Wounds : a compendium of clinical research and practice最新文献

Background: As the incidence of diabetes continues to rise throughout the world, including Africa, diabetic foot complications are a significant factor in morbidity, hospital length of stay, and health care costs. An emphasis on prevention through patient education may reverse this trend.

Objective: To survey patients with diabetes in Cameroon, West Africa, to assess their knowledge about foot care and prevention of complications, with the goal of improving diabetic foot education across a hospital system.

Methods: The sample included 130 patients with diabetes at 2 hospitals within the Cameroon Baptist Convention Health Services. Participants were seen in outpatient clinics or as inpatients. Nurses trained in wound care conducted the study between December 23, 2021, and August 26, 2022. Investigators administered an examiner-designed oral survey to collect foot care knowledge and disease-related data and performed a standard diabetic foot examination to assess for evidence of sensory, motor, or autonomic neuropathy. Participants were assigned a risk category based on the history and examination results. Afterward, each participant was taught about diabetic foot care.

Results: An oral survey found that patients knew little about foot care or its role in preventing foot complications. Using the International Diabetes Federation risk categorization for diabetic foot complications, 81% of the participants were found to be at high risk or very high risk for foot ulceration and amputation.

Conclusion: These findings demonstrate the need for improved teaching on self-care of the feet and personal measures to prevent wounds and amputations during education of patients with diabetes and at sites where patients with diabetes encounter the health care system.

Background: Split-thickness skin grafts (STSG) over tendon or bone often fail. In such cases, an attempt to create a neo-dermis or restore a dermal-like covering is indicated. This study compared the outcomes of dermal regeneration template (DRT) use in lower extremity (LE) wound closure when combined with STSG procedures.

Methods: Medical records of patients with chronic LE wounds who underwent STSG from 2014 to 2022 were reviewed. Wounds that were treated with DRT prior to STSG ("DRT") were compared those that were not ("non-DRT"). Both groups were acquired concurrently over the 8-year period. All outcomes evaluated were in relation to the STSG procedure.

Results: A total of 387 wounds in 261 patients were identified. One hundred seventy-three (43.5%) wounds were treated with DRT and 214 (55.3%) were not. No demographic differences were observed between the 2 groups. Prevalent comorbidities included diabetes (54.4%) and peripheral vascular disease (40.0%). Median wound size (28 cm2, interquartile range: 55) and depth were similar between the groups. The DRT group demonstrated significantly less graft failure than the non-DRT group (5.2% vs. 19.2%, respectively; P < .001) and higher rates of postoperative ambulation within 30 days (48.7% vs. 36.0%, respectively; P = .040) and 60 days (63.6% vs. 42.6%, respectively; P = .006). In a multivariate model, DRT independently reduced STSG failure and infection but not reoperation or amputation. Mortality trended to be lower in the DRT group (12.4% vs. 18.6%, P = .172).

Conclusions: DRT plays a key role as a temporizing measure to significantly enhance STSG take and promote ambulation in patients with chronic wounds but does not decrease the need for future major limb amputation.

Many coverage challenges in wound care stem from a lack of shared clarity among researchers, manufacturers, payers, and regulators about the clinical evidence payers need to make positive coverage determinations. The Alliance of Wound Care Stakeholders, a multidisciplinary trade association, convened its Wound Care Evidence Summit in May 2022 to explore this issue and identify shared challenges and solutions with a diverse range of policymakers, payers, and researchers. This article focuses on payers' clinical evidence requirements and the processes used when making coverage determinations, as discussed at the Summit. The authors explore the role of alternative sources of evidence beyond randomized clinical trials that were raised in the discussions: clinical practice guidelines, health technology assessments, and clinical consensus. The article reviews discussions around the use of these in coverage decisions and explores potential solutions to achieve evidence-based practice and coverage policies that meet the needs of all patients with chronic wounds.

Background: Complex surgical wounds and nonhealing wounds can develop intricate anatomical variations such as tunnels or sinusoids, making it difficult to assess deep bacterial status. This can lead to false-negative results.

Objective: To propose an alternative bedside diagnostic method using proprietary fluorescence (FL) imaging to visualize high bacterial loads on a sterile cotton applicator probe.

Case report: In 2 cases of challenging surgical wounds, a sterile cotton applicator was used to collect material from deep within complex, tunneled, or sinusoidal wounds. The applicator was immediately imaged at the bedside for FL signals, and prompt therapeutic action was taken in response to moderate to heavy bacterial detection of multiple species, including Pseudomonas. This newly developed C-Swab test successfully provided point-of-care information on live bacterial presence (or absence) from deep inside wounds, independent of the superficial skin assessment. In those cases, FL scans for superficial bacteria on the skin sometimes appeared negative, while the C-Swab test revealed infection triggering bacteria at deeper levels. This test can be used to evaluate treatment efficacy at subsequent visits (eg, post antibiotics) without major tissue disruption (eg, having to enlarge a wound for inspection).

Conclusion: The addition of the C-Swab test to workflows yields clinically significant information for diagnosis and proactive bacterial management.

Background: Infection in the patient with burn injury is a leading cause of morbidity and mortality worldwide. Clinicians in low- and middle-income countries are often left with no option other than to commence empirical antibiotics.

Objective: To determine the magnitude of infection in patients with burn injury, the sources of these infections, the prevalent microorganisms and their sensitivity pattern, and the sensitivity of the microorganisms to empirical therapy.

Materials and methods: This prospective observational study was conducted in a regional burn center in western Nigeria between October 2010 and March 2020.

Results: A total of 364 patients were included in the study, with males constituting 58.5% (213) of the patients and females 41.5% (151) of the patients. The median patient age was 22 years. Flame was the most common cause of burn injury (61.5% [n = 224]). The median total body surface area burn was 22%. The majority of the patients had a clinical diagnosis of infection (85.4% [n = 311]), with the burn wound (60.8%), respiratory tract (22.2%), and urinary tract (6.1%) constituting the clinical sources of the infection. The most prevalent causes of burn wound infection were Klebsiella pneumoniae (K pneumoniae) (30.2%), Staphylococcus aureus (S aureus) (24.3%), and Pseudomonas aeruginosa (P aeruginosa) (21.0%). All cultured bacteria with the exception of Citrobacter freundii were sensitive to amikacin, with K pneumoniae and S aureus being the most sensitive to it, and P. aeruginosa being more sensitive to ceftazidime. The most commonly prescribed empirical antibiotics were amikacin (20.3%) and levofloxacin (19.8%). The cultured organisms in burn injury patients with wound infection showed high sensitivity and specificity to empirical antibiotics therapy.

Conclusion: The results of this study indicate that the source of infection determines the most likely organism and its sensitivity profile.

Background: Atypical mycobacteria (ATB) are a rare cause of surgical site infections (SSIs). They present with clinical features of erythema, induration, and sinus formation, which recur despite conventional treatment. Early diagnosis is difficult and requires a high index of suspicion for further investigations to confirm atypical mycobacterial infection. Treatment encompasses a combination of polymicrobial agents and surgical debridement.

Objective: To describe the clinical presentation, diagnostic challenges, and treatment outcomes of atypical mycobacterial infections in surgical sites.

Materials and methods: Written informed consent was obtained from all participants in this observational retrospective descriptive study. Scientific and ethical clearance was granted by the Ethical Clearance Committee at M.S Ramaiah Medical College and Hospital, Bengaluru. The study included 5 female patients from a tertiary care hospital in Bengaluru, India, who presented with SSIs that did not resolve with standard treatment. Discharge or wound scrapings from these patients with delayed infections were examined for the causative agent, with ATB isolates identified using solid and liquid culture methods.

Results: ATB were isolated in 3 clean and 2 clean-contaminated surgeries, that is, in 60% and 40% of cases, respectively. Discharge alone did not yield growth in any of the cases (0%), whereas tissue scrapings revealed ATB in all 5 patients (100%). The most common organism cultured was Mycobacterium fortuitum (60%), followed by Mycobacterium abscessus (20%) and Mycobacterium chelonae (20%). Clarithromycin and ciprofloxacin alone for a period of 3 to 6 months yielded a 100% cure rate (5 of 5 patients).

Conclusion: ATB infections are a rare cause of postoperative SSIs. These infections require multimodal management, with complete resolution possible after appropriate therapy. This series emphasizes the significance of ATB infection of surgical sites as a notable cause of postoperative morbidity.

Background: Hidradenitis suppurativa (HS) is a chronic, recurrent, and debilitating inflammatory condition characterized by abscesses, comedones, and nodules. The heterogeneous presentation of HS often leads to diagnostic challenges, with clinical mimics such as cutaneous metastases (CMs) being of particular importance. CMs can present as initial manifestations of metastatic disease, necessitating accurate identification to guide potentially lifesaving treatment. However, the diagnostic and therapeutic approaches for HS and CMs differ significantly, underscoring the need for prompt and accurate differentiation.

Case report: This report presents 3 cases of primary malignancies in which CMs mimicked HS. Case 1 had diffuse large B-cell lymphoma; case 2 had a history of right breast atypical ductal hyperplasia and borderline low-grade ductal carcinoma in situ, along with triple-negative invasive ductal carcinoma of the left breast with extensive metastasis to the iliac bone and lung; and case 3 had invasive mammary carcinoma of the right breast with axillary lymph node involvement. All 3 patients presented with nodular lesions resembling HS, but further investigation, including molecular testing, confirmed the diagnosis of CMs.

Conclusion: The clinical overlap between HS and CMs, which can present with similar features such as nodules, abscesses, and draining lesions, underscores the critical importance of distinguishing these entities. Despite their similar clinical appearance, HS and CMs have vastly different management protocols. Accurate diagnosis of CMs enables timely and appropriate intervention, which in turn aids in optimizing clinical outcomes and ensuring the use of effective treatment strategies for affected patients.

Background: Martorell hypertensive ischemic leg ulcer (HYTILU) is a chronic, hard-to-heal wound linked to hypertension. This study explores nanofat grafting as a regenerative alternative to traditional skin grafting for improved healing and patient outcomes.

Objective: To explore the efficacy of nanofat grafting in the management of HYTILU and compare it with skin grafting.

Materials and methods: This was a retrospective single-center pilot study involving 23 patients with HYTILU treated with adipose-derived stromal cells (adipose-derived stromal cells/nanofat). The primary outcomes were ulcer healing rate, pain reduction, and improvements in quality of life, as measured by SCAR-Q (a scar quality of life questionnaire) and the Vancouver Scar Scale, over a period of 6 months posttreatment.

Results: This study revealed a significant decrease in ulcer size from an initial mean of 39.69 cm² to complete healing, with an average healing time of 4.65 months. The mean visual analog scale pain scores significantly decreased from an initial score of 5.87 to 0.39 at 3 months postinjection (P < .0001). Quality of life was significantly improved after treatment, as underscored by higher SCAR-Q scores and lower Vancouver scale scores, indicating better scar quality and minimal adverse effects.

Conclusion: These study results underscore nanofat grafting as a superior alternative to traditional skin grafting for HYTILU, offering advantages in terms of healing time, pain management, and patient quality of life. Further research is needed to confirm these findings and assess the use of nanofat in the management of other chronic wounds.

Background: Considering the rising incidence and cost associated with chronic wounds, further investigation of safe and effective treatments is needed.

Objective: To conduct a retrospective analysis of patients with chronic wounds in order to evaluate the healing effect of vaporous hyperoxia therapy (VHT) used adjunctively with standard wound care.

Materials and methods: The data of patients with chronic wounds (≥4 weeks' duration) who received commercial treatment with VHT between February 28, 2020, and August 30, 2022, were reviewed. After debridement (as appropriate), the limb was placed in the treatment chamber, and a 56-minute treatment of alternating cycles of a low-frequency, noncontact, nonthermal ultrasonic mist and concentrated oxygen therapy was administered twice weekly. Wounds were offloaded and dressed appropriately. The number of wounds healed at 16 weeks, percentage area reduction (PAR), and percentage volume reduction (PVR) were analyzed, and Kaplan-Meier time to heal analysis was performed.

Results: Forty patients with 53 wounds were evaluated. The mean (standard deviation [SD]) comorbidity count per patient was 4.6 (2.5). At 16 weeks, 33 wounds healed (62%), and 40 wounds healed at 1 year, including 35 of 47 diabetic foot ulcers (74%). Five patients treated with VHT and fewer than 5 cellular and/or tissue-based products (CTPs) achieved healing. The mean healing time was 14.5 weeks (95% confidence interval, 9.9-18.1). The mean (SD) PAR and PVR over 16 weeks were 69% (156.7%) and 82% (70.3%), respectively.

Conclusion: This real-world analysis demonstrates that VHT healed most chronic wounds within 14 weeks. In addition, VHT appears to accelerate healing in wounds that are also treated with CTPs.

Preclinical studies for wound healing disorders are an essential step in translating discoveries into therapies. Also, they are an integral component of initial safety screening and gaining mechanistic insights using an in vivo approach. Given the complexity of the wound healing process, existing guidelines for animal testing do not capture key information due to the inevitable variability in experimental design. Variations in study interpretation are increased by complexities associated with wound aetiology, wounding procedure, multiple treatment conditions, wound assessment, and analysis, as well as lack of acknowledgement of limitation of the model used. Yet, no standards exist to guide reporting crucial experimental information required to interpret results in translational studies of wound healing. Consistency in reporting allows transparency, comparative, and meta-analysis studies and avoids repetition and redundancy. Therefore, there is a critical and unmet need to standardise reporting for preclinical wound studies. To aid in reporting experimental conditions, The Wound Reporting in Animal and Human Preclinical Studies (WRAHPS) Guidelines have now been created by the authors working with the Wound Care Collaborative Community (WCCC) GAPS group to provide a checklist and reporting template for the most frequently used pre-clinical models in support of development for human clinical trials for wound healing disorders. It is anticipated that the WRAHPS Guidelines will standardise comprehensive methods for reporting in scientific manuscripts and the wound healing field overall. This article is not intended to address regulatory requirements but is intended to provide general guidelines on important scientific considerations for such studies.