Cost-of-illness of leg ulcers in the community

Standardized Wound Care: Patchwork Practices?

Standardized care is crucial in healthcare for ensuring consistent, safe, high-quality, efficient, and evidence-based practices. Care pathways that standardize procedures promote adherence to best practices, reduce variability in treatment, and encourage collaboration among healthcare teams. This approach ultimately improves patient outcomes, enhances safety, and boosts the overall effectiveness of healthcare services. However, despite these benefits being widespread across most of the U.S. healthcare system, wound care stands out as an area where standards can vary significantly. The inconsistency in wound care standards in the United States is influenced by several factors. These include limited structured clinical education, the discretion of healthcare providers in following guidelines, differences in wound care settings, varying access to advanced treatments and technology, patient demographics and socioeconomic status, as well as differences in state laws and regional or institutional practices. Addressing these disparities requires a comprehensive approach that considers the complex interplay of the above-mentioned factors. Targeted interventions are needed to improve access, equity, and the quality of wound care services for all patients, regardless of where they live, their socioeconomic status, or their healthcare coverage. By understanding and actively addressing these factors, we can work towards achieving more standardized, evidence-based, and patient-centered practices in wound care across the nation.

Review of Mixed Arterial Venous Leg Ulcers (MAVLU) Disease in Contemporary Practice

BACKGROUND

Mixed Arterial and Venous Leg Ulcers (MAVLU) are challenging. Clinical evidence specific to MAVLU management is scarce. We evaluated our recent experience with MAVLU patients and reviewed current data regarding MAVLU epidemiology, aetiology, diagnostic assessment and management options.

METHODS

A prospective leg ulcer database was retrospectively interrogated to determine the prevalence and clinical outcome of MAVLU over 2-year period (2021-2022). The literature was reviewed to determine if optimal treatment strategies.

RESULTS

307 patients attended the ulcer clinic over a 2-year period. Most were venous leg ulcers (71%), 24% were arterial and 5% were MAVLU. The highest healing rate was in MAVLU (93%), followed by (74%) and (41%), in arterial and venous leg ulcer groups, respectively.

CONCLUSION

Evidence-based guidelines for MAVLU remain lacking. Well-developed randomised controlled trials are warranted to guide current clinical practice.

Clinical use of 0.1% polyhexanide and propylbetaine on acute and hard-to-heal wounds: a literature review

OBJECTIVE

To summarise the findings on the effect of the clinical use of 0.1% polyhexanide-propylbetaine (PHMB/betaine) solution/gel on acute and hard-to-heal (chronic) wound healing.

METHOD

A literature search was conducted in MEDLINE, CINAHL, Embase, Scopus and the CENTRAL Trials Registry of the Cochrane Collaboration. Paired reviewers conducted title and abstract screening and full-text screening to identify experimental, quasi-experimental and observational studies. Study quality and risk of bias were not formally evaluated.

RESULTS

A total of 17 studies met the eligibility criteria. The findings from 12 studies indicated that the use of 0.1% PHMB/betaine solution/gel had: a low risk of contact sensitivity; could help debridement during wound cleansing; aided effective wound bed preparation; reduced wound size, odour and exudate; improved pain control; reduced microbial load; and enhanced wound healing. The results of three studies indicated that both 0.1% PHMB and saline solution were effective in reducing bacterial load, while another showed that adding 0.1% PHMB to tie-over dressings had no effect on reducing bacterial loads in wounds. Another study concluded that disinfection and granulation of pressure ulcers with hydrobalance dressing with 0.3% PHMB was faster and more effective than using 0.1% PHMB/betaine.

CONCLUSION

The findings of this literature review showed that 0.1% PHMB/betaine solution/gel appeared to be useful and safe for wound cleansing, was effective in removing soft debris and slough from the wound bed, and created a wound environment optimal for healing. Although these actions cannot be attributed solely to this treatment modality, these results do highlight the unique action of this combined product. However, more robust studies are needed to confirm these results.

Use of biosurgery for the treatment of foot ulcers infected with therapy-resistant bacteria: a case report

Biosurgery (larval therapy) has been used for centuries. However, in recent times, this treatment has been replaced with the use of antibiotics for the treatment of wounds. Due to increasing antibiotic resistance, larval therapy is once again coming to the fore as an effective and efficient treatment. Due to the increasing ageing population, along with an increase in patients with arterial occlusive disease, diabetes and immobility, the number of patients with hard-to-heal wounds will increase. The stressors associated with wounds, such as pain, limited physical functionality, depression and social withdrawal, have a negative impact on patient quality of life. This case report documents the performance of biosurgery in a patient with multimorbidities.

Single cells and bacterial biofilm populations in chronic wound infections

Chronic wounds and chronic ulcers are an increasing problem associated with high health care burden and patient burden. The arrested healing of chronic wounds has, in part, been attributed to the presence of biofilms. Substantial research has documented the presence of biofilms in chronic wounds, and many mechanisms of host-pathogen interactions have been uncovered to explain the arrested healing. However, the paradigm of whether biofilms are only observed in chronic infections was recently challenged when biofilms were also observed in acute infections. Here, we characterize the distribution of bacteria in lower leg wounds with particular emphasis on Pseudomonas aeruginosa and Staphylococcus aureus by confocal laser scanning microscopy combined with PNA-FISH staining and routine culture of bacteria. We show that 40% of wounds contained either P. aeruginosa or S. aureus biofilms and demonstrate the presence of scattered single cells in tissues stained with a universal bacterial PNA-FISH probe. Thus, we demonstrate that chronic wounds do not only harbor bacteria organized in biofilms, but also carry populations of scattered single cells and small cell clusters of only a few bacteria. Our findings may influence diagnostic tools being developed to only target biofilms, where single-cell subpopulations thus may be overlooked and possibly lead to false-negative results.

Novel jointured green synthesis of chitosan‑silver nanocomposite: An approach towards reduction of nitroarenes, anti-proliferative, wound healing and antioxidant applications

Here we present the simple green synthesis of chitosan‑silver nanocomposite (CS-Ag NC) by employing kiwi fruit juice as reducing agent. The structure, morphology, and composition of CS-Ag NC were determined using characterization techniques such as XRD, SEM-EDX, UV-visible, FT-IR, particle size, and zeta potential. The prepared CS-Ag nanocomposite was effectively used as catalyst in the reduction of 4-nitrophenol (4-NP) to 4-aminophenol (4-AP) in the presence of NaBH4 as reductant, in aqueous medium at room temperature. The toxicity of CS-Ag NC was assessed on Normal (L929) cell line, Lung cancer (A549) cell line and Oral cancer (KB-3-1) cell line and their respective IC50values observed were 83.52 μg/mL, 66.74 μg/mL and 75.11 μg/mL. The CS-Ag NC displayed significant cytotoxic activity and the cell viability percentage for normal, lung and oral cancer cell lines were found to be 42.87 ± 0.0060, 31.28 ± 0.0045 and 35.90 ± 0.0065 respectively. Stronger cell migration was exemplified by CS-Ag NC and the percentage of wound closure (97.92%) was substantially identical to that of the standard drug ascorbic acid (99.27%). Further CS-Ag nanocomposite was subjected for in vitro antioxidant activity.

Chorioallantoic Membrane Assay at the Cross-Roads of Adipose-Tissue-Derived Stem Cell Research

With a history of more than 100 years of different applications in various scientific fields, the chicken chorioallantoic membrane (CAM) assay has proven itself to be an exceptional scientific model that meets the requirements of the replacement, reduction, and refinement principle (3R principle). As one of three extraembryonic avian membranes, the CAM is responsible for fetal respiration, metabolism, and protection. The model provides a unique constellation of immunological, vascular, and extracellular properties while being affordable and reliable at the same time. It can be utilized for research purposes in cancer biology, angiogenesis, virology, and toxicology and has recently been used for biochemistry, pharmaceutical research, and stem cell biology. Stem cells and, in particular, mesenchymal stem cells derived from adipose tissue (ADSCs) are emerging subjects for novel therapeutic strategies in the fields of tissue regeneration and personalized medicine. Because of their easy accessibility, differentiation profile, immunomodulatory properties, and cytokine repertoire, ADSCs have already been established for different preclinical applications in the files mentioned above. In this review, we aim to highlight and identify some of the cross-sections for the potential utilization of the CAM model for ADSC studies with a focus on wound healing and tissue engineering, as well as oncological research, e.g., sarcomas. Hereby, the focus lies on the combination of existing evidence and experience of such intersections with a potential utilization of the CAM model for further research on ADSCs.

Topically Confined Enhancement of Cutaneous Microcirculation by Cold Plasma

INTRODUCTION

We aim to explore potentials and modalities of cold atmospheric pressure plasma (CAP) for the subsequent development of therapies targeting an increased perfusion of the lower leg skin tissue. In this study, we addressed the question whether the microcirculation enhancement is restricted to the tissue in direct contact with plasma or if adjacent tissue might also benefit.

METHODS

A dielectric barrier discharge (DBD)-generated CAP device exhibiting an electrode area of 27.5 cm2 was used to treat the anterior lower leg of ten healthy subjects for 4.5 min. Subsequently, hyperspectral imaging was performed to measure the tempospatially resolved characteristics of microcirculation parameters in superficial (up to 1 mm) and deeper (up to 5 mm) skin layers.

RESULTS

In the tissue area covered by the plasma electrode, DBD-CAP treatment enhances most of the perfusion parameters. The maximum oxygen saturation increase reached 8%, the near-infrared perfusion index (NIR) increased by a maximum of 4%, and the maximum tissue hemoglobin increase equaled 14%. Tissue water index (TWI) was lower in both the control and the plasma groups, thus not affected by the DBD-CAP treatment. Yet, our study reveals that adjacent tissue is hardly affected by the enhancements in the electrode area, and the effects are locally confined.

CONCLUSION

Application of DBD-CAP to the lower leg resulted in enhancement of cutaneous microcirculation that extended 1 h beyond the treatment period with localization to the tissue area in direct contact with the cold plasma. This suggests the possibility of tailoring application schemes for topically confined enhancement of skin microcirculation, e.g., in the treatment of chronic wounds.

Evidenzbasierte Lokaltherapie chronischer Wunden

Chronische Wunden sind zumeist durch Grunderkrankungen wie Diabetes mellitus oder Gefäßerkrankungen bedingt und stellen eine große Problematik in der zunehmend alternden Gesellschaft dar. Die inadäquate Behandlung geht oftmals mit protrahierter Wundheilung, erhöhten Risiken für Komplikationen, eingeschränkter Lebensqualität der Betroffenen und langwierigen Therapien mit hohen Behandlungskosten einher.

Die erfolgreiche Therapie setzt eine frühzeitige adäquate Diagnostik, Kausaltherapie sowie Wundbehandlung möglichst auf Basis evidenzbasierter Medizin voraus. Diese Behandlung sollte dann in qualifizierten Versorgungsstrukturen anhand konkreter Behandlungspfade erfolgen. Somit können in der täglichen Praxis eine verbesserte Wundheilung mit gesteigerter Lebensqualität der Patienten sowie ein medizinökonomischer Vorteil erreicht werden.

In diesem Übersichtsartikel wird die evidenzbasierte Lokaltherapie chronischer Wunden mit Schwerpunkt auf Wundverbänden mit TLC-Sucrose-Octasulfat-Beschichtung dargestellt. Leitlinien und Behandlungspfade sowie pharmaökonomische Aspekte werden dabei berücksichtigt.

Synthesis and Characterization of Silver Nanoparticles from Rhizophora apiculata and Studies on Their Wound Healing, Antioxidant, Anti-Inflammatory, and Cytotoxic Activity

Silver nanoparticles (AgNPs) have recently gained interest in the medical field because of their biological features. The present study aimed at screening Rhizophora apiculata secondary metabolites, quantifying their flavonoids and total phenolics content, green synthesis and characterization of R. apiculata silver nanoparticles. In addition, an assessment of in vitro cytotoxic, antioxidant, anti-inflammatory and wound healing activity of R. apiculata and its synthesized AgNPs was carried out. The powdered plant material (leaves) was subjected to Soxhlet extraction to obtain R. apiculata aqueous extract. The R. apiculata extract was used as a reducing agent in synthesizing AgNPs from silver nitrate. The synthesized AgNPs were characterized by UV-Vis, SEM-EDX, XRD, FTIR, particle size analyzer and zeta potential. Further aqueous leaf extract of R. apiculata and AgNPs was subjected for in vitro antioxidant, anti-inflammatory, wound healing and cytotoxic activity against A375 (Skin cancer), A549 (Lung cancer), and KB-3-1 (Oral cancer) cell lines. All experiments were repeated three times (n = 3), and the results were given as the mean ± SEM. The flavonoids and total phenolics content in R. apiculata extract were 44.18 ± 0.086 mg/g of quercetin and 53.24 ± 0.028 mg/g of gallic acid, respectively. SEM analysis revealed R. apiculata AgNPs with diameters ranging from 35 to 100 nm. XRD confirmed that the synthesized silver nanoparticles were crystalline in nature. The cytotoxicity cell viability assay revealed that the AgNPs were less toxic (IC₅₀ 105.5 µg/mL) compared to the R. apiculata extract (IC₅₀ 47.47 µg/mL) against the non-cancerous fibroblast L929 cell line. Antioxidant, anti-inflammatory, and cytotoxicity tests revealed that AgNPs had significantly more activity than the plant extract. The AgNPs inhibited protein denaturation by a mean percentage of 71.65%, which was equivalent to the standard anti-inflammatory medication diclofenac (94.24%). The AgNPs showed considerable cytotoxic effect, and the percentage of cell viability against skin cancer, lung cancer, and oral cancer cell lines was 31.84%, 56.09% and 22.59%, respectively. R. apiculata AgNPs demonstrated stronger cell migration and percentage of wound closure (82.79%) compared to the plant extract (75.23%). The overall results revealed that R. apiculata AgNPs exhibited potential antioxidant, anti-inflammatory, wound healing, and cytotoxic properties. In future, R. apiculata should be further explored to unmask its therapeutic potential and the mechanistic pathways of AgNPs should be studied in detail in in vivo animal models.

Exploring healthcare provider and patient perspectives on current outpatient care of venous leg ulcers and potential interventions to improve their treatment: a mixed methods study in the ulcus cruris care project

Background

The project "Ulcus Cruris Care" aims to improve primary care for patients with venous leg ulcer (VLU) in General Practitioner (GP) practices using a complex intervention comprised of educational components, standardized treatment recommendations, computer-assisted documentation, and case management by non-physician medical assistants (MAs). Prior to implementing and testing the intervention components in general practices, in-depth exploration of current outpatient treatment of VLU patients and relevant implementation determinants was pursued.

Methods

A mixed-methods study explored views of GPs, MAs, and patients regarding current VLU outpatient care and the planned intervention components to identify potential implementation determinants. Data were collected through semi-structured guide-based telephone interviews (n = 29) and a survey questionnaire (n = 28). Interviews were transcribed verbatim. Analysis was inductive initially and finalized in a deductive-inductive approach based on domains of the Theoretical Domains Framework to support structuring of relevant implementation determinants. Survey data were analyzed descriptively.

Results

Current VLU outpatient care was described as frequently tailored to individual wounds and gradient. In general, workload was shared by GPs (diagnostics, counselling) and MAs (wound care). All care providers were aware of compression therapy, yet not all of them considered it essential for VLU care. Standardized operating procedures and educational components including e-learning were considered supportive. Stronger involvement of non-physician assistants was seen as opportunity to optimize VLU care. Concerns were identified regarding integration of software-supported case management into daily practice routines and regarding potential limitations in decision-making autonomy when using standard operating procedures.

Conclusions

Findings in this study emphasize a need for educational interventions addressing VLU care providers as well as patients, particularly with regards to compression therapy. The conception of the planned intervention appears to be adequate and a structured guideline-based case management might be a promising approach for optimization of VLU treatment.

Is combined physical therapy more effective than topical hyperbaric oxygen therapy in the treatment of venous leg ulcers? Preliminary study

Introduction

Recently, increased frequency of chronic leg ulcers has been observed. The aim of the study was to compare therapeutic efficacy of combined physical therapy to topical hyperbaric oxygen therapy in the treatment of venous leg ulcers.

Materials and Methods

Participants included 36 patients (14 females and 22 males) between 18 and 80 years of age with chronic venous leg ulcers. They were randomly divided into two study groups. Group I underwent topical hyperbaric oxygen therapy; group II underwent combined physical therapy. Before and after the therapeutic cycle (15 procedures) measurement of ulceration size by planimetry and analysis of laboratory parameters of blood was performed.

Results

In both groups, a statistically significant reduction of ulcer surface area was obtained (25.11±17.8cm2 to 16.93±13.89cm2, p=0.000196) vs. (34.17±14.82cm2 to 23.99±15.15cm2, p=0.004337). Blood morphology revealed a statistically significant reduction in patients from group II who underwent combined physical therapy (p=0.01). In both groups, statistically significant reduction of fibrinogen level (p=0.01 and p<0.001), and total protein level (p=0.01) was achieved. In group II reduction of the inflammation marker C-reactive protein (CRP) was noted.

Conclusions

Topical hyperbaric oxygen therapy and combined physical therapy had statistically significant effects on the reduction of surface area of treated venous leg ulcers. The changes in morphological and biochemical parameters may indicate the anti-inflammatory and anti-clotting action effects of combined physical therapy.

A Comparative Study Between Vacuum Dressing and Normal Saline Dressing for Chronic Non-Healing Ulcers

Introduction

Isn’t it a boon that all living organisms possess the ability to heal their injuries? The wound healing is faster when the normal physiology of the wound healing is maintained. Our understanding of wound healing has undergone dramatic changes in the recent past. Almost all materials and methods available on earth have been used and tested to facilitate the process of wound healing. The mental agony and the disability suffered by patients with chronic ulcers have led to the reappraisal of the basic components of the wound healing process and how they are influenced by biological, mechanical, and physical forces.

The Department of General Surgery in our Government Chengalpattu Medical College and Hospital, Chengalpattu, Tamil Nadu, India, admits and treats a large volume of patients with wounds and ulcers. Here many materials are being used regularly for dressing to make wound healing faster. Vacuum dressings were also done on many patients, and promising results were observed. This kindled our interest in conducting this prospective study and comparing wound healing with vacuum dressing versus normal saline dressing.

Materials and methods

A total of 74 patients were included in the study, out of which 37 patients were randomly included in the experimental group and vacuum dressing was done, while the other 37 included in the control group were treated with dressing done with normal saline moistened gauze and bandage roll. Rates at which the wound healed were compared.

Results

We were able to observe a statistically significant difference in the rate of appearance of granulation tissue between the two and increased clearance of bacteria and toxins. The study group promised better progress as compared to the control group in various aspects.

Conclusion

Vacuum dressing brings an obvious improvement in the healing of non-healing ulcers and decreases the overall duration of stay in the hospital.

Clinical Efficacy and Safety of Long-Term Compression in Patients with Mixed Arterial and Venous Etiology Ulcers in the Leg

Elastic compressions are standard treatment for leg ulcers of venous etiology. The effect of compressions on ulcers of mixed (arterial or venous) etiology, however, has rarely been studied. The objective of this study was to evaluate the variation in transcutaneous oxygen pressure (TcPO2) in patients with ulcers of mixed arterial or venous etiology treated with 1 month of compression. This prospective cohort study was conducted at a university hospital in France. Patient eligibility was for those attending a consultation of a work-up of a leg ulcer of mixed arterial-venous etiology lasting at least 4 to 6 weeks. Compressions were prescribed according to the hemodynamic status and were evaluated by the ankle-brachial index and toe-brachial index using a decision-making algorithm based on French national guidelines. Quality of life was assessed using the Short-Form 36-Item (SF-36) questionnaire. In total, 32 patients were included between September 30, 2018 and May 31, 2019. A difference was observed between TcPO2 before compression (49.3 ± 13.01 mm Hg) and after 1 month (51.2 ± 15.05 mm Hg), average change 1.9 ± 2.04 mm Hg ( p  = 0.025). The average ulcer size prior to compression was 49 ± 102 cm ² versus 37 ± 94 cm ² after 1 month of effective compression, corresponding to a reduction of 12 ± 8 cm ² ( p  < 0.001). There was a reduction in the bodily pain dimension of the SF-36. Compressions adapted to the hemodynamic status led to an increase in TcPO2, a reduction in wound size, and an improvement to bodily pain in patients with leg ulcers of mixed arterial-venous etiology.

Development of a model to predict closure of chronic wounds in Germany: Claims data analysis

Patients with chronic leg ulcer, pressure ulcer, or diabetic foot ulcer suffer from significant disease burden. With a view to improving healthcare provision sustainably, a predictive model of time to closure (time-to-event analysis) based on claims data was developed. To identify potential predictors of wound closure, clinical information absent from statutory health insurance (SHI) data was modelled. In patients with leg ulcers, age of the patient (hazard ratios [HR] 0.99), increasing number of comorbidities (HR 0.94), inpatient stays (HR 0.74), and treatment by a specialised wound care professional (HR 1.18) were significant predictors of time to closure (adjusted model). In almost all models, the number of inpatient stays and of comorbidities predicted a lower probability of healing. In addition, the age and the sex of the patient were found to be significant predictors in some models (leg ulcer: HR 0.99; pressure ulcer: HR 0.99). Increasing number of comorbidities and inpatient stays were predictors for closure time in all models. Since these predictors may give an indication of wound severity, further clinical information should be considered in future models, as also indicated by the moderate values of the c-statistics. This requires future data linkage between SHI and primary studies (eg, registers).

Custos diretos médios da assistência ambulatorial, hospitalar e domiciliar prestada aos pacientes com feridas crônicas

RESUMO Objetivo: Analisar os custos diretos médios da assistência ambulatorial, hospitalar e domiciliar prestada aos pacientes com feridas crônicas. Método: Pesquisa quantitativa, exploratório-descritiva, do tipo estudo de caso, realizada numa Unidade de Tratamento Integral de Ferida. Obtiveram-se os custos multiplicando-se o tempo despendido pelos profissionais pelo custo unitário da mão de obra da respectiva categoria, somando-se aos custos dos materiais e terapias tópicas. Resultados: Os custos da assistência ambulatorial corresponderam a US$4,25 (DP ± 7,60), da hospitalar a US$3,87 (DP ± 17,27) e da domiciliar a US$3,47 (DP ± 5,73). Nessas três modalidades, os custos diretos com os curativos e consultas médicas foram os mais representativos: US$7,76 (DP ± 9,46) e US$6,61 (DP ± 6,54); US$7,06 (DP ± 24,16) e US$15,60 (DP ± 0,00); US$4,09 (DP ± 5,28) e US$15,60 (DP ± 0,00), respectivamente. Conclusão Considerando a assistência integral aos pacientes com feridas crônicas, o custo direto médio total foi de US$10,28 (DP ± 17,21), sendo a modalidade ambulatorial a mais representativa na sua composição. Constatou-se diferença estatística significante (valor p = 0,000) entre os custos da assistência domiciliar e ambulatorial, domiciliar e hospitalar e ambulatorial e hospitalar.

Average direct costs of outpatient, hospital, and home care provided to patients with chronic wounds

ABSTRACT Objective: To analyze the average direct costs of outpatient, hospital, and home care provided to patients with chronic wounds. Method: Quantitative, exploratory-descriptive case study, carried out in a Comprehensive Wound Care Unit. Costs were obtained by multiplying the time spent by professionals by the unit cost of labor in the respective category, adding to the costs of materials and topical therapies. Results: Outpatient care costs corresponded to US$4.25 (SD ± 7.60), hospital care to US$3.87 (SD ± 17.27), and home care to US$3.47 (SD ± 5.73). In these three modalities, direct costs with dressings and medical consultations were the most representative: US$7.76 (SD ± 9.46) and US$6.61 (SD ± 6.54); US$7.06 (SD ± 24.16) and US$15.60 (SD ± 0.00); US$4.09 (SD ± 5.28) and US$15.60 (SD ± 0.00), respectively. Conclusion: Considering comprehensive care for patients with chronic wounds, the mean total direct cost was US$10.28 (SD ± 17.21), with the outpatient modality being the most representative in its composition. There was a statistically significant difference (p value = 0.000) between the costs of home and outpatient, home and hospital, and outpatient and hospital care.

Clinical evaluation of UrgoStart Plus dressings in real-life conditions: results of a prospective multicentre study on 961 patients

AIMS

This study aimed to evaluate the performances of lipid colloid technology with nano-oligosaccharide factor (TLC-NOSF) dressings with polyabsorbent fibres in an unselected population of patients under real-life conditions.

METHODS

A large, prospective, multicentre, observational study with three polyabsorbent TLC-NOSF dressings (UrgoStart Plus Pad, UrgoStart Plus and UrgoStart Plus Border, Laboratoires Urgo, France) was conducted in Germany between January 2019 and June 2020. Main outcomes included wound healing rate, clinical assessment of wound healing progression, local tolerance and acceptance of dressings, and changes in health-related quality of life (HRQoL) of the patients, assessed with the validated Wound-QoL questionnaire.

RESULTS

A total of 961 patients with wounds of various aetiologies (leg ulcers (LU), diabetic foot ulcers (DFU), pressure ulcers (PU) and other types of wounds) were treated with the evaluated dressings in 105 centres for a mean duration of 62 days (standard deviation 37 days). By the last visit, a wound closure or an improvement in wound healing was reported in 92.0% of the treated wounds. The highest wound closure rates were achieved when the dressings were used as first-line treatment: 71.3% in DFUs, 52.9% in LUs, 53.6% in PUs and 61.8% in the other wounds. Improvement of the wound healing process was also associated with an 87.5% relative reduction of sloughy tissue, a decrease of the level of exudate in 68.9% of the wounds, and an improvement in the periwound skin condition in 66.4% of the patients at the final visit. The dressings were 'very well' or 'well' tolerated and 'very well' or 'well' accepted by the large majority of patients. The HRQoL questionnaires were completed both at initial and final visits by 337 patients, representative of the total cohort. Despite the relatively short duration of the wounds, the HRQoL of the patients was already impaired at baseline, with 81.6% of the patients being severely affected in at least one aspect of their HRQoL. By the final visit, significant improvements in each dimension of the patients' HRQoL were reported (p<0.001), along with a reduction of the proportion of patients in need of intervention and in the number of actions needed per patient in relation to their HRQoL.

CONCLUSIONS

These results are consistent with previous clinical evidence on TLC-NOSF dressings. They confirm the good healing properties and safety profile of these dressings, and that a significant improvement in patient HRQoL is achieved in non-selected patients treated in real-life practice. These data support the use of such dressings as a first-line intervention and until wound healing in the management of chronic wounds, in association with appropriate standard of care.

A narrative review of the epidemiology and economics of chronic wounds

Chronic wounds have a debilitating effect on the quality of life of many individuals, and the large economic impact on health system budgets warrants greater attention in policy making and condition management than is currently evident. The aim of this narrative review is to summarize the nature and extent of the chronic wound problem that confronts health systems across the world. The first section is used to highlight the underlying epidemiology relating to chronic wounds, while the second explores the economic costs associated with them and the relative efficiency of measures designed to manage them.

Cost-effectiveness analysis of superabsorbent wound dressings in patients with moderate-to-highly exuding leg ulcers in Germany

The study aims to estimate the cost‐effectiveness of superabsorbent wound dressings compared to the standard‐of‐care (SoC) dressings mix for treatment of patients with moderate‐to‐highly exuding leg ulcers in the German healthcare settings. A model‐based cost‐effectiveness analysis was conducted from the German statutory health insurance perspective, following German specific and international recommendations of good research practice. An individual‐level (microsimulation) state‐transition model has been used with a cycle length of 1 week and time horizon of 6 months. Several comprehensive systematic reviews were conducted to inform all model inputs, including clinical parameters, efficacy, quality of life, resources utilisation, and cost inputs. In addition, primary data from two clinical trials were used. Based on this cost‐effectiveness analysis, using superabsorbent wound dressings instead of the SoC dressings of patients with moderate‐to‐highly exuding leg ulcers in Germany can lead to an improved healing rate of 2.57% (benefit ratio 1.08), improved health‐related quality of life of 0.152 quality‐adjusted life weeks, and total direct cost savings of €771 per patient in 6 months. Robustness of results was confirmed in sensitivity and scenario analyses.

Multicomponent compression system use in patients with chronic venous insufficiency: a real-life prospective study

OBJECTIVE

Compression therapy is the cornerstone of therapeutic management of patients with chronic venous insufficiency (CVI). This study aimed to evaluate the efficacy and safety of a multicomponent compression system in an unselected population of patients with CVI problems under real-life conditions.

METHOD

A prospective, multicentre, observational study with a multicomponent two-bandage compression system (UrgoK2, Laboratoires Urgo, France) was conducted in 103 centres in Germany. Main outcomes included wound healing rate, wound healing progression, assessment of oedema and ankle mobility, local tolerability and acceptance of the compression therapy.

RESULTS

A total of 702 patients with venous leg ulcers (VLU) and/or with lower limb oedema due to CVI were treated with the evaluated system for a mean (±standard deviation) duration of 27±17 days. By the last visit, 30.9% of wounds had healed and 61.8% had improved. Limb oedema was resolved in 66.7% of patients and an improvement of ankle mobility was reported in 44.2% of patients. The skin condition under the compression therapy was also considered as improved in 73.9% of patients and a substantial reduction of pain was achieved, both in number of patients reporting pain and in pain intensity. Compression therapy with the evaluated system was 'very well' or 'well' tolerated and 'very well' or 'well' accepted by >95% of patients. These positive outcomes were in line with the general opinion of physicians on the evaluated compression bandages, which were judged 'very useful' or 'useful' for >96.6% of patients. Similar results were reported regardless of the treated condition, VLU and/or limb oedema.

CONCLUSION

Real-life data documented in this large observational study of non-selected patients receiving compression therapy in daily practice confirm the benefits and safety profile of the evaluated compression system. This study also confirms the high-level of performance and acceptability of the system, regardless of the characteristics of the wounds or patients at initiation of the treatment. The data support the use of this multicomponent compression system as one first-line intervention in patients with symptoms caused by CVI.

Maggot Therapy as a Part of a Holistic Approach in the Treatment of Multimorbid Patients with Chronic Ulcer

Patients with chronic wounds (leg ulcers, decubitus, and diabetic foot ulcers) suffer from marked restrictions in their quality of life and can often no longer adequately carry out their everyday tasks. The need for nursing and medical care increases when other illnesses and complaints are present at the same time. Qualified wound care and the treatment of comorbidities are therefore of particular importance. The treatment of this disease, which is increasing in number, requires a holistic, multimodal treatment approach which, in addition to professional wound care, also includes comorbidities in the treatment. This case study describes an old treatment method for refractory wounds, the so-called "maggot therapy", and shows how this is integrated into a holistic, multimodal therapeutic approach.

Green synthesis of silver nanoparticles from aqueous extract of Scutellaria barbata and coating on the cotton fabric for antimicrobial applications and wound healing activity in fibroblast cells (L929)

Scutellaria barbata is a perennial herb which was vastly prescribed in Chinese medicine to treat inflammations, infections and it is also used a detoxifying agent. We synthesized silver nanoparticles with Scutellaria barbata extract and characterized the nanoparticles with UV–Vis spectroscopic analysis, TEM, AFM, FTIR and XRD. The biofilm inhibiting property of synthesized silver nanoparticles were examined with XTT reduction assay and the antimicrobial property was examined with well diffusion method. The silver nanoparticles were also coated with cotton fabrics and their efficacy against antimicrobials was analyzed to prove its application. The cytotoxic property of synthesized silver nanoparticles was examined with L929 fibroblast cells using MTT assay. Finally we analyzed the wound healing property of synthesized silver nanoparticles with wound scratch assay. The result of our UV–Vis spectroscopic analysis confirms Scutellaria barbata aqueous extract reduced silver ions and synthesized silver nanoparticles. The characterization studies TEM, AFM, FTIR and XRD confirms the synthesized silver nanoparticles are in ideal shape and size to be utilized as a drug. The XTT reduction assay proves silver nanoparticles effectively inhibits the biofilm formation in both resistant and sensitive strains. Antimicrobial sensitivity tests confirms synthesized silver nanoparticles and cotton coated synthesized silver nanoparticles both are effective against gram positive, gram negative and fungal species. Further the results of MTT assay confirms the synthesized silver nanoparticles are non toxic and finally the wound healing potency of the nanoparticles was confirmed with wound scratch assay. Over all our results authentically confirms the silver nanoparticles synthesized with Scutellaria barbata aqueous extract is potent wound healing drug.

[Treatment of chronic hard-to-heal wounds with hyaloronic acid ester: a case series of six patients]

The treatment of chronic wounds is usually a major challenge for the involved medical staff. Various different treatment options have to be tested achieving a satisfactory result. In this retrospective case report, we describe successful treatments with hyaluronan acid ester fleece in six patients with chronic wounds of different origins. Furthermore, all patients received compression bandages or compression stockings, two patients were treated additionally with pressure relief devices and all were debrided if necessary. The chronic wounds of five out of the six patients healed completely over a period of 1.5-11 months or only with a minimal residual defect. However, one patient was still resistant to therapy over five months. In summary, the treatment with hyaluronan esters achieved good results especially in patients with complex medical history that makes a successful therapy particularly difficult.

Le transfert des connaissances en soins de plaies chez les infirmières : une revue intégrative des écrits

Introduction&#160;: Wound care represents a public health issue and is an important concern for nursing care.Context&#160;: Despite the availability of best practice recommendations and clinical practice guidelines, there is a lack of use of this evidence in clinical practice.Objectives&#160;: The aim of this integrative review is to identify the barriers to nurses&#8217; optimal knowledge transfer in wound care.Method&#160;: An integrative literature review based on Whittemore and Knalf&#8217;s (2005) methodology was conducted&#160;; six databases were searched.Results&#160;: Of the 82 articles that were retrieved, 13 were retained for analysis. They were all published in English. The literature highlights a theory&#8211;practice gap in wound care. Barriers related to knowledge, attitudes, and environmental factors contribute to this gap.Discussion&#160;: Nursing could benefit from interventions to improve its role in wound care. The perspectives of new graduate nurses as well as nurses working in rural healthcare settings were limited.Conclusion&#160;: A strategic plan, adapted to the situation of each healthcare facility, could improve the quality of wound care practice.

[Standard of patient-centred care before admission to a university wound centre]

Hintergrund und Fragestellung

Die Versorgungswege von Patienten mit chronischen Wunden sind häufig sehr langwierig. Dies kann zu einer verminderten Versorgungsqualität und zu einer verspäteten Diagnose der eigentlichen Ursache führen. Gleichzeitig existieren zertifizierte Einrichtungen für diese Patientengruppe. Die vorliegende Arbeit untersucht mögliche Gründe für eine verzögerte Zuweisung an diese Zentren und ob eine spezifische Patientenauswahl an universitäre Zentren gelangt.

Patienten und Methoden

Durch eine retrospektive Auswertung der Patientendatensätze zum Zeitpunkt der Erstvorstellung im zertifizierten Wundzentrum wurden Variablen zum Versorgungszustand vor der universitären Vorstellung analysiert.

Ergebnisse

Es konnten Datensätze von 177 Patienten ausgewertet werden (53 % weiblich, 47 % männlich). Die Altersspanne lag zwischen 27 und 95 Jahren. Die mittlere Bestandsdauer der Wunde betrug 22 Monate. Eine Gefäßdiagnostik war im Vorfeld in 32 % (arterielle Diagnostik) bzw. 36 % (phlebologische Diagnostik) durchgeführt worden. Eine Gewebeprobe war in 9 % der Fälle entnommen worden, v. a. bei Patienten mit > 24 Monaten bestehender Wunde. In nur 45 % der Fälle stimmte die externe Diagnose mit der im Wundzentrum abschließend gestellten Diagnose überein.

Diskussion

Die Versorgungssituation von Patienten mit chronischen Wunden außerhalb spezialisierter Versorgungsstrukturen ist als unzureichend anzusehen. Eine frühzeitige Versorgung nach etablierten Standards in Diagnostik und Therapie sowie zeitnahe Überweisung bei stagnierendem Verlauf an eine Spezialsprechstunde sind anzustreben.

What Is the Best Option for Treating Venous Leg Ulcer Infection? Is It Systemic or Local Antimicrobials or a Combination of Both? A Retrospective Cohort Study

Study aimed to find out best option (systemic or local antimicrobial or combination of both) for treating venous leg ulcer infection. Patients’ files were reviewed retrospectively. Participants were divided into three groups. First group was treated by systemic antibiotics only (SABG). Second group received local antibiotics only (LABG). Third group was treated by combination of both (SLABG). Treatment strategies were compared based on multiple parameters using Pearson chi-squared test & relative risk (RR). 456 participants identified: 153 in SABG, 152 in LABG and 151 in SLABG. It was found that SLABG group was statistically significantly better than other single treatment strategies regarding all parameters (except bacterial resistance): (i) ulcer healing within usual duration (10-14 days) was 2.4 time higher (RR 2.4, 95% CI: 1.84, 3.12), (ii) probability of not recurring ulcer was 2.6 time higher (iii) probability of not getting increased wound size, abscess,cellulites was 5 times higher (iv) probability of not developing septicemia was 40% higher (v) probability of not requiring surgical intervention was 30% higher (vi) fewer patients needed prolonged hospitalization & lower cost was 8 times more likely (vii) patients were 3 times more satisfied during treatment .Probability of bacterial resistance was six times higher with SLABG and 5 times higher with SABG compared to LABG. For RR & CI values for all above parameters, see results below Ultimately, combination of both systemic and local antimicrobials may be best option to treat venous leg ulcer infection with out- weight with emergence of antibiotic-resistance microorganism.

Incidence of chronic wounds in Singapore, a multiethnic Asian country, between 2000 and 2017: a retrospective cohort study using a nationwide claims database

OBJECTIVES

Chronic wounds are common, costly and impair quality of life, yet epidemiological data are scarce. We aimed to estimate the incidence trend of a multiethnic Asian population.

DESIGN

Retrospective cohort study.

SETTING

Singapore's nationwide claims database.

PARTICIPANTS

Singaporeans and permanent residents.

OUTCOMES

Patients were identified by International Classification of Disease, Ninth Revision, Australian Modification (ICD-9-AM) and ICD-10-AM codes from all admissions between 2000 and 2017, and categorised according to aetiology: venous, arterial, diabetic and pressure. Comorbidities were extracted from a national database of Charlson Comorbidity Index scores.

RESULTS

Between 2000 and 2017, 124 023 wound-related claims among 86 631 patients were identified. Age-specific rate (ASR) and age-adjusted incidence rates of all wounds increased over 18 years, with greatest increases among those aged ≥80. In 2017, the median age of patients was 74 (IQR 63-84). Half were male (51%). 70% were ethnic Chinese, 15% Malay and 9% Indian. In 2017, the crude incidence rate (CIR) was 15 per 100 000 persons (95% CI 14 to 16) for venous wounds, 56 (95% CI 53 to 58) for arterial, 168 (95% CI 164 to 173) for diabetic and 183 (95% CI 179 to 188) for pressure wounds. The CIR of any chronic wound was 296 (95% CI 291 to 301). ASRs were greatest in patients aged ≥80: 92 (95% CI 74 to 112) for venous, 478 (95% CI 436 to 522) for arterial, 1791 (95% CI 1710 to 1876) for diabetic, 3647 (95% CI 3530 to 3766) for pressure and 4277 (95% CI 4151 to 4407) for any wound. Compared with the Chinese, Indians had thrice the ASRs of venous and arterial wounds and double the ASR of diabetic wounds. Malays had double the ASRs of arterial and diabetic wounds.

CONCLUSIONS

Chronic wounds are common in the elderly with significant ethnic disparities in this Asian cohort. With the incidence expected to rise with ageing populations, it is crucial to address health disparities and evaluate utilisation and cost to inform clinical practice and health policy.

Electrospinning of natural polymers for the production of nanofibres for wound healing applications

Wound healing is a highly regulated process composed of four overlapping phases: (1) coagulation/haemostasis, (2) inflammation, (3) proliferation and (4) remodelling. Comorbidities such as advanced age, diabetes and obesity can impair natural tissue repair, rendering the wound in a pathological state of inflammation. This results in significant discomfort for patients and considerable financial costs for healthcare systems. Due to the complex nature of wound healing, current treatments are ineffective at dealing with delayed healing. With flexible properties that can be tailored, nanomaterials have emerged as alternative therapeutics for many biomedical applications. A nanofibrous network can be made via electrospinning polymers using a high electric field to create a responsive meshwork that can be used as a medical dressing. A nanofibrous device has properties that can overcome the limitations of traditional dressings, such as: (1) adaptability to wound contour; (2) controlled drug delivery of therapeutics; (3) gaseous exchange; (4) exudate absorption and (5) surface functionalisation to further enhance the biological activity of the dressing. This review details emerging trends in nanotechnology to specifically target wound healing applications. Particular focus is given to the most common natural polymers that could address many unmet healthcare needs.

Validation of predictive factors for infection in adults with chronic leg ulcers: A prospective longitudinal study

AIMS AND OBJECTIVES

To validate the ability of factors to predict infection in adults with chronic leg ulcers over a 12-week period.

BACKGROUND

Leg ulcers affect ~3% of older adults and are often hard to heal. Infection is a leading contributor for delayed healing, causing delayed wound healing, increased hospitalisation, increased healthcare costs and reduced patient quality of life. The importance of early identification of infection has been highlighted for decades, yet little is known about factors that are associated with increased risk of infection in this specific population.

DESIGN

A longitudinal, prospective observational study in a single centre.

METHODS

Between August 2017 and May 2018, a total of 65 adults with chronic leg ulcers were prospectively observed for a 12-week period. Patients were recruited from an outpatient wound clinic at a tertiary hospital in Australia. Data were collected from recruitment (baseline) and each visit (weekly or fortnightly) up until 12 weeks. Descriptive statistics were calculated for all variables. A Cox proportional hazards regression model was used to identify predictive factors for infection. The TRIPOD guidelines for reporting were followed (See Data S1).

RESULTS

The sample consisted of 65 adults with chronic leg ulcers, and 9.2% of these had their ulcer infected at baseline. Two predictive factors, using walking aids and gout, were found to be significantly related to increased likelihood of developing infection within 12 weeks.

CONCLUSION

The present study showed that patients who either used walking aids or were diagnosed with gout were at greater risk of infection compared to those without these factors.

RELEVANCE TO CLINICAL PRACTICE

These findings provide new information for clinicians in early identification of patients at risk of infection, and for patients in enhancing their awareness of their own risk.

Lock Stock and Barrel of Wound Healing

Any kind of injury may lead to wound formation. As per World Health Organization Report, "more than 5 million people die each year due to injuries. This accounts for 9% of the world's population death, nearly 1.7 times the number of fatalities that result from HIV/AIDS, tuberculosis and malaria combined. In addition, ten million people suffer from non-fatal injuries which require treatment". This scenario leads to increased health and economic burden worldwide. Rapid wound healing is exigent subject-field in the health care system. It is imperative to be updated on wound care strategies as impaired wound healing may lead to chronic, non-healing wounds and thus further contributes to the national burden. This article is a comprehensive review of wound care strategies. The first and second part of this review article focuses on the understanding of wound, its types and human body's healing mechanism. Wound healing is natural, highly coordinated process that starts on its own, immediately after the injury. However, individual health condition influences the healing process. Discussion of factors affecting wound healing has also been included. Next part includes the detailed review of diverse wound healing strategies that have already been developed for different types of wound. A detailed description of various polymers that may be used has been discussed. Amongst drug delivery systems, oligomers, dendrimers, films, gels, different nano-formulations, like nanocomposites, nanofibers, nanoemulsions and nanoparticles are discussed. Emphasis on bandages has been made in this article.

Wireless Direct Microampere Current in Wound Healing: Clinical and Immunohistological Data from Two Single Case Reports

Chronic pressure ulcers are hard-to-heal wounds that decrease the patient’s quality of life. Wireless Micro Current Stimulation (WMCS) is an innovative, non-invasive, similar to electrode-based electrostimulation (ES) technology, that generates and transfers ions that are negatively-charged to the injured tissue, using accessible air gases as a transfer medium. WMCS is capable of generating similar tissue potentials, as electrode-based ES, for injured tissue. Here, through immunohistochemistry, we intended to characterize the induced tissue healing biological mechanisms that occur during WMCS therapy. Two single cases of bedridden due to serious stroke white men with chronic non-healing pressure ulcers have been treated with WMCS technology. WMCS suppresses inflammatory responses by decreasing the aggregation of granulocytes, followed by stimulating myofibroblastic activity and a new formation of collagen fibers, as depicted by immunohistochemistry. As a result, WMCS provides a special adjunct or stand-alone therapy choice for chronic and non-healing injuries, similar to electrode-based ES, but with added (i.e., contactless) benefits towards its establishment as a routine clinical wound healing regime.

Bacterial-binding dressings in the management of wound healing and infection prevention: a narrative review

The aim of this review was to present the clinical data on the use of the family of bacterial-binding dressings (Sorbact; dialkylcarbamoyl chloride-coated) in the treatment of a variety of acute and chronic wounds. The findings are discussed in terms of the effectiveness of the bacterial-binding dressings on bacterial bioburden reduction, infection prevention, initiation/progression of wound healing and cost-effectiveness. The evidence in support of the bacterial-binding dressings is strongest in the area of infection prevention in surgical wounds, with several controlled trials showing the prophylactic benefit of the dressing in these wounds. Wound bioburden management in chronic wounds is supported by a number of clinical studies. In total, 29 published clinical studies (with a total of 4044 patients) were included in this review.

Human Wounds and Its Burden: An Updated Compendium of Estimates

Significance: A 2018 retrospective analysis of Medicare beneficiaries identified that ∼8.2 million people had wounds with or without infections. Medicare cost estimates for acute and chronic wound treatments ranged from $28.1 billion to $96.8 billion. Highest expenses were for surgical wounds followed by diabetic foot ulcers, with a higher trend toward costs associated with outpatient wound care compared with inpatient. Increasing costs of health care, an aging population, recognition of difficult-to-treat infection threats such as biofilms, and the continued threat of diabetes and obesity worldwide make chronic wounds a substantial clinical, social, and economic challenge. Recent Advances: Chronic wounds are not a problem in an otherwise healthy population. Underlying conditions ranging from malnutrition, to stress, to metabolic syndrome, predispose patients to chronic, nonhealing wounds. From an economic point of view, the annual wound care products market is expected to reach $15-22 billion by 2024. The National Institutes of Health's (NIH) Research Portfolio Online Reporting Tool (RePORT) now lists wounds as a category. Future Directions: A continued rise in the economic, clinical, and social impact of wounds warrants a more structured approach and proportionate investment in wound care, education, and related research.

Dynamic Optical Coherence Tomography Is a New Technique for Imaging Skin Around Lower Extremity Wounds

Chronic wounds such as venous leg ulcers invariably heal slowly and recur. In the case of venous leg ulcers, poor healing of chronic wounds is variously attributed to ambulatory hypertension, impaired perfusion and diffusion, presence of chronic inflammation at wound sites, lipodermatosclerosis, and senescence. The aim of this study was to investigate whether a new technique, optical coherence tomography (OCT), which permits imaging of blood capillaries in the peri-wound skin, can provide new insights into the pathology. OCT and its recent variant, dynamic OCT, permit rapid noninvasive depth-resolved imaging of the capillaries in the superficial dermis via a handheld probe, showing the morphology and density of vessels down to 20 µm in diameter. We used dynamic OCT to investigate 15 chronic wounds and assess characteristics of the vessels at the 4 poles around the wounds, the wound bed, adjacent dermatosclerosis, and unaffected skin. The results of the study show that both vessel morphology and density in the wound edges are dramatically different from that in healthy skin, showing clusters of glomuleri-like vessels (knot-like forms or clumps) and an absence of linear branching vessels, and also greater blood perfusion. Such vessel shapes are reported to be associated with tissue growth. The OCT imaging procedure was rapid and well tolerated by patients and provided new information not available from other devices. Thus, OCT appears to have great promise as a tool for the evaluation and study of chronic ulcers.

Budget impact of antimicrobial wound dressings in the treatment of venous leg ulcers in the German outpatient care sector: a budget impact analysis

Background: Hard-to-heal wounds are associated with high treatment costs and, in Germany, are mostly treated in the outpatient care sector. Wound dressings are the main cost-drivers in venous leg ulcer (VLU) care which prescription is budget-restricted. Objective: To determine to what extent the choice of antimicrobial dressing affects the spending in outpatient care by investigating the budget impact of the bioburden-reducing dressing Cutimed Sorbact. Methods: The budget impact analysis was performed comparing three different scenarios of the intervention mix of antimicrobial dressings. A Markov model was used to estimate the VLU progression during one year. The budget impact was determined by comparing the dressing and medicine resource use and costs of the three scenarios. Results: This analysis confirms the high treatment costs of VLU care. ScenarioA leads to a decreased resource use of antimicrobial dressings and results in 20.86% lower treatment costs after 12 months. The increased use of Cutimed Sorbact has a positive budget impact. Conclusion: This analysis indicates that the treatment of VLU patients may result in an exceedance of the budget per patient that is available to the treating practitioner. The choice of wound dressing, however, may positively affect the prescribers' budget spending in outpatient care.

Combined therapy in the treatment of mixed etiology leg ulcer - case report

The most frequent causes of leg ulcers are chronic venous disease (CVD) related mainly to venous hypertension and peripheral arterial disease (PAD) related to disseminated atheromatous lesions in lower limb arteries. In 15%-21% of patients, ulcers of mixed venous-arterial etiology occur, which are usually more resistant for conservative therapy (compression therapy, pharmacotherapy, wearing elastic stockings, leg elevation and massage, change of lifestyle, and regular physical exercises). The contemporary model of complex therapy of leg ulcers in the course of chronic venous and arterial insufficiency more often also comprises numerous physical therapy procedures as associated therapy. This paper presents beneficial results of treatment applied to a 58-year-old patient with 1-month lasting painful chronic ulcers of both shins of mixed venous-arterial etiology, resistant to conservative therapy, which was performed by using the device Laserobaria-S for local combined physical therapy including simultaneous action of hyperbaric oxygen, extremely low-frequency (ELF) variable magnetic field, and low-energy light radiation. As a result of a 9-week therapeutic cycle consisting of 30 daily procedures, a complete healing of ulcers in both shins with accompanying subsidence of pain and substantial reduction in the intensity of local inflammation around the ulcer was obtained. The patient reported no side effects, and no complications were observed during the therapy.

Diabetic foot syndrome in patients with diabetes. A multicenter German/Austrian DPV analysis on 33 870 patients

AIMS

The diabetic foot syndrome (DFS) is a serious complication in patients with diabetes increasing the risk for minor/major amputations. This analysis aimed to examine differences in diabetes patients with or without DFS stratified by type 1 (T1D) or type 2 diabetes (T2D).

MATERIAL AND METHODS

Adult patients (≥20y of age) with diabetes from the German/Austrian diabetes patients follow-up registry (DPV) were included. The cross-sectional study comprised 45 722 subjects with T1D (n_DFS  = 2966) and 313 264 with T2D (n_DFS  = 30 904). In DFS, minor/major amputations were analysed. To compare HbA_1C , neuropathy, nephropathy, cardiovascular disease risk factors, and macrovascular complications between patients with or without DFS, regression models were conducted. Confounders: age, sex, diabetes duration.

RESULTS

In patients with DFS, a minor amputation was documented in 27.2% (T1D) and 25.9% (T2D), a major amputation in 10.2% (T1D) and 11.3% (T2D). Regression models revealed that neuropathy was more frequent in subjects with DFS compared with patients without DFS (T1D: 70.7 vs 29.8%; T2D: 59.4% vs 36.9%; both P < 0.0001). Hypertension, nephropathy, peripheral vascular disease, stroke, or myocardial infarction was more common compared with patients without DFS (all P < 0.0001). In T1D with DFS, a slightly higher HbA_1C (8.11% vs 7.95%; P < 0.0001) and in T2D with DFS a lower HbA_1C (7.49% vs 7.69%; P < 0.0001) was observed.

CONCLUSIONS

One third of the patients with DFS had an amputation of the lower extremity. Especially neuropathy or peripheral vascular disease was more prevalent in patients with DFS. New concepts to prevent DFS-induced amputations and to reduce cardiovascular risk factors before the occurrence of DFS are necessary.

Protease activity as a prognostic factor for wound healing in venous leg ulcers

BACKGROUND

Venous leg ulcers (VLUs) are a common type of complex wound that have a negative impact on people's lives and incur high costs for health services and society. It has been suggested that prolonged high levels of protease activity in the later stages of the healing of chronic wounds may be associated with delayed healing. Protease modulating treatments have been developed which seek to modulate protease activity and thereby promote healing in chronic wounds.

OBJECTIVES

To determine whether protease activity is an independent prognostic factor for the healing of venous leg ulcers.

SEARCH METHODS

In February 2018, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase and CINAHL.

SELECTION CRITERIA

We included prospective and retrospective longitudinal studies with any follow-up period that recruited people with VLUs and investigated whether protease activity in wound fluid was associated with future healing of VLUs. We included randomised controlled trials (RCTs) analysed as cohort studies, provided interventions were taken into account in the analysis, and case-control studies if there were no available cohort studies. We also included prediction model studies provided they reported separately associations of individual prognostic factors (protease activity) with healing. Studies of any type of protease or combination of proteases were eligible, including proteases from bacteria, and the prognostic factor could be examined as a continuous or categorical variable; any cut-off point was permitted. The primary outcomes were time to healing (survival analysis) and the proportion of people with ulcers completely healed; the secondary outcome was change in ulcer size/rate of wound closure. We extracted unadjusted (simple) and adjusted (multivariable) associations between the prognostic factor and healing.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion at each stage, and undertook data extraction, assessment of risk of bias and GRADE assessment. We collected association statistics where available. No study reported adjusted analyses: instead we collected unadjusted results or calculated association measures from raw data. We calculated risk ratios when both outcome and prognostic factor were dichotomous variables. When the prognostic factor was reported as continuous data and healing outcomes were dichotomous, we either performed regression analysis or analysed the impact of healing on protease levels, analysing as the standardised mean difference. When both prognostic factor and outcome were continuous data, we reported correlation coefficients or calculated them from individual participant data.We displayed all results on forest plots to give an overall visual representation. We planned to conduct meta-analyses where this was appropriate, otherwise we summarised narratively.

MAIN RESULTS

We included 19 studies comprising 21 cohorts involving 646 participants. Only 11 studies (13 cohorts, 522 participants) had data available for analysis. Of these, five were prospective cohort studies, four were RCTs and two had a type of case-control design. Follow-up time ranged from four to 36 weeks. Studies covered 10 different matrix metalloproteases (MMPs) and two serine proteases (human neutrophil elastase and urokinase-type plasminogen activators). Two studies recorded complete healing as an outcome; other studies recorded partial healing measures. There was clinical and methodological heterogeneity across studies; for example, in the definition of healing, the type of protease and its measurement, the distribution of active and bound protease species, the types of treatment and the reporting of results. Therefore, meta-analysis was not performed. No study had conducted multivariable analyses and all included evidence was of very low certainty because of the lack of adjustment for confounders, the high risk of bias for all studies except one, imprecision around the measures of association and inconsistency in the direction of association. Collectively the research indicated complete uncertainty as to the association between protease activity and VLU healing.

AUTHORS' CONCLUSIONS

This review identified very low validity evidence regarding any association between protease activity and VLU healing and there is complete uncertainty regarding the relationship. The review offers information for both future research and systematic review methodology.