Utility of Thermographic Imaging for Callus Identification in Wound and Foot Care.

Calluses are thickened skin areas that develop due to repeated friction, pressure, or other types of irritation. While calluses are usually harmless and formed as a protective surface, they can lead to skin ulceration or infection if left untreated. As calluses are often not clearly visible to the patients, and some areas of dead skin can be missed during debridement, accessory tools can be useful in assessment and follow-up. The practical question addressed in this article is whether or not thermal imaging adds value to callus assessment. We have performed a theoretical analysis of the feasibility of thermographic imaging for callus identification. Our analytical calculations show that the temperature drop in the epidermis should be on the order of 0.1 °C for the normal epidermis in hairy skin, 0.9 °C for glabrous skin, and 1.5-2 °C or higher in calluses. We have validated our predictions on gelatin phantoms and demonstrated the feasibility of thermographic imaging for callus identification in two clinical case series. Our experimental results are in agreement with theoretical predictions and support the notion that local skin temperature variations can indicate epidermis thickness variations, which can be used for callus identification. In particular, a surface temperature drop on the order of 0.5 °C or more can be indicative of callus presence, particularly in callus-prone areas. In addition, our analytical calculations and phantom experiments show the importance of ambient temperature measurements during thermographic assessments.

Rapid Diagnosis of Pseudomonas aeruginosa in Wounds with Point-Of-Care Fluorescence Imaing.

Pseudomonas aeruginosa (PA) is a common bacterial pathogen in chronic wounds known for its propensity to form biofilms and evade conventional treatment methods. Early detection of PA in wounds is critical to the mitigation of more severe wound outcomes. Point-of-care bacterial fluorescence imaging illuminates wounds with safe, violet light, triggering the production of cyan fluorescence from PA. A prospective single blind clinical study was conducted to determine the positive predictive value (PPV) of cyan fluorescence for the detection of PA in wounds. Bacterial fluorescence using the MolecuLight i:X imaging device revealed cyan fluorescence signal in 28 chronic wounds, including venous leg ulcers, surgical wounds, diabetic foot ulcers and other wound types. To correlate the cyan signal to the presence of PA, wound regions positive for cyan fluorescence were sampled via curettage. A semi-quantitative culture analysis of curettage samples confirmed the presence of PA in 26/28 wounds, resulting in a PPV of 92.9%. The bacterial load of PA from cyan-positive regions ranged from light to heavy. Less than 20% of wounds that were positive for PA exhibited the classic symptoms of PA infection. These findings suggest that cyan detected on fluorescence images can be used to reliably predict bacteria, specifically PA at the point-of-care.

Supportive care of cancer patients with a self-applied photobiomodulation device: a case series.

PURPOSE: Oral mucositis (OM) and prolonged wound healing are common side-effects of cancer treatments. Photobiomodulation (PBM), previously called low-level laser, is currently part of the official guideline for OM prevention. However, all the PBM protocols relate to office-based devices, operated by professional health caregivers, requiring frequent applications. In the following case series, we present our experience with a self-applied consumer home-use PBM device for supportive care. METHODS: Five patients receiving cancer treatment presented at the clinic (female:male 3:2, 55-76 years old) with OM grade 3/4 (n=2), post-surgical non-healing wounds (n=3), and dermatitis (n=1). The PBM treatment (808 nm, 250 mW peak power, 15KHz, 5 J/min, ray size 4.5×1.0cm2) was self-applied by the patients. The protocol included extra/intra-oral applications, over the wound bed/margins and adjacent lymph nodes. RESULTS: The treatment was found effective for resolving OM with rapid pain relief and accelerated healing in post-operative wounds and dermatitis, without reported adverse events. Patients found routine easy to follow and painless, and the protocol was easily integrated as an adjuvant treatment to standard care at the clinic or home while not requiring additional time from the staff. CONCLUSIONS: Side-effects induced by cancer therapy have a detrimental effect on the patient's well-being and may delay or even prevent the patients from completing treatment regimens. PBM is already an established tool for supportive treatment in cancer patients. The advent of a self-applied personal PBM treatment with easy-to-apply protocols for a variety of side-effects makes this technology an important accessible and safe supportive care option.

Prospective Multicenter Evaluation of an Advanced Extracellular Matrix for Wound Management.

OBJECTIVE: To evaluate an advanced extracellular matrix made of ovine forestomach matrix (OFM) for healing a variety of wound types. METHODS: Participants were enrolled from inpatient, outpatient, and home healthcare settings. The OFM was used to treat all wounds and applied to the wound bed every 3 to 7 days until closure. RESULTS: Researchers enrolled 29 participants with 33 wounds. Average time to wound closure was 8.2 weeks, the percentage of wounds that reduced in size by 50% or more at 4 weeks was 64%, the average wound area reduction at 4 weeks was 66%, and 73% of wounds had closed at 12 weeks. No adverse effects were observed. CONCLUSIONS: This represents the first Canadian evaluation of OFM for the treatment of wounds, and the positive healing outcomes observed could support more widespread adoption of this matrix.

At-Home Self-Applied Photobiomodulation Device for the Treatment of Diabetic Foot Ulcers in Adults With Type 2 Diabetes: Report of 4 Cases.

Diabetic foot ulcers (DFUs) incidence is increasing with the rising global prevalence of diabetes. In spite of following best practice standard of care, most DFUs are slow to heal. Photobiomodulation (PBM), previously known as low-level laser therapy, has been shown to accelerate healing of acute or chronic wounds, and specifically DFUs. However, the frequent applications required translates to frequent visits at the clinic, which are difficult for patients with DFU. In the following case series, we present our preliminary experience with a recently approved (Health Canada) consumer home-use PBM device as an adjuvant to standard treatment. Four men presented at the clinic (67 to 84 years of age) with DFUs/diabetic leg ulcers. The PBM treatment (808 nm, 250-mW peak power, 15 KHz, 5 J/min, ray size 4.5×1.0 cm2) was applied by the patients themselves at the clinic or at home. In the cases presented, all wounds closed within 1 to 3 weeks with no reported adverse events. Patients found the routine easy to follow and painless. In wounds that involved pain, patients reported pain reduction after 1 to 3 treatments. Based on our previous experience with these patients, self-applied PBM as an adjunct therapy led to accelerated healing and rapid pain alleviation compared with standard care alone. In summary, hard-to-heal diabetic wounds are a burden for patients, a burden for caregivers and costly for the health-care system. These observations support the view that the home-use device can be easily integrated as an adjuvant treatment to standard care at the clinic or home and, most importantly, encourage patient involvement in his or her own care.

Is "free" really free? Ethical implications of short-term discounts and giveaways to hospitals.

Canadian hospitals participate in provincial and national procurement processes to help reduce healthcare costs. This allows for redirection of funds to direct patient care, along with creating networks, integrating services, and improving innovative solutions. To be competitive, vendors offer creative solutions and provide free or low-cost supplies to hospitals with the hope that patients will continue to purchase those items when discharged. What is not always factored into the procurement decision-making processes is the potential financial impact of the supplies required for patients when discharged from hospital services and other ethical implications of accepting free/reduced-cost supplies. This column provides some guidance for health leaders in this respect.

Use of a bacterial fluorescence imaging device: wound measurement, bacterial detection and targeted debridement.

OBJECTIVE: Diagnostics which provide objective information to facilitate evidence-based treatment decisions could improve the chance of wound healing. Accurate wound measurements, objective bacterial assessment, and the regular, consistent tracking of these parameters are important aspects of wound care. This study aimed to assess the accuracy, clinical incorporation and documentation capabilities of a handheld bacterial fluorescence imaging device (MolecuLight i:X). METHOD: Benchtop wound models with known dimensions and clinical wound images were repeatedly measured by trained clinicians to quantify accuracy and intra/inter-user coefficients of variation (COV) of the imaging device measurement software. In a clinical trial of 50 wounds, wound dimensions were digitally measured and fluorescence images were acquired to assess for the presence of bacteria at moderate-to-heavy loads. Finally, fluorescence imaging was implemented into the routine assessment of 22 routine diabetic foot ulcers (DFU) to determine appropriate debridement level and location based on bacterial fluorescence signals. RESULTS: Wound measurement accuracy was >95% (COV <3%). In the clinical trial of 50 wounds, 72% of study wounds demonstrated positive bacterial fluorescence signals. Levine sampling of wounds was found to under-report bacterial loads relative to fluorescence-guided curettage samples. Furthermore, fluorescence documentation of bacterial presence and location(s) resulted in more aggressive, fluorescence-targeted debridement in 17/20 DFUs after standard of care debridement failed to eliminate bacterial fluorescence in 100% of DFU debridements. CONCLUSION: The bacterial fluorescence imaging device can be readily implemented for objective, evidenced-based wound assessment and documentation at the bedside. Bedside localisation of regions with moderate-to-heavy bacterial loads facilitated improved sampling, debridement targeting and improved wound bed preparation.

Fluorescence imaging guided dressing change frequency during negative pressure wound therapy: a case series.

OBJECTIVE: Knowledge of wound bioburden can guide selection of therapies, for example, the use of negative pressure wound therapy (NPWT) devices with instillation in a heavily contaminated wound. Wound and periwound bacteria can be visualised in real-time using a novel, non-contact, handheld fluorescence imaging device that emits a safe violet light. This device was used to monitor bacterial burden in patients undergoing NPWT. METHODS: Diverse wounds undergoing NPWT were imaged for bacterial (red or cyan) fluorescence as part of routine wound assessments. RESULTS: We assessed 11 wounds undergoing NPWT. Bacterial fluorescence was detected under sealed, optically-transparent (routine) adhesive before dressing changes, on foam dressings, within the wound bed, and on periwound tissues. Bacterial visualisation in real-time helped to guide: (1) bioburden-based, personalised treatment regimens, (2) clinician selection of NPWT, with or without instillation of wound cleansers, and (3) the extent and location of wound cleaning during dressing changes. The ability to visualise bacteria before removal of dressings led to expedited dressing changes when heavy bioburden was detected and postponement of dressing changes for 24 hours when red fluorescence was not observed, avoiding unnecessary disturbance of the wound bed. CONCLUSION: Fluorescence imaging of bacteria prompted and helped guide the timing of dressing changes, the extent of wound cleaning, and selection of the appropriate and most cost-effective NPWT (standard versus instillation). These results highlight the capability of bacterial fluorescence imaging to provide invaluable real-time information on a wound's bioburden, contributing to clinician treatment decisions in cases where bacterial contamination could impede wound healing.

Understanding Real-Time Fluorescence Signals from Bacteria and Wound Tissues Observed with the MolecuLight i:XTM.

The persistent presence of pathogenic bacteria is one of the main obstacles to wound healing. Detection of wound bacteria relies on sampling methods, which delay confirmation by several days. However, a novel handheld fluorescence imaging device has recently enabled real-time detection of bacteria in wounds based on their intrinsic fluorescence characteristics, which differ from those of background tissues. This device illuminates the wound with violet (405 nm) light, causing tissues and bacteria to produce endogenous, characteristic fluorescence signals that are filtered and displayed on the device screen in real-time. The resulting images allow for rapid assessment and documentation of the presence, location, and extent of fluorescent bacteria at moderate-to-heavy loads. This information has been shown to assist in wound assessment and guide patient-specific treatment plans. However, proper image interpretation is essential to assessing this information. To properly identify regions of bacterial fluorescence, users must understand: (1) Fluorescence signals from tissues (e.g., wound tissues, tendon, bone) and fluids (e.g., blood, pus); (2) fluorescence signals from bacteria (red or cyan); (3) the rationale for varying hues of both tissue and bacterial fluorescence; (4) image artifacts that can occur; and (5) some potentially confounding signals from non-biological materials (e.g., fluorescent cleansing solutions). Therefore, this tutorial provides clinicians with a rationale for identifying common wound fluorescence characteristics. Clinical examples are intended to help clinicians with image interpretation-with a focus on image artifacts and potential confounders of image interpretation-and suggestions of how to overcome such challenges when imaging wounds in clinical practice.

Utility of a sensor-based technology to assist in the prevention of pressure ulcers: A clinical comparison.

Detection of subcutaneous tissue damage before it is visible can trigger early intervention and decrease hospital-acquired pressure ulcer (HAPU) rates. The objective of this two-phase study was to evaluate the clinical utility of the Sub-Epidermal Moisture (SEM) Scanner (Bruin Biometrics (BBI), LLC), a hand-held device that assesses increases in interstitial fluid or subepidermal moisture, indicating early tissue damage. Phase 1: Patients were provided standard-of-care risk assessment and interventions and were scanned with the SEM Scanner, but the resulting SEM scores were not used to determine interventions. This gave a baseline pressure ulcer incidence rate. Phase 2: This phase is the same as Phase 1 except the resulting SEM scores were used in conjunction with risk assessment scores to determine appropriate interventions and care planning. In Phase 1, 12 of the 89 subjects or 13.5% developed visible pressure ulcers-4 Stage I's, 6 Stage II's, 1 Stage III, and 1 deep tissue injury. In Phase 2, 2 of the 195 subjects or 1.0% developed visible pressure ulcers-1 Stage I and 1 Stage II. Patients in Phase 2 were more incontinent, less mobile, and had longer lengths of stay than those in Phase 1. Use of the Scanner resulted in a 93% decrease in HAPU. No deep injuries developed in Phase 2.

A Randomized Controlled Trial Determining Variances in Ostomy Skin Conditions and the Economic Impact (ADVOCATE Trial).

PURPOSE: To compare ostomy-related costs and incidence of peristomal skin complications (PSCs) for ceramide-infused ostomy skin barriers and control skin barriers. DESIGN: The ADVOCATE trial is a multi-centered randomized controlled trial, and double-blinded international study with an adaptive design. SUBJECTS AND SETTING: The sample comprised 153 adults from 25 sites from the United States, Canada, and Europe. Participants were seen in hospital and outpatient care settings. METHODS: Data were collected by investigators at each site during face-to-face visits and during telephone check-in calls between visits. Cost of care data were collected using a questionnaire developed specifically for the study. The peristomal skin was assessed using the Ostomy Skin Tool. Health-related quality of life was measured using the SF-12v2. Patient-reported outcomes were collected using a patient-centered study-specific questionnaire. Cost of care was analyzed via analysis of covariance comparing total cost of care for 12 weeks between the 2 groups. The incidence of PSC was analyzed via Barnard's exact test comparing the incidence of PSCs between the control and treatment groups. Tertiary outcomes were exploratory in nature and not statistically powered. RESULTS: Use of the ceramide-infused barrier significantly reduced stoma-related cost of care over a 12-week period, resulting in a $36.46 decrease in cost (14% relative decrease). The adjusted average costs were $223.73 in the treatment group and $260.19 in the control group (P = .017). The overall incidence of PSCs in the study was 47.7%; PSC incidence was 40.5% for the treatment group versus 55.4% for controls (P = .069, 95% confidence interval of the difference: -1.2 to 30.4). Significantly more participants using the ceramide-infused skin barrier were "very satisfied" with barrier performance (75% vs 55%; P = .033), prevention of leakage (63% vs 38%; P < .01), and prevention of itching (53% vs 31%; P = .016). General postoperative improvement in health-related quality of life was noted in both groups. CONCLUSIONS: The use of a ceramide-infused barrier significantly decreased cost and increased satisfaction with patient-reported outcomes.

Clinician Panel Recommendations for Use of Negative Pressure Wound Therapy with Instillation.

Addition of an instilled topical wound solution to negative pressure wound therapy (NPWT) is designed to facilitate regular wound cleansing to help improve outcomes of some complex wounds, but the addition of instillation to NPWT adds a level of complexity to the wound care process. The paucity of knowledge and experience with instillation may affect optimal use of this treatment modality. In an effort to address this knowledge gap, a 2-day panel meeting of nurses (N = 11) with experience using negative pressure wound therapy with instillation and dwell time (NPWTi-d) was convened to discuss their usage recommendations for managing wounds with this treatment modality in the acute care setting. Panelists reviewed available evidence and presented recommendations for managing wounds treated with NPWTi-d. Panelists agreed NPWTi-d is primarily suited to prepare surgical or nonsurgical wounds for delayed primary closure and preparing/protecting periwound skin improves maintenance of a tight seal. Educating a team of nurses on basic NPWTi-d troubleshooting, providing a short checklist of tasks to perform every shift, and organizing needed supplies and resources may help continuity of care and prevent problems. Panelists also emphasized the im- portance of wound assessment and documentation and recommend educating the patient, family members, and other members of the patient-care team. Research to compare the safety, ef cacy, and effectiveness of NPWTi-d and other irrigation techniques on patient outcomes and research to validate these recommendations is needed.

Bates-Jensen wound assessment tool: pictorial guide validation project.

PURPOSE: A group of 3 WOC nurses and a nurse researcher, in partnership with the author of the Bates Wound Assessment Tool (BWAT), sought to validate wound photographs depicting each characteristic of the instrument. INSTRUMENT: The BWAT contains 13 items that assess wound size, depth, edges, undermining, necrotic tissue type, amount of necrotic, granulation and epithelialization tissue, exudate type and amount, surrounding skin color, edema, and induration. These are rated using a modified Likert scale; a score of 1 indicates the healthiest and 5 indicates the most unhealthy attribute for each characteristic. In 2001, the PSST was revised and renamed the Bates-Jensen Wound Assessment Tool to reflect the global use of the tool with wound types beyond pressure ulcers. METHODS: Phase 1 involved the selection of digitalized wound photographs for 11 of the BWAT wound characteristics by the researchers. The photographs needed to be of high resolution and good quality for eventual publication and validated by the original BWAT author as being representative of the intended characteristic. In phase 2, a face-to-face validation exercise was completed to include, edit, or exclude these photographs. Corrections were made; additional photographs were obtained for the remaining characteristics and to replace those not validated. Phase 3 involved an electronic survey that achieved validation online. PARTICIPANTS: Phase 2 participants consisted of 15 WOC nurses with a mean of 11.5 years of experience with wounds. Phase 3 had 8 WOC nurses and 1 master's prepared wound care specialist, with approximately 10 years of experience. One third of participants in each phase were familiar with the BWAT. In a separate exercise to rate photographs that would be used for testing the implementation of the pictorial guide, 7 WOC nurses and 2 RNs who used the BWAT regularly and 2 researchers participated in a face-to-face discussion. RESULTS: A total of 214 photographs were reviewed in this study. Seventy-three percent (n = 55) of the photographs for the pictorial guide were endorsed in phase 2, and 100% (n = 53) in phase 3 to demonstrate the 65 BWAT characteristics. In addition, photographs that could be used for a competency exercise and for pre- and posttests were also rated by the panels. CONCLUSIONS: The photographic content of the BWAT pictorial guide has been validated by a small group of wound care experts. The purpose of the exercise was to create a visual learning aid to enhance the education around wound assessment and as a resource for nurses in practice. Now published in a pocket guide format, it is a standardized way to teach BWAT wound assessment skills in a consistent format.