Wound Masterclass - June 2023

Volume 2: Issue 5 - June 2023

woundmasterclass.com Open Access | Peer Reviewed | International | Quarterly ISSN 2753-6963

Connecting Global Wound Care Through Cutting-Edge Tech

Topical Oxygen: Where Does It Fit in Your Practice Wound Healing with Your Tablet: Breaking Barriers Across the Care Continuum Technology for Early Detection of Skin and Tissue Damage Social Determinants of Health, Epigenetics, and the Biochemical Response to Stress Support Surface Testing: How to Use What We Get

Masterclass GUIDES

Hidradenitis Suppurativa

Onychomycosis Fungal Nail

Official Journal of the Association for the Advancement of Wound Care®

Editorial Board

United Kingdom & Europe Dr Negin Shamsian

Prof Dimitri Beeckman

Dr Przemysław Lipiński

Prof Dr C. Can Cedidi

Dr Guido Ciprandi

Consultant Plastic & Reconstructive Surgeon (Locum)

Professor of Nursing Science, Ghent University (Belgium) and Vice-Head of the School of Health Sciences, Örebro University (Sweden)

Wound Surgeon, National Representative of Poland in D-Foot International

Clinic Director for Plastic, Reconstructive & Aesthetic Surgery

Professor of Wound Care at the Universities of Rome, Pavia, Turin, Trieste and Pisa

Łódź, Poland

Bremen, Germany

Specialist in thoracic surgery and pediatric surgery

Chief Editor of Wound Masterclass

Ghent, Belgium

London, United Kingdom

Rome, Italy

Dr Paul Chadwick

Mr Harm Jaap Smit

Ms Lian Stoeldraaijers

Prof Declan Patton

National Clinical Director, Royal College of Podiatry

Wound Biologist, Erasmus MC Academy Rotterdam

President, Dutch Association of Diabetes Podiatrists

Manchester, United Kingdom

Rotterdam, Netherlands

Valkenswaard, Netherlands

Director of Nursing and Midwifery Research and Deputy Director of SWaT Research Center, RCSI University of Medicine and Health Sciences Dublin, Ireland

Prof Jan Kottner

Prof Dr Luca Dalla Paola

Dr Sebastian Probst

Prof Dr Marco Romanelli

Professor of Nursing Science, Charité - Berlin University of Medicine

Specialist in Endocrinology, Metabolic Diseases and Diabetology

EWMA President

Berlin, Germany

Expert in medical and surgical treatment of Diabetic Foot

Full Professor and Chairman, Division of Dermatology, Department of Clinical and Experimental Medicine, University of Pisa

Ferrara, Italy

Professor of Tissue Viability and Wound Care at the School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, Geneva

Pisa, Italy

Genf, Switzerland

North America Mr Frank Aviles

Ms Kara Couch

Dr Kenneth Burhop

Mr Tobe Madu

Wound Care Clinical Coordinator, Natchitoches Regional Medical Center

President-Elect, Association for the Advancement of Wound Care

Life Sciences Advisor and Consultant

Data Scientist, Net Health

Associate Research Professor of Surgery, School of Medicine and Health Studies George Washington University

Natchitoches LA, United States

San Diego CA, United States

Atlanta GA, United States

Director, Wound Care Services, The George Washington University Hospital

Arlington VA, United States

Dr Windy Cole

Dr M. Mark Melin

Dr Leo Nherera

Dr Brandon Bosque

Director of Wound Care Research, Kent State University of Podiatric Medicine

Medical Director of the M Health Wound Healing Institute

Director, Global Head of Health Economics & Outcomes Research

Foot and Ankle Surgeon

National Director of Clinical Safety, Quality and Education, Woundtech

Adjunct Associate Professor, University of Minnesota Surgical Department

Fort Worth TX, United States

Streetsboro OH, United States

Philadelphia PA, United States

Mineapolis MN, United States

Dr Mitch Sanders

Prof David Armstrong

Dr Aliza Lee

Dr Alton R. Johnson

CSO and EVP Alira Health.

CEO of WoundForce Inc. and Firefly Innovations LLC.

Professor of Surgery and Director, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of USC

Clinical Research Investigator, Department of Veterans Affairs

Podiatric Surgeon

Salem VA, United States

Ann Arbor MI, United States

Boston MA, United States

Los Angeles CA, United States

Dr Jonathan Johnson

Dr David Alper

Dr Ruth Bryant

Surgical Director, Comprehensive Wound Care Services

Trustee - Board of Trustees, American Podiatric Medical Association

Nurse Scientist and WOC nurse, Abbott Northwestern Hospital

Board Member - American Diabetes Association (New England)

Washington DC, United States

Surgical staff (Emeritas) - Mount Auburn Hospital Cambridge, MA, United States

Minneapolis MN, United States

Boston MA, United States

East Asia

Australia

South & Central America

Dr Joon Pio Hong

Dr Ross D Farhadieh

Professor of Plastic and Reconstructive Surgery at the University of Ulsan College of Medicine and Asan Medical Center

Cosmetic Plastic & Reconstructive Surgeon Sydney, Australia

Prof Dr Harikrishna K. R. Nair President Elect, WUWHS - World Union of Wound Healing Societies

Ms Terry Swanson

Dr Eduardo Camacho

Vice Chair, International Wound Infection Institute

Plastic and Reconstructive Surgeon

Victoria, Australia

Mexico City, Mexico

President, Asia Pacific Association of Diabetic Limb Problems Kuala Lumpur, Malaysia

Dr Honda Hsu Plastic Surgeon and Associate Professor, Tzu Chi General Hospital Hualien, Taiwan

Middle East Sr Trish Idensohn

Prof Amit Gefen

Wound Nurse Specialist, Consultant and Educator

Professor of Biomedical Engineering, Tel Aviv University

Durban, South Africa

Head and Neck Surgeon, Associate Professor Instituto Universitario Hospital Italiano Buenos Aires, Argentina

Seoul, South Korea

Africa

Dr Luis Alejandro Boccalatte

Tel Aviv, Israel

Wound Care Physician

June 2023

Connecting Global Wound Care Through Cutting-Edge Tech | Dr Negin Shamsian

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Peripheral Arterial Disease (PAD) National Action Plan | Dr Karen Bauer

4-6

Technology Update - Micro and Macro Assessment of Perfusion | Dr Alisha Oropallo

8 - 11 13 - 14

editor@woundmasterclass.com

Topical Oxygen: Where Does It Fit in Your Practice | Dr Gregory Bohn

Commercial Inquiries

Technology of the Foot Defender | Dr Jason Hanft

16 - 17

Disparities in Wound Care: Social Determinants of Health, Epigenetics, and the Biochemical Response to Stress | Dr Laura Swoboda

20 - 23

Technology for Early Detection of Skin and Tissue Damage | Dr Ruth A. Bryant

26 - 29

Development and Psychometric Evaluation of a Decision Support Tool to Prevent Community Acquired Pressure Injury for the SCI Clinic | Dr Barbara M. Bates-Jensen

30 - 31

Washington and Its Impact on Wound Care: Coding, Coverage and Payment Policies Through a Wound Care Lens | Ms Marcia Nusgart

32 - 33

Wound Healing with Your Tablet: Breaking Barriers Across the Care Continuum | Dr Jonathan Johnson

36 - 37

Wound Bed Preparation to Optimize Topical Therapy | Dr Gregory Bohn

38 - 40

Support Surface Testing: How to Use What We Get | Mr Evan Call

42 - 43

Chief Editor Miss Negin Shamsian Commercial Director Mr Alec Wright Contact Editor

commercial@woundmasterclass.com

Article Submissions submissions@woundmasterclass.com

Published by Clarus Communications Ltd., Oxford, United Kingdom No part of this issue is to be copied or reproduced without permission of the publisher © Clarus Communications Ltd.

This publication is intended for online distribution and this issue is not suitable for print in this form To inquire about obtaining a printable version of this issue or any article therein, please contact the editor

Cover image:

Masterclass GUIDES Licenced from Adobe Stock Credit: jamesteohart

Hidradenitis Suppurativa

46 - 49

Onychomycosis Fungal Nail

50 - 53

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For more information contact info@omni-stat.com visit www.omni-stat.com 1. In Vitro and In Vivo Data on file at Omni-stat Medical Inc. 2. Millner R, Lockhart AS, Marr R.Chitosan arrests bleeding in major hepatic injuries with clotting dysfunction: an in vivo experimental study in a model of hepatic injury in the presence of moderate systemic heparinisation.Ann R Coll Surg Engl 2010; 92(7):559-561 3. Snyder RJ, Sigal BD.The importance of hemostasis in chronic wound care: an open-label controlled clinical study of OMNI-STAT (chitosan) versus standard of care in post-debridement treatment of patients with chronic wounds with or without concomitant use of anticoagulants.Wound Care Hyperb Oxygen 2013; 4(2):9-16

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Connecting Global Wound Care Through Cutting-Edge Tech We have had an outstanding series of events as part of the Wound Masterclass Academy including podcasts, the Global Innovation in Wound Care Summit series and MasterSeries 60 Minutes. Please register for all our free wound care content: woundmasterclass.com/Register

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dvancements in technology are revolutionizing the field of wound care and helping providers better treat all sorts of wounds. New high-tech wound dressings, bioengineered skin products, negative pressure devices, and telehealth solutions are bringing improved healing times and outcomes.

One area seeing major innovation is smart wound dressings. These high-tech bandages can detect critical factors impeding healing, including inflammation, infection, and exudate.

Some contain microsensors that continuously monitor wound temperature, pH, moisture, and bacterial growth and transmit feedback to caregivers through connected apps and cloud platforms. Others have microchips that track application time and dosage. Armed with real-time data, doctors and nurses can swiftly intervene at signs of complications.

Wearable negative pressure wound therapy (NPWT) devices are also game-changers.

Traditionally bulky and cumbersome, new streamlined, portable NPWT pumps deliver targeted air pressure to dressed wounds anywhere patients go. This mobilization enhanced by longlife batteries aids circulation and faster healing.

Telehealth solutions likewise enable remote wound care. Through online portals, patients can upload wound images and key metrics trackable through smart bandages and mobile apps. AI-powered diagnostic tools analyze the digital wound data and create care plans, while chat features connect patients with remote specialized wound nurses.

Exciting advances are happening on the cellular level too, some products leverage skin cell spraying or harvesting technologies

to regenerate skin right on wounds. Others utilize 3D bioprinters to directly print skin and muscle tissue onto injuries. These revolutionary techniques mean non-healing wounds get reconstructed cell layers rather than traditional wound coverings.

Biomedical engineers continue stretching possibilities for cybernetic limb replacements for wound-causing amputations. High-tech prosthetics now connecting to electrical impulses from remaining muscles and nerves restore more intuitive mobility. Integrated sensors relay tactile information on touch, pressure, temperature, and vibration back to the brain through programs decoding these signals into discernable sensations.

Through ground breaking steps melding medicine, engineering, AI, robotics, 3D printing, and material science, technology advances equip caregivers to confront wound adversities like never before. Still endless potential remains untapped in the frontier where tech meets flesh. Ongoing interdisciplinary innovations portend a future where complex injuries heal quicker and more comprehensively than previously fathomable.

Dr Negin Shamsian Consultant Plastic & Reconstructive Surgeon (Locum) Chief Editor of Wound Masterclass London, United Kingdom

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AAWC PRESENTATIONS AT A GLANCE

Peripheral Arterial Disease (PAD) National Action Plan Editorial Summary Among the public as well as health care professionals, there is a poor understanding of PAD prevention and early detection leading to under-treatment despite the recognition that it leads to nontraumatic lower extremity amputations, death, MI and stroke. The PAD National Action Plan was generated to transform awareness, knowledge, assessment and management of patients with and at risk for PAD. This article is an overview of the goals and research of the PAD National Action Plan.

Introduction

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ach year, approximately 150,000 leg amputations are administered in the United States. Black and Native American people, and other groups that are more likely to have a lower socioeconomic status, are at the highest risk of leg amputations.

The public and professionals in healthcare have a poor understanding of peripheral arterial disease prevention and early detection. There is undertreatment, in spite of the recognition that it may lead to non-traumatic lower extremity amputations, death, MI and stroke.

The national action plan was generated to transform awareness, knowledge, better assessment, and management for those who are at risk, and patients that have PAD. PAD is an atherothrombotic disease outside of the coronary arteries. Acute Limb Ischemia (ALI) is 2 weeks severe hypoperfusion of the limb.

Critical Limb Ischemia (CLI) is more or less 2 weeks of ischemic rest pain, with non-healing wound/ ulcers or gangrene. A very low ABI or TBI does not necessarily mean that the patient has CLI.

Epidemiology

Presentation by Dr Karen Bauer

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In 2015, 5.6% of the global population was affected with PAD. By 2050, an estimated 19 million Americans will also be affected by it.

Since 2000-2015, there has been a 45% global increase, and this has been disproportionate with low to middle income counties. It is more common in black women and men, at 16.9% and 13.2%, compared to white women and men,

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at 12.1% and 10.9%. It usually affects those aged 65 and older. In high income countries, it is more common for men to have PAD, while in low-middle income countries, women are more likely to have it. 46% - 68% of patients with PAD have diseases in one or more vascular beds.

PAD’s risk factors are similar to coronary artery disease (CAD) and cardiovascular disease (CVD). However, the epidemiologic data gives PAD recognition as a unique entity.

Disease Burden There are high mortality and morbidity rates worldwide. Direct costs are reportedly higher than those for CAD: polyvascular disease/ hospitalization rates. The prevalence of CLTI is 1.3% among individuals aged 40 years or older (11% of overall PAD). It is also the third leading cause of atherosclerotic cardiovascular disease (ASCVD) morbidity and mortality after myocardial infarction (MI) and stroke.

Figure 1:

Peripheral Arterial Disease (PAD) National Action Plan

Figure 2

Figure 3

PAD is a CHD and cerebrovascular disease risk equivalent for ASCVD. PAD is high risk for all cause of mortality.

Gaps in Care PAD is unfortunately underrecognized and underdiagnosed. The main misconception is that limb diseases are unable to be fatal. PAD is not recognised to be a disabling condition; it is mainly wrongly seen as a sign of aging.

Black Americans are more likely to have PAD more than any other racial and ethnic groups.

They have more atypical symptoms and are more likely to suffer worse outcomes from the disease. There is also a higher prevalence of cardiovascular risk factors within this demographic.

Regions with intense vascular care have much lower amputation rates. Similarly, the wealthier regions have lower amputation rates. Overall, the disparities between white and black increase where the sources are the greatest.

The goal is to reduce serious complications and improve the quality of life for people living with PAD. This can be achieved by improving public awareness of the symptoms and diagnosis of PAD. By diversifying the national patient advisory group, messaging needs can be better identified. In addition to this, the approach should be prioritised to reach at risk groups.

Funding should also be secured in order to launch and sustain PAD consumer awareness initiatives.

From the perspective of patients (specifically from wounds due to chronic limb-threatening ischemia), they have limited coping mechanisms. They are also overwhelmed by the care of their wounds. Patients suffering have a strong desire to do everything to prevent limb loss but find it difficult to translate this into real life.

Another goal is to enhance professional education for multi-disciplinary providers who care for people with PAD. This involves teaching professionals on how to empower patients with PAD, improving their experience and satisfaction. Also, to develop and disseminate educational curriculum and guidelines to multidisciplinary providers. Fundamentally increasing awareness, detection, and screening of patients at risk for PAD. It is also important to activate healthcare systems that can provide enhanced programs for the detection and treatment of PAD patients, with an improved understanding of patient-centred outcomes for PAD. This will allow for the improvement of PAD detection, treatment, and timely referral for revascularization. It can also develop approaches for patient-centred PAD care and stablish standards and accreditation for supervised exercise therapy (SET) programs.

As per the 2016 AHA/ACC guidelines, Supervised Exercise Therapy (SET) is an important piece of care for claudicants prior to revascularization. SET may also improve modifiable cardiovascular risk factors. The barriers for home-based exercise programs

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Peripheral Arterial Disease (PAD) National Action Plan include the lack of supervision, potential lack of self-environment, and the lack of reimbursement.

Another aim is to reduce the rates of nontraumatic lower extremity amputations related to PAD by public outcome reporting and public health interventions. This can be achieved by establishing systems for public reporting of amputations at the hospital level, developing and implementing public policy for payment and service delivery model to improve PAD care, including screening. Also urging expert organisations, government agencies, the media, and public organisations to highlight amputation.

In order to increase and sustain research to better understand the prevention, diagnosis and treatments of PAD, a range of things should be done. This includes increasing the number of scientist that are studying peripheral artery disease, both junior and senior. Also conducting advance research in CLTI and leveraging data science to expand PAD knowledge and generate research hypothesis.

The last goal aims to coordinate PAD advocacy efforts to influence national policy, enabling it to translate accordingly into health care actions. Methods that can be done to achieve this include developing resources to train PAD volunteers as advocates, creating a PAD actions. Methods that can be done to achieve this include developing resources to train PAD volunteers as advocates, creating a PAD advocacy toolkit, furthering the advocacy agenda by aligning with partner organisations’ advocacy campaigns, and mobilising PAD advocates to influence lawmakers in support of the agenda and cause.

PAD can be evaluated via:

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Physical examination – ABI, TBI, Segmental Pressures

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Transcutaneous oxygen measurement

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Pulse waveform or pulse wave recording

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Skin Perfusion Pressure

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Duplex imaging

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Angiogram, CTA, MRA

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Florescence angiography • Thermography perfusion

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Conclusion To conclude, there are many things that can be done to mitigate the disproportionate effects PAD have on patients, as well as to ease its effects on patients living and coping with it. A much higher awareness regarding this matter and better implemented strategies can transform the lives of many.

References 1. Aday, A. W., & Matsushita, K. (2021). Epidemiology of Peripheral Artery Disease and Polyvascular Disease. Circulationresearch, 128(12), 1818–1832 | Bauersachs, R., Zeymer, U., Brière, J. B., Marre, C., Bowrin, K., &Huelsebeck, M. (2019). Burden of Coronary Artery Disease and Peripheral Artery Disease: A Literature Review. Cardiovascular therapeutics, 2019, 8295054 https://doi.org/10.1155/2019/8295054.

2. Colantonio, L. D., Hubbard, D., Monda, K. L., Mues, K. E., Huang, L., Dai, Y., Jackson, E. A., Brown, T. M., Rosenson, R. S., Woodward, M., Muntner, P., &Farkouh, M. E. (2020).

Atherosclerotic Risk and Statin Use Among Patients With Peripheral Artery Disease. Journal of the American College of Cardiology, 76(3), 251–264. https://doi.org/10.1016/j.jacc.2020.05.048 3. Criqui, M. H., Matsushita, K., Aboyans, V., Hess, C. N., Hicks, C. W., Kwan, T. W., McDermott, M. M., Misra, S., Ujueta, F., & American Heart Association Council on Epidemiology and Prevention; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular Radiology and Intervention; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; and Stroke Council (2021).

Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association.

Circulation, 144(9), e171–e191. https://doi.org/10.1161/CIR.0000000000001005 4. Nedunchezhian, Reddy, Weggener, O’Connell, & Ferdinand 2022 5. Hackler, E. L., 3rd, Hamburg, N. M., & White Solaru, K. T. (2021). Racial and Ethnic Disparities in Peripheral Artery Disease. Circulation research, 128(12), 1913–1926. https://doi. org/10.1161/CIRCRESAHA.121.318243 6. Durazzo, T. S., Frencher, S., &Gusberg, R. (2013). Influence of race on the management of lower extremity ischemia: revascularization vs amputation. JAMA surgery, 148(7), 617–623.

Goodney, P et al.,(2013). Regional intensity of vascular care and lower extremity amputation rates. Journal of vascular surgery, 57(6), 1471–1480. https://doi.org/10.1016/j.jvs.2012.11.068 7. Ceja Rodriguez, M., Mark, J. R., Gosdin, M., & Humphries, M. D. (2021). Perceptions of patients with wounds due to chronic limb-threatening ischemia. Vascular medicine (London, England), 26(2), 200– 206. https://doi.org/10.1177/1358863X20987896 8. Gerhard-Herman, M. D., et al. (2017). 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.

Circulation, 135(12), e726–e779. https://doi.org/10.1161/CIR.0000000000000471 9. Pymer, S.,et al..(2021). An updated systematic review and meta-analysis of home-based exercise programs for individuals with intermittent claudication. Journal of vascular surgery, 74(6), 2076–2085.e20. https://doi.org/10.1016/j.jvs.2021.03.063

AAWC PRESENTATIONS AT A GLANCE

Technology Update - Micro and Macro Assessment of Perfusion Editorial Summary This article examines innovations in the assessment and management of macro and microperfusion abnormalities that accompany venous and arterial disease, considering what is new and when to use these in clinical practice.

Introduction

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hronic Venous Insufficiency (CVI) is the most common vascular disease with it affecting over 25 million people.

It affects 1 out of every 2 females over the age of 50. It is the most common cause of adult leg edema. The sequelae consists of edema, varicose veins, skin discoloration, skin thickening, and ulceration. Its symptoms include leg edema, fatigue, cramping, heaviness, pain, itching, and achiness.

Pathophysiology Chronic venous insufficiency pathophysiology looks to see disruption of the one-way valve system in veins. The blood flow refluxes due to the incompetent valves and pools in the lower extremities. Dilation of the veins to accommodate volume results in development of varicosities. Treatment is focused on the superficial system (the great and small saphenous veins in the leg).

Advanced Wound Care Dressings Advanced wound care dressings are determined by wound location, size, the amount of exudate present. It is also, dependent on the frequency of dressing change, and the payer’s source or cost and availability.

Endovenous Intervention Presentation by Dr Alisha Oropallo

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Faster healing rates of venous ulcers, when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, versus compression alone,

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or with delayed intervention of an ulcer that has not reached closure after six months.

Compression Therapy Consists of elastic, with bandages conforming to the size and shape of the leg, or inelastic multi layers. Stockings or custom garments of a 30mmHg to 40mmHg compression may also be involved.Leg elevation above the heart level with compression therapy is also effective as it helps to increase microcirculatory flow . There are three types of pneumatic compression pumps, delivering variances of pressure gradient, inflation, and deflation cycles.

Types of Skin Replacement Products There are many types of skin replacements.

Allografts are harvested from and transplanted between the same species and is achieved via cadaveric skin. On the other hand, Xenografts are skin replacements harvested from a different species. This can include from porcine, bovines and equines. Thirdly, there is the Allogeneic matrix option where the sources may be the placenta, umbilical cord, amnion, and chorion.

Another source may be the composite matrix, in which it is a combination of inorganic or organic material. Similarly, the acellular matrix is a surgical mesh, developed for animal or human skin.

Treatment modalities include conservative management, injectable foam, sclerotherapy, YAG laser therapy, stab avulsion/phlebectomy.

It also includes vein ablation (closure) which can be achieved via radiofrequency ablation, laser, and chemical adhesive methods.

Technology Update - Micro and Macro Assessment of Perfusion Preservation methods and conservative management involves a range of methods.

This includes compression therapy/stockings, leg elevation, pain management, exercise, and weight loss.

Radiofrequency (RFA) or Laser (EVLT) Vein Ablation is an in-office procedure lasting 20-30 minutes. It is thermal ablation carried out under local tumescent anaesthesia. Its closure rate is approximately 98%, and it holds a low risk; the occurrence of deep vein thrombosis (DVT) or an infection is less than 1%. The procedure improves the quality of the patient’s life, as well as reducing and/or resolving the patient’s symptoms.

Endovascular embolization (non-thermal, non-tumescent, non-sclerosant ablation) with approximately 98%, and it holds a low risk; the occurrence of deep vein thrombosis (DVT) or an infection is less than 1%. The procedure improves the quality of the patient’s life, as well as reducing and/or resolving the patient’s symptoms.

Endovascular embolization (non-thermal, non-tumescent, non-sclerosant ablation) with coaptation is a system that delivers a small amount of specially formulated medical adhesive (cyanoacrylate) to the incompetent vein. The adhesive (glue) permanently seals the vein and blood is rerouted into the deep venous system. The key is to deliver the cyanoacrylate and compress the leg manually for optimal coaptation of the vein walls using recommended timed intervals. A small amount of ‘foam’ is injected into the incompetent vein, displacing the blood, effectively filling the lumen for circumferential contact. There is endothelial destruction with very low polidocanol concentration. The vein contracts, narrowing the lumen, and collapsing the vein.

Patient Outcome and Satisfaction The closure rates for vein ablations is 98%.

There is a reduction of recurrent ulcerations, and an improvement in ulcer healing rates. The complication risk is low, again, less than 1% for DVT or infections.

can return to normal activity post procedure.

Figure 1 shows 1 month follow up photos.

The VIRTUS trial was a prospective, multicentre trial demonstrating a twelve-month safety and effectiveness using of a dedicated venous stent for ICVO. It demonstrates improvements in clinical symptoms and quality of life using the Venous Clinical Severity Score (VCSS), through a 1-year follow up.

Double blinded randomized controlled trial (RCT) demonstrates pain relief via visual analogue scale. There was significant clinical improvement in the VCSS and in the SF-36 quality of life in patients randomized to iliac vein stenting versus best medical management.

Although it is not statistically significant, the rate of venous leg ulcer healing improved.

Despite the successful endovenous thermal ablation vein closure, there is a 5-year recurrence rate of 20.9% after endovenous thermal ablation.

This may be due to the presence of underlying ICVO. In a retrospective study, symptoms that continued to persist during a mean of four months post EVTA that underwent vein stent placement, results in further symptomatic relief in about 1/3 of patients treated with venous stenting.

To conclude, the surgical approaches to venous insufficiency with ulcerations may vary. The interdisciplinary team approach consists of inpatients, outpatients, rehabs, hospices, and homes. It also consists of vascular testing, nutrition (L-Arginine, L-Glutamine), compression therapy, negative pressure, dressing management and oxygen therapy.

The measurement of tissue perfusion/ oxygenation helps to answer key questions in limb preservation and wound care. This features whether there is an adequate perfusion to heal a wound or a reconstructive surgical procedure, and also whether there is a need for revascularization and is the revascularisation Figure 1

Phlebectomy is also an in-office procedure, carried out under local anaesthesia. The veins are marked with a skin marker, with the patient standing. There are then small skin incisions created via a vein hook. The patient

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Technology Update - Micro and Macro Assessment of Perfusion adequate – this regards pre and post revascularization (Angiosome perfusion). Also, whether the debridement is adequate.

Figure 2

The measurement also allows for the assessment of the response to advanced wound care modalities – topical oxygen therapy, and hyperbaric oxygen therapy. In addition to these questions, there is also the one-off seeing whether there is adequate perfusion to support tissue products, as well as when to determine when a wound is really healed rather than it being simply covered.

The traditional measures of tissue perfusion (non-invasive vascular lab) include ABIs, foot wave forms, toe pressures, toe wave forms, forefoot PVR, duplex scan, and tcP02.

The traditional measures that are used to evaluate tissue perfusion/ oxygenation are often limited by medial calcinosis, scarring, wounds, prior amputations, and infection. Non-invasive vascular studies measure macro circulation vs microcirculation. Current methods can be technically challenging, time consuming and costly. In conjunction with this, they do not measure global perfusion of the foot, or focal perfusion in the wound.

Non-Invasive vascular lab – ABIs can be used as a standard measure of perfusion in many wound care centres. However, there are limitations of it. ABIs can be falsely elevated in calcific vessels (diabetes and renal failure).

Secondly, they measure the pressure where the cuff is located, rather than where the distal signal is heard. In many reports there will be a pressure for the AT, PT and at times for the peroneal arteries. Thirdly, they do not measure pressure or perfusion in the foot.

When looking at the assessment of foot perfusion in the non-invasive vascular lab, it is shown that arterial wave forms in foot, PVRs, digital wave forms and toe pressures, or TBIs can indeed measure perfusion in the foot. They do not measure global perfusion of the foot and can miss regional malperfusion in the area of a wound. They are not provided by many screening labs.

Fluorescent Angiography Fluorescent angiography is a diagnostic technique that uses Indocyanine Green (ICG) – a fluorescent dye injected IV to allow the sequential visualisation of blood flow.

ICG has a strong record of safe clinical use. It is excreted hepatically, not contraindicated

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in patients that have a compromised renal function. ICG has only a 3–5-minutehalf-life and it may repeat multiple studies. However, it is only contraindication is that it should be used with caution in patients that have a history of sensitivity to iodides.

With fluorescent angiography, the ICG is injected IV. The injected agent lights up blood flowing through the veins and arteries in real time, and the camera is then able to capture live images of the patient’s vasculature. These images can then be captured on a computer screen, analysed and saved and printed for medical reference.

The method is currently not used routinely in our wound care clinic. It requires an IV and is time consuming to perform and analyse results.

Rather, it is utilised selectively in clinic for assessing perfusion to determine amputation level or healing potential for advanced podiatric procedures. It is also used in OR spy technology to assess flaps or spy assisted amputation.

Near Infrared Spectroscopy (NIRS) NIRS technology is an imaging technology based on the principle that light is absorbed and reflected differently by oxygenated and non-oxygenated haemoglobin. It is based on measuring and analysing light in the near infrared spectrum (600-1000mn). The technology is used to measure the proportion of oxygen bound to the haemoglobin in the

Technology Update - Micro and Macro Assessment of Perfusion blood of the capillary bed. It measures site specific tissue oxygenation (StO2). NIRS does not require any injection, and it adds minimal time to a tissue encounter. It is point of care measurement of tissue oxygenation.

Assessing Tissue Oxygenation in the Diabetic Foot Preventing Amputations Diabetes is a risk factor for foot ulceration.

Similarly, foot ulceration is a risk factor for amputation. Associated PAD is a significant confounding factor that increases the risk for amputation in a patient with a diabetic foot ulcer. The timelier and accurate assessment of peripheral arterial disease is an important aspect of routine podiatric care, and it is a critical component of a limb preservation initiative.

References 1. H. Brem et al / The American Journal of Surgery 188 (Suppl to July 2004) 1S–8S 2. BMJ 2018;362:k3115 doi: 10.1136/bmj.k3115 (Published 14 August 2018) 3. Gohel MS, Heatley F, Liu X, et al.; EVRA Trial Investigators. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378(22):2105-2114 4. Lei, J., Rodriguez, S., Jayachandran, M., Solis, E., Epnere, K., Perez-Clavijo, F., Wigley, S., &Godavarty, A. (2018). Assessing the Healing of Venous Leg Ulcers Using a Noncontact NearInfrared Optical Imaging Approach. Advances in wound care, 7(4), 134–143.

5. Management of Venous leg Ulcers (2014) Journal of Vascular Surgery, volume 60 issue 2 DOI:https://doi.org/10.1016/j.jvs.2014.04.049 6. Pivotal study of Endovenous Stent Placement for Symptomatic Iliofemoral Venous Obstruction (2019) Razavi M K, Black S, Gagne P, Chiacchierini R, Nicolini P, Marston P DOI:https://doi.org/10.1161/CIRCINTERVENTIONS.119.008268 7. Rossi FH, Kambara AM, Izukawa NM, et al. Randomized double-blinded study comparing medical treatment versus iliac vein stenting in chronic venous disease. J VascSurg Venous LymphatDisord. 2018;6(2):183-191. doi:10.1016/j.jvsv.2017.11.003 8. Wallace T, El-Sheikha J, Nandhra S, et al. Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins. Br J Surg. 2018;105(13):1759-1767. doi:10.1002/bjs.10961

Using NIRS to screen diabetic patients: • • •

StO270% or greater – Normal, may proceed with treatment StO240% - 69% - Order vascular studies StO239% or less – Order vascular studies and vascular consult to consider invasive assessment and potential intervention

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Wound Masterclass - Vol 2 - June 2023

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PROVEN SUSTAINED HEALING Evidence Based Therapy:

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REFERENCES: - A Multinational, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Trial to Evaluate the Efficacy of Cyclical Topical Wound Oxygen (TWO2) Therapy in the Treatment of Chronic Diabetic Foot Ulcers; Robert G. Frykberg, Peter J. Franks, et al. The TWO2 Study; Diabetes Care 2020;43:616-624 | https://doi.org/10.2337/dc19-0476.

- Reduced Hospitalizations and Amputations in Patients with Diabetic Foot Ulcers Treated with Cyclical Pressurized Topical Wound Oxygen Therapy: Real-World Outcomes; Advances in Wound Care; 2021

AAWC PRESENTATIONS AT A GLANCE

Topical Oxygen: Where Does It Fit in Your Practice Editorial Summary The role that oxygen plays in wound healing becomes more apparent as research into its mechanism of action identifies critical pathways of action. The development of portable units that deliver oxygen topically to a wound have been demonstrated to be effective.

Understanding the differences between the available technologies is important to a wound care clinician and may help in choosing the best modality to achieve specific clinical outcomes.

This article is a concise overview of these themes.

Introduction

A

s a multi-disciplinary and multimodality approach for Diabetic Foot Ulcers, Topical Oxygen is a comprehensive wound care solution. At the lowest possible cost, it is able to use all appropriate available modalities in order to achieve healing in the shortest time possible, all whilst providing treatment in a caring and healing environment. As backed by evidence, it is the best practice approach.

The Wagner Classification • • • • • •

Grade 0 Callus without an Ulcer present Grade 1 Superficial Ulcer without apparent infection Grade 2 A deep ulcer, without abscess or osteomyelitis Grade 3 A deep ulcer with abscess, cellulitis, and/or osteomyelitis Grade 4 Partial Gangrene Grade 5 Gangrene of the entire Foot

Benefits of Hyperbaric Oxygen There are many benefits of hyperbaric oxygen, both physiologic and pharmacological with systemic effects. In regard to physiologic effects there is an antibiotic potentiation, improved leukocyte function and bacteria killing, and an enhanced collagen synthesis with crosslinking. For Pharmacological effects, there are direct antimicrobial effects, toxin synthesis suppression, blunting of systemic inflammatory responses, prevention of leukocyte activation and adhesion, PDGF-BB receptor stimulation (with multiple effects), VEGF release and

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angiogenesis, and also detoxification (CO, CN, H2S).

The beneficial effects of Hyperbaric Oxygen in treating an infection include antibacterial effects. Whilst a patient received the HBO treatment, there was an improved leukocytebacterial-killing (adequate leukocyte count critical for benefit), a suppression of exotoxin production (may persist hours), and an increased effectiveness of antibiotics.

Hyperbaric Oxygen Ischemic Tissues

Treatment

and

Oxygen Gradient (which is thought to be 20mmHg) is the signal in order to initiate biochemical steps to angiogenesis. It remains under the same regulatory control as in normal wound healing. When perfusion develops to eliminate oxygen gradients, the biochemical messenger response sequence shuts off.

Vascular architecture achieves 75-80% of normal tissue and persists for years. This is consistent in theory, in that the mechanism shuts off when the gradient dips below 20mmHg and not necessarily when it is zero.

Stem Cell Mobilization by Hyperbaric Oxygen Hyperbaric Oxygen mobilizes stem/progenitor cell release from bone marrow via a nitric oxide dependent mechanism. The population of CD34 cells in peripheral circulation doubled in response to single HBO treatment (2 ATA, 120 mins). Over the course of 20 treatmentsCD34 cells increased 8 times, whilst the total count of white body cells remained unchanged, as

Presentation by Dr Gregory Bohn

The Role of Topical Autologous Plasma Rich Membranes in Healing Diabetic Foot Ulcers shown in Figure 1.

Figure 1

Healing is a synchrony of multiple critical factors in the process. O2 and its reactive species stimulate VEGF Expression. Chronic hypoxia impairs VEGF and impairs wound healing and tissue dysfunction. Supplement topical O2 sustains VEGF, angiogenesis, and fibroblast differentiation. Topical Oxygen has the potential of benefiting some wound types.

Conclusion

Molecular Biomarkers of Oxygen Therapy in Patients Diabetic Foot Ulcers Growth factors had significantly increased from 280% to 820% of base levels during the initial week andhad decreased in the subsequent weeks. Cytokines increased significantly (up to 680% compared to baseline levels) in the first two weeks, and then decreased. The significant increases in the transcutaneous oxygen pressure measurement indicated for increased oxygen perfusion in the wound periphery. Overall, this is evidence that the topical oxygen saturated the wound bed and diffused to surrounding tissues.

To summarise, Hyperbaric Oxygen Treatment effects have been studied as systemic circulating effects. It is therapy delivered in a Clinic with Hyperbaric Chambers. Intermittent therapy for specified number of times. Restricted indications and types of wounds. Diabetic foot wounds and injury most common. On the other hand, Topical Wound Oxygen (TWO2) has local effects, and is delivered at home or in another outpatient setting. It requires continuous therapy for a number of days or weeks, with wider indications as per type of wound and severity.

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Wound Masterclass - Vol 1 - June 2022

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Tissue Health Status Assessment

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AAWC PRESENTATIONS AT A GLANCE

Technology of the Foot Defender Editorial Summary This article explores the Foot Defender, an innovative new product that helps to heal diabetic foot wounds. It describes the concept of offloading of the foot, identifies the role of consumerization to engage patients in adhering to plan of care, and compares and contrasts offloading devices commercially available.

Introduction

Figure 2

S

tatistics show that within the first 6-18 Decembers after initial evaluation, 24% of Diabetic foot wounds lead to limb amputation. It has been found that pressure prevents diabetic wounds from healing.

Furthermore, it has be found that walking and standing continuously aggravate/worsen Diabetic Foot Ulcers (DFU’s).2 Research indicates that pressure relief in a total contact cast is associated with changes in the histology of neuropathic foot ulcers, which indicates a reduction of inflammatory and reactive components and an acceleration of the reparative process.1

Figure 3

The Foot Defender The Foot Defender aims to provide superior pressure reduction.

Figure 1 shows the walking average maximum pressure of 3 minutes on a treadmill (1.5 mph 4% grade 200lbs male US Size 12 shoe).

Figure 2 shows the average maximum pressure of 3 minutes on a treadmill (1.5 mph 4% grade) Figure 1

Presentation by Dr Jason Hanft

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Wound Masterclass - Vol 2 - June 2023

Figure 4

Satellite Symposium: Technology of the Foot Defender The Foot Defender is designed to reduce pressure and to meet the patients daily living needs. Figure 4 outlines the skeleton of the Foot Defender and the role of the different sections.

1.

It has a custom engineered semi rigid anterior AFO

2.

Highly adjustable padded spat for easy ingress and removal

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High quality padded upper made with performance athletic footwear materials

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Friction reducing, antimicrobial, water resistant, top cover

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Medium density force reducing foam

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AbsorbiumTM propriety visco-elastic polymer designed for maximum impact force reduction

References 1. Piaggesi A, Viacava P, Rizzo L, Naccarato G, Baccetti F, Romanelli M, Zampa V, Del Prato S. Semiquantitative analysis of the histopathological features of the neuropathic foot ulcer: effects of pressure relief. Diabetes Care. 2003 Nov;26(11):3123-8. doi: 10.2337/ diacare.26.11.3123. PMID: 14578249.

2. https://www.cdc.gov/diabetes/data/statistics-report/index.html 3. Gonzalez, MH, Bochar, S, Novotny, J, et al. Upper extremity infections in patients with diabetes mellitus. J Hand Surg Am 1999; 24(4): 682–686 Mann, RJ, Peacock, JM. Hand infections in patients with diabetes mellitus. J Trauma 1977; 17(5): 376–380 4. Upper limb infections: A comparison between diabetic and non-diabetic patients Shan Hua Lim, Tunku Sara Tunku Ahmad, Cassidy Devarajooh, February 1, 2022 Research Article Find in PubMed https://doi.org/10.1177/23094990221075376 Prevalence of lower-extremity amputation among patients with diabetes mellitus: Chin-Hsiao Tseng CMAJ. 2006 Jan 31; 174(3): 319–323. : 10.1503/cmaj.050680

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Wound Masterclass - Vol 2 - June 2023

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FOOT DEFENDER A faster path to healing

Diabetic foot ulcers (DFU’s) require offloading to heal. Shoes are ineffective and can no longer be the standard of care. Foot Defender combines a clinically proven design that reduces force with game-changing aesthetics for greater compliance.

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AAWC PRESENTATIONS AT A GLANCE

Disparities in Wound Care: Social Determinants of Health, Epigenetics, and the Biochemical Response to Stress Editorial Summary This article addresses disparities in wound care beginning with a discussion on the scientific basis of how social determinants of health and stress impact chronic diseases, wound prevalence, and wound healing; followed by reviewing chronic disease risk factors and their connection to social determinants of health through processes including the biochemical response to stress and epigenetic changes. These processes can alter the trajectory for patients both by contributing to the development of conditions associated with wounds as well as limiting successful outcomes in hard-to-heal wounds.

Figure 1: Chronic stress can lead to delayed wound healing.

Social Determinants of Health

T

he social determinants of health (SDoH) determine 80% of health outcomes. They look to see the conditions and environments in which people live. They affect a wide range of health, functioning, quality of life outcomes, and risks.

Chronic Stress

Release of catecholamines and cortisol

Chronic inflammation and immune system dysfunction

Disparities and ‘care deserts’ are due to economic stability, the quality and access to education and health care, and the context of the community.

Adverse Childhood Experiences (ACE)

Epigenetics

ACE are life stressors that can lead to significant impacts on future health outcomes. It is a form of historical trauma that can cause long term health issues. It is not solely the case that ACEs predispose children to social or emotional disorder, but also to physical illnesses. Early adversity has long lasting impacts; obesity, diabetes, cancer and autoimmune diseases all have an impact over how wounds occur.

Epigenetics, where ‘epi’ means above the genome, regards the study of changes in organisms caused by the modification of gene expression, rather than alteration of the genetic code itself. Stress and neglect, i.e., historical trauma as identified via ACEs, can change the expression of DNA. It can cause for epigenetic changes. Such stress and environmental exposures can contribute to epigenetic changes, such as DNA hypo and hyper methylation, histone modification, and telomere shortening.

Chronic Exposure to Stress

Presentation by Dr Laura Swoboda

20

Delayed wound healing

As shown in Figure 1, chronic stress can lead to delayed wound healing. It can also cause immune dysfunction, and atherosclerotic vascular disease. Short term stress can see cortisol, initially an anti-inflammatory agent, mobilize glucose to use during the stress response. Long term stress is pro-inflammatory (oxidative and nitrosative), increases the experience of pain, and aids in cellular death and aging, as well as tissue degradation.

Wound Masterclass - Vol 2 - June 2023

Epigenetics are heritable. This can be, for example, shown via the incidence of the Hongerwinter, 1944-45. Germany had blocked the delivery of supplies to the west of the Netherlands. Official rations had fallen to less than 1000 kcal a day, and eventually dropped to 500 kcal. This caused large-scale starvation, including for pregnant women. It caused an increased occurrence of obesity, diabetes, schizophrenia, neural-tube defects, infant size at birth, and central nervous system development.

Disparities in Wound Care: Social Determinants of Health, Epigenetics, and the Biochemical Response to Stress Figure 2

Epigenetic changes during pregnancy can be a biochemical source of generational trauma.

This can come from chronic stress, smoking, food insecurity and environmental exposures.

Epigenetics can look like this in action: initial diabetes, causes for histone modifications, leading to the macrophage phenotype changing, and resulting in inflammation.

A social genomics review shows multiple studies on how social influences impact stress and wound healing. Social isolation has the ability to impact 200 genes. It downregulates the antiviral response and production of antibodies.

It upregulates the inflammation cascade. There is a known and established correlation between social isolation and delayed wound healing.

The frequency of wound clinic visits can influence the rate of healing. More frequent wound clinic visits are linked with better healing, as opposed to the lesser frequent visits.

Figure 3

There are also racial and ethnic disparities.

There are investigative needs regarding the differences in skin biomechanics in racial/ ethnic groups. Differences have been found, for example, concerning viscoelasticity and hydration. There are also disparities in comorbid disease states and healing. For other dermatologic care, disparities can be shown. black and hispanic populations have reduced access to outpatient dermatologic care. 75% of countries with majority black and hispanic populations have zero dermatologists. black and hispanic patients are more likely to use EDs for dermatologic care. The usual visual cues for pressure injury identification may be insufficient in darkly pigmented skin; the visual signs and symptoms that are applicable to those of lighter skin tones cannot translate over to those with darker skin tones. There are disparities in pressure injury prevalence, incidence, severity, and healing.

Racial and ethnic differences in hospital admissions for cellulitis in the United States; A

Biochemical responses to psychological stress in chronic wounds: hypoxia, decreased cytokines, alterations in matrix metalloproteinases, alterations in immune response (increased infection), decreased neutrophil infiltration, antimicrobial peptides which leads to increased rates of infection, microbiome alterations and biofilm promotion. Higher reported stress levels on the day of biopsy have been shown to have delayed healing.

Cross sectional Analysis: 9

There are many disparities in wound care.

This includes skin colour, age, the location (rural or urban), highly/low resourced locations, insurance status, and the overall access available for wound care clinicians, tools, products, and advanced therapies.

There is also disparate care based on insurance coverage. Patients may not medically benefit from advanced therapies because insurance has limited use due to wound type, wound size, co-morbidities, etc. In 2020, 8.6% of Americans were un-insured, and 28% of Americans were under-insured.

•

Examined in hospital admissions –378,350 (24.3%)

•

Hospital discharges – 1,118,791 (75.7%)

•

Admitted patients were more likely to be white, older (>65 years), in urban teaching hospitals, and have Medicare

•

Black and Hispanic patients had higher odds of being discharged

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Disparities in Wound Care: Social Determinants of Health, Epigenetics, and the Biochemical Response to Stress This delays health care or causes people to avoid it because of costs that are twice the rate of people who are insured but not underinsured.

There are wound research gaps; the current criteria commonly excludes real world patient situations.

Figure 5

Case Studies The first case regards a 55-year-old female with PAD, protein deficiency, and DVT. They could not afford co-pay for warfarin, and had developed recurrent DVT, and cerebral vascular attack.

She now had a primarily palliative wound to the left leg. She presented the wound to the clinic, taping together OTC non-adherent dressings and pieces of old 2-layer compression wraps, due to her running out of dressings. There was increased drainage from poor bioburden management, and daily dressing changes.

The second case looks at a 77-year-old who cycled one hour, daily. They had an unwitnessed fall and had been found unconscious. They presented exposed muscle in the knee, palpable tendons to hand, and undermining to both wounds, as shown in Figure 5.

Figure 5

At the 4 week follow up, the patient’s hand was completely epithelialized, with the knee almost completely, as shown in Figure 6. The positive determinants of health included the patient’s lack of psychiatric issues and ability to adhere to the decided plan of care. The patient was also able to get to the wound centre for advanced therapies three times a week. They had good nutrition, were caucasian, and middle class.

They were able to exercise regularly. They also had great insurance and was therefore able to access advanced therapies immediately.

The third case looks to compare male patients of stage 5 pressure injury. They both have private insurance; however, one is in a rural location, and the other an urban. The patient in the urban location was a 69-year-old hispanic male, with a spinal cord injury related to MVA. He had a strong family support, with a wife being a registered nurse in oncology, and a family friend living next door being able to help out.

His plan of care consisted of home health, and negative pressure therapy. On the other hand, the patient in the rural location was a 65-yearold white male. He also had a spinal cord injury, however his was related to a fall from the roof.

He had a strong family support; his wife worked near the home at the local convenience store and adult children were living near-by and helping, with his daughter being a licensed practical nurse. His plan of care consisted of home health, packing site with Silver Alginate, and covering with absorbent dressing.

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Disparities in Wound Care: Social Determinants of Health, Epigenetics, and the Biochemical Response to Stress The fourth case study looks at a 42-year-old black male. He had a non-healing diabetic foot ulcer on his right foot, for over a year. He has ESRD and is receiving dialysis, and is diabetic.

Treatments have been attempted, with fempop to improve perfusion, bioengineered skin substitutes, and total contact casting. The standard of care is debridement, cleaning, and topicals.

Conclusion It is clear there are many opportunities for further research and process improvement in how and where we deliver care. Social determinants of health contribute to the development of conditions associated with wounds, and also limits successful healing outcomes.

References 1. Medicaid’s Role in Addressing Social Determinants of Health. Robert Wood Johnson Foundation. Published 2019 Feb 1. Retrieved 11/17/21 from https://www.rwjf.org/en/library/ research/2019/02/medicaid-s-role-in-addressing-social- determinants-of-health.html 2. Preventing Adverse Childhood Events. Centre for Disease Control and Prevention. Last reviewed 4/6/21. Retrieved 11/16/21 from https://www.cdc.gov/violenceprevention/aces/ fastfact.html 3. Lang J, McKie J, Smith H, et al. Adverse childhood experiences, epigenetics and telomere length variation in childhood and beyond: a systematic review of the literature. Eur Child Adolesc Psychiatry. 2020;29(10):1329-1338. doi:10.1007/s00787019-01329-1 4. Dube SR, Fairweather D, Pearson WS, Felitti VJ, Anda RF, Croft JB. Cumulative childhood stress and autoimmune diseases in adults. Psychosom Med. 2009;71(2):243-250. doi:10.1097/ PSY.0b013e3181907888 5. Ports KA, Holman DM, Guinn AS, et al. Adverse Childhood Experiences and the Presence of Cancer Risk Factors in Adulthood: A Scoping Review of the Literature From 2005 to 2015. J PediatrNurs. 2019;44:81-96. doi:10.1016/j.pedn.2018.10.009 6. Cunningham TJ, Ford ES, Croft JB, Merrick MT, Rolle IV, Giles WH. Sex-specific relationships between adverse childhood experiences and chronic obstructive pulmonary disease in five states. Int J Chron Obstruct Pulmon Dis. 2014;9:1033-1042.

Published 2014 Sep 26. doi:10.2147/COPD.S68226 7. Dong M, Giles WH, Felitti VJ, et al. Insights into causal pathways for ischemic heart disease: adverse childhood experiences study. Circulation. 2004;110(13):1761-1766. doi:10.1161/01.

CIR.0000143074.54995.7F 8. Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Phys Ther.

2014;94(12):1816-1825. doi:10.2522/ptj.20130597 9. Maes M, Galecki P, Chang YS, Berk M. A review on the oxidative and nitrosative stress (O&NS) pathways in major depression and their possible contribution to the (neuro) degenerative processes in that illness. Prog NeuropsychopharmacolBiol Psychiatry. 2011;35:676–692.

10. Zunszain PA, Anacker C, Cattaneo A, et al. Glucocorticoids, cytokines and brain abnormalities in depression. Prog NeuropsychopharmacolBiol Psychiatry. 2011;35:722–729.

11. Ahmed M, de Winther MPJ, Van den Bossche J. Epigenetic mechanisms of macrophage activation in type 2 diabetes. Immunobiology. 2017;222(10):937-943. doi:10.1016/j. imbio.2016.08.011 12. Mossel DM, Moganti K, Riabov V, et al. Epigenetic Regulation of S100A9 and S100A12 Expression in Monocyte-Macrophage System in Hyperglycemic Conditions. Front Immunol.

2020;11:1071. Published 2020 Jun 2. doi:10.3389/fimmu.2020.01071 13. Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am. 2011;31(1):81-93. doi:10.1016/j. iac.2010.09.010 14. Kim JH, Ruegger PR, Lebig EG, et al. High Levels of Oxidative Stress Create a Microenvironment That Significantly Decreases the Diversity of the Microbiota in Diabetic Chronic Wounds and Promotes Biofilm Formation. Front Cell Infect Microbiol.

2020;10:259. Published 2020 Jun 3. doi:10.3389/fcimb.2020.00259 15. Regueira Y, Fargo JD, Tiller D, et al. Comparison of Skin Biomechanics and Skin Color in Puerto Rican and Non-Puerto Rican Women. P R Health Sci J. 2019;38(3):170-175.

16. Sullivan R. A 5-year retrospective study of descriptors associated with identification of stage I and suspected deep tissue pressure ulcers in persons with darkly pigmented skin. Wounds.

2014;26(12):351-359.

17. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [date graphic was accessed], from https://health. gov/healthypeople/objectives-and-data/social-determinantshealth 18. Centers for Disease Control and Prevention. (2021). Violence prevention: The ACE pyramid (adapted by RYSE Youth Center). https://www.cdc.gov/violenceprevention/aces/about.html 19. Bates-Jensen BM, Anber K, Chen MM, et al. Natural History of Pressure Injury Among Ethnically/Racially Diverse Nursing Home Residents: The Pressure Ulcer Detection Study. J GerontolNurs. 2021;47(3):37-46. doi:10.3928/00989134-20210210-03 20. Bliss DZ, Gurvich O, Savik K, et al. Racial and ethnic disparities in the healing of pressure ulcers present at nursing home admission. Arch GerontolGeriatr. 2017;72:187-194. doi:10.1016/j. archger.2017.06.009 21. Zheng NS, Shung DL, Kerby EH. Racial and ethnic differences in hospital admissions for cellulitis in the United States: A cross-sectional analysis [published online ahead of print, 2022 Aug 27]. J Am Acad Dermatol. 2022;S0190-9622(22)02613-5. doi:10.1016/j.jaad.2022.08.038 22. Fayne RA, Borda LJ, Egger AN, Tomic-Canic M. The Potential Impact of Social Genomics on Wound Healing. Adv Wound Care (New Rochelle). 2020;9(6):325-331. doi:10.1089/ wound.2019.1095 23. Yao, B., Cheng, Y., Wang, Z. et al. DNA N6-methyladenine is dynamically regulated in the mouse brain following environmental stress. Nat Commun 8, 1122 (2017). https://doi. org/10.1038/s41467-017-01195-y 24. Keisler-Starkey, K & Bunch, L. Health Insurance: Coverage in the United States: 2020.

United States Census Bureau. Sept 2021. Retrieved 9/6/22 from https://www.census.gov/library/ publications/2021/demo/p60-274.html 25. Inserro, A. Incremental Steps Helpful but Not Enough to End Underinsurance Issue, Panelists Say. American Journal of Managed Care. April, 2022. Retrieved 9/6/22 from https:// www.ajmc.com/view/incremental-steps-helpful-but-not-enough-toend-underinsurance-issue-panelists-say 26. Gauthier T, Chen W. Modulation of Macrophage Immunometabolism: A New Approach to Fight Infections. Front Immunol. 2022;13:780839. Published 2022 Jan 26. doi:10.3389/ fimmu.2022.780839 27. Koehly LM, Persky S, Philip Shaw, et al. Social and behavioral science at the forefront of genomics: Discovery, translation, and health equity. Soc Sci Med. 2021;271:112450. doi:10.1016/j.socscimed.2019.112450 28. Cole SW, Hawkley LC, Arevalo JM, Cacioppo JT. Transcript origin analysis identifies antigen-presenting cells as primary targets of socially regulated gene expression in leukocytes.

Proc Natl Acad Sci U S A. 2011;108(7):3080-3085. doi:10.1073/pnas.1014218108 29. Carter MJ, Fife CE. Clinic visit frequency in wound care matters: data from the US wound registry. J Wound Care. 2017;26(Sup1):S4-S10. doi:10.12968/jowc.2017.26.Sup1.S4 30. Warriner RA 3rd, Wilcox JR, Carter MJ, Stewart DG. More frequent visits to wound care clinics result in faster times to close diabetic foot and venous leg ulcers. Adv Skin Wound Care.

2012;25(11):494-501. doi:10.1097/01.ASW.0000422629.03053.06 31. Hooper J, Shao K, Feng H. Racial/Ethnic Health Disparities in Dermatology in the United StatesPart 1: Overview of Contributing Factors and Management Strategies. J Am Acad Dermatol.2022.

32. Vaidya T, Zubritsky L, Alikhan A, Housholder A. Socioeconomic and geographic barriers todermatology care in urban and rural US populations. J Am Acad Dermatol. 2018;78(2):406408.5.

33. Abokwidir M, Davis SA, Fleischer AB, Pichardo-Geisinger RO. Use of the emergency department for dermatologic care in the United States by ethnic group. J Dermatolog Treat.2015;26(4):392-394.

34. LH Lumey, Aryeh D Stein, Henry S Kahn, Karin M van der Pal-de Bruin, GJ Blauw, Patricia A Zybert, Ezra S Susser, Cohort Profile: The Dutch Hunger Winter Families Study, International Journal of Epidemiology, Volume 36, Issue 6, December 2007, Pages 1196–1204, https://doi.org/10.1093/ije/dym126

Wound Masterclass - Vol 2 - June 2023

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AAWC PRESENTATIONS AT A GLANCE

Technology for Early Detection of Skin and Tissue Damage Editorial Summary Early detection of pressure injuries has been demonstrated to reduce the incidence of pressure Injuries. Adoption into practice however is slow. In this article the current evidence for the early detection of pressure injury development and deterioration is discussed.

Introduction

Ultrasound

he current method to detect skin and tissue damage is by visually observing bony prominences for signs of early damage. The skin is checked for erythema and stage 1 Prl (non-blanchable redness), or for a deep tissue injury (shown through a purple or maroon discoloured intact skin or blood-filled blister). However, by the time the skin colour changes it usually means some damage has already occurred. Furthermore, this method does not work well for medium and dark skin tones.

T

An ultrasound (Figure 2) can detect macroscopic pockets of fluids (also known as edema) that are visible to the radiologist.

There are different types of technology available to interrogate tissues below the skin surface:

Figure 3. The devices transmit a high-frequency low power electromagnetic wave of 300 through electrodes placed on the skin. It measures the surface electrical capacity between two concentric circle electrodes.

• • •

Thermography Ultrasound Subepidermal moisture (SEM)

Thermography Thermography (Figure 1) uses temperature as an indicator of tissue perfusion. The longwave infrared thermography (LWIT) measures radiant heat from the body surface. It enables a picture of the area of concern to be captured and it can detect the temperature of the tissue relative to the level of tissue perfusion. It has the potential to detect local hypothermia before visual recognition.

Presentation by Dr Ruth A. Bryant

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Wound Masterclass - Vol 2 - June 2023

The muscle layers become thinner, and less defined with stage 1 Prl. There are specific patterns associated with PrI severity such as a cloud-like pattern shows deterioration and size increase, and a cobblestone-like pattern shows stable wound characteristics and size decrease.

Subepidermal Moisture

The electromagnetic energy that is not absorbed by tissue water is reflected, measured, and displayed on the device.

Technology for Early Detection of Skin and Tissue Damage Figure 1: Thermography.

Figure 2: Ultrasound.

Figure 3: Subepidermal moisture.

References 1. Bates-Jensen, BM, Anber, K, Chen, et al. Natural History of Pressure Injury Among Ethnically, Racially Diverse Nursing Home Residents: The Pressure Ulcer Detection Study .

Journal of Gerontological Nursing, in press.

2. Bates-Jensen, BM, McCreath, HE, Nakagami, G. Patlan, A. Subepidermal moisture detection of heel pressure injury: the Pressure Ulcer Detection study outcomes. International Wound Journal. 2018; 15(2): 297-309. PMID:29250926.

Bates-Jensen BM, McCreath HE, Patlan A. Subepidermal Moisture Detection of Pressure Induced Tissue Damage on the Trunk: The Pressure Ulcer Detection (PUD) Study Outcomes. Wound Repair Regen. 2017; 25(3): 502-11. PMID: 28494507 3. Bates-Jensen BM, McCreath HE, Pongquan V. Subepidermal moisture is associated with early pressure ulcer damage in nursing home residents with dark skin tones: pilot findings. J Wound Ostomy Continence Nurs. 2009 May-Jun;36(3):277-84. PMID: 19448508.

4. Baumgarten M., Margolis D., van Doorn C., et al. (2004). Black/White differences in pressure ulcer incidence in nursing home residents. J Am Geriatr Soc, 52(8), 1293-8.

5. Bliss, D. Z., Gurvich, O., Savik, K., et al. (2015). Are there racial-ethnic disparities in time to pressure ulcer development and pressure ulcer treatment in older adults after nursing home admission? J Aging Health, 27(4), 571-93.

6. Bliss, D. Z., Gurvich, O., Savik, K., et al. (2017). Racial and ethnic disparities in the healing of pressureulcers present at nursing home admission. Arch GerontolGeriatr, 72, 187-194.

7. Cai, S., Mukamel, D. B., & Temkin-Greener, H. (2010). Pressure ulcer prevalence among black and white nursing home residents in New York state: Evidence of racial disparity? Med Care, 48(3), 233- 9.

8. Coffey RM, Andrews RM, Moy E. Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators. Med Care. 2005;43(3 Suppl):I48-I57. doi:10.1097/00005650-200503001-00008 9. Delmore, B., Ayello, E. A., Smith, D., et al. (2019). Refining heel pressure injury risk factors in the hospitalized patient. Adv Skin Wound Care, 32(11), 512-519.

10. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.) EPUAP/ NPIAP/PPPIA. 11. Fogerty MD, Abumrad NN, Nanney L, Arbogast PG, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Repair Regen. 2008;16(1):11-18. doi:10.1111/j.1524-475X.2007.00327.x 12. Fogerty M, Guy J, Barbul A, Nanney LB, Abumrad NN. African Americans show increased risk for pressure ulcers: a retrospective analysis of acute care hospitals in America.

Wound Repair Regen. 2009;17(5):678-684. doi:10.1111/j.1524-475X.2009.00522.x 13. Gerardo, MP, Teno, JM, &Mor, V. (2009). Not so black and white: nursing home concentration of Hispanics associated with prevalence of pressure ulcers. JAMDA, 10(2): 127-132.

14. Grabowski, DC. (2004). The admission of Blacks to high-deficiency nursing homes. Med Care, 42(5), 456-64.

Harms, S., Bliss, D. Z., Garrard, J., et al. (2014). Prevalence of pressure ulcers by race and ethnicityfor older adults admitted to nursing homes. J GerontolNurs, 40(3), 20-6.

15. Howard D. L., & Taylor Y. J. J. (2009). Racial and gender differences in pressure ulcer developmentamong nursing home residents in the Southeastern United States. Women Aging, 21(4), 266-78.

16. Li, Y., Yin, J., Cai, X., Temkin-Greener, J., &Mukamel, D. B. (2011). Association of race and sites ofcare with pressure ulcers in high-risk nursing home residents. JAMA, 306(2), 179-86.

17. McCreath, H. E., Bates-Jensen, B. M., Nakagami, G., et al. (2016). Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development. J Adv Nurs, 72(9), 2077-2085.

18. Mor V., Zinn J., Angelelli J., Teno J. M., & Miller S. C. (2004). Driven to tiers: socioeconomic and racial disparities in the quality of nursing home care. Milbank Q, 82(2), 227-56.

19. Romano PS, Geppert JJ, Davies S, Miller MR, Elixhauser A, McDonald KM. A national profile of patient safety in U.S. hospitals. Health Aff (Millwood). 2003;22(2):154-166. doi:10.1377/hlthaff.22.2.154 20. Saladin LK, Krause JS. Pressure ulcer prevalence and barriers to treatment after spinal cord injury: comparisons of four groups based on race-ethnicity.

NeuroRehabilitation. 2009;24(1):57-66. doi:10.3233/NRE-2009-0454 21. Seibert J, Barch D, Bernacet A, et al. Examining Social Risk Factors in a Pressure Ulcer Quality Measure for Three Post-Acute Care Settings. Adv Skin Wound Care. 2020;33(3):156163. doi:10.1097/01.ASW.0000651456.30210.8a 22. Shen JJ, Cochran CR, Mazurenko O, et al. Racial and Insurance Status Disparities in Patient Safety Indicators among Hospitalized Patients. Ethn Dis. 2016;26(3):443-452. Published 2016 Jul 21. doi:10.18865/ed.26.3.443 23. Shimada SL, Montez-Rath ME, Loveland SA, Zhao S, Kressin NR, Rosen AK. Racial Disparities in Patient Safety Indicator (PSI) Rates in the Veterans Health Administration.

In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; August 2008.

24. Yap, T. L., Kennerly, S., Horn, S. D., et al. (2019). Influence of nutrition and nonnutritional factors on pressure injury outcomes among at-risk Asian nursing home residents.

Adv Skin Wound Care, 32(10), 463-469.

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AAWC PRESENTATIONS AT A GLANCE

Development and Psychometric Evaluation of a Decision Support Tool to Prevent Community Acquired Pressure Injury for the SCI Clinic Editorial Summary Pressure injuries (PrI) are the second leading cause of hospitalization in people with spinal cord injury (SCI). The majority of PrIs are community-acquired, but little guidance in community-acquired PrI (CAPrI) prevention exists. Current PrI prevention clinical guidelines are institutionally based, and do not directly address community risk factors. There are no instruments to guide CAPrI prevention for persons with SCI. This article describes the development and validation of an iPad based decision support tool to prevent CAPrIs in individuals with SCI for use in SCI clinics.

Introduction

Figure 1: Current guidelines.

O

f people with SCI (spinal cord injury), 95% experience high levels of Prl (Prolactin) in their lives. It is a costly medical condition with treatments totalling to approximately $26,735 per person a year. PrlS have been seen to cost $89 million annually.

There are some guidelines which may prevent Prl however these are utilised by institutions not necessarily members of the public. There seems to be a lack of standardised screenings to prevent CAPrls in patients with SCI, there are also no decision support tools.

Figure 2: Provider perspective of CAPrl prevention.

Figure 1 displays the current guidelines.6,7 Figures 2 displays the provider perspective of CAPrl prevention, and Figure 3 displays the veteran perspective.

Method The study adopted a modified Delphi technique as this is recommended for use in the healthcare setting due to its reliability when determining consensus for a clinical problem, such as pressure injuries.1,2,3,4,5 The method uses a systematic sequence of rounds of voting, and it helps to determine an expert group consensus where there is a lack of evidence and opinion is significant.2

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Wound Masterclass - Vol 2 - June 2023

Figure 3: Veteran perspective of CAPrl prevention.

Development and Psychometric Evaluation of a Decision Support Tool to Prevent Community Acquired Pressure Injury for the SCI Clinic

Figure 9

Figure 10

Veteran Item

Average % agreement across all 3 questions for Veteran item

Average % agreement across all 5 questions for Provider actions

Final Veteran Survey Sections In Veteran Voice

3. Fix it?

93

99

Current Pressure Injury

Positioning/ mobility practices (w/c, bed, transfer, activity)

13. Provider help/ involvement

--

100

Change in current health status

Nutrition

9a. Equipment, wheelchair

100

96.7

Chronic conditions (depression screen, management)

Caregiver issues (agency, family)

9a. Equipment, bathroom

--

99

Source of motivation to prevent CAPrls

Environment (home, neighborhood)

9a. Equipment, assistive devices

98

100

Life activities

9c. Skin care cleansing

100

94.9

Equipment assessment/ needs (mattress, w/c, cushion, bathroom, etc.)

Coordinating care

9e. Positioning, wheelchair

--

97

Supply assessment/ needs (skin, foot, bowel/ bladder)

--

100

Skin care practices (visual, cleansing, lotion, bowel/ bladder)

Coping skills

9e. Positioning, transfer 9l. Coping

96.2

89.6

Health behaviors Involvement in preventive care

This study gathered an expert, interprofessional panel of veterans and caregivers; there were 22 participants. The authors developed a structured formal questionnaire and had a 4pt Likert scale ranging from strongly disagree to strongly agree. Each round the experts completed the questionnaire and their responses were summarised, described statistically and the survey, with feedback was returned to the experts. This was repeated until there was a 75% consensus between the panel.

Questions 1-8 were about health, both physical and psychological. Questions 9 included supplies, nutrition, environmental risks, coordination, practices, life integration, equipment, and caregiver. Questions 10-14 were about health behaviours.

Data Collection The Delphi was conducted using Research Electronic Data Capture (REDCap). It is an application used by researchers for small and medium sized research projects, to store and manage data. It can also be used to create surveys.

The data can be exported into statistical programs such as SPSS, Excel, R, etc.). The data can be imported raw or with full headers and answer labels as label data is also imported.

Completed surveys are provided with a time and date stamp and participants can input data through an emailed link; they are not required to create a REDCap account.

Results Two rounds of the Delphi surveys were conducted. Round one had a response rate of 91% and round two had a 100% response rate. The A priori level of agreement was set at 75%, and all questions in both parts one and

two had an agreement level above 75%. All the questions in the second round of the Delphi were above 83% agreement.

Delphi Round 1 There were 468 comments on the veteran items and 400 comments on the provider actions. Many comments on veteran items were in relation to the language suggested changes/edits. Most of the commentary on provider actions related to the inclusion of more appropriate referrals.

Delphi Round 2 There were 3 veteran items (53 comments) and 3 providers actions (101 comments). The comments for the veteran and provider items followed the same theme as Delphi round 1.

The Final Tool Figure 10 displays what the final tool looks like after the study.

References 1. Bennett C, Vakil N, Bergman J, Harrison R, Odze R, Vieth M, Sanders S, Gay L, Pech O, Longcroft-Wheaton G, Romero Y, Inadomi J, Tack J, Corley DA, Manner H, Green S, Al DD, Ali H, Allum B, Anderson M, Curtis H, Falk G, Fennerty MB, Fullarton G, Krishnadath K, Meltzer SJ, Armstrong D, Ganz R, Cengia G, Going JJ, Goldblum J, Gordon C, Grabsch H, Haigh C, Hongo M, Johnston D, Forbes-Young R, Kay E, Kaye P, Lerut T, Lovat LB, Lundell L, Mairs P, Shimoda T, Spechler S, Sontag S, Malfertheiner P, Murray I, Nanji M, Poller D, Ragunath K, Regula J, Cestari R, Shepherd N, Singh R, Stein HJ, Talley NJ, Galmiche JP, Tham TC, Watson P, Yerian L, Rugge M, Rice TW, Hart J, Gittens S, Hewin D, Hochberger J, Kahrilas P, Preston S, Sampliner R, Sharma P, Stuart R, Wang K, Waxman I, Abley C, Loft D, Penman I, Shaheen NJ, Chak A, Davies G, Dunn L, Falck-Ytter Y, DeCaestecker J, Bhandari P, Ell C, Griffin SM, Attwood S, Barr H, Allen J, Ferguson MK, Moayyedi P, Jankowski JA. Consensus statements for management of Barrett’s dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process. Gastroenterology. 2012;143(2):336–46.

2. Meshkat B, Cowman S, Gethin G, Ryan K, Wiley M, Brick A, Clarke E, Mulligan E. Using an e-Delphi technique in achieving consensus across disciplines for developing best practice in day surgery in Ireland. J Hosp Adm. 2014;3(4):1–8. doi:10.5430/jha.v3n4p1.

3. Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J, Marteau T. Consensus development methods, and their use in clinical guideline development. Health Technol Assess. 1998;2(3):i–88.

4. Powell C. The Delphi technique: myths and realities. J Adv Nurs. 2003;41(4):376–82. doi:10.1046/j.1365-2648.2003.02537.x.

5. Wood L, Black P, Heng D, Kollmannsberger C, Moore R, Soulieres D, Jewett M. Using the Dephi technique to improve clinical outcomes through the development of quality indicators in renal cell carcinoma. J Oncology Practice. 2013;9(5):262–7. doi:10.1200/jop.2012.000870.

6. Consortium for Spinal Cord Medicine., Paralyzed Veterans of America. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury : A Clinical Practice Guideline for Health-Care Providers.; 2014.

7. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (2019). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. The international guideline (3rdedition). https://npiap.com/page/ Guidelines

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AAWC PRESENTATIONS AT A GLANCE

Washington and Its Impact on Wound Care: Coding, Coverage and Payment Policies Through a Wound Care Lens Editorial Summary CMS’s ever evolving coding, coverage and payment policies impact all specialties in wound care - physicians and non-physicians – and the impact is felt differently in different sites of care. This article explores recently implemented policy changes relevant to wound care, upcoming policy changes being considered, their impact to wound care, and advocacy initiatives to protect and defend wound care.

Alliance of Wound Care Stakeholders

T

he unified voice for the wound care community is known as the Alliance of Wound care stakeholders.

They can influence regulatory agencies and decision makers. It is an association of patient organisations, wound care provider groups, non-clinical and clinical associations and more.

The Alliance aims to advocate on public policy issues that could create barriers to patient accessing treatments and care. The Alliance is focused on certain key areas such as appropriate coding, quality measures, wound care research, coverage and payment for wound care products and services.1

should be used for services or products in the LCD.2 Figure 1

Coverage, Coding and Payment The foundation of reimbursement includes coding, coverage, and payment. Payment cannot exist without proper coding and coverage, however the existence of the two does not guarantee sufficient payment. Coding is the language that defines the service or procedure, and coverage determines the criteria and extent of benefits. There are different coverage policies such as the national coverage determinations (NCDs) and local coverage determinations (LCDs).1

Presentation by Ms Marcia Nusgart

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Local Coverage Determinations provide coverage, documentation, and other explicit necessities. Each jurisdiction has their own policies with different requirements; however, the public are given the opportunity to submit feedback which can influence the outcome of the policies. Local Coverage Articles contain codes or other parameters that

Wound Masterclass - Vol 2 - June 2023

Unified voice The Alliance provide a unified wound care voice on policies, regulation and legislation.

For example, the group submits commentary to regulatory agencies and their contractors as well as holding educational sessions.

Protection of Product category and Coverage Issues The Alliance protects and defend product categories that are important to wound care clinicians. This includes preserving coverage, coding, and payment. The Alliance convinced the FDA to classify antimicrobial wound dressings as class II with special controls, this clearly shows their ability to influence regulatory agencies as mentioned previously.

Title The Alliance also works to combat obstructive clinically inaccurate LCDs/LCAs.

Payment Issues

References 1. https://www.woundcarestakeholders.org/about/the-alliance 2. https://www.cms.gov/MAC-info

The Alliance works to protect patient access to CTPs in physician’s offices and HOPPS. They conduct two meetings with CMS Senior staff to address unintended payment features under current coding policies, and to discuss educational seminars on CTPs. The Alliance recommends policy updates to enable PBDs to be recompensed for an adequate amount of CTP products for larger wounds, so that they did not need to cover the cost themselves or refer patients out to reduce costs. The Alliance also wants PBDs to be able to equalize the payment for CTP application for wounds/ulcers of the same size, regardless of the anatomic location, as opposed to the current method of reimbursement at different levels depending on wound location.

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SSI prevention: now in your hands

Leukoplast®

Leukomed® Sorbact® SSIs are the third most commonly reported type of healthcare-acquired infection and the most costly¹. They place a significant impact on patient welfare² as well as presenting a heavy financial burden for the NHS³.

New NICE Medical Technologies Guidance New NICE medical technologies guidance recommends the use of Leukomed® Sorbact® for prevention of surgical site infection (SSI) in wounds with low to moderate exudate after caesarean section and vascular surgery.

To view please go to https://www.nice.org.uk/guidance/mtg55 The guidance states that Leukomed Sorbact:

For more information, please contact support.leukomedsorbact@leukoplast.com 1. Wounds UK (2020) Best Practice Statement: Post-operative wound care – reducing the risk of surgical site infection. Wounds UK, LondonCcc 2. Taylor L, Mills E, George S, Seckam A (2020) Reducing SSI rates for women birthing by caesarean section. J Community Nurs 34(3): 50–3 3. Jenks PJ, Laurent M, McQuarry S, Watkins R. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. J Hosp Infect 2014; 86(1):24–33. https://doi.org/10.1016/j.jhin.2013.09.012 Leukoplast® and Leukomed® are registered trademarks of BSN medical Gmbh. Sorbact® is a registered trademark of ABIGO Medical AB. © NICE 2021 Leukomed Sorbact for preventing surgical site infection.

Available from https://www.nice.org.uk/guidance/mtg55/ All rights reserved. Subject to Notice of rights. NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this publication.

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• reduces SSI in caesarean section and vascular surgery • may reduce antibiotic use • may reduce readmissions from wound complications

AAWC PRESENTATIONS AT A GLANCE

Wound Healing with Your Tablet: Breaking Barriers Across the Care Continuum Editorial Summary The COVID-19 pandemic led to a pivot in healthcare which expanded awareness and a wider availability of advanced treatment options. Mobile and telemedicine practices can deliver care and education to patients where they reside. This article explores the impact of these changes.

Introduction

A

s technology and advances in wound care have developed, so too have the options available to maximize wound care in different care settings. The COVID-19 pandemic led to a pivot in healthcare which expanded awareness and a wider availability of advanced treatment options. Mobile and telemedicine practices can deliver care and education to patients where they reside, which reduces their travel time and provides access to expert consultation to those who reside in more rural areas.3,4

Wound Care and Telemedicine In 2019 the market size for wound care and telemedicine was $45 billion, and it is expected to grow at a CAGR of 19.3% by 2026. In 2020 the annual revenue generated by Teladoc was $554.6 million, and according to the world health organisation (WHO), 58% of countries are using telemed services. These figures are a result of patients (approximately 89%) preferring telehealth over physical hospital visits.

Presentation by Dr Jonathan Johnson

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There are different types of telemedicine practices. Store and forward (asynchronous) refers to digital photographs and clinical data sent to a wound care specialist over the internet. It can also refer to real time televideo conferencing (synchronous) which would include live interaction/communication with a wound care specialist, and remote monitoring.

This is when the patient’s care provider continually monitors vital signs, glucose levels etc. of a patient who is in a remote care facility

Wound Masterclass - Vol 2 - June 2023

or at home. Another type of telemedicine is mobile/digital health which is the practice of providing health care and public information through mobile devices.2 It has been found that telemedicine/telewound care has resulted in an increase in patient utilization, chronic care management and an improvement in user experience. There is integrated data sharing and wearable technology such as fitbits allow for remote patient monitoring.1 There are numerous electronic wound care resources and pieces of technology that can track wounds such as Swift medical, Ekare, Teladoc, WoundMatrix, SnapMD, Silhouette, MolecuLighti:X, TA and Doxy.me.6,2

Aging in Place As the population becomes older, it becomes increasingly more important for people to maintain independence for as long as possible.

This can be made feasible with technology and mobile care which can allow for the delivery of early intervention and preventative care.

Technology is seen as a potential resource for aging in place which can be defined as ‘living in the community with levels of independence as opposed to living in residential care’.7 Evidence shows the importance of monitoring individuals closely as technology use can change over time.5,2

Improving Patient Experience To ensure that the patient has a positive experience when using telemedicine products, it is important to contact the patient prior to

Wound Healing with Your Tablet: Breaking Barriers Across the Care Continuum

“The patient may require support from their family or caregiver to access and use the technology or wound visualisation software.”

the appointment. A step-by-step instruction guide should be sent on how to connect, and a call to ensure technology is compatible is paramount. The patient may require support from their family or caregiver to access and use the technology or wound visualisation software.

There should also be an alternative plan in case of connectivity challenges.

Do Clinicians Want Digital Healthcare?

The American medical association (AMA) compared survey results between 2016 and 2022 to find out if clinicians want healthcare digitised. The AMA found an 8% increase in the number of physicians who believed it helped patient care (85% vs 93%). Telehealth visits increased from 14% to 80% and the use of remote patient monitoring devices increased from 12% to 30%, which is more than double.1

The Strengths and Limitations of Digital Wound Care Figure 1 shows strengths and limitations of digital wound care.

References 1. AMA Digital Health Study, 2022. https://www.ama-assn.org/about/research/ama-digitalhealth-care-2022-study-findings 2. Board on Health Care Services; Institute of Medicine. The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington (DC): National Academies Press (US); 2012 Nov 20. 3, The Evolution of Telehealth: Where Have We Been and Where Are We Going? Available from: https://www.ncbi.nlm.nih.gov/books/NBK207141/ 3. Chen L, Cheng L, Gao W, Chen D, Wang C, Ran X. Telemedicine in Chronic Wound Management: Systematic Review And Meta-Analysis. JMIR MhealthUhealth. 2020 Jun 25;8(6):e15574.

4. Koonin LM, Hoots B, Tsang CA, et al. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep 2020;69:1595–1599.

5. Peek STM, Luijkx KG, Vrijhoef HJM, Nieboer ME, Aarts S, van der Voort CS, Rijnaard MD, Wouters EJM. Understanding changes and stability in the long-term use of technologies by seniors who are aging in place: a dynamical framework. BMC Geriatr. 2019 Aug 28;19(1):236.

6. Jordan S, McSwiggan J, Parker J, Halas GA, Friesen M. An mHealth App for DecisionMaking Support in Wound Dressing Selection (WounDS): Protocol for a User-Centered Feasibility Study. JMIR Res Protoc. 2018 Apr 24;7(4):e108. doi: 10.2196/resprot.9116. PMID: 29691213; PMCID: PMC5941095.

7. Davey J, Nana G, Joux V, Arcus M. Accommodation options for older people in Aotearoa/ New Zealand. New Zealand: Wellington; 2004.

Figure 1: Strengths and limitations of digital wound care.

Strengths

Weaknesses

No appointment wait time

Lack of hands-on wound assessment (palpation, depth)

Decrease in ER visits

Odour issues

Post-surgical chronic wounds

Learning curve for patients and clinician with technology

Convenience from patients’ home

Diagnostic accuracy, depth/ undermining/tunnelling

Streamlines care plan

Complex wounds may need to be referred for debridement, procedures

Less pain for patient (eliminated car journey to the appointment)

Risk of disparity in available technology

Cost effective Wound care supplies delivered to home Enhanced quality of life Improved clinical outcomes

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AAWC PRESENTATIONS AT A GLANCE

Wound Bed Preparation to Optimize Topical Therapy Editorial Summary This article provides the essentials of evidence based wound bed preparation as well as wound bed features that provide clues to topical therapy selection. It reviews host factors and wound etiologies that factor into topical and advanced therapy selection, and how to ensure best outcomes for advanced therapies by pairing wound bed preparation and biofilm based wound management with appropriate topical therapy for the patient and their wounds.

Introduction

Figure 1

C

hronic wounds have a damaged ECM, increased bioburden, and increased protease. 78.2% of chronic wounds have chronic biofilm, as do 6% of acute wounds.

Debridement Frequency and Healing DFU/ VLU Wounds serially debrided within the first four weeks of the treatment period had a median wound area reduction 54% higher than wounds that were not debrided. The wounds that eventually healed, and those that failed to, had not both shown greater area reduction, following visits with debridement. Figure 1 depicts this.

To compare two treatments, standard dressing care, or debridement; standard dressing enables wounds to be 79.2% healed, within 128.9 days. On the other hand, debridement allows for wounds to be healed 95.5% in 46.73 days. These statistics show that debridement is more favorable and effective.

Proactive Therapy

Presentation by Dr Gregory Bohn

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Proactive therapy allows for early and aggressive implementation of a broad-spectrum therapy or treatment plan from day one. It resolves inflammation whilst balancing protease and the breakdown of ECM/ healing. It also builds tissue and restores ECM for tissue development. It targets both acute wounds and chronic wounds via its early intervention.

Wound Masterclass - Vol 2 - June 2023

Elevated Protease Activity and NonHealing Wounds 28% of chronic wounds have elevated protease activity (EPA), as defined by their thresholds.

A positive EPA indicates chronic wounds have 90% chance of not healing. Wounds with high elastase did not necessarily also hold high MMP levels. Similarly, wounds with high MMP levels did not necessarily have high elastase levels.

Multiple Proteases Contribute to NonHealing Wounds Individual protease is not a causation of the EPA. A wound is not required to have high levels of all proteases in order for it to be non-healing.

Individual proteases seem to hold the ability to compensate for one another in providing a highly proteolytic wound environment. This highlights the requirement to measure multiple proteases in order to determine if proteolytic activity is causing a problem in the wound and preventing it from healing and making progress.

Wound Bed Preparation to Optimize Topical Therapy

Point of Care Protease Assessment Can wound assessment of protease activity direct treatment of the chronic wound if it is elevated? 28% of wounds have EPA and require collagen to balance. There is still the query of the other 72% that don’t have high EPA and require ECM. Similarly, the query of whether wounds with low protease levels not healing for other reasons.

Collagen Dressing

size is a negative risk factor for healing at 12 weeks. By secondary intent, its rate of healing is 0.6 – 0.7 mm per day. Figure 2 shows the venous ulcer healing by secondary intention with collagen. Size is a negative risk factor for healing at 12 weeks. By secondary intent, its rate of healing is 0.6 – 0.7 mm per day. Figure 2 shows the venous ulcer healing by secondary intention with collagen.

A retrospective review of advanced graft expenditures and wound resolutions in a VA wound centre:

Oxidized Cellulose (surgical) may be used and is utilised during surgery in order to stop bleeding.

Oxidized Cellulose (ORC) impregnated with processed collagen (gelatin) as wound dressing (2000s). ECM collagen had demonstrated value of minimally processed collaged source.

• • •

Collagen Extra Cellular Matrix This has been created in order to reduce excess MMP activity: collagen dressings are able to act as a sacrificial substrate. Intact and native extracellular matrix will promote tissue granulation and epithelialization for final wound closure . Extracellular Matrix regulates cellular function and next phenotype expression.

Showed standardization of assessment, treatment, and management of wounds to promote wound closure Established a dual protocol algorithm: o Decision and Treatment arms Utilized CECM Collagen dermal as the first line collagen of treatment o Clinical decision for treatment was based on whether there was a 30% - 50% wound size reduction over 4 weeks • •

>30% WSR - continue with CECM Collagen <30% WSR – advance to biologic

Graumlich: no difference between ORC collagen and hydrocolloid. No stage 3 healers at 4 weeks. CECM collagen with hydrocolloid 20 patients. 61% healed stage 3 at 4 weeks.

Figure 2

Figure 2

This matrix has many types of functioning’s: guide and regulate cellular, morphology, cellular differentiation, migration, proliferation, cellular survival during tissue development, angiogenesis and granulation tissue formation, and chronic wound healing.

Venous Ulcer Combining Protease Management and Biofilm Management Strategy Figure 11 shows a wound of a 68-year-old female – a painful VLU present for 9 months. It is 14.35 sq cm in size (3.5 cm x 4.1 cm). Its large

Managing MMPs: Collagen Collagen acts as a sacrificial substrate MMPs attack the collagen fibres within the dressings instead of the body’s ECM. It also reduces excess MMP activity.

The next generation collagen serves as a functional role of ECM. It’s microarchitecture to support cell function. It also cofactors to orchestrate cellular interaction, as well as attracting stem cells to the wound site.

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Wound Bed Preparation to Optimize Topical Therapy

Dermal Template Collagen Provides Multiple Components Of The Extracellular Matrix

•

Intact type I collagen – major structural protein on dermis

•

Intact type III collage – an important fibrillar collagen

•

Intact type IV collagen – basement membrane component

•

Intact elastin – major protein responsible for skin elasticity

•

Intact fibronectin – multidomain cell adhesion protein

•

Intact laminin – basement membrane component

•

Intact FGF2 (bFGF)

•

Intact hyaluronic acid (HA – major water holding molecule)

ORC Collagen Contains No Intact Collagens Or Elastin

•

➢ 50% gelatin (denatured type I collagen)

•

➢ 50% oxidized regenerated cellulose

Biofilm regenerates in as little as 24 hours.

Non-Cytotoxic management to retard or slow reformation to elevate MMP production or infection. Non cytotoxic bioburdern management strategy includes hypochlorous acid (HOCL). It is generated by myeloperoxidative burst by neutrophils, monocytes and macrophages. This is significant activity against aerobic, anaerobic, fungal and viral pathogens. HOCL collagen is used to treat 18 tissue cultured wounds positive for pathogens. 17 out of 18 wound tissue culture is found negative at 2 weeks.

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Conclusion To summarise, the model of chronicity involves biofilm and host response to that biofilm. Host inflammation destructive to ECM and healing.

In the era of diagnosticts in wound care, it will help to identify opportunity to interveme.

Finally, the early and aggressive therapy can be concluded as the preferred approach, and step down when plausible.

References 1. Mast, B., & Schultz, G. (1996). Interactions of cytokines, growth factors, and proteases in acute and chronic wounds. Wound Repair and Regeneration, 4(4), 411-420.

2. Malone M, Barjnsholt T, McBain AJ, James GA, Stoodley P, Leaper D, Tachi M, Shultz G, Swanson T, Wolcott RD “The prevalence of biofilms in chronic wounds: A systematic review and meta-analysis of published data” Journal of Wound Care, 2017 Jan 2;26(1):20-25.

3. James G, et al; Biofilms in chronic wounds. Wound Repair and Regeneration: 16(1) 2008 p 37-44.

4. Mast, B., & Schultz, G. (1996). Interactions of cytokines, growth factors, and proteases in acute and chronic wounds. Wound Repair and Regeneration, 4(4), 411-420.

5. Piaggesi et al Diab Med 1998 15 5 412-7 6. Bohn, G. A., G. S. Schultz, B. A. Liden, M. N. Desvigne, E. J. Lullove, I. Zilberman, M. B. Regan, M. Ostler, K. Edwards, G. M. Arvanitis and J. F. Hartman (2017). “Proactive and Early Aggressive Wound Management: A Shift in Strategy Developed by a Consensus Panel Examining the Current Science, Prevention, and Management of Acute and Chronic Wounds.” Wounds 29(11): S37-S42.

7. Schultz G et al; Consensus guidelines for the identification and treatment of biofilms in chronic nonhealing wounds Wound Rep Reg (2017) 25 744–757 8. Beidler, S. K., Douillet, C. D., Berndt, D. F., Keagy, B. A., Rich, P. B., & Marston, W. A. (2008). Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Repair and Regeneration, 16(5), 642-648.

9. Serena, Cullen, et al Protease Activity Levels Associated with Healing Status of Chronic Wounds 2011 10. Ibid.

11. Serena, et al, Bacterial proteases: A marker for a ‘state of pathogenesis’ in chronic wounds, 2015 12. Armstrong, Bauer, Bohn, Principles of Best Diagnostic Practice in Tissue Repair and Wound Healing: An Expert Consensus Diagnostics 2021, 11, 50.

13. Serena, Cullen, et al Protease Activity Levels Associated with Healing Status of Chronic Wounds 2011 14. Rohde, H., Burdelski, C., Bartscht. K. et al. Induction of Staphylococcus epidermidis biofilm formation via proteolytic processing of the accumulation associated protein by staphylococcal and host proteases. Mol Microbial 2005; 55: 6, 1883-1895 15. Bohn, Ovine-Based Collagen Matrix Dressing: Next-Generation Collagen Dressing for Wound Care February 2016 Advances in Wound Care 5(1):1-10 16. Gibson D, Yang Q, Schultz G Description of MMP Activity Levels and Wound Surface Area Changes in Venous Leg Ulcers. SAWC Spring 2014 17. Ibid.

18. Schultz, G., Ladwig, G., & Wysocki, A. (2005). Extracellular matrix: Review of its roles in acute and chronic wounds. Worldwide Wounds. Retrieved from http://www.worldwidewounds. com/2005/august/Schultz/Extrace-Matric-Acute-Chronic-Wounds.html 19. Tonnesen MG et al. Angiogenesis in Wound Healing. The Society for Investigative Dermatology, Inc. Vol 5, 1; 2000.

20. Pastar I et al. Epithelialization in Wound Healing: A Comprehensive Review. Adv in Skin and Wound Care, Vol 3, 7; 2014.

21. Schultz, Davidson, Krisner et al. Dynamic Reciprocity in the Wound Microenvironment Wound Repair Regeneration 2011 Mar 19 (2) 134-148 22. Negron L, Lun S, May BC. Ovine forestomach matrix biomaterial is a broad-spectrum inhibitor of matrix metalloproteinases and neutrophil elastase. Int Wound J. 2012 Nov 1.

23. Bohn G A New Ovine Collagen Dressing Demonstrates Cost Effectiveness in the Treatment of Venous Leg Ulcers SAWC Spring 2013 Denver CO 24. www.medetec.co.uk/book%20abstracts/wound-healing-mechanisms.pdf accessed 4/1/2023 25. Ferreras D., Craig S., Malcomb R., Utilization of an ovine collagen dressing with an intact extracellular matrix (CECM) within a dual-protocol algorithm to improve wound closure times and reduce expenditures in a VA Hospital poster presentation at SAWC Fall 2015 26. ibid 27. Dempsey SG, Miller CH, Schueler J, Veale RWF, Day DJ, et al. (2020) A novel chemotactic factor derived from the extracellular matrix protein decorin recruits mesenchymal stromal cells in vitro and in vivo. PLOS ONE 15(7): e0235784. https://doi.org/10.1371/journal. pone.0235784 28. Bohn GA, et al, Can The Use of *Hypochlorous Acid Change Your Dressing Selection in Treating Chronic Wounds? CSASWC 2014 poster presentation

You can’t treat what you can’t see

Red fluorescence indicates bacterial loads (>104 CFU/g)

Point-of-Care Imaging Systems for Detection of Elevated Bacterial Loads and Digital Wound Measurement

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MolecuLight i:X ®

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For a DEMONSTRATION or QUOTE, visit moleculight.com | info@moleculight.com ©2022 MolecuLight Inc. All Rights Reserved. MolecuLight®, MolecuLight i:X ® and DX™, and the MolecuLight logo are trademarks or registered trademarks or copyrighted materials of MolecuLight. The MolecuLight i:X ® and DX Imaging Devices have received FDA 510(k) clearance and are approved by Health Canada and have CE marking.

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©2022 MolecuLight® Inc. All Rights Reserved. MKT 2352 Rev 1.0

AAWC PRESENTATIONS AT A GLANCE

Support Surface Testing: How to Use What We Get Editorial Summary This article explores how to apply support surface microclimate test results to bed selection and settings in protection of patients from heat and moisture-based stresses; how to use the support surface test results for pressure, friction, and shear to make surface selections, and guide support surface settings and nursing practice for prevention and treatment of pressure injuries. Also covered is implementation and proper utilization of support surfaces and nursing practices to overcome the limitations of beds in protection of at-risk patients.

Introduction

S

tandard hospital mattresses are not suitable for patients with pressure injuries or for those at high risk for obtaining a pressure injury. Support surfaces are overlays/mattresses and the solution to this issue. Whichever way the support surface is designed, the aim is to distribute body pressure evenly while reducing shearing forces, moisture, and control heat.1

There are six official elements to consider when allocating the correct support surface to a patient:

different function and intended use.

Immersion and Envelopment define pressure, meaning how far the patient sinks into the surface as well as how well force can be distributed to the available surface. Figure 1 displays an example of these tests.

Immersion Holds the mass and height of average male.

The material is 50-60% foam and 80+% air. The friction reduces immersion and anything else on the surface impacts immersion. The surfaces react to chucks, sheets, overlays differently.

Body Analog 1. Pressure – Immersion and envelopment allow the pressure to be spread over a greater area 2. Friction, based on the sheet or overlay should help to balance the positioning 3. Shear – type of surface, friction – this will help to reduce sliding 4. Heat – Type of surface – this will allow skin on the surface to breathe 5. Moisture – surface selection will enable moisture reduction 6. Nursing practices interact with each of the other 5 features, and it provides all the interventions. It is arguably the single greatest impact.

Presentation by Mr Evan Call

42

This device measures the accumulation of heat and humidity. It reports the temperature in °C and reports humidity in relative humidity.

These two values are highly cognitive to the typical user as it is human nature to know what high humidity and high temperature feel like.

Figure 2.

Sweating Guarded Hot Plate This measures the heat movements through flux sensors when the surrounding areas are dry and when they are wet. Clinicianscan use this deviceto calculate the potential removal of moisture in normal operation. Figure 3.

Heated Bladder Method There are multiples test to measure the different elements. To test Immersion and Envelopment, clinicians have 3 different tests.

This is because each support surface had a

Wound Masterclass - Vol 2 - June 2023

This machine measures the weight of moisture removed in grams. It can measure continuous removal for over 3 hours. Figure 4.

Support Surface Testing: How to Use What We Get Figure 1: Immersion.

Figure 2: Body analog.

Figure 3: Sweating Guarded Hot Plate.

Figure 4: Heated Bladder Method.

Figure 5: Final ranking after considering each of the test results and care practices.

References 1. McNichol L, Mackey D, Watts C, Zuecca N. Choosing a support surface for pressure injury prevention and treatment. Nursing. 2020 Feb;50(2):41-44. doi: 10.1097/01.

NURSE.0000651620.87023.d5. PMID: 31904618; PMCID: PMC7329246.

2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. 2009.

Prevention and treatment of pressure ulcers: clinical practice guideline. National Pressure Ulcer Advisory Panel 3. National Pressure Ulcer Advisory Panel Support Surface Standards Initiative TIG048A-Ss Features and Physiology, 15 Aug 2009 Washington DC 4. Kokate JY, Leland Kj, Held AM, Hansen GL, Kveen GL, Johnson BA, Wilke MS, Sparrow EM, Iaizzo PA. Temperature-modulated pressure ulcers: A porcine model. Arch Phys Med Rehabil. 1995;76(7):666–73. [PMID: 7605187] DOI:10.1016/S0003-9993(95)80637-7 5. Arrhenius, S. [On the rate of reaction of the inversion of sucrose by acids].

ZeitschriftfuerphysikalischeChemie. 1889;4:226–48. German.

6. National Health Statistics Reports Number 122 December 20, 2018 Mean Body Weight, Height, Waist Circumference, and Body Mass Index Among Adults: United States, 1999–2000 Through 2015–2016 by Cheryl D. Fryar, M.S.P.H., Deanna Kruszon-Moran, Sc.M., Qiuping Gu, M.D., and Cynthia L. Ogden, Ph.D. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics

7. Iaizzo PA, Kveen GL, Kokate JY, Leland KH, Hansen GL, Sparrow EM, Prevention of Pressure Ulcers by Focal Cooling: Histological Assessment in a Porcine Model. Wounds: A Compendiium of Clinical Research and Practice. 1995; 7(5)161-169 8. Fader M, Bain D, Cottenden A. Effects of absorbent incontinence pads on pressure management mattresses. Journal of Advanced Nursing, 48(6):569-574.

9. Patel S., Knapp C. F., Donofrio J. C., Salcido R. Temperature Effects on Surface PressureInduced Changes in Rat Skin Perfusion: Implications in Pressure Ulcer Development. Journal of Rehabilitation Research and Development. 1999:36(3). Landis, E. M. (1930). MicroInjection Studies of Capillary Blood Pressure in Human Skin. Heart 15: 209 – 228, 1930 10. American National Standards Institute, Inc. Requirements and Test Methods for Full Body Support Surfaces. Jan 2019.

7. Iaizzo PA, Kveen GL, Kokate JY, Leland KH, Hansen GL, Sparrow EM, Prevention of Pressure Ulcers by Focal Cooling: Histological Assessment in a Porcine Model. Wounds: A Compendiium of Clinical Research and Practice. 1995; 7(5)161-169 8. Fader M, Bain D, Cottenden A. Effects of absorbent incontinence pads on pressure management mattresses. Journal of Advanced Nursing, 48(6):569-574.

9. Patel S., Knapp C. F., Donofrio J. C., Salcido R. Temperature Effects on Surface PressureInduced Changes in Rat Skin Perfusion: Implications in Pressure Ulcer Development. Journal of Rehabilitation Research and Development. 1999:36(3). Landis, E. M. (1930). MicroInjection Studies of Capillary Blood Pressure in Human Skin. Heart 15: 209 – 228, 1930 10. American National Standards Institute, Inc. Requirements and Test Methods for Full Body Support Surfaces. Jan 2019.

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Submit Your Research to Our Journal Case reports, randomized controlled trials, clinical reviews, audits, and research projects submissions@woundmasterclass.com

Image licenced from Adobe Stock. Credit: Rawpixel.com

Masterclass GUIDES Introduction This Masterclass Guide explains Hidradenitis Suppurativa and its treatments.

What Is Hidradenitis Suppurativa?

Hidradenitis Suppurativa Keywords ■ HS Symptoms ■ HS Stages ■ Chronic inflammatory disease ■ Inflammatory nodules ■ Pus-discharging tunnels

■ Hidradenitis Suppurative ■ HS Diagnosis ■ HS Treatment ■ HS Epidemiology ■ HS Quality of Life

Figure 1: Stages of Hidradenitis Suppurativa.

■ Hidradenitis suppurativa (HS) is a chronic inflammatory disease ■ It primarily affects skin folds like armpits, groin, buttocks, or perianal area

■ Common symptoms include inflammatory nodules, abscesses, and pus-filled tunnels

■ The condition is characterized by recurrent and painful skin lesions

Stage 1

Stage 2

Stage 3

■ HS can cause pain, tenderness, and inflammation in the affected areas

■ The exact cause of HS is not fully understood ■ Factors like genetics, hormones, immune dysfunction, and follicular occlusion may contribute

■ Treatment aims to manage symptoms, reduce inflammation, and prevent new lesions

■ The condition is characterized by recurrent and painful skin lesions ■ Options include medications, lifestyle changes, wound care, and surgical interventions

■ Early HS skin lesions can resemble other skin conditions, such as bacterial abscesses, leading to frequent misdiagnosis

■ This misdiagnosis often results in an average delay of around 7 years in reaching a correct diagnosis

■ Clinicians may use scoring systems to assist in diagnosis, and

patient-reported outcome measures (PROMs) are also utilized for stratification and treatment planning

A Guide to Early Diagnosis ■ Recognition of symptoms: Being aware of the common symptoms

of HS, such as recurring painful nodules, abscesses, and sinus tracts in skin folds, can help in early identification

■ Clinical examination: A thorough physical examination by a

dermatologist is essential for evaluating the nature and location of skin lesions, as well as their chronicity

■ Differential diagnosis: Distinguishing HS from other skin conditions that may present with similar symptoms, such as folliculitis or abscesses, requires careful consideration and expertise

■ Diagnostic criteria: There are no specific laboratory tests or imaging studies available for diagnosing HS. Instead, diagnosis is primarily based on clinical criteria, including the characteristic presentation, distribution, and chronicity of the lesions

■ Specialist referral: If HS is suspected, it is advisable to seek

evaluation from a dermatologist or a healthcare professional experienced in managing HS to ensure an accurate diagnosis and appropriate treatment plan

■ Prompt intervention: Early diagnosis allows for timely initiation Figure 2:

of management strategies, which can help alleviate symptoms, prevent disease progression, and minimize complications

■ Diagnostic delay: The average delay in diagnosing HS can lead to

a delay in initiating appropriate treatment, resulting in prolonged suffering and disease progression

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Masterclass GUIDES

Hidradenitis Suppurativa

UNEMPLOYMENT

EMBARRASSMENT

DEPRESSION

PAIN

IMPAIRED SELF IMAGE

NO EFFECTIVE TREATMENT

Quality of Life

Pain and disease severity:

Sleep disturbances:

Emotional and psychological impact:

The majority of HS patients experience pain, and the severity of pain often correlates with the severity of the disease. Pain can affect daily activities and quality of life.

Insomnia or disturbed sleep due to pain is a common complaint among HS patients. Pain can disrupt sleep patterns, leading to fatigue and decreased well-being.

HS is a disfiguring condition, causing embarrassment and negatively affecting self-esteem. Patients, especially women, may experience impaired sexual lives. The burden on personal and private life can lead to depression, which is correlated with impaired self-image and an increased risk of suicide.

Work and employment issues:

Social isolation:

Impaired mobility:

HS can result in absenteeism from work and higher unemployment rates compared to the general population. The physical and emotional challenges of the condition can make it difficult for patients to maintain regular employment.

HS can lead to social isolation and withdrawal due to embarrassment about the appearance of the lesions, odor associated with the condition, and the fear of judgment or misunderstanding from others.

The pain, inflammation, and recurrent lesions of HS can limit mobility and physical activities, further impacting daily life and overall wellbeing.

Financial burden:

Coexistence of other health conditions:

Impact on relationships:

HS can result in increased healthcare expenses, including doctor visits, medications, and potential surgical interventions. The financial burden may be exacerbated by work absenteeism or unemployment.

Patients with HS may also have a higher prevalence of other health conditions such as obesity, metabolic syndrome, and autoimmune diseases, further adding to the overall disease burden.

HS can strain personal relationships, including intimate partnerships and friendships, due to the physical and emotional challenges associated with the condition.

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Masterclass GUIDES

Hidradenitis Suppurativa

A Guide to Select the Right Treatment

Antibiotic Therapy Antibiotics, such as tetracyclines, clindamycin, and rifampicin, are commonly used in the treatment of HS. They help reduce bacterial colonization and inflammation, providing symptomatic relief.

Anti-inflammatory Therapy Various anti-inflammatory medications may be prescribed, including non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. These medications can help manage pain, reduce inflammation, and control disease activity.

Surgical Intervention In cases where medications alone fail to adequately control HS, surgical interventions may be considered. Procedures such as incision and drainage of abscesses, excision of affected areas, and reconstructive surgery can be performed to remove affected tissue and promote healing.

Combination Therapy Treatment often involves a combination of antibiotic therapy, anti-inflammatory medications, and surgical interventions tailored to individual patient needs.

Limited Effective Therapies Despite the available treatment options, HS remains challenging to manage. Some patients may not respond well to existing therapies, emphasizing the need for continued research and the development of new treatment approaches.

Multidisciplinary Care The management of HS often requires a multidisciplinary approach, involving dermatologists, wound care specialists, and potentially other healthcare professionals such as pain specialists, psychologists, and nutritionists, to address the various aspects of the condition.

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Hidradenitis Suppurativa

Masterclass GUIDES

Key Points

■ HS is a chronic inflammatory disease characterized by skin lesions such as inflammatory nodules, abscesses, and pusdischarging tunnels

■ The condition primarily affects skin folds in areas like the armpits, groin, buttocks, or perianal region ■ HS often presents with symptoms that mimic other skin diseases, leading to misdiagnosis and diagnostic delays averaging around 7 years

■ Pain and disease severity in HS are commonly reported, with a correlation between the two ■ Insomnia or disturbed sleep due to pain are common complaints among HS patients ■ HS can be disfiguring, leading to embarrassment and impacting the sexual lives of patients, particularly in women ■ Absenteeism from work and higher unemployment rates are observed in HS patients compared to the general population

References 1. Zouboulis CC, Desai N, Emtestam L, et al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol. 2015;29(4):619-644.

2. Alikhan A, Sayed C, Alavi A, et al. North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations. J Am Acad Dermatol. 2019;81(1):7690.

3. Ingram JR, Piguet V, Chua SL, et al. Topical and systemic therapies for hidradenitis suppurativa: a systematic review. Semin Cutan Med Surg. 2017;36(2):55-63.

4. Revuz JE, Canoui-Poitrine F, Wolkenstein P, et al. Prevalence and factors associated with hidradenitis suppurativa: results from two case-control studies. J Am Acad Dermatol. 2008;59(4):596-601.

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How to Cite this Article Masterclass Guide: Hidradenitis Suppurativa. Wound Masterclass. Volume 2. No 5. June 2023

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Masterclass GUIDES

Onychomycosis Fungal Nail

Introduction

Keywords ■ Onychomycosis ■ Tinea pedis ■ Nail Infections ■ Fungal Foot ■ Fungal Nail Infections

Onychomycosis and tinea pedis, also known as fungal foot and nail infections, can cause discomfort and impact quality of life. Early intervention is crucial. Topical treatments provide localized drug delivery and improved adherence. Managing predisposing factors and educating patients on foot hygiene are essential for successful treatment.

What is Onychomycosis?

■ Topical Treatments ■ Early Treatments ■ Fungus ■ Infection ■ Diagnosis

Figure 1:

Onychomycosis refers to a condition characterized by a fungal infection of the nails, specifically affecting the toenails. It is caused by various types of fungi, including dermatophytes, yeasts, and molds. The condition can be challenging to treat and may require medical intervention to alleviate symptoms, prevent complications, and restore the nails’ health and appearance.

Signs and Symptoms of Onychomycosis:

What Is at Risk?

■ Age: Fungal toenail infections are more prevalent in older adults due to agerelated changes in nail structure and reduced immune function

■ Poor Foot Hygiene: Inadequate foot hygiene can create a moist environment that promotes fungal growth

■ Trauma or Injury: Previous trauma or injury to the toenail can weaken the nail’s protective barrier, making it more susceptible to fungal invasion

■ Hyperhidrosis: Excessive sweating of the feet can create a warm and moist environment that encourages fungal growth

■ Diabetes: Individuals with diabetes are at higher risk of developing fungal

toenail infections due to compromised immune function, poor circulation, and nerve damage, which can affect nail health

■ Diabetes: Individuals with diabetes are at higher risk of developing fungal

toenail infections due to compromised immune function, poor circulation, and nerve damage, which can affect nail health

■ Weakened Immune System: People with weakened immune systems, such as those with HIV/AIDS, undergoing chemotherapy, or taking immunosuppressive medications

■ Nail Trauma or Disease: Conditions that affect the nails, such as psoriasis or

nail psoriasis, can damage the nail structure, making it more prone to fungal infections

■ Environmental Exposure: Regular exposure to moist environments like public pools, communal showers, and locker rooms increases the risk of fungal toenail infections

■ Wearing Tight or Occlusive Footwear: Shoes that do not allow proper

■ Nail Discoloration: ■

The affected toenail may change color, often turning yellow, brown, or white

■ Thickened Nails and Distorted Nail Shape: ■

Fungal infections can cause the affected toenail to become thickened and noticeably larger than the surrounding healthy nails. The nail may also become brittle and crumbly, as well as the shape becomes irregular

■ Nail Fragility: ■

Fungal toenails tend to be fragile and prone to splitting, cracking, or breaking easily. This can lead to discomfort or pain, particularly when pressure is applied to the affected nail

■ Subungual Debris: ■

The presence of debris may be observed under the affected toenail, which can contribute to the thickened and discolored appearance of the nail

■ Nail Lifting: ■

The infected toenail may start to separate or lift from the nail bed, creating a gap. This can allow for the accumulation of debris and create an entry point for secondary bacterial infections

■ Nail Odor: ■

Fungal toenail infections may emit an unpleasant odor, particularly when moisture and bacteria are present within the affected nail

ventilation can create a warm and damp environment, promoting fungal growth

■ Genetic Predisposition: Some individuals may have a genetic predisposition to fungal infections, making them more susceptible to developing onychomycosis

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Onychomycosis Fungal Nail

Masterclass GUIDES

A Guide to Diagnosis

Clinical Evaluation: A healthcare professional will assess the appearance of the affected toenails, considering factors such as discoloration, thickening, deformities, and the presence of debris. Medical history, including any predisposing factors or previous treatments, will also be considered.

Nail Sampling: In some cases, a sample of the affected toenail or debris underneath the nail may be collected for laboratory analysis. This can be done using various techniques such as nail clippings, nail scraping, or a superficial biopsy.

Microscopic Examination: The collected nail sample is examined under a microscope to identify the presence of fungal elements, such as hyphae (fungal filaments) or spores. This can help confirm the diagnosis of onychomycosis and identify the specific fungal species involved.

Fungal Culture: The nail sample can be cultured on specific fungal growth media to encourage the growth of fungi. This allows for the identification of the causative fungal species and can help guide treatment decisions. Fungal culture may take several weeks to yield results.

Polymerase Chain Reaction (PCR) Testing: PCR testing is a molecular technique used to detect and identify fungal DNA in nail samples. It is a sensitive and specific method that can provide rapid and accurate results for diagnosing onychomycosis.

What Research Says on Treatment: Topical therapy increases patient compliance while decreasing treatment costs. However, because topical treatment penetrates poorly over the nail plate, research is focusing on various chemical, mechanical, and physical approaches to increase drug delivery.

Thioglycolic acid, Hydroxypropyl--cyclodextrin (HP--CD), Sodium lauryl sulfate (SLS), carbocysteine, N-acetylcysteine, and other penetration enhancers have been found to improve medication penetration over the nail plate. Physical treatments such as iontophoresis, laser, and Photodynamic therapy have shown encouraging results, but their long-term appropriateness need to be proven. Another study mentions how onychomycosis therapies that have recently been approved include efinaconazole, tavaborole, and laser therapy, with lasers only being approved to temporarily enhance the quantity of clear nail.

Iontophoresis and photodynamic therapy are two more onychomycosis therapies still being studied.

Images licenced from Adobe Stock. Credit: otello-stpdc, Vasyl, WavebeakMediaMicro, angellodeco, kamiphotos, muro

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Masterclass GUIDES

Onychomycosis Fungal Nail

A Guide to Select the Right Treatment Topical Antifungal Therapies:

■ ■ ■

Topical antifungal creams, solutions, gels, and lacquers are applied directly to the affected nails. They offer localized drug delivery and are effective for mild to moderate cases Common topical antifungal agents include azoles (e.g., clotrimazole, ketoconazole), ciclopirox, and amorolfine. These medications inhibit the growth of fungal cells Treatment duration can range from weeks to months, with regular application according to specific product instructions

Oral Antifungal Medications:

■ ■

Systemic oral antifungal medications are prescribed for moderate to severe onychomycosis or when topical therapy is ineffective Terbinafine and itraconazole are the most commonly used oral agents. They inhibit the synthesis of fungal cell components, leading to the death of fungal cells

■

Treatment duration varies based on the medication and the extent of the infection, typically lasting several weeks to a few months

■

Oral antifungal medications may carry potential systemic side effects and require monitoring of liver function and drug interactions

Combination Therapy:

■

Combination therapy involves the simultaneous use of topical and oral antifungal treatments to enhance efficacy and improve treatment outcomes

■

This approach is particularly useful in severe or recurrent cases of onychomycosis or when the infection involves multiple nails

Procedural Interventions:

■

In certain cases, procedural interventions may be considered to treat onychomycosis, especially when other treatments fail or are not feasible

■

Nail debridement or avulsion can be performed to remove infected nail material, allowing for more effective topical or systemic therapy

■

Laser therapy, using devices that emit specific wavelengths to target fungal cells, is a developing option but requires further research to establish its efficacy

Adjunctive Measures:

■

Patient education on foot hygiene, regular nail trimming, and proper footwear to reduce reinfection risk

■

Addressing underlying risk factors such as excessive moisture, peripheral vascular disease, immunosuppression and diabetes

■

Monitoring treatment response through follow-up visits, repeated fungal cultures, or periodic nail sampling

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Wound Masterclass - Vol 2 - June 2023

Masterclass GUIDES

Onychomycosis Fungal Nail Key Points

■ Onychomycosis refers to a condition characterized by a fungal infection of the nails ■ Medical personnel need to be cautious as older adults, trauma, hyperhidrosis, people with diabetes, weakened immune system, and etc, are at risk of onychomycosis

■ Signs and symptoms of onychomycosis include: nail discoloration, thickened nails, nail fragility, subungual debris, nail lifting, and nail odor

■ The diagnosis through clinical evaluation, nail sampling, microscopic examination, fungal culture, and/ or polymerase chain reaction (PCR)

■ The treatments for onychomycosis include: topical antifungal therapy, oral antifungal medications, combination therapy, procedural Interventions, and adjunctive measure

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Aggarwal R;Targhotra M;Kumar B;Sahoo PK;Chauhan MK; Treatment and management strategies of onychomycosis [Internet]. U.S. National Library of Medicine. Available from: https://pubmed.ncbi.nlm.nih.gov/32234349/ NH; GAS. Onychomycosis in the 21st Century: An update on diagnosis, epidemiology, and treatment [Internet]. U.S. National Library of Medicine; 2017. Available from: https://pubmed.ncbi.nlm.nih.gov/28639462/ Bodman MA, Krishnamurthy K. Onychomycosis [Internet]. PubMed. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441853/#:~:text=Onychomycosis%20is%20a%20fungal%20infection Elewski BE. Onychomycosis: pathogenesis, diagnosis, and management. Clinical microbiology reviews [Internet]. 1998;11(3):415–29. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC88888/ ‌‌Leung AKC, Lam JM, Leong KF, Hon KL, Barankin B, Leung AAM, et al. Onychomycosis: An Updated Review. Recent Patents on Inflammation & Allergy Drug Discovery. 2020 Mar 30;14(1):32–45.

Lim SS, Ohn J, Mun JH. Diagnosis of Onychomycosis: From Conventional Techniques and Dermoscopy to Artificial Intelligence. Frontiers in Medicine [Internet]. 2021 Apr 15;8:637216. Available from: https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC8081953/

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How to Cite this Article Masterclass Guide: Onychomycosis Fungal Nail. Wound Masterclass. Volume 2. No 5. June 2023

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