Wounds

CHICAGO — Spray recombinant human thrombin achieved hemostasis within 20 minutes in 91.5% of patients following burn wound excision in a prospective safety study in 71 patients.

Recombinant human thrombin (rThrombin) was also minimally immunogenic, principal investigator Dr. David G. Greenhalgh said at the annual meeting of the American Burn Association (ABA).

One patient had specific, low-titer antibodies to rThrombin at baseline, but no increase in titer post treatment. A second patient developed non-neutralizing antibodies to rThrombin at day 29.

The findings are encouraging because rThrombin was developed as an alternative to bovine plasma-derived thrombin, which has been available since the 1940s, but carries a black box warning about severe bleeding risks associated with potential antibody development, explained Dr. Greenhalgh, professor and chief of burn surgery, University of California, Davis. Roughly 20%-90% of patients treated with topical bovine thrombin develop antibodies to the preparation.

In January 2008, the Food and Drug Administration approved Recothrom, the first and only rThrombin for use as a topical hemostat in combination with an absorbable gelatin sponge. The product is devoid of human or animal plasma proteins, which also minimizes the risk of pathogen transmission, he said.

The current open-label, multiple-site study evaluated the safety of spray rThrombin in 71 patients, aged 2–75 years, who received a partial- or full-thickness autologous sheet or mesh graft following excision of burn wounds covering 1%-4% of their total body surface area. The spray was applied at 5-minute intervals for up to 20 minutes. Sheet grafts were received by 53 patients and mesh grafts by 18.

Hemostasis was achieved without the use of tourniquets or clysis, which makes the 91.5% hemostasis rate even more impressive, because both reduce the rate of bleeding, Dr. Greenhalgh said.

At day 29, one graft was infected and four grafts failed. Other adverse events reported were pain (25 patients), pruritus (18), deep vein thrombosis (1), adult respiratory distress syndrome (1), and GI hemorrhage (1).

There were no study drug discontinuations or deaths in the study, which was sponsored by ZymoGenetics Inc. (Seattle); the company markets rThrombin in the United States as Recothrom.

Session moderator and former ABA president Dr. Glenn D. Warden asked whether immunogenicity might be a concern with repeated use of rThrombin over larger wounds.

Dr. Greenhalgh answered that it would be beneficial to conduct a study to evaluate repeated use, but that he felt better about human recombinant products than bovine plasma-based products because of their reduced risk of viral transfer and antibody development.

When asked if human recombinant products were too costly for regular use, Dr. Greenhalgh said, "It's not something that's going to break the bank … I think it's going to be reasonable, compared to what's available."

Dr. Greenhalgh, who reported no conflicts of interest, said he uses spray rThrombin in combination with tourniquets for excisions on hands or arms and in combination with topical and injected epinephrine and cautery for large tangential excisions on the trunk.

CHICAGO — Spray recombinant human thrombin achieved hemostasis within 20 minutes in 91.5% of patients following burn wound excision in a prospective safety study in 71 patients.

Recombinant human thrombin (rThrombin) was also minimally immunogenic, principal investigator Dr. David G. Greenhalgh said at the annual meeting of the American Burn Association (ABA).

One patient had specific, low-titer antibodies to rThrombin at baseline, but no increase in titer post treatment. A second patient developed non-neutralizing antibodies to rThrombin at day 29.

The findings are encouraging because rThrombin was developed as an alternative to bovine plasma-derived thrombin, which has been available since the 1940s, but carries a black box warning about severe bleeding risks associated with potential antibody development, explained Dr. Greenhalgh, professor and chief of burn surgery, University of California, Davis. Roughly 20%-90% of patients treated with topical bovine thrombin develop antibodies to the preparation.

In January 2008, the Food and Drug Administration approved Recothrom, the first and only rThrombin for use as a topical hemostat in combination with an absorbable gelatin sponge. The product is devoid of human or animal plasma proteins, which also minimizes the risk of pathogen transmission, he said.

The current open-label, multiple-site study evaluated the safety of spray rThrombin in 71 patients, aged 2–75 years, who received a partial- or full-thickness autologous sheet or mesh graft following excision of burn wounds covering 1%-4% of their total body surface area. The spray was applied at 5-minute intervals for up to 20 minutes. Sheet grafts were received by 53 patients and mesh grafts by 18.

Hemostasis was achieved without the use of tourniquets or clysis, which makes the 91.5% hemostasis rate even more impressive, because both reduce the rate of bleeding, Dr. Greenhalgh said.

At day 29, one graft was infected and four grafts failed. Other adverse events reported were pain (25 patients), pruritus (18), deep vein thrombosis (1), adult respiratory distress syndrome (1), and GI hemorrhage (1).

There were no study drug discontinuations or deaths in the study, which was sponsored by ZymoGenetics Inc. (Seattle); the company markets rThrombin in the United States as Recothrom.

Session moderator and former ABA president Dr. Glenn D. Warden asked whether immunogenicity might be a concern with repeated use of rThrombin over larger wounds.

Dr. Greenhalgh answered that it would be beneficial to conduct a study to evaluate repeated use, but that he felt better about human recombinant products than bovine plasma-based products because of their reduced risk of viral transfer and antibody development.

When asked if human recombinant products were too costly for regular use, Dr. Greenhalgh said, "It's not something that's going to break the bank … I think it's going to be reasonable, compared to what's available."

Dr. Greenhalgh, who reported no conflicts of interest, said he uses spray rThrombin in combination with tourniquets for excisions on hands or arms and in combination with topical and injected epinephrine and cautery for large tangential excisions on the trunk.

CHICAGO — Spray recombinant human thrombin achieved hemostasis within 20 minutes in 91.5% of patients following burn wound excision in a prospective safety study in 71 patients.

Recombinant human thrombin (rThrombin) was also minimally immunogenic, principal investigator Dr. David G. Greenhalgh said at the annual meeting of the American Burn Association (ABA).

One patient had specific, low-titer antibodies to rThrombin at baseline, but no increase in titer post treatment. A second patient developed non-neutralizing antibodies to rThrombin at day 29.

The findings are encouraging because rThrombin was developed as an alternative to bovine plasma-derived thrombin, which has been available since the 1940s, but carries a black box warning about severe bleeding risks associated with potential antibody development, explained Dr. Greenhalgh, professor and chief of burn surgery, University of California, Davis. Roughly 20%-90% of patients treated with topical bovine thrombin develop antibodies to the preparation.

In January 2008, the Food and Drug Administration approved Recothrom, the first and only rThrombin for use as a topical hemostat in combination with an absorbable gelatin sponge. The product is devoid of human or animal plasma proteins, which also minimizes the risk of pathogen transmission, he said.

The current open-label, multiple-site study evaluated the safety of spray rThrombin in 71 patients, aged 2–75 years, who received a partial- or full-thickness autologous sheet or mesh graft following excision of burn wounds covering 1%-4% of their total body surface area. The spray was applied at 5-minute intervals for up to 20 minutes. Sheet grafts were received by 53 patients and mesh grafts by 18.

Hemostasis was achieved without the use of tourniquets or clysis, which makes the 91.5% hemostasis rate even more impressive, because both reduce the rate of bleeding, Dr. Greenhalgh said.

At day 29, one graft was infected and four grafts failed. Other adverse events reported were pain (25 patients), pruritus (18), deep vein thrombosis (1), adult respiratory distress syndrome (1), and GI hemorrhage (1).

There were no study drug discontinuations or deaths in the study, which was sponsored by ZymoGenetics Inc. (Seattle); the company markets rThrombin in the United States as Recothrom.

Session moderator and former ABA president Dr. Glenn D. Warden asked whether immunogenicity might be a concern with repeated use of rThrombin over larger wounds.

Dr. Greenhalgh answered that it would be beneficial to conduct a study to evaluate repeated use, but that he felt better about human recombinant products than bovine plasma-based products because of their reduced risk of viral transfer and antibody development.

When asked if human recombinant products were too costly for regular use, Dr. Greenhalgh said, "It's not something that's going to break the bank … I think it's going to be reasonable, compared to what's available."

Dr. Greenhalgh, who reported no conflicts of interest, said he uses spray rThrombin in combination with tourniquets for excisions on hands or arms and in combination with topical and injected epinephrine and cautery for large tangential excisions on the trunk.

SAN DIEGO — Although fluid intake can be safely increased in nursing home residents who have, or are at risk for, pressure ulcers and do not routinely ingest the prescribed amount of fluid, levels of subcutaneous oxygen may remain low, results from a multicenter study demonstrated.

"In the nursing home population, hydration is a serious issue," Nancy A. Stotts, R.N., Ed.D., said at the annual meeting of the Wound Healing Society. "Some of the estimates are that up to half of all nursing home residents are underhydrated."

The investigators recorded routine fluid intake for 5 days in 64 residents of five nursing homes in Northern California. The residents were then randomized to receive, for 5 days, the target amount of fluid prescribed by their physician or the target amount plus 10 mL/kg of body weight, said Dr. Stotts, professor of nursing at the University of California, San Francisco.

They also evaluated levels of subcutaneous oxygen in all study participants for 3 days during treatment. Hypovolemia was defined as 45 mm Hg or less, or a less-than-20% increase in response to an oxygen challenge.

Patients' mean age was 79 years; most were female (38) and cognitively impaired (51). Mean baseline daily fluid intake was 1,374 cc for the group who received prescribed fluid, and 1,707 cc for those who were randomized to the extra fluid. After treatment, the mean daily fluid intake increased significantly for both groups: to 1,787 cc for the group who received prescribed fluid, and to 2,380 cc for those who received the extra fluid.

The mean level of subcutaneous oxygen, however, was 40 mm Hg for patients in the target prescribed group, and 36 mm Hg for patients in the group that received supplemental fluid. Subcutaneous oxygen levels less than 45 mm Hg indicate tissue hypoxia that may be caused by hypovolemia, Dr. Stotts said at the meeting, which was held in conjunction with a symposium on advanced wound care.

No cases of fluid overload or heart failure were observed.

Increased fluid intake "did not reverse the low subcutaneous oxygen, perhaps because of chronic underhydration and osmoreceptor reset," she said. "Further work needs to address the optimal dose and duration of fluid for older adults and other factors that contribute to the low subcutaneous oxygen."

The study was funded by the National Institutes of Health.

SAN DIEGO — Although fluid intake can be safely increased in nursing home residents who have, or are at risk for, pressure ulcers and do not routinely ingest the prescribed amount of fluid, levels of subcutaneous oxygen may remain low, results from a multicenter study demonstrated.

"In the nursing home population, hydration is a serious issue," Nancy A. Stotts, R.N., Ed.D., said at the annual meeting of the Wound Healing Society. "Some of the estimates are that up to half of all nursing home residents are underhydrated."

The investigators recorded routine fluid intake for 5 days in 64 residents of five nursing homes in Northern California. The residents were then randomized to receive, for 5 days, the target amount of fluid prescribed by their physician or the target amount plus 10 mL/kg of body weight, said Dr. Stotts, professor of nursing at the University of California, San Francisco.

They also evaluated levels of subcutaneous oxygen in all study participants for 3 days during treatment. Hypovolemia was defined as 45 mm Hg or less, or a less-than-20% increase in response to an oxygen challenge.

Patients' mean age was 79 years; most were female (38) and cognitively impaired (51). Mean baseline daily fluid intake was 1,374 cc for the group who received prescribed fluid, and 1,707 cc for those who were randomized to the extra fluid. After treatment, the mean daily fluid intake increased significantly for both groups: to 1,787 cc for the group who received prescribed fluid, and to 2,380 cc for those who received the extra fluid.

The mean level of subcutaneous oxygen, however, was 40 mm Hg for patients in the target prescribed group, and 36 mm Hg for patients in the group that received supplemental fluid. Subcutaneous oxygen levels less than 45 mm Hg indicate tissue hypoxia that may be caused by hypovolemia, Dr. Stotts said at the meeting, which was held in conjunction with a symposium on advanced wound care.

No cases of fluid overload or heart failure were observed.

Increased fluid intake "did not reverse the low subcutaneous oxygen, perhaps because of chronic underhydration and osmoreceptor reset," she said. "Further work needs to address the optimal dose and duration of fluid for older adults and other factors that contribute to the low subcutaneous oxygen."

The study was funded by the National Institutes of Health.

SAN DIEGO — Although fluid intake can be safely increased in nursing home residents who have, or are at risk for, pressure ulcers and do not routinely ingest the prescribed amount of fluid, levels of subcutaneous oxygen may remain low, results from a multicenter study demonstrated.

"In the nursing home population, hydration is a serious issue," Nancy A. Stotts, R.N., Ed.D., said at the annual meeting of the Wound Healing Society. "Some of the estimates are that up to half of all nursing home residents are underhydrated."

The investigators recorded routine fluid intake for 5 days in 64 residents of five nursing homes in Northern California. The residents were then randomized to receive, for 5 days, the target amount of fluid prescribed by their physician or the target amount plus 10 mL/kg of body weight, said Dr. Stotts, professor of nursing at the University of California, San Francisco.

They also evaluated levels of subcutaneous oxygen in all study participants for 3 days during treatment. Hypovolemia was defined as 45 mm Hg or less, or a less-than-20% increase in response to an oxygen challenge.

Patients' mean age was 79 years; most were female (38) and cognitively impaired (51). Mean baseline daily fluid intake was 1,374 cc for the group who received prescribed fluid, and 1,707 cc for those who were randomized to the extra fluid. After treatment, the mean daily fluid intake increased significantly for both groups: to 1,787 cc for the group who received prescribed fluid, and to 2,380 cc for those who received the extra fluid.

The mean level of subcutaneous oxygen, however, was 40 mm Hg for patients in the target prescribed group, and 36 mm Hg for patients in the group that received supplemental fluid. Subcutaneous oxygen levels less than 45 mm Hg indicate tissue hypoxia that may be caused by hypovolemia, Dr. Stotts said at the meeting, which was held in conjunction with a symposium on advanced wound care.

No cases of fluid overload or heart failure were observed.

Increased fluid intake "did not reverse the low subcutaneous oxygen, perhaps because of chronic underhydration and osmoreceptor reset," she said. "Further work needs to address the optimal dose and duration of fluid for older adults and other factors that contribute to the low subcutaneous oxygen."

The study was funded by the National Institutes of Health.

SAN DIEGO — High-voltage, pulsed electrical stimulation is an effective adjunct to multidisciplinary attempts at limb salvage in diabetic patients with complex lower extremity wounds, results from a small study demonstrated.

Of 45 wounds in 30 patients, 78% of the wounds healed in a mean of 14 weeks using the electrical stimulation system, Dr. Jeremy J. Burdge reported at the annual meeting of the Wound Healing Society.

"This is a preliminary study," said Dr. Burdge, a plastic and reconstructive surgeon who practices in Columbus, Ohio. "Further research is warranted."

He and his associates evaluated the efficacy of a high-voltage electrical stimulation system manufactured by MicroVas Technologies Inc. (Tulsa, Okla.) in patients who failed to improve despite multidisciplinary treatment approaches, including vascular evaluation and surgical intervention as indicated, aggressive off loading, bacterial infection control, and wound debridement.

"There is a variety of ways in which people speculate that high-voltage pulsed current has improved wound healing," Dr. Burdge said at the meeting, which was held in conjunction with a symposium on advanced wound care. "They fall into several groups of either increasing blood flow through promoting microcirculation, increasing wound healing through attraction of proliferating different cell types, or bacteria inhibition by this type of pulsed current."

More than half (57%) of the patients in the study were men; their mean age was 66 years. Comorbidities included neuropathy (84%), peripheral vascular disease (77%), cardiac disease (37%), and infection (33%). "This was a fairly high-risk group of patients," Dr. Burdge noted. "The mean hemoglobin A1c level was 8.2% and nine patients had undergone previous amputation."

The mean age of wounds was 25 weeks, and mean surface area was 7.8 cm

Emitter pads were placed over each wound. Stimulation was delivered for 45 minutes 2–3 times per week by a narrow pulsed current with a width of 80–100 microseconds at a frequency of 55 Hz. Pulses were delivered for 1.5 seconds, with a 1.5-second interval between pulses. The amplitude was individualized for each patient to maximize fused tetanic muscular contraction.

Dr. Burdge reported that the mean number of stimulation treatments per wound was 23 and that 35 (78%) of the wounds healed in a mean of 14 weeks.

Wound healing was defined as either complete epithelialization of the wound or closure with supplemental skin grafts.

Wounds in eight patients failed to heal. One required a metatarsal amputation, four had below-the-knee amputations, one had necrotic tissue and was lost to follow-up, and two patients are continuing further therapy.

At a mean follow-up of 40 weeks, 88% of wounds had no evidence of recurrence. "We did have four patients who had recurrent wounds," he said. "Two went on to complete healing. One had osteomyelitis and went on to a below-the-knee amputation."

Treatment is pending for the fourth wound that recurred.

Dr. Burdge had no conflicts to disclose.

A 3-month-old heel wound is seen in a 66-year-old male with diabetes and neuropathy.

After 22 treatments and a supplemental skin graft, the wound was considered healed. Photos courtesy Dr. Jeremy J. Burdge

SAN DIEGO — High-voltage, pulsed electrical stimulation is an effective adjunct to multidisciplinary attempts at limb salvage in diabetic patients with complex lower extremity wounds, results from a small study demonstrated.

Of 45 wounds in 30 patients, 78% of the wounds healed in a mean of 14 weeks using the electrical stimulation system, Dr. Jeremy J. Burdge reported at the annual meeting of the Wound Healing Society.

"This is a preliminary study," said Dr. Burdge, a plastic and reconstructive surgeon who practices in Columbus, Ohio. "Further research is warranted."

He and his associates evaluated the efficacy of a high-voltage electrical stimulation system manufactured by MicroVas Technologies Inc. (Tulsa, Okla.) in patients who failed to improve despite multidisciplinary treatment approaches, including vascular evaluation and surgical intervention as indicated, aggressive off loading, bacterial infection control, and wound debridement.

"There is a variety of ways in which people speculate that high-voltage pulsed current has improved wound healing," Dr. Burdge said at the meeting, which was held in conjunction with a symposium on advanced wound care. "They fall into several groups of either increasing blood flow through promoting microcirculation, increasing wound healing through attraction of proliferating different cell types, or bacteria inhibition by this type of pulsed current."

More than half (57%) of the patients in the study were men; their mean age was 66 years. Comorbidities included neuropathy (84%), peripheral vascular disease (77%), cardiac disease (37%), and infection (33%). "This was a fairly high-risk group of patients," Dr. Burdge noted. "The mean hemoglobin A1c level was 8.2% and nine patients had undergone previous amputation."

The mean age of wounds was 25 weeks, and mean surface area was 7.8 cm

Emitter pads were placed over each wound. Stimulation was delivered for 45 minutes 2–3 times per week by a narrow pulsed current with a width of 80–100 microseconds at a frequency of 55 Hz. Pulses were delivered for 1.5 seconds, with a 1.5-second interval between pulses. The amplitude was individualized for each patient to maximize fused tetanic muscular contraction.

Dr. Burdge reported that the mean number of stimulation treatments per wound was 23 and that 35 (78%) of the wounds healed in a mean of 14 weeks.

Wound healing was defined as either complete epithelialization of the wound or closure with supplemental skin grafts.

Wounds in eight patients failed to heal. One required a metatarsal amputation, four had below-the-knee amputations, one had necrotic tissue and was lost to follow-up, and two patients are continuing further therapy.

At a mean follow-up of 40 weeks, 88% of wounds had no evidence of recurrence. "We did have four patients who had recurrent wounds," he said. "Two went on to complete healing. One had osteomyelitis and went on to a below-the-knee amputation."

Treatment is pending for the fourth wound that recurred.

Dr. Burdge had no conflicts to disclose.

A 3-month-old heel wound is seen in a 66-year-old male with diabetes and neuropathy.

After 22 treatments and a supplemental skin graft, the wound was considered healed. Photos courtesy Dr. Jeremy J. Burdge

SAN DIEGO — High-voltage, pulsed electrical stimulation is an effective adjunct to multidisciplinary attempts at limb salvage in diabetic patients with complex lower extremity wounds, results from a small study demonstrated.

Of 45 wounds in 30 patients, 78% of the wounds healed in a mean of 14 weeks using the electrical stimulation system, Dr. Jeremy J. Burdge reported at the annual meeting of the Wound Healing Society.

"This is a preliminary study," said Dr. Burdge, a plastic and reconstructive surgeon who practices in Columbus, Ohio. "Further research is warranted."

He and his associates evaluated the efficacy of a high-voltage electrical stimulation system manufactured by MicroVas Technologies Inc. (Tulsa, Okla.) in patients who failed to improve despite multidisciplinary treatment approaches, including vascular evaluation and surgical intervention as indicated, aggressive off loading, bacterial infection control, and wound debridement.

"There is a variety of ways in which people speculate that high-voltage pulsed current has improved wound healing," Dr. Burdge said at the meeting, which was held in conjunction with a symposium on advanced wound care. "They fall into several groups of either increasing blood flow through promoting microcirculation, increasing wound healing through attraction of proliferating different cell types, or bacteria inhibition by this type of pulsed current."

More than half (57%) of the patients in the study were men; their mean age was 66 years. Comorbidities included neuropathy (84%), peripheral vascular disease (77%), cardiac disease (37%), and infection (33%). "This was a fairly high-risk group of patients," Dr. Burdge noted. "The mean hemoglobin A1c level was 8.2% and nine patients had undergone previous amputation."

The mean age of wounds was 25 weeks, and mean surface area was 7.8 cm

Emitter pads were placed over each wound. Stimulation was delivered for 45 minutes 2–3 times per week by a narrow pulsed current with a width of 80–100 microseconds at a frequency of 55 Hz. Pulses were delivered for 1.5 seconds, with a 1.5-second interval between pulses. The amplitude was individualized for each patient to maximize fused tetanic muscular contraction.

Dr. Burdge reported that the mean number of stimulation treatments per wound was 23 and that 35 (78%) of the wounds healed in a mean of 14 weeks.

Wound healing was defined as either complete epithelialization of the wound or closure with supplemental skin grafts.

Wounds in eight patients failed to heal. One required a metatarsal amputation, four had below-the-knee amputations, one had necrotic tissue and was lost to follow-up, and two patients are continuing further therapy.

At a mean follow-up of 40 weeks, 88% of wounds had no evidence of recurrence. "We did have four patients who had recurrent wounds," he said. "Two went on to complete healing. One had osteomyelitis and went on to a below-the-knee amputation."

Treatment is pending for the fourth wound that recurred.

Dr. Burdge had no conflicts to disclose.

A 3-month-old heel wound is seen in a 66-year-old male with diabetes and neuropathy.

After 22 treatments and a supplemental skin graft, the wound was considered healed. Photos courtesy Dr. Jeremy J. Burdge

SAN DIEGO — A new absorbent silver barrier dressing may help prevent and manage complications of percutaneous endoscopic gastrostomy sites, according to the results of a small study.

In a poster presented at the annual meeting of the Wound Healing Society, researchers led by Kathy Leak, R.N., described use of Allevyn Ag dressing (Smith & Nephew) on percutaneous endoscopic gastrostomy (PEG) sites in five patients.

Before May 2008, the protocol for patients who required PEG sites was to apply a silver binding dressing to help reduce the risks and complications associated with PEG site management. That product, however, "has limitations with regard to its absorption capability, cannot be cut to shape, and does not have the capability of foam dressings in helping to reduce overgranulation," wrote Ms. Leak and her associates at Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, England.

"Also, it requires daily dressing changes and a secondary foam dressing to absorb exudate, both of which are cost prohibitive," they noted.

The silver from the Allevyn Ag dressing is activated by fluid from the wound and then kills the bacteria. At the same time, excess fluid is managed by the dressing.

For the trial, Ms. Leak and her associates monitored five patients with PEG sites treated with Allevyn Ag for complications including erythema, overgranulation, high levels of exudate, soreness, and odor from the insertion site.

In all five cases, the product effectively managed exudate and odor, prevented excoriation to the surrounding skin, and provided enhanced comfort, compared with the previous treatment protocol, she said at the meeting, held in conjunction with a symposium on advanced wound care.

One study participant had been treated for cancer of the esophagus and presented with high levels of exudate that were starting to cause soreness and maceration of the peristomal area. He required a single application of Allevyn Ag, which he left in place for 4 days without incident.

Another study participant had a long-standing malabsorption problem and often developed abscesses around the stoma. After treatment with Allevyn Ag for 2 weeks with twice-daily dressing changes, the abscesses completely resolved.

"The dressing exceeded all our expectations on its speed of action to lower bacterial colonization and improve periskin conditions," Ms. Leak said in an interview, noting that, as of May 2008, patients at Doncaster and Bassetlaw Hospitals who have problematic PEG sites receive Allevyn Ag instead of the silver binding dressing.

Smith & Nephew supplied the Allevyn Ag used for the study. Ms. Leak has no financial interest in the company and reported no other relevant conflicts.

The new silver barrier dressing 'exceeded all our expectations on its speed of action.' MS. LEAK

High levels of exudate were starting to cause soreness and maceration.

The site is shown after a single 4-day application of the silver barrier dressing. Photos courtesy Kathy Leak, R.N.

SAN DIEGO — A new absorbent silver barrier dressing may help prevent and manage complications of percutaneous endoscopic gastrostomy sites, according to the results of a small study.

In a poster presented at the annual meeting of the Wound Healing Society, researchers led by Kathy Leak, R.N., described use of Allevyn Ag dressing (Smith & Nephew) on percutaneous endoscopic gastrostomy (PEG) sites in five patients.

Before May 2008, the protocol for patients who required PEG sites was to apply a silver binding dressing to help reduce the risks and complications associated with PEG site management. That product, however, "has limitations with regard to its absorption capability, cannot be cut to shape, and does not have the capability of foam dressings in helping to reduce overgranulation," wrote Ms. Leak and her associates at Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, England.

"Also, it requires daily dressing changes and a secondary foam dressing to absorb exudate, both of which are cost prohibitive," they noted.

The silver from the Allevyn Ag dressing is activated by fluid from the wound and then kills the bacteria. At the same time, excess fluid is managed by the dressing.

For the trial, Ms. Leak and her associates monitored five patients with PEG sites treated with Allevyn Ag for complications including erythema, overgranulation, high levels of exudate, soreness, and odor from the insertion site.

In all five cases, the product effectively managed exudate and odor, prevented excoriation to the surrounding skin, and provided enhanced comfort, compared with the previous treatment protocol, she said at the meeting, held in conjunction with a symposium on advanced wound care.

One study participant had been treated for cancer of the esophagus and presented with high levels of exudate that were starting to cause soreness and maceration of the peristomal area. He required a single application of Allevyn Ag, which he left in place for 4 days without incident.

Another study participant had a long-standing malabsorption problem and often developed abscesses around the stoma. After treatment with Allevyn Ag for 2 weeks with twice-daily dressing changes, the abscesses completely resolved.

"The dressing exceeded all our expectations on its speed of action to lower bacterial colonization and improve periskin conditions," Ms. Leak said in an interview, noting that, as of May 2008, patients at Doncaster and Bassetlaw Hospitals who have problematic PEG sites receive Allevyn Ag instead of the silver binding dressing.

Smith & Nephew supplied the Allevyn Ag used for the study. Ms. Leak has no financial interest in the company and reported no other relevant conflicts.

The new silver barrier dressing 'exceeded all our expectations on its speed of action.' MS. LEAK

High levels of exudate were starting to cause soreness and maceration.

The site is shown after a single 4-day application of the silver barrier dressing. Photos courtesy Kathy Leak, R.N.

SAN DIEGO — A new absorbent silver barrier dressing may help prevent and manage complications of percutaneous endoscopic gastrostomy sites, according to the results of a small study.

In a poster presented at the annual meeting of the Wound Healing Society, researchers led by Kathy Leak, R.N., described use of Allevyn Ag dressing (Smith & Nephew) on percutaneous endoscopic gastrostomy (PEG) sites in five patients.

Before May 2008, the protocol for patients who required PEG sites was to apply a silver binding dressing to help reduce the risks and complications associated with PEG site management. That product, however, "has limitations with regard to its absorption capability, cannot be cut to shape, and does not have the capability of foam dressings in helping to reduce overgranulation," wrote Ms. Leak and her associates at Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, England.

"Also, it requires daily dressing changes and a secondary foam dressing to absorb exudate, both of which are cost prohibitive," they noted.

The silver from the Allevyn Ag dressing is activated by fluid from the wound and then kills the bacteria. At the same time, excess fluid is managed by the dressing.

For the trial, Ms. Leak and her associates monitored five patients with PEG sites treated with Allevyn Ag for complications including erythema, overgranulation, high levels of exudate, soreness, and odor from the insertion site.

In all five cases, the product effectively managed exudate and odor, prevented excoriation to the surrounding skin, and provided enhanced comfort, compared with the previous treatment protocol, she said at the meeting, held in conjunction with a symposium on advanced wound care.

One study participant had been treated for cancer of the esophagus and presented with high levels of exudate that were starting to cause soreness and maceration of the peristomal area. He required a single application of Allevyn Ag, which he left in place for 4 days without incident.

Another study participant had a long-standing malabsorption problem and often developed abscesses around the stoma. After treatment with Allevyn Ag for 2 weeks with twice-daily dressing changes, the abscesses completely resolved.

"The dressing exceeded all our expectations on its speed of action to lower bacterial colonization and improve periskin conditions," Ms. Leak said in an interview, noting that, as of May 2008, patients at Doncaster and Bassetlaw Hospitals who have problematic PEG sites receive Allevyn Ag instead of the silver binding dressing.

Smith & Nephew supplied the Allevyn Ag used for the study. Ms. Leak has no financial interest in the company and reported no other relevant conflicts.

The new silver barrier dressing 'exceeded all our expectations on its speed of action.' MS. LEAK

High levels of exudate were starting to cause soreness and maceration.

The site is shown after a single 4-day application of the silver barrier dressing. Photos courtesy Kathy Leak, R.N.

A greater percentage of diabetic foot ulcers achieved complete closure with negative pressure wound therapy than with advanced moist wound therapy in a randomized controlled study of more than 300 patients.

There were also significantly fewer secondary amputations seen in the group undergoing negative pressure therapy, Dr. Peter A. Blume and colleagues reported.

Diabetic foot ulcers lead to nonhealing chronic wounds that are difficult to treat and are a significant risk factor for nontraumatic amputation.

Several diabetic foot ulcer treatments have been reported. All of them require integration of multiple treatment modalities, with debridement being the foundation for these therapies. Success of any particular form of treatment is dependent on the appropriate match of patient and treatment factors, according to Dr. Blume of the North American Center for Limb Preservation, New Haven, Conn., and colleagues.

The study goal was to determine whether negative pressure wound therapy (NPWT) was a better or equivalent treatment to advanced moist wound therapy (AMWT) in concurrence with debridement for treating foot ulcers in diabetic adults with adequate blood circulation.

Patients were randomly assigned to either NPWT, which used vacuum-assisted closure, or AMWT, which primarily used hydrogels and alginates. The study could not be blinded because of the distinct nature of the two therapies, according to the study investigators.

The multicenter study enrolled 342 patients with a mean age of 58 years over the period of August 2002 to August 2005; 79% of the patients were men. All patients were initially debrided as needed within 2 days of randomization and received standard off-loading therapy as needed after treatment was initiated.

Treatment was continued until ulcer closure, sufficient granulation tissue formation for healing, or until day 112. All patients were examined weekly for the first 4 weeks then every other week until day 112 or ulcer closure. Patients achieving ulcer closure were followed at 3 and 9 months (Diabetes Care 2008;31:631–6).

Complete ulcer closure was defined as skin closure (100% reepithelialization) without a draining or dressing requirement. Closure occurred in 73 of 169 (43%) of the NPWT patients, compared with 48 of 166 (29%) of the AMWT patients. In addition, significantly more NPWT patients achieved 75% closure (105 of 169, 62%), than did AMWT patients (85 of 166, 51%).

The incidence of secondary amputations was also significantly less for NPWT (4%) than for AMWT (10%).

"Although the exact mechanism of the decrease in secondary amputations remains unclear, treatment of DFUs [diabetic foot ulcers] with NPWT appears to promote significant healing," the authors concluded.

Dr. John Lantis (Saint Luke's Roosevelt Hospital, New York), a study coauthor, disclosed receiving honoraria from KCI USA, which provided the vacuum therapy system used and whose global biometrics group provided the data analysis.

ELSEVIER GLOBAL MEDICAL NEWS

A greater percentage of diabetic foot ulcers achieved complete closure with negative pressure wound therapy than with advanced moist wound therapy in a randomized controlled study of more than 300 patients.

There were also significantly fewer secondary amputations seen in the group undergoing negative pressure therapy, Dr. Peter A. Blume and colleagues reported.

Diabetic foot ulcers lead to nonhealing chronic wounds that are difficult to treat and are a significant risk factor for nontraumatic amputation.

Several diabetic foot ulcer treatments have been reported. All of them require integration of multiple treatment modalities, with debridement being the foundation for these therapies. Success of any particular form of treatment is dependent on the appropriate match of patient and treatment factors, according to Dr. Blume of the North American Center for Limb Preservation, New Haven, Conn., and colleagues.

The study goal was to determine whether negative pressure wound therapy (NPWT) was a better or equivalent treatment to advanced moist wound therapy (AMWT) in concurrence with debridement for treating foot ulcers in diabetic adults with adequate blood circulation.

Patients were randomly assigned to either NPWT, which used vacuum-assisted closure, or AMWT, which primarily used hydrogels and alginates. The study could not be blinded because of the distinct nature of the two therapies, according to the study investigators.

The multicenter study enrolled 342 patients with a mean age of 58 years over the period of August 2002 to August 2005; 79% of the patients were men. All patients were initially debrided as needed within 2 days of randomization and received standard off-loading therapy as needed after treatment was initiated.

Treatment was continued until ulcer closure, sufficient granulation tissue formation for healing, or until day 112. All patients were examined weekly for the first 4 weeks then every other week until day 112 or ulcer closure. Patients achieving ulcer closure were followed at 3 and 9 months (Diabetes Care 2008;31:631–6).

Complete ulcer closure was defined as skin closure (100% reepithelialization) without a draining or dressing requirement. Closure occurred in 73 of 169 (43%) of the NPWT patients, compared with 48 of 166 (29%) of the AMWT patients. In addition, significantly more NPWT patients achieved 75% closure (105 of 169, 62%), than did AMWT patients (85 of 166, 51%).

The incidence of secondary amputations was also significantly less for NPWT (4%) than for AMWT (10%).

"Although the exact mechanism of the decrease in secondary amputations remains unclear, treatment of DFUs [diabetic foot ulcers] with NPWT appears to promote significant healing," the authors concluded.

Dr. John Lantis (Saint Luke's Roosevelt Hospital, New York), a study coauthor, disclosed receiving honoraria from KCI USA, which provided the vacuum therapy system used and whose global biometrics group provided the data analysis.

ELSEVIER GLOBAL MEDICAL NEWS

A greater percentage of diabetic foot ulcers achieved complete closure with negative pressure wound therapy than with advanced moist wound therapy in a randomized controlled study of more than 300 patients.

There were also significantly fewer secondary amputations seen in the group undergoing negative pressure therapy, Dr. Peter A. Blume and colleagues reported.

Diabetic foot ulcers lead to nonhealing chronic wounds that are difficult to treat and are a significant risk factor for nontraumatic amputation.

Several diabetic foot ulcer treatments have been reported. All of them require integration of multiple treatment modalities, with debridement being the foundation for these therapies. Success of any particular form of treatment is dependent on the appropriate match of patient and treatment factors, according to Dr. Blume of the North American Center for Limb Preservation, New Haven, Conn., and colleagues.

The study goal was to determine whether negative pressure wound therapy (NPWT) was a better or equivalent treatment to advanced moist wound therapy (AMWT) in concurrence with debridement for treating foot ulcers in diabetic adults with adequate blood circulation.

Patients were randomly assigned to either NPWT, which used vacuum-assisted closure, or AMWT, which primarily used hydrogels and alginates. The study could not be blinded because of the distinct nature of the two therapies, according to the study investigators.

The multicenter study enrolled 342 patients with a mean age of 58 years over the period of August 2002 to August 2005; 79% of the patients were men. All patients were initially debrided as needed within 2 days of randomization and received standard off-loading therapy as needed after treatment was initiated.

Treatment was continued until ulcer closure, sufficient granulation tissue formation for healing, or until day 112. All patients were examined weekly for the first 4 weeks then every other week until day 112 or ulcer closure. Patients achieving ulcer closure were followed at 3 and 9 months (Diabetes Care 2008;31:631–6).

Complete ulcer closure was defined as skin closure (100% reepithelialization) without a draining or dressing requirement. Closure occurred in 73 of 169 (43%) of the NPWT patients, compared with 48 of 166 (29%) of the AMWT patients. In addition, significantly more NPWT patients achieved 75% closure (105 of 169, 62%), than did AMWT patients (85 of 166, 51%).

The incidence of secondary amputations was also significantly less for NPWT (4%) than for AMWT (10%).

"Although the exact mechanism of the decrease in secondary amputations remains unclear, treatment of DFUs [diabetic foot ulcers] with NPWT appears to promote significant healing," the authors concluded.

Dr. John Lantis (Saint Luke's Roosevelt Hospital, New York), a study coauthor, disclosed receiving honoraria from KCI USA, which provided the vacuum therapy system used and whose global biometrics group provided the data analysis.

ELSEVIER GLOBAL MEDICAL NEWS

SAN DIEGO — WoundStat, a hemostatic agent approved in August 2007, is superior to other combat hemostatic agents used for combat and civilian trauma, results from a swine study demonstrated.

The product, marketed by TraumaCure Inc., consists of a pure granular smectite composite. In the study, it produced hemostasis in the face of high-pressure arterial bleeding within 3 minutes. WoundStat is currently used as a life-saving tool by the U.S. military in Afghanistan.

"The study protocol was to hold for 3 minutes, but in subsequent studies and observations, 2 minutes was more than sufficient for WoundStat to stop the hemorrhage," Robert F. Diegelmann, Ph.D., said at the annual meeting of the Wound Healing Society. It also would be simple for the victim or medic to apply.

Dr. Diegelmann, professor of biochemistry and molecular biology, anatomy, and emergency medicine at Virginia Commonwealth University, Richmond, led the research team that developed WoundStat at the university's reanimation engineering shock center.

He and his associates compared the performance of WoundStat with Z-Medica Corp.'s QuikClot zeolite granules and QuikClot zeolite Advance Clotting Sponge, HemCon Medical Technologies Inc.'s chitosan bandage, and the U.S. Army field gauze bandage in a lethal vascular injury model developed by the Army (J. Trauma 2007;63:276–84). The protocol involved creating a 6-mm arteriotomy in a vessel of 25 male swine. After 45 seconds of hemorrhage, five animals each were randomized to be treated with the Army field bandage (control group), QuikClot zeolite granules, the QuikClot zeolite Advance Clotting Sponge, the HemCon chitosan bandage, or WoundStat.

The application of WoundStat, a premixed composite available in 5.5-ounce packages, also involved the application of 200 mm Hg pressure over the product in the wound for 3 minutes.

In all swine, fluid resuscitation began at the time each product was applied, with 500 mL of Hextend, followed by lactated Ringer's solution at 100 mL/min to achieve and maintain a mean arterial blood pressure of 65 mm Hg. The study's primary end points were survival, survival time, posttreatment blood loss, and amount of resuscitation fluid required.

All swine in the WoundStat group survived to 180 minutes and required only a single application, Dr. Diegelmann said at the meeting, held in conjunction with a symposium on advanced wound care. One animal in the HemCon chitosan bandage group survived, but none of the animals in the other groups survived.

He reported that survival and survival times for animals in the WoundStat group were significantly greater, compared with those in all other groups. In addition, posttreatment blood loss and lost-resuscitation fluid volume were significantly less for animals in the WoundStat group, compared with all other groups.

Dr. Diegelmann disclosed that he is a paid consultant for TraumaCure Inc.

The interaction of whole blood and WoundStat resulted in the aggregated red cells and formation of fibrin matrix seen in this scanning electron micrograph (3,300X) of a sample fixed during a span of 1 minute after the addition of the blood. Courtesy Dr. Robert F. Diegelmann

SAN DIEGO — WoundStat, a hemostatic agent approved in August 2007, is superior to other combat hemostatic agents used for combat and civilian trauma, results from a swine study demonstrated.

The product, marketed by TraumaCure Inc., consists of a pure granular smectite composite. In the study, it produced hemostasis in the face of high-pressure arterial bleeding within 3 minutes. WoundStat is currently used as a life-saving tool by the U.S. military in Afghanistan.

"The study protocol was to hold for 3 minutes, but in subsequent studies and observations, 2 minutes was more than sufficient for WoundStat to stop the hemorrhage," Robert F. Diegelmann, Ph.D., said at the annual meeting of the Wound Healing Society. It also would be simple for the victim or medic to apply.

Dr. Diegelmann, professor of biochemistry and molecular biology, anatomy, and emergency medicine at Virginia Commonwealth University, Richmond, led the research team that developed WoundStat at the university's reanimation engineering shock center.

He and his associates compared the performance of WoundStat with Z-Medica Corp.'s QuikClot zeolite granules and QuikClot zeolite Advance Clotting Sponge, HemCon Medical Technologies Inc.'s chitosan bandage, and the U.S. Army field gauze bandage in a lethal vascular injury model developed by the Army (J. Trauma 2007;63:276–84). The protocol involved creating a 6-mm arteriotomy in a vessel of 25 male swine. After 45 seconds of hemorrhage, five animals each were randomized to be treated with the Army field bandage (control group), QuikClot zeolite granules, the QuikClot zeolite Advance Clotting Sponge, the HemCon chitosan bandage, or WoundStat.

The application of WoundStat, a premixed composite available in 5.5-ounce packages, also involved the application of 200 mm Hg pressure over the product in the wound for 3 minutes.

In all swine, fluid resuscitation began at the time each product was applied, with 500 mL of Hextend, followed by lactated Ringer's solution at 100 mL/min to achieve and maintain a mean arterial blood pressure of 65 mm Hg. The study's primary end points were survival, survival time, posttreatment blood loss, and amount of resuscitation fluid required.

All swine in the WoundStat group survived to 180 minutes and required only a single application, Dr. Diegelmann said at the meeting, held in conjunction with a symposium on advanced wound care. One animal in the HemCon chitosan bandage group survived, but none of the animals in the other groups survived.

He reported that survival and survival times for animals in the WoundStat group were significantly greater, compared with those in all other groups. In addition, posttreatment blood loss and lost-resuscitation fluid volume were significantly less for animals in the WoundStat group, compared with all other groups.

Dr. Diegelmann disclosed that he is a paid consultant for TraumaCure Inc.

The interaction of whole blood and WoundStat resulted in the aggregated red cells and formation of fibrin matrix seen in this scanning electron micrograph (3,300X) of a sample fixed during a span of 1 minute after the addition of the blood. Courtesy Dr. Robert F. Diegelmann

SAN DIEGO — WoundStat, a hemostatic agent approved in August 2007, is superior to other combat hemostatic agents used for combat and civilian trauma, results from a swine study demonstrated.

The product, marketed by TraumaCure Inc., consists of a pure granular smectite composite. In the study, it produced hemostasis in the face of high-pressure arterial bleeding within 3 minutes. WoundStat is currently used as a life-saving tool by the U.S. military in Afghanistan.

"The study protocol was to hold for 3 minutes, but in subsequent studies and observations, 2 minutes was more than sufficient for WoundStat to stop the hemorrhage," Robert F. Diegelmann, Ph.D., said at the annual meeting of the Wound Healing Society. It also would be simple for the victim or medic to apply.

Dr. Diegelmann, professor of biochemistry and molecular biology, anatomy, and emergency medicine at Virginia Commonwealth University, Richmond, led the research team that developed WoundStat at the university's reanimation engineering shock center.

He and his associates compared the performance of WoundStat with Z-Medica Corp.'s QuikClot zeolite granules and QuikClot zeolite Advance Clotting Sponge, HemCon Medical Technologies Inc.'s chitosan bandage, and the U.S. Army field gauze bandage in a lethal vascular injury model developed by the Army (J. Trauma 2007;63:276–84). The protocol involved creating a 6-mm arteriotomy in a vessel of 25 male swine. After 45 seconds of hemorrhage, five animals each were randomized to be treated with the Army field bandage (control group), QuikClot zeolite granules, the QuikClot zeolite Advance Clotting Sponge, the HemCon chitosan bandage, or WoundStat.

The application of WoundStat, a premixed composite available in 5.5-ounce packages, also involved the application of 200 mm Hg pressure over the product in the wound for 3 minutes.

In all swine, fluid resuscitation began at the time each product was applied, with 500 mL of Hextend, followed by lactated Ringer's solution at 100 mL/min to achieve and maintain a mean arterial blood pressure of 65 mm Hg. The study's primary end points were survival, survival time, posttreatment blood loss, and amount of resuscitation fluid required.

All swine in the WoundStat group survived to 180 minutes and required only a single application, Dr. Diegelmann said at the meeting, held in conjunction with a symposium on advanced wound care. One animal in the HemCon chitosan bandage group survived, but none of the animals in the other groups survived.

He reported that survival and survival times for animals in the WoundStat group were significantly greater, compared with those in all other groups. In addition, posttreatment blood loss and lost-resuscitation fluid volume were significantly less for animals in the WoundStat group, compared with all other groups.

Dr. Diegelmann disclosed that he is a paid consultant for TraumaCure Inc.

The interaction of whole blood and WoundStat resulted in the aggregated red cells and formation of fibrin matrix seen in this scanning electron micrograph (3,300X) of a sample fixed during a span of 1 minute after the addition of the blood. Courtesy Dr. Robert F. Diegelmann

CHICAGO — The indications for negative-pressure wound therapy are expanding to include infected wounds and complicated wounds with exposed bone, tendon, or even orthopedic hardware, Dr. Anton Sidawy said.

"While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies," he said at a symposium on vascular surgery sponsored by Northwestern University.

"It is not," Dr. Sidawy cautioned, "going to substitute for a good blood supply to the wound area and appropriate local wound therapy."

Negative-pressure wound therapy, also known as vacuum-assisted closure (VAC) therapy, was developed roughly two decades ago, and involves the application of subatmospheric pressure to a wound through a pump attached to a foam sponge with an adhesive dressing. VAC is thought to accelerate wound contraction, increase local blood flow, and promote wound drainage and edema resolution.

Its widespread success in the diabetic population with microcirculatory pathology also suggests that the microdeformations of the wound surface caused by the negative pressure act on a cellular level to stimulate cell proliferation, angiogenesis, and granulation tissue formation, said Dr. Sidawy, chief of surgical services, Washington VA Medical Center, and professor of surgery at Georgetown and George Washington University Medical Centers, Washington.

Infected wounds typically do not do as well with VAC therapy, but progress has been made with recent studies demonstrating decreased bacterial burden after VAC therapy. Management of infected wounds has been aided by the use of VAC devices that allow for the instillation of fluids so contaminated wounds can be continuously irrigated with antibiotic fluids and by silver-impregnated dressings (GranuFoam Silver Dressing, KCI Inc., San Antonio, Texas) that have antimicrobial effects (Ann. Plast. Surg. 2007;59:58–62).

Physicians in the Iraqi theater have turned to VAC to manage contaminated soft-tissue injuries caused by the blast effect of high-energy missiles. Dr. Sidawy cited a retrospective pilot study of 88 high-energy, contaminated soft-tissue injuries in 77 patients in which all wounds treated with VAC were closed definitively before discharge, with no wound complications (J. Trauma 2006;61:1207–11).

Large, complex circumferential soft tissue defects or burns can be managed with VAC to facilitate the coverage of exposed vessels and stimulate the growth of granulation tissue, Dr. Charles Fox of the Walter Reed Army Medical Center in Washington said in an interview. At times, maintaining a seal on a VAC can be challenging, particularly with external fixation or wounds of the hands and feet.

"An impervious stockinette sealed at either end with a Coban [compression wrap] may be substituted for the large OpSites [dressings] that do not adhere to a very wet cavitary wound," Dr. Fox said. "This strategy has been used for some complicated wounds in the Iraqi theater."

By reducing tissue edema, and thereby reducing the circumference of the extremity and the surface area of the wound, VAC therapy has also revolutionized how physicians treat wounds with exposed bone, tendon, or orthopedic hardware. Such complicated wounds, particularly on the lower third of the leg, traditionally required microvascular free-tissue transfer for coverage of the defect. Now, both small and large defects can be treated with VAC, although larger surface wounds still need free-tissue transfer, Dr. Sidawy said.

In a landmark study, VAC therapy was used to obtain successful coverage without complication in 71 of 75 open wounds of the lower extremity with exposed bone, tendon, or hardware. Of these wounds, 52 were below the knee and orthopedic hardware was exposed in 12 (Plast. Reconstr. Surg. 2001;108:1184–91).

'While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies.' DR. SIDAWY

CHICAGO — The indications for negative-pressure wound therapy are expanding to include infected wounds and complicated wounds with exposed bone, tendon, or even orthopedic hardware, Dr. Anton Sidawy said.

"While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies," he said at a symposium on vascular surgery sponsored by Northwestern University.

"It is not," Dr. Sidawy cautioned, "going to substitute for a good blood supply to the wound area and appropriate local wound therapy."

Negative-pressure wound therapy, also known as vacuum-assisted closure (VAC) therapy, was developed roughly two decades ago, and involves the application of subatmospheric pressure to a wound through a pump attached to a foam sponge with an adhesive dressing. VAC is thought to accelerate wound contraction, increase local blood flow, and promote wound drainage and edema resolution.

Its widespread success in the diabetic population with microcirculatory pathology also suggests that the microdeformations of the wound surface caused by the negative pressure act on a cellular level to stimulate cell proliferation, angiogenesis, and granulation tissue formation, said Dr. Sidawy, chief of surgical services, Washington VA Medical Center, and professor of surgery at Georgetown and George Washington University Medical Centers, Washington.

Infected wounds typically do not do as well with VAC therapy, but progress has been made with recent studies demonstrating decreased bacterial burden after VAC therapy. Management of infected wounds has been aided by the use of VAC devices that allow for the instillation of fluids so contaminated wounds can be continuously irrigated with antibiotic fluids and by silver-impregnated dressings (GranuFoam Silver Dressing, KCI Inc., San Antonio, Texas) that have antimicrobial effects (Ann. Plast. Surg. 2007;59:58–62).

Physicians in the Iraqi theater have turned to VAC to manage contaminated soft-tissue injuries caused by the blast effect of high-energy missiles. Dr. Sidawy cited a retrospective pilot study of 88 high-energy, contaminated soft-tissue injuries in 77 patients in which all wounds treated with VAC were closed definitively before discharge, with no wound complications (J. Trauma 2006;61:1207–11).

Large, complex circumferential soft tissue defects or burns can be managed with VAC to facilitate the coverage of exposed vessels and stimulate the growth of granulation tissue, Dr. Charles Fox of the Walter Reed Army Medical Center in Washington said in an interview. At times, maintaining a seal on a VAC can be challenging, particularly with external fixation or wounds of the hands and feet.

"An impervious stockinette sealed at either end with a Coban [compression wrap] may be substituted for the large OpSites [dressings] that do not adhere to a very wet cavitary wound," Dr. Fox said. "This strategy has been used for some complicated wounds in the Iraqi theater."

By reducing tissue edema, and thereby reducing the circumference of the extremity and the surface area of the wound, VAC therapy has also revolutionized how physicians treat wounds with exposed bone, tendon, or orthopedic hardware. Such complicated wounds, particularly on the lower third of the leg, traditionally required microvascular free-tissue transfer for coverage of the defect. Now, both small and large defects can be treated with VAC, although larger surface wounds still need free-tissue transfer, Dr. Sidawy said.

In a landmark study, VAC therapy was used to obtain successful coverage without complication in 71 of 75 open wounds of the lower extremity with exposed bone, tendon, or hardware. Of these wounds, 52 were below the knee and orthopedic hardware was exposed in 12 (Plast. Reconstr. Surg. 2001;108:1184–91).

'While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies.' DR. SIDAWY

CHICAGO — The indications for negative-pressure wound therapy are expanding to include infected wounds and complicated wounds with exposed bone, tendon, or even orthopedic hardware, Dr. Anton Sidawy said.

"While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies," he said at a symposium on vascular surgery sponsored by Northwestern University.

"It is not," Dr. Sidawy cautioned, "going to substitute for a good blood supply to the wound area and appropriate local wound therapy."

Negative-pressure wound therapy, also known as vacuum-assisted closure (VAC) therapy, was developed roughly two decades ago, and involves the application of subatmospheric pressure to a wound through a pump attached to a foam sponge with an adhesive dressing. VAC is thought to accelerate wound contraction, increase local blood flow, and promote wound drainage and edema resolution.

Its widespread success in the diabetic population with microcirculatory pathology also suggests that the microdeformations of the wound surface caused by the negative pressure act on a cellular level to stimulate cell proliferation, angiogenesis, and granulation tissue formation, said Dr. Sidawy, chief of surgical services, Washington VA Medical Center, and professor of surgery at Georgetown and George Washington University Medical Centers, Washington.

Infected wounds typically do not do as well with VAC therapy, but progress has been made with recent studies demonstrating decreased bacterial burden after VAC therapy. Management of infected wounds has been aided by the use of VAC devices that allow for the instillation of fluids so contaminated wounds can be continuously irrigated with antibiotic fluids and by silver-impregnated dressings (GranuFoam Silver Dressing, KCI Inc., San Antonio, Texas) that have antimicrobial effects (Ann. Plast. Surg. 2007;59:58–62).

Physicians in the Iraqi theater have turned to VAC to manage contaminated soft-tissue injuries caused by the blast effect of high-energy missiles. Dr. Sidawy cited a retrospective pilot study of 88 high-energy, contaminated soft-tissue injuries in 77 patients in which all wounds treated with VAC were closed definitively before discharge, with no wound complications (J. Trauma 2006;61:1207–11).

Large, complex circumferential soft tissue defects or burns can be managed with VAC to facilitate the coverage of exposed vessels and stimulate the growth of granulation tissue, Dr. Charles Fox of the Walter Reed Army Medical Center in Washington said in an interview. At times, maintaining a seal on a VAC can be challenging, particularly with external fixation or wounds of the hands and feet.

"An impervious stockinette sealed at either end with a Coban [compression wrap] may be substituted for the large OpSites [dressings] that do not adhere to a very wet cavitary wound," Dr. Fox said. "This strategy has been used for some complicated wounds in the Iraqi theater."

By reducing tissue edema, and thereby reducing the circumference of the extremity and the surface area of the wound, VAC therapy has also revolutionized how physicians treat wounds with exposed bone, tendon, or orthopedic hardware. Such complicated wounds, particularly on the lower third of the leg, traditionally required microvascular free-tissue transfer for coverage of the defect. Now, both small and large defects can be treated with VAC, although larger surface wounds still need free-tissue transfer, Dr. Sidawy said.

In a landmark study, VAC therapy was used to obtain successful coverage without complication in 71 of 75 open wounds of the lower extremity with exposed bone, tendon, or hardware. Of these wounds, 52 were below the knee and orthopedic hardware was exposed in 12 (Plast. Reconstr. Surg. 2001;108:1184–91).

'While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies.' DR. SIDAWY

WASHINGTON — The vascular surgeon insists that revascularization was a success—and there are outcome images to prove it—but the diabetic foot becomes ischemic anyway, and the wound fails to heal.

This is an all too common scenario for physicians who care for these at-risk limbs and problem wounds. Such failures can be explained in a push-pull model of perfusion in these patients, and this model may well indicate what needs to be done for effective treatment, according to Dr. William J. Ennis.

The push-pull model essentially states that despite the "push" of restored macrocirculation from revascularization, the patient still needs the ability to "pull" blood nutrients into all parts of the limb via a functional microcirculation, said Dr. Ennis of the St. James Center for Comprehensive Wound & Disease Management in Chicago. He spoke at a meeting sponsored by George Washington University Hospital.

But creating "pull" is not an easy task, especially for patients with diabetes. In such individuals, a functional microcirculation may be a problem in its own right because of both physical and physiologic changes in their microvascular system brought on by the long-term chronic disease. In patients with poor microcirculation, successful revascularization of the larger vessels can lead to ischemic reperfusion injury in the tissues that they service. White cells stick and create reactive oxygen species that make it almost impossible for wounds to heal.

Damage models in diabetic foot wound responses after revascularization can borrow from cardiology, according to Dr. Ennis—concepts such as tissue "stunning," whereby tissue is traumatized by the reperfusion injury without being killed and remains capable of recuperating; no reflow, such as that caused by a mechanical obstruction from thrombus; or functional alterations, such as the endothelial dysfunction that is known to occur in diabetics.

It is critical to restore a microvascular "pull" as soon as possible in order for the wound to heal and, in many cases, in order for the limb to survive, according to Dr. Ennis. "It is almost silly for us to think that we can solve the entire process with a simple bypass. We may end up with a mixed pattern, persistent ischemia, and something known as no reflow. These are the patients who get bypass and nothing happens—the wound continues or the open-air site never heals…. It is so frustrating for us as wound clinicians to see a great bypass and still lose a limb. It's not uncommon, and this [microcirculatory problem] is why."

Angiogenesis agents are one option for restoring microcirculatory "pull." One such treatment may be ultrasound. Pulsatile flow in tissue pushes and pulls on the endothelium and causes nitric oxide release. Ultrasound can be used to "fake the tissue out that it is receiving pulsatile flow," according to Dr. Ennis, who along with his colleagues has studied the use of ultrasound to induce angiogenesis, pulsatile flow, and ultimately wound healing.

"We were able to show that there was a difference in angiogenesis at approximately 41/2 weeks with ultrasound therapy. … This was one of the first times we were actually able to quantify the angiogenesis response and correlate it to wound healing," he explained (Advances in Skin & Wound Care 2006;19:437–46).

The future may include novel treatments for reperfusion injury and ischemia such as bone marrow stem cell therapy, which may be available in 5–10 years, and growth factor molecules, many of which are currently being tested in phase I trials, according to Dr. Ennis.

Regardless of which treatment is chosen, it is also important for the vascular and wound-care teams to collaborate on prevention of ischemia after revascularization, Dr. Ennis stated. The certainty of appropriate return of macrovascular circulation must be confirmed, and all other barriers to blood flow need to be addressed.

Preoperatively, it may be possible to use free-radical scavengers or systemic vasodilators. Postoperatively, he advised that tissue-level perfusion be tested for adequacy of revascularization and cautioned against relying on the return of palpable pulse or flow in the bypass graft to do that.

Dr. Ennis disclosed that he was a consultant and received an honorarium from Celleration, which manufactures an ultrasound device for stimulation of wound healing.

WASHINGTON — The vascular surgeon insists that revascularization was a success—and there are outcome images to prove it—but the diabetic foot becomes ischemic anyway, and the wound fails to heal.

This is an all too common scenario for physicians who care for these at-risk limbs and problem wounds. Such failures can be explained in a push-pull model of perfusion in these patients, and this model may well indicate what needs to be done for effective treatment, according to Dr. William J. Ennis.

The push-pull model essentially states that despite the "push" of restored macrocirculation from revascularization, the patient still needs the ability to "pull" blood nutrients into all parts of the limb via a functional microcirculation, said Dr. Ennis of the St. James Center for Comprehensive Wound & Disease Management in Chicago. He spoke at a meeting sponsored by George Washington University Hospital.

But creating "pull" is not an easy task, especially for patients with diabetes. In such individuals, a functional microcirculation may be a problem in its own right because of both physical and physiologic changes in their microvascular system brought on by the long-term chronic disease. In patients with poor microcirculation, successful revascularization of the larger vessels can lead to ischemic reperfusion injury in the tissues that they service. White cells stick and create reactive oxygen species that make it almost impossible for wounds to heal.

Damage models in diabetic foot wound responses after revascularization can borrow from cardiology, according to Dr. Ennis—concepts such as tissue "stunning," whereby tissue is traumatized by the reperfusion injury without being killed and remains capable of recuperating; no reflow, such as that caused by a mechanical obstruction from thrombus; or functional alterations, such as the endothelial dysfunction that is known to occur in diabetics.

It is critical to restore a microvascular "pull" as soon as possible in order for the wound to heal and, in many cases, in order for the limb to survive, according to Dr. Ennis. "It is almost silly for us to think that we can solve the entire process with a simple bypass. We may end up with a mixed pattern, persistent ischemia, and something known as no reflow. These are the patients who get bypass and nothing happens—the wound continues or the open-air site never heals…. It is so frustrating for us as wound clinicians to see a great bypass and still lose a limb. It's not uncommon, and this [microcirculatory problem] is why."

Angiogenesis agents are one option for restoring microcirculatory "pull." One such treatment may be ultrasound. Pulsatile flow in tissue pushes and pulls on the endothelium and causes nitric oxide release. Ultrasound can be used to "fake the tissue out that it is receiving pulsatile flow," according to Dr. Ennis, who along with his colleagues has studied the use of ultrasound to induce angiogenesis, pulsatile flow, and ultimately wound healing.

"We were able to show that there was a difference in angiogenesis at approximately 41/2 weeks with ultrasound therapy. … This was one of the first times we were actually able to quantify the angiogenesis response and correlate it to wound healing," he explained (Advances in Skin & Wound Care 2006;19:437–46).

The future may include novel treatments for reperfusion injury and ischemia such as bone marrow stem cell therapy, which may be available in 5–10 years, and growth factor molecules, many of which are currently being tested in phase I trials, according to Dr. Ennis.

Regardless of which treatment is chosen, it is also important for the vascular and wound-care teams to collaborate on prevention of ischemia after revascularization, Dr. Ennis stated. The certainty of appropriate return of macrovascular circulation must be confirmed, and all other barriers to blood flow need to be addressed.

Preoperatively, it may be possible to use free-radical scavengers or systemic vasodilators. Postoperatively, he advised that tissue-level perfusion be tested for adequacy of revascularization and cautioned against relying on the return of palpable pulse or flow in the bypass graft to do that.

Dr. Ennis disclosed that he was a consultant and received an honorarium from Celleration, which manufactures an ultrasound device for stimulation of wound healing.

WASHINGTON — The vascular surgeon insists that revascularization was a success—and there are outcome images to prove it—but the diabetic foot becomes ischemic anyway, and the wound fails to heal.

This is an all too common scenario for physicians who care for these at-risk limbs and problem wounds. Such failures can be explained in a push-pull model of perfusion in these patients, and this model may well indicate what needs to be done for effective treatment, according to Dr. William J. Ennis.

The push-pull model essentially states that despite the "push" of restored macrocirculation from revascularization, the patient still needs the ability to "pull" blood nutrients into all parts of the limb via a functional microcirculation, said Dr. Ennis of the St. James Center for Comprehensive Wound & Disease Management in Chicago. He spoke at a meeting sponsored by George Washington University Hospital.

But creating "pull" is not an easy task, especially for patients with diabetes. In such individuals, a functional microcirculation may be a problem in its own right because of both physical and physiologic changes in their microvascular system brought on by the long-term chronic disease. In patients with poor microcirculation, successful revascularization of the larger vessels can lead to ischemic reperfusion injury in the tissues that they service. White cells stick and create reactive oxygen species that make it almost impossible for wounds to heal.

Damage models in diabetic foot wound responses after revascularization can borrow from cardiology, according to Dr. Ennis—concepts such as tissue "stunning," whereby tissue is traumatized by the reperfusion injury without being killed and remains capable of recuperating; no reflow, such as that caused by a mechanical obstruction from thrombus; or functional alterations, such as the endothelial dysfunction that is known to occur in diabetics.

It is critical to restore a microvascular "pull" as soon as possible in order for the wound to heal and, in many cases, in order for the limb to survive, according to Dr. Ennis. "It is almost silly for us to think that we can solve the entire process with a simple bypass. We may end up with a mixed pattern, persistent ischemia, and something known as no reflow. These are the patients who get bypass and nothing happens—the wound continues or the open-air site never heals…. It is so frustrating for us as wound clinicians to see a great bypass and still lose a limb. It's not uncommon, and this [microcirculatory problem] is why."

Angiogenesis agents are one option for restoring microcirculatory "pull." One such treatment may be ultrasound. Pulsatile flow in tissue pushes and pulls on the endothelium and causes nitric oxide release. Ultrasound can be used to "fake the tissue out that it is receiving pulsatile flow," according to Dr. Ennis, who along with his colleagues has studied the use of ultrasound to induce angiogenesis, pulsatile flow, and ultimately wound healing.

"We were able to show that there was a difference in angiogenesis at approximately 41/2 weeks with ultrasound therapy. … This was one of the first times we were actually able to quantify the angiogenesis response and correlate it to wound healing," he explained (Advances in Skin & Wound Care 2006;19:437–46).

The future may include novel treatments for reperfusion injury and ischemia such as bone marrow stem cell therapy, which may be available in 5–10 years, and growth factor molecules, many of which are currently being tested in phase I trials, according to Dr. Ennis.

Regardless of which treatment is chosen, it is also important for the vascular and wound-care teams to collaborate on prevention of ischemia after revascularization, Dr. Ennis stated. The certainty of appropriate return of macrovascular circulation must be confirmed, and all other barriers to blood flow need to be addressed.

Preoperatively, it may be possible to use free-radical scavengers or systemic vasodilators. Postoperatively, he advised that tissue-level perfusion be tested for adequacy of revascularization and cautioned against relying on the return of palpable pulse or flow in the bypass graft to do that.

Dr. Ennis disclosed that he was a consultant and received an honorarium from Celleration, which manufactures an ultrasound device for stimulation of wound healing.

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

Boldo (Peumus boldus Mol.) is a slow-growing, shrubby evergreen tree native to the Chilean and Peruvian Andes. It is also found in Morocco and other parts of North Africa, and is cultivated in Europe. The plant has traditionally been used in South American folk medicine, particularly in Chile, Peru, and Brazil, to treat a wide range of conditions of the liver, bowel, and gallbladder (Pharmacol. Res. 1994;29:1–12).

The primary active constituent identified in the tree is boldine, a simple aporphine alkaloid. Several aporphine alkaloids, which are secondary metabolites, are found in boldo leaves, with boldine being the most abundant (Curr. Med. Chem. Anticancer Agents 2005;5:173–82). Boldine is extracted from the leaves and bark of the tree (Phytother. Res. 2000;14:339–43; Pharmazie 2001;56:242–3).

In Germany and other European countries, the boldo plant is used as a medicinal. It is the subject of a German Commission E monograph that details the acceptable uses of the plant as an herbal drug for liver, gallbladder, and gastric conditions (Blumenthal M., et al. [eds.] The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin, Tex.: American Botanical Council and Boston: Integrative Medicine Communications, 1998, pp. 93–4).

Boldine is used worldwide in homeopathic and herbal medicine, and boldine extract is widely acknowledged as a viable herbal remedy in several pharmacopoeias (Chem. Biol. Interact. 2006;159:1–17; Pharmacol. Res. 1994;29:1–12). Indeed, boldine has been demonstrated to possess antioxidant activity in biologic as well as nonbiologic systems, and it has emerged as an ingredient of great interest for its potential in the treatment of free radical-mediated damage or conditions (Pharmacol. Res. 1994;29:1–12).

Antioxidant Actions

Boldine is now considered one of the strongest natural antioxidants (Chem. Biol. Interact. 2006;159:1–17).

In the early 1990s, the traditional use of Peumus boldus extract prompted a team of researchers to validate some of its therapeutic properties. They found that boldine imparted significant protection in vitro against tert-butyl hydroperoxide-induced toxicity in isolated rat hepatocytes, and in vivo against carbon tetrachloride-induced hepatotoxicity in mice. A test in rats with carrageenan-induced edema also revealed significant and dose-dependent anti-inflammatory effects (Planta Med. 1991;57:110–5). The free radical-scavenging and hepatoprotective properties of this natural compound are now considered well established (Phytother. Res. 2000;14:254–60).

A 2001 study demonstrated that boldine imparts chemoprotective activity in murine liver, reducing the metabolic activation of drug-metabolizing enzymes as well as chemical mutagens (Pharmazie 2001;56:242–3).

Alkaloids semisynthesized from boldine have also been shown to inhibit activity against reactive oxygen species and are believed to represent a potential therapy for inflammatory disorders involving production of reactive oxygen species (Chem. Pharm. Bull. [Tokyo] 2004;52:696–9).

In a study in mice, boldine showed significant antioxidant activity, decreasing the oxidation of low-density lipoprotein. It also lessened atherosclerotic lesion formation in LDL receptor-deficient mice that were fed an atherogenic diet. The authors believe that antioxidant capacity, coupled with the traditional tolerance to boldine in humans, renders it a suitable alternative to vitamin E (Atherosclerosis 2004;173:203–10).

More evidence of boldine's antioxidant effects emerged from a study in which it protected intact red blood cells against hemolytic damage caused by the free radical initiator 2,2′-azobis-(2-amidinopropane) (AAPH). The effect was concentration dependent and occurred whether the herb was added simultaneously with, or 1 hour before, AAPH. Erythrocytes previously incubated with AAPH for 2 hours were largely unaffected by the addition of boldine. The investigators concluded that boldine had significant time-dependent cytoprotective as well as antioxidant activity (Phytother. Res. 2000;14:339–43).

It is noteworthy that boldine is found in plants other than the Chilean boldo. In a study of boldine and other aporphine alkaloids isolated from Lindera angustifolia Chen, a Chinese medicinal plant used for edema and rheumatic pain, the extract exhibited significant free radical-scavenging activity against 2,2-diphenyl-1-picrylhydrazyl. It also showed antinociceptive properties, which are thought to be associated with the capacity to scavenge free radicals (J. Ethnopharmacol. 2006;106:408–13).

 Other Therapeutic Actions

Boldine has been shown to exert cytoprotective, anti-tumor promoting, anti-inflammatory, antidiabetic, and antiatherogenic activities, all of which may arise from its free radical-scavenging properties. This potent alkaloid also has been shown to confer significant pharmacologic benefit not related to oxidative stress, such as antitrypanocidal, vasorelaxing, immuno- and neuromodulatory, and cholagogic and/or choleretic activity (Chem. Biol. Interact. 2006;159:1–17).

In a study of carrageenan-induced edema in guinea pigs, boldine exhibited dose-dependent anti-inflammatory activity. It also acted against bacterial pyrogen-induced hyperthermia in rabbits. In addition, an in vitro arm of the same study revealed that boldine inhibited prostaglandin biosynthesis, to which investigators attributed the in vivo anti-inflammatory and antipyretic activities of boldine (Agents Actions 1994;42:114–7).

Boldine is contraindicated in people who have kidney disease, women who are pregnant or breast-feeding, and patients with liver bile duct obstruction or severe liver disease (Brinker F. Herb Contraindications and Drug Interactions. Sandy, Ore.: Eclectic Medical Publications, 1997, p. 26).

Photoprotective Action

In a recent study with the most direct dermatologic implications, boldine was shown to be photostable, with its antioxidative capacity remaining intact, thereby allowing the compound to confer photoprotection (J. Photochem. Photobiol. B 2005;80:65–9). Furthermore, in vitro tests of compounds extracted from lichens and the boldo tree revealed that their ultraviolet filtering power was similar to, or better than, that of octylmethoxycinnamate, suggesting their potential usefulness in sunscreen formulations (J. Photochem. Photobiol. B 2002;68:133–9).

Conclusions

Natural antioxidants are too plentiful, and the number under active investigation for medical and cosmetic uses too copious, to suggest that any one compound is the antioxidant du jour. That said, boldine has been studied with increasing frequency over the past 15 years, after a long history of use in folk medicine, and the evidence is ample enough to suggest that clinical trials are the next important step to determine the medical role of this natural botanical.

Direct applications in dermatology have not yet been seen, but given the antioxidant and anti-inflammatory activities exhibited by this aporphine alkaloid, there is cause to promote its use in research. Boldine is already being incorporated into several cosmeceutical moisturizers, antiaging sera, eye and lip balms, and antioxidant masks available online.

Boldo (Peumus boldus Mol.) is a slow-growing, shrubby evergreen tree native to the Chilean and Peruvian Andes. It is also found in Morocco and other parts of North Africa, and is cultivated in Europe. The plant has traditionally been used in South American folk medicine, particularly in Chile, Peru, and Brazil, to treat a wide range of conditions of the liver, bowel, and gallbladder (Pharmacol. Res. 1994;29:1–12).

The primary active constituent identified in the tree is boldine, a simple aporphine alkaloid. Several aporphine alkaloids, which are secondary metabolites, are found in boldo leaves, with boldine being the most abundant (Curr. Med. Chem. Anticancer Agents 2005;5:173–82). Boldine is extracted from the leaves and bark of the tree (Phytother. Res. 2000;14:339–43; Pharmazie 2001;56:242–3).

In Germany and other European countries, the boldo plant is used as a medicinal. It is the subject of a German Commission E monograph that details the acceptable uses of the plant as an herbal drug for liver, gallbladder, and gastric conditions (Blumenthal M., et al. [eds.] The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin, Tex.: American Botanical Council and Boston: Integrative Medicine Communications, 1998, pp. 93–4).

Boldine is used worldwide in homeopathic and herbal medicine, and boldine extract is widely acknowledged as a viable herbal remedy in several pharmacopoeias (Chem. Biol. Interact. 2006;159:1–17; Pharmacol. Res. 1994;29:1–12). Indeed, boldine has been demonstrated to possess antioxidant activity in biologic as well as nonbiologic systems, and it has emerged as an ingredient of great interest for its potential in the treatment of free radical-mediated damage or conditions (Pharmacol. Res. 1994;29:1–12).

Antioxidant Actions

Boldine is now considered one of the strongest natural antioxidants (Chem. Biol. Interact. 2006;159:1–17).

In the early 1990s, the traditional use of Peumus boldus extract prompted a team of researchers to validate some of its therapeutic properties. They found that boldine imparted significant protection in vitro against tert-butyl hydroperoxide-induced toxicity in isolated rat hepatocytes, and in vivo against carbon tetrachloride-induced hepatotoxicity in mice. A test in rats with carrageenan-induced edema also revealed significant and dose-dependent anti-inflammatory effects (Planta Med. 1991;57:110–5). The free radical-scavenging and hepatoprotective properties of this natural compound are now considered well established (Phytother. Res. 2000;14:254–60).

A 2001 study demonstrated that boldine imparts chemoprotective activity in murine liver, reducing the metabolic activation of drug-metabolizing enzymes as well as chemical mutagens (Pharmazie 2001;56:242–3).

Alkaloids semisynthesized from boldine have also been shown to inhibit activity against reactive oxygen species and are believed to represent a potential therapy for inflammatory disorders involving production of reactive oxygen species (Chem. Pharm. Bull. [Tokyo] 2004;52:696–9).

In a study in mice, boldine showed significant antioxidant activity, decreasing the oxidation of low-density lipoprotein. It also lessened atherosclerotic lesion formation in LDL receptor-deficient mice that were fed an atherogenic diet. The authors believe that antioxidant capacity, coupled with the traditional tolerance to boldine in humans, renders it a suitable alternative to vitamin E (Atherosclerosis 2004;173:203–10).

More evidence of boldine's antioxidant effects emerged from a study in which it protected intact red blood cells against hemolytic damage caused by the free radical initiator 2,2′-azobis-(2-amidinopropane) (AAPH). The effect was concentration dependent and occurred whether the herb was added simultaneously with, or 1 hour before, AAPH. Erythrocytes previously incubated with AAPH for 2 hours were largely unaffected by the addition of boldine. The investigators concluded that boldine had significant time-dependent cytoprotective as well as antioxidant activity (Phytother. Res. 2000;14:339–43).

It is noteworthy that boldine is found in plants other than the Chilean boldo. In a study of boldine and other aporphine alkaloids isolated from Lindera angustifolia Chen, a Chinese medicinal plant used for edema and rheumatic pain, the extract exhibited significant free radical-scavenging activity against 2,2-diphenyl-1-picrylhydrazyl. It also showed antinociceptive properties, which are thought to be associated with the capacity to scavenge free radicals (J. Ethnopharmacol. 2006;106:408–13).

 Other Therapeutic Actions

Boldine has been shown to exert cytoprotective, anti-tumor promoting, anti-inflammatory, antidiabetic, and antiatherogenic activities, all of which may arise from its free radical-scavenging properties. This potent alkaloid also has been shown to confer significant pharmacologic benefit not related to oxidative stress, such as antitrypanocidal, vasorelaxing, immuno- and neuromodulatory, and cholagogic and/or choleretic activity (Chem. Biol. Interact. 2006;159:1–17).

In a study of carrageenan-induced edema in guinea pigs, boldine exhibited dose-dependent anti-inflammatory activity. It also acted against bacterial pyrogen-induced hyperthermia in rabbits. In addition, an in vitro arm of the same study revealed that boldine inhibited prostaglandin biosynthesis, to which investigators attributed the in vivo anti-inflammatory and antipyretic activities of boldine (Agents Actions 1994;42:114–7).

Boldine is contraindicated in people who have kidney disease, women who are pregnant or breast-feeding, and patients with liver bile duct obstruction or severe liver disease (Brinker F. Herb Contraindications and Drug Interactions. Sandy, Ore.: Eclectic Medical Publications, 1997, p. 26).

Photoprotective Action

In a recent study with the most direct dermatologic implications, boldine was shown to be photostable, with its antioxidative capacity remaining intact, thereby allowing the compound to confer photoprotection (J. Photochem. Photobiol. B 2005;80:65–9). Furthermore, in vitro tests of compounds extracted from lichens and the boldo tree revealed that their ultraviolet filtering power was similar to, or better than, that of octylmethoxycinnamate, suggesting their potential usefulness in sunscreen formulations (J. Photochem. Photobiol. B 2002;68:133–9).

Conclusions

Natural antioxidants are too plentiful, and the number under active investigation for medical and cosmetic uses too copious, to suggest that any one compound is the antioxidant du jour. That said, boldine has been studied with increasing frequency over the past 15 years, after a long history of use in folk medicine, and the evidence is ample enough to suggest that clinical trials are the next important step to determine the medical role of this natural botanical.

Direct applications in dermatology have not yet been seen, but given the antioxidant and anti-inflammatory activities exhibited by this aporphine alkaloid, there is cause to promote its use in research. Boldine is already being incorporated into several cosmeceutical moisturizers, antiaging sera, eye and lip balms, and antioxidant masks available online.

Boldo (Peumus boldus Mol.) is a slow-growing, shrubby evergreen tree native to the Chilean and Peruvian Andes. It is also found in Morocco and other parts of North Africa, and is cultivated in Europe. The plant has traditionally been used in South American folk medicine, particularly in Chile, Peru, and Brazil, to treat a wide range of conditions of the liver, bowel, and gallbladder (Pharmacol. Res. 1994;29:1–12).

The primary active constituent identified in the tree is boldine, a simple aporphine alkaloid. Several aporphine alkaloids, which are secondary metabolites, are found in boldo leaves, with boldine being the most abundant (Curr. Med. Chem. Anticancer Agents 2005;5:173–82). Boldine is extracted from the leaves and bark of the tree (Phytother. Res. 2000;14:339–43; Pharmazie 2001;56:242–3).

In Germany and other European countries, the boldo plant is used as a medicinal. It is the subject of a German Commission E monograph that details the acceptable uses of the plant as an herbal drug for liver, gallbladder, and gastric conditions (Blumenthal M., et al. [eds.] The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin, Tex.: American Botanical Council and Boston: Integrative Medicine Communications, 1998, pp. 93–4).

Boldine is used worldwide in homeopathic and herbal medicine, and boldine extract is widely acknowledged as a viable herbal remedy in several pharmacopoeias (Chem. Biol. Interact. 2006;159:1–17; Pharmacol. Res. 1994;29:1–12). Indeed, boldine has been demonstrated to possess antioxidant activity in biologic as well as nonbiologic systems, and it has emerged as an ingredient of great interest for its potential in the treatment of free radical-mediated damage or conditions (Pharmacol. Res. 1994;29:1–12).

Antioxidant Actions

Boldine is now considered one of the strongest natural antioxidants (Chem. Biol. Interact. 2006;159:1–17).

In the early 1990s, the traditional use of Peumus boldus extract prompted a team of researchers to validate some of its therapeutic properties. They found that boldine imparted significant protection in vitro against tert-butyl hydroperoxide-induced toxicity in isolated rat hepatocytes, and in vivo against carbon tetrachloride-induced hepatotoxicity in mice. A test in rats with carrageenan-induced edema also revealed significant and dose-dependent anti-inflammatory effects (Planta Med. 1991;57:110–5). The free radical-scavenging and hepatoprotective properties of this natural compound are now considered well established (Phytother. Res. 2000;14:254–60).

A 2001 study demonstrated that boldine imparts chemoprotective activity in murine liver, reducing the metabolic activation of drug-metabolizing enzymes as well as chemical mutagens (Pharmazie 2001;56:242–3).

Alkaloids semisynthesized from boldine have also been shown to inhibit activity against reactive oxygen species and are believed to represent a potential therapy for inflammatory disorders involving production of reactive oxygen species (Chem. Pharm. Bull. [Tokyo] 2004;52:696–9).

In a study in mice, boldine showed significant antioxidant activity, decreasing the oxidation of low-density lipoprotein. It also lessened atherosclerotic lesion formation in LDL receptor-deficient mice that were fed an atherogenic diet. The authors believe that antioxidant capacity, coupled with the traditional tolerance to boldine in humans, renders it a suitable alternative to vitamin E (Atherosclerosis 2004;173:203–10).

More evidence of boldine's antioxidant effects emerged from a study in which it protected intact red blood cells against hemolytic damage caused by the free radical initiator 2,2′-azobis-(2-amidinopropane) (AAPH). The effect was concentration dependent and occurred whether the herb was added simultaneously with, or 1 hour before, AAPH. Erythrocytes previously incubated with AAPH for 2 hours were largely unaffected by the addition of boldine. The investigators concluded that boldine had significant time-dependent cytoprotective as well as antioxidant activity (Phytother. Res. 2000;14:339–43).

It is noteworthy that boldine is found in plants other than the Chilean boldo. In a study of boldine and other aporphine alkaloids isolated from Lindera angustifolia Chen, a Chinese medicinal plant used for edema and rheumatic pain, the extract exhibited significant free radical-scavenging activity against 2,2-diphenyl-1-picrylhydrazyl. It also showed antinociceptive properties, which are thought to be associated with the capacity to scavenge free radicals (J. Ethnopharmacol. 2006;106:408–13).

 Other Therapeutic Actions

Boldine has been shown to exert cytoprotective, anti-tumor promoting, anti-inflammatory, antidiabetic, and antiatherogenic activities, all of which may arise from its free radical-scavenging properties. This potent alkaloid also has been shown to confer significant pharmacologic benefit not related to oxidative stress, such as antitrypanocidal, vasorelaxing, immuno- and neuromodulatory, and cholagogic and/or choleretic activity (Chem. Biol. Interact. 2006;159:1–17).

In a study of carrageenan-induced edema in guinea pigs, boldine exhibited dose-dependent anti-inflammatory activity. It also acted against bacterial pyrogen-induced hyperthermia in rabbits. In addition, an in vitro arm of the same study revealed that boldine inhibited prostaglandin biosynthesis, to which investigators attributed the in vivo anti-inflammatory and antipyretic activities of boldine (Agents Actions 1994;42:114–7).

Boldine is contraindicated in people who have kidney disease, women who are pregnant or breast-feeding, and patients with liver bile duct obstruction or severe liver disease (Brinker F. Herb Contraindications and Drug Interactions. Sandy, Ore.: Eclectic Medical Publications, 1997, p. 26).

Photoprotective Action

In a recent study with the most direct dermatologic implications, boldine was shown to be photostable, with its antioxidative capacity remaining intact, thereby allowing the compound to confer photoprotection (J. Photochem. Photobiol. B 2005;80:65–9). Furthermore, in vitro tests of compounds extracted from lichens and the boldo tree revealed that their ultraviolet filtering power was similar to, or better than, that of octylmethoxycinnamate, suggesting their potential usefulness in sunscreen formulations (J. Photochem. Photobiol. B 2002;68:133–9).

Conclusions

Natural antioxidants are too plentiful, and the number under active investigation for medical and cosmetic uses too copious, to suggest that any one compound is the antioxidant du jour. That said, boldine has been studied with increasing frequency over the past 15 years, after a long history of use in folk medicine, and the evidence is ample enough to suggest that clinical trials are the next important step to determine the medical role of this natural botanical.

Direct applications in dermatology have not yet been seen, but given the antioxidant and anti-inflammatory activities exhibited by this aporphine alkaloid, there is cause to promote its use in research. Boldine is already being incorporated into several cosmeceutical moisturizers, antiaging sera, eye and lip balms, and antioxidant masks available online.