DECUBITUS ULCER

In nursing homes and residential care facilities nationwide, the incidence of bedsores is estimated to be up to 23%. The agency for Healthcare Research and Quality estimates the prevalence of pressure ulcer to be up to 28% in long-term care. Center Medicaid Services (CMS) estimates the cost of treating a pressure ulcer in acute care to be $43,180. Stage IV ulcer is particularly costly to treat; NIH estimates the cost of treating a Stage IV pressure ulcer to be up to $129,248. The overall annual cost for the treatment of  pressure ulcers has been estimated to be between 5 billion and 8.5 billion dollars. 

Since this is considered a preventable and treatable condition, the presence of an ulcer is considered evidence of substandard care. This can create significant financial and legal issues for hospitals and nursing homes. 

Felony charges of involuntary manslaughter and neglect were filed against a Missouri residential care facility when a resident died of bedsores. Court records show that in nearly 87% of the cases the jury awarded substantial compensation to the plaintiffs.

Even in states that limit monetary awards, punitive damages can be in the millions.

• ·        In California, a jury awarded in Ollison v. Eskaton, $3 million in damages against a nursing home for allowing an elderly woman to die of bedsores (Sacramento Superior Court).

• ·        In Texas, $324,000,000 was awarded with an additional $300 million in punitive damages for the death of elderly patient due to malnourishment and infected decubitus ulcers.

Specific risk factors for pressure ulcer development

• More than 70 years of age
• Poor nutritional status
• Prolonged periods of immobilization
• Incontinence
• Uncontrolled diabetes
• Circulatory problems
• Fractures

Mechanisms for Ulcer 

Today there seems to be a unifying hypothesis of chronic wound pathogenesis based on four main causative factors:

• ·        bacterial colonization of the wound

• ·        local tissue hypoxia

• ·        repetitive ischemia-reperfusion injury

• ·        altered cellular and systemic stress response in the aged patient

While the standard of care is to rotate patients every 2 hours, the unsafe restoration of blood flow to ischemic tissue can cause more damage. This ischemia-reperfusion injury is often encountered in surgical practice this can cause a pressure sore to occur, enlarge, or become chronic. 

This ischemia-reperfusion injury occurs, for example, when a paraplegic or quadriplegic patient is turned from one side to the other, in a well-intentioned attempt to combat prolonged pressure on a given side. 

The reperfusion of hypoxic ischemic tissues with oxygen rich blood results in the formation of toxic Reactive Oxygen Species (ROS), including:

• ·        superoxide anions (O²−),

• ·        hydroxyl radicals (OH−),

• ·        hydrogen peroxide (H²O²

• ·        peroxynitrite

These reactive oxygen species attack cell membrane lipids, proteins, and glycosaminoglycans, causing extensive damage to tissue. So, turning patients every 2 hours can create both local and remote tissue destruction and sometimes even death. Therefore the safe reperfusion of the ischemic area at risk remains the cornerstone of clinical care for decubitus ulcer.

SmartSound technology, in a placebo controlled trial healed Stage IV diabetic ulcer. It has been shown to be unmatched in wound care. The researchers proclaimed, "the total healing of chronic wounds" in less than 8 weeks. Demonstrating a 100% healing rate in Stage 1V ulcer.


Decubitus Ulcer

Strength of Evidence A 

Medical Necessity Mandates Use

This is the most researched and clinically effective form of electrotherapy; it has been given an (A) strength of evidence rating. Medical necessity mandates its use when an ulcer has not healed for thirty days. Kloth and others showed that you could promote healing and prevent amputation even in elderly diabetics with Stage 4, non-responsive ulcer.

Electrotherapy has been shown to control infection, stimulate fibroblast activity and heal Stage 4 diabetic ulcer. Also, therapeutic ultrasound has been shown to accelerate the early phase of wound healing, promote wound closure, and epithelialization. Recent clinical research has suggested the LED photon therapy can help prevent diabetic ulcer and stimulate healing.

The biotechnology and pharmaceutical industries have directed considerable effort toward developing novel therapeutic strategies to limit or prevent Ischemia-reperfusion injury through using NO (nitric oxide). Nitric oxide acts as a vasodilator and it  has been shown to have a protective effect on even the heart, kidney and brain, providing a safe treatment for ischemia.

• Properly modulated ultrasound induces endothelial cells to release nitric oxide, safely restoring circulation in ischemic limbs. 

• Pulsed voltage acts as a vasodilator by inducing nitric oxide and has been shown to be effective in treating both ischemic wounds and diabetic ulcer. In controlled studies, DynaWave pulsed voltage has been shown to provide a 100% healing of stage IV ulcer in less than 8 weeks and help control infection.

• The synergistic combining of pulsed voltage and pulsed ultrasound provides results that are unavailable when used separately. 

• Inducing Nitric Oxide Synthase helps to safely restore circulation to ischemic tissue to prevent and heal ulcer.

Plast Reconstr Surg. 2006 Jun;117(7 Suppl):35S-41S.

Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis.

Mustoe TA, O'Shaughnessy K, Kloeters O.

Source

Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Ill 60611, USA. tmustoe@nmh.org

Abstract

The authors propose a unifying hypothesis of chronic wound pathogenesis based on four main causative factors: local tissue hypoxia, bacterial colonization of the wound, repetitive ischemia-reperfusion injury, and an altered cellular and systemic stress response in the aged patient. Traditional strategies for the treatment of chronic wounds have shown limited success.

PMID:16799373 PubMed - indexed for MEDLINE]

Adv Skin Wound Care. ;17 (6):284-94  15289715  Cit:7

High Cost of Stage IV Pressure Ulcers

Harold Brem, MD, Jason Maggi, MD, David Nierman, MD, Linda Rolnitzky, MS, David Bell, BS, Robert Rennert, BA, Michael Golinko, MD, Alan Yan, MD, Courtney Lyder, ND, and Bruce Vladeck, PhD

Results

“Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during one admission, and $124,327 for community-acquired ulcers over an average of 4 admissions.”

EFFECT OF ELECTRICAL NERVE STIMULATION ON HEALING OF ISCHAEMIC SKIN FLAPS

T Lundeberg a, J Kjartansson b c, U Samuelsson a b

Abstract

Blood circulation was measured by laser doppler flowmetry in fasciocutaneous flaps of 24 patients who underwent reconstructive surgery for mammary carcinoma. 19 of the 24 patients had clinical signs of deficient circulation in the flaps. 14 patients were treated with electrical nerve stimulation (ENS) and 10 with placebo-ENS. Varying degrees of necrosis developed in 8 of the 10 patients who received placebo stimulation but in none of those treated with ENS.

a Department of Physiology II, Karolinska Institute,, United Kingdom

b Department of Plastic and Reconstructive Surgery, Karolinska Hospital, Stockholm, Sweden

c and Department of Plastic Surgery , Landspitalinn, Reykjavik, Iceland

Adv Skin Wound Care. ;16 (2):79-89  12690231  Cit:4

Electrotherapy reverses inframalleolar ischemia: a retrospective, observational study.

Robert Goldman, Barbara Brewley, Linqiu Zhou, Michael Golden

Department of Rehabilitation Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.

OBJECTIVE: To determine if high-voltage pulsed current (HVPC) augments ischemic wound healing and increases periwound perfusion. DESIGN A 5-year, retrospective, observational study was conducted on successive patients with ischemic wounds who were poor candidates for revascularization. MAIN 

RESULTS: The group that received HVPC plus standard care showed smaller wound areas from weeks 20 though 52 after the start of treatment compared with the group that received standard care alone (P <.05; Mann-Whitney test). For the HVPC group, maximum periwound TcPo(2) improved during electrotherapy (6 +/- 8 mm Hg [standard deviation; SD] at baseline improved to 26 +/- 20 SD, during HVPC, P <.05; Wilcoxon signed rank test). 

CONCLUSION: The results of this retrospective trial demonstrate that HVPC plus standard care improved the healing rate of high-risk ischemic wounds. A direct relationship was shown between improved healing rates and increased periwound perfusion.

A comparison of four electrical stimulation types on Staphylococcus aureus growth in vitro.

MedLine Citation: PMID:  15558368     Owner:  NLM     Status:  MEDLINE   

Abstract:

We evaluated the efficacy of common electrical stimulation (ES) types on bacterial growth in vitro using clinically relevant conditions. After ES treatment, the zone of inhibition surrounding each electrode was measured. Zone of inhibition measurements showed a significant inhibitory effect for continuous microADC and HVPC (p < 0.05), but not for LVMmAPC and LVBmAPC. Differences in bacterial growth inhibition were not found for polarity and time. These data suggest that for infected wounds, HVPC and continuous microADC treatments may have an initial bacterial inhibitory effect, which does not significantly change with subsequent treatments.

han-hui Hsu, Tsung-Bin Huang, and Kuan-Pu Wang, Biomed. Eng. Appl. Basis Commun. 22, 367 (2010). DOI: 10.4015/S1016237210002122

 

LOW-INTENSITY ULTRASOUND INCREASES THE ENDOTHELIAL NITRIC OXIDE SYNTHASE (eNOS) EXPRESSION OF ENDOTHELIAL CELLS POSSIBLY VIA THE PHOSPHATIDYLINOSITOL 3-KINASE/AKT/PROTEIN KINASE A SIGNALING PATHWAY

Shan-hui Hsu

·        Corresponding author: Prof. Shan-hui Hsu, Institute of Polymer Science and Engineering, National Taiwan University, No. 1, Roosevelt Road Sec. 4, Taipei 10617, Taiwan. Tel: (886) 233665313; Fax: (886) 233665237.

·        Tsung-Bin Huang, Department of Bioscience Technology, Chang Jung Christian University, Tainan, Taiwan

·        Kuan-Pu Wang, Department of Chemical Engineering, National Chung Hsing University, Taichung, Taiwan

The stimulative effects and the associated mechanism of low-intensity ultrasound on endothelial cells were investigated in this study. The cell proliferation, nitric oxide release, intracellular calcium concentration, and endothelial nitric oxide synthase (eNOS) gene and protein expressions after ultrasound exposure were analyzed. It was found that ultrasound exposure did not change the cell proliferation, but it enhanced the release of nitric oxide and Ca²⁺ ions, and increased the eNOS activity. The above experiments suggested that low-intensity ultrasound may promote eNOS activity of endothelial cells via the phosphatidylinositol 3-kinase/Akt/protein kinase A signaling pathway. 

Ultrasound stimulation restores impaired neovascularization-related capacities of human circulating angiogenic cells

1. Yasuyuki Toyama1,
2. Ken-ichiro Sasaki1,*,
3. Katsuro Tachibana2,
4. Takafumi Ueno1,
5. Hidemi Kajimoto3,
6. Shinji Yokoyama1,
7. Masanori Ohtsuka1,
8. Hiroshi Koiwaya1,
9. Takaharu Nakayoshi1,
10. Yoshiaki Mitsutake1,
11. Hidetoshi Chibana1,
12. Naoki Itaya1 and
13. Tsutomu Imaizumi1

+ Author Affiliations

1.     ¹Department of Internal Medicine, Division of Cardio-Vascular Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan

2.     ²Department of Anatomy, Fukuoka University School of Medicine, Fukuoka, Japan

3.     ³The Cardiovascular Research Institute, Kurume University, Kurume, Japan

• Accepted May 23, 2012.

Abstract

Aims Unsatisfactory effects of therapeutic angiogenesis in critical limb ischaemia may be ascribed to use of circulating angiogenic cells (CACs) derived from atherosclerotic patients with impaired neovascularization-related capacities. We tested whether ultrasound cell stimulation can restore the impaired capacities.

Methods and results During culture of human peripheral blood-derived mononuclear cells for 4 days to achieve CACs, we stimulated the cells in culture daily with low-intensity pulsed ultrasound stimulation (LIPUS). Application of LIPUS to cells in culture derived from healthy volunteers augmented the generation and migration capacities of CACs, increased concentrations of angiopoietin 2 and nitrogen oxides in the culture medium, and increased the expression of phosphorylated-Akt and endothelial nitric oxide synthase in CACs on western blotting. Application of LIPUS to cells in culture derived from atherosclerotic patients also augmented the generation and migration capacities of CACs. Although neovascularization in the ischaemic hindlimb of athymic nude mice was impaired after intramuscular injection of CACs derived from atherosclerotic patients compared with that using CACs derived from healthy volunteers, LIPUS of the cells in culture derived from atherosclerotic patients restored the neovascularization capacities.

Conclusion Therapeutic angiogenesis with LIPUS-pre-treated CACs may be a new strategy to rescue critical limb ischaemia in atherosclerotic patients.