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Objective: To identify markers associated with pressure injury (PrI) history in individuals with spinal cord injury (SCI) using two approaches: skin blood flow (SBF) response toward localized heating, and serum marker for insulin resistance., Methods: For this cross-sectional, observational study of adults with chronic traumatic SCI at T12 and above, researchers recruited two groups of participants: with history of PrI (group 1), and without history of PrI (group 2). The study protocol included obtaining fasting blood samples and measurement of SBF at bilateral heels with localized heating of 42 °C for 30 minutes from all participants. Primary SBF outcomes were initial peak and plateau SBF normalized to baseline SBF. The primary outcome for insulin resistance was Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), calculated from fasting plasma glucose and insulin. Secondary outcomes included demographic and SCI information. Researchers used the Fisher exact test and Wilcoxon-Mann-Whitney test to compare the intergroup difference of categorical and continuous variables, respectively., Results: Sixteen adults completed this study (group 1, n = 7; group 2, n = 9). In comparison with group 2, group 1 had significantly higher HOMA-IR (3.90 ± 0.71 vs 1.45 ± 0.71), suggesting higher insulin resistance, and longer duration of injury (22.54 ± 7.24 vs 7.98 ± 6.58 years). There were no between-group differences in SBF or other secondary outcomes., Conclusions: HOMA-IR is a novel serum index associated with PrI history in persons with chronic SCI. Future longitudinal study is warranted to examine the role of insulin resistance in increasing PrI risk for the SCI population., (Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.)

The major populations at risk for developing pressure ulcers are older adults who have multiple risk factors that increase their vulnerability, people who are critically ill and those with spinal cord injury/disease. The reported prevalence of pressure ulcers in the United States is 2.5 million. However, this estimate is derived from acute care facilities and does not include people who are living at home or in nursing facilities. Despite the implementation of hospital and facility-based preventive measures, the incidence of pressure ulcers has not decreased in decades. In addition to the burden of pain, infection and death, it is estimated that hospital-acquired pressure ulcers cost the health system $26.8 billion annually with over 50% of the cost attributed to treating Stage 3 and 4 pressure injuries. Thus, it is critical to examine the literature and develop guidelines that will improve the outcomes of this complex and costly condition. This guideline update is a compendium of the best available evidence for the treatment of Pressure Ulcers published since the last update in 2015 and includes a new section based on changing demographics entitled 'Palliative wound care for seriously ill patients with pressure ulcers'. The overall goal of the Wound Healing Society Guideline project is to present clear, concise and commercial free guidelines that clinicians can use to guide care, that researchers can use to develop studies that will improve treatment and that both clinicians and researchers can use to understand the gaps in our knowledge base., (© 2023 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.)

Objective: The study describes the development and testing of a dry surface stimulation flexible electrode (herein referred to as Flexatrode), a low-cost, flexible, and scalable elastomeric nanocomposite using carbon black (CB) and polydimethylsiloxane (PDMS)., Methods: Flexatrodes composed of CB and PDMS were developed and tested for mechanical and functional stability up to 7 days. Uniform CB distribution was achieved by optimizing the dispersion process using toluene and methyl-terminated PDMS. Electromechanical testing in the through thickness directions over a long-term duration demonstrated stability of Flexatrode. Thermal stability of Flexatrode for up to a week was tested and validated, thus mitigating concerns of heat generation and deleterious skin reactions such as vasodilation or erythema., Results: 25 wt.% CB was determined to be the optimal concentration. Electrical and thermal stability were demonstrated in the through thickness direction., Conclusion: Flexatrode provides stable electrical properties combined with high flexibility and elasticity. Electrotherapy treated chronic wounds were 81.9% smaller than baseline at day 10. Wounds that received an inactive device (device without any electrical stimulation) were 58.1% smaller than baseline and wounds that received standard of care treatment were 62.2% smaller than baseline., Significance: The increasing need for wearable bioelectronics requiring long-term monitoring/treatment has highlighted the limitations of sustained use of gel-based electrodes. These can include skin irritation, bacterial overgrowth at the electrode site, gel dehydration over time, and signal degradation due to eccrine sweat formation. Flexatrode provides stable performance in a nanocomposite with scalable fabrication, thus providing a promising platform technology for wearable bioelectronics.

Chronic ischemic wounds affect millions of people causing significant pain and disability. They can be considered to be stalled in the inflammatory stage and cannot heal without additional measures. A valid animal model is necessary to evaluate the efficacy of topical wound healing therapies and wearable technologies. A porcine model, although higher in cost, maintenance, and space requirements, is superior to the commonly used rodent or rabbit model for wound healing. Previous studies have shown that pig wounds have greater similarity to human wounds in responses to a variety of treatments, including wound dressings and antibiotics. The current study created a porcine model of large chronic wounds to assess a wearable electroceutical technology, with monitoring of healing variables and infection. Electroceutical therapy is the only adjunctive treatment recommended for chronic wound therapy. A porcine model of large chronic wounds of clinically realistic size was created and utilized to evaluate a wearable electroceutical biotechnology. Multivariate non-invasive assessment was used to monitor wound progression over multiple timepoints. Outcomes suggest that a wearable electrostimulation bandage, has the potential to offer therapeutic benefit in human wounds. The tested wearable device provides the same proven effectiveness of traditional electroceutical therapy while mitigating commonly cited barriers, including substantial time requirements, and availability and complexity of currently available equipment, preventing its implementation in routine wound care. The model is also appropriate for evaluation of other wearables or topical therapeutics., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Published by Elsevier Ltd.)

Background: Epigenetics studies the impact of environmental and behavioral factors on stable phenotypic changes; however, the state of the science examining epigenomic mechanisms of regulation related to secondary health conditions (SHCs) and neuroepigenetics in chronic spinal cord injury (SCI) remain markedly underdeveloped., Objective: This scoping review seeks to understand the state of the science in epigenetics and secondary complications following SCI., Methods: A literature search was conducted, yielding 277 articles. The inclusion criteria were articles (1) investigating SCI and (2) examining epigenetic regulation as part of the study methodology. A total of 23 articles were selected for final inclusion., Results: Of the 23 articles 52% focused on histone modification, while 26% focused on DNA methylation. One study had a human sample, while the majority sampled rats and mice. Primarily, studies examined regeneration, with only one study looking at clinically relevant SHC, such as neuropathic pain., Discussion: The findings of this scoping review offer exciting insights into epigenetic and neuroepigenetic application in SCI research. Several key genes, proteins, and pathways emerged across studies, suggesting the critical role of epigenetic regulation in biological processes. This review reinforced the dearth of studies that leverage epigenetic methods to identify prognostic biomarkers in SHCs. Preclinical models of SCI were genotypically and phenotypically similar, which is not reflective of the heterogeneity found in the clinical population of persons with SCI. There is a need to develop better preclinical models and more studies that examine the role of genomics and epigenomics in understanding the diverse health outcomes associated with traumatic SCI., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Objective: To identify genetic biomarkers predisposing individuals with spinal cord injury (SCI) to recurrent pressure injuries (PIs)., Methods: Repeated measures of the transcriptome profile of veterans with SCI at three Veterans Spinal Cord Injuries and Disorders Centers. Exclusion criteria included having significant active systemic disease at time of enrollment. Researchers obtained comprehensive profiles of clinical and health factors and demographic information relevant to PI history at enrollment and at each follow-up visit by reviewing patients' medical charts. Whole blood samples were collected at 6- to 12-month intervals for 2 to 4 years. In addition to DNA profiling with whole genome sequencing of the patients, RNA sequencing was performed to assess pathways associated with PI risk., Results: Whole genome sequencing analysis identified 260 genes that showed increased prevalence of single-nucleotide variations in exonic regions with high (>20) combined annotation-dependent depletion scores between persons with high versus low intramuscular adipose tissue levels when cross-referenced with persons who had recurrent PIs. Gene set enrichment analysis using Hallmark and KEGG (Kyoto Encyclopedia of Genes and Genomes) gene sets of these candidate genes revealed enrichment in genes encoding proteins involved in fatty acid metabolism (P < .01). Further, RNA sequencing revealed upregulated activity in biological senescence pathways and downregulated activity in antimicrobial protection pathways., Conclusions: Genomic biomarkers may complement electronic health records to support management of complex interactive health issues such as risk of recurrent PIs in people with SCI. These findings may also be leveraged for homogeneous phenotypic grouping of higher-risk individuals., (Copyright © 2023 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Purpose: The purpose of this quality improvement (QI) project was to develop and implement an interactive, evidence-based pressure injury (PI) education program and evaluate the impact on frontline hospice nursing staff knowledge and practice., Participants and Setting: The QI setting was a 12-bed inpatient hospice unit in a tertiary care Veterans Affairs (VA) Medical Center in Cleveland, Ohio. Nineteen licensed and unlicensed hospice nursing staff participated in this pre-/postworkshop project., Approach: Chart audit determined baseline PI incidence and prevalence on the inpatient hospice unit. Interviews with key leaders informed the need to develop and implement innovative PI education opportunities. A literature review determined existing standards regarding the benefits of PI education for nursing staff but did not reveal measurable targets in hospice settings. We developed a PI education intervention based on Kolcaba's Theory of Comfort framework and a Plan-Do-Study-Act (PDSA) performance improvement model. Education was delivered in 7 workshops, lasting 2 hours each. Knowledge, practice, and comfort for inpatient hospice nursing staff were evaluated at baseline and 8 weeks following the final refresher visit. Workshop satisfaction was collected once using standard program evaluation forms after final workshop delivery., Outcomes: We observed a significant improvement in staff PI knowledge (P = .001) and practice (P = .001) after initial workshop attendance and repeat engagement (P = .001). There was a large magnitude of effect for overall knowledge change (d = 1.04); similarly PI care planning and practice showed a large magnitude of effect and significant improvement (P = .001, d = 2.64). Staff comfort with job duties was stable with low effect size (mean 4.52, d = 0.04), and satisfaction with the workshop education was high (100% agreement with trainer effectiveness)., Implications for Practice: We found that frontline hospice nursing staff knowledge and practice improved after attendance at our evidence-based PI education program. Results of this QI project have stimulated ongoing discussion on how to sustain this program in our hospice setting., Competing Interests: The authors report no conflict of interest with the work presented in this article., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Wound, Ostomy, and Continence Nurses Society.)

Objective: Wound dressings that create and maintain a moist environment provide the optimal conditions for wound healing by increasing the rate of epithelialization and angiogenesis. However, current wound dressings require periodic removal which exposes the wound to the surrounding environment, thereby increasing the likelihood for infection and drying out the wound itself. There remains an unmet medical need for the development of an absorbent, flexible, and transparent wound dressing that can conform to the irregular geometry of the wound for a long-term duration. Herein, we report the development of AFTI Derm, an Absorbent, Flexible, Transparent, and Inexpensive moisture-management wound dressing using Polyvinyl alcohol (PVA) as the host material. Methods: AFTI Derm substrates of varying glycerol concentrations (1 wt%, 3 wt%, 5 wt%, 7 wt%, and 10 wt%) were fabricated and tested. The mechanical, absorption, and biological properties of AFTI Derm were evaluated. Results: We found that 5% glycerol served as the optimal concentration for AFTI Derm. The biocompatibility, absorptive capabilities, and scalability render PVA/glycerol an ideal material composition for wound dressings. Benchtop experimentation and pre-clinical testing demonstrate AFTI Derm as a platform for use in wound dressings. Discussion/Conclusion: The development of AFTI Derm broadens the translational utility of this materials platform not only as a material for wound dressings to minimize dressing changes in low to moderate exudate environments, but also as a potential substrate material for smart bandages. Clinical and Translational Impact Statement- AFTI Derm, an absorbent, flexible, and transparent wound dressing, maintains the moist environment required for healing while enabling monitoring of healing without removal and disruption to the wound bed.

There is growing understanding that the consumer's voice in research needs to be stronger. Translational research studies need consumer inclusion in order to be effectively implemented. This narrative article provides the perspective of a Veteran with spinal cord injury (SCI) who is an active member of several study teams and serves as a Consumer Advocate, providing the voice of the person with SCI. Factors that drive people to develop new research ideas are considered. Consumer involvement offers helpful insight into project outcomes that are valuable to the end-user. It is also recognized that data can be interpreted in several different ways depending on the observer. Including the consumer in a research project enables another interpretation, creating a more complete evaluation. Participating in health research is becoming a new standard for persons with many different illnesses and diseases. Greater things are accomplished by physicians, healthcare scientists, engineers, and healthcare consumers interacting together to increase both the quality of research projects and the quality of life for everyone involved, especially the person with the disorder. There will be more acceptance of ideas or projects when consumers are involved from the early steps and learn how the process works from beginning to end., (© 2021. The Author(s).)

Objectives: The aims of the study were to assess reports of wheelchair mobility-related injuries from inadvertent lower extremity displacement (ILED) on footplates, which were submitted to the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database during 2014-2018, characterize injury types, and evaluate MAUDE data quality., Methods: A systematic MAUDE database review was performed. Annual reports were searched using keywords: (a) "power wheelchair" and "injury" and (b) "mechanical (also known as manual) wheelchair" and "injury." Reports related to injuries from ILED on the footplate were reviewed., Results: Reports of 1075 wheelchair injuries were found across the review period. Twenty nine (3%) met our inclusion criteria. The most common source of reports was "manufacturer." The wheelchair was unavailable for evaluation in 55.17% of reports. Manufacturers' submission dates (number of days that passed after they were notified) ranged from 3 to 159. Reported injuries decreased by 60% from 2014 to 2018. The end user used a power wheelchair for all but one report. The most common injuries were single fractures, multiple fractures, wounds/cuts/infections, and amputations (in order of incidence). The most common mechanism was the foot slipping off the footplate during wheelchair mobility., Conclusions: We observed inherent weaknesses in the MAUDE database reporting process and a concerning level of reporting bias. Although there were limited reports of injuries related to ILED on the footplate during wheelchair mobility, the injuries reported were significant. More standardized reporting of the mechanism and impact of these injuries is needed to better inform wheelchair design, prescription, and patient/family education., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Inadvertent lower extremity displacement (ILED) puts the feet of power wheelchair (PWC) users at great risk of traumatic injury. Because disabled individuals may not be aware of a mis-positioned foot, a real-time system for notification can reduce the risk of injury. To test this concept, we developed a prototype system called FootSafe, capable of real-time detection and classification of foot position. The FootSafe system used an array of force-sensing resistors to monitor foot pressures on the PWC footplate. Data were transmitted via Bluetooth to an iOS app which ran a classifier algorithm to notify the user of ILED. In a pilot trial, FootSafe was tested with seven participants seated in a PWC. Data collected from this trial were used to test the accuracy of classification algorithms. A custom figure of merit (FOM) was created to balance the risk of missed positive and false positive. While a machine-learning algorithm (K nearest neighbors, FOM=0.78) outperformed simpler methods, the simplest algorithm, mean footplate pressure, performed similarly (FOM=0.62). In a real-time classification task, these results suggest that foot position can be estimated using relatively few force sensors and simple algorithms running on mobile hardware.Clinical Relevance- Foot collisions or dragging are severe or life-threatening injuries for people with spinal cord injuries. The FootSafe sensor, iOS app, and classifier algorithm can warn the user of a mis-positioned foot to reduce the incidence of injury.

Significance: Chronic wounds fail to heal in a timely manner and exhibit sustained inflammation with slow tissue repair and remodelling. They decrease mobility and quality of life, and remain a major clinical challenge in the long-term care of many patients, affecting 6.5 million individuals annually in the U.S., decreasing mobility and quality of life. Treatment costs are a major burden on the U.S. healthcare system, totalling between $25 and $100 billion annually. Chronic wound severity depends upon several factors such as comorbidities, severity of tissue damage, infection and presence of necrosis and vary greatly in their healing mechanisms. In vivo animal models are critical for studying healing pathways of chronic wounds and seek to replicate clinical factors for trials of topical, systemic, and device-based therapeutics. This comprehensive review discusses murine, rat, lapine, canine, feline and porcine models of chronic wounds., Recent Advances: Foundational chronic wound models for several species are discussed together with refinements and advances in the time period between 2015 and 2020 which have the potential for broad utility in investigating biological and device-based wound treatment therapies for human health., Critical Issues: Chronic wounds fail to heal in a timely manner and have differing aetiologies, rendering no single in vivo animal model universally applicable., Future Directions: Further studies are required to develop clinically relevant chronic wound animal model which reflect the clinical reality of the various influences of age, disease, comorbidities and gender on delayed healing and enhance understanding of the biological processes of human wound healing., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Background: Pressure injuries (PrI) are serious complications for many with spinal cord injury (SCI), significantly burdening health care systems, in particular the Veterans Health Administration. Clinical practice guidelines (CPG) provide recommendations. However, many risk factors span multiple domains. Effective prioritization of CPG recommendations has been identified as a need. Bioinformatics facilitates clinical decision support for complex challenges. The Veteran's Administration Informatics and Computing Infrastructure provides access to electronic health record (EHR) data for all Veterans Health Administration health care encounters. The overall study objective was to expand our prototype structural model of environmental, social, and clinical factors and develop the foundation for resource which will provide weighted systemic insight into PrI risk in veterans with SCI., Methods: The SCI PrI Resource (SCI-PIR) includes three integrated modules: (1) the SCIPUDSphere multidomain database of veterans' EHR data extracted from October 2010 to September 2015 for ICD-9-CM coding consistency together with tissue health profiles, (2) the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) developed from the cohort's free text clinical note (Text Integration Utility) notes, and (3) the clinical user interface for direct SCI-PIR query., Results: The SCI-PIR contains relevant EHR data for a study cohort of 36,626 veterans with SCI, representing 10% to 14% of the U.S. population with SCI. Extracted datasets include SCI diagnostics, demographics, comorbidities, rurality, medications, and laboratory tests. Many terminology variations for non-coded input data were found. SCIPUDO facilitates robust information extraction from over six million Text Integration Utility notes annually for the study cohort. Visual widgets in the clinical user interface can be directly populated with SCIPUDO terms, allowing patient-specific query construction., Conclusion: The SCI-PIR contains valuable clinical data based on CPG-identified risk factors, providing a basis for personalized PrI risk management following SCI. Understanding the relative impact of risk factors supports PrI management for veterans with SCI. Personalized interactive programs can enhance best practices by decreasing both initial PrI formation and readmission rates due to PrI recurrence for veterans with SCI., (© The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: Conflict of interest: The authors report grants from CDMRP Spinal Cord Injury Research Program and grants from Craig H. Neilsen Foundation during the conduct of the study.

Objective: To investigate potential linkages between pressure injury (PrI) recurrence following spinal cord injury (SCI) and muscle-based and circulatory biomarkers, specifically fatty metabolites and inflammatory cytokines. Design: Observational study. Setting: Tertiary Care Center. Participants: 30 individuals with complete or incomplete SCI. Study participants either had never developed a PrI (Group I) or had a history of recurrent PrI (Group II). Interventions: Not applicable. Outcome Measures: Gluteal muscle histology, immunohistochemistry, muscle-based and circulatory fatty metabolites and inflammatory cytokines. Results: Gluteal intramuscular adipose tissue (IMAT) was greater than 15% in most Group II (83%) individuals. Muscle tissue histology confirmed intramuscular structural differences. Fatty acid binding protein 4 (FABP4) and fatty acid binding protein 3 (FABP3) were reliably detected in muscle and blood and significantly correlated with IMAT (P < 0.001). FABP4 was significantly higher in Group II muscle and blood (P < 0.05). FABP3 was significantly higher in Group I muscle (P < 0.05). Circulatory FABP3 levels were lower for Group I. Inflammatory biomarkers were more reliably detected in blood. Colony-Stimulating Factor-1 was slightly higher in Group II muscle. Circulatory interleukin-13 was significantly higher (P < 0.01) in Group I. Vascular endothelial growth factor (VEGF-A) was significantly increased (P < 0.05) in Group I muscle and blood. Conclusion: Identifying individuals with SCI at highest risk for recurrent PrI may impact patient management. IMAT content evaluation illustrates that muscle quality is a key biomarker. Low circulatory inflammatory biomarker expression potentially limits clinical significance for between group differences. Circulatory levels of FABP4 hold great potential as a recurrent PrI risk biomarker.

Regular monitoring of blood flow and pressure in vascular reconstructions or grafts would provide early warning of graft failure and improve salvage procedures. Based on biocompatible materials, we have developed a new type of thin, flexible pulsation sensor (FPS) which is wrapped around a graft to monitor blood pressure and flow. The FPS uses carbon black (CB) nanoparticles dispersed in polydimethylsiloxane (PDMS) as a piezoresistive sensor layer, which was encapsulated within structural PDMS layers and connected to stainless steel interconnect leads. Because the FPS is more flexible than natural arteries, veins, and synthetic vascular grafts, it can be wrapped around target conduits at the time of surgery and remain implanted for long-term monitoring. In this study, we analyze strain transduction from a blood vessel and characterize the electrical and mechanical response of CB-PDMS from 0-50% strain. An optimum concentration of 14% CB-PDMS was used to fabricate 300-μm thick FPS devices with elastic modulus under 500 kPa, strain range of over 50%, and gauge factor greater than 5. Sensors were tested in vitro on vascular grafts with flows of 0-1,100 mL/min. In vitro testing showed linear output to pulsatile flows and pressures. Cyclic testing demonstrated robust operation over hundreds of cardiac cycles, with ±2.6 mmHg variation in pressure readout. CB-PDMS composite material showed excellent potential in biologic strain sensing applications where a flexible sensor with large maximum strain range is needed.

Objective: To investigate intersections between pressure injury (PrI) history, muscle composition, and tissue health responses under physiologically relevant loading conditions for individuals with spinal cord injury (SCI)., Design: Repeated measures study design with annual follow-up for up to 3 years., Setting: Tertiary care center., Participants: Persons with SCI (N=38). Exclusion criteria included having an open pelvic region PrI at the time of recruitment, presence of systemic disease, and/or known sensitivity to contrast., Interventions: Not applicable., Main Outcome Measures: Gluteal muscle composition, ischial interface pressures, tissue oxygenation., Results: Ischial region mean interface pressures are the same for individuals with or without a PrI history. Tissue oxygenation is lower during sitting for persons with a PrI history. Individuals with >15% gluteal intramuscular fat were statistically highly significantly (P<.001) more likely to have a history of severe or recurrent PrI. Intramuscular adipose tissue (IMAT) levels within the gluteal muscle may remain low over time or muscle tissue in the gluteal muscle region may be almost entirely replaced by IMAT. In the current study cohort, it was found that muscle composition also continues to change over time even for individuals with long-standing SCI., Conclusions: Soft-tissue compositional changes, specifically IMAT, provides a reliable indicator of PrI history and may provide a key to personalized PrI risk status for persons with SCI. The current findings confirm that interface pressure mapping alone is a limited indicator for PrI development., (Published by Elsevier Inc.)

Objective: Nonviable necrotic eschar is an impedance to wound healing and can ultimately lead to failure of soft tissue coverage in traumatic or high-risk wounds. Topical therapeutic agents can provide a less invasive management alternative to surgical debridement of eschar. Approach: The case of a 40-year-old male with a traumatic right lower extremity amputation complicated by surgical incision ischemic eschar formation is reported. Honey-based salve with burdock leaf dressings was used to noninvasively manage eschar extending over the incision site. Images were obtained for 5 months of follow-up. Results: Five-month follow-up demonstrated complete resolution of eschar and re-epithelialization of skin in the affected region. Innovation: Honey-based salve with burdock leaf dressings shows promise for enhancing healing outcomes in traumatic wounds that develop nonviable eschar. Conclusion: Surgical debridement of an amputation stump with large ischemic eschar was avoided with the use of honey-based salve with burdock leaf dressings.

Background: Infected wounds are painful and cannot heal, with antibiotics showing reduced efficacy. Appropriate wound electrotherapy may limit incident planktonic and polymicrobial colonization, inhibit biofilm formation and accelerate healing., Methods: The Modular Adaptive Electrotherapy Delivery System (MAEDS) is a lightweight, flexible, battery-powered disposable bandage which delivers controlled reliable electrotherapy to the wound for up to 7 days. Large full-thickness excisional wounds (6 cm diameter) were created in a porcine model and freshly cultured 0.5 McFarland green fluorescent protein-labeled Pseudomonas aeruginosa evenly applied to the wound bed. Control wounds received standard wound care, Tegaderm HP Transparent Dressing (3 M Health Care, St. Paul, MN, USA) applied in a sterile fashion. Treatment wounds received MAEDS electrotherapy for up to 28 days or until healed. Onboard Bluetooth facilitated remote real-time monitoring of MAEDS function. Dressing changes occurred on postoperative day (POD) 1, 3, 5, 7, 10, 14, 21, and 28. Punch biopsies were taken at the wound margin and center. Bacterial samples were processed to determine infection status., Results: Acute infected wounds treated with MAEDS electrotherapy were 92% smaller than baseline by POD21. Healing rate was significantly faster (p < 0.01) and infection significantly decreased (p < 0.0001) at POD10, relative to control wounds., Conclusion: The MAEDS electrotherapy can significantly inhibit infection and enhance healing rate in acute infected wounds., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Inkjet printing has been identified as a cost-effective method to fabricate sensors on polymeric substrates. However, substrate materials suitable for printing are limited by the annealing temperature required by conventional inks. In this article, we describe the fabrication of an inkjet-printed thermistor on polyethylene and cellophane substrates that are not thermally compatible with the conventional inkjet printing processes. Fabrication on these substrates is made possible by a novel plasma-based postprint treatment step that limits the substrate temperature to <50 °C. The sensors exhibited a temperature sensitivity of 0.25 Ω°C -1 that was independent of substrate material. The utility of the fabrication process was demonstrated by fabricating thermistors for common indoor and outdoor applications.

Background: Pressure ulcers (PU) and deep tissue injuries (DTI), collectively known as pressure injuries are serious complications causing staggering costs and human suffering with over 200 reported risk factors from many domains. Primary pressure injury prevention seeks to prevent the first incidence, while secondary PU/DTI prevention aims to decrease chronic recurrence. Clinical practice guidelines (CPG) combine evidence-based practice and expert opinion to aid clinicians in the goal of achieving best practices for primary and secondary prevention. The correction of all risk factors can be both overwhelming and impractical to implement in clinical practice. There is a need to develop practical clinical tools to prioritize the multiple recommendations of CPG, but there is limited guidance on how to prioritize based on individual cases. Bioinformatics platforms enable data management to support clinical decision support and user-interface development for complex clinical challenges such as pressure injury prevention care planning., Objective: The central hypothesis of the study is that the individual's risk factor profile can provide the basis for adaptive, personalized care planning for PU prevention based on CPG prioritization. The study objective is to develop the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury (SCIPUD+) Resource to support personalized care planning for primary and secondary PU/DTI prevention., Methods: The study is employing a retrospective electronic health record (EHR) chart review of over 75 factors known to be relevant for pressure injury risk in individuals with a spinal cord injury (SCI) and routinely recorded in the EHR. We also perform tissue health assessments of a selected sub-group. A systems approach is being used to develop and validate the SCIPUD+ Resource incorporating the many risk factor domains associated with PU/DTI primary and secondary prevention, ranging from the individual's environment to local tissue health. Our multiscale approach will leverage the strength of bioinformatics applied to an established national EHR system. A comprehensive model is being used to relate the primary outcome of interest (PU/DTI development) with over 75 PU/DTI risk factors using a retrospective chart review of 5000 individuals selected from the study cohort of more than 36,000 persons with SCI. A Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) is being developed to enable robust text-mining for data extraction from free-form notes., Results: The results from this study are pending., Conclusions: PU/DTI remains a highly significant source of morbidity for individuals with SCI. Personalized interactive care plans may decrease both initial PU formation and readmission rates for high-risk individuals. The project is using established EHR data to build a comprehensive, structured model of environmental, social and clinical pressure injury risk factors. The comprehensive SCIPUD+ health care tool will be used to relate the primary outcome of interest (pressure injury development) with covariates including environmental, social, clinical, personal and tissue health profiles as well as possible interactions among some of these covariates. The study will result in a validated tool for personalized implementation of CPG recommendations and has great potential to change the standard of care for PrI clinical practice by enabling clinicians to provide personalized application of CPG priorities tailored to the needs of each at-risk individual with SCI., Registered Report Identifier: RR1-10.2196/10871., (©Kath M Bogie, Guo-Qiang Zhang, Steven K Roggenkamp, Ningzhou Zeng, Jacinta Seton, Shiqiang Tao, Arielle L Bloostein, Jiayang Sun. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 06.09.2018.)

Power wheelchair users are at risk for severe injuries caused by foot mis-position on the footplate. This can lead to collisions or foot dragging which are severe or lifethreatening injuries for people with spinal cord injuries. The foot cannot be safely immobilized due to tilting pressure relief injuries, therefore, the foot can easily fall into a vulnerable position without the user realizing it. To reduce the likelihood of injury, we have developed a sensor for monitoring foot position in real time, as the wheelchair is driven. The sensor uses an array of force-sensing resistors and infrared distance sensors to detect the pressure and location of the foot within the immediate confines of the footplate. Sensor arrays with 23 force sensors and 14 infrared sensors per foot were fabricated on standard printed circuit boards and encapsulated in a durable thermoplastic urethane for environmental resistance. Fabricated sensors transmitted foot pressures and position data at 10 Hz using a Bluetooth Low Energy radio. An iOS app was developed to notify users of vulnerable foot position. Measured results confirmed the functionality of the system over typical foot pressures, and indicated that the device is ready for next-stage clinical trials with spinal cord injured power wheelchair users.

Study Aim: Effective pressure relief cushions are identified as a core assistive technology need by the World Health Organization Global Cooperation on Assistive Technology. High quality affordable wheelchair cushions could provide effective pressure relief for many individuals with limited access to advanced assistive technology., Materials: Value driven engineering (VdE) principles were employed to develop a prototype modular cushion. Low cost dynamically responsive gel balls were arranged in a close packed array and seated in bilayer foam for containment and support. Two modular cushions, one with high compliance balls and one with moderate compliance balls were compared with High Profile and Low Profile Roho ® and Jay ® Medical 2 cushions., Methods: ISO 16480-2 biomechanical standardized tests were applied to assess cushion performance. A preliminary materials cost analysis was carried out. A prototype modular cushion was evaluated by 12 participants who reported satisfaction using a questionnaire based on the Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST 2.0) instrument., Results: Overall the modular cushions performed better than, or on par with, the most widely prescribed commercially available cushions under ISO 16480-2 testing. Users rated the modular cushion highly for overall appearance, size and dimensions, comfort, safety, stability, ease of adjustment and general ease of use. Cost-analysis indicated that every modular cushion component a could be replaced several times and still maintain cost-efficacy over the complete cushion lifecycle., Conclusion: A VdE modular cushion has the potential provide effective pressure relief for many users at a low lifetime cost., (Copyright © 2017. Published by Elsevier Ltd.)

Graft wall pulsation amplitude sensing can provide a measure of functional status, e.g. in hemodialysis access grafts. Current implantable graft monitoring sensors require graft modification and direct bloodstream contact. We propose a new class of piezoresistive flexible pulsation sensors which can be wrapped around the graft to measure wall movement. These sensors must be highly flexible to prevent graft constriction; typical strain sensors are too rigid and the strain sensing range is too limited for this application. We describe a novel additive manufacturing (AM) method for printing polydimethylsiloxane (PDMS) with an internal porous structure, such that material compliance may be tuned anisotropically for a given sensor geometry. Prototype flexible pulsation sensors (FPS) consisting of structured PDMS with an embedded conductive PDMS sensor layer were fabricated and tested. Initial tests demonstrated reliable sensor response to 1-Hz cyclic elongation of 20%, and a sensor gauge factor of 1.0.

Purpose: An appropriate wheelchair cushion is integral to pressure ulcer (PU) prevention for the wheelchair user with SCI. For users who find it difficult to remember or perform weight shifts, an alternating pressure air cushion (APAC) may off-load pressure to minimize PU risk. APACs are considered mobility assistive technology (AT). Effective AT delivery includes consideration of the AT consumer as a unique individual. The Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) is a structured and standardized method to measure user satisfaction with AT., Method: Twelve full time wheelchair users with SCI were provided with an APAC six times for 2 weeks daily home use every 3 months. At the completion of the 18-month study period, the 8-variable QUEST 2.0b questionnaire was applied to evaluate satisfaction with APAC use., Results: Users were generally quite satisfied with APAC weight (p < 0.01 relative to neutral). Durability was more likely to be an area of concern. Overall, 92% of participants considered themselves quite satisfied or very satisfied with APAC use (p < 0.001)., Conclusions: Users with SCI were satisfied with the overall performance of the APAC tested after repeated periods of use. The majority of user's were very satisfied with APAC comfort overall. Implications for Rehabilitation Abandonment of AT may be reduced if user satisfaction is evaluated. The QUEST 2.0b is a useful and valid measure of user satisfaction with alternating pressure air cushions. In the current study cohort, users with SCI were satisfied with the performance and comfort of the APAC tested after repeated periods of use.

Study Aim: Pressure ulcers (PU) are a common comorbidity among wheelchair users. An appropriate wheelchair cushion is essential to relieve pressure and reduce PU development during sitting. The microenvironment, specifically excessive heat and moisture, impacts risk for PU development. An effective wheelchair cushion should maintain a healthy microenvironment at the seating interface. Measurement of heat and moisture can characterize microenvironmental conditions at the wheelchair cushion interface under load. We describe the development of a Sitting MicroEnvironment Simulator (SMES) for the reliable assessment of wheelchair cushion microenvironments., Materials: The prototype SMES was developed for use mounted on a Materials Testing Systems (MTS) 810(®) uniaxial servo-hydraulic loading rig and used to assess microenvironmental conditions for Jay Medical Jay 2(®), Roho High Profile Dry Floatation(®) and Low Profile Dry Floatation(®) cushions and a novel modular gel cushion., Methods: Each cushion was assessed for two hours in triplicate. The SMES was used to load the cushions to 300N ± 10N, with an interface surface temperature of 37 °C±1 °C and fluid delivery of 13 mL/h±1 mL/h of water. Interface temperature and humidity were measured at the left ischial tuberosity (IT) region every five minutes., Results: Heat and moisture responses were similar for the three commercial cushions. The modular gel cushion stayed cooler for at least 15 min longer than any commercial cushion., Conclusions: The SMES maintained performance to technical specifications for over one hundred hours of total testing and is a reliable tool for characterizing the microenvironmental conditions of wheelchair cushions., (Published by Elsevier Ltd.)

Ovarian cancer (OvCa) is the most lethal gynecologic disease in the United States, with an overall 5-year survival rate of 44.5%, about half of the 89.2% for all breast cancer patients. To identify factors that possibly contribute to the long-term survivorship of women with OvCa, we conducted a comprehensive online Ovarian Cancer Survivorship Survey from 2009 to 2013. This paper presents the design and implementation of our survey, introduces its resulting data source, the OVA-CRADLE™ (Clinical Research Analytics and Data Lifecycle Environment), and illustrates a sample application of the survey and data by an analysis of prediagnosis symptoms, using text mining and statistics. The OVA-CRADLE™ is an application of our patented Physio-MIMI technology, facilitating Web-based access, online query and exploration of data. The prediagnostic symptoms and association of early-stage OvCa diagnosis with endometriosis provide potentially important indicators for future studies in this field.

Ideally, all chronic wounds would be prevented as they can become life threatening complications. The concept that a wound produces a 'current of injury' due to the discontinuity in the electrical field of intact skin provides the basis for the concept that electrical stimulation (ES) may provide an effective treatment for chronic wounds. The optimal stimulation waveform parameters are unknown, limiting the reliability of achieving a successful clinical therapeutic outcome. In order to gain a more thorough understanding of ES for chronic wound therapy, systematic evaluation using a valid in vivo model is required. The focus of the current paper is development of the flexible modular surface stimulation (MSS) device by our group. This device can be programed to deliver a variety of clinically relevant stimulation paradigms and is essential to facilitate systematic in vivo studies. The MSS version 2.0 for small animal use provides all components of a single-channel, programmable current-controlled ES system within a lightweight, flexible, independently-powered portable device. Benchtop testing and validation indicates that custom electronics and control algorithms support the generation of high-voltage, low duty-cycle current pulses in a power-efficient manner, extending battery life and allowing ES therapy to be delivered for up to 7 days without needing to replace or disturb the wound dressing.

Objective: In a systematic preclinical investigation of ischemic wound healing, we investigated the hypothesis that electrical stimulation (ES) promotes the healing of ischemic wounds. Approach: The effects of varying clinically relevant ES variables were evaluated using our modified version of the Gould F344 rat ischemic wound model. Stimulation was delivered using the novel lightweight integrated, single-channel, current-controlled modular surface stimulation (MSS) device. Stepwise variation allowed the effects of five different stimulation paradigms within an appropriate current density range to be studied. Within each group, 8-10 animals were treated for 28 days or until the ischemic wounds were healed and 5 animals were treated for 12 days. Eight rats received sham devices. A quantitative multivariable outcomes assessment procedure was used to evaluate the effects of ES. Results: Ischemic wounds treated with a decreased interpulse interval (IPI) had the highest rate of complete wound closure at 3 weeks. Wounds treated with decreased pulse amplitude (PA) had a lower proportion of closed wounds than sham ischemic wounds and showed sustained inflammation with a lack of wound contraction. Innovation: Our systematic study of varying ES paradigms using the novel MSS device provides preliminary insight into potential mechanisms of ES in ischemic wound healing. Conclusion: Clinically appropriate ES can more than double the proportion of ischemic wounds closed by 3 weeks in this model. Ninety percent of wounds treated with a decreased IPI healed by 21 days compared with only 29% of ischemic wounds treated with decreased PA, which appears to inhibit healing.

Study Aim: Stereophotogrammetric digital imaging enables rapid and accurate detailed 3D wound monitoring. This rich data source was used to develop a statistically validated model to provide personalized predictive healing information for chronic wounds., Materials: 147 valid wound images were obtained from a sample of 13 category III/IV pressure ulcers from 10 individuals with spinal cord injury., Methods: Statistical comparison of several models indicated the best fit for the clinical data was a personalized mixed-effects exponential model (pMEE), with initial wound size and time as predictors and observed wound size as the response variable. Random effects capture personalized differences., Results: Other models are only valid when wound size constantly decreases. This is often not achieved for clinical wounds. Our model accommodates this reality. Two criteria to determine effective healing time outcomes are proposed: r-fold wound size reduction time, t(r-fold), is defined as the time when wound size reduces to 1/r of initial size. t(δ) is defined as the time when the rate of the wound healing/size change reduces to a predetermined threshold δ < 0. Healing rate differs from patient to patient. Model development and validation indicates that accurate monitoring of wound geometry can adaptively predict healing progression and that larger wounds heal more rapidly. Accuracy of the prediction curve in the current model improves with each additional evaluation., Conclusion: Routine assessment of wounds using detailed stereophotogrammetric imaging can provide personalized predictions of wound healing time. Application of a valid model will help the clinical team to determine wound management care pathways., (Published by Elsevier Ltd.)

Objective: Repeated hospital admissions (RHA) for ongoing pressure ulcer (PU) care remains a significant challenge in the clinical management of the spinal cord injury/disorders (SCI/D) population. The current study investigated the significance of risk factors for PU treatment and RHA., Method: A retrospective chart review of veterans admitted to the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCDVAMC) Spinal Cord Injury (SCI) unit for Category III or IV PUs was carried out. A random sample of 105 individuals with SCI/D, evaluated by the Wound Care Team (WCT) from 2006 to 2009 was assessed. Multiple PU development risk factors were extracted from the electronic health record system using standardised data collection forms and entered into the Spinal Cord Injury Pressure Ulcer Database (SCIPUD). Potential associations with RHA were analysed., Results: Twenty variables were initially identified as potentially related to PU development. Descriptive statistics and statistically significant associations between risk factors and RHA were determined. Demographic factors showed no significant association with RHA. Duration of injury, power wheelchair use and sub-optimally managed spasticity (SMS) were significantly associated with higher RHA. Sub-optimally managed neurogenic bowel (SMNB) at admission was significantly associated with reduced RHA., Conclusion: Factors previously found to be predictive of initial PU development may not, in fact, be predictive of RHA. Some protective trends were observed, such as polypharmacy and marital status, but these did not reach statistical significance in this preliminary study of admission characteristics, warranting further research., Declaration of Interest: There were no external sources of funding for this study. The authors have no conflicts of interests to declare.

A repeated-measures study of 13 adult full-time wheelchair users with spinal cord injury (SCI) was carried out to determine whether alternating-pressure air cushion (APAC) use compared with independent pressure relief (IPR) provides reliable, effective pressure relief for individuals with SCI. Bilateral mean ischial interface pressure (IP), transcutaneous oxygen tension (TcPO2), and unilateral laser Doppler blood flow were evaluated. Blood flow component contributions were determined using short-time Fourier transform (STFT)-based spectral analysis. IPR assessment was carried out at recruitment. Study participants then used an APAC for 2 wk every 3 mo for 18 mo. IPR weight-shifting decreased mean ischial IP (p < 0.05) and increased mean TcPO2 (p < 0.05). All variables rapidly returned to preintervention levels following weight-shifting except for the cardiac component of blood flow. APAC-induced weight-shifting decreased mean ischial IP (p < 0.05). Mean TcPO2 increased and was higher than for IPR. STFT analysis indicated that quiet sitting following APAC-induced weight-shifting produced a higher neurogenic component of blood flow than following IPR (p = 0.02). Thus, IPR positively affects multiple aspects of tissue health but produces transient improvements and must be repeated regularly. APAC activation dynamically and continuously alters IP distribution with more sustained positive tissue health effects.

Reference genes are often used in RT-quantitative PCR (qPCR) analysis to normalize gene expression levels to a gene that is expressed stably across study groups. They ultimately serve as a control in RT-qPCR analysis, producing more accurate interpretation of results. Whereas many reference genes have been used in various wound-healing studies, the most stable reference gene for ischemic wound-healing analysis has yet to be identified. The goal of this study was to determine systematically the most stable reference gene for studying gene expression in a rat ischemic wound-healing model using RT-qPCR. Twelve commonly used reference genes were analyzed using RT-qPCR and geNorm data analysis to determine stability across normal and ischemic skin tissue. It was ultimately determined that Ubiquitin C (UBC) and β-2 Microglobulin (B2M) are the most stably conserved reference genes across normal and ischemic skin tissue. UBC and B2M represent reliable reference genes for RT-qPCR studies in the rat ischemic wound model and are unaffected by sustained tissue ischemia. The geometric mean of these two stable genes provides an accurate normalization factor. These results provide insight on dependence of reference-gene stability on experimental parameters and the importance of such reference-gene investigations.

Objective: To investigate whether combined trunk and gluteal neuromuscular electrical stimulation (NMES) alters seated posture and improves pelvic tissue health in persons with a spinal cord injury., Design: Intervention study; case series., Setting: Research laboratory, medical center., Participants: Seven persons with spinal cord injury recruited from a group of experienced implanted lower extremity NMES system users., Intervention: Combined trunk and gluteal NMES in the sitting position. Five minutes of preintervention sitting was assessed, followed by 5 minutes of NMES application, and then 5 minutes of postintervention., Main Outcome Measures: Pelvic tissue health was evaluated by concurrently measuring transcutaneous oxygen tension (TcPO2) bilaterally over the ischia and the seating interface pressure (IP). TcPO2 data were binned into low (<10 mm Hg), medium (10-30 mm Hg), and high (>30 mm Hg) ranges, and the percentage time that TcPO2 was in each range was calculated. Ischial and sacral regions of interest were defined and the maximum region of interest and mean IP were determined, together with the maximum IP gradient for the entire contact area. Initial seating postures varied; 4 persons were initially sacral sitters. Tissue health responses to NMES were reviewed for sacral and nonsacral sitters., Results: For sacral sitters, the sacral region IP and the maximum IP gradient tended to decrease during NMES and increased again after the intervention. Mean ischial TcPO2 increased during NMES and remained elevated after the intervention, increasing high TcPO2 percentage time for 50% of the sacral sitters both during and after the intervention. Nonsacral sitters showed few changes in tissue health as the result of the application of NMES., Conclusions: Trunk and gluteal stimulation acutely corrects anterior/posterior IP distribution, improving regional tissue health for sacral sitters. This correction requires constant application of NMES. The potential for positive changes in tissue health would be maximized by regular NMES use incorporating weight shifting., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Study Aim: Some individuals with spinal cord injury (SCI) remain pressure ulcer (PU) free whilst others experience a recurring cycle of tissue breakdown. Detailed analysis of gluteal muscle characteristics may provide insights to local tissue viability variability. The study hypothesis was that SCI individuals have altered muscle composition compared to able-bodied (AB)., Materials: Ten AB and ten SCI received a supine pelvic CT scan, with contrast., Methods: Cross-sectional area (CSA) and overall muscle volume were derived using image analysis. Gluteal muscle tissue type was classified at the S2/S3 sacral vertebrae midpoint, the superior greater trochanters margin (GT) and the inferior ischial tuberosities margin (IT) using the linear transformation Hounsfield Unit scale., Results: SCI gluteal CSA was less than for AB throughout the muscle, with the greatest relative atrophy at the IT (48%). Average AB gluteal volume was nearly double SCI. Eight SCI had over 20% infiltrative adipose tissue, three with over 50%. SCI gluteal CSA and intramuscular fat infiltration were significantly negatively correlated (p < 0.05). SCI IT axial slices showed less lean muscle and higher intramuscular fat infiltration than more proximally (p < 0.05)., Conclusion: SCI gluteal muscle characteristics were indicative of impaired tissue viability. SCI disuse muscle atrophy was anticipated; the analytic approach further indicated that intramuscular atrophy was not uniform. SCI muscle composition showed increased proportions of both low density muscle and adipose tissue. CT scan with contrast is effective for gluteal muscle characterization. This assessment technique may contribute to determination of personalized risk for PU development and other secondary complications., (Published by Elsevier Ltd.)

Pressure ulcers are major complications of reduced mobility and/or sensation. Pulsatile lavage therapy delivers localized hydrotherapy directly to the wound utilizing a pulsatile pressurized stream of normal saline. The purpose of this study was to evaluate the clinical safety of pulsatile lavage therapy, provided daily at the bedside, in routine management of Stage III and Stage IV pressure ulcers. Charts from 28 male patients with Stage III and Stage IV pressure ulcers and spinal cord injury (SCI) or spinal cord disorders (SCD) were retrospectively reviewed for documentation of adverse events/safety concerns. Mean therapy duration was 46 days (SD 37 days, range 6-152 days). Treatment was interrupted for 6 days in one patient due to minor wound bleeding. No other adverse events, including backsplash injuries, were documented. The results of this chart review suggest pulsatile lavage therapy can be administered at the patient's bedside without adverse events if appropriate protocols are followed. Additional research to confirm the efficacy and effectiveness of this treatment modality in a broader subject population is warranted.

Objective: To investigate the hypothesis that stereophotogrammetric wound size monitoring shows suitable inter-observer reliability and user acceptance for clinical practice use., Method: Veterans admitted for conservative management of severe pressure ulcers were eligible for inclusion in the study. Three-dimensional (3D) digital wound images were independently captured by two expert and two non-expert nurse-observers using a commercially available stereophotogrammetry system,weekly for 6 weeks.A double-blinded analyst generated 3D wound reconstructions, using software to determine geometry. Clinical opinion of wound progression was provided by an expert physician., Results: Thirteen wounds were assessed with more than 80% of all images being readable. Interclass correlation of 0.9867 (p < 0.000 I) was observed. Compared with clinical opinion, 3D wound measurement was sensitive between improving and static wounds for wound perimeter, volume, depth and length., Conclusion: These preliminary findings suggest that 3D wound measurement minimises differences in wound measurement between expert and non-expert observers, suggesting it could be implemented with high reliability in health-care settings where several observers are involved in wound care management.

Pressure mapping alone insufficiently describes tissue health. Comprehensive, quantitative non invasive assessment is crucial. Interface pressures (IPs) and transcutaneous blood gas levels [transcutaneous tissue oxygen (T(c) PO(2) )] were simultaneously assessed over both ischia and the sacrum to investigate the hypotheses: (i) tissue oxygenation decreases with sustained applied pressure; (ii) tissue oxygen and IP are inversely correlated in loaded soft tissues; (iii) multisite assessments are unnecessary because healthy individuals are symmetrical. Measurements were taken at 5-minute intervals for 20 minutes in both sitting and supine lying for a cohort of 20 able-bodied adults. There were no statistically significant changes over time for either variable in 96% of timepoint comparisons. Specifically, no significant differences were seen between 10 and 20 minutes in either position. These findings imply that a 10-minute assessment can reliably indicate tissue health and that tissue may adapt to applied load over time. No statistically significant correlations between T(c) PO(2) and IP were observed. However, the left and right ischia were significantly different for both variables in supine lying (P < 0.001) and for sitting IP (P < 0.010). Thus, even in this healthy cohort, postural symmetry was not observed and should not be assumed for other populations with restricted mobility. If a multisite technique cannot be used, repeated tissue health assessments must use the same anatomic location., (© 2012 The Authors. © 2012 Blackwell Publishing Ltd and Medicalhelplines.com Inc.)

Background: Pressure ulcer development is a common, serious complication after spinal cord injury (SCI). Although many biophysical agents are available for treatment, few randomized controlled trials of their efficacy have been done., Objective: The study objective was to examine the efficacy of low-pressure pulsatile lavage treatment for stage III and IV pressure ulcers in people with SCI., Design: This study was a randomized controlled trial. Participants and assessors were unaware of intervention assignments., Setting: This study was conducted in an SCI tertiary care center inpatient unit., Participants: Participants were 28 people with SCI and stage III and IV pelvic pressure ulcers; 14 participants each were randomly assigned to treatment and control (sham treatment) groups., Intervention: Daily low-pressure pulsatile lavage treatment with 1 L of normal saline at 11 psi of pressure was applied to the treatment group along with standard dressing changes. The control group received only sham treatment and standard dressing changes., Measurements: Linear and volume measurements of pressure ulcer dimensions were obtained weekly for 3 weeks., Results: Statistical analysis with the t test revealed no statistically significant difference in demographics between groups. Random-coefficient models for analysis of linear and volume measurements revealed improvements over time for both groups. Time trend analysis revealed greater measurement decreases for the treatment group. Differences in rates of change (with 95% confidence intervals) for treatment and control groups, respectively, were: depth, -0.24 (0.09 to -0.58) cm/wk; width, -0.16 (0.06 to -0.39) cm/wk; length, -0.47 (0.18 to -1.12) cm/wk; and volume, -0.33 (0.13 to -0.80) cm(3)/wk., Limitations: Study limitations were small sample size and inclusion of only one site. Additionally, participants were not queried about their group assignments., Conclusions: Pulsatile lavage enhanced stage III and IV pelvic pressure ulcer healing rates in people with SCI relative to standard pressure ulcer treatment alone.

The clinical efficacy of electro-therapy in the treatment of chronic wounds is currently debated, and a in-vivo evaluation of stimulation parameters will provide the statistical evidence needed to direct clinical guidelines. A low-cost, wearable electrical stimulation bandage has been developed for use with an established rat ischemic wound model. The bandage consists of a user-programmable stimulator PCB and a plastic bandage with two hydrogel electrodes. The battery-powered bandage may be used for up to seven days between dressing changes, and the stimulator may be reused. The microcontroller-based stimulator uses a boost converter circuit to generate pulses up to 90 V from a 3 V coin cell battery. Consistent operation of the boost converter over the wide input and output voltage ranges is achieved using voltage feedforward and soft-start techniques implemented in firmware. The bandages are laser-cut to shape, and electrical traces are applied using stencils and conductive nickel paint. Both the PCB and electrical traces are encapsulated to protect the animal. The device has been successfully demonstrated using the rat ischemic wound model for a period of seven days, and clinical experiments are ongoing.

Chronic wounds are a major secondary complication for many people with impaired mobility. Electrical stimulation (ES) has been recommended as a adjunctive therapy, however optimal treatment paradigms have not been established. Our group seeks to determine the basic mechanisms underlying ES wound therapy, an area where understanding is currently limited. A feasibility study was carried out to develop the Ahn/Mustoe lapine wound model for systematic investigation of the effects of electrical stimulation on ischemic wound therapy. A standardized surgical procedure incorporated a hybrid stimulation system comprising an implantable mini-stimulator and surface electrodes, with creation of repeatable ischemic wounds. Twenty mature male New Zealand white rabbits (3 kg weight) were employed to evaluate the effects of two empirically selected stimulation paradigms applied continuously for 7-21 days, using each animal as its own control. Outcomes measures included transcutaneous blood gas levels, histology, total RNA content and analysis of alpha2 (I) collagen (COL-I), type IV collagen (COL-IV), alpha1 (V) collagen (COL-V), and vascular endothelial growth factor (VEGF) expression using real-time quantitative PCR. All markers for stimulated wounds showed increased activity relative to non-stimulated control wounds between 7 and 14 days following injury, with peak activity at 14 days. By 21 days post-injury, all activity had returned to near baseline level. VEGF and COL-IV levels were found to be significantly higher for pattern A (110 mus pulse width) compared to pattern B (5 mus pulse width) at 14 days, implying that pattern A may be more effective at promoting angiogenesis. All wounds were fully re-epithelialized by 10 days post-injury. Both COL-I and COL-V showed statistically significant (P < 0.05) increased activity between day 7 and day 14 for pattern A, potentially indicating a continued effect on matrix remodeling. The early closure of all wounds implies that the rabbit ear model may not be valid for chronic wound studies.

Multiple factors affect the specific condition and overall clinical profile of individuals at risk for chronic wounds. The complexity of the pressure ulcer problem lends itself to the application of the National Institute of Health Roadmap Initiative that encourages interdisciplinary research and new organizational models. An overview of research studies relevant to telemedicine and neuromuscular electrical stimulation in the care and prevention of pressure ulcers as well as preliminary results of an innovative multidisciplinary skin care team approach to the primary and tertiary prevention of pressure ulcers are encouraging. The team's pilot study results indicate that patients are satisfied with telehealth provision of care; however, literature and experience also suggest that discrepancies in the inter-rater assessment of wounds using digital photography remain, particularly with regard to wound dimension variables assessed (P<0.01). In another endeavor, the skin care team developed a Longitudinal Analysis with Self-Registration statistical algorithm to assess the effects of electrical stimulation; in a preliminary study, this tool documented improvement in gluteus maximus health and resultant ability to withstand pressure. As the number of groups pursuing multidisciplinary research and care increases, so, too, will the evidence base required to address these common, and complex, chronic wounds.

The process of integrating wound care research into clinical practice incorporates research methodology--i.e., the standardized practices, procedures, and rules by which research is performed--and an evidence-based approach. Using examples from the literature and clinician experience treating pressure ulcers in a 32-bed regional spinal cord injury unit in a tertiary referral center in Cleveland, Ohio, the authors describe this process and review the challenges faced by an interdisciplinary skin care team tasked with implementing evidence-based care. Additional considerations include determining the amount of current wound care that is evidence-based and whether wound prevention and care outcomes are improved through the use of evidence-based medicine. Five years after establishing the skin care team and implementing evidence-based care, improvements in care processes and short-term outcomes--specifically, pressure ulcer prevention and treatment protocols including documentation--have been realized. Studies to ascertain the effects of these changes on long-term outcomes are planned.

Objective: To evaluate the efficacy of gluteal neuromuscular electric stimulation (NMES) using implanted percutaneous electrodes to improve regional tissue health and decrease the risk of pressure ulcer development., Design: Case study of long-term use of gluteal NMES., Setting: Community., Participant: A patient with a C4-level American Spinal Injury Association grade A spinal cord injury, 22 years postinjury at study enrollment, and a clinical history of regular grade II and occasional IV ischial pressure ulcers., Intervention: Gluteal NMES using an electric stimulation system comprising a combination of implanted percutaneous electrodes and an external stimulator (controller)., Main Outcome Measures: Objective measurements of tissue health comprising evaluation of gluteal muscle thickness, interface pressures, and regional blood flow. Subjective self-reported sitting tolerance., Results: Increased gluteal muscle thickness and blood flow together with reduced regional interface pressures occurred. Weight-shifting because of alternating left and right gluteal NMES became more effective over time as the muscles strengthened. Sitting tolerance more than doubled., Conclusions: A gluteal NMES system has been developed that provides both improved regional tissue health and dynamic weight shifting while seated in the wheelchair. In the current case, regular daily use had a positive impact on multiple indirect indicators of tissue health. Continued use was indicated as the positive effects were lost when stimulation was discontinued.

During the last one-half century, electrical stimulation has become clinically significant for improving health and restoring useful function after spinal cord injury. Short-term stimulation can be provided by electrodes on the skin or percutaneous fine wires, but implanted systems are preferable for long-term use. Electrical stimulation of intact lower motor neurons can exercise paralyzed muscles and reverse wasting; improve strength, endurance, and cardiovascular fitness; and may reduce the progression of osteoporosis. Other potential therapeutic uses being investigated include reduction of spasticity, prevention of deep vein thrombosis, and improvement of tissue health. Pacing of intact phrenic nerves in high tetraplegia can produce effective respiration without mechanical ventilation, allowing improved speech, increased mobility, and increased sense of well-being. Improvement of cough has also been demonstrated. Stimulation of intact sacral nerves can produce effective micturition and reduce urinary tract infection; it can also improve bowel function and erection. It is usually combined with posterior sacral rhizotomy to improve continence and bladder capacity, and the combination has been shown to reduce costs of care. Electroejaculation can now produce semen in most men with spinal cord injury. Significant achievements have also been made in restoring limb function. Useful hand grasp can be provided in C5 and C6 tetraplegia, reducing dependence on adapted equipment and assistants. Standing, assistance with transfers, and walking for short distances can be provided to selected persons with paraplegia, improving their access to objects, places, and opportunities that are inaccessible from a wheelchair. This review summarizes the current state of therapeutic and neuroprosthetic applications of electrical stimulation after spinal cord injury and identifies some future directions of research and clinical and commercial development.

Changes in tissue health were monitored in a group of spinal cord injury (SCI) individuals with the use of an implanted neuromuscular electrical stimulation (NMES) system to provide standing and to facilitate standing transfers. Tissue health was evaluated through monitoring tissue oxygen levels in the ischial region along with measuring interface pressures at the seating support interface. Baseline assessments were done at study enrollment and repeated on completion of a conditioning exercise program. Serial assessments of tissue health were performed on eight NMES implant recipients. Unloaded tissue oxygen levels in the ischial region tended to increase after following the NMES exercise program for 8 weeks. Concurrently, pressure distributions at the seating support interface tended to change such that although the total pressure acting at the interface did not change, ischial region pressures showed a significant decrease. These changes indicate that chronic use of NMES has a quantifiable benefit on tissue health.