RESUMO
Significance: We introduce and evaluate emerging devices and modalities for wound size imaging and also promising image processing tools for smart wound assessment and monitoring. Recent Advances: Some commercial devices are available for optical wound assessment but with limited possibilities compared to the power of multimodal imaging. With new low-cost devices and machine learning, wound assessment has become more robust and accurate. Wound size imaging not only provides area and volume but also the proportion of each tissue on the wound bed. Near-infrared and thermal spectral bands also enhance the classical visual assessment. Critical Issues: The ability to embed advanced imaging technology in portable devices such as smartphones and tablets with tissue analysis software tools will significantly improve wound care. As wound care and measurement are performed by nurses, the equipment needs to remain user-friendly, enable quick measurements, provide advanced monitoring, and be connected to the patient data management system. Future Directions: Combining several image modalities and machine learning, optical wound assessment will be smart enough to enable real wound monitoring, to provide clinicians with relevant indications to adapt the treatments and to improve healing rates and speed. Sharing the wound care histories of a number of patients on databases and through telemedicine practice could induce a better knowledge of the healing process and thus a better efficiency when the recorded clinical experience has been converted into knowledge through deep learning.
Assuntos
Pé Diabético/diagnóstico por imagem , Diagnóstico por Imagem/instrumentação , Diagnóstico por Imagem/métodos , Úlcera da Perna/diagnóstico por imagem , Smartphone , Telemedicina/instrumentação , Ferimentos e Lesões/diagnóstico por imagem , Gerenciamento de Dados , Humanos , Aprendizado de Máquina , Software , Telemedicina/métodos , Ferimentos e Lesões/patologiaRESUMO
Objective: High bacterial load contributes to chronicity of wounds and is diagnosed based on assessment of clinical signs and symptoms (CSS) of infection, but these characteristics are poor predictors of bacterial burden. Point-of-care fluorescence imaging (FL) MolecuLight i:X can improve identification of wounds with high bacterial burden (>104 colony-forming unit [CFU]/g). FL detects bacteria, whether planktonic or in biofilm, but does not distinguish between the two. In this study, diagnostic accuracy of FL was compared to CSS during routine wound assessment. Postassessment, clinicians were surveyed to assess impact of FL on treatment plan. Approach: A prospective multicenter controlled study was conducted by 20 study clinicians from 14 outpatient advanced wound care centers across the United States. Wounds underwent assessment for CSS followed by FL. Biopsies were collected to confirm total bacterial load. Three hundred fifty patients completed the study (138 diabetic foot ulcers, 106 venous leg ulcers, 60 surgical sites, 22 pressure ulcers, and 24 others). Results: Around 287/350 wounds (82%) had bacterial loads >104 CFU/g, and CSS missed detection of 85% of these wounds. FL significantly increased detection of bacteria (>104 CFU/g) by fourfold, and this was consistent across wound types (p < 0.001). Specificity of CSS+FL remained comparably high to CSS (p = 1.0). FL information modified treatment plans (69% of wounds), influenced wound bed preparation (85%), and improved overall patient care (90%) as reported by study clinicians. Innovation: This novel noncontact, handheld FL device provides immediate, objective information on presence, location, and load of bacteria at point of care. Conclusion: Use of FL facilitates adherence to clinical guidelines recommending prompt detection and removal of bacterial burden to reduce wound infection and facilitate healing.
Assuntos
Carga Bacteriana/métodos , Pé Diabético/diagnóstico por imagem , Úlcera da Perna/diagnóstico por imagem , Imagem Óptica/métodos , Úlcera por Pressão/diagnóstico por imagem , Infecção da Ferida Cirúrgica/diagnóstico por imagem , Infecção dos Ferimentos/diagnóstico por imagem , Idoso , Estudos Transversais , Pé Diabético/microbiologia , Feminino , Humanos , Úlcera da Perna/microbiologia , Masculino , Pessoa de Meia-Idade , Testes Imediatos , Úlcera por Pressão/microbiologia , Estudos Prospectivos , Método Simples-Cego , Infecção da Ferida Cirúrgica/microbiologia , Estados Unidos , Infecção dos Ferimentos/diagnósticoRESUMO
The prevalence of chronic wounds is sharply rising throughout the world due to an aging population and increases in the incidence of obesity, diabetes, and cardiovascular diseases. People with diabetes, hypertension, and hyperlipidemia are at increased risk for developing peripheral arterial disease (PAD). PAD affects 8 to 12 million people over the age of 40 years in the United States and it is a major contributing factor to the development of lower extremity ulcers. Although a number of noninvasive diagnostic tests are available to detect PAD in lower extremities, they have several clinical limitations. In this review, current understanding of the pathophysiology of commonly seen lower extremity ulcers is described and vascular assessments typically used in practice are evaluated. In addition, application of the LUNA Fluorescence Angiography System (Novadaq, Bonita Springs, FL) for the screening and treatment of complex nonhealing wounds in patients with PAD is discussed.
Assuntos
Angiofluoresceinografia/métodos , Corantes Fluorescentes/administração & dosagem , Verde de Indocianina/administração & dosagem , Úlcera da Perna/diagnóstico por imagem , Extremidade Inferior/irrigação sanguínea , Imagem de Perfusão/métodos , Doença Arterial Periférica/diagnóstico por imagem , Humanos , Úlcera da Perna/fisiopatologia , Úlcera da Perna/terapia , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/terapia , Valor Preditivo dos Testes , Prognóstico , Fluxo Sanguíneo Regional , CicatrizaçãoRESUMO
Accurate and timely diagnosis of leg ulceration is an essential factor in making evidence-based, effective decisions regarding patient management with the aim of swift wound healing and/or referral to the appropriate specialty. Nurses are professionally responsible for ensuring that patients receive the appropriate assessment and evidence-based management. This article examines the most up-to-date guidance on Doppler ultrasound as a key element of this assessment. Approaches to assessment will be explored, with emphasis on the need to include a Doppler ultrasound as one key element of a larger, holistic assessment. An introduction to the ankle-brachial pressure index (ABPI) will be given, followed by a step-by-step guide to standard procedures for carrying out a full Doppler ultrasound. Alternative options for measuring ABPI are also provided.
Assuntos
Úlcera da Perna/diagnóstico por imagem , Ultrassonografia Doppler , Índice Tornozelo-Braço , Enfermagem Baseada em Evidências , Humanos , Úlcera da Perna/etiologia , Avaliação em EnfermagemRESUMO
OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of low-dose ultrasound delivered in conjunction with standard care against standard care alone in the treatment of hard-to-heal venous ulcers. DESIGN: A multicentre, pragmatic, two-armed randomised controlled trial with an economic evaluation. SETTING: Community nurse services; community leg ulcer clinics; hospital outpatient leg ulcer clinics, among both urban and rural settings in England, Scotland, Northern Ireland and Ireland. PARTICIPANTS: Patients with a venous leg ulcer of > 6 months' duration or > 5 cm2 and an ankle-brachial pressure index of ≥ 0.8. In total, 337 patients were recruited to the study. INTERVENTIONS: Participants in the intervention group received low-dose ultrasound (0.5 W/cm2) delivered at 1 MHz, pulsed pattern of 1 : 4, applied to periulcer skin (via a water-based contact gel) weekly for up to 12 weeks alongside standard care. Standard care consisted of low-adherent dressings and compression therapy, renewed as recommended by the patient's nurse and modified if required to reflect changes in ulcer and skin condition. The output of the ultrasound machines was checked every 3 months to confirm intervention fidelity. MAIN OUTCOME MEASURES: The primary end point was time to healing of the largest eligible ulcer (reference ulcer). Secondary outcomes were time to healing of all ulcers, proportion of patients healed, percentage and absolute change in ulcer size, proportion of time patients were ulcer free, cost of treatments, health-related quality of life (HRQoL), adverse events, withdrawal and loss to follow-up. RESULTS: There was a small, and statistically not significant, difference in the median time to complete ulcer healing of all ulcers in favour of standard care [median 328 days, 95% confidence interval (CI) 235 days, inestimable] compared with ultrasound (median 365 days, 95% CI 224 days, inestimable). There was no difference between groups in the proportion of patients with ulcers healed at 12 months (72/168 in ultrasound vs 78/169 standard care), nor in the change in ulcer size at 4 weeks. There was no evidence of a difference in recurrence of healed ulcers. There was no difference in HRQoL [measured using the Short Form questionnaire-12 items (SF-12)] between the two groups. There were more adverse events with ultrasound than with standard care. Ultrasound therapy as an adjuvant to standard care was found not to be a cost-effective treatment when compared with standard care. The mean cost of ultrasound was £197.88 (bias-corrected 95% CI -£35.19 to £420.32) higher than standard care per participant per year. There was a significant relationship between ulcer healing and area and duration at baseline. In addition, those centres with high recruitment rates had the highest healing rates. CONCLUSIONS: Low-dose ultrasound, delivered weekly during dressing changes, added to the package of current best practice (dressings, compression therapy) did not increase ulcer healing rates, affect quality of life (QoL) or reduce recurrence. It was associated with higher costs and more adverse events. There is no evidence that adding low-dose ultrasound to standard care for 'hard-to-heal' ulcers aids healing, improves QoL or reduces recurrence. It increases costs and adverse events. The relationship between ulcer healing rates and patient recruitment is worthy of further study. TRIAL REGISTRATION: Current Controlled Trials ISRCTN21175670. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 13. See the HTA programme website for further project information.
Assuntos
Úlcera da Perna/diagnóstico por imagem , Úlcera da Perna/terapia , Avaliação de Resultados em Cuidados de Saúde/economia , Idoso , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial , Análise Custo-Benefício , Feminino , Humanos , Úlcera da Perna/complicações , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Modelos de Riscos Proporcionais , Qualidade de Vida , Inquéritos e Questionários , Ultrassonografia , Reino UnidoRESUMO
Clinimetric analysis of the measurement of ABPI by Doppler ultrasound suggests this method is valid and reliable if the practitioner is competent and able to interpret the result within the context of a full clinical assessment.
Assuntos
Determinação da Pressão Arterial/métodos , Artéria Braquial/diagnóstico por imagem , Úlcera da Perna/diagnóstico por imagem , Ultrassonografia Doppler/métodos , Tornozelo/irrigação sanguínea , Viés , Competência Clínica , Falha de Equipamento , Prática Clínica Baseada em Evidências , Humanos , Úlcera da Perna/terapia , Avaliação em Enfermagem/métodos , Pesquisa em Avaliação de Enfermagem , Seleção de Pacientes , Postura , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Meias de Compressão , Ultrassonografia Doppler/instrumentação , Ultrassonografia Doppler/normasAssuntos
Traumatismos da Mão/diagnóstico por imagem , Traumatismos da Mão/cirurgia , Úlcera da Perna/diagnóstico por imagem , Úlcera da Perna/cirurgia , Interpretação de Imagem Radiográfica Assistida por Computador/métodos , Retalhos Cirúrgicos , Tomografia Computadorizada por Raios X/métodos , Adulto , Humanos , Masculino , Período Pós-Operatório , Retalhos Cirúrgicos/fisiologia , Sobrevivência de TecidosRESUMO
Doppler ultrasound is used by community nurses to measure the ankle brachial pressure index (ABPI). This is required before applying compression therapy for patients with chronic venous insufficiency and venous leg ulcers.However, emphasis on the ABPI result has resulted in inappropriate referrals to the vascular department which led the author to survey current practice within one primary care trust. Results illustrated variations in how nurses obtain training and maintain their competency in using Doppler ultrasound. This has an impact on the accuracy of interpretation of the ABPImeasurement and subsequent management of the patient. Practical issues also explained the difficulties nurses encountered in using the correct procedure within the community, which may result in unreliable measurements. There is a need to standardize training for all community nurses, and to review the structure of current clinical guidelines to enable a wider analysis of arterial assessment, in order to reduce the emphasis purely on the ABPI measurement.
Assuntos
Enfermagem em Saúde Comunitária/métodos , Enfermagem em Saúde Comunitária/estatística & dados numéricos , Úlcera da Perna/diagnóstico por imagem , Úlcera da Perna/enfermagem , Ultrassonografia Doppler/enfermagem , Ultrassonografia Doppler/estatística & dados numéricos , Tornozelo/diagnóstico por imagem , Determinação da Pressão Arterial/instrumentação , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/enfermagem , Artéria Braquial/diagnóstico por imagem , Competência Clínica/estatística & dados numéricos , Pesquisa em Enfermagem Clínica , Enfermagem em Saúde Comunitária/educação , Enfermagem em Saúde Comunitária/instrumentação , Educação Continuada em Enfermagem/estatística & dados numéricos , Inglaterra , Pesquisas sobre Atenção à Saúde , Humanos , Avaliação em Enfermagem/métodos , Avaliação em Enfermagem/estatística & dados numéricos , Ultrassonografia Doppler/instrumentaçãoRESUMO
Accurate diagnosis of mixed aetiology leg ulcers depends on detailed assessment by a trained practitioner. This paper, the fourth in a six-part series on leg ulcers, describes how reduced compression bandaging can achieve successful outcomes.
Assuntos
Bandagens , Úlcera da Perna/diagnóstico , Úlcera da Perna/enfermagem , Humanos , Úlcera da Perna/complicações , Úlcera da Perna/diagnóstico por imagem , Avaliação em Enfermagem/métodos , Oximetria , Dor/etiologia , Dor/enfermagem , Guias de Prática Clínica como Assunto , UltrassonografiaRESUMO
OBJECTIVES: accurate diagnosis is essential if patients with chronic leg ulceration are to receive optimal treatment. This prospective study describes the findings of a standardised assessment protocol and the initial management of a consecutive series of patients with chronic leg ulceration presenting to a single-visit leg ulcer assessment clinic. METHODS: between January 1993 and January 1999, a total of 555 patients (220 men and 335 women of median age 73, range 28-95 years) with 689 chronic leg ulcers were assessed. Full clinical assessment, ankle:brachial pressure index and lower limb venous duplex scan were performed according to a standardised protocol and diagnostic and management data were recorded prospectively on a computerised database. RESULTS: venous disease alone was responsible for 496 of 689 (72%) ulcers. Isolated superficial venous reflux (SVR) was identified in 52% of limbs and two-thirds of these had superficial venous surgery. Combined SVR and segmental deep venous reflux (DVR) was present in 13%, and full-length DVR was present in 33% of limbs. Nineteen (4%) limbs had deep venous stenosis or obstruction. Overall, superficial venous surgery was performed in 43% and compression bandages or hosiery alone were applied in 52% of limbs. Mixed arterio-venous ulceration was present in 100 (14.5%) limbs of which 56 had arterial revascularisation, 38 had superficial venous surgery and 23 had compression alone. Fifteen limbs with pure arterial ulceration had angioplasty (n=13) or simple dressings alone (n=2). Ulceration due to lymphoedema (n=17), mixed lymphoedema and venous reflux (n=11) and other causes (n=50) were managed by compression, dressings or skin grafting. CONCLUSIONS: a standardised protocol of clinical and duplex assessment can lead to a diagnosis in 97% of chronic leg ulcers. Duplex is essential to confirm or exclude potentially correctable venous disease and allow tailored surgical intervention for those patients who many benefit.
Assuntos
Úlcera da Perna/diagnóstico por imagem , Úlcera da Perna/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Distribuição de Qui-Quadrado , Doença Crônica , Feminino , Humanos , Úlcera da Perna/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Ultrassonografia Doppler DuplaRESUMO
Adequate patient assessment is the most important element of chronic wound management, and the use of holistic techniques enables practitioners to make informed clinical judgements. Doppler ultrasound is integral to the holistic assessment of leg ulcers. This article reviews the procedure for measuring ankle/brachial pressure indices using Doppler ultrasound and outlines various diagnostic tests that employ the Doppler principle.
Assuntos
Úlcera da Perna/diagnóstico por imagem , Úlcera da Perna/enfermagem , Avaliação em Enfermagem/métodos , Ultrassonografia Doppler/enfermagem , Interpretação Estatística de Dados , Saúde Holística , Humanos , Palpação , Educação de Pacientes como Assunto , Seleção de Pacientes , Reprodutibilidade dos Testes , Ultrassonografia Doppler/métodosRESUMO
Leg ulcers are costly to both patients and also the NHS. It is therefore of paramount importance that the treatment regimen is based on a holistic assessment to determine the underlying aetiology. It is only then that an appropriate treatment plan can be formulated. This article reviews the issues involved in the holistic assessment of leg ulcers.
Assuntos
Saúde Holística , Úlcera da Perna/enfermagem , Avaliação em Enfermagem/métodos , Causalidade , Humanos , Úlcera da Perna/diagnóstico por imagem , Úlcera da Perna/etiologia , Planejamento de Assistência ao Paciente , Encaminhamento e Consulta , Higiene da Pele/enfermagem , Ultrassonografia Doppler/enfermagemRESUMO
Successful management of patients with leg ulcers depends on an understanding of the disease process. Accurate assessment is vital in identifying factors which will delay healing and increase the likelihood of ulcer recurrence. With such knowledge nurses can decide when compression therapy is appropriate.