Laser speckle imaging to evaluate scalp flap blood flow during closure in neurosurgical procedures

Background: To measure the degree of relative ischemia caused by skin closure, we explored the potential utility of intraoperative surface blood flow measurement with laser speckle imaging (LSI). Methods: Prospective observational study of eight subjects that underwent intraoperative LSI during elective cranial neurosurgical procedures at the time of skin closure. Results: Seven 1st time incisions, with closure techniques including sutures (n = 3), staples (n = 3), and one after galeal sutures. When compared to the control region, there was a mean 63.7% reduction in flow across all seven subjects (range 18.7–95.32%). Comparing by closure type, a higher flow reduction in the three subjects with suture closure (80.7% reduction) compared to staples (61.9% reduction, P = 0.0379). One subject had a complex wound where tightening and loosening of sutures were performed to ensure adequate perfusion. Suturing resulted in significantly more local decreased flow compared to staples (P < 0.0001). Conclusion: These findings demonstrate the relative feasibility of using LSI for preoperative vascular flow assessment in planning complex incision closure. These data also provide preliminary support for the hypothesis that skin closure itself causes relative ischemia compared to deep approximation or cautery of the skin edge and that the relative ischemia from staples closure is generally less than from suture closure.

Complex wound care by a nurse practitioner in primary care: a quality improvement evaluation on healing rates, costs and patient satisfaction

Complex wounds are a major burden for healthcare professionals. Patients with complex wounds are often referred to hospitals or wound expertise centres. Complex wound care could be organised in primary care, but very little published evidence for this is available. In this study, members of a primary healthcare organisation were interviewed to ascertain how the wound care was organised. Patient characteristics and data regarding wound care, healing rates and costs were collected from medical records. Patients filled in a questionnaire concerning accessibility, communication, medical counselling and the overall experience of their treatment. This study followed 25 patients with a total of 42 wounds. Some 82% of the wounds were healed within a mean treatment duration of 9.7 weeks. Mean treatment costs were calculated at €155 (£130) for healed patients. Patients were generally very satisfied with their treatment, illustrated by an overall 8.7 out of 10 scoring on an amended survey based on the Consumer Quality Index. Treating complex wounds in primary care seemed adequate, with high patient satisfaction and tolerable costs.

Study of wound-healing activity of sodium 2-(adamantane-1-yl)-2-hydrazino-5-phenyl-4-oxobutanoate

Objective. To study a wound-healing activity of the earlier synthesized compound-leader sodium 2- (adamantan-1-yl)-2-hydrazino-5-phenyl-4-oxobutenoate (1), as well as to establish the possibility of its practical application in the ointment dosage form. Materials and methods. The substance-leader 1 was synthesized by the chemical methods described earlier. The experimental 5 % ointment composition based on an aqueous solution of sodium alginate was developed in compliance with the rules for preparing homogeneous ointments. Its effect on the healing of linear aseptic skin wounds in white rats was studied by the method of wound-tensiometry. Results. The experimental 5 % ointment composition with compound 1 was found to significantly increase the scar tensile strength compared to control without treatment. The developed model ointment showed wound-healing activity comparable to that of the reference drug (Levomekol ointment). Conclusions. The selected substance-leader 1 in the composition of a model 5 % hydrophilic ointment based on sodium alginate exhibits pronounced biological activity and is a candidate for further research as a potential pharmaceutical substance with complex wound-healing and anti-inflammatory property.

Loss of Diacylglycerol Kinase α Enhances Macrophage Responsiveness

The diacylglycerol kinases (DGKs) are a family of enzymes responsible for the conversion of diacylglycerol (DAG) to phosphatidic acid (PA). In addition to their primary function in lipid metabolism, DGKs have recently been identified as potential therapeutic targets in multiple cancers, including glioblastoma (GBM) and melanoma. Aside from its tumorigenic properties, DGKα is also a known promoter of T-cell anergy, supporting a role as a recently-recognized T cell checkpoint. In fact, the only significant phenotype previously observed in Dgka knockout (KO) mice is the enhancement of T-cell activity. Herein we reveal a novel, macrophage-specific, immune-regulatory function of DGKα. In bone marrow-derived macrophages (BMDMs) cultured from wild-type (WT) and KO mice, we observed increased responsiveness of KO macrophages to diverse stimuli that yield different phenotypes, including LPS, IL-4, and the chemoattractant MCP-1. Knockdown (KD) of Dgka in a murine macrophage cell line resulted in similar increased responsiveness. Demonstrating in vivo relevance, we observed significantly smaller wounds in Dgka-/- mice with full-thickness cutaneous burns, a complex wound healing process in which macrophages play a key role. The burned area also demonstrated increased numbers of macrophages. In a cortical stab wound model, Dgka-/- brains show increased Iba1+ cell numbers at the needle track versus that in WT brains. Taken together, these findings identify a novel immune-regulatory checkpoint function of DGKα in macrophages with potential implications for wound healing, cancer therapy, and other settings.

Coverage of complex tissue defects following open cervicothoracic spine surgery with a lower trapezius island myocutaneous flap—an interdisciplinary approach

The study design is a clinical case series. The objective of this study was to present the concept and efficacy of the lower trapezius island myocutaneous flap (LTIMF) for management of complex wound healing disorders following open cervicothoracic spine surgery. Wound healing disturbances with myocutaneous defects after open spine surgery at the cervical and upper thoracic spine are well-described complications. In severe cases, plastic reconstructive coverage is often required as a last resort. A review of all adult patients with deep wound dehiscence and tissue defects following open cervicothoracic spine surgery, who were managed with plastic surgery reconstruction using a LTIMF at our institution, was conducted. Synopses of these cases are presented. Seven patients with a mean age of 73 years ± 13 (range 50 to 89 years) were included in this case series. Six out of seven patients had instrumented posterior fusion added to their decompression. All patients were managed with a LTIMF for wound coverage. No spinal implants were removed prior to LTIMF surgery. The mean follow-up was 5.2 months (± 5.4 months). No major flap failure occurred, and all patients presented with satisfactory cosmetic results. The only minor complication was development of a sterile subcutaneous seroma in two patients, which were successfully managed by puncture and aspiration. The LTIMF is an effective and reliable salvage treatment option for spine surgery patients offering stable coverage of deep tissue defects resulting from complex wound healing disorders at the cervical and upper thoracic spine.

Delivery of Bioactive Compounds to Improve Skin Cell Responses on Microfabricated Electrospun Microenvironments

The introduction of microtopographies within biomaterial devices is a promising approach that allows one to replicate to a degree the complex native environment in which human cells reside. Previously, our group showed that by combining electrospun fibers and additive manufacturing it is possible to replicate to an extent the stem cell microenvironment (rete ridges) located between the epidermal and dermal layers. Our group has also explored the use of novel proangiogenic compounds to improve the vascularization of skin constructs. Here, we combine our previous approaches to fabricate innovative polycaprolactone fibrous microtopographical scaffolds loaded with bioactive compounds (2-deoxy-D-ribose, 17β-estradiol, and aloe vera). Metabolic activity assay showed that microstructured scaffolds can be used to deliver bioactive agents and that the chemical relation between the working compound and the electrospinning solution is critical to replicate as much as possible the targeted morphologies. We also reported that human skin cell lines have a dose-dependent response to the bioactive compounds and that their inclusion has the potential to improve cell activity, induce blood vessel formation and alter the expression of relevant epithelial markers (collagen IV and integrin β1). In summary, we have developed fibrous matrixes containing synthetic rete-ridge-like structures that can deliver key bioactive compounds that can enhance skin regeneration and ultimately aid in the development of a complex wound healing device.

Intranasal dexmedetomidine: Procedural sedation in palliative care: A case report

Background: This report describes the use of intranasal dexmedetomidine to control incident pain and facilitate daily change of dressing in a patient with cutaneous breast cancer. Case presentation: A 45-year-old woman with extensive thoracic cutaneous metastatic bilateral breast cancer requiring daily 2-hour dressing changes to manage significant exudate. Pain during change of dressing was severe and unresponsive to usual analgesics. Deeper sedation was not an option as the patient was required to change position 1 hour into dressing change. Case management: Intranasal dexmedetomidine was administered 40 minutes prior to dressing change and provided effective rousable sedation and analgesia for the duration of the procedure. Case outcome: Dexmedetomidine provided rousable sedation, allowing the patient to follow commands and mobilise during the procedure. Pain was controlled. No adverse cardiovascular effects were noted with the use of intranasal dexmedetomidine. Conclusion: Intranasal dexmedetomidine is a potentially useful medication for procedural sedation in the management of complex wound dressings. It provides rousable short-term sedation, anxiolysis and analgesia. Further research into the role of intranasal dexmedetomidine to facilitate challenging dressing changes in a community setting is warranted.

109 Outpatient Nursing Care Charges: A Process Improvement Project

Introduction High wound care complexity in a burn clinic mandates adequate nurse staffing and expertise to manage increasingly large wounds as outpatient. To achieve these service needs, appropriate charge capture is important for revenue generation. Our burn clinic performed a process improvement (PI) project using a Plan, Do, Study, Act (PDSA) cycle to improve the accuracy of charge capture for wound care episodes over the past 2 fiscal years (FY). Methods In the first phase (PLAN), we reviewed charges by 1-month sampling in FY20. We engaged stakeholders (medical and nursing providers, managers, revenue integrity and compliance teams) through iterative meetings. We performed a stakeholder analysis to identify their level of engagement, influence, and attitudes toward this PI. We next devised strategies for stakeholders to champion the project. The team developed and trialed the process by focusing on burn wound care Common Procedural Terminology (CPT) codes. In FY21, nurses began to enter CPT codes in accordance with burn wound care performed (DO). We then repeated a 1-month sampling of charges in FY21 (STUDY). We are now consolidating the new strategy, refreshing stakeholder engagement, and expanding it within our hospital (ACT). Results We identified multiple billing errors and opportunities to improve CPT code documentation for nursing wound care procedures in FY20. Stakeholder interviews revealed a gap between accurate billing and current practice. We proposed to alter the wound care billing workflow. Stakeholder engagement was high and well-represented among professional disciplines. In FY21 implementation, clinic nurses received the clinic coding in-service and were oriented to resource tools. We verified billing practice adherence via the institutional compliance department. FY21 sampling indicated a marked increase in accurate charges for burn wound care in the clinic (net+ $36,691). We have implemented real-time audits, identified and documented problems as they arise, and obtained feedback from nurses. The clinic is investigating non-burn wound care charge capture and has disseminated our findings through institutional shared governance. Conclusions The financial performance of outpatient burn nursing needs to be closely evaluated in today’s shifting healthcare environment. Using a PDSA process led by nurses, the accuracy of charge capture for complex wound care has substantially improved and led to increased revenue. This model is potentially translatable to other specialty clinics.

544 Temporizing Matrix in the Complex Wound: A Retrospective Three-year Review

Introduction A complex wound is a wound that will not heal spontaneously or with simple or standard closure techniques. Often functional structures (bone, tendon, fascia, joint capsule etc.) are exposed and a matrix can be used for bridging of these structures. The Temporizing Matrix is an entirely synthetic matrix made from polyurethane open-cell foam. This matrix was used in the burn center for three years for the indication “complex wound” with good success. The study objective was to evaluate success rate (leading to wound closure after STSG, duration of treatment) and complications (infection, failure, scarring) on this patient cohort. IRB approval was obtained. Methods All charts of patients receiving the Matrix between June 2017 through May 2020 were reviewed. Data collected were demographics, surgery dates, wound descriptions, healing, infection, failure, reapplication, time from application to STSG, time to healing, post discharge complications and scar quality. Results 33 patients with 37 complex wounds were identified to meet inclusion criteria, 61% male, 39% female, age ranging from 3 months to 72 years. The wounds were caused by Burns, necrotizing infections, trauma or amputation post burn. The Matrix was placed for widely exposed structures (70%), failed STSG(3%), thin subcutaneous tissue coverage over amputation stumps (15%) and other reasons (12%). Primary graft success was 97%. Infection rate was 15% with 8% reapplication. Most infections were treated locally. The average Vancouver scar scale rating after discharge was 9/15. Conclusions This temporizing Matrix in preparation to STSG led to successful wound closure in 97% of these complex wounds with low complication rates and an acceptable long-term scar.