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

Background: Necrotizing soft tissue infection (NSTI) is a debilitating disease process that is characterized by rapid clinical progression and extensive tissue destruction, necessitating early surgical excision. Long-term care and outcomes of the resulting complex morbid wounds remain daunting.

Objective: To review the skin-sparing surgery (SSS) approach to NSTIs and patient outcomes, including mortality rate, length of stay (LOS), and health care costs (HCC).

Methods: The electronic medical records of patients treated at an adult regional burn and wound center between 2011 and 2021 and who underwent a SSS approach to wound closure were reviewed. Patients were excluded if surgical reports did not characterize widespread fulminant tissue destruction at multiple levels and use of a SSS approach. LOS, mortality rate, readmission rates, and HCC were also evaluated.

Results: Seventy-one patients were included in the study. The mean number of SSS per patient during initial hospitalization was 3.56, and the mean number including revisions of all anatomic locations was 7.34. The initial hospital LOS averaged 23 days, and the initial encounter mortality rate was 1.4% (n = 1). The readmission rate within 30 days and within 90 days was 17% (n = 12) and 18% (n = 13), respectively. Further, 39.4% of patients were partially managed as outpatients during wound closure. The mean HCC over the treatment course, including indirect costs and direct costs, was $64 645.18 and $44 543.61, respectively.

Conclusion: The results of this study show that the SSS approach to NSTI correlates with low mortality rates, decreased LOS, and low HCC. These findings can inform future studies involving the SSS approach as well as increase awareness of this alternative technique to surgeons caring for patients with NSTI.

Background: Despite the efforts of plastic and orthopedic surgeons to elaborate the most appropriate treatment for lesions of the Achilles region and their reconstruction, no universal guideline exists. Regenerative treatments such as negative pressure wound therapy (NPWT) are increasingly being used in the management of these defects.

Objective: To research the different usage protocols, roles, and outcomes of NPWT in the management and reconstruction of Achilles region defects.

Methods: A scientific literature search was performed by querying Medline and Scopus using the terms "(Achilles tendon) AND ((vac) OR (vacuum assisted closure) OR (negative pressure) OR (NPWT))." The authors used an online screening software. The investigation followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic review.

Results: Of the initial 153 studies identified, only 14 fulfilled the eligibility criteria and were included in this review. Analyzed protocols mainly included surgical debridement combined with the use of NPWT as a primary dressing directly on the tendon or as a secondary dressing covering a split-thickness skin graft (STSG) or a flap. Additionally, the combination of negative pressure with matrices was found to provide optimal results even after STSG failure. Most of the reported complications described in the included studies involved partial loss of graft or flap.

Conclusion: NPWT can be used either as a primary dressing (directly on the lesion) or as a secondary dressing (over a flap or a skin graft) for management of Achilles region defects. The combined use of negative pressure with matrices can also aid in wound reduction.

Background: Pyogenic granulation is a common complication of bromhidrosis surgery, and multiple electrocauterization sessions are usually required to treat this condition.

Objective: To investigate the effectiveness of topical timolol for improving electrocauterization outcomes for pyogenic granulation.

Methods: The medical data of 20 patients who underwent bilateral bromhidrosis surgery followed by electrocauterization treatments for pyogenic granulation between January 2021 and December 2022 were retrospectively reviewed. The first 10 patients did not use topical timolol (non-timolol group), and the second 10 patients applied topical timolol maleate 0.5% drops twice daily (timolol group) after each session of electrocauterization. The total number of electrocauterization sessions received by the patients were compared between the 2 groups.

Results: The number of electrocauterization sessions was significantly less in the timolol group compared with the non-timolol group (median [range]: 3.5 [2-5] vs 5.5 [2-9]; P = .007). There was no statistically significant difference in age and sex distribution between the groups.

Conclusion: Application of topical timolol twice daily is effective in decreasing the number of electrocauterization treatments required to treat pyogenic granulation after bromhidrosis surgery. Topical timolol can enhance wound healing and improve electrocauterization treatment outcomes.

Background: A key element in achieving high-quality research lies in the use of validated tools for effective data collection. To enhance this process, the authors have created comprehensive reporting guidelines for these essential tools.

Objective: As members of the Wound Care Collaborative Community (WCCC) Tools Work Group, to identify tools capable of measuring percentage area reduction (PAR) and/or percentage volume reduction (PVR) and to assess the various features associated with these wound imaging devices.

Methods: Data from publicly available databases and surveys of manufacturers meeting the inclusion criteria were collected in the fourth quarter of 2023 and the second quarter of 2024. The inclusion criteria were medical devices with the US Food and Drug Administration (FDA) FXN (Tape, Camera, Surgical) product code classification capable of length and width wound measurements currently marketed by FDA-listed establishments.

Results: Thirteen FDA-registered establishments with 14 wound imaging devices met the inclusion/exclusion criteria. Representatives from 10 of those establishments engaged in the survey process by completing and returning their WCCC questionnaires. Seven tables were created to summarize the findings across the devices.

Conclusion: More wound imaging devices measure PAR than PVR, and most utilize the perimeter alone or in conjunction with square surface area and/or oval or other shapes for area calculations. While variations in length or width (up to 5%), and area (up to 10%) may occur with the device calculations, these variations are less than is seen with ruler measurements. Several imaging devices incorporate methods to correct for skew, have sophisticated 3-dimensional modeling, and/or use reference markers to enhance overall accuracy and reliability, supporting their measurements as reliable indicators of wound trajectory.

Burn wounds are insults to the skin that can be caused by various sources, including thermal, electrical, or chemical sources, and even natural sources such as the sun. A burn wound is conventionally categorized into 3 distinct zones: (1) coagulation, (2) ischemia/stasis, and (3) hyperemia. In addition to the potential for physiological scarring, burn wounds can lead to microbial infections, such as pneumonia and methicillin-resistant Staphylococcus aureus, that are difficult to treat using conventional antimicrobial therapy. Patients whose burn wounds trigger a systemic inflammatory response experience further deterioration of their medical condition. Moreover, an increase in the incidence of antibiotic resistance poses a major challenge in the treatment of wounds. Researchers are shifting their focus to newer techniques, such as acellular fish skin, hydrogels, negative pressure wound therapy, nanotherapeutics, and stem cell therapy to counter the disadvantages associated with conventional therapy. This review provides an overview of burn wound causes, classifications, and treatments, and it discusses the healing phases of wounds, possible types of infections, the complexities associated with existing conventional treatments, and the advanced techniques currently used in burn wound management that have proven to reduce hospital stays and make treatment more cost-effective.

Background: Failure to adhere to study protocol is among the most common observations during inspections conducted by competent authorities for clinical trials.

Objective: To evaluate patterns of protocol deviations, and to analyze how social determinants of health (SDoH) correlate with the rate of protocol deviations as indicators of study protocol noncompliance.

Materials and methods: Data obtained at a single clinical site from 19 clinical trials with a total of 186 subjects enrolled were analyzed retrospectively, and correlations between SDoH (eg, race/ethnicity, gender [eg, male/female], socioeconomic status, distance traveled, etc) and study protocol noncompliance (ie, rate of deviations) were examined. The Kruskal-Wallis test was performed to compare SDoH variables with rate of deviations per subjects enrolled. Associations between SDoH and deviations were examined using the Spearman correlation test.

Results: A retrospective analysis showed that the majority of deviations were attributed to study visits that had not been performed in a timely manner or were missed, and study procedures that either were not performed or were completed late. The tests demonstrated no statistical significance between age, gender, and race and rates of dropout from the study (P = .1857, P = .3836, and P = .2150, respectively). Increased body mass index was associated with higher dropout rates (P = .0340), which can be an indicator of higher disease burden and an obstacle to trial participation.

Conclusion: Further studies are warranted to investigate how quality in wound care clinical trials can be improved with identification of patients who need more resources based on their SDoH to efficiently mitigate risks, increase access to trials for disadvantaged populations, and improve study protocol compliance.

Background: Calciphylaxis is a rare multifactorial skin disease characterized by thrombosis and calcification of skin subcutaneous vessels, leading to chronic and painful ulcers with skin necrosis. Despite its high morbidity and mortality rates, effective treatments are lacking.

Case report: A 65-year-old female with chronic kidney disease who developed painful bilateral ulcers was successfully treated with topical timolol. Clinical examination and imaging confirmed the diagnosis of calciphylaxis. Treatment with topical timolol resulted in rapid wound healing and pain relief.

Conclusion: This case highlights the potential of topical timolol in promoting wound healing in calciphylaxis ulcers, a novel therapeutic approach not previously reported. Further studies are warranted to validate the efficacy of topical timolol and explore its role in managing calciphylaxis. Despite the challenges in diagnosis and management of calciphylaxis, topical timolol appears promising for improving outcomes in affected patients.

Background: Negative pressure wound therapy (NPWT) is a widely used therapeutic approach for skin and soft tissue defects, and selecting an appropriate negative pressure value is critically important.

Objective: To develop a wound pressure monitoring dressing (WPMD) integrating a novel pressure sensing chip with a previously developed polyvinyl acetate foam dressing.

Materials and methods: Sprague-Dawley male rats were randomly divided into 3 groups to receive -125 mm Hg pressure with the WPMD, -75 mm Hg pressure with the WPMD, or wound dressing without negative pressure (control). Data on pressure changes and wound conditions were collected over 7 consecutive days. Monitoring included pressure changes, gross wound morphology observations, and histopathological analyses.

Results: Monitoring data revealed pressure variations during wound healing ranging from -128 mm Hg to -63 mm Hg in the -125 mm Hg preset group, and from -72 mm Hg to -37 mm Hg in the -75 mm Hg preset group. The WPMD groups exhibited higher wound closure rates than the control group. Ki67, vascular endothelial growth factor receptor 2, transforming growth factor β1, and CD31 expression levels were elevated in the WPMD groups compared with the control group.

Conclusion: The WPMD accurately and sensitively detected real-time pressure changes on wound surfaces under different preset negative pressure values (-125 mm Hg and -75 mm Hg). Furthermore, NPWT significantly accelerated wound healing in the rat model, and the healing rates were better in the -75 mm Hg group than in the -125 mm Hg group at day 5 and day 7. These results underscore the potential application of the WPMD in investigating the relationship between negative pressure values and wound healing rates across various wound types during treatment.

Background: Single-use negative pressure wound therapy (sNPWT) has emerged as a promising intervention for patients at high risk of surgical site complications (SSCs) after a cesarean delivery. However, the available studies primarily compare negative pressure wound therapy to standard dressings rather than evaluating differences between negative pressure wound therapy devices or pressure settings.

Objective: To compare the effectiveness of 2 commonly used sNPWT devices, a -80 mm Hg device and a -125 mm Hg device, in reducing the risk of SSCs following cesarean delivery.

Materials and methods: Real-world data were obtained from a large claims database in the United States from January 2017 through June 2022. Adult patients who had an inpatient encounter in which the -80 mm Hg device or the -125 mm Hg device was used after a cesarean delivery were included. Propensity score matching was used to balance the cohorts. Study end points included incidence of overall surgical site infection (SSI), superficial SSI, dehiscence, seroma, hematoma, deep SSI, length of stay (LOS), and costs.

Results: The study included 5332 cases in each group. Overall SSI, superficial SSI, dehiscence, seroma, and costs were significantly lower with the -80 mm Hg device compared with the -125 mm Hg device (P ≤ .05). No differences between the 2 devices were observed for hematoma, deep SSI, and LOS (P > .05).

Conclusion: Of the 2 commonly used sNPWT devices, use of the -80 mm Hg device was associated with a lower likelihood of developing overall SSI, superficial SSI, dehiscence, and seroma, and was associated with lower costs after cesarean delivery compared with the -125 mm Hg device. There were nonsignificant differences in LOS, deep SSI, and hematoma. Further studies are required to confirm these findings.

Background: A randomized controlled trial reported that bromelain-based enzymatic debridement (BBD) more effectively debrided and granulated venous leg ulcers (VLUs) compared with placebo (gel vehicle, hydrogel) and nonsurgical standard of care (including collagenase ointment [CO]).

Objective: To assess the efficacy of BBD vs CO-based enzymatic debridement in VLUs during the ChronEx trial.

Materials and methods: The Wilcoxon exact test was used to compare the proportion of wounds in each group that achieved complete debridement and granulation at 2 weeks. Kaplan-Meier analysis was used to compare median times to complete debridement and granulation between groups.

Results: Forty-six patients with 46 wounds were treated with BBD, and 8 were treated with CO. Twenty-nine wounds treated with BBD (63%; 95% CI, 48-77) were completely debrided within 2 weeks compared with none treated with CO (P = .001). Twenty-three wounds treated with BBD (50%; 95% CI, 35-65) achieved complete granulation by 2 weeks compared with none with CO (P = .015). The estimated median time to complete debridement and complete granulation, respectively, in the BBD group vs the CO group, respectively, were 9 days vs not achieved (P = .023), and 11 days vs not achieved (P = .014). The groups had comparable safety and pain profiles.

Conclusion: BBD appears to be more effective and faster than CO in achieving complete debridement and granulation of VLUs as part of wound bed preparation.