Bactroban

Editorial

Dr Salcido: As discussed in part 1 of this editorial, 1 telemedicine can be used not only for traditional exchanges of information between hospitals, clinics, and physicians, but also to directly monitor patients' wounds. This monitoring relies on a collaborative partnership between the practitioner and patient.

In part 2, we focus on the outcome of the relationship, the evaluation of the clinical case, and selected strategies to treat the patient and the wound.

An E-mail Exchange

As readers of this journal will recall, the patient is Dr Bamer, a C5-6 quadriplegic with a chronic nonhealing wound on the left lateral aspect of the calf1 (Figure 1). In January, Dr Garner sent me an E-mail message requesting advice on treating his wound. I agreed to see him as a patient.

Dr Bar. Once I established contact with Dr Salcido and he agreed to take my case as a collaborative partnership, communicating about my wound and its progress was easy. After an initial evaluation at the wound care clinic, our primary means of communication was through E-mail messages.

To allow an exchange of images, I obtained a Canon Power Shot S100 digital camera. Each week, I took a picture of the wound; reference markers were included to allow accurate measurement of the wound and objective evaluation of the weekly healing progress. Taking the pictures became part of my morning routine, usually on the weekend when I had more time.

The pictures were then downloaded to my laptop computer, where I kept records of the wound's progress, and E-mailed to Dr Salcido as an attachment to a weekly progress report. This weekly update included a written description of the wound and any questions I might have about my treatment.

A Treatment Decision

In March, I had a setback and the wound temporarily became larger. I saw Dr Salcido in the clinic and he ordered testing to rule out a chronic bone infection (osteomyelitis). At that time, we decided that a more aggressive approach to healing the wound must be under-taken.

One issue was my weight, which had slowly dropped over a number of years from about 150 pounds to an unhealthy 123 pounds. Dr Salcido was concerned that because my weight was so low, I had insufficient lean body mass to facilitate healing.

To address the weight issue and promote wound healing, we decided that I would take a short course of an anabolic steroid. Soon after initiating treatment with the anabolic steroid, the wound began to show dramatic improvement (Figure 1). More progress toward healing was made in the next 2 months than had occurred in the previous year.

Finally, I began to feel confident that the wound could be healed through nonsurgical means. I had been referred twice for surgery by others handling my case, but I had resisted surgery as viable only as a last resort. Surgery would have required a skin graft, an extensive hospital stay, and significant time away from work and family-none of which interested me.

On the Way to Closure

After 2 months, we decided that I no longer needed the anabolic steroid: I had gained 15 pounds and was once again at a more healthy body weight. Although the wound was not completely closed, we both thought that it had shown significant progress and was clearly on the way to complete closure.

And we were right: A month later, I had continued to maintain a stable body weight and the wound had completely closed. Treatment took 6 months from my initial contact with Dr

Salcido to closure (Figure 1). After 1 1/2 years of traveling to different medical facilities, experiencing minimal wound healing, and hearing repeated recommendations for surgery, I was greatly relieved to work with a practitioner who had new ideas and could collaborate in such a convenient and time-efficient fashion. From start to finish, the telemedicine approach to healing of my wound took only 3 office visits and simple weekly E-mail exchanges-a patient's dream come true.

A New Approach to Patient Care

Dr Salcido: This case illustrates the multifaceted issues we face in evaluating and treating persons with chronic wounds in a technology-rich environment. Certainly Dr Barner is not a typical patient. However, his case demonstrates a new approach to patient care that is becoming more prevalent.

From a clinical management perspective, this was an exciting case; the opportunity to report it to the readers of the journal in real time essentially as a prospective case report-made it even more exciting.

During Dr Barrier's initial clinic visit, the wound was debrided, then cleansed with normal saline. We applied mupirocin (Bactroban), an anti-infective ointment, and a nonadherent composite dressing. Dr Bamer was given instruction on how to change the dressing and signs and symptoms that should be reported immediately.

Because of the chronicity of the wound, we decided to proceed deliberately but cautiously. I observed the wound's progress and evaluated and ruled out the usual causes of a chronic nonhealing wound in a lower extremity: vascular, metabolic, infectious, and traumatic. His involuntary weight loss seemed a likely contributing factor. I measured all direct and indirect parameters of nutrition and liver function. His liver function was normal and remained so throughout treatment. Initially, however, his nutritional parameters were low normal-which, coupled with his weight, is why I considered the anabolic steroid.

As Dr Barrier indicated, we discussed the treatment options available, and we decided to start him on the recommended dose of the anabolic steroid oxandrolone2-4 (Oxandrin; Bio-Technology General Corporation, Iselin, NJ). As described, I reviewed images of his wound every week using imaging techniques from Vista Medical (Winnepeg, Manitoba, Canada). The wound is now closed. A report on the long-term follow-up of Dr Bamer and the closed wound is planned for a future issue.

A Revolution in Communication

As this case illustrates, we are in the midst of a revolution in how we interact and do business on a daily basis. I doubt that 5 years ago a patient would have contacted me via E-mail or that we would have had the means to monitor the wound long-distance.

But in those 5 years, the rapid growth of the Internet has changed the way information is disseminated, knowledge is gained, and health care is provided.5,6

We started the previous editorial) with a quote from Microsoft cofounder Bill Gates, who believes that we have underestimated the potential value of the Internet in the next 10 years. Expansion of the Internet has been slowed in the last year or so by the dot com bust and the regulatory stranglehold on broadband Internet deployment.5 Yet I am sure we can all agree with Gates that there is a bright future for the Internet and virtually limitless applications for health care.

In general, the health care industry has not yet embraced the full potential of the Internet. However, this case has shown that new approaches to care that make use of the technology at our disposal can successfully augment face-to-face practitioner/ patient interactions. That can make our practice more efficient, more effective, and more satisfying for all involved.

The Internet is only part of the equation: New and emerging technologies will redouble the possibilities in ever-contracting cycles. New forms of network connectivity, faster wireless technology, and better handheld devices 6 and clinical software applications will help to further extend the reach of health care practitioners and close the communication gap between patient and provider.

One of many issues remaining unsolved, however, is how to reimburse practitioners fair market value for time and effort invested with patients using these technologies.6-7 The question we will all want answered is this: Will health care policymakers and thirdparty payers support us (ie, reimburse us) for these novel methods of patient interaction?

References

1. Salcido R, Barrier KE.The patient.com.Adv Skin Wound Care 2001;14:108,110. 2. Spungen AM, Koehler KM, Modeste-Duncan R, Rasul M, Cytryn AS, Bauman

WA.9 clinical cases of nonhealing pressure ulcers in patients with spinal cord injury treated with an anabolic agent: a therapeutic trial. Adv Skin Wound Care 2001;14:139-44.

3. Demling RH, DeSanti L. Oxandrolone, an anabolic steroid, significantly increases the rate of weight gain in the recover phase after major burns. J Trauma 1997;43:47-51.

4. Demling RH, DeSanti L. Involuntary weight loss and the nonhealing wound: the role of anabolic agents. Adv Wound Care 1999;12(Suppl 1):1 -14.

5. Kleinke, Vaporware.com. The failed promise of the health care Internet. Health Aff (Millwood) 2000;19(6):57-71.

6. Wood GM. Emerging technologies in health care and the patient encounter of the future. Manag Care Interface 2001;14(3):67-70, 87.

7. MarciniakTA, Om CH. Medicare physician payment for practice expense: is it refined? Part 1. Office visit reevaluations. MedGenMed 2001;3(1):El 0.

Richard "Sal" Salcido, MD, and Kenneth E. Barner, PhD

Richard "Sal" Salcido, MD, is the Editor-in-Chief of Advances in Skin & Wound Care. He is the William Erdman Professor and Chairman, Department of Rehabilitation Medicine, Senior Fellow, Institute on Aging, and Associate, Institute of Medicine and Engineering, at the University of Pennsylvania Health System, Philadelphia, PA. Kenneth E. Garner, PhD, is an Associate Professor of Electrical and Computer Engineering at the University of Delaware, Newark, DE. He is a Senior Member of the IEEE and Associate Editor of the IEEE Transactions on Neural Systems and Rehabilitation Engineering.

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