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contamination, but it is also time-consuming and
expensive [12]. The device lacks the ability to
accurately identify the epithelial age of the
wound and is operator dependent.
31.4.4 Digital Imaging
An image of the wound is captured and transferred to a computer. The margin of the wound is
traced using a pointing device and the software
uses a scale near the wound on the photo to calculate the area. Some authors evaluated a handheld device provided by a laser scanner designed
to measure wound surface area and depth [13].
The system was found to be fast and easy to handle and had high intra- and inter-rater reliability
for large wound rather than small ulcers [14]. A
handheld wound measurement device, based on
smartphone technology, seems to be accurate at
different distances and angles. Digital imaging is
a non-contact method that is equally accurate and
reliable as planimetric methods [15]. Digital
images are the most cost-effective [16], noninvasive, and the easiest approach for highresolution wound recording and size measurement
[17]. However, it is also time-consuming and can
be affected by the illumination, location, and size
of the wound.
The high resolution of modern digital images
allows us to have an accurate analysis, not only
the lesion morphology, but also the acquisition of
colour images, that provides a qualitative estimate of the various types of tissue present in the
lesion and in the peri-wound skin [18]. Due to its
reliability, the acquisition of digital photographs
has become the gold standard for testing new
imaging methods. A disadvantage of this method,
especially those performed with cheaper systems, is the inability to assess lesion depth in 2D.
Modern systems provide the depth parameter
by means of algorithms for RGB images processed by image-processing algorithms (segmentation, edge detection, colour processing, active
contour, and volumetric information), allowing
accurate boundary delineation and enabling 3D
reconstruction [3]. Using digital images, it is possible to automatically or semi-automatically
establish the exact size of the skin lesions in each
spatial axis [19]. By implementing digital photography with special analysis software, it is possible to perform a qualitative and quantitative
analysis of the wound bed and wound edges to
convert even colour scales into reproducible
qualitative-quantitative measures. It is possible to
quantify necrosis, brin, rate of reepithelialization, or a particular type of infection,
providing a kind of global overview of the wound
with reliable and reproducible results even over
time and for different ulcers [20]. The use of statistical models allows to predict the evolution of
chronic wounds by monitoring the trend over
time. Standardization of any imaging method is
the best way to consent the reproducibility of the
measurement.
The digital imaging method is equally accurate and reliable compared to the planimetric
approach and is a non-contact method, eliminating the risk of wound contamination [21]. Digital
images can be affected by the illumination, location, and size of the wound, and variations in
camera angle can lead to underestimation of the
wound area [22]. The method is also timeconsuming from the instant the image of the
wound is captured by the camera until the wound
area is estimated by the software.
31.4.5 Wound Volume Measurement
Several 3D techniques for measuring wound volume have been proposed. MAVIS (Measurement
of Area and Volume Instrument System) is a noninvasive method using color-coded structured
light. The camera provides a serial photo used in
a mathematical algorithm resulting in a 3D reconstruction of the wound. It has been described a
3D optical scanner based on structured light integrated with a thermal imager able to measure
wound size and detect the inammation [23].
LifeViz® (QuantiCare, San Mateo, CA) is a 3D
system with a high inter-rater reliability for volume measurements (ICC= 0.9867; P <0.001).
When compared with the simple ruler method,
only measurements of width showed a signicant
difference (P<0.0001) while surface area, depth,
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V. Dini and G. Granieri
and length values were similar [24]. In the Derma
project, a 3D laser scanner was developed based
on the Minolta Vivid 910® scanner (Konica
Minolta, Osaka, Japan) to measure wound size
and classify tissue [25]. The ICC was 0.9832 for
intra-rater reliability and 0·9714 for inter-rater
reliability [26]. Some authors also evaluated a
laser-assisted wound measuring device
(Silhouette Star®, Aranz medical, New Zealand),
but found that this 3D device underestimated
depth and volume (P < 0.05) [27]. Kecelj
Leskovec, etal. evaluated a handheld laser-based
3D measuring device consisting of a laser projector and a digital camera [28]. The laser projector
illuminates the wound with light planes and the
camera records the wound from different angles.
The image is transferred to a computer and reconstructed into a 3D image. The system was found
to be fast, small, easy to handle, and non- invasive,
but determining wound edges and skin irregularities around a wound can be challenge.
31.4.6 Advanced Wound Imaging
Methods
A various advanced imaging tools will be available in the future in the wound research eld.
31.4.6.1 Hyperspectral Imaging (HSI)
A non-invasive optical imaging method can
quantify wound oxygenation and perfusion
parameters [29, 30].Through this method, objective information on the physiology and biochemistry of wound patterns can be obtained [31].
Hyperspectral sensors (detectors) evaluate the
reectance information of an object and provide
reectance spectra for each pixel in the image.
The data thus acquired can be used to reconstruct
3D models. Compared with other optical systems
(such as earlier RGBs, laser-based systems, or
magnetic resonance imaging), HSI has several
advantages such as high achievable spatial resolution and spectral resolution beyond the visible
range. On the other hand, these methods are
expensive and numerous standardized databases
are needed for the proper acquisition of data in a
standardized and reproducible manner [32].
31.4.6.2 Laser Doppler Imaging (LDI)
Laser Doppler perfusion imaging (LDI) allows to
quantify microcirculatory ow in a well-dened
region of interest (ROI) of the skin. Blood ow
analysis can also be integrated with other classical imaging methods such as digital photography
and has been applied for assessment of burns,
scars, pressure ulcers, diabetic foot ulcers, and
venous leg ulcers. Several studies have shown
greater accuracy in predicting the prognosis of
various burn wounds than clinical data alone
[22]. LDI was used to study the microcirculation
of diabetic wounds burns and pressure ulcers. It
has been shown that in stage 1 pressure ulcers,
there is a difference in blood perfusion between
the skin areas of the pressure ulcers and the periwound undamaged skin [33].
31.4.6.3 Laser Speckle Imaging (LSI)
Laser speckle contrast imaging (LSI) is a strictly
qualitative laser-based imaging technique used to
study perfusion. Unlike the LDI technique
described above, this imaging technique is used
to provide quality data on a larger surface. The
advantage of this type of acquisition is that it can
be done quickly almost instantaneously [22].
31.4.6.4 Near-Infrared Spectroscopy
(NIRS)
Near-infrared spectroscopy (NIRS) is based on
the different degree of light absorption in the
near-infrared spectrum of tissue components
with different oxygenation state. The reected
near-infrared light is collected by a detector and
analysed to provide measurements of chromophore content. NIRS has a potential use in
wound assessment, in wound depth measurement and quantication of oedema. In diabetic
wounds in animal models, it has been shown to
differentiate diabetic ulcers, based on reduced
perfusion and greater tissue disorganization
than in nondiabetic controls. NRIS methods
have also been used to analyse the process of
lesion neovascularization [15].
31.4.6.5 Thermography
Thermography is a non-invasive method and represents one of the most technically developed
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methods of thermal imaging. When this technique is used under controlled conditions, the
information recorded supersedes the data
obtained from other thermometers.
Dynamic active thermography (ADT) is an
advanced thermographic technique that involves
recording steady-state temperatures using a standard IR camera following thermal excitation of
the tissue by a light source, usually halogen
lamps. A second set of temperature measurements is taken after thermal excitation, and subsequent analysis allows quantication of the
thermal diffusivity of tissue components and
wound regions [34]. Liquid crystal thermography
(LCT) uses a plate of thermochromic liquid crystals to measure tissue temperature distribution
[35, 36]. Liquid crystals absorb heat radiated
from the tissue, and the plate emits a spectrum of
colours that correlates with temperature readings.
The infrared scanning has been used to predict
burn depth with 90 percent accuracy, conrmed
by histology [37]. These predictions were based
on the simple principle that supercial burns may
be warmer than healthy skin for the inammatory
process, while deeper burns would be colder than
healthy skin due to vascular damage.
Studies comparing static thermography
methods with dynamic methods have demonstrated the superiority of the latter in terms of
accuracy, specicity, and sensitivity in determining the degree of depth of burn wounds [27].
Thermographic devices are cheaper and easier
to use than laser methods (LDI), and are much
more accurate than visual assessment. In the
evaluation of the diabetic foot, it has been established that increased temperature can be considered a reliable marker of inammation by
providing predictive data on the risk of ulceration at the different sites explored and has also
been correlated with the risk of amputation and
infection [38]. The elevated resolution and noninvasiveness of thermographic systems make
them valuable options for the detection and
diagnosis of several skin diseases or abnormalities, including infections, inammatory processes, or malignancies characterized by
increased skin temperature.
The main limitations are due to technical difculties such as proper positioning of the patient
and lack of correlations with validated quantitative scales [22].
31.4.7 Other Devices Are asFollows
Videomicroscopy allows the visualization of
skin tissue at the cellular level and can be used
for non-invasive histological analyses [39]. It
measures directly, without artifacts caused by
histological sampling, the microstructures of
wound and periwound micro-vascularization.
Optical Coherence Tomography (OCT)
generates high-resolution images of tissue microstructure in 2D images by exploiting low coherence interferometry [22].
A variant of OCT that takes advantage of the
bi-refringence characteristics of tissue elements
(e.g., collagen) is polarization-sensitive OCT
(PS-OCT), using a polarizer, we can determine
the depth of lesions with an accuracy comparable
to histological analysis [40]. Ultra-highresolution OCT allows identication of wound
size, epidermal migration, dermal-epidermal
junction formation, and wound composition,
lending itself as a detailed and non-invasive metric of wound healing. OCT can be used to monitor wound re-epithelialization, as it accurately
differentiates epidermal and dermal layers.
31.4.7.1 Fluorescence Imaging (FLIM)
FLIM and second harmonic imaging (SHG) were
combined and used in the study of wound healing. Through FLIM, cell metabolism rates can be
monitored by measuring NADH levels while
SHG can assess collagen deposition at the wound
bed site. These methods taken together are comparable to histochemical analysis and may be
suitable for the study of the wound healing process [41].
Devices that assess the uorescence of
endogenous bacterial porphyrins non-invasively
and in real-time have also been proposed. Grampositive bacteria emit a red uorescence, while
pyoverdine of Pseudomonas aeruginosa and
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V. Dini and G. Granieri
other Gram-negative bacteria emit a cyan uorescence. Light green uorescence corresponds
to slough, dark green uorescence to granulation tissue, black color for necrotic tissue and
dark red- purple- black for vascularized areas
[42]. Le, et al used this technology on 350
patients. They found that 82% had bacterial
loads >104CFU/g with failure to detect infection in 85% of cases using the Clinical Signs
and Symptoms Checklist (CSSC) assessment
alone [43]. In a retrospective study, including
229-foot ulcers, uorescence imaging was correlated with a 49% reduction of antimicrobial
dressings, a 33% in systemic antibiotic, and a
23% increase in wound healing rate [44].
31.4.7.2 Confocal Microscopy (CM)
CM is a high-resolution optical detection technique using a light source and lens that allows
images to be acquired at multiple depth levels.
The greatest advantage of this technique is based
on the ability to evaluate the skin in vivo by
applying a kind of real-time cyto-histology providing information on histologic cellular and
architectural morphology of epidermis, dermis,
and skin appendages. By changing the focal
depth, this technique acquires a series of horizontal section images, which can be reprocessed to
provide a nal image.
been used to evaluate the supercial layers of the
skin, wounds, and scar [49]. Moreover, Doppler
signal can study the microcirculation within the
wound edge and wound bed allowing to provide
prognostic parameters of the wound healing
process.
31.5 Conclusion
The documentation of time-evolution wound area
and characteristics are important for the monitoring of the healing and effectiveness of the treatment. The assessment of wound requires an
effective and accurate measurement in a precise,
user friendly, and reproducible method. The
objective measurement of physical parameters
related to the wound bed and the surrounding
skin has increased exponentially due to the development of new technologies. Over the recent
past, several developed objective and noninvasive
techniques for wound assessment have been
developed. These techniques are important
research tools to investigate the different phases
of wound healing and to determine potential therapeutic effectiveness of drugs and devices. Many
of the devices used in research today will be
modied for clinical practice in the future.
31.4.7.3 Ultrasound
Conventional ultrasound (US) (frequency< 15 MHz) and Doppler US evaluation
are frequently used in diagnostic and therapeutic
algorithms of chronic lower extremity, to evaluate the nature of the lesions and identify the presence of alterations in the deep and supercial
circulation [45, 46].
US has also been used to study the depth of
wounds and dene the involvement of various
skin structures [47]. When evaluating a skin
wound with US, it is recommended that highly
trained personnel is recruited, because this technology is operator dependent [48].
High frequency ultrasound (frequency > 15 MHz) (HFUS) and ultra-high frequency ultrasound (frequency > 50 MHz)
(UHFUS) with Doppler signal evaluation have
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Telemedicine andArticial
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Intelligence
MicheleBlasina, MartinaPangos,
andSergioPillon
32
Telemedicine (tèle, from the gr. far) is understood
as a mode of healthcare service delivery and consists of the transmission of medical and healthcare information useful to supplement traditional
healthcare provision, increasing its effectiveness
and efciency.
This is exercised ‘at a distance’ with the function of prevention, continuous monitoring of vital
parameters, diagnosis of pathologies and treatment. Further services that can be provided are
rehabilitation and care.
This system, which was imagined as early as
the nineteenth century and developed in its modern sense in the mid-nineteenth century, is mainly
based on the use of computer systems that guarantee synchronicity and remote viewing of information, but above all put operators and patients
in close communication with each other.
The advantages it offers are numerous and by
now well known: equity of access to care, allowing rural communities far from treatment centres
M. Blasina
Inrmary Outpatient Wound Care Clinic, University
Health Company (ASUGI), Trieste, Italy
M. Pangos
Outpatient Wound Care Clinic, University Health
Company (ASUGI), Trieste, Italy
e-mail: martina.pangos@asugi.sanita.fvg.it
S. Pillon (*)
Digital Transformation Department, ASL Frosinone,
Frosinone, Italy
e-mail: sergio.pillon@aslfrosinone.it
to be reached; continuity of care, especially for
patients with chronic diseases.
Probably, for the purposes of patient safety,
the most signicant aspect is that of nding clinical health information in a synchronous mode,
reducing waiting times and allowing continuous
communication between clinician and patient. In
support of this, a 2016 systematic review performed in the context of chronic ulcer patients
indicated that the integrated use of Telemedicine
systems reduced the number of hospitalizations
by 72% and the use of ambulances for transfer to
centers by 56%.
As is well known, the opportunity to reduce
the number of avoidable transfers translates into
increased compliance on the part of users and at
the same time satises a need for training of local
health workers, who benet from the consultation of a specialized operator.
Thus, these systems, if correctly used, entail
an inevitable reduction in accesses and, in perspective, in costs relating to improper admissions
or avoided admissions; in support of this, a systematic review associated with a subsequent
meta-analysis highlighted the extent to which
Telemedicine systems reduced the risk of amputation, even though they did not signicantly
affect healing times of injuries of various kinds.
Finally, a systematic review from 2010 to
2017 regarding the use of telemedicine in plastic
surgery and dermatology indicated that it was
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_32
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“safe” and had comparable or superior efcacy to
the traditional in-person visit.
In the European context, the rst countries to
equip themselves with these systems were those
in the Scandinavian area, which are most affected
by low population density phenomena, where
long distances need to be covered to reach highintensity care centers. This has gone hand in hand
with massive digitization of healthcare systems, a
fundamental prerequisite for integration to ERM
(electronic records management) systems.
One aspect considered fundamental, necessary,
is that of maintaining privacy in every step of telemedicine use; this can only be achieved through
support of a technical center and protected enabled
devices and for the use of these images.
Listed below is a summary of the healthcare
services that can be delivered under Telemedicine,
as described in the “Organizational Guidelines
Containing the Digital Model for the
Implementation of Home Care” formulated under
the National Recovery and Resilience Plan 2022.
Televisit: Televisit is a health act in which the
physician interacts remotely with the patient and
may result in the prescription of medications or further clinical insights. This act therefore allows
transfer health information without moving the
patient, thus ensuring continuity of care and
enabling the assessment of treatment choices and
the progress of the clinical picture from time to
time.
Teleconsultation: This is a remote consultation activity between physicians that allows a
physician to seek the advice of one or more physicians regarding a patient’s clinical situation.
Teleconsultation among professionals can also
take place asynchronously, meaning without the
requesting physician being connected while waiting to receive feedback from the physician(s) to
whom he/she has requested the consultation. In
addition, teleconsultation can also take place
with the presence of the patient, i.e., it is carried
out in real time using operational modalities similar to those of Televisita and is congured as a
multidisciplinary visit.
Medical Teleconsultation This is a health
activity, not necessarily medical but still specic
to the health professions. It consists of a request
for support during the performance of healthcare
activities, which is followed by a video call in
which the health professional being addressed
provides the other, or others, with guidance in
decision-making and/or the proper execution of
care actions directed toward the patient.
Teleconsultation can be conducted in the presence of the patient, or in a deferred manner.
Telehealth: It is a professional act pertaining
to the related health profession (nurse/physiotherapist/logopedist/etc.) and is based on the
remote interaction between the professional and
patient/caregiver through a video call, to which
the sharing of referral data or images can be
added if necessary. The purpose of telehealth is to
facilitate the proper performance of care activities, which are mostly performed at home.
Telemonitoring: Allows the remote sensing
and transmission of vital and clinical parameters
on a continuous basis, thanks to sensors that
interact with the patient (biometric technologies
with or without applied parts).The objective of
tele-monitoring is to over time control the trend
of the detected parameters, allowing both the
detection of parameters with greater frequency
and uniformity than previously possible, and the
reduced need for the patient to perform outpatient checks in person.
Telecontrol: Medical telecontrol enables
remote monitoring of the patient. This activity is
characterized by a cadenced series of contacts
with the physician, who puts the progress of the
clinical picture under control, by means of video
call in association with the sharing of clinical
data collected from the patient, both before and
during the same video call.
Telerehabilitation: It is a healthcare activity
pertaining to health professionals; it consists of the
remote delivery of services and performances
intended to enable, restore, improve, or otherwise
maintain the psychophysical functioning of people
of all age groups, with congenital or acquired disabilities or disorders, or at risk of developing them.
The use of Teletechnologies properly applies
to the eld of chronic skin ulcers, given the
essentially clinical approach that underlies the
initial assessment and monitoring of the appearance of the lesions.
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The use of Telemedicine in these healthcare
pathways makes it possible to optimize the whole
social-health management in the following
aspects:
• Increased intensity of care with improved
quality of life for patients.
• Real-time involvement of expert nurses and
medical specialists by the patient and
caregivers.
• Future transfer of activities to self-care and
task shifting, which reduce and optimize pro-
fessionals’ work time.
No treatment comes without difculties or
disadvantages; Telemedicine in the setting of
chronic wounds suffers from dependence on
other caregivers to take photos or videos does not
return sensations such as touch or smell at the
time of assessment, if used in exclusively photographic mode may not provide sufcient information on depth, quantity, and quality of
exudate.
In the clinical experience of the writer,
Telemedicine in the home setting is an incredible
advantage because it connects users, clinical situations, and especially professionals by avoiding
travel, which not only brings economic and practical benets but also can be incorporated into
environmental sustainability projects for
decreased automobile pollution.
With this digital data sharing organization, it
has been possible to remotely monitor patients
leaving the hospital with virtuous pathways of
caretaking, for example, for outcomes of operations such as skin aps or orthopedic surgeries,
limb infections, and to accompany the evaluation
of effectiveness of tools such as negative pressure
therapy. The only problems might arise from
issues with lighting and environment that may
negatively affect the effects of the call; for example, a difcult location of a lesion may be difcult to medicate but equally difcult to frame
with a lens.
Telemedicine also seems to have the additional effect of making the person feel safer
through the increased connection with specialists
and practitioners, and thus feel more taken care
of; this factor certainly positively inuences healing, a factor observed in a Telemedicine pilot
project performed on 30 home users with difcult wounds in the province of Trieste in which
no one had to physically go to a third-level
hospital.
However, paraphrasing a far more famous
phrase, done with telemedicine, we now need
to be Telemedics and Telehospitalists. Today,
Televista, Teleconsultation, Telehealth and
fully electronic prescribing, without the paper
“reminder” part, are entering the NHS with
force. Even reimbursability, which seemed like
an obstacle, has proven to be a false problem:
specic- regional codes, analogy, even co-pay
exemption for Tuscany region. The Italian
Ministry of Health guidelines, for example, for
the resumption of outpatient activities recommend the use of teleview and teleconsultation,
and a very recent document “Guidelines for
Telemedicine Services” (not only home and
not only in the NHS) published in the Ofcial
Gazette in November 2022 expresses very
clear concepts of scenario and operational
detail [1].
With some problems with Italian constructs
and a few typos, the minister of health in consultation with the minister delegated for technological innovation and digital transition, just before
the end of the Draghi government, published the
guidelines document in the Ofcial Gazette. For
medical colleagues, these are not guidelines as
we usually understand them, they are not based
on established evidence, they do not give parameters on the strength of recommendations, they
are real rules.
The decree reads as follows:
1. The “Guidelines for Telemedicine Services-
Functional Requirements and Levels of
Service,” referred to in Article 12, paragraph
15 -undecies, of Decree-Law No. 179 of
October 18, 2012, set forth in Annex A to this
decree, which constitutes an integral part
thereof, are approved.
2. The Guidelines referred to in the preceding
paragraph establish the technical requirements essential to ensure national homogeneity
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and efciency in the implementation of telemedicine services.
Who, how, what, when and where.
It would thus seem to be exclusively about
technical rules; in fact, the decree goes into more
than just technical aspects in the annex mentioned above. One of the very rst paragraphs
deserves to be fully read and is titled “Population.
In order for a care recipient to benet from telemedicine services implemented at the regional
level, he must be eligible from a clinical, technological, cultural point of view and according to
the autonomy or availability of a caregiver , if
necessary, in the use of telemedicine services.”
This sentence is important because it denes the
basis of telemedicine and, the one addressed in
the document, is clearly dened. We know that
the term telemedicine does not mean much, telemedicine is dened by healthcare acts performed
with “tele” in front. In this decree, it is clearly
stated that” the minimum services that the
regional telemedicine infrastructure must provide
are as follows:
• Televisit.
• Teleconsultation/Teleconsultation.
• Telemonitoring.
• Telehealth.
Going back to the patient, for each of the four
activities described in the previous paragraph, the
patient must be eligible according to four
parameters:
• The clinic.
• The technology available to him or her.
• he culture,
• The level of autonomy or availability of sup-
port (caregiver or similar).
As a result, we have a potentially explosive
mix of responsibilities from which, for example,
for item A, there is a specic assessment 1,2,3,4;
for item B, another assessment of parameters
1,2,3,4 because they are obviously different
healthcare acts and require different clinical,
technological, caregiving assessments, and digital skills.
The OJ explains that “since telemedicine is a
remote service, certain capabilities and technological equipment are required as well as compatible clinical conditions for the service;
therefore, it is necessary to assess whether the
patient is “enrollable“ for this type of service.”
Unfortunately, to date, it is not known what
the cultural, technological, clinical, and autonomy parameters are, so someone will have to
decide, again hoping not to have to explain to a
judge, why this unfortunate person made that
choice to prescribe, for example, telemonitoring
on that patient, who then died during telemonitoring due to a missed clinical, cultural, technological, or autonomy problem. Guidance on
enrollment in the guidelines goes on to point to
the rst person in the chain of judgment:
“Clinical eligibility is at the unchallengeable
judgment of the physician, who, based on the
patient’s clinical and social conditions, will consider whether to offer the patient telemedicine
services (e.g., a follow-up visit in televised
mode). In addition, both the suitability and the
technological equipment the patient has (e.g.,
smartphones with adequate features for the
installation of specic televisit apps), and the
ability to use the appropriate telemedicine kits
will be evaluated. In the latter case, an inspection
may also be necessary to verify the physical,
infrastructural and hygienic characteristics of the
patient’s home. Contextually, aspects related to
the digital literacy of the patient and/or caregiver
should be veried in order to assess the appropriateness of the devices and the degree of autonomy in their use.”
Having established, in the rst place, through
these Italian regulations, that clinical eligibility is
in the unquestionable judgment of the physician,
on what guidelines, evidence, documents can the
poor man rely on to support his “unquestionable
judgment”? Of course, there are solutions:
AiSDeT (Italian society of Digital health and
telemedicine, have decided to pursue an intersociety forum by summoning the general states
of telemedicine, because while some scientic
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