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International Wound Journal, Volume 17, Issue 1, Page 235-235, February 2020.

An integrated experimental‐computational study of the microclimate under dressings applied to intact weight‐bearing skin


Pressure ulcers (PUs) are one of the most prevalent adverse events in acute and chronic care. The root aetiological cause of PUs is sustained cell and tissue deformations, which triggers a synergistic tissue damage cascade that accelerates over relatively short time periods. Changes in skin microclimate conditions are known to indirectly contribute to PU‐risk levels or to exacerbation of existing wounds. It is therefore surprising that information concerning heat accumulation under dressings is poor. Here, we aimed to investigate the effects of dressings on the microclimate of weight‐bearing buttocks skin in 1‐hour supine lying sessions. Using a novel and originally developed experimental‐computational approach, we compared the combined influence of the mechanical and thermal properties of a polymeric membrane dressing (PolyMem, Ferris Mfg. Corp., Fort Worth, TX) on skin microclimate under and near the dressings with those of a standard placebo foam dressing. We specifically identified the thermal conductivity properties of dressings as being highly important in the context of protective dressing performances, given its association with potential heat accumulation under dressings. Accordingly, this article highlights, for the first time in the literature, the relevance of thermal properties of a dressing in effectively mitigating the risk of developing PUs or aggravating an injury, and offers a systematic, methodological bioengineering process for assessing the thermal performances of dressings.

Human Amniotic Membrane: A New Option for Graft Donor Sites – Systematic Review and Meta‐analysis


There are currently no standardised guidelines on the optimum dressing used for graft donor sites. The aim was to compare the outcomes of human amniotic membrane (HAM) vs routine dressings in split‐thickness skin graft (STSG) donor site healing. A systematic review and meta‐analysis was performed and a search of electronic information was conducted to identify all randomised controlled trials comparing the outcomes of HAM vs routine dressings in STSG donor sites. Wound healing and infection rate were primary outcome measures. Secondary outcome measures included severity of pain, discharge from donor site, the number of dressing changes, pruritus, and comfort. Fixed effect modelling was used for the analysis. Four studies enrolling 157 patients were identified. There was a significant difference between HAM and routine groups with wound healing time (P < .0001) and proportion of wounds healed by day 12 (P = .01). There was no significant difference between the two groups in infection rates (P = .27). For all secondary outcomes, HAM had improved results. HAM dressings are a superior option when compared with routine dressings used in current clinical practice for STSG donor sites as they improve wound healing and do not increase the infection rate.

Biological dermal templates with native collagen scaffolds provide guiding ridges for invading cells and may promote structured dermal wound healing


Dermal substitutes are of major importance in treating full thickness skin defects. They come in a variety of materials manufactured into various forms, such as films, hydrocolloids, hydrogels, sponges, membranes, and electrospun micro‐ and nanofibers. Bioactive dermal substitutes act in wound healing either by delivery of bioactive compounds or by being constructed from materials having endogenous activity. The healing success rate is highly determined by cellular and physiological processes at the host‐biomaterial interface during crucial wound healing steps. Hence, it is important to design appropriate wound treatment strategies with the ability to work actively with tissues and cells to enhance healing. Therefore, in this study, we investigated biological dermal templates and their potential to stimulate natural cell adherence, guidance, and morphology. The most pronounced effect was observed in biomaterials with the highest content of native collagen networks. Cell attachment and proliferation were significantly enhanced on native collagen scaffolds. Cell morphology was more asymmetrical on such scaffolds, resembling native in vivo structures. Importantly, considerably lower expression of myofibroblast phenotype was observed on native collagen scaffolds. Our data suggest that this treatment strategy might be beneficial for the wound environment, with the potential to promote improved tissue regeneration and reduce abnormal scar formation.

Comparative analysis on the effect of Z‐plasty versus conventional simple excision for the treatment of sacrococcygeal pilonidal sinus: A retrospective randomised clinical study


Sacrococcygeal pilonidal sinus is one of common diseases in general department. However, it is characterised, for surgeons, by high post‐surgical recurrence and high incidence of post‐surgical wound complications. Due to that fact, this retrospective randomised clinical study was designed to evaluate the surgical procedure effect of Z‐plasty (ZP), compared with convention simple excision (SE). A total of 67 patients from May 2015 to May 2019 in our department were studied into two groups randomly, the group of ZP and the group of SE. The patients' characteristics, surgical data, hospital length of stay (LOS), and post‐surgery complications were recorded. Statistical approaches were proceed with P‐value analysis. The results are as follows. No significant differences were found between these two groups of the ages, gender distribution, Body Mass Index (BMI), smoking history, diabetes mellitus, and blood hypertension. The estimated blood loss, specimen volume, distance to anus, and drain output on the first day of post‐surgery between the two groups were not statistically significant, either. However, surgical time in the ZP group was longer than that in the SE group (P < .0001). LOS in the ZP group was obviously shorter than that in the SE group (P = .0051). Furthermore, the patients of the ZP group were tending to suffer from fewer post‐surgical complications than the ones of the SE group. In a conclusion, we hold the point view that the surgical procedure of ZP can lead a better outcome than SE because it demonstrated shortened LOS and fewer post‐surgical complications.


International Wound Journal, Volume 17, Issue 1, Page 236-236, February 2020.

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 and of 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.

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


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

Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: A multicentre prospective cohort study


Pressure ulcers lead to discomfort for patients and may have an important impact on a patient's quality of life. Measure the incidence and prevalence of pressure ulcers in a Hospice environment; evaluate the risk factors associated with pressure ulcers; and calculate the incidence of Kennedy Terminal Pressure Ulcers. This multicentre prospective cohort study enrolled 440 cancer patients in advanced phase, consecutively admitted to five hospices of the AUSL della Romagna (Italy), during a period of 1 year. Five hundred more patients were excluded from the study because of inability to sign the consent form or refusal to participate. All patients were adults above 18 years of age. The National Pressure Advisory Panel Classification System was used to evaluate the pressure ulcers. Potential risk predictors were evaluated through the Braden Scale, the Numerical Scale, and the Pain Assessment in Advanced Dementia Scale. Starting in September 2016, 214 (48.6%) females and 226 (51.4%) males were analysed. The incidence of pressure ulcers in the total population was 17.3%. The risk factors that influence the development of pressure ulcers were age, proximity to death, and duration of stay in Hospice. The incidence of Kennedy Terminal Pressure Ulcers was 2.7%. This study demonstrates that 17.3% of all patients admitted to a hospice setting developed a pressure ulcer. The longer the patients stay in hospice and the clinical condition deteriorates, the higher the risk of developing a pressure ulcer.

Issue Information

International Wound Journal, Volume 17, Issue 1, Page 1-4, February 2020.

Use of home negative pressure wound therapy in peripheral artery disease and diabetic limb salvage


Use of negative pressure wound therapy (NPWT) in peripheral artery disease (PAD) and diabetic limb salvage (DLS) improves wound healing by providing moist wound conditions, reducing exudate, controlling wound‐bed infection, and stimulating granulation. NPWT duration may take several weeks, and home‐based NPWT allows patient to recover in the community while minimising risks of prolonged hospitalisation. The aim of this study is to review the use and outcomes of home NPWT in PAD and DLS. The methodology is the retrospective review of patients who were discharged with home NPWT after in‐patient PAD revascularisation and DLS debridement or minor amputations. The results included a total of 118 patients who received home NPWT between January 2017 and December 2017. The mean age was 62.8 years with 66% male and 34% female patients. The study population comprised 25% smokers, 98% patients with diabetics, 35% with ischemic heart disease, and 21% with end‐stage renal failure (ESRF). Of which, 56% of patients required revascularisation while 31% of patients underwent foot debridement, 48% underwent toe amputations, and 20% underwent forefoot amputations. All patients received in‐patient NPWT for a week before being discharged on home NPWT for 4 weeks. Then, 62% received targeted antibiotics regime while 36% received empirical antibiotics on discharge; 60% of patients achieved wound healing on home NPWT, with 9% requiring split‐thickness skin graft; 4% required further surgical debridement, 16% required further minor amputation while 20% required major amputation. 9% required further home NPWT extension, with a mean length of 7.1 ± 4.7 weeks' extension. Overall survival of 1 year was 89%. Risk factors that predict the failure of home NPWT includes subjects with a background of ESRF and wet gangrene on presentation. Home NPWT is a useful adjunct in the management of PAD and DLS foot wounds.

A novel measurement instrument for pressure‐injury risk assessment competence: Theoretical procedures, simulation, and psychometric quality


This study developed a measuring instrument of pressure‐injury risk assessment competence for nursing education adopting theoretical procedures based on competence structuration to support the psychometric quality. The objective of this study is testing the psychometric properties of the instrument using simulation strategy and to determine the instrument's standardisation and normalisation. A methodological study was designed. The instrument was developed by a content‐validated theoretical construct administered to 155 undergraduate nursing students from universities in the northeast and south of Brazil using simulation. The instrument was applied over three phases: before the lecture on pressure‐injury risk assessment competence, after scenario of simulation experience, and after debriefing experience. The instrument comprised 32 items. The factorial analysis found that three domains explained 64.6% and 62.18% of the total variance in post‐scenario and debriefing cases. The perfect and very high discrimination index of the instrument indicated minimal differences in measured latent trait levels. It also found that reliability was excellent (0.973 and 0.967). Moreover, an equation applicable to instruments using study's theoretical procedure was proposed. The instrument was found to be a valid, accurate, and reliable educational tool for pressure‐injury risk assessment competence.

Is wound photography becoming sloppy?

International Wound Journal, Volume 17, Issue 1, Page 5-6, February 2020.

How patient migration in bed affects the sacral soft tissue loading and thereby the risk for a hospital‐acquired pressure injury


Head‐of‐bed (HOB) elevation is a common clinical practice in hospitals causing the patient's body to slide down in bed because of gravity. This migration effect likely results in tissue shearing between the sacrum and the support surface, which increases the risk for pressure injuries. StayInPlace (HillRom Inc.) is a commercial migration‐reduction technology (MRT) incorporated in intensive care bedframes. Yet, the effects of migration‐reduction on tissue shear stresses during HOB elevation are unknown. We analysed relationships between migration and resulting sacral soft tissue stresses by combining motion analysis and three‐dimensional finite element modelling of the buttocks. Migration data were collected for 10 subjects, lying supine on two bedframe types with and without MRT, and at HOB elevations of 45°/65°. Migration data were used as displacement boundary conditions for the modelling to calculate tissue stress exposures. Migration values for the conventional bed were 1.75‐ and 1.6‐times greater than those for the migration‐reduction bed, for elevations of 45° and 65°, respectively (P < .001). The modelling showed that the farther the migration, the greater the tissue stress exposures. Internal stresses were 1.8‐fold greater than respective skin stresses. Our results, based on the novel integrated experimental‐computational method, point to clear biomechanical benefits in minimising migration using MRT.

Preparation of placental tissue transplants and their application in skin wound healing and chosen skin bullous diseases ‐ Stevens‐Johnson syndrome and toxic epidermal necrolysis treatment


Unique properties of amniotic membrane make it a promising source for tissue engineering and a clinically useful alternative for patients suffering from chronic wounds including, for example, ulcers, burns, ocular surface damages and wounds occurring in the course of bullous diseases like stevens‐johnson syndrome and toxic epidermal necrolysis. Its use has many advantages over standard wound care, as it contains pluripotent cells, nutrients, anti‐fibrotic and anti‐inflammatory cytokines, growth factors and extracellular matrix (ECM) proteins. Placental tissues can be prepared as a medical component, an advanced therapy medicinal product or a tissue graft. In addition to basic preparation procedures such as washing, rinsing, cutting, drying and sterilisation, there are many optional steps such as perforation, crosslinking and decellularisation. Finally, transplants should be properly stored—in cryopreserved or dehydrated form. In recent years, many studies including basic science and clinical trials have proven the potential to expand the use of amniotic membrane and amnion‐derived cells to the fields of orthopaedics, dentistry, surgery, urology, vascular tissue engineering and even oncology. In this review, we discuss the role of placental tissues in skin wound healing and in the treatment of various diseases, with particular emphasis on bullous diseases. We also describe some patented procedures for placental tissue grafts preparation.

Pressure injury data in Australian acute care settings: A comparison of three data sets


Hospital‐acquired pressure injuries (HAPIs) represent a serious clinical and economic problem. The cost of treating HAPIs in Australian public hospitals was recently reported at AUS$983 million per annum. There are three main sources of data for documenting pressure injury (PI) occurrence in Australian hospitals: incident reporting, medical record coded data, and real‐time surveys of pressure injury. PI data reported at hospital level and to external agencies using these three different sources are variable. This reporting issue leads to inaccurate data interpretation and hinders improvement in accuracy of PI identification and PI prevention. This study involved a comparison of the three different data sources in selected Australian hospitals, to improve the accuracy and comparability of data. Findings from this study provide benchmark areas for improvement in PI documenting and reporting. Better understanding the agreement between the three data sets could lead to a more efficient and effective sharing of data sources.

Multiple subcutaneous haematomas of the legs causing skin necrosis in an elderly patient affected by corticosteroid‐induced skin atrophy: Case report and review of literature


Corticosteroid‐induced skin atrophy (CISA) consists of a thinning of the skin and subcutaneous tissues, representing the natural consequence of a prolonged glucocorticosteroids use, both systemic as well as topical. It is characterised by the loss of elasticity and skin thickness, associated with an increased skin fragility leading to ecchymoses, haematomas, and steroid purpura. The management of CISA is a challenge for physicians, as the pathology is reversible in a minimal percentage of cases and only after a short topical steroid or low‐dose course therapy. Often wounds with large loss of substance represent the more common complication, after a surgical drainage which is often necessary. Skin necrosis with compartment syndrome of a leg is another potential risk for these patients. Here, we report a case of an elderly patient affected by multiple subcutaneous haematomas of the legs causing skin necrosis, arisen after the use of anticoagulants for a deep venous thrombosis. The patient was successfully treated with surgical drainage, negative pressure wound therapy (NPWT), and porcine xenograft with no complications. Finally, we discuss the evidence of the current literature on topic.

News and views

International Wound Journal, Volume 17, Issue 1, Page 7-9, February 2020.

¿Qué conocen las enfermeras de Galicia sobre las voluntades anticipadas?

Miriam Vázquez-Campo, Eva Tizón-Bouza, Alba-Elena Martínez-Santos, Lucía Vilanova-Trillo
Enferm Clin. 2020;30:16-22

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