Chronic wound prevalence and the associated cost of treatment in Medicare beneficiaries: changes between 2014 and 2019

Silk fibroin/chitosan/montmorillonite sponge dressing: Enhancing hemostasis, antimicrobial activity, and angiogenesis for advanced wound healing applications

Open wounds present a significant challenge in healthcare, requiring careful management to prevent infection and promote wound healing. Advanced wound dressings are critical need to enhance their hemostatic capabilities, antimicrobial properties, and ability to support angiogenesis and sustained moisture for optimal healing. This study introduces a flexible hemostatic dressing designed for open wounds, integrating chitosan (CS) for hemostasis and biocompatibility, silk fibroin (SF) for mechanical strength, and montmorillonite (MMT) for enhanced drug transport. The CSSF@MMT dressings showed promising mechanical strength and swift hemostasis. The CIP-loaded CSSF@MMT demonstrated sustained release for up to one week, exhibiting antibacterial properties against both Gram-positive and Gram-negative bacteria. In vitro cell migration assay demonstrated that erythropoietin-loaded CSSF@MMT dressings promoted the proliferation and migration of endothelial cells. Similarly, the chick embryo chorioallantoic membrane study indicated the same dressings exhibited a significant increase in vascular regeneration. This research suggests that the CSSF@MMT sponge dressing, incorporated with CIP and erythropoietin, holds promise in effectively halting bleeding, creating a protective environment, diminishing inflammation, and fostering wound tissue regeneration. This potential makes it a significant advancement in open wound care, potentially lowering the need for limb amputation and decreasing wound care burden worldwide.

Experiences of patients with hard-to-heal wounds: insights from a pilot survey

OBJECTIVE

To learn about the experiences of people who seek treatment for hard-to-heal wounds, we distributed a nationwide pilot survey, asking questions about the nature of their wound, how it shaped their daily lives, pathways to receiving care and experiences with treatment. The long-term objective is to quantify the journey of patients with hard-to-heal wounds to identify ideal intervention points that will lead to the best outcomes. This article summarises the findings, implications, limitations and suggestions for future research.

METHOD

Qualitative data were self-reported from patients with hard-to-heal wounds (open for ≥4 weeks) in a pilot chatbot survey, (Wound Expert Survey (WES)) provided online in the US on Meta platforms (Facebook and Instagram) between 2021 and 2022.

RESULTS

The US national pilot survey attracted responses from 780 patients, 27 of whom provided a video testimonial. Some 57% of patients delayed treatment because they believed their wound would heal on its own, and only 4% saw a wound care specialist. Respondents reported the cost of care as the most frequent reason for not following all of a doctor's treatment recommendations. Queries regarding quality of life (QoL) revealed that more than half (65%) said they have negative thoughts associated with their wound at least every few days. Some 19% of respondents said their wound had an odour and, of them, 34% said odour had a major or severe negative impact on their self-confidence. Economically, nearly one-quarter of respondents said having a wound led to a drop in their total household income and 17% said their wound led to a change in their employment status.

CONCLUSION

A national pilot survey of patients with hard-to-heal wounds revealed that many delay seeking professional assistance and only a small minority see a wound care specialist. Experiencing an ulcer, even for a few months, can have significant negative effects on a patient's QoL. Patients frequently had negative thoughts associated with their wound, and odour compounded these negative effects, leading to major or severe negative impacts on self-confidence. Households experienced a decline in income, due to both the direct reduction or loss of patient employment and the additional time spent by family members assisting in patient recovery. Thus, a variety of factors contribute to poor outcomes for patients with hard-to-heal wounds. To validate and extend these preliminary results, future surveys of patients with hard-to-heal wounds should focus on additional reasons patients do not seek professional help sooner. To improve health outcomes and QoL, assessment of patient socioeconomic variables should occur whenever wound closure stalls.

A low-cost, antimicrobial aloe-alginate hydrogel film containing Australian First Nations remedy 'lemon myrtle oil' (Backhousia citriodora) - Potential for incorporation into wound dressings

Chronic wounds pose a global public health challenge, particularly in remote settings where access to specialised wound care and dressings can be limited and cost-prohibitive. First Nations communities in Australia are at a significantly higher risk for developing chronic wounds and this risk further increases for people living in remote regions. There is an urgent need to develop inexpensive but effective wound dressings to improve wound outcomes. Over the past decade, sodium alginate (SA)-based hydrogel polymers have emerged as a cost-effective and biocompatible component in wound dressings, and many have been successfully commercialised. In this study, we have developed and evaluated various prototypes of SA-based hydrogels with the addition of another low-cost component, aloe vera (AV) to further tailor the physicochemical properties of the hydrogel. Since the presence of microbes is a major contributor to the pathophysiology of chronic wounds, we also evaluated the antimicrobial activity of lemon myrtle oil (LMO) (Backhousia citriodora) incorporated into the hydrogel, a remedy used traditionally by First Nations Australians. Novel formulations of AV-SA-LMO hydrogel prototypes in the absence and presence of lemon myrtle oil (at a concentration of 5 μg/mL) were assessed for their physicochemical and antimicrobial properties and compared to a commercially available hydrogel-based dressing. The addition of lemon myrtle oil imparted viscoelastic behaviour for improved processability of AV-SA-LMO hydrogel prototypes, while increasing protein adhesion, enhancing physical properties, and demonstrating antimicrobial activity against the common wound-infecting microbes Staphylococcus epidermidis and Candida albicans. Fourier transmission infrared (FTIR) spectra confirmed the molecular structures of the hydrogel prototypes as predicted. The prototypes also demonstrated biocompatibility with the HaCaT human keratinocyte cell line. This study has provided preliminary evidence that a 25:75 aloe vera:sodium alginate hydrogel with 5 μg/mL lemon myrtle oil has comparable physicochemical characteristics to a commercial hydrogel-based wound dressing and antimicrobial properties against S. epidermidis and C. albicans.

Crosslinking gelatin with robust inherent antibacterial natural polymer for wound healing

Gelatin-based biomaterials are widely acknowledged as a promising choice for wound dressings, given their similarity to the extracellular matrix and biocompatibility. However, the challenge of cross-linking gelatin while preserving its biocompatibility and cost-effectiveness persists. This study aimed to enhance the properties of gelatin by incorporating the oxidized lignosulfonate (OLS) biopolymer as an inexpensive and biocompatible natural material. The polyphenolic structure of OLS acts as both a cross-linking agent and an antibacterial component. The OLS/gelatin films were prepared using a casting method with varying weight ratios (0.1, 0.2, 0.3, 0.4, and 0.5 w/w). FTIR analysis confirmed the formation of Schiff-base and hydrogen bonds between gelatin and OLS. The resulting films exhibited enhanced mechanical properties (Young's modulus ∼40 MPa), no cytotoxicity, and excellent cell adhesion and morphology. Antimicrobial tests showed significant activity against Escherichia coli and Staphylococcus aureus, with higher activity against S. aureus (17 mm inhibition zone and 99 % bactericidal rate). In vivo studies in a mouse model demonstrated that the gelatin/0.2OLS dressing significantly improved wound healing, including re-epithelialization, collagen formation, inflammation reduction, and blood vessel density, compared to untreated wounds. These findings suggest that the synthesized novel gelatin/OLS wound dressing has promising healing and antibacterial properties.

Efficacy and safety of autologous whole blood clot in diabetic foot ulcers: a randomised controlled trial

OBJECTIVE

Diabetic foot ulcers (DFUs) present a significant global health challenge, resulting in high morbidity and economic costs. Current available treatments often fail to achieve satisfactory healing rates, highlighting the need for novel therapies. This study evaluated the safety and efficacy of a novel autologous whole blood clot (AWBC)-a blood-based, biodegradable provisional matrix-in conjunction with standard of care (SoC) when compared to SoC alone in the treatment of hard-to-heal DFUs.

METHOD

A multicentre, prospective, blinded assessor, randomised controlled trial was conducted at 16 sites across the US, South Africa and Turkey. A cohort of patients with hard-to-heal DFUs was enrolled and randomised to either the AWBC group or the control group. The primary endpoint was complete wound closure at 12 weeks, while secondary endpoints included time to heal and percentage area reduction (PAR) at four and eight weeks. Data were analysed using both intention-to-treat (ITT) and per-protocol (PP) populations.

RESULTS

The cohort included 119 patients. AWBC treatment resulted in a significantly higher healing rate compared to the control in both ITT (41% versus 15%, respectively; p=0.002) and PP populations (51% versus 18%, respectively; p=0.0075). AWBC treatment also resulted in a shorter mean time to heal and higher durability of wound closure. Safety analysis showed a similar incidence of adverse events (AEs) between groups, with no device-related AEs.

CONCLUSION

The AWBC system, by modulating the wound microenvironment and providing a functional extracellular matrix, offered a promising new approach to treating hard-to-heal DFUs, demonstrating superior healing outcomes compared to SoC alone in this study.

A multicentre clinical trial evaluating the outcomes of two application regimens of a unique keratin-based graft in the treatment of Wagner grade one non-healing diabetic foot ulcers

Diabetic foot complications that lead to lower extremity amputations pose a significant challenge to the entire global health system. In this multicentre clinical trial, 26 patients with chronic Wagner one diabetic foot ulcers (DFUs) were treated with a unique human keratin matrix graft applied either weekly or bi-weekly, in addition to standard of care. The hypothesis was that bi-weekly application would be similar to weekly application. The primary endpoint was complete wound closure by 12 weeks, and secondary endpoints included healing time, percent area reduction and weekly changes in peripheral neuropathy, pain and quality of life. In the intent-to-treat population, 77% (10/13) of DFUs treated with bi-weekly application healed compared with 69% (9/13) treated with weekly application. The mean time to heal within 12 weeks in the bi-weekly group was 61 days and in the weekly group was 54 days. The mean percent area reduction at 12 weeks was 94.7% in the bi-weekly group compared with 84.8% in the weekly group. The number of grafts used in the bi-weekly group was 3.9 compared with 6.2 in the weekly group. The results of this trial confirm our hypothesis that whether bi-weekly or weekly application of the unique keratin matrix graft is used to treat nonhealing indolent DFUs, there is a high rate of complete healing. Based on these results, future studies should be conducted that further investigate the use of this novel human keratin matrix graft for the treatment of chronic DFUs.

Antiseptic management of critical wounds: differential bacterial response upon exposure to antiseptics and first insights into antiseptic/phage interactions

BACKGROUND

With the antibiotic crisis, the topical antibacterial control including chronic wounds gains increasing importance. However, little is known regarding tolerance development when bacteria face repetitive exposure to the identical antiseptics as commonly found in clinical practice.

MATERIALS AND METHODS

Clinical isolates foremost of chronic wounds were exposed in vitro to dilutions of two antiseptics used for wound therapy: polyhexanide or octenidine. Adaptive response was determined by growth/kill curves, minimal inhibitory concentration (MIC), and whole genome sequencing. Antiseptic/bacteriophage combinations were studied by liquid-infection assays and bacterial plating.

RESULTS

Polyhexanide acted stronger against Escherichia coli and Proteus mirabilis while octenidine was more potent against Staphylococcus aureus . Otherwise, the antiseptic efficacy varied across isolates of Klebsiella pneumoniae , Pseudomonas aeruginosa , and Acinetobacter baumannii . Upon repetitive exposure with constant antiseptic concentrations P. aeruginosa and P. mirabilis adaptation was evident by a reduced lag-phase and a twofold increased MIC. Under increasing octenidine concentrations, P. aeruginosa adapted to an eightfold higher dosage with mutations in smvA , opgH , and kinB affecting an efflux pump, alginate and biofilm formation, respectively. S. aureus adapted to a fourfold increase of polyhexanide with a mutation in the multiple peptide resistance factor MprF, also conferring cross-resistance to daptomycin. Antiseptic/bacteriophage combinations enhanced bacterial inhibition and delayed adaptation.

CONCLUSION

Different bacterial species/strains respond unequally to low-level antiseptic concentrations. Bacterial adaptation potential at phenotypic and genotypic levels may indicate the necessity for a more nuanced selection of antiseptics. Bacteriophages represent a promising yet underexplored strategy for supporting antiseptic treatment, which may be particularly beneficial for the management of critical wounds.

Efficacy and Safety of Honey Dressings in the Management of Chronic Wounds: An Updated Systematic Review and Meta-Analysis

Chronic wounds impose a substantial economic burden on healthcare systems and result in decreased productivity. Honey possesses diverse properties, rendering it a promising, cost-effective, and efficacious intervention strategy for the management of chronic wounds. However, the findings are controversial. We have presented an updated and comprehensive systematic review and meta-analysis to evaluate the efficacy and safety of honey dressings in the management of chronic wounds. Nine electronic databases were systematically searched to identify relevant studies published prior to 22 March 2024. A total of eight studies, including 906 individuals that met the inclusion criteria, were incorporated. The findings demonstrated a significant acceleration in wound healing time with honey dressings (MD = -17.13, 95% CI -26.37 to -7.89, p = 0.0003) and an increase in the percentage of wound healing (MD = 18.31, 95% CI 8.86 to 27.76, p = 0.0001). No statistically significant differences were observed in the healing rate (RR = 2.00, 95% CI 0.78 to 5.10, p = 0.15), clearance time of bacteria (MD = -11.36, 95% CI: -25.91 to 3.18, p = 0.13) and hospital stay duration. Honey may decrease the VAS score but may increase the incidence of painful discomfort during treatment. The topical application of honey is an effective therapeutic approach for managing chronic wounds, but the quality of the evidence was very low due to the quality of risk of bias, inconsistency, and publication bias, highlighting the necessity for larger-scale studies with adequately powered RCTs to ensure the safety and efficacy of honey dressings in chronic wound healing.

Exploring Synergistic Effects of Bioprinted Extracellular Vesicles for Skin Regeneration

Regenerative medicine represents a paradigm shift in healthcare, aiming to restore tissue and organ function through innovative therapeutic strategies. Among these, bioprinting and extracellular vesicles (EVs) have emerged as promising techniques for tissue rejuvenation. EVs are small lipid membrane particles secreted by cells, known for their role as potent mediators of intercellular communication through the exchange of proteins, genetic material, and other biological components. The integration of 3D bioprinting technology with EVs offers a novel approach to tissue engineering, enabling the precise deposition of EV-loaded bioinks to construct complex three-dimensional (3D) tissue architectures. Unlike traditional cell-based approaches, bioprinted EVs eliminate the need for live cells, thereby mitigating regulatory and financial obstacles associated with cell therapy. By leveraging the synergistic effects of EVs and bioprinting, researchers aim to enhance the therapeutic outcomes of skin regeneration while addressing current limitations in conventional treatments. This review explores the evolving landscape of bioprinted EVs as a transformative approach for skin regeneration. Furthermore, it discusses the challenges and future directions in harnessing this innovative therapy for clinical applications, emphasizing the need for interdisciplinary collaboration and continued scientific inquiry to unlock its full therapeutic potential.

Counting the Cost of Cellular and/or Tissue-Based Products in Diabetic Foot Ulcers: Is There a Justifiable Price Limit per Square Centimeter?

Objective: To identify how cellular and/or tissue-based products (CTPs) relate to value in terms of cost per quality-adjusted life years (QALYs) in wound care in comparison with treatments in other medical fields. Approach: This is a cross-sectional study and a cost-effectiveness analysis. Payment limits for each CTP were obtained via the Healthcare Common Procedure Coding System Q codes and formulated as cost inputs into a cost-utility model published for treatment of Wagner 1 diabetic foot ulcers using dehydrated human amnion and chorion allograft versus standard of care (SOC). Additional changes to cap the number of CTP applications and adjustments for recent inflation were made. The literature was searched for other cost-utility models in other diabetes-related diseases as a comparison. Results: When the payment limit was ≤$140 per square centimeter, interventions were dominant (less costly, better outcomes) compared with SOC. When the limit exceeded $430 per square centimeter, the cost-effectiveness threshold of $100,000/QALY was exceeded. Newer Q codes are generally much more expensive and likely to not be cost-effective, similar to the results for many other chronic diabetes-related diseases . Innovation: This study presents decision makers with tools, by which they can determine as to whether a given CTP is likely to be cost-effective for patients. Conclusion: Over a third of all CTPs will very likely result in noncost-effective interventions. This number is likely to be higher when wounds are larger or used in other wound types where they are less efficacious. The recent trend in much higher costs for CTPs is worrisome.

Comparative Effectiveness of Placental Allografts in the Treatment of Diabetic Lower Extremity Ulcers and Venous Leg Ulcers in U.S. Medicare Beneficiaries: A Retrospective Observational Cohort Study Using Real-World Evidence

Objective: To compare the effectiveness of cellular tissue products (CTP) versus standard care in U.S. Medicare beneficiaries with diabetic lower extremity ulcers (DLEUs) or venous leg ulcers (VLUs). Approach: We performed a retrospective cohort study using real-world evidence from U.S. Medicare claims for DLEUs or VLUs between 2016 and 2020. There were three cohorts evaluated: viable cryopreserved placental membrane (vCPM) or viable lyopreserved placental membrane (vLPM); other CTP; and standard care. Claims were collapsed into episodes of care. Univariate and bivariate statistics were used to examine the frequency distribution of demographics and clinical variables. Multivariable zero-inflated binomial regressions were used to evaluate mortality and recurrence trends. Logistic regression compared three adverse outcomes (AOs): amputation; 1-year mortality; and wound recurrence. Results: There were 333,362 DLEU episodes among 261,101 beneficiaries, and 122,012 VLU episodes among 80,415 beneficiaries. DLEU treatment with vLPM was associated with reduced 1-year mortality (-26%), reduced recurrence (-91%), and reduced AOs (-71%). VLU treatment with vCPM or vLPM was associated with reduced 1-year mortality (-23%), reduced recurrence (-80%), and 66.77% reduction in AOs. These allografts were also associated with a 49% and 73% reduced risk of recurrence in DLEU and VLU, respectively, compared with other CTPs. Finally, vCPM or vLPM were associated with noninferior prevention of AOs related to amputation, mortality, and recurrence (95% CI: 0.69-1.14). Conclusions: DLEUs and VLUs treated with vCPM and vLPM allografts are associated with lowered 1-year mortality, wound recurrence, and AOs in DLEUs and VLUs compared with standard care. Decision makers weighing coverage of placental allografts should consider these added short- and long-term clinical benefits relative to costly management and high mortality of Medicare's most frequent wounds.

Incorporation of natural and synthetic polymers into honey hydrogel for wound healing: A review

Background and Aims

The difficulty in treating chronic wounds due to the prolonged inflammation stage has affected a staggering 6.5 million people, accompanied by 25 billion USD annually in the United States alone. A 1.9% rise in chronic wound prevalence among Medicare beneficiaries was reported from 2014 to 2019. Besides, the global wound care market values were anticipated to increase from USD 20.18 billion in 2022 to USD 30.52 billion in 2030, suggesting an expected rise in chronic wounds financial burdens. The lack of feasibility in using traditional dry wound dressings sparks hydrogel development as an alternative approach to tackling chronic wounds. Since ancient times, honey has been used to treat wounds, including burns, and ongoing studies have also demonstrated its wound-healing capabilities on cellular and animal models. However, the fluidity and low mechanical strength in honey hydrogel necessitate the incorporation of other polymers. Therefore, this review aims to unravel the characteristics and feasibility of natural (chitosan and gelatin) and synthetic (polyvinyl alcohol and polyethylene glycol) polymers to be incorporated in the honey hydrogel.

Methods

Relevant articles were identified from databases (PubMed, Google Scholar, and Science Direct) using keywords related to honey, hydrogel, and polymers. Relevant data from selected studies were synthesized narratively and reported following a structured narrative format.

Results

The importance of honey's roles and mechanisms of action in wound dressings were discussed. Notable studies concerning honey hydrogels with diverse polymers were also included in this article to provide a better perspective on fabricating customized hydrogel wound dressings for various types of wounds in the future.

Conclusion

Honey's incapability to stand alone in hydrogel requires the incorporation of natural and synthetic polymers into the hydrogel. With this review, it is hoped that the fabrication and commercialization of the desired honey composite hydrogel for wound treatment could be brought forth.

Double-modified, thio and methylene ATP analogue facilitates wound healing in vitro and in vivo

Recent data indicate that extracellular ATP affects wound healing efficacy via P2Y2-dependent signaling pathway. In the current work, we propose double-modified ATP analogue-alpha-thio-beta,gamma-methylene-ATP as a potential therapeutic agent for a skin regeneration. For the better understanding of structure-activity relationship, beside tested ATP analogues, the appropriate single-modified derivatives of target compound, such as alpha-thio-ATP and beta,gamma-methylene-ATP, were also tested in the context of their involvement in the activation of ATP-dependent purinergic signaling pathway via the P2Y2 receptor. The diastereomerically pure alpha-thio-modified-ATP derivatives were obtained using the oxathiaphospholane method as separate SP and RP diastereomers. Both the single- and double- modified ATP analogues were then tested for their impact on the viability and migration of human keratinocytes. The involvement of P2Y2-dependent purinergic signaling was analyzed in silico by molecular docking of the tested compounds to the P2Y2 receptor and experimentally by studying intracellular calcium mobilization in the human keratinocytes HaCaT. The effects obtained for ATP analogues were compared with the results for ATP as a natural P2Y2 agonist. To confirm the contribution of the P2Y2 receptor to the observed effects, the tests were also performed in the presence of the selective P2Y2 antagonist-AR-C118925XX. The ability of the alpha-thio-beta,gamma-methylene-ATP to influence cell migration was analyzed in vitro on the model HaCaT and MDA-MB-231 cells by wound healing assay and transwell migration test as well as in vivo using zebrafish system. The impact on tissue regeneration was estimated based on the regrowth rate of cut zebrafish tails. The in vitro and in vivo studies have shown that the SP-alpha-thio-beta,gamma-methylene-ATP analogue promotes regeneration-related processes, making it a suitable agent for enhance wound healing. Performed studies indicated its impact on the cell migration, induction of epithelial-mesenchymal transition and intracellular calcium mobilization. The enhanced regeneration of cut zebrafish tails confirmed the pro-regenerative activity of this ATP analogue. Based on the performed studies, the SP-alpha-thio-beta,gamma-methylene-ATP is proposed as a potential therapeutic agent for wound healing and skin regeneration treatment.

Multifunctional antibacterial hydrogels for chronic wound management

Chronic wounds have gradually evolved into a global health challenge, comprising long-term non-healing wounds, local tissue necrosis, and even amputation in severe cases. Accordingly, chronic wounds place a considerable psychological and economic burden on patients and society. Chronic wounds have multifaceted pathogenesis involving excessive inflammation, insufficient angiogenesis, and elevated reactive oxygen species levels, with bacterial infection playing a crucial role. Hydrogels, renowned for their excellent biocompatibility, moisture retention, swelling properties, and oxygen permeability, have emerged as promising wound repair dressings. However, hydrogels with singular functions fall short of addressing the complex requirements associated with chronic wound healing. Hence, current research emphasises the development of multifunctional antibacterial hydrogels. This article reviews chronic wound characteristics and the properties and classification of antibacterial hydrogels, as well as their potential application in chronic wound management.

Advancements in Dermatological Applications of Curcumin: Clinical Efficacy and Mechanistic Insights in the Management of Skin Disorders

Curcumin, derived from Curcuma longa (turmeric), exhibits significant potential in dermatology, addressing conditions like atopic dermatitis, psoriasis, chronic wounds, skin cancer, and infections through its anti-inflammatory, antioxidant, anticancer, and antimicrobial properties. This review synthesizes evidence on curcumin's mechanisms, including modulation of immune responses and promotion of wound healing, showcasing its efficacy in reducing inflammation, cytokine levels, and enhancing skin barrier functions. Studies highlight curcumin's ability to selectively target tumor cells, suggesting a multifaceted approach to cancer therapy with minimal side effects. Despite promising therapeutic benefits, challenges remain in bioavailability, potency, and targeted delivery, underscoring the need for further research to optimize dosages, delivery methods, and assess long-term safety. The integration of curcumin into dermatological practice requires a balanced consideration of evidence-based efficacy and safety. Curcumin's comprehensive utility in dermatology, coupled with the necessity for advanced scientific exploration, emphasizes the importance of combining traditional knowledge with contemporary research to improve patient care in dermatology. This approach could significantly enhance outcomes for individuals with skin-related conditions, marking curcumin as a versatile and promising agent in the field.

A review of the current state of natural biomaterials in wound healing applications

Skin, the largest biological organ, consists of three main parts: the epidermis, dermis, and subcutaneous tissue. Wounds are abnormal wounds in various forms, such as lacerations, burns, chronic wounds, diabetic wounds, acute wounds, and fractures. The wound healing process is dynamic, complex, and lengthy in four stages involving cells, macrophages, and growth factors. Wound dressing refers to a substance that covers the surface of a wound to prevent infection and secondary damage. Biomaterials applied in wound management have advanced significantly. Natural biomaterials are increasingly used due to their advantages including biomimicry of ECM, convenient accessibility, and involvement in native wound healing. However, there are still limitations such as low mechanical properties and expensive extraction methods. Therefore, their combination with synthetic biomaterials and/or adding bioactive agents has become an option for researchers in this field. In the present study, the stages of natural wound healing and the effect of biomaterials on its direction, type, and level will be investigated. Then, different types of polysaccharides and proteins were selected as desirable natural biomaterials, polymers as synthetic biomaterials with variable and suitable properties, and bioactive agents as effective additives. In the following, the structure of selected biomaterials, their extraction and production methods, their participation in wound healing, and quality control techniques of biomaterials-based wound dressings will be discussed.

Use of hypothermically stored amniotic membrane on diabetic foot ulcers: a multicentre retrospective case series

OBJECTIVE

The aim of this retrospective case series was to report on the outcomes of diabetic foot ulcers (DFUs) managed with hypothermically stored amniotic membrane (HSAM).

METHOD

Deidentified case data of patients who received HSAM were obtained from wound care sites across the US. Data were collected, beginning at the first patient visit to the wound care site (first presentation), at the visit in which the first HSAM application occurred (baseline), and at each subsequent visit over 12 weeks of treatment (follow-up). All patients received standard of care (SoC) between first presentation and baseline.

RESULTS

Of the 50 patients in the study, 68% were male. Mean age of the entire cohort was 66.7 years. Of the DFUs, 88% were present for <6 months at first presentation. Mean wound area was 3.5cm2, and mean percentage area reduction was -68.3% from first presentation to baseline. The mean number of HSAM applications was 5.5, and mean number of days between applications was 7.5. A >60% area reduction was attained in 96.0% of DFUs, and 78% attained complete wound closure (CWC) by week 12. The median time to CWC was 55 days.

CONCLUSION

The results of this retrospective case series suggest positive outcomes for DFUs managed with HSAM. A reduction in time to CWC may lead to lesser financial burden and improved quality of life for DFU patients.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

Dehydrated human amnion/chorion membrane to treat venous leg ulcers: a cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of dehydrated human amnion/chorion membrane (DHACM) in Medicare enrolees who developed a venous leg ulcer (VLU).

METHOD

This economic evaluation used a four-state Markov model to simulate the disease progression of VLUs for patients receiving advanced treatment (AT) with DHACM or no advanced treatment (NAT) over a three-year time horizon from a US Medicare perspective. DHACM treatments were assessed when following parameters for use (FPFU), whereby applications were initiated 30-45 days after the initial VLU diagnosis claim, and reapplications occurred on a weekly to biweekly basis until completion of the treatment episode. The cohort was modelled on the claims of 530,220 Medicare enrolees who developed a VLU between 2015-2019. Direct medical costs, quality-adjusted life years (QALYs), and the net monetary benefit (NMB) at a willingness-to-pay threshold of $100,000/QALY were applied. Univariate and probabilistic sensitivity analyses (PSA) were performed to test the uncertainty of model results.

RESULTS

DHACM applied FPFU dominated NAT, yielding a lower per-patient cost of $170 and an increase of 0.010 QALYs over three years. The resulting NMB was $1178 per patient in favour of DHACM FPFU over the same time horizon. The rate of VLU recurrence had a notable impact on model uncertainty. In the PSA, DHACM FPFU was cost-effective in 63.01% of simulations at the $100,000/QALY threshold.

CONCLUSION

In this analysis, DHACM FPFU was the dominant strategy compared to NAT, as it was cost-saving and generated a greater number of QALYs over three years from the US Medicare perspective. A companion VLU Medicare outcomes analysis revealed that patients who received AT with a cellular, acellular and matrix-like product (CAMP) compared to patients who received NAT had the best outcomes. Given the added clinical benefits to patients at lower cost, providers should recommend DHACM FPFU to patients with VLU who qualify. Decision-makers for public insurers (e.g., Medicare and Medicaid) and commercial payers should establish preferential formulary placement for reimbursement of DHACM to reduce budget impact and improve the long-term health of their patient populations dealing with these chronic wounds.

DECLARATION OF INTEREST

Support for this analysis was provided by MiMedx Group, Inc., US. JLD, and RAF are employees of MiMedx Group, Inc. WHT, BH, PS, BGC and WVP were consultants to MiMedx Group, Inc. VD, AO, MRK, JAN, NW and GAM served on the MiMedx Group, Inc. Advisory Board. MRK and JAN served on a speaker's bureau. WVP declares personal fees and equity holdings from Stage Analytics, US.

Associations Among Wound-Related Factors Including Biofilm, Wound-Related Symptoms and Systemic Inflammation in Older Adults with Chronic Venous Leg Ulcers

Objective: The purposes of this observational prospective study were to (1) characterize the wound-related factors (wound area, the presence of biofilm, and total bacteria), wound-related symptoms (fatigue, pain, exudate, itching, and edema or swelling), and systemic inflammation (level of serum C-reactive protein [CRP]), and (2) explore associations between wound-related factors, wound-related symptoms, and systemic inflammation in older individuals with chronic venous leg ulcers (CVLUs) over 8 weeks of wound treatment. Approach: A total of 117 participants who received standardized care (weekly sharp debridement) for chronic venous ulcer were enrolled. We collected clinical data every 2 weeks during the 8 weeks of the study period or until the wound was healed (if healed before 8 weeks). Associations among variables were estimated using a Bayesian approach applied to general linear mixed models. Results: Based on Bayes factor (BF) value, there was extremely strong evidence for the association of biofilm with mean total bacteria (BF >1,000). There was moderate evidence of a direct association between biofilm presence and levels of CRP (BF 4.3) and moderate evidence of direct associations between biofilm and wound-related symptoms, pain and exudate (BF 5.12, 8.49, respectively). Innovation: Wound-related symptoms and the level of systemic CRP were associated with biofilm among patients who were receiving weekly sharp debridement. Symptom severity associated with CVLUs requires assessment and management of wound-related factors and levels of inflammation in addition to symptom assessment. Conclusion: This study is the first to examine associations among biofilm, as wound-related factors, systemic inflammation, wound-related symptoms, and wound healing in clinical settings. Symptom severity, level of systemic CRP, and wound-related factors should be considered as well as assessment of biofilm in CVLU in older individuals with CVLU.

Remote assessment and monitoring with advanced wound therapy to optimise clinical outcomes, access and resources

OBJECTIVE

Patients in rural communities may have limited access to wound care; however, this may be mitigated by using a shared care approach. This study assessed the impact of a remote assessment and monitoring tool in combination with adjunctive continuous topical oxygen therapy (cTOT) in patients with diabetes and hard-to-heal wounds.

METHOD

Patients with hard-to-heal wounds (defined as no visible improvement in the previous four weeks) were enrolled to this 12-week pilot study to validate a shared care approach using an Advanced Digital Wound Care Platform-telehealth (ADWCPt) system (eKare Inc., US) coupled with cTOT. Patient and wound assessments were reviewed by the clinician either remotely, via telehealth calls, or at the clinic, and the number of face-to-face clinic visits was recorded. Patient health status scores were captured before and after the study, along with feedback on usability of the remote platform and cTOT device.

RESULTS

The wounds in all eight patients studied reduced in size over 12 weeks (mean percentage area reduction 92.0%), and two wounds were completely re-epithelialised. Another wound almost healed (99.2% wound area reduction). Clinical interactions consisted of self-assessments (n=80, 50.0%), video assessments with the clinician (n=27, 16.9%), and face-to-face interactions in clinic (n=53, 33.1%). Operational efficiencies encompassed a 54.0% increase in the number of clinical interactions, whereas clinical time was reduced by 25.8%. Health status scores improved across all eight patients and feedback on the shared approach and cTOT device was favourable.

CONCLUSION

A shared care model with ADWCPt coupled with an innovative cTOT device saved time and resources, improving patient access and engagement, along with a marked improvement in the wound healing trajectory.

Functional electrospun nanofibers: fabrication, properties, and applications in wound-healing process

Electrostatic spinning as a technique for producing nanoscale fibers has recently attracted increasing attention due to its simplicity, versatility, and loadability. Nanofibers prepared by electrostatic spinning have been widely studied, especially in biomedical applications, because of their high specific surface area, high porosity, easy size control, and easy surface functionalization. Wound healing is a highly complex and dynamic process that is a crucial step in the body's healing process to recover from tissue injury or other forms of damage. Single-component nanofibers are more or less limited in terms of structural properties and do not fully satisfy various needs of the materials. This review aims to provide an in-depth analysis of the literature on the use of electrostatically spun nanofibers to promote wound healing, to overview the infinite possibilities for researchers to tap into their biomedical applications through functional composite modification of nanofibers for advanced and multifunctional materials, and to propose directions and perspectives for future research.

The Impact of Underlying Conditions on Quality-of-Life Measurement Among Patients with Chronic Wounds, as Measured by Utility Values: A Review with an Additional Study

Significance: Quality of life (QoL) is important to patients with chronic wounds and is rarely formally evaluated. Understanding what comorbidities most affect the individual versus their wounds could be a key metric. Recent Advances: The last 20 years have seen substantial advances in QoL instruments and conversion of patient data to a single value known as the health utilities index (HUI). We review these advances, along with wound-related QoL, and analyze real-world comorbidities challenging wound care. Critical Issues: To understand the impact of underlying comorbidities in a real-world patient population, we examined a convenience sample of 382 patients seen at a hospital-based outpatient wound center. This quality reporting study falls outside the regulations that govern human subject research. Comorbid conditions were used to calculate HUIs using a variety of literature-reported approaches, while Wound-Quality-of-Life (W-QoL) questionnaire data were collected from patients during their first visit. The mean number of conditions per patient was 8; 229 patients (59.9%) had utility values for comorbidities/conditions, which were worse/lower than their wounds' values. Sixty-three (16.5%) patients had depression and/or anxiety, 64 (16.8%) had morbid obesity, and 204 (53.4%) had gait and mobility disorders, all of which could have affected W-QoL scoring. The mean minimum utility value (0.5) was within 0.05 units of an average of 13 studies reporting health utilities from wound care populations using the EuroQol 5 Dimension instrument. Future Directions: The comorbidity associated with the lowest utility value is what might most influence the QoL of patients with chronic wounds. This finding needs further investigation.

Treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers

OBJECTIVE

To retrospectively evaluate the comorbidities, treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers (VLUs).

METHOD

Medicare Limited Data Standard Analytic Hospital Inpatient and Outpatient Department Files were used to follow patients who received medical care for a VLU between 1 October 2015 and 2 October 2019. Patients diagnosed with chronic venous insufficiency (CVI) and a VLU were propensity matched into four groups based on their treatment regimen. Episode claims were used to document demographics, comorbidities and treatments of Medicare enrolees who developed VLUs, as well as important outcomes, such as time to ulcer closure, rates of complications and hospital utilisation rates. Outcomes were compared across key propensity-matched groups.

RESULTS

In total, 42% of Medicare enrolees with CVI (n=1,225,278), developed at least one VLU during the study, and 79% had their episode claim completed within one year. However, 59% of patients developed another VLU during the study period. This analysis shows that only 38.4% of VLU episodes received documented VLU conservative care treatment. Propensity-matched episodes that received an advanced treatment or high-cost skin substitutes for a wound which had not progressed by 30 days demonstrated the best outcomes when their cellular, acellular, matrix-like product (CAMP) treatment was applied weekly or biweekly (following parameters for use). Complications such as rates of infection (33%) and emergency department visits (>50%) decreased among patients who received an advanced treatment (following parameters for use).

CONCLUSION

Medicare enrolees with CVI have diverse comorbidities and many do not receive sufficient management, which contributes to high rates of VLUs and subsequent complications. Medicare patients at risk of a VLU who receive early identification and advanced CAMP treatment demonstrated improved quality of life and significantly reduced healthcare resource utilisation.