Wound Care: Yesterday, Today, and Tomorrow€¦ · Monofilament Test for Neuropathy . Testing for...
Transcript of Wound Care: Yesterday, Today, and Tomorrow€¦ · Monofilament Test for Neuropathy . Testing for...
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Wound Care:
Yesterday, Today, and Tomorrow
Terry Treadwell, MD, FACS
Institute for Advanced Wound Care
Montgomery, Alabama
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Where Have We Been?
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History of Wound Care
First recorded treatment of wounds in Edwin-
Smith Papyrus from ancient Egypt dating
from 3000 B.C.
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3 Healing “Gestures”
of the Egyptians
1. Wash the wound
2. Make a “plaster”-
(plaster most commonly composed of
honey, grease [animal fat] and lint
[vegetable fiber]
3. Bandage the wound
Brown, H. A Brief History of Wound Healing, 1998
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Among the Earliest Wound Care
“Products”
BEER!!
Sumerians brewed at least 19 types
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Early Wound Care Product
HONEY
Used in India and Egypt before the time of
Christ
Brown, H. A History of Wound Healing, 1998
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Early Venous Ulcer Treatment
“For an obstinate ulcer, sweet
wine and a lot of patience should
be enough”
Hippocrates describing treatment of a
patient with varicose veins and ulcer
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Healing Rates of Varicose Ulcer
Therapy -- 1964
• 71% healed “at last clinical visit”
• Duration of healing noted to range
from 8 weeks to 3 years
• 43% recurrence rate for all therapies
• “Patient could expect to spend 6 to 7
weeks in the hospital.”
Dale AW, Foster JH. Leg Ulcers: Comprehensive Plan of Diagnosis
and Management. Trans South Surg Assoc. 1964;75:
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Treatment of Diabetic Foot
Ulcers
• Until 1922 there were
essentially NO diabetic foot
ulcers
• Banting, Best, and Macleod
discovered insulin in 1922
• After insulin, treatment was
amputation
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Where Is Wound Care Going in the
Future?
Wound
Center
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Do We Really Need a Wound
Treatment Center?
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What is a “wound treatment
center” and why do we need one?
A wound treatment center is a place where
physicians and other personnel who are
interested and have expertise in wound
management come together with the
resources needed for appropriate and
quality care to treat patients with wounds
that are difficult to heal.
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HELP!
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WOUND CENTER, PLEASE
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WHY A WOUND TREATMENT
CENTER?
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
At 12
weeks
At 24
weeks
Healing Rates
Office
Specialized Clinic
Gahuri, AS, et.al. European Jour Vasc Surg 1998;16(3):238-244
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WHY A WOUND TREATMENT
CENTER?
0
0.1
0.2
0.3
0.4
0.5
0.6
At 6
months
At 12
months
Recurrence Rates
Office
Specialized Clinic
Gahuri, AS, et.al. European Jour Vasc Surg 1998;16(3):238-244
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What Does the Future Hold?
• More importance placed on multi-specialty wound care teams
• More specialization for wound care providers
• More wound care physicians practicing full-time wound care
• More advances in care of patients with wounds
• Challenges in reimbursement and cost-effective care
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Why Won‟t These Ulcers Heal?
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Good Therapy?
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Why Won‟t These Chronic Wounds
Heal???
• Do not progress beyond the inflammatory or proliferative phases of healing
• Cellular dysfunction and disregulation in the wound
1. Hyper-proliferation of cells at wound margins
2. Failure of epidermal cells to migrate across the wound
3. Abnormal response of cells to growth factors
3. Over-expression of matrix molecules
4. Production of “toxic” wound fluid
Schultz G, Falanga V, et. al., Wound Rep Reg 2003;11(Supp):1-28
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Prepare the Wound for Healing
Wound bed preparation is necessary
to correct the cellular imbalances
present in chronic wounds allowing
the wound to heal or be receptive to
our therapy.
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Optimal Wound Bed Preparation
• Maintenance of optimal moisture balance
• Complete debridement of devitalized and poorly functioning tissue
• Restoration of bacterial balance
• Optimize cellular function
• Treatment of edema / lymphedema
Schultz GS, Falanga V, et. al., Wound Rep Reg 2003;11(Supp):1-28
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Effect of Debridement of Chronic
Wounds
• Removes necrotic and ischemic tissues
• Removes infected tissues
• Exposes receptors so that growth factors can get to them
• Removes senescent and non-functioning cells
• Stimulates healing
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Need for Debridement
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Debridement
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Diabetic Foot Post Debridement
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What‟s New in Debridement?
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Maggot Therapy
Diabetic Ulcer of Toe
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Published - 2004
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Maggot Therapy
Wound before maggot therapy Maggots before application to wound
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Maggot Therapy
At time of application of maggots At time of dressing change 3 days later
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Maggot Therapy
Wound and maggots at dressing change Wound after maggot therapy
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VERSAJET Hydrosurgery System
Smith & Nephew
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Low Frequency, Low Intensity
Ultrasonic Debridement
Mist Therapy
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Low Frequency, High Intensity
Ultrasonic Wound Treatment System
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Ultrasonic Debridement
Diabetic Foot Ulcer
Before After
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Ultrasonic Debridement
Diabetic Foot Ulcer
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INFECTION and BUGS
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Topical Treatments
• Neosporin, Bactroban, other topical
antibiotics
• Iodosorb and Iodoflex
• Silvadene
• Silver dressings
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New Treatment for Infection?
• 9 antibiotic molecules in cockroach brain!
• Kills 90% MRSA on contact
• Kills all gram – bacteria on contact
• Not toxic to human cells (ie. no side effects)
DiSalvo D. Cockroach Brains: The Next Best Source of Natural
Antibiotics. Mental_Floss Magazine. 2011;10(2):47
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Punch Biopsy Culture Technique
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Effect of Local Anesthesia on
Wound Bacteria
• EMLA cream has rapid and powerful antibacterial effect (within 30 minutes)
• DO NOT use for anesthesia before culturing tissue samples
• 1% preservative-free lidocaine has antibacterial effect but only after 2 hours
• USE for anesthesia if cultures done within 2 hours of use
Berg JO, Mossner BK, et.al. Antibacterial properties of EMLA and lidocaine in wound
tissue biopsies for culturing. Wound Rep Reg 2006;14: 581-585
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Looking to the Future
in Infection Control
• What will the role of cultures be?
• What wounds are best treated with silver dressings?
• Are there other anti-infectives other than silver?
• What will be available to combat bacterial resistance to antibiotics?
• How important are biofilms in the treatment of chronic wounds?
• What do we have to effectively treat biofilms?
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Biofilms
• “Communities” of organisms
• Adhere to solid surfaces (1)
• Organgisms are imbedded in an extracellular polysaccharide matrix or glycocalyx (2)
• Imbedded organisms are resistant to antimicrobial agents (1)
• May contain a single or multiple species of organisms, including fungi (2)
(1) Bello YM, et.al. Wounds 2001;13(4):127-131
(2) Costerton JW, et.al. Annual Rev Microbiol 1995;49:711-745
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Treatment of Biofilms
• Debridement
• Macrolide antibiotic (erythromycin)^
• Treatment with Biofilm-dissolving agents*
• Bioelectric treatment combining antibiotics and electric therapy
• Future therapy?
^Mitsuya Y, et.al. J Infect Chemother 2000;6(1):45-50 *Martin LK, et.al. Wound Healing 2005, pp.83-101
*Whitchurch CB, et.al. Science 2002;295(5559):1485
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Ultrasonic Debridement
Before After
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Biofilm Therapy
Pre-treatment Treated with Biofilm-dissolving
Material
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Biofilms and Bioelectric Antibiotics
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Biofilms and Bioelectric Antibiotics
Ag +
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Sickle Cell Ulcer
19 y/o man with sickle cell disease and ulcer for 10
months. Ulcer is unresponsive to therapy.
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Bioelectric Administration Device
Battery
Electrodes
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Sickle Cell Ulcer with Bioelectric
Silver Therapy
Positive electrode
Silver dressing
covering wound
Negative electrode
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Sickle Cell Ulcer -- Healed
Healed after 36 weeks bioelectric silver therapy
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Bioelectric Silver Therapy
Location of
Wound
Pre-Therapy After 3 weeks of
Therapy
Upper level (surface to 2mm depth)
.027 .321
Lower level (2mm to 5mm depth)
.021 .077
Tissue Silver Levels (PPM)
Unpublished Data: Institute for Advanced Wound Care, 2006
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Vascular Disease in the Chronic
Wound Patient
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Doppler Study and Ankle
Pressure Measurements
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What‟s New in Vascular Evaluation
Laser Doppler and TcPo2
Evaluation Scanning Laser Doppler
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Treatment of Sickle Cell Ulcer
with Nitric Oxide Producing Medication
0
10
20
30
40
50
60
70
Ulcer Site Control site
Pre Treatment
Post Treatment
46.10
16.04
67.21 69.17
TcPO2 at ulcer site and control site when treated with Metanx
(nitric oxide producing medication) showing marked improvement
TcPO2
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Vascular Bypass
Peroneal Artery Graft Dorsalis Pedis Artery Graft
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Balloon Angioplasty and Stent
Placement
Iliac Artery Balloon Angioplasty and Stent Placement
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Route of NV1FGF Administration
• Therapeutic genes can be administered
by a variety of methods, including systemic
injection, local injection into the tissue,
or using a gene gun.
• NV1FGF is administered as an intramuscular
injection to the patient’s leg.
Source: Applied Molecular Genetics; Miesfeld R; Copyright ©1999 and John Wiley & Sons, Inc.
This material is used by permission of John Wiley & Sons, Inc.
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Example: New collateral blood vessels
induced
in an ischemic limb by gene transfer of
vascular
endothelial growth factor (VEGF).
Therapeutic Angiogenesis
for Peripheral Arterial Disease
Source: Reprinted with permission from Elsevier ( The Lancet 1996;348: 370)
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Neuropathy In The Diabetic
Patient
“Neuropathy is the single most
important factor leading to ulceration
in the diabetic patient.”
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Neurosensory Testing
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Monofilament Test for Neuropathy
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Testing for Neuropathy with
Ballpoint Pen
Ballpoint Pen with Point Extended Barely Indent Skin and Note Sensation
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Monofilament vs Ballpoint Pen in
Diagnosing Neuropathy
Diabetes Neuropathy Filament Pen Correlation
Yes
20
18+ 2- 18+ 2- 18+ 2- 100%
No
10
4+ 6- 4+ 6- 4+ 6- 100%
Data – Institute for Advanced Wound Care, 2009
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Tuning Fork Testing for Diabetic
Neuropathy
Apply Tuning Fork to IP Joint of Great Toe
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Neuropathy in Diabetics
• Sensory
• Autonomic
• Motor
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Treatments for Diabetic
Peripheral Neuropathy
• Tricyclic antidepressants (Elavil, Pamelor)
• Antiepileptic medications (Dilantin, Neurontin,
Lamictal, Lyrica)
• Local anesthetic / antiarrhythmia medications
(Mexitil)
• Pain medications (Ultram, Ultracet, Percodan,
Tylox, Oxycontin)
• Metanx
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New Therapies for the Treatment
of Peripheral Neuropathy
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MIRE Therapy: Monochromatic Near-
infrared Photo Therapy
Anodyne Therapy
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Possible Cause of Diabetic Peripheral
Neuropathy
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Improvement of Diabetic Peripheral
Neuropathy Treated with LY333531
NTSS-6 = Neuropathy
Total Symptom Score-6
Vinik AI,et.al. Diabetes 2002; 51(Suppl 2): abstract 316-OR
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Peripheral Nerves Involved by
Neuropathy
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Peripheral Nerves Before and After
Treatment with Topiramate (Topamax)
Before
After
Vinik A, et.al. Diabetes Federation Conference Presentation,
Abstract 918, Paris, France, August 24-29,2003
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Treatment of Peripheral Neuropathy
• Metanx
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Treatment of Peripheral Neuropathy
• Bone marrow stem cells
• Umbilical cord stem cells
Naruse K, Hamada Y, et al. Therapeutic Neovascularization Using Cord Blood-
Derived Endothelial Progenitor Cells for Diabetic Neuropathy. Diabetes
2005;54:1823-1828
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What‟s Next?
Hum…
Where do I go
from here?
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SKIN “SUBSTITUTES”
and CELL THERAPY
• Acellular skin “substitutes” – AlloDerm,
Biobrane, Integra, Dermagraft-TC, Oasis,
Promogran, Puraply, Graft-jacket, Biovance
• Single-layer skin “substitute” – Epicel,
Dermagraft, Vitrex, InterCytex
• Bilayered, living skin construct – Apligraf, OrCel
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Tissue Engineered Skin Products:
The Ideal Therapy for Chronic
Wounds?
• Provide cells responsive to the wound
environment
• Provide a “living factory” producing
numerous growth factors, cytokines, and
matrix proteins
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DERMAGRAFT
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DERMAGRAFT
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InterCytex Dermal Matrix
Fibroblasts in Gel Matrix
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Composite Cultured Skin
“OrCel”
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OrCel vs Human Skin
Orcel Human Skin
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APLIGRAF
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APLIGRAF®
(Graftskin) Human Skin
Photomicrographs of hematoxylin-eosine-stained cross-sections of APLIGRAF® (left) and human skin (right) 250.
HISTOLOGIC COMPARISON
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What Evidence Is There That These
Products Work?
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FDA Approval Status
Apligraf Dermagraft Regranex Oasis Integra Graftjacket
PMA Yes Yes Yes
510K Yes Yes
Tissue Yes
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FDA Product Indications
Apligraf Dermagraft Regranex Oasis Integra
DFU Yes Yes Yes
VLU Yes
Other
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“Smart Therapy”
• “Cultured skin…acts as a „smart
material‟ responding to its environment
to bring about the desired effect.”
Sabolinski M, Alvarez O, Auletta M, Mulder G, Parenteau NL,
Biomaterials 1996; 17(3):311-320
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DIABETIC FOOT ULCER
Pre Apligraf
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DIABETIC FOOT ULCER
12 Weeks Post Apligraf
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DIABETIC HEEL ULCER
Heel ulcer before Heel after debridement
debridement
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DIABETIC HEEL ULCER
APPLICATION OF APLIGRAF
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DIABETIC HEEL ULCER
16 WEEKS POST APLIGRAF
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Venous Ulcer
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Venous Ulcer
8 weeks post application Healed at 33 weeks
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Looking for The Evidence??
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