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

Background: Achievement of moisture balance can be a critical factor affecting time to closure of nonhealing wounds, and dry wounds can take much longer to heal than those with high exudate levels. Whether the goal of management is to donate moisture to the wound or control excessive fluid until the cause has been identified and addressed, choice of dressing and other wound management products can affect nursing resources, clinical outcomes, concordance, and quality of life for the patient.

Case reports: The cases discussed illustrate differences in management approaches for dry and wet wounds and show how clinician support tools (eg, tissue type, infection/inflammation, moisture imbalance, epithelial edge advancement [TIME] clinical decision support tool) can facilitate treatment decisions. Dressing selection in particular can be challenging given the range of wound types, increasing demands on wound care practitioner time and the requirements necessitated by individualized patient treatment goals. Development of wound management decision tools can help to simplify product selection, and use of patient discussion guides can help to identify patients and caregivers who have the confidence to help implement their wound management plan.

Conclusion: Adopting wound management decision tools has the potential to ease the increasing burden of wound care to health care systems, patients, and society.

Background: Chronic hard-to-heal wounds, such as diabetic foot ulcers, venous leg ulcers, and pressure ulcers, present significant safety concerns, patient burdens, and challenges to health care systems globally.

Objective: To review the mechanism of action and clinical function of bromelain-based enzymatic debridement (BBD) in the context of wound care, focusing on the mechanism of action of BBD and its formulation for chronic wounds in particular.

Methods: A literature review was conducted to assess both bromelain's mechanism of action as well as clinical and preclinical studies on the use of BBD, searching the PubMed and Google Scholar databases for articles published between November 1992 and July 2024.

Results: The literature review shows that BBD, a mixture of proteolytic enzymes derived from the pineapple plant, demonstrates multifaceted actions beneficial to wound healing. It selectively targets devitalized tissue, inhibits bacterial biofilm formation, promotes granulation tissue formation, and maintains moisture balance, thus facilitating a conducive wound microenvironment. Clinical studies and in vivo experiments support the efficacy of BBD in expediting wound debridement, in the formation of granulation tissue, and in reducing bioburden.

Conclusion: The mechanistic insights presented in this review underscore the potential of BBD as a novel standard in chronic wound care that warrants further exploration and clinical validation across diverse wound classifications.

Background: Evidence-based medicine and patient-reported outcome measures (PROMs) are helpful tools in the wound care field, but few studies correlating quality of life (QoL) changes with objective changes exist.

Objective: To investigate the QoL changes following the shift from primary dressings alone to elastic compression bandages in patients with a new diagnosis of vascular skin ulcer, and to evaluate a possible correlation between objective and subjective changes.

Materials and methods: This study included 122 patients with a new diagnosis of vascular skin ulcer, who had previously used only primary dressings alone. The WOUND-Q was administered at time 0, and after 1 month, 6 months, and 12 months of appropriate compression bandage use. Standardized photographs were taken at the first visit. Group 1 consisted of 51 patients (vascular ulcers of mixed origin), group 2 had 31 patients (arterial origin), and group 3 had 40 patients (venous origin). Software was used for statistical analysis.

Results: The ulcer areas decreased by a mean (standard deviation [SD]) of 4.47 (1.76) cm2, 4.06 (0.73) cm2, and 5.04 (0.34) cm2 for groups 1, 2, and 3, respectively, to a mean (SD) area of 3.19 (2.94) cm2, 2.23 (1.78) cm2, and 4.79 (2.56) cm2, respectively, at 12 months. Almost all WOUND-Q values tended to improve over time for the drainage, smell, and life impact scales. The Spearman correlation coefficient r value was 0.3430 for group 1, 0.5893 for group 2, and 0.3959 for group 3 for correlation between the delta of areas and the delta of the life impact.

Conclusion: Introducing compression bandages improved QoL of patients with vascular skin ulcers. Drainage and smell tended to improve over a 1-year period following the switch. A correlation was found between improvements in ulcer area reduction and improvement in life impact scale data.

Background: The Wound Care Collaborative Community (WCCC) assesses shortcomings and unmet needs in wound care by partnering with key stakeholders, such as the National Institutes of Health, the US Food and Drug Administration (FDA), industry leaders, and expert health care providers and researchers, to advance the study of wound healing. Through this work, the WCCC has identified a few key barriers to innovation in wound care. The WCCC aims to accelerate the development of science-based, patient-centered solutions and address public policy challenges related to ensuring patients receive early access to innovative treatment options.

Objective: To develop consensus recommendations that would address current deficiencies in wound care and promote improved innovation and patient access with an expert panel discussion based on both the work conducted within the WCCC and the existing evidence. These recommendations include the voices of the at-large, US-based wound care community.

Methods: In May 2024, a multi-panel summit with 65 leading voices in clinical practice, academia, industry, and the FDA convened in person in Orlando, Florida. Thirty-two participants with backgrounds in clinical practice, surgery, industry, academia, and research took part in panel discussions. Following the panel meeting, the group corresponded via email and a formal survey process to create consensus recommendations, with the ultimate goal of identifying and overcoming barriers to innovation in wound care.

Results: A total of 32 experts convened during the 1-day summit, each representing key stakeholders. Five panel discussions took place to discuss the obstacles to innovation, including alternative primary and co-primary endpoints, generating and reporting evidence, real-world evidence in policy decision-making, and the appropriate standard of care in wound management. From these discussions, 12 consensus statements were generated. The statements, their proportion of agreement or disagreement, and summary comments are presented in the order they appeared at the presentation. Overall, greater than or equal to 85% agreement was received on all statements.

Conclusion: The consensus recommendations promote and encourage a standardized path forward to established, consistent metrics that facilitate innovation and quality assessment, improving patient access to advancements in healing.

Background: Caustic substances can inflict severe damage on tissues upon contact. Knowledge about skin damage caused by sodium hypochlorite is quite limited, with only a few reports available in the literature.

Case report: A 79-year-old female with severe cognitive decline presented with multiple skin ulcerations that were covered by a blackish-greyish eschar and surrounded by a purple erythematous halo. During the medical examination, in a moment of clarity the patient confessed to self-inflicting the wounds through injections of bleach at night. Analysis of the liquid beneath the eschar from the ulcer swab and the histological examination confirmed the compatibility of lesions with the injection of sodium hypochlorite.

Conclusion: Intradermal injection of sodium hypochlorite can cause severe damage to the skin tissue, with rapid formation of ulcerations covered by a blackish-greyish eschar. The surrounding skin may have an erythematous, swollen appearance and a purple-colored halo around it. Moreover, for a patient with a neuropsychiatric medical history, negative laboratory findings, or irregular skin lesions, self-induced ulcerations should always be considered in the differential diagnosis.

Background: There is limited use of the term skin failure in the clinical setting; however, it is valid to question the differences between skin failure and other injuries (eg, pressure injuries). The evaluation of skin failure should be based on specific clinical characteristics to strengthen the knowledge of this phenomenon and to set standards of care.

Objective: To evaluate the available evidence about characteristics of and clinical instruments for skin failure diagnosis and evaluation in adult patients with advanced or end-stage disease.

Methods: Between April 4 and May 18 2023, a scoping review was conducted and included literature on skin failure classification and diagnosis in patients aged 18 years or older in any health context. Articles that included a pediatric population or dermatologic diagnoses not related to the current concept of skin failure and articles referring only to a theoretical definition of skin failure were excluded. The databases searched were PubMed, CINAHL, Web of Science, LILACS, ScienceDirect, and the Cochrane Database of Systematic Reviews. Grey literature was retrieved via the "DART E-theses Portal" and "CAPES Thesis Portal."

Results: A total of 196 articles were identified. The final sample included 8 studies related to the theoretical concept of skin failure. The most cited factors related to acute skin failure were sepsis, hypoperfusion, vasopressor use, oxygenation, nutritional status, acute organ compromise, mechanical ventilation, and chronic diseases. One specific tool was identified to assess skin failure that included the same characteristics revealed by this scoping review.

Conclusion: There is limited evidence regarding clinical indicators for the evaluation of skin failure. The results of this exploratory review suggest specific clinical features of skin failure which may consider other elements than those related to pressure injuries. Primary studies are needed to strengthen the diagnosis of skin failure and its inclusion in routine health care practice at any stage of disease.

Background: Wound debridement is crucial for effective wound management and essential for removing necrotic tissue, reducing bacterial load, and encouraging granulation. While surgical debridement is prevalent, it can be traumatic and can potentially delay healing by enlarging the wound area.

Objective: To summarize the existing literature on the role of proteolytic enzymes in wound debridement, with a focus on their applications, benefits, limitations, and future potential in wound care management.

Methods: A systematic search was conducted in PubMed (National Library of Medicine) and Google Scholar, reviewing English-language publications from 1974 to 2023. Keywords included "enzymatic debridement", "wound healing", "collagenase", "bromelain", "proteolytic enzymes", and "debridement".

Results: Enzymatic debridement has emerged as a promising, less invasive alternative to surgical debridement. Bromelain, which targets heat-denatured proteins, shortens healing times and improves scar quality. Collagenase and papain have been widely used globally, highlighting their efficacy in various wound types, although concerns have been noted about papain's safety. Preliminary studies on enzymes such as chymotrypsin, aurase, actinidin, Antarctic krill (Euphausia superba) enzymes, and dispase also show encouraging results. A limited number of studies comparing various debriding enzymes in the literature were identified, revealing significant differences between them, highlighting the need for additional comparative research studies.

Conclusions: The advantages of enzymatic debridement over surgical debridement, particularly in nontraumatic applications and with enhanced healing times with the former, underscore its potential in clinical settings. Further research is warranted to optimize use of enzymatic debridement and understand the full scope of benefits and limitations of these enzymes in wound management.

Background: Deep tissue injury (DTI), a pressure-related injury to the subcutaneous tissue under intact skin, has been featured in several recent studies. DTI is hard to detect, and by the time the injury becomes visible, extensive injury to the underlying tissue has often already occurred, resulting in a potentially serious and difficult-to-heal full-thickness pressure injury. Thus, early detection of subcutaneous injuries is essential, and previous reports describe the use of ultrasonography and magnetic resonance imaging (MRI) for this purpose. The current report compares ultrasonography with MRI for detection of subcutaneous injuries.

Case report: In the 2 cases reported herein, the use of ultrasonography and MRI led to the detection of DTI and intervention before the injuries reached the skin surface. In case 1, DTI was suspected on MRI, and ultrasonography confirmed findings typical of DTI, leading to the diagnosis. In case 2, MRI was used to detect abnormal findings at a stage in which no abnormalities were found on ultrasonography.

Conclusion: In both cases, MRI clearly identified abnormal findings, which suggests that it is superior to ultrasonography for visualizing deeper tissue. Consequently, the authors of the current report propose that compared with ultrasonography, use of MRI for the detection of DTI would lead to earlier intervention and healing.

Background: The Wound Care Collaborative Community (WCCC) aims to assess current usable real-world data (RWD) sources to determine which real-world databases (DBs) are suitable and usable for studying the natural history of chronic wounds. Randomized controlled trials (RCTs) do not fully reflect the complexity of patients with chronic wounds. Using RWD, establishment of a scientifically grounded "road map" for RCTs is needed to better navigate the real-world complexity of the patients with chronic wounds. The long-term objectives include identifying patients ineligible to receive evidence-based advanced treatment and diagnostic options, reducing patient suffering, and providing decision support for regulatory bodies, payers, and clinicians.

Objective: To identify available and usable RWD on US chronic wound care patients, as an early step toward the WCCC's objectives.

Methods: Using B.R.I.D.G.E. TO DATA® methodology, the WCCC conducted a comprehensive RWD landscape analysis and systematically screened 34 potential sources for chronic wounds. Multiple data elements helped determine suitability and usability.

Results: Four clinical US DBs have "high potential" for elucidating the natural history of chronic wounds; a fifth met the WCCC criteria but has data access restrictions.

Conclusion: Identifying suitable, usable real-world DBs for research is complex. Only 1 DB was found that is fit for purpose and matches the goals to study the natural history of patients with chronic wounds.

Background: Use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) of a topical wound solution has been limited in some settings due to perceptions of setup complexity. Typically, some guesswork was needed to estimate an adequate volume of solution to instill without causing leaks. A novel smart technology is recently available in certain NPWTi-d systems that automatically estimates and instills a solution volume according to wound dimensions.

Objective: To report experience with this smart instillation NPWTi-d system technology in managing 4 complex wounds containing large areas of devitalized tissue and/or yellow fibrinous slough.

Materials and methods: NPWTi-d was applied via a reticulated open cell foam dressing with through holes (ROCF-CC). The smart instill button was selected to automatically determine a volume of topical solution to instill, followed by a 10-minute dwell time and 2-hour cycle of -125 mm Hg negative pressure.

Results: The average NPWTi-d duration was 17.0 days, and no air or solution leaks occurred during therapy. Dressings were changed 3 times per week. All wounds were converted to clean granulating wounds during therapy.

Conclusion: In this case series, smart technology simplified setup and facilitated regular cleansing and removal of devitalized tissue through the ROCF-CC dressing.