Local Wound Care for Malignant and Palliative Wounds

Radical Scavenging, Hemocompatibility, and Antibacterial Activity against MDR Acinetobacter baumannii in Alginate-Based Aerogels Containing Lipoic Acid-Capped Silver Nanoparticles

Retaining the hemocompatibility, supporting cell growth, and exhibiting anti-inflammatory and antioxidant properties, while having antimicrobial activity, particularly against multidrug-resistant bacteria (MDR), remain a challenge when designing aerogels for biomedical applications. Here, we report that our synthesized alginate-based aerogels containing either 7.5 or 11.25 μg of lipoic acid-capped silver nanoparticles (AgNPs) showed improved hemocompatibility properties while retaining their antimicrobial effect against MDR Acinetobacter baumannii and the reference strain Escherichia coli, relative to a commercial dressing and polymyxin B, used as a reference. The differences in terms of the microstructure and nature of the silver, used as the bioactive agent, between our synthesized aerogels and the commercial dressing used as a reference allowed us to improve several biological properties in our aerogels with respect to the reference commercial material. Our aerogels showed significantly higher antioxidant capacity, in terms of nmol of Trolox equivalent antioxidant capacity per mg of aerogel, than the commercial dressing. All our synthesized aerogels showed anti-inflammatory activity, expressed as nmol of indomethacin equivalent anti-inflammatory activity per mg of aerogel, while this property was not found in the commercial dressing material. Finally, our aerogels were highly hemocompatible (less than 1% hemolysis ratio); however, the commercial material showed a 20% hemolysis rate. Therefore, our alginate-based aerogels with lipoic acid-capped AgNPs hold promise for biomedical applications.

European consensus-based interdisciplinary guideline for invasive cutaneous squamous cell carcinoma: Part 2. Treatment-Update 2023

In order to update recommendations on treatment, supportive care, education, and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Association of Dermato-Oncology (EADO), the European Dermatology Forum (EDF), the European Society for Radiotherapy and Oncology (ESTRO), the European Union of Medical Specialists (UEMS), the European Academy of Dermatology and Venereology (EADV), and the European Organisation of Research and Treatment of Cancer (EORTC) was formed. Recommendations were based on an evidence-based literature review, guidelines, and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable), and distant metastatic cSCC. For common primary cSCC, the first-line treatment is surgical excision with postoperative margin assessment or micrographically controlled surgery. Achieving clear surgical margins is the most important treatment consideration for patients with cSCCs amenable to surgery. Regarding adjuvant radiotherapy for patients with high-risk localised cSCC with clear surgical margins, current evidence has not shown significant benefit for those with at least one high-risk factor. Radiotherapy should be considered as the primary treatment for non-surgical candidates/tumours. For cSCC with cytologically or histologically confirmed regional nodal metastasis, lymph node dissection is recommended. For patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiotherapy, anti-PD-1 agents are the first-line systemic treatment, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drugs Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC, include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiotherapy. Multidisciplinary board decisions are mandatory for all patients with advanced cSCC, considering the risks of toxicity, the age and frailty of patients, and co-morbidities, including immunosuppression. Patients should be engaged in informed, shared decision-making on management and be provided with the best supportive care to improve symptom management and quality of life. The frequency of follow-up visits and investigations for subsequent new cSCC depends on underlying risk characteristics.

European consensus-based interdisciplinary guideline for diagnosis and treatment of basal cell carcinoma-update 2023

Basal cell carcinoma (BCC) is the most common malignant tumour in white populations. Multidisciplinary experts from European Association of Dermato-Oncology (EADO), European Dermatology Forum, European Society for Radiotherapy and Oncology (ESTRO), Union Européenne des Médecins Spécialistes, and the European Academy of Dermatology and Venereology developed updated recommendations on diagnosis and treatment of BCC. BCCs were categorised into 'easy-to-treat' (common) and 'difficult-to-treat' according to the new EADO clinical classification. Diagnosis is based on clinico-dermatoscopic features, although histopathological confirmation is mandatory in equivocal lesions. The first-line treatment of BCC is complete surgery. Micrographically controlled surgery shall be offered in high-risk and recurrent BCC, and BCC located on critical anatomical sites. Topical therapies and destructive approaches can be considered in patients with low-risk superficial BCC. Photodynamic therapy is an effective treatment for superficial and low-risk nodular BCCs. Management of 'difficult-to-treat' BCCs should be discussed by a multidisciplinary tumour board. Hedgehog inhibitors (HHIs), vismodegib or sonidegib, should be offered to patients with locally advanced and metastatic BCC. Immunotherapy with anti-PD1 antibodies (cemiplimab) is a second-line treatment in patients with a progression of disease, contraindication, or intolerance to HHI therapy. Radiotherapy represents a valid alternative in patients who are not candidates for or decline surgery, especially elderly patients. Electrochemotherapy may be offered when surgery or radiotherapy is contraindicated. In Gorlin patients, regular skin examinations are required to diagnose and treat BCCs at an early stage. Long-term follow-up is recommended in patients with high-risk BCC, multiple BCCs, and Gorlin syndrome.

Managing malignant wounds in patients receiving palliative care

Malignant wounds are a complication of cancer and usually develop in patients with advanced disease. Physical symptoms associated with these wounds include pain, bleeding, exudate, malodour and pruritus, while patients may also experience various distressing psychosocial effects. The aim for nurses is to manage these physical symptoms and psychosocial effects, thus enhancing quality of life for patients and their families. This article discusses the symptoms and effects associated with malignant wounds, and explains what is involved in a wound assessment. It also outlines strategies that can be used to manage or eliminate wound-related symptoms and enhance patients' quality of life.

Fungating Malignancies: Management of a Distinct Wound Entity

GENERAL PURPOSE

To provide information on the surgical management of fungating malignancies as a distinct wound entity.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will:1. Identify characteristics of patients in a study examining the treatment of fungating malignancies.2. Select common symptoms experienced by patients with fungating malignancies.3. Explain issues related to the surgical treatment of fungating malignancies.4. Identify a reason why patients with fungating breast masses may avoid medical care.

Topical therapy for pain management in malignant fungating wounds: A scoping review

AIMS AND OBJECTIVES

To map and synthesise the existing literature on topical therapies for malignant fungating wounds pain management and the gaps involved.

BACKGROUND

Most cancer patients with malignant fungating wounds suffer from wound-related pain, affecting their quality of life. Unfortunately, even though pain is a relevant symptom in cancer and palliative care, little is currently known about topical treatments' availability and impact on pain management.

DESIGN

A scoping review following JBI® methodology METHODS: Searches were performed in CINAHL, LILACS, Embase, Web of Science, PubMed, Cochrane, NICE, Scopus, JBISRIR and grey literature, in English, Portuguese and Spanish, with no time limit. Two authors independently reviewed all citations and a third was called in case of divergence, and studies in adults with malignant fungal wounds reporting topical pain interventions were included. In addition, a data extraction tool for synthesis and thematic analysis was developed. This study followed the PRISMA-ScR Checklist.

RESULTS

Seventy publications were selected from 796 records retrieved from databases. The studies mainly included non-systematic reviews and case studies with only six clinical trials. According to the narrative synthesis, twenty therapies were identified, including the use of wound dressings (58.6%), analgesic drugs (55.7%), topical antimicrobials (25.7%), skin barriers (15.7%), cryotherapy (5.7%) and negative pressure wound therapy (4.3%). Therapies were recommended to be applied to the wound bed or the periwound skin. In 68.5% of the studies, a standardised assessment for pain was not described.

CONCLUSIONS

Topical therapies applied to malignant fungating wounds or periwound areas had been examined for pain management. However, their effectiveness was analysed in a few interventional studies, indicating the need for further primary studies to inform evidence-based practice.

IMPLICATION FOR PRACTICE

Highlighted topical therapies for clinical practice consideration are opioids, anaesthetics and antimicrobials, with positive results described in randomised clinical trials. This study did not include patients.

Nursing of A Non-Hodgkin's Lymphoma Patient with A Facial Malignant Fungating Wound

Malignant fungating wounds are severe skin lesions caused by any primary tumor, causing patient suffering and disturbing their family members. In this article, we summarize the experience of nursing a patient with non-Hodgkin's lymphoma complicated with a facial malignant wound. Initially, a chemotherapy regimen was formulated as the main treatment for the patient. Throughout the patient's treatment course, we evaluated the patient holistically, conducting debridement, anti-infection, and drainage management under the guidance of moist wound healing. Throughout the entire process, psychological nursing and health education were provided to the patient and family. Eventually, the patient's wound symptoms were well controlled, and the wound healed completely.

Terapia tópica para el tratamiento del dolor en heridas neoplásicas malignas: protocolo de revisión de alcance

BACKGROUND

A total of 14.5% of cancer patients develop malignant neoplastic wounds (MNW), characterised as friable, exudative, fetid, bleeding, and painful. Some studies report that all patients with MNW experience pain, but there is lack of scientific evidence to support their treatment.

OBJECTIVE

To map and examine the existing evidence on topical therapies to manage pain in adult patients with MNW.

METHOD

A scoping review protocol was designed, according to the Joanna Briggs Institute (JBI) methodology. The databases CINAHL, LILACS, Embase, Scopus, Web of Science, PubMed, Cochrane, NICE, Scopus, JBISRIR and the grey literature, for searching published and unpublished studies in English, Portuguese and Spanish. The selection will be made by at least two reviewers. The summary of the results will be narrative, with graphs and tables. Qualitative and quantitative studies and reviews will be included, describing the use of topical pain therapies in patients with MNW.

CONCLUSION

This study will allow to classify and discuss the available topical therapies, and to recommend future primary studies.

Management of Nonhealable and Maintenance Wounds: A Systematic Integrative Review and Referral Pathway

GENERAL PURPOSE

To synthesize the evidence regarding nonhealable and maintenance wound management and propose an interprofessional referral pathway for wound management.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES

After participating in this continuing professional development activity, the participant will apply knowledge gained to:1. Identify the ideas from the authors' systematic review that could prove useful in understanding nonhealable and maintenance wound management.2. Select evidence-based management strategies for nonhealable and maintenance wound management.

ABSTRACT

OBJECTIVEThis systematic integrative review aims to identify, appraise, analyze, and synthesize evidence regarding nonhealable and maintenance wound management to guide clinical practice. An interprofessional referral pathway for wound management is proposed.

DATA SOURCES

An electronic search of Scopus, Web of Science, PubMed, Academic Search Ultimate, Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature database with Full Text, Health Source: ConsumerEdition, Health Source: Nursing/Academic Edition, and MEDLINE was conducted for publications from 2011 to 2019. Search terms included (nonhealable/nonhealing, chronic, stalled, recurring, delayed healing, hard-to-heal) and wound types most associated with nonhealable or maintenance wounds. Published studies were hand searched by the authors.

STUDY SELECTION

Studies were appraised using two quality appraisal tools. Thirteen reviews, six best-practice guidelines, three consensus studies, and six original nonexperimental studies were selected.

DATA EXTRACTION

Data were extracted using a coding framework including treatment of underlying causes, patient-centered concerns, local wound care, alternative outcomes, health dialogue needs, challenges within resource restricted contexts, and prevention.

DATA SYNTHESIS

Data were clustered by five wound types and local wound bed factors; further, commonalities were identified and reported as themes and subthemes.

CONCLUSIONS

Strong evidence on the clinical management of nonhealable wounds is limited. Few studies describe outcomes specific to maintenance care. Patient-centered care, timely intervention by skilled healthcare providers, and involvement of the interprofessional team emerged as the central themes of effective management of maintenance and nonhealable wounds.

European interdisciplinary guideline on invasive squamous cell carcinoma of the skin: Part 2. Treatment

In order to update recommendations on treatment, supportive care, education and follow-up of patients with invasive cutaneous squamous cell carcinoma (cSCC), a multidisciplinary panel of experts from the European Dermatology Forum, the European Association of Dermato-Oncology and the European Organization of Research and Treatment of Cancer was formed. Recommendations were based on evidence-based literature review, guidelines and expert consensus. Treatment recommendations are presented for common primary cSCC (low risk, high risk), locally advanced cSCC, regional metastatic cSCC (operable or inoperable) and distant metastatic cSCC. For common primary cSCC (the most frequent cSCC type), first-line treatment is surgical excision with postoperative margin assessment or microscopically controlled sugery. Safety margins containing clinical normal-appearing tissue around the tumour during surgical excision and negative margins as reported in the pathology report are necessary to minimise the risk of local recurrence and metastasis. In case of positive margins, a re-excision shall be done, for operable cases. Lymph node dissection is recommended for cSCC with cytologically or histologically confirmed regional nodal involvement. Radiotherapy should be considered as curative treatment for inoperable cSCC, or for non-surgical candidates. Anti-PD-1 antibodies are the first-line systemic treatment for patients with metastatic or locally advanced cSCC who are not candidates for curative surgery or radiation, with cemiplimab being the first approved systemic agent for advanced cSCC by the Food and Drug Administration/European Medicines Agency. Second-line systemic treatments for advanced cSCC include epidermal growth factor receptor inhibitors (cetuximab) combined with chemotherapy or radiation therapy. Multidisciplinary board decisions are mandatory for all patients with advanced disease who require more than surgery. Patients should be engaged with informed decisions on management and be provided with best supportive care to optimise symptom management and improve quality of life. Frequency of follow-up visits and investigations for subsequent new cSCC depend on underlying risk characteristics.

Revisión de las prácticas de enfermería en cuidado paliativo de pacientes con heridas oncológicas

Introducción: Los pacientes con heridas oncológicas o tumorales tienen unas necesidades específicas de cuidado, por dolor, exudado y mal olor; por lo tanto, los profesionales de enfermería deben brindar un cuidado integral y proporcionar confort y alivio de síntomas, a fin de mejorar la calidad de vida del paciente y su familia. Objetivo: Consolidar hallazgos de la literatura sobre prácticas de enfermería en cuidado paliativo de pacientes con heridas oncológicas en el manejo del exudado, dolor y olor. Método: Revisión integrativa mediante la búsqueda electrónica de artículos bajo la pregunta orientadora: ¿cuáles son las prácticas de enfermería en cuidado paliativo de pacientes con heridas oncológicas en cuanto al manejo del exudado, dolor y olor?, en el periodo 2000-2017, idioma inglés, español o portugués, en las bases de datos IdeA, Pubmed, ScienceDirect, SciELO, ProQuest y Dialnet. Resultados: Se identificaron 52 artículos, de los cuales 22 se ajustaban a la pregunta y presentaban información relevante. Esta revisión logró consolidar aspectos importantes sobre las prácticas de enfermería en cuidado paliativo, siendo de utilidad para profesionales de enfermería como un referente de intervenciones dirigidas a esta población con necesidades especiales de cuidado. Conclusión: Se requieren más estudios sobre el manejo de estos síntomas; no obstante, las prácticas documentadas hasta el momento se basan en una adecuada técnica, limpieza de la herida y control de carga bacteriana, elección de apósito atraumático de alta capacidad de absorción y múltiples intervenciones no farmacológicas.

Holistic management of malignant wounds in palliative patients

Malignant wounds are a complication of cancer, and usually occur in those individuals with advanced disease. When healing ceases to be the goal, treatment is centred around symptom control and improving quality of life. Caring for individuals with malignant wounds presents challenges for patients, their families and nurses alike. This article discusses the holistic management of malignant wounds, with an emphasis on the control of both physical and psychosocial symptoms of wound management, as well as the impact that this may have on all those involved. Common physical symptoms of malignant wounds include malodour, bleeding, pain, exudate and pruritis. Psychosocial symptoms may result in social isolation and depression. All these symptoms have a huge impact, not only on patients and their families, but also on healthcare professionals both during and after care. Managing these symptoms requires a multidisciplinary approach to facilitate the best possible outcomes for patients and their caregivers.

Evidence supporting wound care end points relevant to clinical practice and patients' lives. Part 2. Literature survey

Patients with wounds bear significant clinical, personal, and economic burdens yet complete wound healing is the only United States Food and Drug Administration (FDA) recognized primary clinical trial end point. The overall goal of this project is to work with FDA to expand the list of acceptable primary end points, recognizing that new and innovative treatments, devices, and drugs may not have complete healing as the focus. Part 1 of the project surveyed 628 wound care experts who identified and content-validated 15 end points most relevant to clinical practice and benefitting patients' lives as primary outcomes in clinical trials. Part 2 is focused on critical appraisal of the evidence in the wound care literature supporting FDA criteria to qualify these 15 end points as primary end points in clinical trials. Further research involved systematic review of the literature regarding the most promising end points. Forty volunteer, interdisciplinary, wound healing experts in fields related to the end points compiled evidence from systematic MEDLINE searches and society databases supporting the FDA criteria of reliability, clinical construct validity, capacity to detect concurrent or longitudinal change, and responder analysis. The search revealed 485 references involving over 462,000 subjects supporting FDA-required parameters for all 15 end points More than 50 references supported FDA-required parameters qualifying the following outcomes for use in clinical trials supporting interventions for FDA clearance: Pain reduction, Physical function and ambulation, Infection reduction, Time to heal, and Percent wound area reduction in 4-8 weeks. Among these, only Time to heal is currently recognized by the FDA as a primary wound outcome in clinical trials. These results suggest that wound science is already serving patients and professionals by improving these content-validated outcomes that merit regulatory consideration.

Palliative analgesia with topical sevoflurane in cancer-related skin ulcers: a case report

A Caucasian 39-year-old male patient with a poorly-differentiated infiltrating epidermoid penile carcinoma with urethral invasion was diagnosed. The patient received concomitant adjuvant chemotherapy with radiotherapy in the palliative setting, which produced painful ulceration of tumour lesions at loco-regional level (Numerical Rate Scale, NRS=9). The patient consented for treatment with direct topical sevoflurane instillations, at initial doses of 1 mL/cm² of ulcerated area, as per unit protocol. The local use of undiluted sevoflurane achieved a marked reduction of the pain score in both nociceptive and irruptive pains (average NRS=3 immediately post-application). This improvement was corroborated by a decline in total morphine needs, any adverse events associated with major opiates. PGI-I and CGI-I scales were used before and after treatment with topical sevoflurane to assess patient and clinician perceptions of improvement in the quality of life. The pharmacy of our hospital had the responsibility to elaborate pre-loaded syringes with sevoflurane so that the patient was instilled simply and comfortably.

Intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral

Objetivo: identificar intervenciones de enfermería para el diagnóstico de olor fétido en herida tumoral. Métodos: revisión integradora de la literatura a partir de las bases de datos MEDLINE, CINAHL, LILACS e Cochrane, que resultó en la selección de 48 artículos científicos acerca de la temática investigada. Resultados: con base en las evidencias empíricas identificadas en los artículos incluidos en el estudio, se elaboraron 24 intervenciones de enfermería para el control y la reducción del olor fétido en heridas tumorales. Conclusiones: las intervenciones de enfermería presentadas en el estudio posibilitan la promoción de la calidad de vida al paciente con herida tumoral en cuidado paliativo. Como sugerencia posterior al Consejo Internacional de Enfermeros, se deben validar clínicamente para que su inserción se realice en el subconjunto terminológico cuidados paliativos para una muerte digna, de la Clasificación Internacional para la Práctica de Enfermería (CIPE®).

The relationship between malignant wound status and pain in breast cancer patients

PURPOSE

Skin metastasis is one of the most frequent metastases in breast cancer patients. Patients with malignant wounds experience numerous symptoms, including serious wound pain. However, the features of pain related to malignant wounds have not been investigated. Nurses can experience a dilemma when treating these patients due to a lack of knowledge of the pain. The aims of this study were to examine the quality and intensity of malignant wound pain and to determine the association between wound status and pain in the patients with malignant wounds.

METHODS

Cross-sectional study was conducted. Participants were recruited from a breast centre based in a general hospital. We collected the patients' demographic and wound management data and assessed wound condition. Patients evaluated wound pain intensity and quality over the preceding week using the short-form McGill Pain Questionnaire (SF-MPQ). The association between SF-MPQ results, wound condition, and the time interval for wound care was evaluated using the Spearman's correlation coefficient. The protocol was approved by the Ethical Committee of the each facilities.

RESULTS

The median age of the 22 enrolled patients was 61.5 years, and the median time after diagnosis of malignant wound was 15.5 months. Overall, 77.3% of patients complained of pain. Malignant wound pain significantly correlated with the degradation of wound edges, granulation tissue, and the time interval for wound care.

CONCLUSION

We consider that it is necessary to provide pain-control care focused on the wound edge and granulation tissue of malignant wounds through the assessment of malignant wound pain and condition.

Management of non-healable or maintenance wounds with topical povidone iodine

Although complete healing may appear to be the logical goal for most patients and clinicians, some wounds do not have the potential to heal due to a number of factors such as inadequate vasculature, coexisting medical conditions and medications that prohibit the healing process. Local management of wounds that are considered to have poor potential for healing remains elusive. The purpose of this article is to review the evidence that supports the use of topical antiseptic agents in non-healable wounds. Retrospective chart audit was conducted to evaluate the use of povidone iodine in the management of wounds that were deemed to have poor healing potential.