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

Background: There is substantial literature supporting the use of cellular and/or tissue-based product (CTP) in managing Wagner grade 1 and 2 diabetic foot ulcers (DFUs) and, to a lesser extent, venous leg ulcers (VLUs). Several studies advocate CTP therapy as an effective method for promoting healing in chronic DFUs and VLUs.

Objective: To evaluate how the number of CTP applications affect healing and wound area reduction (WAR) rates of DFUs and VLUs.

Methods: A multicenter private wound care practice, electronic health record, and database were used to analyze Medicare patients receiving CTPs between January 1, 2018, and December 31, 2023. Wound treatments occurred in the nursing home, private office, and home settings, not in hospital outpatient department settings. This privately funded, non-vendor-sponsored, real-world retrospective analysis included wound closure and WAR rates after each CTP application. Analysis includes current (2024) aspects of proposed local coverage determination changes that limit the number of CTP applications to 4. A paired t test was used to compare mean wound area before CTP applications and after completing CTP applications over a 16-week period. Effect sizes were analyzed using Cohen d, and correlations between the number of CTP applications and WAR were determined using the Pearson correlation coefficient.

Results: A total of 257 wounds were reviewed for analysis, of which 123 were DFUs and 134 were VLUs. For both DFUs and VLUs, there was a significant difference in the average initial wound areas (cm2) compared with the average wound areas after the CTP application series (P < .001).

Conclusion: This comprehensive retrospective real-world analysis of Medicare patients receiving CTP therapy in conjunction with standard of care treatment of DFUs and VLUs demonstrated significant reduction in the average wound area after completing a CTP application series. The results of this study could be used as a guide for the average number of CTP applications required for the effective treatment of DFUs and VLUs.

Background: A new indication for use of silver collagen oxidized regenerated cellulose (ORC) dressing in conjunction with negative pressure wound therapy (NPWT) and reticulated open cell foam (ROCF) dressings has recently become available.

Objective: An in-person meeting with 7 health care providers (HCPs) was held to identify clinical care settings and appropriate use of silver collagen ORC dressings in conjunction with NPWT and ROCF dressings.

Methods: Consensus statements were developed using a modified Delphi technique. An additional 25 HCPs completed an anonymous survey on the consensus statements. Consensus was defined as ≥80% agreement among survey respondents.

Results: Use of silver collagen ORC dressings with NPWT and ROCF dressings was recommended in inpatient and outpatient health care settings. Use in traumatic wounds, surgical wounds, diabetic ulcers, venous leg ulcers, and pressure injuries/ulcers was supported. Use was not recommended in the presence of exposed unprotected organs or exposed unprotected vessels, when the potential for inadequate wound hemostasis exists, acutely ischemic wounds, third-degree burns, or surgically closed incisions, or with patient hypersensitivity to product components.

Conclusions: Limited evidence exists on use of NPWT in conjunction with silver collagen ORC dressings. A panel developed 12 consensus statements detailing the recommended and contraindicated uses of NPWT in conjunction with silver collagen ORC dressings.

Background: Cutaneous pathology on the male chest has a broad differential diagnosis that includes both malignant and benign processes. Surgeons-including surgical oncologists, dermatologic surgeons, plastic surgeons, and thoracic surgeons-may be consulted for management or evaluation of these conditions at various stages of the diagnostic work-up. No single surgical specialty manages all cutaneous pathology that arises on the male chest.

Case report: To illustrate the challenges and utility of imaging for diagnosis in the male breast, a clinical example is provided of an 82-year-old male who presented with an ulcerated plaque on the chest with involvement of the nipple areolar complex. The patient underwent shave biopsy and was initially diagnosed with basal cell carcinoma; however, after resection he was found to have invasive mammary carcinoma.

Conclusion: Careful assessment, investigation, and understanding of pathology that may present on the male chest are key to making the correct diagnosis and avoiding treatment delays.

Fish skin has emerged as a potential candidate for improving wound healing due to its notable results in human trials, in which it has been directly applied as a dressing on wounds. The current review explores the mechanisms by which fish skin can boost the wound healing process. The natural wound healing process involves inflammation at the wound site to initiate tissue repair. The body balances this inflammation through interleukin signaling, and imbalances can cause chronic wounds or scarring. The wound site also secretes epidermal growth factor, which activates the Ras/Raf/MEK/ERK and PI3K/Akt pathways. These pathways promote angiogenesis (ie, replacing injured blood vessels) and epithelialization (ie, replacing injured skin). Delays in these pathways increase the healing time. The rich contents of omega-3, collagen, and selenium in fish skin boost wound healing by inhibiting compounds that can cause over-inflammation during interleukin signaling. They also upregulate the Ras/Raf/MEK/ERK and PI3K pathways by altering lipid composition (via omega-3), binding with collagen receptors (via collagen), and modulating selenoproteins (via selenium). The mechanisms discussed in this review support the finding that fish skin is a promising candidate with a strong potential to naturally boost the wound healing process in clinical settings. Continued investigation into the application of fish skin as a practical and commercial wound healing agent is warranted. Future study of additional wound healing properties of fish skin, such as microbial protection of open wounds, is recommended.

Background: Wound healing typically occurs in 4 sequential stages: hemostasis, inflammation, proliferation, and remodeling. During the proliferation stage, the wound undergoes granulation, angiogenesis, and epithelialization. Granulation involves the growth of connective tissue and blood vessels to fill the wound space. Granulation tissue provides a scaffold for subsequent tissue regeneration, supports angiogenesis, and aids in wound contraction. Classically, it also supports epithelialization. The timing and extent of granulation and epithelialization may vary depending on the size and type of wound. In certain cases, especially with superficial wounds or partial-thickness injuries, the intact blood supply from deeper tissue layers may be sufficient to support epithelialization without significant granulation tissue formation. However, this pathway has not been described for full-thickness wounds.

Case reports: The current case report describes wound healing in 2 patients with multiple comorbidities who presented with nonhealing stage IV pressure injuries. After extensive therapy, reepithelialization and wound healing occurred without typical granulation tissue formation.

Conclusion: The achievement of epithelialization without prior granulation may suggest the existence of an alternative wound healing pathway for full-thickness wounds in which epithelialization occurs independent of robust granulation.

Background: Diabetic foot ulcers (DFUs) present devastating complications. Management of these wounds includes applying a vacuum device composed of a fenestrated tube embedded in a foam dressing and connected to a vacuum pump to collect the fluid in a vessel.

Objective: To review the effectiveness of negative pressure wound therapy (NPWT) in treating DFUs and evaluate the clinical outcomes of full and partial wound healing.

Methods: A systematic review and meta-analysis of randomized controlled trials was conducted after searching the PubMed, Web of Science, and Cochrane Library databases. Studies that described the use of NPWT in the management of DFUs were included and compared with different interventions for the proposed outcomes.

Results: A total of 14 studies were included, 1 of which was later excluded during internal validation. Wound healing outcomes were analyzed in 2 studies, showing the superiority of total wound healing in the NPWT group. Ten studies compared the effect of different interventions on wound area reduction and 8 of these results were best with NPWT. Three studies showed clinical and statistical homogeneity (I² = 100%), making it possible to conduct a meta-analysis.

Conclusion: Although the articles included in this systematic review have limitations regarding methodological quality and clinical heterogeneity, the results showed the potential benefit of NPWT in healing and wound area reduction. These outcomes are essential in the prevention of amputation in patients with DFU.

Background: Venous leg ulcers (VLUs) are the most common type of chronic wound in the lower extremity and are often associated with redness, swelling, and pain at the site of the wound. The primary focus of VLU treatment is the promotion of wound healing through compression therapy, wound debridement, and elevation of the affected limb. Acellular matrices have gained traction as a potential adjunct to wound healing in diabetic foot ulcers. However, the clinical effect of acellular products in the setting of VLUs has not been well reported.

Objective: To review the published evidence on the use of acellular products in the management of VLUs.

Methods: PubMed, Embase, Cochrane, and Google Scholar databases were initially searched on March 2, 2023, for literature on VLU and acellular dermal matrix. Later, the search was broadened to include any and all acellular matrices, and a secondary search of the same databases was conducted on February 20, 2024. Articles obtained through collateral methods were also included.

Results: A total of 27 articles were identified for review. All studies were human studies. Four articles had level I evidence and 7 articles had level II evidence, while the remaining articles had level III or IV evidence. Studies included both large and small wound sizes ranging from 0.5 cm² to 100 cm2. Product application occurred once to twice weekly for 4 weeks to up to 36 months. Overall, regardless of ulcer size, the majority of studies reported favorable wound healing outcomes with the use of a variety of acellular skin coverage products with few complications. Some studies also reported pain reduction with the use of acellular skin substitutes in a small cohort of patients.

Conclusion: Acellular products appear to have the potential to support healing in VLUs. However, more large-scale randomized controlled trials that provide level I evidence are needed.

Background: The Kahramanmaras earthquakes in Turkey on February 6, 2023, resulted in more than 100 000 injuries and 50 500 deaths. The main causes of morbidity and mortality in earthquake-affected patients include crush syndrome, trauma-related extremity injuries, and wound infections.

Objective: To investigate infective complications, causative microorganisms, treatments, and treatment responses in pediatric patients.

Methods: The case series involved 12 earthquake victims admitted to a tertiary treatment center between February 9 and 24, 2023. Wound sample cultures were obtained from patients with infected wounds via wound secretions and tissue samples collected during surgery.

Results: Nine patients were male (75%), and the mean age of patients was 12.6 ± 3.7 years. Seven patients (58.3%) experienced crush syndrome. Seven patients (58.3%) underwent fasciotomy operations. The main infectious complications were wound infections (58.3%) and urinary tract infections (25%). Nine different organisms were found to cause wound infection, with Enterococcus faecium (41.6%), Acinetobacter baumanii (33.3%), and Pseudomonas aeruginosa (16.6%) being the major bacterial isolates. All Acinetobacter strains were multidrug-resistant (MDR).

Conclusion: Major disasters such as earthquakes are rare, and infections are the major complications that increase morbidity and mortality. Initial appropriate treatment contributes to improved outcomes, as MDR strains are common pathogens in these patients.

Background: Cutaneous squamous cell carcinoma (cSCC) frequently occurs in photoexposed areas. Surgery remains the mainstay of treatment in attempts to reduce recurrence, but it must be combined with other therapy because of the limited excision possible in the region of the eyelid, lip, and nose. Photodynamic therapy (PDT) is a relatively new treatment modality that involves the administration of a photosensitizing drug and its subsequent activation by specific wavelengths of light to produce reactive oxygen species that specifically destroy target cells.

Case report: An 87-year-old female presented 4 weeks after initial resection with recurrent medium-differentiated cSCC measuring 5.2 cm × 3 cm × 2 cm in the left upper eyelid. Subsequent treatment involved palliative resection with an additional 1 cm at 3 margins of the tumor (excluding the bottom edge of the double eyelid line) and 3 applications of PDT using 5-aminolevulinic acid as the photosynthesizing agent in the open wound over a 2-week period. The wound healed well within 6 weeks. During the following 4 years, the patient showed satisfactory progress in both aesthetics and function, with no sign of recurrence or metastasis.

Conclusion: Refractory cSCC was successfully managed using a combination of PDT and secondary healing, and functions of the head and face were well protected. These results suggest that such management warrants consideration in clinical settings.

Background: Little is known about the usefulness of collagen powder in secondary intention healing in patients undergoing cutaneous surgery.

Objective: To investigate the clinical outcomes associated with application of collagen powder in cutaneous surgery and patients' perceptions of the procedure.

Methods: A retrospective chart review of 266 patients who underwent Mohs surgery or excisional surgery at a single institution between January 2020 and January 2022, and who had secondary intention healing of wounds assisted by powdered collagen was conducted. Personal interviews were conducted with 63 of those patients (23.7%). Tumor characteristics, estimated healing times, and patient satisfaction were scored. The Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale were used to assess the resulting wound bed. All data underwent statistical analysis.

Results: Of 266 granulating wounds with an average defect size of 6.0 cm2, excisional surgery was performed in 143 (54%) and Mohs surgery in 123 (46%). Most procedures (92.1%) were undertaken for nonmelanoma skin cancers. The average healing time was 6.3 weeks. The mean patient score for ease of use and overall impression of collagen application was 8.2 on a scale of 1 to 10, with 10 being most favorable.

Conclusion: When clinically appropriate, granulation assisted by collagen powder should be considered for augmenting secondary intention healing.