Systematic review of topical interventions for the management of odour in patients with chronic or malignant fungating wounds

Chronic wounds adversely affect the quality of life of individuals and odour is a well-recognised associated factor. Odour can affect sleep, well-being, social interactions, diet and potentially wound healing. This systematic review aims to examine the effectiveness of topical interventions in the management of odour associated with chronic and malignant fungating wounds. A systematic review guided by PRISMA recommendations of randomised controlled trials where odour intensity/odour is the primary outcome was undertaken. Inclusion criteria were adults (18 years and over) with chronic venous, arterial, diabetic or pressure ulcers or with malignant fungating wounds where odour has been managed through topical application of pharmacological/non-pharmacological agents. Searches were conducted in CENTRAL, CINAHL, EMBASE, MEDLINE, Scopus, and Web of Science. Eligibility screening, risk of bias assessment and data extraction was completed by authors working independently. Searches retrieved 171 titles and abstracts (157 post de-duplication). Thirteen studies were retained for full text review of which five (n = 137 individuals) examining the following treatments remained: metronidazole (n = 4), silver (n = 1). Meta-analysis was not possible but individual studies suggest improved outcomes (i.e., reduced odour) using metronidazole. Treatment options to manage wound odour are limited and hampered by lack of clinical trials, small sample sizes, and absence of standardised outcomes and consistent measurement. Whereas metronidazole and silver may have a role in controlling wound odour, robust and well-designed interventions with rigorous procedures and standardised odour outcomes are necessary to evaluate their contribution.     

Development and validation of a survey designed to measure patient experience of and preference for surgical wound care discharge education: A pilot study

Aim of the studyTo develop and undertake validation testing of a survey designed to measure patients’ experiences of and preferences for surgical wound care discharge education.Materials and methodsA literature review and content analysis was undertaken on patients' experiences of and preferences for surgical wound care discharge education. Four themes were uncovered in the literature (wound care discharge education, preferences for discharge education delivery, participation in wound care decisions and patient ability to manage their surgical wound to prevent wound complications), which guided item generation. Three types of validity testing occurred including: 1) face validity testing by the research team; 2) content validity testing (using Delphi study) with an international panel of experts including patients, clinicians and researchers; and 3) content validity (using pilot-testing) of the survey with seven patients from the target population.ResultsInitially 106 items were generated from the literature, and of these, 55 items were subjected to content validity testing by an international panel of 41 experts. After two Delphi rounds, 18 items were retained. Most patients provided limited and very minor feedback during pilot-testing. However, pilot-testing resulted in a revised survey administration plan to deliver the survey via telephone, including adding prompts and preambles to items.ConclusionAn 18-item survey comprised of three groups of items and an individual item was rigorously developed. The survey requires further testing among a larger sample of patients to confirm the items reflect important aspects of patients’ experiences of and preferences for surgical wound care discharge education.     

Slow release iodine preparation and wound healing: in vitro effects consistent with lack of in vivo toxicity in human chronic wounds

BACKGROUND: Antiseptic agents, particularly slow-release preparations, are increasingly being used in the management of chronic wounds. One such agent, cadexomer iodine, carries iodine (0.9% weight/weight) immobilized in beads of dextrin and epichlorhydrin and has been demonstrated to be highly effective in promoting healing of exudative wounds. However, there have been no studies directly assessing the potential lack of toxicity of cadexomer iodine on human cutaneous tissues. OBJECTIVES: To determine if, within a certain concentration range, cadexomer iodine is non-toxic to human cells and cutaneous tissue and to assess histologically human chronic exudative wounds that are being treated with cadexomer iodine. METHODS: We examined the effects of varying concentrations of cadexomer iodine on the viability of human fibroblasts in culture (by trypan blue exclusion). The morphology, cellular proliferation capacity (measured by [3H]thymidine uptake), ability to produce alpha 1(I) procollagen chain mRNA, and cell outgrowth from neonatal foreskin explants were also evaluated in human fibroblasts after incubation with various concentrations of cadexomer iodine. Moreover, biopsies of chronic exudative wounds concurrently treated with cadexomer iodine were stained with haematoxylin and eosin or a Gram stain and evaluated microscopically. RESULTS: At concentrations of up to 0.45%, cadexomer iodine was found to be non-toxic to fibroblasts in vitro; there were no changes in viability, morphology, cellular proliferation, ability to produce collagen, and cell outgrowth from explants. In vivo, skin biopsies of chronic exudative wounds being treated with cadexomer iodine demonstrated no evidence of cell necrosis, displayed re-epithelialization, and revealed bacteria within the cadexomer beads. CONCLUSIONS: These studies demonstrate that cadexomer iodine has definite non-toxic concentration ranges for fibroblasts in vitro, which are consistent with a lack of cellular toxicity in human chronic exudative wounds treated with cadexomer iodine. Cadexomer iodine may also have the additional property of trapping microorganisms.     

Non‐interventional study to investigate the efficacy and safety of Tegaderm™ Matrix in the treatment of patients with therapy‐refractory chronic wounds

Background: Despite a variety of therapeutic approaches, many patients with chronic wounds remain refractory to treatment. Products such as Tegaderm? Matrix were developed especially for such patients to alter the wound environment and reactivate the stagnant wound healing process. Patients and Methods: In this prospective post‐authorization observational product study, a total of 314 patients with therapy‐refractory chronic wounds of various origins were evaluated. Beside to the wound area reduction and healing rate, the occurrence of adverse events was documented. Results: On average the wounds were 10 months old. The average wound size was 17.3 cm² (median 6.3 cm²) at the initial visit. In the course of treatment the wound size decreased to 13.0 cm² (median 3.5 cm²) and was finally reduced to 9.3 cm² (median 0.9 cm²) at end of the study. Taking the criteria of the European Wound Management Association for improving the quality of clinical studies into consideration, a wound size reduction of at least 50 % is the parameter for successful treatment of chronic wounds. This study demonstrated a wound size reduction of at least 50 % for 72.9 % of the patients with therapy‐refractory chronic wounds when treated with Tegaderm? Matrix. The safety profile was evaluated; only 4.7 % of the patients experienced a treatment‐related adverse event such as a burning sensation. Conclusions: The results of the study demonstrate that Tegaderm? Matrix along with treatment of underlying causes is a well tolerated wound dressing promoting wound size reduction up to healing for the majority of patients with previously therapy‐refractory chronic wounds.     

Non‐invasive assessment of healing of bacteria infected and uninfected wounds using optical coherence tomography

Background/purpose: Bacterial infection is one of the main predisposing factors for the delay in wound healing. To facilitate a timely decision for correct therapy, it is important to accurately monitor the morphological changes in the infected wounds using noninvasive tools. In the present study, we have explored the use of optical coherence tomography (OCT) for monitoring the healing of superficial wounds infected with Staphylococcus aureus in mice under in vitro and in vivo conditions and studied the changes in collagen birefringence in the infected wounds. Methods: The tape stripping method was used for generating superficial skin wounds in mice and wounds were infected with S. aureus. For in vitro studies, infected and uninfected wound tissues were resected, back scattered intensity and birefringence changes in collagen during wound healing were studied on the 2, 4 and 10th day of postinfection using polarization‐sensitive (PS) OCT and images were compared with histology. Real‐time OCT was used for studying the kinetics of healing of infected wounds under in vivo conditions. Results: From the PS‐OCT images, different phases of wound healing such as inflammation, reepithelialization and collagen remodeling could be identified. The edematic regions appeared prominent in infected wounds. Compared with uninfected wounds, reepithelization and collagen remodeling phases of wound healing were delayed significantly in the infected wounds. These changes were comparable with the different stages of wound healing observed under in vivo conditions. Conclusion: OCT imaging can provide a rapid assessment of the morphological changes associated with bacteria‐infected and uninfected wounds and thereby aid in timely treatment planning.     

The role of oxygen‐associated therapies for the healing of chronic wounds,particularly in patients with diabetes

This paper discusses the role of molecular oxygen as an aid to wound healing, and the potential value of the three major therapies which allow the delivery of oxygen to the wound site: Hyperbaric Oxygen Therapy (HBOT), Topical Oxygen Therapy (TOT) and a new sterile wound dressing, Oxyzyme^TM. We summarize studies which have been undertaken using these interventions, and discuss their reported effect on chronic, non‐healing wounds, in particular, on ulcers associated with Diabetes. The main conclusions drawn from the studies reviewed indicate that therapeutic oxygen can be used as an aid to the healing of chronic wounds; and benefits are clearly evident with the use of both HBOT and TOT. There is also potential for the use of a new, portable, topical oxygen delivery system, oxyzyme. However its use is still embryonic and studies on its effectiveness are limited. More robust measures of its efficacy are urgently needed.     

Perioperative management of patients on anti-platelets and anti-coagulants presenting for dermatological surgical procedures. A UK survey

There are an increasing number of our patients on antiplatelet and anticoagulant medications. In the absence of clear guidelines for the perioperative management of these patients presenting for operative dermatological procedures, we undertook a pilot survey of the current practices of dermatologists in the United Kingdom. The aims of our study were to determine whether there was uniformity of practice and whether the modes of practice differed from those outlined in the literature for other related specialities, and to debate whether there is a need for national guidelines with this regard. A postal survey of 185 dermatologists was conducted. The response rate was 50%. Overall, most respondents (61%) stated that their practice was primarily based on personal preference and only 30% stated that it was based on the local Unit policy. Only 34% of the Consultants based their practice on evidence-based medicine. There appeared to be significant variations in current practice amongst dermatologists. Some aspects of practice were found to vary from those recommended in the literature. The findings of this study emphasise the importance of national guidelines for the use of anti-platelet and anti-coagulant medications in cutaneous surgery specifically and in surgery in general.     

The prevalence,management and outcome for patients with lower limb ulceration identified in a wound care survey within one English health care district

482 people with leg ulcers were identified among those receiving health care in Bradford, UK. Of these wounds 195 (40.4%) were venous leg ulcers. Typically the people who experienced these wounds were elderly Caucasian females however a sub-group of younger males of Asian descent were seen to experience ulcers involving neuropathy. The leg ulcers were typically small in size although 33 people had wounds over 25 cm² in surface area. The leg ulcers tended to persist with many present for at least 1 year with 4 wounds active for over 5 years. 205 people had experienced previous episodes of leg ulcer occurrence. Of the leg ulcers encountered 18.0% (n = 87) were infected and where wounds were swabbed for their microbial burden MRSA was identified in 8.5% of cases. Use of Doppler ultrasound to assess the aetiology of the wound had been performed in 66.4% of cases and where wounds remained undiagnosed (n = 69) only 8 had been Doppler assessed. While 75% of all venous leg ulcers received compression 48 people with venous leg ulcers did not have compression applied to their wound.     

The prevalence,management, equipment provision and outcome for patients with pressure ulceration identified in a wound care survey within one English health care district

The prevalence of pressure ulceration within the population receiving health care in Bradford, UK was 0.74 people with a pressure ulcer per 1000 population (95% CI 0.6–0.8). This prevalence includes a number of tertiary referrals and if these are removed the prevalence falls to 0.71 people with a pressure ulcer per 1000 population. Of the pressure ulcers encountered 195 (53.7%) were classed as grade 2 pressure ulcers with 80 grade 3 wounds and 40 grade 4 pressure ulcers. Forty-eight pressure ulcers were identified as grade 1 wounds but the accuracy of this classification may be in doubt given that 24 apparent grade 1 pressure ulcers were reported to have visible wound beds with common reports of slough and granulation tissue. Severe pressure ulcers differed from less severe partial thickness wounds – grade 3 and 4 pressure ulcers tended to be larger, of longer duration, with greater coverage of the wound bed with necrotic tissue and less granulation and epithelial tissue. Wound exudate was heavier where people presented with severe pressure ulcers while there was a greater probability of wound infection (37.5% of grade 4 pressure ulcers were infected). Given these challenges it was perhaps unsurprising that people with severe pressure ulcers were more likely to have been risk assessed, to have had a critical incident form completed (although only 35% of grade 4 pressure ulcers were identified as having been reported on a critical incident form), to be provided with a powered PR mattress in bed and to be dressed with an antimicrobial dressing. The time to treat each severe pressure ulcer tended to be longer than was the treatment times for less severe wounds. Only 40 people with pressure ulcers (11%) as their most serious wound were located in hospital, suggesting that current pressure ulcer epidemiology and costs may be understated given their reliance on previous hospital based surveys of pressure ulcers. Another potential confounder of pressure ulcer epidemiological studies may be the number of nursing home beds in the surveyed population. On breaking down the Bradford audit data by postcode the pressure ulcer prevalence ranged between 0.13 and 1.39 people with a pressure ulcer per 1000 population with the higher prevalence proportions found in postcodes with large numbers of nursing home beds. It would appear to be prudent to record the number of nursing home beds within community based populations where pressure ulcers (and potentially other wounds) are being recorded.     

Extending psychosocial assessment of patients with psoriasis in the UK,using a self‐rated,web‐based survey

Background. Quality of life self‐rating using a web‐based survey has not previously been evaluated for psoriasis in the UK. Aim. To use an open‐access web‐based survey to assess the effect of psoriasis on patients’ daily life. Methods. The survey was conducted using a dedicated website endorsed by a UK psoriasis patient charity. Results. In total, 1760 patients (1102 women, 658 men; median age range 40–44 years) assessed their psoriasis using the website. Psoriasis was ‘very’ or ‘extremely’ active in 52%, and 71% had been diagnosed > 10 years previously. Psoriasis had negatively affected the working life of 59% of patients, and the educational performance of 31%. Conclusions. The use of an open‐access web‐based survey may address potential bias in previous studies, but may itself introduce a bias towards younger patients. This is the first report of a web‐based survey of UK patients with psoriasis, providing further recent evidence of how psoriasis affects patients’ lives.     

Skin areas,clinical severity,duration and risk factors of intertrigo: A secondary data analysis

AimTo describe the skin areas most often affected by intertrigo, the clinical severity and duration of intertrigo and possible risk factors.Materials and methodsSecondary analysis of data from 2013 to 2016 collected by the International Prevalence Measurement of Care Quality in Dutch hospitals, care homes and community care.ResultsIn total, n = 7865 (mean age 80.1 years) subjects were included in this analysis. The inguinal, breast and gluteal cleft skin areas were most often affected by intertrigo. The skin was often inflamed but not eroded. Strongest associations between intertrigo at inguinal skin and diabetes mellitus (OR 1.8; 95% CI 1.1–3.1), intertrigo at sub mammary folds and urinary incontinence (OR 1.6; 95% CI 0.9–2.9) and between intertrigo at gluteal cleft and urinary incontinence (OR 2.9; 95% CI 1.4–5.2) were observed.ConclusionThe inguinal region, sub mammary folds and gluteal clefts are most often affected by intertrigo. Female sex, urinary incontinence and high BMI seem to enhance intertrigo risk at all of these skin areas.     

Bone marrow cells differentiate into wound myofibroblasts and accelerate the healing of wounds with exposed bones when combined with an occlusive dressing

BACKGROUND: The usefulness of bone marrow cells in accelerating wound healing has not been evaluated despite increasing evidence that bone marrow contains mesenchymal stem cells that have multipotentiality to differentiate into various types of cells after they enter the microenvironment of a specific tissue (niche). OBJECTIVES: To determine the effects of bone marrow cells and occlusive dressings in promoting wound healing in rats. METHODS: We investigated by grafting, biopsy and immunohistochemistry whether various types of cells derived from green fluorescent protein (GFP)-transgenic rats would differentiate into wound component cells when administered topically on the wounds of rats. We also investigated whether topical application of bone marrow cells with an occlusive dressing would accelerate the healing of wounds with exposed bones, as measured by planimetry. RESULTS: GFP-labelled bone marrow cells contained multipotent stem cells that sufficiently differentiated into wound myofibroblasts presenting with alpha-smooth muscle actin in granulation tissue. Other types of cells, including myocytes, adipocytes, peripheral blood cells from buffy coat and dermal fibroblasts, did not express myofibroblast characteristics morphologically or immunohistochemically. Application of bone marrow cells and an occlusive dressing accelerated the repair of wounds with exposed bones, compared with an occlusive dressing only or with the topical administration of bone marrow cells plus a semidry to dry dressing. CONCLUSIONS: Our study indicates that bone marrow cells accelerate the healing of wounds at least in part through their differentiation into wound myofibroblasts. Thus, treatment of wounds with bone marrow cells and a supportive occlusive dressing is effective in promoting the formation of healthy granulation tissue and also for the preparation of an ideal wound bed.     

A novel sustained-release matrix based on biodegradable poly(ester amide)s and impregnated with bacteriophages and an antibiotic shows promise in management of infected venous stasis ulcers and other poorly healing wounds

Healing of poorly vascularized and venous stasis ulcers is often refractory to therapy, particularly when they are infected. Systemic antibiotic therapy may be of little benefit in this setting because of poor penetration of the antibiotic into the wound and the frequent associated emergence of bacterial strains resistant to common antimicrobial agents. Given the clinical significance of these problems, there is a need to explore alternative management approaches for these difficult-to-treat wounds. PhagoBioDerm is a novel wound-healing preparation consisting of a biodegradable polymer impregnated with an antibiotic and lytic bacteriophages, which was recently licensed for sale in the Republic of Georgia (one of the former Soviet Union republics). In 1999-2000, in Tbilisi, Georgia, 107 patients who had ulcers that had failed to respond to conventional therapy were treated with PhagoBioDerm alone or in combination with other interventions. The wounds/ulcers healed completely in 67 (70%) of 96 patients for whom follow-up data were available. In 22 cases in which microbiologic data were available, healing was associated with the concomitant elimination of, or a reduction in, specific pathogenic bacteria in the ulcers. Our findings suggest that this slow-release biopolymer is safe and of possible benefit in the management of refractory wounds, and they support the apparent utility of bacteriophages in this setting. Further studies, including carefully designed clinical trials, will be required to rigorously evaluate the efficacy of this novel wound dressing preparation.     

不同术式对子宫肌瘤患者性心理及性功能影响的临床对比研究

目的:探讨不同术式对子宫肌瘤患者性心理及性功能的影响。方法:选取2011年6月至2014年6月于我院住院经手术治疗的125例子宫肌瘤患者,依据不同手术方式分为三组,A组为子宫全切保留双侧附件的患者52例,B组为接受子宫全切加双侧子宫附件切除术的患者37例,C组为接受子宫肌瘤剥除术的患者36例。分别于术前以及术后6个月通过女性性功能评价量表对患者的性心理以及性功能进行评价,同时检测患者外周血中性激素的水平。通过统计学分析予以比较。结果:子宫全切术保留双侧附件的患者术后性心理评分较术前低,同时性激素中的卵泡刺激素以及促黄体生成素较术前升高,雌激素较术前降低,差异具有统计学意义(P<0.05);子宫全切术并切除双侧附件的患者术后性心理评分、性欲评分、性高潮评分以及射精时间评分较术前低,异常症状较术前升高,同时性激素中的卵泡刺激素以及促黄体生成素较术前升高,雌激素较术前降低,差异具有统计学意义(P<0.05);接受子宫肌瘤剥除术的患者性心理、性功能以及性激素水平较术前均无明显变化(P>0.05),结论:不同手术方式对子宫肌瘤患者性心理、性功能以及内分泌功能具有不同程度的影响,其中子宫全切加双侧子宫附件切除术对患者三方面的影响最为严重,子宫肌瘤剥除术对患者的影响最轻,子宫全切保留双侧附件的影响居中。     

A postal survey of patients with nickel and chromate dermatitis

A postal survey was made of 75 patients with nickel and chromate dermatitis who had been discharged from the clinic; 69% of patients replied to the questionnaire and in 81% of these the dermatitis was still active. In many patients (48%) this was causing significant disability long after initial presentation to the clinic (average of 56.5 months). All patients had patch tests performed and the relevance of this is discussed with reference to nickel dermatitis.     

A study on the management of hidradenitis suppurativa with retinoids and surgical excision

Background:

Hidradenitis suppurativa is a chronic skin condition involving the apocrine glandular zones. Affected patients may present with acute abscesses, but the condition often progresses to a chronic state with persistent pain, sepsis, sinus tract, fistula formation, purulent discharge, and dermal scarring. The treatment of patients with severe disease can be difficult and may require complex surgical intervention.

Materials and Methods:

For this study, we selected 30 patients from the outpatient department. The patients were divided into two groups of 15 patients each. In patients of group I, oral acitretin 0.5 mg/kg body weight was given alone. Oral acitretin was given for a period of 12 weeks, and follow-up of the patients was done every 4 weeks for a period of 6 months. In patients of group II, oral acitretin 0.5 mg/kg was given plus a wide surgical excision was done.

Results and Discussion:

In our study, the commonest site of involvement of hidradenitis suppurativa was axilla in 83.3% patients, perineum was involved in 13.3% patients, and periumbilical involvement was seen in 3.3% patients. The commonest clinical feature was nodules seen in 90% patients; pain was seen in 60% patients, dermal scarring in 73.3% patients, malodorous discharge in 33.3% patients, abscess in 30% patients, and fistulous tracts were seen in 20% patients. The recurrence rate was low (20%) in group II patients in whom oral acitretin was given plus surgical excision was done as compared with group I (40%) in whom oral acitretin was given alone.