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]]>Pressure injuries affect up to 3 million adults in the United States, and efforts to prevent them have demonstrated only modest impact in their epidemiology. Pressure injuries cost $9.1 to $11.6 billion per year, and result in decreased quality of life, prolonged hospital admissions and rehabilitation, increased chance of placement in long-term care, and adverse outcomes that include pain, infections, scarring, disability and death. Pressure injuries trigger the need for surgical procedures that include debridements, myocutaneous flaps, amputations, grafts, and ostomies for fecal diversion.
Over the past year I provided education to national organizations including the American College of Physicians and AMDA-The Society for Post-Acute and Long-term Care Medicine. In addition, I had the privilege of writing textbook chapters for Springer Publishing Company and the American Geriatrics Society. I also edited a forthcoming volume of Clinics in Geriatric Medicine entitled Pressure Injuries and Chronic Wounds, and contributed a chapter entitled Pressure Injuries and Skin failure. The education gap for physicians is substantial. Doctors need to be taught how to assess and document wounds, prognosticate healing, address underlying comorbidities, and choose among the multiplicity of consultants and wound care treatment modalities. The task is huge, but I am pleased to make a small contribution to closing the gap.
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]]>The post Academic Promotion at the Mount Sinai School of Medicine appeared first on Jeffrey M Levine, MD.
]]>I am delighted to announce my promotion to Clinical Professor of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai. I am honored and grateful to be part of the Mount Sinai Health System – one of the largest academic medical systems in the New York metro area, with more than eight hospitals and 400 outpatient practices, and a leading school of medicine and graduate education. The Brookdale Department of Geriatrics & Palliative Medicine, which is one of the largest departments of its kind in the country, is ranked No. 1 in US News & World Reports Best Hospitals.
My affiliation with Mount Sinai began in 1985 when I moved to New York City to train as a fellow in the newly established Department of Geriatrics. I chose this program because of visionary leaders that included Robert Butler MD – a world-renowned gerontologist, and Leslie Libow MD who advocated the nursing home for a center of learning. Their inspiration set me on a path to carve out a niche in care of chronic wounds for older adults. It has become my professional mission to develop educational programs for doctors on the art and science of wound care which includes pressure injuries, vascular ulcers, wounds related to malignancy, traumatic and post-surgical wounds, and many others.
I am currently based at the New Jewish Home in Manhattan where I provide wound care consultation through Advantage Surgical & Wound Care. Teaching medical students, residents, and fellows has been a passion, and over the years I had the honor and privilege of mentoring trainees through dozens of research projects related to wound care. In pursuit of my educational efforts, I have also had the opportunity to write several textbook chapters on care of chronic wounds in older adults. I am grateful that Mount Sinai and the New Jewish Home have provided me the opportunity to practice wound care and continue my involvement in education.
I would like to thank the professor-level faculty from around the country who provided recommendations that facilitated the promotion process.
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Related posts
Wound Care in the Geriatrics Review Syllabus
New Review on Aging Skin, with Considerations for Clinicians
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This video presentation was delivered in March 2023 in the Winter Talk series sponsored by NYC Urban Sketchers, hosted by Mark Leibowitz. Here I discuss how I have integrated medicine with art, and art with medicine, in the course of my career as a medical doctor in Manhattan.
I’ve had many people inspire me in my pursuit of both medicine and art, including Andreas Vesalius, Anton Chekhov, AJ Cronin, and Frank Netter. I would like to quote one of the doctors who inspired me. His name is William Carlos Williams, who was a practicing physician and a giant in the 20th century world of poetry. He wrote his poems on prescription pads between patients who came to his office in Rutherford, New Jersey. Late in his life as he looked back on his career, he said this:
“When they ask me, as of late they frequently do, how I have for so many years continued an equal interest in medicine and the poem, I reply that they amount for me to nearly the same thing.”
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Aging on the Covers of The Gerontologist
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]]>The post New Textbook Chapter on Pressure Injuries & Chronic Wounds appeared first on Jeffrey M Levine, MD.
]]>I am thrilled that my chapter entitled Pressure Injury and Chronic Wounds was just published in a major new reference work. The textbook is entitled Geriatric Medicine: A Person Centered Evidence Based Approach and is available on Springerlink. My chapter is illustrated by photos taken over years in practice, and illustrations that demonstrate pressure injury staging and aging skin.
This chapter is part of a large multidisciplinary reference work with over 70 peer-reviewed chapters designed to present a comprehensive and state-of-the-art update that incorporates existing literature with clinical experience. Geriatric medicine is defined by a focus on function and quality of life and the approach to care must be grounded in the principles of person centered care. This book will serve as an unparalleled resource for meeting these challenges.
Updated and revised from the previous edition, it is published by Springer International Publishing, the biggest publisher of medical textbooks worldwide. Designed to be published in print, e-book and as a perpetual online living reference work, this text creates a cutting-edge moment for cumulating, updating and extending studies of geriatric medicine beyond the present and into the future.
Despite the high prevalence of chronic wounds, wound care is undertaught in medical training, and research and education on wound care has lagged behind other geriatric syndromes such as falls, dementia, and frailty. The differential diagnosis of chronic wounds covers a wide range of entities, often posing a diagnostic challenge. The geriatrician needs to be familiar with concepts of prevention, diagnosis, treatment, and how to best collaborate with colleagues in allied specialties for co-management of chronic wounds to promote dignity, autonomy, quality of life, and favorable outcomes. I feel honored and pleased to be able to make this contribution that will provide medical practitioners with the basics of care for pressure injuries and chronic wounds.
For more information on my chapter click here.
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Related posts:
A Review of the Skin Failure Concept
Wound Care in the Geriatrics Review Syllabus
New Review on Aging Skin, with Considerations for Clinicians
Is the Pressure Injury Staging System Obsolete?
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]]>The post Pressure Relief and Pressure Redistribution: What is the Difference? appeared first on Jeffrey M Levine, MD.
]]>Pressure Relief: Pressure relief involves actively relieving or reducing the pressure on specific areas of the body that are at risk of developing pressure ulcers. This is typically achieved by changing the individual’s position or providing support to vulnerable areas. Specific pressure relief techniques include:
Pressure Redistribution: Pressure redistribution, on the other hand, is a broader concept that encompasses strategies and equipment designed to distribute pressure more evenly across the body’s surface, thereby reducing the risk of pressure ulcers. This approach focuses on creating a supportive and evenly distributed surface that minimizes localized pressure points. Pressure redistribution methods and equipment include:
In summary, pressure relief focuses on actively relieving pressure on specific body areas at risk of developing pressure ulcers through repositioning and offloading techniques, while pressure redistribution involves using specialized equipment and surfaces to evenly distribute pressure across the body’s surface, reducing the overall risk of pressure ulcers. Both strategies are essential components of pressure ulcer prevention and management in healthcare settings
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]]>The post Malnutrition Can Impact Wound Healing appeared first on Jeffrey M Levine, MD.
]]>Malnutrition can have a significant impact on wound healing. Proper wound healing is a complex process that involves various cellular and biochemical reactions. When the body is malnourished, it lacks the essential nutrients necessary for these processes, which can lead to delayed or impaired wound healing. Here are some key relationships between malnutrition and wound healing:
1. Protein Deficiency: Protein is crucial for tissue repair and the production of collagen, which is essential for wound healing. Malnourishment, especially a lack of adequate protein intake, can lead to a delay in wound closure and reduced tensile strength of the healed tissue.
2. Vitamin and Mineral Deficiencies: Essential vitamins and minerals, such as vitamin C, vitamin A, zinc, and copper, play vital roles in wound healing. Deficiencies in these nutrients can impair the immune response, collagen formation, and the overall healing process.
3. Weakened Immune System: Malnutrition weakens the immune system, making the body more susceptible to infections. Infections can further delay wound healing and may lead to more serious complications.
4. Reduced Energy Levels: Malnutrition can result in decreased energy levels, which can hinder the body’s ability to carry out the energy-intensive processes involved in wound healing.
5. Impaired Tissue Regeneration: Malnutrition can affect the body’s ability to regenerate new tissue, resulting in the formation of weaker, less functional scar tissue.
6. Delayed Inflammation Response: Inflammation is a natural part of the wound healing process and helps to clear away damaged tissue and pathogens. Malnutrition can delay the onset and resolution of inflammation, prolonging the overall healing time.
7. Poor Circulation: Malnutrition can lead to circulatory problems, reducing the delivery of oxygen and nutrients to the wound site. Proper blood flow is essential for optimal wound healing.
It’s important to note that malnutrition can take various forms, including protein-energy malnutrition (commonly seen in conditions like kwashiorkor and marasmus), as well as micronutrient deficiencies. The specific impact on wound healing will depend on the type and severity of malnutrition.
To promote effective wound healing, it’s essential for individuals who are malnourished or at risk of malnutrition to address their nutritional deficiencies through dietary improvements or, in severe cases, medical interventions such as nutritional supplements, feeding tubes, or intravenous nutrition. The physician should work closely with the nutritionist to monitor and manage the nutritional status of patients with wounds to optimize the healing process.
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]]>The post Wound Bed Preparation is a Crucial Strategy to Heal Chronic Wounds appeared first on Jeffrey M Levine, MD.
]]>There are dozens of wound care products available, and the practitioner is often overwhelmed and confused by the variety of choices. The best way to choose the correct product is understanding the concept of wound bed preparation – a crucial aspect of wound care that creates a systematic approach to an optimal strategy for wound healing. It encompasses various actions to facilitate the healing process by addressing the condition of the wound bed. Wound bed preparation helps reduce the risk of infection, promotes tissue regeneration, and accelerates the healing process. The following 9 steps are key considerations involved in wound bed preparation:
1. Assessment: Begin by assessing the wound’s characteristics, including size, depth, location, and etiology (e.g., surgical, traumatic, pressure ulcer). If the wound is a pressure injury, evaluate the wound’s stage.
2. Wound Debridement: Debridement is the removal of dead, damaged, or infected tissue from the wound bed. This step is essential to promote the growth of healthy tissue. Debridement methods include surgical, mechanical (using dressings or irrigation), enzymatic (using topical enzymes), and autolytic debridement (allowing the body’s natural processes to remove dead tissue).
3. Infection Control: Address any signs of infection by taking appropriate measures, such as prescribing antibiotics or implementing antimicrobial dressings.
4. Moisture Balance: Excessive dryness or moisture can impede healing. Use appropriate wound dressings to manage moisture levels. For instance, use moist dressings for dry wounds and absorbent dressings for excessively moist wounds.
5. Wound Bed and Peri-wound Protection: Protect newly formed tissue by applying appropriate wound dressings or skin substitutes to keep the wound bed covered and maintain a healing environment. The area around the wound should be clean and free of excess moisture and debris.
6. Promote Granulation Tissue Formation: Granulation tissue is a component of a healing wound and consists of new blood vessels and collagen. Maintain an environment that supports granulation tissue formation through appropriate dressings and management of tissue perfusion. Provision of calories, protein, and micronutrients is important to optimize nutritional status for granulation tissue formation.
7. Pain Management: Address pain and discomfort associated with the wound by providing analgesics or using wound care techniques that minimize pain during dressing changes. Premedication before dressing changes is an option, as is reducing dressing frequency.
8. Patient Education: Educate the patient and caregivers on wound care procedures, dressing changes, signs of infection, and the importance of adherence to the treatment plan.
9. Monitoring and Reassessment: Regularly monitor the wound’s progress and reassess its condition to ensure that the chosen treatment plan is effective. Adjustments may be necessary based on the wound’s response.
In summary, Wound bed preparation is a dynamic process that may require multiple interventions and ongoing care. The goal is to create an environment conducive to healing, reduce complications, and promote the restoration of normal tissue. Healthcare professionals, including wound care specialists, play a critical role in managing wound bed preparation for patients.
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]]>The post Vitamins and Wound Healing appeared first on Jeffrey M Levine, MD.
]]>Wound healing is a complex biological process that involves inflammation, tissue formation, and tissue remodeling. Vitamin supplements can play a role in wound healing by supporting various aspects of the body’s natural healing processes. Here are some key vitamins and minerals that are important for wound healing:
1. Vitamin C: Vitamin C, also known as ascorbic acid, is essential for collagen synthesis, a protein that helps in the formation of skin, blood vessels, and connective tissue. Collagen is a crucial component of wound healing. Adequate vitamin C intake can promote tissue repair and reduce the risk of infection.
2. Vitamin A: Vitamin A is important for maintaining the integrity of skin and mucous membranes. It aids in the production of new skin cells and helps with the early stages of wound healing. Vitamin A deficiency can lead to delayed wound healing.
3. Vitamin E: Vitamin E is an antioxidant that helps protect cells from oxidative damage. It may promote wound healing by reducing inflammation and preventing tissue damage caused by free radicals.
4. Vitamin K: Vitamin K plays a role in blood clotting and wound healing. It helps in the formation of blood clots, which are essential for stopping bleeding from wounds.
5. Zinc: Zinc is a mineral that plays a crucial role in the synthesis of DNA, collagen, and other proteins necessary for tissue repair. Zinc deficiency can impair wound healing and increase the risk of infection. Some experts advocate routine zinc supplementation to promote wound healing, but this is controversial.
6. Vitamins: Various B vitamins, such as B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (pantothenic acid), B6 (pyridoxine), and B12 (cobalamin), are involved in metabolic processes that support tissue growth and repair.
7. It’s important to note that while these vitamins and minerals can support the wound healing process, they are most effective when obtained through a balanced diet. If someone has a deficiency in any of these nutrients, supplementation may be necessary under the guidance of a healthcare professional. However, excessive intake of certain vitamins or minerals can be harmful, so it’s crucial to avoid megadoses without medical supervision.
In addition to vitamin supplements, other factors such as adequate protein intake, hydration, and overall nutritional status play a significant role in wound healing. Proper wound care, cleanliness, and infection prevention are also essential for optimal healing, along with treating any underlying diseases such as diabetes, anemia, and any cause of low cardiac output or decreased oxygen delivery.
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]]>The post Teaching Wound Care at the American College of Physicians Annual Meeting appeared first on Jeffrey M Levine, MD.
]]>In my introductory remarks I asked the question, “How many of you have had a lecture on wound care in medical school.” Looking out on the sea of faces, many of whom were young residents and attendings, only ONE person hesitantly raised their hand.
It is unfortunate and puzzling that wounds are not on the American medical school curriculum, as they are a major public health challenge. Chronic wounds impact over 15% of Medicare beneficiaries and incur over $30 billion in annual cost. Chronic wounds incur adverse outcomes such as pain, infection, amputation, prolonged rehabilitation, hospital readmission, accelerated physical deterioration, and death. Besides the cost of dressings and daily care, chronic wounds are associated with depression, social isolation, and patient and family dissatisfaction. The most common wound types are listed below.
Lack of knowledge by front-line physicians such as internists has serious implications for quality of care for patients with chronic wounds. Lesions often go unexamined and are often not present on the physician’s problem list. When confronted with a wound, the untrained physician will be unfamiliar with diagnostic and treatment approaches or when to utilize consultants. Many wounds are therefore not caught early, not treated correctly, and infection can be missed or undertreated. Kudos to ACP for including a section on wound care in their annual didactic.
Common Wound Types Encountered in Medical Practice
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RELATED POSTS
A Review of the Skin Failure Concept
Wound Care in the Geriatrics Review Syllabus
New Review on Aging Skin, with Considerations for Clinicians
Is the Pressure Injury Staging System Obsolete?
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]]>The post Elder Abuse on Film: A Geriatrician’s Viewpoint. appeared first on Jeffrey M Levine, MD.
]]>The film starkly depicts Jane’s horrific abuse of Blanche. As I watched the story unfold, I realized that it presents a portrayal of elder abuse, starkly illustrating various manifestations of this geriatric syndrome wrapped into one case. As a geriatrician, the scenes shared similarities with cases I had encountered over my three decades of practice.
Blanche suffers several types of abuse at the hands of her sister, which can be classified as follows:
* Verbal abuse. Blanche is called names and verbally demeaned by Jane.
* Physical abuse. Blanche is struck several times in the movie by Jane, including one chilling scene where she is viciously kicked as she lay on the floor.
* Deprivation of services. Blanche desperately tries to call a physician and Jane interrupts, making sure the doctor does not arrive.
* Psychological abuse. Blanche is kept socially isolated by Jane, and the phone – her only means of communication with the outside world – is taken away.
* Starvation and willful neglect. Blanch is deprived of food, and given meals that discourage her from eating (I won’t spoil the movie for those who want to watch).
* Physical restraint. Blanche is eventually tied to the trapeze bar while in her bed.
* Financial exploitation. Jane practices Blanche’s signature and signs checks in her sister’s name.
The psychological complexity of their relationship unfolds as the victim recognizes her sister’s disturbed mind and tries in vain to appeal to the reasonable aspects of her personality. Crawford presents an accurate portrayal of a person embarrassed, frustrated, and overwhelmed by her isolated, abusive situation. She desperately tries to get help while Jane descends into a world of fantasy, self-delusion, and violence. In doing so, Jane reveals several hallmarks of an abusive personality, not the least of which is the defense mechanism of denial, illustrated in scenes were Jane covers her ears when the topic of discussion turns to her own behavior.
Variations in the events featured in this film are unfortunately encountered in day-to-day medical practice, but may go unreported and unnoticed. In the film, the abuser was the victim’s sister, but abusers can have many roles including spouse, adult child, or unrelated caregiver. Although primary care providers are sometimes in the best position to diagnose and intervene, they may not be trained in warning signs or reporting mechanisms.
Early in my Geriatric career I wrote an article entitled Elder Neglect and Abuse: A Primer for Primary Care Physicians, the content of which is still relevant. I would recommend anyone interested in this topic to start by reading this article, then to view this film.
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Click Here to watch a key scene when Blanche confronts Jane about her neglect and abuse.
Related post:
Art, Dementia, and Elder Abuse: The Sad Story of Peter Max
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