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Zhang P, Chen X, Yin Z, Zhou X, Jiang Q, Zhu W, Xiang D, Tang Y, Shi F. Interactive Skin Wound Segmentation Based on Feature Augment Networks. IEEE J Biomed Health Inform 2023; 27:3467-3477. [PMID: 37099475 DOI: 10.1109/jbhi.2023.3270711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Skin wound segmentation in photographs allows non-invasive analysis of wounds that supports dermatological diagnosis and treatment. In this paper, we propose a novel feature augment network (FANet) to achieve automatic segmentation of skin wounds, and design an interactive feature augment network (IFANet) to provide interactive adjustment on the automatic segmentation results. The FANet contains the edge feature augment (EFA) module and the spatial relationship feature augment (SFA) module, which can make full use of the notable edge information and the spatial relationship information be-tween the wound and the skin. The IFANet, with FANet as the backbone, takes the user interactions and the initial result as inputs, and outputs the refined segmentation result. The pro-posed networks were tested on a dataset composed of miscellaneous skin wound images, and a public foot ulcer segmentation challenge dataset. The results indicate that the FANet gives good segmentation results while the IFANet can effectively improve them based on simple marking. Comprehensive comparative experiments show that our proposed networks outperform some other existing automatic or interactive segmentation methods, respectively.
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Tan P, Basonbul RA, Lim J, Moiemen N. Performance of portable objective wound assessment tools: a systematic review. J Wound Care 2023; 32:74-82. [PMID: 36735520 DOI: 10.12968/jowc.2023.32.2.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Accurate wound assessment is crucial for determining the progression of healing and guides treatment strategies. Portable wound assessment devices can be useful in providing an accurate evaluation in the community where most cases are treated. The objective of this review was to compare the performance of various portable wound assessment techniques used for wound healing assessment described in the literature. METHOD In April 2020, electronic databases were searched, using appropriate search terms, for all available publications on the use of portable wound assessment devices on human and artificial wounds. The primary outcome was the reliability and reproducibility of measurement while the secondary outcome was the feasibility of the instrument. All studies underwent quality assessment of diagnostic accuracy studies (QUADAS) to examine the quality of data. RESULTS A total of 129 articles were identified and 24 were included in the final review; 17 articles discussed two-dimensional (2D) devices; three articles discussed three-dimensional (3D) devices; and four articles discussed application-based devices. Most studies (n=8) reported on a 2D device that had an ICC of 0.92-0.99 for area measurement and a coefficient of variance of 3.1% with an error of 2.3% in human wounds and 1.55-3.7% in artificial wounds. The inter/intra observer reliability was 0.998 and 0.985, respectively with a scan time of two minutes per wound. The median QUADAS score was 12. CONCLUSION Based on the presented evidence, 2D-based portable wound assessment devices were the most studied and demonstrated good performance. Further studies are required for 3D and application-based measurement instruments.
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Affiliation(s)
- Poh Tan
- Burns and Plastics Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Medical Centre, Birmingham, UK.,The Scar Free Foundation Centre for Burns Research, University Hospital Birmingham Foundation Trust, Birmingham, UK
| | - Razan A Basonbul
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine in Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Joanne Lim
- Department of Obstetrics and Gynaecology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK
| | - Naiem Moiemen
- Burns and Plastics Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Medical Centre, Birmingham, UK.,The Scar Free Foundation Centre for Burns Research, University Hospital Birmingham Foundation Trust, Birmingham, UK
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Ibraheem WI, Bhati AK, Hakami NA, Alshehri AD, Wadani MHM, Ageeli FME. Comparison of Digital Planimetry and Ruler Methods for the Measurement of Extraction Socket Wounds. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010135. [PMID: 36676759 PMCID: PMC9863287 DOI: 10.3390/medicina59010135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
- Weal I. Ibraheem
- Department of Preventive Dental Sciences, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia
- Correspondence: (W.I.I.); (A.K.B.)
| | - Ashok Kumar Bhati
- Department of Preventive Dental Sciences, College of Dentistry, Jazan University, Jazan 45142, Saudi Arabia
- Correspondence: (W.I.I.); (A.K.B.)
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Effectiveness of Semi-Supervised Active Learning in Automated Wound Image Segmentation. Int J Mol Sci 2022; 24:ijms24010706. [PMID: 36614147 PMCID: PMC9821322 DOI: 10.3390/ijms24010706] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/18/2022] [Accepted: 12/26/2022] [Indexed: 01/04/2023] Open
Abstract
Appropriate wound management shortens the healing times and reduces the management costs, benefiting the patient in physical terms and potentially reducing the healthcare system's economic burden. Among the instrumental measurement methods, the image analysis of a wound area is becoming one of the cornerstones of chronic ulcer management. Our study aim is to develop a solid AI method based on a convolutional neural network to segment the wounds efficiently to make the work of the physician more efficient, and subsequently, to lay the foundations for the further development of more in-depth analyses of ulcer characteristics. In this work, we introduce a fully automated model for identifying and segmenting wound areas which can completely automatize the clinical wound severity assessment starting from images acquired from smartphones. This method is based on an active semi-supervised learning training of a convolutional neural network model. In our work, we tested the robustness of our method against a wide range of natural images acquired in different light conditions and image expositions. We collected the images using an ad hoc developed app and saved them in a database which we then used for AI training. We then tested different CNN architectures to develop a balanced model, which we finally validated with a public dataset. We used a dataset of images acquired during clinical practice and built an annotated wound image dataset consisting of 1564 ulcer images from 474 patients. Only a small part of this large amount of data was manually annotated by experts (ground truth). A multi-step, active, semi-supervised training procedure was applied to improve the segmentation performances of the model. The developed training strategy mimics a continuous learning approach and provides a viable alternative for further medical applications. We tested the efficiency of our model against other public datasets, proving its robustness. The efficiency of the transfer learning showed that after less than 50 epochs, the model achieved a stable DSC that was greater than 0.95. The proposed active semi-supervised learning strategy could allow us to obtain an efficient segmentation method, thereby facilitating the work of the clinician by reducing their working times to achieve the measurements. Finally, the robustness of our pipeline confirms its possible usage in clinical practice as a reliable decision support system for clinicians.
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Tsai WH, Chou CH, Huang TY, Wang HL, Chien PJ, Chang WW, Lee HT. Heat-Killed Lactobacilli Preparations Promote Healing in the Experimental Cutaneous Wounds. Cells 2021; 10:3264. [PMID: 34831486 PMCID: PMC8625647 DOI: 10.3390/cells10113264] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/16/2021] [Accepted: 11/19/2021] [Indexed: 12/19/2022] Open
Abstract
Probiotics are defined as microorganisms with beneficial health effects when consumed by humans, being applied mainly to improve allergic or intestinal diseases. Due to the increasing resistance of pathogens to antibiotics, the abuse of antibiotics becomes inefficient in the skin and in systemic infections, and probiotics may also provide the protective effect for repairing the healing of infected cutaneous wounds. Here we selected two Lactobacillus strains, L. plantarum GMNL-6 and L. paracasei GMNL-653, in heat-killed format to examine the beneficial effect in skin wound repair through the selection by promoting collagen synthesis in Hs68 fibroblast cells. The coverage of gels containing heat-killed GMNL-6 or GMNL-653 on the mouse tail with experimental wounds displayed healing promoting effects with promoting of metalloproteinase-1 expression at the early phase and reduced excessive fibrosis accumulation and deposition in the later tail-skin recovery stage. More importantly, lipoteichoic acid, the major component of Lactobacillus cell wall, from GMNL-6/GMNL-653 could achieve the anti-fibrogenic benefit similar to the heat-killed bacteria cells in the TGF-β stimulated Hs68 fibroblast cell model. Our study offers a new therapeutic potential of the heat-killed format of Lactobacillus as an alternative approach to treating skin healing disorders.
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Affiliation(s)
- Wan-Hua Tsai
- Research and Development Department, GenMont Biotech Incorporation, Tainan 741014, Taiwan; (W.-H.T.); (C.-H.C.); (T.-Y.H.)
| | - Chia-Hsuan Chou
- Research and Development Department, GenMont Biotech Incorporation, Tainan 741014, Taiwan; (W.-H.T.); (C.-H.C.); (T.-Y.H.)
| | - Tsuei-Yin Huang
- Research and Development Department, GenMont Biotech Incorporation, Tainan 741014, Taiwan; (W.-H.T.); (C.-H.C.); (T.-Y.H.)
| | - Hui-Ling Wang
- School of Biomedical Sciences, Chung Shan Medical University, Taichung 402306, Taiwan; (H.-L.W.); (P.-J.C.)
| | - Peng-Ju Chien
- School of Biomedical Sciences, Chung Shan Medical University, Taichung 402306, Taiwan; (H.-L.W.); (P.-J.C.)
| | - Wen-Wei Chang
- School of Biomedical Sciences, Chung Shan Medical University, Taichung 402306, Taiwan; (H.-L.W.); (P.-J.C.)
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 402306, Taiwan
| | - Hsueh-Te Lee
- Institute of Anatomy & Cell Biology, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Taiwan International Graduate Program in Molecular Medicine, National Yang Ming Chiao Tung University and Academia Sinica, Taipei 115024, Taiwan
- Brain Research Center, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
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Moeini S, Gottlieb H, Jørgensen TS, Larsen MRB, Brorson S. Treatment of Diabetic Foot Ulcers With Inforatio Technique to Promote Wound Healing: A Feasibility Trial. INT J LOW EXTR WOUND 2021; 22:241-250. [PMID: 33909504 DOI: 10.1177/15347346211002364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Chronic foot ulcers have extensive consequences for diabetic patients' quality of life and increase risks of amputation and death. The aim of this trial was to assess the feasibility of conducting a larger clinical trial to evaluate the clinical effect of inforatio technique on healing of diabetic foot ulcers (DFUs). Inforatio technique is a novel minimal invasive procedure where small cuts are made on wound beds with punch biopsy tools. This study was a feasibility trial conducted at an outpatient wound care clinic at Zealand University Hospital. Twelve patients with DFUs were included. During a 90-day follow-up, participants visited the clinic 5 times and received inforatio technique twice. Feasibility was assessed with regard to recruitment, acceptability, burden, benefits, protocol adherence, and adverse events. The recruitment rate was 1 patient per eighth day (95% confidence interval [CI] = [4th-13th]), and the retention rate was 100% (95% CI = [74-100]). During follow-up, healing was observed for 4 ulcers (33%, 95% CI = [10-65]) with a mean time for healing of 59 days (range, 22-89) (95% CI = [5-113]). Five ulcers had a reduction of wound area and 3 ulcers had an increase in area from baseline to 90-day follow-up. No temporal relationship was found between inforatio application and wound area increase. There were no patient-reported harmful effects and no adverse events with probable relation to inforatio technique. Patient acceptability and participant adherence were promising. Thus, a larger clinical trial for evaluating the clinical effect of inforatio technique is considered feasible to conduct.
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Affiliation(s)
- Sahar Moeini
- 524788Zealand University Hospital, Koege, Denmark
| | | | | | | | - Stig Brorson
- 524788Zealand University Hospital, Koege, Denmark
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Biagioni RB, Carvalho BV, Manzioni R, Matielo MF, Brochado Neto FC, Sacilotto R. Smartphone application for wound area measurement in clinical practice. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:258-261. [PMID: 33997567 PMCID: PMC8095078 DOI: 10.1016/j.jvscit.2021.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/13/2021] [Indexed: 11/03/2022]
Abstract
A total of 85 consecutive patients had their wound area measured. The procedure was executed in two parts. The first was to take photographs of the wound using a smartphone and measure the area using the imitoMeasure application (imito; imito AG, Zurich, Switzerland) by two raters. The second was to take photographs of the same wound using a 10-megapixel digital camera and posterior measurement of the area using ImageJ software (National Institutes of Health, Bethesda, Md) by one operator. The mean area of the wounds was 12.20 ± 10.45 cm2 for imito and 12.67 ± 10.86 cm2 for ImageJ measurement. The interclass correlation coefficient (ICC) between ImageJ and imito was 0.978 for a single measure and 0.989 for the average measure. Considering the two measurements, the ICC demonstrated excellent interobserver correlation using imito (0.987). Larger wounds had a greater difference between the methods (4.28% greater with the ImageJ measurement when considering areas >9 cm2). No difference was found between iOS (ICC, 0.995) and android (ICC, 0.970) smartphone operating systems. The smartphone application is a useful method for area measurement with excellent accuracy compared with digital photography and the ImageJ processing tool.
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Affiliation(s)
- Rodrigo Bruno Biagioni
- Division of Vascular Surgery, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
| | | | - Renato Manzioni
- Division of Vascular Surgery, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
| | | | | | - Roberto Sacilotto
- Division of Vascular Surgery, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
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Vu H, Nair A, Tran L, Pal S, Senkowsky J, Hu W, Tang L. A Device to Predict Short-Term Healing Outcome of Chronic Wounds. Adv Wound Care (New Rochelle) 2020; 9:312-324. [PMID: 32286205 PMCID: PMC7155926 DOI: 10.1089/wound.2019.1064] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 11/03/2019] [Indexed: 11/12/2022] Open
Abstract
Objective: While myriads of studies have suggested that a survey of wound pH environment could indicate wound healing activities, it is not clear whether wound alkalinity can be used as a prognostic indicator of nonhealing wounds. Currently available systems cannot reliably assess the pH environment across wounds, which is the objective of this study. Approach: A disposable device, DETEC® pH, was developed and characterized on its ability to map wound alkalinity by pressing a freshly recovered wound dressing against its test surface. By comparing the wound's alkalinity and size reduction rates (∼7 days) following pH measurement, we assessed the capability of wound alkalinity to prognosticate subsequent short-term wound size reduction rates. Results: The device had high accuracy and specificity in determining the alkalinity of simulated wound fluids soaked onto wound dressing. The type of wound dressing type had an insignificant effect on its detection sensitivity. Upon testing discarded wound dressings from human patients, the device quickly determined alkaline and acidic wounds. Finally, statistical analyses of wound size reduction rates in wounds with various alkalinities confirmed that wound alkalinity has a strong influence on, at least, short-term wound healing activity. Innovation: Without directly contacting the patient, this device provides a quick assessment of wound alkalinity to prognosticate immediate and short-term wound healing activities. Conclusion: DETEC® pH may serve as a prognosis device for wound care specialists during routine wound assessment to predict wound healing progress. This information can assist the decision-making process in a clinical setting and augur well for chronic wound treatment. DETEC® pH can also be used as an aid for home health care nurses or health care providers to screen nonhealing wounds outside clinics.
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Affiliation(s)
- Hong Vu
- Progenitec, Inc., Arlington, Texas
| | | | - Lan Tran
- Progenitec, Inc., Arlington, Texas
| | - Suvra Pal
- Department of Mathematics, University of Texas at Arlington, Arlington, Texas
| | | | | | - Liping Tang
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas
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9
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Li S, Mohamedi AH, Senkowsky J, Nair A, Tang L. Imaging in Chronic Wound Diagnostics. Adv Wound Care (New Rochelle) 2020; 9:245-263. [PMID: 32226649 PMCID: PMC7099416 DOI: 10.1089/wound.2019.0967] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/14/2019] [Indexed: 01/18/2023] Open
Abstract
Significance: Chronic wounds affect millions of patients worldwide, placing a huge burden on health care resources. Although significant progress has been made in the development of wound treatments, very few advances have been made in wound diagnosis. Recent Advances: Standard imaging methods like computed tomography, single-photon emission computed tomography, magnetic resonance imaging, terahertz imaging, and ultrasound imaging have been widely employed in wound diagnostics. A number of noninvasive optical imaging modalities like optical coherence tomography, near-infrared spectroscopy, laser Doppler imaging, spatial frequency domain imaging, digital camera imaging, and thermal and fluorescence imaging have emerged over the years. Critical Issues: While standard diagnostic wound imaging modalities provide valuable information, they cannot account for dynamic changes in the wound environment. In addition, they lack the capability to predict the healing outcome. Thus, there remains a pressing need for more efficient methods that can not only indicate the current state of the wound but also help determine whether the wound is on track to heal normally. Future Directions: Many imaging probes have been fabricated and shown to provide real-time assessment of tissue microenvironment and inflammatory responses in vivo. These probes have been demonstrated to noninvasively detect various changes in the wound environment, which include tissue pH, reactive oxygen species, fibrin deposition, matrix metalloproteinase production, and macrophage accumulation. This review summarizes the creation of these probes and their potential implications in wound monitoring.
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Affiliation(s)
- Shuxin Li
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas
| | - Ali H. Mohamedi
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas
| | | | | | - Liping Tang
- Department of Bioengineering, University of Texas at Arlington, Arlington, Texas
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Abstract
OBJECTIVE Wound dimensional assessments are important in determining the progress of a wound and the effect of interventions on wound healing. The FastSCAN (FS; Polhemus Inc, Colchester, Vermont) and Silhouette Mobile (SM; ARANZ Medical, Christchurch, New Zealand) are portable devices that quantify surface area, depth, and volume of wounds. This study evaluated their reliability in producing accurate wound measurements. DESIGN AND SETTING This study was conducted at the Waikato Hospital, Hamilton, New Zealand. PATIENTS AND INTERVENTION Eleven vascular patients with a combined total of 16 wounds underwent simultaneous wound measurements using three-dimensional computed tomography (CT) reconstruction, FS, and SM. MAIN OUTCOME MEASURE The validity of FS and SM was tested against CT. Additionally, the interoperator reliability and intraoperator reliability of FS and SM were determined. MAIN RESULTS The intraoperator reliability and interoperator reliability for volume recordings of the SM were 0.97 and 0.97, respectively, and for the FS were 0.96 and 0.97, respectively. The FS and SM measurements were not significantly different from CT. The SM consistently produced smaller wound volume and depth measurements compared with CT. In contrast, overestimation was observed for FS when compared with CT. However, the volume measurements in one wound were anomalous, being 10 times larger than CT measurements. Excluding this wound, there were strong correlations in wound volumes for SM and CT (r = 0.81; P ≤ .0001), for FS and CT (r = 0.99; P ≤ .001), and for SM and FS (r = 0.99; P ≤ .0001). CONCLUSIONS Measurements from FS and SM were comparable to CT. Therefore, SM and FS devices both offer the benefit of being noncontact portable devices that produce reproducible and reliable readings.
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11
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Measuring Surface Area of Skin Lesions with 2D and 3D Algorithms. Int J Biomed Imaging 2019; 2019:4035148. [PMID: 30774651 PMCID: PMC6350543 DOI: 10.1155/2019/4035148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/02/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose The treatment of skin lesions of various kinds is a common task in clinical routine. Apart from wound care, the assessment of treatment efficacy plays an important role. In this paper, we present a new approach to measure the skin lesion surface in two and three dimensions. Methods For the 2D approach, a single photo containing a flexible paper ruler is taken. After semi-automatic segmentation of the lesion, evaluation is based on local scale estimation using the ruler. For the 3D approach, reconstruction is based on Structure from Motion. Roughly outlining the region of interest around the lesion is required for both methods. Results The measurement evaluation was performed on 117 phantom images and five phantom videos for 2D and 3D approach, respectively. We found an absolute error of 0.99±1.18 cm2 and a relative error 9.89± 9.31% for 2D. These errors are <1 cm2 and <5% for five test phantoms in our 3D case. As expected, the error of 2D surface area measurement increased by approximately 10% for wounds on the bent surface compared to wounds on the flat surface. Using our method, the only user interaction is to roughly outline the region of interest around the lesion. Conclusions We developed a new wound segmentation and surface area measurement technique for skin lesions even on a bent surface. The 2D technique provides the user with a fast, user-friendly segmentation and measurement tool with reasonable accuracy for home care assessment of treatment. For 3D only preliminary results could be provided. Measurements were only based on phantoms and have to be repeated with real clinical data.
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Van den Bussche K, Verhaeghe S, Van Hecke A, Beeckman D. The Ghent Global IAD Monitoring Tool (GLOBIAD-M) to monitor the healing of incontinence-associated dermatitis (IAD): Design and reliability study. Int Wound J 2018; 15:555-564. [PMID: 29797507 DOI: 10.1111/iwj.12898] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 01/17/2018] [Accepted: 01/17/2018] [Indexed: 01/20/2023] Open
Abstract
The aim of this study was to design and evaluate the reliability of the Ghent Global incontinence-associated dermatitis (IAD) Monitoring Tool (GLOBIAD-M). The tool was designed based on the internationally validated Ghent Global IAD Categorisation Tool (GLOBIAD). After designing and validation by experts, one trained researcher carried out 36 observations of 9 patients affected with IAD. Photographs of the IAD lesions were independently assessed by a second trained researcher. Measures for inter-rater agreement (po ) and reliability [Cohen's Kappa (ĸ) and intra-class correlation coefficients (ICC)] were analysed. The po ranged between 0.86 for the item 'maceration' and 0.97 for the item 'clinical signs of infection'. The ĸ for the item 'GLOBIAD classification' was 0.61 [95% confidence interval (CI) 0.28-0.95] and 0.72 (95% CI 0.50-0.95) for 'maceration'. The lowest ĸ was found for the item 'oedema' (0.27; 95% CI -0.24-0.79). The ICC of the item 'redness' was 0.83 (95% CI 0.69-0.91) and 0.87 (95% CI 0.76-0.93) for 'skin loss'. The inter-rater agreement and reliability of the GLOBIAD-M appears to be good for the assessment of photographs by experts. This tool could support clinical decision-making for IAD treatment. Further validation with clinicians is, however, needed.
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Affiliation(s)
- Karen Van den Bussche
- Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Department of Public Health, Ghent University, Ghent, Belgium
| | - Sofie Verhaeghe
- Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Department of Public Health, Ghent University, Ghent, Belgium.,Department Health Care, VIVES University College, Roeselare, Belgium
| | - Ann Van Hecke
- Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Department of Public Health, Ghent University, Ghent, Belgium.,Nursing Department, Ghent University Hospital, Ghent, Belgium
| | - Dimitri Beeckman
- Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Department of Public Health, Ghent University, Ghent, Belgium.,School of Nursing & Midwifery, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
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13
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Wang SC, Anderson JAE, Evans R, Woo K, Beland B, Sasseville D, Moreau L. Point-of-care wound visioning technology: Reproducibility and accuracy of a wound measurement app. PLoS One 2017; 12:e0183139. [PMID: 28817649 PMCID: PMC5560698 DOI: 10.1371/journal.pone.0183139] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/31/2017] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Sheila C. Wang
- Department of Medicine, Division of Dermatology, McGill University, Montreal, Quebec, Canada
- * E-mail:
| | | | - Robyn Evans
- Wound Care Centre, Women’s College Hospital, Toronto, Ontario, Canada
| | - Kevin Woo
- School of Nursing, Queen’s University, Kingston, Ontario, Canada
| | - Benjamin Beland
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Denis Sasseville
- Department of Medicine, Division of Dermatology, McGill University, Montreal, Quebec, Canada
| | - Linda Moreau
- Department of Medicine, Division of Dermatology, McGill University, Montreal, Quebec, Canada
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14
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Yang S, Park J, Lee H, Lee JB, Lee BU, Oh BH. Error rate of automated calculation for wound surface area using a digital photography. Skin Res Technol 2017; 24:117-122. [PMID: 28718523 DOI: 10.1111/srt.12398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although measuring would size using digital photography is a quick and simple method to evaluate the skin wound, the possible compatibility of it has not been fully validated. PURPOSE To investigate the error rate of our newly developed wound surface area calculation using digital photography. METHODS Using a smartphone and a digital single lens reflex (DSLR) camera, four photographs of various sized wounds (diameter: 0.5-3.5 cm) were taken from the facial skin model in company with color patches. The quantitative values of wound areas were automatically calculated. The relative error (RE) of this method with regard to wound sizes and types of camera was analyzed. RESULTS RE of individual calculated area was from 0.0329% (DSLR, diameter 1.0 cm) to 23.7166% (smartphone, diameter 2.0 cm). In spite of the correction of lens curvature, smartphone has significantly higher error rate than DSLR camera (3.9431±2.9772 vs 8.1303±4.8236). However, in cases of wound diameter below than 3 cm, REs of average values of four photographs were below than 5%. In addition, there was no difference in the average value of wound area taken by smartphone and DSLR camera in those cases. CONCLUSION For the follow-up of small skin defect (diameter: <3 cm), our newly developed automated wound area calculation method is able to be applied to the plenty of photographs, and the average values of them are a relatively useful index of wound healing with acceptable error rate.
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Affiliation(s)
- S Yang
- Medical Physics Division, Stanford University, Palo Alto, USA
| | - J Park
- Department of Electronics Engineering, Ewha Woman's University, Seoul, Republic of Korea
| | - H Lee
- Department of Electronics Engineering, Ewha Woman's University, Seoul, Republic of Korea
| | - J B Lee
- Department of Dermatology, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - B U Lee
- Department of Electronics Engineering, Ewha Woman's University, Seoul, Republic of Korea
| | - B H Oh
- Department of Dermatology, Keimyung University School of Medicine, Daegu, Republic of Korea
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15
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16
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Sequential Change of Wound Calculated by Image Analysis Using a Color Patch Method during a Secondary Intention Healing. PLoS One 2016; 11:e0163092. [PMID: 27648569 PMCID: PMC5029888 DOI: 10.1371/journal.pone.0163092] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 09/02/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Photographs of skin wounds have the most important information during the secondary intention healing (SIH). However, there is no standard method for handling those images and analyzing them efficiently and conveniently. OBJECTIVE To investigate the sequential changes of SIH depending on the body sites using a color patch method. METHODS We performed retrospective reviews of 30 patients (11 facial and 19 non-facial areas) who underwent SIH for the restoration of skin defects and captured sequential photographs with a color patch which is specially designed for automatically calculating defect and scar sizes. RESULTS Using a novel image analysis method with a color patch, skin defects were calculated more accurately (range of error rate: -3.39% ~ + 3.05%). All patients had smaller scar size than the original defect size after SIH treatment (rates of decrease: 18.8% ~ 86.1%), and facial area showed significantly higher decrease rate compared with the non-facial area such as scalp and extremities (67.05 ± 12.48 vs. 53.29 ± 18.11, P < 0.05). From the result of estimating the date corresponding to the half of the final decrement, all of the facial area showed improvements within two weeks (8.45 ± 3.91), and non-facial area needed 14.33 ± 9.78 days. CONCLUSION From the results of sequential changes of skin defects, SIH can be recommended as an alternative treatment method for restoration with more careful dressing for initial two weeks.
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17
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Spectral Clustering for Unsupervised Segmentation of Lower Extremity Wound Beds Using Optical Images. J Med Syst 2016; 40:207. [DOI: 10.1007/s10916-016-0554-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/14/2016] [Indexed: 11/26/2022]
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18
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Borzdynski CJ, McGuiness W, Miller C. Comparing visual and objective skin assessment with pressure injury risk. Int Wound J 2016; 13:512-8. [PMID: 26179873 PMCID: PMC7949774 DOI: 10.1111/iwj.12468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 05/03/2015] [Accepted: 05/05/2015] [Indexed: 01/28/2023] Open
Abstract
Contemporary approaches to pressure injury (PI) risk identification rely on the use of risk assessment tools and visual skin assessment. Objective biophysical measures that assess skin hydration, melanin, erythema and lipids have not been traditionally used in PI risk; however, these may prove useful as a risk assessment tool. The relationship between subjective visual assessments of skin condition, biophysical measures and PI risk warrants investigation. This study used a descriptive correlational design to examine the relationship between measures of skin hydration, colour (melanin and erythema) and lipids at PI-prone areas amongst geriatric persons (n = 38), obtained using biophysical skin measures and visual skin assessment. Twice daily measures of epidermal hydration, colour and lipids were assessed using the SD202 Skin Diagnostic (Courage + Khazaka GmBH, Cologne, Germany) over pressure-prone areas of the body of study participants over seven consecutive days. Concurrent visual assessment of skin hydration and colour was performed. Results obtained using the SD202 Skin Diagnostic were compared with results gathered from visual assessment and examined for their association with participants' PI risk based on scores of the Norton Risk Assessment Scale. While epidermal hydration and skin colour reading scores did not vary significantly over the data collection period, lipid readings could not be registered on any occasion. With the exception of skin dryness, skin parameters via both objective and subjective means had significant, positive correlations. Statistically significant correlations emerged between visual assessment of skin wetness at the sacrum (r = -0·441, P < 0·01) and ischia (r = -0·468, P < 0·01) and Norton Risk Assessment Scale scores. It was found that the objective assessment of epidermal hydration (skin wetness) was also significantly associated with PI risk at the sacrum (r = -0·528, P < 0·01), as well as the right ischia (r = -0·410, P < 0·05) and left ischia (r = -0·407, P < 0·05). Erythema, when assessed objectively, was significantly correlated with PI risk at the sacrum (r = -0·322, P < 0·05). Such findings indicating that the finer measures afforded by the SD202 Skin Diagnostic in the assessment of the subtle red hues displayed in erythematous skin may provide an additional advantage over traditional, clinician assessment.
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Affiliation(s)
- Caroline J Borzdynski
- La Trobe University, Melbourne VIC Australia, Eltham Retirement Centre, Eltham VIC, Australia
| | - William McGuiness
- Deputy Head, Division of Nursing and Midwifery, La Trobe University, Melbourne VIC, Australia
| | - Charne Miller
- La Trobe University, Melbourne VIC Australia, Alfred Health Clinical School, The Alfred Centre, Pahran VIC, Australia
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19
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Rashaan ZM, Stekelenburg CM, van der Wal MBA, Euser AM, Hagendoorn BJM, van Zuijlen PPM, Breederveld RS. Three-dimensional imaging: a novel, valid, and reliable technique for measuring wound surface area. Skin Res Technol 2016; 22:443-450. [PMID: 26853829 DOI: 10.1111/srt.12285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2015] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Z M Rashaan
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands. .,Burn Center Beverwijk, Red Cross Hospital, Beverwijk, the Netherlands.
| | - C M Stekelenburg
- Department of Plastic and Reconstructive Surgery, VU University of Amsterdam, Amsterdam, the Netherlands.,The MOVE Research Institute, VU University of Amsterdam, Amsterdam, the Netherlands
| | - M B A van der Wal
- The MOVE Research Institute, VU University of Amsterdam, Amsterdam, the Netherlands.,Associations of Dutch Burn Centers, Beverwijk, the Netherlands
| | - A M Euser
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - B J M Hagendoorn
- Burn Center Beverwijk, Red Cross Hospital, Beverwijk, the Netherlands
| | - P P M van Zuijlen
- Burn Center Beverwijk, Red Cross Hospital, Beverwijk, the Netherlands.,Department of Plastic and Reconstructive Surgery, VU University of Amsterdam, Amsterdam, the Netherlands.,The MOVE Research Institute, VU University of Amsterdam, Amsterdam, the Netherlands
| | - R S Breederveld
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.,Burn Center Beverwijk, Red Cross Hospital, Beverwijk, the Netherlands.,Associations of Dutch Burn Centers, Beverwijk, the Netherlands
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20
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Liu P, Huang J, Zhang S, Xu RX. Multiview hyperspectral topography of tissue structural and functional characteristics. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:16012. [PMID: 26823110 DOI: 10.1117/1.jbo.21.1.016012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/16/2015] [Indexed: 05/15/2023]
Affiliation(s)
- Peng Liu
- University of Science and Technology of China, Department of Precision Machinery and Precision Instrumentation, 96 Jinzhai Rd., Hefei, Anhui 230027, China
| | - Jiwei Huang
- The Ohio State University, Department of Biomedical Engineering, 1080 Carmack Rd., Columbus, Ohio 43210, United States
| | - Shiwu Zhang
- University of Science and Technology of China, Department of Precision Machinery and Precision Instrumentation, 96 Jinzhai Rd., Hefei, Anhui 230027, ChinabThe Ohio State University, Department of Biomedical Engineering, 1080 Carmack Rd., Columbus, Ohio 43
| | - Ronald X Xu
- University of Science and Technology of China, Department of Precision Machinery and Precision Instrumentation, 96 Jinzhai Rd., Hefei, Anhui 230027, ChinabThe Ohio State University, Department of Biomedical Engineering, 1080 Carmack Rd., Columbus, Ohio 43
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21
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Foltynski P, Ladyzynski P, Ciechanowska A, Migalska-Musial K, Judzewicz G, Sabalinska S. Wound Area Measurement with Digital Planimetry: Improved Accuracy and Precision with Calibration Based on 2 Rulers. PLoS One 2015; 10:e0134622. [PMID: 26252747 PMCID: PMC4529141 DOI: 10.1371/journal.pone.0134622] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/10/2015] [Indexed: 11/19/2022] Open
Abstract
Introduction In the treatment of chronic wounds the wound surface area change over time is useful parameter in assessment of the applied therapy plan. The more precise the method of wound area measurement the earlier may be identified and changed inappropriate treatment plan. Digital planimetry may be used in wound area measurement and therapy assessment when it is properly used, but the common problem is the camera lens orientation during the taking of a picture. The camera lens axis should be perpendicular to the wound plane, and if it is not, the measured area differ from the true area. Results Current study shows that the use of 2 rulers placed in parallel below and above the wound for the calibration increases on average 3.8 times the precision of area measurement in comparison to the measurement with one ruler used for calibration. The proposed procedure of calibration increases also 4 times accuracy of area measurement. It was also showed that wound area range and camera type do not influence the precision of area measurement with digital planimetry based on two ruler calibration, however the measurements based on smartphone camera were significantly less accurate than these based on D-SLR or compact cameras. Area measurement on flat surface was more precise with the digital planimetry with 2 rulers than performed with the Visitrak device, the Silhouette Mobile device or the AreaMe software-based method. Conclusion The calibration in digital planimetry with using 2 rulers remarkably increases precision and accuracy of measurement and therefore should be recommended instead of calibration based on single ruler.
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Affiliation(s)
- Piotr Foltynski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
- * E-mail:
| | - Piotr Ladyzynski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Anna Ciechanowska
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Karolina Migalska-Musial
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Grzegorz Judzewicz
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Stanislawa Sabalinska
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
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22
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Abstract
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.
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23
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Aldaz G, Shluzas LA, Pickham D, Eris O, Sadler J, Joshi S, Leifer L. Hands-free image capture, data tagging and transfer using Google Glass: a pilot study for improved wound care management. PLoS One 2015; 10:e0121179. [PMID: 25902061 PMCID: PMC4406552 DOI: 10.1371/journal.pone.0121179] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 01/28/2015] [Indexed: 11/18/2022] Open
Abstract
Chronic wounds, including pressure ulcers, compromise the health of 6.5 million Americans and pose an annual estimated burden of $25 billion to the U.S. health care system. When treating chronic wounds, clinicians must use meticulous documentation to determine wound severity and to monitor healing progress over time. Yet, current wound documentation practices using digital photography are often cumbersome and labor intensive. The process of transferring photos into Electronic Medical Records (EMRs) requires many steps and can take several days. Newer smartphone and tablet-based solutions, such as Epic Haiku, have reduced EMR upload time. However, issues still exist involving patient positioning, image-capture technique, and patient identification. In this paper, we present the development and assessment of the SnapCap System for chronic wound photography. Through leveraging the sensor capabilities of Google Glass, SnapCap enables hands-free digital image capture, and the tagging and transfer of images to a patient's EMR. In a pilot study with wound care nurses at Stanford Hospital (n=16), we (i) examined feature preferences for hands-free digital image capture and documentation, and (ii) compared SnapCap to the state of the art in digital wound care photography, the Epic Haiku application. We used the Wilcoxon Signed-ranks test to evaluate differences in mean ranks between preference options. Preferred hands-free navigation features include barcode scanning for patient identification, Z(15) = -3.873, p < 0.001, r = 0.71, and double-blinking to take photographs, Z(13) = -3.606, p < 0.001, r = 0.71. In the comparison between SnapCap and Epic Haiku, the SnapCap System was preferred for sterile image-capture technique, Z(16) = -3.873, p < 0.001, r = 0.68. Responses were divided with respect to image quality and overall ease of use. The study's results have contributed to the future implementation of new features aimed at enhancing mobile hands-free digital photography for chronic wound care.
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Affiliation(s)
- Gabriel Aldaz
- Center for Design Research, Stanford University, Stanford, CA, United States of America
| | - Lauren Aquino Shluzas
- Center for Design Research, Stanford University, Stanford, CA, United States of America
- * E-mail:
| | - David Pickham
- Stanford Health Care, Stanford, CA, United States of America
| | - Ozgur Eris
- Delft University of Technology, Delft, The Netherlands
| | - Joel Sadler
- Center for Design Research, Stanford University, Stanford, CA, United States of America
| | - Shantanu Joshi
- Center for Design Research, Stanford University, Stanford, CA, United States of America
| | - Larry Leifer
- Center for Design Research, Stanford University, Stanford, CA, United States of America
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24
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Shah A, Wollak C, Shah JB. Wound Measurement Techniques: Comparing the Use of Ruler Method, 2D Imaging and 3D Scanner. J Am Coll Clin Wound Spec 2015. [PMID: 26199893 DOI: 10.1016/j.jccw.2015.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The statistics on the growing number of non-healing wounds is alarming. In the United States, chronic wounds affect 6.5 million patients. An estimated US $25 billion is spent annually on treatment of chronic wounds and the burden is rapidly growing due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide.(1) Accurate wound measurement techniques will help health care personnel to monitor the wounds which will indirectly help improving care.(7,9) The clinical practice of measuring wounds has not improved even today.(2,3) A common method like the ruler method to measure wounds has poor interrater and intrarater reliability.(2,3) Measuring the greatest length by the greatest width perpendicular to the greatest length, the perpendicular method, is more valid and reliable than other ruler based methods.(2) Another common method like acetate tracing is more accurate than the ruler method but still has its disadvantages. These common measurement techniques are time consuming with variable inaccuracies. In this study, volumetric measurements taken with a non-contact 3-D scanner are benchmarked against the common ruler method, acetate grid tracing, and 2-D image planimetry volumetric measurement technique. A liquid volumetric fill method is used as the control volume. Results support the hypothesis that the 3-D scanner consistently shows accurate volumetric measurements in comparison to standard volumetric measurements obtained by the waterfill technique (average difference of 11%). The 3-D scanner measurement technique was found more reliable and valid compared to other three techniques, the ruler method (average difference of 75%), acetate grid tracing (average difference of 41%), and 2D planimetric measurements (average difference of 52%). Acetate tracing showed more accurate measurements compared to the ruler method (average difference of 41% (acetate tracing) compared to 75% (ruler method)). Improving the accuracy in measuring chronic wounds might improve overall care of patients with non-healing wounds. This study consistently shows that the 3-D scanner is a more accurate, quicker, and safer method for measuring wounds.
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Affiliation(s)
- Aj Shah
- Sophomore, Keystone school, San Antonio, TX
| | | | - J B Shah
- President, South Texas Wound Associates, PA ; Medical Director, Northeast Baptist Wound Healing Center, San Antonio, Texas ; Co-Medical Director, Mission Trail Baptist Wound Healing Center, San Antonio, Texas
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25
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Wang SC, Anderson JA, Jones DV, Evans R. Patient perception of wound photography. Int Wound J 2014; 13:326-30. [PMID: 24872018 DOI: 10.1111/iwj.12293] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/31/2014] [Accepted: 04/03/2014] [Indexed: 11/27/2022] Open
Abstract
The objectives of this study were to provide an assessment of photographic documentation of the wound from the patients' perspective and to evaluate whether this could improve patients' understanding of and involvement in their wound care. Our results revealed that most patients visiting the wound care clinic have difficult-to-see wounds (86%). Only 20% of patients monitor their wounds and instead rely on clinic or nurse visits to track the healing progress. There was a significant association between patients' ability to see their wound and their subsequent memory of the wound's appearance. This was especially true for patients who had recently begun visiting the wound care clinic. This relationship was not present in patients who had visited the clinic for 3 or more years. Patients reported that the inability to see their wounds resulted in feeling a loss of autonomy. The majority of patients reported that photographing their wounds would help them to track the wound progress (81%) and would afford them more involvement in their own care (58%). This study provides a current representation of wound photography from the patients' perspective and reveals that it can motivate patients to become more involved in the management of their wounds - particularly for patients with difficult-to-see wounds.
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Affiliation(s)
- Sheila C Wang
- Undergraduate Medical Education, University of Toronto, Toronto, Canada
| | - John Ae Anderson
- Department of Psychology, University of Toronto & Rotman Research Institute, Toronto, Canada
| | - Duncan Vb Jones
- Department of Human Biology, University of Toronto, Toronto, Canada
| | - Robyn Evans
- Wound Care Centre, Women's College Hospital, Toronto, Canada
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26
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Reliability and validity of the revised photographic wound assessment tool on digital images taken of various types of chronic wounds. Adv Skin Wound Care 2014; 26:360-73. [PMID: 23860221 DOI: 10.1097/01.asw.0000431329.50869.6f] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to examine the validity and reliability of the revised Photographic Wound Assessment Tool (revPWAT) on digital images taken of various types of chronic, healing wounds. SETTING This multicenter trial was performed in a variety of settings where chronic wounds are assessed. PARTICIPANTS A total of 206 different photographs taken of 68 individuals with 95 chronic wounds of various etiologies were reviewed in this study. Wound etiologies included people with venous/arterial leg wounds (n = 13), diabetic foot wounds (n = 18), pressure ulcers (n = 32), and wounds of other etiologies (n = 5). MAIN OUTCOME MEASURES An initial wound assessment using the revPWAT was performed at the bedside, and 3 digital photographs were taken-2 within 72 hours when no change had occurred, and a third was taken 3.5 to 6 weeks later. MAIN RESULTS The revPWAT scores derived from photographs assessed by the same rater on different occasions and by different raters showed moderate to excellent intrarater intraclass correlation coefficients (ICCs) (ICC = 0.52-0.93), as well as test-retest (ICC = 0.86-0.90) and interrater (ICC = 0.71) reliability. There was excellent agreement between bedside assessments and assessments using photographs (ICC = 0.89). CONCLUSION The revPWAT is a valid and reliable tool to assess chronic wounds of various etiologies where digital images are viewed.
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27
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Foltynski P, Ladyzynski P, Wojcicki JM. A New Smartphone-Based Method for Wound Area Measurement. Artif Organs 2013; 38:346-52. [DOI: 10.1111/aor.12169] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Piotr Foltynski
- Institute of Biocybernetics and Biomedical Engineering; Polish Academy of Sciences; Warsaw Poland
| | - Piotr Ladyzynski
- Institute of Biocybernetics and Biomedical Engineering; Polish Academy of Sciences; Warsaw Poland
| | - Jan M. Wojcicki
- Institute of Biocybernetics and Biomedical Engineering; Polish Academy of Sciences; Warsaw Poland
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28
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Foltynski P, Ladyzynski P, Sabalinska S, Wojcicki JM. Accuracy and precision of selected wound area measurement methods in diabetic foot ulceration. Diabetes Technol Ther 2013; 15:712-21. [PMID: 23902402 DOI: 10.1089/dia.2013.0026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIM The present study assesses precision and accuracy of four selected methods of wound area measurements in diabetic foot wounds. MATERIALS AND METHODS The areas of 16 wound shapes were measured using linear measurement with elliptical estimation (Elliptical method), using the Visitrak™ (Smith & Nephew, London, United Kingdom) device, the SilhouetteMobile™ device (ARANZ Medical Ltd., Christchurch, New Zealand), and the TeleDiaFoS system (Nalecz Institute of Biocybernetics and Biomedical Engineering, Warsaw, Poland). The actual area of a wound shape was determined with a tested scanner and specifically developed software. Accuracy of the area measurement method was assessed by the relative error (RE), whereas precision was assessed by the coefficient of variation (CV). RESULTS The overall absolute REs were 13.3%, 6.8%, 2.1%, and 2.3% for the Elliptical method, the Visitrak device, the TeleDiaFoS system, and the SilhouetteMobile device, respectively. The accuracy of the Visitrak device was remarkably reduced for wound areas smaller than 2 cm². The overall CVs were 6.0%, 6.3%, 1.6%, and 3.1% for the Elliptical method, the Visitrak device, the TeleDiaFoS system, and the SilhouetteMobile device, respectively. The precision of the Visitrak device was revealed to be remarkably lower for small wounds (<2 cm²). CONCLUSIONS The Elliptical method gives overestimation up to 33%; thus, it should not be used in applications where the actual wound area is an important parameter (like the prediction of wound healing). The TeleDiaFoS system and the SilhouetteMobile device showed the best accuracy of all used methods; however, the precision of the TeleDiaFoS system was revealed to be higher than the precision of the SilhouetteMobile device. The accuracy and the precision of the Visitrak device are significantly reduced for wounds smaller than 2 cm².
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Affiliation(s)
- Piotr Foltynski
- Nałęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland.
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29
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Kottner J, Hillmann K, Fimmel S, Seite S, Blume-Peytavi U. Characterisation of epidermal regeneration in vivo: a 60-day follow-up study. J Wound Care 2013; 22:395-400. [DOI: 10.12968/jowc.2013.22.8.395] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J. Kottner
- Clinical Research Centre for Hair and skin science, Department of Dermatology and Allergy, Charité university Medicine Berlin, Germany
- La Roche-Posay laboratoire Pharmaceutique, Asnieres, France
| | - K. Hillmann
- Clinical Research Centre for Hair and skin science, Department of Dermatology and Allergy, Charité university Medicine Berlin, Germany
- La Roche-Posay laboratoire Pharmaceutique, Asnieres, France
| | - S. Fimmel
- Clinical Research Centre for Hair and skin science, Department of Dermatology and Allergy, Charité university Medicine Berlin, Germany
- La Roche-Posay laboratoire Pharmaceutique, Asnieres, France
| | - S. Seite
- Clinical Research Centre for Hair and skin science, Department of Dermatology and Allergy, Charité university Medicine Berlin, Germany
- La Roche-Posay laboratoire Pharmaceutique, Asnieres, France
| | - U. Blume-Peytavi
- Clinical Research Centre for Hair and skin science, Department of Dermatology and Allergy, Charité university Medicine Berlin, Germany
- La Roche-Posay laboratoire Pharmaceutique, Asnieres, France
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Whitcomb E, Monroe N, Hope-Higman J, Campbell P. Demonstration of a microcurrent-generating wound care device for wound healing within a rehabilitation center patient population. J Am Coll Clin Wound Spec 2013; 4:32-9. [PMID: 24527381 DOI: 10.1016/j.jccw.2013.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 07/03/2013] [Accepted: 07/05/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Wound care in a rehabilitation environment is a costly and difficult problem. The goal of this retrospective study is to evaluate differences in wound closure outcomes in acute and chronic wounds when treated with a microcurrent-generating wound care device as compared to standard wound care methods. METHODS Data files of 38 patients who received either standard wound treatment (SOC; n = 20), or were treated with a microcurrent-generating wound device (MCD, n = 18), were retrospectively reviewed. Wounds were assessed until deemed clinically to have closed or healed with up to 100% epithelialization. All patients (18-99 years) with single wounds were included. The number of days to wound closure and the rate of wound volume reduction were compared across groups. Persistent reduction of wound size improvement was also examined. RESULTS The wounds in the SOC group closed on average at 36.25 days (SD = 28.89), while the MCD group closed significantly faster in 19.78 days (SD = 14.45), p = 0.036. The rate of volume reduction per day was -3.83% for SOC vs. -9.82% volume reduction per day (p = 0.013) for the MCD group. The SOC group had 50% of its wounds close monotonically vs. 83.3% in the MCD group (p = 0.018). CONCLUSION This two-center retrospective study demonstrated a 45.4% faster, and more robust healing of wounds with the use of the MCD, when compared to SOC in a rehabilitation center environment. This translates into improved patient care, and potentially significant cost savings. Economic benefits for the use of MCD compared to other wound care methods are planned for future research.
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Affiliation(s)
- Emily Whitcomb
- Bethany Health and Rehab Center, Nashville, TN, USA ; Trevecca Health and Rehab Center, Nashville, TN, USA
| | - Nina Monroe
- Bethany Health and Rehab Center, Nashville, TN, USA
| | | | - Penny Campbell
- Bethany Health and Rehab Center, Nashville, TN, USA ; Trevecca Health and Rehab Center, Nashville, TN, USA ; Vomaris Wound Care, Inc., Chandler, AZ, USA
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Objective Quantification of Subjective Parameters in Scars by Use of a Portable Stereophotographic System. Ann Plast Surg 2012. [DOI: 10.1097/sap.0b013e3182584031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Scientific and Clinical Abstracts From the WOCN® Society's 44th Annual Conference. J Wound Ostomy Continence Nurs 2012. [DOI: 10.1097/won.0b013e3182546a04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Objective quantification of subjective parameters in scars by use of a portable stereophotographic system. Ann Plast Surg 2012; 67:641-5. [PMID: 22123541 DOI: 10.1097/sap.0b013e3182380877] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Current evaluation of scars predominantly relies on subjective evaluation and lacks objective evidence for quantification of therapeutic outcomes by methods suitable for application in daily clinical practice. The aim of this study was to analyze 3-dimensional parameters obtained by use of a portable stereophotographic system in conjunction with subjective clinical findings. METHODS After validation of the stereophotographic system on plastic scar molds (n = 20), we analyzed subjective evaluations of patients' own, and lay and expert observers by a visual analog scale, and compared the findings for volume and surface irregularity to the objectively calculated values during follow-up of selected scars. RESULTS Setup and image acquisition took 8 ± 2 seconds. Volumetric parameters highly correlated with real values (R2 = 0.9678). Expert's subjective evaluations were confirmed for volumetric calculations in 5 of 6 sample scars, but only in 2 of 6 for surface irregularity. DISCUSSION Portable stereophotography can be used in a clinical setting and retains 3-dimensional features in digital reconstructions for subjective assessments, while simultaneously acquiring objective parameters. The objective parameters enabled to complement or even replace subjective clinical findings, and this method proved to be useful for follow-up of therapeutic outcomes in scars.
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Foltynski P, Ladyzynski P, Migalska-Musial K, Sabalinska S, Ciechanowska A, Wojcicki J. A new imaging and data transmitting device for telemonitoring of diabetic foot syndrome patients. Diabetes Technol Ther 2011; 13:861-7. [PMID: 21568750 DOI: 10.1089/dia.2011.0004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Proper healing of ulcers and wounds on the feet of diabetes patients is important in order to prevent amputation. If the wound area reduction during the first 4 weeks of the treatment is not 40% or more, reevaluation of the treatment is necessary. The wound area evaluation is not complicated when the patient stays at a hospital, but when he or she goes home the physician does not have a tool allowing monitoring of the wound area. METHODS AND RESULTS The aim of the present article is to present a new device able to take a wound picture and send it automatically to the database. This device, called the Patient's Module (PM), is also able to download data from the memories of blood pressure and blood glucose meters and send the data to the database. The PM is able to operate within the TeleDiaFoS system (developed earlier in collaboration with the Department and Clinic of Gastroenterology and Metabolic Diseases, Medical University of Warsaw, Warsaw, Poland) aimed at monitoring of treatment of patients with diabetic foot syndrome. The PM was tested on 10 type 2 diabetes patients during a 3-month period. CONCLUSIONS The study revealed that the PM can be used as a home telemonitoring device, and the analysis of the data sent from patient's home enables the assessment of wound healing progress, giving the physician the possibility for earlier change of the treatment if the wound area reduction is not satisfactory.
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Affiliation(s)
- Piotr Foltynski
- Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland.
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Abstract
OBJECTIVE The objective of this study was to enhance conventional wound assessment and documentation of clinicians by incorporating the use of digital imaging into the medical record using standardized photography requirements. DESIGN A review of current literature, existing clinician practice, and identification of barriers preceded the development and implementation of a clinical practice guideline, with a performance checklist, aimed at improving the wound photography (WP) process. In addition, establishing standards of practice and behavior modification were used to improve clinician proficiency in digital photography. SETTING AND PARTICIPANTS Wound clinicians providing specialty care within the acute care setting. MAIN OUTCOME MEASUREMENTS Following educational sessions, evaluation of clinician competence in using equipment and adherence to standard digital imaging protocols with the use of a performance checklist permitted educators to validate clinician skill. MAIN RESULTS Establishing consistency in digital imaging results is an overall enhancement of the WP process by increasing clinician satisfaction and efficiency, improving assessment skills, and enriching documentation. Competency strengthens one's skill set and serves to create a common language, leading to improved communication among clinicians and resulting in enhanced wound assessment. CONCLUSIONS WP plays a valuable role in delivering effective patient care by strengthening wound assessments and documentation. Recognizing the need for consistent standards, clinical educators from Lehigh Valley Health Network designed an educational program using a multifaceted approach, including clinical practice guideline development, education, and competency assessment. Enmeshing current practices, expert opinion, and clinician knowledge resulted in an innovative process using interdependent, yet independent, components to achieve enhanced wound assessment.
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Barone S, Paoli A, Razionale AV. Assessment of chronic wounds by three-dimensional optical imaging based on integrating geometrical, chromatic, and thermal data. Proc Inst Mech Eng H 2011; 225:181-93. [PMID: 21428152 DOI: 10.1243/09544119jeim705] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- S Barone
- Department of Mechanical, University of Pisa, Italy
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Abstract
OBJECTIVE Evaluate the effectiveness of telemedicine (TM) with digital cameras in treating wounds in a home care setting. DESIGN Randomized controlled study. PARTICIPANTS AND SETTING One hundred three subjects with 160 pressure ulcers (PrUs) or nonhealing surgical wounds referred to a metropolitan Visiting Nurse Agency. INTERVENTIONS Subjects were randomly assigned to 1 of 3 groups. Group A (n = 40): weekly visits with TM and wound care specialist (WCS) consults; group B (n = 28): weekly visits with weekly consults with WCSs; and group C (n = 35): usual and customary care. MAIN OUTCOME MEASURES Outcome measures were time to heal, costs, length of stay (LOS), nursing visits, wound status, and change in size. RESULTS There was a similar distribution of subject characteristics in all 3 groups, but group A had disproportionally larger and more numerous PrUs and larger nonhealing surgical wounds. Group A had increased time to heal, LOS, costs, and visits compared with groups B and C; wound status was similar in all groups. CONCLUSIONS Uneven distribution of severity and type of wounds among groups, with greatest percentage of large wounds in TM group. Larger wounds consume more resources. TM is a useful communication tool in wound management but with limited power when randomization does not include wound size or type. Two important benchmarks were established for home care. First, it took 51 days, on average, to heal or improve PrUs and 34 days to heal or improve surgical wounds regardless of group. Second, nearly 90% of wounds improved or healed.
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Rogers LC, Bevilacqua NJ, Armstrong DG, Andros G. Digital planimetry results in more accurate wound measurements: a comparison to standard ruler measurements. J Diabetes Sci Technol 2010; 4:799-802. [PMID: 20663440 PMCID: PMC2909508 DOI: 10.1177/193229681000400405] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cutaneous wound measurements are important to track the healing of a wound and direct appropriate therapy. The most commonly used method to calculate wound area is an estimation by multiplying the longest length by the widest width. Other devices can provide an accurate and precise measurement of the true area (TA). This study aim was to compare wound areas calculated by computerized planimetry with standard area estimation by multiplying the longest length by the widest width (l x w). METHODS We reviewed the wound records of 10 patients with circular or oval wounds and estimated the area with the l x w method. We compared this with the TA obtained by a specialized planimetric camera. RESULTS Average wound size was 4.3 cm(2) by l x w estimation and 3 cm(2) by TA calculation. We found the l x w method overestimated wound area an average of 41%. CONCLUSIONS Standard, manual (l x w) measurement of cutaneous wounds inaccurately overestimates wound area by roughly 40%.
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Affiliation(s)
- Lee C Rogers
- Amputation Prevention Center, Valley Presbyterian Hospital, Los Angeles, California, USA.
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Ayello EA, Capitulo KL, Fife CE, Fowler E, Krasner DL, Mulder G, Sibbald RG, Yankowsky KW. Legal Issues in the Care of Pressure Ulcer Patients: Key Concepts for Health Care Providers: A Consensus Paper from the International Expert Wound Care Advisory Panel. J Palliat Med 2009; 12:995-1008. [DOI: 10.1089/jpm.2009.9939] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | | | | | - Gerit Mulder
- Wound Treatment and Research Center, Department of Surgery/Division of Trauma, University of California San Diego School of Medicine, San Diego, California
| | - R. Gary Sibbald
- Wound Healing Clinic, Women's College Hospital, University of Toronto, Canada
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