Patricio Meneses

Evaluation of Clinical Effectiveness of Mist Ultrasound Therapy for the Healing of Chronic Wounds

OBJECTIVES: (1) To determine the incidence of wound closure for chronic nonhealing lower extremity wounds of various etiologies using MIST ultrasound therapy, a 510(K)-approved, low-frequency, noncontact ultrasound device indicated for the cleansing and debridement of chronic wounds. (2) To determine the optimum treatment duration for therapy with this low-frequency, noncontact ultrasound device, quantifying end points that correlate with a maximal clinical response and identifying potential synergistic therapies that could be used in conjunction with this therapy. (3) To analyze the impact of low-frequency noncontact ultrasound therapy on the microcirculatory flow patterns within the wound bed. DESIGN: A noncomparative clinical outcomes trial utilizing low-frequency, noncontact ultrasound. SETTING: A tertiary-referral hospital-based wound clinic. PATIENTS: Twenty-three patients from a single tertiary-referral hospital-based wound clinic. Control data were obtained from a previously published, prospectively collected database from the same clinic. INTERVENTIONS: During an 8-month period, a total of 29 lower extremity wounds in 23 patients who met criteria for inclusion were treated with low-frequency, noncontact ultrasound therapy. Standard of care was provided for 2 weeks for all wounds screened for the study. A failure to achieve an area reduction greater than 15% qualified the patient for enrollment to the trial and the addition of low-frequency, noncontact ultrasound therapy to the current treatment regimen. MAIN OUTCOME MEASURES: Wound healing, area and volume reduction, and laser Doppler-derived mean voltage (a marker for microcirculatory flow) are the main outcome measures for the study. RESULTS: Overall, 69% of the wounds in the study were healed using an intent-to-treat model. When low-frequency, noncontact ultrasound was used as a stand-alone device, median time to healing was 7 weeks. Historic controls were healed with a median time to healing of 10 weeks; however, a statistically significant number of these patients required wound-related hospitalization and surgical procedures to achieve closure compared with the wounds in the present study. CONCLUSIONS: Treatment with low-frequency, noncontact ultrasound achieved healing in chronic wounds when used as a stand-alone device or in combination with moist wound care in 69% of cases. Response to low-frequency, noncontact ultrasound was evident within 4 weeks of therapy. Earlier transition to secondary procedures and decreased utilization of inpatient care might result in more cost-effective wound healing than the current standard of care. A well-designed health economic-based trial is warranted to assess this technology.

Algal phospholipids by 31P NMR: Comparing isopropanol pretreatment with simple chloroform/methanol extraction

1. A modified Folch procedure [potassium (ethylenedinitrilo)-tetraacetic acid at pH 6 substituted for KCl] is suitable for the extraction of marine algae. 2. The quantitative 31P nuclear magnetic resonance phospholipid profiles of four marine algae, Gracilaria verrucosa, Bryothamnion triquetrum, Padina gymnospora, and Caulerpa sertularioides, were obtained from Folch and Nichols extractions of both fresh and dried algae, and essentially identical results were obtained using either extraction procedure. 3. Extracts of air-dried algae are statistically different when compared to extracts of living algae, suggesting that tissue handling is a critical factor in phospholipid extractions.

Comparison of membrane phospholipids of the rabbit and pig crystalline lens

Crystalline lenses excised from 5-7-month-old rabbits and pigs were extracted for lipids with chloroform/methanol, 2/1 using the Folch method. The extracted crude lipids were analyzed at 202 MHz by 31P-NMR spectroscopy. Twelve membrane phospholipids were detected. Both rabbit and pig phospholipid profiles contained phosphatidylcholine (PC), lysophosphatidylcholine, phosphatidylcholine plasmalogen, phosphatidylethanolamine (PE), phosphatidylethanolamine plasmalogen (PE plas), phosphatidylserine, sphingomyelin (SPH), and an uncharacterized phospholipid. In addition, pig lens profiles contained lysophosphatidylethanolamine, phosphatidylinositol, cardiolipin and phosphatidylglycerol. The data indicate that these two animal models have significant differences in membrane phospholipid profiles. In each species, however, the bulk phospholipid component resides in the neutral phospholipids PC, PE, PE plas, and SPH.

Current Status of the Use of Modalities in Wound Care: Electrical Stimulation and Ultrasound Therapy

Summary: Wound healing is a complex pathway that requires cells, an appropriate biochemical environment (i.e., cytokines, chemokines), an extracellular matrix, perfusion, and the application of both macrostrain and microstrain. The process is both biochemically complex and energy dependent. Healing can be assisted in difficult cases through the use of physical modalities. In the current literature, there is much debate over which treatment modality, dosage level, and timing is optimal. The mechanism of action for both electrical stimulation and ultrasound are reviewed along with possible clinical applications for the plastic surgeon.

Effects of exercise training and anabolic steroids on plantaris and soleus phospholipids: A 31P nuclear magnetic resonance study

1. The purpose of this study was to examine the effect of exercise, anabolic steroid treatment, and a combination of both treatments on the phospholipid composition of predominantly fast twitch (plantaris) and slow twitch (soleus) skeletal muscles. The 4 experimental groups analyzed were sedentary control (C), steroid-treated (S), exercise-trained (E), and exercise plus steroid-treated (ES). 2. Among the 11 phospholipids quantitated, for the plantaris muscle, phosphatidylcholine was reduced in ES relative to C, while phosphatidylethanolamine and phosphatidylethanolamine plasmalogen were elevated in E and ES relative to C. For the soleus muscle, phosphatidylserine was reduced in S and E relative to C, and cardiolipin was elevated in E relative to C. 3. Of the 27 metabolic indices calculated for the plantaris, 15 changed significantly among E and ES relative to S and C, while for the soleus, only three indices changed among the four groups, two among E and ES relative to S and C and one between S and C. 4. For the plantaris muscle, the results are consistent with an exercise-induced alteration of membrane phospholipid composition that increases ion translocation activity. For the soleus muscle, this membrane alteration essentially does not take place. 5. Steroid treatment had little to no statistically significant effect on plantaris and soleus muscle phospholipid systems, regardless of the imposed regimen.

Human sciatic nerve phospholipid profiles from non-diabetes mellitus, non-insulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus individuals. A 31P NMR spectroscopy study

1. Human sciatic nerve phospholipids obtained from non-diabetes mellitus (NDM), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) patients, after lower extremity amputation, were studied by 31P NMR spectrometry. 2. Nine phospholipids resonances in NDM and NIDDM groups were identified as followed: Ethanolamine plasmalogen (Eplas, Chemical shift = 0.07 delta); phosphatidylethanolamine (PE, 0.03 delta); phosphatidylserine (PS, -0.05 delta); sphingomyelin (SM, -0.09 delta); lysophosphatidylcholine (LPC, -0.28 delta); phosphatidylinositol (PI, -0.30 delta); alkylacylphosphorylcholine (A1.PC, -0.78 delta); phosphatidylcholine (PC -0.84 delta), and an unknown resonance (U, 0.13 delta). 3. In the IDDM group a resonance of lysophosphatidylinositol (LPI, 0.01 delta) was detected in addition to the nine phospholipids listed above. 4. IDDM showed that PI and A1.PC were elevated and U was lower when compared with NDM; also, Eplas was lower when compared with NIDDM. PC was elevated and PS was lower when compared with both NDM and NIDDM. 5. Indices calculated from this data, showed that the choline ratio and choline/ethanolamine ratio were elevated; while ethanolamine ratio, and myelin ratio were lower in IDDM group, when compared with both NDM and NIDDM groups. 6. Inactivation of the cholineacethyltransferase enzyme (ChAT) and enhancement of the phospholipidmethyltransferase enzyme (PLMT), secondary to an insulin deficiency, are proposed as an interpretation of these findings.

Wound care specialization: A proposal for a comprehensive fellowship program

This article represents a process paper describing the development, at our facility, of a wound care fellowship that was scheduled to begin in July of 2003. The proposed program is in no way a finished product or our statement of how the program must be. This article is presented as a call to wound care professionals for input, criticism, guidance, and—we hope—adoption and acceptance of wound care fellowships in some format in the future. After many years of work in this field, it has become apparent that without medical specialization wound care will never rise from its current status of part‐time avocation to full‐time occupation. After a brief background and description of the present status of wound care education, an initial curriculum, program objectives, and clinical rotation schedule are presented. We look forward to the day when this program will have been replaced with a fully accredited, readily accepted, board‐certifiable fellowship program with all the rights and responsibilities afforded the other medical specialties.

Push–pull theory: Using mechanotransduction to achieve tissue perfusion and wound healing in complex cases

Wound healing has evolved from gauze therapy to the use of proteomics, gene therapy, and cellular-based therapies in the short time span of 45 years. Education for health care providers has not kept pace with the logarithmic acceleration in technology development and treatment options. A patient with a non-healing wound requires a comprehensive work-up, including a focus on six primary points of interest. These points include the status of tissue perfusion, role of bacterial contamination, pressure applied to the tissue, the immune status of the host, co-morbid medical conditions including the patients psychosocial status, and lastly, the status of the wound itself. Even after re-establishing macrovascular flow, many wounds either fail to improve or paradoxically worsen. Potential mechanisms for these unexpected findings include reperfusion injury, no-reflow, and the presence of stunned/hibernating tissue. Using the concept of mechanotransduction, the clinician can simulate normal pulsatile blood flow and re-establish adequate microvascular perfusion. Treatment regimens may include negative pressure therapy, electrical stimulation, ultrasound therapy, and other energy-based modalities.

Effects of Moist-Chamber and McCarey-Kaufman Medium Storage on the Metabolic Status of the Cornea: A 31P-Magnetic Resonance Analysis

The rate of change in concentration of corneal phosphatic metabolites of cat corneas stored in moist chamber and McCarey-Kaufman (M-K) medium was determined in order to provide a basis for prediction of the corneal metabolic status at a given storage time. Perchloric acid corneal extracts were examined by phosphorus-31 magnetic resonance after storage at 4 degrees C of whole globes under moist-chamber conditions up to 48 h and of excised corneas in M-K medium up to 168 h. A significant decline in the corneal concentrations of ATP and a significant increase in inorganic phosphate occurred for both storage methods; however, depending on the metabolite, the rate of decline or increase was significantly greater for the moist-chamber-stored corneas. The phosphorylated sugars significantly increased and the glycerophosphodiesters significantly decreased in the moist-chamber-stored corneas, whereas both metabolites remained unchanged in the M-K-medium-stored corneas. There was no significant change in the dinucleotides and nucleoside diphospho-sugars during the time course for both storage methods. A threefold greater rate of decline was noted in the tissue energy modulus for the moist-chamber-stored corneas than for the M-K-medium-stored corneas (-0.0465 vs. -0.0121 modulus values/h). M-K medium was significantly more effective in the maintenance of high-energy phosphatic metabolites. The mathematical model for these rate determinations provides a basis for prediction of the corneal metabolic status at a given time in moist-chamber or M-K medium storage.

pH of organ-culture-stored corneas

Abstract Changes in intracorneal and storage‐medium pH values of organ‐culture‐stored cat corneas were monitored over a 4‐week period. The intracorneal pH was determined using the phosphorus‐31 magnetic resonance spectroscopy (31P MRS) chemical shift of inorganic orthophosphate in conjunction with a standard pH titration curve. We incubated 32 adult cat corneas using two similar standard organ‐culture methods, one with chondroitin sulfate (method 1) and the other without (method 2). Time‐course data at 0, 1, 3 and 4 weeks of storage were used to calculate the rate of pH change. The intracorneal pH was not changed significantly for either organ‐culture method; however, the storage‐medium pH rate of change declined significantly for both methods (method 1, 0.15 pH units/week; method 2, 0.12 pH units/week). The difference between intracorneal and storage‐medium pH values over time increased at a rate of 0.12 and 0.11 pH units/week for method 1 and method 2, respectively. The declining storage‐medium pH in conjunction with the maintenance of intracorneal pH contributes to an increased metabolic demand on the cornea.