SAWC Abstract Preview: The 24th Annual Spring Symposium on Advanced Wound Care and the Wound Healing Society Meeting

April 14–17, 2011 Gaylord Texan Hotel and Convention Center Dallas, Texas

The SAWC and WHS are back in Texas for what promises to be an information-packed conference. More than 300 abstracts (potential oral and poster presentations) were submitted for judging. The winning oral abstracts to follow are included to help you plan your session attendance. Oral abstracts will be offered during sessions 30 through 32 and 40 through 42. Posters can be viewed throughout the Symposium; presenters are available Day 2 from 7:30 a.m. to 9:00 a.m. Ostomy Wound Management congratulates all SAWC presenters for sharing their research.

The topical effect of plant derived oil, monoterpene (periklean-oh liquid gel), on methicillin-resistant Staphylococcus aureus and Acintobacter baumannii in an in vivo porcine wound model

Patricia Mertz, BS; Joel Gil; Jose Vales; Abel Claro; and Stephen C. Davis

  Aim: The purpose of this study was to determine the effect of a topical monoterpene preparation (Periklean-OH) on the growth of two human pathogens, methicillin-resistant Staphylococcus aureus (MRSA; USA 300)1 and Acinetobacter baumanniiin vivo wound model.

  Methods: Forty-eight wounds measuring 10 mm x 7 mm x 0.5 mm deep were created on a pig using an electrokeratome. One side of the animal was inoculated with MRSA (USA-300) and the other AB (ATCC 19606). Four wounds were randomly assigned to one of the following treatment groups: Periklean-OH 0.1%^, Periklean-OH 0.25^, Periklean-OH 0.5%^,Periklean-OH 1%^,Vehicle^ or untreated (^-Zaycor Inc., Miami, FL). All treatment groups were covered with a polyurethane film dressing. Twenty-four hours after treatment, wounds were cultured using a well-described scrub technique. After serial dilutions organisms were grown on selective media and quantitated using the Spiral Plater System, all plates were incubated aerobically at 37˚ C. Conclusions: Wounds treated with Periklean-OH showed a progressive decrease in organism counts with higher concentrations. The active compound appears to be more effective against AB. The 1% formulation showed a 96.98% and 99.99% reduction of log CFU/mL of MRSA and AB after 24 hours treatment, respectively, when compared to untreated wounds. This is a pilot study; additional animals are needed to substantiate these findings. These results may have significant clinical implications, especially against Gram-negative A. baumannii infected wounds.

Role of limited access dressing in eliminating multi-drug resistant organisms capable of forming biofilms in wound infections

P. Kumar; I. Bair;; K. Chawla; S. Sarkar; and A. Sarkar
  Background: Limited-access dressing (LAD) is the combination of intermittent negative pressure and moist wound dressing used in the management of both acute and chronic wounds (such as burn wound, diabetic foot ulcer, necrotizing fasciitis) by preventing bacterial invasion at the wound site and reduce the hospital acquired infections. The objective of the present study is to evaluation of the efficacy of LAD in wound care management by checking the bacterial growth before and after the LAD, testing antibiotic susceptibility including ESBL, AmpC, and MBL and ability to form biofilm in vitro.

  Methods and Materials: Swabs were collected from the wound according to the conventional microbiological method before applying and after removing the LAD. Identification and antibiotic susceptibility were performed using CLSI guidelines. The strains were checked for multidrug-resistant enzyme production using disk approximation method and biofilm formation ability was tested using microtiter well method.

  Results: Out of 60 patients evaluated in this study, bacterial growth was detected in 57 patients (95%), usage of LAD resulted in no growth in 34 patients (59.6%), and reduction in the number of organisms was noted in 19/57(33.33%) patients. Among isolates (n = 93) from the first sample, 35 (37.6%) were biofilm producers, 24 (25.4%) were ESBL producers, 8 (8.6%)were AmpC producers, and 17 (18.2%) were MBL producers. LAD effectively removed organisms that produced biofilm in 34 cases, ESBL in 20 cases, AmpC in 6 cases and MBL in 12 cases.

  Other isolates from the pre-LAD treatment sample (n = 93) were Pseudomonas spp. (36, 38.7%) Klebsiella pneumonia (13, 13.93%), Klebsiella oxytoca (7, 7.52%), and Acinetobacter spp. (9, 9.6%). Commonly isolated organisms from the post-LAD treatment sample (n = 26) were Pseudomonas spp. (10, 38.4%), Proteus mirabilis (6, 23.07%), and K. oxytoca (4, 15.38%).

  Conclusion: LAD not only prevents hospital strains from colonizing and causing wound infections, but it also eradicates ESBL, AmpC, and MBL and organisms that produce biofilm, opening a new window in treatment of resistant wound infection.

An in vitro study assessing the ability of collagen/ORC/silver to reduce inflammatory protease activity compared to other dressings

Breda Cullen, PhD; Molly Gibson; and Rachael Coulson

  Aim: This study compares collagen/oxidized regenerated cellulose (ORC)/silver to other dressings to evaluate their capability to reduce inflammatory proteases, in vitro.

  Introduction: A chronic wound generates an excessive amount of inflammatory proteases, causing it to be detained in an inflammatory cycle. High levels of inflammatory proteases have a detrimental impact on the wound healing process; consequently, many different treatment options are used to try and rebalance the wound environment.   

  Method: Biopsies of each dressing were incubated at 37˚ C in a protease solution. Fluorometric assays were used to measure the activity of the protease solution over time to determine how effective each of the dressings was at reducing the activity of the inflammatory proteases. Each dressing was tested for the ability to reduce neutrophil-derived elastase and matrix metalloprotease (MMP) activity.

  Results: The ability to reduce the level of inflammatory proteases was found to differ between the dressings tested. The results show that collagen/ORC/silver was more effective at reducing the level of neutrophil-derived elastase and MMP activity than collagen-only dressings, dressings impregnated with NOSF, and other silver-containing dressings.

  Conclusion: This study demonstrates the effectiveness of different dressings to reduce protease activity using an in vitro model.

  Collagen/ORC/silver has the ability to reduce protease activity more effectively than any of the other dressings that were tested. This unique combination of collagen/ORC/silver provides benefits that cannot be achieved by either collagen or silver alone. Collagen/ORC/silver is effective at reducing inflammatory protease activity, suggesting this therapy is able to help rebalance the environment of the chronic wound to promote healing.

Interaction of PMN-derived reactive oxygen species with 2-hydroxyethyl methacrylate

John Kao, PhD; and Jeffrey A. Niezgoda, MD

  Introduction: During the inflammatory stage of wound healing, the polymorphonuclear cells engage bacteria via oxidative pathways. Excess or uncontrolled reactive oxygen species (ROS) can slow healing by interfering with metabolic enzymes, causing oxidative degradation of lipids within the cell membranes with associated wound inflammation. This study provides in vitro data to support the theoretical basis for recent clinical reports that claim enhanced wound healing trajectories have been realized with the application of ROS-scavenging hydrogels.

  Materials and Methods: Primary human polymorphonuclear neutrophils (PMNs) were seeded into test chamber A (consisting of a polycarbonate surface with 0.3µm pores) at 1 x 106 cell/mL in RPMI+10% autologous human serum. After 2 hours, the PMNs were rinsed with DPBS and test chamber A containing the adherent PMN was moved to a new chamber B containing various approximate amounts of 2-hydroxyethyl methacrylate* (2-HEMA; Wound-Be-Gone, Wake Pharma US, Chicago, IL). The extracellular ROS probe, OxyBurst H2HFF BSA (10µg/mL; Invitrogen), which fluoresces upon oxidation, supplemented with 100 nM phorbol myristate acetate (PMA), then was added to both chambers. After incubation with the probe and stimulant for 2 hours, supernatant from both chamber A and chamber B was removed to a separate well plate for fluorescence detection.

  Results: PMN-derived ROS present in the cell culture supernatant over 2 hours in the presence of various amounts of 2-hydroxyethyl methacrylate showed a significant increase in background fluorescence with the addition of 2-HEMA.   

  Conclusion: The decrease seen in extracellular ROS levels may be indicative of antioxidant properties of 2-hydroxyethyl methacrylate. The observed clinical outcomes associated 2-HEMA — improved healing, decreased inflammation, and reduced wound pain — previously theoretically attributed to the binding of excessive ROS, appear to have scientific support.

Hyperbaric oxygen therapy: the solution for acute wounds?

AM Eskes; DT Ubbink; M Lubbers; C Lucas; and H Vermeulen

  Background: Hyperbaric oxygen therapy (HBOT) has been used as a treatment for acute wounds. However, the effectiveness of HBOT for acute surgical and traumatic wounds is unclear.

  Methods: For this purpose, we undertook a Cochrane systematic review. All available randomized controlled trials (RCTs) comparing HBOT with other HBOT regimens or other interventions in patients with acute surgical and traumatic wounds were searched in CENTRAL, Medline, Embase, Cinahl (up to April 2009) and the Cochrane library (up to issue 2, 2009).

  Selection of trials, trial quality assessment, data extraction, and data synthesis were conducted by two authors independently. Any disagreements were referred to a third author. Primary endpoints were wound healing and adverse effects; secondary endpoints were mortality, pain scores, quality of life, patient satisfaction, activities daily living, increase in transcutaneous oxygen pressure (TcPO₂), amputation, length of hospital stay, and costs.

  Results: Three trials totaling 219 patients were included. These studies, with some methodological flaws, focused on many different outcome parameters, so the results could not be pooled. In one study involving 48 patients, HBOT was compared with usual care and resulted in a significantly higher percentage healthy graft area in split-skin grafts in favor of HBOT (95% healthy graft area: risk ratio [RR] 0.50; 95% confidence interval [CI] 0.30 to 0.83). In another trial, crush injuries treated with HBOT showed a quicker complete wound healing than with sham HBOT (RR 0.13; 95%CI 0.02 to 0.90) and less adverse effects (additional surgical procedures: RR 1.60; 95%CI 1.03 to 2.50). Other endpoints were not addressed.

  Conclusion: Although there is insufficient evidence from this review to support the routine use of HBOT for patients with acute surgical or traumatic wounds, the application of HBOT on crush injuries may be justified if costs are acceptable and HBOT facilities are available at the time of presentation.

Ultra-light, single-patient-use negative pressure wound therapy devices as a bolster over split-thickness skin grafts

Allen Gabriel, MD; Brinda Thimmappa, MD; Christopher Rubano, MD; and Toni Storm-Dickerson, MD

  Introduction: Negative pressure wound therapy (NPWT) is a well-accepted method of actively bolstering split-thickness skin grafts (STSGs) in difficult recipient wound beds. However, the process of obtaining home care reimbursement for placement of a rental NPWT device over a graft can take days. As a result, otherwise-healthy patients often remain hospitalized for the single purpose of receiving NPWT treatment over a flap or graft before discharge. An affordable, for-sale, disposable NPWT device may provide earlier transition into the home.

  Methods: A prospective small pilot study was conducted to evaluate a new ultra-lightweight, portable, single-patient-use NPWT system (V.A.C.VIA™ Therapy, KCI Licensing, Inc., San Antonio, TX) over STSGs. A thin, porous barrier layer was applied over the STSG, followed by reticulated open-cell foam, drape, and tubing disc. Pressure was initiated at -125 mm Hg via the ultra-lightweight (0.3kg) NPWT device. All patients were discharged on the day of surgical graft placement and treated as outpatients. Patients returned to the clinic 4 to 6 days post STSG placement for dressing removal. STSG was inspected for take rate and quality.

  Results: Six STSG patients (3 male and 3 female) were treated; average age was 59 years. Recipient beds were located on the hip, lower extremities, scalp, or buttock. Average duration of NPWT usage was 4.8 days and the average take rate was 98.5%.

  Conclusion: The disposable NPWT system functioned safely and effectively in this small pilot series; constant pressure was maintained over the graft with no complications. In our experience, the purchase versus rental and model of NPWT procurement was more cost-effective for this otherwise healthy patient population; hospital stay was reduced by at least 1 day per patient. A reduced patient stay could potentially result in a per-patient day savings of $1,993, based on an industry-derived, averaged US daily acute-community hospital cost.

Cost to heal among 7,900 patients at outpatient wound centers: data from the US wound registry

Caroline Fife, MD; Marissa Carter; David Walker; and Brett Thomson

  Background: Although RCTs are useful for determining product efficacy, they are not the best way to determine effectiveness (or cost effectiveness) in real world situations. We performed an initial assessment of cost to heal by retrospectively analyzing prospectively collected data from 59 hospital based outpatient wound centers in 18 states.

  Methods: Clinics using the Intellicure electronic health record (EHR) allowed data to be deidentified and pooled to create the US Wound Registry. The EHR automatically and internally calculates the physician and the facility charges as well as prescriptions and dressing products. There were 7,099 patients with 33,061 wounds in 179,279 visits.

  Results: There were wide variations in cost to heal when analyzed by wound/ulcer type but the average cost to heal per wound was $3,927. Jeopardized flaps and grafts were the most expensive wound/ulcer type with a mean cost per wound of $9,358. Diabetic foot ulcers were the most expensive chronic ulcers and were twice as expensive as other types with an average cost per patient of $5,391. The average cost per wound for pressure ulcers was $3,349. Factors that increased cost to heal were need for antibiotics, renal failure (particularly if pain medication was required), immunocompromise (eg, prednisone), and current smoking. Among wounds that ultimately healed, the proportion of costs were as follows: home health 26%, dressings 11%, NPWT 19%, HBOT 25%, physician charges 18%, bioengineered skin costs 1%.

  Conclusion: Wound healing cost studies often are restricted to acute care settings but these preliminary data suggest the majority of wound care costs may occur on the outpatient side because patients are followed for long periods of time. Not all wounds achieved healing and nonhealing wounds were among the most expensive. These 7,099 patients accrued a total cost of $29,249,500.

Can doctors accurately classify donor site wounds using the Red-Yellow-Black scheme? An inter-observer analysis

A Eskes; A Gribnau; L Gerben; H Vermeulen; and DT Ubbink

  Background: A uniform and correct judgment of donor sites is pertinent to medical decision-making and may improve communication between doctors and nurses. The Red-Yellow-Black-scheme (RYB) is a well-known scheme to classify chronic and acute wounds based on wound color and moistness. We investigated whether this RYB-scheme is also useful to classify donor site wounds.

  Methods: A set of 31 digital photographs of donor site wounds in various stages of wound healing were presented to 11 international wound experts. They classified these photographs using the RYB-scheme into six wound categories. An additional category was “completely healed.” If the majority of experts agreed upon the category, the photograph was retained in the set and the chosen category was considered as the correct classification. Subsequently, the remaining 23 photographs were judged by 25 doctors of our department of surgery. Inter-observer agreement (IOA) was expressed as a kappa value.

  Results: IOA among the experts on the final set of 23 photographs was poor ( = 0.17; 95% Confidence Interval [CI]: 0.11 to 0.24). IOA among the doctors was also poor ( = 0.28; 95% CI: 0.20 to 0.37). The three photographs of healed wounds in the set were classified correctly by 92% of the doctors (95% CI: 66 to 100). Red and moist wounds (n = 10) were classified correctly by 63% of the doctors (95% CI: 44 to 83). The remaining red and dry and yellow wounds were classified correctly by only half of the doctors. Experts as well as doctors hardly ever classified a wound as black.

  Conclusion: Clinicians as well as wound experts have difficulty with classifying donor site wounds by means of the RYB scheme. Apparently, this scheme is not a useful tool to classify donor site wounds in a uniform manner.

Molecular surgery approach to debridement

Olivera Stojadinovic; Irena Pastar; Elizabeth Lebrun; Katherine A. Gordon; Shari Jackson; Harold Brem; Evangelos Badiavas; Robert Kirsner; and Marjana Tomic-Canic

  Chronic wounds are a widespread and serious clinical problem with high rates of morbidity, disability, and mortality. The major obstacles to prompt and complete healing of chronic wounds are the inability to assess surgical preparation of the wound site and lack of objective criteria for predicting which wounds are not likely to respond to standard treatment protocols and will require alternative interventions. The critical first step in treatment is surgical debridement to remove infected tissue and stimulate wound re-epithelialization. However, there are no objective criteria for distinguishing healing-competent from healing-impaired tissue and therefore no methods for gauging the success of surgery. The objective of this project is to determine whether a subset of cellular and tissue biomarkers (presence of hyper- and para-keratosis and nuclear betacatenin, K15), may be utilized to determine healing properties of the tissue. To do this, we collected specimens from 10 diabetic foot ulcer patients before and after debridement and used histopathology and immunohistochemistry methods to evaluate tissue specimens. We found that nonhealing tissue of each patient contains robust presence of nuclei in cornified epidermal layer (parakeratosis), increased nuclear presence of betacatenin, and loss of epidermal stem cell marker K15. The majority of the post-debridement specimens exhibited reduction or complete loss of parakeratosis, decrease or loss of nuclear betacatenin, and restoration of K15. We conclude that these tissue and cellular biomarkers may be utilized to guide surgical debridement in the future.

Pulsed acoustic cellular expression technology in the treatment of diabetic foot ulcers: a sham-controlled, double-blinded, randomized clinical trial

Robert D. Galiano, MD; and the dermaPACE® Diabetic Foot Ulcer Study Group

  Introduction: Diabetes is a growing epidemic, affecting 189 million people worldwide; 25% of these will develop a diabetic foot ulcer (DFU). This prospective, randomized, double-blinded, sham-controlled, multicenter, parallel group study evaluated the safety and efficacy of pulsed acoustic cellular expression (PACE) technology for the treatment of DFUs.

  Methods and Materials: Participants included 206 patients with Grade 1/2 DFUs persisting 30+ days, randomized into active treatment (n = 107) or sham (n = 99). Four 20-minute PACE active or sham treatments were delivered over 2 weeks. All patients received standard of care including wet-to-dry dressings and offloading boots if needed. The study’s primary endpoint was wound closure (re-epithelialization without drainage/dressing requirements). Secondary endpoints included time to closure, area reduction, accelerated healing, safety, and pain.

  Results: There was a highly significant reduction in wound size compared to sham (P = 0.0035 week 6, P = 0.0021 week 8, P = 0.0007 week 10, and P = 0.0041 week 12) beginning 4 weeks following active treatment and throughout the 12-week evaluation period. Though not statistically significant, PACE treatment increased the proportion of DFUs that healed at 12 weeks by 36%. By 12 weeks, the average reduction in target ulcer size of PACE patients was 54%, versus 7% of sham. A composite analysis conducted for patients achieving 90% to 100% closure showed statistical significance (P = 0.0161) compared to sham. Of PACE patients who achieved ≥90% closure within 12 weeks, the median percent reduction exceeded 99%; these patients were 1.5 times as likely to achieve 90% to 100% closure compared to sham. Of the patients achieving closure, the recurrence rate was more than four times greater among sham patients compared to PACE patients, 20% versus 4.5%, respectively.

  Conclusions: Nearly twice as many PACE patients achieved 90% to 100% wound closure as sham patients, substantiating the clinical utility of PACE as a novel nonpharmacologic, noninvasive advanced wound healing modality.

Phantom limb pain relieved with pulsed radio frequency energy (PRFE) therapy

Kelly Garbelotti, RN, MSN, FNP

  Purpose: This study describes two cases of reduction in phantom limb pain resulting from the application of pulsed radio frequency energy (PRFE). Phantom limb pain is a chronic, debilitating pain syndrome with a high incidence and lengthy duration. The cause is multi-factorial; theories are divided into peripheral causes, spinal causes, and central causes.

  Prompt treatment may prevent further disruption of the nervous system. Treatments include medication, nerve blocks, electrical nerve stimulation, and mirror therapy. No one technique works in all cases. PRFE therapy triggers a cascade of genetic events thought to lead to an orchestrated wound healing response. Pain reduction with PRFE is thought to be related to this genetic stimulation.

  Methods: Two cases are described in which patients with severe phantom limb pain had significant pain reduction associated with PRFE treatment. Both were older veterans who presented with advanced peripheral vascular disease and history of multiple surgeries and limb amputations. In both cases, constant, sharp, stabbing pain (10/10 on VAS) had persisted for nearly 2 years. Both patients had significant pain medication requirements. PRFE was initiated.

  Results: In response to PRFE, both patients experienced immediate reduction in phantom limb pain to levels of 4–5/10. Medication requirements were markedly reduced, and activity levels dramatically increased.

  Conclusions: Further investigation of PRFE therapy in phantom limb pain is warranted.

Wound care in rural America

Byoung Yang; Sunila Jo; James Harris; Irfan Asghar; Alexandre Andrianov; Tomasz Blaszczak; Joel Hendler; Kathleen McCall; Kristin Reischer; Paul Henrys; Sotirios Papafragkou; Khalid Husain; Dawn Stoliker; Silwana Sirdorczuk; Karen Roberts; Paul Pelletier; George Conover; Denise Anderson; Michael Sullivan; David Jones; and Guy Raymond

  Introduction: Although we are located in a remote, rural health clinic (RHC) in northern Maine with access to limited visiting nurses (available two to three times per week) and limited surgical specialists (vascular surgeon 2 hours away and plastic surgeon 4 hours away), we had surprisingly good results with our physician-run wound care program, open since December 2008.

  Methods and Materials: We reviewed 79 cases that were referred to the Northern Maine Medical Center from December 2008 to December 2010.

  Results: The cases encompass 66 open wounds (venous stasis, n = 16; decubitus, n = 11; trauma, n = 6; diabetic, n = 5; arterial, n = 5; dehiscence, n = 5; skin abscess, n = 4; burn, n = 3, osteomyelitis, n = 3; chemical dermatitis, n = 2; orthopedic hardware infection, n = 2; cast-induced ulcer, n = 1; pyogenic granuloma, n = 1; stump ulcer, n = 1; paronichia, n = 1) and 13 nonwound cases: eczema, Raynaud’s syndrome, tinea corposis, lipedema and lymphedema.

  Of these, 76% (n = 50) of wounds were closed in a mean duration of 12 weeks. Mean office visits for closed wounds were 7.8. The longest period to close a wound was 39 weeks. Greatest number of office visits for a closed wound was 24. Nonclosed wounds (n = 16) included ongoing cases (n = 5), amputations (n = 2), lost follow-up (n = 6), death by nonwound related causes (n = 2) and wound recurrence (n = 1). 58% (n = 38) of wounds received sharp debridements, which occurred a mean of 4.2 times, during an average of 17.6 weeks and 11 visits. A total of nine surgical consultations were made with a vascular surgeon (n = 6), plastic surgeon (n = ) and general surgeon (n=2). Dressing change was conducted by patient (21%), by family (14%), in a rehabilitation facility (10%,) by visiting nurse (10%), in a nursing home (7%), in hospital ambulatory care (2%), and by personal care assistant (2%).

  Conclusion: Our results indicate that even a rural wound care clinic in remote America can successfully manage complicated wounds despite severe logistical limitations.

Testing an online interactive wound care program

Lia van Rijswijk, RN, MSN, CWCN; and Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP

  Computer-based learning programs for healthcare professionals are widely available. The effects of Internet-based learning are generally positive. However, most programs lack interactive capabilities that improve cognition and promote deep learning. Providing safe, evidence- based wound care requires extensive knowledge and assessment proficiency. Because nonexpert clinicians deliver most wound care, they need more wound care education. Research suggests that one set of valid and reliable wound care algorithms may have a protective effect for users with limited wound assessment skills, thus supporting patient safety. Given their strong content and construct validity, an online interactive version of these algorithms was developed to help nonexpert healthcare professionals apply them to clinical practice. After completing 15 wound assessments using acute and chronic wound photographs, users receive a results score for appropriately selected topical therapy, can review incorrect choices, and print a completion certificate.

  The purpose of this study was to ensure that the online program content and construction were correct. Following beta-testing and correcting minor problems and using established quantitative and qualitative methods, a total of 56 wound care experts (66% RN, 12% NP, average age 42) completed the online study.

  Participants identified several programming glitches and needed design improvements. Overall, participant feedback was very positive. Agreement for algorithm selection was strong (80%). Correct algorithm and product selection were higher for the online than for paper-pencil testing and average percent correct dressing choice increased with usage (range 79 % for photo 1 to 95% for photo 15, r = 0.12).

  Results of this study suggest that: 1) testing interactive computer programs affecting patient care is essential; 2) continued validation analysis with large, nonexpert samples is warranted; and 3) interactive digital programs may provide cognitive residue — ie, lingering mental patterns promoting safer thinking.

  Acknowledgments: This study was supported by a research grant from ConvaTec Inc. The study was conducted, the data analyzed, and the abstract written by the authors who are solely responsible for its content. The authors do not have a financial interest in any products discussed in this publication. The authors wish to acknowledge the digital work of Rick Sargent in the interactive design of this program.

Positive wound healing progress using platelet-rich plasma (PRP) gel in patients with low albumin and hemoglobin

Carelyn P. Fylling, RN, MSN, CWS, CLNC; and Laurie M. Rappl, PT, CWS

  Purpose: It is well known in the wound care world that patients with abnormally low albumin and hemoglobin do not heal well. Wounds become chronic and stall due to inadequate cellular nutrients. This study was to determine whether treating these malnourished wounds with topical autologous platelet-rich plasma gel (PRP el, AutoloGel™, Cytomedix, Inc, Gaithersburg, MD) would re-activate the healing process.

  Methodology: Patient age, albumin, hemoglobin, previous wound duration, and objective wound measurements were gathered to determine wound area, volume, amount of undermining, sinus tracts, and tunneling (ST/T). PRP gel is processed at the point of care and contains the patient’s growth factors, cytokines, and chemokines for cell growth and migration, plasma-derived proteins to produce a fibrin matrix scaffold, and anti-inflammatory properties to progress the natural healing process.

  Results: Twenty-two (22) patients with 41 wounds were treated with PRP gel. All these patients had an albumin <2.5 g/dL and hemoglobin <10.5.g/dL. Twenty-one (21) of 22 patients (95%) were treated in long-term acute care hospitals (LTACs). Mean patient age was 63.7 years and previous wound duration was 61.5 weeks. The following data reflect mean outcomes. In 1.3 treatments over 2.1 weeks, 78% of wounds decreased 42.8% in area, 87.8% of the wounds reduced 58.5% in volume. In 1.3 weeks with 2.3 treatments, 10/41 (80%) of the wounds with undermining had 70.4% reduction and 4/41 (75%) of the wounds with sinus tracts or tunneling had 27.4% reduction. No complications occurred in the patients.

  Conclusion: By treating the wounds with PRP gel, rapid size reduction in long-standing wounds occurred in patients with abnormally low albumin and hemoglobin. It appears that the PRP gel re-activates the healing process causing tissue growth in stalled wounds in patients with low laboratory values.

“Real-time” pressure ulcer surveillance drives quality improvement

Lisa Q. Corbett, APRN, ACNS-BC, CWOCN; Rebecca Morton, RN, BSN, CWCN; Nancy Ough, LPN; Barbara J. Falkowski, RN, BSN, CWCN; Catherine Yavinsky, RN, MS, NEA-BC; and Thomas C. Banever, MD, FACS

  Background: Quality standards recommend quarterly measurement of prevalence and incidence of pressure ulcers (PU). Most benchmarked PU data is quarterly point prevalence and results are often retrospective. Increased focus on safety, financial, and regulatory outcome necessitates an accurate accounting of all PU occurrences in real time.

  Objectives: At an 800-bed urban teaching and level-1 trauma hospital, we have developed a system for collecting real-time incidence of PU in addition to national comparison quarterly data collections.

  Methods/Procedures: Real-time pressure ulcer data are collected from electronic and phone requests for wound consultation, wound rounds case finding, and event reporting. A certified wound nurse team and physician collaborator evaluates patients and verifies/determines staging and plan of care. Daily, weekly, and monthly hospital-acquired and present-on-admission PU data are compiled and analyzed by wound database, manual entry, and EMR interface. Discharge coding accuracy is reconciled with PU data. Unit-based data are posted on an intranet quality icon for transparency. Root cause analysis is performed by Skin Champion Resource Nurses. Managers access real-time wound staging on rounding reports. The Hospital Quality Council benchmarks PU data on dashboard. Rapid refinements in bedside care and system processes result from access to real-time PU data. Horizontal service line PU outcome is analyzed for the cardiac surgery, orthopedic, trauma, and rehabilitation programs resulting in specific care improvements.

  Results: Over 2 years, real-time PU data converged with quarterly prevalence and incidence data, validating the methodology. Considerable variation exists in PU rates when monitored in real time. Distribution of real-time data to caregivers affords rapid quality improvement deliverables. Real time surveillance results in accurate coding with improved financial outcome. Hospital-acquired PU rates have declined over 2 years.

  Discussion/Application to Practice: Quarterly prevalence and incidence PU data are helpful for basic quality benchmarking but should be supplemented with detailed real-time analysis to effectively identify processes to reduce PU.

Increase in moisture vapor transfer rate utilizing a novel powered coverlet

Angel Delgado, PhD; Vinoth Ranganathan, MSE, MBA; Steven Reger, PhD

  Pressure ulcers are wounds localized to the skin and/or underlying tissue as a result of pressure and the resulting mechanical forces of shear and/or friction. Additionally, moisture accumulation on the skin and increase in skin temperature, in conjunction with these mechanical forces, can lead to tissue breakdown and potential ulcer formation. Although most therapeutic surface support systems attempt to manage mechanical forces, microclimate factors (ie, moisture and temperature) should not be disregarded. The purpose of our study was to assess moisture management at the skin surface interface using a novel powered coverlet (PCL — (Skin IQ™ Microclimate Manager; KCI Licensing, Inc., San Antonio, TX). The PCL is multilayered (top and bottom vapor-permeable liquid-impermeable layers with a foam spacer in between) and uses a fan blower to draw air flow (negative airflow technology) through the spacer. A human torso was simulated using a water temperature-regulated loading gauge. A rayon fabric moisture reservoir (saturated with 36+/-1g of isotonic saline) simulated sweating human skin and was placed between the loading gauge and a pressure redistribution support surface (PRSS). A change in reservoir weight was used to calculate the moisture vapor transfer rate (MVTR), and the temperature and relative humidity at the support interface below the reservoir were recorded as function of time. The PCL over the PRSS was tested (90-minute assessment) for MVTR and temperature change compared to the PRSS alone (control). Our results indicated a greater ability to remove moisture for the PCL with an MVTR of 129.5g/m2/hour, compared to 34.1g/m2/hour for control. The PCL also had a larger reduction in relative humidity and temperature when compared to control. The ability of PCL to remove nearly four times more moisture than the PRSS alone may improve the support surface microenvironment.

Characterization of novel human mesenchymal stem cell-containing skin substitutes for the treatment of wounds

Dana Yoo, PhD; Timothy Jansen; Jin-Qiang Kuang; Samson Tom; Dayna Buskirk; Alla Danilkovitch-Miagkova; and Michelle A. LeRoux

  Background: Wound healing requires a coordinated interplay among cells, growth factors, and extracellular matrix proteins (ECM). A key cellular component of normal wound healing is the mesenchymal stem cell (MSC), which coordinates the repair response by recruiting host cells and secreting growth factors and matrix proteins. Placental membranes possess necessary components (including MSCs) to promote wound healing. The first use of placental membranes for wound treatment was documented more than 100 years ago, but technical and safety issues prevented the widespread use of viable placental membranes. Three novel, viable products that are placental-derived human MSC-containing skin substitutes for the treatment of wounds have been characterized.

  Methods: Cells were isolated from the skin substitutes and analyzed using fluorescence activated cell sorting (FACS) to identify MSC specific cellular markers (CD105, CD166). Cell viability was assessed by staining cells with fluorescent dyes specific for live or dead cells. The skin substitutes were homogenized and analyzed to assess presence of multiple growth factors and cytokines using protein array and ELISA.

  Results: The presence of MSCs in all three materials was demonstrated by FACS analysis through the expression of characteristic MSC markers, CD105 and CD166. Cellular live/dead staining utilizing specific fluorescent dyes confirmed high cell viability of the products (>70%). Antibody arrays showed growth factors and cytokines known to be integral in the various phases of wound healing including IL-1RA, IL-10, NGAL (inflammatory phase), VEGF, bFGF, PDGF, (proliferative phase), TGFb3, HGF, MMPS, and TIMPS (remodeling phase). Continued expression of proteins was long lasting, persistent for at least 14 days.

  Conclusions: Novel, human MSC-containing skin substitutes have been developed and shown to contain viable MSCs and key factors to promote wound healing. The cellular, growth factor, and ECM profile of these materials demonstrates their potential for healing chronic and surgical wounds as well as burns.

The use of a novel, human mesenchymal stem cell-containing skin substitute in the treatment of refractory wounds: a case series

Walter Conlan, MD, CWS; Melodie Blakely, PT, MS, CWS; and Dot Weir, RN, CWON, CWS

  Introduction: Although there have been advances in the treatment of recalcitrant, chronic wounds with the advent of products that contain fibroblasts or keratinocytes, recent research has focused on improving outcomes utilizing stem cells. The human mesenchymal stem cell (MSC) has shown promise in the treatment of a variety of acute and chronic illnesses. In addition to the multilineage differentiation capacity, and trophic effects of MSCs useful for regenerative medicine, MSCs regulate immune and inflammatory responses providing therapeutic potential in chronic wounds.The application of MSCs in a novel skin substitute preparation were investigated in a series of refractory wounds that had failed conventional treatment.

  Methods: Patients with refractory wounds were treated at an outpatient wound care center. All patients received standard of care including local wound debridement and antibiotics when indicated. Patients were seen regularly in clinic, and treatments were at the discretion of individual providers.

  Results: Four patients (1 female, 3 males) ranging in age from 34 to 94 years underwent treatment of their wounds with the MSC-containing skin substitute. Wound types were varied and comprised one chest wound in a patient after automatic implantable cardiac defibrillator removal, one heel pressure ulcer, one anterior ankle ulcer in a paraplegic, and two patients with recalcitrant toe ulcers. Average wound size was 2.6 cm2 (range 0.8–5.7 cm2) and all failed at least one previous therapy including topical growth factors, collagen dressings, or living skin equivalents. Patients received an average of 3.2 treatments (range 1–9) with closure of all wounds in a median of 3 weeks (range 2–12). No complications were reported.

  Conclusions: A human MSC-containing skin substitute (Grafix Prime, Osiris Therapeutics, Inc., Columbia, MD) shows promise in the treatment of refractory wounds and should be considered in patients with recalcitrant wounds who have failed conventional therapies.

Effects of 35 kHz on aerosolization of bacteria

Tiffany Williams; Drew Alston; Andy Meixne; and Teresa Conner-Kerr

  The positive effects of debridement on wound healing are now well accepted. Devitalized tissue is known to harbor micro-organisms, prolong inflammation, and impede wound healing processes. Thus, debridement is a primary component of wound bed preparation. Various methods of debridement are available to wound care clinicians including mechanical energy-based debridement systems that employ acoustic energy delivered with a gentle spray. However, concern has been expressed about the potential for these systems to produce environmental contamination and exposure of providers via aerosolization of micro-organisms. The purpose of this study was to determine if low frequency ultrasound (LFU) delivered at 35 kHz through a gentle spray produced environmental contamination. 35 kHz LFU was tested under two conditions: 1) treatment of agar plates with bacterial cultures of Staphylococcus aureus (SA) using open system testing with full fluid flow and 2) application of the LFU to investigator’s forearms for 30 seconds per test condition. An Anderson air sampling system was used to collect air samples for 30 seconds per each LFU treatment. Air samples were collected at baseline to determine background levels of micro-organisms in the air and then at 6,12, 24, and 48 inches from the treatment area to simulate common treatment distances of providers from the wound bed during a patient care session. Under open system testing, no more than 1–2 SA was detected at any of the treatment distances tested (test performed on two separate occasions with three replications). Background micro-organisms were collected in small numbers. Treatment of the investigators’ (four individuals with bilateral treatment) forearms (forearm treated in three separate longitudinal quadrants) for 30 seconds with contact technique produced the following results: baseline = 6 bacteria and during LFU at 6 inch = 12 bacteria, 12 inches = 5 bacteria, and 48 inches = 5 bacteria. 35 LFU does not appear to produce significant aerosolization of bacteria.

The role of fibroblasts from the deep dermis in fibroproliferative disorders of the skin

Jie Ding; Zengshuan Ma; Peter Kwan; Heather Shankowsky; and Edward E Tredget

  Introduction: Hypertrophic scar (HTS) is a common and significant negative outcome of burn injury to the deep layer of dermal skin. Our hypothesis is that deep dermal fibroblasts contribute to the hypertrophic scarring due to their profibrotic characteristics and special regulation of bone marrow-derived mesenchymal stem cells (BM-MSCs) on them.

  Methods: Dermal fibroblasts were cultured from three paired superficial and deep dermis areas of normal individual skin using dermatome. in vitro, cell proliferation, collagen production, and profibrotic gene expression as well as the effect of BM-MSCs were investigated and compared between deep fibroblasts and superficial fibroblasts. Meanwhile, a Laser Doppler study to create superficial and deep burn in vivo was performed and the skin wounds were collected from eight superficially and deeply burn patients. The profibrotic gene expressions were examined in the wounds.

  Results: Deep dermal fibroblasts produced more collagen after 24-hour incubation, which are slower in proliferation compared to superficial fibroblasts. They express more profibrotic gene, such as type I collagen (Col1), smooth muscle actin (SMA), transforming growth factor beta (TGFbF), stromal cell derived factor 1 (SDF1), less metallopeptidase 1 (MMP1), and more MMP inhibitor TIMP1-4. BM-MSCs down-regulated MMP1 expression in deep fibroblasts but didn’t change TIMP1. Skin wounds from deep burn significantly expressed more Col1, SDF1 and TIMP1— 4 wounds from superficial burn patients.

  Conclusion: Deep dermal fibroblasts express and produce more collagen, express less MMP1, but more TIMP1 than superficial fibroblasts, and BM-MSCs down-regulated MMP1 gene in deep fibroblasts, but didn’t change TIMP1. Furthermore, high-level SDF1 may attract more BM-MSCs into the wounds, where they regulate the deep fibroblasts in a fibrotic way. All these could break the balance of collagen metabolism and result in collagen accumulation in the wounds following a deep dermal injury, which is a critical feature of HTS.

  Acknowledgment: The Firefighters Burn Trust Fund of the University of Alberta

Use of a biocellulose dressing to deliver topical vancomycin, reduce methicillin-resistant Staphylococcus aureus (MRSA) and Gram-positive organisms and promote healing in lower extremity wounds

Karen W. Albaugh, PT, DPT, MPH, CWS; Scott A. Biely, PT, DPT, OCS; and Joseph P. Cavorsi, MD

  Objectives: The purpose was to determine the efficacy of a biocellulose wound dressing in delivering topical vancomycin and facilitating healing in otherwise stagnant wounds.

  Subjects: Twenty-three patients with wounds of various etiologies, swab cultures positive for MRSA or other Gram-positive bacteria, and failure to heal or to respond to antimicrobial dressings were selected for inclusion. Chronicity ranged between 5 and 121 weeks.

  Method: A 3-week pre-treatment period was compared to a 3-week period with the antibiotic-infused dressing. Swab cultures were taken weekly. One g of vancomycin was infused into a 3.5" x 3.5" biocellulose dressing at the time of application. Dressings were changed three times per week. Exudate level, wound surface area, and level of bacterial growth for each subject were recorded weekly and plotted against time for qualitative analysis of change.

  Results: There was an average 14.5% increase in surface area per week during the 3 weeks prior to treatment. During treatment, there was a 24.6% decrease in surface area per week, representing a significantly greater reduction in surface area per week as compared to the changes seen pre-treatment (P = 0.02). All 23 wounds experienced a reduction or complete eradication of MRSA or Gram-positive bacteria. Trough blood levels revealed no systemic absorption of the antibiotic. There was a significant difference (P = 0.016) between exudate level pre- and post initiation of vancomycin. All wounds went on to close, with time to heal averaging 8.18 weeks from start of treatment.

  Clinical relevance: The results suggest the hydrophilic nature of the biocellulose dressing is an ideal vehicle to deliver the antibiotic topically. Additionally, the composition of the dressing helps maintain an optimal balance of wound moisture. These findings offer the possibility of dosing a discreet area of affected tissue without the side effects of a systemic drug.

Effective of a polyhexanide wound cleanser (PWC) on the bacterial burden of chronic venous ulcers

Oscar M. Alvarez, PhD; Martin Wendelken, DPM, RN; Lee Markowitz, DPM; and Christopher Comfort, MD

  Purpose: This was a prospective, randomized, controlled, clinical trial to evaluate the effect of PWC on the quantitative microbiology of chronic venous ulcers.

  Methods: Eighteen subjects with venous ulcers (ranging in size from 7. 6 to 53.2 cm2) were randomized into one of two treatment arms. One arm (N =14) received wound cleansing with PWC (Prontosan® Wound Irrigation Solution, B. Braun Medical Inc, Bethlehem, PA) and the other (N = 4) with normal saline soaks (NSS). All other aspects of care between treatment arms were identical and consisted of nonadherent wound dressing and compression therapy with a four-layer bandage system (Profore® Smith & Nephew Inc, Largo FL). Quantitative bacteriology was performed on tissue biopsies from wounds at baseline (before treatment) and at 14 days following treatment. Treatment was performed at day 0 and once weekly for 2 weeks. The rate of wound healing, wound odor and wound exudate also was evaluated.

  Results: Group S. aureus — baseline day 14 difference: PWC 237500 12500 225000; Control 162500 167500 -5000; Wilcoxon Rank Sum R=14 (n1 = 4, n2 = 4), P <0.05. Group Gram- positive cocci — baseline day 14 difference: Prontosan 135000 0 135000; Control 237500 152500 85000; Wilcoxon Rank Sum R=13 (n1 = 4, n2 =3), P <0.05. Less wound odor was recorded by the subjects the PWC treatment arm. Wound healing rates were not statistically significant between treatment arms.

  Conclusion: Cleansing with PWC significantly lowered the population of S. aureus and Gram-positive cocci. There were also marked differences (not statistically significant) in the number of Enterococcus faecalis and Gram-negative rods.

Incidence and risk factors for clinical complications at saphenous vein graft harvesting sites following aorto-coronary bypass surgery procedures

Jiayi Hu, HBSc; Laura Teague, RN-EC, MN, NP; Ann-Marie McLaren, DCh, BSc, MClSc; Rosane Nisenbaum, PhD; Lisa Bunn, RN; James Mahoney, MD, FRCS(C)

  Purpose: This retrospective review aims to estimate the incidence of postoperative lower extremity wound complications (LEC) related to open vein harvesting (OVH) and endoscopic vein harvesting (EVH) following aorto-coronary bypass surgery (ACB). The incidence of LEC was recorded during hospital stay. This study identifies patient-related risk factors that may help predict LEC occurrence.

  Methods: Following ethics approval, 1,379 consecutive patient records were reviewed from one Canadian tertiary hospital in Toronto, Canada for a 2-year period (2008–2010). Demographic information, comorbidities, method of vein harvesting (OVH versus EVH), intraoperative and postoperative complications were recorded. Univariate analyses were performed to evaluate the association between patient-related factors and incidence of complications using chi-square or Fisher’s exact tests. Multivariate logistic regression estimated odds ratios (OR) and 95% confidence intervals (CI).

  Results: The most common LEC was hematoma (2.83% of patients), followed by cellulitis (0.80%), incisional dehiscence (0.36%), and tissue necrosis (0.07%). The overall LEC rate was 3.92%. In univariate analyses, risk factors for LEC included postoperative leg edema (P = 0.0058), old age (P <0.0001), female gender (P = 0.0302), EVH (P = 0.0045), and delirium (P = 0.0486). Patient comorbidities (eg, anemia) tended to associate with LEC, but these findings were not statistically significant. Patients with LEC tended to stay in hospital for >6 days (P = 0.0021). In multivariate analysis, postoperative leg edema (OR=2.04, 95% CI=1.16-3.56), EVH (OR=2.40, 95% CI=1.35-4.28), and age 60 (OR=3.96, 95% CI=1.52-10.31 for 60-74; OR =4.28, 95% CI=1.44-12.81 for 75-85; and OR=13.70. 95% CI=4.06-46.20 for >85) remained statistically significant.

  Conclusion: The incidence of LEC among ACB patients is significant and included hematoma, cellulitis, dehiscence, necrosis, and increased length of stay. The significant risk factors identified in this study population included leg edema, EVH and age 60 years. Strategies to mitigate modifiable risk factors, in particular edema control, may improve patient outcomes and quality of life.

Helping Haiti heal: teaching wound care basics to Haitian and volunteer healthcare providers to hopefully leave an enduring footprint

Gregory Bohn, MD, FACS; Melodie Blakely, PT, MD; and Kim Eldridge, RNFA, CNOR, CFCN, WCC

  Independently, four wound care providers arrived in Haiti at a mission healthcare facility to volunteer post earthquake. Coming together as a wound care team, they discussed the challenges they would face in the work and problems that await them for the week tour. After evaluating and assessing needs at the facility and taking inventory of available products and provider knowledge of wound care, they developed a plan to best utilize what supplies and devices were available to provide care. In the process, it became apparent there was a gap in the knowledge of not only Haitian providers but the volunteer staff as well. In discussing how to help the facility best utilize the donated products and resources, they developed an impromptu wound care symposium. Using fruit, debridement skills were taught, advanced therapies and devices were explained, and dressing technologies explained. Enlisting the assistance from an Irish physical therapist, these techniques were demonstrated and taught. This presentation hopefully is a valuable recount of those efforts that others can improve upon in leaving a lasting footprint from their work as volunteers in third-world countries and other locations.