Seeking effective interventions to treat complex wounds: an overview of systematic reviews

[Frontier progress in complex wound repair: from microenvironment regulation to precision medical practice]

Complex wounds, with high incidence rate, high disability rate, and high medical costs, have brought huge burdens to patients and medical systems. Traditional treatment methods of complex wounds have limitations, therefore it is necessary to further improve and develop innovative strategies of diagnosis and treatment to address this clinical challenge. This article reviews and discusses important advances in the field of complex wound repair, as well as new concepts in the construction of modern wound management systems. The aim is to provide a reference for clinical medical staff, researchers, and related industry personnel, promote the sustainable development of complex wound repair field, and ultimately achieve comprehensive recovery of function and aesthetics of patients with complex wounds.

Advanced Wound Care Strategies in Patients with NSTIs

Necrotizing soft tissue infections (NSTIs) are rapidly progressive, life-threatening infections associated with significant morbidity and mortality. Surgical debridement, the cornerstone of treatment, often results in extensive, complex wounds located in anatomically difficult regions. Management of these wounds can be challenging, especially for surgeons with limited experience in complex wound care and reconstruction. Yet, proper management of these wounds is critical to patient recovery and long-term quality of life. This review provides a comprehensive overview of current strategies in NSTI wound reconstruction. It begins by outlining the biological underpinnings of wound healing and the unique challenges posed by NSTI-related wounds. The review then explores a range of dressing materials and advanced wound care modalities, including negative pressure wound therapy, cellular and tissue-based products, and hyperbaric therapy. Finally, it presents a guide to surgical reconstruction techniques, including skin grafting and flap coverage. By consolidating current knowledge and practical guidance, this review seeks to support generalist and acute care surgeons with the knowledge needed to optimize wound healing, enhance functional outcomes, and improve quality of life for NSTI survivors.

The role of exosomes derived from various sources in facilitating the healing of chronic refractory wounds

Chronic refractory wounds (CRWs) represent a common and challenging issue in clinical practice, including diabetic foot ulcers, pressure ulcers, venous ulcers, and arterial ulcers. These wounds significantly impact patients' quality of life and may lead to severe consequences such as amputation. Their treatment requires a comprehensive consideration of both the patient's overall physical condition and the local wound situation. The major challenges in treatment include complex pathogenesis, a long treatment cycle, a high recurrence rate, and heavy economic pressure on the patients. Exosomes represent an emerging therapeutic modality with characteristics such as low immunogenicity, good biostability, and high targeting efficiency in the treatment of diseases. Exosomes derived from different sources exhibit heterogeneity, demonstrating their respective advantages and unique properties in treatment. This article delves into the potential applications and mechanisms of action of exosomes from various sources in the treatment of CRWs, aiming to provide new perspectives and ideas for the management of such wounds.

Cost of Illness of Pressure Injuries in the Inpatient Area of a Socio-Health Center in Spain

ABSTRACT

OBJECTIVE

To estimate the increase in length of stay and cost of illness of pressure injuries (PIs) in the inpatient area of a socio-health center.

METHODS

This was a retrospective cohort study that included a consecutive sampling of patients admitted to the inpatient programs of a socio-healthcare center between January 1, 2016, and December 31, 2018. Data were retrospectively extracted from patients' electronic health records.

RESULTS

During the study period 4,062 patients were admitted to the different hospitalization programs. The patients' mean age was 75.34 ± 13.69 years, and 51.2% of them were men. Of these, 1,421 patients had PIs, and 318 patients had to prolong their hospital stay due to PIs. These 318 patients were admitted 12,089 days longer (mean of 38.01 ± 41.49 days per patient) than patients without a PI, representing an expense of €1,381,006 (US $1,430,722). The cost of illness in the period under study was estimated at €1,922,049 (US $1,991,212). The average cost of PI treatment per patient was €1,352.60 ± €3,351.43 (US $1,401.29 ± $3,472.08), and the average cost of treatment until complete resolution of a PI was €2,064.65 ± €4,282.48 (US $1,470.79 ± $4,436.65). The cost of treatment ranged from €1,419.68 ± €3,100.47 (US $2,138.98 ± $3,212.09) for stage 1 PIs to €6,299.31 ± €10,000.57 (US $6,526.08 ± $10,360.59) for stage 4 PIs.

CONCLUSIONS

This study highlights the significant health and economic impacts of PIs in the inpatient area of a socio-health center. The findings emphasize the necessity of effective prevention strategies to mitigate the occurrence of PIs and their associated costs. By understanding the financial burden of PIs, healthcare providers and policymakers can make informed decisions to improve resource allocation, enhance patient care, and reduce financial strain on the healthcare system.

Local Treatment of Wound Infections: A Review of Clinical Trials from 2013 to 2024

Significance: Management of infection is a critical aspect of wound care. It involves the application of various interventions to treat the wound and prevent the infection from spreading to other parts of the body, which may lead to serious complications, including sepsis. Local treatment of skin wound infections is the favored route of administration, reducing the risk of adverse systemic effects while providing very high therapeutic concentrations at the target site. The purpose of this article was to review clinical trials from 2013 and onward, focusing on local treatment of acute wounds and burns as well as chronic wounds as their primary outcome measurement. Recent Advances: Based on our literature search, 49 clinical trials were focusing on treating infected chronic wounds, and 6 trials studied infection as their primary outcome in acute wounds during the last 10 years. Critical Issues: Currently commercially available local treatments do not prevent the onset of invasive infection. Therefore, there is a need for more effective local therapies. Future Directions: Despite multiple preclinical studies introducing novel and promising strategies in terms of novel antimicrobial agents and delivery methods to prevent and treat skin wound infections locally, many have yet to be tested in a clinical setting. These preclinically tested approaches could still be valuable additions to today's care of infected skin wounds.

Virtual Reality Versus Simulation in the Management of Trauma Based Scenarios-A Systematic Review

Introduction

Simulation allows trainees to practice skills safely. It is the current gold standard method of teaching. More recently, novel methods such as virtual reality and augmented reality are being explored as possible alternative methods.

Aims

To evaluate the current evidence pertaining to simulation and virtual reality as methods of teaching in teaching trauma management.

Methods

Medline and Embase (via Ovid interface) were used to search for articles up to April 2023. A combination of the following MeSH terms were employed in the primary search string - "virtual reality," "simulation," "surgery," "trauma," and "medical education."

Results

3815 studies were initially identified. After de-duplication, 2648 articles were screened using Covidence. Forty articles underwent full text review. Thirteen studies were included in the final review with a pooled total of 489 participants. Significant heterogeneity exists in the range of participants, scenarios and parameters assessed. The overall self-reported perception of VR as a teaching modality is positive and is well accepted however objective assessment and validation is needed.

Conclusion

VR can be useful for training and evaluation of trauma-based scenarios. It is a useful adjunct but is unlikely to replace simulation at present. More robust and replicable studies with larger sample sizes are needed to evaluate the long-term integration of virtual reality and augmented reality into the medical and surgical teaching curriculum.

Enhancing diabetic foot ulcer healing: Impact of the regulation of the FUS and ILF2 RNA‑binding proteins through negative pressure wound therapy

Diabetic foot ulcer (DFU) is a destructive complication of diabetes. Negative pressure wound therapy (NPWT) promotes DFU wound healing through an undetermined mechanism. In the present study, RNA sequencing was performed on wound granulation tissue from 3 patients with DFU before and after 1 week of NPWT. The fused in sarcoma (FUS) and interleukin enhancer binding factor 2 (ILF2) encoding RNA‑binding proteins (RBPs) were screened from the sequencing data, and wound tissue samples from 24 patients with DFU were validated and analyzed before and after receiving NPWT by reverse transcription‑quantitative PCR, western blotting and immunohistochemistry. In addition, in vitro and in vivo experiments were conducted to determine the effect of the expression of FUS and ILF2 on the function of human epidermal keratinocyte cells (HaCaT cells) and the healing of diabetic skin wounds. The results indicated that NPWT induced the upregulation of 101 genes and the downregulation of 98 genes in DFU wound granulation tissue. After NPWT, the expression of FUS and ILF2 was significantly upregulated (P<0.05). Pearson's correlation coefficient showed that the changes in FUS and ILF2 before and after NPWT were negatively correlated with changes in white blood cells, the neutrophil percentage, C‑reactive protein, tumor necrosis factor‑α, reactive oxygen species, lipid peroxides, matrix metalloproteinase (MMP) 2 and MMP9 (P<0.05), but positively correlated with the anti‑inflammatory factor, IL‑4 (P<0.01). There was also a positive correlation (P<0.05) with the 4‑week ulcer healing rate. Additionally, the knockdown of FUS and ILF2 expression inhibited the proliferation and migration of HaCaT cells, while increasing cell apoptosis. In vivo, the knockdown of FUS and ILF2 significantly reduced the rate of skin wound healing in diabetic mice. The results of the present study therefore provide new insights into the mechanism by which NPWT promotes DFU wound healing. In conclusion, the RBPs, FUS and ILF2, promoted DFU wound healing by regulating the function of keratinocytes and reducing the inflammatory response and oxidative stress.

An Immune-Regulating Polysaccharide Hybrid Hydrogel with Mild Photothermal Effect and Anti-Inflammatory for Accelerating Infected Wound Healing

Bacterial infections and excessive inflammation present substantial challenges for clinical wound healing. Hydrogels with mild photothermal (PTT) effects have emerged as promising agents owing to their dual actions: positive effects on cells and negative effects on bacteria. Here, an injectable self-healing hydrogel of oxidized konjac glucomannan/arginine-modified chitosan (OKGM/CS-Arg, OC) integrated with protocatechualdehyde-@Fe (PF) nanoparticles capable of effectively absorbing near-infrared radiation is synthesized successfully. The OC/PF hydrogels exhibit excellent mechanical properties, biocompatibility, and antioxidant activity. Moreover, in synergy with PTT, OC/PF demonstrates potent antibacterial effects while concurrently stimulating cell migration and new blood vessel formation. In methicillin-resistant Staphylococcus aureus-infected full-thickness mouse wounds, the OC/PF hydrogel displays remarkable antibacterial and anti-inflammatory activities, and accelerates wound healing by regulating the wound immune microenvironment and promoting M2 macrophage polarization. Consequently, the OC/PF hydrogel represents a novel therapeutic approach for treating multidrug-resistant bacterial infections and offers a technologically advanced solution for managing infectious wounds in clinical settings.

Impact of Wound Dressing Changes on Nursing Workload in an Intensive Care Unit

The objective of this study is to understand how the type of wound dressing changes (routine or frequent) in patients admitted to intensive care units influences nurses' workload. This study used a database of retrospective and analytical observational study from one Portuguese intensive care unit. The sample included 728 adult patients admitted between 2015 and 2019. The nursing workload was assessed by the TISS-28 scale, both at admission and at discharge. The linear regression results show that patients with frequent dressing changes are associated with a higher nursing workload, both at admission (Coef. 1.65; 95% CI [0.53; 2.77]) and discharge (Coef. 1.27; 95% CI [0.32; 2.22]). In addition, age influences the nursing workload; older people are associated with a higher nursing workload (at admission Coef. 0.07; 95% CI [0.04; 0.10]; at discharge Coef. 0.08; 95% CI [0.05; 0.10]). Additionally, an increase in nursing workload at admission would significantly increase the nursing workload at discharge (Coef. 0.27; 95% CI [0.21; 0.33]). The relative stability of the nursing workload over the studied years is also another important finding (the influence of studied years is non-significant). In conclusion, patients with frequent dressing changes presented higher TISS-28 scores when compared with patients with an exchange of routine dressings, which leads to a higher nursing workload.

An overview on the manufacturing of functional and mature cellular skin substitutes

There are different types of skin diseases due to chronic injuries that impede the natural healing process of the skin. Tissue engineering (TE) has focused on the development of bioengineered skin or skin substitutes that cover the wound, providing the necessary care to restore the functionality of injured skin. There are two types of substitutes: acellular skin substitutes (ASSs), which offer a low response of the body, and cellular skin substitutes (CSSs), which incorporate living cells and appear as a great alternative in the treatment of skin injuries due to them presenting a greater interaction and integration with the rest of the body. For the development of a CSS, it is necessary to select the most suitable biomaterials, cell components, and methodology of biofabrication for the wound to be treated. Moreover, these CSSs are immature substitutes that must undergo a maturing process in specific bioreactors, guaranteeing their functionality. The bioreactor simulates the natural state of maturation of the skin by controlling parameters such as temperature, pressure, or humidity, allowing a homogeneous maturation of the CSSs in an aseptic environment. The use of bioreactors not only contributes to the maturation of the CSSs, but also offers a new way of obtaining large sections of skin substitutes or natural skin from small portions acquired from the patient, donor, or substitute. Based on the innovation of this technology and the need to develop efficient CSSs, this work offers an update on bioreactor technology in the field of skin regeneration.

The clinical impact of hydroresponsive dressings in dynamic wound healing: Part I

OBJECTIVE

Management of any wound, either acute or hard-to-heal, might involve the use of multiple and different wound dressings in its treatment. This approach is necessary to overcome the myriad of clinical challenges the wound presents, as well as any underlying comorbidities that might affect the clinical outcomes. This article describes the clinical effectiveness of a coordinated wound dressing treatment regimen.

METHOD

This was an open-labelled non-comparative study involving patients with a variety of hard-to-heal and acute wounds of differing levels of severity, but all of which required removal of devitalised tissue to enable wound healing to progress. The first phase used the hydroresponsive wound dressing HydroClean (PAUL HARTMANN AG, Germany). The PUSH score was used as the primary measurement parameter.

RESULTS

A total of 86 patients (38 male/48 female), with a mean age of 67.7±21.7 years, took part in the study. The results showed that the hydroresponsive dressing was effective in managing wound exudate production and promoting wound cleansing and debridement, supporting good wound bed preparation. Wound closure was observed in 16/86 (18.6%) wounds at the end of the study (20 weeks). This enabled clinicians to switch to alternative wound dressings to promote subsequent clinical healing outcomes.

CONCLUSION

In this study, the hydroresponsive wound dressing was highly effective in preparing a clean wound bed such that the next stage of wound healing could be supported.

Consensus on the application of negative pressure wound therapy of diabetic foot wounds

Because China is becoming an aging society, the incidence of diabetes and diabetic foot have been increasing. Diabetic foot has become one of the main health-related killers due to its high disability and mortality rates. Negative pressure wound therapy (NPWT) is one of the most effective techniques for the treatment of diabetic foot wounds and great progress, both in terms of research and its clinical application, has been made in the last 20 years of its development. However, due to the complex pathogenesis and management of diabetic foot, irregular application of NPWT often leads to complications, such as infection, bleeding and necrosis, that seriously affect its treatment outcomes. In 2020, under the leadership of Burns, Trauma and Tissue Repair Committee of the Cross-Straits Medicine Exchange Association, the writing group for ‘Consensus on the application of negative pressure wound therapy of diabetic foot wounds’ was established with the participation of scholars from the specialized areas of burns, endocrinology, vascular surgery, orthopedics and wound repair. Drawing on evidence-based practice suggested by the latest clinical research, this consensus proposes the best clinical practice guidelines for the application and prognostic evaluation of NPWT for diabetic foot. The consensus aims to support the formation of standardized treatment schemes that clinicians can refer to when treating cases of diabetic foot.

[National expert consensus on the application of negative pressure wound therapy in the treatment of diabetic foot wounds (2021 version)]

Diabetic foot has a high rate of disability and mortality. Negative pressure wound therapy (NPWT) is one of the effective techniques in treating diabetic foot wounds, but the non-standard use of it often leads to infections, bleeding, necrosis and other complications, which seriously affects the outcome. In 2020, Tissue Repair of Burns and Trauma Committee, Cross-Straits Medicine Exchange Association organized experts from department of burns, department of orthopedics, department of vascular surgery, department of endocrinology, department of wound repair, and other departments engaged in the treatment of diabetic foot to discuss and write the "expert consensus on the application of negative pressure wound therapy in the treatment of diabetic foot wounds". This consensus is based on evidence-based medicine and combined with the latest clinical research progress, aiming to form a standardized plan for the treatment of diabetic foot wounds with NPWT, which can be used as a reference for clinicians, so as to promote the improvement of clinical diagnosis and treatment of diabetic foot.

Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1

OBJECTIVES

We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care.

METHODS

We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis.

RESULTS

We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care.

CONCLUSIONS

Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.

Quality indicators for a community-based wound care centre: An integrative review

The purpose of this review was to identify the role and contribution of community-based nurse-led wound care as a service delivery model. Centres increasingly respond proactively to assess and manage wounds at all stages - not only chronic wound care. We conducted an integrative review of literature, searching five databases, 2007-2018. Based on inclusion and exclusion criteria, we systematically approached article selection and all three authors collaborated to chart the study variables, evaluate data, and synthesise results. Eighteen studies were included, representing a range of care models internationally. The findings showed a need for nurse-led clinics to provide evidence-based care using best practice guidelines for all wound types. Wound care practices should be standardised across the particular service and be integrated with higher levels of resources such as investigative services and surgical units. A multi-disciplinary approach was likely to achieve better patient outcomes, while patient-centred care with strong patient engagement was likely to assist patients' compliance with treatment. High-quality community-based wound services should include nursing leadership based on a hub-and-spoke model. This is ideally patient-centred, evidence-based, and underpinned by a commitment to developing innovations in terms of treatment modalities, accessibility, and patient engagement.

Wound Care Knowledge, Attitudes, and Practices and Mobile Health Technology Use in the Home Environment: Cross-Sectional Survey of Social Network Users

Background

Injury causing wounds is a frequent event. Inadequate or inappropriate treatment of injuries can threaten individual health. However, little is known about wound care knowledge, attitudes, and practices and mobile health (mHealth) use in the home environment in Taiwan.

Objective

This study aimed to evaluate wound care knowledge, attitudes, and practices and mHealth technology use among social network users.

Methods

A cross-sectional survey on social media platforms was conducted on adults aged 20 years and older. Data were collected from social network users in the home environment.

Results

A total of 361 participants were enrolled. The mHealth technology use of participants was positively correlated with wound care knowledge (r=.132, P=.01), attitudes (r=.239, P<.001), and practices (r=.132, P=.01). Participants did not have adequate knowledge (correct rate 69.1%) and were unfamiliar with the guidelines of proper wound care (correct rate 74.5%). Most participants had positive attitudes toward wound care and mHealth technology use. A total of 95.6% (345/361) of participants perceived that the use of mHealth technology can improve wound care outcomes, and 93.9% (339/361) perceived that wound care products should be optimized to be used with a mobile device. However, 93.6% (338/361) of participants had no experience using mHealth technology for wound care.

Conclusions

Our study shows the potential of mHealth technology to enhance wound care knowledge among social network users. Thus, government agencies and medical institutions in Taiwan should provide easy-to-use information products that enhance wound care knowledge, promote adequate behavior toward wound care, and prevent unpredictable or undesirable outcomes.

The effectiveness of negative pressure wound therapy as a novel management of diabetic foot ulcers: an overview of systematic reviews

Background

Diabetic foot ulcer (DFU) is one the serious disabling conditions in patients with diabetes. Several approaches are available to manage DFU including Negative Pressure Wound Therapy (NPWT). The objective of this overview is systematically reviewing the related reviews about the effectiveness, safety, and cost benefits of NPWT interventions.

Methods

In October 2018, electronic databases including Medline, Embase, Scopous, Web of Science, the Cochrane Library and Google scholar were searched for systematic reviews about the NPWT's effectiveness and safety in DFUs. The Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklist was used for the appraisal of the systematic reviews. According to this checklist the studies were categorized as high, moderate, low and critically low quality.

Results

The electronic searches yielded 6889 studies. After excluding duplicates and those not fellfield the inclusion criteria, 23 systematic reviews were considered. The sample size of the reviews ranged between 20 and 2800 patients published since 2004 to 2018. Twenty systematic reviews (86.95%) included only randomized clinical trials (RCT). Regarding the AMSTAR-2 checklist, 7 studies were assigned to high quality, 8 were categorized as low quality and 8 studies belonged to the critically low quality groups. Accordingly, three, two and one out of seven high quality studies approved the effectiveness, safety and cost benefit of the NPWT therapy, respectively. However, some of them declared that there is some flaws in RCTs designing.

Conclusion

This overview illustrated that either systematic reviews or the included RCTs had wide variety of quality and heterogeneity in order to provide high level of evidence. Hence, well-designed RCTs as well as meta-analysis are required to shade the light on different aspects of NPWT.

Palliative Wound Care: Less Is More

Palliative wound care is a philosophy of wound management that prioritizes comfort over healing and attends to the emotional distress these wounds can cause. Intervention strategies focus on management of symptoms such as pain, odor, bleeding, and exudate. Historic treatments such as honey, chlorine, and vinegar have gained renewed interest, and although well suited to the palliative setting, there is an increasing amount of research exploring their efficacy in other contexts. The lived experience of patients and caregivers facing these wounds is often stressful and isolating, and any treatment plan must address these issues along with the physical aspects of care.

Nanocarrier-based systems for wound healing

In general, the systems intended for the treatment and recovery of wounds, seek to act as a coating for the damaged area, maintaining an adequate level of humidity, reducing pain, and preventing the invasion and proliferation of microorganisms. Although many of the systems that are currently on the market meet the purposes mentioned above, with the arrival of nanotechnology, it has sought to improve the performance of these coatings. The variety of nano-systems that have been proposed is very extensive, including the use of very different materials (natural or synthetic) ranging from polymers or lipids to systems derived from microorganisms. With the objective of improving the performance of the systems, seeking to combat several of the problems that arise in a wound, especially when it is chronic, these materials have been combined, giving rise to nanocomposites or scaffolds. In recent years, the interest in the development of systems for the treatment of wounds is notable, which is reflected in the increase in publications related to the subject. Therefore, this document presents generalities of systems involving nanocarriers, mentioning some examples of representative systems of each case.

Factors associated with complex surgical wounds in breast and abdomen: a case-control observational study

OBJECTIVE

to identify factors associated with complex surgical wounds in the breasts and abdomen in outpatients.

METHOD

observational case-control study involving 327 patients, distributed into 160 cases (complex surgical wound) and 167 controls (simple surgical wound). Data were extracted from the medical records and a binary logistic regression model was used for analysis, considering a significance level of 5%.

RESULTS

the factors associated with greater chance of occurrence of complex surgical wound were 18 to 59 years of age (p = 0.003), schooling < 8 years (p = 0.049), radiotherapy (p < 0.001), hysterectomy (p = 0.003), glycemia (≤ 99 mg/dL) and arterial hypertension (p = 0.033), while quadrantectomy (p = 0.025) served as a protective factor.

CONCLUSION

radiotherapy was the most significant factor for surgical wound complications. Glycemic alteration was an unexpected result and shows the need for further studies related to this topic.

Effectiveness of Transcutaneous Electrical Nerve Stimulation Energy in Older Adults: A Pilot Clinical Trial

OBJECTIVE

To evaluate the effectiveness of a transcutaneous electric nerve stimulation (TENS) device typically used for pain suppression (analgesia) during pressure injury (PI) healing, peripheral vascularization, and secondary pain in older adults with chronic PIs and cognitive impairment.

DESIGN AND SETTING

This pilot clinical trial followed patients from 6 nursing homes.

PATIENTS AND INTERVENTION

Twenty-two patients with PIs in the distal third of their lower limbs (7 men, 15 women) were included in this study. The control group completed standard wound care (SWC), whereas the experimental group received SWC and TENS. A total of 20 sessions were conducted for each group over 2 months, 3 times a week.

MAIN OUTCOME MEASURE

PI area, PI healing rate, blood flow, skin temperature, oxygen saturation, and level of pain at baseline and posttreatment.

MAIN RESULTS

Significant improvements were achieved in PI area (mean difference, 0.92; 95% confidence interval [CI], 0.15-1.67; P =.024), healing rate (3; 95% CI, 1-4.99; P =.009), skin temperature (1.82; 95% CI, 0.35-3.28; P =.021), and pain (1.44; 95% CI, 0.49-2.39; P =.008) in the experimental group, whereas none of the variables revealed a significant change in the control group.

CONCLUSIONS

The effect of local and spinal TENS combined with the SWC for PI produced a significant improvement in size, healing, skin temperature, and pain levels.

Hydrogels for Atopic Dermatitis and Wound Management: A Superior Drug Delivery Vehicle

Wound management, in addition to presenting a significant burden to patients and their families, also contributes significantly to a country’s healthcare costs. Treatment strategies are numerous, but in most cases not ideal. Hydrogels, three-dimensional polymeric materials that can withstand a great degree of swelling without losing structural integrity, are drawing great attention for their use as topical wound management solutions in the form of films and as vehicles for drug delivery, due to their unique properties of high water content, biocompatibility, and flexibility. Hydrogels, both naturally and synthetically derived, can be tuned to respond to specific stimuli such as pH, temperature and light and they are ideally suited as drug delivery vehicles. Here we provide a brief overview of the history and characteristics of hydrogels, assess their uses in wound management and drug delivery, and compare them with other types of common drug delivery vehicle.

Dressings and topical agents for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and promote healing, and there are many options to choose from including alginate, hydrocolloid and protease-modulating dressings. Topical agents have also been used as alternatives to dressings in order to promote healing.A clear and current overview of all the evidence is required to facilitate decision-making regarding the use of dressings or topical agents for the treatment of pressure ulcers. Such a review would ideally help people with pressure ulcers and health professionals assess the best treatment options. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

OBJECTIVES

To assess the effects of dressings and topical agents for healing pressure ulcers in any care setting. We aimed to examine this evidence base as a whole, determining probabilities that each treatment is the best, with full assessment of uncertainty and evidence quality.

SEARCH METHODS

In July 2016 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) comparing the effects of at least one of the following interventions with any other intervention in the treatment of pressure ulcers (Stage 2 or above): any dressing, or any topical agent applied directly to an open pressure ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factor treatments, platelet gels and larval therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction. We conducted network meta-analysis using frequentist mega-regression methods for the efficacy outcome, probability of complete healing. We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (saline gauze). We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals for individual treatments compared with every other, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

MAIN RESULTS

We included 51 studies (2947 participants) in this review and carried out NMA in a network of linked interventions for the sole outcome of probability of complete healing. The network included 21 different interventions (13 dressings, 6 topical agents and 2 supplementary linking interventions) and was informed by 39 studies in 2127 participants, of whom 783 had completely healed wounds.We judged the network to be sparse: overall, there were relatively few participants, with few events, both for the number of interventions and the number of mixed treatment contrasts; most studies were small or very small. The consequence of this sparseness is high imprecision in the evidence, and this, coupled with the (mainly) high risk of bias in the studies informing the network, means that we judged the vast majority of the evidence to be of low or very low certainty. We have no confidence in the findings regarding the rank order of interventions in this review (very low-certainty evidence), but we report here a summary of results for some comparisons of interventions compared with saline gauze. We present here only the findings from evidence which we did not consider to be very low certainty, but these reported results should still be interpreted in the context of the very low certainty of the network as a whole.It is not clear whether regimens involving protease-modulating dressings increase the probability of pressure ulcer healing compared with saline gauze (risk ratio (RR) 1.65, 95% confidence interval (CI) 0.92 to 2.94) (moderate-certainty evidence: low risk of bias, downgraded for imprecision). This risk ratio of 1.65 corresponds to an absolute difference of 102 more people healed with protease modulating dressings per 1000 people treated than with saline gauze alone (95% CI 13 fewer to 302 more). It is unclear whether the following interventions increase the probability of healing compared with saline gauze (low-certainty evidence): collagenase ointment (RR 2.12, 95% CI 1.06 to 4.22); foam dressings (RR 1.52, 95% CI 1.03 to 2.26); basic wound contact dressings (RR 1.30, 95% CI 0.65 to 2.58) and polyvinylpyrrolidone plus zinc oxide (RR 1.31, 95% CI 0.37 to 4.62); the latter two interventions both had confidence intervals consistent with both a clinically important benefit and a clinically important harm, and the former two interventions each had high risk of bias as well as imprecision.

AUTHORS' CONCLUSIONS

A network meta-analysis (NMA) of data from 39 studies (evaluating 21 dressings and topical agents for pressure ulcers) is sparse and the evidence is of low or very low certainty (due mainly to risk of bias and imprecision). Consequently we are unable to determine which dressings or topical agents are the most likely to heal pressure ulcers, and it is generally unclear whether the treatments examined are more effective than saline gauze.More research is needed to determine whether particular dressings or topical agents improve the probability of healing of pressure ulcers. The NMA is uninformative regarding which interventions might best be included in a large trial, and it may be that research is directed towards prevention, leaving clinicians to decide which treatment to use on the basis of wound symptoms, clinical experience, patient preference and cost.

Spatiotemporal characterization of hydration process of asymmetric polymeric wound dressings for decubitus ulcers

Pressure ulcers belong to the most chalenging clinical problems. As hydration level of such wounds is important for optimal healing, preparation of new wound dressing (WD) materials for pressure ulcers requires thorough in vitro evaluation as prerequisite to final in vivo testing. The aims of the study were to: (a) develop a simple method of preparation of asymmetric polymeric membrane, (b) to propose a set of in vitro methods for membrane characterization during hydration. A polyvinyl alcohol asymmetric membrane with homogeneous skin layer and porous spongy layer was developed with nonadhesive properties and ability to absorb and retain the water. Complementary methods, including magnetic resonance imaging, allowed quantitative assessment of spatiotemporal aspects of membrane hydration, that is, global water uptake; swelling; local hydration in terms of proton density mapping; spatial distribution of T₂ relaxation time; Young's modulus; piercing resistance. The proposed method of initial wound dressing evaluation seems to be promising to compare various WD formulations, to assess the time required to prepare WD membrane to be applied to the wound and to assess how long WD retains desired working properties. The developed asymmetric membrane seems to be a good candidate for further evaluation. It was found that: Young's modulus of hydrated membrane was comparable to those of human skin; asymmetrical structure was retained during the entire hydration period; each layer had its own distinct, hydration related, properties and their spatiotemporal evolution; relatively slow changes of membrane properties during the potential WD application time-span of several hours was observed. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 843-853, 2018.

Effectiveness of a Short-Term Treatment of Oxygen-Ozone Therapy into Healing in a Posttraumatic Wound

Introduction. A number of studies suggest that oxygen-ozone therapy may have a role in the treatment of chronic, nonhealing, or ischemic wounds for its disinfectant and antibacterial properties. Nonhealing wounds are a significant cause of morbidity. Here we present a case of subcutaneous oxygen-ozone therapy used to treat a nonhealing postoperative wound in a young man during a period of 5 weeks. Case Presentation. A 46-year-old man had a motorcycle accident and underwent amputation of the right tibia and fibula. At the discharge he came to our attention to start rehabilitation treatment. At that time the wound was ulcerated but it was afebrile with no signs of inflammation and negativity to blood tests. At 2 months from the trauma despite appropriate treatment and dressing, the wound was slowly improving and the patient complained of pain. For this reason in addition to standard dressing he underwent oxygen-ozone therapy. After 5 weeks of treatment the wound had healed. Conclusion. In patients with nonhealing wounds, oxygen-ozone therapy could be helpful in speeding the healing and reducing the pain thanks to its disinfectant property and by the increase of endogenous oxygen free radicals' scavenging properties. Compared to standard dressing and other treatments reported in the literature it showed a shorter time of action.

A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types

BACKGROUND

Complex wounds present a substantial economic burden on healthcare systems, costing billions of dollars annually in North America alone. The prevalence of complex wounds is a significant patient and societal healthcare concern and cost-effective wound care management remains unclear. This article summarizes the cost-effectiveness of interventions for complex wound care through a systematic review of the evidence base.

METHODS

We searched multiple databases (MEDLINE, EMBASE, Cochrane Library) for cost-effectiveness studies that examined adults treated for complex wounds. Two reviewers independently screened the literature, abstracted data from full-text articles, and assessed methodological quality using the Drummond 10-item methodological quality tool. Incremental cost-effectiveness ratios were reported, or, if not reported, calculated and converted to United States Dollars for the year 2013.

RESULTS

Overall, 59 cost-effectiveness analyses were included; 71% (42 out of 59) of the included studies scored 8 or more points on the Drummond 10-item checklist tool. Based on these, 22 interventions were found to be more effective and less costly (i.e., dominant) compared to the study comparators: 9 for diabetic ulcers, 8 for venous ulcers, 3 for pressure ulcers, 1 for mixed venous and venous/arterial ulcers, and 1 for mixed complex wound types.

CONCLUSIONS

Our results can be used by decision-makers in maximizing the deployment of clinically effective and resource efficient wound care interventions. Our analysis also highlights specific treatments that are not cost-effective, thereby indicating areas of resource savings. Please see related article: http://dx.doi.org/10.1186/s12916-015-0288-5.