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AnteayerInternational Wound Journal

Potential cost‐effectiveness of using adjunctive dehydrated human amnion/chorion membrane allograft in the management of non‐healing diabetic foot ulcers in the United Kingdom


The aim of this study was to estimate the cost‐effectiveness of using dehydrated human amnion/chorion membrane (dHACM) allografts (Epifix) as an adjunct to standard care, compared with standard care alone, to manage non‐healing diabetic foot ulcers (DFUs) in secondary care in the United Kingdom, from the perspective of the National Health Service (NHS). A Markov model was constructed to simulate the management of diabetic lower extremity ulcers over a period of 1 year. The model was used to estimate the cost‐effectiveness of using adjunctive dHACM, compared with standard care alone, to treat non‐healing DFUs in the United Kingdom, in terms of the incremental cost per quality‐adjusted life year (QALY) gained at 2019/2020 prices. The study estimated that at 12 months after the start of treatment, use of adjunctive dHACM instead of standard care alone is expected to lead to a 90% increase in the probability of healing, a 34% reduction in the probability of wound infection, a 57% reduction in the probability of wound recurrence, a 6% increase in the probability of avoiding an amputation, and 8% improvement in the number of QALYs. Additionally, if £4062 is spent on dHACM allografts per ulcer, then adjunctive use of dHACM instead of standard care alone is expected to lead to an incremental cost per QALY gain of £20 000. However, if the amount spent on dHACM allografts was ≤£3250 per ulcer, the 12‐month cost of managing an ulcer treated with adjunctive dHACM would break‐even with that of DFUs treated with standard care, and it would have a 0.95 probability of being cost‐effective at the £20 000 per QALY threshold. In conclusion, within the study's limitations, and within a certain price range, adjunctive dHACM allografts afford the NHS a cost‐effective intervention for the treatment of non‐healing DFUs within secondary care among adult patients with type 1 or 2 diabetes mellitus in the United Kingdom.

Pyridoxamine ameliorates methylglyoxal‐induced macrophage dysfunction to facilitate tissue repair in diabetic wounds


Methylglyoxal (MGO) is a highly reactive dicarbonyl compound formed during hyperglycaemia. MGO combines with proteins to form advanced glycation end products (AGEs), leading to cellular dysfunction and organ damage. In type 2 diabetes mellitus (T2DM), the higher the plasma MGO concentration, the higher the lower extremity amputation rate. Here, we aimed to identify the mechanisms of MGO‐induced dysfunction. We observed that the accumulation of MGO‐derived AGEs in human diabetic wounds increased, whereas the expression of glyoxalase 1 (GLO1), a key metabolic enzyme of MGO, decreased. We show for the first time that topical application of pyridoxamine (PM), a natural vitamin B6 analogue, reduced the accumulation of MGO‐derived AGEs in the wound tissue of type‐2 diabetic mice, promoted the influx of macrophages in the early stage of tissue repair, improved the dysfunctional inflammatory response, and accelerated wound healing. In vitro, MGO damaged the phagocytic functions of M1‐like macrophages induced by lipopolysaccharide (LPS), but not those of M0‐like macrophages induced by PMA or of M2‐like macrophages induced by interleukins 4 (IL‐4) and 13 (IL‐13); the impaired phagocytosis of M1‐like macrophages was rescued by PM administration. These findings suggest that the increase in MGO metabolism in vivo might contribute to macrophage dysfunction, thereby affecting wound healing. Our results indicate that PM may be a novel therapeutic approach for treating diabetic wounds. MGO forms protein adducts that cause macrophage dysfunction. These adducts cause cell and organ dysfunction that is common in diabetes. Pyridoxamine scavenges MGO to ameliorate this dysfunction, promoting wound healing. Pyridoxamine could be used therapeutically to treat non‐healing diabetic wounds.

Effect of vacuum sealing drainage on healing time and inflammation‐related indicators in patients with soft tissue wounds

Por: Xin Xue · Na Li · Liqing Ren


The aim of this study was to investigate the therapeutic effects of vacuum sealing drainage (VSD) on wound repair time and inflammation‐related indicators in patients with soft‐tissue wounds in comparison with traditional treatment. From January 2018 to January 2020, 130 enrolled patients with soft‐tissue wounds were randomly divided into two groups: VSD group (65 cases) and routine dressing change (RDC) group (65 cases). The inflammation‐related indicators including erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), white blood cell (WBC), and procalcitonin (PCT) of preoperative stage and postoperative day 3 (POD 3) and POD 7 were recorded. Wound healing was observed 3 and 7 days after treatment, and the clinical efficacy, changes in the wound (coverage rate and thickness of granulation tissue and bacterial clearance rate), wound‐cleaning time, wound‐healing time, and hospital stay time were recorded after treatment as well. No significant difference was observed in terms of the baseline between the two groups. On POD 3 and POD 7, CRP, WBC, and PCT levels in the VSD group were lower than those in the RDC group, while ESR levels were higher, with significant differences (P < .05). After treatment, the wound‐cleaning time, wound‐healing time, and hospital length of stay of the VSD group were all lower than those of the RDC group, with significant differences (P < .05). VSD has a significant effect on the treatment of patients with soft‐tissue wounds, which can effectively shorten the time of wound healing and reduce inflammation‐related indicators. Compared with traditional RDC, VSD is more worthy of clinical application.

Experience with negative‐pressure wound therapy with instillation in complex infected orthopaedic wounds


Chronic exudative wounds are frequently seen in hospitalised patients, consuming hospital resources and leading to increased morbidity. Negative‐pressure therapy (NPWT) with topical instillation “NPWTi” may be used to improve the wound healing process, with the unique features (removal of wound exudate, edema reduction, promotion of tissue perfusion and granulation tissue formation, as well as drawing the edges of the wound to facilitate, in addition to the cyclic cleansing mechanism). This report is a descriptive study of our experience with NPWTi on complex infected orthopaedic wounds as a potential method to decrease the need for multiple surgical debridements required for the closure of such wounds. A prospective observational study was conducted. Twenty patients with complex infected orthopaedic wounds were enrolled in our study. These patients were consulted by the Bone and Joint Infection Service and enrolled to receive NPWTi intraoperatively and to be used during their inpatient stay. Twenty patients with 20 complex infected lower limb wounds were included in our study. Of all the 20 wounds, the etiology was post‐surgical in 80% (n = 16) and post‐traumatic in 20% (n = 4). None of the patients received previous treatment with conventional NPWT before participation in the study. There were 11 males (55%) and 9 females (45%) with an average age of 57 years (22‐83). All wounds were located in the lower limbs, with 25% leg (n = 5), 20% thigh (n = 4), 20% knee (n = 4), 20% foot (n = 4), 10% heel (n = 2), and 5% ankle (n = 1). The average length of treatment with NPWTi was 5.2 days (2‐10). Successful wound closure within 6 weeks was achieved in 65% of the cases (n = 13). Of the closed wounds (n = 13), 54% (n = 7) were closed primarily and 46% (n = 6) were closed by secondary procedures (skin graft or skin flap). NPWTi is still considered a novel technique that can be used in the management of complex wounds, and the goal of this prospective study is to report our experience with NPWTi in the management of complex infected orthopaedic lower limb wounds. Randomised control studies with optimally matched wounds comparing NPWTi to the conventional methods of treatment are warranted.

A new silver dressing, StopBac, used in the prevention of surgical site infections


Ideal dressings of surgical wounds should provide moist, semi‐permeable, and antiseptic environments for optimal wound healing. To maximise patient comfort, surgical dressings must be hypoallergenic, not restrict movement, and allow patients to manage their personal hygiene. From the aspect of health care personnel, dressings should enable visual monitoring of the wound without the need for removing them, thus reducing the number of dressing changes. The active antimicrobial effect of silver cations has been demonstrated by many studies. StopBac is a unique surgical dressing based on the sol‐gel process. Silver cations are bound in a colloidal solution in an organic‐inorganic hybrid organosilicate oligomer. This gel is deposited on a pad using spray atomisation. The result is a polymer nanolayer matrix with prolonged and controlled release of silver ions. This pad forms part of a waterproof hypoallergenic transparent adhesive bandage. The goal of this study was to prospectively evaluate the ability of StopBac to prevent surgical site infections (SSIs) in patients after abdominal surgery. The secondary goal was to compare costs and determine the properties of this new material. A total of 32 patients were included in the study. The patients were followed up until their surgical wounds healed completely. An SSI occurred only in one patient.

Issue Information

International Wound Journal, Volume 18, Issue 2, Page 125-127, April 2021.

News and Views

International Wound Journal, Volume 18, Issue 2, Page 131-133, April 2021.


International Wound Journal, Volume 18, Issue 2, Page 242-242, April 2021.

Technological impact of COVID‐19

International Wound Journal, Volume 18, Issue 2, Page 129-130, April 2021.

The role of near‐infrared fluorescence imaging with indocyanine green dye in pedicle division with the paramedian forehead flap


The paramedian forehead flap is considered the gold standard for nasal reconstruction following oncologic surgery. During the 21‐day delay in two‐stage surgery protocols, many patients report considerably reduced quality of life because of the pedicle. This prospective case series study examined the usefulness of near‐infrared (NIR) fluorescence with indocyanine green (ICG) for flap perfusion assessment and identified variables associated with time to flap perfusion. Ten patients (mean age 75.3 ± 11.6 years) with diagnosis of basal cell carcinoma (n = 9) or squamous cell carcinoma (n = 1) underwent intravenous indocyanine injection and NIR fluorescence imaging for assessment of flap vascularisation 2 to 3 weeks after stage 1 surgery. NIR fluorescence imaging showed 90% to 100% perfusion areas in all patients after 14 to 21 days. Early pedicle division occurred in two patients on postoperative days 14 and 16. One minor complication (wound healing disorder) was seen following flap takedown after 14 days. There were no associations between time to flap perfusion and defect size or flap area. NIR fluorescence imaging with ICG dye is a useful method for non‐invasive perfusion assessment when used in conjunction with clinical assessment criteria. However, a decision for early pedicle division may raise risk of complications in specific patient groups and must therefore be made with great care.

Efficacy of Versajet hydrosurgery system in chronic wounds: A systematic review


Studies demonstrating the effectiveness of hydrosurgery for chronic wounds are extremely limited. This systematic review aimed to evaluate the efficacy of hydrosurgery compared with conventional debridement in chronic wounds, skin ulcers, and non‐acute wounds. This PROSPERO‐registered review was performed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. A systematic search was performed in PubMed, Scopus, and Cochrane Library databases. Abstracts of all studies were screened independently by two reviewers. The bias of prospective randomised controlled studies was assessed using the Cochrane Collaboration's tool for assessing the risk of bias and RevMan 5.4 software, whereas the bias of retrospective comparative studies was evaluated using the Risk of Bias Assessment Tool for Non‐randomised Studies. Two prospective randomised controlled trials, two retrospective comparative studies, and three prospective non‐comparative studies were included. Hydrosurgery enabled rapid debridement. The Versajet Hydrosurgery System saved 8.87 minutes compared with the conventional methods. Similarly, the debridement quality was high with this system. The debridement number needed to achieve adequate wound beds was fewer in the hydrosurgery group than in the conventional group. These superiorities lead to subsequent success and cost‐effectiveness. As there were only two prospective randomised controlled studies, and much information was missing, the risk of bias was unclear. This review confirmed that hydrosurgery is useful for the debridement of chronic wounds, considering the procedural speed and quality.

Investigation of the status and influence factors of caregiver's quality of life on caring for patients with chronic wound during COVID‐19 epidemic


The objectives of this study were to investigate the status and influence factors of caregiver's quality of life (QOL) on caring for patients with chronic wound during COVID‐19 epidemic. A prospective cross‐sectional study of 83 informal caregivers was included. The characteristics of informal caregivers as well as their QOL assessment by the Family Dermatology Life Quality Index (FDLQI) were measured, respectively. Single‐factor analysis and multiple regression analysis were carried out to explore the independent influence factors of QOL of caregiver on caring for patient with chronic wound. 62.65% of the caregivers were female with a mean age of (54.24 ± 12.6) years, and 34.9% of the caregivers were parents. The mean FDLQI score was 13.01 ± 7.53 at a high level. The following variables influenced the FDLQI scores of caregivers: self‐care ability of patients, patient's satisfaction of home‐based wound care, and home‐based wound care need of caregivers. The model was able to explain 29.9% of variance in QOL of caregiver (F = 6.561, P = .000, R 2 = 0.299, adjusted R 2 = 0.253). In conclusion, the impact of chronic wound disease on the QOL of caregivers is heavy during COVID‐19 epidemic. Wound professionals are suggested to pay attention to wound care need at home and QOL of caregiver on caring for patients with chronic wound during COVID‐19 epidemic and develop tailored wound health education and support programme in order to improve the QOL of caregivers.

Modified compression therapy in mixed arterial–venous leg ulcers: An integrative review


Leg ulcers remain an increased burden to healthcare cost and morbidity in modern society. While most leg ulcers are venous in origin, recognition and prompt identification of concomitant arterial occlusive disease is critical to determine underlying aetiology and subsequent management. This integrative review presents the current evidence to establish the role of modified compression therapy (MCT) in treatment of mixed arterial venous leg ulcers (MAVLU). A literature search was conducted using the electronic databases CINAHL, MEDLINE, PUBMED, and Embase. Ten studies met the eligibility criteria and were subsequently analysed. Our review concludes that MCT, with compression pressures between 20 and 30 mmHg, can promote healing in MAVLU with moderate arterial insufficiency (0.5 ≤ ABPI ≤0.8). If ABPI is <0.5, MCT can be considered once restoration of acceptable ABPI is achieved. Intolerance, lack of response or further deterioration of disease within 3 months should prompt further arterial imaging and intervention. MCT is generally well tolerated with no adverse outcomes reported. A holistic yet individualised approach is vital in order to account for all factors influencing this patient‐led decision‐making process, ultimately ensuring effective treatment, which improves patient's quality of life and reduces socioeconomic burden of the disease.

Influence of incentive nursing intervention on recovery of burn patients after vacuum sealing drainage


To observe the effect of application of incentive nursing intervention (INI) on recovery in burn patients undergoing vacuum sealing drainage (VSD). From January 2017 to January 2020, a total of 82 consecutive burn patients were prospectively enrolled, and divided into INI group and routine nursing intervention (RNI) group according to random number table method. The causes of inadequate drainage were collected, the incidence was calculated, and the occurrence of inadequate drainage at different locations was compared. The pain degree and comfort status before and after the intervention were observed, and the wound healing time, hospital stay, and satisfaction after the intervention were recorded. The reasons for inadequate drainage during the treatment of VSD included negative pressure insufficient, drainage tube blockage because of escharosis, replacement of negative pressure internal sac not standard, loose sealing of the semi‐permeable membrane, and the negative pressure tube fell off, compressed or reflexed. The baseline characteristics between the two groups were comparable (P > .05). The incidence of each cause and total incidence of inadequate drainage in INI group were lower than those in RNI group (P < .05, respectively). The incidences of inadequate drainage of all burn sites in INI group were lower than those in RNI group, and the difference of limbs wound between the two group was statistically significant (P < .05). After intervention, the pain intensity of INI group was lower than that of RNI group (P < .05), and the holistic comfort of INI group was higher than that of RNI group (P < .05). The wound healing time and hospital stay time in INI group were lower than those in RNI group, and the total satisfaction rate in INI group was higher than that in RNI group (P < .05, respectively). Applying INI can effectively reduce the incidence of insufficient drainage, reduce pain, improve comfort, shorten wound healing time and hospital stay, and thus improve the overall satisfaction rate of patients, which is worthy of clinical promotion and application.

Platelet‐rich plasma for striae distensae: What do we know about processed autologous blood contents for treating skin stretchmarks?—A systematic review


Striae distensae, also known as stretch marks, particularly associated with female sex, pregnancy, obesity, and/or hormonal change, are linear bands of benign dermal lesions. Although not posing any health risk, aesthetically unpleasing stretch marks can cause significant psychological distress among those affected. In abundance of therapeutic approaches, some literature sources proclaim platelet‐rich plasma to be a promising treatment modality for striae distensae. We aimed to shed some light on the current literature evidence of platelet‐rich plasma for treating stretch marks and performed an English literature analysis with two independent reviewers in accordance with PRISMA guidelines searching the PubMed and Web of Science databases in June 2019. Of the 12 found studies, 6 matched inclusion criteria. With no control groups in two, just two other reports used intraindividual comparisons, and all but one publication performed histopathological assessments. All studies observed clinical and subjective improvements without using validated scores or patient‐reported outcome measures (PROMs). The main findings were that multiple treatments with platelet‐rich plasma demonstrated increased epidermal thickness, rete ridges formation, and collagen/elastin formation, while decreasing the inflammatory cell infiltrate. The current literature evidence supporting the use of platelet‐rich plasma for striae distensae is poor. We propose in this review an outline for a study protocol with intraindividual control groups, standardised scores, validated PROMs, and participant incentives to enhance the scientific power in future clinical trials.

The Z‐plasty contributes to the coalescence of a chronic non‐healing wound


This study aimed to explore the treatment effect of Z‐plasty on a non‐healing wound. A total of 72 patients diagnosed with a chronic non‐healing wound in Peking University Third Hospital from November 2009 to August 2019 were retrospectively analysed. Among them, 27 patients were treated with Z‐plasty, and 45 patients were treated with the general method. Detailed patient information was retrieved from medical records, including age, gender, body mass index (BMI), alcohol, smoking, and comorbidities (diabetes mellitus, hypertension, heart disease). Surgical parameters included operation time and intraoperative blood loss. Wound swelling, epidermal blisters, wound edge colour, and skin temperature at 1 day after surgery were assessed to evaluate the blood supply of the wound. Surgical complications included infection, haematoma, dehiscence, and non‐healing within 2 weeks postoperatively. Student t test (for continuous data) and Chi‐square test (for categorical data) were conducted to determine the statistical difference. We found no significant differences in age, gender, BMI, alcohol, smoking, and comorbidities between the two groups. Z‐plasty did not show any advantages in the surgical time, invasive blood loss, hospital days, and hospitalisation expenses. The incidence of abnormal wound edge colour with Z‐plasty was significantly lower than that with the general treatment (P < .05), and the Z‐plasty enables better healing of the patient's wound (P < .05). Z‐plasty promoted better recovery of chronic non‐healing wounds than direct suturing.

Verapamil‐containing silicone gel reduces scar hypertrophy


A hypertrophic scar is a common dermal fibroproliferative lesion usually treated with topical silicone. Verapamil, a type of calcium channel blocker, is considered a candidate drug for the treatment of hypertrophic scars. Here, we report that the addition of verapamil to topical silicone gel enhances treatment outcomes of hypertrophic scars. Upon creation of hypertrophic scars with the rabbit ear model, varying concentrations of verapamil‐added silicone gel (0.1, 1, and 10 mg/g) were applied daily for 28 days. After the animals were euthanised, microscopic measurement was performed for (a) scar elevation index (SEI), (b) fibroblast count, and (c) capillary count. On gross analysis, features of hypertrophic scars were significantly alleviated in the verapamil‐added groups. On histologic examination, verapamil‐added groups showed (a) reduced SEI (1.93 (1.79‐2.67) for control vs 1.34 (1.21‐1.51) for silicone only and 1.13 (1.01‐1.65) for verapamil‐added silicone), (b) fibroblast count 700.5 (599.5‐838.5) for control, 613.25 (461‐762.5) for silicone only, and 347.33 (182.5‐527) for verapamil‐added silicone), and (c) capillary formation (52 (35.5‐96.5) for control, 46 (28‐64.5) for silicone only, and 39.83(24‐70) for verapamil‐added silicone) (Kruskal‐Wallis test, P < .05). On western blot, expression levels of collagen I protein was lower in the 1 mg/g and 10 mg/g verapamil‐added silicone compared with control. Therefore, we suggest a therapeutic concentration of verapamil‐added silicone gel of at least over 1 mg/g. Further study regarding maximally effective concentration and deeper insight into the mechanism of action should follow.

The retention effect of staff education programme: Sustaining a decrease in hospital‐acquired pressure ulcers via culture of care integration


Hospital‐acquired pressure ulcers (HAPUs) negatively affect patients during hospitalisation, putting patients at risk for further complications. HAPUs are one of the hospital quality key performance indicators (KPIs) that necessitate quality initiatives and/or programmes to minimise its occurrence and consequences. When quality initiatives are put into place and proven effective, the next important focus is sustainability of the effects. The original Saudi Arabian study based on data collected from 50 441 patients, showed that implementation of the pressure ulcer prevention programme (PUPP) was successful showing a statistically significant reduction of HAPUs from 0.20% in 2014 to 0.06% in 2018 (P value <.001). The aim of this follow‐up check of the original study was to assess if the PUPP's effectiveness success was retained. Also, to try and determine why the implemented quality improvement programme to prevent HAPUs was so successfully retained. Designed and conducted as a systemic review, it tracked the outcomes of pressure ulcer rates during and post PUPP implementation that mostly focused on evidence‐based staff education, concentrating on years 2016 to 2018. Statistically significant reductions were captured by data that have been presented through Pearson Chi squares. HAPU decline was notable between year 2017 and 2018. This was followed by a further reduction in year 2018. The results determine retention effect sustainability of the initial positive results achieved. By doing so, the study was further able to establish that the PUPP had been integrated into the hospital system's care culture as evidenced by the reduction of HAPUs despite a large inpatient growth. Consideration of what contributing factors led to this successful integration of new knowledge into the care culture are also examined. KPIs can be used as indicators to help reinforce staff education. Culture of care (support of values and interventions taught during the PUPP) offer hope that these may be duplicated in future improvement projects. The supportive nature of a given culture of care may in fact be just as important as the practical education provided to staff members.

Cellular and molecular changes that predispose skin in chronic spinal cord injury to pressure ulcer formation


Patients with spinal cord injury have a predisposition to develop pressure ulcers. Specific characteristics of the patients' skin potentially involved have not yet been identified. The purpose of this investigation was to determine whether loss of neuronal control affects cellular and molecular homeostasis in the skin. Intact afflicted skin, wound edge of pressure ulcers, and control skin were analysed. Platelets, transforming growth factor‐ β 1, and activin A were identified by immunohistochemistry. Transforming growth factor‐ β ‐like activity was determined by bioassay, and gene expression by DNA microarray analysis or RT‐PCR. In afflicted skin, enhanced platelet extravasation was detected. Transforming growth factor‐ β 1 and activin A accumulated in the dermal‐epidermal junction zone. Transforming growth factor‐ β ‐like activity and activin A expression were increased in intact afflicted skin (compared to control skin) and were further enhanced in pressure ulcers. In vitro, activity was generated by fibroblast‐epithelial cell interactions, which also induced activin A. Thus, loss of neuronal control in spinal cord injury appears to trigger inappropriate wound healing processes in the patients' skin. Plasma leakage and increased transforming growth factor‐ β ‐like activity combined with shear forces potentially enhance the risk for pressure ulcer formation.

International study to develop the WOUND‐Q patient‐reported outcome measure for all types of chronic wounds


Patient‐reported outcome measures (PROMs) for chronic wounds mainly focus on specific types of wounds. Our team developed the WOUND‐Q for use with all types of wounds in any anatomic location. We conducted 60 concept elicitation interviews with patients in Canada, Denmark, the Netherlands, and the United States. Analysis identified concepts of interest to patients and scales were formed and refined through cognitive interviews with 20 patients and input from 26 wound care experts. Scales were translated into Danish and Dutch. An international field‐test study collected data from 881 patients (1020 assessments) with chronic wounds. Rasch measurement theory (RMT) analysis was used to refine the scales and examine psychometric properties. RMT analysis supported the reliability and validity of 13 WOUND‐Q scales that measure wound characteristics (assessment, discharge, and smell), health‐related quality of life (life impact, psychological, sleep impact, and social), experience of care (information, home care nurses, medical team, and office staff), and wound treatment (dressing and suction device). The WOUND‐Q can be used to measure outcomes in research and clinical practice from the perspective of patients with any type of wound.