A retrospective evaluation of digital wound imaging to predict response to hyperbaric oxygen treatment

As new wound care treatments become available, correct initial treatment selection and dynamic modification of regimens, based on wound response to treatment, must be applied to improve outcomes and reduce cost. One alternative is wound morphometry using digital wound images to evaluate wound response to treatment in realtime. To determine whether wound area measurements taken during the first 3 weeks of hyperbaric oxygen treatment predict eventual treatment response and how demographic and disease factors impact hyperbaric oxygen treatment response, a retrospective study using digital wound images, demographic data, and available clinical laboratory values was conducted. Participants included 29 wound care patients with nonhealing wounds of the lower extremities receiving treatment at a hyperbaric wound care facility. Conventional wound care (ie, debridement, dressing changes, and topical agents) plus hyperbaric oxygen treatment (100% oxygen breathing at 2.4 atmospheres absolute for 90 minutes) given once every weekday for up to 20 weeks was provided. Graphical analysis of normalized wound area over time revealed two groups: minimal responders (n=13) and robust responders (n=16). Minimal response was characterized by delayed onset of wound area reduction and virtual cessation of reduction by week 3. Robust response was continuous, sustained, and resulted in average wound area reduction of 80% by end of treatment, compared to 47% in minimally responsive patients. Age, blood glucose, and serum creatinine significantly affected the wound healing response to hyperbaric oxygen treatment (P<0.05). Digital images obtained during the first 3 weeks of treatment predicted if a patient is minimally responsive to hyperbaric oxygen treatment with 100% accuracy. Area measurements obtained in this manner can be used to identify patients minimally responsive to hyperbaric oxygen treatment, enabling rapid assessment of treatment response to make timely changes in therapy in order to optimize treatment outcomes.     

Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot

The purpose of this retrospective study was to evaluate outcomes of people with large diabetic foot wounds treated with subatmospheric pressure dressing therapy immediately following surgical wound debridement. Data were abstracted from the medical records of 31 consecutive patients with diabetes, 77.4% male (n = 24), aged 56.1 +/- 11.7 years, presenting for care at two large multidisciplinary wound care centers. All patients received surgical debridement for indolent diabetic foot wounds and were subsequently started on a regimen of subatmospheric pressure dressing therapy delivered using a vacuum-assisted closure device for a mean of 4.7 +/- 4.2 weeks (mode = 2 weeks) using a protocol that called for cessation of therapy when the wound bed approached 100% coverage with granulation tissue with no exposed tendon, joint capsule, or bone. Outcomes evaluated included time to complete wound closure, proportion of patients achieving wound healing at the level of initial debridement, and complications associated with use of the device. The mean duration of wounds before therapy was 25.4 +/- 23.8 weeks. In patients treated with subatmospheric pressure dressing therapy, 90.3% (n = 28) of wounds healed at the level of debridement without the need for further bony resection in a mean 8.1 +/- 5.5 weeks. The remaining 9.7% (n = 3) went on to higher level amputation (below knee amputation = 3.2%, [n = 1] and transmetatarsal amputation = 6.5% [n = 2]). Complications included periwound maceration (19.4% [n = 6]), periwound cellulitis (3.2% [n = 1]), and deep space infection (3.2% [n = 1]). The authors concluded that appropriate use of subatmospheric pressure dressing therapy to achieve a rapid granular bed in diabetic foot wounds may have promise in treatment of this population at high risk for amputation and that a large, randomized trial is now indicated.     

A case study of negative pressure wound therapy to manage acute necrotizing fasciitis

Acute necrotizing fasciitis is a devastating infectious process that requires immediate surgical debridement. Intravenous antibiotic treatment, hyperbaric oxygen therapy, and wound management are considered the standard of care. Subsequent wound closure is achieved with split-thickness skin grafting, delayed surgical closure, or healing by secondary intention. When a patient refuses additional surgical treatment or is no longer a surgical candidate, as was the case with a patient who presented with acute necrotizing fasciitis caused by Clostridium perfringens in the upper extremity, secondary intention healing is the only treatment option. Following surgery and intravenous antibiotic treatment, her wounds were managed with topical negative pressure wound therapy. No adverse events occurred and the wounds were almost completely healed 63 weeks following surgery. Research to develop evidence-based protocols of care for the closure of these wounds is needed.     

Production of platelet-rich plasma gel from elderly patients under antithrombotic drugs: Perspectives in chronic wounds care

Platelet-Rich Plasma (PRP) is an autologous biological therapy obtained by centrifuging the patient’s own blood to concentrate platelets. The addition of autologous thrombin and calcium chloride to PRP allows the production of a semi-solid form called PRP gel. PRP gel is increasingly used in a variety of tissue defects and predominantly in the management of non-healing chronic wounds. The topical application of PRP gel seems promising due to the capability of platelets to store and secrete growth factors (GF), fibrin and cytokines, which are essentials for wound healing. Most patients who suffered from chronic wounds are elderly patients with co-morbidities and polypharmacy including antithrombotic drugs such as antiplatelet agents (AP) or anticoagulants (AC), which could hamper the feasibility of this autologous platelet-derived therapy. To date, no study has investigated PRP gel formation in patients with AP or AC. The aim of this study was to evaluate the influence of AP or AC drugs on the production of PRP gel formation from elderly patients. Different biological characteristics were determined to qualify the production of PRP gel from such patients (Interquartile range (IQR) = 75–92 years) compared to healthy volunteers (IQR = 23–37 years). No significant difference was observed in the volume, composition (quantity of platelets, leukocytes and red blood cells) and functionality of platelets from PRP except a higher ADP-induced P-selectin expression in healthy donors compared with elderly patients. Autologous thrombin characteristics were similar in the two groups. Gel time formation (IQR: 120–195 seconds for controls and 135–210 seconds for elderly patients) and final composition of PRP gel were not significantly modified. Concentrations of theoretical thrombin generated in the serum and in the gel were inversely correlated with the time of formation of PRP gel (r² = 0.57, p = 0.012). Altogether these data indicate that PRP gel preparation is not impacted by the use of antithrombotic drugs. Such results support the feasibility of using this innovative autologous biotherapy in the management of elderly patients with non-healing chronic wounds.     

Managing a traumatic wound in a geriatric patient

Clinical management of a wound in a geriatric patient requires an understanding of age-related changes in the skin and the knowledge to make appropriate treatment choices. This case study describes clinical assessment and management of a traumatic hip wound in a 75-year-old patient. In addition to addressing his nutritional status by providing supplements, topical wound care preparations, including papain-urea and castor oil/balsam of Peru/trypsin, were used as a conservative approach to address debridement and periwound skin concerns. Extra vigilance is required to assess wounds in geriatric patients to determine proper wound treatment and achieve optimum results. Additional studies to evaluate optimal treatment strategies in the clinical management of traumatic wounds in the geriatric population are needed.     

Enhanced healing and cost-effectiveness of low-pressure oxygen therapy in healing necrotic wounds: a feasibility study of technology transfer

Recent advances in topical hyperbaric oxygen technology identified the use of low-pressure topical hyperbaric oxygen therapy in enhancing wound healing. This study prospectively examined the feasibility of technology transfer from university to Health Maintenance Organization personnel, using topical hyperbaric oxygen therapy to heal necrotic wounds. Fifteen patients with 24 gangrenous and/or necrotic wounds that did not improve or worsened after at least 6 weeks of standard wound care were treated with topical hyperbaric oxygen therapy by trained HMO personnel. Four patients underwent digital amputation for osteomyelitis and/or gangrene followed by topical hyperbaric oxygen therapy. Assessment parameters included wound healing and cost of wound care before and after topical hyperbaric oxygen therapy. Six of the six Level 2 wounds healed within 2 to 4 weeks, nine of the ten Level 3 wounds healed within 4 to 10 weeks, and seven of the eight Level 4 wounds healed within 4 to 12 weeks. The ulcers improved by a mean of 0.829 cm2 per day. T test (SSPS 7.5) showed significant improvement per day after topical hyperbaric oxygen therapy, t = 5.217, df = 24, P < 0.0001 (95% CI = 1.13-0.49). Wound healing with topical hyperbaric oxygen therapy was associated with decreased costs. The results of this support the feasibility of transfer of new wound healing technology from research to HMO personnel.     

A prospective, randomized, controlled trial of autologous platelet-rich plasma gel for the treatment of diabetic foot ulcers

Nonhealing diabetic foot ulcers are a common cause of amputation. Emerging cellular therapies such as platelet-rich plasma gel provide ulcer management options to avoid loss of limb. The purpose of this prospective, randomized, controlled, blinded, multicenter clinical study was to evaluate the safety and efficacy of autologous platelet-rich plasma gel for the treatment of nonhealing diabetic foot ulcers. One hundred, twenty-nine (129) patients were screened; 72 completed a 7-day screening period and met the study inclusion criteria. Patients were randomized into two groups - the standard care with platelet-rich plasma gel or control (saline gel) dressing group - and evaluated biweekly for 12 weeks or until healing. Healing was confirmed 1 week following closure and monitored for another 11 weeks. An independent audit led to the exclusion of 32 patients from the final per-protocol analysis because of protocol violations and failure to complete treatment. In this group, 13 out of 19 (68.4%) of the platelet-rich plasma gel and nine out of 21 (42.9%) of the control wounds healed. After adjusting for wound size outliers (n = 5), significantly more platelet-rich plasma gel (13 out of 16, 81.3%) than control gel (eight out of 19, 42.1%) treated wounds healed (P = 0.036, Fisher's exact test). Kaplan-Meier time-to-healing also was significantly different between groups (log-rank, P = 0.0177). No treatment-related serious adverse events were reported and bovine thrombin used in the preparation of PRP did not cause Factor V inhibition. When used with good standards of care, the majority of nonhealing diabetic foot ulcers treated with autologous platelet-rich plasma gel can be expected to heal.     

Comparison of wound irrigation and tangential hydrodissection in bacterial clearance of contaminated wounds: results of a randomized, controlled clinical study

Thorough irrigation of contaminated or infected traumatic and open surgical wounds is considered standard practice. High-power pulse lavage is frequently used to facilitate the removal of surface contaminants and bacteria but studies to compare the results of various irrigation techniques are limited. The purpose of this randomized, controlled clinical study was to compare the ability of a high-pressure parallel waterjet (pressure range 5,025 to 7,360 psi) to pulse lavage (pressure 40 psi) in reducing wound bacterial counts. The higher velocity instrument utilizes a waterjet oriented parallel to the surface of the wound and can be used to cut and remove necrotic tissues. After obtaining informed consent, 21 patients who presented with open surgical and traumatic wounds were randomly assigned to high-pressure parallel waterjet (n = 12) or pulse lavage (n = 9). Pre- and post irrigation tissue culture results showed an average decrease in absolute bacterial counts of 90.8% in the high-pressure parallel waterjet and 86.9% in the pulse lavage group. The difference between the two treatment groups was not statistically significant. The results of this study confirm that cleansing contaminated or infected acute wounds using high pressure (at least 15 psi) reduces wound bacterial counts. Studies to compare the clinical outcomes of various irrigation techniques and pressure ranges are warranted and the potential benefit of selective debridement using the high-pressure parallel waterjet should be investigated.     

Conservative management of Achilles tendon wounds: results of a retrospective study

Achilles tendon wounds are therapeutically challenging. The tendon`s functional importance, the paucity of soft tissue surrounding the ankle, and common patient comorbidities often limit surgical reconstructive procedure options. Depending on wound depth and overall patient health, secondary intention healing of these wounds can take many months. At the authors' wound care center, patients who are referred with recalcitrant, deep Achilles tendon wounds and who are able to visit the center two to three times per week are offered a protocol of topical hyperbaric oxygen (THBO) followed by low-level laser therapy (LLLT) and moisture-retentive dressings. A retrospective study was conducted to evaluate the outcomes of patients who received treatment for a deep Achilles tendon wound during the years 2004 through 2008. Patients who were seen but did not obtain care at the center were contacted via telephone. Of the 80 patients seen, 15 were referred for amputation, 52 obtained treatment elsewhere, and 13 received the THBO/LLLT protocol. Patient median age was 73 years (range 52-90 years) and most (85%) had diabetes mellitus. Average wound size was 90 cm2 (range 6.25-300 cm2) with an average duration of 11.7 months (range 2-60 months) before treatment. Complete re-epithelialization was achieved in 10 patients (77%) following a mean treatment time of 19 ± 10 weeks (range 5-42 weeks). Of those, seven remained ambulatory and ulcer-free at mean follow-up of 3.3 ± 1.8 years. Eight of the 52 patients (15%) who were not treated in the authors' center reported their ulcer was healed and 15 (29%) underwent amputation. Considering the severity of these wounds, the observed treatment outcomes are encouraging and may present a reasonable alternative for some patients with Achilles tendon wounds. Research is needed to clarify the role of these modalities in the conservative treatment of patients with Achilles tendon ulceration.     

Prevalence of chronic wounds in Quebec home care: an exploratory study

Because the prevalence of chronic wounds in Quebec is unknown, researchers conducted a chronic wound prevalence feasibility study in severely ill, elderly, or bedridden home care patients. Questionnaires seeking information about the number of wounds, patient comorbidities, and characteristics of the most severe wound (etiology, location, duration, progress, and treatments) were mailed to the head nurse and home care nurses of 149 local community health centers. Information regarding nurse and general health center needs related to chronic wound prevention and care also was solicited from nurses in 52 health centers. Data were obtained from 488 patients (average age 68.5 years); an overall prevalence rate of 1.4% was determined. Most patients (81%) had one or two wounds and pressure ulcer was the most common etiology (37% of wounds). Wounds had existed for a mean of 26.8 months (range 0 to 180, median 12 months). Most (94%) patients had a family physician but only one third of family physicians were responsible for the wound care provided/prescribed. Lack of time was the most frequently cited reason for not completing the survey. Wound chronicity, severity (44% of pressure ulcers were Stage III), lack of improvement (60% cited no improvement or worsening of ulcer), the absence of protocols and training in some local community service centers, and inappropriate use of therapeutic modalities are important reasons for concern and provide opportunities for improvement. Sample size and the absence of verifiable data limit the external validity of the findings but results indicate that chronic wounds are a common and important concern among home healthcare patients in Quebec. Improvements in data collection and patient protocols of care are needed to facilitate the acquisition of much-needed wound prevalence and outcomes data to help agencies provide optimal patient care.     

Outcomes of hyaluronan therapy in diabetic foot wounds

The purpose of this study was to evaluate outcomes of persons with neuropathic diabetic foot wounds treated with a hyaluronan-containing dressing. Data were abstracted for 36 patients with diabetes, 72.2% male, aged 60.0+/-10.7 years and a mean glycated hemoglobin (HbA(1c)) of 9.5+/-2.5% presenting for care at two large, multidisciplinary wound care centers. All patients received surgical debridement for their diabetic foot wounds and were placed on therapy consisting of hyaluronan dressing (Hyalofill, Convatec, USA) with dressing changes taking place every other day. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks. Hyalofill therapy was used until the wound bed achieved 100% granulation tissue. Therapy was then followed by a moisture-retentive dressing until complete epithelialization. In total, 75.0% of wounds measuring a mean 2.2+/-2.2 cm(2) healed in the 20-week evaluation period. Of those that healed in this period, healing took place in a mean 10.0+/-4.8 weeks. The average duration of Hyalofill therapy in all patients was 8.6+/-4.2 weeks. Deeper (UT Grade 2A) wounds were over 15 times less likely to heal than superficial (1A) wounds (94.7 vs. 52.9%, Odds Ratio=15.9, 95% Confidence Interval=1.7-142.8, P=0.006). We conclude that a regimen consisting of moist wound healing using hyaluronan-containing dressings may be a useful adjunct to appropriate diabetic foot ulcer care. We await the completion of a multicenter randomized controlled trial in this area to either support or refute this initial assessment.     

Pharmacotherapy as adjunctive treatment for serious foot wounds in the patient with diabetes: a case study

Chronic foot wounds in patients with diabetes present significant treatment challenges. A 54-year-old woman with type 2 diabetes and two wounds (one on the left great toe and the other on the left medial plantar surface) visited the clinic after the chronic wounds failed to respond to treatment such as hydrotherapy. Subsequent comprehensive care, including debridement; opening tunnels distal, proximal, and medial from the plantar wound; application of a growth factor-stimulant; and treatment with cilostazol to improve both macro- and microvascular circulation provided excellent wound healing. Amputation was avoided and the patient returned to her regular routine within 6 months. Pharmacotherapy may provide new adjunctive therapy options in the treatment of chronic foot wounds in patients with diabetes mellitus. Controlled clinical studies to ascertain the effects of this treatment are warranted.     

Use of platelet-derived growth factor for delayed perineal wound healing in patients with inflammatory bowel disease: a case series

Abdominoperineal resection (APR) is the operative procedure of choice in patients with anorectal complications of inflammatory bowel disease (IBD) where a restorative proctocolectomy is either undesirable or impossible to perform. The challenge in these patients is poor perineal wound healing. A retrospective chart review was conducted of 118 patients (average age 44 years, range 28-73) with intractable IBD who underwent APR to evaluate perineal wound healing outcomes. Forty-four (44) had Crohn's disease (CD) and 74 had ulcerative colitis (UC). Three months after surgery, the wounds of 10 patients (six with CD and four with UC) remained unhealed with a standard protocol of sterile gauze dressings, sitz baths, and irrigation as needed. In these patients, daily topical application of a small amount of platelet-derived growth factor (rhPDGF) was added to the regimen of care. Six of the 10 unhealed wounds healed following rhPDGF application (average 80 days). The four patients whose wounds did not heal after 6 to 12 months had CD and underwent surgical revision followed by topical rhPDGF application. These wounds healed after an average of 107 days. The results of this case series confirm that delayed perineal wound healing is common following APR, especially in patients with CD, and may confirm previously reported observations that the effects of rhPDGF are most encouraging in small area defects that can be filled. Studies to evaluate the safety, efficacy, and effectiveness of this treatment modality are warranted.     

The impact of telemedicine on outcomes of chronic wounds in the home care setting

Since 1997, more than 2,700 home care agencies have closed due to changes in reimbursement. With the implementation of a prospective payment system, there is concern--not only regarding the survival of the remaining home care agencies, but also whether adequate care can be provided to the patient. Chronic wound care is both prevalent and costly in home care. Factors contributing to cost include inconsistency of wound assessment and documentation and low usage of advanced wound products. These factors lead to lengthened healing time, more frequent visits by practitioners, and low healing rates. Involving a wound specialist can improve patient outcomes while decreasing cost. The authors examined the utilization of telemedicine in situations where wound specialists consulted with the home health nurse in the patient's home regarding care of chronic wounds. During the two-way video visit, the wound specialist assessed the patient and the wounds and made recommendations for treatment. The wound specialist also collected outcome data during the visits. This data was then compared with like data collected as a baseline prior to the telemedicine intervention. Results revealed improved healing rates, decreased healing time, decreased number of home health visits, and a decreased number of hospitalizations related to wound complications. Telemedicine was deemed a viable option for delivering quality, cost-effective care to chronic wound patients in the home care setting.     

Insulin-degrading activity in wound fluid

Patients with diabetes are at great risk of developing lower extremity ulcers. The management of diabetic foot ulcers typically includes early recognition and appropriate clinical care. Recent advances in wound treatment include topical growth factor therapy, which has been successful in diabetic wounds. Growth factors are decreased in wound fluid; this may be due to decreased supply, increased binding, or increased degradation of the naturally occurring growth factors. This study investigates the activity of the insulin-degrading enzyme in wound fluid. Wound fluid was obtained from patients with (n = 17) and without (n = 4) diabetes. Insulin degradation was assayed by incubating [(125)I]insulin with wound fluid and precipitation in trichloroacetic acid. Fluid from nondiabetics degraded 2.22 +/- 0.73%, whereas diabetic fluid degraded significantly more (6.13 +/- 1.48%; P < 0.05). In patients with diabetes, the degradation of insulin by wound fluid correlated with glucose control (hemoglobin A(1c); r(2) = 0.5353; P < 0.001), and patients with worse outcomes (i.e. amputation) had higher wound fluid insulin degradation. The biochemical characteristics of insulin degradation in the wound fluid were consistent with the characteristics of insulin-degrading enzyme. These data suggest that glucose control is a critical factor in wound healing, but a reduction in the insulin-degrading activity in the wound fluid is also a potential therapeutic target.     

Infection in chronic wounds: controversies in diagnosis and treatment

Chronic wounds all have bacterial contamination, which will not impair healing. Wound contamination must be distinguished from wound colonization and infection. Bacterial infection in wounds depends on the number of organisms present, their virulence, and host resistance. The most important indicators of infection are both local and systemic host characteristics and a holistic assessment of the patient. Several specimen collection and culture techniques are available to measure bacterial burden in the chronic wound. Advantages and disadvantages of each one discussed along with a rational approach to systemic antibiotic therapy. The presence of foreign material such as skin grafts or skin substitutes may lower the bacterial burden that may impair healing from 1.0 x 10(6) colony-forming units to 1.0 x 10(5) or less. The benefits of wound debridement, wound irrigation, and local nonantibiotic modes of treatment have been proven but the use of topical antibiotics and antiseptics requires further assessment. More widespread use of multiple nonantibiotic modalities of treatment for infected chronic wounds and rational antibiotic prescribing should reduce the risk of future antimicrobial resistance such as MRSA.     

A multidisciplinary, therapy-based, team approach for efficient and effective wound healing: a retrospective study

This paper presents a 4-year retrospective study (1994 to 1998) of therapy-based treatment outcomes for chronic wounds of all stages and most common etiologies. Treatment in this study consists of outpatient wound treatments given by trained therapists and nurses who were supervised by the podiatrist or internist. Many patients were referred to the clinic for last-resort treatment (i.e., electrical stimulation, topical hyperbaric therapy, etc.) before major lower extremity amputations: hip disarticulation, above knee amputation (AKA), below-knee amputation (BKA). This study does not consider age, sex, chronicity, or ethnicity because the authors want to demonstrate the effectiveness of this treatment approach for healing chronic wounds notwithstanding these variables. Wound healing was achieved in 100% of patients who completed their treatment program (233 patients with 242 wounds). This study shows the total average healing time for wounds is 7 weeks for Stage II wounds, 10 weeks for Stage III wounds, and 19 weeks for Stage IV wounds. The average healing time for diabetic wounds is 14 weeks (wounds of neuropathic origin heal in 12 weeks and wounds of ischemic origin heal in 16 weeks). The average healing time for venous stasis wounds is 8 weeks. The study includes patients with ischemia who are not candidates for revascularization. The authors assert that the most effective treatment for wound healing is a therapy-based, multidisciplinary team approach. This retrospective study shows that the goal of complete healing is attainable.     

Low-frequency, therapeutic ultrasound treatment for congenital ectodermal dysplasia in toddlers

Hay-Wells Syndrome is a rare genetic disorder characterized by ankyloblepharon, ectodermal dysplasia, and cleft palate. Recalcitrant scalp wounds with secondary infections are common. This case series describes the use of acoustic pressure wound therapy in 3-year-old fraternal twins (male and female) with HWS-associated scalp wounds. Present since infancy, the wounds were severe and extensive at presentation to the authors' wound clinic. Previous management consisted of standard topical treatments, including foam; oxidized, regenerated-cellulose/collagen with silver; calcium alginate; silver sulfadiazine cream; and biologic tissue matrix. Following admission to the authors' wound clinic, acoustic pressure wound therapy was administered one to three times weekly for 3 to 10 minutes for 7 months in addition to standard topical treatments to provide nonsurgical debridement and reduce wound bioburden without inflicting additional pain. Substantial improvements occurred during the first 5 weeks of consistent treatment. When treatments became sporadic due to health and family issues, wound deterioration occurred. After 7 months, wound sizes decreased by 31.3% in the boy and 1.1% in the girl, 70% of the wound surface in both children was covered with granulation tissue, and no clinical signs of infection were evident. The treatments were well tolerated. So far, the twins each received a total of 37 treatments. Consistent, long-term acoustic pressure wound therapy improved the status of severe, recalcitrant, Hay-Wells Syndrome-associated scalp wounds.