More than one way to measure a wound: an overview of tools and techniques

The Influence of Honey and Hydrogel Products Therapy on Healing Time in Diabetic Foot

BACKGROUND

Diabetic foot ulcer is a serious and common complication of diabetes that often leads to significant morbidity and even amputation if not properly treated. Current treatment options, such as wound dressing, have limitations in promoting efficient healing. There is a need for effective interventions that can expedite the healing process and enhance the time required for complete healing.

METHODOLOGY

This prospective single-blinded randomized control trial studied diabetic mellitus type 2 patients with ulcer in their second-degree feet from February 2019 to February 2023 in the Diabetic Foot Center, King Fahad Specialist Hospital Al Qassim-KSA.

RESULTS

This study involved 120 patients with a mean age of 59.64 ± 10.21. And 63% to 52.5% of them were males and 57% to 47.5% were females. The mean healing time was about 12.76 ± 4.08 days. Cases were divided into 4 equal groups with altered treatment procedures: honey alone, hydrogel alone, honey, and hydrogel combination alternately (3 intervention groups), and fucidin ointment or cream alone (1 control group), with 30 participants in each group. We revealed that the mean healing times for honey alone, hydrogel alone, and honey and hydrogel alternately were 12.20, 13.97, and 10.83 days, respectively. While it was 14.03 days in the control Fucidin ointment or cream [significantly P < .05 (P = .004)].

CONCLUSION

From the findings of the present study, we noticed that faster healing time among diabetic foot cases could be accomplished by treatment with a combination of honey and hydrogel alternately. Therefore, this therapy is effective in reducing the risk of diabetic foot ulcers.

Hyperspectral imaging-based cutaneous wound classification using neighbourhood extraction 3D convolutional neural network

OBJECTIVES

Hyperspectral imaging is an emerging imaging modality that beginning to gain attention for medical research and has an important potential in clinical applications. Nowadays, spectral imaging modalities such as multispectral and hyperspectral have proven their ability to provide important information that can help to better characterize the wound. Oxygenation changes in the wounded tissue differ from normal tissue. This causes the spectral characteristics to be different. In this study, it is classified cutaneous wounds with neighbourhood extraction 3-dimensional convolutional neural network method.

METHODS

The methodology of hyperspectral imaging performed to obtain the most useful information about the wounded and normal tissue is explained in detail. When the hyperspectral signatures of wounded and normal tissues are compared on the hyperspectral image, it is revealed that there is a relative difference between them. By taking advantage of these differences, cuboids that also consider neighbouring pixels are generated, and a uniquely designed 3-dimensional convolutional neural network model is trained with the cuboids to extract both spatial and spectral information.

RESULTS

The effectiveness of the proposed method was evaluated for different cuboid spatial dimensions and training/testing rates. The best result with 99.69% was achieved when the training/testing rate was 0.9/0.1 and the cuboid spatial dimension was 17. It is observed that the proposed method outperforms the 2-dimensional convolutional neural network method and achieves high accuracy even with much less training data. The obtained results using the neighbourhood extraction 3-dimensional convolutional neural network method show that the proposed method highly classifies the wounded area. In addition, the classification performance and the2computation time of the neighbourhood extraction 3-dimensional convolutional neural network methodology were analyzed and compared with existing 2-dimensional convolutional neural network.

CONCLUSIONS

As a clinical diagnostic tool, hyperspectral imaging, with neighbourhood extraction 3-dimensional convolutional neural network, has yielded remarkable results for the classification of wounded and normal tissues. Skin color does not play any role in the success of the proposed method. Since only the reflectance values of the spectral signatures are different for various skin colors. For different ethnic groups, The spectral signatures of wounded tissue and the spectral signatures of normal tissue show similar spectral characteristics among themselves.

Comparison of Digital Planimetry and Ruler Methods for the Measurement of Extraction Socket Wounds

Background and objectives: The purpose of the study was to evaluate and compare ruler and digital planimetry methods to measure extraction socket wounds. Materials and Methods: In total, 41 extraction socket wounds were selected for assessment of wound area by ruler and digital planimetry methods. In the simple ruler method, the periodontal probe was utilized to measure the length and breadth of the extraction wound, whereas in the digital planimetry technique, Pictzar software was used. Data were analyzed using R software version 4.1.1 and Excel. For intergroup comparisons of wound surface area, Welch t-tests were used, and paired t-tests were used for intragroup comparisons. Intra-class correlation coefficients (ICC) and 95% confidence intervals (CIs) were used to evaluate the inter-method reliabilities of surface area. Results: Both ruler and digital planimetry techniques showed post-operative reductions in surface area. A significant difference was reported between the two techniques; however, the ruler method measurements were overestimated compared to those obtained with digital planimetry. Conclusions: This study concludes that digital planimetry techniques provide more accurate results when compared with the simple ruler method.

Weight Surveillance and Heart Failure Self-assessment in Patients with Chronic Leg Wounds: A Pilot Study

OBJECTIVE

To determine if a weight check and heart failure symptom evaluation with each wound care visit could impact wound healing in patients with heart failure and chronic leg wounds.

METHODS

This was a descriptive, correlational study at an outpatient wound healing center in the Pacific Northwest. A convenience sample of individuals currently enrolled at the center with leg wounds and heart failure was identified from standardized electronic medical records. The comparison group received standard care. The intervention group received a body weight check via digital scale and heart failure self-assessment via a standardized assessment tool. Outcome measures included healing rates with weight exacerbation, number of referrals, and hospitalizations for exacerbations.

RESULTS

A total of four participants received the intervention, and three were in the control group. Descriptive analysis showed no significant differences between groups or between weight and left ventricle ejection fraction to wound surface area change. A significant positive correlation was observed between past referrals and past hospitalization (rs = 0.79; P = .033; 95% confidence interval, 0.10-0.97). The intervention group had abnormal spikes in wound size that coincided with weight gain. There were no referrals or hospitalizations during the intervention phase, and it is possible that heart failure self-assessment with every wound care visit prevented exacerbations.

CONCLUSIONS

Despite the use of an evaluation tool, the intervention and comparison groups had no significantly different outcomes. It is unclear if the intervention was not effective because of the methodology or study limitations. Further research with a larger sample, standardized tools for wound assessment, and a lengthier intervention phase is recommended.

The effectiveness of Diabetic Foot Clinic in prevention and healing of diabetic foot ulcers

OBJECTIVE

To assess the effects of the primary prevention and the healing of diabetic foot ulcers at Diabetic Foot Clinic at a university hospital in Thailand.

STUDY DESIGN

Prospective descriptive study.

METHODS

Diabetic patients with diabetic foot ulcers or pre-ulcerative lesions who regularly were followed at the outpatient Diabetic Foot Clinic, were recruited. The data were collected prospectively. Prevention and healing of diabetic foot ulcers were assessed and measured.

RESULTS

Thirty-five diabetic patients with diabetic foot ulcers (n=21) and pre-ulcerative lesions (n=28) were recruited. Weekly wound radius reduction was 1.1±1.1 (mean±SD) mm/week. Fifty-seven percent of the ulcers achieved the surrogate 50% area reduction within 4 weeks. The percentage of healed ulcers at 12 and 16 weeks were 38.1%, and 47.6%, respectively. The percentage of improvement of the pre-ulcerative lesion was 78.6%. The most common complication was soft tissue infection (19%) which required surgical debridement (14.2%) and minor amputation (4.8%).

CONCLUSION

The effectiveness of the Diabetic Foot Clinic was assessed by the reduction of the ulcer radius, ability to reach the surrogate 50% area reduction, and the improvement of the pre-ulcerative lesion. The weekly reduction of the ulcer radius was 1.1±1.1mm/week. The percentage of reaching the surrogate 50% area reduction within 4 weeks was 57%. The percentage of improvement of the pre-ulcerative lesion was 78.6%.

Effectiveness of saline water and lidocaine injection treatment of intractable plantar keratoma: a randomised feasibility study

Background

An intractable plantar keratoma (IPK) is a conical thickening of the epidermis’ stratum corneum and a common cause of foot pain which can have a significant, detrimental impact on the mobility, quality of life and independence of individuals. Conservative treatments are currently offered to patients with IPK, but they are unsatisfactory since they do not offer a sufficient or permanent reduction of symptoms. The purpose of this study was the evaluation of the feasibility, safety and effectiveness of innovative treatments for intractable plantar keratoma (IPK).

Methods

A randomized single blind trial with 40 patients divided with block randomization in four parallel groups was conducted to compare treatment combinations: conservative sharp debridement only or sharp debridement with needle insertion, physiological water injection or lidocaine injection. All patients obtained the same treatment four times at a four-week interval. At each visit, visual analog scale (VAS), Foot Function Index (FFI) and IPK size were evaluated. VAS and FFI were also completed at a six and twelve-month follow-up.

Results

Our findings in regards to feasibility demonstrated recruitment challenges because of the anticipated pain that would be provoked by needle insertion may not be worth the potential pain relief compared to debridement alone from the patient’s perspective. This was also the principal cause of drop out. Our preliminary results show no main effect of group for any of the clinical outcomes: pain felt on VAS, FFI score, IPK’s size (p > 0.05). However, the analysis revealed a statistically significant effect of time on VAS (p < 0.001), FFI score (p < 0.001) and IPK’s size (width and depth (p < 0.001); length (p = 0.001)), but no group x time interaction was found (p > 0.05).

Conclusions

This study demonstrates that IPK treatment consisting of sharp debridement with needle insertion, physiological saline water injection or lidocaine injection is feasible and safe. There was a non-statistically significant trend toward diminishing pain intensity compared to scalpel debridement alone. The pain provoked by needle insertion and injection treatments must be addressed with a scientifically proven protocol to make it more comfortable for patients before these treatments could be considered in further studies.

Trial registration

ClinicalTrials.gov, NCT04777227. 2 March, 2021 - Retrospectively registered (All participants were recruited prior to registration).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00467-7.

Characterization of staphylococci sampled from diabetic foot ulcer of Jordanian patients

AIMS

The aim of this study was to isolate and characterize staphylococcal isolates from diabetic foot ulcers (DFU) in Jordanian patients.

METHODS AND RESULTS

Selected aerobic pathogens recovered from DFU specimens and patients' nares with a focus on staphylococci were investigated. Antimicrobial susceptibilities and the prevalence of methicillin-resistant staphylococci (MRS) were determined. SCCmec types and toxigenic characteristics were analysed and spa typing was performed for methicillin-resistant Staphylococcus aureus (MRSA) isolates. The relationship between toxigenic characteristics of MRSA and the Wagner ulcer grading system was statistically analysed. A total number of 87 DFU patients were recruited for the study. The DFU cultures were polymicrobial. Members of the genus Staphylococcus were the most common among DFU-associated isolates found in 48·3% (n = 42) of all patients enrolled. Coagulase-negative staphylococci (CoNS) comprised 63·3% of staphylococci isolated from DFUs predominated by Staphylococcus epidermidis in both DFU (7·6%) and nares (39·2%). Staphylococcus aureus was isolated from DFUs and nares in 14·2 and 9·8%, respectively, while 93 and 70% of these isolates were MRSA. Most of MRSA carried SCCmec type IV (76·2%) while SCCmec elements were non-typeable in most methicillin resistant coagulase negative staphylococci (MR-CoNS) (61·9%). The most frequent MRSA spa type was t386 (23·8%). Most MRSA and MR-CoNS exhibited resistance towards aminoglycosides, fluoroquinolones and macrolides and susceptibility towards vancomycin, mupirocin and linezolid. No association was found between the possession of pvl, tst, sea and hlg toxins and Wagner ulcer grading system (P value >0·05).

CONCLUSIONS

This analysis of Jordanian DFU culture demonstrated its polymicrobial nature with predominance of Staphylococcus sp.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study is the first of its type to assess the microbiology of DFU among Jordanian patients. The results will help in the appropriate application of antimicrobial chemotherapy in the management of DFU.

Experimental models and methods for cutaneous wound healing assessment

Wound healing studies are intricate, mainly because of the multifaceted nature of the wound environment and the complexity of the healing process, which integrates a variety of cells and repair phases, including inflammation, proliferation, reepithelialization and remodelling. There are a variety of possible preclinical models, such as in mice, rabbits and pigs, which can be used to mimic acute or impaired for example, diabetic and nutrition-related wounds. These can be induced by many different techniques, with excision or incision being the most common. After determining a suitable model for a study, investigators need to select appropriate and reproducible methods that will allow the monitoring of the wound progression over time. The assessment can be performed by non-invasive protocols such as wound tracing, photographic documentation (including image analysis), biophysical techniques and/or by invasive protocols that will require wound biopsies. In this article, we provide an overview of some of the most often needed and used: (a) preclinical/animal models including incisional, excisional, burn and impaired wounds; (b) methods to evaluate the healing progression such as wound healing rate, wound analysis by image, biophysical assessment, histopathological, immunological and biochemical assays. The aim is to help researchers during the design and execution of their wound healing studies.

Integrated sensing and delivery of oxygen for next-generation smart wound dressings

Chronic wounds affect over 6.5 million Americans and are notoriously difficult to treat. Suboptimal oxygenation of the wound bed is one of the most critical and treatable wound management factors, but existing oxygenation systems do not enable concurrent measurement and delivery of oxygen in a convenient wearable platform. Thus, we developed a low-cost alternative for continuous O₂ delivery and sensing comprising of an inexpensive, paper-based, biocompatible, flexible platform for locally generating and measuring oxygen in a wound region. The platform takes advantage of recent developments in the fabrication of flexible microsystems including the incorporation of paper as a substrate and the use of a scalable manufacturing technology, inkjet printing. Here, we demonstrate the functionality of the oxygenation patch, capable of increasing oxygen concentration in a gel substrate by 13% (5 ppm) in 1 h. The platform is able to sense oxygen in a range of 5-26 ppm. In vivo studies demonstrate the biocompatibility of the patch and its ability to double or triple the oxygen level in the wound bed to clinically relevant levels.

Fundamentals of Enterprise Photodocumentation: Connecting the Clinical and Technical-a Review of Key Concepts

Photodocumentation is an invaluable tool in many specialties, including dermatology, facial plastic and reconstructive surgery, and wound management. As digital cameras and camera-enabled smartphones have become omnipresent in our society, they have brought photodocumentation to all corners of healthcare organizations including the emergency department as well as family medicine and pediatrics. Simultaneously, enterprise imaging programs have evolved enabling access to all medical images for all providers throughout these organizations. Through their unique perspective, enterprise imaging teams have an opportunity to guide development of high quality, ethical programs that are compliant with legal and regulatory requirements. Clinical and technical standards for photodocumentation are not fully evolved and thus establishing an enterprise photodocumentation program will require communication and education. Development of such a program requires an understanding of the clinical, ethical, and technical issues around photodocumentation. This article explores how photodocumentation is utilized, the patient's experience, current quality concerns, tools and technical issues around image acquisition, and the topics of informed consent, privacy, security, and lifecycle and health information management.

Depth-sensitive Raman spectroscopy for skin wound evaluation in rodents

Raman spectroscopy has demonstrated great potential for skin wound assessment. Given that biochemical changes in wound healing is depth dependent as the skin is a layered structure, depth sensitive Raman spectroscopy could enhance the power of Raman spectroscopy in this application. Considering the critical importance of rodent studies in the field of skin wound assessment, it is necessary to develop and validate a system that can perform depth sensitive measurements in rat skin with a proper target depth range. In this manuscript, we report the design, optimization and evaluation of a new snapshot depth-sensitive Raman instrument for rat skin measurements. The optical design and optimization process are presented first. The depth sensitive measurement performance is characterized on both ex vivo porcine skin with a gradient of layer thickness and ex vivo rat skin samples with wounds. The statistical analysis of the measured Raman spectra demonstrates the feasibility of differentiation between the wound edge and healthy skin. Moreover, the accuracy of classification improves monotonically as more data from new depths are used, which implies that each depth offers additional information useful for classification. This instrument demonstrates the ability to perform snapshot depth sensitive Raman measurements from rat skin, which paves the way towards in vivo preclinical studies of rat skin wounds.

Sinus Wounds Management

With aging populations and the increased incidence of cerebrovascular disease, diabetes, and other diseases, more and more patients suffer from pressure injuries. Pressure injuries are often difficult to heal because of the presence of sinus tracts, which make it difficult to clean and change dressings. Sinus wounds are common in patients with pressure injuries, but also occur after abdominal wall incision and in patients who have experienced a physical trauma that created a wound. It is difficult for clinicians to observe, evaluate, and repair sinus wounds because of the small surface defect and large and deep basement of each wound. This article reviews existing assessment methods and treatments for sinus wounds and proposes a new evaluation method and treatment (three-dimensional reconstruction and endoscopic techniques) to further improve treatment and provide better quality of care for patients with this type of wound.

Wound-Healing Effect of Honey Gel and Film

Background:

Honey has been formulated into gel and film dosage forms for burn wound as previously reported.

Aims:

In this study, we evaluated the ability of honey gel and film to promote the healing of burns and incision wounds on the skin of Sprague-Dawley female white rats.

Materials and Methods:

Twenty-four female rats were divided into four groups, which were treatment groups (for honey gel or film), negative control, and positive control (treated with marketed product “B”), respectively. Burn and incision wound were created by the method previously reported with slight modification. Parameters such as the percentage of wound closure and the tensile strength of the incision wound were determined.

Results:

The experimental results showed that honey film has a greater effectiveness to accelerate the healing for burns and incision wound in comparison to the negative control.

Conclusions:

Two-way analysis of variance indicates the type of treatment group, and time has a significant effect on the burn wound (P < 0.05). Honey film shows the significant difference (P < 0.05) with other group on the incision wound.

[Application of transcutaneous oxygen pressure in scar assessment]

Objective

To review the application and research progress of transcutaneous oxygen pressure (TcPO ₂) in scar assessment.

Methods

The original articles about scar and TcPO ₂ were reviewed and analyzed.

Results

Hypoxia environment plays an important role in the progression of scar tissue. TcPO ₂ can accurately reflect the oxygen tension of scar tissue, which is of great significance in the assessment of scar maturity, the guidance of scar treatment, and the study of correlations between hypoxia and the progression of scar.

Conclusion

TcPO ₂ measurement is important in the study of scar evaluation, treatment, and correlation between hypoxia and scar formation.

Hyperspectral imaging as a possible tool for visualization of changes in hemoglobin oxygenation in patients with deficient hemodynamics – proof of concept

There is a lack of imaging tools for the evaluation of spatial alterations in microcirculation including blood oxygen saturation and hemoglobin distribution but recent innovative developments in hyperspectral technology may offer a solution. We examined different hemodynamic disorders in patients suffering from scleroderma, Dupuytren surgery, chronic foot ulcera and skin infections. Superficial and deeper blood oxygen saturation, hemoglobin distribution and water content were determined using hyperspectral imaging (HSI). In the patient with scleroderma, distinct cutaneous low perfused regions correlated with macroscopic skin aspects and seem to be potential therapy control marker. With HSI accurate clinical evaluation of a macroscopic conspicuous wound after Dupuytren surgery was possible and influenced further surveillance decisions. HSI clearly revealed the spatial geometry and also the clinically related perfusion parameters of abscess formation and chronic ulcer wounds. The hemodynamically relevant parameters like blood oxygen saturation (1 mm to approx. 6 mm subcutaneous), total hemoglobin distribution and tissue water content can be easily determined and visualized with HSI in near real time. Hence, this technique seems to be suitable for routine diagnostics of acute and chronic wounds as well as for the examination of systemic hemodynamic disturbances. Special indications may be transplant surveillance and monitoring of therapeutical interventions.

Point-of-care wound visioning technology: Reproducibility and accuracy of a wound measurement app

BACKGROUND

Current wound assessment practices are lacking on several measures. For example, the most common method for measuring wound size is using a ruler, which has been demonstrated to be crude and inaccurate. An increase in periwound temperature is a classic sign of infection but skin temperature is not always measured during wound assessments. To address this, we have developed a smartphone application that enables non-contact wound surface area and temperature measurements. Here we evaluate the inter-rater reliability and accuracy of this novel point-of-care wound assessment tool.

METHODS AND FINDINGS

The wounds of 87 patients were measured using the Swift Wound app and a ruler. The skin surface temperature of 37 patients was also measured using an infrared FLIR™ camera integrated with the Swift Wound app and using the clinically accepted reference thermometer Exergen DermaTemp 1001. Accuracy measurements were determined by assessing differences in surface area measurements of 15 plastic wounds between a digital planimeter of known accuracy and the Swift Wound app. To evaluate the impact of training on the reproducibility of the Swift Wound app measurements, three novice raters with no wound care training, measured the length, width and area of 12 plastic model wounds using the app. High inter-rater reliabilities (ICC = 0.97-1.00) and high accuracies were obtained using the Swift Wound app across raters of different levels of training in wound care. The ruler method also yielded reliable wound measurements (ICC = 0.92-0.97), albeit lower than that of the Swift Wound app. Furthermore, there was no statistical difference between the temperature differences measured using the infrared camera and the clinically tested reference thermometer.

CONCLUSIONS

The Swift Wound app provides highly reliable and accurate wound measurements. The FLIR™ infrared camera integrated into the Swift Wound app provides skin temperature readings equivalent to the clinically tested reference thermometer. Thus, the Swift Wound app has the advantage of being a non-contact, easy-to-use wound measurement tool that allows clinicians to image, measure, and track wound size and temperature from one visit to the next. In addition, this tool may also be used by patients and their caregivers for home monitoring.

Three-dimensional imaging: a novel, valid, and reliable technique for measuring wound surface area

PURPOSE

The aim of this study was to investigate the validity and reliability of a novel three-dimensional imaging technique using Artec MHT^™ 3D Scanner for measuring the wound surface area.

METHODS

The validity was tested by measuring the surface area of 60 stickers (gold standard) on 20 volunteers. Stickers with standardized areas of 2590, 7875, and 15,540 mm² were applied on the thorax, forearm, and thigh, respectively. For the reliability test, 58 burn wounds on 48 patients were assessed twice by two different observers with the Artec MHT^™ 3D Scanner. Scanning, post-processing, and surface area measurements were performed by two clinicians.

RESULTS

The results for the validity analysis showed an intraclass correlation coefficient of 0.99 and coefficient of variation of the thorax, forearm, and thigh were 1.1%, 0.9%, and 0.6%, respectively. The reliability analysis showed an intraclass correlation coefficient of 0.99, a coefficient of variation of 6.3%, and limits of agreement between measurements of two observers were calculated at 0 ± 0.17 × mean surface area.

CONCLUSION

Three-dimensional imaging using the Artec MHT^™ 3D Scanner is a valid and reliable method for measuring the wound surface area.

Application of hyaluronic acid in the healing of non-experimental open wounds: A pilot study on 12 wounds in 10 client-owned dogs

Aim:

Veterinarians have frequently to deal with wounds to the skin, subcutis, and underlying muscle. The aim was to explore the application of hyaluronic acid (HA)-containing dressing on open skin wounds in dogs. The progress of healing was assessed by wound area reduction and two scoring scales applied in human medicine.

Materials and Methods:

Ten client-owned dogs with 12 cutaneous open wounds healed by the second intention were included. All wounds were treated using available in commerce HA-containing wound dressing from admission to complete re-epithelialization. At every clinical examination, wound area and scale scoring assessments were performed.

Results:

After debridement, an increased wound size was obtained while an improvement was determined by both grading systems. The median numbers of return to the clinic for bandage change were 5 times. The median time to complete wound healing was 34.5 days. The mean wound area at day 7, 14, 21, and 28 were, respectively, 90.4%, 47.7%, 22.4%, and 14.8% of the original size (for linear measurement) and 95.5%, 54.4%, 23.10%, and 14.8% of the original size (for software measurement). Regarding wound healing assessment tools, the agreement between two operators was considered high for both scales.

Conclusions:

HA-containing dressing may be a possible wound treatment for cutaneous open wounds in dogs. The assessment of wound quality using scale scoring system could be useful especially in the 1^st week and to direct clinical decision-making process.

Reliability of vascular access site bruise measurement

BACKGROUND AND PURPOSE

Vascular access site (VAS) bruising is common following invasive cardiac procedures. The extent of VAS bruising is underreported because of the lack of reliable measurement methods. This study examined the reliability of linear measurement and planimetry to measure VAS bruise size.

METHODS

There were 40 participants with VAS bruising after invasive cardiac procedures who completed VAS bruise measurement. Participants, a principal investigator, and a research assistant completed measurements independently. Inter-rater reliability was determined using intraclass correlation coefficient (ICC), 2-way random effects model.

RESULTS

The ICC for linear measurement and planimetry was high (.929 and .914 respectively). Both methods were reliable measures of VAS bruise size.

CONCLUSIONS

Linear measurement or planimetry can be used with confidence to measure VAS bruising in clinical and research contexts.

Hyperspectral imaging-based wound analysis using mixture-tuned matched filtering classification method

Hyperspectral imaging is a technology that is beginning to occupy an important place in medical research with good prospects in future clinical applications. We evaluated the role of hyperspectral imaging in association with a mixture-tuned matched filtering method in the characterization of open wounds. The methodology and the processing steps of the hyperspectral image that have been performed in order to obtain the most useful information about the wound are described in detail. Correlations between the hyperspectral image and clinical examination are described, leading to a pattern that permits relative evaluation of the square area of the wound and its different components in comparison with the surrounding normal skin. Our results showed that the described method can identify different types of tissues that are present in the wounded area and can objectively measure their respective abundance, which proves its value in wound characterization. In conclusion, the method that was described in this preliminary case presentation shows promising results, but needs further evaluation in order to become a reliable and useful tool.

Evaluation of the clinimetrics of transcutaneous oxygen measurement and its application in wound care

Transcutaneous oxygen (TcPO2) measurement is a non-invasive diagnostic tool increasingly being used in clinical practice. Existing evidence suggests that reduction of TcPO2 is correlated with an increase in skin ischaemia, and its measurement has been shown to have predictive value for wound healing in diabetic patients, success rate of hyperbaric oxygen therapy, amputation rate in patients suffering from peripheral vascular disease or with ischaemic ulcers. This article evaluates the clinimetrics of TcPO2 measurement in adults with discussion of its potential application in clinical practice.

A comparison of 3 wound measurement techniques: effects of pressure ulcer size and shape

PURPOSE

The aim of this study was to examine the levels of agreement among 3 techniques used in wound measurement comparing more spherical versus irregularly shaped wounds.

DESIGN

The design of this study is evaluative research.

SUBJECTS AND SETTING

Sixty-five consecutive patients with 80 pressure ulcers of various sizes referred from a university hospital in Izmir, Turkey, were evaluated.

METHODS

The 80 pressure ulcers identified on the 65 participants were divided into 2 groups based on pressure ulcer shape and wound surface area. Twenty-four of the 80 ulcers (30%) were characterized as irregularly shaped and greater than 10 cm. Fifty-six were regularly shaped (approximating a circle) and less than 10 cm. Pressure ulcer areas were measured using 3 techniques: measurement with a ruler (wound area was calculated by measuring and multiplying the greatest length by the greatest width perpendicular to the greatest length), wound tracing using graduated acetate paper, and digital planimetry. The level of agreement among the techniques was explored using the intraclass correlation coefficient (ICC).

RESULTS

Strong agreement was observed among the techniques when assessing small, more regularly shaped wounds (ICC = 0.95). Modest agreement was achieved when measuring larger, irregularly shaped wounds (ICC = 0.70).

CONCLUSION

Each of these techniques is adequate for measuring surface areas of smaller wounds with an approximately circular shape. Measurement of pressure ulcer area via the ruler method tended to overestimate surface area in larger and more irregularly shaped wounds when compared to acetate and digital planimetry. We recommend digital planimetry or acetate tracing for measurement of larger and more irregularly shaped pressure ulcers in the clinical setting.

Assessment of the Size of the Surgical Site in Minimally Invasive Hip Surgery

Objective: Minimally invasive approaches to the hip are beneficial to the patient, but reduce the space available for manipulation by the surgeon. Determining the available working space is important for the development of surgical instruments, to track movements during surgery, as well as to classify the invasiveness of the procedure. Approach: We evaluate three measurement methods to assess the volume of eight surgical sites in a cadaver study. The cavities were filled with an alginate cast to determine its dimensions. Second, the depth, height, and width of the surgical site were measured with a ruler and the volume was calculated. Last, the surface registration method was used to reconstruct the site. Results: We found that the mold filling method provides accurate results in determining the volume of a surgical site. The manual method using a ruler showed excellent reliability, but the calculations tended to overestimate the volume of the surgical site. In contrast, surface reconstruction tended to underestimate the volume of a surgical site, but the results closer resembled the ones derived from the mold filling method. Innovation: We presented a new method to assess the size of the surgical site intraoperatively in minimally invasive hip surgery. Conclusion: The manual method is reliable, but not as accurate as the surface reconstruction, while the mold filling method cannot be used in an intraoperative setup. Although surface reconstruction showed deficits regarding reliability, due to the lack of direct contact to the patient, it remains an appealing technique to measure the surgical site.

Raman spectroscopy enables noninvasive biochemical characterization and identification of the stage of healing of a wound

Accurate and rapid assessment of the healing status of a wound in a simple and noninvasive manner would enable clinicians to diagnose wounds in real time and promptly adjust treatments to hasten the resolution of nonhealing wounds. Histologic and biochemical characterization of biopsied wound tissue, which is currently the only reliable method for wound assessment, is invasive, complex to interpret, and slow. Here we demonstrate the use of Raman microspectroscopy coupled with multivariate spectral analysis as a simple, noninvasive method to biochemically characterize healing wounds in mice and to accurately identify different phases of healing of wounds at different time-points. Raman spectra were collected from "splinted" full thickness dermal wounds in mice at 4 time-points (0, 1, 5, and 7 days) corresponding to different phases of wound healing, as verified by histopathology. Spectra were deconvolved using multivariate factor analysis (MFA) into 3 "factor score spectra" (that act as spectral signatures for different stages of healing) that were successfully correlated with spectra of prominent pure wound bed constituents (i.e., collagen, lipids, fibrin, fibronectin, etc.) using non-negative least squares (NNLS) fitting. We show that the factor loadings (weights) of spectra that belonged to wounds at different time-points provide a quantitative measure of wound healing progress in terms of key parameters such as inflammation and granulation. Wounds at similar stages of healing were characterized by clusters of loading values and slowly healing wounds among them were successfully identified as "outliers". Overall, our results demonstrate that Raman spectroscopy can be used as a noninvasive technique to provide insight into the status of normally healing and slow-to-heal wounds and that it may find use as a complementary tool for real-time, in situ biochemical characterization in wound healing studies and clinical diagnosis.

Using vacuum-assisted suspension to manage residual limb wounds in persons with transtibial amputation: a case series

BACKGROUND

Persons with amputation and residual limb wounds would benefit from the ability to continue wearing a prosthesis while healing. Sockets with vacuum-assisted suspension may reduce intra-socket motion and be less disruptive to wound healing. The purpose of this case series was to measure residual limb wound size over time in persons with transtibial amputation while using prostheses with vacuum-assisted suspension.

CASE DESCRIPTION AND METHODS

Six subjects with residual limb wounds were fit with vacuum-assisted suspension sockets. Wound surface area was calculated using ImageJ software at the time of fit and each subsequent visit until closure. FINDINGS AND OUTCOME: Average wound surface area at initial measurement was 2.17 ± 0.65 cm(2). All subjects were instructed to continue their normal activity level while wounds healed, with a mean of 177.6 ± 113 days to wound closure.

CONCLUSION

Results suggest that well-fitting sockets with vacuum-assisted suspension in compliant individuals did not preclude wound healing. Further research is required to substantiate these case-based observations.

CLINICAL RELEVANCE

Residual limb wounds are typically treated by suspension of prosthetic use until healing occurs, increasing the risk of long-term prosthesis nonuse. Our results suggest that vacuum-assisted suspension sockets may be used while healing occurs.

Assessment methods for the evaluation of vitiligo

There is no standardized method for assessing vitiligo. In this article, we review the literature from 1981 to 2011 on different vitiligo assessment methods. We aim to classify the techniques available for vitiligo assessment as subjective, semi-objective or objective; microscopic or macroscopic; and as based on morphometry or colorimetry. Macroscopic morphological measurements include visual assessment, photography in natural or ultraviolet light, photography with computerized image analysis and tristimulus colorimetry or spectrophotometry. Non-invasive micromorphological methods include confocal laser microscopy (CLM). Subjective methods include clinical evaluation by a dermatologist and a vitiligo disease activity score. Semi-objective methods include the Vitiligo Area Scoring Index (VASI) and point-counting methods. Objective methods include software-based image analysis, tristimulus colorimetry, spectrophotometry and CLM. Morphometry is the measurement of the vitiliginous surface area, whereas colorimetry quantitatively analyses skin colour changes caused by erythema or pigment. Most methods involve morphometry, except for the chromameter method, which assesses colorimetry. Some image analysis software programs can assess both morphometry and colorimetry. The details of these programs (Corel Draw, Image Pro Plus, AutoCad and Photoshop) are discussed in the review. Reflectance confocal microscopy provides real-time images and has great potential for the non-invasive assessment of pigmentary lesions. In conclusion, there is no single best method for assessing vitiligo. This review revealed that VASI, the rule of nine and Wood's lamp are likely to be the best techniques available for assessing the degree of pigmentary lesions and measuring the extent and progression of vitiligo in the clinic and in clinical trials.

Wound healing assessment: does the ideal methodology for a research setting exist?

INTRODUCTION

Studies on dressings frequently measure wound healing to demonstrate performance. Knowledge of existing methodologies available for wound healing assessment, including their advantages and limitations, is paramount when evaluating the literature on dressings.

METHODOLOGY

Medline and Cochrane databases were searched for wound healing assessment methodologies used in research or in clinical practice.

RESULTS

Twenty-nine methodologies were identified and classified into 8 categories: scales (n = 4), one-dimensional measurements (n = 2), area measurements (n = 4), volume measurements (n = 6), 3-dimensional wound reproduction systems (n = 5), methodologies based on wound physical characteristics (n = 3), rates and surrogates end point calculated from variation in wound dimensions (n = 4), and time to wound healing (n = 1). The main problems encountered during wound healing assessment include the following: boundary definition, assessor's contact with the wound, irregular wound shape, and difficulty in evaluating early healing.

CONCLUSION

At this time, an ideal methodology does not exist. Research in this area is lacking and should be the focus in wound healing evaluation.

Bioelectrical impedance assessment of wound healing

Objective assessment of wound healing is fundamental to evaluate therapeutic and nutritional interventions and to identify complications. Despite availability of many techniques to monitor wounds, there is a need for a safe, practical, accurate, and effective method. A new method is localized bioelectrical impedance analysis (BIA) that noninvasively provides information describing cellular changes that occur during healing and signal complications to wound healing. This article describes the theory and application of localized BIA and provides examples of its use among patients with lower leg wounds. This promising method may afford clinicians a novel technique for routine monitoring of interventions and surveillance of wounds.

Area of the diabetic ulcers estimated applying a foot scanner-based home telecare system and three reference methods

BACKGROUND

Diabetic foot ulcer area is a basic parameter used for monitoring the wound healing and effectiveness of the treatment applied. TeleDiaFoS (developed earlier in collaboration with the Department and Clinic of Gastroenterology and Metabolic Diseases, Medical University of Warsaw, Warsaw, Poland) is one of just a few systems available that make possible monitoring of the wound size remotely based on the foot scans transmitted to the physician from a patient's home. The aim of this study was to compare the diabetic foot ulcer areas measured using TeleDiaFoS with the results obtained using three reference methods.

METHODS

The reference measurements were conducted using the elliptical method with a ruler, the wound tracing method and planimetrics with the Visitrak (Smith & Nephew, London, UK) system, and the pattern-coded structured light method with the Silhouette (ARANZ Medical, Christchurch, New Zealand) system. Regression and Bland-Altman analyses were performed. The study group consisted of 23 diabetes patients with plantar foot ulcers.

RESULTS

Thirty-three wounds were successfully examined. The measurement method influenced the measured area significantly (P=0.00005). The correlation coefficients between TeleDiaFoS and the ruler, Visitrak, and Silhouette methods were 0.949, 0.985, and 0.987, and the limits of agreement equaled -1.3±5.5 cm(2), -0.4±2.2 cm(2), and -0.6±2.1 cm(2), respectively. The strong linear relationships obtained can be used to convert the wound area measured with TeleDiaFoS to the corresponding value of each of the reference methods.

CONCLUSIONS

The results indicate that the wound area of plantar ulcers in diabetes might be monitored effectively using the TeleDiaFoS system based on the foot scans that the patient can produce at home with no assistance of other persons.

Non-interventional study to investigate the efficacy and safety of Tegaderm™ Matrix in the treatment of patients with therapy-refractory chronic wounds

BACKGROUND

Despite a variety of therapeutic approaches, many patients with chronic wounds remain refractory to treatment. Products such as Tegaderm™ Matrix were developed especially for such patients to alter the wound environment and reactivate the stagnant wound healing process.

PATIENTS AND METHODS

In this prospective post-authorization observational product study, a total of 314 patients with therapy-refractory chronic wounds of various origins were evaluated. Beside to the wound area reduction and healing rate, the occurrence of adverse events was documented.

RESULTS

On average the wounds were 10 months old. The average wound size was 17.3 cm(2) (median 6.3 cm(2)) at the initial visit. In the course of treatment the wound size decreased to 13.0 cm(2) (median 3.5 cm(2)) and was finally reduced to 9.3 cm(2) (median 0.9 cm(2)) at end of the study. Taking the criteria of the European Wound Management Association for improving the quality of clinical studies into consideration, a wound size reduction of at least 50% is the parameter for successful treatment of chronic wounds. This study demonstrated a wound size reduction of at least 50% for 72.9% of the patients with therapy-refractory chronic wounds when treated with Tegaderm™ Matrix. The safety profile was evaluated; only 4.7% of the patients experienced a treatment-related adverse event such as a burning sensation.

CONCLUSIONS

The results of the study demonstrate that Tegaderm™ Matrix along with treatment of underlying causes is a well tolerated wound dressing promoting wound size reduction up to healing for the majority of patients with previously therapy-refractory chronic wounds.

Wound healing effect of Haruan (Channa striatus) spray

Haruan (Channa striatus) is a type of fresh water fish in Malaysia that is known to promote wound healing. Haruan water extract has been formulated in an aerosol system which can produce a film for wound dressing. As topical preparation, Haruan spray needs to be evaluated in terms of the possibility to cause irritation reaction or toxic response. Three experiments were carried out to evaluate the safety of Haruan spray which are Primary Skin Irritation test, Intracutaneous test and Systemic Injection test. The result shows that Haruan spray gave no significant responses to all the above tests. The investigation of the effect of Haruan spray as wound dressing in the healing process was performed in Sprague-Dawley rats where 6-cm long full-thickness incision wound and burn wound were made on the back of the animals. Haruan spray was tested and compared with blank formula as control. Tensile strength test of treated wound was carried out at the 3rd, 6th, 9th and 12th day after wounding and treatment. The burn wounds contraction was measured daily for 21 days. Results showed that haruan water extract spray formula is not only effective but also safe for application to both incision and burn wounds.

On the potential of ultrasound elastography for pressure ulcer early detection

PURPOSE

Pressure ulcers are areas of soft tissue breakdown induced by a sustained mechanical stress that damages the skin and underlying tissues. They represent a considerable burden to the society in terms of health care and cost. Yet, techniques for prevention and detection of pressure ulcers still remain very limited. In this article, the authors investigated the potential of ultrasound elastography for pressure ulcer early detection. Elastography is an imaging technique providing local information on biological tissue mechanical properties. It is relevant for pressure ulcer detection as this pathology is associated with a gradual stiffening of damaged tissues, beginning in the deeper tissues and progressing toward the skin surface.

METHODS

A 2D ultrasound elastography method was proposed and its ability in terms of pressure ulcer detection was validated through numerical simulations and physical acquisitions on pressure ulcer mimicking phantoms. In vivo experiments on a rat model are also reported. A maintained pressure was applied on the animal thigh, with a view to generate a pressure ulcer, and ultrasound data were acquired and processed before and after application of this pressure.

RESULTS

Numerical simulations demonstrated that a pressure ulcer can theoretically be detected at a very early stage with ultrasound elastography. Even when the ulcer region was characterized by a low stiffening (ratio of 1.8 relative to normal tissues), the corresponding elastogram clearly underlined the pathological area. This observation was confirmed by the results obtained on a physical phantom mimicking a pressure ulcer at an early stage. Computed elastograms showed strain differences between areas mimicking healthy and pathological tissues. Results corresponding to in vivo experiments revealed a difference in the way tissues behaved before and after the pressure was applied on the animal thigh, which strongly suggests the presence of a pathological area.

CONCLUSIONS

Experiments demonstrated that ultrasound elastography is a promising technique for pressure ulcer detection, especially at an early stage of the pathology, when the disease is still visually undetectable. In the absence of any gold standard method, this is also a first step toward the development of a quantitative technique.

Leading wound care technology: The ARANZ medical silhouette

Despite major advances in medical technology and wound care, wound assessment and documentation still rely mainly on rudimentary measures. Many practitioners continue to estimate wound size using maximal length, width, and depth measurements with rulers and probes. Others use acetate tracings or equivalent measures to outline the wound onto a grid to estimate surface area and document wound border changes. Even fewer practitioners seem to routinely photograph wounds with an included scale for more visual records. This article presents a recently developed device that is changing clinical documentation, assessment, auditing, and interservice communication-the ARANZ Medical Silhouette (ARANZ Medical Limited, Christchurch, New Zealand).

Assessment of chronic wounds by three-dimensional optical imaging based on integrating geometrical, chromatic, and thermal data

Chronic wounds represent a particular debilitating health care problem, mainly affecting elderly people. A full and correct diagnosis of tissue damage should be carried out considering both dimensional, chromatic, and thermal parameters. A great variety of methods have been proposed with the aim of producing objective assessment of skin lesions, but none of the existing technologies seem to be robust enough to work for all ulcer typologies. This paper describes an innovative and non-invasive system that allows the automatic measurement of non-healing chronic wounds. The methodology involves the integration of a three-dimensional (3D) optical scanner, based on a structured light approach, with a thermal imager. The system enables the acquisition of geometrical data, which are directly related to chromatic and temperature patterns through a mapping procedure. Damaged skin areas are detected by combining visible and thermal imaging. This approach allows for the automatic measurement of extension and depth of ulcers, even in the absence of significant and well-defined chromatic patterns. The proposed technology has been tested in the measurement of ulcers on human legs. Clinical tests have demonstrated the effectiveness of this methodology in supporting medical experts for the assessment of chronic wounds.

Comparative analysis of two methods for wound bed area measurement

Wound bed area measurements are considered to be an essential part of the wound assessment process. Wound care professionals should be aware of the reliability and validity of the techniques they use. The purpose of this study was to assess whether wound care professionals are able to make as accurate and reproducible a measurement of the wound bed area using two methods for area measurement. Five wound care professionals independently assessed 2285 digital wound images for the wound bed area. Each image was measured in random order, three times, and in four angles by providing the rotated versions of each image (0°, 90°, 180° and 270°). Two techniques were compared: free hand drawing and closed polygon (CP) graph algorithm. Comparison of the two techniques showed differences that are, in our opinion, not acceptable in clinical practice when these techniques are used interchangeably and/or the measurements are carried out by different observers. Variations observed between wounds and observers seem related to the difference in perception of the wound bed margin. Our results indicate that repetition of CP graph area measurement results in the lowest difference in repetitive measurements. Study limitations are related to an incomplete consensus on definitions of wound, wound bed, wound edge and wound border. The development of an ontology related to wound images could aid to reduce these ambiguities.

Near infrared wound monitor helps clinical assessment of diabetic foot ulcers

BACKGROUND

The efficacy of using diffuse near infrared spectroscopy (NIRS) in predicting wound healing in diabetic foot ulcers was demonstrated by conducting a pilot human study.

METHOD

Sixteen chronic diabetic wounds were followed and assessed for subsurface oxyhemoglobin concentration using the NIRS device. Weekly measurements were conducted until there was wound closure, limb amputation, or 20 completed visits without healing. Wound size and degree of wound contraction were measured by image analysis of digital photographs, and results were compared to NIRS results.

RESULTS

In the 16 patients followed, seven wounds healed, six limbs were amputated, and three wounds remained opened after 20 visits. Initial values of subsurface hemoglobin concentration, in all wounds, were higher than in nonwound control sites. Healed wounds exhibited a consistent reduction of hemoglobin concentration several weeks prior to closure, and the absolute hemoglobin concentration approached the value at the control site. In wounds that did not heal or ended in amputations, the hemoglobin concentration remained elevated throughout the study. A negative slope for the rate of change of hemoglobin concentration was indicative of healing across all wounds.

CONCLUSIONS

Evaluation of diabetic foot ulcers using NIRS may provide an effective and more complete measurement of wound healing compared to current clinical approaches.

Noninvasive assessment of diabetic foot ulcers with diffuse photon density wave methodology: pilot human study

A pilot human study is conducted to evaluate the potential of using diffuse photon density wave (DPDW) methodology at near-infrared (NIR) wavelengths (685 to 830 nm) to monitor changes in tissue hemoglobin concentration in diabetic foot ulcers. Hemoglobin concentration is measured by DPDW in 12 human wounds for a period ranging from 10 to 61 weeks. In all wounds that healed completely, gradual decreases in optical absorption coefficient, oxygenated hemoglobin concentration, and total hemoglobin concentration are observed between the first and last measurements. In nonhealing wounds, the rates of change of these properties are nearly zero or slightly positive, and a statistically significant difference (p<0.05) is observed in the rates of change between healing and nonhealing wounds. Differences in the variability of DPDW measurements over time are observed between healing and nonhealing wounds, and this variance may also be a useful indicator of nonhealing wounds. Our results demonstrate that DPDW methodology with a frequency domain NIR device can differentiate healing from nonhealing diabetic foot ulcers, and indicate that it may have clinical utility in the evaluation of wound healing potential.

Three-dimensional assessment of skin wounds using a standard digital camera

In this paper, after an overview of the literature concerning the imaging technologies applied to skin wounds assessment, we present an original approach to build 3-D models of skin wounds from color images. The method can deal with uncalibrated images acquired with a handheld digital camera with free zooming. Compared with the cumbersome imaging systems already proposed, this novel solution uses a low-cost and user-friendly image acquisition device suitable for widespread application in health care centers. However, this method entails the development of a robust image processing chain. An original iterative matching scheme is used to generate a dense estimation of the surface geometry from two widely separated views. The best configuration for taking photographs lies between 15 ( degrees ) and 30 ( degrees ) for the vergency angle. The metric reconstruction of the skin wound is fully automated through self-calibration. From the 3-D model of the skin wound, accurate volumetric measurements are achieved. The accuracy of the inferred 3-D surface is validated by registration to a ground truth and repetitive tests on volume. The global precision around 3% is in accordance with the clinical requirement of 5% for assessing the healing process.

Occlusive dressings and the healing of standardized abrasions

CONTEXT

Acute skin trauma during sport participation, resulting in partial-thickness abrasions, is common. The limited investigations focusing on the acute wound environment and dressing techniques and the subsequent lack of evidence-based standards complicate clinical wound care decisions.

OBJECTIVE

To examine the effects of occlusive dressings on healing of standardized, partial-thickness abrasions.

DESIGN

Controlled, counterbalanced, repeated-measures design.

SETTING

University laboratory.

PATIENTS OR OTHER PARTICIPANTS

Sixteen healthy women (n = 10) and men (n = 6).

INTERVENTION(S)

Four standardized, partial-thickness abrasions were inflicted. Film, hydrogel, and hydrocolloid occlusive dressings and no dressing (control) were applied. Participants returned on postwound days 1, 3, 5, 7, 10, and 14 for digital imaging. Wound healing time was measured by change in wound contraction (cm(2)) and change in wound color (chromatic red) and luminance in red, green, and blue color values.

MAIN OUTCOME MEASURE(S)

Wound contraction, color (chromatic red), and luminance.

RESULTS

A day-by-dressing interaction was found for wound contraction, color, and luminance. Post hoc testing indicated that the film and hydrocolloid dressings produced greater wound contraction than the hydrogel and no dressing on days 7 and 10. Film, hydrogel, and hydrocolloid dressings also resulted in greater wound contraction than the control on day 14. Hydrocolloid dressings produced smaller measures of color and greater measures of luminance than no dressing on day 7. Film, hydrogel, and hydrocolloid dressings also resulted in smaller measures of color and greater measures of luminance compared with no dressing on days 10 and 14.

CONCLUSIONS

When compared with the control (no dressing), the film, hydrogel, and hydrocolloid occlusive dressings were associated with a faster healing rate of partial-thickness abrasions across time measured by wound contraction, color, and luminance. Overall, these data indicate that occlusive dressings were more effective in healing than no dressing was.