Faculty Bibliography

Foot ulceration in patients with diabetes increases the risk of lower extremity amputation. Major amputations produce substantial adverse consequences, increase length of hospital stay, diminish quality of life, and increase mortality. In this article, we describe approaches that decrease amputations and improve the quality of life for patients with diabetes and foot ulcers. We highlight the role of the perioperative nurse, who is essential to providing optimal patient care in the perioperative period. Perioperative care of patients with diabetes involves providing optimal surveillance for a break in the skin of the foot, screening for neuropathy, following guidelines for foot ulcer infections, preparing for pathophysiology-based debridement, using adjuvant therapies, and offloading the patient's affected foot. Nurses should understand the disease process and pathophysiology and how to use these approaches in the perioperative setting to assist in curtailing the morbidity and mortality associated with foot ulcers in patients with diabetes.

Care for patients with chronic wounds can be complex, and the chances of poor outcomes are high if wound care is not optimized through evidence-based protocols. Tracking and managing every variable and comorbidity in patients with wounds is difficult despite the increasing use of wound-specific electronic medical records. Harnessing the power of big data analytics to help nurses and physicians provide optimized care based on the care provided to millions of patients can result in better outcomes. Numerous applications of machine learning toward workflow improvements, inpatient monitoring, outpatient communication, and hospital operations can improve overall efficiency and efficacy of care delivery in and out of the hospital, while reducing adverse events and complications. This article provides an overview of the application of big data analytics and machine learning in health care, highlights important recent advances, and discusses how these technologies may revolutionize advanced wound care.

GENERAL PURPOSE/UNASSIGNED:To provide information about the effect of psychiatric comorbidities on wound healing in patients with diabetes mellitus (DM). TARGET AUDIENCE/BACKGROUND:This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES/UNASSIGNED:After participating in this educational activity, the participant should be better able to:1. Discuss the connection between DM and the development of psychiatric comorbidities.2. Identify the drugs recommended in the treatment of these psychiatric comorbidities.3. List cautions and contraindications related to the drugs discussed. ABSTRACT/UNASSIGNED:In patients with diabetes mellitus type 2, psychiatric comorbidities such as depressive and anxiety disorders are 60% or more prevalent than in the general population. The severity of mental illness and the duration of diabetes have been shown to correlate with worsening glycemic control, thus impeding wound healing. A retrospective chart review was conducted in all patients with diabetes mellitus admitted to the wound service with prior or current psychiatric symptoms of anxiety, depression, or cognitive impairment. A psychopharmacologic protocol was developed based on the clinical data collected and treatment parameters used by the behavioral health consultation liaison service.

PURPOSE/OBJECTIVE:To clarify the histopathology of acute osteomyelitis, chronic osteomyelitis, primary vasculitis, and secondary-type vasculitis. TARGET AUDIENCE/BACKGROUND:This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES/OUTCOMES/UNASSIGNED:After participating in this educational activity, the participant should be better able to:1. Describe the parameters and significance of this study.2. Identify chronic wound diagnosis and treatment.3. Differentiate the histopathology of osteomyelitis and vasculitis. ABSTRACT/UNASSIGNED/: OBJECTIVE:The presence of a chronic wound can result in significant morbidity/mortality. Understanding the pathological alterations of wound tissue that are refractory to standard wound therapy is essential for effective wound management and healing. The authors describe 4 wound etiologies, specifically, acute osteomyelitis, chronic osteomyelitis, primary vasculitis, and secondary-type vasculitis. SETTING/METHODS:A tertiary care hospital. DESIGN/METHODS:A retrospective review of 1392 wound operations performed during a 24-month period at a tertiary care hospital was conducted. Tissue specimens reviewed included soft tissue infections of the lower extremity, sacrum, hip/pelvis, trunk, perineum, and buttocks. MAIN RESULTS/RESULTS:Acute osteomyelitis is defined as bone tissue with a predominance of polymorphonuclear leukocytes, evidence of osteoclast bone resorption with scalloping of the cortical bone edges, and bone detritus. Chronic osteomyelitis is defined as bone tissue with a significant amount of fibrosis surrounding devitalized tissue and heavy infiltration of lymphocytes and plasma cells. Primary-type vasculitis is defined primarily as inflammation and necrosis of blood vessel walls. In cutaneous lesions of granulomatosis with polyangiitis, ulceration with numerous inflammatory granulomas is seen in the papillary dermis. Secondary vasculitis is defined by vessel wall infiltration by inflammatory cells and fibrinoid necrosis of the small vessel wall. CONCLUSIONS:Pathologies of these 4 types of wounds can complicate standard algorithms designed for diagnosis and treatment, and accurate diagnosis through histopathologic analysis can help tailor targeted treatment.

The development and management of pressure ulcers (PUs) among hospital and nursing home patients is one of the greatest preventable challenges to healthcare worldwide. For over 50 years, pressure mapping and subjective comfort has been the primary indicators for mattress selection. Our research demonstrates that mattress/patient interface pressure and relative blood/oxygen perfusion do not inversely correlate and pressure is not a meaningful, real-time indicator of tissue ischemia and risk of pressure ulcer development. Developed in our research is a real-time sensor system to simultaneously measure and record these parameters over the anatomical sites at risk for PUs. Measurements focused on the heel, sacrum, trochanter, ischium, scapula and occipital. A modified pressure mapping system is used for interface pressure measurements and integrated with multiple near-infrared sensors to measure specific deep tissue hemoglobin saturated oxygen or rSO2. Testing and mattress design development was done during the period of 2008 to present. Over 200 human tests of commercially available mattresses were conducted in supine, 30 degree, and 70 degree positions, ranging in times of up to four hours. During this time period, we utilized 20 test subjects-eight female and 12 male-with ages ranging from 18 to 65 years. The result of this proprietary off-loading device evaluation and design system shows that the new Oxy-Matâ„¢ (Off-Loading Technologies, Tarrytown, NY) Non-Powered Mattress System consistently provides optimized tissue perfusion as measured by natural deep tissue oxygen saturation levels. In extensive laboratory and clinical evaluations, the Oxy-Matâ„¢ was shown to be functionally superior to CMS Group 2 powered mattresses. Another outcome of our research was that a powered mattress system may not be appropriate for most sensate and semi-ambulatory patients. Further research is underway.

We review and report on accumulated data showing the benefits offered by hyperbaric oxygen (HBO2) therapy as an adjunct in the treatment of coronary artery bypass graft (CABG) patients. It has been shown that ischemia-reperfusion injury is deleterious to the myocardium, causing left ventricular dysfunction, structural damage to the myocytes and endothelial cells, myocardial stunning, reperfusion arrhythmias and potentially irreversible injury. There is a substantial body of evidence pointing to the role of HBO2 in mitigating the harmful effects of ischemia-reperfusion injury. Specifically, we review evidence from a number of studies which clearly point to both clinical and cost benefits HBO2 offers when used to precondition non-emergent patients having on-pump coronary arterial bypass graft surgery. Study data show that adding adjunctive HBO2 into the plan of care leads to improved myocardial function, reduces length of stay in the ICU, and limits post-surgical complications. Further, it has only minimal impact on the presurgical preparation, i.e., time must be allowed for the hyperbaric treatment(s), and no role in the surgery or post-surgical care of the patient. The studies pointing to clinical and cost benefit of preconditioning have been conducted outside the United States. Given the pressure on costs in all areas of health care, it seems that a therapeutic approach, which has been shown to be of benefit in both animal and human trials over the course of many years, should attract funding for a properly structured study designed to test whether significant and simultaneous improvements in clinical outcomes and cost reductions can be achieved within the framework of a U.S. healthcare facility.