How precise is the evaluation of chronic wounds by health care professionals?

Thermographic assessment of skin temperature after lumbar spine surgery: Useful method for detection of wound complications? A pilot study

BACKGROUND

Wound complications after lumbar spine surgery may result in prolonged hospitalization and increased morbidity. Early identification can trigger appropriate management.

OBJECTIVE

The aim of this study was to investigate the efficacy of infrared-based wound assessment (FLIR) after lumbar spine surgery in the context of identifying wound healing disorders.

METHODS

62 individuals who underwent lumbar spine surgery were included. The immediate postoperative course was studied, and the patient's sex, age, body mass index (BMI), heart rate, blood pressure, body temperature, numeric rating scale for pain (NRS), C-reactive protein (CRP), leukocyte, and hemoglobin levels were noted and compared to thermographic measurement of local surface temperature in the wound area.

RESULTS

Measurement of local surface temperature in the wound area showed a consistent temperature distribution while it was uneven in case of wound healing disorder. In this instance, the region of the wound where the wound healing disorder occured had a lower temperature than the surrounding tissue (p> 0.05).

CONCLUSIONS

This study demonstrates the ongoing importance of clinical wound assessment for early detection of complications. While laboratory parameter measurement is crucial, FLIR may serve as a cost-effective supplemental tool in clinical wound evaluation. Patient safety risks appear minimal since local ST is measured without touch.

Automated Prediction of Photographic Wound Assessment Tool in Chronic Wound Images

Many automated approaches have been proposed in literature to quantify clinically relevant wound features based on image processing analysis, aiming at removing human subjectivity and accelerate clinical practice. In this work we present a fully automated image processing pipeline leveraging deep learning and a large wound segmentation dataset to perform wound detection and following prediction of the Photographic Wound Assessment Tool (PWAT), automatizing the clinical judgement of the adequate wound healing. Starting from images acquired by smartphone cameras, a series of textural and morphological features are extracted from the wound areas, aiming to mimic the typical clinical considerations for wound assessment. The resulting extracted features can be easily interpreted by the clinician and allow a quantitative estimation of the PWAT scores. The features extracted from the region-of-interests detected by our pre-trained neural network model correctly predict the PWAT scale values with a Spearman's correlation coefficient of 0.85 on a set of unseen images. The obtained results agree with the current state-of-the-art and provide a benchmark for future artificial intelligence applications in this research field.

Effectiveness of Semi-Supervised Active Learning in Automated Wound Image Segmentation

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.

Fully Automated Wound Tissue Segmentation Using Deep Learning on Mobile Devices: Cohort Study

Background

Composition of tissue types within a wound is a useful indicator of its healing progression. Tissue composition is clinically used in wound healing tools (eg, Bates-Jensen Wound Assessment Tool) to assess risk and recommend treatment. However, wound tissue identification and the estimation of their relative composition is highly subjective. Consequently, incorrect assessments could be reported, leading to downstream impacts including inappropriate dressing selection, failure to identify wounds at risk of not healing, or failure to make appropriate referrals to specialists.

Objective

This study aimed to measure inter- and intrarater variability in manual tissue segmentation and quantification among a cohort of wound care clinicians and determine if an objective assessment of tissue types (ie, size and amount) can be achieved using deep neural networks.

Methods

A data set of 58 anonymized wound images of various types of chronic wounds from Swift Medical’s Wound Database was used to conduct the inter- and intrarater agreement study. The data set was split into 3 subsets with 50% overlap between subsets to measure intrarater agreement. In this study, 4 different tissue types (epithelial, granulation, slough, and eschar) within the wound bed were independently labeled by the 5 wound clinicians at 1-week intervals using a browser-based image annotation tool. In addition, 2 deep convolutional neural network architectures were developed for wound segmentation and tissue segmentation and were used in sequence in the workflow. These models were trained using 465,187 and 17,000 image-label pairs, respectively. This is the largest and most diverse reported data set used for training deep learning models for wound and wound tissue segmentation. The resulting models offer robust performance in diverse imaging conditions, are unbiased toward skin tones, and could execute in near real time on mobile devices.

Results

A poor to moderate interrater agreement in identifying tissue types in chronic wound images was reported. A very poor Krippendorff α value of .014 for interrater variability when identifying epithelization was observed, whereas granulation was most consistently identified by the clinicians. The intrarater intraclass correlation (3,1), however, indicates that raters were relatively consistent when labeling the same image multiple times over a period. Our deep learning models achieved a mean intersection over union of 0.8644 and 0.7192 for wound and tissue segmentation, respectively. A cohort of wound clinicians, by consensus, rated 91% (53/58) of the tissue segmentation results to be between fair and good in terms of tissue identification and segmentation quality.

Conclusions

The interrater agreement study validates that clinicians exhibit considerable variability when identifying and visually estimating wound tissue proportion. The proposed deep learning technique provides objective tissue identification and measurements to assist clinicians in documenting the wound more accurately and could have a significant impact on wound care when deployed at scale.

A suspended layer additive manufacturing approach to the bioprinting of tri-layered skin equivalents

Skin exhibits a complex structure consisting of three predominant layers (epidermis, dermis, and hypodermis). Extensive trauma may result in the loss of these structures and poor repair, in the longer term, forming scarred tissue and associated reduction in function. Although a number of skin replacements exist, there have been no solutions that recapitulate the chemical, mechanical, and biological roles that exist within native skin. This study reports the use of suspended layer additive manufacturing to produce a continuous tri-layered implant, which closely resembles human skin. Through careful control of the bioink composition, gradients (chemical and cellular) were formed throughout the printed construct. Culture of the model demonstrated that over 21 days, the cellular components played a key role in remodeling the supporting matrix into architectures comparable with those of healthy skin. Indeed, it has been demonstrated that even at seven days post-implantation, the integration of the implant had occurred, with mobilization of the adipose tissue from the surrounding tissue into the construct itself. As such, it is believed that these implants can facilitate healing, commencing from the fascia, up toward the skin surface—a mechanism recently shown to be key within deep wounds.

Point-of-Care Ultrasound as a Tool to Assess Wound Size and Tissue Regeneration after Skin Grafting

Chronic wounds can be difficult to heal and are often accompanied by pain and discomfort. Multiple skin substitutes or cellularized/tissue-based skin products have been used in an attempt to facilitate closure of complex wounds. Allografts from cadaveric sources have been a viable option in achieving such closure. However, early assessment of graft incorporation has been difficult clinically, often with delayed evidence of failure. Visual cues to assess graft integrity have been limited and remain largely superficial at the skin surface. Furthermore, currently used optical imaging techniques can penetrate only a few millimeters deep into tissue. Ultrasound (US) imaging offers a potential solution to address this limitation. This work evaluates the use of US to monitor wound healing and allograft integration. We used a commercially available dual-mode (US and photoacoustic) scanner operating only in US mode. We compared the reported wound size from the clinic with the size measured using US in 45 patients. Two patients from this cohort received an allogenic skin graft and underwent multiple US scans over a 110-d period. All data were processed by two independent analysts; one of them was blinded to the study. We measured change in US intensity and wound contraction as a function of time. Our results revealed a strong correlation (R² = 0.81, p < 0.0001) between clinically and US-measured wound sizes. Wound contraction >91% was seen in both patients after skin grafting. An inverse relationship between wound size and US intensity (R² = 0.77, p < 0 .0001) indicated that the echogenicity of the wound bed increases as healthy cells infiltrate the allograft matrix, regenerating and leading to healthy tissue and re-epithelization. This work indicates that US can be used to measure wound size and visualize tissue regeneration during the healing process.

Assessment of diabetic foot ulcers based on pictorial material: an interobserver study

OBJECTIVE

The frequent change in clinicians, and the emerging use of photographic documentation in wound management, could require a more diverse treatment of patients due to poor interobserver agreement. The aim of this study was to assess the interobserver agreement of a commonly used classification system for diabetic foot ulcers (DFUs), the Meggitt-Wagner classification, and to compare the agreement on classification with the agreement in treatment recommendations.

METHOD

An interobserver study was conducted based on a questionnaire linked to 30 photographs of DFUs. Different groups of observers were tested to investigate whether there was a difference between professions or level of education: experienced orthopaedic wound care doctors (n=7); nurses specialised in wound care (n=8) and untrained nurses assigned to a diabetic wound care training course (n=23). Krippendorff's alpha was used to calculate interobserver agreement, and an agreement of >0.67 was defined as substantial.

RESULTS

The Krippendorff's alpha value for interobserver agreement on the Meggitt-Wagner classification was 0.52 for the doctors group, 0.67 for the specialised nurses and 0.61 for the untrained nurses. The corresponding values regarding agreement on recommendation of surgical revision of the wound were 0.35, 0.22 and 0.15, respectively. The choice of dressing type or antibiotic treatment had even lower interobserver agreement.

CONCLUSIONS

The interobserver agreement on the Meggitt-Wagner classification was substantial in the specialised nurse group, but the evaluation and treatment of DFUs should not be exclusively based on pictorial materials.

Extended Perfusion Parameter Estimation from Hyperspectral Imaging Data for Bedside Diagnostic in Medicine

Background: Hyperspectral Imaging (HSI) has a strong potential to be established as a new contact-free measuring method in medicine. Hyperspectral cameras and data processing have to fulfill requirements concerning practicability and validity to be integrated in clinical routine processes. Methods: Calculating physiological parameters which are of significant clinical value from recorded remission spectra is a complex challenge. We present a data processing method for HSI remission spectra based on a five-layer model of perfused tissue that generates perfusion parameters for every layer and presents them as depth profiles. The modeling of the radiation transport and the solution of the inverse problem are based on familiar approximations, but use partially heuristic methods for efficiency and to fulfill practical clinical requirements. Results: The parameter determination process is consistent, as the measured spectrum is practically completely reproducible by the modeling sequence; in other words, the whole spectral information is transformed into model parameters which are easily accessible for physiological interpretation. The method is flexible enough to be applicable on a wide spectrum of skin and wounds. Examples of advanced procedures utilizing extended perfusion representation in clinical application areas (flap control, burn diagnosis) are presented.

Computer-Assisted Wound Assessment and Care Education Program in Registered Nurses: Use of an Interactive Online Program by 418 Registered Nurses

PURPOSE

The purpose of this descriptive study was to evaluate use of a previously validated, online, interactive wound assessment and wound care clinical pathway in a group of RNs. Specific aims were to (a) evaluate the proportions of correct, partially correct, and incorrect algorithmic decisions and dressing selections, (b) compare response rates between nurses who are and who are not wound care certified, and (c) evaluate its ease of use, educational value, and applicability in clinical practice.

DESIGN

Descriptive study.

SUBJECTS AND SETTING

Participants were recruited using convenience and snowball sampling methods. Four hundred eighteen nurses completed all 15 assessments; nearly half held a bachelors' degree in nursing (189, 45%), more than two-thirds worked in an inpatient acute care settings (277, 68%), and 293 (70%) were not certified in wound care.

METHODS

After providing written informed consent and completing the participant demographics form, participants assessed 15 photographs of wounds with accompanying moisture descriptions and completed an algorithm and dressing selection for each. All responses were anonymously collected by the program. Existing, retrospective, program data were also downloaded and data from nurses who completed all assessments were extracted and analyzed. Descriptive statistics were used to analyze all variables. Selection outcomes and survey responses between nurses who were and who were not wound care certified were compared using a 2-sample Student t test assuming unequal variances. Individual responses for the first 6 wounds were compared to the last 6 wounds using a paired t test.

RESULTS

The mean (M) proportions of fully or partially correct (operationally defined as safe but not fully correct) algorithm and dressing choice were 81% (SE: 0.88, 95% confidence level: 1.73) and 78.1% (SE: 0.70, 95% confidence level: 1.39), respectively. Wound care-certified nurses had higher mean algorithm scores than those who were not certified (M: 89.2%, SE: 1.27 vs M: 77.8%, SE: 1.10, P < .001). Most incorrect/partially correct choices were attributable to incorrect necrotic tissue assessment (n = 845, 58%). The difference between fully correct first 6 and last 6 algorithm choices was statistically significant (M: 310, SE: 0.02 vs M: 337, SE: 9.32, P = .04). On a Likert scale of 1 (not at all) to 5 (very), average scores for ease of program and algorithm use, educational value, and usefulness for clinicians ranged from M: 4.14, SE: 0.08 to M: 4.22, SE: 0.08.

CONCLUSIONS

Results suggest that the algorithm is valid and has potential educational value. Initial evaluation also suggests that program refinements are needed. Evaluation of participant responses indicated potential problems with the definitions used for necrotic tissue or assessment knowledge deficits. Results also substantiate the importance of instructional design and testing online education programs. More research is needed to uncover potential gaps in nurses' wound care knowledge that may hamper evidence-based practices adoption and the need to develop effective, evidence-based education-delivery techniques.

Hyperspectral imaging in perfusion and wound diagnostics – methods and algorithms for the determination of tissue parameters

Blood perfusion is the supply of tissue with blood, and oxygen is a key factor in the field of minor and major wound healing. Reduced perfusion of a wound bed or transplant often causes various complications. Reliable methods for an objective evaluation of perfusion status are still lacking, and insufficient perfusion may remain undiscovered, resulting in chronic processes and failing transplants. Hyperspectral imaging (HSI) represents a novel method with increasing importance for clinical practice. Therefore, methods, software and algorithms for a new HSI system are presented which can be used to observe tissue oxygenation and other parameters that are of importance in supervising healing processes. This could offer an improved insight into wound perfusion allowing timely intervention.

Using reusable learning objects (RLOs) in wound care education: Undergraduate student nurse's evaluation of their learning gain

BACKGROUND

Both nationally and internationally concerns have been expressed over the adequacy of preparation of undergraduate nurses for the clinical skill of wound care. This project describes the educational evaluation of a series of Reusable Learning Objects (RLOs) as a blended learning approach to facilitate undergraduate nursing students learning of wound care for competence development. Constructivism Learning Theory and Cognitive Theory of Multimedia Learning informed the design of the RLOs, promoting active learner approaches. Clinically based case studies and visual data from two large university teaching hospitals provided the authentic learning materials required. Interactive exercises and formative feedback were incorporated into the educational resource.

METHODS

Evaluation of student perceived learning gains in terms of knowledge, ability and attitudes were measured using a quantitative pre and posttest Wound Care Competency Outcomes Questionnaire. The RLO CETL Questionnaire was used to identify perceived learning enablers. Statistical and deductive thematic analyses inform the findings.

RESULTS

Students (n=192) reported that their ability to meet the competency outcomes for wound care had increased significantly after engaging with the RLOs. Students rated the RLOs highly across all categories of perceived usefulness, impact, access and integration.

CONCLUSION

These findings provide evidence that the use of RLOs for both knowledge-based and performance-based learning is effective. RLOs when designed using clinically real case scenarios reflect the true complexities of wound care and offer innovative interventions in nursing curricula.

Automated measurement of pressure injury through image processing

AIMS AND OBJECTIVES

To develop an image processing algorithm to automatically measure pressure injuries using electronic pressure injury images stored in nursing documentation.

BACKGROUND

Photographing pressure injuries and storing the images in the electronic health record is standard practice in many hospitals. However, the manual measurement of pressure injury is time-consuming, challenging and subject to intra/inter-reader variability with complexities of the pressure injury and the clinical environment.

DESIGN

A cross-sectional algorithm development study.

METHODS

A set of 32 pressure injury images were obtained from a western Pennsylvania hospital. First, we transformed the images from an RGB (i.e. red, green and blue) colour space to a YC_b C_r colour space to eliminate inferences from varying light conditions and skin colours. Second, a probability map, generated by a skin colour Gaussian model, guided the pressure injury segmentation process using the Support Vector Machine classifier. Third, after segmentation, the reference ruler - included in each of the images - enabled perspective transformation and determination of pressure injury size. Finally, two nurses independently measured those 32 pressure injury images, and intraclass correlation coefficient was calculated.

RESULTS

An image processing algorithm was developed to automatically measure the size of pressure injuries. Both inter- and intra-rater analysis achieved good level reliability.

CONCLUSIONS

Validation of the size measurement of the pressure injury (1) demonstrates that our image processing algorithm is a reliable approach to monitoring pressure injury progress through clinical pressure injury images and (2) offers new insight to pressure injury evaluation and documentation.

RELEVANCE TO CLINICAL PRACTICE

Once our algorithm is further developed, clinicians can be provided with an objective, reliable and efficient computational tool for segmentation and measurement of pressure injuries. With this, clinicians will be able to more effectively monitor the healing process of pressure injuries.

Improved detection of clinically relevant wound bacteria using autofluorescence image-guided sampling in diabetic foot ulcers

Clinical wound assessment involves microbiological swabbing of wounds to identify and quantify bacterial species, and to determine microbial susceptibility to antibiotics. The Levine swabbing technique may be suboptimal because it samples only the wound bed, missing other diagnostically relevant areas of the wound, which may contain clinically significant bacteria. Thus, there is a clinical need to improve the reliability of microbiological wound sampling. To address this, a handheld portable autofluorescence (AF) imaging device that detects bacteria in real time, without contrast agents, was developed. Here, we report the results of a clinical study evaluating the use of real-time AF imaging to visualise bacteria in and around the wound bed and to guide swabbing during the clinical assessment of diabetic foot ulcers, compared with the Levine technique. We investigated 33 diabetic foot ulcers (n = 31 patients) and found that AF imaging more accurately identified the presence of moderate and/or heavy bacterial load compared with the Levine technique (accuracy 78% versus 52%, P = 0·048; adjusted diagnostic odds ratio 7·67, P < 0·00022 versus 3·07, P = 0·066) and maximised the effectiveness of bacterial load sampling, with no significant impact on clinical workflow. AF imaging may help clinicians better identify the wound areas with clinically significant bacteria, and maximise sampling of treatment-relevant pathogens.

Evaluation of the assessment and documentation of chronic wounds in residential social care in the Czech Republic

OBJECTIVE

Accurate evaluation of non-healing, chronic wounds followed by the selection of an appropriate therapeutic strategy is a must for the foundation of health-care management. Assessment of non-healing chronic wounds in clinical practice in the Czech Republic is not standardised in acute care settings or in residential social care facilities. The aim of the study was to analyse the methods being used to assess non-healing, chronic wounds in residential social services in the Czech Republic, where more patients with chronic wounds are present because of the increasing incidence of wounds in old age.

METHOD

The research was carried out at 66 residential social care institutions across all regions of the Czech Republic. A mixed model was used for the research (participatory observation including creation of field notes and content analysis of documents for documentation and analysis of qualitative and quantitative data). The same methodology was used in previous work which has been done in acute care settings in 2013.

RESULTS

The results of this research have corroborated the inconsistencies in procedures used by general nurses for assessment of non-healing, chronic wounds. However, the situation was found to be more positive with regard to the evaluation of basic/fundamental parameters of a wound (e.g. size, depth and location of the wound) compared with the evaluation of more specific parameters (e.g. exudate or signs of infection). This included not only the number of observed variables, but also the action taken. Both were improved when a consultant for wound healing was present.

CONCLUSION

An effective strategy for wound management depends on the method and scope of the assessment of non-healing, chronic wounds in place in clinical practice in observed facilities; improvement may be expected following the general introduction of 'non-healing, chronic wound assessment' algorithm.

The relationship among pressure ulcer risk factors, incidence and nursing documentation in hospital-acquired pressure ulcer patients in intensive care units

AIMS AND OBJECTIVES

To explore the quality/comprehensiveness of nursing documentation of pressure ulcers and to investigate the relationship between the nursing documentation and the incidence of pressure ulcers in four intensive care units.

BACKGROUND

Pressure ulcer prevention requires consistent assessments and documentation to decrease pressure ulcer incidence. Currently, most research is focused on devices to prevent pressure ulcers. Studies have rarely considered the relationship among pressure ulcer risk factors, incidence and nursing documentation. Thus, a study to investigate this relationship is needed to fill this information gap.

DESIGN

A retrospective, comparative, descriptive, correlational study.

METHOD

A convenience sample of 196 intensive care units patients at the selected medical centre comprised the study sample. All medical records of patients admitted to intensive care units between the time periods of September 1, 2011 through September 30, 2012 were audited. Data used in the analysis included 98 pressure ulcer patients and 98 non-pressure ulcer patients. The quality and comprehensiveness of pressure ulcer documentation were measured by the modified European Pressure Ulcer Advisory Panel Pressure Ulcers Assessment Instrument and the Comprehensiveness in Nursing Documentation instrument.

RESULT

The correlations between quality/comprehensiveness of pressure ulcer documentation and incidence of pressure ulcers were not statistically significant. Patients with pressure ulcers had longer length of stay than patients without pressure ulcers stay. There were no statistically significant differences in quality/comprehensiveness scores of pressure ulcer documentation between dayshift and nightshift.

CONCLUSION

This study revealed a lack of quality/comprehensiveness in nursing documentation of pressure ulcers. This study demonstrates that staff nurses often perform poorly on documenting pressure ulcer appearance, staging and treatment. Moreover, nursing documentation of pressure ulcers does not provide a complete picture of patients' care needs that require nursing interventions.

RELEVANCE TO CLINICAL PRACTICE

The implication of this study involves pressure ulcer prevention and litigable risk of nursing documentation.

Non-healing foot ulcers in diabetic patients: general and local interfering conditions and management options with advanced wound dressings

Medical knowledge about wound management has improved as recent studies have investigated the healing process and its biochemical background. Despite this, foot ulcers remain an important clinical problem, often resulting in costly, prolonged treatment. A non-healing ulcer is also a strong risk factor for major amputation. Many factors can interfere with wound healing, including the patient's general health status (i.e., nutritional condition indicated by albumin levels) or drugs such as steroids that can interfere with normal healing. Diabetic complications (i.e., renal insufficiency) may delay healing and account for higher amputation rates observed in diabetic patients under dialysis treatment. Wound environment (e.g., presence of neuropathy, ischaemia, and infection) may significantly influence healing by interfering with the physiological healing cascade and adding local release of factors that may worsen the wound. The timely and well-orchestrated release of factors regulating the healing process, observed in acute wounds, is impaired in non-healing wounds that are blocked in a chronic inflammatory phase without progressing to healing. This chronic phase is characterised by elevated protease activity (EPA) of metalloproteinases (MMPs) and serine proteases (e.g., human neutrophil elastase) that interfere with collagen synthesis, as well as growth factor release and action. EPA (mainly MMP 9, MMP-8 and elastase) and inflammatory factors present in the wound bed (such as IL-1, IL-6, and TNFa) account for the catabolic state of non-healing ulcers. The availability of wound dressings that modulate EPA has added new therapeutic options for treating non-healing ulcers. The literature confirms advantages obtained by reducing protease activity in the wound bed, with better outcomes achieved by using these dressings compared with traditional ones. New technologies also allow a physician to know the status of the wound bed environment, particularly EPA, in a clinical setting. These may be helpful in guiding a clinician's options in treating very difficult-to-heal ulcers.

Assessment and documentation of non-healing, chronic wounds in inpatient health care facilities in the Czech Republic: an evaluation study

The foundation of health care management of patients with non-healing, chronic wounds needs accurate evaluation followed by the selection of an appropriate therapeutic strategy. Assessment of non-healing, chronic wounds in clinical practice in the Czech Republic is not standardised. The aim of this study was to analyse the methods being used to assess non-healing, chronic wounds in inpatient facilities in the Czech Republic. The research was carried out at 77 inpatient medical facilities (8 university/faculty hospitals, 63 hospitals and 6 long- term hospitals) across all regions of the Czech Republic. A mixed model was used for the research (participatory observation including creation of field notes and content analysis of documents for documentation and analysis of qualitative and quantitative data). The results of this research have corroborated the suspicion of inconsistencies in procedures used by general nurses for assessment of non-healing, chronic wounds. However, the situation was found to be more positive with regard to evaluation of basic/fundamental parameters of a wound (e.g. size, depth and location of a wound) compared with the evaluation of more specific parameters (e.g. exudate or signs of infection). This included not only the number of observed variables, but also the action taken. Both were significantly improved when a consultant for wound healing was present (P = 0·047). The same applied to facilities possessing a certificate of quality issued by the Czech Wound Management Association (P = 0·010). In conclusion, an effective strategy for wound management depends on the method and scope of the assessment of non-healing, chronic wounds in place in clinical practice in observed facilities; improvement may be expected following the general introduction of a 'non-healing, chronic wound assessment' algorithm.

Point-of-care autofluorescence imaging for real-time sampling and treatment guidance of bioburden in chronic wounds: first-in-human results

Background

Traditionally, chronic wound infection is diagnosed by visual inspection under white light and microbiological sampling, which are subjective and suboptimal, respectively, thereby delaying diagnosis and treatment. To address this, we developed a novel handheld, fluorescence imaging device (PRODIGI) that enables non-contact, real-time, high-resolution visualization and differentiation of key pathogenic bacteria through their endogenous autofluorescence, as well as connective tissues in wounds.

Methods and Findings

This was a two-part Phase I, single center, non-randomized trial of chronic wound patients (male and female, ≥18 years; UHN REB #09-0015-A for part 1; UHN REB #12-5003 for part 2; clinicaltrials.gov Identifier: NCT01378728 for part 1 and NCT01651845 for part 2). Part 1 (28 patients; 54% diabetic foot ulcers, 46% non-diabetic wounds) established the feasibility of autofluorescence imaging to accurately guide wound sampling, validated against blinded, gold standard swab-based microbiology. Part 2 (12 patients; 83.3% diabetic foot ulcers, 16.7% non-diabetic wounds) established the feasibility of autofluorescence imaging to guide wound treatment and quantitatively assess treatment response. We showed that PRODIGI can be used to guide and improve microbiological sampling and debridement of wounds in situ, enabling diagnosis, treatment guidance and response assessment in patients with chronic wounds. PRODIGI is safe, easy to use and integrates into the clinical workflow. Clinically significant bacterial burden can be detected in seconds, quantitatively tracked over days-to-months and their biodistribution mapped within the wound bed, periphery, and other remote areas.

Conclusions

PRODIGI represents a technological advancement in wound sampling and treatment guidance for clinical wound care at the point-of-care.

Trial Registration

ClinicalTrials.gov NCT01651845; ClinicalTrials.gov NCT01378728

An unexpected presentation of a traumatic wound on the lower lip: a case report

Introduction

Traumatic lip injuries present major challenges in terms of reconstructive options and the outcome of surgical management. The aetiology of lip injuries includes human bite as interpersonal violence. Bite wounds are always considered to be complex injuries contaminated with unique polymicrobial inoculum. A classification of facial bite injuries has been included and the surgical management of these lesions has also been discussed. We report a rare bite injury on the lower lip that resembled an ulcerative process.

Case presentation

A 30-year-old African man presented with a severe tissue defect on his lower lip to a Dental and Oral Department in Tanzania. He explained that 12 days ago he had been involved in a fight and someone had bitten his lower lip. An orofacial examination confirmed a serious loss of lip tissue that resembled a chronic ulcerative process. Accurate assessment of the lesion was made by a thorough evaluation of some parameters such as size, depth, presence of granulation tissue, fibrin coverage, wound edges, exudates and/or necrosis. A surgical debridement under local anaesthesia was carried out. Afterwards a layered suture was performed. Eventually the healing was complete and satisfactory.

Conclusions

A severe bite avulsive wound on the lower lip, despite the elapsed time before treatment, may have an excellent prognosis after a simple surgical procedure.

Nutrition-related status and granulation tissue colour of pressure ulcers evaluated by digital image analysis in older patients

OBJECTIVE

Granulation tissue colour may be an indicator for nutritional assessment in pressure ulcer (PU) care. This study evaluated the relationship between nutritional status, anaemia and diabetes, and granulation tissue colour of PUs by colour analysis of digital photographs in the clinical setting.

METHOD

The cross-sectional study included 42 older patients with 51 full-thickness PUs from 10 institutions. Patient demographics, wound status, nutritional status and dietary intakes were obtained from medical charts. From a wound image, the granulation red index was processed by computer software and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (%GRI80) was calculated.

RESULTS

Haemoglobin levels were positively associated with %GRI80 levels (p=0.007) in the crude model, but not in the adjusted model (p=0.260). The interaction term between diabetes and protein intake was significantly associated with %GRI80 levels in the adjusted models (p=0.010). At protein intakes of 0.95 g/kg or higher, diabetic wounds exhibited lower %GRI80 levels than non-diabetic wounds (p=0.002). At protein intakes of less than 0.95 g/kg, %GRI80 levels did not differ between diabetic and non-diabetic patients (p=0.247). Protein intakes of 0.95 g/kg or higher were associated with higher %GRI80 levels in non-diabetic patients (p=0.015), but not in diabetic patients (p=0.127).

CONCLUSION

Granulation tissue colour, evaluated by the objective and quantitative analysis of digital photography, is related to haemoglobin level, diabetes and dietary intakes in clinical settings.

An audit to assess the perspectives of U.S. wound care specialists regarding the importance of proteases in wound healing and wound assessment

Chronic wounds represent an aberrant biochemistry that creates a toxic proteolytic milieu which can be detrimental to the healing process. Rebalancing the wound microenvironment and addressing elevated protease activity (EPA) could therefore help facilitate healing. To understand how clinicians currently diagnose and manage excessive proteolytic activity, 183 survey responses from US wound specialists were collated and analysed to find out their perceptions on the role of proteases. The majority of respondents (>98%) believed proteases were important in wound healing and that a point-of-care (POC) protease test could be useful. This study yielded a low response rate (7.1%, n = 183); however, there were adequate data to draw significant conclusions. Specialists perceived that fibrin, slough, granulation tissue and rolled wound edges could indicate EPA. About 43% of respondents, however, failed to give a correct response when asked to review photographs to determine if excessive protease activity was present, and the perceived visual signs for EPA did not correlate with the wounds that had EPA; no statistical differences between professions were observed. Respondents chose debridement, wound cleansing and advanced therapies as important in reducing excessive protease activity. It was concluded that specialists have a need for POC diagnostic tests. On the basis of the responses to wound photos, it was determined that there were no visual cues clinicians could use in determining excessive protease activity. Additional research is recommended to evaluate the efficacy of a POC diagnostic test for protease activity and the treatments and therapies applied when EPA is found.

Concurrent validation and reliability of digital image analysis of granulation tissue color for clinical pressure ulcers

Granulation tissue color is one indicator for pressure ulcer (PU) assessment. However, it entails a subjective evaluation only, and quantitative methods have not been established. We developed color indicators from digital image analysis and investigated their concurrent validity and reliability for clinical PUs. A cross-sectional study was conducted on 47 patients with 55 full-thickness PUs. After color calibration, a wound photograph was converted into three images representing red color: erythema index (EI), modified erythema index with additional color calibration (granulation red index [GRI]), and , which represents the artificially created red-green axis of L(*) a(*) b(*) color space. The mean intensity of the granulation tissue region and the percentage of pixels exceeding the optimal cutoff intensity (% intensity) were calculated. Mean GRI (ρ=0.39, p=0.007) and (ρ=0.55, p<0.001), as well as their % intensity indicators, showed positive correlations with a(*) measured by tristimulus colorimeter, but erythema index did not. They were correlated with hydroxyproline concentration in wound fluid, healthy granulation tissue area, and blood hemoglobin level. Intra- and interrater reliability of the indicator calculation using both GRI and had an intraclass correlation coefficient >0.9. GRI and from digital image analysis can quantitatively evaluate granulation tissue color of clinical PUs.