Chronic Wounds: Factors Influencing Healing Within 3 Months and Nonhealing After 5-6 Months of Care.
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Chronic wounds affect approximately 2.5 million to 4.5 million people in the US and are particularly a problem for the elderly. Nonhealing or slow healing wounds represent a major health burden and drain on resources, contributing to substantial disability, morbidity, and costs. This study was conducted to identify factors that influence the healing of chronic wounds within 3 months of starting treatment, compared to factors influencing nonhealing wounds after 5 or 6 months of treatment. A retrospective review of medical records of subjects with chronic pressure, diabetic, or venous ulcers using a structured data collection form and protocol was conducted at 4 sites located in disperse geographic areas. The sample consisted of 400 subjects with at least 3 months of data. Demographic, case mix, wound characteristics, and treatment characteristics were analyzed. Consistent with the literature, wounds that were larger, deeper, infected, draining larger amounts of exudate, and/or covered with slough or eschar were significantly less likely to heal within 3 months and more likely not to heal after 5-6 months of treatment. Medicaid insurance coverage and being non-white were also associated with poorer healing. A lower percentage of antimicrobial dressings was associated with faster healing, while a lower percentage of moisture-management dressings was associated with nonhealing after 5-6 months. The analysis also showed that inappropriate management of wound exudate and necrotic tissue was associated with poorer healing outcomes. While the influence of insurance coverage and race on healing needs further exploration, healing rates could improve in certain centers through better adherence to evidence-based wound management recommendations.Keywords:
Eschar
Chronic wound
Medical record
Wound care
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Abstract Background Indications for negative-pressure wound therapy (NPWT) in vascular surgical patients are expanding. The aim of this review was to outline the evidence for NPWT on open and closed wounds. Methods A PubMed, EMBASE and Cochrane Library search from 2007 to June 2016 was performed combining the medical subject headings terms ‘wound infection’, ‘abdominal aortic aneurysm (AAA)’, ‘fasciotomy’, ‘vascular surgery’ and ‘NPWT’ or ‘VAC’. Results NPWT of open infected groin wounds was associated with shorter duration of wound healing by 47 days, and was more cost-effective than alginate dressings in one RCT. In one RCT and six observational studies, NPWT-related major bleeding and graft preservation rates were 0–10 and 83–100 per cent respectively. One retrospective comparative study showed greater wound size reduction per day, fewer dressing changes, quicker wound closure and shorter hospital stay with NPWT compared with gauze dressings for lower leg fasciotomy. NPWT and mesh-mediated fascial traction after AAA repair and open abdomen was associated with high primary fascial closure rates (96–100 per cent) and low risk of graft infection (0–7 per cent). One retrospective comparative study showed a significant reduction in surgical-site infection, from 30 per cent with standard wound care to 6 per cent with closed incisional NPWT. Conclusion NPWT has a central role in open and infected wounds after vascular surgery; the results of prophylactic care of closed incisions are promising.
Negative-pressure wound therapy
Groin
Wound care
Wound dehiscence
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To study the outcome of patients with sinonasal teratocarcinosarcoma treated at a single institution.We reviewed the medical records of 22 patients with histopathologically proven sinonasal teratocarcinosarcoma diagnosed during the period 1993-2007. Treatment was completed in 16 patients.Fourteen patients underwent surgery (six received craniofacial resection, four open surgery and four endoscopic resection); this was followed by radiation therapy with or without chemotherapy in 11 patients. Two patients received chemoradiation as the definitive treatment. At median follow up in surviving patients of 34 months (range one to 180 months), only five were controlled. Disease recurred in 11 patients, with a median time to recurrence of seven months. The two-year disease-free survival rate and the overall survival rate were 28 and 46 per cent, respectively.Sinonasal teratocarcinosarcoma appears to be an aggressive disease, with the majority of patients suffering locoregional failure. Multimodality treatment, in the form of a combination of surgery, radiation therapy and chemotherapy, appears to be the optimal approach.
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A 50-year-old man with diabetes (patient 1) underwent left below-knee amputation (BKA) for a nonhealing infected foot ulcer. Necrotic eschars developed on the residual limb (Figure 1). He was referred to the dermatology department postoperatively for wound care prior to a planned above-knee amputation (AKA). A 62-year-old man with diabetes (patient 2) underwent bilateral BKA for gangrene secondary to foot ulcerations. One month postoperatively he was referred to the dermatology department for wound care of necrotic eschars involving both distal residual limbs. A 56-year-old man (patient 3) with diabetic neuropathy affecting both upper and lower extremities developed cellulitis and gangrene following thermal burns to the left sole. One month following BKA, the wound dehisced, and an adherent necrotic eschar formed at the distal residual limb. A 62-year-old woman with diabetes (patient 4) with ischemic gangrene of the left toes underwent BKA. After amputation, her residual limb developed ischemic necrosis with painful adherent eschar formation.
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Adequate wound bed preparation is essential for healing of leg ulcers, and consists of controlling exudate and edema, decreasing the bacterial burden, promoting healthy granulation tissue, and removing necrotic tissue. Currently, there is no classification system for wound bed preparation that has predictive value. Based on past work and the authors' experience, we have now developed and tested a new classification system that scores the following parameters: healing edges (wound edge effect), presence of eschar, greatest wound depth/granulation tissue, amount of exudate amount, edema, peri-wound dermatitis, peri-wound callus and or fibrosis, and a pink/red wound bed. Each parameter receives a score from 0 (worst score) to 2 (best score), and all the parameter scores are added for a total score. Each wound can have a maximum score of 16 (the best score possible), to a minimum score of 0 (the worst score possible). We used this wound bed score (WBS) system in a study of 177 patients with venous ulcers who had been prospectively treated with and randomized to either conventional therapy (compression alone) or a living bilayered skin construct (BSC). We evaluated serial photographs at baseline to determine whether the results would be predictive of complete wound closure and could validate the WBS. We found that wounds that ultimately achieved full closure had a statistically significant higher WBS than those that did not heal (p = 0.0012). This was also true when separating wounds by treatment modality: standard therapy (p = 0.044) and treatment with a BSC (p = 0.011). When dividing the WBS in the following quartile groups: scores 4-10, 10-12, 12-13, and 13-16, the percentage of healed wounds correlated with the WBS (p = 0.0008). For all wounds, a one unit increase in total WBS resulted on average in a 22.8% increase in odds of healing (OR = 1.228). This WBS seems to have validity in predicting complete wound closure in wounds treated with either standard therapy or advanced modalities, such as BSC. If confirmed and widely adopted in this and other types of wounds, it could be a useful tool in both the clinical and research setting.
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Wounds with a covering of eschar require debridement before optimal wound healing can proceed. There are several different methods available but these have been derived empirically with no direct evidence of the structure or composition of the tissue they are designed to remove, or of the potential autolytic mechanisms which are the targets for some of these treatments. The aim of this study therefore was to determine the composition of chronic wound eschar and hence identify potential targets for the induction of autolytic debridement. Chronic wound eschar was removed by surgical debridement and analysed using immunohistochemistry, polyacrylamide gel electrophoresis (PAGE) and gelatin zymography. Immunohistochemistry using antibodies specific for extracellular matrix (ECM) proteins revealed a definite tissue structure, consisting of many fibrous regions and fine fibrillar elements separated by areas of tissue which were of a more irregular and amorphous nature. An antibody specific for all leucocytes revealed the presence of leucocytes in the region of tissue closest to the wound bed. The presence of this leucocyte population correlated to elevated levels of gelatinase activity as identified by gelatin zymography. PAGE analysis identified various protein species in the range 3.5-60 kDa molecular weight. These data indicate that wound debridement is likely to require multiple enzyme specificities to degrade the eschar and that these enzymes may be supplied by inflammatory leucocytes infiltrating the eschar from the wound bed. The various protein species demonstrated by PAGE may represent ECM proteins, those with lower molecular weight possibly representing the degradation products of autolytic debridement.
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Debridement (dental)
Chronic wound
Zymography
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Healthcare professionals use words like "frustrating," "expensive," and "time-consuming" to describe chronic wound care. Healing a wound that has been present for an extended period of time is difficult. Often the problem is not just the wound but also the "woundedness" of the individual with the wound. The patient's needs in chronic wound care often continue over months, years, or even a lifetime. This article addresses more than the wound--it offers healthcare professionals' accounts of patient stories and their active involvement in the long journey toward chronic wound healing.
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Chronic wound
Health Professionals
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PURPOSE Small studies have indicated that the addition of acoustic pressure wound therapy (APWT) to conventional wound care may hasten healing of chronic wounds. We evaluated our early clinical experience using APWT as an adjunct to conventional wound care. DESIGN The study was a retrospective chart review of consecutive patients receiving APWT in addition to conventional wound care in a hospital-based, primarily outpatient setting. METHODS Medical records of all patients treated with APWT between August 2006 and October 2007 were reviewed. Analysis included the 41 patients with 52 wounds who received APWT at least 2 times per week during the study period. Statistical comparisons were made for wound dimensions, tissue characteristics, and pain at start versus end of APWT. RESULTS Thirty-eight percent of wounds (N = 20) healed completely with a mean 6.8 weeks of APWT. Median wound area and volume decreased significantly (88% [P < .0001] and 100% [P < .0001], respectively) from start to end of APWT. The proportion of wounds with greater than 75% granulation tissue increased from 26% (n = 12) to 80% (n = 41) (P < .0001), and normal periwound skin increased from 25% (n = 13) to 54% (n = 28) (P = .0001). Presence of greater than 50% fibrin slough decreased from 50% (n = 24) to 9% (n = 4) of wounds (P = .006). CONCLUSIONS This early experience supplementing conventional wound care with APWT suggests it may promote healing in chronic wounds, where the ordered cellular and molecular processes leading to healing have stalled.
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Chronic wound
Adjuvant Therapy
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