Tag Archives: Diabetes

Wound-healing molecule found in parasitic worm could help prevent amputations

A substance found in parasitic worms’ spit might help prevent thousands of amputations a year, scientists in north Queensland have said.

James Cook University researchers in Cairns are harnessing the molecule produced by a Thai liver parasite that can “supercharge” the healing of wounds.

Australian Institute of Tropical Health and Medicine parasitologist Michael Smout said non-healing wounds were of particular concern for diabetics and smokers.

Dr Smout said the parasite used the molecule to keep its host healthy and prolong its own life.

“It’ll live for a decade or two, and it’s munching around your liver, and zipping up the wounds as it goes,” he said.

Read more.

Reduction of 50% in Diabetic Foot Ulcers With Stem Cells

MUNICH — Local injection of mesenchymal stem cells derived from autologous bone marrow shows promise in healing recalcitrant neuropathic diabetic foot ulcers, a novel study from Egypt shows.

Presenting the results at the European Association for the Study of Diabetes (EASD) 2016 Annual Meeting, Ahmed Albehairy, MD, from Mansoura University, Egypt, said: “In patients who received the mesenchymal stem cells, ulcer reduction was found to be significantly higher compared with patients on conventional treatment after both 6 weeks and 12 weeks of follow-up. This is despite the fact that initial ulcer size was larger in the stem-cell–treated group.” Continue reading »

Clinical Notes, September 2016

Electrical stimulation and pressure ulcer healing in SCI patients

A systematic review of eight clinical trials of 517 patients with spinal cord injury (SCI) and at least one pressure ulcer indicates that electrical stimulation increases the healing rate of pressure ulcers. Wounds with electrodes overlaying the wound bed seem to have faster pressureulcer healing than wounds with electrodes placed on intact skin around the ulcer.

A quantitative, pooled analysis and systematic review of controlled trials on the impact of electrical stimulation settings and placement on pressure ulcer healing rates in persons with spinal cord injuries,” published in Ostomy Wound Managementstates that the overall quality of the studies was “moderate” and that future trials “are warranted.”

Effect of antiseptics on maggot viability

The short-term application of wound antiseptics on wound beds does not impair the viability of maggots, according to a study in International Wound Journal.

Viability of Lucilia sericata maggots after exposure to wound antiseptics” reports that the maggots can survive up to 1 hour of exposure to antiseptics, such as octenidine, povidone-iodine, or polyhexanide.

Global impact of diabetes underestimated

The prevalence of global diabetes has been seriously underestimated by at least 25%, according to a study published in Nature Reviews Endocrinology.

Diabetes mellitus statistics on prevalence and mortality: facts and fallacies” indicates that there may be more than 100 million people with diabetes globally than previously thought.

Axillary evaluation and lymphedema

A retrospective cohort study in Epidemiology reports that women with ductal carcinoma in situ who receive an axillary evaluation have higher rates of lymphedema, without breast cancer-specific or overall survival benefit.

Axillary evaluation and lymphedema in women with ductal carcinoma in situ” included 10,504 women.

Topical insulin and pressure ulcers

A randomized, controlled trial to assess the effect of topical insulin versus normal saline in pressure ulcer healing” concludes that topical insulin is safe and effective in reducing the size of pressure ulcers compared to normal saline-soaked gauze.

Participants of the study, published in Ostomy Wound Management, received either normal saline dressing gauze or insulin dressing twice daily for 7 days. The insulin was sprayed over the wound surface with an insulin syringe, allowed to dry for 15 minutes, and then covered with sterile gauze.

Sexual function and ostomy

Sexual function and health-related quality of life in long-term rectal cancer survivors” reports that long-term sexual dysfunction is common in patients who have undergone surgery for rectal cancer, with more problems seen in patients who have a permanent ostomy.

The study, published in the Journal of Sexual Medicine, included 181 patients with an ostomy and 394 patients with anastomosis.

Effect of venous leg ulcers on body image

Many patients with venous leg ulcers have low self-esteem and negative feelings about their bodies, according to a prospective study published in Advances in Skin & Wound Care.

The impact of venous leg ulcers on body image and self-esteem” included 59 participants. The mean score on the Rosenberg Self-esteem Scale was 22.66, indicating low self-esteem.

Assessing footwear in patients with diabetes

Inappropriate footwear is the most common source of trauma in patients with diabetes. Frequent and proper assessment of appropriate footwear is essential for protecting the diabetic foot from ulceration.

Here is a step-by-step process for evaluating footwear. Be sure to evaluate footwear with the patient walking, standing, and sitting.

Observe wear patterns for areas of high pressure or abnormalities

Check the inside of shoe, upper area, and soles.

Check that pressure under the sole of the shoe is even, so no one part wears out excessively.

Assess wear. Normal wear should occur at the lateral heel and medial central forefoot; there also may be slight curvature on the undersurface of the sole at the toe area.

Inspect inside of the shoes

Observe and feel for wrinkled lining, protruding rough seams, and foreign objects.

Observe for drainage on the insole or socks.

Check that soles are sufficiently thick to prevent puncture wounds.

Ensure that shoes have supportive, cushioned soles, with nonslip liners to absorb shock and reduce pressure under the feet.

Observe for correct fit

Check for sizing. In general, there should be about a thumbnail (approximately ½ to ¾ inch) distance between the end of your longest toe and the tip of the shoe.

Check heel-to-ball length:

Measure the distance from the patient’s heel to the first and fifth metatarsal heads.

Bend the shoe to determine toe break and repeat the measurement on the other shoe.

The two measurements should be close to the same.

Check width. The sides of the shoe should not compress the sides of the foot, with the shoe fitting snugly but not tightly. The widest part of foot should be in the widest part of shoe. The correct width allows the toes to rest flat on the insole without being compressed.

Verify that there is no rubbing of the feet or slipping in the shoe and that the heel cup fits snugly.

Be sure the shoe follows the natural outline of the foot.

Observe for a secure fastening mechanism, which should be adjustable with laces, Velcro, or buckles.

Observe that socks are being worn with shoes to reduce friction

Check that socks meet the following criteria:

Socks are nonconstricting with no tight band around ankle or calf.

Socks with prominent seams are worn turned inside-out.

Socks are made of absorbent materials, such as cotton.

Lighter-colored or white socks are worn when there is an open wound to help alert wearers with compromised sensation to a draining wound.

Check that socks meet individual patient needs:

Patients with a partial foot require a sock that will conform to the shape without distal prominent seams or excess material at the distal end.

For active patients, socks can be obtained with silicone over high-stress areas to prevent shear for full or partial feet.

Inspect shoes to determine if they meet the characteristics for the ideal diabetic foot shoe

The shoe is foot-shaped and has a soft heel counter to keep the foot in place.

The shoe upper is made of leather or other breathable material.

The leather over the forefoot is as soft as possible.

The inside lining of the shoes is smooth and free from seams and/or wrinkles.

• The shoe has a heel height that is not excessive (under 5 cm).

Note: A number of studies have shown that wearing athletic shoes can reduce plantar pressure and lead to fewer calluses.

The simplest intervention for a patient who is at risk for ulceration would be a good-fitting, well-cushioned pair of athletic shoes if the patient’s foot fits well in the upper area.

Provide patient education

Patient education about the importance of appropriate footwear choices is critical for the prevention of diabetic foot ulceration and possible amputation. In addition to the points already discussed, patients should be advised to:

change their shoes twice daily

ensure shoes are in a good state of repair

check shoes for foreign objects before putting them on.

Provide patients with guidance on how to buy new shoes. (See Tips for buying shoes for patients with diabetes.) 

Nancy Morgan, cofounder of the Wound Care Education Institute, combines her expertise as a Certified Wound Care Nurse with an extensive background in wound care education and program development as a nurse entrepreneur.

Information in Apple Bites is courtesy of the Wound Care Education Institute (WCEI), © 2016.

Selected reference

Cavanagh PR, Ulbrecht JS. The biomechanics of the foot in diabetes mellitus. In Levin ME, O’Neil LW, Bowker JH, et al, eds. The Diabetic Foot. 7th ed. Philadelphia: Mosby Elsevier; 2008.

Clinical Notes

Management of biofilm recommendations

The Journal of Wound Care has published Recommendations for the management of biofilm: a consensus document,” developed through the Italian Nursing Wound Healing Society.

The panel that created the document identified 10 interventions strongly recommended for clinical practice; however, panel members noted that, “there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence.”

Statins reduce CVD risk in patients with diabetes

Statins reduce the risk of cardiovascular disease (CVD) and death in patients with type 1 diabetes without a history of CVD, according to a study published in Diabetes Care.

Association between use of lipid-lowering therapy and cardiovascular diseases and death in individuals with type 1 diabetes” included more than 24,000 individuals from the Swedish National Diabetes Register who were followed for a mean of 6 years.

International diabetes organizations support bariatric surgery

Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations,” published in Diabetes Care, supports including metabolic (bariatric) surgery as a treatment option for people with type 2 diabetes who are obese. The statement notes when metabolic surgery is recommended and when it should be considered.

The 2nd Diabetes Surgery Summit was convened in collaboration with leading diabetes organizations to develop the guidelines. The multidisciplinary group included 48 international clinicians and scholars from leading diabetes associations; 75% were not surgeons. Draft conclusions were presented and opened to public comment. Following comment, they were amended.

Medicare-VHA dual use associated with poorer chronic wound healing

Veterans with chronic wounds who are enrolled in Medicare and access care through Medicare and the Veterans Health Affairs (VHA) experience poorer healing of chronic wounds, according to a study in Wound Repair and Regeneration.

Medicare-VHA dual use is associated with poorer chronic wound healing” was a retrospective study that followed 227 Medicare-enrolled individuals who used the VHA and who had a chronic lower limb wound. Individuals were followed until the wound was healed or up to 1 year.

“Dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use,” the study authors note. The risks of amputation or death were higher for dual users.

Sacral dressing may help prevent ulcers in ICU patients

Prophylactic sacral dressing for pressure ulcer prevention in high-risk patients,” published in the American Journal of Critical Care, reports that the dressing reduced the number of sacral pressure ulcers in three ICUs by 3.4 to 7.6 per 1,000 patient days depending on the unit.

Data were collected for 7 months and compared to 7 months before the dressings were used, and patients were identified as high risk by using an evidencebased tool. The study authors note that heightened awareness by the care team and increased education also are key in preventing pressure ulcers.

Scale has limited ability to predict pressure ulcers

A study that evaluated the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) found that the scale could predict pressure ulcers occurring within 2 to 3 days after it was administered in acute care, but didn’t predict ulcer development over a longer term within acute or inpatient rehabilitation.

Predictive validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) in acute care and inpatient rehabilitation in individuals with traumatic spinal cord injury,” published in NeuroRehabilitation, used retrospective analysis to determine the findings.

Braden Q and Glamorgan scales compared in children

The Journal of Tissue Viability has published A comparison of the performance of the Braden Q and the Glamorgan paediatric pressure ulcer risk assessment scales in general and intensive care paediatric and neonatal units,” which found that both work  well in these settings.

The study authors note, however, that the Braden Q may be better at predicting risk in general pediatric units. More than 500 pediatric admissions were included in the study.

Axillary reverse mapping may reduce lymphedema

Researchers report that using axillary reverse mapping during surgery to help identify lymph nodes and vessels reduces the risk of lymphedema in patients undergoing sentinel lymph node biopsy and/or axillary node dissection.

A total of 654 patients participated in Does axillary reverse mapping prevent lymphedema after lymphadenectomy?,” published in Annals of Surgery.

Muslims and QOL after ostomy surgery

Muslims who undergo ostomy surgery experience significant reductions in health-related quality of life (QOL) — greater reductions than seen in non-Muslim patients, according to a study in Journal of Wound Care and Ostomy.

Quality of life after ostomy surgery in Muslim patients: a systematic review of the literature and suggestions for clinical practice” notes that factors associated with the difference include “psychological factors, social isolation, underreporting of complications, and sexual dysfunction leading to breakdown of marital relations as well as diminished religious practices.”

Chronic venous insufficiency consensus statement

Circulation has published “Investigation of chronic venous insufficiency: a consensus statement,” which “provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations.”

Clinical Notes—May/June 2016

Moldable skin barrier effective for elderly patients with ostomy

A study in Gastroenterology Nursing reports that compared to a conventional skin barrier, a moldable skin barrier significantly improves self-care satisfaction scores in elderly patients who have a stoma. The moldable skin barrier also caused less irritant dermatitis and the costs for leakage-proof cream were lower.

The application of a moldable skin barrier in the self-care of elderly ostomy patients” included 104 patients ages 65 to 79 who had a colostomy because of colorectal cancer.

Risk factors for severe hypoglycemia in older adults with diabetes identified

Risk factors associated with severe hypoglycemia in older adults with Type 1 diabetes” include glucose variability and greater lack of awareness of hypoglycemia.

Participants in the case-control, multi-center study, published in Diabetes Care, were age 60 or older and had a history of diabetes dating back 20 years or more.

Thermal imaging via smartphone helps detect inflammation

Early detection of inflammation in wounds promotes early treatment, and clinicians may have an additional assessment tool available to them. A recent study published in the Journal of Wound Care concludes the FLIR ONE, a thermography device that connects to a smartphone, can be successfully used to assess subclinical inflammation in patients with pressure ulcers and diabetic foot in clinical settings.

Use of smartphone attached mobile thermography assessing subclinical inflammation: A pilot study” included 16 thermal images from eight patients and found good criterion-related validity and inter-rater reliability when the FLIR ONE results were compared to those from a handheld device. The findings may open the door to more thermal imaging assessment at the bedside.

Role of skin substitutes in treatment of diabetic foot ulcers analyzed

Systematic review and meta-analysis of skin substitutes in the treatment of diabetic foot ulcers,” published in Wound Repair and Regeneration, concludes that skin substitutes “can, in addition to standard care, increase the likelihood of achieving complete ulcer closure compared with standard care alone in the treatment of diabetic foot ulcer.”

The authors caution, however, that long-term effectiveness, including limb salvage and recurrence, is not known, and cost-effectiveness is not clear. The review included 17 randomized clinical trials, with a total of 1,655 patients.

Tap water safe alternative for wound cleaning

“Tap water is a safe alternative to sterile normal saline for wound cleansing in a community setting,” concludes a study in the Journal of Wound, Ostomy and Continence Nursing.

Tap water versus sterile normal saline in wound swabbing: A double-blind randomized controlled trial” studied 22 people with 30 wounds. Half were in the tap water group and half in the sterile normal saline group. Researchers found no differences in the proportion of wound infection and healing between the two groups.

Review of skin grafting in patients with chronic leg ulcers

Autologous split-thickness skin grafting remains the gold standard in terms of safety and efficacy for chronic leg ulcers, according to a review article in International Wound Journal.

Skin grafting for the treatment of chronic leg ulcers—a systematic review in evidencebased medicine” also found that skin grafts are more successful in patients who have chronic venous leg ulcers, compared to other types. The researchers noted that skin tissue engineering is “rapidly expanding” and holds promise for better outcomes when treating patients with long-lasting chronic wounds.

C difficile may be risk factor for pouch failure after reconstruction

Patients with a history of preoperative Clostridium difficile colitis may be at higher risk for pouch failure after ileal pouchanal anastomosis reconstruction following total proctocolectomy for ulcerative colitis, according to a study in Inflammatory Bowel Disease.

The authors of “Clostridium difficile infection in ulcerative colitis: Can alteration of  the gut-associated microbiome contribute to pouch failure?” defined pouch failure as permanent ostomy diversion or pouch excision. Of 417 patients in the study, 28 (6.7%) developed pouch failure.

Lymphedema education lacking

Researchers of a study in the Journal of Cancer Education report that only 19.9% of 180 women with lymphedema after breast cancer surgery reported they had received education or information about the condition postoperatively.

The importance of awareness and education in patients with breast cancer-related lymphedema” also reports that, “The degree and duration of lymphedema were lower in patients who had been informed or educated about lymphedema as compared to the patients who had not been informed or educated, but the difference was not statistically significant.”

Color charts help improve pressure ulcer risk assessment

Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development,” published in the Journal of Advanced Nursingconcludes that the color charts provide a “more objective measurement of skin tone than demographic categories.”

The researchers state that use of the charts can improve pressure ulcer risk assessment when current clinical guidelines are less effective.

Clinical Notes

Self-management ostomy program improves HRQOL

A five-session ostomy self-care program with a curriculum based on the Chronic Care Model can improve health-related quality of life (HRQOL), according to a study in Psycho-Oncology.

A chronic care ostomy self-management program for cancer survivors” describes results from a longitudinal pilot study of 38 people. Participants reported sustained improvements in patient activation, self-efficacy, total HRQOL, and physical and social well-being. Most patients had a history of rectal cancer (60.5%) or bladder cancer (28.9%).

Assessment scale may help predict pressure ulcer development in patients with fecal incontinence

A study in the International Wound Journal has found that higher scores on the Incontinence-Associated Dermatitis and its Severity (IADS) tool are associated with an increased likelihood of developing a pressure ulcer in patients with fecal incontinence.

The authors of “Prospective study on Incontinence-Associated Dermatitis and its Severity instrument for verifying its ability to predict the development of pressure ulcers in patients with fecal incontinence” suggest that patients with IADS scores higher than 8 points should be classified as being at risk of developing a pressure ulcer and receive “intensive care as a proactive measure” to prevent pressure ulcer development.

Keratin-based products effective for burn treatment

Researchers report in Burns that compared to standard products, novel keratin-based products facilitate healing with minimal scarring in patients with superficial and partial thickness burns.

Keratin-based products for effective wound care management in superficial and partial thickness burns injuries” notes that the keratin products are cost-effective, associated with minimal pain and itch, and easy to use in community-based care.

Sirolimus-eluting stents help wound healing in patients with ischemic PAD

Infrapopliteal sirolimus-eluting stents (SES) accelerate wound healing in patients with ischemic peripheral arterial disease (PAD) compared with balloon angioplasty, according to a study of 200 patients in JACC: Cardiovascular Interventions.

Wound healing outcomes and health-related quality-of-life changes in the ACHILLES Trial: 1-year results from a prospective randomized controlled trial of infrapopliteal balloon angioplasty versus sirolimus-eluting stenting in patients with ischemic peripheral arterial disease” also reported a trend of more quality-of-life gains for patients receiving an SES.

Incontinence of older persons affects QOL of their caregivers

Impact of incontinence on the quality of life of caregivers of older persons with incontinence: A qualitative study in four European countries” concludes that incontinence has a strong effect on the quality of life (QOL) of caregivers.

The study in Archives of Gerontology and Geriatrics included 50 interviews with caregivers in Italy, the Netherlands, the Slovak Republic, and Sweden. The researchers discovered that families need to learn new competencies in caring for the older person with incontinence and that incontinence remains “a taboo and a high stigmatizing condition” for caregivers. The concept that incontinence is unavoidable in older patients, along with shame and embarrassment, prevents caregivers from seeking help at an early stage.

Trauma patients vulnerable to device-related pressure ulcers

Pressure ulcers in trauma patients with suspected spine injury: a prospective cohort study with emphasis on device-related pressure ulcers” reports the incidence of pressure ulcers in 254 patients with suspected spine injury as 28.3%, with 60.7% of those related to devices.

The study, published in the International Wound Journal, found pressure ulcers in 16 different locations on the body. The researchers conclude that the proportion of device-related pressure ulcers is “very high in trauma patients.”

Intensive therapy for patients with diabetes reduces CV complications

Intensive diabetes treatment and cardiovascular outcomes in Type 1 Diabetes: The DCCT/ EDIC Study 30-year follow-up” reports that intensive treatment reduced the incidence of cardiovascular (CV) disease by 30% and the incidence of major CV events (nonfatal myocardial infarction, stroke, or cardiovascular death) by 32%.

Authors of the study, published in Diabetes Care, note that lower HbA1c levels accounted for the observed treatment effect on CV disease risk, and that increased albuminuria was also associated with CV disease risk.

Clinical Notes

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CN_Risk

Modified Braden risk score proposed

A study in Ostomy Wound Management states the risk classification of patients using Braden Scale scores should comprise three (rather than five) levels: high risk, with a total score ≤11; moderate risk, with a total score of 12 to 16; and mild risk, with a total score ≥17.

The retrospective analysis of consecutively admitted patients at risk for pressure ulcer to an acute-care facility included 2,625 patients, with an age range from 1 month to 98 years; 3.1% developed a pressure ulcer.

The authors of “A retrospective analysis of pressure ulcer incidence and modified Braden Scale score risk classifications” conclude that the modified Braden Scale “may be more convenient and feasible in clinical practice.”

CN_DialysisAmputations and foot-related hospitalization in dialysis patients

Amputations and foot-related hospitalisations disproportionately affect dialysis patients,” even though the incidence of foot ulcers is the same in dialysis patients and patients with an ulcer history.

The study in International Wound Journal included 150 consecutive patients with diabetes who were on dialysis and 150 patients with a history of foot ulceration. Each patient was followed for 30 months.

CN_FootPlantar shear plays important role in foot ulcers

Considering both plantar shear and pressure, as opposed to pressure alone, is more effective in preventing foot ulcers, according to a study in Diabetes Care.

Peak plantar shear and pressure and foot ulcer locations: A call to revisit ulceration pathomechanics” notes that pressure is a poor predictor of foot ulcer in patients with diabetes, and pressure-reducing therapeutic footwear has minimal effect in preventing recurrent ulceration.

The authors write that their findings indicate that plantar shear has a “clinically significant role in ulceration” and that ulcers at different sites may have different pathologies. They also call for more research on plantar shear.

CN_amputationLower extremity amputation in patients with diabetes

A longitudinal study in Diabetes Care reports that people with diabetes who have undergone lower-extremity amputation “are more likely to die at any given point in time” compared to those who have not experienced amputation.

Diabetes, lower-extremity amputation, and death” notes that complications from diabetes account for only some of the variation.

CN_CPRAHA releases new CPR guidelines

The American Heart Association has published the “2015 Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)” in the journal Circulation. The guidelines recommend chest compressions at a rate of 100 to 120 per minute and to a depth of at least 2 inches (avoiding depths greater than 2.4 inches). Other recommendations include having clinicians perform steps simultaneously to reduce the time to the first chest compression.

Bystanders should use mobile phones to immediately call 911, placing the phones on speaker, so the dispatcher can offer assistance. Untrained bystanders should provide Hands-Only CPR, and bystanders who are trained in CPR should add breaths in a 30:2 compressions-to-breath ratio.

CN_diabetesDiabetes increases risk of fracture

Type 1 diabetes is associated with an increased risk of fracture across the life span: A population-based cohort study using The Health Improvement Network (THIN)” included patients with and without diabetes, who were matched on parameters such as age and sex.

The risk of fracture was lowest in males and females younger than 20 years and highest in men ages 60 to 69, according to the study, which was published in Diabetes Care. Lower extremity fractures accounted for a higher proportion of incident fractures in participants with diabetes compared to those without. Secondary analyses for incident hip fractures identified the highest hazard ratio of 5.64 in men ages 60 to 69 and the highest hazard ratio of 5.63 in women ages 30 to 39.

CN_ostomyNurses play important role in quality of life for ostomy patients

Analysing the role of support wear, clothing and accessories in maintaining ostomates’ quality of life,” published in Gastrointestinal Nursing, notes that nurses with expertise in stoma care can help patients with ostomies achieve optimal quality of life by using their expertise to guide patients in making decisions that will help them return to the activities, sports, hobbies, and lifestyle they enjoyed before surgery.

Liposuction may be helpful for lymphedema

Complete reduction of arm lymphoma following breast cancer—A prospective twenty-one years’ study” concludes that liposuction is effective for treating chronic, nonpitting leg lymphedema in patients who don’t respond to conservative treatment.

The study, published in Plastic and Reconstructive Surgery, included 146 women, with a mean age of 63 and a mean duration of arm swelling of 9 years. It notes that reduced volume is maintained through constant use of compression garments.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Clinical Notes

Factors affecting medication adherence in patients with diabetes identified

Factors associated with better adherence to antidiabetic medications taken by patients with diabetes include older age, male sex, higher education, higher income, use of mail-order vs. retail pharmacies, primary care vs. nonendocrinology specialist prescribers, higher daily total pill burden, and lower out-of-pocket costs.

Determinants of adherence to diabetes medications: Findings from a large pharmacy claims database,” published in Diabetes Care, also found that patients who are new to diabetes therapy are less likely to be adherent. The study included more than 200,000 patients who were treated for diabetes with noninsulin medications.

LMW heparin may improve healing of chronic venous ulcers

International Wound Journal has published “Low molecular weight heparin improves healing of chronic venous ulcers especially in the elderly,” a study that included 284 patients.

The healing rate for those receiving low-molecular-weight (LMW) heparin was around 80% at 12 months, compared to around 60% for those who didn’t receive heparin. Older patients received the most benefit and also had the lowest recurrence rate.

Comparison of dressings for pediatric donor skin-graft sites

Compared to foam and hydrofiber, calcium alginate is the optimum dressing for pediatric donor skin-graft sites, according to a study in the Journal of Burn Care & Research.

Management of pediatric skin-graft donor sites: A randomized controlled trial of three wound care products” included 57 children, and the median size of the donor site was 63.50 cm2. The median days for healing for those in the calcium alginate group was 7.5, compared to 8 days for hydrofiber and 9.5 days for foam.

Insulin pump clinical safety appraised

Insulin pump risks and benefits: A clinical appraisal of pump safety standards, adverse event reporting, and research needs,” is a Joint Statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group published in Diabetes Care. The article contains several recommendations for reducing adverse effects caused by user error, including:

  • Select appropriate candidates for pump therapy.
  • Provide those beginning pump therapy with appropriate and ongoing education and support.
  • Ensure that healthcare professionals supporting pump users are themselves well trained and supported.

The article also notes that the clinical studies required before marketing an insulin pump are “small and over-reliant on bench testing” and that once a pump is on the market, “insufficient data are made publicly available on its long-term use in a real-world setting.”

Resistance training may improve lymphedema

According to a poster presented at a Florida State University symposium, “Resistance training improves muscular strength and lymphedema in breast cancer survivors,” 33 female participants experienced moderate- to high-intensity resistance therapy over 12 weeks. The researchers found that participants tolerated therapy well and that lymphedema was significantly decreased.

Ability to stop insulin varies with bariatric surgery type

Insulin cessation and diabetes remission after bariatric surgery in adults with insulin-treated type 2 diabetes,” published in Diabetes Care, found that patients who had Roux-en-Y gastric bypass surgery were more likely than those who had laparoscopic adjustable gastric banding to be able to stop insulin after surgery.

Pilot studies find acupuncture reduces lymphedema

Acupuncture research at Memorial Sloan Kettering Cancer Center” reports acupuncture significantly reduces arm circumference in patients with lymphedema.

The article, published in the Journal of Acupuncture and Meridian Studies, discusses two pilot studies that indicate acupuncture is safe for patients who have had breast cancer surgery.

Clinical practice guidelines for ostomy surgery released

Diseases of the Colon & Rectum has published “Clinical practice guidelines for ostomy surgery.” The American Society of Colon and Rectal Surgeons developed the guidelines, which discuss ostomy creation, closure, and complications.

The guidelines state that the “optimal care for patients undergoing ostomy surgery includes preoperative, perioperative, and postoperative care by an ostomy nurse specialist.”
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

More from The Buzz Report: A wound care clinician’s best friend

 

 By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMSPDF-icon

 

Keeping clinicians up to date on clinical knowledge is one of the main goals of the Wild On Wounds (WOW) conference,held each September in Las Vegas. Each year, I present the opening session of this conference, called “The Buzz Report,”which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss innovative new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management.

In the January issue, I discussed some of the updates from my 2014 Buzz Report, and now I’d like to share more, with appropriate updates since the September WOW conference.

Necrotizing fasciitis

Necrotizing fasciitis, also called the “flesh-eating disease,” is a progressive,rapidly spreading inflammatory infection located in deep fascia with necrosis of the subcutaneous tissues. Early diagnosis and treatment of necrotizing fasciitis are critical to saving the life of the patient.

Summarized in an article by Edlich and colleagues published in Medscape, two studies found the following:

• Of 27 patients studied, 20 died, for an overall mortality rate of 73%; 11 of the patients whose treatment was delayed for more than 12 hours died.

• The average time from admission to operation was 90 hours in nonsurvivors of necrotizing soft-tissue infections, compared to 25 hours in survivors.

To promote prompt diagnosis and treatment, the National Necrotizing Fasciitis Foundation launched a program that connects patients and their families from all over the United States and other countries with John Crew, MD, FACS, vascular surgeon and medical director for the Advanced Wound Care Center at Seton Medical Center in Daly City, California.

Crew consults with physicians (at no fee) about his groundbreaking treatment of necrotizing fasciitis, which earned him a nomination for the prestigious Lister Legacy Prize in early 2014. Crew’s treatment plan includes the use of Neutro -Phase® in combination with negative pressure wound therapy. His treatment approach has saved patients’ limbs—and lives.

If you have a patient with necrotizing fasciitis, contact Crew, who is available 24/7, at 908-422-7744. For more information, visit the National Necrotizing Fasciitis Foundation.

Bedside assessment

It’s always hard to choose which published articles to focus on, but three caught my eye as being particularly useful for bedside assessment.

Burn care

Burn care is its own specialty within wound care, but some injuries don’t require a specialist burn unit. The article Best practice guidelines: Effective skin and wound management in non-complex burns,” published in Wounds International, is an excellent resource for clinicians.

The article focuses on hands-on and relevant clinical information for evaluation and management of noncomplex burn injuries that are appropriate for treatment in locations outside specialist burns units, with steps for the immediate emergency management of all burns. The article also highlights the importance of correctly and expediently identifying complex wounds that indicate the patient must be transferred rapidly for specialist care, and discusses ongoing management of newly healed burn wounds as well as postdischarge rehabilitation.

Nutritional needs

Good nutrition includes not only adequate macronutrients, such as protein, carbohydrate, and fat, but also micronutrients—vitamins and minerals—for wound healing. Several micronutrient deficiencies can be identified through a simple skin assessment.

The article “Learning the oral and cutaneous signs of micronutrient deficiencies,” published in the Journal of Wound, Ostomy & Continence Nursing, notes that the hallmark symptom of vitamin B deficiency is glossitis, a reddish tongue with a smooth surface. B12 deficiency is characterized by hypertrophic papillae scattered across the villous surface of the tongue, and signs of B3 deficiency include dermatitis (pellagra), which is characterized by a crepe-paper appearance with wrinkles in the skin and flat surfaces between the wrinkles.

Vitamin C deficiency can manifest as purpura, skin tears, and “plastic-wrap” skin, in which the dermis is so thin that blood vessels can easily be seen beneath a transparent epidermis.

When cutaneous symptoms of vitamin deficiency appear, serum studies should be obtained to confirm the deficiency so prompt treatment can begin.

International ostomy guidelines

The new World Council of Enterostomal Therapists (WCET) International Ostomy Guidelines are evidence-based practice guidelines that are internationally focused rather than country specific. The guidelines can be applied in all countries or care settings, whether resource challenged or resource abundant. The WCET guidelines include cultural, religious, and ethnic considerations for ostomy patients that are international in perspective. You can purchase the full version (64 pages) of the guidelines with the evidence tables, or download a free summary.

New products

Here are several new products from 2014 that you should know about. Granulotion® Medicated Lotion. This over-the-counter lotion is designed to help support the healing of excessive granulation tissue. Granulotion was developed by a nurse practitioner, Christopher R. Speaker, APN, FNP-BC, who was frustrated with steroids and silver nitrate as the only treatment options for hypergranulation tissue. The product is nontoxic and nonsteroidal, with ingredients that provide anti-itch benefits, antimicrobial properties, skin barrier for protection, and the ability to shrink granulation tissue that develops at gastrostomy, jejunostomy, tracheostomy, ileostomy, and colostomy sites.

SenSura® Mio ostomy appliance. This appliance fits to individual body contours and maintains a secure seal over abdomens uneven from scarring, skin folds, hernias, and other problems. SenSura Mio has a soft, elastic, hydrocolloid adhesive barrier that shapes and follows body contours when ostomates bend and stretch. The pouch is made from water-resistant textile material that gives the pouch the feel of clothing and is a neutral gray designed to stay unnoticed under all colors of clothing.

RightSpot™ pH Indicator. This small, noninvasive, in vitro diagnostic device is used to verify gastric acidity to avoid misplacement of nasogastric feeding and percutaneous endoscopic gastrostomy tubes. The RightSpot indicator strip is placed on the tube and gastric fluid is aspirated; as the aspirate saturates the strip, the strip changes color according to the level of pH in the aspirate. The color of the indicator strip is compared to a color chart on the device. A pH below 4.5 indicates gastric acidity.

Hydrofera Blue® Ready Foam. This antibacterial dressing is made of polyurethane foam, methylene blue, and gentian violet. It can be used on a variety of wounds and also under compression bandages or a total contact cast. It has broad-spectrum antibacterial activity and can be left in place for up to 7 days. This new version of Hydrofera Blue doesn’t require hydration before application or a secondary dressing.

Perfect Choice Next Generation NO STINGOstomy Barrier Paste. Designed to help extendwear time, this no-sting skin barrier and filler paste has easy-on, easy-off application and removal.

NOTraum Silicone Foam Dressing. This absorbent foam dressing has a silicone border, which means no trauma for the wound and supporting skin upon removal. The dressing adheres easily and securely to dry, intact skin. It keeps the wound bed moist, but doesn’t adhere to the wound bed, thereby preventing trauma.

Staytex™ tubular dressings. This tubular stretch bandage secures and maintains primary wound dressings to the affected site. The unique weave of the Staytex tube keeps the dressing in place, yet is comfortable and free of latex. It’s available in precut lengths or rolls that can be cut to fit, and is washable and reusable.

Stay tuned

I’m already gathering the latest and greatest for the 2015 Buzz Report, so look for a new edition of The Buzz Report in 2016!

Selected references

Edlich RF, Gubler, KD, Long WB III, et al. Necrotizing fasciitis. Medscape. http://emedicine.medscape.com/article/2051157-overview

International best practice guidelines: Effective skin and wound management of non-complex burns. Wounds International. www.woundsinternational.com/pdf/content_11308.pdf

Kaminski MV Jr, Drinane JJ. Learning the oral and cutaneous signs of micronutrient deficiencies. J Wound Ostomy Continence Nurs. 2014 Mar-Apr;41(2):127-35.

McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing softtissue infections. Ann Surg. May 1995;221(5):558-63; discussion 563-5.

Rouse TM, Malangoni MA, Schulte WJ. Necrotizing fasciitis: a preventable disaster. Surgery. Oct 1982; 92(4):765-70.

Zulkowski K, Ayello EA, Stelton S, eds. WCET International Ostomy Guideline. Perth, Australia: World Council of Enterostomal Therapists; 2014.

Donna Sardina is editor-in-chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.