Abstract: Background. The evaluation and treatment of heel pressure injuries are a significant and expensive sequela of the aging population. Although the workup of patients with lower extremity tissue loss usually involves an assessment of the arterial blood flow by means of noninvasive vascular testing, the results may be misleading in patients with heel pressure injuries when the ankle-brachial index (ABI) does not provide direct information about perfusion of the rearfoot. The objective of this retrospective, observational investigation was to determine if noninvasive vascular testing provides accurate and reliable results in patients with heel pressure injuries. (more…)
By Pamela Anderson, MS, RN, APN-BC, CCRN, and Terri Townsend, MA, RN, CCRN-CMC, CVRN-BC
Jan Smith, age 59, is admitted to the coronary intensive care unit with an acute inferior myocardial infarction (MI). Recently diagnosed with hypertension and hyperlipidemia, she smokes a pack and a half of cigarettes daily. She reports she has always been healthy and can’t believe she has had a heart attack. (Note: Name is fictitious.)
On physical exam, the cardiologist finds decreased femoral pulses bilaterally and recommends immediate cardiac catheterization. Fortunately, primary percutaneous coronary intervention (PCI) is readily available at this hospital. PCI is the preferred reperfusion method when it can be provided by skilled cardiologists in a timely manner.(more…)
With this PDF, which you can download, you can have the interpretation of common noninvasive tests for lower extremity arterial disease at your fingertips.
Donna Sardina is Editor-in-Chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.
I recently visited an 83-year-old patient in the hospital after EMTs rushed her to the ER with an infected leg wound. Her ordeal started inconspicuously when she bumped into the sharp edge of a table and developed a small cut. The patient’s wound didn’t close, but she ignored it until she woke up in pain one morning two weeks after first injuring her leg. Her daughter called 911 after noticing angry, red skin discoloration and pus – both signs of an infection. Our medical team treated her with IV antibiotics and cleared up the infection, but the wound did not fully close until at least a month later, well after she was discharged from the hospital.
How different the story is when children get a cut. They may scream initially, but within days, the scab falls off, revealing new skin. Why was healing so delayed in my 83-year-old patient compared to a healthy child?
The answer is age. Decades of life slow down healing for most tissues, and wounds in skin can offer a window into why this slowdown occurs.
Three stages of wound healing
I am physician who studies how aging predisposes patients to diseases like diabetes and whether behavioral changes such as intermittent fasting may slow down aging. In order to understand why the skin wound in my older patient healed so slowly, it is important to first understand how wounds heal under the ideal conditions of youth.
The first stage is inflammation, essentially the body’s attempt to clean the wound. During the inflammatory phase, immune cells called phagocytes move into the wound, kill any contaminating bacteria, and ingest and dispose of dead cells and debris.
Inflammation sets the stage for the regenerative phase, where several processes work in concert to regrow damaged skin. Replacement skin cells are born when cells at the edge of the wound divide, while fibroblast cells lay down a supportive scaffolding called the extracellular matrix. This holds the new cells together. Any damaged supporting structures of the skin, such as the blood vessels that supply critical oxygen and nutrients, also need to regrow. The second stage effectively closes the wound and restores a protective barrier against bacteria.
Once the wound is fully closed, the remodeling phase will rebuild the tissue in a stronger way. Jpbarrass via Wikimedia Commons
The regenerative phase is a relatively quick, but tenuous fix – new skin is fragile. The final remodeling phase plays out over a couple of years as the new skin is progressively strengthened by several parallel processes. The extracellular matrix, which was initially laid down in a haphazard fashion, is broken down and replaced in a more durable way. Any residual cells from prior phases that are no longer needed – such as immune cells or fibroblasts – become inactive or die. In addition to strengthening the new skin, these collective actions also account for the tendency of scars to visibly fade with time.
One major way aging can derail the orderly and efficient progression through the stages of healing is through the health problems that stem from diseases of old age.
Diabetes is one example of a disease that is strongly associated with older age. One of the many ways that diabetes negatively affects healing is by causing blood vessels to narrow. As a consequence of inadequate circulation, crucial nutrients and oxygen do not reach the wound in sufficient quantities to fuel the second regenerative phase.
Diabetes is just one of many age-related diseases that disrupts normal processes in the body such as wound healing.
When cells divide more slowly – or when they stop dividing altogether due to senescence – skin becomes thinner. The replacement of fat cells, which form a cushioning layer under the skin, also declines with age. The skin of older patients is therefore more prone to injury in the first place.
Once an older person’s skin is injured, the skin has a harder time healing properly as well. Aging and senescent immune cells cannot defend against bacteria, and the risk of serious skin infection rises. Then in the regenerative stage, slow rates of cell division translate into slow skin regrowth. My patient exhibited all of these negative effects of age – her thin, almost translucent skin ruptured from a minor bump, became infected and took nearly two months to fully regrow.
But senescent cells are more than just dysfunctional bystanders. For reasons that are not yet fully understood, senescent cells release toxic byproducts that damage surrounding tissue and drive inflammation – even when there’s no bacterial threat present. Some of these byproducts can even accelerate senescence in neighboring cells. This suggests that intrinsic aging of cells is in essence contagious and senescent cells actively fuel an uncontrolled cycle of inflammation and tissue damage that further impedes successful regeneration and healing.
A whole body problem
As the most outwardly visible tissue of the body, the skin provides a window into why people heal more slowly with age, but all tissues can be injured and are susceptible to the effects of aging. Injuries may be small, repetitive and build up over time – like the effect of smoking on the lungs. Or they may be discrete and dramatic – such as the death of heart cells with a heart attack. Different tissues may heal in different ways. Yet all tissues share a sensitivity to the repercussions of an aging immune system and a decline in the ability to regrow dead or damaged cells.
Understanding why healing slows down with age is important, but my patient asked a very practical question that physicians often face in one form or another: “Doctor, what can you do for me?”
Unfortunately, current treatment of wounds is fairly old-fashioned and often ineffective. Some of the options available include wound dressing changes, antibiotics when the wound is infected or treatment in a high oxygen chamber when circulation is bad due to diabetes.
There is hope, though, that medicine can do better and that progress in understanding the aging process will lead to new therapies. Neutralizing senescent cells in mice, for example, improves a variety of age-associated diseases. While it is way too early to say that researchers have discovered the fountain of youth, I am optimistic for a future when physicians will bend the aging curve and make skin and other organs heal faster and better.
Hansen’s disease, also called leprosy, is treatable today – and that’s partly thanks to a curious tree and the work of a pioneering young scientist in the 1920s. Centuries prior to her discovery, sufferers had no remedy for leprosy’s debilitating symptoms or its social stigma.
This young scientist, Alice Ball, laid fundamental groundwork for the first effective leprosy treatment globally. But her legacy still prompts conversations about the marginalization of women and people of color in science today.
Alice Augusta Ball, born in Seattle, Washington, in 1892, became the first woman and first African American to earn a master’s degree in science from the College of Hawaii in 1915, after completing her studies in pharmaceutical chemistry the year prior.
After she finished her master’s degree, the college hired her as a research chemist and instructor, and she became the first African American with that title in the chemistry department.
Doctors now understand that leprosy, also called Hansen’s disease, is minimally contagious. But in 1865, the fear and stigma associated with leprosy led authorities in Hawaii to implement a mandatory segregation policy, which ultimately isolated those with the disease on a remote peninsula on the island of Molokai. In 1910, over 600 leprosy sufferers were living in Molokai.
Doctors had attempted to use nearly every remedy imaginable to treat leprosy, even experimenting with dangerous substances such as arsenicand strychnine. But the lone consistently effective treatment was chaulmoogra oil.
Chaulmoogra oil is derived from the seeds of the chaulmoogra tree. Health practitioners in India and Burma had been using this oil for centuries as a treatment for various skin diseases. But there were limitations with the treatment, and it had only marginal effects on leprosy.
The oil is very thick and sticky, which makes it hard to rub into the skin. The drug is also notoriously bitter, and patients who ingested it would often start vomiting. Some physicians experimented with injections of the oil, but this produced painful pustules.
Dr. Isabel Kerr, a European missionary, administering to a patient a chaulmoogra oil treatment in 1915, prior to the invention of the Ball Method. George McGlashan Kerr, CC BY
The Ball Method
If researchers could harness chaulmoogra’s curative potential without the nasty side effects, the tree’s seeds could revolutionize leprosy treatment. So, Hollmann turned to Ball. In a 1922 article, Hollmann documents how the 23-year-old Ball discovered how to chemically adapt chaulmoogra into an injection that had none of the side effects.
The Ball Method, as Hollmann called her discovery, transformed chaulmoogra oil into the most effective treatment for leprosy until the introduction of sulfones in the late 1940s.
In 1920, the Ball Method successfully treated 78 patients in Honolulu. A year later, it treated 94 more, with the Public Health Service noting that the morale of all the patients drastically improved. For the first time, there was hope for a cure.
Ball’s death meant she didn’t have the opportunity to publish her research. Arthur Dean, chair of the College of Hawaii’s chemistry department, took over the project.
Dean mass-produced the treatment and published a series of articles on chaulmoogra oil. He renamed Ball’s method the “Dean Method,” and he never credited Ball for her work.
Ball’s other colleagues did attempt to protect Ball’s legacy. A 1920 article in the Journal of the American Medical Association praises the Ball Method, while Hollmann clearly credits Ball in his own 1922 article.
Ball is described at length in a 1922 article in volume 15, issue 5, of Current History, an academic publication on international affairs. That feature is excerpted in a June 1941 issue of Carter G. Woodson’s “Negro History Bulletin,” referring to Ball’s achievement and untimely death.
Joseph Dutton, a well-regarded religious volunteer at the leprosy settlements on Molokai, further referenced Ball’s work in a 1932 memoir broadly published for a popular audience.
Historians such as Paul Wermager later prompted a modern reckoning with Ball’s poor treatment by Dean and others, ensuring that Ball received proper credit for her work. Following Wermager’s and others’ work, the University of Hawaii honored Ball in 2000 with a bronze plaque, affixed to the last remaining chaulmoogra tree on campus.
In 2019, the London School of Hygiene and Tropical Medicine added Ball’s name to the outside of its building. Ball’s story was even featured in a 2020 short film, “The Ball Method.”
The Ball Method represents both a scientific achievement and a history of marginalization. A young woman of color pioneered a medical treatment for a highly stigmatizing disease that disproportionately affected an already disenfranchised Indigenous population.
In 2022, then-Gov. David Ige declared Feb. 28 Alice Augusta Ball Day in Hawaii. It was only fitting that the ceremony took place on the Mānoa campus in the shade of the chaulmoogra tree.
American Nurse Today, Woundcare Advisor and Angelini present: Innovations in Wound Care: Case Studies Basic Wound Cleansing and use of Collagen in Diabetic Foot Ulcer
This 30-minute presentation featurea learning opportunities that will provide in-depth instruction and demonstration in wound care treatments. After this webinar, the learner will be able to:
Identify the role of proper wound cleansing
Discuss how to select and use non-toxic wound cleansers
Describe advantages of collagen for managing a chronic wound
Martha Kelso, RN, HBOT, CEO, WCP Wound Care Plus, LLC, is the founder and Chief Executive Officer of Wound Care Plus, LLC (WCP). As a visionary and entrepreneur in the field of mobile medicine, she has operated mobile wound care practices nationwide for many years. She enjoys educating on the art and science of wound healing and how practical solutions apply to healthcare professionals today. Martha enjoys being a positive change in healthcare impacting clients suffering from wounds and skin issues of all etiologies. Martha started her career as a Certified Nurse Aide at the age of 15 in Kansas before moving to Kansas City, MO to attend nursing school. Long Term Care nursing was her first love and her biggest challenge.
Introduction: Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures. (more…)
A new study shows a clear association between the prophylactic use of five-layer foam sacral dressings and reductions in pressure injury rates. Specifically, the study looked at the prophylactic use of Mölnlycke’s Mepilex® Border Sacrum dressing in the acute care setting over a six-year period (2010-2015). (more…)
For surgical collaboration; rural telemedicine, nurses and doctors at Hospitals use Google Glass. Indianapolis-based Hodei Technology is bringing Glass to hospitals in two different ways: as a tool for surgeons to teach, communicate, and collaborate (via a product called Ikasi) and, via a product called Gemini, as a new kind of telemedicine, which CEO Guy Mascaro describes as “first person point-of-view telepresence”.
A lot of people think Google Glass, the tech company’s experiment with augmented reality and wearable computing, died when the Glass Explorer program closed up shop in 2015. In fact, the technology has continued to find a home with enterprise applications, particularly in healthcare. (more…)
Safety and Efficacy Study of VM202 in the Treatment of Chronic Non-Healing Foot Ulcers. This study will assess the safety and efficacy of using gene therapy via intramuscular injections of the calf for patients with chronic non-healing foot ulcers.
The first patient has been dosed in a Phase III trial assessing ViroMed’s VM202, the first pivotal study of a gene therapy indicated for patients with nonhealing diabetic foot ulcers (NHU) and concomitant peripheral artery disease (PAD).
The Phase III trial (NCT02563522) is a double-blind, placebo-controlled, multicenter study designed to evaluate VM202 for safety and efficacy in 300 adults with a diabetic foot ulcer and concomitant PAD. Two hundred patients will be randomized to VM202 and the other 100 to placebo, ViroMed’s U.S. division VM BioPharma said yesterday. (more…)
AlloFuse® Select CM – clinically proven to activate and support bone formation and can be used in a variety of spinal, neurologic, and orthopedic procedures.
AlloSource, one of the nation’s largest providers of cartilage, bone, skin, soft-tissue, and cellular allografts to advance patient healing in surgical procedures and wound care, today announced the release of AlloFuse® Select CM, a premium addition to AlloSource’s AlloFuse portfolio. (more…)
A new patient resource has launched in the UK offering primary care healthcare professionals (HCPs) the opportunity to help patients self-care for their wounds and minimise scarring.
The new patient booklet resource, ‘Supporting you to care for wounds and to minimise scarring’, created with help from expert Dermatologist, Justine Hextall, and supported by Bio-Oil, has been developed following research demonstrating the the frequency that HCP’s are required to provide support to patients in primary care, with one in five (20%) being asked for advice on a weekly basis. (more…)
Martha Kelso, RN, HBOT, CEO, WCP Wound Care Plus, LLC, is the founder and Chief Executive Officer of Wound Care Plus, LLC (WCP). As a visionary and entrepreneur in the field of mobile medicine, she has operated mobile wound care practices nationwide for many years. She enjoys educating on the art and science of wound healing and how practical solutions apply to healthcare professionals today. Martha enjoys being a positive change in healthcare impacting clients suffering from wounds and skin issues of all etiologies. Martha started her career as a Certified Nurse Aide at the age of 15 in Kansas before moving to Kansas City, MO to attend nursing school. Long Term Care nursing was her first love and her biggest challenge.
