Healing Trajectory Research Articles

Healing rate calculation in the diabetic foot ulcer: Comparing different methods

The determination of healing rate in the diabetic foot wound is an important assessment parameter that is part of the overall clinical decision-making process in wound treatment. A number of methods that have been used to calculate healing, ranging from length and width measurement, surface area measure changes expressed as a function of time and linear advancement of the wound edge. The objective of this study was to compare surface area measures to linear advancement of the wound edge in 228 diabetic foot ulcers. Each wound was measured using the two methods and analyzed using linear regression to determine the best modeling of the healing process in these wounds. Results indicated that the total surface area change per day was superior to the linear advancement parameter in this group of wounds and that the area measurement was significantly more likely to predict the healing trajectory in the subgroup of wounds that took more than 28 days to heal. Contrary to expectations, the linear advancement method was correlated to initial wound size in the longer duration wounds suggesting that in these chronic wounds, differing healing phases render the surface area calculation method superior to the linear advancement parameter.

Dehydrated amniotic membrane allografts for the treatment of chronic wounds: a case series

A retrospective case series demonstrating the use of dehydrated human amniotic membrane (dHAM) allografts in the treatment of wounds of various aetiologies. Amniotic membrane was applied to a series of chronic wounds referred to a formal wound clinic for aggressive management, after prior, traditional treatment methods were found ineffective, over a period of 1 month. In each case, failure of traditional therapy was followed by placement of a dehydrated amniotic membrane allograft and the healing time course was documented with charted measurements. Wounds treated with the amniotic membrane allograft demonstrated improved healing, with a change in the healing trajectory from that previously noted. Dehydrated human amniotic membrane represents a potentially effective addition to existing wound care therapies, with further formal clinical studies indicated.

Retrospective Analysis of Pulsed Radiofrequency Energy Therapy Use in the Treatment of Chronic Pressure Ulcers

: The purpose of the study was to evaluate the benefit of using pulsed radiofrequency energy (PRFE) therapy in the treatment of chronic pressure ulcers. : A retrospective analysis was performed using case series data from the Provant Wound Registry, which consists of demographic characteristics and wound healing outcomes for patients treated with the Provant Therapy System. : The analysis subset consisted of data from 39 distinct centers, including both residential and ambulatory care facilities. : The analysis included data from 89 patients. The majority of patients (89%) were cared for in residential facilities, whereas 11% of patients were cared for in ambulatory care facilities. : Specific outcomes that assessed wound healing between the initial time point and at the 4-week follow-up were as follows: percent wound surface area reduction (PWAR), proportion of wounds achieving 50% reduction or greater in wound surface area (50% PWAR), and the rate of wound healing (wound healing trajectory in centimeters squared per day). : Overall, there was a 51% median reduction in wound surface area (PWAR) after 4 weeks of PRFE therapy for wounds in the study, with 51% of wounds (56/110) achieving 50% reduction or greater in wound surface area (50% PWAR). Rate of healing measurements for the overall study group showed a median wound healing trajectory of 0.13 cm/d at 4 weeks. : Compared with historical controls and other studies using similar surrogate wound healing markers, these results suggest PRFE therapy is a beneficial adjuvant treatment option for healing chronic pressure ulcers.

Chronic wounds - is cellular 'reception' at fault? Examining integrins and intracellular signalling.

As with all physiologic processes, chronic wounds are associated with unique intracellular and cellular/extracellular matrix (ECM) receptor types and signalling messages. These cellular receptors mediate responses of the epidermis to provisional wound matrix and change in form and number in cases of impaired wound healing. Integrins are the major cell-surface receptors for cell adhesion and migration and epidermal keratinocytes express several integrins that bind ECM ligands in provisional wound ECM. Integrin receptors and more particularly integrin clusters and focal adhesion points appear to influence epidermal and dermal cell matrix interactions, cell motility, cell phenotype and ultimate healing trajectory. In chronic wounds, a variety of changes in receptors have been identified: decreased integrin α5β1 receptors affect the integration of fibronectin and subsequent keratinocyte migration; integrin αvβ6 stimulate transforming growth factor (TGF)-β and may increase the susceptibility to ulceration and fibrosis; however, TGF-β signal receptors have been found to be dysfunctional in many chronic wounds; additionally receptor interactions result in increased senescent cells including fibroblasts, myofibroblasts and even keratinocytes - this produces a degradative ECM and wound bed and corrosive chronic wound fluid. The activation or inhibition of integrin receptors by various agents may provide an excellent means of influencing wound healing. This process offers an earlier intervention into the wound healing cascade promoting intrinsic healing and elaboration of growth factors and ECM proteins, which may be more cost effective than the traditional attempts at extrinsic addition of these agents.

Family-Centered Care of the Surgical Neonate

When infants require surgery, the family experiences a crisis. Surgical care of the infant and their family requires constant information sharing between health care providers (HCPs) and families. Parents' information needs and their readiness to learn vary along the infant's trajectory of healing. Information is acquired by parents from many sources and over time parents become an important source of information during the infant's stay in the neonatal intensive care unit (NICU). Family-centered approaches in all phases of surgical care (preoperative, postoperative and preparation for discharge) empowers and supports parents and ultimately leads to optimal outcomes.

Anger in the Trajectory of Healing From Childhood Maltreatment

When a girl is abused during childhood, she may not experience anger, only helplessness or numbness. Only later may the emotion of anger surface. Little is known about anger cognitions or behaviors as they occur across the years of the healing trajectory from childhood maltreatment. Data for the present secondary analysis were derived from a large narrative study of women thriving in adulthood despite childhood abuse. The purpose of this analysis was to examine the phenomenon of anger and its role in the recovery process of 6 midlife women. The 6 cases were purposefully selected because their interviews contained rich descriptions of anger experiences. Because each woman was interviewed 3 times over a 6- to 12-month period, 18 transcripts were available for in-depth examination. A typology was constructed, depicting 5 types of anger. Anger ranged from nonproductive, self-castigating behavior to empowering, righteous anger that enabled women to protect themselves from further abuse and to advocate for abused children. Study findings are relevant to extant theories of women's anger and feminist therapies.

Ritual and Performance in Domestic Violence Healing: From Survivor to Thriver Through Rites of Passage

This article describes a group for domestic violence survivors to help them move past a "liminal" state in which their social identity is characterized by being "victim" or "survivor" to one of "incorporation" defined by "thriving" and joy. Through the creation and use of healing rituals, blessings, poetry, art and music, the women in the group establish "communitas" and support each other in the work of self-reclamation and healing. The group, "Rites of Passage" is intended for women who have completed shelter-based crisis interventions, and uses a structured curriculum that integrates theoretical and philosophical concepts from anthropology, post-modernism, humanistic psychology, social work, and existentialism. Through the Rites of Passage group, women identify and traverse a healing trajectory to construct an identity founded on strength and fulfillment. Patterned after non-western sex-segregated rites of transition, those who go through the group celebrate its conclusion with a defining ritual that publically marks their change in identity and status.

Biosimulation of acute phonotrauma: An extended model

Personalized, preemptive, and predictive medicine is a central goal of contemporary medical care. The central aim of the present study was to investigate the utility of mechanistic computational modeling of inflammation and healing to address personalized therapy for patients with acute phonotrauma. Computer simulation. Previously reported agent-based models (ABMs) of acute phonotrauma were extended with additional inflammatory mediators as well as extracellular matrix components. The models were calibrated with empirical data for a panel of biomarkers--interleukin (IL)-1β, IL-6, IL-8, IL-10, tumor necrosis factor-α and matrix metalloproteinase-8--from individual subjects following experimentally induced phonotrauma and a randomly assigned voice treatment namely voice rest, resonant voice exercise, and spontaneous speech. The models' prediction accuracy for biomarker levels was tested for a 24-hour follow-up time point. The extended ABMs reproduced and predicted trajectories of biomarkers seen in experimental data. The simulation results also agreed qualitatively with various known aspects of inflammation and healing. Model prediction accuracy was generally better following individual-based calibration as compared to population-based calibration. Simulation results also suggested that the special form of vocal fold oscillation in resonant voice may accelerate acute vocal fold healing. The calibration of inflammation/healing ABMs with subject-specific data appears to optimize the models' prediction accuracy for individual subjects. This translational application of biosimulation might be used to predict individual healing trajectories, the potential effects of different treatment options, and most importantly, provide new understanding of health and healing in the larynx and possibly in other organs and tissues as well.

Analysis of run-in and treatment data in a wound outcomes registry: clinical impact of topical platelet-rich plasma gel on healing trajectory

Randomised controlled trials in chronic wounds typically exclude patients with comorbidities and confounding factors. Well-designed observational studies can provide complementary clinical evidence that randomised trials cannot address. This study determined if wound care registry outcomes could be an alternative data source and if the results would be robust and valid. Changes in wound area and depth were hypothesised to be different between run-in therapies and platelet-rich plasma (AutoloGel™, Cytomedix, Inc) treatment. From a treatment registry of 285 chronic wounds, 46 had run-in and post-treatment data. Seven chronic wound categories were identified. Mean wound age at study start was 52·4 days. General linear model repeated measures showed a credible and robust data set. Statistically significant differences for wound area and depth were observed between run-in and post-treatment period at multiple time points. Wound area and depth ≥50% reduction were analysed using Kaplan-Meier methods. During run-in, 15% of wound area improved compared to 28% post-treatment and 11% of wound depth improved during run-in compared to 39% post-treatment. Significant clinical outcomes indicated many previously non responsive wounds began actively healing in response to platelet-rich plasma therapy, indicating that registry data can be used as a complementary source of evidence.

The Process of Healing Transformations

This article presents an emerging model of healing transformations to guide nurses in caring for those living with a chronic illness. A review of the literature on chronic illness and its relationship to lifestyle behavior change and transformative nursing practice is included. Derived from qualitative narratives, this work reports the clusters of phenomena within each phase of the model. The model emerged from data gathered during 36 in-depth interviews with 18 men and women living with chronic skin wounds. During two interviews, each participant shared important life stories and meaningful reflections on living with a chronic skin wound. Using the theory of health as expanding consciousness, analysis of each participant's life story revealed individual life patterns and patterns across participants. These patterns were validated and reflected on with participants during the second interview. Synthesizing participants' patterns of responses, the model of healing transformations emerged. Developed from clients' experiences, the model of healing transformations provides rich insight into the nature of healing and the central role of the nurse practicing from a holistic perspective in this process. Nurses make a positive difference in the healing trajectory of those living with chronic illnesses such as chronic skin wounds.

Survey of fungi and yeast in polymicrobial infections in chronic wounds

To assess the incidence, abundance and species diversity of fungi in chronic wounds, as well as to describe the associations of major fungi populations. Comprehensive molecular diagnostic reports were evaluated from a total of 915 chronic wounds in a retrospective study. Of the 915 clinical specimens, 208 (23%) were positive for fungal species. These samples were further compared in a compiled dataset, and sub-classified among the four major chronic wound types (decubitus ulcer, diabetic foot ulcer, non-healing surgical wound, and venous leg ulcer). The most abundant fungi were yeasts in the genus Candida; however, Curvularia, Malessezia, Aureobasidium, Cladosporium, Ulocladium, Engodontium and Trichtophyton were also found to be prevalent components of these polymicrobial infections. A notable bacterial/fungal negative correlation was found to be apparent between Staphylococcus and Candida. There were also significant relationships between both bacterial and fungal genera and patient metadata including gender, diabetes status and cardiovascular comorbidities. This microbial survey shows that fungi are more important wound pathogens and opportunistic pathogens than previously reported, exemplifying the impact of these under-reported pathogens. With the application of modern cost-effective and comprehensive molecular diagnostics, clinicians can now identify and address this significant component of chronic wound bioburden with targeted therapies, thereby improving healing trajectories.

The Effect of Percutaneous Intervention on Wound Healing in Patients With Mixed Arterial Venous Disease

Open venous ulcers in patients with combined arterial and venous insufficiency are notoriously hard to treat. Patients with an ankle-brachial index (ABI) of 0.5-0.8 have been shown to heal poorly. Because adequate compression therapy is contraindicated in patients with an ABI of <0.7, we decided to undertake an aggressive approach of percutaneous revascularization for these patients. A total of 27 patients with clinical and duplex scan evidence of chronic venous insufficiency, active leg ulcers, and impaired arterial perfusion (ABI: <0.7) were treated using a protocol that required performing percutaneous revascularization before ambulatory compression therapy. The patients were followed at 2-week intervals (average) before and after revascularization. Wound measurements and time to complete closure were also recorded. The results of the patients were compared with their own previous wound healing trajectories. Additionally, their healing rate was compared with previously published rates of impaired arterial perfusion venous wound closure; 25% closure at 10 weeks, 50% at 19 weeks. At enrollment, the average ABI and wound sizes were 0.56 and 12 cm(2), respectively. On average, the wounds had remained open for 17 weeks. After the intervention, the average ABI was 0.97, average time taken to complete closure was 10 weeks, closure rate at 10 weeks was 75%, and absolute closure rate was 100%. Although previous studies have shown that closure of mixed arterial venous ulcers occur without arterial intervention, attaining a near normal ABI allows for timelier wound closure. Therefore, we advocate an aggressive approach of percutaneous revascularization in this population.

Computerised analysis of standardised ultrasonographic images to monitor the repair of surgically created core lesions in equine superficial digital flexor tendons following treatment with intratendinous platelet rich plasma or placebo

The effectiveness of new therapies to treat tendon injuries is difficult to determine and is often based on semi-quantitative methods, such as grey level analysis of ultrasonographic images or subjective pain scores. The alternatives are costly and long-lasting end-stage studies using experimental animals. In this study, a method of ultrasonographic tissue characterisation (UTC), using mathematical analysis of contiguous transverse ultrasonographic images, was used for intra-vital monitoring of the healing trajectory of standardised tendon lesions treated with platelet rich plasma (PRP) or placebo. Using UTC it was possible to detect significant differences between the groups in the various phases of repair. At end stage, over 80% of pixels showed correct alignment in the PRP group, compared with just over 60% in the placebo group (P<0.05). UTC also showed significant differences in the course of the healing process between PRP treated and placebo treated animals throughout the experiment. It was concluded that computerised analysis of ultrasonographic images is an excellent tool for objective longitudinal monitoring of the effects of treatments for superficial digital flexor tendon lesions in horses.

Quantifying Vocal Fatigue Recovery: Dynamic Vocal Recovery Trajectories after a Vocal Loading Exercise

We quantified the recovery of voice following a 2-hour vocal loading exercise (oral reading). Eighty-six adult participants tracked their voice recovery using short vocal tasks and perceptual ratings after an initial vocal loading exercise and for the following 2 days. Short-term recovery was apparent, with 90% recovery within 4 to 6 hours and full recovery at 12 to 18 hours. Recovery was shown to be similar to a dermal wound healing trajectory. The new recovery trajectory highlighted by the vocal loading exercise in the current study is called a vocal recovery trajectory. By comparing vocal fatigue to dermal wound healing, this trajectory is parallel to a chronic wound healing trajectory (as opposed to an acute wound healing trajectory). This parallel suggests that vocal fatigue from the daily use of the voice could be treated as a chronic wound, with the healing and repair mechanisms in a state of constant repair. In addition, there is likely a vocal fatigue threshold at which point the level of tissue damage would shift the chronic healing trajectory to an acute healing trajectory.

The Improvement of Wound-Associated Pain and Healing Trajectory With a Comprehensive Foot and Leg Ulcer Care Model

The Improvement of Wound-Associated Pain and Healing Trajectory With a Comprehensive Foot and Leg Ulcer Care Model

The Improvement of Wound-Associated Pain and Healing Trajectory With a Comprehensive Foot and Leg Ulcer Care Model

Pain is a major concern for subjects with chronic wounds, but its optimal management remains elusive. The aim of this study was to validate an organized pain management approach using the Wound Associated Pain model in subjects with chronic leg and foot ulcers. We completed a prospective cohort study that documented pain in chronic wound subjects over a 4-week period. A total of 111 subjects with chronic leg and foot ulcers were recruited from the community and ambulatory wound care clinics. Using a systematic approach based on the Wound Associated Pain model, we demonstrated improved overall wound healing outcomes in 111 subjects with chronic leg and foot ulcers. Using an 11-point numerical rating scale, the average level of pain was reduced from 6.3 at week 0 to 2.8 at week 4 (P < .001). The average healing rate was 0.39 cm per week and the average relative reduction in size was 59.36% (t = 2.31; P = .023). To examine the relationship between pain and wound healing, pain levels were compared in subjects who achieved wound closure and those who did not. The mean pain score was 1.67 for the healed subjects in contrast to 3.21 for those who did not achieve complete wound closure (P < .041). A comprehensive patient assessment can improve chronic leg and foot ulcer wound-related pain and healing rates. The mean pain scores are lower for patients with healed ulcers than for those who do not obtain complete wound closure.

Mathematical model for wound healing following autologous keratinocyte transplantation

In times of increasing economical pressure on the health care systems, it is important to optimise the outpatient treatment of chronic wounds. Another aim of wound healing research is to discover agents to accelerate healing. Wound healing trajectories or healing velocities can provide information to demonstrate the endpoints for wound healing. A great problem in clinical trials is to specify these parameters. Therefore, we developed a mathematical model for more transparency. In this initial project, we observed 19 wounds to construct the wound healing trajectories after transplantation of autologous keratinocytes, and the results are so encouraging that investigation in this area will continue. The developed mathematical model describes the clinical observed healing process. It was possible to find parameters to distinguish between old and young patients, retrospectively or prospectively calculate the healing rates and to determine exactly the endpoint of healing. Therefore, our model might be very useful in practices or for studies.

V.A.C.® Therapy in Home Care

Around the world, the numbers of patients with acute and chronic wounds is increasing as the population ages. In addition, a global epidemic of diabetes mellitus is emerging as we move to a faster paced life style with relatively sedentary occupations, refined foods, and an increase in obesity. Healthcare professionals need to look for new solutions to treat patients with wounds that will improve patient’s quality of life at an affordable cost for health care systems. The care of chronic wounds is shifting from institutions to home care in the community, with consequent new challenges related to the coordinated delivery of care Clinical decisions regarding the care of the individual patient should be based on current best evidence to optimize individual patient outcomes. Although many aspects of wound care are subjected to the scientific methods for the pursuit of clinical knowledge, consideration of clinical expertise and patient preference is equally important. We advocate the term ‘evidence informed practice’ to recognize the merit of tacit knowledge and personal interpretation, reflection, deliberation, and application of evidence. It is by recognizing that this paradigm shift is required the disparity between knowledge and its implementation can be minimized. To optimize wound healing, clinicians must address the underlying cause of the patients wound and patient centered concerns prior to selecting local wound treatments. Several experimental studies have documented that negative pressure wound therapy (NPWT) has improved tissue proliferation by altering molecular and cellular responses. In this supplement, key clinical studies and analyses are presented to substantiate the clinical efficacy and safety of NPWT. Wu and Armstrong appraised the literature focusing on diabetic foot ulcers (DFUs) that were treated by surgical interventions. They reported a significant improvement in healing and reduction in subsequent surgical interventions using NPWT. The authors highlighted the potential cost savings and improvement on quality of life. Fife et al. reviewed data from 1331 patients with DFUs treated in the community. The number of adverse events reported while patients were treated with NPWT was similar to patients in the control group receiving conventional dressings. More importantly, wounds that were treated with NPWT demonstrated faster healing trajectories. In the article by Trueman, economic studies are reviewed and demonstrate the home care cost effectiveness of NPWT using V.A.C. technology for pressure ulcers. This supplement reviews abundant evidence to illustrate the benefits of NPWT with V.A.C. technology on various types of chronic wounds across the continuum of patient care settings. Early implementation and regular evaluation of NPWT is crucial to promote the best possible patient outcomes and cost savings. Needless to say, many barriers and challenges to implement advanced wound therapy exist within the health care system. We are presenting an educational model built on the principles of the educational evidence based literature to translate the NPWT via V.A.C. technology for the successful treatment of carefully selected home care patients. This model highlights the importance of professional development and leadership to ensure the appropriate utilization of NPWT. The third meeting of the World Union of Wound Healing Societies will give us the opportunity to bring together a panel from North America and Europe to help translate the use of new technology into the home care arena. The authors of this supplement will have a unique opportunity to share experiences outlined in this volume with a global audience of interprofessional wound healers. Optimal patient outcomes require the implementation of new scientific evidence based research into clinical practice incorporating the knowledge of successful strategies from the educational evidenced based literature. Negative pressure wound therapy using V.A.C. technology is an intervention that can facilitate faster healing that is important for patients, healthcare professionals and providers of health care systems. R. Gary Sibbald is a Consultant/Advisor, a member of the Speaker’s bureau and has and is receiving grant/research funding from Coloplast, Smith and Nephew, 3M, KCI, Molnlycke, Covidien and Johnson & Johnson. Kevin Woo was and is a Consultant/Advisor for Coloplast, Molnlycke, KCI, the Registered Nurses Association of Ontario and Merck. He is a member of the Speaker’s Bureau for Johnson & Johnson, Coloplast and Molnlycke. Has and is receiving grant/research funding from the Canadian Association of Wound Care.

This Month in Anesthesiology

The characteristics of diabetic cardiomyopathy and its consequences on anesthetic management are reviewed.Better understanding of methadone metabolism is likely to improve the safety and outcomes of methadone use in patients.Hyperglycemia that occurred during renal ischemia–reperfusion resulted in severe functional injury.To study the relation between body mass index (BMI) and perioperative outcomes in children, Tait et al. prospectively collected data from 2,025 children presenting for surgery during a 20-month period. Using BMI classifications developed specifically for children, the team identified 17.3% of the children as obese. Incidence and severity of respiratory adverse events were recorded at five points throughout the perioperative period. Obese children had a higher incidence of difficult mask ventilation, airway obstruction, and oxygen desaturation. Although events were managed without serious sequelae, it is important to identify risk factors associated with obesity to optimize anesthetic care of these children.Kodali et al. undertook two studies to evaluate airway changes associated with labor and delivery. In the first study of 61 parturients, the team used conventional Samsoon’s modification of Mallampati airway class to classify airways at the onset and end of labor. In the second study, the team used acoustic reflectometry to measure upper airway volumes at the same junctures. During Study 1, there was a significant increase in airway class from pre- to postlabor, with 33% of patients increasing one grade higher. Study 2 revealed significant decreases in oral volume, pharyngeal area, and pharyngeal volume during labor and delivery. Due to these observed changes, it is essential to carefully evaluate a woman’s airway just before administering anesthesia during labor rather than relying on prelabor data. See the accompanying Editorial View on page 347 The regenerative potential of endothelial progenitor cells (EPCs) has been investigated in a variety of animal models of vascular injury and ischemia. In this issue, Lam et al. report on the effects of EPCs in a rabbit model of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) that produced pulmonary endothelial dysfunction. Endothelial dysfunction was attenuated in rabbits treated with autologous EPCs, and infiltration and activity of leucocytes in the lung parenchyma was also significantly reduced. Transplanted EPCs might have the potential for becoming a cell-based, endothelium-targeted therapeutic strategy for the prevention and treatment of ALI/ARDS. See the accompanying Editorial View on page 354 Pain from bone injury is poorly understood. Freeman et al. induced closed mid-diaphyseal fracture of the left femur 21 days after pin placements in male and female rats. The animals’ pain behaviors were assessed at day 0 (before fracture) and at several days up to three weeks after fracture. There were no gender differences in degree of after-fracture guarding, flinching, and weight-bearing, or required morphine. Histologic analysis of bone and nerve tissues allowed characterization of the fracture pain and bone healing trajectories. Use of this fracture model could lead to discovery of analgesics to effectively treat fracture pain without inhibiting fracture healing. See the accompanying Editorial View on page 349 This article has been selected for the Anesthesiology CME Program.

Life Trajectories of Female Child Abuse Survivors Thriving in Adulthood

A narrative study of thriving adult female survivors of childhood maltreatment was undertaken to discover how they had achieved success. Life trajectory patterns, turning points, and setbacks were identified. Data consisted of 81 interview transcripts derived from a series of three interviews, spaced over 6 to 12 months, with 27 survivors. The childhood abuse was intrafamilial, beginning as early as infancy and continuing, in most cases, until participants left home. The onset and pace of the healing trajectory were quite variable, including a roller-coaster pattern as well as patterns of slow, steady progress and continued struggle. Four types of redemption narratives were delineated. Survivors had not been spared depression but had made achievements in work and education and displayed remarkable generativity, parenting their own children well, and mentoring other young girls, especially victims of abuse.