Karen L. Andrews

Pressure Ulcers: Prevention and Management

OBJECTIVE To describe important aspects of pressure ulcer prevention and management, especially in elderly patients. DESIGN We reviewed pertinent published material in the medical literature and summarized effective strategies in the overall management of the elderly population with pressure ulcers. RESULTS Pressure ulcers are commonly encountered in geriatric patients. The development of a pressure ulcer is associated with an increased risk of death. Certain well-recognized risk factors, such as immobility and incontinence, may predispose to the development of pressure ulcers; consequently, risk factor modification is an important aspect of prevention and treatment. For existing lesions, various innovative patient support surfaces and wound care products have been developed to alleviate pressure and to facilitate wound healing. The use of a particular product should be based on the clinical setting and the limited scientific evidence available. With treatment, most pressure ulcers eventually heal. CONCLUSION Pressure ulcers are often, but not always, preventable. The occurrence of such an ulcer signals the possible presence of chronic comorbid disease and should prompt a search for underlying risk factors in patients for whom ulcer treatment is considered appropriate.

Expedited Wound Healing with Noncontact, Low-frequency Ultrasound Therapy in Chronic Wounds: A Retrospective Analysis

OBJECTIVE: To evaluate the clinical role of noncontact, low-frequency ultrasound therapy (MIST Therapy System; Celleration, Eden Prairie, Minnesota) in the treatment of chronic lower-extremity wounds. DESIGN: A retrospective observational study. SETTING: A multidisciplinary, vascular wound-healing clinic. PATIENTS: One hundred sixty-three patients who received MIST Therapy plus standard of care (treatment group) and 47 patients who received the standard of care alone (control group). INTERVENTIONS: All wounds in the control and treatment groups received the standard of wound care and were followed for 6 months. In the treatment group, MIST Therapy was administered to wounds 3 times per week for 90 days or until healed. MAIN OUTCOME MEASURES: Proportion of wounds healed and wound volume reduction. Rate of healing was also quantified using 1-way analysis of variance to determine the slope of the regression line from starting volume to ending volume, where a steeper slope indicates a faster healing rate. Outcomes were evaluated in all wounds and etiology-specific subgroups. MAIN RESULTS: A significantly greater percentage of wounds treated with MIST Therapy and standard of care healed as compared with those treated with the standard of care alone (53% vs 32%; P = 0.009). The slope of the regression line in the MIST arm (1.4) was steeper than the slope in the control arm (0.22; P = .002), indicating a faster rate of healing in the MIST-treated wounds. CONCLUSION: The rate of healing and complete closure of chronic wounds in patients improved significantly when MIST Therapy was combined with standard wound care.

Bladder Dysfunction and Management in Multiple Sclerosis

Symptomatic bladder dysfunction occurs at some time in most patients with multiple sclerosis. The relapsing-remitting course and progressive loss of mobility associated with multiple sclerosis make management of urinary urgency and incontinence difficult. Urodynamic evaluation serves as a guideline for appropriate treatment. After accurate diagnosis of bladder dysfunction, a management program is developed with use of fluid schedules, voiding techniques, neuropharmacologic manipulation, intermittent catheterization, surgical treatment, and other adjunctive measures as indicated. The goals of treatment are to protect and preserve renal function, relieve symptomatic voiding dysfunction, and avoid subsequent urinary complications. A management program should be individualized, dynamic, and monitored with periodic, systematic urologic review to maintain these goals.

Urinary Incontinence in the Elderly Population

OBJECTIVE To describe the causes, evaluation, and management of urinary incontinence in the elderly population. DESIGN We reviewed pertinent articles in the medical literature and summarized the types of incontinence and contributing factors. RESULTS Urinary incontinence is common in elderly patients and often has a major role in determining whether a person can remain independent in the community or requires nursing home placement. Urinary incontinence is not a single entity but rather several different conditions, each with specific symptoms, findings on examination, and recommended treatment. Thus, accurate classification is important for appropriate management. Because of the complexity of urinary incontinence, many physicians are uncomfortable with undertaking assessment and treatment. Hence, many patients are not asked about incontinence, and the condition remains untreated and often considered a natural consequence of the aging process. Urinary incontinence can be treated and either cured or alleviated with treatment. CONCLUSION Elderly patients should be asked about symptoms of urinary incontinence because appropriate assessment and treatment can usually provide relief.

Wound management of chronic diabetic foot ulcers: from the basics to regenerative medicine.

Background: Hospital-based studies have shown that mortality rates in individuals with diabetic foot ulcers are about twice those observed in individuals with diabetes without foot ulcers. Objective: To assess the etiology and management of chronic diabetic foot ulcers. Study design: Literature review. Methods: Systematic review of the literature discussing management of diabetic foot ulcers. Since there were only a few randomized controlled trials on this topic, articles were selected to attempt to be comprehensive rather than a formal assessment of study quality. Results: Chronic nonhealing foot ulcers occur in approximately 15% of patients with diabetes. Many factors contribute to impaired diabetic wound healing. Risk factors include peripheral neuropathy, peripheral arterial disease, limited joint mobility, foot deformities, abnormal foot pressures, minor trauma, a history of ulceration or amputation, and impaired visual acuity. With the current treatment for nonhealing diabetic foot ulcers, a significant number of patients require amputation. Conclusion: Diabetic foot ulcers are optimally managed by a multidisciplinary integrated team. Offloading and preventative management are important. Dressings play an adjunctive role. There is a critical need to develop novel treatments to improve healing of diabetic foot ulcers. The goal is to have wounds heal and remain healed. Clinical relevance Diabetic neuropathy and peripheral arterial disease are major factors involved in a diabetic foot ulcer. Despite current treatment modalities for nonhealing diabetic foot ulcers, there are a significant number of patients who require amputations. No known therapy will be effective without concomitant management of ischemia, infection, and adequate offloading.

Noninvasive arterial studies including transcutaneous oxygen pressure measurements with the limbs elevated or dependent to predict healing after partial foot amputation.

ObjectiveNoninvasive arterial studies have been used to determine level of amputation. The objective of this study was to examine each component of the noninvasive arterial studies to determine optimal cut points to predict healing and to evaluate whether physiologic maneuvers could improve the utility of transcutaneous oxygen pressure (TcPO2) values to predict healing of partial foot amputation. DesignThe authors conducted a retrospective, observational study of 307 patients who underwent partial foot amputation and had noninvasive arterial studies in the perioperative period. ResultsThe TcPO2 values were significantly predictive of healing. Specifically, a cut point TcPO2 value of 38 mm Hg had a sensitivity and a specificity of 71% for predicting healing or failure. The optimal cut point was mostly unaffected by patient characteristics. The addition of noninvasive arterial studies recorded in a position with the limb elevated improved prediction in the subgroup with supine TcPO2 values of 38 mm Hg or lower. ConclusionsThe findings of this study validate previous reports and confirm that TcPO2 measurements are valuable to more accurately determine the correct amputation level and, in turn, obtain better outcomes. TcPO2 measurements may provide better prognostic value than do ankle-brachial indices for healing after partial foot amputation. TcPO2 measurements are useful but should not be used in isolation to make treatment decisions regarding amputation level.

The at-risk foot: What to do before and after amputation

The best predicator of amputation is a history of previous amputation. A history of lower extremity ulceration or amputation increases the risk for further ulceration, infection, and subsequent amputation. Early diagnosis, control of risk factors, medical management, and timely revascularization may aid in avoiding limb loss. Treatment combines patient education, orthoses, footwear, and off-loading. Patients at risk should understand the implications of loss of protective sensation, the importance of carefully monitoring their feet, proper care of the foot, and always wearing protective footwear. It is important to control risk factors, protect the limb, recognize early signs of inflammation, and optimize wound care. Lower extremity amputation is a common outcome for patients with an at-risk foot. Amputation may be the best option to optimize function.

The SoftHand Pro: Translation from Robotic Hand to Prosthetic Prototype

This work presents the translation from a humanoid robotic hand to a prosthetic prototype and its first evaluation in a set of 9 persons with amputation. The Pisa/IIT SoftHand is an underactuated hand built on the neuroscientific principle of motor synergies enabling it to perform natural, human-like movements and mold around grasped objects with minimal control input. These features motivated the development of the SoftHand Pro, a prosthetic version of the SoftHand built to interface with a prosthetic socket. The results of the preliminary testing of the SoftHand Pro showed it to be a highly functional design with an intuitive control system. Present results warrant further testing to develop the SoftHand Pro.

Adapting Lymphedema Treatment to the Palliative Setting

Objective: To review the benefits of adapting the complex techniques of formal lymphedema therapy to the more generalized forms of edema often seen in the chronic disease and palliative care settings. Data Sources: Peer-reviewed literature and clinical practice. Conclusion: Lymphedema treatment modalities have much to offer beyond their well-characterized benefit in classical lymphedema. In modified forms, they may improve and lessen the burden of refractory edema originating from a diverse range of causes. Thoughtful planning and practice, however, are essential as an inadequate adaptation may result in unnecessary effort, injury for the patient, or an unsatisfactory outcome.

The Use of Elevation and Dependency to Enhance the Predictive Value of Transcutaneous Oxygen Pressure Measurements in the Assessment of Foot Amputation Healing

To determine whether transcutaneous oxygen pressure (TcPO2) measurements taken while the patient is supine, with the limb elevated, and/or with the limb dependent (below the level of the heart) can be used to predict the healing of partial‐foot amputations.