Selected Abstracts from the SAWC: The 15th Annual Symposium on Advanced Wound Care & 12th Medical Research Forum on Wound Repair

Zinc/iron solution stimulates epithelialization of acute partial thickness wounds

Alex Cazzaniga, BS; Stephen Davis, BS; and Patricia Mertz, BA, University of Miami School of Medicine Department of Dermatology and Cutaneous Surgery, Miami, Fla.

   Zinc has been shown to be beneficial in the wound healing process; however, the combined role of zinc and iron has not been studied. The purpose of this study was to evaluate a new zinc/iron solution (ZIS) on the healing of partial-thickness wounds. Ten pigs received multiple partial-thickness wounds and received one of the following treatments: 1) 0.003% ZIS, 2) vehicle, 3) untreated air exposed. Wounds were treated by sterile four-ply gauze saturated with each agent and then covered with a polyurethane dressing. Wounds were treated daily. Five wounds were excised on days 3 to 8 and evaluated for complete epithelialization using a well-described salt-split technique. A total of 540 wounds were evaluated. All wounds that received any treatment epithelialized sooner than untreated air exposed. The 0.003% ZIS enhanced complete epithelialization as compared to wounds treated with vehicle alone. This data demonstrates that a new zinc/iron agent is effective at stimulating healing which may have important clinical implications.

A leg ulcer prevention program following healing

George Cherry, DPhil; Janice Cameron, RGN, ONC, MPhil; and Susan Poore, RN, Wound Healing Institute, Oxford, UK
   Prevention of recurrence should be an integral part of leg ulcer management. An on-going program of care following healing was developed to reduce the incidence of re-ulceration. The authors' "healed ulcer" clinic was established more than 20 years ago. The primary objectives of the healed ulcer program include fitting compression stockings, maintaining healthy skin, patient education, and regular examination of pedal pulses and Doppler ultrasound to check for the onset of arterial disease. A survey of all patients in the healed leg ulcer program was undertaken over a 2-year period to assess the recurrence rate. A total of 110 patients attended the healed ulcer clinic during the first study year. These patients had been healed by 4 months to 19 years. At the end of the first study year, 14 patients no longer attended the clinic; five people died and nine had ill health. The remaining 96 patients continued to attend regularly every 4 to 6 months. No patients were lost to follow-up during the second year. The results of the survey over the 2-year study period found 75 (78%) patients remained healed at the end of the second year. In the group of 21 (22%) patients that had recurrence of their ulcer, 14 patients had one episode of breakdown and were healed again within 3 to 5 months, and seven patients had various underlying medical problems complicating healing and requiring interventions from other specialities. The authors conclude that time spent on a leg ulcer prevention program following healing can reduce recurrence and prove to be a huge cost saving to the health service.

In vitro evaluation of the bactericidal activity of three wound antiseptics against biofilms of common wound pathogens

Anna Drosou, MD; Alejandro L. Cazzaniga, BS; Stephen C. Davis, BS; Julie L. Silver, and Patricia M. Mertz, BA, Department of Dermatology, University of Miami School of Medicine, Miami, Fla.
   Biofilms (associations of adherent bacteria living in a polysaccharide matrix) have been found in wounds1,2 and are protected from antimicrobials.³ The purpose of this evaluation was to examine the effect of antiseptics on cells living in biofilms.

   Pseudomonas aeruginosa and Staphylococcus aureus biofilms or planktonic cells were treated with povidone-iodine*, hydrogen peroxide**, chlorhexidine***, and PBS. After 10 minutes, 1 hour, or 24 hours, bacteria were quantitated following removal and neutralization of antiseptics.

   Pseudomonas aeruginosa: Planktonic cells were susceptible to antiseptics at all time periods; whereas, the cells in biofilms were reduced by three logs from the control value at 10 minutes and at 1 hour. The values were still at approximately log 5 CFU/mL as compared to 8 CFU/mL. At 24 hours, povidone-iodine and chlorhexidine had reduced the cells in biofilm to <2.3 CFU/mL versus 2.9 CFU/ml as compared to control of 5.8 CFU/mL.

   Staphylococcus aureus: Both planktonic and biofilm cells were susceptible to povidone-iodine and chlorhexidine but not to hydrogen peroxide at 10 minutes and at 1 hour.
The authors concluded that antiseptics appear to be effective against S. aureus biofilms, but are unable to penetrate the thick Pseudomonas biofilm in a short time. Treatment longer than 10 minutes may offer some therapeutic advantages.

   * Betadine Solution, The Pursue Frederick Company, Norwalk, Conn. ** Hydrogen Peroxide Solution 3%, Bergen Brunswing Drug Company, Orange, Calif. *** Hibiclens, Zeneca Pharmaceuticals, Wilmington, Del.

References
1. Bello YM, Falabella AF, Cazzaniga AL, Harrison-Balestra C, Mertz PM. Are biofilms present in chronic wounds? Symposium in Advanced Wound Care. 2001;April-May.
2. Seralta VW, Harrison-Balestra C, Cazzaniga AL, Davis SC, Mertz PM. Lifestyles of bacteria in wounds: Presence of biofilms? Wounds. 2001:13(1):29-34
3. C. Potera. Biofilms invade microbiology. Science. 1996;273:1795-1797

Multinational survey on trauma and pain at wound dressing change

Evonne Fowler, RN, CNS, CWOCN, Kaiser Hospital, Bellflower, Calif.; and, Christine J. Moffatt, RN, PhD; Peter J. Franks, PhD; and Helen Hollinworth, Centre for Research and Implentation of Clinical Practice, Thames Valley University, London, UK
   Pain is a major issue for patients suffering from many different wound types, with little known about how practitioners perceive pain and wound trauma at dressing change. This study was an international survey of practitioners' primary considerations in their approach to pain and tissue trauma at dressing change and the strategies used in the treatment and selection of products.

   The questionnaire consisted of structured questions with multiple choice options. The questionnaire was translated into the appropriate languages for each country. A variety of distribution methods were used, including mailing the survey to members of wound care societies and circulating it to wound conference attendees. Responses were ranked according to frequency of responses within each country.

   Eleven countries took part in the survey (USA, France, Canada, Finland, UK, Switzerland, Sweden, Spain, Austria, Denmark, and Germany) with a total questionnaire response of 3.918. Trauma at wound dressing change was ranked the most important factor by seven of the 11 countries, followed by pain prevention. Leg ulceration was considered the most painful wound at dressing change, with superficial burns ranked second. Practitioners consistently ranked dressing removal as the time of greatest pain, with wound cleansing also implicated. Dressings that dried out and dressings that adhered to the wound were considered to be the most painful, with a similar picture seen for causes of trauma. Most frequent strategies used to overcome these situations were soaking dry dressings and selecting dressings that offered pain-free removal. All countries agreed that gauze was the product that caused the most trauma and pain. Products causing the least trauma and pain were hydrofibers, hydrogels, alginates, and soft silicone dressings. Financial and reimbursement issues were highlighted as the most important factors influencing choice of dressings. Practitioners in the UK (62%) had the greatest freedom to select appropriate dressings for all patients; whereas, Canada had the lowest proportion at 25%.

   This survey not only highlights many common issues regarding trauma and pain for practitioners in wound care, but also presents a number of differences in practice. International comparisons are helpful in identifying differences in attitudes and behavior in wound management.

Quality of life in venous ulceration: use of the SF-36 in a randomized trial of two bandage systems

Peter J. Franks, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK; Julie Stevens RN, Hounslow and Spelthorne Community and Mental Health Trust, London, UK; Catherine Hourican, RN, Riverside Community Healthcare, NHS Trust, London, UK; Debra C. Doherty, RN, South West London Community Healthcare, NHS Trust, London, UK; Theresa O?Connor, RN, Riverside Community Healthcare, NHS Trust, London, UK; Lynn McCullagh, RN, Redbridge Community, NHS Trust, London, UK; and Christine J. Moffatt, RN, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK
   This study aimed to evaluate changes in health- related quality of life (HRQoL) using the MOS Short Form 36 (SF-36) in a multicenter, prospective, randomized trial of two bandage systems in patients suffering from venous ulceration. Newly presenting patients suffering from chronic leg ulceration were considered for the trial, provided they had an ankle brachial pressure index (ABPI)>0.8. Patients entering the trial were randomized to four-layer bandaging (4LB)* or two-layer bandaging (2LB)** both of which were designed to produce sufficient pressure to counteract venous hypertension. Patients completed the SF-36 at entry, after 24 weeks of treatment, and when the patient discontinued bandaging (ulcer closure or patient withdrawal).

   Differences between the baseline and final SF-36 scores were analyzed using the Wilcoxon Signed Rank test. Analysis of the differences in the SF-36 scores at study discontinuation between patients with ulcer closure and those whose ulcers remained open, and between bandage systems, was by random-effects models, adjusting for baseline scores for the eight subscores of the SF-36.

   In all, 109 patients were randomized from the five clinical centers with median (range) ulcer size of 2.3 (0.1 to 26.1) cm². Large mean differences (d) were found between baseline and final assessment in bodily pain (d = 22.4, P <0.0001), role physical (d = 21, P <0.0001), role emotional (d = 11.3, P = 0.001), and social functioning (d = 9.1, P = 0.0001).

   Significant differences were exhibited at study discontinuation in patients with ulcer closure compared with those whose ulcers remained open for bodily pain (d = 21.9, 95% confidence interval [CI] 12.6 to 31.2), general health (d = 5.3, 95% CI 1.0 to 9.0), and social functioning (odds ratio = 0.1, 95% CI 0.03 to 0.3). No significant differences were noted between the two bandage systems at study discontinuation, with pain showing the largest difference in favor of 4LB (d=5.3, 95% CI -4.2 to 14.9).

   Patients suffering from leg ulceration show improvements in HRQoL following effective ulcer management, which was related to ulcer closure. The two bandage systems achieved similar improvements in SF-36 scores over 24 weeks.

   * Profore, Smith and Nephew Inc, Largo, Fla. ** Surepress, Convatec, Princeton, NJ.

Are socio-demographic factors important in the development of chronic leg ulceration?

Peter J. Franks, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK; Debra C. Doherty, RN, South West London Community Healthcare, NHS Trust, London, UK; and Christine J. Moffatt, RN, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK
   Although anecdotal evidence shows that patients suffering from leg ulceration are socially isolated and have deficits in their socio-demographic status, little documentation supports this. As part of a large investigation of leg ulceration in South West London Trust (UK) patients with leg ulceration were interviewed. In all, 113 patients were identified and matched with age/sex matched controls drawn from GP age/sex registers from the same area. Analysis was by conditional logistic regression with results expressed as odds ratios (OR) and 95% confidence intervals (CI).

   The patients had a mean (SD) age of 76 (±13) years; 72 (64%) were women. The ulcer had been present for a median of 8 months (range 0.8 to 144), and 29 out of 100 (29%) patients had an area of ulceration larger than 10 cm² (range 0.5 cm² to 171.5 cm²). Being Afro-Caribbean increased the risk of leg ulceration eight-fold (95% CI 1.8 to 34.7, P <0.001) compared to the white population. A gradient was found with regard to social class, with ulcer patients more likely to come from social class IV and V (OR = 2.8, 95% CI 1.2 to 2.2, P = 0.015). Never having married (OR = 3.0, 1.1 to 7.7, P = 0.025), living in rented housing (P <0.001), and having a mobility deficit (P <0.001) more often occurred in the ulcer patients, while living with a spouse was protective (OR = 0.5, 95% CI 0.2 to 0.99, P = 0.048). Patients with ulceration experienced significantly poorer social support than their controls for all subscales of the MOS social support questionnaire (all P <0.05).

   Chronic leg ulceration is associated with poorer socio-economic status and factors that relate to social isolation. At present, determining whether these associations are causative or a consequence of the ulceration is not possible.

Outcome evaluation of two hydrogels

Susanne Hauchildt Sparholt, Corporate Clinical Documentation Manager, Coloplast A/S, Humlebaek, Denmark; and Flemming Wilhelmsen, MD, Medical Affairs Manager, Coloplast A/S, Humlebaek, Denmark
   Background: Autolytic debridement using hydrogels represents a gentle and effective alternative to surgical and enzymatic debridement. While aiming for clinical excellence, the treatment also should be cost-effective and improve the patient's quality of life.

   Objective: To compare hydrogel performance characteristics, debriding effect, cost-effectiveness and health-related quality of life parameters in treatment of leg ulcers with hydrogel A* and hydrogel B**.

   Study design and methods: Thirty-two patients with venous leg ulcers covered by necrosis, slough, and/or fibrin were randomized and treated for a minimum of 2 weeks and a maximum of 4 weeks with either of the two hydrogels.

   Results: The wound area decreased significantly in both groups. The area covered with necrosis/fibrin/slough decreased faster (P <0.01) in the hydrogel A group than in the hydrogel B group.

   Wound pain intensity experienced since last visit was lowest in the hydrogel A group (P = 0.03) and hydrogel A was easier to apply (P <0.01). The wear-time in the hydrogel A group was 1.5 ± 0.4 days versus 1.4 ± 0.4 days in the hydrogel B group. Two cases of proven allergic dermatitis were reported in the hydrogel B group.

   Discussion: The area covered with necrosis/fibrin/slough was reduced to 66.2% after 2 weeks of treatment in the hydrogel A group; whereas, a similar reduction in the hydrogel B group was reached after 4 weeks. When considering only expenses related to the amount of gel used, the cost per percentage debridement with hydrogel A is DKR 5.8 compared to DKR 18.5 for hydrogel B.

   Conclusion: The use of hydrogel A resulted in significantly faster and efficient debridement, no sign of allergic reactions, significantly easier application, a positive influence on the patients' quality of life caused by significantly lower degree of wound pain, and apparent cost-effectiveness of debridement.

   * Purilon? gel, Coloplast A/S, 3050 Humlebaek, Denmark ** IntraSite? gel, Smith amd Nephew Medical Ltd., Hull, UK

Chronic wound care cost-effectiveness

Morris D. Kerstein, MD, Mt. Sinai Medical Center, New York, NY
   Background: Successful chronic wound management involves proper diagnosis, removing the cause of tissue deterioration, selecting optimal dressings, and ensuring proper dressing use. Moist environments may permit fast wound healing with less pain compared to wounds managed with gauze; the comparative economics of these protocols of wound care need to be explored.

   Methods: CINAHL and MEDLINE medical literature reviews identified controlled studies quantifying dressing effects on venous ulcer or pressure ulcer healing. Peer-validated cost models for wound care protocols were developed from reported results for each wound care modality with pooled evidence from at least 100 wounds. Twelve-week wound care costs for each modality were modeled for a hypothetical managed-care plan with 100,000 covered lives.

   Results: Twenty-six studies of three pressure ulcer protocols (519 patients) and three venous ulcer protocols (843 patients) qualified for inclusion. After 12 weeks of care with gauze, a weighted average of 48% of pressure ulcers or 39% of venous ulcers healed, costing, respectively, $2,179 or $2,939 per ulcer healed. Using hydrocolloid-dressing protocols for 12 weeks, 61% of pressure ulcers or 51% of venous ulcers healed at respective costs of $910 or $1,873 per ulcer healed.

   Conclusion: Wound care costs to heal each pressure or venous ulcer patient in a hypothetical 100,000-patient managed-care plan were respectively $1,269 or $1,066 lower using protocols of care with hydrocolloid dressings rather than with optimally applied gauze. Costs of wound care and costs of healing chronic wounds with protocols including hydrocolloid dressings were lower by 60% to 80% than corresponding costs with gauze-based protocols of care. These findings, plus the realities of healthcare today, provide strong reasons to reconsider the heavy reliance on gauze-based dressing approaches for chronic wounds.

Aerosolization of microorganisms during pulsatile lavage with suction

Harriett B. Loehne, PT, CWS, Archbold Medical Center, Thomasville, Ga.; Stephen A. Streed, MS, CIC, MRL, Pharmaceutical Services, Herndon, Va.; Beth Gaither, MT (ASCP), SM, and Robert J. Sherertz, MD, Wake Forest University Baptist Medical Center, Winston-Salem, NC
   Purpose: To assess the potential for aerosolization of microorganisms from a wound during treatment with pulsatile lavage with suction (PLWS).

   Subjects: Seven patients with open wounds of different etiologies and complexity were treated with PLWS.

   Methods: Swab cultures were obtained before treatment. Volumetric air sampling was performed at 2 and 8 feet from the patient before, during, and after PLWS treatment.

   Analysis: Standard microbiological techniques were used to obtain colony counts and speciation.

   Results: Wound cultures yielded 22 isolates, 10 of which were detected at baseline. Air samples taken during PLWS treatment had 13 out of 22 wound organisms with increased counts. Samples taken after treatment had 10 out of 22 wound isolates with increased counts. Wound isolates were detected at both sampling distances. The median colony count during the treatment was 7 colony forming units (CFU) per cubic meter, with a range of 0 to 104 CFU per cubic meter.

   Conclusion: Aerosolization of wound isolates occurs during PLWS treatment.

   Clinical Relevance: Therapists and others in the room during PLWS treatment should wear appropriate personal protective equipment to limit contact with infectious agents. To prevent possible exposure of other patients, PLWS should be performed in a private room or in a treatment room.

References
1. Frampton MW. An outbreak of tuberculosis among hospital personnel caring for a patient with a skin ulcer. Ann Int Med. 1992;117:312-313.
2. Gammaitoni L, Nucci MC. Using a mathematical model to evaluate the efficacy of TB control measures. Emerg Infect Dis. 1997;3.
3. Hutton MD, Stead WW, Cauthen GM, Bloch AB, Ewing WM. Nosocomial transmission of tuberculosis associated with a draining abscess. J Infect Dis. 1990;161:286-295.
4. Loehne HB. Pulsatile lavage with concurrent suction. In: Sussman C, Bates-Jensen BM, eds. Wound Care -- A Collaborative Practice Manual for Physical Therapists and Nurses, 2nd ed. Gaithersburg, Md: Aspen Publishers, Inc.; 2001:389-403.
5. Loehne HB. Wound debridement and irrigation. In: Kloth LC, McCulloch JM, eds. Wound Healing: Alternatives in Management, 3rd ed. Philadelphia: FA Davis; 2001:203-231.

Sacral skin blood perfusion in relation to other posterior and remote skin sites

Harvey N. Mayrovitz, PhD; Nancy Sims, RN, LMT, CLT; and Lori Durbin, PhD, College of Medical Sciences, Nova Southeastern University, Ft. Lauderdale, Fla.
   Pressure ulcers occur over the sacrum but rarely over the gluteus maximus. This predilection is partly due to pressure concentration effects but other factors may be involved. The authors hypothesized that if resting sacral skin blood flow (SBF) was larger than in surrounding areas, blood flow stoppage during loading might increase risk due to a greater relative SBF deficit. As data on sacral SBF is scarce, the authors' first step was to characterize it in comparison to other skin areas. SBF was measured by laser Doppler imaging (LDI) in 15-cm² areas overlying the sacrum in 30 subjects (15 male) and compared to SBF in posterior sites (gluteus and lower back) and remote sites (hand and fingers). Average sacral SBF (59.1 ± 1.4 a.u.) was significantly (P <0.001) larger than other posterior sites (48.7 ± 2.5 a.u.) and was greater in females (63.0 ± 1.6 versus 55.2 ± 1.8, P <0.01). These results provide the first systematic characterization of resting sacral SBF and are consistent with the tentative hypothesis, suggesting a search for a direct ulcer linkage is warranted. Large spatial variability in SBF (40%) suggests that comparisons of SBF among sites is best done with LDI in contrast to standard laser Doppler monitoring.

Diabetic wound care in a wound and hyperbaric oxygen center: a retrospective review

Beth McCampbell, MD, Department of Surgery, Weill Medical College of Cornell University, New York, NY; Marie Giordano, RN, MS, Kitra Bieghauser, RN, Jill Abshire, RN, Wound and Hyperbaric Oxygen Center, Weill Medical Center, New York, NY; Lisa Staiano-Coico, PhD; Palmer Bessey, MD; Roger Yurt, MD; and Suzanne Schwartz, MD, Department of Surgery, Weill Medical College of Cornell University, New York, NY
   Many burn centers utilize expertise developed from acute injury management to treat other difficult wounds. The authors conducted a 2-year retrospective review of patients treated at the Wound and Hyperbaric Oxygen Center, examining demographics, medical history, wound history, treatment course, complications, and results in people with diabetes. The authors' ultimate goal is development of disease-specific protocols to cost-effectively improve outcomes, with potential for standardization.

   Of 81 patients treated, 20 were diabetic, with 14 charts reviewed. Patients with healed wounds (50%) were compared to those with nonhealed wounds (50%). Medical histories and demographics were similar. Patients with nonhealed wounds had longer ulcer duration (5.7 months versus 2.7 months), higher incidences of neuropathy (57% versus 29%), elevated glucose (43% versus 14%), and larger wounds (4.1 cm² versus 2.6 cm²). A higher incidence of healing was observed in patients treated with HBO (63% versus 33%), cast boots (71% versus 29%), and in those with osteomyelitis (75% versus 17%). Patients with osteomyelitis treated/not treated with HBO demonstrated 100% healing in 83% versus 50%.

   The authors believe HBO is a valuable tool in complex wound management and may be particularly beneficial in diabetics with osteomyelitis. A prospective controlled study is necessary to evaluate outcomes of diabetic wounds treated with HBO.

The meaning of nonhealing: the patient perspective

Christine J. Moffatt, RN, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK; Debra C. Doherty, RN, South West London Community Healthcare, NHS Trust, London, UK; and Peter J. Franks, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK
   Considerable research has highlighted the impact of leg ulceration on patients' lives. However, little attention has been given to the experience of patients whose ulcers fail to heal despite correct treatment and who face the future living with a chronic wound. As part of a larger study, five in-depth interviews were conducted with patients with nonhealing ulceration who found adherence to treatment problematic. Each interview was recorded and transcribed verbatim. Analysis through development of themes was performed by two separate researchers. Codes were compared with agreement achieved at over 95%. Further analysis involved continuous comparison until saturation was achieved and no further themes or alternative perspectives emerged.

   The overarching theme that emerged was the requirement to maintain a sense of balance in life through the development of new strategies for daily living. This involved facing the realities of living with a chronic illness where healing was no longer the primary goal. Of central importance in achieving these aims was controlling symptoms that caused the ulcer to intrude on daily life. Living with unremitting pain and control of exudate were key goals. The patients developed a high degree of expertise in ensuring medical procedures met these goals. However, sometimes these conflicted with professionals opinion, leading to tension and compartmentalizing of staff into "good" and "bad" carers. Patients were acutely aware of professional reactions to their condition, describing it as "insignificant and uninteresting." This research raises many issues that require further exploration as care of patients with intractable wounds is considered.

Professional dilemmas of nonhealing

Christine J. Moffatt RN, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK; Debra C. Doherty, RN, South West London Community Healthcare, NHS Trust, London, UK; and Peter J. Franks, PhD, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London, UK
   This study aimed to explore how professionals cope with patients who have nonhealing wounds.

   Four focus groups were undertaken with community nursing teams caring for patients with nonhealing wounds and who were reported as having difficulty adhering to prescribed treatment regimens. Focus groups were moderated by two researchers with recording and transcription of all data. Focussing exercises and critical incident technique were used. Analysis of coding involved two researchers, with agreement of 96% achieved on initial coding. Analysis focussed on the behavior and attitudes and feelings of staff using a case comparison matrix.

   The professionals frequently developed defensive routines to cope. These included the use of blaming and labeling of patients as "difficult," as well as procedures that distanced themselves from patient contact. This included avoiding continuity by rotating visits through the team or the selection of a "favored" nurse to attend. Individual nurses, including a team leader who had a poor relationship with the patient-abdicated care to another colleague to avoid contact with them. Despite these defenses, professionals were aware of the suffering of these patients, but felt ill-prepared to deal with it. Professional assumptions included the belief that compliance with treatment equated with wound healing and that patients who were unable or unwilling to follow professional instructions were contributing to their own treatment failure. Anger and irritation towards patients were common, as were feelings of guilt, impotence, anxiety, and depression over their inability to bring about wound healing, viewed as professional failure.

   This research raises many professional issues which require further exploration.

Venous screening by photoplethysmography for the pre-ulcer detection of venous insufficiency in the general population

Gregory K. Patterson, MD, FACS, CWS; Tere Sigler, PT, CWS; Harriett Loehne, PT, CWS; Ed Hall, MD, FACS, CWS; N. Clayton Haskins, MD; and Connie Ellison, RVT, RCVT, RDCS, Archbold Memorial Medical Center, Thomasville, Ga.
   Wide-spread disease screening has been a mainstay in the early detection of disease processes and the basis of preventative medicine. Traditionally, vascular screening has been for arterial disease. The authors have not found anyone offering venous screening or any major literature pertaining to the early detection of venous insufficiency (formally referred to as venous stasis disease). The authors screened 186 patients (372 limbs). Venous refill times (VRT) and calf muscle pump function were obtained with a photoplethysmography machine*. Five studies were excluded secondary to being nonreadable by the machine. Of the 181 patients (362 limbs) included in the study, abnormal VRTs were noted in 176 limbs (49% of all limbs). This included 60 bilateral VRTs and 56 unilateral. Normal VRTs were noted in 186 limbs (51%), 65 bilateral and 56 unilateral. A "true" normal study consists of bilateral normal VRTs. This was observed in 65 patients or 36% of the screened population. Of the 116 persons with abnormal VRTs, 84 persons had a moderate-to-severe result in one or both legs (72% of abnormals and 46% of total population screened). The overall incident rate and severity in this population, in which none of these patients had a diagnosis of venous insufficiency or an active venous wound, would indicate that a significant portion of the population would probably benefit from early intervention and monitoring of venous insufficiency. This earlier detection may decrease the number of venous wounds and related complications that the wound care specialist encounters.

   *Vasoquant VQ1000 (ELCAT Medical Systems, Wolfratshausen, Germany).

Lower molecular weight hyaluronic acid in an ionic polymer gel matrix helps create an optimal environment for ulcer healing

Ronald E. Reece, MD, Redding Medical Center, Redding, Calif.; John Quiring, PhD, Nancy L. Fitzgerald, and Jason M. Proos, QST Consultations, LTD, Allendale, Mich.; and Linda Thomas, RN, Redding Medical Center, Redding, Calif.
   The purpose of the study was to ascertain whether a proprietary low molecular weight hyaluronic acid gel ionic polymer gel matrix (HA-Ulcer Gel) placed on nonhealing ulcers would create an environment to aid ulcer healing. High concentrations of hyaluronic acid, particularly in fetal skin, have long been noted to be associated with rapid healing with little scarring. Twenty-eight patients with 53 nonhealing ulcers of a least 1-month duration were treated with a HA-Ulcer Gel. Patients were followed weekly with concurrent standard ulcer care until the ulcers were healed or 4 months elapsed. Forty-seven of the 53 treated ulcers (89% with a 95% CI of 78% to 97%) healed by study completion. The duration of the 50 ulcers before study initiation ranged from 1 to 156.5 weeks, and the time to healing ranged from 1 to 25 weeks with a median healing time of 9.7 weeks. This data suggests that a HA-Ulcer Gel when used in nonhealing ulcers helps create an optimal environment for wound healing to occur.

References
1. Edmonds M, Bates M, Doxford M, Gough A, Foster A. New treatments in ulcer healing and wound infection. Diabetes Metab Res Rev. 2000;Sep-Oct(16 Suppl 1):S51-54.
2. Ballard K, Baxter H. Developments in wound care for difficult to manage wounds. Br J Nurs. 2000;9(7):405-412.
3. Laurent TC, ed. Chemistry, Biology and Medical Applications of Hyaluronan and Its Derivatives. Wenner-Gren International Series, 72, Portland Press, March, 1998.
4. Giovanni Abatangelo G, Weigel PG, eds. New Frontiers in Medical Science: Redefining Hyaluron. Elsevier Science. 1st ed. May 1, 2000.
5. Pajulo OT, Pulkki KJ, Lertola KK, etc. Hyaluronic acid in incision wound fluid: a clinical study with the Cellstick device in children. Wound Repair and Regeneration. 2001;9(3):200–204.
6. Cass DL, Meuli M, Adzick NS. Scar wars: implications of fetal wound healing for the pediatric burn patient. The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, USA. Pediatr Surg Int. 1997;12(7):484–489.
7. Iocono JA, Ehrlich HP, Keefer KA, Krummel TM. Hyaluronan induces scarless repair in mouse limb organ culture. J Pediatr Surg. 1998;33(4):564–567.
8. Estes JM, Adzick NS, Harrison MR, Longaker MT, Stern R. Hyaluronate metabolism undergoes an ontogenic transition during fetal development: implications for scar-free wound healing. J Pediatr Surg. 1993;28(10):1227–1231.
9. Lorenz HP, Adzick NS. Scarless skin wound repair in the fetus. West J Med. 1993;159(3):350–355.
10. Longaker MT, Chiu ES, Adzick NS, Stern M, Harrison MR, Stern R. Studies in fetal wound healing. V. A prolonged presence of hyaluronic acid characterizes fetal wound fluid. Ann Surg. 1991;213(4):292–296.

Effects of support surface relief pressures on heel skin blood perfusion

Harvey N. Mayrovitz, PhD; Nancy Sims, RN, LMT, CL; and Lori Durbin, PhD, College of Medical Sciences, Nova Southeastern University, Ft. Lauderdale, Fla.
   Heel blood flow reduction during bed lying predisposes the heel to pressure ulcers. Because flow during pressure relief must compensate for prior intervals of flow deprivation, the authors studied effects of pressure-relief magnitude (PRM) on heel skin blood flow (SBF) with laser-Doppler in 12 healthy persons during 50 minutes of lying. One heel rested on a support cell with its air pressure computer controlled to vary cyclically every 5 minutes between 20 mm Hg during loading and 10, 5, and 0 mm Hg during offloading. Average SBF during each 10-minute full cycle and the hyperemic response after relief were determined. Results showed an inverse relationship between PRM and heel SBF over each cycle and during the hyperemia phase. Full-cycle SBF for PRM of 0, 5, and 10 mm Hg were respectively 34.1 ± 7.5, 26.4 ± 7.5 and 9.3 ± 3.3 a.u. (P <0.001). The authors conclude that the reduced SBF is due to blunting of hyperemia when PRM is too high. At interface pressures near diastolic, little if any functional pressure relief is realized. Thus, a suitable PRM partly depends on a patient’s diastolic blood pressure with lower pressures needing lower pressure-relief levels. Patients with diminished hyperemic reserve or vascular deficits likely need even lower PRM.

Tunneling wound care: use of a flexible intermedullary tip with pulsatile lavage

Fred Shonkwiler, MPT, Shawnee Mission Medical Center, Shawnee Mission, Kan.
   Irrigating and cleaning tunneling wounds to promote healing poses a clinical challenge. A flexible intermedullary tip (FIT) attachment to a pulsatile lavage with suction (PLWS) provided an effective solution to this challenge.

   A 47-year-old male with paraplegia presented with a sacral wound and co-existing paraspinous abscess. Despite surgical debridement, necrotic tissue remained in the wound. Additional surgery was unadvisable. Physical therapy initiated bedside debridement and irrigation 7 days post-op using the PLWS three times a week. Initial wound dimensions were 45 mm x 26 mm x 90 mm. During treatment six, two tunnels were identified in the wound communicating with the paraspinous abscess (110mm/10 o’clock; 80mm/1 o’clock.). Use of the FIT was initiated with the PLWS to irrigate and cleanse the tunnels. During treatment seven, the FIT’s graduated markings were used to measure both tunnels (160mm/10 o’clock; 170mm/1 o’clock). By treatment eight, both tunnels had closed. Due to ease of entry into narrow wounds, the FIT was continued with the PLWS. Final wound measurements at treatment 19 were 20 mm x 20 mm x 45 mm.

   The FIT proved to be a valuable clinical tool in treating tunneling wounds. The FIT enabled easy access to irrigate narrow opening wounds and the graduated markings aided in measurements.

Reducing digital plantar pressure by sharp debridement and silicone prosthesis

Robert Slater, DPM; I. Hershkovitz, BSc; M. Rapaport, MD; A.A. Buchs, MD; and Y. Ramot, MD, Assaf Harofeh Medical Center, Zerifin, Israel.
   Background: Elevated plantar pressures caused by hyperkeratosis on the distal aspect of digits 2 to 4 are the leading cause of ulceration and digital amputation. Reduction of pressure lowers the risk of ulceration. Although sharp debridement and digital orthoses are commonly used treatments, no study has been done to demonstrate their efficacy.

   Aim: To evaluate the effect of sharp debridement of hyperkeratosis and orthosis made from moldable silicone compound (MSC) on the reduction of pressure under digits 2-4 in diabetic feet.

   Materials and Methods: Fourteen patients with diabetes (18 feet) were examined both before and after sharp debridement while walking with and without orthosis made from MSC. Ten out of 14 patients (13/18 feet) had significant clinical neuropathy as determined by failure to perceive vibration in the hallux and/or failure to detect 10 G Semmes-Weinstein monofilament. All digital pressures were recorded by a pressure analysis mat.

   Results: The mean digital pressure before debridement without MSC was 2.7kg/cm² (range 0.81 to 5.99). Mean digital pressure before debridement with MSC was 1.95 kg/cm² (range 0.9 to 3.83). Following debridement, the mean pressure without MSC was reduced to 1.81 kg/cm² (range 0.94 to 3.45). Mean pressure after debridement with MSC was 1.3 kg/cm squared (range 0.42 to 2.87).

   Conclusions: Both sharp debridement and digital orthosis are effective in reducing the pressure from hyperkeratosis on the plantar aspect of digits 2-4. The most significant and constant reduction in pressure is achieved by combining both treatments

Outcomes of hyaluronan therapy in treatment of indolent diabetic foot ulcers

J.R. Vazquez, E. Espensen, B. Short, and B.P. Nixon, Department of Surgery, Southern Arizona Veterans Affairs Medical Center, Tucson, Ariz.; A.J.M. Boulton, Department of Medicine, Manchester Royal Infirmary, University of Manchester, United Kingdom; Lawrence A. Lavery, Department of Orthopaedics, Loyola University, Chicago, Ill.; and D.G. Armstrong, Southern Arizona Veterans Affairs Medical Center, Tucson, Ariz. and Department of Medicine, Manchester Royal Infirmary, University of Manchester, United Kingdom
   The purpose of this study was to evaluate outcomes of people with neuropathic diabetic foot wounds treated with a hyaluronan-containing dressing. Data were abstracted for 36 patients with diabetes, 72.2% male, aged 60.0 ± 10.7 years and a mean glycated hemoglobin of 9.5 ± 2.5% presenting for care at two large, multidisciplinary wound care centers. All patients received surgical debridement for their diabetic foot wounds and were placed on therapy consisting of hyaluronan dressing (Hyalofill, ConvaTec, USA) with dressing changes taking place every other day. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks. Hyalofill therapy was used until the wound bed achieved 100% granulation tissue. Therapy was followed by a moisture-retentive dressing until complete epithelialization occurred. In total, 75.0% of wounds measuring a mean 2.2 ± 2.2 cm² healed in the 20-week evaluation period. Of those that healed in this period, healing took place in a mean 10.0 ± 4.8 weeks. The average duration of Hyalofill therapy in all patients was 8.6 ± 4.2 weeks. The authors conclude that a regimen consisting of moist wound healing using hyaluronan-containing dressings may be a useful adjunct to appropriate diabetic foot ulcer care. The authors await the completion of a randomized controlled trial in this area to either support or refute this initial assessment.

The leg ulcer measurement tool (LUMT) detects change in wound appearance

M. Gail Woodbury, BScPT, MSc, PhD, Parkwood Hospital, London, Ontario, Canada; Pamela E. Houghton, BScPT, PhD, School of Physical Therapy, University of Western Ontario, London, Ontario, Canada; Karen E. Campbell, RN, MScN, NP/CNS, and David Keast, MD, MSc, CCFP, FCFP, Parkwood Hospital, London, Ontario, Canada
   To assess the effectiveness of wound therapies in clinical and research settings, a measurement tool that will not only describe the current condition of the leg ulcer but will also detect any improvement or deterioration in wound status over time is necessary. To address this need, the Leg Ulcer Measurement Tool (LUMT) was developed. Its content validity, intrarater, and interrater reliability have been reported previously. The ability of the LUMT to detect improvement or deterioration in wound status over time and its responsiveness have been assessed. The leg ulcers of 22 subjects were evaluated monthly for 4 months. In addition to measurement of wound appearance using the LUMT, acetate tracings of the surface area of the wound were made. The tracings were used to classify the wounds as improving toward closure or deteriorating. The responsiveness of the LUMT is illustrated by Repeated Measures ANOVA (P = 0.003) and by a responsiveness coefficient of 0.84. The effect size for the group whose wounds improved toward closure was 1.13 and was –0.22 for those whose wounds deteriorated. These initial results suggest that the LUMT is responsive. The LUMT is an appropriate clinical and/or research tool for evaluating leg ulcers.

Clinical outcomes following excision and primary closure of diabetic foot ulcers

Robert P. Wunderlich, DPM, Staff Physician, DIABETEX Foot Care Center, San Antonio, Tex.; and Lawrence A. Lavery, DPM, MPH., Associate Professor, Loyola University Medical School, Department of Orthopaedics and Rehabilitation, Maywood, Ill.
   Purpose: To evaluate clinical outcomes after excision and primary closure of foot ulcers in patients with diabetes.

   Methods: A retrospective chart review was used to identify 14 diabetic subjects with foot ulcers who underwent surgical excision and primary closure of their wounds. The primary author was the surgeon of record in all cases.

   Results: The authors’ study population had an average age of 63 years ± 10.6 years, with an average duration of diabetes of 13.7 ± 10.4 years. The patients failed conservative wound care for 21.6 weeks ± 17.1 weeks before surgical intervention. The mean ulcer surface area was 1.1 cm² ± 0.8 cm². Patients generally had good lower extremity perfusion, with a mean ABI of 0.95 ± 0.24. All wounds healed within 9 weeks postoperatively, with an average healing time of 6.0 weeks ± 2.6 weeks. The average follow-up duration was 21.1 months ± 10.4 months, during which time the authors identified one case of ulcer recurrence at the site of the original ulcer.

   Conclusion: Surgical excision followed by primary closure is an effective method to facilitate healing of chronic diabetic foot ulcers in cases where conservative treatment fails.