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

Background: Trauma is among the leading causes of skin loss or degloving. Flaps and skin grafts are common surgical procedures to repair or replace the lost skin over open wounds, and split-thickness skin grafting (STSG) is the most common approach.

Objective: To assess the effect of hyperbaric oxygen therapy (HBOT) on STSG uptake and donor site healing.

Materials and methods: This trial was conducted on patients with traumatic wounds who underwent STSG as per inclusion criteria. The patients were randomized into 2 groups. One group received standard care after skin grafting, and the other received HBOT in addition to standard care. Uptake of STSG was assessed on postoperative day (POD) 4 and POD 7, and donor site healing was assessed on POD 11 and POD 15.

Results: A total of 64 patients aged 18 years to 60 years were included in the study. Mean (standard deviation [SD]) percentage graft uptake on POD 4 was 92.44% (5.98%) in the HBOT group and 88.12% (8.92%) in the control group (P = .036), and on POD 7 was 91.69% (8.71%) in the HBOT group and 83.12% (14.94%) in control group (P = .026). Donor site recovery was also significantly faster in the HBOT group, with a mean (SD) of 15.16 (0.88) days in the HBOT group and 17.97 (2.49) days in the control group (P < .001). In the control group, floating grafts were found in 2 patients, flap necrosis occurred in 4 patients, and 1 patient died due to sepsis, whereas in the HBOT group, significant graft contracture and wound recipient site infection occurred in 1 patient each.

Conclusion: HBOT significantly improved the percentage graft uptake in posttraumatic wounds and resulted in better donor site healing compared with standard care alone.

Background: Negative pressure wound therapy (NPWT) is an effective intervention for challenging wounds across multiple indications. Its application sometimes requires a technique known as 'bridging" to prevent ulcerations caused by delivery port and tubing when positioning the device, which requires extra time and resources. The bridging technique may be adopted when it is considered essential to move the NPWT delivery port away from the wound bed or when treating wounds in close proximity to each other.

Materials and methods: A survey was undertaken by 200 health care professionals (HCPs) in the United States who are experienced in utilizing traditional negative pressure wound therapy (tNPWT) and bridging. Primary objectives were to explore HCP opinion on 2 types of tNPWT delivery ports (soft and hard) between 2 leading manufacturers. Questions focused on the need for bridging, alleviation of complexity in application, and reducing concerns relating to medical device-related pressure injury when applied to awkward anatomical areas.

Results: HCPs (75%; n=150) largely agreed that the bridging technique makes application of tNPWT slightly more challenging. Reasons included additional time taken to apply (74%; n=148), increased dressing resource (67%; n=134), and additional staff required (50%; n=100). Over half (53%; n=106) agreed that the soft port can eliminate the need for bridging. The majority of wound specialists were significantly less likely to favor a hard port (58%; n=116). Two further potential benefits of using a tNPWT soft port include the associated risk of pain/pressure when applying a hard port over a smaller wound size (29%; n=58) and certain anatomical areas which pose a risk of pressure injury or kinked/twisted tubing (31%; n=62).

Conclusion: tNPWT soft ports remain effective regardless of kinks or twists and can eliminate bridging in anatomical areas where patients may weight-bear on tubing or delivery ports, saving time and decreasing risks of periwound trauma.

Background: Intact fish skin graft (IFSG) has been reported to be an adjunct to healing post-Mohs surgical wounds.

Objective: To assess the data that could be found on the use of IFSG in conjunction with Mohs surgery.

Materials and methods: A non-interventional observational registry collected data on the use, indications, and outcomes of IFSG over 32 weeks. This registry collected data on IFSG placed for a broad variety of indications. The primary end point was to determine the percentage of wounds closed at 32 weeks, and the secondary objective was to determine the median number of IFSG applications during this period. The registry was queried for patients who had IFSG placed for wounds created by Mohs surgery.

Results: As of mid-April 2024, 41 participants enrolled in the registry had undergone placement of IFSG post-Mohs surgery. The mean (standard deviation) patient age was 77.6 (8.9) years, and 24% of participants were female (n = 10). Forty of 41 wounds (97.6%) achieved complete wound closure in a median of 5 weeks, and the median number of visits was 5. For closed wounds, the median number of applications was 2.

Conclusion: This registry demonstrates that in a real-world setting, IFSG provides support to aid wound closure. In the post-Mohs setting, only 1 to 2 IFSG applications were required. This study demonstrates how IFSG can be a viable option for Mohs surgeons to consider in the reconstruction paradigm for a variety of wound sizes and anatomic locations.

Background: Leukocytoclastic vasculitis (LCV) is a rarely diagnosed dermatologic hypersensitivity vasculitis. LCV manifests as small, pruritic petechiae or purpura that without treatment can develop into painful, necrotic ulcerations or hemorrhagic bullae. Currently, there is no standardized treatment protocol for LCV wounds, which makes resolution of the wounds difficult.

Case report: This case report discusses the cutaneous manifestation and the treatment protocol used to treat a single patient diagnosed with LCV of the lower extremities. The multidisciplinary treatment approach involves dermatologic, vascular, and podiatric surgeons and encompasses both pharmaceutical and local wound care modalities.

Conclusion: This case further highlights LCV as a rare, challenging condition of the lower extremity that requires a multidisciplinary approach for proper diagnosis and treatment.

Background: Critically ill patients are at increased risk of skin breakdown that may occur in non-pressure locations. Recognition of skin failure as distinct from hospital-acquired pressure injuries (HAPIs) may have significant clinical, financial, and legal implications.

Objective: To apply a novel diagnostic scale in the care of patients with pressure injuries to determine its utility in diagnosing skin failure at a quaternary hospital.

Materials and methods: Critically ill patients at a quaternary hospital from September 2022 through November 2023 with a HAPI diagnosis were included. Charts were retrospectively reviewed for demographics, clinical outcomes, and wound parameters. Skin failure was evaluated using the Hill and Petersen Skin Failure Clinical Indicator Scale (SFCIS), with patients with a score of 15 to 21 considered to have high probability of skin failure.

Results: During the study period, 12 patients were found to meet criteria for skin failure. For those patients, the mean length of stay was 58 days. All patients scored above 15 on the SFCIS, with 3 patients scoring 21 and 9 patients scoring 18. All patients met criteria for impaired blood flow and sepsis or multisystem organ dysfunction syndrome. Four patients met criteria for moderate or severe protein calorie malnutrition with an albumin level of less than 3.5 g/dL. Ten patients received mechanical ventilation for more than 72 hours.

Conclusion: Twelve patients who were identified has having HAPIs were reclassified as having skin failure using the SFCIS. Further work is necessary to validate this scoring system in diagnosing skin failure and the implications associated with its use.

Background: The safety and efficacy of negative pressure wound therapy (NPWT) is well established. The technology has evolved to include 2 device categories: traditional NPWT (tNPWT) and single-use NPWT (sNPWT). Each mode has unique properties benefitting multiple aspects of wound care.

Objective: To assess the proportion of tNPWT-treated wounds that could be amenable to sNPWT, thus determining optimal therapy.

Materials and methods: A de-identified dataset of wounds managed with tNPWT in outpatient clinics in the United States from 2006 through 2020 was analyzed to determine the proportion of wounds that could have been managed with sNPWT based on wound area, depth, and exudate volume, as well as sNPWT dressing size. Descriptive statistics were reported.

Results: A total of 5040 wounds were analyzed. Ten wound types were identified, the most prevalent being surgical open wound (n = 2268 [45%]). All 8 commercially available sNPWT device dressing sizes, from 1 manufacturer, were included in the analysis. Overall, 3403 wounds (68%) would have been suitable to receive sNPWT instead of tNPWT at treatment commencement.

Conclusion: The utilization of tNPWT is ideally positioned for large, deep, highly exuding wounds. However, by assessing a wound's dimensions and exudate volume and type, a more appropriate NPWT device selection can be made; thus, ensuring the delivery of therapy with the most suitable device modality appropriate for the wound and patient while also maximizing resources.

This corrects the article DOI: 10.25270/wnds/23150.

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.

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.

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.