Management of Acute Wounds - Expert Panel Consensus Statement

SIGNIFICANCE

The Wound Healing Foundation recognized the need for consensus-based unbiased recommendations for the treatment of wounds. As a first step, a consensus on the treatment of chronic wounds was developed and published in 2022.(1) The current publication on acute wounds represents the second step in this process. Acute wounds may result from any number of conditions, including burns, military and combat operations, and trauma to specific areas of the body. The management of acute wounds requires timely and evidence-driven intervention to achieve optimal clinical outcomes. This consensus statement provides the clinician with the necessary foundational approaches to the causes, diagnosis and therapeutic management of acute wounds. Presented in a structured format, this is a useful guide for clinicians and learners in all patient care settings.

RECENT ADVANCES

Recent advances in the management of acute wounds have centered on stabilization and treatment in the military and combat environment, Specifically advancements in hemostasis, resuscitation, and the mitigation of infection risk through timely initiation of antibiotics and avoidance of high pressure irrigation in contaminated soft tissue injury. .

CRITICAL ISSUES

Critical issues include infection control, pain management and the unique considerations for the management of acute wounds in pediatric patients.

FUTURE DIRECTIONS

Future directions include new approaches to preventing the progression and conversion of burns through the use of the microcapillary gel, a topical gel embedded with the anti-inflammatory drug infliximab.(38) Additionally, the use of three-dimensional bioprinting and photo-modulation for skin reconstruction following burns is a promising area for continued discovery.

M.O.I.S.T. Concept for the Local Therapy of Chronic Wounds: An International Update

Chronic wounds remain a significant clinical challenge both for those affected and for healthcare systems. The treatment is often comprised and complex. All patients should receive wound care that is integrated into a holistic approach involving local management that addresses the underlying etiology and provides for gold standard therapy to support healing, avoid complications and be more cost effective. There have been significant advances in medicine over the last few decades. The development of new technologies and therapeutics for the local treatment of wounds is also constantly increasing. To help standardize clinical practice with regard to the multitude of wound products, the M.O.I.S.T. concept was developed by a multidisciplinary expert group. The M stands for moisture balance, O for oxygen balance, I for infection control, S for supporting strategies, and T for tissue management. Since the M.O.I.S.T. concept, which originated in the German-speaking countries, is now intended to provide healthcare professionals with an adapted instrument to be used in clinical practice, and a recent update to the concept has been undertaken by a group of interdisciplinary experts to align it with international standards. The M.O.I.S.T. concept can now be used internationally both as an educational tool and for the practical implementation of modern local treatment concepts for patients with chronic wounds and can also be used in routine clinical practice.

The role community-based healthcare providers play in managing hard-to-heal wounds

It is common for community-based healthcare providers (CHPs)-many of whom have not received specialised training in wound care-to deliver initial and ongoing management for various wound types and diverse populations. Wounds in any setting can rapidly transition to a stalled, hard-to-heal wound (HTHW) that is not following a normal healing trajectory. Failure to recognise or address issues that cause delayed healing can lead to increased costs, healthcare utilisation and suffering. To encourage early intervention by CHPs, a panel of wound care experts developed actionable evidence-based recommendations for CHPs delineating characteristics and appropriate care in identifying and treating HTHWs. A HTHW is a wound that fails to progress towards healing with standard therapy in an orderly and timely manner and should be referred to a qualified wound care provider (QWCP) for advanced assessment and diagnosis if not healed or reduced in size by 40%-50% within 4 weeks. HTHWs occur in patients with multiple comorbidities, and display increases in exudate, infection, devitalised tissue, maceration or pain, or no change in wound size. CHPs can play an important initial role by seeing the individual's HTHW risk, addressing local infection and providing an optimal wound environment. An easy-to-follow one-page table was developed for the CHP to systematically identify, evaluate and treat HTHWs, incorporating a basic toolkit with items easily obtainable in common office/clinic practice settings. A flow chart using visual HTHW clinical cues is also presented to address CHPs with different learning styles. These tools encourage delivery of appropriate early interventions that can improve overall healthcare efficiency and cost.

Best practice for wound repair and regeneration use of cellular, acellular and matrix-like products (CAMPs)

There are currently over 80 biomaterials derived from autologous, allogeneic, synthetic and xenogeneic sources, or a combination of any or all these types of materials, available for soft-tissue coverage to effect wound closure. Often generically referred to as cellular and/or tissue-based products (CTPs), they are manufactured under various trade names and marketed for a variety of indications.

IWII Wound Infection in Clinical Practice consensus document: 2022 update

ABSTRACT

Wound infection is a major challenge for clinicians globally, with accurate and timely identification of wound infection being critical to achieving clinical and cost-effective management, and promotion of healing. This paper presents an overview of the development of the International Wound Infection Institute (IWII)'s 2022 Wound Infection in Clinical Practice consensus document. The updated document summarises current evidence and provides multidisciplinary healthcare providers with effective guidance and support on terminology, paradigms related to biofilm, identification of wound infection, wound cleansing, debridement and antimicrobial stewardship. Integral to the update is revision of wound infection management strategies which are incorporated within the IWII's Wound Infection Continuum (IWII-WIC) and management plan. The aim of the 2022 IWII consensus document update was to provide an accessible and useful clinical resource in at least six languages, incorporating the latest evidence and current best practice for wound infection and prevention. Dissemination techniques for the consensus are discussed and highlighted.

Embedding Wound Hygiene into a proactive wound healing strategy

Foreword. Wound Hygiene: the next stage

Since a panel published the first consensus document on Wound Hygiene in March 2020, there has been a flurry of activity in support of this newly established concept in proactive wound healing. 1 The document concluded that all wounds, particularly hard-to-heal ones, will benefit from Wound Hygiene, which should be initiated at the first referral, following a full holistic assessment to identify the wound aetiology and comorbidities, and then implemented at every dressing change until full healing occurs. 1 The consensus has since been bolstered by educational webinars; competency-based skills training and support; development of international Wound Hygiene ambassadors; a survey of 1478 respondents, published in July 2021; 2 and a case study supplement, published in January 2022, featuring a range of wound types, anatomies and underlying conditions on the improvements in wound-healing progress that can be achieved. 3 Wound Hygiene has gained its own identity and is now a term in and of itself, that encompasses a 4-step protocol of care. It is an antibiofilm approach that is increasingly being used across wound care. The results of the survey 2 were particularly encouraging for seeing how far Wound Hygiene has come, and how quickly: More than half (57.4%) had heard of the concept of Wound Hygiene Of those, 75.3% have implemented Wound Hygiene Overall, following implementation of Wound Hygiene, 80.3% of respondents reported improved healing rates. 2 However, the top three barriers identified by the survey—lack of confidence, competence and research data—show that there is more to be done to support Wound Hygiene in practice. 2 As a result, a consensus panel of international key opinion leaders convened virtually in the summer of 2021 to discuss what has been done so far, the outputs of the survey, and ideas for addressing the unmet needs identified by the results. The result is this publication, which represents an addendum to the initial consensus document, broadening support for implementation of Wound Hygiene. This document will reflect on the reasons Wound Hygiene has been successful in its first two years of implementation, reiterating its DNA: Do not wait to treat hard-to-heal wounds Use a simple 4-step approach Enable all healthcare professionals to implement and use Wound Hygiene. The document will also discuss the evolution of the Wound Hygiene concept, focusing on how and when to implement Wound Hygiene on all tissue types of hard-to-heal wounds, and proposing what these are. The panel has expanded the framework in which Wound Hygiene is used, with the ultimate objective of introducing the concept of ‘embedding Wound Hygiene intro a proactive wound healing strategy.’ Key inefficiencies are often observed along the journeys of people living with hard-to-heal wounds. The limited number of specialised healthcare professionals and the resulting delays in reaching them may increase the likelihood of a hard-to-heal wound developing. In a world where so much is happening so quickly that we may, at times, feel powerless to drive change, the panel wants to provide further guidance to propel the use of Wound Hygiene. The concept of Wound Hygiene is resonating, and the panel wants you to know that in whatever region you work, in whatever area of clinical practice, you are enabled to make this change. Wielding the 4-step Wound Hygiene protocol consistently is a key action every healthcare professional in every care setting can take to tackle the global wound care crisis. Wound Hygiene has taken off—now, where do we want to land? In a place where Wound Hygiene is practised on all wounds, at every stage, until healing. The panel once again recognises that the community of global healthcare providers should consider their local standards and guidelines when applying the recommendations of this document. To this end, the panel has created a flexible 3-phase framework that situates Wound Hygiene as integral to proactive wound healing. The panel hopes you will continue to implement Wound Hygiene and see the benefits it can bring to people living with wounds, as well as those who care for them.

Chronic wounds: Treatment consensus

The Wound Healing Foundation (WHF) recognised a need for an unbiased consensus on the best treatment of chronic wounds. A panel of 13 experts were invited to a virtual meeting which took place on 27 March 2021. The proceedings were organised in the sub-sections diagnosis, debridement, infection control, dressings, grafting, pain management, oxygen treatment, outcomes and future needs. Eighty percent or better concurrence among the panellists was considered a consensus. A large number of critical questions were discussed and agreed upon. Important takeaways included that wound care needs to be simplified to a point that it can be delivered by the patient or the patient's family. Another one was that telemonitoring, which has proved very useful during the COVID-19 pandemic, can help reduce the frequency of interventions by a visiting nurse or a wound care center. Defining patient expectations is critical to designing a successful treatment. Patient outcomes might include wound specific outcomes such as time to heal, wound size reduction, as well as improvement in quality of life. For those patients with expectations of healing, an aggressive approach to achieve that goal is recommended. When healing is not an expectation, such as in patients receiving palliative wound care, outcomes might include pain reduction, exudate management, odour management and/or other quality of life benefits to wound care.

Quality Improvement Within a Mental Health Setting: Alcohol Detoxification

Aims We describe a clinical audit on alcohol detoxification, using NICE guidelines as a comparable standard. NICE guidelines recommend completing a thorough alcohol history, documentation of a physical examination including screening for Wernicke's encephalopathy, monitoring of vital signs and liver investigations. Breath alcohol level and standardised assessment of withdrawal should be completed in addition to documentation of chlordiazepoxide and thiamine prescriptions. The reported mental health service completed the first cycle of the audit as part of a large-scale, international audit on alcohol detoxification by the Prescribing Observatory for Mental Health, UK (POMH-UK). Two additional audit cycles were completed within the service to ensure continuous quality improvement and clinical effectiveness. Methods Retrospective chart reviews were performed for admissions within pre-defined 6-month periods. Inclusion criteria: ICD-10 F10 diagnosis; prescription of alcohol detoxification schedule. Results This mental health service demonstrated greater compliance with the NICE standards in comparison to other services in the POMH-UK audit. The second-cycle audit showed increased compliance in most areas compared to the initial results. The third-cycle audit focused on two specific areas that required improvement to optimise quality improvement - Breath Alcohol Level and Clinical Institute of Withdrawal Assessment, documentation of which improved from 79% to 85% and 39% to 91% respectively in the final audit cycle. Conclusion The results of this audit indicate that adherence to defined clinical standards within this mental health service exceeds that of the benchmark POMH-UK data. The effectiveness of electronic patient records in improving adherence to set clinical standards, specifically in relation to documentation of clinical parameters is evident. The report also confirms continued improved results with each audit cycle within the service.

Venous Leg Ulcers: A Review of Published Assessment and Treatment Algorithms

Significance: Chronic venous disease (CVD) is prevalent in the aging population and leads to venous leg ulcers (VLUs). These wounds can last and recur for years, significantly impacting quality of life. A large body of literature exists on CVD and VLU diagnosis and treatment. Multiple algorithms, guidelines, and consensus documents have been published on this topic, highlighting the importance of this issue in clinical practice. However, these documents are not fully aligned with each other. Recent Advances: The latest update of the internationally used classification system for CVD was recently published. Our review aims to summarize the existing information to provide an educational tool for clinicians new to this topic, and to highlight the commonalities between the published recommendations. Critical issues: VLUs need to be treated with consideration for the extent of venous disease present in the patient. This requires a good understanding of the various components involved and the possible additional concomitant conditions by the first-line clinician who encounters the patient. A multidisciplinary team is necessary for a successful overall treatment plan, and this plan should be tailored to each patient's specific needs and lifestyle. Future Directions: Compression is still the mainstay of treatment for CVD and VLUs. Compression is needed long term, but it does not suffice by itself to prevent recurrences without interventional correction. Venous intervention should be offered early to prevent or slow disease progression and reduce recurrence.

A review of iodine-based compounds, with a focus on biofilms: results of an expert panel

Biofilms play a central role in the chronicity of non-healing lesions such as venous leg ulcers and diabetic foot ulcers. Therefore, biofilm management and treatment is now considered an essential part of wound care. Many antimicrobial treatments, whether topical or systemic, have been shown to have limited efficacy in the treatment of biofilm phenotypes. The antimicrobial properties of iodine compounds rely on multiple and diverse interactions to exert their effects on microorganisms. An expert panel, held in Las Vegas during the autumn Symposium on Advanced Wound Care meeting in 2018, discussed these properties, with the focus on iodine and iodophors and their effects on biofilm prevention and treatment.

Fish skin grafts compared to human amnion/chorion membrane allografts: A double-blind, prospective, randomized clinical trial of acute wound healing

Chronic, nonhealing wounds consume a great deal of healthcare resources and are a major public health problem, associated with high morbidity and significant economic costs. Skin grafts are commonly used to facilitate wound closure. The grafts can come from the patient's own skin (autograft), a human donor (allograft), or from a different species (xenograft). A fish skin xenograft from cold-water fish (Atlantic cod, Gadus morhua) is a relatively recent option that shows promising preclinical and clinical results in wound healing. Chronic wounds vary greatly in etiology and nature, requiring large cohorts for effective comparison between therapeutic alternatives. In this study, we attempted to imitate the status of a freshly debrided chronic wound by creating acute full-thickness wounds, 4 mm in diameter, on healthy volunteers to compare two materials frequently used to treat chronic wounds: fish skin and dHACM. The purpose is to give an indication of the efficacy of the two therapeutic alternatives in the treatment of chronic wounds in a simple, standardized, randomized, controlled, double-blind study. All volunteers were given two identical punch biopsy wounds, one of which was treated with a fish skin graft and the other with dehydrated human amnion/chorion membrane allograft (dHACM). In the study, 170 wounds were treated (85 wounds per group). The primary endpoint was defined as time to heal (full epithelialization) by blinded assessment at days 14, 18, 21, 25, and 28. The superiority hypothesis was that the fish skin grafts would heal the wounds faster than the dHACM. To evaluate the superiority hypothesis, a mixed Cox proportional hazard model was used. Wounds treated with fish skin healed significantly faster (hazard ratio 2.37; 95% confidence interval: (1.75-3.22; p = 0.0014) compared with wounds treated with dHACM. The results show that acute biopsy wounds treated with fish skin grafts heal faster than wounds treated with dHACM.

P3770Interatrial block: a prognostic factor for atrial fibrillation in cryptogenic stroke patients

Background

Atrial fibrillation (AF) is a well-known risk factor for ischemic stroke. Interatrial block (IAB), resulting from a conduction delay in Bachmann's bundle, is an electrical abnormality that, especially in its advanced (A-IAB) form, has been associated with atrial fibrotic cardiopathy and remodeling, sharing a common pathologic substrate with AF. Therefore, IAB has been proposed as a marker of atrial electromechanical dysfunction that may predispose to the development of AF. We hypothesized that IAB could be a marker of AF in patients with cryptogenic stroke (CS).

Methods

We retrospectively screened a cohort of CS patients with no prior history of AF, and collected their demographic, cardiovascular risk factors and other co-morbidities, stroke severity and resultant functional disability (NIHSS and mRS scales), CHA2DS2-VASc score, baseline 12-lead ECG, transthoracic echocardiogram, and neuroimaging studies on admission. All patients underwent continuous ECG monitoring for at least 48h. Forty-eight (64%) patients underwent additional out-patient 24h Holter monitoring following hospital discharge. P-wave (PW) analysis of baseline ECG classified patients into three groups: normal p-wave duration (N, PW <120 ms), partial IAB (P-IAB, PW ≥120 ms) and advanced IAB (A-IAB, PW ≥120 ms and biphasic morphology in leads DII, DIII and aVF). AF episodes (defined as irregular supraventricular arrhythmias without detectable PWs lasting >30 s), frequent premature atrial contractions (PACs) (>1%) and atrial tachyarrhythmia episodes (runs of >3 consecutive PACs) were detected on 24h Holter readings. Ischemic brain lesions were classified as cortical, subcortical or lacunar in relation to their localization and maximal diameter.

Results

Out of the 80 consecutive CS patients identified, 5 were excluded due to poor quality ECG readings. A high prevalence of both P-IAB (n=30, 40%) and A-IAB (n=23, 30.7%) was found in the final analysis with 75 CS patients. No differences were found between demographics, cardiovascular risk factors and co-morbidities, NIHSS, mRS and CHA2DS2-VASc scores, left atrial size and left ventricular ejection fraction among the 3 ECG categories. Cortical ischemic brain lesions were more frequent in patients in the IAB groups than in the N ECG group. After a mean follow-up of 522 days, AF was clinically diagnosed in 13 patients (17%), with an increasing risk in accordance to the severity of the IAB (p<0.05) (Figure 1A). 24h Holter readings showed greater frequency of PACs and atrial tachyarrhythmia episodes in patients with IAB (p<0.05) (Figure 1B).

Figure 1

Conclusions

In CS, IAB is associated with a greater risk to develop AF and its presence identifies a subgroup of patients with probable atrial fibrotic cardiopathy that could potentially benefit from early oral anticoagulation in secondary prevention.

Meaningful changes in the Short Form 12 physical and mental summary scores after total knee arthroplasty

BACKGROUND

The aim of this study was to identify minimal clinically important difference (MCID), minimal important change (MIC) and minimal detectable change (MDC) for the Short Form (SF-) 12 physical and mental component summary (PCS, MCS) scores after total knee arthroplasty (TKA) using an anchor based methodology.

METHODS

During a 10-year period, 2589 TKA were performed. SF-12 PCS and MCS scores were recorded preoperatively and at one year postoperatively. At one year, patients were asked "How much did the knee replacement surgery improve the quality of your life?" Their response was recorded as: a great improvement, moderate improvement, little improvement, no improvement at all, or the quality of my life is worse. Patients recording a little (n = 211) and no (n = 115) were used to calculate the MCID and the MIC. The MDC90 was calculated using distribution based methods for the whole cohort.

RESULTS

The MCID was 1.8 (p = 0.04) for the PCS and 1.5 (p = 0.33) for the MCS score. The MIC was 2.7 (p = 0.04) for the PCS and -1.4 (p = 0.17) for the MCS score. The MDC90 was 8.9 for the PCS and 13.8 for the MCS score.

CONCLUSION

The MCID for the PCS can be used to compare the outcomes between groups, and the MIC can be used to ensure that a clinical difference has been observed for a cohort of patients. The values for the MDC90 can be used to assess whether or not an individual patient has experienced a change.

Surfactants: Role in biofilm management and cellular behaviour

Appropriate and effective wound cleaning represents an important process that is necessary for preparing the wound for improved wound healing and for helping to dislodge biofilms. Wound cleaning is of paramount importance to wound bed preparation for helping to enhance wound healing. Surfactant applications in wound care may represent an important area in the cleaning continuum. However, understanding of the role and significance of surfactants in wound cleansing, biofilm prevention and control, and enhancing cellular viability and proliferation is currently lacking. Despite this, some recent evidence on poloxamer-based surfactants where the surfactants are present in high concentration have been shown to have an important role to play in biofilm management; matrix metalloproteinase modulation; reducing inflammation; and enhancing cellular proliferation, behaviour, and viability. Consequently, this review aims to discuss the role, mode of action, and clinical significance of the use of medically accepted surfactants, with a focus on concentrated poloxamer-based surfactants, to wound healing but, more specifically, the role they may play in biofilm management and effects on cellular repair.

The rate and predictors of patient satisfaction after total knee arthroplasty are influenced by the focus of the question: a standard satisfaction question is required

Aims

The primary aim of this study was to assess the rate of patient satisfaction one year after total knee arthroplasty (TKA) according to the focus of the question asked. The secondary aims were to identify independent predictors of patient satisfaction according to the focus of the question.

Patients and Methods

A retrospective cohort of 2521 patients undergoing a primary unilateral TKA were identified from an established regional arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 12-Item Short-Form Health Survey (SF-12) scores were collected preoperatively and one year postoperatively. Patient satisfaction was assessed using four questions, which focused on overall outcome, activity, work, and pain. Logistic regression analysis was used to identify independent preoperative predictors of increased stiffness when adjusting for confounding variables.

Results

Using patient satisfaction with the overall outcome (n = 2265, 89.8%) as the standard, there was no difference in the rate of satisfaction for pain relief (n = 2277, odds ratio (OR) 0.95, 95% confident intervals (CI) 0.79 to 1.14, p = 0.60), but patients were more likely to be dissatisfied with activities (79.3%, n = 2000/2521, OR 2.22, 95% CI 1.96 to 2.70, p < 0.001) and work (85.8%, n = 2163/2521, OR 1.47, 95% CI 1.23 to 1.75, p < 0.001). Logistic regression analysis identified different predictors of satisfaction for each of the focused satisfaction questions. Overall satisfaction was influenced by diabetes (p = 0.03), depression (p = 0.004), back pain (p < 0.001), and SF-12 physical (p = 0.008) and mental (p = 0.01) components. Satisfaction with activities was influenced by depression (p = 0.001), back pain (p < 0.001), WOMAC stiffness score (p = 0.03), and SF-12 physical (p < 0.001) and mental (p < 0.001) components. Satisfaction with work was influenced by depression (p = 0.007), back pain (p < 0.001), WOMAC function (p = 0.04) and stiffness (p = 0.05) scores, and SF-12 physical (p < 0.001) and mental (p < 0.001) components. Satisfaction with pain relief was influenced by diabetes (p < 0.001), back pain (p < 0.001), and SF-12 mental component (p = 0.04).

Conclusion

The focus of the satisfaction question significantly influences the rate and the predictors of patient satisfaction after TKA. Cite this article: Bone Joint J 2018;100-B:740-8.

Three groups of dissatisfied patients exist after total knee arthroplasty: early, persistent, and late

AIMS

The primary aim of this study was to assess whether patient satisfaction one year after total knee arthroplasty (TKA) changed with longer follow-up. The secondary aims were to identify predictors of satisfaction at one year, persistence of patient dissatisfaction, and late onset dissatisfaction in patients that were originally satisfied at one year.

PATIENTS AND METHODS

A retrospective cohort consisting of 1369 patients undergoing a primary TKA for osteoarthritis that had not undergone revision were identified from an established arthroplasty database. Patient demographics, comorbidities, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and Short Form 12 (SF-12) questionnaire scores were collected preoperatively, and one and five years postoperatively. In addition, patient satisfaction was assessed at one and five years postoperatively. Logistic regression analysis was used to identify independent predictors of satisfaction at one and five years.

RESULTS

The overall rate of satisfaction did not change from one (91.7%, n = 1255) to five (90.1%, n = 1234) years (p = 0.16). Approximately half (n = 53/114) of the patients who were dissatisfied at one year became satisfied with their TKA at five years, whereas 6% (n = 74/1255) of those who were satisfied at one year became dissatisfied at five years. At one year, patients with lung disease (p = 0.04), with depression (p = 0.001), with back pain (p < 0.001), undergoing unilateral TKA (p = 0.001), or with a worse preoperative WOMAC pain score (p = 0.04) were more likely to be dissatisfied. Patients with gastric ulceration (p = 0.04) and a worse WOMAC stiffness score (p = 0.047) were at increased risk of persistent dissatisfaction at five years. In contrast, a worse WOMAC pain score (p = 0.01) at one year was a predictor of dissatisfaction in previously satisfied patients at five years.

CONCLUSION

Three groups of dissatisfied patients exist after TKA: 'early' dissatisfaction at one year, 'persistent' dissatisfaction with longer follow-up, and 'late' dissatisfaction developing in previously satisfied patients at one year. All three groups have different independent predictors of satisfaction, and potentially addressing risk factors specific to these groups may improve patient outcome and their satisfaction. Cite this article: Bone Joint J 2018;100-B:161-9.

Management of Chronic Wounds: Diagnosis, Preparation, Treatment, and Follow-up

Management of chronic wounds remains challenging in terms of prevalence and complexity. Considerable progress has been made in understanding the science of wound healing during the past decade, sparking volumes of publications and the development of hundreds of dressing and therapy options. There is a need for a simpli ed overview of evidence-based criteria to assist in the accurate diagnosis and appropriate management of chronic wounds in all care settings. An expert panel of 11 wound healing specialists experienced in various care settings convened to discuss best practices and recommended guidelines for managing major chronic wound types. Prior to the meeting, panel members reviewed 8 preselected peer-reviewed articles and 1 white paper containing treatment algorithms for all major chronic wound types. During the meeting, each panelist presented current evidence-based guidelines regarding a specific chronic wound type and case studies to illustrate concepts in the guidelines. This publication is a result of the panel discussion and presents an overview of literature- and experience- based criteria to help guide chronic wound diagnosis, assessment, treatment, and follow-up. A cycle of steps is presented as a framework to guide holistic care for all patients with chronic wounds, including de- hisced surgical wounds, diabetic foot ulcers, venous leg ulcers, arterial insu ciency ulcers, and pressure ulcers/injuries. Emphasis is placed on criteria to assist accurate diagnosis and dressing/therapy selection, holistic elements of patient and wound bed preparation, interventions to achieve patient adherence to a care plan, and follow-up to help prevent wound recurrence.

Using a diagnostic tool to identify elevated protease activity levels in chronic and stalled wounds: a consensus panel discussion

Care of chronic and stalled wounds is hampered by the lack of diagnostic tools to help direct clinicians to specific treatments or diagnose specific conditions. Studies have shown a correlation between high protease levels and nonhealing wounds; a diagnostic protease test is under development. Seven wound care experts (two podiatrists, two vascular surgeons, a physician expert in hyperbaric oxygen therapy, a physical therapist with a specialty in home health, and a registered nurse) met to reach consensus on several aspects about a point-of-care protease test. They agreed that although disease states interfere with wound healing, such states do not automatically mean that wound healing will be impaired or that the wound becomes stalled after inception; and that patient comorbidities, patient factors, patient medications, and the microenvironment of the wound all affect the risk of nonhealing. They also agreed that: 1) appropriate protease activity was important in healing, 2) measuring just one individual protease would be unlikely to be representative of the proteolytic environment of the wound, 3) no diagnostic or theranostic tests to detect high protease activity levels in a wound is currently available, and 4) the development of a simple, widely available protease diagnostic test could dramatically change the provision of care, especially in outpatient settings. If subsequent research confirms that high protease activity levels delay healing, confirmation that a stalled wound has high protease activity levels could better target protease-modulating therapies and improve outcomes. Extensive validation of a protease test will be necessary from proof-of-concept pilot studies to controlled clinical trials to demonstrate that use of the test improves outcomes of care.

UNILATERAL INHIBITION OF THE RENAL SHWARTZMAN PHENOMENON FOLLOWING INJECTION OF BACTERIAL FILTRATE INTO THE RENAL ARTERY

A positive Shwartzman reaction, as indicated by thrombosis and focal hemorrhage in one or more organs, was elicited in 19 of 34 rabbits in which the preparatory injection of bacterial filtrate was made into the left renal artery and the reacting injection was made in the ear vein 24 hours later. In 24 of the 34 rabbits the kidneys were undisturbed throughout the duration of the experiment except for the intra-arterial injection of the left. In 12 of these 24 a positive Shwartzman reaction was observed in the uninjected right kidneys. In only 1 of the 24 injected left kidneys were there changes that might be construed as representing a positive Shwartzman reaction. The changes in this kidney consisted of glomerular thrombosis, not associated with hemorrhage or necrosis. The positive renal Shwartzman reactions seen in the right kidneys were similar to those reported by Apitz and Gerber as representing the renal changes occurring as part of a generalized Shwartzman reaction. The retention of the bacterial filtrate of the preparatory injection in the left kidney, by obstructing both vein and artery for 15 minutes, did not lessen the refractory state. The removal of the right kidney prior to the experiment, with the subsequent demonstration that circulation through the remaining left kidney was not impaired by the intra-arterial injection of filtrate, indicated that the refractory state of the injected kidney was not the result of failure of the reacting dose of filtrate to reach the kidney. In the unilaterally nephrectomized rabbits the development of a positive reaction in other organs indicated that the lack of reaction in the kidney represented a local refractory state. No explanation of the phenomenon was disclosed by these experiments.

Pyoderma Gangrenosum in a Patient with Bruton's X-linked Agammaglobulinemia: Shared Pathogenesis of Altered Tumor Necrosis Factor Alpha?

Individuals with Bruton's X-linked agammaglobulinemia (XLA) inherit a defect in the Btk gene, critical for B-cell differentiation. As a result, there is an absence of mature B-cells in the peripheral circulation with a marked reduction in serum levels of all immunoglobulin subtypes, predisposing patients with XLA to recurrent bacterial infections. Btk also functions in myeloid and dendritic cells, specifically in Toll-like receptor (TLR) signaling. TLRs are important in the recognition of foreign pathogens and elaboration of cytokines, such as tumor necrosis factor alpha (TNF-α). This suggests that the pathophysiology of XLA involves additional and unexplored immune dysregulation. The coexistence of pyoderma gangrenosum (PG) in a patient with Bruton's XLA has been rarely reported. PG is an uncommon, ulcerating, neutrophilic dermatosis. Although its etiology is unknown, it is noninfectious and thought to involve abnormal immune and neutrophil responses. Anti-TNF agents have been effective in treating some patients with PG, suggesting TNF-α may play a role in the pathogenesis of PG. Here we report the association of PG and Bruton's XLA, and demonstrate the presence of TNF-α within the lesion of PG.

Reversible cytotoxic cerebral edema in cerebral fat embolism

We present a case of cerebral fat embolism (CFE) that demonstrated evidence of diffuse white matter cytotoxic edema on diffusion-weighted magnetic resonance imaging, in addition to punctate hyperintensities on T2-weighted and diffusion-weighted imaging. The case suggests that CFE represents a combination of occlusive arteriolar disease and secondary neurotoxicity.

Application of standardized mistletoe extracts augment immune response and down regulates metastatic organ colonization in murine models

The immunomodulatory and antimetastatic activity of standardized aqueous mistletoe extracts from plants grown on fir trees (ME-A) and pine trees (ME-P) were evaluated in BALB/c-mice. Regular subcutaneous (s.c.) and intraperitoneal (i.p.) applications (three times per week for 14 consecutive days; 5 and 50 microg per injection and mouse) upregulated thymus weight and peripheral blood leukocyte counts in tumor bearing mice. To check the influence of ME-A and ME-P treatment on growth of experimental metastases, RAW 117 H 10 lymphosarcoma cells and L-1 sarcoma cells were intravenously inoculated into BALB/c-mice to establish liver and lung colonization. ME-A and ME-P were regularly administered starting 24 h after tumor cell challenge. Organ colonization was investigated on day 14 after tumor cell inoculation and demonstrated statistically significant (P<0.05) reductions of experimental liver and lung metastases for ME-A and ME-P treated mice.

Flow-cytometric detection of lactase expression in normal and coeliac intestinal epithelium

OBJECTIVE

Enterocyte lactase expression is a useful marker of gluten toxicity. In this study, the technique of flow cytometry was evaluated to quantify lactase expression in coeliac disease (CD).

METHODS

Duodenal enterocyte suspensions were obtained from 23 patients with CD, four patients with dermatitis herpetiformis (DH), and 33 control subjects. The percentage of enterocytes that reacted with anti-lactase monoclonal antibody was determined by flow cytometry. In some subjects, organ culture of duodenal biopsies in the presence of various stimuli (including gluten fractions) was performed before enterocyte analysis.

RESULTS

This study demonstrated that lactase expression can be readily investigated semi-quantitatively using flow cytometry. Moreover, the level of expression correlated with the extent of mucosal damage in gluten-sensitive individuals. However, in organ culture experiments, lactase expression did not change in the presence of gluten or after marked T-cell activation for 48 h.

CONCLUSIONS

Measurement of enterocyte lactase expression by flow cytometry is a useful adjunctive test in the diagnosis and monitoring of gluten-sensitive enteropathy. However, lactase expression is not a suitable marker of gluten-induced toxicity in organ culture.

Randomized trial of folic acid supplementation and serum homocysteine levels

BACKGROUND

Lowering serum homocysteine levels with folic acid is expected to reduce mortality from ischemic heart disease. Homocysteine reduction is known to be maximal at a folic acid dosage of 1 mg/d, but the effect of lower doses (relevant to food fortification) is unclear.

METHODS

We randomized 151 patients with ischemic heart disease to 1 of 5 dosages of folic acid (0.2, 0.4, 0.6, 0.8, and 1.0 mg/d) or placebo. Fasting blood samples for serum homocysteine and serum folate analysis were taken initially, after 3 months of supplementation, and 3 months after folic acid use was discontinued.

RESULTS

Median serum homocysteine level decreased with increasing folic acid dosage, to a maximum at 0.8 mg of folic acid per day, when the homocysteine reduction (placebo adjusted) was 2.7 micromol/L (23%), similar to the known effect of folic acid dosages of 1 mg/d and above. The higher a person's initial serum homocysteine level, the greater was the response to folic acid, but there were statistically significant reductions regardless of the initial level. Serum folate level increased approximately linearly (5.5 nmol/L for every 0.1 mg of folic acid). Within-person fluctuations over time in serum homocysteine levels, measured in the placebo group, were large compared with the effect of folic acid, indicating that monitoring of the reduction in an individual is impractical.

CONCLUSIONS

A dosage of folic acid of 0.8 mg/d appears necessary to achieve the maximum reduction in serum homocysteine level across the range of homocysteine levels in the population. Current US food fortification levels will achieve only a small proportion of the achievable homocysteine reduction.

Genome sequence of Halobacterium species NRC-1

We report the complete sequence of an extreme halophile, Halobacterium sp. NRC-1, harboring a dynamic 2,571,010-bp genome containing 91 insertion sequences representing 12 families and organized into a large chromosome and 2 related minichromosomes. The Halobacterium NRC-1 genome codes for 2,630 predicted proteins, 36% of which are unrelated to any previously reported. Analysis of the genome sequence shows the presence of pathways for uptake and utilization of amino acids, active sodium-proton antiporter and potassium uptake systems, sophisticated photosensory and signal transduction pathways, and DNA replication, transcription, and translation systems resembling more complex eukaryotic organisms. Whole proteome comparisons show the definite archaeal nature of this halophile with additional similarities to the Gram-positive Bacillus subtilis and other bacteria. The ease of culturing Halobacterium and the availability of methods for its genetic manipulation in the laboratory, including construction of gene knockouts and replacements, indicate this halophile can serve as an excellent model system among the archaea.

Increased HLA-DR and CD44 antigen expression in the gut: evidence of extraarticular immunological activity in rheumatoid arthritis

OBJECTIVE

To examine the gastrointestinal (GI) immune system in rheumatoid arthritis (RA) for evidence of activation.

METHODS

Duodenal biopsies from 25 patients with RA were obtained by endoscopy. Single cell suspensions from the epithelial layer and lamina propria were prepared. Flow cytometry was used to examine the expression of CD4, CD8, T cell receptor-gammadelta (TCR-gammadelta), TCR-alphabeta, HLA-DR, CD44, and interleukin 2 receptor on gut T lymphocytes. Fifteen disease control (DC) individuals and 6 patients with osteoarthritis (OA) taking longterm nonsteroidal antiinflammatory drug (NSAID) therapy were also investigated. Peripheral blood T lymphocytes from all individuals were examined for the expression of these surface molecules.

RESULTS

HLA-DR expression was significantly increased on intraepithelial lymphocytes (IEL) and enterocytes from patients with RA (n = 13) compared with the 2 control groups (p<0.01). Immunohistochemistry also revealed increased expression of HLA-DR on enterocytes from patients with RA. RA IEL (n = 6) expressed significantly higher levels of CD44 (p<0.02). In the lamina propria, a small but significant gammadelta T lymphocyte population (mean 5.5%, range 2-12%) was detected in rheumatoid factor positive RA patients (n = 8) compared with RF negative RA patients (n = 8, mean 2%, range 0.4-6%; p<0.01) and the disease control group (n = 15, mean 2%, range 0.5-5%; p<0.01). None of these changes were detectable in peripheral blood lymphocytes from patients with RA.

CONCLUSION

This study demonstrates evidence of activation of specific components of the GI immune system in RA. Peripheral blood T lymphocytes from patients with RA did not show increased expression of activation markers, suggesting that changes in the RA GI tract are not systemic but localized. Moreover, these changes appear to be independent of NSAID therapy.

Lansoprazole is superior to ranitidine as maintenance treatment for the prevention of duodenal ulcer relapse

AIM

To compare lansoprazole 30 mg once daily, lansoprazole 15 mg once daily and ranitidine 150 mg once nightly in the prevention of duodenal ulcer relapse in patients whose duodenal ulcers had been previously healed with lansoprazole 30 mg once daily or ranitidine 300 mg nightly.

METHODS

A double-blind, parallel group, randomized multicentre study conducted in 33 centres in the UK, Eire, Sweden and Australia. Two hundred and nineteen patients with a duodenal ulcer were randomized to receive lansoprazole 30 mg and 217 to receive ranitidine 300 mg for 8 weeks. Patients were then re-randomized to receive lansoprazole 30 mg (122 patients), lansoprazole 15 mg (121 patients) or ranitidine 150 mg (116 patients) for 12 months. All patients had an endoscopically-proven duodenal ulcer at baseline and were considered suitable for long-term maintenance therapy to prevent relapse.

RESULTS

Significantly more patients were healed on lansoprazole (98%) compared to ranitidine (89%) (P < 0.001, Fisher's exact test). Lansoprazole provided more rapid symptom relief than ranitidine. Lansoprazole 30 mg and lansoprazole 15 mg increased the probability of not relapsing in comparison to ranitidine (P = 0.001 and 0.06, respectively, life-table analysis). Relapse rates over the 12 months were lower in the lansoprazole treatment groups (lansoprazole 30 mg, 5%; lansoprazole 15 mg, 12%; and ranitidine, 21%; lansoprazole 30 mg vs. ranitidine 150 mg, P = 0.002). Symptoms were well controlled in both groups during the maintenance phase. All treatments were well tolerated with no major differences seen in adverse event profiles between treatment groups.

CONCLUSIONS

Both doses of lansoprazole (30 mg and 15 mg) were superior to ranitidine 150 mg in the prevention of duodenal ulcer relapse. Lansoprazole was superior to ranitidine in terms of symptom control and duodenal ulcer healing. Both treatments were well tolerated.

Carriage of Neisseria meningitidis and Neisseria lactamica among ethnic Greek school children from Russian immigrant families in Athens

During February and March 1995, a survey of meningococcal carriage in 625 school children was carried out in a suburb of Athens in which there was a large number of ethnic Greeks who had immigrated from Russia beginning in the early 1990s. The objectives of the study were: (1) to determine if factors associated with carriage of meningococci observed in a previous study of Greek school children were similar for the immigrant population; (2) to compare phenotypic characteristics of meningococci from the immigrant population with those isolated from children in Athens. Overall isolation rate for meningococci was 82/625 (13.1%), significantly higher than that found for school children in Athens (5.8%) during the winter of 1990 1991 (5.8%) (chi=25.98, P=0.0000003). By univariate analysis, carriage was not associated with sex, number of individuals per household, blood group, secretor status, socioeconomic level or maternal smoking; however, it was associated with fathers' smoking. The high proportion of men who smoked compared with the low proportion of women smokers might contribute to this finding. The main serogroup of meningococci isolated from this population was A (28%). While serogroup A appears to be more prevalent among Russian and Kurdish immigrants (14%) than among Greek school children or military recruits (4%), there has not been an increase in group A meningococcal disease in Greece. The isolation rate for N. lactamica was high 105/625 (17.3%). A few of these strains bound some of the monoclonal antibodies used for meningococcal serotyping and subtyping, and they are being examined in greater detail.

Perceived social support and community adaptation in schizophrenia

Prompted by the continuing transition to community care, mental health nurses are considering the role of social support in community adaptation. This article demonstrates the importance of distinguishing between kinds of social support and presents findings from the first round data of a longitudinal study of community adaptation in 156 people with schizophrenia conducted in Brisbane, Australia. All clients were interviewed using the relevant subscales of the Diagnostic Interview Schedule to confirm a primary diagnosis of schizophrenia. The study set out to investigate the relationship between community adaptation and social support. Community adaptation was measured with the Brief Psychiatric Rating Scale (BPRS), the Life Skills Profile (LSP) and measures of dissatisfaction with life and problems in daily living developed by the authors. Social support was measured with the Arizona Social Support Interview Schedule (ASSIS). The BPRS and ASSIS were incorporated into a client interview conducted by trained interviewers. The LSP was completed on each client by an informal carer (parent, relative or friend) or a professional carer (case manager or other health professional) nominated by the client. Hierarchical regression analysis was used to examine the relationship between community adaptation and four sets of social support variables. Given the order in which variables were entered in regression equations, a set of perceived social support variables was found to account for the largest unique variance of four measures of community adaptation in 96 people with schizophrenia for whom complete data are available from the first round of the three-wave longitudinal study. A set of the subjective experiences of the clients accounted for the largest unique variance in measures of symptomatology, life skills, dissatisfaction with life, and problems in daily living. Sets of community support, household support and functional variables accounted for less variance. Implications for mental health nursing practice are considered.

Quality of life during acute and intermittent treatment of gastro-oesophageal reflux disease with omeprazole compared with ranitidine. Results from a multicentre clinical trial. The European Study Group

AIMS

To investigate quality of life in patients with gastro-oesophageal reflux disease.

PATIENTS

A series of 704 patients were randomised to treatment with ranitidine 150 mg bd, omeprazole 10 mg om or omeprazole 20 mg om for 2 weeks. Asymptomatic/mildly symptomatic patients were followed for 12 months.

METHODS

The Psychological General Well-Being index and the Gastrointestinal Symptom Rating Scale were completed before and during short-term and intermittent treatment.

RESULTS

The quality of life response rate was > 80%. The majority of the patients receiving omeprazole 20 mg om (55%) had symptom relief after 2 weeks despite the fact that more patients on ranitidine required 4 weeks' treatment and an increased dose. There was no difference in the reflux dimension of Gastrointestinal Symptom Rating Scale between treatments in the initial treatment phase, but the total Gastrointestinal Symptom Rating Scale score improved significantly more on omeprazole 10 mg om than on ranitidine 150 mg bd (p = 0.006). Both doses of omeprazole improved the total Psychological General Well-Being score more than ranitidine (omeprazole 10 mg om versus ranitidine 150 mg bd, p = 0.005, omeprazole 20 mg om versus ranitidine 150 mg bd, p = 0.031). During follow-up, relapsing patients returned to pre-treatment symptom and well-being scores, but these dimensions were restored after treatment.

CONCLUSION

The quality of life is impaired in patients presenting with reflux symptoms. Irrespective of whether the patients presented with endoscopy positive or endoscopy negative reflux disease, treatment on demand improved the quality of life.

Recommendations for using reverse staging to complete the MDS-2

The use of the Minimum Data Set (MDS) for documentation in long term care has resulted in the widespread reliance on reverse staging to document the healing of pressure and venous ulcers. This article presents a pragmatic approach for defining the healing process in a staging nomenclature so that it is physiologically accurate.

Human umbilical vein endothelial cells: a new easily available source of endomysial antigens

OBJECTIVE

To evaluate human umbilical vein endothelial cells (HUVEC) as an alternative source of endomysial antigen (EmAg) and to assess their suitability for the detection of endomysial antibodies (EmA) in coeliac disease (CD).

METHODS

HUVEC were reacted on glass slides with patient sera and examined by fluorescent microscopy. Flow cytometry was used to determine whether the EmAg was expressed on the surface of the cells or was intracellular. Absorption studies were used to confirm the specificity of results.

RESULTS

The data presented here show that HUVEC contain an intracellular antigen that binds to immunoglobulin A (IgA) from patients with active CD. Correlation studies showed that HUVEC antibodies were present in the sera of all patients that contained EmA and reticulin IgA antibodies whereas reticulin antibodies were only present in 24 of the 31 patients who were either EmA or HUVEC positive. All of the sera tested which were negative for EmA were also negative for HUVEC antibodies. Ten patients with Crohn's disease and 10 patients with ulcerative colitis were negative for HUVEC or EmA reactivity, as were 16 control subjects attending the gastroenterology clinic with non-specific symptoms and normal small intestinal biopsies.

CONCLUSIONS

These findings suggest that the antigen found in HUVEC is antigenically similar to that found in reticulin and endomysium and that all three antigens may be the same. In contrast to the monkey oesophagus, HUVEC offer an easily available antigen for the serological diagnosis of coeliac disease.

Chemotherapy with vincristine/ifosfamide/carboplatin/etoposide in small cell lung cancer

Although chemotherapy is considered the cornerstone of treatment for small cell lung cancer (SCLC), the majority of SCLC patients relapse and die of their disease within 2 years of diagnosis. Until newer, more effective drugs are developed, both optimization of available chemotherapeutic regimens and the use of combined chemotherapy/radiotherapy will be required to improve the survival of SCLC patients. Combining ifosfamide, carboplatin, and etoposide, among the most active single agents against SCLC, into the ICE regimen was a logical move that has resulted in improved response and survival rates. In limited and extensive SCLC, respectively, ICE and ICE administered with vincristine (VICE) have achieved overall response rates of 79% to 94% and 77% to 100% and 2-year survival rates of 24% to 33% and 9% to 25%, respectively. Treatment-related toxicities, especially myelosuppression, have hindered efforts to accelerate the administration of ICE and VICE regimens and to incorporate them into combined-modality treatments. However, the use of hematologic support measures, including growth factors and peripheral blood progenitor cells, may pave the way for maximizing the effectiveness of these regimens.