Advances in wound care最新文献

Objective: New treatment options are emerging for chronic wounds, which represent a growing problem because of population ageing and increasing burden of chronic disease. While promising, the existing evidence for advanced modalities is commonly derived from small and/or poorly controlled studies and clear criteria for selecting patients, who are likely to benefit from these expensive options are lacking. In this study, we develop and validate a machine learning model to predict if a chronic wound, independent of etiology, is expected to heal within 12 weeks to identify cases in potential need of advanced treatment options. Approach: Retrospective analysis of electronic health record data from 2014 to 2018 covering 532 wound care clinics in the United States and 261,398 patients with 620,356 unique wounds. Prediction of 12-week healing trajectories with a machine learning model. Results: The best-performing model in a training dataset of a randomly drawn 75% subset of wounds contained variables for patient demographics, comorbidities, wound characteristics at initial presentation, and changes in wound dimensions over time, with the latter group being the most influential predictors. The final machine learning model had a high predictive accuracy with area under the receiver operating characteristic curves of 0.9 and 0.92 after 4 and 5 weeks of treatment, respectively. Innovation: A machine learning model can identify chronic wounds at risk of not healing by week 12 with high accuracy in the early weeks of treatment. Conclusions: If embedded in real-world care, the generated information could be able to guide effective and efficient treatment decisions.

Objective: To verify the noninferiority of the effectiveness of "semiocclusive dressing" (SOD) treatment using plastic wrap or low-adherent absorbent wound dressings compared with occlusive dressing (OD) treatment for National Pressure Injury Advisory Panel stage II pressure injuries. Approach: This 12-week, open-label, randomized, controlled, noninferiority trial was conducted at one hospital and three care facilities. Of the 115 participants, 56 were assigned to SOD treatment and 59 to OD treatment. The study design adhered to the CONSORT 2010 extension statement for noninferiority trials. The primary outcome was a comparison of the healing times for both treatments, with the noninferiority margin set at 7.0 days. Secondary outcomes included treatment costs, Kaplan-Meier curves, and incidence of adverse events. Results: The mean healing times for SOD and OD treatments were 19.7 and 22.5 days, respectively (p = 0.4175). The 95% confidence interval of the difference was -4.0 to 9.6. Since its lower limit was within the noninferiority margin, SOD treatment was confirmed to be not significantly worse than OD treatment. OD treatment had a significantly higher mean cost than SOD treatment (p < 0.0001). Kaplan-Meier curves for both groups were similar (p = 0.249). The incidence of adverse events in both groups was comparable. Innovation: Uniquely, the SOD does not tightly adhere to or completely occlude the wound and can manage abundant exudate. Therefore, SOD treatment maintains an adequately moist environment to facilitate wound healing. Conclusion: SOD treatment was more cost-effective than OD treatment for stage II pressure injuries. [Figure: see text].

Significance: Wound healing is a complex process, and while the epidermis and dermis receive significant attention, the role of the hypodermis is important. The adipose-rich hypodermis or subcutaneous layer supports overall skin function, and loss or injury can impair wound healing, result in adhesions and/or contracture, and restrict soft-tissue mobility. Traditional wound management methods are often insufficient for hypodermal injuries, necessitating innovative approaches. Recent Advances: Hypodermal adipose-based solutions, including fat grafting and stem cell therapies, show promise for reconstruction. Fat grafting enhances soft-tissue bulk and contour, enhances mechanical properties, and promotes angiogenesis, offering versatility in addressing a range of wound scenarios, including challenging cases. Adipose-derived stem cells exhibit regenerative potential, modulate inflammation, and facilitate tissue repair, making them valuable for scar revision, skin rejuvenation, and managing chronic wounds. Acellular adipose derivatives, such as exosomes and liquid extracts, contain bioactive molecules that support tissue regeneration and collagen production. Adipose-derived acellular extracellular matrix holds promise in wound healing by enhancing cell behavior and angiogenesis. Critical Issues: In this review, we will discuss adipose-centered options for improvement of wound healing and for restoration of the hypodermis together as a cluster of efficient and cost-effective wound management in cases of complex soft-tissue injuries. Future Directions: These innovative therapies, while requiring further research, hold significant potential to simplify procedures, reduce costs, and improve the quality of life for patients facing challenging wounds.

Significance: Wound healing in irradiated skin remains a clinical challenge, with radiation therapy (XRT) resulting in excess collagen deposition and cell death resulting in poor tissue quality. This frequently results in chronic wounds that compromise patient outcomes and quality of life. Recent Advances: Improved understanding of the pathophysiology behind radiation-induced soft tissue injury has led to the development of promising treatments. These include dermal substitutes, placental derivatives, fibronectin, injectable fat-derived and plasma-derived compounds, hyperbaric oxygen, and deferoxamine. Critical Issues: Many traditional approaches to wound healing are often limited by poor tissue quality seen following XRT. A better understanding of mechanisms by which radiation induces these pathological changes may lead to the development of more effective therapeutics. Future Directions: Treatments leveraging recent insights into collateral radiation injury may help to condition tissue to promote healing/regeneration of wounds. Although animal studies and human case reports have been promising, wide-scale clinical studies examining their efficacy are still needed before many of these novel strategies may be adopted to help the millions of patients worldwide suffering from radiation-related cutaneous wounds.

Objective: Patients with complex chronic wounds are at high risk for poor outcomes. This study assessed the relationship between nurse staffing and outcomes among patients with complex and noncomplex chronic wounds. [Figure: see text] Approach: This cross-sectional study linked three 2021 datasets: RN4CAST survey, Medicare Provider Analysis and Review claims, and American Hospital Association data. Nurse staffing was derived from the RN4CAST item asking nurses whether "there are enough nurses to get the work done." We calculated the hospital-level percentage of nurses who reported staffing inadequacy. Multilevel statistical modeling measured the association between staffing and in-hospital mortality and length of stay, adjusted for patient and hospital covariates and stratified among patients with complex and noncomplex chronic wounds. We followed STROBE criteria. Results: The sample included 19,027 patients with chronic wounds (66.7% complex) in 216 hospitals. Every 10% increase in nurses reporting staffing inadequacy was associated with 6% higher odds of in-hospital mortality among patients with complex wounds, with no significant relationship among patients with noncomplex wounds. Every 10% increase in staffing inadequacy was associated with longer lengths of stay, by a factor of 1.04, for patients with both complex and noncomplex wounds. Innovation: By linking nurse-reported staffing to outcomes for patients with chronic wounds, this study identifies a policy-relevant pathway to improve outcomes, particularly for those with complex wounds. Conclusion: Nurse staffing adequacy is consequential for patients with chronic wounds as it relates to length of stay and is particularly important in preventing in-hospital mortality among the highest-risk patients-those with complex wounds.

Objective: Livedoid vasculopathy is a skin disease characterized by recurrent painful ulcerations of the lower leg leading to scar formation (atrophie blanche). Ulceration results from thrombosis of the cutaneous microcirculation and is often preceded by irregular broken circles of skin discoloration (livedo racemosa) in the lower extremities. Intense local ischemic pain, ulcerations, and irreversible scarring have a severe impact on patients' quality of life. There are currently no approved treatments for livedoid vasculopathy, making off-label therapy the only option. The German S1 guideline for treatment of livedoid vasculopathy recommends anticoagulation with low-molecular-weight heparins, rivaroxaban, and other direct oral anticoagulants as first-line therapy. Approach: We present a single-center follow-up study of 26 patients with livedoid vasculopathy (following STROBE). Patients treated according to the German S1 guideline consented to be monitored with a cross-sectional study questionnaire providing data on demographics, treatment protocol, disease course (pain, disease activity, and relapses), quality of life (Dermatology Life Quality Index score), and daily life impact. Results: Prolonged guideline-followed treatment of livedoid vasculopathy leads to effective management of pain and disease activity. Patients report therapy satisfaction and profit by sustained benefits in quality of life. Innovation: In this study, we analyzed the long-term efficacy of guideline-followed treatment in patients with livedoid vasculopathy over a period of up at least 3 months to more than 24 months. Conclusion: Guideline-followed treatment with anticoagulants like rivaroxaban is an effective long-term therapy option for patients with livedoid vasculopathy.

Significance: Fibrosis is associated with high rates of morbidity and mortality and poses a heavy burden on the health care system. Different regions of the body heal at different rates with varying degrees of fibrosis, with regions such as the extremities and trunk being more prone to scarring than the face and mucosa. Therapies that leverage the unique mechanisms underlying these anatomical differences in wound healing may be effective in mitigating fibrosis and scarring. Recent Advances: Recent studies in mice have revealed fibroblast-intrinsic signaling pathways that contribute to scar formation in different areas of the body, such as engrailed-1-positive fibroblasts and paired-related homeobox-1-positive fibroblasts in dorsal, ventral, and dermal scars, respectively. Novel approaches that target specific molecular pathways within fibroblasts may pave the way for effective therapies in replicating features of scar-resistant skin and facilitating wound healing. Critical Issues: Clinical practice and animal studies have shown some body regions to be more susceptible to fibrosis than others. However, our understanding on cellular and molecular mechanisms that contribute to this phenomenon remains limited. Future Directions: Advances in antiscarring therapy will benefit from harnessing several aspects of wound healing in regions less prone to fibrosis, including reducing mechanical tension, controlling angiogenic response, and modulating fibroblast subtypes. [Figure: see text] [Figure: see text].

Objective: Evaluate quality of life (QoL) of patients with malignant wounds at baseline and through the course of management at a dedicated malignant wound care clinic. Methods: Retrospective review of patients with malignant wounds seen at a dedicated wound care clinic between January 2016 and April 2023 who completed the Skindex-16, a validated dermatologic QoL questionnaire. Clinical symptoms and management data were extracted from electronic medical records. Results: At baseline, patients reported high Skindex-16 scores across symptoms (mean = 64.2, standard deviation [SD] = 33.3), emotions (mean = 44.8, SD = 31.2), and functioning (mean = 67.7, SD = 29.7) domains. Overall Skindex-16 scores significantly improved over time, with a mean reduction of 4.9 points per visit (p = 0.002). Multimodal symptom management, including both topical and systemic treatments, and modern dressings were commonly utilized. Clinical Implications: Early referral to specialized wound care allows timely initiation of symptom-directed interventions to reduce pain, bleeding, odor, and infection risk. QoL improvements are often seen after the first follow-up visit, with the greatest benefit between the first and second visits. Access to structured wound care not only alleviates symptom burden but also supports continuation of oncologic treatment. Innovation: This study is the first to longitudinally assess malignant wound-related quality using a dermatology-specific instrument, the Skindex-16, in a real-world clinical setting. These findings highlight a model for integrating dermatologic wound care into supportive oncology and demonstrate that malignant wounds, often regarded as irreversible, can be meaningfully palliated with dedicated care. Conclusion: Dedicated wound care was associated with statistically significant improvements in QoL for patients with malignant wounds. Early referral to specialized wound clinics may enhance palliative care for these patients.

Significance: Pressure injury is one of the most common health problems among hospitalized patients worldwide, and accurate and timely diagnosis is crucial for its treatment. Research on the application of artificial intelligence in the diagnosis of pressure injury is increasing, but there is currently no comprehensive meta-analysis to evaluate the accuracy of artificial intelligence in diagnosing different pressure injury stages. Recent Advances: This study synthesizes evidence on artificial intelligence diagnosis of pressure injury, focusing on evaluating diagnostic performance across different stages using core metrics including sensitivity, specificity, and the area under the summary receiver operating characteristic (SROC) curve. Critical Issues: Key findings from 21 included studies (12 contributing 47 eligible datasets) indicate high overall diagnostic accuracy of artificial intelligence for pressure injury, with sensitivity of 0.74 (95% confidence interval [CI]: 0.69-0.78), specificity of 0.93 (95% CI: 0.91-0.94), and area under the SROC curve of 0.92 (95% CI: 0.90-0.94). Moreover, the area under the SROC curve varies across different stages of pressure injury, with area under the curve values for stage 1, stage 2, stage 3, stage 4, unstageable, and deep tissue pressure injury of 0.95 (0.93-0.97), 0.85 (0.82-0.88), 0.88 (0.84-0.90), 0.94 (0.92-0.96), 0.96 (0.94-0.97), and 0.98 (0.96-0.99), respectively. Future Directions: Artificial intelligence models based on pressure injury image data show substantial potential for clinical application in pressure injury diagnosis. However, the need for high-quality studies with rigorous reporting and external validation remains critical to address current limitations and advance clinical translation.

Significance: Wound healing in pediatric patients is affected by physiology, growth, and development considerations unique from those in adults. In the following report, we review the primary literature on aging and wound healing and highlight clinical wound healing applications for the pediatric patient across age ranges from neonates and infants in the first year of life to adolescents (aged 10-19 years by World Health Organization definition). Recent Advances: We characterize the differences in wound healing biology between infants, adolescents, and adults and discuss wound care strategies for pediatric surgical patients, highlighting evidence-based guidelines for wound management. We discuss relevant animal models and review the multidisciplinary aspects of providing wound care for children. Critical Issues: Pediatric surgical patients have specialized wound care needs. Optimizing wound care outcomes for infants, children, and adolescents relies on an understanding of their wound-healing biology and unique physiological, psychological, and social considerations. Future Directions: Future directions in pediatric wound care will focus on validating and optimizing emerging technologies through pediatric-specific clinical trials, while also addressing key knowledge gaps in topical agent pharmacokinetics and advancing regenerative approaches like mesenchymal stem cell therapies tailored to the unique biology of infants and children.