagnostic test to detect EPA in clinical practice could enable clinicians to identify wounds that are nonhealing, thus enabling targeted treatment with protease modulating therapies.

Use of a fluorescence angiography system in assessment of lower extremity ulcers in patients with peripheral arterial disease: A review and a look forward.

The prevalence of chronic wounds is sharply rising throughout the world due to an aging population and increases in the incidence of obesity, diabetes, and cardiovascular diseases. People with diabetes, hypertension, and hyperlipidemia are at increased risk for developing peripheral arterial disease (PAD). PAD affects 8 to 12 million people over the age of 40 years in the United States and it is a major contributing factor to the development of lower extremity ulcers. Although a number of noninvasive diagnostic tests are available to detect PAD in lower extremities, they have several clinical limitations. In this review, current understanding of the pathophysiology of commonly seen lower extremity ulcers is described and vascular assessments typically used in practice are evaluated. In addition, application of the LUNA Fluorescence Angiography System (Novadaq, Bonita Springs, FL) for the screening and treatment of complex nonhealing wounds in patients with PAD is discussed.

A randomized, investigator-blinded, controlled pilot study to evaluate the safety and efficacy of a poly-N-acetyl glucosamine-derived membrane material in patients with venous leg ulcers.

BACKGROUND: Standard care for venous leg ulcers (VLUs) has remained unchanged over several decades despite high rates of initial treatment failure and ulcer recurrence. OBJECTIVE: We sought to evaluate the efficacy, safety, and tolerability of an advanced, poly-N-acetyl glucosamine (pGlcNAc), nanofiber-derived, wound-healing technology among patients with VLUs (Talymed, Marine Polymer Technologies Inc, Danvers, MA). METHODS: In this randomized, investigator-blinded, parallel-group, controlled study, eligible patients were randomized to treatment with standard care plus pGlcNAc (applied only once, every other week, or every 3 weeks) or to standard care alone. The primary end point was the proportion of patients with complete wound healing at week 20 in the intent-to-treat population (all randomized subjects), with last observation carried forward. RESULTS: Among 82 randomized patients, 71 completed the study with 7 lost to follow-up and 4 discontinued because of systemic infection. There were no significant group differences with regard to baseline demographic, illness, and VLU characteristics. At 20 weeks, the proportion of patients with completely healed VLUs was 45.0% (n = 9 of 20), 86.4% (n = 19 of 22), and 65.0% (n = 13 of 20) for groups receiving standard care plus pGlcNAc only once, every other week, and every 3 weeks, respectively, versus 45.0% (n = 9 of 20) for those receiving standard care alone (P < .01 for pGlcNAc every other week vs standard care). The novel pGlcNAc advanced wound-healing technology was well tolerated and safe. LIMITATIONS: Limitations were small sample size and patients unblinded to treatment allocation. CONCLUSION: These pilot study results suggest that the pGlcNAc advanced wound-healing technology is well tolerated and effective.

Acoustic pressure wound therapy for management of mixed partial- and full-thickness burns in a rural wound center.

Infection, pain, and cosmetically unacceptable scarring frequently complicate full-thickness burns. Outpatient management can be difficult without specialized care. A retrospective case series study was conducted in a rural wound center lacking specialized burn care to assess the clinical effectiveness of acoustic pressure wound therapy, a noncontact low-frequency, nonthermal ultrasound wound therapy that accelerates healing through positive pressure, stimulating fibroblasts, clearing bacteria and debris, and relieving pain. Data from the records of 14 consecutively treated outpatients (age range 5 months to 78 years old) with mixed partial- and full-thickness burns involving the trunk, extremities, or both, averaging 7% of body surface area (range: 1% to 24%), were reviewed. Patients received acoustic pressure wound therapy with standard burn care. Burn thickness was determined by clinical appearance. Treatment effectiveness was evaluated based on scarring characteristics of healed wounds (ie, cosmetic appearance) and pain resolution. Pain was patient-rated using a 10-point visual analog scale (0 = no pain, 10 = severe). Patients were followed for 6 months post-healing. Pain improved with therapy (range: two to 10 treatments). No patient required hospitalization or developed complications related to infection. Pliable, nonhypertrophic scars developed in 86% of patients and hypertrophic scars developed in 14%. Repigmentation was seen in 79% of patients, with only minor irregularities; hypopigmentation occurred in 21%. Scars available for follow-up (71%) remained unchanged. Acoustic pressure wound therapy with standard burn care was found to heal mixed partial- and full-thickness burns and reduced pain in outpatients, resulting in cosmetically acceptable scarring without infectious complications, surgery, or skin grafts and may prove beneficial for inpatient management of extensive full-thickness burns. Further study is warranted.

The effect of noncontact, low-intensity, low-frequency therapeutic ultrasound on lower-extremity chronic wound pain: a retrospective chart review.

Pain associated with chronic wounds and related wound care modalities presents a persistent clinical challenge in patient care, yet evidence supporting the effects of interventions on wound pain remains sparse. In response to initial clinical observations that several patients with painful chronic lower-extremity wounds reported a reduction in wound pain shortly after ultrasound therapy was initiated, a retrospective chart review and analysis of reported pain scores was conducted. The records of 15 consecutive patients (eight women, seven men, age range 28 to 88 years) with painful, nonhealing, lower-extremity wounds treated for 2 to 4 weeks with noncontact, low-intensity, low-frequency therapeutic ultrasound were reviewed and recorded pain scores abstracted. Mean pain scores decreased from 8.07 (+/- 1.91) pre-treatment to 1.67 (+/- 1.76) post-treatment (P = 0.0003). No patients reported worsening pain after treatment commenced. This preliminary evidence suggests that prospective, controlled clinical studies to evaluate the effect of this treatment on wound-related pain are warranted.