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

Background: Key wound environment parameters include pH, hydration, and the balance between tissue remodeling and deposition of new tissue. When prolonged inflammation is present, the proliferation phase of wound healing can be delayed because excessive protease production due to persistent inflammation can destroy newly formed tissue and prevent wounds from filling and reepithelializing.

Objective: To conduct an in vitro study of the ability of polygalacturonic acid (PG), a natural pectin derivative present in ripening fruit, to inhibit 3 destructive wound proteases and prevent dehydration in environments in which significant evaporation can occur.

Materials and methods: In vitro enzyme inhibition assay kits were used to detect the ability of PG to inhibit key wound proteases matrix metalloproteinase (MMP)-2, MMP-9, and neutrophil elastase (NE). Transepidermal evaporative water loss from a polyvinyl alcohol skin substitute hydrogel was gravimetrically measured.

Results: PG could partially inhibit MMP-2 (>50% inhibition relative to negative controls), MMP-9 (>50% inhibition relative to negative controls), and NE (>25% inhibition relative to negative controls) and thereby potentially blunt some of the destructive effects of excess proteases where prolonged inflammation is present. In an in vitro transepidermal evaporative water loss assay, PG also helped retain moisture and inhibited dehydration (>25% reduction relative to negative controls).

Conclusions: These findings suggest that PG can be a useful addition to ointments and dressings in wound care and warrants further in vivo testing.

Background: Chronic skin ulceration is a serious pathological condition for which the adjuvant use of platelet-rich plasma (PRP) has been indicated. However, evidence for the use of PRP in patients with chronic skin ulcers remains insufficient due to a large heterogeneity in experimental designs, PRP composition, and preparation protocols.

Objective: To assess previously published reports of the clinical effect of plasma rich in growth factors (PRGF) on chronic skin wounds.

Methods: A comprehensive search of the PubMed, Cochrane Library, and Scopus databases was performed to identify randomized controlled trials (RCTs) assessing the effect of PRGF on chronic ulcer healing, with no limitation regarding publication date (up to September 1, 2022). Percentage area reduction and probability of complete healing in chronic ulcers, pain reduction, infection risk, and cost savings were analyzed. A meta-analysis was performed, and the overall evidence was qualified using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

Results: A total of 113 studies were identified. After full-text screening, 5 RCTs met the inclusion criteria. The meta-analysis showed a significant effect of PRGF on both wound area reduction (mean difference, 56.90% [95% CI, 52.28-61.51], I² = 0%; P = .56) and on the probability of complete healing (RR, 7.07 [95% CI, 1.84-27.16], I² = 0%; P = .53) in chronic ulcers. The overall risk of bias rating was "some concerns," whereas the certainty of evidence was high for both outcomes. A qualitative analysis suggested that PRGF did not increase infection risk and was able to reduce wound pain.

Conclusion: The use of PRGF significantly enhances wound area reduction and also the probability of complete healing in chronic ulcers. More studies are needed to assess the effect of PRGF on pain and infection, as well as its cost-effectiveness.

The International Working Group on the Diabetic Foot (IWGDF) has consistently published evidence-based guideline recommendations on the prevention and management of diabetes-related foot complications. In 2023, the group published their first guidelines on the diagnosis and treatment of Charcot neuro-osteoarthropathy (CNO) in persons with diabetes. The guidelines highlight 26 recommendations based on 4 categories: diagnosis, identification of remission, treatment, and prevention of re-activation. As reviewed in the guidelines, there are 2 recommendations suggesting the use of temperature assessment and monitoring as a tool for management of patients with CNO. Utilizing the systematic review and the GRADE system of evaluation, the authors deemed the level of evidence around temperature monitoring and Charcot to be low with a conditional recommendation for use. The purpose of this manuscript is to summarize the IWGDF guidelines while highlighting the role of foot temperature monitoring. Several case examples are given to illustrate the use of temperature monitoring in patients with CNO. Until there are guidelines determining active vs quiescent CNO, skin temperature monitoring can be a fast, easy-to-use, and effective tool for the clinician.

Background: Lower extremity wounds in patients with diabetes are difficult to heal due to an overabundance of pro-inflammatory M1 macrophages, reduced phagocytosis of necrosed cells, and circulatory issues. Keratin biomaterials have been shown to address some of these concerns by encouraging the proliferation of anti-inflammatory M2 macrophages, thereby creating more favorable conditions for wound healing resembling those of patients without diabetes.

Objective: To investigate the effect of a novel human keratin matrix (HKM) on wound healing.

Materials and methods: Ten patients with diabetes with lower extremity wounds at risk for delayed healing underwent wound debridement and application of HKM. Patients received weekly follow-up care and reapplication of HKM until healing occurred; wound size at each visit was used to calculate healing rate.

Results: Increased healing rates were noted with HKM compared with standard of care (SOC), including debridement and collagen treatment in all 8 patients who had received SOC prior to HKM treatment. When HKM treatment was alternated with SOC in 2 patients due to other medical conditions, healing rates decreased with SOC and then increased after reintroduction of HKM applications.

Conclusions: These results suggest that HKM may help regulate the pathological processes that contribute to wound chronicity to "kick-start" wound healing. This case series demonstrates that HKM is a promising technology to improve healing rates in nonhealing lower extremity wounds in patients with diabetes.

Background: Purpura fulminans (PF) is a rare, life-threatening condition involving consumptive coagulopathy and intravascular thrombosis, causing purpura and necrosis in the skin and soft tissue.

Case report: A 4-year-old Tajik girl with PF secondary to varicella-zoster virus (VZV) infection presented with purplish red, diffuse, painful lesions localized to the entire right leg. Her vaccination status was unknown, and she did not have concurrent chronic illness. Ten days before admission, the girl was admitted to another hospital in Tajikistan with a diagnosis of chickenpox and PF. She was then transferred to the hospital of the authors of the current report due to the enlargement of lesions to the gluteal region, a change in the color of lesions from red to black, and the detection of arterial thrombosis via Doppler ultrasonography. Multiple surgical debridements were performed to manage tissue necrosis, and the patient's right leg was amputated at the 18th week of admission. The patient was discharged after 26 weeks of hospitalization.

Conclusion: Although VZV infections mostly cause mild and self-limiting eruptive disease, they can progress, with life-threatening complications, including PF. To prevent VZV infection and resulting complications, immunization with live attenuated vaccines and maintaining population immunity above a certain threshold are the most important strategies to prevent the circulation of the virus.

Background: Sufficient oxygen is critical for multiple processes in wound healing. Nonhealing wounds have low tissue oxygen levels due to damaged microvasculature and comorbidities limiting tissue perfusion. Hypoxia may be reversed using continuous topical oxygen therapy (cTOT). Objective measures to identify and track hypoxic wounds and their response to adjunctive oxygen are key.

Objective: To understand the effect of cTOT on recalcitrant wounds by tracking wound area and changes in tissue oxygenation using a near-infrared spectroscopy (NIRS) device.

Materials and methods: Five patients with nonhealing wounds received treatment with cTOT over 5 weeks. Routine wound measures and tissue oxygenation were recorded over that period.

Results: Reductions in wound area and improvements in tissue oxygenation were seen in all 5 patients, with 3 patients healing within 5 weeks despite the previous long duration of their wounds. Trends in tissue oxygenation and relative wound surface area over the treatment period demonstrated a reduction in wound area as tissue oxygenation improved.

Conclusion: This case series reinforces previous studies that cTOT is an effective, noninvasive treatment as a key adjunct to standard care in nonhealing wounds. Moreover, point-of-care tools such as the NIRS imaging device provided objective information concerning tissue oxygenation improvements, thus giving useful insights to the clinician.

Background: Incapacitating wounds are common in rural areas of tropical developing countries. In this setting, injury and bite wounds often become chronic due to poor wound management.

Objective: To summarize more than 20 years of research, culminating with testing the use of Available Technology Dressings (ATDs), a very specific sustainable moist dressing technique, which can be taught to patients and lay health care providers.

Methods: Case studies, literature reviews, and qualitative and quantitative usual practice surveys provided the foundation for a 3-armed 12-week, evaluator-blinded, noninferiority RCT of the ATD technique. The ATD technique consists of (1) daily thorough wound irrigation, (2) protecting the periwound with a moisture barrier, (3) protecting the wound by conforming cut-to-fit thin food-grade plastic with slits to the wound bed, (4) fluffing absorbent material over the slits, and (5) holding the dressing in place (and, if possible, applying compression) with a snug wrap. ATDs were compared with saline-soaked wet-to-moist gauze (WTM, the negative control) and polymeric membrane dressings (PMDs, the positive control), evaluating safety, effectiveness, quality of life, pain, cost, dressing time, and acceptability in 40 Jamaicans with SCLUs.

Results: Wound experts throughout rural areas of Ghana, Zambia, and Cambodia prefer moist wound management, but lack the tools to provide it consistently. Food-grade plastic outperforms all other improvised dressings. Thin plastic bags are affordable and available worldwide. In the RCT, ATDs (13 participants) outperformed WTMs (16 participants) and were only modestly inferior to PMDs (11 participants) for the parameters of wound size, pain, and safety. ATDs were the least expensive, most available, most acceptable choice.

Conclusion: ATDs warrant further study.

Background: The use of negative pressure wound therapy with instillation and dwell time (NPWTi-d) has been shown to be effective in removing nonviable tissue, reducing bioburden, and promoting granulation tissue formation in acute and chronic infected wounds.

Objective: To illustrate the clinical efficacy of the use of pure hypochlorous acid (pHA) antimicrobially preserved wound cleansing solution as the instillation fluid for NPWTi-d (NPWTi-d/pHA) in wound bed preparation in patients with complex wounds.

Case report: The treatment protocol for use of NPWTi-d/pHA in preparing wound beds for final closure is demonstrated in 3 illustrative cases of patients with complex wounds resulting from necrotizing infection and trauma with heavy contamination. All 3 patients developed a healthy-appearing wound bed deemed suitable for primary closure an average of approximately 1 month following initial surgical debridement.

Conclusion: The cases presented demonstrate the ability of a pHA antimicrobially preserved wound cleansing solution used as the instillation fluid with NPWTi-d to aid in bacterial reduction, mechanical debridement, and promotion of wound healing. Use of NPWTi-d/pHA in these cases of extensive necrotizing infection and posttraumatic injury with heavy contamination allowed for final closure an average of 1 month after initial surgical debridement.

Background: Marjolin ulcer (MU) is an aggressive cutaneous malignancy that commonly occurs in those with a chronic wound such as post-burn scar.

Case report: A 20-year-old male who sustained a flame burn over the scalp at 3 months of age developed a nonhealing ulcer over the burn scar 20 years later, which was treated with adequate surgical margins with adjuvant mold brachytherapy. Two months after completion of that treatment, he developed parotid nodal metastasis with positron emission tomography (PET)-positive bilateral cervical, supraclavicular, right suboccipital, and mesenteric lymph nodes that were treated with concurrent chemoradiation. One month later, the patient developed an ulcerative lesion involving the left parotid region with PET showing infiltration of the parotid gland, but with resolution of other previous sites of uptake. The patient was treated surgically with radical parotidectomy with elective neck dissection and reconstruction with locoregional flap. At 6-month follow-up, the patient developed extensive locoregional recurrence and distant metastasis and was started on oral metronomic therapy. The patient was alive with stable disease at 3-month follow-up after initiation of palliative chemotherapy.

Conclusion: Despite timely multimodality therapy, MU may present with a hostile clinical course with a short disease-free interval and early recurrence.

Background: Full-thickness skin defects often are managed with split-thickness skin grafting. The wound healing process, including formation of new vessels during the healing of skin grafts, is complex.

Objective: To evaluate the microcirculatory changes in the treated tissue after skin grafting to analyze perfusion dynamics during the wound healing process.

Materials and methods: Fourteen full-thickness skin defects were created on the back of 14 adult male Lewis rats. All wounds were treated with autologous split-thickness skin grafts. The perfusion dynamics were assessed for 84 days with an O2C device that combines a laser light to determine blood flow and white light to determine postcapillary SO2 and the rHb.

Results: Blood flow increased for 50 days after grafting. SO2 decreased in superficial skin layers (depth of 2 mm) and increased in deep skin layers (depth of 8 mm) during the entire observation period. The rHb increased until day 10 in superficial layers and until day 20 in deep tissue layers.

Conclusion: The microcirculatory changes reflect the different phases of wound healing. Long after the skin transplants were macroscopically healed, alterations in microcirculation were still detected. These alterations were caused by the long-lasting changes in tissue metabolism due to the formation, conversion, and degradation of the dermal matrix and vessels during wound healing and scar formation.