Poster session 8: Wound healing

Poster session 8: Wound healing
Assessment of protein intake and requirement among diabetic patients with foot
Sara Jaffri, Baqai Baqai Medical University, Karachi, Pakistan
Musarrat Riaz, Baqai Medical University, Karachi, Pakistan
Zahid Miyan, Baqai Medical University, Karachi, Pakistan
Abdul Basit, Baqai Medical University, Karachi, Pakistan
Objectives: To evaluate protein intake & requirement among patients with diabetic foot
Methodology: This study was conducted among Type 2 diabetic patients presenting with
foot ulcers at Baqai Institute of Diabetology & Endocrinology (BIDE), a tertiary care diabetes
center of Karachi, Pakistan, in the month of, July and August 2014. Formal approval of the
study was obtained from Institutional Review Board of BIDE. Dietary intake of these patients
was taken through predesigned questionnaire based on 24 hour dietary recall interview and
the demographic data was obtained from Health Management System (HMS). Total grams
of protein were calculated from all the food groups and. Protein requirement of patients were
calculated according to their body weight and severity of wound. SPSS version 13 was used
for analysing the results.
Results: Dietary intake of 50 patients with diabetic foot ulcer was recorded out of which 72%
were males. Mean age of the participants and average duration of Diabetes was 57.62 ±
8.33 years and 11.72 ± 7.92 years respectively. Protein consumption of patients was 3 days
of a week at lunch and dinner was 34 %. Mean protein intake of males was 78.48gms and
females were56.58gms. Requirement of protein is higher than the consumption which is
141.93 gms for males and 87.95 gms for females calculated according to their body weight
and severity of wound.
Conclusion: Dietary counseling should be a part of the treatment among patients with
diabetic foot ulcer to identify their nutritional needs and suggesting them better option to
fulfiltheir protein requirement essential for wound healing process.
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Effects of vacuum-therapy on skin microcirculation in patients suffering from diabetic
foot ulcer in context of TcPO2 & wound healing
Sandeep Raj Pandey, Medanta-The Medcity, Gurgaon, India
Aim: To, investigate the short-term effect of impinging vacuum-therapy by vacuumed(VC)
P6 or P7 on skin microcirculatory perfusion in the foot of patients suffering diabetic foot ulcer
in context of TcPO2 & wound healing.
Methods: Nineteen patients with diabetic foot ulcer underwent vacuum-therapy by
vacuumed P6 or P7 for 40 minutes for several days(3 to 10 days). The leg was positioned in
an air-tight plexiglass cylinder in which hypobaric (-110 mm Hg) and hyperbaric (70 mm Hg)
pressure could be generated alternately, in order to improve peripheral circulation and suck
infected & necrotic tisuues. The effect on skin microcirculation was investigated using
transcutaneous oxygen tension measurements (TcpO2) and photos observing wound
Results: Three of the, patients experienced ischaemic symptoms during VC, probably
because the leg was pinched off through inflation of the cuff. Patients capillary microscopic
parameters changed slightly at first vacuum . After several vacuum, TcpO2 parameters
improved significantly(3 to 19 mmhg) along with better wound healing .
Conclusion: Vacuum-therapy significantly improves total skin perfusion and oxygenate on
being an essential factor in the occurrence of ischaemic symptoms with context of Tcpo2 &
wound healing. We therefore conclude that this instrument in its present form is an aid in the
treatment of diabetic foot management.
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Negative determinants of diabetic foot ulcer healing: 6-month follow-up of a large
multicentre cohort
Kris Doggen, Scientific Institute of Public Health, Brussels, Belgium
Dimitri Aerden, University Hospital Brussels, Brussels, Belgium
Hilde Beele, University Hospital Ghent, Ghent, Belgium
Kevin Deschamps, University Hospitals Leuven, Leuven, Belgium
Isabelle Dumont, Diabetic foot centre Ransart, Ransart, Belgium
Patricia Félix, CHR de la Citadelle, Liège, Belgium
Patrick Lauwers, University Hospital Antwerp, Antwerp, Belgium
Astrid Lavens, Scientific Institute of Public Health, Brussels, Belgium
Giovanni Matricali, University Hospitals Leuven, Leuven, Belgium
Caren Randon, University Hospital Ghent, Ghent, Belgium
Eric Weber, CSL Vivalia, Arlon, Belgium
Viviane Van CasterenScientific Institute of Public Health, Brussels, Belgium
Aim: Knowing the determinants that negatively influence diabetic foot ulcer (DFU) healing is
crucial for improving DFU care. We identified negative determinants of DFU healing in
diabetic foot clinics (DFC) participating in a quality improvement (QI) initiative with periodical
audits and feedback (anonymous benchmarking). [1]
Methods: In 2011, 32 Belgian DFCs followed 1528 patients with a DFU of Wagner grade 2
or more for six months or until healing, major amputation or death, whichever occurred first.
Cumulative incidence functions were studied and Cox proportional hazards regression was
used to identify determinants of healing by using a forward selection method, taking into
account competing risks (major amputation and death), missingness of covariates and
clustering of outcomes in DFCs.
Results: At 6 months, the overall probability of healing, major amputation and death was
60.1, 4.3 and 4.4% respectively. 31.3% of patients had a DFU that was not healed.
Multivariate analysis identified 6 significant (P<0.05) negative determinants of healing:
presence of contralateral ulcer(s) at presentation reduced predicted 6-month healing
probability by 27.1%, presence of peripheral artery disease by 21.1%, presence of
midfoot/heel ulcers (vs. toe) by 19.7%, presence of additional ipsilateral ulcer(s) by 14.4%,
presence of renal insufficiency by 13.5% and referral delay by 5.6% per additional 3 month
delay. Notably, plantar vs. dorsal location was not significantly associated with DFU healing.
Conclusions: Presence of bilateral DFUs is particularly detrimental for healing. Compared
to previous observational studies and especially Eurodiale [2], our data, collected routinely
for QI purposes, yielded a similar set of negative determinants of healing, thus highlighting
their external validity. Our findings could be incorporated in a useful QI tool in which riskadjusted outcomes of DFCs are benchmarked to each other and over time.
[1] Doggen K, Diabetes Metab Res Rev. 2014;30:435-443.
[2] Pickwell K, Diabetes Metab Res Rev. 2013;29:377-383.
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Stressing the dressing: Is there a real-time association between stress markers and
wound healing outcomes during outpatient visits?
Saman Parvaneh, University of Arizona, Tucson, AZ, United States
Gurtej Grewal, University of Arizona, Tucson, AZ, United States
Javad Razjouyan, University of Arizona, Tucson, AZ, United States
Robert Menzies, Hamad Medical Co, Doha, Qatar
Talal Talal, Hamad Medical Co., Doha, Qatar
David Armstrong, University of Arizona, Tucson, AZ, United States
Bijan Najafi, University of Arizona, Tucson, AZ, United States
Aims:, Previous studies have suggested that stress is an important risk factor for slower
wound healing and susceptibility to infection. The purpose of this study was to objectively
assess real-time physiological stress response (PSR) in people with diabetic foot ulcers
during a clinical visit and explore its association with wound healing outcomes
Methods: 20 subjects with diabetes (Age: 59±10), and non infected, non-ischemic wounds
were enrolled., Using a mobile based wearable sensor (Bioharness-Zephyr Technology®),
uni-channel ECG was collected during baseline clinic visit for a period of approximately 45
min including waiting, dressing, and post-dressing period. An automated code was designed
to estimate real-time PSR based on measuring heart rate variability (HRV). Baseline PSR
was identified during the first 3 minutes, when subjects were asked to be relaxed prior
meeting with the caregiver. Extreme and high PSR were defined when HRV was in the
range of 60-85% and below 60% of baseline HRV, respectively. Association between wound
healing outcomes and PSR was assessed in a sub-sample of 6 patients at 12 weeks’ followup.
Results: Results revealed that all patients experienced high or extreme stress with time
ranging through the majority (13% to 87%) of their outpatient visit and in particular during
wound dressing time. A negative correlation (r=-0.65, p<0.05) was observed between
percentage of total experienced PSR during dressing change and rate of wound healing at 1
week. Subjects with greater than 60% PSR at baseline had 62% slower wound size change
at 1 week (p<0.05). On the same note, healed subjects at 12 weeks had 52% lower mean
stress response during dressing change.
Conclusions: Our pilot study highlights the feasibility and potential benefits of continuous
PSR monitoring in diabetic patients during clinic visit using single wearable mobile health
technology. Pilot results are concordant with other works in the literature suggesting that
stress may negatively impact wound healing.
Funding: Qatar National Research Fund – NPRP 4-1026-3-277
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Impact of initial glycemic control on the healing rate of the diabetic foot lesions
Samir Ouizi, University Diabetes Centre, Riyadh 11411, Saudi Arabia
Background: The prevalence of diabetes among Saudi population is almost 24%, and
mainly type 2, due to life style changes and some genetic background. It is generally
assumed that poor glycemic control may delay wound healing. So, the impact of glycemic
control on healing of diabetic foot ulcers remains to be explored.
Aim: To identify the impact of glycemic control on diabetic foot ulcer healing outcome.
Methods: Medical podiatric records of 335 diabetic patients with diabetic foot wounds from
the Foot Unit at University Diabetes center between September 2011 - November 2013 were
collected. Diabetes control was based on the HbA1c values, podiatric exam includes
sensory testing performed by using a VPT, vascular status evaluation was based on pedal
pulses palpation and/or ankle brachial pressure index (ABPI). Wound care was done up on
the standard of the IWGDF (debridement, infection control, vascular control, and offloading).
Wound assessment was done up on PEDIS classification and Healed wound was defined as
complete closure without discharge.
Results:, Mean age, diabetes duration, and HbA1c were 58±0.6 years 17±0.4years, and 9.4
±0.1% respectively. Diabetic peripheral neuropathy and peripheral vascular disease was
94.92% and 35% respectively. 47.46% of the total ulcers were infected and 70% were
located at the plantar aspect of the foot, the mean wound size was 5 25cm² and the wound
severity type was grade III classification (9.8%). Foot Deformity and Charcot foot was 65%
and 15.22% respectively. History of ulceration and amputation was 33.5% while all wounds
healed within a mean of 13.31 weeks.
Conclusion: Better Diabetic foot ulcers outcome rely on well organized diabetic foot team
rather than better glycemic control.
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Impact of severe sleep apnoea and CPAP therapy on diabetic foot wound recovery in
acute recalcitrant diabetic foot ulcers - a case series
Prash Vas, Kings College Hospital, London, United Kingdom
Raju Ahluwalia, Kings College Hospital, London, United Kingdom
Ana Manas, Kings College Hospital, London, United Kingdom
Michael Edmonds, Kings College Hospital, London, United Kingdom
Aim: Whilst great progress has been made in managing diabetic foot disease, non-healing,
or slow healing ulcers are common. Factors such as pressure, ischaemia and uncontrolled
infection are usually sought out and treated., Obstructive Sleep apnoea (OSA) and diabetes
share a bidirectional relationship and recent studies confirm significant under recognition of
OSA in, diabetes. There are no current reports on the, clinical impact of OSA on course or
management of foot ulcers
Methods/Case Series: Three neuropathic patients with triphasic distal vascular waveforms.
They presented with acute foot ulcers and underwent emergency surgical debridement.
Subsequently, they all received standard care whilst in hospital with optimization of
glycaemia, daily wound care and offloading. However, it was difficult to achieve satisfactory
granulation and the wounds looked typically devitalised and grey. Repeat vascular studies
and tissue microbiology were negative . Diagnosis and treatment of unrecognised severe
OSA (apnoea-hypopnea index, AHI >30 in all) with continuous positive airway pressure
therapy (CPAP) allowed our first two patients to quickly granulate wounds and achieve
control. Our third patient declined CPAP therapy and continues to have a recalcitrant wound.
Conclusion: We observe that diabetes individuals with severe untreated OSA may have
delayed acute wound healing correctable with institution of CPAP therapy. The clinical
picture is typically like ischaemia or infection. Diabetes foot clinics are currently not set up to
detect and treat OSA but we would recommend those managing the diabetic foot should
actively look for and consider treating OSA as per guidelines in acute non-healing or slowly
progressive, ulcers when all other factors have been fully optimized.
Representative image of Case 1
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Risk factors of diabetic foot ulceration associated with prolonged healing (>12 weeks)
in king saud university diabetes center
Mohammed Derwish, University Diabetes Center, Riyadh, Saudi Arabia
Introduction: Saudi Arabia ranks number 4 with 3.6 million diabetes cases, with the highest
diabetes prevalence (23.9%). King Saud University diabetes center is a referral center
dealing with diabetic foot ulcers. We sought to identify risk factors of diabetic foot ulceration
associated with prolonged healing (>12 weeks) to enable better local management protocol.
Methods: Total of 335 diabetic patients with healed foot ulcer, was seen in the university
diabetes center from years 2011 to 2013. (Data are mean ± SE). Patients were split into two
groups according to duration of healing. The first, more than 12 weeks to heal group (n=
126) and those with ulcers that healed less than 12 weeks group (n=208). Podiatric
assessment was carried out including Foot musculoskeletal examination, diabetic peripheral
neuropathy (DPN) screening using vibration perception threshold, vascular assessment
using ankle brachial pressure index and for wound assessment Texas classification was
Results: Most of our patients were quite younger with a mean age of 58.5±0.6. 94.2% of
both healed group had DPN (VPT >25), 96.7%, versus 90% in the (<12 weeks) and (> 12
weeks), groups respectively. Abnormal ABPI was found in 35.13%. Mean diabetes duration
was 17.9 ±0.4 and, diabetes was poorly managed in both groups with a mean, HbA1c, 9.4
±0.1., , , , , , , , , , , , , , , , , , , , , , , , , , , , , All patients had some form of foot deformity while
Charcot neuro-arthropathy was 7.8%, in the (>12 weeks) group versus 25.98% among the
(>12 weeks) group. Wound baseline was 47.35weeks versus, 74.24 weeks in the (<12
weeks) and, (> 12 weeks), groups respectively. Wounds were mainly neuropathic, located at
the planter foot aspect and larger in (>12 weeks) group versus the (< 12 weeks), group, 4.2
cm² and 6.3 cm² respectively., Most of the prolonged healed group had more history of both
ulceration and amputation 22% for the ( <12 weeks) group versus 45%, in ( > 12 weeks)
Discussion:, Advancement was found in our management protocol in term of wound
healing time for both group although the prolonged healed patients presented late or were
treated in non-specialized clinic (Wound Baseline was 58.26 weeks for both group. So, there
is an urgent need for foot care clinics and team approach.
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Performing transcutaneous angiography by a novel imaging technique as a parameter
to prognosticate wound healing in diabetic foot ulcers
Rumneek Sodhi, Medanta-The medicity, Haryana, India
Method: The SPY fluorescent imaging system consists of a charged coupled device (CCD)
camera, a laser light source and a distance sensor. Once the camera is positioned, 5cc of
diluted ICG (Indocyanine green dye) is pushed through an IV line and is flushed immediately
with 10 cc of distilled water; simultaneously the room lights are dimmed and camera images
are captured at two different, angles for a minute each.
41 patients with diabetic (Ischemic & Non-ischemic) foot ulcers were all included in this
study. Transcutaneous oxygen tension (TcpO2), Ankle Brachial Index, peripheral arterial
ultrasound and serial photographs of the wound were also captured and studied at each
'SPY" study visit.
Follow up with the SPY fluorescent imaging system was done on baseline, 2 weeks, 4
weeks and 8 weeks respectively and improvement in perfusion was recorded in numeric
percentage (%). 27 patients had to also undergo endovascular revascularisation to establish
adequate vascularity and 14 were treated with just local wound care.
Results: The difference in fluorescence was recorded in all 41 patients and it indicated
relative blood flow change (increase or decrease) accompanying the perfusion. This
information enabled us to revise management already done, or consider adjunct therapies
that may have otherwise not been recognized as needed, in other words we tried to optimize
outcomes of interventions performed to obtain wound closure as soon as possible.
In Conclusion: This SPY Imaging Technology is actually a surgeon’s delight that produces
clinically relevant visual images of blood flow indicating tissue perfusion, when captured in
real-time, pre & post intervention to prognosticate wound closure, level of amputation, and
even limb salvage.
The study has not been funded by anyone.
Spy Transcutaneous angiography in a diabetic foot ulcer
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Assessment of wound healing by digital photography: making the case for automated
and systematic processing
Nathalie Denecker, UZ Brussel, Jette, Belgium
Elisabeth Dewaele, UZ Brussel, Jette, Belgium
Dimitri Aerden, UZ Brussel, Jette, Belgium
Background: Wound assessment is of primary importance in the development of any
wound treatment regime. Textual description of a wound in the patient’s medical file is prone
to subjectiveness as the lexicon used to describe wound characteristics varies among
investigators. In addition, time restraints do not allow exhaustive description of the wound
status. The adagium that “a picture is worth a thousand words” is therefor frequently applied
to wound assessment: digital photographs of wounds are taken to increase objectiveness
and facilitate follow-up between distinct wound care specialists.
Discussion: The value of photography in the assessment of wound healing is briefly
highlighted, especially when pictures are taken systematically and periodically. Wound
characteristics that are accurately recorded by digital photography are: wound extent
(area/perimeter), localisation, wound bed (granulation tissue, firbin, necrosis), surrounding
tissue (erythema, eczema).
However, systematic documentation of wound healing becomes extremely challenging when
a high volume of outpatients has to be processed. Historically, the authors found that the
acquisition and categorisation of digital photographs from multiple wounds in a multitude of
patients proved cumbersome and frustrating. This prompted the authors to develop an ITsolution that greatly improved workflow while remaining reliable and user-friendly. In a video,
we demonstrate how data acquisition and filing is accomplished within a few minutes, and
can be accomplished by a nurse with minimal IT-training. Hardware requirements consist of
a WIFI network, Apple iOS devices (iPad or iPhone) as well as a server computer.
Finally, the authors experienced some unanticipated benefits from their newly developed
application: the documenting system proved valuable both from a medico-legal standpoint as
well as a patient motivational tool.
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Use of novel 3D digital technology for assessment of diabetic foot ulceration
Maureen Bates, King's College Hospital, London, United Kingdom
Timothy Jemmott, King's College Hospital, London, United Kingdom
Nina Petrova, King's College Hospital, London, United Kingdom
Chris Manu, King's College Hospital, London, United Kingdom
Michael Edmonds, King's College Hospital, London, United Kingdom
Aim: We describe our experience with a new technology for 3D digital wound assessment in
the management of patients with diabetes foot ulceration.,
Method: We studied prospectively 11 patients with diabetes who presented to our Diabetic
Foot Clinic with foot ulcers. Ulcer healing was monitored with the new imaging system*,
which allowed us to measure area, depth and volume and enabled us to store a digital
record of the ulcer. At each visit, the wound assessment software calculated the percentage
area reduction from baseline. Treatment outcomes were evaluated at, weeks 1, 3, 5 and 12.
Results: The ulcer area at presentation was 1.6±2 cm2 (mean±SD ), (range 0.6 cm2 - 6.3
cm2) and the ulcer volume was 0.17±0.32 cm3, (range 0.04 cm3 to 0.89 cm3). During the
observational period, the foot ulcers healed in 7 patients and improved in 2 patients. Ulcer
deterioration was observed in 2 patients. Follow up ulcer measurements and treatment
outcomes are presented in the Table, below.
Conclusion: This new system enabled us to easily compare the foot ulcer image between
visits and allowed, us to accurately analyse the wound measurements. The detection of
subtle deleterious changes prompted us to review patients within the multi-disciplinary clinic
for management optimisation. The accurate and objective wound assessment gave the
professional and patient an early indication of how the patient was responding to treatment.
The system was fast and easy to use with the bonus of being a non-contact wound
assessment method.
*SilhouetteStar 3D Camera
Funding: No external funding
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