Nutritional Considerations in Wound Care

Handgrip Strength But Not Malnutrition According to Global Leadership Initiative on Malnutrition Criteria Is a Risk Factor for Mortality in Hospitalized Patients with Ischemic Diabetic Foot Ulcers

Objective: This study aimed to test the hypothesis that patients with malnutrition and impaired muscle function determined by hand grip strength (HGS) will have adverse outcomes. Approach: We conducted a prospective observational study of 77 patients admitted for ischemic diabetic foot ulcers (IDFU). Global Leadership Initiative on Malnutrition (GLIM) criteria were used to diagnose malnutrition. Values obtained with a dynamometer were dichotomized into values < and ≥ mean according to the values obtained in both sexes. The Cox proportional hazards model and the Kaplan-Meier method were applied. STROBE guidelines for cohorts were met in the present study. Results: In total, 55 patients (71.4%) were malnourished. Malnutrition according to GLIM criteria was not associated with adverse outcomes. HGS < mean was associated with patient age, duration of diabetes mellitus, body mass index, brachial circumference, plasma albumin, prealbumin, hemoglobin, transferrin, and HbA_1c levels. Predictive variables of mortality after applying multivariate Cox model were age >69years (hazard ratio [HR] 4.0, 95% confidence interval [CI] 1.3-12.0, p = 0.01), and HGS < mean (HR 3.7, 95% CI 1.2-11.3, p = 0.01). Survival time in patients with HGS < mean was shorter than in those with HGS ≥ mean, p < 0.01. Innovation: HGS is an easy and useful tool associated with nutritional parameters and with prognosis in patients admitted for IDFU. Conclusions: Neither malnutrition nor muscle function impairment were associated with limb loss or a need for readmission. Patients with HGS < mean presented shorter survival times. As HGS is a simple and cost-effective tool, it should be implemented as part of the nutritional admission evaluation.

Effects of Nutrition Intervention on Blood Glucose, Body Composition, and Phase Angle in Obese and Overweight Patients with Diabetic Foot Ulcers

Nutrition can play an important role in the treatment of chronic wounds such as diabetic foot ulcers (DFUs); however, diet therapy is not currently part of the standard care for DFUs. There are numerous controversies about dietary recommendations, especially regarding calories and macronutrients, for overweight and obese patients with DFUs. This study examined the effects of nutrition education and supplementation on body composition in overweight and obese patients with DFUs. Twenty-nine patients with DFUs between the ages of 30 and 70 years were randomly assigned to either the treatment group (nutritional supplements, diet education, and standard care) or the control group (standard care). At baseline, the mean body mass index (BMI) was 33.5 kg/m2 for the treatment group and 34.1 kg/m2 for the control group. HbA1c decreased in both groups, with no significant difference between the groups. On average, patients in the treatment group lost less lean body mass and gained less fat than the control group ((3.8 kg vs. 4.9 kg) and (0.9 kg vs. 3.6 kg), respectively). While the interaction between group and time did not reach statistical significance for any of the study variables after adjustments for confounding variables, the observed changes are clinically relevant.

Nutrition and cutaneous wound healing

Wound healing is a complex and energy-demanding process. The relationship between nutrition and wound healing has been recognized for many centuries. Several studies have indicated that nutritional deficiencies are more prevalent among patients with chronic wounds. Malnutrition may alter the inflammatory response, collagen synthesis, and wound tensile strength, all of which are crucial for wound healing. Although the specific role of nutrition and supplementation in wound care remains uncertain, it is necessary to identify and correct nutritional imbalances to avoid any potential deterioration of the healing process. It is also important to recognize the differences in pathophysiology between acute and chronic wounds. A burn, surgical, or a traumatic wound is different from a diabetic foot ulcer, which is different from a pressure ulcer. Chronic wounds are more prevalent in the aging population, and patients often have underlying comorbidities, such as diabetes mellitus, peripheral vascular disease, connective tissue disease, or other systemic illnesses that may alter energy metabolism and contribute to impaired healing. Management approaches to acute wound care may not apply universally to chronic wounds. In this review, we discuss the available data and possible roles for nutrition in wound healing.

Ultrapulsed CO2 Resurfacing of Photodamaged Facial Skin in Vegan and Omnivore Patients: A Multicentric Study

BACKGROUND AND OBJECTIVES

Skin photoaging is related to extrinsic environmental exposures, mainly represented by ultraviolet radiation. One of the treatment options is laser resurfacing. As nutritional status is involved in cutaneous photodamage, we evaluated whether dietary patterns can also influence the response to facial resurfacing. Our prospective multicentric study involves three dermatologic centers specialized in laser therapy in northern Italy. The study aims to compare the outcome of a CO₂ ablative laser therapy between omnivore and vegan patients.

STUDY DESIGN/MATERIALS AND METHODS

Fifty-three omnivore and fifty-three vegan women undergoing ultrapulsed CO₂ resurfacing for photodamaged facial skin were enrolled in this study. Clinical improvement was evaluated 3 and 6 months after the treatment using the modified Dover score.

RESULTS

After laser treatment, vegans showed slower complete re-epithelialization (P < 0.001*) and disappearance of the erythema (P < 0.001*). After 3 and 6 months, vegans showed worse outcomes in terms of fine lines (P < 0.001* and P < 0.001*, respectively) and tactile roughness (P = 0.003* and ​​​​P = 0.002*, respectively) compared with omnivores, while they did not differ in mottled pigmentation.

CONCLUSIONS

The present study suggests that diet influences the clinical outcome of fractioned CO₂ laser treatment. Lasers Surg. Med. © 2021 Wiley Periodicals LLC.

Comparison of Postsurgical Scars Between Vegan and Omnivore Patients

BACKGROUND

Postsurgical skin healing can result in different scars types, ranging from a fine line to pathologic scars, in relation to patients' intrinsic and extrinsic factors. Although the role of nutrition in influencing skin healing is known, no previous studies investigated if the vegan diet may affect postsurgical wounds.

OBJECTIVE

The aim of this study was to compare surgical scars between omnivore and vegan patients.

METHODS AND MATERIALS

This is a prospective observational study. Twenty-one omnivore and 21 vegan patients who underwent surgical excision of a nonmelanoma skin cancer were enrolled. Postsurgical complications and scar quality were evaluated using the modified Scar Cosmesis Assessment and Rating (SCAR) scale.

RESULTS

Vegans showed a significantly lower mean serum iron level (p < .001) and vitamin B12 (p < .001). Wound diastasis was more frequent in vegans (p = .008). After 6 months, vegan patients had a higher modified SCAR score than omnivores (p < .001), showing the worst scar spread (p < .001), more frequent atrophic scars (p < .001), and worse overall impression (p < .001).

CONCLUSION

This study suggests that a vegan diet may negatively influence the outcome of surgical scars.

Nutritional Supplementation Concurrent with Nutrition Education Accelerates the Wound Healing Process in Patients with Diabetic Foot Ulcers

Trials on nutritional supplements for the treatment of diabetic foot ulcer (DFU) have only evaluated the effects of supplementation with specific nutrients. Additionally, nutrition education has not been a systematic part of these studies. The aim of this study was to evaluate the effects of a nutrient-dense formula combined with nutrition education on wound healing in DFU patients. Twenty-nine patients were randomly assigned to the treatment group (n = 15) receiving two servings of supplements daily plus nutrition education or control group (n = 14) that received the standard of care but no additional nutritional or educational intervention. Both groups were followed for a maximum of 12 weeks. Wound healing, as measured by planimetry, was examined at baseline and every four weeks until complete wound closure or up to 12 weeks. There were no significant differences between groups for BMI, age, duration of diabetes, wound age estimation, or wound area at baseline. The treatment group experienced a faster wound healing rate (6.43 mm²/week more reduction in the wound area) than the control group. The mean reduction in the wound area during the first four weeks of the study was almost 13-fold greater in the treatment group compared to the control group (18.0 mm²/week vs. 1.4 mm²/week, respectively). Our findings showed that nutrition supplementation plus nutrition education significantly accelerated wound healing in DFU patients compared to those who just received a standard-of-care regimen.

Photodynamic therapy for actinic keratosis in vegan and omnivore patients: the role of diet on skin healing

Background: Photodynamic therapy (PDT) is an approved and effective treatment for actinic keratosis (AK). The time of complete skin healing is estimated to range between 5 and 10 days, but the role of nutrition in influencing it has never been evaluated.Objective: The aim of this study was to compare the time of skin healing and side effects in omnivores and vegans treated with PDT for AK.Materials and methods: Thirty omnivore and thirty vegan patients, treated with PDT for AK, were enrolled. Side effects, according to local skin response (LSR) score, were compared after 3, 7, and 30 days; the time of complete skin healing was recorded.Results: At day 3, day 7, and day 30 post treatment, vegan group showed higher total LSR score (p = .008, p < .001, p < .001, respectively), highlighting higher edema and vesiculation at day 3 (p < .001, p = .002, respectively), erythema, desquamation, edema, and vesiculation at day 7 (p < .001, p < .001, p < .001, p < .001, respectively) and erythema and desquamation after 30 days (p < .001, p < .001, respectively). The difference of complete skin healing was statistically significant (p < .001).Conclusions: The present study suggests that diet may have a prognostic and predictive role on PDT outcomes in term of side effects and time of skin repair.

Impact of breastfeeding and/or bottle-feeding on surgical wound dehiscence after cleft lip repair in infants: A systematic review

BACKGROUND

Immediately after cleft lip repair, breastfeeding and bottle-feeding are generally restricted to avoid placing tension on the surgical incision. However, no consensus about feeding methods after cleft lip repair has been reached. The objective of this systematic review was to examine the impact of breastfeeding and/or bottle-feeding on surgical wound dehiscence after cleft lip repair in infants.

MATERIAL AND METHODS

We searched PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Mednar from October to November 2017. Two reviewers independently assessed eligibility for inclusion and checked critical appraisal of the study quality.

RESULTS

Three randomized controlled trials and two cohort studies involving 342 infants were included in this review. Two cases of surgical wound dehiscence occurred in the control group of alternative feeding. In three of five studies, surgical wound dehiscence did not occur in either the intervention or control group within the first week postoperatively.

CONCLUSIONS

This review showed no increased risk of surgical wound dehiscence in infants with breastfeeding and/or bottle-feeding after cleft lip repair compared with infants with alternative feeding methods. It may not be necessary to restrict breastfeeding and/or bottle-feeding immediately after cleft lip repair.

Correlation between chronic venous ulcer exudate proteins and clinical profile: A cross-sectional study

Chronic venous ulcers affect the quality of life of patients around the world. The aims of this study were to identify the proteins expressed in chronic venous ulcer exudates, to categorize them according to their roles and to correlate them with the clinical and epidemiological aspects of the disease. The study population consisted of 37 ulcers from 28 patients, and the inflammatory exudates of these thirty-seven ulcers were subjected to tryptic digestion and mass spectrometry analysis. Twenty-three patients were female (62.2%), and five (37.8%) were male. The patients had a mean age of 70 (±10.1) years. Of the patients, 73% adhered to compression and rest, 81.1% reported a history of primary varices, 54.1% reported a history of systemic arterial hypertension, 54.1% reported a history of devitalized tissue in the wound bed and 64.9% reported ulcers with more than ten years of evolution. Seventy-six proteins were identified, and they were grouped according to their primary role in the healing process. Eight correlations between clinical and epidemiological data and protein expression were noteworthy: diabetes mellitus vs. Ig gamma-2 and apolipoprotein-A1 and albumin; congestive heart failure vs. Ig lambda-2; colonization vs. actin; compressive therapy vs. Ig kappa; systemic arterial hypertension vs. alpha-2-macroglobulin and apolipoprotein-A1; area of ulcer vs. apolipoprotein-A1; race vs. heavy chain Ig and Ig γ-1 chain; age and race vs. Ig γ-1 chain. These associations may help to elucidate the prognosis and chronicity of chronic venous ulcers based on secreted proteins.

Scar management in burn injuries using drug delivery and molecular signaling: Current treatments and future directions

In recent decades, there have been tremendous improvements in burn care that have allowed patients to survive severe burn injuries that were once fatal. However, a major limitation of burn care currently is the development of hypertrophic scars in approximately 70% of patients. This significantly decreases the quality of life for patients due to the physical and psychosocial symptoms associated with scarring. Current approaches to manage scarring include surgical techniques and non-surgical methods such as laser therapy, steroid injections, and compression therapy. These treatments are limited in their effectiveness and regularly fail to manage symptoms. As a result, the development of novel treatments that aim to improve outcomes and quality of life is imperative. Drug delivery that targets the molecular cascades of wound healing to attenuate or prevent hypertrophic scarring is a promising approach that has therapeutic potential. In this review, we discuss current treatments for scar management after burn injury, and how drug delivery targeting molecular signaling can lead to new therapeutic strategies.

Nutrition and Lower Extremity Ulcers: Causality and/or Treatment

The association between malnutrition, impaired wound healing, and the presence of chronic wounds has been recognized for a long time. It is widely believed that the lack of adequate nutrition increases the risk of developing wounds which have a great likelihood of progressing to chronicity due to lack of appropriate healing responses. This risk is particularly high in the aging population. For the individual patient, as well as patient populations, the diagnosis of malnutrition has been in dispute; further, there is lack of agreement of when and how to intervene nutritionally in those with wounds or healing deficits. This article examines the relationship of nutritional status with the presence and clinical evolution of leg ulcers in humans, focusing on diabetic and venous leg ulcers; we will further review the effect of nutritional therapy on the outcome of these ulcers.

Evaluation of Effects of Topical Estradiol Benzoate Application on Cutaneous Wound Healing in Ovariectomized Female Mice

Estrogen promotes cutaneous wound healing in ovariectomized (OVX) female mice. However, the effects of topical estrogen application on wounds remain unclear. Therefore, the aim of this study was to compare the effects of topical estrogen application on wounds with standard treatment methods. Eight-week-old C57BL/6J female mice underwent OVX and received two full-thickness wounds four weeks later. Mice were divided into three groups: topical estradiol benzoate (EB) (0.75 μg/g/day) wound treatment, subcutaneous estradiol (E2) pellets (0.05 mg, 21 days), and topical E2 (0.01 g/day) skin application. Wound healing was observed until day 14. Wound area ratios were significantly smaller in the topical EB wound treatment group than in the subcutaneous E2 pellet group on days 1–14 (p < 0.05) and topical E2 skin application group on days 1–9 (p < 0.05). Neutrophil and macrophage numbers were significantly smaller in the topical EB wound treatment group than in the subcutaneous E2 pellet and topical E2 skin application groups on day 7 (p < 0.05). Moreover, the number of new blood vessels and ratio of myofibroblasts were significantly larger in the topical EB wound treatment group than in the subcutaneous E2 pellet and topical E2 application skin groups on day 7 (p < 0.05). These results demonstrate that the application of estrogen to wounds reduced inflammatory responses and promoted angiogenesis and wound contraction more than the two other standard treatment methods.

Pressure ulcers: Current understanding and newer modalities of treatment

This article reviews the mechanism, symptoms, causes, severity, diagnosis, prevention and present recommendations for surgical as well as non-surgical management of pressure ulcers. Particular focus has been placed on the current understandings and the newer modalities for the treatment of pressure ulcers. The paper also covers the role of nutrition and pressure-release devices such as cushions and mattresses as a part of the treatment algorithm for preventing and quick healing process of these wounds. Pressure ulcers develop primarily from pressure and shear; are progressive in nature and most frequently found in bedridden, chair bound or immobile people. They often develop in people who have been hospitalised for a long time generally for a different problem and increase the overall time as well as cost of hospitalisation that have detrimental effects on patient's quality of life. Loss of sensation compounds the problem manifold, and failure of reactive hyperaemia cycle of the pressure prone area remains the most important aetiopathology. Pressure ulcers are largely preventable in nature, and their management depends on their severity. The available literature about severity of pressure ulcers, their classification and medical care protocols have been described in this paper. The present treatment options include various approaches of cleaning the wound, debridement, optimised dressings, role of antibiotics and reconstructive surgery. The newer treatment options such as negative pressure wound therapy, hyperbaric oxygen therapy, cell therapy have been discussed, and the advantages and disadvantages of current and newer methods have also been described.

The effect of 17β-estradiol on cutaneous wound healing in protein-malnourished ovariectomized female mouse model

Cutaneous wound healing is delayed by protein malnutrition (PM). On the other hand, estrogen promotes cutaneous wound healing by its anti-inflammatory and cell proliferation effects. Therefore, we hypothesized that estrogen administration in protein-malnourished ovariectomized (OVX) female mice might improve the inflammatory response and promote cutaneous wound healing as well as normal nutrition. To test this hypothesis, we used full-thickness excisional wounds in Control SHAM, PM SHAM, PM OVX and PM OVX+17β-estradiol mice. The Control diet included 200 g/kg protein and the PM diet included 30 g/kg protein. The ratio of wound area in the Control SHAM group was significantly smaller than those in the three PM groups. In addition, microscopic findings also showed that the ratio of collagen fibers, the ratio of myofibroblasts and the number of new blood vessels in the Control SHAM group were significantly greater than those in the three PM groups. However, the number of Ym1-positive cells as an anti-inflammatory M2-like macrophage marker in the PM OVX+17β-estradiol group was significantly higher than those in the other three groups. These results indicate that the appearance of anti-inflammatory M2-like macrophages was promoted by estrogen administration; however, it could not promote cutaneous wound healing upon a low-protein diet. Therefore, it may be confirmed that nutrition is more important for promoting cutaneous wound healing than estrogen administration.

Nutritional interventions for preventing and treating pressure ulcers

BACKGROUND

Pressure ulcers affect approximately 10% of people in hospitals and older people are at highest risk. A correlation between inadequate nutritional intake and the development of pressure ulcers has been suggested by several studies, but the results have been inconsistent.

OBJECTIVES

To evaluate the effects of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers.

SEARCH METHODS

In March 2014, for this first update, we searched The Cochrane Wounds Group Specialised Trials Register, the Cochrane Central register of Controlled Trials (The Cochrane Library), the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library), the Health Technology Assessment Database (HTA) (The Cochrane Library), the Cochrane Methodology Register (The Cochrane Library), NHS Economic Evaluation Database (The Cochrane Library), Ovid Medline, Ovid Embase and EBSCO CINAHL. No date, language or publication status limits were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the effects of enteral or parenteral nutrition on the prevention and treatment of pressure ulcers, which measured the incidence of new ulcers, ulcer healing or changes in pressure ulcer severity. There were no restrictions on types of patient, setting, date, publication status or language.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened for inclusion, and disagreement was resolved by discussion. Two review authors independently extracted data and assessed quality using the Cochrane Collaboration tool for assessing risk of bias.

MAIN RESULTS

We included 23 RCTs, many were small (between 9 and 4023 participants, median 88) and at high risk of bias.Eleven trials compared a combination of nutritional supplements, consisting of a minimum of energy and protein in different dosages, for the prevention of pressure ulcers. A meta-analysis of eight trials (6062 participants) that compared the effects of mixed nutritional supplements with standard hospital diet found no clear evidence of an effect of supplementation on pressure ulcer development (pooled RR 0.86; 95% CI 0.73 to 1.00; P value 0.05; I(2) = 13%, random effects). This outcome is at unclear or high risk of bias.Fourteen trials evaluated the effects of nutritional supplements on the healing of existing pressure ulcers: seven trials examined mixed nutritional supplements, three the effects of proteins, two trials examined zinc, and two studies examined ascorbic acid. The included trials were heterogeneous with regard to participants, interventions, comparisons and outcomes and meta-analysis was not appropriate. There was no clear evidence of an improvement in pressure ulcer healing from the nutritional supplements evaluated in any of these individual studies.

AUTHORS' CONCLUSIONS

There is currently no clear evidence of a benefit associated with nutritional interventions for either the prevention or treatment of pressure ulcers. Further trials of high methodological quality are necessary.

Nutrition for wound healing

The importance of the role of nutrition in wound healing is an area that has been widely explored over the last decade. It is well recognised that both macronutrients (protein, fat and carbohydrate) and micronutrients (vitamins, minerals and trace elements) play important parts in the healing of both chronic wounds and acute injuries. The term 'wound' encompasses many different situations from leg ulcers to laparostomy wounds. This article provides an overview of the role of different nutrients in the healing of wounds and guidance to nurses on first-line assessments, which can be used to ensure the patient is receiving adequate nutrition for successful wound healing. It will focus on commonly seen wounds in primary and secondary care but will not cover specialist wound management, such as laparostomy sites and burns, as these must always be cared for by experienced and specialist multidisciplinary teams.

Understanding the role of nutrition and wound healing

Optimal wound healing requires adequate nutrition. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition has also been related to decreased wound tensile strength and increased infection rates. Malnourished patients can develop pressure ulcers, infections, and delayed wound healing that result in chronic nonhealing wounds. Chronic wounds are a significant cause of morbidity and mortality for many patients and therefore constitute a serious clinical concern. Because most patients with chronic skin ulcers suffer micronutrient status alterations and malnutrition to some degree, current nutrition therapies are aimed at correcting nutrition deficiencies responsible for delayed wound healing. This review provides current information on nutrition management for simple acute wounds and complex nonhealing wounds and offers some insights into innovative future treatments.

A minimally invasive human in vivo cutaneous wound model for the evaluation of innate skin reactivity and healing status

Individual variability in skin reactivity and healing capacity after trauma are important clinical issues. The aims were to develop an in vivo, human wound model based on a standardised minimal skin injury and to demonstrate therapeutic effect of simple wound therapies in terms of morphological wound outcome with changes in skin blood perfusion as a quantified indicator of wound healing. In a series of experiments, wounds were induced on the normal forearm skin of volunteers using a blood collection lancet. This was well tolerated. Wounds were assessed by naked eye examination or laser Doppler perfusion imaging (LDPI) at baseline and at up to 6 further time points up to 96 h in control wounds and wounds treated by commonly used occlusive dressing options. Assessment by clinical observation with 10x magnification showed over 96 h a progression of erythema, surface crust, a new keratinisation layer and finally healed areas. LDPI quantifying wound erythema showed a peak at 24 h and near normal levels at 96 h. Inter-individual variability was evident but intra-individual variability was much less pronounced. Wounds treated with occlusion showed a statistically significant more rapid return to baseline blood perfusion as measured by LDPI compared to controls supported by favourable healing parameters in the clinical assessment. The paper exemplifies use of non-invasive, bioengineering technique for quantification of individual innate variability in skin reactivity, wound healing capacity and therapeutic effect in a well-tolerated in vivo, human, minimal skin trauma model.

Wound healing essentials: let there be oxygen

The state of wound oxygenation is a key determinant of healing outcomes. From a diagnostic standpoint, measurements of wound oxygenation are commonly used to guide treatment planning such as amputation decision. In preventive applications, optimizing wound perfusion and providing supplemental O(2) in the perioperative period reduces the incidence of postoperative infections. Correction of wound pO(2) may, by itself, trigger some healing responses. Importantly, approaches to correct wound pO(2) favorably influence outcomes of other therapies such as responsiveness to growth factors and acceptance of grafts. Chronic ischemic wounds are essentially hypoxic. Primarily based on the tumor literature, hypoxia is generally viewed as being angiogenic. This is true with the condition that hypoxia be acute and mild to modest in magnitude. Extreme near-anoxic hypoxia, as commonly noted in problem wounds, is not compatible with tissue repair. Adequate wound tissue oxygenation is required but may not be sufficient to favorably influence healing outcomes. Success in wound care may be improved by a personalized health care approach. The key lies in our ability to specifically identify the key limitations of a given wound and in developing a multifaceted strategy to specifically address those limitations. In considering approaches to oxygenate the wound tissue it is important to recognize that both too little as well as too much may impede the healing process. Oxygen dosing based on the specific need of a wound therefore seems prudent. Therapeutic approaches targeting the oxygen sensing and redox signaling pathways are promising.

Nutritional status and wound severity of overweight and obese patients with venous leg ulcers: a pilot study

Obesity is a chronic disease that is linked to the presence of numerous chronic illnesses, including venous disease. Venous disease can lead to chronic wounds, which may be exacerbated by vitamin, mineral, and macro-nutritional deficiencies. A cross-sectional observational design was used to examine the nutritional status of patients with chronic venous leg ulcers (VLUs) who are overweight or obese and to explore the relationship between nutritional status and severity of venous ulceration. Nutritional status was evaluated using anthropometric measurements, nutrient analysis from a 3-day dietary intake log, serum albumin, vitamins A and C, and zinc levels. Wound severity was assessed using the Leg Ulcer Measurement Tool (LUMT). Eight patients participated; six patients were men, and all eight patients were more than 50 years of age. Patients had an average daily caloric intake below their estimated caloric need. When compared with recommended daily intake levels, dietary nutrient intake was suboptimal for protein, vitamin C, and zinc. Serum levels were below normal for at least one of these nutrients in six patients. A positive correlation was found only between serum albumin, average daily intake, and percent recommended daily intake of protein (r(s) = 0.93, P = .003). An inverse relationship was found between LUMT score and serum vitamin A levels (r(s) = -0.83, P = .01), and a positive correlation was observed between LUMT score and serum vitamin C (r(s) = 0.74, P = .04). No clear relationships were shown among serum zinc, albumin, and LUMT scores. Overweight and obese patients with VLU show nutritional deficits that are similar to those of the broader population of patients with leg ulcers. The relationships found between vitamins A and C and leg ulcer severity warrant further exploration. The nutritional differences in the study need to be examined in a larger sample of overweight and normal-weight patients to determine whether overweight patients are at greater risk for prolonged VLU because of poor nutrition than non-overweight patients.

Tissue viability in tomorrow's NHS

This article is based on the inaugural lecture of the UK's first and only Professor of Tissue Viability, Richard White, given at the University of Worcester in January. In it he asks how our discipline can best adapt to meet existing and future needs.

Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds

BACKGROUND

Palliative wound care should be centered on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient's tolerance or stamina. Palliative wound care is the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing (total closure). Palliative wound care strategies must also work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease. Palliative wound care is much more than pain, exudate and odor management. Common curative treatment goals such as physical correction of the underlying pathology, addressing nutrition and other supportive aspects of care, and sensible (nonharmful) local wound treatments should never be ignored.

OBJECTIVE

(1) To provide a fresh and effective approach to palliative wound care by integrating individual clinical expertise with clinical and laboratory evidence from the (curative) wound healing literature and (2) to share our (Calvary Hospital) experience and approach to palliative wound care in an inpatient, home, and outpatient setting. This approach can be summarized with the mnemonic S-P-E-C-I-A-L (S = stabilizing the wound, P = preventing new wounds, E = eliminate odor, C = control pain, I = infection prophylaxis, A = advanced, absorbent wound dressings, L = lessen dressing changes). Throughout this paper we will offer rationale, principles and recipes, for each of the steps of the "SPECIAL" approach in an effort to facilitate the caring for chronic wounds in palliative medicine.

CONCLUSIONS

A practical marriage of wound palliation (symptom management) with current wound healing concepts to provide options for the palliative care provider and improve the practice of palliative medicine.

Optimizing outcomes of surgery in advanced age--perioperative factors to consider

The gynecologic surgeon should be knowledgeable about the normal physiologic changes associated with aging and skilled at assessing baseline medical comorbidities, neuropsychiatric, nutritional, social, and functional status as increasing numbers of older women seek and undergo surgical interventions to improve their quality of life. A multidisciplinary approach to the perioperative care of the older woman, aiming for prevention and early intervention, can help minimize both typical surgical complications and "geriatric" complications.

Supplementation with High-Dose Ascorbic Acid Improves Intestinal Anastomotic Healing

BACKGROUND/AIM

Ascorbic acid modulates tissue healing but the value of ascorbic acid supplementation during anastomotic healing remains unclear. We examined the role of ascorbic acid treatment in experimental intestinal resection.

METHODS

Male Wistar albino rats (n = 30) were divided into three groups: sham treatment (group 1), and daily ascorbic acid treatment with 100 mg/kg (group 2) or 200 mg/kg (group 3) via the intramuscular route. Following sacrifice on the 7th postoperative day, bursting pressure of the anastomoses was measured. Hydroxyproline assessment and histological analysis were carried out.

RESULTS

The bursting pressure values of groups 2 (171.4 +/- 4.3 mm Hg) and 3 (196.4 +/- 2.2 mm Hg) were higher than that of group 1 (139.1 +/- 4.1 mm Hg; p < 0.05). In addition, the hydroxyproline level of group 3 (249.2 +/- 25.1 microg/mg) was higher than that of groups 1 (157.9 +/- 14.9 microg/mg) and 2 (187.9 +/- 14.8 microg/mg; p < 0.05). The histopathological scores indicated improved healing in groups 3 (6.0 +/- 0.2) and 2 (4.4 +/- 0.4), compared to group 1 (2.7 +/- 0.3; p < 0.05).

CONCLUSION

In the present study, supraphysiologic doses of ascorbic acid improved anastomotic healing. Therefore, vitamin C supplementation poses as a beneficial treatment in the context of collagen accumulation, inflammatory response, and anastomotic strength. However, the clinical value of high-dose ascorbic acid supplementation in the clinical setting is yet to be established.