Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy

OBJECTIVE: To assess the efficacy of maggot therapy for treating foot and leg ulcers in diabetic patients failing conventional therapy. RESEARCH DESIGN AND METHODS: Retrospective comparison of changes in necrotic and total surface area of chronic wounds treated with either maggot therapy or standard (control) surgical or nonsurgical therapy. RESULTS: In this cohort of 18 patients with 20 nonhealing ulcers, six wounds were treated with conventional therapy, six with maggot therapy, and eight with conventional therapy first, then maggot therapy. Repeated measures ANOVA indicated no significant change in necrotic tissue, except when factoring for treatment (F [1.7, 34] = 5.27, P = 0.013). During the first 14 days of conventional therapy, there was no significant debridement of necrotic tissue; during the same period with maggot therapy, necrotic tissue decreased by an average of 4.1 cm(2) (P = 0.02). After 5 weeks of therapy, conventionally treated wounds were still covered with necrotic tissue over 33% of their surface, whereas after only 4 weeks of therapy maggot-treated wounds were completely debrided (P = 0.001). Maggot therapy was also associated with hastened growth of granulation tissue and greater wound healing rates. CONCLUSIONS: Maggot therapy was more effective and efficient in debriding nonhealing foot and leg ulcers in male diabetic veterans than was continued conventional care.     

Role of nitric oxide in wound healing

Chronic wounds mainly affect elderly individuals and persons with comorbid diseases due to a compromised immune status. An age-related decline in immune function deters proper healing of wounds in an orderly and timely manner. Thus, older adults with 1 or more concomitant illnesses are more likely to experience and sufferfrom a nonhealing wound, which may drastically decrease their quality of life and financial resources. Novel therapies in wound care management rely heavily on our current knowledge of wound healing physiology. It is well established that normal wound healing occurs sequentially and is strictly regulated by pro-inflammatory cytokines and growth factors. A multitude of commercial products such as growth factors are available; however, their effectiveness in healing chronic wounds has yet to be proven. Recently, investigators have implicated nitric oxide (NO) in the exertion of regulatoryforces on various cellular activities of the inflammatory and proliferative phases of wound healing. Gene therapy in animal studies has shown promising results and is furthering our understanding of impaired wound healing. The purpose of this article is to review the literature on NO and its role in wound healing. A discussion of the physiology of normal healing and the pathophysiology of chronic wounds is provided.     

The Rehabilitation Nurse in the Home Care Setting: Treating Chronic Wounds as a Disability

Rehabilitation nurses have moved into the home care setting; along with other home care nurses, they treat clients with chronic wounds. A rehabilitation nurse, however, views the homebound client needing wound care as having a disability that requires lifestyle modification. Rehabilitation nurses also treat clients with other disabilities who are at risk for developing wounds, so they are in an ideal position to instruct clients in wound prevention. Rehabilitation nurses in home care have the skills and expertise to assess clients needing wound care for deficits that might otherwise be overlooked.     

Wound management in patients with chronic wounds in ambulatory nursing--a pilot study

Currently relevant data about prevalence of chronic wounds and wound management in home care nursing services are not available for Germany. In this study 38 home care nursing services were surveyed by means of a questionnaire. Response rate was 61%. Results showed that almost 9% of the home care nursing services treated patients suffering from chronic wounds. The most common wound was the pressure ulcer with a prevalence of 4.1%, followed by leg ulcer (2.7%) and the diabetic foot (1%). The questionnaire about wound management was completed for 47 patients of 24 home care services. 29 of the patients were females and 18 males. The average age of the patients was 78 years. Important diagnostic information about the nature and the recurrence rate of the wounds was not available to the nursing staff. The average time that a wound existed was 6.7 years with a range of 3 weeks to 45 years. 87% of the patients had their wound dressings on a daily basis. The average time needed for wound dressing was 17 minutes. Wound management often occurred in a idiosyncratic way and did not always follow evidence based practice. Wound management can be significantly improved by the use of modern wound dressing, reduction of the frequency of wound dressings, standardized wound documentation and better co-operation with doctors, nursing experts and health insurance organisations. Basis on the convenience nature of the sample results of this survey should be generalized and interpreted with caution. This study gives clear indications of the significance of the problem. More studies with representative samples are needed.     

In-home wound care management utilizing information technology

Chronic wounds are a major healthcare crisis, presenting challenges for home health agencies lacking specially trained staff to properly monitor and manage these wounds. Consequently, the home health industry needs to improve wound management methods and technologies to properly care for patients with chronic wounds. Saint Francis University's Center of Excellence for Remote and Medically Under-Served Areas partnered with a home health agency (University of Pittsburgh Medical Center Lee Regional Community Nursing Service) to identify a solution to this problem.     

Overview: acute and chronic wounds

Knowledge of normal wound healing and the changes associated with chronic wounds have advanced significantly. Distinct characteristics identified through basic and clinical studies are found in nonhealing wounds, including bacterial and growth factor imbalances, increased inflammatory responses, and proteolytic forces that tip the balance toward tissue degradation rather than repair.This article describes the alterations that reduce healing and that also have important implications for the management of chronic wounds and presents a focus for future developments in wound therapy.     

Discussing the relationship between quality care and cost-effective care in Swiss pediatric wound care.

The growing individual and public demand for high-quality care within a context of restricted budgets dominates the political as well as medical agenda. This demand for "quality care" has developed an "industry" and lobby relating to auditing practice even in the small subpopulation of pediatric surgical patients. With children, complex and nonhealing wounds are quite rare, but there are pressures to provide modern and high-quality wound care even in Switzerland. Thus, in accordance with practice in neighboring countries, guidelines for wound care have been established in the Swiss healthcare sector. Their validity and reliability in the context of cost-effective versus quality care are critically discussed in this paper.     

Topical negative pressure therapy

Topical negative pressure therapy (TNP) has been available for clinical use in wound management since the late 1990s. It has been shown to be of particular benefit for the treatment of chronic nonhealing wounds and has also recently been positively linked to wound bed preparation.     

Infectious diseases of refugees and immigrants: dengue fever

PURPOSE: To describe the assessment and management of chronic wounds and detail current recommendations for optimal wound care practices. DATA SOURCES: Selected scientific literature, clinical practice guidelines, and the authors' clinical experience. CONCLUSION: Multiple factors play a role in the problems associated with chronic wounds. Wound care is costly in regards to medical care, as well as costly in terms of the hardship placed on the patient, family and staff. Too often, wound care practices are based on rituals than research. IMPLICATIONS FOR PRACTICE: The assessment and management of chronic wounds needs to be individualized according to a thorough assessment of the wound, the patients' lifestyle, and the caregiver's knowledge and skill for managing th wound. It is also important to know what wound care products are available and the types of wounds appropriate for their use.     

Fish scale: An unusual foreign body

Retained foreign bodies can be a source of infection and a cause of disability. A 63-year-old white man presented with a nonhealing wound of the right second finger of 1 month's duration. The injury occurred while cleaning fish. Radiographs and subsequent wound exploration showed a retained fish scale in a finger wound. In addition to foreign bodies, atypical infectious organisms must be considered in nonhealing wounds associated with fish or water.     

The use of honey for the treatment of two patients with pressure ulcers

Chronic wounds such as pressure ulcers, leg ulcers and diabetic wounds are a common problem among older people and alternative methods to the current time-consuming and costly practices of wound management in the nursing home need to be identified. To this end, we trialled the use of a honey alginate on two elderly males in our nursing home who were suffering from pressure ulcers (one on the ankle and one on the sacral region), to evaluate its effectiveness as a viable alternative to the current wound management practices in nursing homes. The use of honey resulted in a rapid and complete healing of both wounds. In addition, the antibacterial activity of honey had a deodorizing effect on the wounds and its anti-inflammatory actions helped reduce the level of pain. Similar healing results are also being observed in other patients with pressure-induced ulcers and as a result honey alginates are now being used as the 'standard' treatment for chronic wounds in our nursing home.     

A Nonhealing Wound on the Right Heel

This case study describes a 54-year-old woman who presents to her primary care provider with a nonhealing wound on the right heel. It is a common health issue associated with various diseases that the patient seeks care from health care providers. A chronic wound warrants an accurate differential diagnosis to avoid delayed treatment of the associated condition.     

The cost and efficacy of two wound treatments

Using the physiology of moist wound healing as the framework, this nonexperimental, retrospective chart review compared the rate of wound healing and cost of wound care associated with wet-to-dry normal saline gauze dressings to the rate of wound healing and cost of wound care associated with amorphous hydrogel dressings for patients with infrainguinal arterial disease and diabetes. These patients were discharged from the hospital to home care for management of perioperative arterial surgical wound dehiscence and nonhealing ulcerations. The sample included 25 patients who used wet-to-dry normal saline gauze dressings and 25 patients who used amorphous hydrogel dressings. Repeated measures of analysis of covariance revealed a similar rate of wound healing in the two groups. The overall cost of wound care was significantly higher (P = .006) for patients in the normal saline group, with a higher number and cost of home nursing visits. The cost of supplies was not significantly different between groups, although amorphous hydrogel dressings cost an average of $50 more than wet-to-dry normal saline gauze dressings. The two treatments are equally efficacious in promoting wound healing, but amorphous hydrogel dressings are significantly more cost effective and, thus, a better value for the home care dollar. AORN J 77 (May 2003) 984-1004.     

Nurse driven outpatient wound center: Reducing readmission with wound care excellence

There is a growing need for new and innovative ways to care for patients in the ambulatory setting, including providing wound care for patients.A vascular surgery department in a large urban academic medical center noted there was an increasing number of patients with chronic wounds that needed weekly care. The number of patients, the time needed to provide wound care, and limited clinic space was creating a strain on traditional clinic hours.Collaboration between one of the vascular surgery advanced practice registered nurses (APRN) and vascular registered nurse (RN) led to the creation of a vascular wound clinic. Patients with chronic wounds were identified by vascular surgeons at one institution and referred to the wound clinic. A retrospective chart review was used to look at number of patients, number of visits per patient, surgical interventions, number of wounds closed, size of wounds, and complications.The ability to provide a single point of contact for the patient's vascular surgery and wound care needs allowed the clinic to provide comprehensive care for 29 patients and close more than 75% of wounds. The retrospective chart review found that patients receiving weekly wound care with clear communication from the multidisciplinary team, the nursing and nurse practitioner interventions kept most patients out of the hospital, with only two unplanned readmissions to the hospital, neither due to chronic wounds.This nursing led wound clinic was able to accommodate complex vascular surgery patients, heal chronic wounds, and decrease unplanned readmissions. Expanding the clinic to assist with limb salvage and more podiatric patients is providing a new patient base and improving the care for the community that it serves.     

Home nursing care of a woman with a malignant wound in a primary health care setting

The gradual increase in life expectancy in the Spanish population has led to an increase cancer episodes (the second leading cause of mortality in Spain), and an increase in wounds of neoplastic origin, which have a different healing time from other wounds. This article describes the case of an 85 year-old woman with a malignant wound, due to a recurrent skin lymphangiosarcoma, and her inclusion in the Primary Care home care program with the home care support team (PADES). The overall assessment of the person and not just "the wound", and an individualised nursing care plan led to pain control, wound healing and prevention of complications (constipation, worsening of the injury). Tumour wound care using the process of moist wound healing has been effective even in a fragile tissue. Monitoring and surrounding skin care is essential for the wound not to deteriorate further. In addition, hospitalisation of the patient, with the negative impact it could have on the quality of life of both the patient and her family, was avoided.     

Honey as a dressing for chronic wounds in adults

The aim of this review was to identify whether in adults with chronic wounds the use of honey as a wound dressing improves wound management outcomes. As no randomized controlled trials or comparative studies comparing the use of honey as a chronic wound dressing with usual treatment could be found, the review is based on case studies and serial case studies. These were reviewed using a framework broadly based on wound care case study guidelines (Nelson, 2000) and cohort study guidelines (Greenhalgh and Donald, 2000). Based on the case studies reviewed, honey appears to be a useful dressing in adults with chronic wounds, but the available evidence is weak and therefore must be interpreted with caution.     

A randomized controlled trial of topical tea tree preparation for MRSA colonized wounds

BackgroundThe prevalence of MRSA (Methicillin-resistant Staphylococcus aureus) colonized wounds in home care residents is expected to grow continuously as a result of the substantial proportion of older people requiring institutionalized care due to chronic disease and declining functional status, which contribute to more frequent skin breakdown and wound formation. Tea tree oil has been claimed to have anti-bacterial, analgesic and anti-inflammatory effects that have been suggested in many in-vitro studies to have good efficacy against MRSA. The aims of this study were to evaluate the effectiveness of 10% topical tea tree preparation to eradicate MRSA and to ascertain its influence on wound healing for MRSA-colonized wounds.MethodsIt was a randomized controlled trial, single-blind study. Those with stage II or above MRSA-colonized wounds and who had given their informed consent formed the sample. The determined sample size was based on the effect size of our previous pilot study, which was 0.46. Five outcome measurements were taken for the MRSA bacterial count and wound healing condition at baseline and at 1-week intervals during the 4-week dressing intervention period.ResultsThirty-two participants were recruited from two non-government nursing homes, 16 in the control group and 16 in the tea tree oil group. The control group residents received routine saline gauze dressing, while the tea tree oil group residents received the 10% topical tea tree preparation dressing. In the tea tree oil group, all chronic wounds that had previously been delayed in healing were healed within 28 days without adverse reaction. MRSA was also completely eradicated in 14 (87.5%) out of 16 wounds in the group receiving the 10% topical tea tree preparation.ConclusionThe 10% topical tea tree preparation was effective in reducing the quantity of colonized MRSA in and promoting healing of chronic wounds among elderly.     

Serial measurements increase the accuracy of laser Doppler assessment of burn wounds

Traditional methods of judging burn depth by clinical evaluation of the wound based on appearance and sensation remain in wide use but are subject to individual variation by examiner. In addition to the clinical difficulties with burn wound management, observer dependency of wound assessment complicates clinical trials of burn wound therapy. A laser Doppler flowmeter with a multichannel probe was used to measure burn wound perfusion as a tool to predict wound outcome. Serial measurement with laser Doppler flowmetry had an 88% specificity and a positive predictive value of 81% for identifying nonhealing wounds. These results suggest that laser Doppler flowmetry is a potentially useful tool for burn wound assessment.     

La enfermera de práctica avanzada en la adecuación de los tratamientos de las heridas crónicas complejas

AimTo determine the impact of advanced practice nurses in chronic wound care in the adequacy of treatments for patients with chronic wounds and the consumption of dressings in the districts where they have been implemented.MethodA quasi-experimental pre-poststudy without a control group with 3 measurements: pre-implementation in 2015, one year after implementation in 2016, and 2 years post-implementation in 2017, in the health districts (HD) where the role of the advanced practice nurse in chronic wound care was piloted in Andalusia. The main variables were trained professionals, consultancies, prevalence of chronic wounds, adequacy of treatments and economic cost in materials for the participating HD.ResultsThe training of a total of 2,717 health teams with a total of 95,095 teaching hours was achieved. In addition, a total of 3,871 consultancies were performed. The prevalence of patients with injuries in the home care (HC) programme and in care homes diminished significantly, to almost half. The adequacy of the treatments increased to 90% and savings of more than 250,000€ in dressings were achieved in just 2 years.ConclusionThe prevalence of chronic wounds during the 2 years of implementation decreased by almost half. Adequacy of training and consultancy was achieved, rationalising health expenditure and ensuring efficient care for patients with chronic wounds.     

Care of patients with fungating malignant wounds

Any nurse who has cared for a patient with a fungating malignant wound will know that this is a challenging aspect of the care provided to patients with advanced cancer. This article examines the aetiology of fungating wounds and three core principles of fungating wound management and patient care. This is an under-researched area of clinical care and the literature that guides malignant wound care is drawn from disciplines such as oncology, chronic wound care and palliative care.