3YP Chronic Wounds Preventing, managing, and treating chronic wounds in hospital and at home

1. 3YPChronic WoundsPreventing, managing, and treating chronic wounds in hospital and at home Dr Carmelo Velardo & Dr Julian Dye

2. Session 1 Objectives • Introduction to the clinical and healthcare problems • Role and potential of engineering in treatment Break • Your solutions • 3YP principles & guidelines

3. Chronic wounds Introduction What chronic wounds are What are the problems Wound healing pathologies Why wounds become chronic What factors are involved in the pathology of chronic wounds Treatment modalities What the concept is of levels of treatment How to classify treatment and management strategies Holistic context of wounds Why patients have chronic wounds What the underlying problems are Whose problems

4. What are chronic wounds? • What is the definition? When does a wound become chronic? • How & where are they encountered? • What are the problems? • Whose problems? • Why do they occur?

5. Venous leg ulcer http://www.cheltenhamvascularunit.co.uk/Venous%20ulcer1a.JPG

6. Normal wound healing • Progression or cascade

7. Wound healing • Healing by 1st intent, 2nd intent, accelerated healing, if not ….chronicity. • Wound healing is tissue rebuilding • What is vital for wound healing • Heirarchical process • Progression of cell responses • Vascularisation • What cells are involved where do they come from? • Host response is critical • Tissue engineering • Wound management • Patient management

8. 3 Stages of wound healing • Neutrophils/monocytes • TNFα, IL1β, IL6 • IL8, MCP-1 • Fibrocytes, Stem cells, EPC, Macrophages • VEGF, bFGF, TGFβ, HGF • Collagen-I, EDA-fibronectin • Myofibroblasts, Macrophages • TGFβ, CTGF • Collagen-I, collagen-III • MMPs/TIMPs

9. Wound healing granulation responseAcute excision (H&E histology) Eschar/slough Inflammatory zone 1 mm Fibro-vascular zone Wound bed

10. Wound healing progression

11. Clinical needs for soft tissue reconstructionOff-the-shelf acellular scaffolds (2/3 degree skin loss) • Burns & acute trauma • Pressure ulcers • Oncological reconstruction • Venous leg ulcers • Diabetic foot ulcers

12. What are the Clinical problems?Understanding the pathology map Partial thickness Full thickness Elective Aseptic surgery Traumatic Infective burden Acute Chronic %TBA Diabetic Venous Pressure Locus: face hands torso

13. Why wounds become chronic 1. Underlying (ongoing or chronic) disease • Vascular disease • Heart failure • Type II diabetes • Immobility

14. Why wounds become chronic 2. Wound infection • loss of skin barrier • Commensural flora • Hygene problems • Antibiotic resistence • Biofilm formation

15. Why wounds become chronic 3. Inflammation • Dessication– cell damage - inflammation • Free radicals • Proteolysis • Anergy

16. The chronic wound ‘triad’ injury Underlying disease (Vascular compromise) Acute inflammation angiogenesis Failure to heal Healing response Wound infection Chronic inflammation Resolution (restoration of homeostasis)

17. Common types of chronic wound • Pressure Ulcers immobility paralysed patients particular risk • Venous leg ulcers lack of venous drainage, varicose veins, secondary to heart failure • Diabetic foot ulcers glycosylated proteins, microvascular disease Less common • Arterial ulcers primary arteriosclerosis • Venous & lymphatic ulcers compromised lymphatic drainage • Surgical wounds compromised wound healing

18. Treatment modalities • Wound healing is a cellular process – ‘in vivo bioreactor’ needs a homeostatic environment • Prevention of Dessication • Vacuum therapy • Temperature therapy • Electrical /electromagenetic therapy • Light therapy • Wound detoxification • Maggot therapy • High pressure debridement • Disinfectant therapy • Proteolytic scavenging • Antibiosis • Growth factor treatment • Wound scaffolds – proangiogenic matrices • Tissue engineered cell/matrix therapies

19. Holistic context withdrawn unwell Autonomy - Dependence needy Well Healthy Fit Cost-economic balance Social impact direct indirect friends family Social circle informal patient employment Welfare support clinic Caring support Nursing service formal hospital

20. Chronic wounds: what you need to know! Introduction What chronic wounds are What are the problems Wound healing pathologies Why wounds become chronic What factors are involved in the pathology of chronic wounds Treatment modalities What the concept is of levels of treatment How to classify treatment and management strategies Holistic context of wounds Why patients have chronic wounds What the underlying problems are Whose problems

21. Chronic Wounds Role & Potential of Engineering in improving treatment and management

22. Example strategies: Vac therapy Aims to stimulate healing and wound closure • Reduce wound fluid • Contract wound margin Mechanisms reduction of microbiological burden reduction of wound growth factors and proteases mechanical stimulation Recent advances: portability & miniaturisation Outstanding issues: VAC alone can be ineffective

23. KCI Acelity S&N Molnlycke

24. Example strategies: compression bandaging Aims to improve venous drainage • Reduce oedema • Improve tissue perfusion Mechanisms reduce fluid leakage from venules improve tissue oxygenation Recent advances: practice guidelines Outstanding issues: Achieving & maintaining effective pressure unreliable

25. Example strategies: absorbent dressing Aims to absorb wound fluid • Reduce wound fluid • Contract wound margin Mechanisms reduction of microbiological burden reduction of wound growth factors and proteases mechanical stimulation Recent advances: absorbent/swelling hydrogel

26. Example strategies: Protease scavenging treatment Aims to stimulate healing and wound closure • Reduce wound inflammation Mechanisms stimulation of wound healing reduction of wound growth factors and proteases mechanical stimulation Recent advances: Composite materials

27. Example strategies: Multichambered Airbed for ITU patients Aims to prevent pressure damage by cycles of inflation/deflation. • Prevent prolonged tissue compression • Stimulate perfusion Recent advances: modularity for sterilisation between patients

28. Ideas which could make a difference • Smart scaffold • Thermal • Light • Wound Monitoring • Pressure off-loading • Exercising • Managing diet (type II diabetes)

29. Resources • Weblearn 3YP • http://www.woundcarehandbook.com/

30. Session 2 Plan • Dr Carmelo Velado: The Digital healthcare revolution • Potential of digital healthcare, addressing different levels of care patient engagement and empowerment • Applications for chronic wound management • Discussion & Grouping • Supervision Q & A

31. Break

32. Your solutions The 3YP challenge

33. Aims and Objectives • Identify an unmet need • Analyse the existing solutions • Propose a new engineering solution • Develop a teamwork strategy to plan the solution • Manage your project to timelines • Deliver a professional progress report during the project • Deliver a professional project report, logbook and team presentation

34. Research • Specific clinical problem • Current treatments and management strategies • Problems, identify un-met needs

35. Interests & skills matching • Identify your background alignment with the problem, initial interests and ideas • Reflect on your research reading & thinking • Prepare to negotiate

36. Approaches to design • Survey and analysis of existing solutions • Un-met needs analysis • Stated & identified problems or limitations of current practice & technologies • Creative definition of unmet need • Solution concept • Incremental improvement • Design step change • Radical innovation

37. Your team • Team roles • Managing • Defining the goal • Dividing work • Co-ordinating and collaborating • Meetings • Minutes • Progress presentations • Achieving the deliverables

38. Timeframe • W1 • Survey clinical issues • Start surveying existing treatments • W2 • Build concept of treatment levels • Brainstorm • W3 • Finalise teams • Formulate treatment modality • Team presentation

39. Your Solution • Aims & Objectives of the 3YP • Approaches to engaging with the problem • Setting up your team • What teamwork will entail

40. The 3YP Principles & Guidelines

41. 3YP principles

42. Challenges • Teamwork • Each roles is required to contribute to the goal • Equal value of each member • Participation • Leadership & coordination • Decision-making process

43. Expectations • Teamwork • Separate Regular Meeting outside Tuesday supervision • Meetings will be minuted • Co-operation expected • Individual effort required • Documentation, regular lab-book entries • Weekly Supervision meetings Tues 2-4pm during term. • Attendence is required. • Lab-books will be reviewed regularly • Progress discussed

44. Project timelines

45. Milestones As a guideline; • Michealmas General objectives: understand problem, consider treatment modalities week7 Logbook review week 8 Team Progress presetnation • EoTMilestone • – • decide modality • Project plan and team’s contributions • Hilary EoT Milestone – develop specific design solution Ideas substantiated, team efforts consolidated Trinity write up, logbook hand ins & presentation

46. Logbooks Organisation • Research performed (referenced works consulted) • Design Objectives • Detailed Engineering analysis • H&S, sustainability issues • Design work • Conclusions • Minutes • Team-work contributions

47. Assessment Informal • Logbooks & Minutes • Team presentations • Progress reports to the group Formal (External examiner will mark) • Marks out of 100 awarded roughly as follows • Final report 60 marks • Final presentation 20 marks • Logbooks 10 marks • Teamwork 10 marks • Contribution to the Course 3YP = 1 paper [=1/5.5 examination units] N.B. Teamwork management has its own demands, therefore documenting the management of your team is an important outcome

48. The project report • 30 pages A4 per student inclusive. • Report text should be Ariel 11 font, double line spaced, pages with 2cm margins. • Each team-member’s role & work must be identified. In the write up, each member’s work should have a named header. • Report plan should be completed for supervisory review by 8th week HT • Draft report should be handed in for review by 0th week TT.

49. The final presentation • Each team-member contributes around 5 minutes to the presentation the project. • Should be structured with • Introduction • Aims • Research • Solution • Conslusions • Up to teams to decide how to do this.

50. Managing workload • 3YP is 1 out of 5.5 examination units, so roughly 20% of the year’s effort. • Invest early • Define the project clearly, and time plan • Trinity will be busy with revision – DON’T LEAVE TASKS TOO LATE • Christmas Vac is an opportunity for concentrated research efforts • Easter vac – report writing (probably coordinated)