Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

Artificial Intelligence Versus Human Systematic Literature Review Into Negative-pressure Wound Therapy in Plastic Surgery

Background

The potential of artificial intelligence (AI) to support physician evidence-based medicine is vast. We compared AI's ability to perform a systematic review of the literature to that of human investigators. Negative-pressure wound therapy (NPWT), a mainstay of wound management with a large but varied body of evidence, was therefore chosen as the subject of this investigation. Producing high-level evidence of NPWT's impact on wound healing has been challenging due to trial design issues, making a systematic review important and challenging. In this article, NPWT efficacy and the ability of AI to assess levels of evidence were evaluated.

Methods

A literature search was conducted using PubMed, SCOPUS, and CINAHL. The resulting articles were screened using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The Grading of Recommendations, Assessment, Development, and Evaluations criteria were applied by both humans and AI to analyze the quality and evidence of each article.

Results

Eighteen studies on 3131 patients were reviewed. Seven studies addressed length of stay; five showed shorter stays with NPWT. Fourteen studies examined infection rates. Eight found significant improvement with the use of NPWT. Twelve articles analyzed time to wound closure, and nine of those articles found reduced time when NPWT was utilized. AI generally assigned lower quality of evidence scores compared with humans.

Conclusions

AI is a promising tool but remains limited in accurately determining evidence quality. AI's lower scores may reflect reduced bias. Multiple confounders and the diversity of its application lead to a lack of high-level evidence of NPWT's efficacy.

Enhanced localized pressure-mediated non-viral gene delivery

Topically applied therapies must not only be effective at the molecular level but also efficiently access the target site which can be on milli/centimetre-scales. This bottleneck is particularly inhibitory for peptide and nucleic acid macromolecule drug delivery strategies, especially when aiming to target wounded, infected, and poorly perfused tissues of significant volume and geometry. Methods to drive fluid-flow or to enhance physical distribution of such formulations after local administration in accessible tissues (skin, eye, intestine) would be transformative in realizing the potential of such therapeutics. We previously developed a technology termed Glycosaminoglycan (GAG)-binding enhanced transduction (GET) to efficiently deliver a variety of cargoes intracellularly, using GAG-binding peptides and cell penetrating peptides (CPPs) in the form of nanoparticles. Herein, we demonstrate that the most simplistic GET formulation is relatively poor in diffusing into tissue matrix (tested in collagen scaffolds). Changing nanoparticle physicochemical properties can enhance penetration, however the use of a pressure differential, generating fluid-flow significantly enhances effective gene delivery over milli/centimetre scales. We adapted clinically used pressure systems to administer both negative (Negative pressure (NP) wound therapy; NPWT) and positive pressures (PP; Insufflator). Pressure differences generated enhanced distribution, and we were able to show for the first-time localized gene transfer in vitro in cell scaffolds and enhanced transfection of ex vivo skin explants. The ability to simply control intra-tissue localization of gene delivery on milli/centimetre scales using pressure application will facilitate new drug delivery strategies for accessible tissues. Importantly site-specific enhancement of penetration and activity of novel nanotechnologies and gene therapeutics could be transformative for future regenerative medicine strategies.

Natural polysaccharides combined with mussel-inspired adhesion for multifunctional hydrogels in wound hemostasis and healing: A review

As naturally derived macromolecular polymers, polysaccharides have garnered significant attention in recent years as promising candidates for fabricating multifunctional hydrogels, particularly for wound healing applications, owing to their inherent biocompatibility, biodegradability, and structural diversity. However, the inherently weak skin adhesion of natural polysaccharide hydrogels has motivated the exploration of mussel-inspired catechol-based adhesion strategies to overcome this limitation. Incorporating mussel-inspired modifications into natural polysaccharides can imbue them with unique properties such as enhanced adhesion, antioxidant activity, antibacterial properties, and chelation capabilities, considerably broadening their potential for wound hemostasis and healing applications. This review comprehensively overviews recent advances in mussel-inspired polysaccharide hydrogels, focusing on the combination of natural polysaccharides, including chitosan, alginate, hyaluronic acid, cellulose, and dextran, with mussel-inspired catechol. We delve into their fabrication strategies and highlight their promising biomedical applications, with a particular emphasis on wound hemostasis and diverse wound healing processes. Mussel-inspired modification strategies for polysaccharide hydrogels are expected to remain a focal point within the fields of wound hemostasis and healing, paving the way for more impactful research endeavors.

The Efficacy of Modified Ilizarov Distraction-Tension Device on Limb Wound Difficult to Cover with Skin Flaps

INTRODUCTION

Closure of complex limb wounds poses challenges and requires innovative approaches. This research aimed to evaluate the effectiveness of a modified distraction-tension device using Ilizarov external fixation for wound closure in challenging cases.

METHODS

A retrospective analysis was conducted on 43 patients with extremity wounds that were difficult to cover with skin flaps between January 2019 and December 2022. Tension-relieving traction was applied using the Ilizarovexternal fixator apparatus, tailored to individual wound characteristics. Three types of wire-pin connections were used in this study. The distraction begins on the third postoperative day, with a speed of 0.5mm/d. Clinical wound healing scores were evaluated at 5 and 30 days postoperatively. Complications were documented following the Paley classification system.

RESULTS

Traction using modified Ilizarovexternal fixation promoted a significant reduction in wound size. The mean traction period was 11.2 ± 7.3 days, and the mean healing duration was 17.0 ± 3.7 days. The clinical wound healing score improved from 3.7 ± 2.9 at 5 days to 1.7 ± 0.7 at 30 days postoperatively (p < 0.05). Complications were minimal, with no significant obstacles or sequelae observed. Direct closure healing was achieved in 21 cases, skin graft healing in 13 cases, and suture healing in 9 cases. No recurrences were reported. Using Paley's classified complications, there were 17 problems, 9 obstacles, and 0 sequelae.

CONCLUSION

The Ilizarov tension-relieving traction shows promise in facilitating wound closure that is challenging to manage with skin flaps. The modified three types of pin-skin connection configuration could satisfy various types of wound closure.

Quotation errors related to the wound management of open lower limb fractures (WOLLF) randomized clinical trial

PURPOSE

We assessed the accuracy of quotations in the published literature of the Wound Management of Open Lower Limb Fractures (WOLLF) Randomized Clinical Trial.

METHODS

A literature search was performed to identify all citations of WOLLF from 2018 to 2021. Duplicate papers, non-English language papers, textbooks, technical tip videos, Ph.D. theses, and other grey literature were excluded from analysis. Eligible publications had their full text assessed by 2 independent reviewers who used a validated framework of error classification.

RESULTS

We identified 62 original papers that met our eligibility criteria and referenced WOLLF. Of the 62 papers, 12 contained a quotation error (12/62, 19%). Errors were classified into major and minor. There were 7 major errors and 5 minor errors. The majority of quotation errors (7/12, 58%) occurred due to multi-referencing, where groups of references were used to support single assertions. There was substantial agreement between the two independent reviewers as determined by a Kappa coefficient of 0.761.

CONCLUSION

Our study demonstrated a 19% quotation error rate in the literature regarding WOLLF. The majority were due to multi-referencing. We suggest that both authors and reviewers carefully check the source literature of key references.

Recent advances in biomimetic hemostatic materials

Although the past decade has witnessed unprecedented medical advances, achieving rapid and effective hemostasis remains challenging. Uncontrolled bleeding and wound infections continue to plague healthcare providers, increasing the risk of death. Various types of hemostatic materials are nowadays used during clinical practice but have many limitations, including poor biocompatibility, toxicity and biodegradability. Recently, there has been a burgeoning interest in organisms that stick to objects or produce sticky substances. Indeed, applying biological adhesion properties to hemostatic materials remains an interesting approach. This paper reviews the biological behavior, bionics, and mechanisms related to hemostasis. Furthermore, this paper covers the benefits, challenges and prospects of biomimetic hemostatic materials.

Wound specific quality of life after blast or gunshot injury: Validation of the wound QoL instrument

BACKGROUND

Acute blast or gunshot wounds have a negative effect on the patients' health related quality of life (HRQoL). No validated instrument exists to assess the HRQoL of patients with such wounds. Therefore, we aimed to test and validate a subscale of an existing HRQoL instrument among patients with acute blast or gunshot wounds.

METHODS

We used data from a randomized controlled trial comparing negative pressure wound therapy with standard treatment of civilian adults with acute extremity blast or gunshot wounds. We evaluated the reliability (internal consistency, stability) and validity of the body subscale of the Wound QoL instrument using the World Health Organisation 20 question self-reporting questionnaire as gold standard.

RESULTS

A total of 152 participants were included in the study. The participants were predominantly (93.4%) male, and median age was 29.0 years (IQR 21.0-34.0). The internal consistency was acceptable while a test-retest analysis indicated instability in the Wound QoL instrument. The content validity of the instrument was considered satisfactory; however, the criterion validity was found to be insufficient.

CONCLUSIONS

Our results indicate that Wound QoL is a promising instrument for the assessment of wound specific HRQoL among patients with acute blast or gunshot wounds. Further testing and validation is needed.

Device for Negative Pressure Wound Therapy in Low-Resource Regions: Open-Source Description and Bench Test Evaluation

Background: Negative (vacuum) pressure therapy promotes wound healing. However, commercially available devices are unaffordable to most potential users in low- and middle-income countries (LMICs), limiting access to many patients who could benefit from this treatment. This study aimed to design and test a cheap and easy-to-build negative pressure device and provide its detailed open-source description, thereby enabling free replication. Methods: the negative pressure device was built using off-the-shelf materials available via e-commerce and was based on a small pump, a pressure transducer, and the simplest Arduino controller with a digital display (total retail cost ≤ 75 US$). The device allows the user to set any therapeutic range of intermittent negative pressure and has two independent safety mechanisms. The performance of the low-cost device was carefully tested on the bench using a phantom wound, producing a realistic exudate flow rate. Results: the device generates the pressure patterns set by the user (25–175 mmHg of vacuum pressure, 0–60 min periods) and can drain exudate flows within the clinical range (up to 1 L/h). Conclusions: a novel, low-cost, easy-to-build negative pressure device for wound healing displays excellent technical performance. The open-source hardware description provided here, which allows for free replication and use in LMICs, will facilitate the application and wider utilization of this therapy to patients.

Cost analysis of negative-pressure wound therapy versus standard treatment of acute conflict-related extremity wounds within a randomized controlled trial

Background

Clinical outcomes after negative-pressure wound therapy (NPWT) and standard treatment of conflict-related extremity wounds are similar. In resource-limited settings, cost affects the choice of treatment. We aimed to estimate treatment-related costs of NPWT in comparison with standard treatment for conflict-related extremity wounds.

Methods

We derived outcome data from a randomized, controlled superiority trial that enrolled adult (≥ 18 years) patients with acute (≤ 72 h) conflict-related extremity wounds at two civilian hospitals in Jordan and Iraq. Primary endpoint was mean treatment-related healthcare costs (adjusted to 2019 US dollars).

Results

Patients were enrolled from June 9, 2015, to October 24, 2018. A total of 165 patients (155 men [93.9%]; 10 women [6.1%]; and median [IQR] age, 28 [21–34] years) were included in the analysis. The cost per patient treated with NPWT was $142 above that of standard treatment. Overall, results were robust in a sensitivity analysis.

Conclusions

With similar clinical outcomes compared to standard care, our results do not support the use of NPWT in routine treatment of conflict-related extremity wounds at civilian hospitals in resource scarce settings.

Trial registration NCT02444598.

Global emergency medicine: A scoping review of the literature from 2020

OBJECTIVE

The objective was to identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research (OR) and review articles (RE) in global emergency medicine (EM) published in 2020 in the peer-reviewed and gray literature.

METHODS

A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review (GEMLR) Group to identify those that met our criteria of OR or RE in the domains of disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and EM development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in-depth narrative summarization.

RESULTS

The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year's search. From these, 364 were scored based on their full text. Nearly three-fourths of the scored articles constituted OR, of which nearly three-fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID-19. Research involving ECRLS again constituted most of the articles in this year's review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in-depth narrative critiques.

CONCLUSIONS

The number of studies relevant to global EM identified by our search was very similar to that of last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to DHR. The number of COVID-19-related articles is likely to continue to increase in subsequent years.

TGF-β loaded exosome enhances ischemic wound healing in vitro and in vivo

Rationale: With over seven million infections and $25 billion treatment cost, chronic ischemic wounds are one of the most serious complications in the United States. The controlled release of bioactive factor enriched exosome from finbrin gel was a promising strategy to promote wound healing. Methods: To address this unsolved problem, we developed clinical-grade platelets exosome product (PEP), which was incorporate with injectable surgical fibrin sealant (TISSEEL), to promote chronic wound healing and complete skin regeneration. The PEP characterization stimulated cellular activities and in vivo rabbit ischemic wound healing capacity of TISSEEL-PEP were performed and analyzed. Results: PEP, enriched with transforming growth factor beta (TGF-β), possessed exosomal characteristics including exosome size, morphology, and typical markers including CD63, CD9, and ALG-2-interacting protein X (Alix). In vitro, PEP significantly promoted cell proliferation, migration, tube formation, as well as skin organoid formation. Topical treatment of ischemic wounds with TISSEEL-PEP promoted full-thickness healing with the reacquisition of hair follicles and sebaceous glands. Superior to untreated and TISSEEL-only treated controls, TISSEEL-PEP drove cutaneous healing associated with collagen synthesis and restoration of dermal architecture. Furthermore, PEP promoted epithelial and vascular cell activity enhancing angiogenesis to restore blood flow and mature skin function. Transcriptome deconvolution of TISSEEL-PEP versus TISSEEL-only treated wounds prioritized regenerative pathways encompassing neovascularization, matrix remodeling and tissue growth. Conclusion: This room-temperature stable, lyophilized exosome product is thus capable of delivering a bioactive transforming growth factor beta to drive regenerative events.

The polytrauma patient: Current concepts and evolving care

Principles of care in the polytraumatized patient have continued to evolve with advancements in technology. Although hemorrhage has remained a primary cause of morbidity and mortality in acute trauma, emerging strategies that can be applied pre-medical facility as well as in-hospital have continued to improve care. Exo-vascular modalities, including the use of devices to address torso hemorrhage and areas not amenable to traditional tourniquets, have revolutionized prehospital treatment. Endovascular advancements including the resuscitative endovascular balloon occlusion of the aorta (REBOA), have led to dramatic improvements in systolic blood pressure, although not without their own unique complications. Although novel treatment options have continued to emerge, so too have concepts regarding optimal time frames for intervention. Though prior care has focused on Injury Severity Score (ISS) as a marker to determine timing of intervention, current consensus contends that unnecessary delays in fracture care should be avoided, while respecting the complex physiology of certain patient groups that may remain at increased risk for complications. Thromboelastography (TEG) has been one technique that focuses on the unique pathophysiology of each patient, providing guidance for resuscitation in addition to providing information in recognizing the at-risk patient for venous thromboembolism. Negative pressure wound therapy (NPWT) has emerged as a therapeutic adjuvant for select trauma patients with significant soft tissue defects and open wounds. With significant advancements in medical technology and improved understanding of patient physiology, the optimal approach to the polytrauma patient continues to evolve.

How influential is the stiffness of the foam dressing on soft tissue loads in negative pressure wound therapy?

Negative pressure wound therapy (NPWT) is an established adjunctive modality for treatment of both acute and chronic wounds. However, little is known about the optimal settings and combination of treatment parameters and importantly, how these translate to target tissue strains and stresses that would result the fastest healing and buildup of good-quality tissues. Here we have used a three-dimensional open wound computational (finite element) model that contains viscoelastic skin, adipose and skeletal muscle tissue components for determining the states of tissue strains and stresses in and around the wound when subjected to NPWT with foam dressings of varying stiffnesses. We found that the skin strain state is considerably more sensitive to the pressure level than to the stiffness of the foam dressing within a 8.25 to 99 kPa range which covers the current industry standard. Accordingly, peri-wound skin strains and stresses which stimulate cell proliferation/migration and angiogenesis and thereby, healing of the wound, can be more effectively controlled by adjusting the pressure level than by varying the stiffness of the foam dressing.

Delivering health and nutrition interventions for women and children in different conflict contexts: a framework for decision making on what, when, and how

Existing global guidance for addressing women's and children's health and nutrition in humanitarian crises is not sufficiently contextualised for conflict settings specifically, reflecting the still-limited evidence that is available from such settings. As a preliminary step towards filling this guidance gap, we propose a conflict-specific framework that aims to guide decision makers focused on the health and nutrition of women and children affected by conflict to prioritise interventions that would address the major causes of mortality and morbidity among women and children in their particular settings and that could also be feasibly delivered in those settings. Assessing local needs, identifying relevant interventions from among those already recommended for humanitarian settings or universally, and assessing the contextual feasibility of delivery for each candidate intervention are key steps in the framework. We illustratively apply the proposed decision making framework to show what a framework-guided selection of priority interventions might look like in three hypothetical conflict contexts that differ in terms of levels of insecurity and patterns of population displacement. In doing so, we aim to catalyse further iteration and eventual field-testing of such a decision making framework by local, national, and international organisations and agencies involved in the humanitarian health response for women and children affected by conflict.

Closed-incision negative-pressure wound management in surgery—literature review and recommendations

Background

Wound healing deficits and subsequent surgical site infections are potential complications after surgical procedures, resulting in increased morbidity and treatment costs. Closed-incision negative-pressure wound therapy (ciNPWT) systems seem to reduce postoperative wound complications by sealing the wound and reducing tensile forces.

Materials and methods

We conducted a collaborative English literature review in the PubMed database including publications from 2009 to 2020 on ciNPWT use in five surgical subspecialities (orthopaedics and trauma, general surgery, plastic surgery, cardiac surgery and vascular surgery). With literature reviews, case reports and expert opinions excluded, the remaining 59 studies were critically summarized and evaluated with regard to their level of evidence.

Results

Of nine studies analysed in orthopaedics and trauma, positive results of ciNPWT were reported in 55.6%. In 11 of 13 (84.6%), 13 of 15 (86.7%) and 10 of 10 (100%) of studies analysed in plastic, vascular and general surgery, respectively, a positive effect of ciNPWT was observed. On the contrary, only 4 of 12 studies from cardiac surgery discovered positive effects of ciNPWT (33.3%).

Conclusion

ciNPWT is a promising treatment modality to improve postoperative wound healing, notably when facing increased tensile forces. To optimise ciNPWT benefits, indications for its use should be based on patient- and procedure-related risk factors.

Effectiveness of fire needle combining with moist healing dressing to promote the growth of granulation tissue in chronic wounds: A case report

In this case study, we analyzed the wound-healing process of a patient with a chronic wound who underwent fire needle treatment, and we tracked the coverage of granulation tissue and decrease of slough and exudate. An 85-year-old man had repeated right shoulder and back pain, itching, and skin festering for more than 1.5 years. A fire needle was administered combined with moist dressing once every 5 days to promote wound healing. After six rounds of fire needle treatment, granulation tissue formed over the surface of the wound base, the depth of the wound had become shallow, and the wound area was reduced. No complications occurred during the intervention. Fire needle therapy combined with a moist wound-healing dressing can be an effective alternative approach in managing chronic wounds.