Advances in wound care最新文献

Objective: The objective of this study was to evaluate the impact of a multidisciplinary team (MDT) approach in the management of diabetic foot ulcers (DFUs). Approach: A multidisciplinary diabetic foot care center (MDDFCC) was opened at our institution in August 2018. Outcomes of DFU treatment, including re-admission, amputation, and mortality rates, were compared before and after opening the MDDFCC. Results: Patients seen after the MDDFCC was opened had a lower risk of 1-year re-admission (hazard ratio [HR] = 0.697, 95% confidence interval [CI]: 0.387-0.988), 1-year major amputation (HR = 0.447, 95% CI: 0.091-0.984), and 1-year disease-specific mortality (HR = 0.277, 95% CI: 0.105-0.730). PEDIS score (HR = 2.343, 95% CI: 1.264-2.971), history of dialysis (HR = 1.858, 95% CI: 1.258-4.053), and consultation with a physiatrist (HR = 0.368, 95% CI: 0.172-0.788), orthopedist (HR = 0.105, 95% CI: 0.042-0.261), or social worker (HR = 0.370, 95% CI: 0.082-0.871) were associated with 1-year major amputation. One-year major amputation (HR = 2.636, 95% CI: 1.586-4.570), age (HR = 1.094, 95% CI: 1.051-1.140), and C-reactive protein level (HR = 1.052, 95% CI: 1.008-1.098) were associated with 1-year disease-specific mortality. Innovation: Plastic surgeons received patients at the MDDFCC, with active participation by all contributing members. This arrangement brought advantages, including more aggressive and timely surgical intervention, a more timely and higher rate of percutaneous transluminal angioplasty, and equally robust integrated medical care by all other members. Conclusion: The MDDFCC approach may be a potential organizational structure with for treating DFUs, resulting in significant improvements in outcomes of DFU including a lower re-admission, amputation, and mortality.

Objective: To evaluate global, regional, and national trends in the prevalence and disability-adjusted life years (DALYs) of pressure injuries (PIs) from 1990 to 2021 and project future trends to 2035, based on data from the Global Burden of Disease (GBD) study. Approach: This study used GBD 2021 data to analyze PIs prevalence and DALYs by age, sex, and Sociodemographic Index (SDI) region. The Bayesian age-period-cohort model was employed for temporal trend analysis and future projections. Results: From 1990 to 2021, the global prevalence slightly decreased from 8.246 to 7.920 per 100,000 (estimated annual percentage change -0.023%), whereas DALYs decreased by 9.7%. High-SDI regions presented significant DALY reductions (-39.3%), whereas middle- and low-middle-SDI regions presented increased prevalence rates (20.5% and 28.9%, respectively). The prevalence was highest in the ageing population, peaking in the 95+ year age group. Projections estimate that there will be 720,660 global cases by 2035, with the greatest burden expected among older adults in developing regions. Innovation: This study provides a comprehensive longitudinal analysis of PIs, revealing global disparities and emphasizing demographic-specific risks, especially in ageing populations and low-SDI regions. Bayesian modeling offered robust future projections. Conclusion: Despite modest improvements globally, significant disparities in the prevalence of PIs persist, particularly in developing regions and among older adults. Targeted interventions, preventive strategies, and health care policies are critical for addressing these challenges and mitigating future disease burdens.

Objectives: To elucidate the global disease burden and care quality associated with pressure injury (PI). Approach: This study examined temporal trends in PI incidence over the past 32 years. Decomposition analysis attributed these trends to demographic and epidemiological shifts, and cross-national health inequities were quantified. The Quality of Care Index (QCI) was constructed using principal component analysis to assess spatiotemporal variations in global PI care quality. A log-linear age-period-cohort model was employed to forecast trends over the next 15 years. Results: In 2021, there were nearly 2.47 million PI cases globally, a 115.92% increase from 1.14 million in 1990. Decomposition analysis revealed that population aging and demographic growth were the primary drivers of increasing PI incidence. Lower QCI was concentrated in African countries and those with low sociodemographic index (SDI). Incidence rates increased gradually with improving SDI. Significant health inequalities existed among 204 countries and regions, with minimal changes in inequality slope indices over time. Projections indicate a gradual increase to 3.5 million PI cases globally by 2035. Innovation: This study developed a novel comprehensive indicator, the QCI, and for the first time, shed light on health inequalities in PI across 204 countries and territories. Conclusion: Over the past 32 years, the global disease burden of PI has been significant, accompanied by health inequalities across countries and regions. For nations with low SDI, there remains considerable room for improvement in the quality of care for PI, necessitating more effective strategies to address health care disparities.

Significance: This systematic review was conducted to assess the quality of clinical practice guidelines (CPGs) on prevention and management of pressure injury (PI) in patients undergoing prone position ventilation (PPV) and summarize the recommendations based on the analyses of the CPGs. Recent Advances: We searched the PubMed, Cochrane library, Embase databases, guideline websites, professional association, quality standards, and Wound-Related Research Journals from January 1, 2010 to August 31, 2024. Included guidelines were those with recommendations for prevention and management of PI in patients undergoing PPV published in English. Four researchers independently assessed the eligible studies and extracted the data. Appraisal of Guidelines Research & Evaluation (AGREE II) instrument and the Reporting Items for Practice Guidelines in Healthcare checklist were used to assess the quality of the CPGs. Critical Issues: A total of 13 CPGs were included in this review. AGREE II demonstrated that the highest mean score was based on the scope and purpose and was 73.65 ± 10.91, whereas the lowest mean score was based on the editorial independence and was 49.79 ± 19.49. The scores of inter-rater agreements for AGREE-II quality appraisal ranged from 0.86 to 0.96. Recommendations for prevention and management of PI in patients undergoing PPV were inconsistent. Future Directions: The included CPGs were limited due to methodological issues and exhibited discrepancies in the coverage of important topics. Therefore, existing evidence should be used to propose identifiable recommendations and strengthen the rigor and standardization of guideline development in future research.

Significance: Recent reports recognize transepidermal water loss (TEWL) as a critical objective parameter measuring clinical wound healing endpoint. At the site of wound repair, TEWL measures functional wound closure as marked by re-establishment of barrier function at the wound site. This review article addresses recent developments in clinical TEWL measurement in the context of human skin health and wound care. To that end, emphasis is placed on the review of registered clinical studies reported in ClinicalTrials.gov for which TEWL results have been posted or published. Recent Advances: The U.S. Food and Drug Administration (FDA) defines complete wound closure as the achievement of 100% re-epithelialization of the wound surface, with no detectable exudate, drainage, or need for wound dressing, as verified during two sequential clinical assessments conducted at least 14 days apart. Clinically, wounds may meet this current FDA-recommended clinical criteria for wound closure, yet not achieve functional wound closure which requires the re-establishment of barrier function at the site of repair. Such wounds are likely to recur. High TEWL posthealing predicts wound recurrence. Thus, TEWL measurement at the site of repair posthealing is emerging as a significant measurement of wound healing endpoint. Critical Issues: Appropriate clinical measurement of TEWL requires a basic understanding of the related technologies and their appropriate use. Such understanding will help achieve the necessary rigor and reproducibility in clinical measurement. Future Directions: Recent reports on the critical significance of TEWL in wound care open new horizons wherein TEWL is likely to have broader applications involving altered skin barrier functions, such as during aging and other factors that determine skin health. Evidence to support revisiting the FDA definition of wound closure to include restoration of barrier function at the site of closure is strong. Widespread adoption of TEWL in wound care practices to determine functional wound closure is anticipated.

Objective: Chronic wounds have a high prevalence and poor outcomes in a geriatric population. It is unknown whether higher rates of successful wound healing are associated with better long-term outcomes. We sought to determine the association of risk-adjusted healing rates in wound care clinics with postdischarge outcomes. Approach: This observational study compared outcomes of Medicare patients with chronic wounds who received care at clinics with the highest risk-adjusted wound healing rates (n = 91) to those with the lowest rates (n = 88) in a network of 510 specialized U.S. wound care clinics. All 12,703 patients with chronic wounds at the clinics that could be identified in Medicare data were included. The outcomes were incidences of wound recurrence, gangrene, sepsis, and amputation after discharge. Results: The study included 6,462 and 6,241 patients in top- and bottom-performing clinics, respectively. Being treated in a top-performing clinic was associated with a lower cumulative incidence of all four outcomes. The difference was statistically significantly lower for wound recurrence (adjusted hazard ratio [aHR] = 0.82, 95% confidence interval [CI] 0.76-0.87, p < 0.001) and gangrene (aHR = 0.62, 95% CI 0.52-0.76, p < 0.001) but not for sepsis (aHR = 0.88, 95% CI 0.76-1.001, p = 0.065) and amputation (aHR = 0.75, 95% CI 0.65-1.00, p = 0.055). Innovation: This study is the first to suggest that patients treated in clinics with better wound-healing outcomes also have better outcomes after discharge. This finding can inform analyses to understand differences in practice patterns that lead to better outcomes. Conclusion: Treatment of chronic wounds in wound care clinics with higher risk-adjusted healing rates is associated with a lower risk of wound-related adverse events during follow-up, particularly in the first year. More research is needed to understand the factors that contribute to this effect and to determine interventions to improve outcomes sustainably as well as assess the impact of changes in outcomes on resource utilization and patients' quality of life.

Significance: Negative pressure wound therapy (NPWT) was introduced in clinical practice in the early 1990s and has become widely used to manage wounds in inpatient and outpatient care. Recent Advances: Evolutions of the initial technology include the development of new dressing interfaces and tubing configurations, the addition of instillation to improve cleansing, and various changes in design to improve portability. Research has been conducted to understand mechanisms of action and to demonstrate clinical utility. NPWT has been suggested as a valuable approach for various complex and/or nonhealing wounds, and recommendations for its use have emerged in several guidelines. Future Directions: The evidence, composed of a combination of randomized controlled trials, case series, cohort studies, real-world evidence, systematic reviews, meta-analyses, and expert opinion, is heterogeneous and still building. This special mini forum issue presents the current state of the science for NPWT and new studies providing insights on some innovative ways clinicians use this technology to help improve outcomes in a variety of wound types.

Objective: A new configuration of closed-incision negative pressure therapy (ciNPT) dressings now covers the incision and a broader area of peri-incisional tissues. We have implemented these ciNPT dressings following simple mastectomy (SM) or skin-sparing mastectomy with implant-based reconstruction (IBR). This study assesses patient-reported outcomes of this new protocol. Approach: Patients underwent SM or IBR for breast cancer. ciNPT with wide-coverage dressings were placed over the entire breast, and -125 mmHg was applied for 14 days. Upon dressing removal, patients rated their experience using the Wound-Q™ Suction Device Scale and recorded their satisfaction on a Likert scale ranging 1-5. Results: Thirteen SM patients and 12 IBR patients were included in the study. The median age was 62 years, and SM patients were significantly older (p < 0.01). Patients rated the ciNPT device highest on items relating to its function and appearance, and lowest on noise and interference with sleep and physical activity. The overall mean score for the combined cohort was 64.8/100. The mean score for SM patients (74.8 ± 19.9) was significantly greater than for IBR patients (53.9 ± 9.6, p < 0.01). The mean overall patient satisfaction rating was 3.92 on a 5-point scale; 4.0 in the SM group and 3.8 in the IBR group. Innovation: This study is the first to report on the patient experience with these newly available wide-coverage ciNPT dressings. Conclusion: Overall, the dressing was well-tolerated by patients, and satisfaction was high. The positive reception of ciNPT with wide-coverage dressings supports continued use at our hospital.

Objective: To evaluate if treatment of diabetic wounds by copper oxide impregnated dressings (COD) is noninferior to negative pressure wound therapy (NPWT). Approach: Following the CONSORT guidelines, patients with diabetes mellitus (type 1 or type 2) and noninfected wounds eligible for treatment with NPWT were randomized into two groups. One group received NPWT followed by standard wound care dressings, whereas the other was treated exclusively with COD. The primary outcome was wound size reduction, measured blindly using a 3D wound-imaging system. Secondary outcomes included patient and caregiver convenience (assessed via visual analog scores), cost, and additional wound parameters. Results: COD showed statistically significant noninferiority to NPWT in wound size reduction throughout the study (p < 0.01). The percentage of wounds that closed was 47.83% (11/23) and 34.78% (8/23) in the COD and NPWT arms, respectively (p > 0.05). The average time to wound closure, adjusted to potential confounders, such as gender, age, body mass index, diabetes, and smokers, was similar in both arms (p > 0.05). COD were found to be more convenient than NPWT for both patients (p < 0.001) and caregivers (p = 0.003), with a significantly shorter application time (p < 0.001). The COD cost was 14% of NPWT cost ($470 compared with $3,360). Innovation: COD may be considered as the first line of treatment for diabetic foot wounds when NPWT seems indicated. Conclusions: Using copper dressings as a first line of treatment of diabetic wounds, when NPWT is indicated, is expected to reduce health costs, improve convenience, and increase compliance without compromising the final outcome.

Objective: Oral mucosal wound healing is not completely understood, and effective therapies are lacking. This study explores the potential of an adipose-derived stem cell (ADSC) exosome sheet in enhancing intraoral wound healing in rats. Approach: An ADSC exosome sheet derived from Tisseel and rat adipose tissue (ADSC-exo) was applied to 16 rats with 6 mm full-thickness mucosal hard palate wounds. Eight wounds received ADSC-exo with a superficial occlusive dressing (ADSC-exo group), and eight received only an occlusive dressing (control group). Wound closure was monitored on days 0, 2, 4, 7, and 10, with dressings changed every 2 days. On day 10, rats were sacrificed, and wounds (n = 8 per group) were collected for immunohistochemical analysis. In vitro, four ADSC-exosome concentrations (0, 4.5 × 10¹¹, 9 × 10¹¹, and 18 × 10¹¹ exosomes/mL; n = 4 per group) were applied to rat oral mucosal fibroblasts to assess migration speed. Results: ADSC-exo accelerated wound closure (18% ± 5% vs. 35% ± 9% of initial wound area; p = 0.002) and fibroblast migration (for 18 × 10¹¹ exosomes/mL at 24 h: 29.7% ± 3% vs. 62.2% ± 4% of initial gap area; p < 0.0001) compared with the control. ADSC-exo promoted reepithelialization (87% ± 14% vs. 21% ± 6%; p < 0.0001), proliferation (34 ± 12 vs. 18 ± 7 Ki67+/high-power field [HPF]; p = 0.004), and neovascularization (28 ± 9 vs. 11 ± 5 CD31+/HPF; p = 0.0002) while reducing inflammation (4 ± 1 vs. 13 ± 9 CD68+/HPF; p < 0.0001) and increasing M2 macrophages (9.2 ± 2 vs. 4.2 ± 3 CD163+/HPF; p = 0.0008). ADSC-exo increased Transforming Growth Factor beta 1 (TGF-β1) (1.3 ± 0.3 vs. 0.9 ± 0.2; p = 0.006), Smad3 (0.9 ± 0.02 vs. 0.7 ± 0.1; p = 0.006), and collagen I (1.5 ± 0.9 vs. 0.5 ± 0.3; p = 0.005) while downregulating caspase-3 (0.7 ± 0.3 vs. 1.1 ± 0.2; p = 0.003) and Bax (0.9 ± 0.2 vs. 1.4 ± 0.1; p < 0.0001). Innovation: This is the first study to demonstrate the pro-wound healing effects of an ADSC exosome sheet on intraoral wounds. This paves the way for future research and clinical applications of ADSC exosomes in mucosal wound healing. Conclusions: Application of an ADSC-exo to rat mucosal wounds significantly improved wound healing. Mechanistically, these effects may be linked to upregulated activity of the TGF-β/Smad pathway.