1 Fundamentals of Chronic Wound CareNamchi Le, MD This presentation contains confidential and proprietary information of Healogics™ Hospital partner or physician must first secure the express written consent of Healogics before disclosing the same to any third party. © 2016 by Healogics, Inc. All rights reserved

2 1) The ideal wound dressing....(select all that apply):Maintains wound bed moisture balance without maceration Is cost effective Causes minimal pain on removal Prevents microbial re- contamination 10

3 2) Hyperbaric oxygen therapy ....(select all that apply):Derives its therapeutic benefit through the creation of reactive oxygen and nitrogen species Is an adjunctive healing tool utilized in the advance wound care center Has no effect on the inflammatory healing phase Supports growth factor production 10

4 3) A pressure ulcer that proceeds into, but not beyond, the subcutaneous layer is correctly staged as- 1 2 3 4 10

5 4) The primary mechanism by which hyperbaric oxygen treatment increases oxygen delivery to hypoxic tissues is via- Transport dissolved in plasma Transport by diffusion through the skin Transport bound to hemoglobin Transport by absorption into leukocytes, eosinophils, and basophils 10

6 5) All patients with a lower extremity ulcer or wound require a vascular assessment beyond a simple pulse examination True False 10

7 What is a Chronic Wound? “An insult or injury that has failed to proceed through an orderly and timely repair process to produce anatomic and functional integrity” ‘To begin with, we need to define the playing field, so the first question is …’ Masoro and Austad, 2006 ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

8 By the Numbers… …the cost of “success”?Chronic wounds affect 6.5 million Americans per year at a treatment cost of $25 billion per year Additional $39 billion in lost wages per year $15.3 billion estimated expense on wound care products in 2010 To answer this question, we simply need to do a little math… …the cost of “success”? ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

9 with Diabetes MellitusThe Cost of Failure: 26 million Americans with Diabetes Mellitus Well if there is a cost to success, what is the cost of failure? Let’s consider the 26 million American diabetics… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

10 20% will develop a wound… … 20 % of whom will develop a wound in there lifespan… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

11 …increasing their risk of amputation by 46%...©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

12 …27% require a 2nd amputation within the year…©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

13 …65% are dead 5 years later (clip art of a cross/ grave)©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

14 SKIN 101: Anatomy From an anatomic perspective the skin is composed of three layers, the epidermis -(‘trb’)-thin/avascular, regenerates every 4-6 wks, barrier to microbes and our environment. The dermis- (‘tf’)thicker/tensile strength, functional elements of skin (vessels, follicles, cells of regeneration (fibroblasts). The Sub q (‘mac’) major n/v/l, adipose and connective tissue (Hess & Kirsner, 2003) ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

15 SKIN 101: Functions Protects internal structures Sensory perceptionTemperature and fluid regulation Metabolism and absorption Immunologic role Social communication Read …and it’s important in self esteem. If you don’t think so, keep in mind that there are an estimated 50k tanning salons in the US alone, with 5% of Americans as regular customers. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

16 SKIN 101: Physiology (How Do Wounds Heal?)First Day of injury- Hemostasis - Vasoconstriction, platelet release, clot formation First Week- Inflammation - Vasodilation - Neutrophils and macrophages clean the wound and produce growth factors First Month- Proliferation - Angiogenesis - Collagen fiber synthesis by fibroblasts First Year- Maturation -Shrinking and strengthening of the scar read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

17 When Things Go Wrong… Wound Detectives We need to become HistoryLocation Size Appearance of the wound’s edge bed periphery Wound Detectives “However, when things go wrong and healing stops or fails to proceed accordingly, we need to become wound detectives… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

18 Size Does Matter Size Width Length Depth Tunneling UnderminingAnd perhaps contrary to popular belief, size DOES matter in wound care at least. Wound Measurements are important in assessing the progress of wound closure , as well as helping us communicate effectively as wound care providers. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

19 TIME Is Critical! …And we need to remember that in wound care, as in many other things, TIME is critical. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

20 Take TIME to Assess the WoundTissue viability Infection Moisture content Edge evaluation We need TIME to assess the wound. What is TIME you ask?...It s an acronym for a bedside tool to help me evaluate wounds in a systematic fashion in my clinic. Let’s look at some examples… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

21 T = Tissue viability T = TissueNonviable tissue in a wound bed is a deterrent to healing and must be removed… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

22 I = Infection IS the wound infected? First, we need to remember that low levels of bacteria in the wound may actually be beneficial to healing by stimulating proteolytic enzymes and neutrophil release. Second, We need to distinguish between contaminated wounds (contain low #s of non replicating bacteria), colonized wounds (replicating bacteria without a host response) and infected wounds (high bacterial burden with a host response that delays healing including erythema, pain, and purulent discharge) ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

23 M = Moisture Balance A clean moist wound bed is critical for epithelial cell migration across its surface. While the old adage, ‘if it’s wet make it dry…isn't always true, it does convey the time-honored principle of dynamic moisture balance in effective wound healing. This is especially important, as we will see, in dressing selection. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

24 E = Edge of Wound We need to look carefully at the wound edge. Hard, rolled, undermined edges are also a deterrent to epithelial cell migration across the wound bed and must be sharply excised. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

25 Comprehensive PATIENT AssessmentWhen we assess the wound, we need to remember to assess the patient beneath the wound. As it’s been said, we need to see the whole patient, rather than just the hole in the patient. To this end, we need to remember the Titanic Principle… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

26 TITANIC Principle Diabetes Venous Hypertension Trauma MalignancyPeripheral Arterial Disease Psychosocial Issues It was the massive substructure of the ice beneath that caused the ship to founder. In the same way, if we try to heal the wound without addressing the underlying diabetes… then we are not likely to be successful. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

27 Let’s Look Beneath the Wound…When did the wound occur? Who has taken care of the wound? What treatment has been successfully used in the past? What studies have been performed (i.e., arteriogram)? read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

28 Nutrition Assessment The Bricks and Mortar of wound healingMalnutrition decreases - Wound tensile strength WBC function and antibody levels When we assess the patient, we must remember to assess his/her nutritional status, just as we know we can’t build a house without bricks and mortar, we can’t heal a wound without proper nutrition. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

29 Goals of Nutrition Provide adequate calories and proteinPositive nitrogen balance AAs:Arginine, leucine (HMB), glutamine Provide 100% of RDA for vitamins and minerals Maintain adequate hydration → wound perfusion Monitor glycemic control So with this in mind, what are our goals from a nutritional standpoint? We to provide adequate calories and protein, with the goal of achieving a positive nitrogen balance, with special attention to the addition of arg, leu, and glut to our protein source….and we need to maintain adequate hydration, because this translates into wound perfusion at the microvascular level….And lastly we need to monitor glycemic control, as we understand that chronic hyperglycemia is a deterrent to wound healing. …(HMB is hydroxy methylbutyrate (derived from leucine)). Mirtallo - MN & Wnd Hlng ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

30 1. Venous Ulcer Location: midcalf to heel (Gaitor area)Appearance: shallow, irregular, exudate is common, painful Origin: Venous valve incompetence Venous hypertension Extravascular blood loss/edema RBCs → hemosiderin staining WBCs → enzyme-mediated tissue destruction read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

31 Venous Ulcer (mention ‘champagne bottle’ deformity)©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

32 Treatment Compression Therapy Multilayer short stretch DebridementTrental / Doxycycline Closure Skin graft Skin substitutes (Apligraf/ Dermagraft) Endo-venous closure (laser ablation: VNUS) ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

33 2. Arterial Ulcer Location: distal lower extremityAppearance: distinct margin (cookie cutter), with central necrosis in setting of PAD: Cool extremity Diminished /absent pulses Shiny skin /hair loss read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

34 Arterial Ulcer ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

35 Restore Blood Flow Large vessel bypass/ endarterectomy/ profundoplastyEndovascular procedures Balloon angioplasty (with or without stent) Laser ablation Atherectomy ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED. 35

36 3. Diabetic Ulcer Location: plantar aspect of the foot beneath a bony prominence. Appearance: ill-defined borders, prominent callus, and palpable pulses. ‘perfect storm’ ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

37 Diabetic Ulcer ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

38 DFU: Management PrinciplesOff-loading Debridement / dressing selection (clean, moist wound bed) Evaluate and correct ischemia /osteomyelitis Adjunctive therapy Skin substitutes (Apligraf / Dermagraft) HBOT “Its about MECHANICS, not MEDICINE… it’s more important what you TAKE OFF the wound than what you PUT ON” ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

39 4. Pressure Ulcer Location: beneath a bony prominence (heel, sacrum).Appearance: irregular in size and depth. Origin: Prolonged contact with inappropriately padded surface → focal ischemic necrosis. Worsened by friction / moisture malnutrition co- morbidities. read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

40 Pressure Ulcer Staged according to DEPTH of injury…©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

41 Stage 1 Stage I pressure ulcer: Intact skin with nonblanchable erythema, typically the first sign of deep tissue injury (DTI) ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

42 Stage II Stage II pressure ulcer: Partial-thickness skin loss into the dermis. May also present as an intact or ruptured serum-filled blister (NPUAP, 2007). ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

43 Stage III Stage III pressure ulcer: Full-thickness tissue loss into subcutaneous fat. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

44 Stage IV Stage IV pressure ulcer: Full-thickness tissue loss with exposed bone, tendon, or muscle. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

45 PU: Management PrinciplesPressure avoidance Frequent repositioning Avoid bed rest Pressure reducing surface Nutrition: ensure proper intake and monitor Continence and moisture control (when possible) Wound care Debridement Dressing selection Infection surveillance / control ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

46 5. Atypical Wounds Depend upon Causative factors Examples:Brown Recluse Spider Bite Post radiation treatment Malignancy Autoimmune process ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

47 Atypical Wounds: AutoimmuneRA, Sojourns Pyoderma Vasculitis ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

48 Make the Diagnosis Malignant Melanoma (Stage 4 )35 y/o golf pro with heel wound that just wouldn’t heal…bx→ stage 4 melanoma Malignant Melanoma (Stage 4 ) ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

49 Wisdom of the Ages… “For an obstinate ulcer, sweet wine and a lot of patience should be enough.” Hippocrates “Dressings deceive both doctor and patient into thinking that by covering the wound they are curing it.” Dr. Paul Brand ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

50 Appropriate Dressings…Meet specific requirements of the wound (clean, moist wound bed) Goals and objectives of treatment Comfort for the patient Provide balance between cost and benefit We would all like to use appropriate dressings in the care of our patients. These are the ones that meet… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

51 Inappropriate Dressings…Compromise peri-wound integrity Maceration Tape injury Contact dermatitis Delay wound healing Wound bed injury Hypergranulation Dehydration Increase Pain Increase risk of Infection ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

52 Dressing Decision TreeSo with this in mind…Here is an example of a dressing decision tree we use in our clinic (apologize for the print). The concept is that one size doesn’t fit all, and that dressings are selected based on the unique presentation of the wound and patient. For example, if the wound is highly exudative, we are going to want to absorb that drainage in order to avoid tissue maceration. So in this case, we might select a hydrofiber or calcium alginate. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

53 HBO – Hyperbaric Oxygen Therapywhen all the above have been maximized, ie nutrition, disease management, appropriate dressings, adequate pressure relief regimen and the wound does has not progressed we may have to consider some advanced adjunctive modalities to promote healing. Here is an example of a hyperbaric oxygen chamber. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

54 What HBO isn't… It has nothing to do with home box office, and if it you think it’s sexy, you either have a few personal issues..or you work in a wound center. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

55 What is HBO? Breathing 100% Oxygen at increased atmospheric pressureThe patient is enclosed in a clear, acrylic chamber Pressure within the chamber is gradually increased ( ATA) Typical treatment length is 90 mins - 2hrs ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

56 Chamber Description Mono-place Dual-place chamber Multi-place chamberread . Multi-place chamber ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

57 CMS- Approved uses of HBOEnhancement of selected problem wounds (including diabetes mellitus) Necrotizing soft tissue infections Refractory osteomyelitis Delayed radiation injury Compromised skin grafts and flaps read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

58 UHMS- approved IndicationsAir or Gas Embolism Carbon Monoxide Gas Gangrene Crush Injury Acute Traumatic Ischemia Decompression Sickness Exceptional Blood Loss Anemia Additionally, the UHMS or undersea hyperbaric medical society, an international governing body for the appropriate use of HBO, has approved a 7 additional indications as well. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

59 (Atmosphere’s Absolute- ATA)HBO Lingo ASCENT ALTITUDE FLIGHT HYPOBARIC ENVIRONMENT SEA LEVEL DESCENT DEPTH DIVE HYPERBARIC ENVIRONMENT ⅛ 1 3 6 Photo courtesy of PADI HBO has its own Lingo and is supported by scientific principles we should review as we understand its benefit for our patients. At sea level, we all live with the weight of 1 atmosphere pressing upon us at around 15pis. When we ‘dive’ a patient, we pressurize the chamber to a predetermined ‘depth’ ( Typically 2 ATA). This the equivalent of being under an additional 15 psi. or 33ft of sea water. Pressure (Atmosphere’s Absolute- ATA) ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

60 The Four Mechanisms of HBO1. Mechanical 2. Oxygen delivery 3. Antimicrobial effect 4. Poison Antidote Alters the size of gas bubbles Supplies O2 to ischemic tissues/cell signaler Bacteriostatic/cidal Reverse effects of CO and Cyanide through gas exchange We talked about the science of HBO, now I want to look at the 4 main mechanisms that benefit our patients with this therapy. For the purposes of our discussion today, let’s focus on the two that are most pertinent to wound care… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

61 Both roles are critical in tissue viability and wound healingAddressing Hypoxia Oxygen → Metabolite Stimulating angiogenesis Oxygen → Cell signaler Increases growth factors and their availability Both roles are critical in tissue viability and wound healing Oxygen is a potent tissue metabolite and cell signaler, stimulating both angiogenesis and growth factor activity; both of which are critical in wound healing. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

62 Oxygen and Wound HealingThe rate of wound healing is oxygen dependent. Tissue PO2 > 40 mmHg is necessary in normal wound healing. Wound hypoxia impairs - Local response to infection Mechanics of tissue repair Read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

63 How Does HBO Effect Hypoxic Wounds?1. Local Effects: Transient correction of tissue hypoxia. Vasoconstriction with edema reduction while preserving tissue oxygenation. Stimulation and support of angiogenesis. Read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

64 How does HBO Effect Hypoxic Wounds?2. Physiological Effects: HBO is bactericidal and improves WBC function Enhanced collagen synthesis and cross-linking 3. Pharmacological Effects: Ameliorates ischemia- reperfusion injury Stimulates growth factor activation (PDGF-B, VEGF) Read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

65 HBOT Prescription: Diabetic and Hypoxic WoundsPRESSURE – 2.0 ATA DURATION – 90 minutes at depth FREQUENCY – Daily Clinical Considerations: CMS MANDATE Must demonstrate measurable improvement after 30 days to justify continued treatment Treatment duration: 30 – 60 treatments read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

66 A Case in point… Day 1: Dusky appearance Dry tendonNo signs of healing HBO initiated→ This patient stepped on a nail, developed an abscess and presented to the WHC with a large area of necrotic tissue. His wound was surgically debrided and treated with standard wound care with no improvement. The wound is dusky, the tendon is dry, and few signs of healing are noted. TCOM was completed determining tissue hypoxia and a vascular consult was obtained to rule out a corrective surgical measure. HBOT was recommended. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

67 10 Days Later… Improved granular bed Viable tendonNo evidence of infection Read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

68 30 Days Later… Significant depth reduction Tendon nearly coveredReady for graft Read ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

69 45 Days Later… Skin Grafted and HEALED!Healed… This patient was saved BKA amputation and all associated financial and personal costs. ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

70 What are possible Side Effects?HBOT has few, but may include: Otic barotrauma Temporary vision changes Fatigue Seizures Paresthesias ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

71 Evidence that Demands a VerdictLondahl et al Diabetes Care, 2010 RPCT: 94 pts, Wagner 2-4, > 3 mos dur. Compared HBO to hyperbaric air (HBA, 40 Rx) 25/48 (52%) healed in the HBOT group and 12/42 (29%) in the HBA group (P = 0.03). In patients completing >35 HBOT sessions, healing of the index ulcer in 23/38 (61%) for HBOT group & 10/37 (27%) in HBA group (P = 0.009). ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

72 Putting the pieces togetherNormal Healing Evaluate Wounds and Patients Common Wounds So in summary, who benefits from this process? Dressing Selection Hyperbaric Oxygen Therapy ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

73 What Can You Do? Recognize who is at RISK for chronic woundsPerform an accurate assessment of the WOUND and the PATIENT Implement PREVENTATIVE measures Nutritional support Surface offloading/ Skin protection Choose appropriate DRESSINGS Make prompt REFERRALS for wound care and HBOT …but let me remind you of some things you can do to benefit these ‘challenging’ patients. As caregivers, we have to… ©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.

74 Questions? THANK YOU Thank you.©2016 HEALOGICS, INC. CONFIDENTIAL & PROPRIETARY. ALL RIGHTS RESERVED.