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Isaac AL, Tritto M, Colwell RR, Armstrong DG. Metagenomics of diabetic foot ulcer undergoing treatment with total contact casting: a case study. J Wound Care 2022; 31:S45-S49. [PMID: 36113855 DOI: 10.12968/jowc.2022.31.sup9.s45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Diabetic foot ulcers (DFUs) are characterised by the presence of many microbes, some of which may not be identified by traditional culture techniques. Total contact casting (TCC) remains the gold-standard for offloading, yet little is known about the microbiome of wounds that progress from hard-to-heal to closed within a TCC. METHOD A patient with a DFU underwent weekly treatment with TCC to closure. Samples for next-generation sequencing (NGS) and bioinformatics analysis of tissue samples were collected during each visit. Detection, identification, characterisation of the microbial community and abundance of microbes in each sample were compared. RESULTS Abundance of microbes, identified by species and strain, changed with each treatment visit. By the final week of treatment, species diversity of the wound microbiome had decreased significantly, highlighted by an observed decrease in the number of total microorganisms present. Resistance genes for tetracyclines were detected in the first sample, but not in subsequent samples. CONCLUSION The results of this study suggest dynamic microbiological changes associated with DFUs as they progress to healing within a TCC. As NGS becomes more readily available, further studies will be helpful to gain an improved understanding of the significance of the wound microbiome in patients with DFUs.
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Affiliation(s)
- Adam L Isaac
- Foot and Ankle Specialists of the Mid-Atlantic (FASMA), LLC, Rockville, MD, US
| | - Michael Tritto
- Foot and Ankle Specialists of the Mid-Atlantic (FASMA), LLC, Rockville, MD, US
| | - Rita R Colwell
- CosmosID, Inc., Rockville, MD, US
- Institute for Advanced Computer Studies, University of Maryland, College Park, MD, US
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, US
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Eriksson E, Liu PY, Schultz GS, Martins‐Green MM, Tanaka R, Weir D, Gould LJ, Armstrong DG, Gibbons GW, Wolcott R, Olutoye OO, Kirsner RS, Gurtner GC. Chronic wounds: Treatment consensus. Wound Repair Regen 2022; 30:156-171. [PMID: 35130362 PMCID: PMC9305950 DOI: 10.1111/wrr.12994] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/23/2021] [Accepted: 01/09/2022] [Indexed: 12/17/2022]
Abstract
The Wound Healing Foundation (WHF) recognised a need for an unbiased consensus on the best treatment of chronic wounds. A panel of 13 experts were invited to a virtual meeting which took place on 27 March 2021. The proceedings were organised in the sub-sections diagnosis, debridement, infection control, dressings, grafting, pain management, oxygen treatment, outcomes and future needs. Eighty percent or better concurrence among the panellists was considered a consensus. A large number of critical questions were discussed and agreed upon. Important takeaways included that wound care needs to be simplified to a point that it can be delivered by the patient or the patient's family. Another one was that telemonitoring, which has proved very useful during the COVID-19 pandemic, can help reduce the frequency of interventions by a visiting nurse or a wound care center. Defining patient expectations is critical to designing a successful treatment. Patient outcomes might include wound specific outcomes such as time to heal, wound size reduction, as well as improvement in quality of life. For those patients with expectations of healing, an aggressive approach to achieve that goal is recommended. When healing is not an expectation, such as in patients receiving palliative wound care, outcomes might include pain reduction, exudate management, odour management and/or other quality of life benefits to wound care.
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Affiliation(s)
| | - Paul Y. Liu
- Department of Plastic Surgery, Rhode Island HospitalAlpert Medical School of Brown UniversityProvidenceRIUSA
| | - Gregory S. Schultz
- Department of Obstetrics and Gynecology and Institute for Wound ResearchUniversity of FloridaGainesvilleFAUSA
| | - Manuela M. Martins‐Green
- Department of Molecular, Cell and Systems BiologyLaboratory of Wound Healing Biology, University of CaliforniaRiversideCAUSA
| | - Rica Tanaka
- Juntendo University School of MedicineTokyoJapan
| | - Dot Weir
- Saratoga Hospital Center for Wound Healing and Hyperbaric MedicineSaratoga SpringsNew YorkUSA
| | - Lisa J. Gould
- Department of SurgerySouth Shore HospitalSouth WeymouthMassachusettsUSA
| | - David G. Armstrong
- Keck School of Medicine of University of Southern CaliforniaLos AngelesCAUSA
| | - Gary W. Gibbons
- Boston University School of Medicine, Center for Wound Healing South Shore HealthWeymouthMAUSA
| | | | - Oluyinka O. Olutoye
- Center for Regenerative MedicineAbigail Wexner Research Institute, Nationwide Children's HospitalColumbusOHUSA
- Department of SurgeryThe Ohio State UniversityColumbusOHUSA
| | - Robert S. Kirsner
- Dr Philip Frost Department of Dermatology and Cutaneous SurgeryUniversity of Miami Miller School of MedicineMiamiFAUSA
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G. Armstrong D, Bauer K, Bohn G, Carter M, Snyder R, Serena TE. Principles of Best Diagnostic Practice in Tissue Repair and Wound Healing: An Expert Consensus. Diagnostics (Basel) 2020; 11:E50. [PMID: 33396217 PMCID: PMC7824433 DOI: 10.3390/diagnostics11010050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic wound treatment currently relies heavily on visual assessment by clinicians; however, the clinical signs and symptoms of infection and inflammation are unreliable in chronic wounds. The specialty of wound care has witnessed the advent of advanced interventions, such as cellular and/or tissue based products (CTP). The success of advanced therapies relies on preparing the wound bed by reducing bacterial burden and inflammation. The lack of diagnostics in chronic wound care leads to uncertainty in the adequacy of wound bed preparation. Recent research suggests that two novel point-of-care diagnostic tests can assist in the detection of chronic inflammation known as elevated neutrophil derived protease activity (EPA) and bacterial pathogenesis known as bacterial protease activity(BPA) in chronic wounds. Despite the evidence, however, clinicians report that incorporating diagnostics into every day practice is challenging and across the globe, they have requested guidance on their use. Methods and Recommendations: A panel of wound care experts, experienced with these tests, met to develop guidelines on their use in wound care practice. The consensus panel concluded that the clinician should test for BPA first. The panel maintained that the risk of invasive infection resulting from the presence of pathogenic bacteria was the greatest threat to the patient's health. If the BPA test is negative, the panel recommended testing for EPA. In addition, it was suggested that if the wound failed to progress after the elevated BPA was treated and subsequent testing was negative for BPA, the clinician should consider testing for EPA. Conclusions: In this manuscript, the consensus panel suggests pathways for testing, treating, and retesting for EPA and BPA. The panel expects that following the algorithm has the potential to improve healing outcomes, result in more cost-effective use of advanced therapies, and improve antimicrobial stewardship by guiding antimicrobial use.
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Affiliation(s)
- David G. Armstrong
- Keck School of Medicine of USC, Southwestern Academic Limb Salvage Alliance (SALSA), Los Angeles, CA 99033, USA;
| | - Karen Bauer
- Department of Surgery, University of Toledo Physicians, Toledo, OH 43614, USA;
| | - Greg Bohn
- General Surgery Tawas St Joseph Hospital & Ascension St Joseph Hospital, Tawas City, MI 48763, USA;
| | | | - Robert Snyder
- Clinical Research Barry University SPM, Brand Research Center, Barry University, Miami, FL 33321, USA;
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Armstrong DG. Comment on "An observational pilot study using a purified reconstituted bilayer matrix to treat non-healing diabetic foot ulcers". Int Wound J 2020; 18:554-555. [PMID: 33241635 PMCID: PMC8273616 DOI: 10.1111/iwj.13514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- David G Armstrong
- Southern Arizona Limb Salvage Alliance, University of Arizona, Tucson, Arizona, USA
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Cabal Mirabal CA, Berlanga Acosta J, Fernández Montequín J, Oramas Díaz L, González Dalmau E, Herrera Martínez L, Sauri JE, Baldomero Hernández J, Savigne Gutiérrez W, Valdés JL, Tabio Reyes AL, Pérez Pérez SC, Valdés Pérez C, Armstrong AA, Armstrong DG. Quantitative Studies of Diabetic Foot Ulcer Evolution Under Treatment by Digital Stereotactic Photography. J Diabetes Sci Technol 2019; 13:821-826. [PMID: 31195816 PMCID: PMC6955448 DOI: 10.1177/1932296819853843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Imaging the lower extremity reproducibly and accurately remains an elusive goal. This is particularly true in the high risk diabetic foot, where tissue loss, edema, and color changes are often concomitant. The purpose of this study was to evaluate the reproducibility of a novel and inexpensive stereotaxic frame in assessment of wound healing. METHODS The main idea is to keep constant and reproducible the relative position of extremities related to the sensor used for the examination during a serial studies by stereotaxic digital photographic sequence. Ten healthy volunteers were evaluated at 10 different time moments to estimate the foot position variations in the stereotaxic frame. The evolution of 40 of DFU patients under treatment was evaluated before and during the epidemical grow factor intralesional treatment. RESULTS The wound closing and granulation speeds, the relative contribution of the contraction and tissue restauration mechanism were evaluated by stereotaxic digital photography. CONCLUSIONS The results of this study suggest that the stereotaxic frame is a robust platform for serial study of the evolution of wound healing which allow to obtain consistent information from a variety of visible and hyperspectral measurement technologies. New stereotaxic digital photography evidences related to the diabetic foot ulcer healing process under treatment has been presented.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Alexandria A. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
- David G. Armstrong, DPM, MD, PhD, Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck Medical Center of USC, 1520 San Pablo St, Ste 4300, Los Angeles, CA 90033, USA.
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Affiliation(s)
- David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.
| | - Geoffrey C Gurtner
- Department of Surgery, Stanford University College of Medicine, Stanford, CA, USA
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Armstrong DG, Hurwitz BL, Lipsky BA. Set Phages to Stun: Reducing the Virulence of Staphylococcus aureus in Diabetic Foot Ulcers. Diabetes 2015. [PMID: 26207033 DOI: 10.2337/db15-0543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- David G Armstrong
- Southern Arizona Limb Salvage Alliance, Department of Surgery, The University of Arizona Health Sciences Center, Tucson, AZ
| | - Bonnie L Hurwitz
- Department of Agricultural and Biosystems Engineering, The University of Arizona, Tucson, AZ
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Department of Medicine, University of Geneva, Geneva, Switzerland Division of Medical Sciences, Green Templeton College, University of Oxford, Oxford, U.K
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