Abstract Pressure ulcers (PrUs) affect approximately 2.5 million patients and account for 60,000 deaths annually. They are associated with an additional annual cost of $43,000 per related hospital stay and a total cost to the US health care system as high as $25 billion. Despite the implementation of national and international PrU prevention guidelines and toolkits, rates of facility‐acquired PrU s and PrUs in people with spinal cord injury are still high. A new paradigm is needed that distinguishes between prevention and treatment research methods and includes not only the causative factors of pressure and tissue deformation but also patient‐specific anatomical differences and the concomitant biological cellular processes, including reperfusion injury, toxic metabolites, ischemia, cell distortion, impaired lymphatic drainage, and impaired interstitial fluid flow that compound existing tissue damage. The purpose of this article is to summarize the highlights from the first annual Pressure Ulcer Summit held February 9–10, 2018 in Atlanta, Georgia (sponsored by the Association for the Advancement of Wound Care in partnership with multiple professional organizations). This international, interdisciplinary summit brought together key stakeholders in wound care and PrU prevention and management to highlight advances in pathophysiology of pressure‐induced tissue damage; explore challenges in current terminologies, documentation, and data collection; describe innovations in clinical care; and identify research opportunities to advance the science of PrU prevention and management.
The global landscape of wound care is shrouded in shadows and plagued by inadequate education, inconsistent standards and a marked lack of understanding and confusion about how to treat wounds that impacts patients and providers. Despite the significant burden of chronic wounds on healthcare systems worldwide, the field remains under-resourced, overlooked and poorly represented within the curricula of modern-day professional school training. It is time that we raise awareness locally and globally to shed light on the pressing issues that hinder progress in wound care and advocate for a more enlightened approach that prioritises education, innovation and patient-centric care. While non-healing, hard-to-heal or 'chronic' wounds represent a 'silent pandemic' that is seemingly in lock step with the ever-growing increase in diabetes and obesity, it is well documented that major gaps in basic wound education and management exist for both primary care and front line clinicians [1-4]. These gaps in knowledge and care are transdisciplinary and global, affecting the acute and post-acute care settings. However, with advancements in non-invasive diagnostics that enable personalised and actionable evidence-based treatments, coupled with enhanced education and early intervention there is enormous potential to (i) prevent the development of chronic wounds, (ii) reduce hospitalizations and (iii) significantly reduce the financial and emotional toll of this pandemic on the globe's healthcare delivery systems [5]. Thus, it is imperative that trainees across the care continuum receive all the tools needed to optimise wound care so that the right treatment for the right reason and at the right time is delivered to each and every patient, regardless of wound type, aetiology or socio-economic status. A comprehensive curriculum must include basic education about the science of wound repair and regeneration, along with a standardised approach to basic wound care, while emphasising the cost-savings and benefits of deploying interprofessional teams to advance the care of these complex and costly cases. A vast literature confirms that trainees rank their knowledge about wound care as low, yet desire to have practical skills that will help them care for their patients. The medical curriculum is at a crossroads, as the amount of information exceeds capacity in terms of time and expertise. This has restricted the ability to incorporate basic education about wound pathophysiology, wound diagnosis and wound treatment. Despite the gaps and inconsistencies, there are stories of successful expansion of the knowledge base and integration of wound care into the healthcare professionals' basic curriculum. This perspective article examines the challenges and solutions to this pressing problem. At the May 2024 Annual Conference of the Wound Healing Society (WHS), the International session explored global solutions to wound healing education. Susan Volk, VMD, PhD, DACVS, chair of the WHS International Relations committee, Ira Herman, PhD and Lisa Gould, MD, PhD moderated the session that included presentations from recognised experts in wound education and interviews with clinicians around the globe who discussed their experience, challenges and novel solutions to providing basic wound education to clinicians and patients. The session opened with a brief animated video, 'Wound Healing Lessons from the Home: Intergenerational Learning Saves Limbs and Lives'. The video, crafted by Ira Herman and Lisa Gould depicts an 11-year-old girl who advocates for her grandmother who is suffering with the complications of diabetes and a long-standing foot ulcer. The animation demonstrates the power and potential of intergenerational learning for patients being cared for at home and sends the message that early diagnosis and treatment can save limbs and lives, while illustrating the critical need to inspire the next generation of clinicians and researchers. The video closes with a call to action, presenting the staggering facts about the current 'pandemic' facing all those in need of healing. In the end, it is all about education. This was followed by a combination of live presentations and video interviews that highlight the problems encountered across the globe along with novel solutions to expand wound education for all learners. Dr. Gary Sibbald, a dermatologist and internist, internationally known for his expertise in wound care and education, is the project lead on ECHO (Extension for Community Healthcare Outcomes) Ontario Skin & Wound that virtually reaches a wide variety of healthcare professionals including Northern and Indigenous centres. Project ECHO emphasises interprofessional collaboration, early screening and patient education. Using a spoke and hub model, there is an emphasis on educating healthcare professionals in practice, developing interprofessional teams, use of multimodal didactic methods, case-based interactive learning and virtual skills training, leading to evidence-based care management plans with outcome evaluation. The project has trained more than 450 healthcare professionals in 96 health care organisations and provided team consultations to more than 120 complex patients. More than 90% of participants said the learning met their needs and 87% changed their practice. The project emphasises treating patients in their communities, by 'moving knowledge, not patients' [6]. Dr. Kirsi Isoherranen, president of EWMA (European Wound Management Association) and chief physician of the Helsinki Wound Healing Centre in Finland described two cohort studies, one in Finland and one in the United States, that highlight the diagnostic delay between primary care physicians and wound care team physicians. In these studies, as many as 26% of patients seen by general practitioners lacked a diagnosis, while less than 2% of wounds seen by the wound team lacked a diagnosis [7, 8]. This leads to delays in treatment, particularly as patients in clinical practice are becoming more complicated. She recommended the use of checklists and described a validated digital checklist called the Wound Navigator that provides structure to support clinical decision making that is particularly helpful when primary care physicians are faced with complex wounds [9]. In addition, she outlined the use of mnemonic aids to facilitate diagnosing wounds [10, 11]. The importance of early diagnostics in lower leg ulcers has also been highlighted in a recent EWMA document [12]. To amplify the global impact of wounds and wound education, five clinicians described successful programmes and the challenges that they have encountered in their respective countries. Anthony Sassi, PA-C works in a Federally Qualified Health Center in rural Vermont, US. He described the lack of basic wound education for physician assistants in training that led him to seek an elective outside of the curriculum. He is a proponent of early training and exposure prior to employment for all clinicians, but also noted the unmet need for clinicians practicing in rural settings where resources and specialists are limited. Cornelia Erfurt-Burge, MD is a dermatologist at the University Hospital in Erlangen, Germany. She explained that she was not exposed to chronic wounds in her basic medical education but is now employed in a clinic where she treats patients with complex wounds. That prompted her to survey the medical students, who noted that they had no lectures about wound care. She developed a digital education module about wound care that is offered as an elective in dermatology. She is now working with general practitioners to integrate an obligatory lecture about diseases of the leg into their curriculum. Her university also offers an interprofessional skills course in which medical students and nurses work side by side, learn from each other and learn the relevance of wound care regardless of future specialty [13]. Terry Swanson, NP was one of the first nurse practitioners in Victoria, Australia. She has made wound care and wound education a focus of her profession and provides consultation services across Australia. She explained that while general practitioners are the medical gatekeepers in Australia, they do not have the knowledge or skills to treat patients with wounds. She discussed the work that Wounds Australia did to bring the Australian Medical Association (AMA) to the realisation that general practitioners require this education. The AMA is now funding an initiative to provide education for general practitioners that will allow them to recognise and provide the specialised care that patients with diabetic foot ulcers require [14]. Roch Christian Johnson, MD, MSc, PhD is an epidemiologist and infectious disease specialist who discussed a novel project in Benin, West Africa to provide wound education for patients with Buruli ulcers and leprosy. He highlighted the integration of the education team, including a social anthropologist, to explore current wound practices and provide basic wound education for the village caregivers. In depth discussions about 'do's' and 'don'ts' led them to identify basic principles of wound care that would fit with the practices and social structure of the villages. From this, they developed practical tools and methods to provide wound education and community awareness. He discussed the success with basic wound hygiene and the challenges of sustainability [15, 16]. Simone McConnie, BScPod Med, MChS HPC is the Caribbean Regional Coordinator of Dfoot International. Dfoot was developed as an outgrowth of the successful Step by Step project in Tanzania to reduce amputations with screening and prevention programmes for patients with diabetes and diabetic foot ulcers. She emphasised the great need to get buy-in from the government, highlighting the success of the programme in Domenica and the need for sustainability that requires ongoing training and resources for the continuum of care [17, 18]. Lessons learned from these interviews include (1) the gravity of having wounds, especially foot wounds, in undeveloped countries, (2) the need to integrate into the local culture, (3) keeping wound care basic but evidence-based, (4) involving local leaders, whether that be in the University, the Minister of Health or a major medical association and (5) the benefit of government funding for sustainability. (The entire video may be viewed at the following link: https://www.youtube.com/watch?v=s0t1-nfHSwU. A transcript is included as a Supporting Information). An online survey conducted prior to the 2024 Wound Healing Society meeting confirmed that basic wound education should be transdisciplinary and interprofessional (Figure 1). However, wounds have no home in the usual systems-based curriculum and cross so many disciplines that there is no 'ownership'. It is possible to turn this into a positive attribute. For example, in the basic science curriculum when students learn the basics of inflammation it would be logical to make the connection to inflammatory ulcers, including the skin and gastrointestinal tract, the microbiome and the pharmacology of anti-inflammatory drugs including monoclonal antibodies. The pathophysiology of diabetic wounds also addresses inflammation and is a perfect platform for reviewing vascular and neuroanatomy, pathophysiology of advanced glycation end products, renal physiology, endocrinology, nutrition, microbiology, foot anatomy and biomechanics of ambulation. This same disease state can lead to discussions of social determinants of health, health economics, population health and understanding health insurance programmes. All based on one wound. The goal of the International WHS session was to bring together passionate educators, innovators and practitioners, all of whom are willing to push the envelope and demand basic wound education for all clinicians and caregivers, current and future. The session illustrated pilot projects that can be utilised to support a larger global strategy. Given the growth of this 'silent epidemic' and the under-recognised disability of our patients, it is imperative that we work together to bring basic wound education to the forefront of medical education. The authors declare no conflicts of interest. Data S1. Video transcript (attachment). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
Abstract Pyoderma gangrenosum (PG) is a rare, painful neutrophilic dermatosis characterized by rapidly progressing skin ulcers. Despite the importance of local wound care in managing PG, there is no consensus or evidence‐based guidelines. This systematic review aimed to investigate local wound care strategies for PG. A comprehensive search of Embase, MEDLINE, and the Cochrane Library yielded 1213 references, from which 269 studies were included, covering 351 patients. The most reported treatment methods included sharp debridement (11%), topical corticosteroids (27%) and non‐adherent dressings (12%). However, no clear correlation between these treatments and healing outcomes was found likely due to confounding factors such as varied wound sizes, superinfection and inconsistent reporting. Additionally, directed wound care regimens have not been able to show statistical significance for healing outcomes. Our study describes the current local wound care landscape and underscores a critical gap in the current literature regarding standardized treatment protocols for PG.
Hyperbaric oxygen (HBO) therapy is a versatile modality that has applications across several medical fields. HBO therapy has become a valuable asset in the management of compromised tissue grafts and flaps. Although classified together, grafts and flaps are distinctly different, in that grafts depend on the wound bed for revascularization, whereas flaps have an inherent blood supply. Evidence has shown that in a compromised graft suffering from hypoxia, HBO can maximize viability and reduce the need for repeat grafting. By comparison, compromised flaps can suffer from both ischemic and reperfusion injury, which can also be attenuated by HBOT to maximize viability. The beneficial effects of HBO occur by several mechanisms, including hyper-oxygenation, fibroblast proliferation, collagen deposition, angiogenesis, and vasculogenesis. Animal studies have demonstrated several of these mechanisms, including an increase in the number, size, and growth distance of blood vessels after HBO. Likewise, clinical studies have found positive responses in multiple types of tissue grafts and flaps, with some cases involving irradiated fields. Altogether, the data emphasizes that early identification of flap or graft compromise is absolutely critical, with maximized chance for viability when HBO is initiated as soon as possible.
Cancers of the head and neck include oral cavity, oropharynx, hypopharynx, nasopharynx, larynx, nasal fossa, paranasal sinuses, thyroid, salivary glands and vermilion surfaces (Parker et al, 2004). Incidence of these cancers has risen in the past 30 years, particularly in people under the age of 65 years. Risk factors include cigarette smoking and excessive alcohol abuse. At time of diagnosis patients often present with swallowing difficulties due to tumour location and size. Further oncological treatments such as surgery and radiotherapy can exacerbate these difficulties and cause major nutritional problems. Dietary management in relation to texture modification and nutritional content of meals needs to be addressed as well as feeding strategies recommended by the speech and language therapist. Good communication between all members of the multidisciplinary team is paramount in ensuring that patients have the necessary support, education and quality of life they need.
Calcific uremic arteriolopathy (CUA; calciphylaxis) is a severe form of vascular calcification with no approved therapies. A standardized wound assessment tool is needed to evaluate changes in calciphylaxis wounds over time. A prospective, single-arm study of 14 patients with calciphylaxis reported improvement for the primary endpoint of wound healing using the 13-item Bates-Jensen Wound Assessment Tool (BWAT), although that tool was developed for assessment of pressure ulcers. This report describes development of BWAT-CUA, an 8-item modification of BWAT focusing on prototypical features of calciphylaxis lesions. The BWAT-CUA has a range of 8 (best) to 40 (worst) and was used ad hoc to analyze BWAT data collected in the prospective study. Using BWAT-CUA, relative improvement in calciphylaxis wounds was 30% overall (from 21.2 to 14.9; p = 0.0016) and 34% in the subset of 12 patients with ulceration at baseline (from 23.3 to 15.3; p = 0.0002). BWAT-CUA is a primary endpoint in an ongoing randomized, placebo-controlled phase 3 study of SNF472 recruiting patients with end-stage kidney disease and at least one ulcerated calciphylaxis lesion. BWAT-CUA, a newly developed tool for assessment of calciphylaxis wound severity and improvements over time, may be used in clinical research and in clinical practice.
Abstract Preclinical studies for wound healing disorders are an essential step in translating discoveries into therapies. Also, they are an integral component of initial safety screening and gaining mechanistic insights using an in vivo approach. Given the complexity of the wound healing process, existing guidelines for animal testing do not capture key information due to the inevitable variability in experimental design. Variations in study interpretation are increased by complexities associated with wound aetiology, wounding procedure, multiple treatment conditions, wound assessment, and analysis, as well as lack of acknowledgement of limitation of the model used. Yet, no standards exist to guide reporting crucial experimental information required to interpret results in translational studies of wound healing. Consistency in reporting allows transparency, comparative, and meta‐analysis studies and avoids repetition and redundancy. Therefore, there is a critical and unmet need to standardise reporting for preclinical wound studies. To aid in reporting experimental conditions, The W ound R eporting in A nimal and H uman Preclinical S tudies (WRAHPS) Guidelines have now been created by the authors working with the Wound Care Collaborative Community (WCCC) GAPS group to provide a checklist and reporting template for the most frequently used preclinical models in support of development for human clinical trials for wound healing disorders. It is anticipated that the WRAHPS Guidelines will standardise comprehensive methods for reporting in scientific manuscripts and the wound healing field overall. This article is not intended to address regulatory requirements but is intended to provide general guidelines on important scientific considerations for such studies.
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