Educational Webinar: Nutritional Advancements in Wound Management

Good afternoon. Thank you for joining us today. My name is Brandon Martin. I am the manager of customer engagement here at mckesson Medical Surgical and I'm so excited to welcome you to today's Clinical Connections presentation, Nutritional Advancements in wound care, presented by Nestle Health Science. Before we get started, I'd like to direct your attention to our disclaimer while you're reviewing that information. I will remind you that today's presentation is being recorded within a day or two. You can expect to receive a link to the recording and a copy of the presentation. If you have a question, feel free to enter it into the Q and A panel at the bottom left corner of your webinar window at any time and we will do our best to answer at the end of the presentation. Our speaker today is Mary Miranowski. Mary is a registered dietitian nutritionist and Medical Affairs manager at Nestle Health Science. She earned her Bachelor's of Science in Dietetics at the University of Minnesota and her Master's of Science in Nutrition Education at American University in Washington DC. Over the past 14 plus years, Mary has specialized in the clinical evidence surrounding the efficacy and effectiveness of perioperative immune nutrition protocols as part of enhanced recovery pathways. Since every surgery involves wound healing. Mary has also provided clinical support in the wound space over the last several years, she facilitates Nestle Nutrition Institute webinars as well as educational programs at Aspen and other society meetings, Mary. It is such a pleasure having you with us today. Thank you so much. Uh Without further ado I turn the floor over to you. Thank you, Brandon. Thank you so much. And um I can't uh tell you how glad I am to be here. I wanna thank mckesson Medical Surgical for this opportunity um to speak on nutrition and wounds and um I'll get things uh going uh straight away here. Um I also have a disclosure and Brandon also made this very clear that I am an employee of Nestle Health Science. So we wanna be completely transparent about that and I think you've already got this picture of me up. So you know who's speaking to you and here are our objectives for about the next I'd say 45 minutes. I'm hoping to have a good 15 minutes for questions. Um I want to describe for you um different risk factors around wounds, their prevalence and the associated health economics. And then I wanna share with you a screening and nutritional assessment tool for malnutrition and pressure injury risk because that has bearing on the review I will provide of the nutritional guidelines from the National Pressure Injury Advisory Panel. And then we'll take a little bit deeper dive in those nutrients that they advise for the malnourished patient with partial lymph, full thickness wounds by discussing the role of key nutrients uh necessary to support the closure of those wounds. So that's our program. Um My next slide is really a little bit of a historical one just so you can see where these National Pressure Injury uh advisory panel guidelines, how they've developed over time. Um If I look back to like 2000 or prior to 2009, really the best thing that we had to point to uh was a chapter in the Aspen core curriculum on wound healing. But then in 2009, the NP IP came out with some guidelines in conjunction with a panel in Europe. Then in 2014, those guidelines were refreshed and a Pan Pacific panel alliance joined. And in 2019, we truly have global guidelines for pressure injury. It's very, very cool because in the nutrition world, I don't know about in, in other health professions, but there's often a lot of variation from one country or area of the globe to the next. And we actually have consistency in this w space uh with just a lot of um agreement uh on the uh conclusions that they've drawn. So if you, if you go to the NP uh NPIAP website, you will find have the opportunity to get this little quick reference guide from them. And um in it's, it's really kind of the cliff notes version of the guidelines. And so I find it very, very helpful, they do a good job of identifying various different risk factors that have grades A or B. So um just by way of review such things such as diabetes, um fever, mobility issues, the presence of a stage one pressure injury, the amount of time in the or for perfusion or circulation. And then of course, malnutrition, which is where I'm gonna spend a lot of our time today. But these are the factors that increase the risk of a chronic wound to the greatest extent and have been identified by the um specific to pressure injury. And then just some background again on wound prevalence. Um This is from a resource I found from that was published in 2018. And um, it's really the best thing I've ever found on Medicare data about wounds. Um I wish there was something a little bit more up to date, but this has got some specificity that I think is, is very, um interesting in that if you've ever wondered from the standpoint of how many Medicare beneficiaries are affected by chronic wounds. It's almost 15% which equates at least in 2018 to 8.2 million patients. So it's, it's highly prevalent and the five most common causes of chronic wounds in addi or four most common causes. In addition to pressure injury are skin disorders, you'll see a case study later of an immune, um, an inflammatory uh, disease that causes some really, uh bad wounds, um, surgical wounds, trauma, wounds, and other forms of chronic ulcers. And when you look at the information I have here at the right of the side, you know, you can see that the units for all these dollars are all in the billions. There's no millions there. It's 32 billion total was the cost um as published in 2018, an annual cost for um just Medicare beneficiaries, that's not counting all the other people that are dealing with chronic wounds are with wounds. Half of that cost or about 15 billion was attributed to non healing wounds. And then if you're interested, the breakdown between um the treatment of these wounds in the outpatient setting or the inpatient setting shows about twice the um investment or you know, cost, I guess I should say in that outpatient space than an inpatient. So I hope you find that interesting if we look a little deeper at the inpatient space, um, pressure injury is one of those things that is defined as a hospital acquired condition. And if it is a stage three or four, you're probably aware that um there is no additional reimbursement for Medicare to cover that cost. Now, this is data from 2017 and believe it or not, this is the latest data on these um hospital acquired conditions. Um that's been summarized by uh the Department of Health and Human Services. And the reason is two fold. One is that or the reason it's kind of old data is two fold. One is that there is a 2 to 3 year lag on the reporting of this data by the A HR Q. And the other reason is that during the the COVID period, um the the reporting of this data was kind of put on a hiatus and so the most frequent they not frequent. But the most recent data that I can share with you is here today. And the last time that it was reported, the good news is is that we see a lot of blue arrows going down. And overall these hospital acquired conditions that hospitals are evaluated on by Medicare show a 13% improvement. Um the uh unfort overall. But unfortunately, here we have the purple arrow highlighted because um with pressure uh injury because the prevalence of that is one of the few things that has increased. So we definitely do have more to do in that space. And if we look just at, you know, one hospital acquired pressure injury, um that is, you know, of a significant stage, the um data will estimate a cost, an additional cost that will not be reimbursed of $14,000 per patient. And that equates to almost a 12 day um longer hospital length of stay or it's 11.6 days versus 4.9 days. So that's actually like around, you know, six or seven days. And then those patients that develop one of these in the hospital, they have a 23% higher chance of getting readmitted in 30 days, which of course is another quality measure. So, uh there's more suffice it to say there's more work to do in this space. And um it is associated with a significant amount of cost, not just in kind of a bottom or uh an actual number, but what it means to Medicare reimbursement in terms of the quality scores that a hospital gets. And um you know, I put this slide in the presentation back when COVID started and I've left it in. It's a great little tip sheet that's been provided by the npiap to um guide nurses that are working with patients that are extremely sick and are in prone positioning. And even though COVID-19 is thankfully not as prevalent as it was when this first came out. I think it, it's um it's, it's a great little tip sheet for any time you're working with a prone position, a patient in a prone position. And it just reminds uh um the nurses to try to make small shifts in body position and to reposition the head every couple of or 2 to 4 hours. And then to be really mindful about the ECMO catheter since that is a big catheter. It's a big cannula to um carefully secure it and off load, uh the pressure points asso that would otherwise be associated with it to help to decrease the risk of pressure injury. But let's move forward with the um the understanding that we let's, you know, think of this is an example of we've got a patient that has a pressure injury and um we need to kind of figure out what stage is it and what are the nutrition recommendations and that's what I wanna apply um with you next. So I do apologize that this is such a text heavy slide, but I have to tell you that the only way that the NPIAP would allow me to put these pictures and um these definitions in here is absolutely verbatim. So I'm gonna summarize in talking with you today. But um I do, I know it may be hard to read and apologize for that. So with, with stage one pressure injury, we essentially we don't have any breaks in the skin, we just have red, you know, areas um that are non blanch. Um in terms of the stage two pressure injury, then I think you can clearly compare pictures here with these buttocks that with the depress the stage two, you clearly have loss of, of a layer of skin. And so you're going down into the dermis layer because you've lost the uh epidermis. And then if we compare stages three and four, which are even, which are more serious pressure injuries, these are full thickness, um, pressure injuries where stage one, you're going down into the tissue um below the dermis. And with stage, excuse me, that's stage three. But with stage four, you may be getting down to things like the muscle, the tendons, the bone, you know, like in this situation and that's really the most severe. So with stage two, you have, um, you have um partial skin loss or partial thickness as they call it. And then with stages three and four, those are full thickness, um, pressure injuries. So knowing the stage of the pressure injury will become more, will become important as I go along because you'll see that um, the guideline around nutrition is written particularly for stages two and above. Ok. So from there, you know, we have this patient with a pressure injury, we've assessed what stage their, their wound is at the next thing to do in order to figure out the appropriate nutrition intervention is to do a nutrition screen and assessment. And this is very important because the guidelines are actually written specifically for the malnourished for the um, someone who's at risk of malnutrition. And so in order to figure that out, there are a lot of different tools that um dieticians use and they're definitely institution specific ones often used as well. I'm gonna spend a little time with you today around something called the mini nutrition assessment or the MN A. And um I want to share that with you because after I go over these basics, I'm gonna share some research because some, you know, research has been done in relationship to pressure injury risk with this assessment tool that I think you might find really interesting. So here's the MN A, it's a one sided sheet of paper or, you know, that's also available electronically and it basically is just six questions and um you know, food intake, weight loss, history, mobility, acute disease, neuropsych, psychological and body mass index. And then each of those answers to those six questions is gonna give you a point value. So 0 to 7 points would classify the patient as um malnourished 8 to 11 at risk of malnutrition. And both of those designations would qualify that patient with a stage two or greater wound for some specialized nutrition intervention. So here we have a study with the MN A and it's, it's pretty interesting. This is um a group of elderly in patients, but quite large over 400 of them. And three things happened here. Um One is that they all had their um arginine levels, their serum arginine, which is an amino acid level. It's, they all had that level checked in their blood. And then they were also divided into groups where one group was assessed using that mini nutrition assessment. And the other group received a combination of something called the subjective global assessment and the Braden scale and I'll say a little bit more about the Braden scale in a minute, but they wanted to see, you know, which of these three things was the best predictor about the patient's risk for pressure injury. And it turned out that if you had an MN A score less than eight, so you fell into that, um you know, malnourished category that was a stronger predictor of pressure injury development than the level of arginine in your plasma or the use of the uh SG A combined with the Braden scale. So, um I think it's really interesting that a simple, you know, six questions like that over, you know, in a fairly large population of um folks was quite um predictive of how at risk they were of developing a pressure injury. But I would be very remiss not to talk about the Braden scale when we talk about assessing risk of pressure injury because this is a well validated tool that is probably used by nurses in more settings than any other uh tool. And um it has a variety of different categories here that are being assessed, one of which is nutrition and primarily what's um assessed is their intake. But um just like with the MN A, you end up getting a point value for um each category here, sensory perception, moisture and so on. And then if a score of 12 or less is uh computed that patient would be at high risk. So here's where it kinda all comes together. I, I think I mentioned earlier that nutritional assessment is vital to following guideline recommendations. And um I've talked a lot about this guideline and I'm finally gonna show it to you. So see I'm giving just an example here that if you use the M and a score, um you're gonna come up with one of three possibilities, normal nutritional status being at risk of malnutrition or malnourished. Now, do notice that when it comes to the patients that are have normal nutritional status, our pressure injury guidelines do not give us any recommendations. And um that's why in the next slide, I'm gonna share some additional data with you. The, the um the NP IP guidelines are really specific to advising what to do that's special for the malnourished patient and the at risk of malnutrition patient. And this guideline down here guideline 4.1. 0, specifically applies to the malnourished patient that has a stage two or greater. So that could be a stage three, a stage four or an unstageable pressure injury. And what is recommended for those patients is that they be given um not only high calories and high protein but also supplemental arginine and um increased amounts of zinc and antioxidants as compared to standard uh formulas or oral supplements. So this applies to both oral supplements and in formulas. But in the case of the, well nourished patient. I was able to find a study here. Um Oh, wait, you know what, I'm gonna come back to that. I'm first gonna show you the um data that supports this guideline for the malnourished patients. So what we have are three randomized control trials that have been combined into a meta analysis. Um 273 patients total across these randomized control trials. And um these patients all had stage two or greater pressure injury. And the trials looked at um things from the in terms of the rate of healing in relationship to the size of the injuries. And they had two groups in each of the studies. One received special specialized nutrition that was high calorie, high protein, you know, had supplemental arginine and increased amounts of zinc and antioxidants. And that was compared with a um standard diet that provided primarily calories and protein. And I will tell you of these three randomized control trials. The largest one was like 200 patients and they had iso nitrogenous iso chloric controls, which means they could really get at the incremental benefit of the um additional components that are listed here in this bullet point. And they found that the, the group that received the specialized formulas, whether it was oral along with the regular diet or tube feeding, um that they had significantly reduced surface area, almost 16% reduced surface area uh in relationship to the specialized nutrition. Um a higher proportion had a greater than 40% reduction in size at eight weeks. And in conclusion, the specialized nutrition was shown through these randomized controlled trials to be preferable for partial and full thickness pressure, ulcer healing. Ok. And um uh what I wanna do next is then take a little bit of a deeper dive into um each of those components. So in terms of the very first one on the list, you're probably not surprised it's protein. Um protein is so, so important because it's involved in all four stages of wound healing. Um Even the stage where you know, if it's a traumatic wound and you need the, the blood to clot. The platelet function is um going to be related to the protein. Um nurture of that person. Uh Also you have, you know, leukocyte formation that has to do with the inflammatory stage of of wound healing. And then the proliferative stage where you're trying to lay down collagen, the fibroblast there really lay the road map for collagen synthesis. So, you know, ambulatory, healthy people walking around need about a gram of protein per day, per kilogram per day. And so these needs are 25 to 50% higher than that if you're trying to heal a wound. Um in terms of calories, when they say high in calories, they mean like 30 to 35 calories per kilo. On average, you wanna make sure you have enough to provide for the increased energy needs of healing. And then you want to make sure that you have enough calories so that you can spare this protein for synthesis and all the other functions that you see listed there. And then the NPIAP guidelines, they don't, they don't um comment specifically on fluid needs. But um fluid is just so important to um the perfusion of tissue and the oxygenation of tissue that I wanted to make sure that I included that. So, a good rule of thumb on how much fluid someone needs per day, free fluid that is free water would be 1 mL per calorie per day. All right. So I'm gonna move now from protein and calories and uh water to arginine and arginine like protein has a great number of functions when it comes to um assisting the body with wound healing. I mean, after all, it is a bu it's an amino acid, it's a building block of protein. Um It, it itself is a precursor to um collagen production. It supports the immune response helps with perfusion and oxygenation. And um also promotes amino acid transport into the tissue and even stimulates insulin, which we know is the hormone most important for anabolism or for you know, the creation of new tissue. So, uh the, the data will show that between 4.5 to 9 g a day of um supplemental arginine to the malnourished patient with a partial or full thickness wound um is helpful and you typically that's not hard to achieve with the specialized oral supplement. Um A tube feeding in general is gonna, you know, that has supplemental arginine will provide 7 to 12 g per 1000 calories. So that's also within the range of what's been studied. But this is a very important thing here. This little um this third bullet is that when they talk about the need to supplement our needs. Um, at least in these malnourished patients with partial and full thickness wounds. It's, it's it's effective and efficacious because it was studied in concert with additional calories, additional protein, higher amounts of zinc and antioxidants. And so it's, it's part of a full solution as opposed to a piecemeal supplement. So I hope that's helpful um to think about it that way. And for those of you who are visual learners, um this just kind of shows you um why arginine as an immuno nutrient is so important to wound healing. Um Here, it's, there are really two enzymes, one to the left and one to the right here that act upon our domain. And one is endothelial nitric oxide. And this endothelial nitric oxide that's produced amongst all of the um like the capillaries. Your endothelium is so um important because that nitric oxide helps to increase oxygenation and micro perfusion. And then on the other side of things you have this Argena enzyme that helps to produce hydroxyproline leading to collagen. So you can see how those two things working together are so important for wounds and then not to be outdone by this in the middle. Because this is the immune part of the equation. Our T cells are so important for us in um avoiding infection. And their main fuel source, one of their most preferred preferred fuels is arginine. And so if you can make sure that the arginine status is there for the T cell function, you can decrease that risk of infection. And any time you keep an infection out of a wound, you're gonna have a wound that can close sooner than later. But I mentioned a little earlier on that the guideline, the guideline really doesn't address the well nourished patient. And I do have this data here in spinal cord injury. Um 18 spinal cord injury patients um across these 18, they had 30 pressure injuries in this stage, 2 to 4 range. However, 94% of them were well nourished according to an assessment tool. Um And so what they did is they supplemented them, not with all the ingredients that are in the guideline for the malnourished patient, but they gave them a product that had um arginine combined with vitamin C and vitamin E. So some arginine and some antioxidants and then compared the time to healing of these pressure injuries with a historical control, with a comparable amount of pressure injuries of the same magnitude that it did not receive the intervention. And so the blue bars are the um historical controls and the orange are the intervention group. And you can see here that um the study group had a two times faster time to healing 10 weeks versus like 21 weeks on average. And that whether it was a stage 23 or four type of injury, um they had a faster healing rate across all stages. So, um I, I do what this is an important little piece of evidence to consider and I'll and I'll bring it back up when we get to the algorithm that um was applied in the case studies that I'm gonna share. But we'll move on now from arginine because the guideline also talks about providing increased amounts of zinc. Um zinc is amazing, you know, it's involved with 200 different enzymes that are involved in wound healing. And when you think about fibroblast proliferation, collagen synthesis and epithelialization, that's three out of four of the phases of wound healing where zinc is important. And so it's um there are definitely oral nutritional supplements that do have increased amounts of zinc and in the person that's able to eat, this is um a big uh area of when you, when we're talking to them about high protein foods. Um we also want to really stress some of those high protein foods in particular because of their high zinc content. And then other antioxidants of course, are also called out besides zinc, vitamin C and E um vitamin C has multiple um functions here that are very, very important uh because it is an antioxidant, of course, it helps reduce oxidative damage. But then it's also required to convert prolene and lysine into collagen. So that's very, very important. And the value of giving these vitamins, of course is um has been studied when they are provided within the scope of an oral nutritional supplement or a tube feeding. That's, that's why I discussed those randomized control trials with you at the beginning because I really wanted you to see that the efficacy is when a formula or an oral nutritional supplement is provided that touches all these bases. And then lastly, some micro nutrients that were shown to be provided in higher quantity in those randomized control tiles, selenium copper and manganese, all of them um antioxidants that help to reduce oxidative damage. So uh just one little last word about these phases of wound healing uh is more of a comment from kind of a 30,000 ft view. Uh is to just notice that as you go through the different phases, you know, they go from really a short phase here with the hemostasis and inflammatory period to a longer phase with the proliferative um activity when the collagen is being lit down and then really the remodeling of of even a closed wound may be up to two years because you're um strengthening the bonds between um for that college and network to um strengthen the wound. And so that tends to be a really long uh can be a long phase of uh healing, but it nutrition is very, very important throughout all those phases. So next, we will, I'm gonna take you to this algorithm and I had the honor of consulting with a wound physician on this who really wanted to come up with an algorithm that she could use in her clinic that uh would address partial and full sickness wounds. Now, there's one big leap of faith here that you definitely need to be aware of because the guidelines, the guidelines that I applied or that I've applied in this presentation that I've talked about are really specific to pressure injuries. Yes, they're for partial and full sickness, pressure injury. But this p this wound physician that I was working with, she wanted to address not only pressure injury but other partial and full thickness wounds. So the the best wound guidelines that we have is this one for pressure injury. And in this algorithm, it's being applied to other partial and full thickness wounds. So I just wanna be completely transparent about that. Um But of course, it starts with figuring out whether you have that malnourished or at risk patient or a well nourished patient. So that's why you need the screening tool if we go down that well, nourished side. Um Her algorithm points to an L arginine supplement very similar to what was used with those spinal cord injury patients. But the other side of the algorithm is the pressure injury guidelines for the malnourished patients. And there you can see that if there is no renal disease, then a very high protein immuno nutrition, oral nutritional supplement that provides L Argen need and additional calories that is also carbohydrate controlled. Um because so many of this wound physicians patients and I'm sure yours too have diabetes. So that's what she's prescribing there. And if there is renal involvement and they're not on dialysis, uh the recommendation here is to consult the nephrologist just because there's, you know, quite a difference in someone with stage two, renal failure versus someone who's end stage. And, you know, it's, it's best to uh collaborate uh with someone that can help you determine the best course of action. Now, if they are on dialysis, of course, there are a lot of calorically dense oral nutritional supplements that help to provide protein as well while providing electrolyte control. So that's kind of, you know, that's a good place to start with those folks. Uh One thing for sure that uh this wound physician does is give everyone protein source education as long as of course they're able to eat and the handouts that she uses. Um Oh, yes, I see here. It's been 30 days. And so this is a algorithm that she puts in place for a minimum of 30 days she expects to have to use it for, um, you know, 8 to 12 weeks, uh, at a time because depending on the severity of the wound, it just takes that long to get, get these closed. But you can see in the next slide that, um, these are the handouts she uses in order to teach them about what protein is. And to emphasize choosing these high protein foods at every meal. So to kind of round things up today, I have two case studies of some severe chronic wounds that this wound physician um treated um at her practice using that algorithm. And both of these resulted in posters at the Wound Healing Society meeting that took place in Phoenix last April. So it's really fun to get to, to tell you about these um cases. Some at fir first, I'm gonna just go over some similarities in these two cases. Uh Both these folks had full thickness wounds that were limb threatening and both were nutritionally provided nutritional intervention because the idea was that surgery was coming up and they really wanted to do everything they could to try to salvage in both cases. A lower leg. Um Both these cases, as you'll see from their MN A scores were malnourished and I've already mentioned this about pre surgical nutrition intervention. Um Both of them received the education about high protein foods and then um the physician taste tested the high protein immuno nutrition with both of these patients and asked them to commit to consuming two servings of the, the, the supplement a day um for 30 days. And so this was really important because she had a limited amount of samples and she really wanted to make sure that the um they would be utilized. And you know, she also chose some very motivated patients that wanted to do everything they could to prevent losing their leg. So all in all each day from these supplements, the patients receive 400 calories, 36 g of protein and an additional 8.4 g of L arginine. And they were provided with a one month supply of these samples and also a record keeper with some flavoring tips and such and I'll show you in a second. Um The compliance was quite good and the doctor confirmed it each time the patients came in, she asked them to bring this record keeper with them and she expected them to indicate as they went along out of the two cartons, they were supposed to drink each day. How much had they drank? How many cartons did they achieve for the week? And there this little sheet hung on their fridges and also provided some tips um for flavoring. And so this was a great tool to use and you know, really, I think, encouraged accountability. So this is the first case, this is what the poster looked like at the Wound Healing Society. Um I'll go into a little bit more detail so you can learn more about this gentleman. He was a 57 year old white male and um he had lost 15% of his usual body weight in the last 30 days. His mobility was, you know, of course, quite hampered with this bad wound on his lower um shin. Um, he had a uh mini nutrition assessment score of seven. So he was malnourished and had some um muscle wasting that you can see there. And that was the initial wound. Let's see, in terms of the size of this wound, you can see that the tendon is exposed, but it was 34 cubic centimeters. And the cause of it was pyoderma gangrenosum and that was biopsy confirmed. And that's one of those inflammatory immune conditions that I mentioned as being one of the five top sorts of wounds or cate fits into one of those categories of common wounds. The um the best treatment for it is high dose oral predniSONE, which I'm sure many of you on the call know is another risk factor for wound development. So using those steroids actually would potentially make it harder for someone to heal. Um But he started on this one month immuno nutrition program for that algorithm and he took that for a month and then he also had a month of high protein, oral nutritional supplements that he took for another month. So he was really preparing for this surgery for like two months. And here you see the initial consultation um in the wound clinic and then here you actually the next appointment, it actually, it looks big. It's bigger, obviously because they, they debrided tissue. But I hope you can see how this is after about two weeks of um, the supplementation that he's got like this light pink area of granulation tissue coming through here. So that was quite encouraging for everyone. And then, um they also noted that a month, you know, at the end of that 1st 30 days of supplementation, he had put on £14 which was fantastic, improved his nutritional status. And then so two months later, you know, since after the initial consultation, he went through surgery and you can see that they removed the tendon and that in order to close this uh really um dramatic wound, they had to use a skin flab and they were concerned that once they got the skin flap on there, would the pyoderma gangrenosum come back and wreck the flap? And um it did not, he continued on the predniSONE. And um think what you can see here is really an amazingly well healed wound three months later, despite the high steroid dose dose. And, you know, a nice little side note is that this guy is a pro he was a professional bass fisherman. And so whenever I talk about this case study, I always imagine that he's been back out in his boat catching fish and uh just makes me feel good. And then our, our second case is this um poster also presented at the uh Wound Healing Society. And I'll take you through that. This is a young woman. She was only 34 years old and she ended up getting septic and in the hospital in the IC U for three weeks during that time, she developed, of course, you know, she had low uh hypertension and um from being so sick, she developed D IC the disseminated intravascular coagulopathy. And so she was essentially, you know, throwing clots to smaller blood vessels and um causing foot ischemia. And from those blood clots, essentially, you know, the tissue was cut off from an oxygen supply. And so three months after getting out of the hospital, she um came to the wound clinic, she had a £15 weight loss, an MN A score indicating malnutrition and then just some really bad um ulcerations of her, the left plantar and lateral foot. And so the other guy's total area um um of his w his wound was 34 centimeters, but when you added hers together, it was 70 centimeters um for one of those areas, um and square centime or um cub centimeters. So it's, they're quite, quite big wound. Um They also found that from throwing these clots, um her perfusion pressure to the uh lateral foot on the left side was insufficient for healing And so this did not bode well for saving her leg because um you know, there was a difficulty in trying a difficulty that they were aware of in trying to get adequate oxygen to that wound on the lateral side. And so um the physician started in with one month of immuno nutrition according to the algorithm. And then you can see here and here was that initial consultation and you can also see the planter, the heel, you know, just so much necrotic tissue here. Um Two weeks in everyone was really, really excited because she has lots of pink granulation tissue here and some even around the heel where they had debrided it. Um And that was despite what they knew about um the oxygen being impaired and getting to the wound. Um a month later, she had surgery, an extensive foot resection. Um they took out infected bone, they removed ischemic tissue and stitched everything up. And about three months later, she was in a place where this was healed and she could do some intensive physical therapy to try to restore her ambulation because excuse me, this is a lady, you know, she's in her thirties. She had a six year old daughter and um you know, it's just was trying to do everything not to lose, lose the leg. And I'm very happy to, to say that this patient um as the result of, you know, all of the different cares that she received and, and largely her own motivation, uh, made it to being able to wear a brace and be completely mobile again. And I know that she's since been to Disney World with her family. So it's, it's just, it's a wonderful thing to be able to see that. And, um, just in conclusion here before we open it up for questions, um, I hope that I've made the, the points that the pressure injuries and other full thickness and partial thickness wounds are costly. And unfortunately, on the increase, um, in order to clap, you know, provide the proper nutrition intervention, it's essential to use some type of a tool to identify it. And um because that will really help you to know if the patient needs the additional calories and protein along with the other specialized ingredients or if you might, if they are well nourished and they're um otherwise getting enough protein and calories from their diet, then it may be possible just to do some supplementation with arginine and um, antioxidants. Um I also hope I've made it clear that um, immuno nutrition with L arginine, even though it's been used a lot in surgery and surgical wounds has a role in chronic wounds. I think that's demonstrated by these case studies. And um, just try to, um, remember that the way that the guideline's written is to consider the contents of zinc and other antioxidants, the vitamin C, the vitamin E and those other micronutrients look at what those quantities are as part of oral supplements and tube feedings that you're considering recommending because the more of those you can get um at appropriate levels within a single product. Um But really the easier it is to intervene. So with that, I um I will turn it back to Brandon and um I'm really excited to take some of your questions. Thank you so much Mary. Uh and just a reminder to our audience, if you have a question for Mary, uh in the lower left hand corner of your uh webinar screen there, uh you will not only see a window for adding your questions but also uh a box for downloading um PDF versions of today's presentation. I know we've had a few questions about slides and things like that. So, uh let's see. Our first question uh is uh related to L arginine supplementation. We've had a couple of questions. I'm just gonna kind of put them together here. Um So basically how much L arginine supplementation is needed and for how long, particularly uh if you have an indi an individual who cannot meet their daily requirements of calories and protein. So, where are you? OK, great. That's a great question. And um the amount is in, in per, per the, the data that I've shared. It's between 4.5 and 9 g a day of supplemental arginine. And um with the situation of a partial or full sickness wound I think you should expect to need to use it for in the neighborhood of 8 to 12 weeks. But II I think it's really, you know, when I showed you those case studies in the algorithm, those were 30 days because it, it really is um important that you see some kind of improvement or change in that first month um to, to kind of carry on with it a little bit blindly and not re evaluate for a period. As long as two months seems too much. You wanna see something within 23 weeks that starts to look like some improvement, something encouraging. I hope, I hope that answers that brandy. Uh Now does that change? Um Depending on the the patient, we have a question here um for someone who a patient who is considered obese, uh how are calorie and protein requirements estimated there? Yeah, that is a great question. Uh The Npiap guideline does not address that. Um It just kind of gives these average ranges and um, you know, the Aspen, the American Society of Parenteral and Enteral Nutrition. The guidelines that were published there in 2016 address some calories per kilo recommendations dependent on BM I level. And um that is one place you could look to if you want to try to come up with. Um I think they give two different methods where one uses an adjusted ideal body weight and one uses or no one uses actual body weight. And the other one uses um idea uh ideal body weight. And the other one uses actual, but, you know, those are critically ill patients. And so it's kind of a select audience that, that, that research is reflective of. Um I do think that in general it's not realistic to think that someone can heal a significant wound and, and lose weight at the same time. So you, you have to approach it somewhat with trial and error. You know, you make your best estimate based on how they've been eating and what their weight history is and you want to make sure that you're providing a little bit more than that because, you know, to cover the energy needs of the wound. But I think it's really worthwhile to completely concentrate on getting that wound healed regardless of um overweight or obesity and um addressing any weight loss issues after that. Excellent. Um uh There, here's an interesting question. Uh So is LR Janine, um does that have any uh uh prescription medication interaction? Um uh does it, does it need a prescription itself? Uh L Argen is an amino acid and so it's a su uh you know, it falls within a dietary supplement kind of re uh regulatory environment. Um when it's added to a nutritional formula or an oral nutritional supplement, it's added as, as part of what is classified as a medical food. So it kind of sits in between the drug and the, the food you buy at the grocery store space. Um You do not need a prescription to you, you know, purchase the oral nutritional supplements that do contain it, but the label does specifically say that it should be used under a doctor's supervision. And so I think it's important to have discussions with the doctor as it relates to use of arginine and a patient's um individual situation because there are just a myriad of medications out there and of course health conditions and you really want someone to advise, advise you appropriately and individually, someone that can really have the view of the whole medical record. Sure. Sure. Uh Now, in your recent experience, have you seen any um issues with um uh related to um the continued supply chain issues? Um As far as um having available arginine or, or some of the other things mentioned? Yeah, I mean, personally, I am aware that um a lot of of arginine supplementation or arginine supplement products uh um have been in short supply and um I my understanding is that everything is being done to um replenish and, and make that supply healthy. But I think I feel for uh I feel for the clinicians and for the patients because it's been hard to, to um sometimes get your hands on what is needed. Certainly. Um uh and then just related to other uh supplements um in the guidelines to do guidelines, address giving supplements like vitamin C and zinc separate from the amounts that occur in a source of calories and protein. So I feel like I'm gonna jump in a little bit there. Yeah. No, no. It's a great question. And I know that a lot of times those items are supplemented separately and have been done as such for quite a while. And so I love giving this talk because it really helps to show that the best science we have is not for individual supplementation of those items, but rather to look for formulas and oral supplements that tick all these boxes. And so, um I mean, I think that, you know, zinc supplementation, vitamin C supplementation with wounds, it's been going on a long time and I think it will continue to. But um if you look into those randomized control trials and you look at the differences between those oral supplements and those tube feedings that were specialized versus in the control group, you will see that the amounts of all these various nutrients that were different are not always huge, but it implies to me the complexity of the nutrition that's needed across these different stages of wound healing and the importance of getting all those components um together and Right. Sure. Yeah. So uh we're, we're getting very close to the end of the hour, but I, I do wanna try to squeeze in this one last question. It, it looks interesting. Is there name sound uh occurring naturally in any, um, food or vegetables or things like that. Arg, does arginine occur naturally? Yes. Uh, ok. You know. Yes, it does. Um, one of the foods that's very high in arginine are peanuts, believe it or not. But when you start to look at how many peanuts someone would have to eat that might not have the greatest appetite to get, like, at least 4 g of arginine a day. It's tough because most of us get about a total of 4 g from everything we eat in a day. And then that's just a baseline requirement. We're not actually supplementing over and above that because you know, for a wound. But um the other thing I will say is in just in interesting facts about foods is that one of the precursors to arginine is cle and the body can convert cle to arginine in the kidney if it's got good kidney function and a food that is exceptionally high in cline is watermelon, believe it or not. So, um I hope that's a fun fact that uh you'll find of interest. Well, it's a fun fact for me because I snack on peanuts pretty much all day and I love watermelon. So it's good to know. Well, uh Mary, thank you so much. We are at the end of the hour. I wanna be respectful of everyone's time. Uh So I wanna go ahead and thank you all for uh taking the time to join us. Today uh For a full list of our upcoming events. Uh Please do visit us at M MS dot McKesson dot com slash educational dash webinars. You can register for a future webinar share with your colleagues or sign up to receive regular updates on our webinar schedule. Uh If you um for all of you that attended today, uh you will receive a link to the recording of this presentation. Um Mary, thank you again so much for joining us today, sharing your time and ex expertise. I really appreciate it. Thank you, Brandon. Thank you to everyone on the call. Thank you. Have a great day, everyone.