**4. Conclusion**

The complexity and multifaceted nature of diabetic foot ulceration requires a coordinated approach by a multidisciplinary team of healthcare providers yet even when optimal treatment is provided one study suggests only about 50% of diabetic foot ulcers will be healed after 12-20 weeks. Experts suggest the most cost-effective way to approach wound care in this population is through implementation of a standardized treatment regimen with assessment of wound healing rate every 4 weeks. Advanced wound care therapies should be reserved for those diabetic foot ulcers with healing rates < 50% after 4 weeks. All diabetic foot ulcers are initially managed with a standardized treatment regime and re-assessed every 4 weeks. Wounds healing at a rate of 50% or more continue with the standard regimen while those healing at a rate below 50% receive more aggressive treatment approaches. It should be emphasized that these advanced wound care therapies are in addition to the standard treatments of offloading, debridement, ischemia and infection management.

Diabetic foot ulcers and LEAs present challenges to clinicians not only as serious but ultimately preventable sources of pain, suffering and death to individuals but as virtual black holes to health care resources. A clearer understanding of the nature of these complications and the threats they pose will enable healthcare providers to make informed decisions and implement best practices of care.

#### **5. Acknowledgment**

This study was supported by the Oklahoma Center for the Advancement of Science and Technology (OCAST HR09-048).

#### **6. References**

12 Rehabilitation Medicine

Wound healing is regulated at least in part by the action of growth factors at various points in the healing cascade. Growth factors are polypeptides transiently produced by cells that exert hormone-like effects on other cells by binding to surface receptors and activating cellular proliferation and differentiation. Some of the more important growth factors for healing include platelet-derived growth factor, transforming growth factor alpha and beta, fibroblast growth factor and epithelial growth factor. Many growth factors are decreased in chronic diabetic foot ulcers. An example of a topically applied growth factor is the genetically engineered, recombinant DNA platelet-derived growth factor, becaplermin. Becaplermin addresses the lack of platelet-derived growth factor-BB and stimulates chemotaxis and mitogenesis of neutrophils, fibroblasts and monocytes. On a cautionary note, the FDA issued a black box warning for this product citing increased risk of death

Living skin equivalents (LSE) comprise another class of advanced local wound care products that is rapidly expanding. These tissue-engineered skins offer notable advantages over skin grafting: because their use is non-invasive, anesthesia is not required, they can be applied in out-patient settings and potential donor site complications such as infection and scarring are avoided. Bioengineered tissue acts not only as a biological dressing but also facilitates healing by filling the wound with extracellular matrix and inducing the expression of growth factors and cytokines which in turn facilitate the healing cascade. LSEs are available for epidermal, dermal and composite (dermal and epidermal) wounds. Autologous grafts or autografts are comprised of cells harvested from the patient then cultured. Grafts from these master cell cultures can then be subcultured into sheets and obtained from an unrelated donor. Allergenic grafts are tissue engineered from neonatal

The complexity and multifaceted nature of diabetic foot ulceration requires a coordinated approach by a multidisciplinary team of healthcare providers yet even when optimal treatment is provided one study suggests only about 50% of diabetic foot ulcers will be healed after 12-20 weeks. Experts suggest the most cost-effective way to approach wound care in this population is through implementation of a standardized treatment regimen with assessment of wound healing rate every 4 weeks. Advanced wound care therapies should be reserved for those diabetic foot ulcers with healing rates < 50% after 4 weeks. All diabetic foot ulcers are initially managed with a standardized treatment regime and re-assessed every 4 weeks. Wounds healing at a rate of 50% or more continue with the standard regimen while those healing at a rate below 50% receive more aggressive treatment approaches. It should be emphasized that these advanced wound care therapies are in addition to the standard treatments of offloading, debridement, ischemia and infection management.

Diabetic foot ulcers and LEAs present challenges to clinicians not only as serious but ultimately preventable sources of pain, suffering and death to individuals but as virtual black holes to health care resources. A clearer understanding of the nature of these complications and the threats they pose will enable healthcare providers to make informed

**3.10 Advanced wound care products** 

fibroblasts and keratinocytes.

decisions and implement best practices of care.

**4. Conclusion** 

from cancer in patients who used 3 or more tubes of the product.


Diabetic Foot Ulceration and Amputation 15

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**2** 

*USA* 

**Stroke Rehabilitation** 

*The University of Pennsylvania,* 

*Department of Physical Medicine & Rehabilitation,* 

*Division of Pediatric Rehabilitation Medicine, The Children's Hospital of Philadelphia,* 

Stroke is defined a sudden neurological impairment resulting from interruption of the blood supply and brain tissue damage. The most common symptom of a stroke is sudden weakness and/or numbness of the face, arms or legs, most often on one side of the body. Other symptoms include: confusion, difficulty speaking or understanding speech; difficulty seeing with one or both eyes; difficulty walking, dizziness, loss of balance or coordination; severe headache with no known causes; fainting or unconsciousness. Generally stroke means compromise of arterial blood supply (arterial stroke). Venous stroke is very rare in

Strokes can be classified as either hemorrhagic or non-hemorrhagic (infarction). This classification helps to decide early therapeutic intervention. Hemorrhagic stroke is not indicated for t-PA (tissue plasminogen activator) protocol. Hemorrhagic stroke is most commonly related with hypertension or aneurysm in adults and with congenital vascular abnormality in children. Non-hemorrhagic stroke is more common than hemorrhagic stroke (8:2) in the United States and European countries1,2, however a more recent study shows 6:4

The diagnostic procedures of stroke are identical in both adult and children. A meticulous history and neurological examination are the mainstays of diagnosis. Head CT (computerized tomography) is useful to differentiate hemorrhagic and non-hemorrhagic stroke in very acute phase. A brain MRI (magnetic resonance image) is requested if head CT is not diagnostic. Intracranial as well as extracranial vessels can be evaluated by a MRA (magnetic resonance arteriography). MRV (magnetic resonance venography) is indicated for

In very acute phase of stroke (within 3 hours), a thrombolytic agent (t-PA) is recommended as a standard treatment for non-hemorrhagic strokes in adult. It decreases mortality and

Right hemisphere function is to control not only the movement of the left side of the body, but also analyze spatial orientation (distance, depth, position, size, and stereotaxis) and

improves functional outcome, in spite of hemorrhagic complications5.

**1. Introduction** 

adult but not uncommon in children.

venous stroke diagnosis.

ratio3. This ratio varies in different races and cultures4.

**2. Right versus left hemisphere stroke** 

Chong Tae Kim

