Long‐term follow‐up comparison of two different bi‐layer dermal substitutes in tissue regeneration: Clinical outcomes and histological findings

Double layer dermal substitute (DS) consist of a 3‐dimensional collagen structures and a superficial silicon layer that are positioned within the defect provide to promote tissue regeneration in skin wounds. DS often have unique physical characteristics due to differences in manufacturing techniques. The aim of this study is the clinical and histological comparison of Nevelia and Integra double layer DSs in patients with post‐traumatic injury wounds. Thirty patients with post‐traumatic wounds localised on the inferior limbs were randomised in 2 groups Nevelia or Integra, followed by autologous dermal epidermal graft (DEG). Clinical results were evaluated through the healing time; Manchester Scar Scale (MSS) and Visual Analog Scale (VAS) at 1, 2, and 3 weeks and after 1 and 3 years. Histological and immunohistochemical evaluation were performed at 0, 2, and 3 weeks. The difference in healing time between groups (P = .467, log‐rank test), pain and self‐estimation was not statistically significant after 35, 42, and 49 days and at 1‐year follow up. Histological data showed evident healing of wound after 2 weeks compared with preoperative with both DSs. At 3 weeks reepithelialisation and dermal regeneration were evident with both substitutes; however Nevelia showed early regenerative properties in terms of epidermal proliferation and dermal renewal compared with Integra. Nevelia showed also a more evident angiogenesis vs Integra evaluated as α‐SMA immunohistochemistry. Differences in the MSS score were statistically significant at 3 years follow up in favour of Nevelia group (P = .001). At long‐term follow up, Nevelia showed a better clinical outcome measured as MSS score vs Integra measured as MSS. Histological and immunohistochemistry data showed that Nevelia allows faster neoangiogenesis and tissue regeneration with neoformed tissue architecture closer to the physiology of the skin.     

Exploring the prevalence and management of wounds for people with dementia in long‐term care

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long‐term care (LTC). A scoping literature review, a cross‐sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence‐based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia‐specific facilities and a lack of research in this area limits evidence in guiding practice.     

Impact of negative‐pressure wound therapy on bacterial behaviour and bioburden in a contaminated full‐thickness wound

The use of negative‐pressure wound therapy (NPWT) has displayed significant clinical benefits in the healing of infected wounds. However, the effects of NPWT on bacterial colonisation and infection of traumatic wounds has been controversial. The aim of this study is to evaluate the impact of NPWT treatment in rabbits with a contaminated full‐thickness wound on bacterial behaviour, including colony morphology, spatial distribution, fissional proliferation, and bacterial bioburden. Full‐thickness wounds were created on the back of rabbits, and were inoculated with bioluminescent Staphylococcus aureus. The wounds were treated with sterile gauze dressings and NPWT with continuous negative pressure (−125 mm Hg). Wound samples were harvested on days 0 (6 hours after bacterial inoculation), 2, 4, 6, and 8 at the centre of wound beds before irrigation. Scanning electron microscopy and transmission electron microscopy (TEM) analyses were performed to determine the characteristic bacteriology. Laser scanning confocal microscopy was performed to obtain bioluminescent images, which were used to observe spatial distribution of the GFP‐labelled S. aureus within the tissue and quantify the bacterial bioburden. NPWT resulted in sparse amounts of scattered bacteria on the wound surface or as sparsely spaced single colonies within the tissue. Wound bioburden on day 8 in the NPWT and gauze groups was 34.6 ± 5.5% and 141.9 ± 15.4% of the baseline values (N = 6), respectively (P < .0001). TEM showed a lack of S. aureus active fission within NPWT‐treated tissue. NPWT can impact S. aureus colony morphology and spatial distribution both on the surface and within wound tissue, and reduce S. aureus as early as 48 hours after therapy initiation. Additionally, NPWT inhibits bacterial fissional proliferation in microcolonies.     

Clinical outcome and microvascular blood flow in VAC®‐ and Sorbalgon®‐treated peri‐vascular infected wounds in the groin after vascular surgery – an early interim analysis

Vacuum‐assisted wound closure (VAC®) therapy is considered to be superior to conventional dressings in the treatment of peri‐vascular groin infections after vascular surgery at our department. Therefore, we performed an early interim analysis of the clinical outcomes in these seriously ill patients at risk of amputation and death. Patients were randomised to either VAC® (n = 5) or Sorbalgon® (n = 5; best alternative treatment) therapy after surgical debridement. Non‐invasive, laser Doppler perfusion imaging (LDPI) studies of the skin adjacent to the undressed wound were performed after 14 days of wound treatment. There was no difference in LDPI values in VAC® versus Sorbalgon® treated patients (P = 0·46). One patient in the VAC® group suffered from two re‐bleeding episodes, leading to vascular resection and transfemoral amputation and in the Sorbalgon® group two had a complete wound healing time of more than 4 months and one had a visible interposition bypass graft in the groin after 1 month of treatment. No patient died of the groin infection. Although not statistically proven, fewer wound treatment failures were recorded in the VAC® group, justifying this early interim analysis. LDPI studies were feasible.     

The use of povidone‐iodine and sugar solution in surgical wound dehiscence in the head and neck following radio‐chemotherapy

Povidone‐iodine is known for successfully treating surgical wounds; the combination between povidone‐iodine and sugar, also called Knutson's formula, has been proposed to improve wound healing. Currently, no studies have investigated the effects of Knutson's formula to treat defects in wound closure following radio‐chemotherapy in the head and neck region. The aim of this study is to evaluate the efficacy of Knutson's formula in improving the wound‐healing process in patients who underwent radio‐chemotherapy after surgery for head and neck cancer. The study, conducted from August 2013 to January 2017, included a sample of 34 patients (25 males and 9 females; age range: 60‐75 years) treated with radio‐chemotherapy after head and neck cancer surgery. All patients suffered from defect of wound regeneration. Patients were randomly divided into two groups: patients in the study group (n = 18) were treated with Knutson's formula; patients in the control group (n = 16) were treated with traditional topical drugs. In the study group, 16 of 18 (88.9%) patients reached complete wound closure 1 month after treatment, with no wound infections. In the control group, only three patients (18.7%) showed complete wound closure within a month; in addition, one patient required systemic antibiotic treatment because of supra‐bacterial infection of the wound. In our sample, the combination of povidone‐iodine and sugar had a higher success rate compared with traditional topical treatment in the treatment of wound defect closure in oncological patients who underwent radio‐chemotherapy.     

Wound management: Investigating the interprofessional decision‐making process

Our aim is to develop a robust socio‐geographical transferable theory outlining the basic social process used by members of an interprofessional health care team when making decisions around wound care management. Using a qualitative multigrounded theory approach, three focus groups were held at the Royal Victoria Regional Health Centre in Barrie, Ontario, Canada, comprised of 13 clinicians who participate in wound care decision‐making. Data were analysed using an approach developed for multigrounded theory. A Critical Realist theoretical lens was applied to data analysis in the development of conclusions. Ten categories were identified before thematic saturation. Category interactions developed a perceived basic social process outlining how interprofessional clinicians determine how they approach wound care decisions: patient factors, scope of practice, equipment and supplies, internal clinician factors, knowledge and education, interprofessional team, assessment, wound care specialist consultation, and care plan, as well as documentation and communication. Understanding how wound care decision‐making is determined by interprofessional health care providers will assist clinical leaders and policy makers in creating a foundation for determining resource allocation, allowing clinicians to use evidence‐based practice to improve patient and clinician satisfaction, wound healing time, decrease costs, and prevent wound recurrence.     

Effects and safety of atmospheric low‐temperature plasma on bacterial reduction in chronic wounds and wound size reduction: A systematic review and meta‐analysis

The use of atmospheric low‐temperature plasma (AP) on chronic wounds and its effect on microbial bioburden in open wounds has not been explored with a systematic review and meta‐analysis. PRISMA guidelines were followed and PubMed, Embase, CENTRAL, and CINAHL databases searched for randomised controlled trials (RCTs), which compared AP with no AP for the management of open, chronic wounds. The primary outcomes of reduction of bioburden or wound size were included. Meta‐analyses were performed; odds ratio (OR) and 95% confidence intervals (CIs) were extracted and pooled in a random effects model. Four RCTs investigated the effect of AP on chronic wound healing. Chronic wounds treated with AP did not show a significant improvement in healing (AP vs control: OR = 1.46; 95% CI = 0.89‐2.38; P = 0.13). Five further RCTs investigated the reduction of bioburden in wounds, but AP demonstrated no significant reduction of bioburden (AP vs control: OR = 0.85; 95% CI = 0.45‐1.62; P = 0.63). All nine RCTs recorded the presence of any severe adverse events (SAEs) in the 268 patients studied, with only one unrelated SAE identified in each group (AP vs control: OR = 1.00; 95% CI = 0.05‐19.96; P = 1.00). Use of AP in wound care is safe, but the retrieved evidence and meta‐analysis show that there is no clinical benefit of AP in chronic open wounds using currently available AP device settings.     

Topical cannabis‐based medicines – A novel paradigm and treatment for non‐uremic calciphylaxis leg ulcers: An open label trial

Non‐Uremic Calciphylaxis (NUC) is a rare condition that often manifests as intractable and painful integumentary wounds, afflicting patients with a high burden of co‐morbidity. The Endocannabinoid System (ECS) is a ubiquitous signalling system that is theorised to be dysregulated within wound beds and associated peri‐wound tissues. Preclinical research has shown that the dominant chemical classes derived from the cannabis plant, cannabinoids, terpenes, and flavonoids, interact with the integumentary ECS to promote wound closure and analgesia. This is a prospective open label cohort study involving two elderly Caucasian females with recalcitrant NUC leg ulcers of greater than 6 months duration. Topical Cannabis‐Based Medicines (TCBM) composed of cannabinoids, terpenes, and flavonoids were applied daily to both the wound bed and peri‐wound tissues until complete wound closure was achieved. Wounds were photographed regularly, and the digital images were subjected to planimetric analysis to objectively quantify the degree of granulation and epithelization. Analgesic utilisation, as a surrogate/proxy for pain scores, was also tracked. The cohort had a mean M3 multimorbidity index score of 3.31. Complete wound closure was achieved in a mean of 76.3 days. Additionally, no analgesics were required after a mean of 63 days. The treatments were well tolerated with no adverse reactions. The positive results demonstrated in very challenging wounds such as NUC, among highly complex patients, suggest that TCBM may have an even broader role within integumentary and wound management. This treatment paradigm warrants being trialled in other wound types and classes, and ultimately should be subjected to randomised controlled trials.     

Functional characterisation of bioactive peptide derived from terrestrial snail Cryptozona bistrialis and its wound‐healing property in normal and diabetic‐induced Wistar albino rats

A peptide might be an exciting biomaterial or template for the development of novel wound‐healing agents. In this report, it was isolated from the terrestrial snail Cryptozona bistrialis by enzymatic digestion and was evaluated for its in vitro wound‐healing activity in NIH/3T3 mouse fibroblasts cell line and in vivo wound‐healing activity in normal and diabetic‐induced Wistar albino rats. The C. bistrialis protein was digested by the papain enzyme, and 21.79 kDa peptide (Cb‐peptide) was purified by reversed‐phase high‐performance liquid chromatography and identified by MALDI (matrix‐assisted laser desorption/ionization)‐TOF analysis. The isolated Cb‐peptide was characterised by various analytical methods. The peptide demonstrated a capacity to prevent the development of pathogenic bacterial and fungal cultures and proved that it promotes significant wound‐healing activity in the wound scratch assay method by rapid cell migration and closure of wound. Isolated Cb‐peptide was lyophilised and formulated to ointment and analysed for in vivo wound‐healing activity in normal and diabetic (alloxan monohydrate)‐induced Wistar albino rats. Cb‐peptide ointment‐treated groups showed a greater degree of wound healing and early and complete period of epithelialisation in normal and diabetic‐induced Wistar albino rats. Cb‐peptide ointment‐treated groups showed significant excision and incision wound‐healing activity. A conclusion was reached that the peptide isolated from C. bistrialis showed greater wound‐healing activity compared with vehicle control and standard control.     

A prospective pilot study of thigh‐administered intermittent pneumatic compression in the management of hard‐to‐heal lower limb venous and mixed aetiology ulcers

This was a prospective observational pilot study of a unique intermittent pneumatic compression (IPC) device designed to be applied in the thigh region of the affected limb in patients with lower limb ulceration of both venous and mixed (venous and arterial) aetiologies. This compression system consists of a circumferential three‐chamber thigh garment and an electronic pneumatic compression pump operating over a repeated 4‐minute cycle. Patients were recruited from outpatient wound clinics. Those recruited were treated with standard therapy in addition to IPC, which was applied for 2 hours per day, and followed up for a total of 8 weeks. The primary objective of the study was to examine the effects of IPC on wound healing over an 8‐week period. The other objectives were to assess patients’ experiences of pain and the acceptability of IPC device. Twenty‐one patients were recruited, and wounds progressed towards healing in 95.24% (20/21) of the patients. Pain scores decreased in 83.33% (15/18) of the patients. Most patients felt that the thigh‐applied IPC device was comfortable and easy to apply and remove. The thigh‐administered IPC device can be recommended for use in routine clinical practice, especially when other treatment options are limited.     

Wound‐healing effect of adipose stem cell‐derived extracellular matrix sheet on full‐thickness skin defect rat model: Histological and immunohistochemical study

The potential use of extracellular matrix (ECM) as a source of wound dressing material has recently received much attention. The ECM is an intricate network of various combinations of elastin, collagens, laminin, fibronectin, and proteoglycans that play a key role in stimulating cell proliferation and differentiation. We evaluated the efficacy of an ECM sheet derived from human adipose tissue as a wound dressing material to enhance healing. We prepared a novel porous ECM sheet dressing scaffold from human adipose tissue. in vitro analysis of the ECM sheets showed efficient decellularisation; absence of immunostimulatory components; and the presence of a wide number of angiogenic and bioactive factors, including collagen, elastin, and proteoglycans. To evaluate in vivo efficacy, full‐thickness excisional wounds were created on the dorsal skin of a rat, and the ECM sheets; secondary healing foam wound dressing, Healoderm; or a conventional dressing were applied to each wound site. Photographs were taken every other day, and the degree of reepithelialisation of the wounds was determined. Application of an ECM sheet dressing enhanced the macroscopic wound‐healing rate on days 4, 7, and 10 compared with that in the control group. Microscopic analysis indicated that the reepithelialisation rate of the wound was higher in the ECM group compared with that in the control group; the reepithelialisation rate was better than that of the secondary healing foam wound dressing. Moreover, a denser and more organised granulation tissue was formed in the ECM sheet group compared with that in the secondary healing foam wound dressing and control groups. The ECM sheet also showed the highest microvessel density compared with the secondary healing foam wound dressing and control groups. Based on these data, we suggest that a bioactive ECM sheet dressing derived from human adipose can provide therapeutic proteins for wound healing.     

A randomised,controlled, non‐inferiority trial comparing the performance of a soft silicone‐coated wound contact layer (Mepitel One) with a lipidocolloid wound contact layer (UrgoTul) in the treatment of acute wounds

Wound contact layer (WCL) dressings are intended to protect tissue during the healing process. A randomised controlled trial was undertaken to compare 2 such dressings. Outpatients with acute wounds were randomly allocated to treatment with either a soft silicone‐coated WCL (intervention group, n = 59) or a lipidocolloid‐impregnated WCL (control group, n = 62). At the first dressing removal (day 3), 89.8% of patients in the intervention group experienced non‐painful dressing removal (defined as a pain rating <30 mm on a 100 mm visual analogue scale), compared with 73.6% of patients in the control group (P = .017) (per protocol population). At day 21, wounds were considered as healed in 66.1% of patients in the intervention group compared with 43.5% in the control group (P = .012) (intention‐to‐treat population). Both dressings were well tolerated and rated highly in terms of in‐use characteristics, although the soft silicone‐coated WCL was rated significantly higher than the lipidocolloid‐impregnated WCL in terms of its ability to remain in place (P= .016). The results indicate that the soft silicone‐coated WCL is suitable for the management of acute wounds as it can minimise dressing‐associated pain and support healing.     

Infection in neuro‐muscular scoliosis deformity correction

Assess the outcome of a standardised protocol for the treatment of post‐operative wound infection in patients undergoing deformity correction for neuro‐muscular scoliosis (NMS). Retrospective review of 443 consecutive patients with a minimum 18 months’ follow‐up, following a primary posterior deformity correction for NMS. In patients who developed a wound complication, the patient demographic and comorbidities, causative pathogen, number of re‐operations, length of stay (LOS), rate of cure, and complications were analysed. Forty‐four patients (9.9%) developed a wound infection. Marginally more infections were mono‐microbial (23) than poly‐microbial (21). Coagulase negative staphylococcus and Staphylococcus aureus were the most commonly cultured pathogens. Seventeen patients were treated with antibiotics alone, while 27 patients also required surgical debridement. The average LOS for those treated with antibiotics alone was 12 days (range: 9‐15 days), in contrast to those requiring debridement, which was 35 days (range: 35‐70 days). All patients were cured from their infection and ultimately achieved fusion. Infection is common in NMS deformity correction. This is marginally more common as a mono‐microbial than poly‐microbial infection with most pathogens being staphylococcal in origin. Our defined treatment strategy resulted in a cure for all patients and capacity for all patients to achieve fusion.     

In vitro cellular viability studies on a concentrated surfactant‐based wound dressing

In this study, three cellular cytotoxic assays (direct contact assay, extraction assay, and cell insert assay) were applied to evaluate the effects of a concentrated surfactant gel preserved with antimicrobials and a concentrated surfactant gel with 1% silver sulfadiazine on both the mouse fibroblast cell line L929 and human dermal fibroblasts (HDFa). Also, the in vitro wound model was wounded by a 100 μL pipette tip and used to assess cell migration and wound closure after treatment with both gels. A needle‐scratched membrane disruption model was used to preliminarily evaluate membrane stabilisation and the membrane‐resealing effects of concentrated surfactant gels. It was demonstrated that the concentrated surfactant gel preserved with antimicrobials was not toxic to both L929 and HDFa. However, the concentrated surfactant gel with 1% silver sulfadiazine demonstrated a degree of cytotoxicity to both cell types. After treatment with a concentrated surfactant gel preserved with antimicrobials, cell movement to close the scratch gap was enhanced at 24 and 48 hours. The results also showed that cells treated with the concentrated surfactant gel preserved with antimicrobials decreased cell necrosis and improved cell resistance of the f‐actin rearrangement after a needle scratch. The results demonstrated that a concentrated surfactant gel preserved with antimicrobials is non‐cytotoxic and has ability to accelerate wound closure by enhancing cell mobility. Furthermore, the concentrated surfactant gel appeared to stabilise the plasma membrane and demonstrated a resealing ability and helped to retain the plasma membrane integrity and enhanced wound healing.     

Evaluation of an ultra‐lightweight,single‐patient‐use negative pressure wound therapy system over dermal regeneration template and skin grafts

As the use of negative pressure wound therapy (NPWT) over skin grafts has increased, traditional methods of NPWT system reimbursement and application are increasingly being challenged. A simplified method of accessing and operating NPWT in the outpatient setting is needed, particularly in cases where immediate outpatient use of NPWT is optimal. We evaluated use of a new ultra‐lightweight, off‐the‐shelf, disposable, single‐patient‐use NPWT system (SP‐NPWT; V.A.C.Via? Therapy, KCI USA, Inc., San Antonio, TX) over dermal regeneration template (DRT) and/or skin grafts. SP‐NPWT was initiated over a DRT and/or skin graft in 33 patients with 41 graft procedures. Endpoints were recorded and compared to a historical control group of 25 patients with 28 grafts bolstered with traditional rental NPWT (V.A.C.® Therapy, KCI USA, Inc.). Average length of inpatient hospital stay was 0·0 days for the SP‐NPWT group and 6·0 days for the control group (P < 0·0001). The average duration of SP‐NPWT post‐DRT or skin graft was 5·6 days for the SP‐NPWT group and 7·0 days for the control (P < 0·0001). Preliminary data suggest that, compared to traditional NPWT, off‐the‐shelf SP‐NPWT may provide a quicker, seamless transition to home, resulting in decreased hospital stay and potential cost savings.     

Towards algorithm‐enabled home wound monitoring with smartphone photography: A hue‐saturation‐value colour space thresholding technique for wound content tracking

Automated tracking of wound‐healing progress using images from smartphones can be useful and convenient for the patient to perform at home. To evaluate the feasibility, 119 images were taken with an iPhone smartphone during the treatment of a chronic wound at one patient's home. An image analysis algorithm was developed to quantitatively classify wound content as an index of wound healing. The core of the algorithm involves transforming the colour image into hue‐saturation‐value colour space, after which a threshold can be reliably applied to produce segmentation using the Black‐Yellow‐Red wound model. Morphological transforms are used to refine the classification. This method was found to be accurate and robust with respect to lighting conditions for smartphone‐captured photos. The wound composition percentage showed a different trend from the wound area measurements, suggesting its role as a complementary metric. Overall, smartphone photography and automated image analysis is a promising cost‐effective way of monitoring patients. While the current setup limits our capability of measuring wound area, future smartphones equipped with depth‐sensing technology will enable accurate volumetric evaluation in addition to composition analysis.