Robert S Kirsner

University of Miami Miller School of Medicine, Miami, Florida, United States

Are you Robert S Kirsner?

Claim your profile

Publications (456)1895.61 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: We evaluated the comparative effectiveness of a bioengineered living cellular construct (BLCC) and a dehydrated human amnion/chorion membrane allograft (dHACM) for the treatment of diabetic foot ulcers (DFUs). Using a wound-care specific electronic medical record database we assessed real-world outcomes in 218 patients with 226 DFUs receiving treatment in 2014 at 99 wound care centers. The analysis included DFUs ≥1 and <25cm(2) with duration <=1 year and area reduction <=20% in 14 days prior to treatment (N=163, BLCC; N=63, dHACM). The average baseline areas and durations were 6.0 cm(2) and 4.4 months for BLCC and 5.2 cm(2) and 4.6 months for dHACM, respectively. Patients treated with dHACM had more applications compared to those treated with BLCC (median 3.0 vs. 2.0) (p=0.003). A Cox model adjusted for key covariates including area and duration found the median time to closure for BLCC was 13.3 weeks compared to 26 weeks for dHACM, and the proportion of wounds healed were significantly higher for BLCC by 12 weeks (48% versus 28%) and 24 weeks (72% versus 47%) (p=0.01). Treatment with a bioengineered living cellular technology increased the probability of healing by 97% compared with a dehydrated amniotic membrane (hazard ratio = 1.97 [95% confidence interval 1.17, 3.33], p=0.01). This article is protected by copyright. All rights reserved. © 2015 by the Wound Healing Society.
    Wound Repair and Regeneration 06/2015; DOI:10.1111/wrr.12332 · 2.77 Impact Factor
  • Romi Bloom, Kyle T Amber, Shasa Hu, Robert Kirsner
    06/2015; DOI:10.1001/jamadermatol.2015.1216
  • [Show abstract] [Hide abstract]
    ABSTRACT: UV radiation is among the most prevalent stressors in humans and diurnal rodents, exerting direct and indirect DNA damage, free-radical production, and interaction with specific chromophores that affects numerous biological processes. In addition to its panoply of effects, UVB (290-320 nm) radiation can specifically affect various local neuroendocrine activities by stimulating the expression of corticotropin-releasing hormone (CRH), urocortin, proopiomelanocortin (POMC), and POMC-derived peptides. Although very little is known about the interplay between the central hypothalamic-pituitary-adrenal (HPA) axis and the skin HPA axis analog, in the current issue Skobowiat and Slominski propose a novel mechanism by which exposure to UVB activates a local HPA axis in skin, which in turn activates the central HPA axis, with the requirement of a functional pituitary gland. This is the first evidence of the local HPA axis in skin contributing to the central neuroendocrine response. This raises intriguing possibilities regarding how local production of cortisol and other HPA axis molecules in skin influence overall systemic levels of cortisol and help regulate local and central HPA axes in the context of homeostasis, skin injury, and inflammatory skin disorders.
    Journal of Investigative Dermatology 06/2015; 135(6):1469-71. DOI:10.1038/jid.2015.56 · 6.37 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Livedoid vasculopathy (LV) is a thrombo occlusive disorder presenting with recurrent painful ulcers of lower extremities. Association of LV with increased level of lipoprotein (a) (LP(a)), a risk factor for cardiovascular disease, has been reported. Danazol has been used with success in the management of LV, but none of the previous studies looked at the correlation between response to the treatment and level of LP(a). The aim of this study was to demonstrate the efficacy of low-dose danazol in the treatment of LV and its effects on LP(a). We present four cases with LV who were successfully treated with low-dose danazol, assessing the clinical characteristics and laboratory tests including the level of LP(a). The average age of the patients was 45 years and the mean duration of the disease was 19 years. The treatment regime of danazol 200 mg daily led to complete healing of ulcers and reduction in pain and a 70% (ranging from 52 to 87%) reduction in the level of LP(a). The limitation of this study is " small sample size. " In our patients with LV, low-dose danazol led to clinical improvement along with significant reduction in the level of LP(a).
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Livedoid vasculopathy (LV) is a thrombo occlusive disorder presenting with recurrent painful ulcers of lower extremities. Association of LV with increased level of lipoprotein (a) (LP(a) ), a risk factor for cardiovascular disease, has been reported. Danazol has been used with success in the management of LV, but none of the previous studies looked at the correlation between response to the treatment and level of LP(a). The aim of this study was to demonstrate the efficacy of low-dose danazol in the treatment of LV and its effects on LP(a). We present four cases with LV who were successfully treated with low-dose danazol, assessing the clinical characteristics and laboratory tests including the level of LP(a). The average age of the patients was 45 years and the mean duration of the disease was 19 years. The treatment regime of danazol 200 mg daily led to complete healing of ulcers and reduction in pain and a 70% (ranging from 52 to 87%) reduction in the level of LP(a). The limitation of this study is "small sample size." In our patients with LV, low-dose danazol led to clinical improvement along with significant reduction in the level of LP(a). © 2015 Wiley Periodicals, Inc.
    Dermatologic Therapy 03/2015; DOI:10.1111/dth.12225 · 1.48 Impact Factor
  • JAMA Dermatology 02/2015; 151(6). DOI:10.1001/jamadermatol.2014.5112 · 4.30 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: This study compares two different negative pressure wound therapy (NPWT) modalities in the treatment of venous leg ulcers (VLUs), the ultraportable mechanically powered (MP) Smart Negative Pressure (SNaP(®)) Wound Care System to the electrically powered (EP) Vacuum-Assisted Closure (V.A.C.(®)) System. Approach: Patients with VLUs from 13 centers participated in this prospective randomized controlled trial. Each subject was randomly assigned to treatment with either MP NPWT or EP NPWT and evaluated for 16 weeks or complete wound closure. Results: Forty patients (n=19 MP NPWT and n=21 EP NPWT) completed the study. Primary endpoint analysis of wound size reduction found wounds in the MP NPWT group had significantly greater wound size reduction than those in the EP NPWT group at 4, 8, 12, and 16 weeks (p-value=0.0039, 0.0086, 0.0002, and 0.0005, respectively). Kaplan-Meier analyses showed greater acceleration in complete wound closure in the MP NPWT group. At 30 days, 50% wound closure was achieved in 52.6% (10/19) of patients treated with MP NPWT and 23.8% (5/21) of patients treated with EP NPWT. At 90 days, complete wound closure was achieved in 57.9% (11/19) of patients treated with MP NPWT and 38.15% (8/21) of patients treated with EP NPWT. Innovation: These data support the use of MP-NPWT for the treatment of VLUs. Conclusions: In this group of venous ulcers, wounds treated with MP NPWT demonstrated greater improvement and a higher likelihood of complete wound closure than those treated with EP NPWT.
    02/2015; 4(2):75-82. DOI:10.1089/wound.2014.0575
  • [Show abstract] [Hide abstract]
    ABSTRACT: The Performance Improvement (PI) CME format improves physician performance in other specialties but data are lacking in dermatology. We sought to assess the impact of a PI CME activity on physician practice patterns for patients with psoriasis, which was developed, implemented, and evaluated by the American Academy of Dermatology (AAD), in part to assist dermatologists in fulfilling Part IV of their Maintenance of Certification requirements. In this PI CME activity, participants: (1) self-audited patient charts, which met inclusion criteria in stage A, and reflected on their results, benchmarked against peers; (2) reviewed educational materials in stage B and developed an improvement plan; and (3) self-audited a different set of patient charts following the plan's implementation. Aggregate stage A and C data were analyzed using χ(2) tests. We found a statistically significant improvement in the advisement of patients with psoriasis regarding their increased risk for cardiovascular disease, to contact their primary care provider for cardiovascular risk assessment, and in shared decision making regarding the treatment plan. We also found an overall statistically significant improvement in history taking per the guidelines. Learner chart selection bias, self-reporting of chart data, and lack of a control group are limitations. The AAD psoriasis PI CME activity demonstrated significantly improved dermatologists' documentation of patient's history, counseling of patients for lifestyle behaviors, and shared decision making. Copyright © 2014 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.
    Journal of the American Academy of Dermatology 01/2015; 72(3). DOI:10.1016/j.jaad.2014.11.010 · 5.00 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Non-healing wounds are associated with an inflammatory and proteolytic wound environment, and recent therapeutic strategies have been focused on reversing these changes. Connexins, as members of gap junctions, are important in intercellular signaling and wound repair. Connexin 43 (Cx43) downregulation is associated with normal wound healing, and it has been found to be upregulated in non-healing venous leg ulcers (VLUs). Ghatnekar et al. (2014) report findings of a small phase II trial performed in Indian patients with chronic VLUs, reporting that ACT1, a mimetic peptide of Cx43, accelerates healing in the treatment group. Despite standard care with compression therapy and adjuvant therapy for refractory wounds, at present in clinical practice a significant number of patients remain unhealed. The potential for ACT1 exists to help heal refractory VLUs, but it faces additional regulatory hurdles.
    Journal of Investigative Dermatology 01/2015; 135(1):19-23. DOI:10.1038/jid.2014.444 · 6.37 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Patients with venous leg ulcers (VLUs) have calf muscle pump dysfunction, which is associated with reduced ankle range of motion (ROM). Physical therapy or exercise that targets ankle joint mobility may lead to improvement in calf muscle pump function and subsequent healing. However, little is known regarding the effect of physical therapy or exercise on healing and quality of life (QOL), which is impaired in patients with VLUs. To systematically review the current literature on the effect of physical therapy on healing and QOL outcomes in patients with VLUs and to identify research gaps that warrant further investigation. PubMed (MEDLINE), CINHAHL, and Cochrane databases were searched in April 2014. We found 10 articles, consisting of randomized clinical trials and single-arm cohort studies with small sample sizes, that used physical therapy or exercise for patients with open or healed VLUs. Although there is evidence that exercise strengthens the calf muscle pump and improves ankle ROM, few studies have investigated the effect of these interventions on QOL and healing, and few involved the supervision of a physical therapist. The lack of evidence and randomized clinical trials suggests the need for further investigation on physical therapy-oriented exercise on wound healing and QOL. In addition, more studies are needed to investigate sustainability of the increased ankle ROM after physical therapy has ended or if VLU reoccurrences are prevented.
    JAMA Dermatology 12/2014; 151(3). DOI:10.1001/jamadermatol.2014.3459 · 4.30 Impact Factor
  • Wound Repair and Regeneration 12/2014; 23(1). DOI:10.1111/wrr.12247 · 2.77 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Older adults are more likely to have chronic wounds than younger people, and the effect of chronic wounds on quality of life is particularly profound in this population. Wound healing slows with age, but the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The effect of age and accompanying multimorbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables; lack of standardization in data collection; and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this article, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify research questions to guide future study of age-associated changes in chronic wound healing. © 2015 by the American Geriatrics Society and the Wound Healing Society.
    Wound Repair and Regeneration 12/2014; 23(1). DOI:10.1111/wrr.12245 · 2.77 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The skin has recently been found to be an extra-adrenal site for glucocorticoid (GC) synthesis that likely acts to modulate local inflammation. Psychological, physiological, and physical stress, both acute and chronic, triggers immune-protective or -damaging responses, including increases in systemic GC levels, which, according to Lin et al. (this issue), may be beneficial in inflammatory skin disease. However, little is known about the interplay between local and systemic production of GCs and the effect of stress (local or systemic) in regulating tissue-specific GC synthesis, its impact on skin homeostasis, and its effect of skin disease.
    Journal of Investigative Dermatology 12/2014; 134(12):2869-72. DOI:10.1038/jid.2014.363 · 6.37 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: PURPOSE:: The purpose of this learning activity is to provide information about the etiology and treatment of atrophie blanche. TARGET AUDIENCE:: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES:: After participating in this educational activity, the participant should be better able to:1. Discuss the pathophysiology of atrophie blanche.2. Explore treatment options for livedoid vasculopathy. ABSTRACT: Atrophie blanche (AB) is a porcelain-white scar that may be seen at the base of a healed ulcer or in association with livedoid vasculopathy (LV). The term AB originally had been used synonymously with LV, whereas LV is a noninflammatory thrombotic condition presenting as either a primary or secondary event (often associated with coagulation).
    Advances in Skin & Wound Care 11/2014; 27(11):518-524. DOI:10.1097/01.ASW.0000455098.98684.95 · 1.63 Impact Factor
  • Journal of the American Academy of Dermatology 11/2014; 71(5):1028-9. DOI:10.1016/j.jaad.2014.06.043 · 5.00 Impact Factor
  • Jose E Ollague, Robert S Kirsner
    Journal of Investigative Dermatology 11/2014; 134(11):e22. DOI:10.1038/jid.2014.394 · 6.37 Impact Factor
  • Katherine L. Baquerizo Nole, Robert S. Kirsner
    [Show abstract] [Hide abstract]
    ABSTRACT: Chronic wounds affect more than 6 million people annually in the US alone, and the cost to the healthcare system is an estimated $25 billion (1). Despite recent technology advances in tissue engineering and drugs, more cost effective treatments are needed. With approximately 5 million hair follicles (HF) (2) continuously generating hair over the body, is it possible to harness this growth potential in wound management? Jimenez et al. (3) Exp Dermatol 2014 provide compelling reasons to engender hope, guiding us first through basic science research supporting the role of HF in wound healing, the influence of hair cycling, follicular stem cells (FSC), and signaling to HF neogenesis, and then providing examples of currently available hair-related therapies in wound management.This article is protected by copyright. All rights reserved.
    Experimental Dermatology 11/2014; 24(2). DOI:10.1111/exd.12607 · 4.12 Impact Factor
  • JAMA Dermatology 08/2014; 150(9). DOI:10.1001/jamadermatol.2014.1431 · 4.30 Impact Factor
  • Daniel G Federman, Robert S Kirsner, John Concato
    [Show abstract] [Hide abstract]
    ABSTRACT: IMPORTANCE Sunscreen is an important part of sun protection to prevent skin cancer but may not be recommended as often as guidelines dictate. OBJECTIVE To evaluate trends in sunscreen recommendation among physicians to determine whether they are following suggested patient-education guidelines regarding sun protection, and to assess data regarding physician sunscreen recommendations to determine the association with patient demographics, physician specialty, and physician diagnosis. DESIGN, SETTING, AND PARTICIPANTS The National Ambulatory Medical Care Survey was queried to identify patient visits to nonfederal outpatient physician offices at US ambulatory care practices (January 1, 1989-December 26, 2010) during which sunscreen was recommended. MAIN OUTCOMES AND MEASURES Frequency of sunscreen recommendation. RESULTS According to the National Ambulatory Medical Care Survey, there were an estimated 18.30 billion patient visits nationwide. Physicians mentioned sunscreen at approximately 12.83 million visits (0.07%). Mention of sunscreen was reported by physicians at 0.9% of patient visits associated with a diagnosis of skin disease. Dermatologists recorded the mention of sunscreen the most (86.4% of all visits associated with sunscreen). However, dermatologists reported mentioning sunscreen at only 1.6% of all dermatology visits. Sunscreen was mentioned most frequently to white patients, particularly those in their eighth decade of life, and least frequently to children. Actinic keratosis was the most common diagnosis associated with sunscreen recommendation. CONCLUSIONS AND RELEVANCE Despite encouragement to provide patient education regarding sunscreen use and sun-protective behaviors, the rate at which physicians are mentioning sunscreen at patient visits is quite low, even for patients with a history of skin cancer. The high incidence and morbidity of skin cancer can be greatly reduced with the implementation of sun-protective behaviors, which patients should be counseled about at outpatient visits.
    JAMA The Journal of the American Medical Association 07/2014; 312(1):87-88. DOI:10.1001/jama.2014.4320 · 30.39 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Limitation of ankle movement may contribute to calf muscle pump failure, which is thought to contribute to venous leg ulcer formation, which affects nearly 1 million Americans. We therefore wished to study ankle movement in patients with venous leg ulcers and its effect on healing. Using goniometry, we measured baseline ankle range of motion in venous leg ulcer patients from a Phase 2 dose-finding study of an allogeneic living cell bioformulation. Two hundred twenty-seven patients were enrolled in four active treatment groups and one standard-care control group, all receiving compression therapy. Goniometry data from a control group of 49 patients without venous disease, from a previous study, was used for comparison. We found patients with active venous leg ulcers had significantly reduced ankle range of motion compared with the control group (p = 0.001). After 12 weeks of therapy, baseline ankle range of motion was not associated with healing, as there was no significant difference between healed and nonhealed groups, suggesting that ankle range of motion is not important in venous leg ulcer healing or, more likely, is overcome by compression. However, patients with venous ulcers located on the leg (as opposed to the ankle) had significantly higher ankle range of motion for plantar flexion and inversion (p = 0.021 and p = 0.034, respectively) and improved healing with both cell bioformulation and standard care (p = 0.011), suggesting that wound location is an important variable for ankle range of motion as well as for healing outcomes.
    Wound Repair and Regeneration 07/2014; 22(4). DOI:10.1111/wrr.12186 · 2.77 Impact Factor

Publication Stats

6k Citations
1,895.61 Total Impact Points

Institutions

  • 1991–2015
    • University of Miami Miller School of Medicine
      • Department of Dermatology and Cutaneous Surgery
      Miami, Florida, United States
  • 1990–2014
    • University of Miami
      • • Department of Dermatology and Cutaneous Surgery
      • • Department of Medicine
      كورال غيبلز، فلوريدا, Florida, United States
  • 2012
    • University of North Carolina at Chapel Hill
      North Carolina, United States
    • Canterbury District Health Board
      Christchurch, Canterbury Region, New Zealand
  • 1999–2010
    • Yale-New Haven Hospital
      • Department of Laboratory Medicine
      New Haven, Connecticut, United States
  • 2007–2008
    • Wayne State University
      • College of Nursing
      Detroit, MI, United States
    • Emory University
      • Department of Gynecology and Obstetrics
      Atlanta, Georgia, United States
  • 2004–2008
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 1995–2007
    • Yale University
      • • Department of Internal Medicine
      • • School of Medicine
      New Haven, Connecticut, United States
  • 2005
    • University Of Miami Hospital
      Miami, Florida, United States
  • 2000
    • Albert Einstein College of Medicine
      New York City, New York, United States