Poster session 8: Wound healing P8.01 Assessment of protein intake and requirement among diabetic patients with foot ulcers Sara Jaffri, Baqai Baqai Medical University, Karachi, Pakistan Musarrat Riaz, Baqai Medical University, Karachi, Pakistan Zahid Miyan, Baqai Medical University, Karachi, Pakistan Abdul Basit, Baqai Medical University, Karachi, Pakistan Objectives: To evaluate protein intake & requirement among patients with diabetic foot ulcers. Methodology: This study was conducted among Type 2 diabetic patients presenting with foot ulcers at Baqai Institute of Diabetology & Endocrinology (BIDE), a tertiary care diabetes center of Karachi, Pakistan, in the month of, July and August 2014. Formal approval of the study was obtained from Institutional Review Board of BIDE. Dietary intake of these patients was taken through predesigned questionnaire based on 24 hour dietary recall interview and the demographic data was obtained from Health Management System (HMS). Total grams of protein were calculated from all the food groups and. Protein requirement of patients were calculated according to their body weight and severity of wound. SPSS version 13 was used for analysing the results. Results: Dietary intake of 50 patients with diabetic foot ulcer was recorded out of which 72% were males. Mean age of the participants and average duration of Diabetes was 57.62 ± 8.33 years and 11.72 ± 7.92 years respectively. Protein consumption of patients was 3 days of a week at lunch and dinner was 34 %. Mean protein intake of males was 78.48gms and females were56.58gms. Requirement of protein is higher than the consumption which is 141.93 gms for males and 87.95 gms for females calculated according to their body weight and severity of wound. Conclusion: Dietary counseling should be a part of the treatment among patients with diabetic foot ulcer to identify their nutritional needs and suggesting them better option to fulfiltheir protein requirement essential for wound healing process. www.diabeticfoot.nl Page 1 of 10 P8.02 Effects of vacuum-therapy on skin microcirculation in patients suffering from diabetic foot ulcer in context of TcPO2 & wound healing Sandeep Raj Pandey, Medanta-The Medcity, Gurgaon, India Aim: To, investigate the short-term effect of impinging vacuum-therapy by vacuumed(VC) P6 or P7 on skin microcirculatory perfusion in the foot of patients suffering diabetic foot ulcer in context of TcPO2 & wound healing. Methods: Nineteen patients with diabetic foot ulcer underwent vacuum-therapy by vacuumed P6 or P7 for 40 minutes for several days(3 to 10 days). The leg was positioned in an air-tight plexiglass cylinder in which hypobaric (-110 mm Hg) and hyperbaric (70 mm Hg) pressure could be generated alternately, in order to improve peripheral circulation and suck infected & necrotic tisuues. The effect on skin microcirculation was investigated using transcutaneous oxygen tension measurements (TcpO2) and photos observing wound healing. Results: Three of the, patients experienced ischaemic symptoms during VC, probably because the leg was pinched off through inflation of the cuff. Patients capillary microscopic parameters changed slightly at first vacuum . After several vacuum, TcpO2 parameters improved significantly(3 to 19 mmhg) along with better wound healing . Conclusion: Vacuum-therapy significantly improves total skin perfusion and oxygenate on being an essential factor in the occurrence of ischaemic symptoms with context of Tcpo2 & wound healing. We therefore conclude that this instrument in its present form is an aid in the treatment of diabetic foot management. www.diabeticfoot.nl Page 2 of 10 P8.03 Negative determinants of diabetic foot ulcer healing: 6-month follow-up of a large multicentre cohort Kris Doggen, Scientific Institute of Public Health, Brussels, Belgium Dimitri Aerden, University Hospital Brussels, Brussels, Belgium Hilde Beele, University Hospital Ghent, Ghent, Belgium Kevin Deschamps, University Hospitals Leuven, Leuven, Belgium Isabelle Dumont, Diabetic foot centre Ransart, Ransart, Belgium Patricia Félix, CHR de la Citadelle, Liège, Belgium Patrick Lauwers, University Hospital Antwerp, Antwerp, Belgium Astrid Lavens, Scientific Institute of Public Health, Brussels, Belgium Giovanni Matricali, University Hospitals Leuven, Leuven, Belgium Caren Randon, University Hospital Ghent, Ghent, Belgium Eric Weber, CSL Vivalia, Arlon, Belgium Viviane Van CasterenScientific Institute of Public Health, Brussels, Belgium Aim: Knowing the determinants that negatively influence diabetic foot ulcer (DFU) healing is crucial for improving DFU care. We identified negative determinants of DFU healing in diabetic foot clinics (DFC) participating in a quality improvement (QI) initiative with periodical audits and feedback (anonymous benchmarking). [1] Methods: In 2011, 32 Belgian DFCs followed 1528 patients with a DFU of Wagner grade 2 or more for six months or until healing, major amputation or death, whichever occurred first. Cumulative incidence functions were studied and Cox proportional hazards regression was used to identify determinants of healing by using a forward selection method, taking into account competing risks (major amputation and death), missingness of covariates and clustering of outcomes in DFCs. Results: At 6 months, the overall probability of healing, major amputation and death was 60.1, 4.3 and 4.4% respectively. 31.3% of patients had a DFU that was not healed. Multivariate analysis identified 6 significant (P<0.05) negative determinants of healing: presence of contralateral ulcer(s) at presentation reduced predicted 6-month healing probability by 27.1%, presence of peripheral artery disease by 21.1%, presence of midfoot/heel ulcers (vs. toe) by 19.7%, presence of additional ipsilateral ulcer(s) by 14.4%, presence of renal insufficiency by 13.5% and referral delay by 5.6% per additional 3 month delay. Notably, plantar vs. dorsal location was not significantly associated with DFU healing. Conclusions: Presence of bilateral DFUs is particularly detrimental for healing. Compared to previous observational studies and especially Eurodiale [2], our data, collected routinely for QI purposes, yielded a similar set of negative determinants of healing, thus highlighting their external validity. Our findings could be incorporated in a useful QI tool in which riskadjusted outcomes of DFCs are benchmarked to each other and over time. [1] Doggen K, Diabetes Metab Res Rev. 2014;30:435-443. [2] Pickwell K, Diabetes Metab Res Rev. 2013;29:377-383. www.diabeticfoot.nl Page 3 of 10 P8.04 Stressing the dressing: Is there a real-time association between stress markers and wound healing outcomes during outpatient visits? Saman Parvaneh, University of Arizona, Tucson, AZ, United States Gurtej Grewal, University of Arizona, Tucson, AZ, United States Javad Razjouyan, University of Arizona, Tucson, AZ, United States Robert Menzies, Hamad Medical Co, Doha, Qatar Talal Talal, Hamad Medical Co., Doha, Qatar David Armstrong, University of Arizona, Tucson, AZ, United States Bijan Najafi, University of Arizona, Tucson, AZ, United States Aims:, Previous studies have suggested that stress is an important risk factor for slower wound healing and susceptibility to infection. The purpose of this study was to objectively assess real-time physiological stress response (PSR) in people with diabetic foot ulcers during a clinical visit and explore its association with wound healing outcomes Methods: 20 subjects with diabetes (Age: 59±10), and non infected, non-ischemic wounds were enrolled., Using a mobile based wearable sensor (Bioharness-Zephyr Technology®), uni-channel ECG was collected during baseline clinic visit for a period of approximately 45 min including waiting, dressing, and post-dressing period. An automated code was designed to estimate real-time PSR based on measuring heart rate variability (HRV). Baseline PSR was identified during the first 3 minutes, when subjects were asked to be relaxed prior meeting with the caregiver. Extreme and high PSR were defined when HRV was in the range of 60-85% and below 60% of baseline HRV, respectively. Association between wound healing outcomes and PSR was assessed in a sub-sample of 6 patients at 12 weeks’ followup. Results: Results revealed that all patients experienced high or extreme stress with time ranging through the majority (13% to 87%) of their outpatient visit and in particular during wound dressing time. A negative correlation (r=-0.65, p<0.05) was observed between percentage of total experienced PSR during dressing change and rate of wound healing at 1 week. Subjects with greater than 60% PSR at baseline had 62% slower wound size change at 1 week (p<0.05). On the same note, healed subjects at 12 weeks had 52% lower mean stress response during dressing change. Conclusions: Our pilot study highlights the feasibility and potential benefits of continuous PSR monitoring in diabetic patients during clinic visit using single wearable mobile health technology. Pilot results are concordant with other works in the literature suggesting that stress may negatively impact wound healing. Funding: Qatar National Research Fund – NPRP 4-1026-3-277 www.diabeticfoot.nl Page 4 of 10 P8.05 Impact of initial glycemic control on the healing rate of the diabetic foot lesions Samir Ouizi, University Diabetes Centre, Riyadh 11411, Saudi Arabia Background: The prevalence of diabetes among Saudi population is almost 24%, and mainly type 2, due to life style changes and some genetic background. It is generally assumed that poor glycemic control may delay wound healing. So, the impact of glycemic control on healing of diabetic foot ulcers remains to be explored. Aim: To identify the impact of glycemic control on diabetic foot ulcer healing outcome. Methods: Medical podiatric records of 335 diabetic patients with diabetic foot wounds from the Foot Unit at University Diabetes center between September 2011 - November 2013 were collected. Diabetes control was based on the HbA1c values, podiatric exam includes sensory testing performed by using a VPT, vascular status evaluation was based on pedal pulses palpation and/or ankle brachial pressure index (ABPI). Wound care was done up on the standard of the IWGDF (debridement, infection control, vascular control, and offloading). Wound assessment was done up on PEDIS classification and Healed wound was defined as complete closure without discharge. Results:, Mean age, diabetes duration, and HbA1c were 58±0.6 years 17±0.4years, and 9.4 ±0.1% respectively. Diabetic peripheral neuropathy and peripheral vascular disease was 94.92% and 35% respectively. 47.46% of the total ulcers were infected and 70% were located at the plantar aspect of the foot, the mean wound size was 5 25cm² and the wound severity type was grade III classification (9.8%). Foot Deformity and Charcot foot was 65% and 15.22% respectively. History of ulceration and amputation was 33.5% while all wounds healed within a mean of 13.31 weeks. Conclusion: Better Diabetic foot ulcers outcome rely on well organized diabetic foot team rather than better glycemic control. www.diabeticfoot.nl Page 5 of 10 P8.06 Impact of severe sleep apnoea and CPAP therapy on diabetic foot wound recovery in acute recalcitrant diabetic foot ulcers - a case series Prash Vas, Kings College Hospital, London, United Kingdom Raju Ahluwalia, Kings College Hospital, London, United Kingdom Ana Manas, Kings College Hospital, London, United Kingdom Michael Edmonds, Kings College Hospital, London, United Kingdom Aim: Whilst great progress has been made in managing diabetic foot disease, non-healing, or slow healing ulcers are common. Factors such as pressure, ischaemia and uncontrolled infection are usually sought out and treated., Obstructive Sleep apnoea (OSA) and diabetes share a bidirectional relationship and recent studies confirm significant under recognition of OSA in, diabetes. There are no current reports on the, clinical impact of OSA on course or management of foot ulcers Methods/Case Series: Three neuropathic patients with triphasic distal vascular waveforms. They presented with acute foot ulcers and underwent emergency surgical debridement. Subsequently, they all received standard care whilst in hospital with optimization of glycaemia, daily wound care and offloading. However, it was difficult to achieve satisfactory granulation and the wounds looked typically devitalised and grey. Repeat vascular studies and tissue microbiology were negative . Diagnosis and treatment of unrecognised severe OSA (apnoea-hypopnea index, AHI >30 in all) with continuous positive airway pressure therapy (CPAP) allowed our first two patients to quickly granulate wounds and achieve control. Our third patient declined CPAP therapy and continues to have a recalcitrant wound. Conclusion: We observe that diabetes individuals with severe untreated OSA may have delayed acute wound healing correctable with institution of CPAP therapy. The clinical picture is typically like ischaemia or infection. Diabetes foot clinics are currently not set up to detect and treat OSA but we would recommend those managing the diabetic foot should actively look for and consider treating OSA as per guidelines in acute non-healing or slowly progressive, ulcers when all other factors have been fully optimized. Representative image of Case 1 www.diabeticfoot.nl Page 6 of 10 P8.07 Risk factors of diabetic foot ulceration associated with prolonged healing (>12 weeks) in king saud university diabetes center Mohammed Derwish, University Diabetes Center, Riyadh, Saudi Arabia Introduction: Saudi Arabia ranks number 4 with 3.6 million diabetes cases, with the highest diabetes prevalence (23.9%). King Saud University diabetes center is a referral center dealing with diabetic foot ulcers. We sought to identify risk factors of diabetic foot ulceration associated with prolonged healing (>12 weeks) to enable better local management protocol. Methods: Total of 335 diabetic patients with healed foot ulcer, was seen in the university diabetes center from years 2011 to 2013. (Data are mean ± SE). Patients were split into two groups according to duration of healing. The first, more than 12 weeks to heal group (n= 126) and those with ulcers that healed less than 12 weeks group (n=208). Podiatric assessment was carried out including Foot musculoskeletal examination, diabetic peripheral neuropathy (DPN) screening using vibration perception threshold, vascular assessment using ankle brachial pressure index and for wound assessment Texas classification was used. Results: Most of our patients were quite younger with a mean age of 58.5±0.6. 94.2% of both healed group had DPN (VPT >25), 96.7%, versus 90% in the (<12 weeks) and (> 12 weeks), groups respectively. Abnormal ABPI was found in 35.13%. Mean diabetes duration was 17.9 ±0.4 and, diabetes was poorly managed in both groups with a mean, HbA1c, 9.4 ±0.1., , , , , , , , , , , , , , , , , , , , , , , , , , , , , All patients had some form of foot deformity while Charcot neuro-arthropathy was 7.8%, in the (>12 weeks) group versus 25.98% among the (>12 weeks) group. Wound baseline was 47.35weeks versus, 74.24 weeks in the (<12 weeks) and, (> 12 weeks), groups respectively. Wounds were mainly neuropathic, located at the planter foot aspect and larger in (>12 weeks) group versus the (< 12 weeks), group, 4.2 cm² and 6.3 cm² respectively., Most of the prolonged healed group had more history of both ulceration and amputation 22% for the ( <12 weeks) group versus 45%, in ( > 12 weeks) group. Discussion:, Advancement was found in our management protocol in term of wound healing time for both group although the prolonged healed patients presented late or were treated in non-specialized clinic (Wound Baseline was 58.26 weeks for both group. So, there is an urgent need for foot care clinics and team approach. www.diabeticfoot.nl Page 7 of 10 P8.08 Performing transcutaneous angiography by a novel imaging technique as a parameter to prognosticate wound healing in diabetic foot ulcers Rumneek Sodhi, Medanta-The medicity, Haryana, India Method: The SPY fluorescent imaging system consists of a charged coupled device (CCD) camera, a laser light source and a distance sensor. Once the camera is positioned, 5cc of diluted ICG (Indocyanine green dye) is pushed through an IV line and is flushed immediately with 10 cc of distilled water; simultaneously the room lights are dimmed and camera images are captured at two different, angles for a minute each. 41 patients with diabetic (Ischemic & Non-ischemic) foot ulcers were all included in this study. Transcutaneous oxygen tension (TcpO2), Ankle Brachial Index, peripheral arterial ultrasound and serial photographs of the wound were also captured and studied at each 'SPY" study visit. Follow up with the SPY fluorescent imaging system was done on baseline, 2 weeks, 4 weeks and 8 weeks respectively and improvement in perfusion was recorded in numeric percentage (%). 27 patients had to also undergo endovascular revascularisation to establish adequate vascularity and 14 were treated with just local wound care. Results: The difference in fluorescence was recorded in all 41 patients and it indicated relative blood flow change (increase or decrease) accompanying the perfusion. This information enabled us to revise management already done, or consider adjunct therapies that may have otherwise not been recognized as needed, in other words we tried to optimize outcomes of interventions performed to obtain wound closure as soon as possible. In Conclusion: This SPY Imaging Technology is actually a surgeon’s delight that produces clinically relevant visual images of blood flow indicating tissue perfusion, when captured in real-time, pre & post intervention to prognosticate wound closure, level of amputation, and even limb salvage. The study has not been funded by anyone. Spy Transcutaneous angiography in a diabetic foot ulcer www.diabeticfoot.nl Page 8 of 10 P8.09 Assessment of wound healing by digital photography: making the case for automated and systematic processing Nathalie Denecker, UZ Brussel, Jette, Belgium Elisabeth Dewaele, UZ Brussel, Jette, Belgium Dimitri Aerden, UZ Brussel, Jette, Belgium Background: Wound assessment is of primary importance in the development of any wound treatment regime. Textual description of a wound in the patient’s medical file is prone to subjectiveness as the lexicon used to describe wound characteristics varies among investigators. In addition, time restraints do not allow exhaustive description of the wound status. The adagium that “a picture is worth a thousand words” is therefor frequently applied to wound assessment: digital photographs of wounds are taken to increase objectiveness and facilitate follow-up between distinct wound care specialists. Discussion: The value of photography in the assessment of wound healing is briefly highlighted, especially when pictures are taken systematically and periodically. Wound characteristics that are accurately recorded by digital photography are: wound extent (area/perimeter), localisation, wound bed (granulation tissue, firbin, necrosis), surrounding tissue (erythema, eczema). However, systematic documentation of wound healing becomes extremely challenging when a high volume of outpatients has to be processed. Historically, the authors found that the acquisition and categorisation of digital photographs from multiple wounds in a multitude of patients proved cumbersome and frustrating. This prompted the authors to develop an ITsolution that greatly improved workflow while remaining reliable and user-friendly. In a video, we demonstrate how data acquisition and filing is accomplished within a few minutes, and can be accomplished by a nurse with minimal IT-training. Hardware requirements consist of a WIFI network, Apple iOS devices (iPad or iPhone) as well as a server computer. Finally, the authors experienced some unanticipated benefits from their newly developed application: the documenting system proved valuable both from a medico-legal standpoint as well as a patient motivational tool. www.diabeticfoot.nl Page 9 of 10 P8.10 Use of novel 3D digital technology for assessment of diabetic foot ulceration Maureen Bates, King's College Hospital, London, United Kingdom Timothy Jemmott, King's College Hospital, London, United Kingdom Nina Petrova, King's College Hospital, London, United Kingdom Chris Manu, King's College Hospital, London, United Kingdom Michael Edmonds, King's College Hospital, London, United Kingdom Aim: We describe our experience with a new technology for 3D digital wound assessment in the management of patients with diabetes foot ulceration., Method: We studied prospectively 11 patients with diabetes who presented to our Diabetic Foot Clinic with foot ulcers. Ulcer healing was monitored with the new imaging system*, which allowed us to measure area, depth and volume and enabled us to store a digital record of the ulcer. At each visit, the wound assessment software calculated the percentage area reduction from baseline. Treatment outcomes were evaluated at, weeks 1, 3, 5 and 12. Results: The ulcer area at presentation was 1.6±2 cm2 (mean±SD ), (range 0.6 cm2 - 6.3 cm2) and the ulcer volume was 0.17±0.32 cm3, (range 0.04 cm3 to 0.89 cm3). During the observational period, the foot ulcers healed in 7 patients and improved in 2 patients. Ulcer deterioration was observed in 2 patients. Follow up ulcer measurements and treatment outcomes are presented in the Table, below. Conclusion: This new system enabled us to easily compare the foot ulcer image between visits and allowed, us to accurately analyse the wound measurements. The detection of subtle deleterious changes prompted us to review patients within the multi-disciplinary clinic for management optimisation. The accurate and objective wound assessment gave the professional and patient an early indication of how the patient was responding to treatment. The system was fast and easy to use with the bonus of being a non-contact wound assessment method. *SilhouetteStar 3D Camera Funding: No external funding www.diabeticfoot.nl Page 10 of 10
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