Health professionals' perceptions of maggot debridement therapy

BACKGROUND

Maggot debridement therapy (MDT), or the use of maggots in dead tissue removal, has been shown to be beneficial in wound healing. Yet MDT in the US is often only used once conventional debridement methods have failed.

METHOD

In this study, nine health professionals, experienced in MDT, were interviewed in order to identify and analyse the perceived societal barriers to MDT acceptance and usage in the US.

RESULTS

Through qualitative analysis, using the grounded theory framework, this study found that among those interviewed, insurance reimbursement restrictions and stigmatisation of medicinal maggots were the factors driving resistance to MDT use.

CONCLUSION

Specifically, the 'yuck' factor and the perception of MDT as an 'ancient' modality contributed towards MDT stigma; in addition, lack of outpatient insurance coverage deterred MDT use. These findings provide useful information regarding the perceptual and systemic barriers that prevent greater acceptance of MDT. Ultimately, these barriers must be understood if we are to facilitate MDT implementation and improve MDT usage in the future.

Development of a porcine hard-to-heal wound model: evaluation of a bromelain-based enzymatic debriding agent

AIMS

We describe the development of a novel porcine eschar model and compare the debridement efficacy of various concentrations of a novel bromelain-based enzymatic agent with collagenase.

METHODS

Full thickness excisional wounds were created on pigs and injected intradermally with various doses of doxorubicin. Wounds were monitored for a period of 46 days for the development of eschar and wound closure. After determining the optimal concentration and dose of doxorubicin resulting in non-healing eschars, these conditions were used to create additional wounds on another set of animals. The resulting eschars were treated with various concentrations of a novel bromelain-based enzymatic agent (EscharEx-02) or collagenase. The primary endpoint was greater than 95% removal of the central eschar.

RESULTS

Consistent eschars composed of two distinct areas (a central area of exudate and slough representing the hard-to-heal wound bed, and a peripheral area of full-thickness mummified necrosis) were seen after injection of doxorubicin (0.5 ml/cm² of stock solution 0.75mg/ml) at one and six days after wound creation. Complete removal of the central eschar was achieved in all wounds after five and eight treatments with 5% and 2% EscharEx-02 respectively. Complete removal of the central eschar with collagenase was achieved in 0% and 82% of the wounds after 10 and 16 treatments respectively.

CONCLUSIONS

We describe a porcine model for creating eschars similar to hard-to-heal wounds in humans. A novel bromelain-based enzymatic debridement agent was more effective than a commercially available collagenase in removing eschars in this wound model.

Evaluation of pro-angiogenic properties of an inorganic silica gel fibre fleece

Hard-to-heal wounds represent an increasing health and economic burden on society. At present, therapy options for hard-to-heal wounds are often unsatisfactory, and the development of more effective wound treatments is urgently needed. We have shown that orthosilicic acid-releasing silica fibre fleece (SIFIB), via its pronounced anti-inflammatory properties, exhibited a significantly enhanced effect on wound closure kinetics in a porcine wound model in vivo. In this present study, we have examined in vitro the impact of the pro-angiogenic potential of SIFIB. Using an in vitro angiogenesis assay we describe for the first time how an inorganic biodegradable silica-based material significantly improved endothelial microvessel-like structure formation. We further demonstrate that the molecular mechanism of this pro-angiogenic activity of SIFIB is based on a significantly increased and tumour necrosis factor (TNF)α-dependent VEGF protein expression. In conclusion, due to its positive effects on angiogenesis, our results further indicate that decomposition products of silica-based biodegradable inorganic materials might represent very relevant therapeutic components of modern wound dressings for the treatment of hard-to-heal wounds.

Management of hard-to-heal leg ulcers with an acid-oxidising solution versus standard of care: the MACAN study

OBJECTIVE

The efficacy of available wound dressings in the treatment of hard-to-heal wounds is limited. A new therapeutic approach using an acid-oxidising solution (AOS) was developed. Its effect on healing progress, tolerability and safety properties were investigated in a clinical study, and compared with standard of care (SOC) wound dressings. The study aimed to demonstrate the non-inferiority of AOS to SOC in terms of wound healing progress.

METHOD

This open-label, randomised controlled trial was conducted at two study centres in Austria with patients with either infected or non-infected hard-to-heal leg ulcers of different aetiology. Patients were treated for six weeks either with AOS or SOC wound dressings. Outcome assessments included the percentage of granulation and re-epithelialisation tissue, wound size reduction, changes in wound pH, infection control and wound pain, local tolerability and adverse events (AEs). Healing time and rate were also assessed.

RESULTS

A total of 50 patients took part. In the AOS group, wounds exhibited higher amounts of granulation and re-epithelialisation tissue, and a faster and more pronounced wound size reduction compared with wounds in the SOC group. In the AOS-treated versus SOC-treated patients, a greater percentage of complete healing of hard-to-heal ulcers was achieved by the end of the study period (32% versus 8%, respectively). Furthermore, the wound pH decreased significantly faster in these wounds (p<0.0001). In all patients with infected leg ulcers, local infection was overcome more rapidly under AOS treatment. In the AOS group, one AE and no serious adverse events (SAEs) were detected versus 24 AEs and two SAEs in the SOC group.

CONCLUSION

In this study, AOS proved to be a highly effective treatment to support wound healing in infected or non-infected hard-to-heal leg ulcers of different aetiology. Efficacy was found to be not only non-inferior but superior to SOC wound dressings. Furthermore, tolerability and safety profiles were favourable for AOS.

Community setting survey evaluating AQUACEL dressings

OBJECTIVE

This study aimed to collect and analyse real-life data to characterise the initial use of Hydrofiber Technology dressings for the management of exuding wounds in France.

METHOD

An online survey of nurses provided data from patients managed with two dressings-AQUACEL Extra or AQUACEL Ribbon-as the primary dressing. At baseline, sociodemographic data, relevant medical histories and wound characteristics were recorded. The status of the wounds was then examined on days seven and 14 of management, together with scores of both clinician and patient satisfaction.

RESULTS

The survey included 1093 patients with a mean age of 65.9 years, comprising 53.3% women; 615 (56.3%) patients presented with acute wounds and 478 with hard-to-heal wounds. Wounds were reported to have healed or improved in 79.4% and 88.1% of the patients after 7 and 14 days, respectively. After 14 days, the wounds were smaller (p<0.001), and the percentage of sloughy wound bed tissue had decreased (p<0.001), while the percentage of granulation tissue and epithelialisation increased significantly (p=0.024 and p=0.047, respectively). Tolerance of the dressing was good, with low levels of pain reported, both while wearing the dressing and on removal. On day 14, nurses reported a high level of satisfaction, while 70% and 42.7% of patients with acute and hard-to-heal wounds, respectively, were 'very satisfied'.

CONCLUSION

The Hydrofiber Technology dressings aided wound healing when used in the management of a wide range of acute and hard-to-heal wounds in medical and surgical indications. User satisfaction was high from both healthcare professionals and patients.

Cost effectiveness of a specialist wound care service

The Burden of Wounds Study estimated the cost of wound care across the UK to be £5.3 billion, with £3 billion associated with hard-to-heal wounds. This article looks at potential cost savings of managing hard-to-heal leg ulcers in a specialist wound care service using a multidisciplinary team (MDT) approach. This unique approach includes: a consultant dermatologist; a podiatrist specialising in mobility and gait; a clinical psychologist; clinical nurse specialists; and allied health professionals from tissue viability and lymphoedema services. Bringing together specialists from supporting disciplines provides a one-stop service for the patient. We conducted a retrospective analysis (over 365 days) of wound healing in patients attending the service for management of leg ulcers with differing aetiologies, including venous and atypical leg ulceration. Many of the patients referred to the service had a long wound history, between two and nine years, with a duration up to 25 years in the most complex cases. Within this complex cohort of patients, higher levels of focused compression was required (Accelerate Strapping, Accelerate, UK) for retromalleolar ulceration and management of foot oedema needing toe bandaging or garments. Wound healing was achieved in 72% of patients across all wound aetiologies, demonstrating the impact that a specialist MDT team can have on positive healing outcomes, and which can result in cost savings to the health economy and an improved quality of life for the patient.

Hyperbaric oxygen therapy for paediatric patients: an unintended consequence of the COVID-19 pandemic

OBJECTIVE

Hyperbaric oxygen therapy (HBOT) is a useful adjunctive treatment for selected complicated wounds, including severe diabetic lower extremity ulcerations and compromised skin grafts or flaps. The Sars-CoV-2 (COVID-19) pandemic has disrupted healthcare delivery, with its effects extending to delivery of HBOT. During the pandemic, paediatric patients in our geographic region who were referred for HBOT faced challenges as centres temporarily closed or were unprepared to treat younger patients. Our monoplace HBOT centre modified existing practices to allow for treatment of these patients. This study aims to outline the steps necessary to adapting a pre-existing HBOT centre for the safe treatment of paediatric patients.

METHOD

A retrospective review was performed to identify patients 18 years of age or younger referred for HBOT during 2020. Patient characteristics, referral indications and HBOT complications were collected. Changes implemented to the HBOT centre to accommodate the treatment of paediatric patients were documented.

RESULTS

A total of seven paediatric patients were evaluated for HBOT and six were treated. The mean patient age was four years (range: 1-11 years). Referral diagnoses included sudden sensorineural hearing loss, skin flap or graft compromise, and radiation-induced soft tissue necrosis. All patients tolerated HBOT treatment in monoplace chambers without significant complications noted. Enhancements made to our clinical practice to facilitate the safe and effective treatment of paediatric patients included ensuring the availability of acceptable garments for paediatric patients, maintaining uninterrupted patient grounding (in relation to fire safety), and enhancing social support for anxiety reduction.

CONCLUSION

The results of our review show that paediatric patients can be safely treated within the monoplace hyperbaric environment.

Electrical stimulation for pain reduction in hard-to-heal wound healing

OBJECTIVE

Despite treatment advances over the past 30 years, the societal impact of hard-to-heal wounds is increasingly burdensome. An unresolved issue is wound pain, which can make many treatments, such as compression in venous leg ulcers, intolerable. The aim of this review is to present the evidence and stimulate thinking on the use of electrical stimulation devices as a treatment technology with the potential to reduce pain, improve adherence and thus hard-to-heal wound outcomes.

METHOD

A literature search was conducted for clinical studies up to August 2020 reporting the effects of electrical stimulation devices on wound pain. Devices evoking neuromuscular contraction or direct spinal cord stimulation were excluded.

RESULTS

A total of seven publications (three non-comparative and four randomised trials) were identified with four studies reporting a rapid (within 14 days) reduction in hard-to-heal wound pain. Electrical stimulation is more widely known for accelerated healing and is one of the most evidence-based technologies in wound management, supported by numerous in vitro molecular studies, five meta-analyses, six systematic reviews and 30 randomised controlled trials (RCTs). Despite this wealth of supportive evidence, electrical stimulation has not yet been adopted into everyday practice. Some features of electrical stimulation devices may have hampered adoption in the past.

CONCLUSION

As new, pocket-sized, portable devices allowing convenient patient treatment and better patient adherence become more widely available and studied in larger RCTs, the evidence to date suggests that electrical stimulation should be considered part of the treatment options to address the challenges of managing and treating painful hard-to-heal wounds.

Diagnosis and treatment impacts on wound care efficiency drivers: real-world analysis

Objective: The prevalence and economic burden of wounds are growing. Any wound has the potential to become hard-to-heal and require frequent care. Clinicians need to find ways to absorb demand on services without compromising outcomes. Drivers of wound care efficiency-time-to-heal, frequency of dressing change and the incidence of complications-can be evaluated to shape future wound management. A survey of wound care was conducted by clinicians from five centres in Sweden over a one-week period, during which clinicians documented every wound once. At the time of surveying, 49% of wounds were considered to be improving, infection incidence was 11.7% and dressings were changed a mean of 2.2 times per week, with highly exuding wounds changed 6.9 times per week. The data highlighted the importance of diagnosing patient and wound characteristics in selecting treatments and organising care. Recognised gaps in diagnoses potentially identify opportunities to influence healing, complication incidence and intensity of nursing, thus reducing demand on resources. In conclusion, this survey highlights opportunities to reduce the burdens these drivers present. Through improved diagnosis and alignment to recognised care pathways, there is potential to improve patient outcomes and alleviate the strains placed upon wound care providers.

Evaluation of a novel bioactive wound dressing: an in vitro and in vivo study

OBJECTIVE

Hard-to-heal wounds, such as pressure ulcers and diabetic ulcers, are a major challenge for wound dressings. The aim of this study was to develop a bioactive dressing based on polymers and natural materials with unique biological and therapeutic properties.

METHOD

The dressing was composed of an active layer containing polyvinyl alcohol (PVA), honey, curcumin and keratin, and an upper layer with lower hydrophilicity comprising PVA to induce flexibility. Physicochemical properties of the dressing were characterised by Fourier transform infrared spectroscopy, field emission scanning electron microscopy, swelling behaviour and antibacterial measurements. A wound healing study was performed using an experimental rat model and two different compositions of the bioactive dressing were compared with a commercial wound dressing (Comfeel, Coloplast, Denmark). Histopathological evaluation was conducted for this purpose.

RESULTS

Characterisation results showed that a smooth bilayer film with two homogenous but distinct layers was produced. The dressing also provided adequate moisture to the wound environment without infection and adhesion due to dryness occurring. Our results exhibited significant bactericidal activity against Gram-negative (Escherichia coli) and Gram-positive (Staphylococcus aureus) bacteria and improved the wound healing process without any scarring. Histopathological findings demonstrated a significant higher healing rate in vivo together with well-formed epidermis, granulation tissue formation and tissue contraction, when compared with the commercial wound dressing.

CONCLUSION

Our results demonstrated acceptable physical and healing effects for the novel bioactive wound dressing; however, more investigations are recommended.

Debriding effect of amino acid-buffered hypochlorite on hard-to-heal wounds covered by devitalised tissue: pilot study

OBJECTIVE

Wounds such as lower extremity ulcers are serious, costly and frequently hard to heal. Guidelines conclude that new dressings and treatments generally fail to show superiority compared with standard of care. Several mechanisms are probably responsible for impaired healing of hard-to-heal wounds, including inflammation and infection. Amino acid-buffered hypochlorite has presumed antiseptic and antibacterial properties and has been shown to be useful in the treatment of diabetic foot ulcers (DFUs). We evaluated the debriding effect of amino acid-buffered hypochlorite (ChloraSolv) on full skin hard-to-heal lower extremity ulcers covered with devitalised tissue (≥50%), with six applications over 5 weeks and follow-up at 12 weeks.

METHOD

This was an open-label, single-arm, multicentre, pre-market pilot investigation. We recruited subjects with a lower extremity ulcer, covered with devitalised tissue (≥50%), who were candidates for cleansing and debridement/desloughing. There was a weekly application of the investigational device for five weeks. Follow-up for wound status evaluation was performed at 12 weeks from baseline.

RESULTS

We evaluated 57 subjects (33 males, 24 females, median age 73 years, range 51-90 years) (intention-to-treat). Of these, 61.4% had a leg ulcer and 38.6% a foot ulcer. The median wound size at baseline was 7.7cm² (range 2.1-52cm²) with devitalised tissue coverage of 76.5%. After 5 weeks, a decrease of 72.7% in devitalised tissue was seen, and 71.4% of the subjects showed a decrease in devitalised tissue of ≥50% (evaluated independently using PictZar). At 12 weeks' follow-up the decrease in devitalised tissue was 84.4%. Wound-related pain was reported by ten subjects, resulting in 17 adverse events (AEs). Among these, 12 AEs from eight subjects were recorded as possibly or probably related to the investigational device and one AE was reported to have a causal relationship with the investigational device.

CONCLUSION

This clinical study suggests that amino acid-buffered hypochlorite can be effective and well tolerated in the treatment of hard-to-heal lower extremity ulcers to dissolve and remove devitalised tissue.

An audit to assess the impact of prescribing a monofilament fibre debridement pad for patients with unhealed wounds after six months

A monofilament fibre debridement pad has been found to be a rapid and effective mechanical method of removing dry skin, biofilm and debris from acute and chronic wounds with minimal patient discomfort. Evidence of its impact on prescribing and wound healing, however, has been more limited. The aim of this audit was to show evidence of the monofilament fibre debridement pad's impact on wound treatment costs through an analysis of NHS wound-care prescribing data in England. A dataset for 486 uniquely identified patients who had been newly prescribed the monofilament fibre debridement pad was obtained from the NHS Business Services Authority. All data were anonymised. Costs were identified for the six months before and six months after the month of first prescription of the monofilament fibre debridement pad. The total cost of wound-care prescribing fell by 14% or £101,723 in the six months after the intervention compared with the six months before. The average monthly expenditure per patient fell from £244 before the intervention to £209 (n=486) after. These results indicate that use of the monofilament fibre debridement pad could reduce prescribing costs and the use of antimicrobial and negative pressure therapies. Further research is warranted to investigate the clinical role of the monofilament fibre debridement pad in wound healing.

The characteristics and impact of hard-to-heal wounds: results of a standardised survey

The effective management of hard-to-heal wounds has increasingly important implications for those who provide wound care services within healthcare systems. The burden of wounds in the population continues to grow, as does the demand for wound care, against a backdrop of cost constraints and increasing expectations. The need to improve both outcomes and efficiency in wound care is therefore paramount and the time taken to heal wounds is an important factor in determining both. Survey methodology was used to collect data across 10 community wound care providers in the UK, Ireland, Finland, Norway and Denmark between February and August 2017. This allowed for analysis of wounds and their characteristics, dressing selection and nursing practice across a typical wound caseload. Data from 1057 wounds demonstrates that the characteristics and consequences of hard-to-heal wounds are different from improving wounds. However, wounds are, in general, treated in the same way, irrespective of whether they are hard-to-heal or improving, suggesting that the healing status of a wound is not a major factor in treatment selection. Early intervention to return hard-to-heal wounds to a healing trajectory may be a useful approach to improving efficiency in wound care.

Effectiveness of autologous platelet-rich plasma gel in the treatment of hard-to-heal leg ulcers: a randomised control trial

OBJECTIVE

Regenerative medicine products such as autologous platelet-rich plasma (autologous PRP) gel may speed up the process of healing. Clinical studies show promising results in the treatment of diabetic foot ulcers (DFUs), however there is lack of scientific evidence of autologous PRP effectiveness in treating leg ulcers of other aetiology. This study evaluates the effectiveness of autologous PRP gel in the treatment of hard-to-heal leg ulcers compared with existing conventional treatment.

METHOD

A prospective, randomised controlled, open-labelled clinical trial was carried out between 2014 and 2018. An eight-week study protocol was chosen or until 100% wound re-epithelialisation was observed. Wound size reduction, granulation tissue formation, microbiological wound bed changes and safety were evaluated.

RESULTS

A total of 69 patients (35 in the autologous PRP group and 34 in the control group) were included in the study; 25.71% of the autologous PRP group and 17.64% of control group had ulcers completely re-epithelialised (p>0.05). Wound size reduction in the autologous PRP group was 52.35% and 33.36% in the control group (p=0.003). The autologous PRP group showed superiority over conventional treatment in wound bed coverage with granulation (p=0.001). However, more frequent wound contamination was observed at the end of treatment in the autologous PRP group (p=0.024). No severe adverse events were noted during the study. Both treatment methods were considered equally safe.

CONCLUSION

Topical application of autologous PRP gel in leg ulcers of various aetiology show beneficial results in wound size reduction and induces the granulation tissue formation. However, it is associated with more frequent microbiological wound contamination.

Cost-effectiveness of adjunct haemoglobin spray in the treatment of hard-to-heal wounds in a UK NHS primary care setting

OBJECTIVE

To evaluate the cost-effectiveness of topical haemoglobin spray as adjunct therapy in the treatment of hard-to-heal wounds within a UK National Health Service (NHS) community setting.

METHOD

In a previously published comparative clinical evaluation, 50 consecutive patients treated with topical haemoglobin spray, as adjunct to standard care and followed up over 26 weeks, were compared with 50 consecutive retrospective controls from the same clinic treated with the same standard care protocol in the year prior to the introduction of adjunct topical haemoglobin spray. A de novo cost-effectiveness and break-even analysis were performed, using data from the previously published clinical evaluation, for all patients (intent-to-treat) and for patients with complete follow-up using a micro-costing approach and considering only wound care dressing costs.

RESULTS

At 26 weeks, the total cost of dressings for all patients in the intervention group was £6953 with 874 cumulative weeks healed, compared with £9547 with 278 cumulative weeks healed for all patients in the control group. The incremental cost-effectiveness ratio (ICER), the incremental cost per additional week healed with adjunct topical haemoglobin spray, is therefore negative (dominant). Total treatment costs per week were lower from week six onwards, with break-even estimated to be at week 10.2. When considering only patients with complete follow-up, the results were similarly dominant, with a mean 10.9 more weeks healed, a mean dressing cost saving per patient of £81.83 by week 26 (-37%). Cost savings were realised from week five, and a break-even was estimated to occur at week 8.0.

CONCLUSION

Topical haemoglobin spray has the potential to restore the healing process, reduce healing times and reduce dressing costs in a NHS community setting, within a few weeks of adoption.

Cost-effectiveness of soluble beta-glucan gel in hard-to-heal wounds: an evaluation

OBJECTIVE

To evaluate the cost-effectiveness of a soluble beta-glucan-containing gel as short-term adjunct therapy in the treatment of hard-to-heal wounds in a UK community health-care setting.

METHODS

A comparative clinical evaluation involving consecutive patients treated for up to eight weeks with a beta-glucan-containing gel as adjunct to standard care. This was compared with consecutive patients as retrospective controls, and using the same standard care protocol from a year previously. The inclusion criteria was wounds that were slow-healing or stalled (<40% healing in four weeks).

RESULTS

A total of 300 patients took part. Complete follow-up at 24 weeks was available for 144 patients in the beta-glucan group, and 136 patients in the standard care group. At 24 weeks, the beta-glucan group had a 96% healing rate compared with 75% in the standard care group (p<0.001). The improvement in healing was associated with a reduction in the mean number of weeks of treatment per patient (7.2 and 10.7 for beta-glucan and standard care, respectively), and a reduction in the mean cost of treatment (£576 versus £685 for beta-glucan and standard care, respectively). Treatment costs included nursing time, prescription medications and dressings. In a subset of ulcer wounds (50% of the full sample), at 24 weeks the beta-glucan group had a 92% healing rate compared with 46% in the standard care group (p<0.001). Mean weeks of treatment were 10.4 versus 17.6, leading to a reduction in treatment cost of £388 per patient (£1227 versus £839) over 24 weeks.

CONCLUSION

The results of this evaluation suggest that short-term use of the beta-glucan gel as an adjunct to standard care on slow-healing wounds can shorten healing times and reduce NHS costs.