The Future of Wound Care.

The occurrence of chronic wounds is a major global health issue. These wounds are difficult to heal as a result of disordered healing mechanisms. The most common types of chronic wounds are diabetic ulcers, pressure ulcers, arterial/venous ulcers and nonhealing surgical wounds. Although bacteria are an important cause of chronic nonhealing wounds, fungi also play a substantial role in them. The fungal infection rate varies with different chronic wound types, but overall, the prevalence of fungi is extremely underestimated in the clinical treatment and management of chronic wounds. Wounds and ulcers can be colonized by host cutaneous, commensal or environmental fungi and evolve into local infections, causing fungemia as well as invasive fungal disease. Furthermore, the fungi involved in nonhealing wound-related infections help commensal bacteria resist antibiotics and the host immune response, forcing wounds to become reservoirs for multiresistant species, which are considered a potential key factor in the microbial bioburden of wounds and ulcers. Fungi can be recalcitrant to the healing process. Biofilm establishment is the predominant mechanism of fungal resistance or tolerance to antimicrobials in chronic nonhealing wounds. Candida albicans yeast and Trichophyton rubrum filamentous fungi are the main fungi involved in chronic wound infection. Fungal species diversity and drug resistance phenotypes in different chronic nonhealing wound types will be emphasized. In this review, we outline the latest research on fungi in chronic wounds and discuss challenges and future perspectives related to diagnosing and managing chronic wounds.

Introduction: Prevention and management of biofilm in acute and chronic wounds in ICU settings is critical, as biofilm significantly impedes wound healing. Approximately 90% of all wounds are affected by biofilm. It is not feasible to eliminate biofilm using a single wound-cleaning technology. Early intervention and the combined use of multiple technologies for biofilm removal are essential to promote wound healing. Rapid and effective treatment is vital to prevent severe complications such as infections or amputations in intensive care units. Drawing on extensive knowledge of available technologies and their mechanisms of action, we adopted a multimodal approach to treat wounds with biofilm. The primary objective was to prevent and manage biofilm in both acute and chronic wounds. Methods: Five patients with infected acute and traumatic wounds—including chronic osteomyelitis tunnel wound, gunshot injuries, shrapnel wounds, surgical incisions, and fasciotomies—underwent Three-Step Multimodal Biofilm-Focused Protocol consisting of three sequential steps: Step 1: Cleansing and moistening wounds with a solution containing active pure HOCl (pH 2.5) for at least 30 minutes. Step 2: Cleansing and moistening wounds with a polyhexamethylene biguanide (PHMB) and betaine solution, left in place for 30 minutes, followed by cleaning with a debridement pad. Step 3: Application of a synergistic ionic silver (0.01%)–menthol liquid dressing with unique properties (cleansing, disinfecting, removing waste and slough, destroying biofilm). This dressing offers broad-spectrum antibacterial activity and accelerates healing. Wet pads were left in the wounds for the remainder of the day. Results / Discussion: All wounds demonstrated improvement, with the formation of new granulation tissue. Subsequent treatments included negative pressure therapy, secondary surgical closure, or skin grafting. Gunshot and shrapnel wounds healed successfully, limb amputation was avoided, and the chronic osteomyelitis tunnel wound contracted. This Three-Step Multimodal Biofilm-Focused Protocol enhanced wound healing, prevented amputations, and accelerated recovery. The method was later applied to other complex wounds in ICU patients.

This thesis focuses on the development of active multifunctional dressing materials and nanoparticle formulations with suitable exploitation characteristics for chronic wounds treatment. Chronic wounds a growing clinical challenge in the aging and/or reduced mobility population include pressure, venous, arterial and diabetic neuropathic ulcers. Due to the nonhealing character of these ulcers their management requires an intensive medical intervention at huge healthcare costs. The prolonged inflammation and elevated concentrations of oxidative and proteolytic enzymes in all chronic wounds, imposes the need for novel functional dressing materials to actively modulate the wound environment at molecular level and stimulate the healing process. Based on an extensive analysis of the current state-of-the-art in chronic wound healing, the proper dressings should combine both antimicrobial and enzyme inhibitory functions coupled to optimal hydrophilicity. Such integrated approach would allow for the suppression of the persistent inflammation and stimulation of the synthesis of the dermal tissue components. Biopolymers with intrinsic antimicrobial and wound repair properties appear as appropriate matrix materials to be further upgraded with bioactive molecules (therapeutics) that couple high reactivity with the ability to address specific targets in the biochemical environment of chronic wounds. Therapeutic devices can be designed in different forms depending on the particular clinical application, i.e. wound type and its characteristics. During the thesis realisation biopolymer-based platforms were generated in various designs and functionalised with active agents for controlled inhibition of major chronic wound enzymes. The capacity of all developed materials to inhibit proteolytic (e.g. collagenase) and oxidative (e.g. myeloperoxidase) enzymes involved in chronic inflammation was evaluated in vitro. In the first approach sponge-like biopolymer matrices were produced via freeze-drying technique and controlled chemical cross-linking. These matrices were further impregnated with natural polyphenolic compounds. Modulation of the deleterious wound enzyme activities was achieved upon release of active agent from the platform. The exploitation characteristics of the sponges, i.e. mechanical properties, biostability, biocompatibility, extent and duration of wound enzymes inhibition, were tuned by: the biopolymer composition, concentration of the cross-linking agent, and the proper selection of the bioactive phenolic compounds. The second approach aimed at the permanent functionalisation of the biopolymeric platforms with thiol-bearing compounds. In this case the active agent is expected to act from the platform, without being released into the wound. The obtained thiolated biopolymers were further processed into functional nanomaterials of different design: *Nanoscale films/coatings were built using a layer-by-layer approach for alternate deposition of oppositely charged polyelectrolytes. Naturally occurring glycosaminoglycans were used as counterions to cationic thiolated conjugates. *Nanoparticle formulations were obtained from thiolated conjugates in a one-step sonochemical process. In both cases the biopolymer thiolation degree was identified as a key factor for the successful fabrication of the multilayered coatings and nanoparticles, as well as to achieve control of the thickness/size of the functional nanomaterials. In addition, tuneable inhibition/adsorption of the deleterious enzymes coupled to fibroblast attachment/proliferation was observed by ruling the biopolymer modification degree.

Effective debridement with micro water jet technology (MWT): A retrospective clinical application observation of 90 patients with acute and chronic wounds

Chronic wounds, commonly known as ulcers, represent a significant challenge to public health, impacting millions of individuals every year and imposing a significant financial burden on the global health system. Chronic wounds result from the interruption of the natural wound-healing process due to internal and/or external factors, resulting in slow or nonexistent recovery. Conventional medical approaches are often inadequate to deal with chronic wounds, necessitating the exploration of new methods to facilitate rapid and effective healing. In recent years, regenerative medicine and tissue engineering have emerged as promising avenues to encourage tissue regeneration. These approaches aim to achieve anatomical and functional restoration of the affected area through polymeric components, such as scaffolds or hydrogels. This review explores collagen-based biomaterials as potential therapeutic interventions for skin chronic wounds, specifically focusing on infective and diabetic ulcers. Hence, the different approaches described are classified on an action-mechanism basis. Understanding the issues preventing chronic wound healing and identifying effective therapeutic alternatives could indicate the best way to optimize therapeutic units and to promote more direct and efficient healing.

Significance: Chronic wounds affect 10.5 million (up 2.3 million from the 2014 update) of U.S. Medicare beneficiaries. Chronic wounds impact the quality of life of nearly 2.5% of the total population of the United States. This fraction is larger in the elderly. These wounds can lead to a range of complications and health care costs. Given the aging population, the continued threat of diabetes and obesity worldwide, and the persistent problem of infection, it is expected that chronic wounds will continue to be a substantial clinical, social, and economic challenge. Disparities in the prevalence and management of chronic wounds exist, with underserved communities and marginalized populations often facing greater challenges in accessing quality wound care. These disparities exacerbate the public health burden. Recent Advances: U.S. Centers for Medicare and Medicaid Services had proposed revision of its local coverage determination limiting the use of skin substitute grafts/cellular and/or tissue-based products for the treatment of diabetic foot ulcers and venous leg ulcers in the U.S. Medicare population. In response to the comment phase, this proposal has been put on hold. The U.S. Food and Drug Administration (FDA) has renewed its focus on addressing nonhealing chronic wounds and has outlined efforts to address identified barriers to product development for nonhealing chronic wounds. The new approach places emphasis on engaging key wound healing stakeholders, including academia, professional associations, patient groups, reimbursement organizations, and industry. Finally, recent advances demonstrating that wounds closed by current FDA definition of wound closure may remain functionally open because of deficiencies in restoration of barrier function warrant revisiting the wound closure endpoint. Such "closed" wounds that are functionally open, also known as invisible wounds, are likely to be associated with high wound recurrence. Future Directions: Addressing the public health problem of chronic wounds will require a multifaceted approach that includes prevention, improved wound care management, and addressing the underlying risk factors.

We sought to examine whether vacuum-assisted closure (VAC) is associated with fewer surgical site infections (SSIs) or infections of chronic wounds than other management procedures for surgical wounds. The PubMed and Scopus databases were searched systematically. Randomized controlled trials (RCTs) comparing the development of SSIs or infections of chronic wounds between patients treated with VAC for acute or chronic wounds and those whose wounds were treated without VAC were considered eligible for inclusion in the study. Eight RCTs met the inclusion criteria for the study. Four of the studies included chronic or diabetic lower extremity wounds and four included fractures. In three of four studies reporting on fractures, the wounds were not closed post-operatively, whereas in one study primary closure of the wound was performed. With regard to wounds left open after the stabilization of fractures, patients whose wounds were treated with VAC developed fewer SSIs than those whose wounds were treated without VAC ([367 patients (196 with VAC; 171 without VAC) relative risk [RR], 0.47; 95% CI 0.28-0.81]). On the contrary, no difference in the development of SSIs occurred among patients with chronic or diabetic lower-extremity wounds treated with VAC and those whose wounds were treated without VAC ([638 patients (320 with VAC; 318 without VAC) RR 1.67; 95% CI: 0.71-3.94]). The available evidence suggests that the development of infections in wounds treated with VAC depends on the type of wound being treated.

Objetivos: buscar evidencias disponibles en la literatura acerca del uso de Aloe sp (sábila) en la cicatrización de heridas agudas y crónicas. Materiales y método: se trata de una revisión integradora realizada en las bases de datos LILACS, PubMed y Scopus, en el periodo de febrero a marzo del 2015. La búsqueda resultó en 178 publicaciones. Resultados: siete estudios constituyeron la revisión, los cuales involucraron personas con heridas de cesárea, heridas de episiotomía, quemaduras, área donadora de injerto, heridas posthemorroidectomía y heridas fisuarias anales crónicas. Se evidenció que la sábila promueve la cicatrización de heridas, además de disminuir el dolor en fisuras anales crónicas y quemaduras. Conclusiones: la sábila representa una nueva terapéutica en el tratamiento de heridas; sin embargo, las evidencias disponibles sobre su eficacia y seguridad son ineficientes para legitimar su uso en la cicatrización de heridas agudas y crónicas; por lo tanto, no se pueden generalizar.

Depending on the healing time, skin wounds can be divided into two classes: acute and chronic wounds [1, 2]. Acute wounds are characterized by broken or punctured skin layers and usually heal over a short time frame. Acute wounds can be further divided into different types based upon their causes, for example: surgical incision, thermal, abrasion, laceration, gunshot wounds, etc. In addition to epidermal cells, acute wounds may involve a part or the full thickness of the dermal layer. Chronic wounds, which have become an epidemic, take a long time to heal as they are mostly associated with diseases like diabetes and obesity.

Objective: To investigate the incidence and risk factors of lower extremities deep venous thrombosis (DVT) in patients with chronic refractory wounds (chronic wounds). Methods: A retrospective analysis of 722 cases of chronic wounds admitted to the First People's Hospital of Zhengzhou from January 1, 2015 to December 31, 2018 was carried out, and clinical data such as gender, age, wound involves the lower extremities, wound type, duration of wound, D-dimer level and complicated diabetes, hypertension, coronary heart disease, cerebral infarction, pneumonia and sepsis/septic shock were collected. The patients were divided into DVT group and non-DVT group according to the color ultrasound test. Multivariate binary logistic regression analysis was used to screen the independent risk factors of DVT in patients with chronic wounds. Results: There were 55 (7.6%) patients in DVT group, of which 44(80.0%) were diagnosed as chronic DVT by conventional lower extremities venous color ultrasound screening at admission, and the remaining 11(20.0%) were newly diagnosed during hospitalization. There were no significant differences in gender, wound involves the lower extremities, duration of wound, complicated diabetes and hypertension between DVT group and non-DVT group (all P>0.05); and the differences were statistically significant in age, wound type, D-dimer level, complicated coronary heart disease, cerebral infarction, pneumonia and sepsis/septic shock (all P<0.05). Multivariate binary logistic regression analysis showed age [OR=2.260 (95%CI: 1.584-3.224)], D-dimer level [OR=14.201 (95%CI: 6.101-33.055)], complicated coronary heart disease [OR=2.731 (95%CI: 1.210-6.162)] and sepsis/septic shock [OR=3.170 (95%CI: 1.115-9.016)] were independent risk factors for DVT (all P<0.05). Conclusion: Chronic wounds patients have a higher incidence of DVT, most of which are chronic DVT, and age, D-dimer level, complicated coronary heart disease and sepsis/septic shock are independent risk factors for DVT in chronic wounds.

Given that local elevated protease activity (EPA) has been implicated in impaired wound healing, a prospective single-center study was conducted to assess protease activity in various wound types. Protease activity was determined using an easy-to-use test system (Woundchek Protease Status Test Kit; Systagenix, Gatwick, United Kingdom) in 160 wounds in 143 patients. The assay detects the combined activity of inflammatory proteases, mainly matrix metalloproteinases 8 and 9 and human neutrophil elastase. Local EPA was detected in 29 of 153 validly tested wounds (18.95%). No difference was detected between acute and chronic wounds, regardless of associated or causative conditions, with the sole exception of surgical wounds. Surgical wounds showed EPA significantly less frequently than nonsurgical wounds. Among nonsurgical wounds, EPA was detected more frequently in acute compared with chronic wounds. Wounds with signs of unimpeded healing (granulation or epithelialization) showed EPA less often than wounds covered with necrotic tissue or a fibrin layer. However, 14% of wounds with epithelialization or granulation exhibited EPA potentially impeding wound healing. Wounds treated with moisture-retentive wound dressings showed EPA significantly less frequently compared with wounds bandaged with dressings with less moisture-retentive properties. Remarkably, none of the wounds treated with collagen/oxidized regenerated cellulose/silver, which is a protease-modulating dressing, showed EPA. To the study authors' knowledge, this is the largest study assessing EPA in various wound types. The convenient applicability of the test system provides a basis for future studies assessing the pathophysiologic relevance of EPA. In some unsuspicious wounds, early detection of EPA might precede impaired healing and prompt protease-modulating treatment before failure to heal becomes apparent.

Dermal templates are well established in the treatment of burn wounds and acute nonburn wounds. However, the literature regarding their use for reconstruction of chronic, nonhealing wounds is limited. This study describes a series of patients with chronic wounds reconstructed with a commercially available bilayer, acellular dermal replacement (ADR) containing a collagen-glycosaminoglycan dermal template and a silicone outer layer. A retrospective review was performed of 10 patients treated for chronic wounds with ADR and negative pressure dressing followed by split-thickness skin graft between July 2006 and January 2009. Data collected included age, gender, comorbidities, medications, wound type or location, wound size, the number of applications of ADR, the amount of ADR applied (in square centimeter), the amount of time between ADR placement and grafting, complications, need for reoperation, and percentage of graft take after 5 and 14 days. The mean age of study subjects was 44 years. All patients in the study had comorbidities that interfere with wound healing and were treated for lower extremity wounds (four to legs, five to ankles, and one to foot). The wounds had a variety of causative factors including venostasis ulcers (6, 60%), trauma in diabetic patients (2, 20%), brown recluse bite (1, 10%), and a wound caused from purpura fulminans (1, 10%). The average wound size and amount of ADR applied was 162±182 cm². Each patient required only one application of ADR. The average time between ADR placement and skin grafting was 36.5 days. The mean percentage of graft take at 5 days was 89.55%, 14 days was 90%, and 21 days was 87.3%. Only two patients required regrafting, and one of these grafts was lost because of patient noncompliance. ADR can be used successfully in the treatment of chronic wounds. ADR provides direct wound coverage and can conform to a variety of anatomical sites. This study demonstrates that the use of ADR in treating chronic wounds results in high rates of skin graft take. Favorable results were obtained despite the majority of patients having comorbidities that would normally interfere with wound healing.

WOUND MANAGEMENT IN POSTACUTE CARE

Background: Treatment of acute and chronic wounds are a major challenge. In modern medicine, numerous approaches to wound healing are known. One of them is the use of epidermal autologous grafts. The purpose of this article is to present the use of automated epidermal harvesting system (CELLUTOMETM Epidermal Harvesting System; KCI, an Acelity company, San Antonio, TX, USA) in General Hospital dr. Jože Potrč Ptuj, Slovenija.Case presentation: Treatment of a patient with a chronic wound after ruptured varicose veins on the right shin, a patient with a chronic wound after crash injury and a patient with nonhealing postoperative wound using CELLUTOMETM Epidermal Harvesting System are described.Conclusion: Our results showed the positive effects of epidermal autologous grafts on the healing process of various types of wounds and confirmed the advantages of this system for the production of epidermal autologous grafts.

Background: Treatment of acute and chronic wounds are a major challenge. In modern medicine, numerous approaches to wound healing are known. One of them is the use of epidermal autologous grafts. The purpose of this article is to present the use of automated epidermal harvesting system (CELLUTOMETM Epidermal Harvesting System; KCI, an Acelity company, San Antonio, TX, USA) in General Hospital dr. Jože Potrč Ptuj, Slovenija.Case presentation: Treatment of a patient with a chronic wound after ruptured varicose veins on the right shin, a patient with a chronic wound after crash injury and a patient with nonhealing postoperative wound using CELLUTOMETM Epidermal Harvesting System are described.Conclusion: Our results showed the positive effects of epidermal autologous grafts on the healing process of various types of wounds and confirmed the advantages of this system for the production of epidermal autologous grafts.