Abstract: Background. The diabetic foot is a common site of infections that frequently result in significant patient morbidity and mortality. Antibiotic treatment is an important part of therapy with selection of the specific agent depending on the stage of ulceration. Recently, ertapenem has entered use as first line therapy for moderate to severe diabetic foot infections. The following prospective study recounts the experience of using ertapenem as tertiary salvage therapy following failure of first and second-line antibiotics. Methods. Forty consecutive patients with di

Index: WOUNDS 2012;24(1):10–17

  Abstract: Data from registries can be especially useful in the evaluation of healthcare effectiveness. Thus, the goal of this study was to report on use of the US Wound Registry to investigate the outcomes of a broad population of patients undergoing treatment. Using a 5-year slice of de-identified data from electronic health records originating from 59 hospital-based outpatient wound centers in 18 states, outcomes, patient and wound variables, and costs for facility and physician fees and procedures were analyzed for 5240 patients with 7099 wounds. Mean patient age was 61.7 years with 52.3% being male and the majority Caucasian (73.1%) and Medicare beneficiaries (52.6%). The mean number of serious comorbid conditions per patient was 1.8, with the most common being diabetes (46.8%), obese or overweight (71.3%), and having cardiovascular or peripheral vascular disease (51.3%). More than 1.6% of patients died in service or within 4 weeks of the last visit. Almost two thirds of wounds healed (65.8%) with an average time to heal of 15 weeks and 10% of wounds taking 33 weeks or more to heal. The average wound surface area was 19.5 cm². Half of wounds that healed did so with only the use of moist wound care (50.8%) and without the need for advanced therapeutics. Mean cost to heal per wound was $3927 with jeopardized flaps and grafts the most expensive ($9358). This Registry would seem ideal for comparative effectiveness research in wound care, as it includes patients often excluded from randomized controlled trials and reflects actual practice.

Index: WOUNDS 2012;24(1):3–9

  Abstract: Evidence-based medicine (EBM) uses the current best evidence to inform decisions about care of individual patients, healthcare procedures, and technologies. The “gold standard” for optimal evidence in the Cochrane system is Level I randomized, controlled trials (RCTs) and meta-analyses of several RCTs. In order to achieve this level of evidence, one of the most important measures is the use of outcomes/endpoints. This article will provide, in short form, recommendations on how to achieve rigorous endpoints or outcomes in studies on wound management. Consistency in measuring endpoints/outcomes improves quality of care. To achieve such consistency it is important to 1) use predefined and robust outcomes; 2) adapt outcomes to the intervention under investigation; and 3) use the best evidence available. Also, it is emphasized that the use of complete wound closure or healing as an outcome measure is not always possible or suitable. Remaining patient-focused clarifies which other endpoints are relevant. Finally, “basic care” must be clearly defined and standardized when used as a comparative intervention in a RCT. In conclusion, the use of correct, clinically relevant outcomes or endpoints is of vital importance when establishing optimal evidence in wound healing and care.

Index: WOUNDS 2011;23(11):342–349

  Abstract: Fournier’s gangrene (FG) is a complex condition that requires surgical debridement, hemodynamic support, antibiotics, and appropriate wound management. This study is the first to assess the use of a low-vacuum negative pressure wound therapy (LV-NPWT) system with low-adherent contact surface in two cases of FG. Methods. The protocol-of-care included twice weekly dressing changes and irrigation with a povidone-iodine-water mixture. Assessments included wound progression (% granulation tissue), ratings of dressing ingrowth, pain during treatment and at dressing changes, patient comfort, and ease-of-use. Results. A 51-year-old man (Patient A) developed FG after surgical removal of a perianal abscess. He received 16 days of LV-NPWT with five dressing changes. A 64-year-old man (Patient B) with multiple comorbidities, developed FG after traumatic injury. He received 20 days of LV-NPWT with six dressing changes. In both patients, LV-NPWT promoted rapid granulation tissue formation. Pain scores averaged low-to-moderate during treatment and dressing changes, and tissue ingrowth was minimal. Conclusion. Overall, ratings were favorable for LV-NPWT ease-of-use and patient comfort. Despite the complexity of these wounds, with the use of LV-NPWT, both wounds progressed to a point where they were able to successfully receive surgical closure with skin grafts and/or flaps. These cases may suggest that LV-NPWT may have a potential role in complex wound management.

Index: WOUNDS 2011;23(11):332–341

  Abstract: Scar contracture is a debilitating disease that affects many people worldwide. There are currently no effective preventative medical treatments. A pivotal step to attaining the goal of developing a treatment is the testing of anti-scarring agents in preclinical hierarchical animal models of human scarring. Methods. A 2-cm x 2-cm, full-thickness, excisional wound was created in the rats’ mid-scapular area. Three experiments were performed. The first experiment determined the optimal dressing in wound contraction. The second experiment developed upon the results of the first experiment, and determined how anatomic site of osmotic pump implantation affected wound healing. The third experiment determined how the size of osmotic pump affected wound healing. Wound healing parameters including rate of wound contraction, systemic and local toxicity, proliferation, collagen architecture, and collagen production were assessed. Results. The results of the present study showed that covering the wound with Tegaderm™ (3M Health Care, St. Paul, MN) alone had the most linear wound contraction rate with the smallest standard error of the mean. Implantation of all osmotic pump sizes, when implanted intraperitoneally, was tolerated and did not interfere with wound healing. In contrast, subcutaneous implanted pumps caused significant discomfort in the rats. Conclusion. Implantation of an osmotic pump intraperitoneal in the rat excisional wound model, where the wound is covered with Tegaderm, provides for a reproducible, accurate, preclinical animal model to study anti-scar contracture treatments.

Index: WOUNDS 2011;23(11):328–331

  Abstract: Ischemic postconditioning (IPOC) is a useful manipulation to reduce the undesirable effects of ischemia-reperfusion (IR) injury. The effects of IPOC were studied in an axial pattern skin flap model. Methods. The skin flaps of 40 rabbits were randomly divided into four groups. Ischemic postconditioning was performed using six 10-second cycles of repeated ischemia/reperfusion periods. The animals were allocated into four groups: group 1 (control); group 2 (ischemia); group 3 (postconditioning); group 4 (postconditioning 10 minutes later). Flap viability was assessed 1 week after the operation. The surviving flap area was recorded as a percentage of the entire flap area. Fisher’s least significant difference (LSD) test was used for statistical analysis among different groups to evaluate the effects of ischemic preconditioning against ischemia. Results. The mean ± SD of surviving flap areas for groups 1, 2, 3, and 4 were 97.86 ± 0.62, 31.64 ± 1.04, 48.95 ± 0.82, and 30.01 ± 1.12, respectively. Statistical difference did not exist between group 2 and 4, but they were statistically different (P < 0.05) when compared to group 1 or group 3. Conclusion. Ischemic postconditioning has a protective effect on ischemic flaps, but postconditioning should be performed just after the ischemic event.

Index: WOUNDS 2011;23(10):309–319

  Abstract: Negative pressure wound therapy (NPWT) with reticulated open-cell foam (ROCF) dressings (ROCF G, V.A.C.® GranuFoam™ Dressing, KCI USA, Inc, San Antonio, TX) creates a healing environment that removes wound exudates, reduces edema, and promotes perfusion and granulation tissue formation. Controlled instillation of saline during NPWT (NPWTi) may further enhance healing by facilitating automatic and contained volumetric wound irrigation and cleansing. A new ROCF dressing (ROCF-V, V.A.C. VeraFlo™ Dressing, KCI USA, Inc, San Antonio, TX) has been developed for use with NPWTi; benchtop and in vivo tests compared the properties and performance of both ROCF-G and ROCF-V. Pore size and density (contributors to microdeformation) are similar for both ROCF-G and ROCF-V, while mechanical testing demonstrates ROCF-V is stronger than ROCF-G under both tensile and tear loading. ROCF-V surface energy is higher than ROCF-G, making ROCF-V less hydrophobic. Under wet conditions ROCF-V wicks more fluid and shows less pressure drop than ROCF-G, suggesting ROCF-V may be better suited for NPWTi. After 7 days of therapy in a porcine full-thickness excisional wound model, NPWTi with ROCF-V resulted in a 43% increase (P < 0.05) in granulation tissue thickness compared to NPWT with ROCF-G. These data suggest NPWTi with ROCF-V creates a wound healing environment that provides enhanced granulation tissue formation compared to standard NPWT with ROCF-G.

Index: WOUNDS 2011;23(9):285–292

  Abstract: The ability to predict the prognosis of a pressure ulcer is re¬quired to establish appropriate management in the early phase. The present study reports the usefulness of a combined assessment tech¬nique using ultrasonography and thermography for predicting delayed wound healing. Methods. This retrospective cohort study included 37 patients with Stage I or II pressure ulcers. The patients were followed up for at least 3 weeks. The ultrasonographic and thermographic as¬sessments were conducted at the initial multidisciplinary team round. The presence of four ultrasonographic features (unclear layered struc¬ture, hypoechoic lesion, discontinuous fascia, and heterogeneous hy¬poechoic area) and one thermographic feature (increased temperature) were determined from within the wound bed. Wound healing was re¬assessed after 2 weeks and the rate of area reduction was calculated to determine whether the pressure ulcer was healing properly. A mul¬tivariate logistic analysis was used to assess the predictive values of the possible assessment features. Results. A comprehensive review of the ultrasonographic and thermographic assessments of the pressure ulcers found that the combination of unclear layered structure and increased temperature was beneficial for predicting wound healing. When a pressure ulcer presented with an unclear layered structure and increased temperature in the wound bed, the risk of delayed wound healing or wound deterioration was 6.85 times higher compared with a pressure ulcer that did not have these manifestations. Conclusion. The combination of ultrasonographic and thermographic assessments facilitates precise prediction of pressure ulcer outcomes.

Index: WOUNDS 2011;23(9):276–284

  Abstract: Hemodynamic 3D infrared thermal stereoscopic imaging (TSI) was tested as a new non-invasive diagnostic method for studying chronic vascular leg ulcers. The aim was to test this new diagnostic approach in investigating mixed arterio-venous wounds. Duplex ultrasonography is the most useful test for investigating hemodynamic alterations in patients with vascular cutaneous ulcers; however, it fails to provide any information about microvascular dysfunctions, which could play a significant role in the development of skin wounds. The study of thermal patterns at the wound site represents a method of investigating cutaneous microcirculation—temperature gradients indicating abnormal blood flow in the margins and bed of wounds with vascular disorders are well correlated with clinical findings. Methods. In order to evaluate the predominance of the arterial or venous component in vascular mixed ulcers of the leg and to understand the underlying pathology of the ulcers, 3D thermography was tested in three different hemodynamic positions. A total of 20 physiological and 20 pathological patients were assessed standing, supine, or in a discharging position (legs raised above heart level). Results. A relatively constant temperature trend was observed in healthy subjects, while a different reaction was recorded in those with ulcerated legs. Moreover, a different temperature trend was noted among the varying hemodynamic positions and a trend difference was also observed between arterial and venous ulcers in clinical investigation tests. Conclusion. TSI appears to be a safe, user-friendly, rapid, and promising procedure for distinguishing both arterial and venous involvement in mixed arterio-venous leg ulcers.

Index: WOUNDS 2011;23(9):267–275

  Abstract: Traditional wound tracing technique consists of tracing the perimeter of the wound on clear acetate with a fine-tip marker, then placing the tracing on graph paper and counting the grids to calculate the surface area. Standard wound measurement technique for calculating wound surface area (wound tracing) was compared to a new wound measurement method using digital photo-planimetry software ([DPPS], PictZar® Digital Planimetry). Methods. Two hundred wounds of varying etiologies were measured and traced by experienced examiners (raters). Simultaneously, digital photographs were also taken of each wound. The digital photographs were downloaded onto a PC, and using DPPS software, the wounds were measured and traced by the same examiners. Accuracy, intra- and interrater reliability of wound measurements obtained from tracings and from DPPS were studied and compared. Both accuracy and rater variability were directly related to wound size when wounds were measured and traced in the traditional manner. Results. In small (< 4 cm²), regularly shaped (round or oval) wounds, both accuracy and rater reliability was 98% and 95%, respectively. However, in larger, irregularly shaped wounds or wounds with epithelial islands, DPPS was more accurate than traditional measuring (3.9% vs. 16.2% [average error]). The mean inter-rater reliability score was 94% for DPPS and 84% for traditional measuring. The mean intrarater reliability score was 98.3% for DPPS and 89.3% for traditional measuring. In contrast to traditional measurements, DPPS may provide a more objective assessment since it can be done by a technician who is blinded to the treatment plan. Planimetry of digital photographs allows for a closer examination (zoom) of the wound and better visibility of advancing epithelium. Conclusion. Measurements of wounds performed on digital photographs using planimetry software were simple and convenient. It was more accurate, more objective, and resulted in better correlation within and between examiners.