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Úlceras crônicas são algumas das principais causas de morbi-mortalidade, devido a sua alta probabilidade de infecção e sepse; por esse motivo, elas tem um impacto significativo na saúde pública e no dispêndio de recursos com assistência médica. Úlceras (ou feridas) são caracterizadas por uma perda de substância tecidual, provocando a descontinuidade do tecido cutâneo e adjacentes, alterando a estrutura anatômica e fisiológica das regiões afetadas. As mais comuns são: cirúrgicas, venosas (de estase, varicosa), arteriais, neurotróficas (hanseníase, diabetes, alcoolismo), por pressão ou mistas. A membrana de celulose bacteriana (CB) é utilizada como curativo temporário para tratamento dessas úlceras de pele de diversas origens, devido à excelente conformação no corpo, manutenção da umidade local, redução da dor e aceleração da regeneração do epitélio. A própolis tem mostrado possuir efeitos antibacteriano, antifúngico, antiviral, anti-inflamatório, hepatoprotetor, antioxidante, antitumoral e imunomodulatórios. Outro tratamento para úlceras muito utilizado é a laserterapia de baixa intensidade (LBI), cujos efeitos regenerativos são comprovados; além de promover a cicatrização de úlceras, promove o alívio da dor, melhora da circulação local e diminuição da inflamação. O objetivo deste trabalho foi avaliar a eficácia da aplicação de curativos temporários de CB pura ou com própolis associados ou não a aplicação de LBI em indivíduos que apresentavam úlceras crônicas. A amostra conteve 8 pacientes, num total de 12 úlceras, divididos aleatoriamente em 05 grupos: Grupo Membrana de CB Pura (G1), Grupo Membrana de CB com Própolis (G2), Grupo Laser (G3), Grupo Membrana de CB Pura + Laser (G4), Grupo de Membrana de CB com própolis + Laser (G5). Sessenta e sete por cento das úlceras tratadas evoluíram para cicatrização total, apresentando aumento da velocidade de cicatrização em comparação com o tempo de existência da úlcera. Do restante das úlceras tratadas, somente uma teve sua área final aumentada devido a fatores como diabetes descompensada e infecção bacteriana; as outras tiveram uma grande evolução e chegaram próximas da reepitelização total. Todos os tratamentos se mostraram efetivos no tratamento de úlceras crônicas, porém o diferencial na cura foi a utilização de membranas de CB pura e com própolis. / Chronic skin ulcers are a major source of morbidity-mortality due to their high probability of infection and sepsis; for this reason, they have a significant impact on public health and the expenditure of healthcare resources. Skin ulcers (or wounds) are characterized by a loss of tecidual substance, interrupting cutaneous tissue and changing their anatomic and physiologic structures. The most commom ulcers are: cirurgical, venous, arterials, neurotrophics, pressure ulcers or mixed factors. Bacterial cellulose (BC) membrane is used as a temporary curative for the treatment of several types of skin ulcers due to its amazing body conformation, keeping the humidity, reducing the pain and accelerating the ephitelium healing process. Propolis have shown antimicrobial, antifungal, antiviral, anti-inflammatory, hepatoprotective, antioxidant, antitumor and immunity modulation effects. Another treatment for skin ulcers is low-level laser therapy (LLLT), who have regenerative effects, and it also promoves the ulcer cicatrization, pain relief, better local circulation and reduces the inflammation. The aim of this study was to evaluate the effectiveness of pure BC and propolis BC membrane curative application, associated or not to LLLT in individuals who had chronic ulcers. The sample contained 8 patients and 12 ulcers, randomly divided in 5 groups: Pure BC Membrane Group (G1), Propolis BC Membrane Group (G2), Laser Group (G3), Pure BC Membrane + Laser Group (G4) and Propolis BC Membrane + Laser (G5). Sixty seven per cent of the treated ulcers progressed to full cicatrization, increasing the speed of cicatrization when compared to the existent period of the ulcer. The resto of treated ulcers had a great evolution and got close to the total reepithelization, except for one that had increased its final area because of decompensated diabetes and bacterial infection. All treatments had shown effectiveness for the treatment of chronic skin ulcers, however the differential on healing process was the use of pure BC membranes and propolis BC membranes.

Painful cutaneous ulcers are a clinical challenge as the pain can be difficult to control, frequently requiring a combination of pharmacological and non-pharmacological measures. There is evidence suggesting topical opioid application might be efficacious in the management of painful cutaneous ulcers, however this is largely based on case reports. Methods A series of clinical and laboratory studies were undertaken to determine the utility of opioids applied topically to painful cutaneous ulcers, these included surveys of hospice admissions to determine the prevalence of painful ulcers and the effective dose of topical opioid; a randomised, double-blind, placebo-controlled crossover trial design to assess the utility of morphine/IntraSite gel mixture, HPLC analysis to determine the mixture’s bioavailability and physical stability, and microbiological studies to determine its microbiological stability. Results A survey of 323 hospice admissions over a two-year period identified 125 patients with 221 ulcers, mostly caused by either pressure (183 ulcers) or trauma (25); 147 (67%) of all ulcers were painful. Compared to placebo, morphine/IntraSite mixture was more efficacious; it was safe and well tolerated in this population. Morphine applied topically appears to have an analgesic effect even at low doses of morphine irrespective of background analgesic medication. HPLC analyses suggested morphine and its metabolites might be detectable in the plasma of patients with large ulcers, but only at low concentrations. In addition morphine/IntraSite gel mixture was physically and, under certain storage conditions, microbiologically stable for 28 days allowing the mixture to be prepared and stored before use. Conclusions The studies confirmed that painful cutaneous ulcers are a significant clinical problem in hospice patients and that morphine/IntraSite mixture can be used safely and effectively in this patient group. Bioavailability studies support the possibility that the opioid analgesic effect is local rather than systemic, and stability studies show the morphine/IntraSite combination, once mixed, can be stored for up to 28 days, allowing the mixture to be prepared and stored before use. Given that ulcers can vary in aetiology, size, severity and temporal characteristics of pain, an individualised titration protocol is recommended. Further research is required to confirm and extend these findings to other ulcers and clinical settings.

Úlceras crônicas são algumas das principais causas de morbi-mortalidade, devido a sua alta probabilidade de infecção e sepse; por esse motivo, elas tem um impacto significativo na saúde pública e no dispêndio de recursos com assistência médica. Úlceras (ou feridas) são caracterizadas por uma perda de substância tecidual, provocando a descontinuidade do tecido cutâneo e adjacentes, alterando a estrutura anatômica e fisiológica das regiões afetadas. As mais comuns são: cirúrgicas, venosas (de estase, varicosa), arteriais, neurotróficas (hanseníase, diabetes, alcoolismo), por pressão ou mistas. A membrana de celulose bacteriana (CB) é utilizada como curativo temporário para tratamento dessas úlceras de pele de diversas origens, devido à excelente conformação no corpo, manutenção da umidade local, redução da dor e aceleração da regeneração do epitélio. A própolis tem mostrado possuir efeitos antibacteriano, antifúngico, antiviral, anti-inflamatório, hepatoprotetor, antioxidante, antitumoral e imunomodulatórios. Outro tratamento para úlceras muito utilizado é a laserterapia de baixa intensidade (LBI), cujos efeitos regenerativos são comprovados; além de promover a cicatrização de úlceras, promove o alívio da dor, melhora da circulação local e diminuição da inflamação. O objetivo deste trabalho foi avaliar a eficácia da aplicação de curativos temporários de CB pura ou com própolis associados ou não a aplicação de LBI em indivíduos que apresentavam úlceras crônicas. A amostra conteve 8 pacientes, num total de 12 úlceras, divididos aleatoriamente em 05 grupos: Grupo Membrana de CB Pura (G1), Grupo Membrana de CB com Própolis (G2), Grupo Laser (G3), Grupo Membrana de CB Pura + Laser (G4), Grupo de Membrana de CB com própolis + Laser (G5). Sessenta e sete por cento das úlceras tratadas evoluíram para cicatrização total, apresentando aumento da velocidade de cicatrização em comparação com o tempo de existência da úlcera. Do restante das úlceras tratadas, somente uma teve sua área final aumentada devido a fatores como diabetes descompensada e infecção bacteriana; as outras tiveram uma grande evolução e chegaram próximas da reepitelização total. Todos os tratamentos se mostraram efetivos no tratamento de úlceras crônicas, porém o diferencial na cura foi a utilização de membranas de CB pura e com própolis. / Chronic skin ulcers are a major source of morbidity-mortality due to their high probability of infection and sepsis; for this reason, they have a significant impact on public health and the expenditure of healthcare resources. Skin ulcers (or wounds) are characterized by a loss of tecidual substance, interrupting cutaneous tissue and changing their anatomic and physiologic structures. The most commom ulcers are: cirurgical, venous, arterials, neurotrophics, pressure ulcers or mixed factors. Bacterial cellulose (BC) membrane is used as a temporary curative for the treatment of several types of skin ulcers due to its amazing body conformation, keeping the humidity, reducing the pain and accelerating the ephitelium healing process. Propolis have shown antimicrobial, antifungal, antiviral, anti-inflammatory, hepatoprotective, antioxidant, antitumor and immunity modulation effects. Another treatment for skin ulcers is low-level laser therapy (LLLT), who have regenerative effects, and it also promoves the ulcer cicatrization, pain relief, better local circulation and reduces the inflammation. The aim of this study was to evaluate the effectiveness of pure BC and propolis BC membrane curative application, associated or not to LLLT in individuals who had chronic ulcers. The sample contained 8 patients and 12 ulcers, randomly divided in 5 groups: Pure BC Membrane Group (G1), Propolis BC Membrane Group (G2), Laser Group (G3), Pure BC Membrane + Laser Group (G4) and Propolis BC Membrane + Laser (G5). Sixty seven per cent of the treated ulcers progressed to full cicatrization, increasing the speed of cicatrization when compared to the existent period of the ulcer. The resto of treated ulcers had a great evolution and got close to the total reepithelization, except for one that had increased its final area because of decompensated diabetes and bacterial infection. All treatments had shown effectiveness for the treatment of chronic skin ulcers, however the differential on healing process was the use of pure BC membranes and propolis BC membranes.

The purpose of this thesis was two-fold: first, to develop a Patient Satisfaction Questionnaire which reflects patient satisfaction with dressings used in the care of ulcerating metastatic skin lesions; and second, to evaluate patient satisfaction and patient preference with two types of dressings: Mesalt dressings and continuous wet saline dressings. The Patient Satisfaction Questionnaire was developed to measure patient satisfaction with dressing performance. Patients with ulcerating metastatic skin lesions were asked to identify important characteristics for evaluating patient satisfaction with dressings. These questions were validated and reviewed for clarity by the patients. A visual analogue scale was used as the response scale. Testing for reliability was limited. Mesalt dressings were compared to continuous wet saline dressings by evaluating patient satisfaction with pre-defined criteria. The criteria for evaluation included ease of application and removal, discomfort during and between dressing changes, control of odor, and patient preference. The study used a cross-over design in which each patient used one dressing for a month and the other dressing for the next month. Although 14 patients were involved in the study, only 10 were statistically analyzed. The remaining four patients were excluded because they were unable to complete a portion of each treatment. Two major findings were identified. First, regarding the Patient Satisfaction Questionnaire, patients with ulcerating metastatic skin lesions had numerous ideas about what should be asked to evaluate patient satisfaction with dressings. They considered the questionnaire to be an appropriate format and the questions generated by the investigator to be both important and understandable. Second, the findings of the study indicated that the Mesalt dressings received significantly more positive ratings when compared with continuous wet saline dressings for ease of application and odor control. Mesalt dressings were also significantly preferred to continuous wet saline dressings. The knowledge gained through this study is useful when helping patients decide which dressings to use in the care of ulcerating metastatic skin lesions. The Mesalt dressing appears to be a favorable choice, particularly when ease of application and odor control is important. / Applied Science, Faculty of / Nursing, School of / Graduate

Diabetes affects 25.8 million Americans. Complications related to this growing disease impact public health. One secondary complication of diabetes is changes in skin that can contribute to an increased risk for ulceration. Skin of people with diabetes has not been characterized over time nor has the skin’s acute response to exercise been assessed. The objective of this project was to establish the changes in skin properties over time, within different ambient environments, and after acute exercise. This objective sought to address the central hypothesis that skin will demonstrate decreased stiffness and increased elasticity as a result of acute physical activity. Skin stiffness, compliance, and thickness measurements of the plantar foot were compared across time and environment. Skin stiffness and compliance were also compared before and after treadmill walking. First, three devices were validated. Accuracy of the StepWatch was validated for people using assistive devices. The tissue interrogation device (TID), a novel device that measures tangential skin stiffness, and the myotonometer, which measures skin compliance, were validated using elastomer phantoms. Both were found suitable to measure plantar skin properties. Second, skin properties of 16 persons with and without diabetes were measured over time and environmental condition. Skin was variable across subjects over time, but was stable within subjects over a month, supporting the use of a repeated measures approach to interventional study on the plantar skin in people with diabetes. Previous findings for general skin characteristics were supported including the tendency for persons with diabetes to have a thinner epidermis and a thicker dermis than persons without diabetes. Tangential skin stiffness was determined to be less stiff in people with diabetes when measured in a medial-lateral direction. People with diabetes had lower tissue compliance than those without. Skin properties varied across environmental condition, supporting the consideration of testing environment when evaluating skin. Finally, changes in skin properties were evaluated in 32 persons with diabetes before and after treadmill (TM) walking. Using the TID, skin stiffness (tangential) at the great toe of people with diabetes (663.705±4.796 N/m) and without (647.753±5.328 N/m) were different (p=0.040). Stiffness immediately following TM walking did not differ from pre-walking stiffness, but subsequent trials had increased stiffness. Similar, but not significant responses were noted at the first metatarsal head. Compliance using normal loading increased after walking with statistical differences lasting 30-60 minutes.

Tropical ulcer is a very specific form of cutaneous ulceration. It occurs worldwide in most tropical and a number of subtropical areas. The disease occurs mainly in older children and young adults with children under the age of 5 and adults over 45 years rarely being affected. Ulcers occur most commonly on the lower leg but may occur on the upper limb. Although most ulcers normally heal slowly over many weeks or months, some ulcers may recur. Recognised complications include squamous cell carcinoma, gangrene and osteitis, although these are rare. A number of authors have reported on the disease and suggested diet, trauma and infection as aetiological factors for this condition. This survey was thus conducted to assess as many of these factors as possible. The study took place in 5 tropical areas, namely Zambia, Gambia, southern India, Fiji and Papua New Guinea. Consultations took place at hospitals, rural clinics, health centres and villages. Although many authors have suggested that the disease is related to malnutrition, few have objectively assessed the nutritional status of the patients and compared it with controls. Those studies which included objective assessments were limited to small areas and only investigated specific parameters. In order to investigate the immune response of the host to an anaerobic infection, the antibody levels to the organisms isolated from the ulcers were measured by an ELISA test. The local host response to an infection with a Fusobacterium species was assessed by the number of antibody secreting B-lymphocytes at the site of the ulcers. These parameters may play a role in the localisation of the ulcers and account for recurrent infections.

A terapia laser de baixa intensidade (TLBI) vem sendo utilizada no tratamento de feridas devido aos seus efeitos cicatrizantes. No entanto, espécies bacterianas podem ser detectadas em úlceras cutâneas crônicas, não estando claro quais os melhores parâmetros a serem utilizados para se obter maior eficácia da inibição das bactérias que podem vir a colonizar essas feridas, já que são escassos os estudos que associam diferentes linhagens de bactérias, com diferentes comprimentos de onda e fluências da TLBI. O objetivo do estudo foi analisar a influência da TLBI no crescimento bacteriano in vitro. Para realização do estudo foram utilizadas linhagens da S. aureus (ATCC 25923), P. aeruginosa (ATCC 27853) e E. coli (ATCC 25922), as quais foram repicadas e incubadas por um período de 24 horas, à temperatura de 37º C. Após o crescimento bacteriano, as células foram suspensas em solução fisiológica com turvação de 0,5 na escala de McFarland (1,5 X 108 UFC/mL-1). Em seguida foram realizadas cinco diluições seriadas até alcançar a concentração de 1,5 X 103 UFC/mL-1. Uma alíquota de 300 L desta suspenção foi transferida para poços da placa de microtitulação e então expostas a irradiação. A seguir uma fração de 100 L foi espalhada sobre a superfície do meio de cultura sólido Mueller-Hinton em placas de Petri (90 x 15 mm), incubada a 37° C e após 24, 48 e 72 horas foram realizadas às contagens de UFC (unidades formadoras de colônias). A irradiação laser (laserpulse - Ibramed® Amparo, SP Brasil) foi realizada nos comprimentos de onda de 450, 660, 830 e 904 nm, nas fluências de 0 (controle), 3, 6, 12, 18 e 24 J/cm2, aplicado de forma direta e perpendicular a placa, a uma distância de 2 mm, sobre uma área de 1 cm2. Todos os dados foram submetidos ao teste de normalidade Shapiro-Wilk, sendo os dados referentes a contagem das UFC submetidos ao teste de Kruskal Wallis e post hoc de Dunn com nível de significância de 5%. A irradiação laser inibiu o crescimento da S. aureus em todos os comprimentos de ondas testados, nas fluências superiores a 12 J/cm², com maiores taxas de inibição em 24 J/cm2 (79,6%). Ao analisar o comportamento da taxa de inibição bacteriana, pode-se observar uma tendência similar entre todos os comprimentos de onda. No entanto, para a P. aeruginosa a TLBI foi capaz de inibir o crescimento em todos os comprimentos de onda, somente na fluência de 24 J/cm², não sendo possível identificar um padrão de inibição. A E. coli apresentou um padrão de inibição nos comprimentos de onda de 450 e 830 nm. Para os comprimentos de onda de 660 e 904 nm pode-se identificar inibição somente em 12 e 18 J/cm2, respectivamente. Assim, pode-se afirmar que a TLBI foi capaz de inibir o crescimento bacteriano em todos os comprimentos de onda, não apresentando o mesmo padrão de inibição entre as espécies bacterianas, comprimento de onda e fluências testadas, se mantendo por até 72 horas após a irradiação. / Low level laser therapy (LLLT) has been used in treatment of wounds due your healing effects. Some bacteria\'s species can be detected in almost all chronic ulcers, being not clear which are the best parameters to more effective inhibition of bacteria that may colonize these wounds. There are just a few studies that relate different bacteria types with different wavelength and different fluence of LLLT. Thus, the study objective is analyze the LLLT effect of bacterial growth in vitro. In this study were used S. aureus (ATCC 25923), P. aeruginosa (ATCC 27853) and E. coli (ATCC 25922), which were transplanted and incubated for 24 hours at a temperature of 37° C. After bacterial growth, the cells were suspended in saline with a turbidity of 0.5 McFarland scale (1.5 X 108 CFU/mL-1). Next, five serial dilutions were performed to achieve a concentration of 1.5 X 103 CFU/mL-1. An aliquot 300 L of this suspension was transferred to wells of a microtiter plate and then exposed to irradiation. Then 100 L of a fraction was spread on the surface of solid culture medium Mueller-Hinton in Petri dishes (90 x 15 mm) plates, incubated at 37° C and after 24, 48 and 72 hours to CFU counts were made (colony forming units). The laser irradiation (Laserpulse - Ibramed® - Amparo, SP - Brazil) was performed at wavelengths of 450, 660, 830 and 904 nm, the fluence of 0 (control), 3, 6, 12, 18 and 24 J/cm2 and applied directly perpendicular to the plate at a distance of 2 mm over an area of 1 cm2. All data were subjected to test normality the Shapiro-Wilk test, and the data for CFU counts submitted to test the Kruskal Wallis test and post hoc Dunn\'s test with a significance level of 5%. The laser irradiation inhibited the growth of S. aureus in all wavelengths tested in the higher fluences to 12 J/cm2, with higher rates of 24 J/cm2 inhibition (79.6%). In analyzing the behavior of the rate of bacterial inhibition, one can observe a similar trend among all wavelengths. However, for the LLLT P. aeruginosa was able to inhibit the growth of all wavelengths, the only fluence 24 J/cm2, it is not possible to identify a standard of inhibition. E. coli showed a standard of inhibition at a wavelength of 450 and 830 nm. For the wavelengths of 660 and 904 nm can be identified only inhibition at 12 and 18 J/cm2, respectively. Thus, it can be stated that LLLT was able to inhibit bacterial growth in all wavelengths, not presenting the same standard inhibition among bacterial species, the wavelength and fluence tested by keeping for up to 72 hours after irradiation.

A terapia laser de baixa intensidade (TLBI) vem sendo utilizada no tratamento de feridas devido aos seus efeitos cicatrizantes. No entanto, espécies bacterianas podem ser detectadas em úlceras cutâneas crônicas, não estando claro quais os melhores parâmetros a serem utilizados para se obter maior eficácia da inibição das bactérias que podem vir a colonizar essas feridas, já que são escassos os estudos que associam diferentes linhagens de bactérias, com diferentes comprimentos de onda e fluências da TLBI. O objetivo do estudo foi analisar a influência da TLBI no crescimento bacteriano in vitro. Para realização do estudo foram utilizadas linhagens da S. aureus (ATCC 25923), P. aeruginosa (ATCC 27853) e E. coli (ATCC 25922), as quais foram repicadas e incubadas por um período de 24 horas, à temperatura de 37º C. Após o crescimento bacteriano, as células foram suspensas em solução fisiológica com turvação de 0,5 na escala de McFarland (1,5 X 108 UFC/mL-1). Em seguida foram realizadas cinco diluições seriadas até alcançar a concentração de 1,5 X 103 UFC/mL-1. Uma alíquota de 300 L desta suspenção foi transferida para poços da placa de microtitulação e então expostas a irradiação. A seguir uma fração de 100 L foi espalhada sobre a superfície do meio de cultura sólido Mueller-Hinton em placas de Petri (90 x 15 mm), incubada a 37° C e após 24, 48 e 72 horas foram realizadas às contagens de UFC (unidades formadoras de colônias). A irradiação laser (laserpulse - Ibramed® Amparo, SP Brasil) foi realizada nos comprimentos de onda de 450, 660, 830 e 904 nm, nas fluências de 0 (controle), 3, 6, 12, 18 e 24 J/cm2, aplicado de forma direta e perpendicular a placa, a uma distância de 2 mm, sobre uma área de 1 cm2. Todos os dados foram submetidos ao teste de normalidade Shapiro-Wilk, sendo os dados referentes a contagem das UFC submetidos ao teste de Kruskal Wallis e post hoc de Dunn com nível de significância de 5%. A irradiação laser inibiu o crescimento da S. aureus em todos os comprimentos de ondas testados, nas fluências superiores a 12 J/cm², com maiores taxas de inibição em 24 J/cm2 (79,6%). Ao analisar o comportamento da taxa de inibição bacteriana, pode-se observar uma tendência similar entre todos os comprimentos de onda. No entanto, para a P. aeruginosa a TLBI foi capaz de inibir o crescimento em todos os comprimentos de onda, somente na fluência de 24 J/cm², não sendo possível identificar um padrão de inibição. A E. coli apresentou um padrão de inibição nos comprimentos de onda de 450 e 830 nm. Para os comprimentos de onda de 660 e 904 nm pode-se identificar inibição somente em 12 e 18 J/cm2, respectivamente. Assim, pode-se afirmar que a TLBI foi capaz de inibir o crescimento bacteriano em todos os comprimentos de onda, não apresentando o mesmo padrão de inibição entre as espécies bacterianas, comprimento de onda e fluências testadas, se mantendo por até 72 horas após a irradiação. / Low level laser therapy (LLLT) has been used in treatment of wounds due your healing effects. Some bacteria\'s species can be detected in almost all chronic ulcers, being not clear which are the best parameters to more effective inhibition of bacteria that may colonize these wounds. There are just a few studies that relate different bacteria types with different wavelength and different fluence of LLLT. Thus, the study objective is analyze the LLLT effect of bacterial growth in vitro. In this study were used S. aureus (ATCC 25923), P. aeruginosa (ATCC 27853) and E. coli (ATCC 25922), which were transplanted and incubated for 24 hours at a temperature of 37° C. After bacterial growth, the cells were suspended in saline with a turbidity of 0.5 McFarland scale (1.5 X 108 CFU/mL-1). Next, five serial dilutions were performed to achieve a concentration of 1.5 X 103 CFU/mL-1. An aliquot 300 L of this suspension was transferred to wells of a microtiter plate and then exposed to irradiation. Then 100 L of a fraction was spread on the surface of solid culture medium Mueller-Hinton in Petri dishes (90 x 15 mm) plates, incubated at 37° C and after 24, 48 and 72 hours to CFU counts were made (colony forming units). The laser irradiation (Laserpulse - Ibramed® - Amparo, SP - Brazil) was performed at wavelengths of 450, 660, 830 and 904 nm, the fluence of 0 (control), 3, 6, 12, 18 and 24 J/cm2 and applied directly perpendicular to the plate at a distance of 2 mm over an area of 1 cm2. All data were subjected to test normality the Shapiro-Wilk test, and the data for CFU counts submitted to test the Kruskal Wallis test and post hoc Dunn\'s test with a significance level of 5%. The laser irradiation inhibited the growth of S. aureus in all wavelengths tested in the higher fluences to 12 J/cm2, with higher rates of 24 J/cm2 inhibition (79.6%). In analyzing the behavior of the rate of bacterial inhibition, one can observe a similar trend among all wavelengths. However, for the LLLT P. aeruginosa was able to inhibit the growth of all wavelengths, the only fluence 24 J/cm2, it is not possible to identify a standard of inhibition. E. coli showed a standard of inhibition at a wavelength of 450 and 830 nm. For the wavelengths of 660 and 904 nm can be identified only inhibition at 12 and 18 J/cm2, respectively. Thus, it can be stated that LLLT was able to inhibit bacterial growth in all wavelengths, not presenting the same standard inhibition among bacterial species, the wavelength and fluence tested by keeping for up to 72 hours after irradiation.

[ES] La Fotogrametría es una ciencia y tecnología que tiene utilidad médica creciente. Una aplicación médica destacable de la Fotogrametría es la medición de las úlceras de la piel. Las úlceras de la piel constituyen un problema médico y social importante: por su elevado coste económico, afectación de la salud y calidad de vida, frecuente cronicidad y complicaciones. La medición de la úlcera es necesaria y útil para el seguimiento clínico. La disminución de variables de tamaño de la úlcera indica su progresión hacia la cicatrización. Los procedimientos tradicionales de medición unidimensional y bidimensional, como la regla graduada y la planimetría con acetato, se siguen utilizando por su sencillez y comodidad de uso. Sin embargo, son invasivos y tienen inconvenientes técnicos, como inexactitud e imprecisión. Otros procedimientos de medición tridimensional (3D), como la inyección de líquido y los moldes de pasta, pueden tener, además, efectos adversos, como dolor, irritación o reacción alérgica. Algunos procedimientos sin contacto que utilizan técnicas de escaneo con luz estructurada o láser: 1/ necesitan dispositivos de escaneo específicos; 2/ no se ha demostrado su utilidad en la práctica clínica; 3/ tienen un coste elevado. Por otra parte, no hay un procedimiento de referencia (patrón oro) para la medición del volumen de las úlceras cutáneas. Una optimización de las técnicas utilizadas para la valoración objetiva de la evolución de las úlceras de la piel ayudaría a comparar la eficacia de los distintos tratamientos y seleccionar los más adecuados, así como predecir el tiempo de curación. Por todo lo anterior, se justifica el desarrollo de un procedimiento de medición de úlceras basado en una técnica fotogramétrica sin contacto, como la estereofotogrametría. El objetivo general de esta tesis es desarrollar un procedimiento fotogramétrico para el escaneo, medición, clasificación tisular y seguimiento clínico de úlceras cutáneas; y validar dicho procedimiento en un estudio clínico con pacientes, evaluando su fiabilidad y exactitud. El procedimiento SfM-3DULC está basado en las técnicas estereofotogramétricas SfM (Structure from Motion) y MVS (Multi View Stereo) y utiliza como software de escaneo Agisoft PhotoScan y como software de medición del modelo 3D el programa 3DULC, creado por los autores. Este procedimiento escanea y reconstruye un modelo digital 3D de la úlcera utilizando una cámara digital, con la que se adquieren una serie de fotografías desde varias localizaciones y orientaciones. Para la validación del procedimiento SfM-3DULC, se realizó un estudio piloto en el que se evaluó su fiabilidad y exactitud. También se propuso una nueva variante del procedimiento ImageJ, en la que se utiliza una ortofotografía (Ortho-ImageJ), para medir el área proyectada. Por último, se compararon las mediciones realizadas por un grupo de dermatólogos y otro grupo de no expertos. Todas las variables medidas por dermatólogos usando SfM-3DULC mostraron excelentes puntuaciones de fiabilidad intra-evaluador (ICC > 0.99) e inter-evaluador (ICC > 0.98). En conclusión, el software 3DULC desarrollado, en su versión 1.0: 1/ Interviene en la fase de medición de la úlcera cutánea, tras su escaneo. 2/ Es autónomo respecto al procedimiento de escaneo, y podría utilizarse junto a cualquier otra técnica que obtenga una nube de puntos de la úlcera cutánea. 3/ Detecta el contorno de la úlcera de forma asistida basándose en su respuesta espectral. 4/ Clasifica las zonas de la úlcera cutánea según su tipo de tejido utilizando un árbol de decisión. 5/ Mide las siguientes variables morfométricas de la úlcera cutánea: coeficiente de circularidad, coeficiente de lisura, longitud máxima, perímetro, profundidad máxima, área proyectada, área de la superficie excavada, área de la superficie de referencia y volumen. 6/ Presenta los resultados con un informe HTML que facilita la interpretación por personal sanitario. / [CA] La Fotogrametria és una ciència i tecnologia que té utilitat mèdica creixent. Una aplicació mèdica destacable de la Fotogrametria és el mesurament de les úlceres de la pell. Les úlceres de la pell constitueixen un problema mèdic i social important: pel seu elevat cost econòmic, afectació de la salut i qualitat de vida, freqüent cronicitat i complicacions. El mesurament de l'úlcera és necessària i útil per al seguiment clínic. La disminució de variables de mida de l'úlcera indica la seva progressió cap a la cicatrització. Els procediments tradicionals de mesurament unidimensional i bidimensional, com el regle graduat i la planimetria amb acetat, es continuen utilitzant per la seva senzillesa i comoditat d'ús. No obstant això, són invasius i tenen inconvenients tècnics, com inexactitud i imprecisió. Altres procediments de mesurament tridimensional (3D), com la injecció de líquid i els motles de pasta, poden tenir, a més, efectes adversos, com dolor, irritació o reaccions al·lèrgiques. Alguns procediments sense contacte que utilitzen tècniques d'escaneig amb llum estructurada o làser: 1 / necessiten dispositius d'escaneig específics; 2 / no s'ha demostrat la seva utilitat en la pràctica clínica; 3 / tenen un cost elevat. D'altra banda, no hi ha un procediment de referència (patró or) per al mesurament del volum de les úlceres cutànies. Una optimització de les tècniques utilitzades per a la valoració objectiva de l'evolució de les úlceres de la pell ajudaria a comparar l'eficàcia dels diferents tractaments i seleccionar els més adequats, així com predir el temps de curació. Per tot l'anterior, es justifica el desenvolupament d'un procediment de mesurament de úlceres basat en una tècnica fotogramètrica sense contacte, com la estereofotogrametría. L'objectiu general d'aquesta tesi és desenvolupar un procediment fotogramètric per a l'escaneig, mesurament, classificació tissular i seguiment clínic d'úlceres cutànies; i validar aquest procediment en un estudi clínic amb pacients, avaluant la seva fiabilitat i exactitud. El procediment SFM-3DULC està basat en les tècniques estereofotogramétricas SFM (Structure from Motion) i MVS (Multi View Stereo) i utilitza com a programari d'escaneig Agisoft PhotoScan i com a programari de mesurament de el model 3D el programa 3DULC, creat pels autors. Aquest procediment escaneja i reconstrueix un model digital 3D de l'úlcera utilitzant una càmera digital, amb la qual s'adquireixen una sèrie de fotografies des de diverses localitzacions i orientacions. Per a la validació de l'procediment SFM-3DULC, es va realitzar un estudi pilot en el qual es va avaluar la seva fiabilitat i exactitud. També es va proposar una nova variant del procediment ImageJ, en què s'utilitza una ortofotografia (Ortho-ImageJ), per mesurar l'àrea projectada. Finalment, es van comparar les mesures realitzades per un grup de dermatòlegs i un altre grup de no experts. Totes les variables mesures per dermatòlegs usant SFM-3DULC van mostrar excel·lents puntuacions de fiabilitat intra-avaluador (ICC> 0.99) i inter-avaluador (ICC> 0.98). En conclusió, el programari 3DULC desenvolupat, en la seva versió 1.0: 1 / Intervé en la fase de mesurament de l'úlcera cutània, després de la seva exploració. 2 / És autònom respecte a l'procediment d'escaneig, i podria utilitzar-costat de qualsevol altra tècnica que obtingui un núvol de punts de l'úlcera cutània. 3 / Detecta el contorn de l'úlcera de forma assistida basant-se en la seva resposta espectral. 4 / Classifica les zones de l'úlcera cutània segons el seu tipus de teixit utilitzant un arbre de decisió. 5 / Mesura les variables morfomètriques de l'úlcera cutània: coeficient de circularitat, coeficient de llisor, longitud màxima, perímetre, profunditat màxima, àrea projectada, àrea de la superfície excavada, àrea de la superfície de referència i volum. 6 / Presenta els resultats amb un informe HTML que facilita la interpretació per personal sanitari. / [EN] Photogrammetry is a science and technology of increasing medical utility. A notable medical application of photogrammetry is the measurement of skin ulcers. Skin ulcers are a major medical and social problem: due to their high economic cost, impact on health and quality of life, frequent chronicity and complications. Ulcer measurement is necessary and useful for the clinical follow-up. Decreasing ulcer size variables indicate progression towards healing. Traditional one- and two-dimensional measurement procedures, such as the graduated ruler and acetate planimetry, are still used because of their simplicity and ease of use. However, they are invasive and have technical drawbacks, such as inaccuracy and imprecision. Other three-dimensional (3D) measurement procedures, such as liquid injection and paste moulds, may also have adverse effects, such as pain, irritation or allergic reaction. Some non-contact procedures that use structured light or laser scanning techniques: 1/ require specific scanning devices; 2/ have not been demonstrated to be useful in clinical practice; 3/ are expensive. Moreover, there is no reference procedure (gold standard) for the measurement of skin ulcer volume. Optimisation of the techniques used for the objective assessment of the evolution of skin ulcers would help to compare the efficacy of different treatments and to select the most appropriate ones, as well as to predict healing time. Therefore, the development of an ulcer measurement procedure based on a non-contact photogrammetric technique, such as stereophotogrammetry, is justified. The main objective of this thesis is to develop a photogrammetric procedure for the scanning, measurement, tissue classification and clinical follow-up of skin ulcers; and to validate this procedure in a clinical study with patients, evaluating its reliability and accuracy. The SfM-3DULC procedure is based on the stereophotogrammetric techniques SfM (Structure from Motion) and MVS (Multi View Stereo) and uses Agisoft PhotoScan as scanning software and 3DULC as 3D model measurement software. This procedure scans and reconstructs a 3D digital model of the ulcer using a digital camera, which acquires photographs from various locations and orientations. In order to validate the SfM-3DULC procedure, a pilot study was conducted to assess its reliability and accuracy. A new variant of the ImageJ procedure was also proposed, in which an orthophotography (Ortho-ImageJ) is used to measure the projected area. Finally, measurements made by a group of dermatologists and a group of non-experts were compared. All the variables measured by dermatologists using SfM-3DULC showed excellent scores of intra-rater reliability (ICC > 0.99) and inter-rater reliability (ICC > 0.98). In conclusion, the 3DULC software developed, in its version 1.0: 1/ Is used to measure the skin ulcer, after its scan. 2/ Is autonomous with respect to the scanning procedure, and could be used with any other technique that obtains a point cloud of the skin ulcer. 3/ Outlines the edge of the ulcer semi-automatically, based on its spectral response. 4/ Classifies skin ulcer areas according to their tissue type, using a decision tree. 5/ Measures the following morphometric variables of the skin ulcer: circularity coefficient, evenness coefficient, maximum length, perimeter, maximum depth, projected area, surface area, reference surface area and volume. 6/ Presents the results with an HTML report that facilitates its interpretation by healthcare personnel. / Esta tesis doctoral fue financiada con una beca predoctoral de la Generalitat Valenciana – Consellería de Educación, Investigación, Cultura y Deporte, y el Fondo Social Europeo (ACIF/2018/160). / Sánchez Jiménez, D. (2022). SfM-3DULC: Desarrollo y validación de un procedimiento fotogramétrico para el escaneo, medición, clasificación tisular y seguimiento clínico de úlceras cutáneas [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/181691