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AnteayerInternational Wound Journal

Prophylactic incisional negative pressure wound therapy for gynaecologic malignancies


Wound complications are an important cause of postoperative morbidity among patients with gynaecologic malignancies. We evaluated whether the placement of closed-incisional negative pressure therapy (ciNPT) at the time of laparotomy for gynaecologic cancer surgery reduced wound complication rates. A retrospective cohort study with primary wound closure performed by a gynaecologic oncologist was carried out. We evaluated two cohorts of patients who underwent surgery in 2017 with standard closure and patients who underwent surgery in 2019 with the placement of prophylactic ciNPT. Postoperative outcomes were examined. A total of 143 patients were included, 85 (59.4%) vs 58 (40.6%) with standard closure and ciNPT, respectively. The total complication rate in our sample was 38.71%. The rate of surgical complications in patients treated with ciNPT was 6.9% compared with 31.8% (P = .000) in patients treated with standard closure. In the analysis of complications, a significant reduction in infections (17.1%), seromas (15.4%), and wound dehiscence (17.1%) were observed when ciNPT was applied. The median hospital stay was 8 vs 6 days in the standard closure vs ciNPT groups (P = .048). The use of the prophylactic ciNPT following a laparotomy may decrease wound complications and hospital stays in oncological patients. ciNPT could be considered as part of clinical practice in patients at high risk of wound complications, such as patients with gynaecological malignancies.

The influence of a biofilm‐dispersing wound gel on the wound healing process


Topical antimicrobials that reduce the bacterial bioburden within a chronically-infected wound may have helpful or harmful effects on the healing process. We used murine models of full-thickness skin wounds to determine the effects of the novel biofilm-dispersing wound gel (BDWG) and its gel base on the healing of uninfected wounds. The rate of wound closure over 19 days was comparable among the BDWG-treated (BT) wounds and the controls. Compared with the controls, histology of the BT wounds showed formation of a stable blood clot at day 1, more neovascularisation and reepithelialisation at day 3, and more organised healing at day 7. Fluorescence-activated cell sorting analysis showed a lower percentage of neutrophils in wounded tissues of the BT group at days 1 and 3, and significantly more M2 macrophages at day 3. Levels of proinflammatory cytokines and chemokines were increased over the uninjured baseline within the wounds of all treatment groups but the levels were significantly lower in the BT group at day 1, modulating the inflammatory response. Our results suggest that BDWG does not interfere with the wound healing process and may enhance it by lowering inflammation and allowing transition to the proliferative stage of wound healing by day 3.

Wounds in chronic leg oedema


Wounds and chronic oedema are common disorders, but rarely studied together. The objective of this cross-sectional study was to investigate the point-prevalence and risk factors of wounds on the leg, in chronic leg oedema. Forty sites in nine countries were included. Of 7077 patients with chronic leg oedema, 12.70% had wounds. Independent risk factors were: peripheral arterial disease (odds ratio (OR) 4.87, 95% confidence intervals (CI) 3.63-6.52), cellulitis within the past 12 months (OR 2.69, 95% CI 2.25-3.21), secondary lymphoedema (OR 2.64, 95% CI 1.93-3.60), being male (OR 2.08, 95% CI 1.78-2.44), being over 85 years of age (OR 1.80, 95% CI 1.23-2.62), underweight (OR 1.79, 95% CI 1.14-2.79), bed bound (OR 1.79, 95% CI 1.01-3.16), chair bound (OR 1.52, 95% CI 1.18-1.97), diabetes (OR 1.47, 95% CI 1.23-1.77), and walking with aid (OR 1·41, 95% CI 1.17-1.69). 43.22% of those with wounds had clinically defined well-controlled oedema, associated with a significantly lower risk of wounds (OR 0.50, 95% CI 0.42-0.58, P < .001). Hard/fibrotic tissue (OR 1.71, 95% CI 1.19-2.48), and a positive Stemmers sign (OR 1.57, 95% CI 1.05-2.35) were associated with wounds. The study reinforces the importance of measures to control oedema, as controlled swelling was associated with a 50% lower risk of wounds.

Effectiveness of the Lapidus plate system in foot surgery: A PRISMA compliant systematic review


Lapidus arthrodesis is an established standard procedure to correct various foot surgery problems and hallux limitus, hypermobility of the first ray, hallux abductus valgus, and symptomatic lesser metatarsal. After decades, many fixation methods in the orthopaedic surgery industry have been developed for decreasing complications and improving this technique. The aim of this PRISMA compliant systematic review is to analyse the effectiveness of several lapidus plate systems in foot surgery. We have carried out the first systematic review of the relevant published literature so as to systematically evaluate the scientific knowledge available now on this association, assigning predefined eligibility criteria. Fourteen studies were selected which had an overall of 738 cases. The first tarsal metatarsal joint and hallux valgus were treated by the application of different types of Lapidus plate system. The optimal level of the fixation in these procedures is related with the type and system insertion place of the plate with or without screw in each specific foot disease. There is an insufficient number of studies about the effectiveness of the different types of Lapidus plate system in foot surgery, and there is a need to increase outcomes knowledge on the level of the fixation, sort of the system, and insert place in foot surgery.


International Wound Journal, Volume 18, Issue 4, Page 556-556, August 2021.

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International Wound Journal, Volume 18, Issue 4, Page 420-421, August 2021.

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International Wound Journal, Volume 18, Issue 4, Page 413-415, August 2021.

What makes a hydrogel‐based dressing advantageous for the prevention of medical device‐related pressure ulcers


The synergistic influences of geometrical, mechanical and thermal mismatches between a skin-contacting medical device and the skin may cause tissue stress concentrations and sharp temperature gradients, both of which contribute to the risk for medical device-related pressure ulcers. In this work, we developed an innovative, integrated experimental bioengineering approach encompassing mechanical stiffness, friction and thermal property studies for testing the biomechanical suitability of a hydrogel-based dressing in prophylaxis of injuries caused by devices. We characterised the viscoelastic stress relaxation of the dressing and determined its long-term elastic modulus. We further measured the coefficient of friction of the hydrogel-based dressing at dressing-device and skin-dressing interfaces, using a tilting-table tribometer. Lastly, we measured the thermal conductivity of the dressing, using a heat-flow meter and infrared thermography-based method. All measurements considered dry and moist conditions, the latter simulating skin perspiration effects. Our results revealed that the long-term stiffness and the thermal conductivity of the hydrogel-based dressing matched the corresponding properties of human skin for both dry and moist conditions. The dressing further demonstrated a relatively high coefficient of friction at its skin-facing and device-facing aspects, indicating minimal frictional sliding. All these properties make the above dressing advantageous for prevention of device-related injuries.

Impact of dermal matrix thickness on split‐thickness skin graft survival and wound contraction in a single‐stage procedure


Optimal treatment of full-thickness skin injuries requires dermal and epidermal replacement. To spare donor dermis, dermal substitutes can be used ahead of split-thickness skin graft (STSG) application. However, this two-stage procedure requires an additional general anaesthetic, often prolongs hospitalisation, and increases outpatient services. Although a few case series have described successful single-stage reconstructions, with application of both STSG and dermal substitute at the index operation, we have little understanding of how the physical characteristics of dermal substitutes affects the success of a single-stage procedure. Here, we evaluated several dermal substitutes to optimise single-stage skin replacement in a preclinical porcine model. A porcine full-thickness excisional wound model was used to evaluate the following dermal substitutes: autologous dermal graft (ADG; thicknesses 0.15-0.60 mm), Integra (0.4-0.8 mm), Alloderm (0.9-1.6 mm), and chitosan-based hydrogel (0.1-0.2 mm). After excision, each wound was treated with either a dermal substitute followed by STSG or STSG alone (control). Endpoints included graft take at postoperative days (PODs) 7 and 14, wound closure at POD 28, and wound contracture from POD 28-120. Graft take was highest in the STSG alone and hydrogel groups at POD 14 (86.9% ± 19.5% and 81.3% ± 12.3%, respectively; P < .001). There were no differences in graft take at POD 7 or in wound closure at POD 28, though highest rates of wound closure were seen in the STSG alone and hydrogel groups (93.6% ± 9.1% and 99.8% ± 0.5%, respectively). ADG-treated wounds demonstrated the least amount of wound contracture at each time point. Increase dermal substitute thickness was associated with worse percent graft take at PODs 14 and 28 (Spearman ρ of −0.50 and −0.45, respectively; P < .001). In this preclinical single-stage skin reconstruction model, thinner ADG and hydrogel dermal substitutes outperformed thicker dermal substitutes. Both substitute thickness and composition affect treatment success. Further preclinical and clinical studies to optimise this treatment modality are warranted.

Improving hand hygiene in a low‐resource setting: A nurse‐led quality improvement project


Hand hygiene is a simple but often ignored practice in health care systems worldwide, but it is integral for nosocomial infection prevention, with many hospital-acquired infections being linked to inadequate hand hygiene practice. At the burns unit in Kamuzu Central Hospital, 50% of patients were found to have acquired pseudomonas infections: one of the contributing factors being inadequate hand hygiene. This quality improvement project was part of a course for nurses to introduce change for patient benefit, with the aim of increasing the baseline figures for hand hygiene practices and hand hygiene facilities from 37% and 22%, respectively (baseline collected in November 2019). Using robust, standard quality improvement processes, measures were put in place such as checklists to observe hand hygiene compliance and facilities, appointment of a hand hygiene committee who monitored and sustained activities of the project, procurement and distribution of handrub and placement of hand-washing buckets and soap at strategic points. The project saw an increase in availability of hand-washing facilities to 95.6% and hand hygiene practices increase to >80% within 6 months. The project demonstrates that low cost interventions, led by nurses, can make a real difference to practice in resource poor countries.

A bioreactor for studying negative pressure wound therapy on skin grafts


Negative pressure wound therapy (NPWT) has become the prevailing standard of care for treating complex soft tissue wounds and is now being considered for use in alternative applications including improving skin graft take. While it is generally agreed that negative pressure leads to improved wound healing, universal consensus on its optimal application is not supported in the literature. We describe the design and validation of a bioreactor to determine the prospective benefits of NPWT on skin grafts and engineered skin substitutes (ESS). Clinically relevant pressures were applied, and the native human skin was able to withstand greater negative pressures than the engineered substitutes. Both skin types were cultured under static, flow-only, and −75 mm Hg conditions for 3 days. While it remained intact, there was damage to the epidermal-dermal junction in the ESS after application of negative pressure. The normal skin remained viable under all culture conditions. The engineered skin underwent apoptosis in the flow-only group; however, the application of negative pressure reduced apoptosis. Vascular endothelial growth factor levels were significantly higher in the normal flow-only group, 152.0 ± 75.1 pg/mg protein, than the other culture conditions, 81.6 ± 35.5 pg/mg for the static and 103.6 ± pg/mg for the negative pressure conditions. The engineered skin had a similar trend but the differences were not significant. This bioreactor design can be used to evaluate the impacts of NPWT on the anatomy and physiology of skin to improve outcomes in wounds after grafting with normal or engineered skin.

Pressure injury prevalence and risk factors in Chinese adult intensive care units: A multi‐centre prospective point prevalence study


Despite increasing preventive efforts, pressure injury still occurs in intensive care patients. This study was aimed to describe pressure injury prevalence, risk factors, and prevention practices in adult intensive care patients. This was a multi-centre, one-day, prospective point prevalence study in which a total of 198 intensive care units from 21 provinces in China participated. Overall and ICU-acquired prevalence in intensive care patients were 12.26% and 4.31%, respectively. Consistent with earlier reports, almost half of the ICU-acquired pressure injuries were at stage I, one-fourth were at stage 2, and the most common body sites for pressure injuries were sacral and heel region. Risk factors identified were consistent with prior studies. Repositioning was the most commonly used pressure injury prevention strategy, followed by alternating pressure mattresses/overlays, floating heels, and air-filled mattresses/overlays. These reflect a good level of adherence to recommended international pressure injury prevention clinical practice guidelines. The results provide a baseline reference for overall and ICU-acquired prevalence among adult intensive care patients in China. Future research on what contributed to the lower pressure injury incidence in China needs to be conducted to inform healthcare organisations on their future preventive strategies for pressure injury prevention.

A novel atmospheric‐pressure air plasma jet for wound healing


Current low-temperature plasma (LTP) devices essentially use a rare gas source with a short working distance (8 to 20 mm), low gas flow rate (0.12 to 0.3 m3/h), and small effective treatment area (1-5 cm2), limiting the applications for which LTP can be utilised in clinical therapy. In the present study, a novel type of LTP equipment was developed, having the advantages of a free gas source (surrounding air), long working distance (8 cm), high gas flow rate (10 m3/h), large effective treatment area (20 cm2), and producing an abundance of active substances (NOγ, OH, N2, and O), effectively addressing the shortcomings of current LTP devices. Furthermore, it has been verified that the novel LTP device displays therapeutic efficacy in terms of acceleration of wound healing in normal and Type I diabetic rats, with enhanced wound kinetics, rate of condensation of wound area, and recovery ratio. Cellular and molecular analysis indicated that LTP treatment significantly reduced inflammation and enhanced re-epithelialization, fibroblast proliferation, deposition of collagen, neovascularization, and expression of TGF-β, superoxide dismutase, glutathione peroxidase, and catalase in Type I diabetic rats. In conclusion, the novel LTP device provides a convenient and efficient tool for the treatment of clinical wounds.

Diabetic foot ulcer, the effect of resource‐poor environments on healing time and direct cost: A cohort study during Syrian crisis


Diabetic foot ulcer (DFU) is one of the slowest healing wounds that hurt the human body. Many studies from developed countries are concerned about materials, procedures, and equipment that accelerate the healing time. In Sweden, the diabetic foot management costs around 24965$/patient. In this review, we would evaluate the healing time of DFUs during what is considered one of the worst humanitarian crisis of the 21st century. 1747 DFUs were studied from the main diabetic foot clinic in Damascus (2014-2019). We predicted many variables that could prolong the healing time. The cost according to these variables was also reported. The SINBAD Classification was performed to grade the severity of ulcers. We noticed that the median healing time for DFUs was 8 weeks. Almost half of these ulcers healed between 3 and 12 weeks. The time of healing for men was significantly longer than that for women. While the presence of infection doubled the median time of healing, the presence of peripheral artery disease doubled the mean of the direct health care cost. The location of the ulcer acted as another independent risk factor. In conclusion, DFUs face many barriers to heal during a crisis.The environment with resource-poor settings should be added to the traditional risk factors that delay the healing of DFUs for months or even years. More studies from disaster are as are needed to evaluate low-cost materials that could be cost effective in applying standard care of the diabetic foot.

Knowledge and practice of diabetic foot care and the prevalence of diabetic foot ulcers among diabetic patients of selected hospitals in the Volta Region, Ghana


Diabetic foot ulcers (DFUs) are a common but serious complication of diabetes mellitus (DM). The factors distressing the worth of diabetic foot care (DFC) are knowledge and practice. Foot ulcers are the main cause of amputation and death in people suffering from DM. This study assessed the knowledge and practice of DFC and the prevalence of DFUs and its associated factors among diabetic patients of selected hospitals in the Volta Region, Ghana. A multihospital-based cross-sectional study was conducted among 473 patients with DM who were recruited using the systematic sampling method. Data were collected using a validated, pretested, and structured questionnaire, while medical variables were obtained from patient folders and analysed using SPSS version 23. All statistically significant parameters in bivariate analysis were incorporated in the multivariate logistic regression analysis. The results showed that 63% of diabetic patients had good knowledge of DFC, while 49% competently practiced it. A negative correlation was found between knowledge and practice levels of DFC (r = −0.15, P = <.01). The prevalence of DFUs was 8.7% among the studied diabetic patients. Male diabetic patients were 3.4 times more likely to develop DFUs than female diabetic patients (crude odd ratio [cOR] = 3.35; 95% confidence interval [CI] = 1.75-6.43; P = <.001). Type 1 diabetic patients were five times more likely to develop DFUs than those who had type 2 diabetes (cOR = 5.00; 95% CI = 2.50-10.00; P = <.001). Diabetic patients who had a family history of diabetes were 4.7 times more likely to develop DFUs than those without family history (adjusted odd ratio [aOR] = 4.66; 95% CI = 1.55-13.89; P = .006). Those who had diabetes for 5 to 10 years were 3.3 times more likely to develop DFUs than those who had diabetes for less than 5 years (aOR = 3.28; 95% CI = 1.40-7.67; P = .006). Diabetic patients who had comorbidity were 3.4 times more likely to develop DFUs than those without comorbidity (cOR = 3.35; 95% CI = 1.74-6.45; P = <.001). The study found that there was good knowledge but poor practices of DFC among patients. Health care providers are expected to better educate patients and emphasise self-care practices to patients. Health care providers should also give more attention to patients with associated risk factors to avoid further complications and reduce the occurrence of DFUs.

Oncologic feasibility for negative pressure wound therapy application in surgical wounds: A meta‐analysis


Negative pressure wound therapy (NPWT) decreases postoperative complications of various surgeries. However, the use of NPWT for oncological surgical wounds remains controversial. To evaluate the association of NPWT with oncologic recurrence in surgical wounds without residual malignancy, we analysed studies that compared NPWT with conventional non-pressure dressings for cancer surgical wounds without residual tumour by August 12, 2020. We compared tumour recurrence rates and postoperative complications between the two procedures. The six studies included 118 patients who received NPWT, and 149 patients who received conventional non-pressure wound care. The overall quality of the included studies was high based on the Newcastle–Ottawa scale score of 7.5. Tumour recurrence after NPWT was not significantly different compared with conventional non-negative pressure wound care (9.3% versus 11.4%, P = 0.40). There was no significant heterogeneity between the studies (I2 = 3%). Although NTWT was associated with a lower complication rate compared with the control group, the result was non-significant (P = 0.15). Application of NPWT in oncologic resection wounds without residual malignancy revealed no difference in local recurrence and may reduce the risk of postoperative complications compared with conventional non-negative pressure dressings. NPWT can be considered an alternative method for reconstruction in challenging cases.

Histological analysis of fat grafting with platelet‐rich plasma for diabetic foot ulcers—A randomised controlled trial


Diabetic foot ulcers are often unresponsive to conventional therapy and are a leading cause of amputation. Animal studies have shown stem cells and growth factors can accelerate wound healing. Adipose-derived stem cells are found in fat grafts and mixing them with platelet-rich plasma (PRP) may improve graft survival. This study aimed to establish the histological changes when diabetic foot ulcers are treated with fat grafts and PRP. A three-armed RCT was undertaken of 18 diabetic foot ulcer patients: fat grafting; fat grafting with PRP; and routine podiatry care. Biopsies were obtained at week 0, 1, and 4, and underwent quantitative histology/immunohistochemistry (H&E, CD31, and Ki67). Treatment with fat and PRP increased mean microvessel density at 1 week to 1645 (SD 96) microvessels/mm2 (+32%-45% to other arms, P = .035). PRP appeared to increase vascularity surrounding fat grafts, and histology suggested PRP may enhance fat graft survival. There was no clinical difference between arms. This study demonstrates PRP with fat grafts increased neovascularisation and graft survival in diabetic foot ulcers. The histology was not, however, correlated with wound healing time. Future studies should consider using apoptosis markers and fluorescent labelling to ascertain if enhanced fat graft survival is due to proliferation or reduced apoptosis. Trial registration NCT03085550.

Wound healing with “spray‐on” autologous skin grafting (ReCell) compared with standard care in patients with large diabetes‐related foot wounds: an open‐label randomised controlled trial


There is an urgent need for interventions that improve healing time, prevent amputations and recurrent ulceration in patients with diabetes-related foot wounds. In this randomised, open-label trial, participants were randomised to receive an application of non-cultured autologous skin cells (“spray-on” skin; ReCell) or standard care interventions for large (>6 cm2), adequately vascularised wounds. The primary outcome was complete healing at 6 months, determined by assessors blinded to the intervention. Forty-nine eligible foot wounds in 45 participants were randomised. An evaluable primary outcome was available for all wounds. The median (interquartile range) wound area at baseline was 11.4 (8.8-17.6) cm2. A total of 32 (65.3%) index wounds were completely healed at 6 months, including 16 of 24 (66.7%) in the spray-on skin group and 16 of 25 (64.0%) in the standard care group (unadjusted OR [95% CI]: 1.13 (0.35-3.65), P = .845). Lower body mass index (P = .002) and non-plantar wounds (P = .009) were the only patient- or wound-related factors associated with complete healing at 6 months. Spray-on skin resulted in high rates of complete healing at 6 months in patients with large diabetes-related foot wounds, but was not significantly better than standard care (Australian New Zealand Clinical Trials Registry: ACTRN12618000511235).

Fluid management and strength postsimulated use of primary and secondary dressings for treating diabetic foot ulcers: Robotic phantom studies


Non-offloaded diabetic heel ulcers and the wound dressings used to treat them may be subjected to considerable bodyweight forces. A novel robotic foot phantom with a diabetic heel ulcer was designed and constructed to test the combined performances of applied primary and secondary dressings, in simulated non-offloaded (standing) and offloaded (supine) postures. We specifically compared the performances of the primary Exufiber dressing (Mölnlycke Health Care) combined with the secondary Mepilex Border Flex dressing (Mölnlycke) against a corresponding pair from an alternative manufacturer. Fluid retention and distribution between the primary and secondary dressings of each pair were determined using weight tests, and mechanical strength of the primary dressings was further measured postsimulated use through tensile testing. The Exufiber and Mepilex Border Flex pair performed similarly in the two simulated postures (retention = ~97%), whereas the comparator pair exhibited a 13%-decrease in retention for a supine to standing transition. Furthermore, the Exufiber dressing delivered up to 2-times more fluid to its paired secondary dressing and endured 1.7-times greater strain energy than the corresponding primary dressing before failure occurred. The present robotic foot phantom and associated methods are versatile and suitable for testing any dressing, in consideration of the relevant clinical factors and practice.