Venous leg ulcer recurrence : deciphering long term patient adherence to preventive treatments and activities

To better understand long term adherence to self-care activities to prevent the recurrence of venous leg ulcers, participants (n=80) were recruited to a prospective longitudinal study after experiencing healing of a venous leg ulcer. Data on demographics, health, psychosocial measures and adherence to prevention strategies (compression therapy, leg elevation and lower leg exercise) were collected every three months for one year after healing. Multivariable regression modelling was used to identify the factors that were independently associated with adherence. Over the year, a significant decline in adherence to all three strategies was observed, predominantly between 6–12 months after healing (p<0.01). Several factors were associated with adherence to more than one preventive activity. Regular follow-up care and a history of multiple previous ulcers were related to improved adherence (p<0.05), while scoring at higher risk for depression and restricted mobility were related to decreasing adherence over time (p<0.05). Patients with osteoarthritis had significantly reduced adherence to compression hosiery (p=0.026). These results provide information to assist care providers plan strategies for prevention of recurrent venous leg ulcers; and suggest a need for regular follow-up care which addresses both the physical and mental health of this population.

Modelling the economic benefits of gold standard care for chronic wounds in a community setting

Chronic leg ulcers are costly to manage for health service providers. Although evidence-based care leads to improved healing rates and reduced costs, a significant evidence-practice gap is known to exist. Lack of access to specialist skills in wound care is one reason suggested for this gap. The aim of this study was to model the change to total costs and health outcomes under two versions of health services for patients with leg ulcers: routine health services for community-living patients; and care provided by specialist wound clinics. Mean weekly treatment and health services costs were estimated from participants’ data (n=70) for the twelve months prior to their entry to a study specialist wound clinic, and prospectively for 24 weeks after entry. For the retrospective phase mean weekly costs of care were $AU130.30 (SD $12.64) and these fell to $AU53.32 (SD $6.47) for the prospective phase. Analysis at a population level suggests if 10,000 individuals receive 12 weeks of specialist evidence-based care, the cost savings are likely to be AU$9,238,800. Significant savings could be made by the adoption of evidence-based care such as that provided by the community and outpatient specialist wound clinics in this study.

The effects of flexible fixation on early stage bone fracture healing

The mechanical microenvironment at a fracture site could potentially influence the outcomes of bone fracture healing. It is known that, should the fixation construct be too stiff, or the gap between the fracture ends be too large, bones are less likely to heal. Flexible fixation or so-called “biological fixation” has been shown to encourage the formation of fracture callus, and therefore result in better healing outcomes. However, till date the nature of the relationship between the degree of mechanical stability provided by a flexible fixation and optimal healing fracture healing outcomes has not been fully understood. This paper presents a computational model that can predict healing out-comes from early stage healing data under various fixation configurations. The results of the simulations demonstrate that the change of mechanical microenvironment of fracture site resulting from the different fixation configurations is of importance for the healing outcomes.

Improved healing of large segmental defects in the rat femur by reverse dynamization in the presence of bone morphogenetic protein-2

Background Large segmental defects in bone do not heal well and present clinical challenges. This study investigated modulation of the mechanical environment as a means of improving bone healing in the presence of bone morphogenetic protein (BMP)-2. Although the influence of mechanical forces on the healing of fractures is well established, no previous studies, to our knowledge, have described their influence on the healing of large segmental defects. We hypothesized that bone-healing would be improved by initial, low-stiffness fixation of the defect, followed by high-stiffness fixation during the healing process. We call this reverse dynamization. Methods A rat model of a critical-sized femoral defect was used. External fixators were constructed to provide different degrees of stiffness and, importantly, the ability to change stiffness during the healing process in vivo. Healing of the critical-sized defects was initiated by the implantation of 11 mg of recombinant human BMP (rhBMP)-2 on a collagen sponge. Groups of rats receiving BMP-2 were allowed to heal with low, medium, and high-stiffness fixators, as well as under conditions of reverse dynamization, in which the stiffness was changed from low to high at two weeks. Healing was assessed at eight weeks with use of radiographs, histological analysis, microcomputed tomography, dual x-ray absorptiometry, and mechanical testing. Results Under constant stiffness, the low-stiffness fixator produced the best healing after eight weeks. However, reverse dynamization provided considerable improvement, resulting in a marked acceleration of the healing process by all of the criteria of this study. The histological data suggest that this was the result of intramembranous, rather than endochondral, ossification. Conclusions Reverse dynamization accelerated healing in the presence of BMP-2 in the rat femur and is worthy of further investigation as a means of improving the healing of large segmental bone defects. Clinical Relevance These data provide the basis of a novel, simple, and inexpensive way to improve the healing of critical-sized defects in long bones. Reverse dynamization may also be applicable to other circumstances in which bonehealing is problematic.

Time kinetics of bone defect healing in response to BMP-2 and GDF-5 characterised by in vivo biomechanics

This study reports that treatment of osseous defects with different growth factors initiates distinct rates of repair. We developed a new method for monitoring the progression of repair, based upon measuring the in vivo mechanical properties of healing bone. Two different members of the bone morphogenetic protein (BMP) family were chosen to initiate defect healing: BMP-2 to induce osteogenesis, and growth-and-differentiation factor (GDF)-5 to induce chondrogenesis. To evaluate bone healing, BMPs were implanted into stabilised 5 mm bone defects in rat femurs and compared to controls. During the first two weeks, in vivo biomechanical measurements showed similar values regardless of the treatment used. However, 2 weeks after surgery, the rhBMP-2 group had a substantial increase in stiffness, which was supported by the imaging modalities. Although the rhGDF-5 group showed comparable mechanical properties at 6 weeks as the rhBMP-2 group, the temporal development of regenerating tissues appeared different with rhGDF-5, resulting in a smaller callus and delayed tissue mineralisation. Moreover, histology showed the presence of cartilage in the rhGDF-5 group whereas the rhBMP-2 group had no cartilaginous tissue. Therefore, this study shows that rhBMP-2 and rhGDF-5 treated defects, under the same conditions, use distinct rates of bone healing as shown by the tissue mechanical properties. Furthermore, results showed that in vivo biomechanical method is capable of detecting differences in healing rate by means of change in callus stiffness due to tissue mineralisation.

Ability of recombinant human bone morphogenetic protein 2 to enhance bone healing in the presence of tobramycin : evaluation in a rat segmental defect model

Objective To determine whether locally applied tobramycin influences the ability of recombinant human bone morphogenetic protein 2 (rhBMP-2) to heal a segmental defect in the rat femur. Methods The influence of tobramycin on the osteogenic differentiation of mesenchymal stem cells was first evaluated in vitro. For the subsequent, in vivo experiments, a 5-mm segmental defect was created in the right femur of each of 25 Sprague-Dawley rats and stabilized with an external fixator and four Kirschner wires. Rats were divided in four groups: empty control, tobramycin (11 mg)/absorbable collagen sponge, rhBMP-2 (11 μg)/absorbable collagen sponge, and rhBMP-2/absorbable collagen sponge with tobramycin. Bone healing was monitored by radiography at 3 and 8 weeks. Animals were euthanized at 8 weeks and the properties of the defect were compared with the intact contralateral femur. Bone formation in the defect region was assessed by dual-energy x-ray absorptiometry, microcomputed tomography, histology, and mechanical testing. Results Tobramycin exerted a dose-dependent inhibition of alkaline phosphatase induction and calcium deposition by mesenchymal stem cells cultured under osteogenic conditions. The inhibition was reversed in the presence of 500 ng/mL of rhBMP-2. Segmental defects in the rat femora failed to heal in the absence of rhBMP-2. Tobramycin exerted no inhibitory effects on the ability of rhBMP-2 to heal these defects and increased the bone area of the defects treated with rhBMP-2. Data obtained from all other parameters of healing, including dual-energy x-ray absorptiometry, microcomputed tomography, histology, and mechanical testing, were unaffected by tobramycin. Conclusions Although our in vitro results suggested that tobramycin inhibits the osteogenic differentiation of mesenchymal stem cells, this could be overcome by rhBMP-2. Tobramycin did not impair the ability of rhBMP-2 to heal critical-sized femoral defects in rats. Indeed, bone area was increased by nearly 20% in the rhBMP-2 group treated with tobramycin. This study shows that locally applied tobramycin can be used in conjunction with rhBMP-2 to enhance bone formation at fracture sites.

Alternate healing and medicine : the roles of naturopathy, homeopathy, osteopathy, chiropractic and medical practice in the health system

This thesis is concerned with understanding the roles of four alternate healing systems and medical practice in the community's health behaviour. The four alternate systems are naturopathy, homoeopathy, osteopathy and chiropractic. The research reported developed from work supported by the Committee of Inquiry into Chiropractic, Osteopathy, Homoeopathy and Naturopathy conducted under the chairmanship of Professor E. C. Webb set up by the Australian Government in 1975. The study concentrates on the factors which influence individual clients in their decisions to consult healers for treatment. An underlying assumption is that an analysis of the processes that effect such decisions will lead to further knowledge of the community's attitudes towards the functions of alternate healing and medicine. A review of the historical backgrounds and current status of the four alternate healing systems leads to the conclusion that they differ in a variety of areas. These areas include treatment modalities, historical backgrounds, occupational development and rapprochement with medicine. Homoeopathy, osteopathy and chiropractic emerged as distinct approaches to healing late in the nineteenth century. Naturopathy tends to be a philosophy or style of life as much as a health system in its own right. Their relationships with medicine also vary; osteopathy and naturopathy receive some acceptance, some homoeopaths are tolerated, whilst chiropractic is ostracised and vilified. A common paradigm of treatment underlies all four alternate approaches to healing. They all eschew the use of synthetic pharmaceuticals and invasive treatments and accept an indigenous theory of disease and a belief in the vis medicatrix naturae or the healing power of nature. An inevitable concomitant of this paradigm is that they believe that healing and health must be self-engendered. They rest within the client and his or her actions, not within the hands, skills or power of the healer. It is these characteristics combined with the alternate healers ' claims to espouse a similar scientific rationale for their approaches, and their functioning as parallel healers to medicine, that establishes their special relationship with medicine. This relationship become s more problematic in the face of medicine's hegemony and claim to unique legitimacy as the community's sole healing system. The interaction between these systems and medical practice can be gauged through articles related to the four alternate healing systems that have appeared in the medical literature. Interest has been cyclical but appears to have markedly increased in the past two decades. In this period it has included exploratory and descriptive writing; concern with controlling and/or eradicating the healers; desire to protect an ignorant and vulnerable public and. finally understanding and exploration of what the alternate healers might have to offer. At the same time, the public or institutionalized role has been one of denial and suppression through ostracism and legal constraints. In spite of medicine's position the alternate healing systems have found growing community acceptance so that it is problematical and probably unacceptable now to consider their use as a 'deviant ' health action. Increasing interest in the characteristics of clients has provided a consensus that they are similar to the adult population and are more likely to suffer from musculoskeletal and chronic illnesses. They are no more likely to be neurotic or gullible than the general community, but probably more practical and more oriented towards an active involvement in the healing process. The impact of these issues is explored, through comparing the strategies taken into account when choosing a treatment. These include attending one of the alternate healers exclusively for a condition; attending an alternate healer and a medical practitioner for the same problem; attending a medical practitioner solely or not consulting any healer. Respondents from surveys of alternate healer clients and the general community were classified according to their use of these four strategies, and the influences on their decisions at different stages of the treatment decision making process were compared.

Formation of blood clot on biomaterial implants influences bone healing

The first step in bone healing is forming a blood clot at injured bones. During bone implantation, biomaterials unavoidably come into direct contact with blood, leading to a blood clot formation on its surface prior to bone regeneration. Despite both situations being similar in forming a blood clot at the defect site, most research in bone tissue engineering virtually ignores the important role of a blood clot in supporting healing. Dental implantology has long demonstrated that the fibrin structure and cellular content of a peri-implant clot can greatly affect osteoconduction and de novo bone formation on implant surfaces. This paper reviews the formation of a blood clot during bone healing in related to the use of platelet-rich plasma (PRP) gels. It is implicated that PRP gels are dramatically altered from a normal clot in healing, resulting conflicting effect on bone regeneration. These results indicate that the effect of clots on bone regeneration depends on how the clots are formed. Factors that influence blood clot structure and properties in related to bone healing are also highlighted. Such knowledge is essential for developing strategies to optimally control blood clot formation, which ultimately alter the healing microenvironment of bone. Of particular interest are modification of surface chemistry of biomaterials, which displays functional groups at varied composition for the purpose of tailoring blood coagulation activation, resultant clot fibrin architecture, rigidity, susceptibility to lysis, and growth factor release. This opens new scope of in situ blood clot modification as a promising approach in accelerating and controlling bone regeneration.

Defect healing and enhanced nucleation of carbon nanotubes by low-energy ion bombardment

Structural defects inevitably appear during the nucleation event that determines the structure and properties of single-walled carbon nanotubes. By combining ion bombardment experiments with atomistic simulations we reveal that ion bombardment in a suitable energy range allows these defects to be healed resulting in an enhanced nucleation of the carbon nanotube cap. The enhanced growth of the nanotube cap is explained by a nonthermal ion-induced graphene network restructuring mechanism.

Investigating the effect of internal fixation stiffness on metaphyseal fracture healing in a mouse model

This project examined the differences in healing of metaphyseal bone, when the implants of variable stiffness are used for fracture fixation. This knowledge is important in development of novel orthopaedic implants, used in orthopaedic surgery to stabilise the fractures. Dr Koval used a mouse model to create a fracture, and then assessed its healing with a combination of mechanical testing, microcomputed tomography and histomorphometric examination.

Perspectives about exercise from adults with venous leg ulcers : an exploratory study

Objective Exercise has the potential to offer a range of health benefits in addition to improving healing outcomes for people with venous leg ulcers. However despite evidence based recommendations, most of these individuals do not engage in regular exercise. The aim of this study was to gain an understanding of the perspectives of adults with venous leg ulcers, in relation to exercise. Method This was a qualitative design using semi-structured interviews and discussions. Ten participants with venous leg ulceration volunteered to participate. Recruitment was through a specialist wound clinic. Verbatim data were collected by an experienced moderator using a semi-structured guide. Data saturation was reached after three group discussions and two interviews. A random selection of transcripts was sent back to the participants for verification. Thematic content analysis was used to determine major themes and categories. Two transcripts were independently analysed, categories and themes independently developed, cross checked and found comparable. Remaining transcripts were analysed using developed categories and codes. Results Regardless of their current exercise routine, participants reported exercising prior to venous leg ulceration and expressed an interest in either becoming active or maintaining an active lifestyle. Overall four themes emerged from the findings: i) participant understanding of the relationship between chronic venous insufficiency and exercise patterns, ii) fear of harm impacts upon positive beliefs and attitudes to exercise, iii) perceived factors limit exercise and iv) structured management facilitates exercise. Conclusion The value of exercise in improving outcomes in venous leg ulcers lies in its capacity to promote venous return and reduce the risk of secondary conditions in this population. Despite motivation and interest in being exercise active, people with venous leg ulcers report many obstacles. Further exploration of mechanisms that assist this patient population and promote understanding about management of barriers, coupled with promotion of enabling factors is vital for improving their exercise participation.

The role of counselling in healing from sexual assault in childhood from the phenomenological perspective of men and women

Serious Childhood Sexual Assault (CSA) has the potential for a wide range of extreme difficulties, not only in childhood but for many years to come. However, the lasting negative impacts are not inevitable and with the right help, those who have experienced CSA can go on to enjoy whole and fulfilling lives. The question posed in this research is “What comprises “the right help”? The present study qualitatively investigated the narratives of men and women with regard to what was deemed important components of counselling which facilitated their healing from childhood sexual assault. Participants consisted of 21 women and 11 men who had sought both individual and group counselling to work through issues stemming from traumatic sexual assault in childhood. Findings presented here describe three superordinate themes which were essential in the healing process, incorporating abuse-specific, client-specific and practitioner-specific components. A final superordinate theme of negative experiences in counselling is also presented, describing unhelpful or negative counselling experiences. Similarities between men and women as to the important components of counselling was remarkable, however important gender differences were also observed.

Testing the effectiveness of a self-efficacy based exercise intervention for adults with venous leg ulcers : protocol of a randomised controlled trial

Background: Exercise and adequate self-management capacity may be important strategies in the management of venous leg ulcers. However, it remains unclear if exercise improves the healing rates of venous leg ulcers and if a self-management exercise program based on self-efficacy theory is well adhered to. Method/Design: This is a randomised controlled in adults with venous leg ulcers to determine the effectiveness of a self-efficacy based exercise intervention. Participants with venous leg ulcers are recruited from 3 clinical sites in Australia. After collection of baseline data, participants are randomised to either an intervention group or control group. The control group receive usual care, as recommended by evidence based guidelines. The intervention group receive an individualised program of calf muscle exercises and walking. The twelve week exercise program integrates multiple elements, including up to six telephone delivered behavioural coaching and goal setting sessions, supported by written materials, a pedometer and two follow-up booster calls if required. Participants are encouraged to seek social support among their friends, self-monitor their weekly steps and lower limb exercises. The control group are supported by a generic information sheet that the intervention group also receive encouraging lower limb exercises, a pedometer for self-management and phone calls at the same time points as the intervention group. The primary outcome is the healing rates of venous leg ulcers which are assessed at fortnightly clinic appointments. Secondary outcomes, assessed at baseline and 12 weeks: functional ability (range of ankle motion and Tinetti gait and balance score), quality of life and self-management scores. Discussion: This study seeks to address a significant gap in current wound management practice by providing evidence for the effectiveness of a home-based exercise program for adults with venous leg ulcers. Theory-driven, evidence-based strategies that can improve an individual’s exercise self-efficacy and self-management capacity could have a significant impact in improving the management of people with venous leg ulcers. Information gained from this study will provide much needed information on management of this chronic disease to promote health and independence in this population. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12612000475842 Trial status: Current follow up

Pathways to peace : a phenomenological exploration of the processes of healing and posttraumatic growth following childhood sexual assault

This thesis explored pathways to healing in men and women who experienced traumatic sexual abuse in childhood and considered themselves to be in a place of wellness. The thesis synthesises current knowledge in this area and has produced a number of models with direct implications for clinical practice. This unique work has also contributed to advancing theoretical understanding of healing following sexual assault.

Predicting the likelihood of non-healing : a venous leg ulcer risk assessment tool

This project developed, validated and tested reliability of a risk assessment tool to predict the risk of failure to heal of patients with venous leg ulcers within 24 weeks. The risk assessment tool will allow clinicians to be able to determine realistic outcomes for their patients, promote early healing and potentially avoid weeks of inappropriate therapy. The tool will also assist in addressing specific risk factors and guide decisions on early, alternative, tailored interventions.