This document discusses a 9 year clinical experience using Kelo-cote silicone gel for wound healing. It provides an overview of different types of wounds and factors that influence healing. Choices for topical therapy are outlined for both dry and wet wounds. The principles and methods of wound bed preparation including debridement are described. Considerations for autolytic, enzymatic, and bacterial balance in wound healing are also covered.
Mesotherapy in Dermatology , by Dr. Amr Ismail MD , Consultant Dermatologist.
Mesotherapy in Depth
Non-prescrition treatment modatlity.
Non Conventional Safe Asethetic Procedure.
Should rely on EBM.
To achieve good results.
Depend on Used Meostherapy Materials.
Classification of Meostherapy Materials
A. Principals :
Ingredients that have been used orally or topically or injectable
for treatment of each indication/condition.
Ingredients with high grade of evidence in treatment of each indication/condition.
Ingredients that have been FDA Approved for treatment of each indication/condition.
B. Complentary :
Ingredients that have been claimed to improve the condition.
Ideal Mesotherapy Materials / Cocktails :
To achieve good results 80- 90 % , your used cocktails should
contain 2 -3 principals.
THE ART OF NON SURGICAL SKIN REJUVENATION. MULTIPLE APPROACHESOsama Moawad
The sudden explosion in recent years of nonsurgical
rejuvenative techniques is patient-driven. The modern
patient, man or woman, desires quick, safe and pre-
dictable nonsurgical techniques that will confer some
form of facial rejuvenation and at the same time allow
them to get back to work or their social lives with a
minimum of downtime. By that is meant a modicum
of bruising and swelling for 2–3 days (i.e., over a week-
end) and not the 2–4 weeks of downtime and scars
that often accompany open surgical techniques.
Whilst nonsurgical techniques are not a substitute
for traditional rejuvenative surgery, the combination
of several nonsurgical tools and procedures has be-
come a powerful adjunct to or a temporizing substi-
tute for open surgery.
Mesotherapy is the procedure to injection of plant, extracts, vitamins, enzymes, hormones, and rejuvenate the skin.
Series of injection allegedly target fat cell to induce lypolysis..
This rejuvenate and nourish skin, stimulates production of collagen and elastin.
Call us regarding Facial aesthetic Treatment:-
Dr. Rajat Sachdeva
+919818894041,01142464041
drrajatsachdeva@gmail.com
Follow us here:-
• Google+ link: https://goo.gl/vqAmvr
• Facebook link: https://goo.gl/tui98A
• Youtube link: https://goo.gl/mk7jfm
• Linkedin link: https://goo.gl/PrPgpB
• Slideshare link : http://goo.gl/0HY6ep
• Twitter Page : https://goo.gl/tohkcI
• Instagram page : https://goo.gl/OOGVig
Learn more:-
• www.sachdevadentalcare.com
• www.dentalclinicindelhi.com
• www.dentalimplantindia.co.in
• www.dentalcoursesdelhi.com
• www.facialaestheticsdelhi.com
Mesotherapy in Dermatology , by Dr. Amr Ismail MD , Consultant Dermatologist.
Mesotherapy in Depth
Non-prescrition treatment modatlity.
Non Conventional Safe Asethetic Procedure.
Should rely on EBM.
To achieve good results.
Depend on Used Meostherapy Materials.
Classification of Meostherapy Materials
A. Principals :
Ingredients that have been used orally or topically or injectable
for treatment of each indication/condition.
Ingredients with high grade of evidence in treatment of each indication/condition.
Ingredients that have been FDA Approved for treatment of each indication/condition.
B. Complentary :
Ingredients that have been claimed to improve the condition.
Ideal Mesotherapy Materials / Cocktails :
To achieve good results 80- 90 % , your used cocktails should
contain 2 -3 principals.
THE ART OF NON SURGICAL SKIN REJUVENATION. MULTIPLE APPROACHESOsama Moawad
The sudden explosion in recent years of nonsurgical
rejuvenative techniques is patient-driven. The modern
patient, man or woman, desires quick, safe and pre-
dictable nonsurgical techniques that will confer some
form of facial rejuvenation and at the same time allow
them to get back to work or their social lives with a
minimum of downtime. By that is meant a modicum
of bruising and swelling for 2–3 days (i.e., over a week-
end) and not the 2–4 weeks of downtime and scars
that often accompany open surgical techniques.
Whilst nonsurgical techniques are not a substitute
for traditional rejuvenative surgery, the combination
of several nonsurgical tools and procedures has be-
come a powerful adjunct to or a temporizing substi-
tute for open surgery.
Mesotherapy is the procedure to injection of plant, extracts, vitamins, enzymes, hormones, and rejuvenate the skin.
Series of injection allegedly target fat cell to induce lypolysis..
This rejuvenate and nourish skin, stimulates production of collagen and elastin.
Call us regarding Facial aesthetic Treatment:-
Dr. Rajat Sachdeva
+919818894041,01142464041
drrajatsachdeva@gmail.com
Follow us here:-
• Google+ link: https://goo.gl/vqAmvr
• Facebook link: https://goo.gl/tui98A
• Youtube link: https://goo.gl/mk7jfm
• Linkedin link: https://goo.gl/PrPgpB
• Slideshare link : http://goo.gl/0HY6ep
• Twitter Page : https://goo.gl/tohkcI
• Instagram page : https://goo.gl/OOGVig
Learn more:-
• www.sachdevadentalcare.com
• www.dentalclinicindelhi.com
• www.dentalimplantindia.co.in
• www.dentalcoursesdelhi.com
• www.facialaestheticsdelhi.com
As age advances, Connective Tissue becomes thinner, collagen and elastin breakdown and results into wrinkles.
PDO is Thread Lift Therapy, where thread will form an integral support structure for tissue of face due to Collagen Synthesis.
MONO; COG: Crew Threads are three types of PDO thread.
COG Thread are designed to anchor more firmly within the skin as it consist of barbs.
COGS provide immediate face lifting effect, helps in producing brighter skin tone and rejuvenate the skin.
Call us regarding Facial aesthetic :-
Dr. Rajat Sachdeva
+919818894041,01142464041
drrajatsachdeva@gmail.com
Follow us here:-
• Google+ link: https://goo.gl/vqAmvr
• Facebook link: https://goo.gl/tui98A
• Youtube link: https://goo.gl/mk7jfm
• Linkedin link: https://goo.gl/PrPgpB
• Slideshare link : http://goo.gl/0HY6ep
• Twitter Page : https://goo.gl/tohkcI
• Instagram page : https://goo.gl/OOGVig
Learn more:-
• www.sachdevadentalcare.com
• www.dentalclinicindelhi.com
• www.dentalimplantindia.co.in
• www.dentalcoursesdelhi.com
• www.facialaestheticsdelhi.com
PRP is widely known in the medical field for promoting skin care benefits. One can get rid of dullness, discoloration and aging in an effective way with PRP Treatment For Face. The procedure encourages healthy tissue growth using patients own blood platelets. This active rejuvenating procedure allows the body to produce healthy skin and support tissue.Focusing on the hottest trend that helps to regain the beauty of skin and body for both men and women can choose.PRP injections for face help to repair the cells and the damage caused by aging and environmental factors. The PRP treatment is also an effective treatment for hair loss. The process itself is safe, fast and promotes follicle enlargement. Platelet Rich Plasma Injections (PRP Injections) can help restore a youthful appearance to the skin.
Microneedling, A brief review by Dr. Mohammad Baghaei Mohammad Baghaei
Microneedling is a physical method that induces modification in the SC mechanically and produces micron-sized channels or pores in the skin. This characteristic of the microneedling technique provides delivery of various molecules or therapeutic substances, including proteins, which would usually not penetrate ...
'Biomimetic Molecules and their application to Aesthetic Medicine' Dr. Patrick J. Treacy
Lecture on Biomimetic Molecules and their application to Cosmetic Medicine given by Dr. Patrick Treacy on behalf of Dermagenica in London in 2012.
Nature provides inspiration for designing materials and systems, which derive their functions from highly organized structures. The ordered organization of hierarchical structures in organisms begins via the molecular recognition of inorganics by proteins that control interactions and followed by the highly efficient self-assembly across scales.Following the molecular biological principle, proteins could also be used in controlling materials formation in practical engineering via self-assembled, hybrid, functional materials structures. In molecular biomimetics, material-specific peptides could be the key in the molecular engineering of biology-inspired materials.
If you want plumper and fuller lip,lip fillers are for you.They are bio compatible injectable collagen which are injected in your lips to give it a more fuller and enhanced look.They are basically hyaluronic acid which has volumizing effect.Your lips might look swollen for a week after the treatment but these symptoms subside eventually.Juvederm and Restylane are the commonly used lip fillers that are approved by FDA.You will likely need some follow up sessions after 6 months or even a year.The whole treatment takes upto an hour and effect usually shows after 15 days.
Dr Sachdeva's Dental clinic and Facial aesthetic centre is one of the leading clinics performing lip fillers and lip augmentation procedures in Delhi. So hurry up and come book an appointment with us at Dr.Sachdeva’s Dental Institute, Ashok Vihar, Delhi which has state of the art clinic and all the latest and advanced equipments.
To book an appointment contact:
Dr. Rajat Sachdeva
Director & Mentor
Dr Sachdeva’s Dental Aesthetic And Implant Institute
I 101, Ashok Vihar Phase 1, Delhi- 110052
Contact us at
Phone : +919818894041,01142464041
Our Websites:
www.sachdevadentalcare.com
www.dentalimplantindia.co.in
www.dentalclinicindelhi.com
www.dentalcoursesdelhi.com
Facebook- dentalcoursesdelhi
Youtube- drrajatsachdeva
Linkedin- drrajatsachdeva
Slideshare- Dr Rajat Sachdeva
Twitter Page- drrajatsachdeva
Instagram page- surgicalmasterrajat
Mesotherapy treatment is frequently used to solve many problems regarding health issues. In this treatment injections are adminstrated into the supposed part of the body.
http://www.informationonmesotherapy.com
MIcro Lift Threads : Latest Revelation in Face and Body Lift http://spectroni...Spectronix Group
Micro Thread Lift (Reandne) is the most Novel Thread Procedure having lots of advantages over Previous Threads based Procedure.
The procedure is performed under Local Anesthetic Cream and has the following advantages for Face Contouring, Neck Lift, Wrinkle Treatment, Breast firming and lifting, Hip up, Saddle Bags and abdomen lift.
The procedure is SAFE, Non Surgical, Shorter Procedure Time, Use of only topical Anesthesia, No downtime, Immediate Effect (3-4 days after procedure). http://spectronixglobal.com/
This presentation explains the various correction and caveats related to using dermal fillers. The intended audience is medical professionals. Dr. Scheiner is a Plastic Surgeon and the President of ASAMP (The American Society of Aesthetic Medical Professionals). ASAMP certifies medical professionals for cosmetic injection procedures (Botox; Dermal Fillers) and is accredited through the American Academy of Family Physicians (up to 14 CME credits).
Botox Injection is a commercially successful non-surgical cosmetic procedure, to gets rid of the deep wrinkles in the skin between eyebrows, of the forehead, of the corner of eyes. Effective for 3 - 4 months, and the procedure is repetitive in nature.
Micro Needling is a minimally invasive procedure that has little downtime, is safe on all skin types and will leave skin looking smoother and younger.
Micro Needling stimulates the bodies natural healing and will rejuvenate the skin and can reduce:
Lines & Wrinkles
Sun Damage
Skin Laxity
Acne Scars
Stretch Marks
Hair Loss and more
www.MDNeedlePen.com
As age advances, Connective Tissue becomes thinner, collagen and elastin breakdown and results into wrinkles.
PDO is Thread Lift Therapy, where thread will form an integral support structure for tissue of face due to Collagen Synthesis.
MONO; COG: Crew Threads are three types of PDO thread.
COG Thread are designed to anchor more firmly within the skin as it consist of barbs.
COGS provide immediate face lifting effect, helps in producing brighter skin tone and rejuvenate the skin.
Call us regarding Facial aesthetic :-
Dr. Rajat Sachdeva
+919818894041,01142464041
drrajatsachdeva@gmail.com
Follow us here:-
• Google+ link: https://goo.gl/vqAmvr
• Facebook link: https://goo.gl/tui98A
• Youtube link: https://goo.gl/mk7jfm
• Linkedin link: https://goo.gl/PrPgpB
• Slideshare link : http://goo.gl/0HY6ep
• Twitter Page : https://goo.gl/tohkcI
• Instagram page : https://goo.gl/OOGVig
Learn more:-
• www.sachdevadentalcare.com
• www.dentalclinicindelhi.com
• www.dentalimplantindia.co.in
• www.dentalcoursesdelhi.com
• www.facialaestheticsdelhi.com
PRP is widely known in the medical field for promoting skin care benefits. One can get rid of dullness, discoloration and aging in an effective way with PRP Treatment For Face. The procedure encourages healthy tissue growth using patients own blood platelets. This active rejuvenating procedure allows the body to produce healthy skin and support tissue.Focusing on the hottest trend that helps to regain the beauty of skin and body for both men and women can choose.PRP injections for face help to repair the cells and the damage caused by aging and environmental factors. The PRP treatment is also an effective treatment for hair loss. The process itself is safe, fast and promotes follicle enlargement. Platelet Rich Plasma Injections (PRP Injections) can help restore a youthful appearance to the skin.
Microneedling, A brief review by Dr. Mohammad Baghaei Mohammad Baghaei
Microneedling is a physical method that induces modification in the SC mechanically and produces micron-sized channels or pores in the skin. This characteristic of the microneedling technique provides delivery of various molecules or therapeutic substances, including proteins, which would usually not penetrate ...
'Biomimetic Molecules and their application to Aesthetic Medicine' Dr. Patrick J. Treacy
Lecture on Biomimetic Molecules and their application to Cosmetic Medicine given by Dr. Patrick Treacy on behalf of Dermagenica in London in 2012.
Nature provides inspiration for designing materials and systems, which derive their functions from highly organized structures. The ordered organization of hierarchical structures in organisms begins via the molecular recognition of inorganics by proteins that control interactions and followed by the highly efficient self-assembly across scales.Following the molecular biological principle, proteins could also be used in controlling materials formation in practical engineering via self-assembled, hybrid, functional materials structures. In molecular biomimetics, material-specific peptides could be the key in the molecular engineering of biology-inspired materials.
If you want plumper and fuller lip,lip fillers are for you.They are bio compatible injectable collagen which are injected in your lips to give it a more fuller and enhanced look.They are basically hyaluronic acid which has volumizing effect.Your lips might look swollen for a week after the treatment but these symptoms subside eventually.Juvederm and Restylane are the commonly used lip fillers that are approved by FDA.You will likely need some follow up sessions after 6 months or even a year.The whole treatment takes upto an hour and effect usually shows after 15 days.
Dr Sachdeva's Dental clinic and Facial aesthetic centre is one of the leading clinics performing lip fillers and lip augmentation procedures in Delhi. So hurry up and come book an appointment with us at Dr.Sachdeva’s Dental Institute, Ashok Vihar, Delhi which has state of the art clinic and all the latest and advanced equipments.
To book an appointment contact:
Dr. Rajat Sachdeva
Director & Mentor
Dr Sachdeva’s Dental Aesthetic And Implant Institute
I 101, Ashok Vihar Phase 1, Delhi- 110052
Contact us at
Phone : +919818894041,01142464041
Our Websites:
www.sachdevadentalcare.com
www.dentalimplantindia.co.in
www.dentalclinicindelhi.com
www.dentalcoursesdelhi.com
Facebook- dentalcoursesdelhi
Youtube- drrajatsachdeva
Linkedin- drrajatsachdeva
Slideshare- Dr Rajat Sachdeva
Twitter Page- drrajatsachdeva
Instagram page- surgicalmasterrajat
Mesotherapy treatment is frequently used to solve many problems regarding health issues. In this treatment injections are adminstrated into the supposed part of the body.
http://www.informationonmesotherapy.com
MIcro Lift Threads : Latest Revelation in Face and Body Lift http://spectroni...Spectronix Group
Micro Thread Lift (Reandne) is the most Novel Thread Procedure having lots of advantages over Previous Threads based Procedure.
The procedure is performed under Local Anesthetic Cream and has the following advantages for Face Contouring, Neck Lift, Wrinkle Treatment, Breast firming and lifting, Hip up, Saddle Bags and abdomen lift.
The procedure is SAFE, Non Surgical, Shorter Procedure Time, Use of only topical Anesthesia, No downtime, Immediate Effect (3-4 days after procedure). http://spectronixglobal.com/
This presentation explains the various correction and caveats related to using dermal fillers. The intended audience is medical professionals. Dr. Scheiner is a Plastic Surgeon and the President of ASAMP (The American Society of Aesthetic Medical Professionals). ASAMP certifies medical professionals for cosmetic injection procedures (Botox; Dermal Fillers) and is accredited through the American Academy of Family Physicians (up to 14 CME credits).
Botox Injection is a commercially successful non-surgical cosmetic procedure, to gets rid of the deep wrinkles in the skin between eyebrows, of the forehead, of the corner of eyes. Effective for 3 - 4 months, and the procedure is repetitive in nature.
Micro Needling is a minimally invasive procedure that has little downtime, is safe on all skin types and will leave skin looking smoother and younger.
Micro Needling stimulates the bodies natural healing and will rejuvenate the skin and can reduce:
Lines & Wrinkles
Sun Damage
Skin Laxity
Acne Scars
Stretch Marks
Hair Loss and more
www.MDNeedlePen.com
EWMA 2013 - Ep543 - Evidence Based Wound Conversion Algorithm for University ...EWMAConference
Francis Derk1, Troy Wilde2,
Tim Pham2, Mike Griffiths3
1South Texas VA Medical Center (San Antonio, United States)
2UTHSC (San Antonio, United States)
3AOTI (Oceanside, United States)
WoundRounds: Clinical Reimbursement and Wound Care webinar slideswoundrounds
Presentation slides for the November 9, 2011 webinar on Clinical Reimbursement & Wound Care presented by Dave Rokes, Post Acute Consulting, sponsored by Wound Rounds
This presentation includes all all Data related to scabies and pediculosis and will helpful who want to study about scabies and pediculosis and their respective types. One thing was kept in mind while making this presentation that all area regarding topic should cover
WOUND DRESSINGS - WCSK - Dr. ESIRU-1-compressed.pdfEsiru John
University of Nairobi, Plastic surgery department public webinar, Presented as part of wound care series in the Kenya Wound Care Society series before Annual symposium.
Akileine complete range of foot care creams and balms that help to effectively treat and ease a range of foot health conditions. Specially developed by ASEPTA Laboratories based in Monaco, products such as Akileine foot cream are relied on across the world.
The range of ASPETO products is split into four main categories of products: the Akileine Red Range, the Akileine Blue Range, the Akileine Green Range and Akildia. There are also other popular products outside of these categories such as Akileine Winter Cream which works to strengthen the skin during cold weather while helping the skin to avoid frostbites.
Shop Now: buff.ly/1WOFMan
Dry skin, scaling, hyperkeratosis? AKILEÏNE offer effective solutions to remove calluses and look soft and hydrated. The original assets have proven their effectiveness in the most severe cases.
Vancomycin mixed with calcium sulphate beads provide a 2-3 week sustained local high antibiotic release elution profile which may impede the formation of a recurrent calpular contracture in conjunction with capsulotomy open and or capsulectomy as well as implant change.
Case presentation of severe papillomatosis of the larynx in non sexually active male teenager and discussion of biopsy finding of severe dysplasia and possible formation of laryngeal cancer
Long Term Weight Loss Following Abdominoplasty: Neurocrine FactorsRex Moulton-Barrett
Long term weight loss was associated with abdominoplasty in a group of 22 patients providing that the BMI was 25 or greater at the time of teh procedure, p< 0.001. Neuropcrine factors are discussed in this pilot study, whish is the first of it's kind.
Role for Turbinectomy In the Crowded Nasal Airway, Is Empty Nose Syndrome A R...Rex Moulton-Barrett
Does Empty Nose Syndrome Occur following turninectomy in patients with a crowded nasal airway? Hoe successful is turbinectomy in relieving nasal obstruction and chronis sinus headaches
LF Energy Webinar: Electrical Grid Modelling and Simulation Through PowSyBl -...DanBrown980551
Do you want to learn how to model and simulate an electrical network from scratch in under an hour?
Then welcome to this PowSyBl workshop, hosted by Rte, the French Transmission System Operator (TSO)!
During the webinar, you will discover the PowSyBl ecosystem as well as handle and study an electrical network through an interactive Python notebook.
PowSyBl is an open source project hosted by LF Energy, which offers a comprehensive set of features for electrical grid modelling and simulation. Among other advanced features, PowSyBl provides:
- A fully editable and extendable library for grid component modelling;
- Visualization tools to display your network;
- Grid simulation tools, such as power flows, security analyses (with or without remedial actions) and sensitivity analyses;
The framework is mostly written in Java, with a Python binding so that Python developers can access PowSyBl functionalities as well.
What you will learn during the webinar:
- For beginners: discover PowSyBl's functionalities through a quick general presentation and the notebook, without needing any expert coding skills;
- For advanced developers: master the skills to efficiently apply PowSyBl functionalities to your real-world scenarios.
Connector Corner: Automate dynamic content and events by pushing a buttonDianaGray10
Here is something new! In our next Connector Corner webinar, we will demonstrate how you can use a single workflow to:
Create a campaign using Mailchimp with merge tags/fields
Send an interactive Slack channel message (using buttons)
Have the message received by managers and peers along with a test email for review
But there’s more:
In a second workflow supporting the same use case, you’ll see:
Your campaign sent to target colleagues for approval
If the “Approve” button is clicked, a Jira/Zendesk ticket is created for the marketing design team
But—if the “Reject” button is pushed, colleagues will be alerted via Slack message
Join us to learn more about this new, human-in-the-loop capability, brought to you by Integration Service connectors.
And...
Speakers:
Akshay Agnihotri, Product Manager
Charlie Greenberg, Host
Software Delivery At the Speed of AI: Inflectra Invests In AI-Powered QualityInflectra
In this insightful webinar, Inflectra explores how artificial intelligence (AI) is transforming software development and testing. Discover how AI-powered tools are revolutionizing every stage of the software development lifecycle (SDLC), from design and prototyping to testing, deployment, and monitoring.
Learn about:
• The Future of Testing: How AI is shifting testing towards verification, analysis, and higher-level skills, while reducing repetitive tasks.
• Test Automation: How AI-powered test case generation, optimization, and self-healing tests are making testing more efficient and effective.
• Visual Testing: Explore the emerging capabilities of AI in visual testing and how it's set to revolutionize UI verification.
• Inflectra's AI Solutions: See demonstrations of Inflectra's cutting-edge AI tools like the ChatGPT plugin and Azure Open AI platform, designed to streamline your testing process.
Whether you're a developer, tester, or QA professional, this webinar will give you valuable insights into how AI is shaping the future of software delivery.
UiPath Test Automation using UiPath Test Suite series, part 3DianaGray10
Welcome to UiPath Test Automation using UiPath Test Suite series part 3. In this session, we will cover desktop automation along with UI automation.
Topics covered:
UI automation Introduction,
UI automation Sample
Desktop automation flow
Pradeep Chinnala, Senior Consultant Automation Developer @WonderBotz and UiPath MVP
Deepak Rai, Automation Practice Lead, Boundaryless Group and UiPath MVP
Slack (or Teams) Automation for Bonterra Impact Management (fka Social Soluti...Jeffrey Haguewood
Sidekick Solutions uses Bonterra Impact Management (fka Social Solutions Apricot) and automation solutions to integrate data for business workflows.
We believe integration and automation are essential to user experience and the promise of efficient work through technology. Automation is the critical ingredient to realizing that full vision. We develop integration products and services for Bonterra Case Management software to support the deployment of automations for a variety of use cases.
This video focuses on the notifications, alerts, and approval requests using Slack for Bonterra Impact Management. The solutions covered in this webinar can also be deployed for Microsoft Teams.
Interested in deploying notification automations for Bonterra Impact Management? Contact us at sales@sidekicksolutionsllc.com to discuss next steps.
Smart TV Buyer Insights Survey 2024 by 91mobiles.pdf91mobiles
91mobiles recently conducted a Smart TV Buyer Insights Survey in which we asked over 3,000 respondents about the TV they own, aspects they look at on a new TV, and their TV buying preferences.
PHP Frameworks: I want to break free (IPC Berlin 2024)Ralf Eggert
In this presentation, we examine the challenges and limitations of relying too heavily on PHP frameworks in web development. We discuss the history of PHP and its frameworks to understand how this dependence has evolved. The focus will be on providing concrete tips and strategies to reduce reliance on these frameworks, based on real-world examples and practical considerations. The goal is to equip developers with the skills and knowledge to create more flexible and future-proof web applications. We'll explore the importance of maintaining autonomy in a rapidly changing tech landscape and how to make informed decisions in PHP development.
This talk is aimed at encouraging a more independent approach to using PHP frameworks, moving towards a more flexible and future-proof approach to PHP development.
State of ICS and IoT Cyber Threat Landscape Report 2024 previewPrayukth K V
The IoT and OT threat landscape report has been prepared by the Threat Research Team at Sectrio using data from Sectrio, cyber threat intelligence farming facilities spread across over 85 cities around the world. In addition, Sectrio also runs AI-based advanced threat and payload engagement facilities that serve as sinks to attract and engage sophisticated threat actors, and newer malware including new variants and latent threats that are at an earlier stage of development.
The latest edition of the OT/ICS and IoT security Threat Landscape Report 2024 also covers:
State of global ICS asset and network exposure
Sectoral targets and attacks as well as the cost of ransom
Global APT activity, AI usage, actor and tactic profiles, and implications
Rise in volumes of AI-powered cyberattacks
Major cyber events in 2024
Malware and malicious payload trends
Cyberattack types and targets
Vulnerability exploit attempts on CVEs
Attacks on counties – USA
Expansion of bot farms – how, where, and why
In-depth analysis of the cyber threat landscape across North America, South America, Europe, APAC, and the Middle East
Why are attacks on smart factories rising?
Cyber risk predictions
Axis of attacks – Europe
Systemic attacks in the Middle East
Download the full report from here:
https://sectrio.com/resources/ot-threat-landscape-reports/sectrio-releases-ot-ics-and-iot-security-threat-landscape-report-2024/
GraphRAG is All You need? LLM & Knowledge GraphGuy Korland
Guy Korland, CEO and Co-founder of FalkorDB, will review two articles on the integration of language models with knowledge graphs.
1. Unifying Large Language Models and Knowledge Graphs: A Roadmap.
https://arxiv.org/abs/2306.08302
2. Microsoft Research's GraphRAG paper and a review paper on various uses of knowledge graphs:
https://www.microsoft.com/en-us/research/blog/graphrag-unlocking-llm-discovery-on-narrative-private-data/
Builder.ai Founder Sachin Dev Duggal's Strategic Approach to Create an Innova...Ramesh Iyer
In today's fast-changing business world, Companies that adapt and embrace new ideas often need help to keep up with the competition. However, fostering a culture of innovation takes much work. It takes vision, leadership and willingness to take risks in the right proportion. Sachin Dev Duggal, co-founder of Builder.ai, has perfected the art of this balance, creating a company culture where creativity and growth are nurtured at each stage.
Leading Change strategies and insights for effective change management pdf 1.pdf
Topical silicone in wound healing
1. A 9 YearA 9 Year Clinical Experience with Kelo-coteClinical Experience with Kelo-cote ®®
The Role of Topical Silicone In Wound HealingThe Role of Topical Silicone In Wound Healing
Rex Moulton-Barrett, MDRex Moulton-Barrett, MD
Plastic and Reconstructive SurgeryPlastic and Reconstructive Surgery
Oakland, CaliforniaOakland, California
2. Not all wounds are created equallyNot all wounds are created equally
• Fresh surgical: sharp edges, tensionless epidermis, layered dermal repairFresh surgical: sharp edges, tensionless epidermis, layered dermal repair
• Traumatized tissue: crushed irregular edges, tensionTraumatized tissue: crushed irregular edges, tension
• Thermal and chemical burns: basal layer and dermis may be absentThermal and chemical burns: basal layer and dermis may be absent
• Post-scar ( hypertrophic/keloid ) excision: tendency to recurPost-scar ( hypertrophic/keloid ) excision: tendency to recur
• Scar prone locations: chin to xiphoid, intra-mucosalScar prone locations: chin to xiphoid, intra-mucosal
• Scar prone races: related to Fitzpatrick skin types: tan easily=scar easilyScar prone races: related to Fitzpatrick skin types: tan easily=scar easily
Epidermis: 40 - 150 microns
Dermis: 140 - 400 microns
E & D: 180 >/= 550 microns
3. Choices In Topical TherapyChoices In Topical Therapy
Dry WoundsDry Wounds
• TapesTapes: control tension, shear through surface protection, hydration: control tension, shear through surface protection, hydration
• Oil based antibiotic ointmentsOil based antibiotic ointments: Polymyxin, Bacitracin, Bactroban,: Polymyxin, Bacitracin, Bactroban,
NeosporinNeosporin
• Skin substitutesSkin substitutes: Biobrane, Alloderm: Biobrane, Alloderm
• Silicone gel:Silicone gel: Kelo-cote, Scarfade, MedermaKelo-cote, Scarfade, Mederma
• Silicone gel sheetingSilicone gel sheeting : Cica-care, Epiform, Mepilex,: Cica-care, Epiform, Mepilex,
Mepitel, SilgelMepitel, Silgel
• Collagens: Clayton ChagallCollagens: Clayton Chagall
• Tissue adhesivesTissue adhesives: cyanoacrylate-Dermabond, Epiglu, Indemil,: cyanoacrylate-Dermabond, Epiglu, Indemil,
LiquibandLiquiband
• Barrier filmsBarrier films: fast drying carrier solvent: Cavillon, Comfeel,: fast drying carrier solvent: Cavillon, Comfeel,
SuperskinSuperskin
5. Components of Normal Wound HealingComponents of Normal Wound Healing
•CoagulationCoagulation
processprocess
•InflammatoryInflammatory
processprocess
•Migratory/Migratory/
ProliferativeProliferative
processprocess
•RemodelingRemodeling
processprocess
Injury: hours / days weeks
A) Immediate to 2-5 days
B) Hemostasis : Vasoconstriction , Platelet
aggregation , Thromboplastin clot
C) Inflammation: Vasodilation , Phagocytosis
A) 2 days to 3 weeks
B) Granulation: Fibroblasts lay collagen, Fills & new capillaries
C) Contraction: Wound edges pull together to reduce defect
D) Epithelialization: Crosses moist surface up to 3 cm
A) 3 weeks to 2 years
B) New collagen forms which increases tensile strength
C) Scar tissue is only 80 percent as strong as original tissue
7. TIMETIME Principles of Wound Bed PreparationPrinciples of Wound Bed Preparation
Wound bed preparation accelerates healingWound bed preparation accelerates healing
Tissue non
viable or
deficient
Infection or
inflammation
Moisture
imbalance
Edge of wound
non advancing
or undermined
Defective
matrix and cell
debris
High bacterial
counts or
prolonged
inflammation
Desiccation
or excess
fluid
Non-migrating
keratinocytes
Non-responsive
wound cells
Debridement Antimicrobials Dressings
compression
Biological agents
Adjunct Therapies
Debridement
Restore wound
base and ECM
proteins
Low bacterial
counts and
controlled
inflammation
Restore cell
migration,
maceration
avoided
Stimulate
keratinocyte
migration
9. Autolytic DebridementAutolytic Debridement
•The process by which the woundThe process by which the wound
bed utilizes phagocytic cells andbed utilizes phagocytic cells and
proteolytic enzymes to removeproteolytic enzymes to remove
debrisdebris
•This process can be promotedThis process can be promoted
and enhanced by maintaining aand enhanced by maintaining a
moist wound environmentmoist wound environment
10. Autolytic Debridement ConsiderationsAutolytic Debridement Considerations
• Less aggressiveLess aggressive
• SlowerSlower
• Easy to performEasy to perform
• Little or no discomfortLittle or no discomfort
• Performed in any settingPerformed in any setting
• Contraindication: infectionContraindication: infection
11. Enzymatic DebridementEnzymatic Debridement
•The use of topically appliedThe use of topically applied
chemical agents to stimulate thechemical agents to stimulate the
breakdown of necrotic tissuebreakdown of necrotic tissue
•Common Topical AgentsCommon Topical Agents
– Papain-UreaPapain-Urea
– Papain-Urea-ChlorophyllinPapain-Urea-Chlorophyllin
– CollagenaseCollagenase
12. Enzymatic DebridementEnzymatic Debridement
Collagenase
• Derived from Clostridium Hystoliticum
• Highly specific for peptide sequence found
in collagen
• Less aggressive debridement
• Site of action – collagen fibers anchoring
necrotic tissue to the wound bed
10
Harper (1972) 11
Boxer (1969) 12
Varma (1973)
13. Enzymatic DebridementEnzymatic Debridement
Papain-UreaPapain-Urea
• Proteolytic enzyme derived papayaProteolytic enzyme derived papaya66
• Urea is added as a denaturantUrea is added as a denaturant66
• Site of action – cysteine residues on proteinSite of action – cysteine residues on protein88
6
Falabella (1998) 8
Sherry and Fletcher (1962)
14. Enzymatic Debridement ConsiderationsEnzymatic Debridement Considerations
• Should be painlessShould be painless
• Less traumatic thanLess traumatic than
surgical or mechanicalsurgical or mechanical
debridementdebridement
• Easy dressing changeEasy dressing change
• Observe caution withObserve caution with
infected woundsinfected wounds
*Agency for Healthcare Research and Quality (1994)
• Consider for individuals who:Consider for individuals who:
– Cannot tolerate surgeryCannot tolerate surgery
– long-term-care facilitylong-term-care facility
– home care*home care*
15. The right method is a clinical decision that requires judgment
Autolytic Collagenase Papain-Urea-Chlorophyllin
16. Bacterial BalanceBacterial Balance
• Intact skin is a physical barrierIntact skin is a physical barrier
• Skin secretes fatty acids and antibacterialSkin secretes fatty acids and antibacterial
polypeptidespolypeptides
• Normal flora prevent pathogenic floraNormal flora prevent pathogenic flora
from establishingfrom establishing
19. 33 ““RulesRules”” for Topical Antimicrobial Agents ?for Topical Antimicrobial Agents ?
• Do not useDo not use antibiotics that are usedantibiotics that are used systemicsystemically – ability toally – ability to
breed resistant organisms (topicalbreed resistant organisms (topical gentamicingentamicin, tobramycin), tobramycin)
• Do not useDo not use agents that are commonagents that are common allergensallergens (neomycin,(neomycin,
gentamicin, amikacin, tobramycin,gentamicin, amikacin, tobramycin, bacitracinbacitracin, lanolin), lanolin)
• Do not use agentsDo not use agents that have highthat have high cellular toxicitycellular toxicity in healablein healable
wounds (povidone iodine, chlorhexidine,wounds (povidone iodine, chlorhexidine, hydrogen peroxidehydrogen peroxide))
22
Sibbald 2003
20. Topical Antimicrobials:Topical Antimicrobials: SilverSilver
• Centuries of useCenturies of use
• Cytotoxicity associated with carriers not silver - ex.Cytotoxicity associated with carriers not silver - ex.
SilverSilver nitratenitrate, Silver, Silver sulfasulfadiazinediazine
• Traditional delivery required repeated applicationsTraditional delivery required repeated applications
due to binding with chlorine and proteinsdue to binding with chlorine and proteins
• New silver dressings allow for continued silverNew silver dressings allow for continued silver
release in to the dressing - up to 7 daysrelease in to the dressing - up to 7 days
17
Demling and DeSanti (2001)
21. Why Silver for Wound Bed Preparation?Why Silver for Wound Bed Preparation?
• Broad spectrum antimicrobial: yeasts, molds &Broad spectrum antimicrobial: yeasts, molds &
bacteria, including MRSAbacteria, including MRSA
• Kills microbes on contact: inhibition cellular respirationKills microbes on contact: inhibition cellular respiration
denatures nucleic acidsdenatures nucleic acids
alters cell membrane permeabilityalters cell membrane permeability
• Does not induce resistance: if used at adequate levelsDoes not induce resistance: if used at adequate levels
• Low mammalian cell toxicityLow mammalian cell toxicity
22. Nanocrystalline SilverNanocrystalline Silver
• Decreased size of silver particlesDecreased size of silver particles
leads to increased proportion ofleads to increased proportion of
surface atomssurface atoms
• The nanocrystalline structure isThe nanocrystalline structure is
responsible for the rapid and longresponsible for the rapid and long
lasting actionlasting action1515
17
Demling and DeSanti (2001)
Magnification of normal Silver
Magnification of Nanocrystalline Silver (< 1 micron)
23. Evaluating Silver ProductsEvaluating Silver Products
• Minimum bactericidal concentration (MBC)Minimum bactericidal concentration (MBC)
- amount of antimicrobial agent- amount of antimicrobial agent
required to kill a given microberequired to kill a given microbe
MBC is represented by a log reduction of 3MBC is represented by a log reduction of 3
Stratton et al (1991)Stratton et al (1991)
– The silver required varies from 5ppm - 50+ ppmThe silver required varies from 5ppm - 50+ ppm
for clinically relevant microbesfor clinically relevant microbes
Yin et al (1999) & Hall (1987)Yin et al (1999) & Hall (1987)
– MBC of silver for MRSA = 60.5 ppmMBC of silver for MRSA = 60.5 ppm
Calculated from Maple et al (1992)Calculated from Maple et al (1992)
24. Moist Wound EnvironmentMoist Wound Environment
Additional benefitsAdditional benefits
•Faster healingFaster healing
•Capacity for autolysisCapacity for autolysis
•Decreased rates of infectionDecreased rates of infection
•Reduced wound traumaReduced wound trauma
•Decreased painDecreased pain
•Fewer dressing changesFewer dressing changes
•Cost effectiveCost effective
25. • DifferentDifferent from acute woundfrom acute wound
• ImbalanceImbalance of growth factors andof growth factors and
pro-inflammatory cytokinespro-inflammatory cytokines
• Excessively high levels ofExcessively high levels of proteasesproteases
• DegradesDegrades ECM and selectivelyECM and selectively inhibitsinhibits proliferating cellsproliferating cells
21
Enoch and Harding, 2003
Exudate from a Chronic Wound
27. Suction Vac TherapySuction Vac Therapy
Management of open woundsManagement of open wounds
• increases granulation rate> 5xincreases granulation rate> 5x ’’ss
• success depends on pore size, -125mmHgsuccess depends on pore size, -125mmHg
• reduces wound volumereduces wound volume
• requires changing every 2 daysrequires changing every 2 days
• vascular ingrowth andvascular ingrowth and
healing appear to be due cell deformationhealing appear to be due cell deformation
• early epithelial cells lack rete pegs andearly epithelial cells lack rete pegs and
are easily strained to 5-20%,are easily strained to 5-20%,
postulated mechanismpostulated mechanism
Saxena, etal, 2004: PRS 114(5)Saxena, etal, 2004: PRS 114(5)
28. Modern Scar Concepts (1)Modern Scar Concepts (1)
• New keratinocytes lack rete pegs, are fragile, deformableNew keratinocytes lack rete pegs, are fragile, deformable
and produce many fibrotic growth factorsand produce many fibrotic growth factors
• Fibroblasts within the injury zone are more sensitive toFibroblasts within the injury zone are more sensitive to
these and other growth factorsthese and other growth factors
• Sulphated side chains develop from chondroitin producedSulphated side chains develop from chondroitin produced
from these fibroblastsfrom these fibroblasts
• The side chains cause water binding and subsequent scarThe side chains cause water binding and subsequent scar
rigidityrigidity
29. Modern Scar Concepts (2)Modern Scar Concepts (2)
CollagenesisCollagenesis - Deposition - Resorption- Deposition - Resorption
CollagenesisCollagenesis
• Scar volume is dependent on the volume of collagenScar volume is dependent on the volume of collagen
• Collagen formation: mRNA mediatedCollagen formation: mRNA mediated
• Fibroblast interferon ß( IFN- ß): inhibitor of collagenesisFibroblast interferon ß( IFN- ß): inhibitor of collagenesis
• Transforming Growth Factor TGF ß 1 (adult): stimulates collagenesisTransforming Growth Factor TGF ß 1 (adult): stimulates collagenesis
• TGF ß 3 (infant): inhibits collagenesisTGF ß 3 (infant): inhibits collagenesis
• Renovo/ Retinae: inhibitors of TGF- ß1 activation: reduced collagenesisRenovo/ Retinae: inhibitors of TGF- ß1 activation: reduced collagenesis
improving scarsimproving scars
• Gamma interferons and other cytokines down regulate collagen andGamma interferons and other cytokines down regulate collagen and
matrix synthesis and increase monocyte retention within the woundmatrix synthesis and increase monocyte retention within the wound
30. Modern Scar Concepts (3)Modern Scar Concepts (3)
Collagenesis -Collagenesis - Deposition -Deposition -
ResorptionResorption
Collagen Deposition & ResorptionCollagen Deposition & Resorption
• Fibroblast and monocyte collagenase:Fibroblast and monocyte collagenase: reduce collagen depositionreduce collagen deposition
• MetalloproteinasesMetalloproteinases inhibit collagenasesinhibit collagenases: promoting collagen deposition: promoting collagen deposition
• Expression of fetal metalloproteinase: loss of scarless healingExpression of fetal metalloproteinase: loss of scarless healing
• Intralesional steroids inhibit fibroblast growthIntralesional steroids inhibit fibroblast growth
inhibit collagen deposition:inhibit collagen deposition:
-- increaseincrease monocytemonocyte collagenasecollagenase secretionsecretion
- no influence on metalloproteinase- no influence on metalloproteinase
- no influence on collagen production- no influence on collagen production
31. Modern Scar Concepts (4)Modern Scar Concepts (4)
++ The Role of Tissue HypoxemiaThe Role of Tissue Hypoxemia --
• -- impedes epithelialisationimpedes epithelialisation
• -- increases infection: neutrophil dependentincreases infection: neutrophil dependent
• + reduces collagenesis in an epithelialised wound+ reduces collagenesis in an epithelialised wound
• + compression and radiation lead to local fibroblastic+ compression and radiation lead to local fibroblastic
hypoxemiahypoxemia
• : Compression and radiation should be used: Compression and radiation should be used afterafter
epithelialisation is completeepithelialisation is complete
32.
33.
34.
35.
36.
37.
38. Summary of Treatments for Hypertrophic Scar andSummary of Treatments for Hypertrophic Scar and
KeloidsKeloids
• SurgerySurgery
• Laser ExcisionLaser Excision
• Pulse Dye Laser ReductionPulse Dye Laser Reduction
• CryotherapyCryotherapy
• Pressure TherapyPressure Therapy
• RadiotherapyRadiotherapy
• Steroid, Interferon, 5-FU Injections, ColchicineSteroid, Interferon, 5-FU Injections, Colchicine
• Topical Aldara 5%Topical Aldara 5%
• Prolonged tapingProlonged taping**
• Silicone gel/sheetingSilicone gel/sheeting** ** patient controlledpatient controlled
inexpensiveinexpensive
non-prescriptionnon-prescription
few if any complicationsfew if any complications
well toleratedwell tolerated
39. Prolonged Paper Tape To ScarProlonged Paper Tape To Scar
• 70 pts acute scars: s/p caesarian section, Brisbane, Australia70 pts acute scars: s/p caesarian section, Brisbane, Australia
• Micropore tape to randomized 1/2 pts after staple removal 4-7 days post-opMicropore tape to randomized 1/2 pts after staple removal 4-7 days post-op
• Tape applied continuously for 12 weeksTape applied continuously for 12 weeks
• The control group received no treatmentThe control group received no treatment
• Scar volume was assessed by ultrasoundScar volume was assessed by ultrasound
• Scar volume was reduced in the treatment group (p<0.05)Scar volume was reduced in the treatment group (p<0.05)
• High correlation between subjective scar rating & intradermal scarringHigh correlation between subjective scar rating & intradermal scarring
( p<0.001)( p<0.001)
• Authors postulate that tension is the cause of significant scarringAuthors postulate that tension is the cause of significant scarring
Atkinson,et al, PRS Nov 2005; 116 (6), 1648-Atkinson,et al, PRS Nov 2005; 116 (6), 1648-
40. Management of Common KeloidsManagement of Common Keloids
• Earlobe - If primary excision:Earlobe - If primary excision:
3 x daily peroxide and triple antibiotic3 x daily peroxide and triple antibiotic
remove nylon 5.0 sutures at 10-14 days, then:remove nylon 5.0 sutures at 10-14 days, then:
Dermajet inject Kenalog (trimacinolone 40mg/ml)Dermajet inject Kenalog (trimacinolone 40mg/ml)
start Kelo-cote after sutures out for at least 3 monthsstart Kelo-cote after sutures out for at least 3 months
start compressive clampstart compressive clamp ““ear-ringear-ring”” : no Nickel: no Nickel
return every 6 weeks for further injectionsreturn every 6 weeks for further injections
• Berman B, Bieley HC. Dermatol Surg 1996 Feb;22(2):126-30
– excision alone: 45-100 % recurrence
– excision and Kenalog injection: < 50 % recurrence
– excision and irradiation: < 10% recurrence
– excision and button compression: no recurrences
42. Management of Common KeloidsManagement of Common Keloids
• Earlobe - if secondary excision:Earlobe - if secondary excision:
excise and within 14 days: post-op irradiationexcise and within 14 days: post-op irradiation
either one dose of 10 Gy or up to 15 Gy in 2-4 fractionseither one dose of 10 Gy or up to 15 Gy in 2-4 fractions
sutures out 14 days post-opsutures out 14 days post-op
Kenalog injection, compressive ear-ring and 6 week follow-upKenalog injection, compressive ear-ring and 6 week follow-up
Klumpar DI, Murray JC, Anscher M. J Am Acad Dermatol 1994 Aug;31(2 Pt 1):225-31
- Dose irradiation most important factor: give >900c Gy- Dose irradiation most important factor: give >900c Gy
- Irradiation completed within 1-3 weeks equally effective- Irradiation completed within 1-3 weeks equally effective
- ear lobe 98% successful at > 1 yr follow-up- ear lobe 98% successful at > 1 yr follow-up
- small subsequent recurrences can be re-irradiated: 15 Gy- small subsequent recurrences can be re-irradiated: 15 Gy
43. Improvement of Erythematous and Hypertrophic Scars by heImprovement of Erythematous and Hypertrophic Scars by he
585-nm Flashlamp-pumped Pulsed Dye Laser,585-nm Flashlamp-pumped Pulsed Dye Laser, Tina Alster.Tina Alster.
Ann Plast Surg 1994;32:186-190Ann Plast Surg 1994;32:186-190
• 14 healthy subjects with hypertrophic and or erythematous scars as a results14 healthy subjects with hypertrophic and or erythematous scars as a results
of traumaof trauma
• Scars were at least 2 years oldScars were at least 2 years old
• Candela flashlamp-pumped dye laser: 6.5-6.75 J/cm2 1-2 treatmentsCandela flashlamp-pumped dye laser: 6.5-6.75 J/cm2 1-2 treatments
• 57% improved: lightening and flatter after one treatment57% improved: lightening and flatter after one treatment
• 83% improved after 2 treatments83% improved after 2 treatments
• Continued improvement over 6 monthsContinued improvement over 6 months
• Improvement was not location specific,Improvement was not location specific, depth of scar not assesseddepth of scar not assessed
44. Irradiation mostly contraindicatedIrradiation mostly contraindicated
Re-resection definitely harmfulRe-resection definitely harmful
Laser excision usually harmfulLaser excision usually harmful
Pulse Dye lasers not helpfulPulse Dye lasers not helpful
Aldara 5% not helpfulAldara 5% not helpful
Silicone sheeting not helpfulSilicone sheeting not helpful
Steroid injections very helpfulSteroid injections very helpful
Kelo-cote helpful if < 5mm raisedKelo-cote helpful if < 5mm raised
45. Kelo-cote® unique formulationKelo-cote® unique formulation
• Kelo-cote® composition:Kelo-cote® composition:
– Long chain polymers of siliconeLong chain polymers of silicone
(Polysiloxanes)(Polysiloxanes)
– Minimal Silicone dixoide cross links polymersMinimal Silicone dixoide cross links polymers
– A volatile solvent allows silicone to dry on theA volatile solvent allows silicone to dry on the
stratum corneum in an ultra-thin sheetstratum corneum in an ultra-thin sheet
46. Silicone CompositionSilicone Composition
Silanes: monomers
R Characteristics
Methyl Hydrophobicity & Low surface tension
Higher Alkyl Organic-compatibility and Paintability
Phenyl Thermo-stabile,Organo-compatible,
Hydrophobic CF3CH2CH2 Solvent resistant
Siloxanes: polymers
more crosslinked: more solid
recurring silicone / oxygen backbone
end / side chains determine functionality
ie.: amine,carboxy, hydroxyl,epoxyl
RR
RR
R:R:
47. Favorable properties related to scar reductionFavorable properties related to scar reduction
• Intermediate forms: elastomers: gel, rubberIntermediate forms: elastomers: gel, rubber
• Solid-liquid binding requires catalystSolid-liquid binding requires catalyst ‘‘curingcuring’’: ie. platinum,: ie. platinum,
stannous octoatestannous octoate
• Delivery in an evaporative solvent may provide the ability to changeDelivery in an evaporative solvent may provide the ability to change
the properties of the silicone upon deliverythe properties of the silicone upon delivery
• Properties influencing scar reduction include:Properties influencing scar reduction include:
– Thickness:Thickness: < 0.254mm< 0.254mm
– Moisture vapor transmission rate:Moisture vapor transmission rate: <15mg/cm2/day<15mg/cm2/day
– Oxygen permeability:Oxygen permeability: > 600cc/100 in.sup.2/day> 600cc/100 in.sup.2/day
– High stretch:High stretch: ,1.5lbs/in stretches > 110% length,1.5lbs/in stretches > 110% length
– Tensile strength:Tensile strength: >100g>100g
– Penetrability:Penetrability: 4-7mm4-7mm
– Peel strength:Peel strength: 2-6 g2-6 g
48. Silicone Mode of ActionSilicone Mode of Action
• Potential TheoriesPotential Theories
– Hydration: increasesHydration: increases
– Oxygenation: decreasesOxygenation: decreases
– Protection: increasesProtection: increases
– Cellular Strain: increases ?Cellular Strain: increases ?
– Modulation of growth factorsModulation of growth factors
49. Silicone Mode of ActionSilicone Mode of Action
HydrationHydration
• Kelo-cote is semi-occlusive aerating and hydratingKelo-cote is semi-occlusive aerating and hydrating
• Silicone absorption is limited to the epidermisSilicone absorption is limited to the epidermis
• Stratum corneum regulates fibroblast /collagenesisStratum corneum regulates fibroblast /collagenesis
• Hydration normalises the collagen synthesisHydration normalises the collagen synthesis
50. Silicone Mode of ActionSilicone Mode of Action
HydrationHydration
• But not all breathable dressings will reduce scarsBut not all breathable dressings will reduce scars
• In a study comparing silicone and hydrogel dressings,In a study comparing silicone and hydrogel dressings,
silicone normalised collagen synthesis,silicone normalised collagen synthesis,
other breathable non-silicone dressings did notother breathable non-silicone dressings did not
• Silicone has a scar reducing characteristic not seen withSilicone has a scar reducing characteristic not seen with
polyurethanespolyurethanes
• Further research ongoingFurther research ongoing
51. Silicone Mode of ActionSilicone Mode of Action
ProtectionProtection
• Microbial, chemical or physical irritation promote excessive collagenMicrobial, chemical or physical irritation promote excessive collagen
production in early scars:production in early scars:
• Keratinocyte dependent: exposed cell release growth factorsKeratinocyte dependent: exposed cell release growth factors
• Fibroblast dependent: Staph epidermidis Immortalization TheoryFibroblast dependent: Staph epidermidis Immortalization Theory
• Intact dermis is necessary for normal wound healingIntact dermis is necessary for normal wound healing
52. Silicone Mode of ActionSilicone Mode of Action
Modulation TheoryModulation Theory
• Silicones oils and sheeting appear to have an influence onSilicones oils and sheeting appear to have an influence on
Fibroblast growth factors and transforming growth factorsFibroblast growth factors and transforming growth factors
• Silicone reduces FGFSilicone reduces FGF growth factors in vivo, yetgrowth factors in vivo, yet
( opposite in vitro )( opposite in vitro )
– Fibroblast are reducedFibroblast are reduced
– Collagenase is increasedCollagenase is increased
• ““Collagen production is normalisedCollagen production is normalised””
53. History of Silicone in Scar ReductionHistory of Silicone in Scar Reduction
• Perkins et al, 1983Perkins et al, 1983: reported silicone a new treatment for hypertrophic scars: reported silicone a new treatment for hypertrophic scars
• Ahn, et al, 1989Ahn, et al, 1989: silicone gel improved texture, color, thickness and: silicone gel improved texture, color, thickness and
itching from small hypertrophic scarsitching from small hypertrophic scars
• Sawada & Sone, 1990Sawada & Sone, 1990: 20% silicone gel 82% improved hypertrophic: 20% silicone gel 82% improved hypertrophic
scars and keloids a.c.t. glycerin 22% improvedscars and keloids a.c.t. glycerin 22% improved
• Sawada &Sone, 1992Sawada &Sone, 1992: silicone gel an elastomer sheeting vs. petroleum,: silicone gel an elastomer sheeting vs. petroleum,
6 months f/u silicone group much softer, less red6 months f/u silicone group much softer, less red
• Pamieri, et al, 1995Pamieri, et al, 1995: Found Vit E enhanced hypertrophic scar and keloids: Found Vit E enhanced hypertrophic scar and keloids
• Phillips, et al. 1996Phillips, et al. 1996: hydrocolloid dressings no evidence to support reduce: hydrocolloid dressings no evidence to support reduce
scarring after hypertrophic scar or keloid establishedscarring after hypertrophic scar or keloid established
Good review: Mustoe, et al, PRS 2002:110(2) 560-Good review: Mustoe, et al, PRS 2002:110(2) 560-
Literature lacks double blind placebo controlled studiesLiterature lacks double blind placebo controlled studies
54. Placebo Controlled Pilot Study Evaluating Kelo-cotePlacebo Controlled Pilot Study Evaluating Kelo-cote
in the Reduction of Scarring Following Cleft Lip Repairin the Reduction of Scarring Following Cleft Lip Repair
10 days post-op10 days post-op 8 weeks post-op8 weeks post-op 8 months post-op8 months post-op
• 33 patients, Santiago, Chile, 199633 patients, Santiago, Chile, 1996
• Methods: mm vertical scar shortening (A-Methods: mm vertical scar shortening (A-
B)B)
mm depth lip notchmm depth lip notch
*average width scar mm*average width scar mm
scar softness 0-3 gradescar softness 0-3 grade
scar erythema 0-3 gradescar erythema 0-3 grade
• 6 week follow-up results6 week follow-up results
**
AA BB
56. Chan, et al, 2005: PRS Sept 15Chan, et al, 2005: PRS Sept 15
• Placebo controlled study prospective clinical trialPlacebo controlled study prospective clinical trial
of silicone gel ( Scarfadeof silicone gel ( Scarfade ®®) in the prevention of) in the prevention of
hypertrophic median sternotomy scarshypertrophic median sternotomy scars
– 100 wounds/50 pts Malaysia100 wounds/50 pts Malaysia
– Reduction of:Reduction of: pigmentation (p=0.02)pigmentation (p=0.02)
vascularity (p=0.001)vascularity (p=0.001)
pliability (p=0.001)pliability (p=0.001)
height (p=0.001)height (p=0.001)
pain (p=0.001)pain (p=0.001)
itchiness (p=0.001)itchiness (p=0.001)
57. Sebastian et al, 2005Sebastian et al, 2005
•• Non-placebo controlled study Kelo-cote on scars: all-comers, up to 48Non-placebo controlled study Kelo-cote on scars: all-comers, up to 48
month follow-upmonth follow-up
• Data 111 patients Germany, Switzerland & AustriaData 111 patients Germany, Switzerland & Austria
• Study: legal requirement forStudy: legal requirement for ‘‘newnew’’ productsproducts
• Independent studyIndependent study
• Data is on all types of scarsData is on all types of scars
• Different ages of scarsDifferent ages of scars
• Measurement tool is Vancouver scar scale, whichMeasurement tool is Vancouver scar scale, which
is standard measurement for scarsis standard measurement for scars
58. Sebastian et al, 2005Sebastian et al, 2005
• Patients & physicians assessment ofPatients & physicians assessment of
tolerability and efficacy using 4 point scaletolerability and efficacy using 4 point scale
• Vancouver scar scaleVancouver scar scale
59. Sebastian et al, 2005Sebastian et al, 2005
Results of patient and physician assessment - EfficacyResults of patient and physician assessment - Efficacy
0
10
20
30
40
50
60
% of respondents
Very
G
ood
G
ood
M
oderate
U
nsatisfactory
Patient and Physician assesement of
efficacy
Doctor
Patient
60. Sebastian et al, 2005Sebastian et al, 2005
Results of patient and physician assessment - TolerabilityResults of patient and physician assessment - Tolerability
0
20
40
60
80
100
% of respondents
V
ery
G
oo
d
G
o
od
M
o
d
erate
U
nsatisfactory
Patient and Physician assesement of
Tolerability
Doctor
Patient
61. Sebastian et al, 2005Sebastian et al, 2005
Decrease in Vancouver Scar Scale - RednessDecrease in Vancouver Scar Scale - Redness
62. Sebastian et al, 2005Sebastian et al, 2005
Decrease in Vancouver Scar Scale - ElevationDecrease in Vancouver Scar Scale - Elevation
63. Sebastian et al, 2005Sebastian et al, 2005
Decrease in Vancouver Scar Scale - HardnessDecrease in Vancouver Scar Scale - Hardness
64. Sebastian et al, 2005Sebastian et al, 2005
Decrease in Vancouver Scar Scale - PainDecrease in Vancouver Scar Scale - Pain
65. Sebastian et al, 2005Sebastian et al, 2005
Results by type of scarResults by type of scar
Type of scar (%)
Mature Scar
10%
Major Keloid
10%
Widespread
Hypertrophic
scar
6%Linear
Hypertrohic
scar
40%
Immature
scar
17%
Minor Keloid
17%
66. Sebastian et al, 2005Sebastian et al, 2005
Results by age of scarResults by age of scar
Age of scar (%)
3-6 months
18%
6-12months
23%
12-24 months
11%
>24 months
21% < 3months
27%
67. Summary of studySummary of study
• Kelo-coteKelo-cote® rated:good/very good > 80% patients & physicians® rated:good/very good > 80% patients & physicians
• Physicians rated tolerability:Physicians rated tolerability: good/very good 100% of patientsgood/very good 100% of patients
• Kelo-coteKelo-cote® decreased: redness, elevation, hardness,itchiness® decreased: redness, elevation, hardness,itchiness
and pain of scars over a two month periodand pain of scars over a two month period
• Kelo-coteKelo-cote® can be used on old and new scars® can be used on old and new scars
• Kelo-cote® can be used to treat all types of scarsKelo-cote® can be used to treat all types of scars
68. Indications for useIndications for use
• Kelo-cote® is indicated for the management of:Kelo-cote® is indicated for the management of:
– Acute healing scarsAcute healing scars
– Hypertrophic scarsHypertrophic scars
– KeloidsKeloids
• Kelo-cote®™ has also been used for scars resulting from:Kelo-cote®™ has also been used for scars resulting from:
– TraumaTrauma
– BurnsBurns
– SurgerySurgery
– AcneAcne
– Post laser erythemaPost laser erythema
69. Length of treatmentLength of treatment
• Minimum treatment should be 2 monthsMinimum treatment should be 2 months
• Treat larger and older scars >3 monthsTreat larger and older scars >3 months
• Active persons apply usually in amActive persons apply usually in am
• May treat with other topicals in pmMay treat with other topicals in pm
70. Instructions for use 0.5 oz Kelo-coteInstructions for use 0.5 oz Kelo-cote
• Ensure the area is clean and dry.Ensure the area is clean and dry.
• ApplyApply a very thin layer and allow to drya very thin layer and allow to dry
• Apply once daily, or twice dailyApply once daily, or twice daily
• Maximum effect, 24 hours of continuous contactMaximum effect, 24 hours of continuous contact
• Once dry, OK to cover with pressure garments, sun block orOnce dry, OK to cover with pressure garments, sun block or
cosmeticscosmetics
• If not dried within 4–5 minutes: too muchIf not dried within 4–5 minutes: too much
• Gently remove the excess and allow the dryingGently remove the excess and allow the drying
• Larger and older scars > 90 daysLarger and older scars > 90 days
• 0.5 oz contains enough Kelo-cote®, for: 7.5–10cm 2x/day for 90 days0.5 oz contains enough Kelo-cote®, for: 7.5–10cm 2x/day for 90 days
• Reduce drying time hotter climates, keep in the refrigeratorReduce drying time hotter climates, keep in the refrigerator
• In colder weather, use low setting on hair dryer to reduce drying timeIn colder weather, use low setting on hair dryer to reduce drying time
71. Warnings and PrecautionsWarnings and Precautions
• Avoid direct contact with eyes, mucousAvoid direct contact with eyes, mucous
membranes, & open woundsmembranes, & open wounds
• Kelo-cote® may stain clothing if notKelo-cote® may stain clothing if not
completely drycompletely dry
• Store below 77°F (25°C)Store below 77°F (25°C)
• Do not use after the expiration dateDo not use after the expiration date
72. Mederma: $25, 50g, EtOH, water,PEG-4,xanthum gum,Mederma: $25, 50g, EtOH, water,PEG-4,xanthum gum,
sorbic acidsorbic acid
Scarguard: $72, 100g, with hydrocortisone, Vit EScarguard: $72, 100g, with hydrocortisone, Vit E
Cimeosil: $56, 14 gram, polysiloxanesCimeosil: $56, 14 gram, polysiloxanes
Skin Esthetique: $24, 170g,dimethicone, arnika, copper,Skin Esthetique: $24, 170g,dimethicone, arnika, copper,
seaweedseaweed
Scarfade: $25, 50g, silicone dioxide, micro quartz crystalsScarfade: $25, 50g, silicone dioxide, micro quartz crystals
+/- vit E,K, co-enzyme Q-10+/- vit E,K, co-enzyme Q-10
Pro-Sil: $17.50, glide-on, siliconePro-Sil: $17.50, glide-on, silicone ““creams and oilscreams and oils””
73. • Kelo-cote® is a uniqe patent protected silicone gelKelo-cote® is a uniqe patent protected silicone gel
• 80% patients rate Kelo-cote® as good or very good in scar reduction80% patients rate Kelo-cote® as good or very good in scar reduction
• 100% physicians rate Kelo-cote® good or very good in pt tolerability100% physicians rate Kelo-cote® good or very good in pt tolerability
• Kelo-cote® softens, flattens &reduces the redness of old & new scarsKelo-cote® softens, flattens &reduces the redness of old & new scars
• Kelo-cote® is a comaparatively cost effective treatmentKelo-cote® is a comaparatively cost effective treatment
74. Clinicial Care:Clinicial Care:’’OlsenOlsen’’s Rules Rule’’
• ““Most wounds heal proportionate to the time andMost wounds heal proportionate to the time and
attention they are givenattention they are given””
• Steristrip minimum of 4 - 7 days & then another 5 daysSteristrip minimum of 4 - 7 days & then another 5 days
after changing stripsafter changing strips
• Early application of Kelo-cote, avoid any contact withEarly application of Kelo-cote, avoid any contact with
clothing for 6 weeks minimum: diapers OKclothing for 6 weeks minimum: diapers OK
• All open wounds treated with 1/2 peroxide, bacitracin,All open wounds treated with 1/2 peroxide, bacitracin,
minimum of twice dailyminimum of twice daily
87. Looking into the FutureLooking into the Future
Bioglass and nano crystal Silver SprayBioglass and nano crystal Silver Spray
Editor's Notes
Before discussing chronic wounds and chronic wound management, it may be important to review the healing process that occurs with acute wounds (surgical or traumatic).
To summarize the biochemical differences between healing wounds and chronic wounds: In healing wounds there is a high level of mitogenic activity. For example fluids collected from acute mastectomy wounds added to cell cultures stimulated DNA synthesis. In contrast fluid collected from chronic venous leg ulcers did not stimulate DNA. There is a distinct difference in the cytokine environment. In the healing wound there is a balance of pro-inflammatory cytokines and their natural inhibitors whereas in the chronic wounds there are increased levels of the pro-inflammatory cytokines. The pro-inflammatory cytokines also influence the levels of matrix metalloproteinases (MMP). Again in the healing wound there is a balance between MMPs and TIMPs however in the chronic wound MMPs levels are significantly elevated. Analysis of chronic wound fluids revealed a 116-fold higher level of protease activity as compared to mastectomy fluids. The high levels of MMPs also degrade various growth factors. The final point here is that while much research has been focused on the molecular environment there must also be consideration of the cells ability to respond to the molecular regulators. There is some interesting data demonstrating that the fibroblasts from venous leg ulcers present for more than 3 years grew more slowly and responded poorly when compared to venous ulcers present less than 3 years. This suggest that fibroblasts in ulcers that have been present for a long time may become senescent Schultz G, Mast B. Molecular Analysis of the Environment of Healing and Chronic Wounds: Cytokines, Proteases and Growth Factors. Wounds 1998;10:1F-9F
While there is still much to learn, this model has been hypothesized to explain the chronic wound. Unlike the acute wound with normal healing, the chronic wound has a persistent pro-inflammatory stimulus. It may be one or several of the factors listed. Repetitive trauma Local tissue ischemia Necrotic tissue Heavy bacterial burden Tissue breakdown The inflammatory cells (neutrophils and macrophages) are drawn to the wound bed. The activated macrophages secrete the inflammatory cytokines Tumor Necrosis Factor-alpha (TNF- ) and interlukin one-beta (IL-1 ). Tumor Necrosis Factor-alpha (TNF- ) and interlukin one-beta (IL-1 ) increase the production of matrix MMPs and reduce the synthesis of TIMPs. (Tissue inhibitors of MMPs) The elevated MMPs degrades the extracellular matrix which impairs cell migration and connective tissue deposition. MMPs also degrade growth factors and their target cell receptors. This prevents the wound from entering the proliferative phase of healing and continues the vicious cycle of the chronic wound. Mast BA, Schultz GS. Interactions of cytokines, growth factors, and proteases in acute and chronic wounds. Wound Repair and Regeneration 1996;4:411-420
The International Advisory Panel on Wound Bed Preparation offered the TIME principles for wound management, an excellent tool for recognizing and managing the barriers to healing. The barriers are observed as: Tissue nonviable or deficient Infection or inflammation Moisture imbalance Edge of Wound non advancing or undermined. The model addresses proposed pathophysiology, clinical actions of the TIME principles and the effect of that action on the wound. Debridement may be episodic or continuous. Various methods of debridement will be discussed later in the presentation. Infection or inflammation may be addressed with topical or systemic antimicrobial/anti-inflammatory agents. Moisture balance can be achieved by either adding moisture to a dry wound with a dressing such as a hydrogel. Absorptive dressing may the appropriate choice for wounds with moderate to large amounts of exudate. Compression therapy may reduce chronic wound fluid associated with edema among patients with venous insufficiency. For the non-advancing wound edge, interventions include addressing the cause and implementing corrective measures: biological agents, skin grafts, debridement and/or adjunct therapies.
When thinking about wound bed preparation there are five methods of debridement: surgical, mechanical, autolytic, enzymatic and biological (larvae). Biological, although returning as an option, is not as commonly used as the others. Therefore this presentation will focus on surgical, mechanical, autolytic and enzymatic debridement. While there are advantages and disadvantages for each method, there are also clinical indications for each method. It is important to considers the patient ’ s overall condition and the goals of care when selecting a debridement method. While there are advantages and disadvantages for each method, there are also clinically appropriate indications for each method. It is important to consider the patient ’ s overall condition and the goals for care when selecting the method of debridement.
Autolytic debridement is defined as the process by which the wound bed utilizes phagocytic cells and proteolytic enzymes to remove debris. Maintaining a moist wound bed helps to promote and enhance autolytic debridement. The process of autolytic debridement results in liquification of necrotic tissue and can result in significant wound fluid and this is a consideration when selecting the appropriate dressing. It is important to remember that when using occlusive dressings there will be an accumulation of wound fluids that have a tan opaque appearance. This is an anticipated normal occurrence (point out picture on slide).
Over the years enzymatic agents have been used to debride necrotic tissue from the wound bed and have become a well established practice among wound care providers. Enzymatic debridement is defined as the use of proteolytic substances, applied topically to the wound, to stimulate the breakdown of necrotic tissue. Enzymatic debriders use chemical agents which are biologically capable of degrading eschar, protein and other nucleic acids. There are several preparations on the market for example Collagenase and Papain-Urea.
Remember that the right method of debridement is a clinical decision that requires judgment of the clinician
It is clear that while bacteria are present on intact skin, infection is rarely a problem. This is attributed to the mechanisms that are in place to control bacteria: The outer layer of the skin provides a physical barrier to invasion The slightly acidic pH of the skin is not conducive to bacterial growth The skin normally secretes fatty acids and antibacterial polypeptides that inhibit bacterial growth The presence of normal flora help to prevent potentially pathogenic bacteria from becoming established. The presence of a wound creates a portal of entry for bacteria. One of the most significant predisposing factors for a wound infection is inadequate blood supply. For example in pressure ulcers or ischemic leg ulcers
It has been well documented that when bacterial levels reach greater than 10 5 there is a negative effect on healing. This has been seen in both the acute and chronic wound.
Silver has been used for centuries for its antimicrobial activity. In fact, ancient Romans used it as a disinfectant for storage of water. More recently is was used by NASA to maintain water purity on the space shuttle. Reports of cytotoxicity with the use of silver preparations has been associated with the carriers and not the silver, The traditional delivery systems used with silver nitrate and silver sulfadiazine required repeated applications. The new technology allows for the consistent delivery of silver over time. Silver has a broad spectrum of activity including MRSA and VRE. There are no documented cases of bacterial resistance to silver and it is unlikely that resistance could occur due to the complex mechanisms by which the silver cation is toxic to the bacteria. These include binding to and disruption of bacterial DNA, respiratory enzymes and cell wall.
When evaluating silver products, one may benefit by understanding the minimum bactericidal concentration (MBC). MBC is the amount of antimicrobial agent required to kill a given microbe. MBC is represented by a log reduction of 3 – for example, decreasing the number of bacteria from 10 7 to 10 4 .
Additional benefits of a moist wound environment include: Decreased healing time Capacity for autolysis Decreased rates of infection Reduced wound trauma Decreased pain Fewer dressing changes Cost effectiveness - When defined as total cost of care to achieve desired outcome and not just cost of dressing. It is the evidence of improved healing and the benefits that have influenced the development of advance wound therapies.
With a small amount of exudate it may be necessary to use hydrogels which will add moisture to the wound environment. Hydocolloids may also be used to maintain a moist wound environment in partial thickness wounds. As the amount of exudate increases it becomes necessary to use a topical dressing capable of absorbing exudate and foams are a good choice for wounds with moderate to large amounts of exudate. Alginate dressing are also appropriate for wound with moderate to large amouns of exudate. It may be necessary to use a specialty absorptive product as the secondary or cover dressing.