Depressive symptoms in patients with wounds: A cross-sectional study

Microbial Dysbiosis in the Skin Microbiome and Its Psychological Consequences

The homeostasis of the skin microbiome can be disrupted by both extrinsic and intrinsic factors, leading to a state of dysbiosis. This imbalance has been observed at the onset of persistent skin diseases that are closely linked to mental health conditions like anxiety and depression. This narrative review explores recent findings on the relationship between the skin microbiome and the pathophysiology of specific skin disorders, including acne vulgaris, atopic dermatitis, psoriasis, and wound infections. Additionally, it examines the psychological impact of these skin disorders, emphasizing their effect on patients' quality of life and their association with significant psychological consequences, such as anxiety, depression, stress, and suicidal ideation in the most severe cases.

Chronic wound-related pain, wound healing and the therapeutic potential of cannabinoids and endocannabinoid system modulation

Chronic wounds represent a significant burden on the individual, and the healthcare system. Individuals with chronic wounds report pain to be the most challenging aspect of living with a chronic wound, with current therapeutic options deemed insufficient. The cutaneous endocannabinoid system is an important regulator of skin homeostasis, with evidence of system dysregulation in several cutaneous disorders. Herein, we describe the cutaneous endocannabinoid system, chronic wound-related pain, and comorbidities, and review preclinical and clinical evidence investigating endocannabinoid system modulation for wound-related pain and wound healing. Based on the current literature, there is some evidence to suggest efficacy of endocannabinoid system modulation for promotion of wound healing, attenuation of cutaneous disorder-related inflammation, and for the management of chronic wound-related pain. However, there is 1) a paucity of preclinical studies using validated models, specific for the study of chronic wound-related pain and 2) a lack of randomised control trials and strong clinical evidence relating to endocannabinoid system modulation for wound-related pain. In conclusion, while there is some limited evidence of benefit of endocannabinoid system modulation in wound healing and wound-related pain management, further research is required to better realise the potential of targeting the endocannabinoid system for these therapeutic applications.

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.

Calreticulin: a multifunctional protein with potential therapeutic applications for chronic wounds

Calreticulin is recognized as a multifunctional protein that serves an essential role in diverse biological processes that include wound healing, modification and folding of proteins, regulation of the secretory pathway, cell motility, cellular metabolism, protein synthesis, regulation of gene expression, cell cycle regulation and apoptosis. Although the role of calreticulin as an endoplasmic reticulum-chaperone protein has been well described, several studies have demonstrated calreticulin to be a highly versatile protein with an essential role during wound healing. These features make it an ideal molecule for treating a complex, multifactorial diseases that require fine tuning, such as chronic wounds. Indeed, topical application of recombinant calreticulin to wounds in multiple models of wound healing has demonstrated remarkable pro-healing effects. Among them include enhanced keratinocyte and fibroblast migration and proliferation, induction of extracellular matrix proteins, recruitment of macrophages along with increased granulation tissue formation, all of which are important functions in promoting wound healing that are deregulated in chronic wounds. Given the high degree of diverse functions and pro-healing effects, application of exogenous calreticulin warrants further investigation as a potential novel therapeutic option for chronic wound patients. Here, we review and highlight the significant effects of topical application of calreticulin on enhancing wound healing and its potential as a novel therapeutic option to shift chronic wounds into healing, acute-like wounds.

Examining the unmet needs of chronic wound patients with common mental disorders

BACKGROUND

Common mental disorders (CMD) are highly morbid conditions not routinely screened for in chronic wound care. A comorbid psychiatric condition's influence on a patient with chronic wounds' quality of life (QoL) is unknown. This study investigates the implications of CMD on QoL in patients with chronic lower extremity (LE) wounds.

METHODS

This cross-sectional study surveyed patients with chronic LE wounds evaluated in our multidisciplinary clinic between June-July 2022. Surveys included validated physical and social QoL questionnaires, including the Lower Extremity Functional Scale (LEFS), Patient-Reported Outcomes Measurement Information System (PROMIS-3a) Scale v2.0, 12-Item Short-Form (SF-12), and a screening tool for common mental disorders, the Self-Reporting Questionnaire 20 (SRQ-20). Data regarding patient demographics, comorbidities, psychiatric diagnoses, and wound care history were retrospectively collected.

RESULTS

Of the 265 identified patients, 39 (14.7%) had documented psychiatric diagnoses, most often depression or anxiety. The diagnosed cohort had higher median SRQ-20 scores (6, IQR: 6 vs. 3, IQR: 5; P < 0.001) and a higher proportion of positive screens for CMD (30.8% vs. 15.5%; P = 0.020) than non-diagnosed patients. There were no differences in physical or social QoL in patients with and without a psychiatric diagnosis. However, individuals screening positively for CMD experienced significantly more pain (T-score 60.2 vs. 51.4, P = 0.0052) and reduced function (LEFS 26.0 vs. 41.0, P < 0.0000).

CONCLUSION

This study illustrates that patients with chronic LE wounds experience potentially meaningful psychologic distress. Further, symptoms of a CMD (SRQ-20 ≥8), rather than a previous diagnosis, may influence pain and functional outcomes. These findings emphasize the potential relevance of psychological distress in this population and reinforce the need for further investigation of actionable responses to this apparent need.

The viability and acceptability of a Virtual Wound Care Command Centre in Australia

The objective of this study was to assess the viability and acceptability of an innovative Virtual Wound Care Command Centre where patients in the community, and their treating clinicians, have access to an expert wound specialist service that comprises a digitally enabled application for wound analysis, decision-making, remote consultation, and monitoring. Fifty-one patients with chronic wounds from 9 centres, encompassing hospital services, outpatient clinics, and community nurses in one metropolitan and rural state in Australia, were enrolled and a total of 61 wounds were analysed over 7 months. Patients received, on average, an occasion of service every 4.4 days, with direct queries responded to in a median time of 1.5 hours. During the study period, 26 (42.6%) wounds were healed, with a median time to healing of 66 (95% CI: 56-88) days. All patients reported high satisfaction with their wound care, 86.4% of patients recommended the Virtual Wound Care Command Centre with 84.1% of patients reporting the digital wound application as easy to use. Potential mean travel savings of $99.65 for rural patients per visit were recognised. The data revealed that the Virtual Wound Care Command Centre was a viable and acceptable patient-centred expert wound consultation service for chronic wound patients in the community.

Impaired wound healing is associated with poorer mood and reduced perceived immune fitness during the COVID-19 pandemic: A retrospective survey

Background and Aims

The coronavirus disease-2019 (COVID-19) pandemic disrupted medical care of patients with chronic wounds, and in combination with other negative effects of lockdown measures, this may have a negative effect on mood and quality of life. Until now, the consequences of the COVID-19 pandemic and associated lockdowns for individuals with impaired wound healing have not been investigated.

Methods

An online survey was conducted to evaluate perceived immune fitness, mood, and health, both before and during the COVID-19 pandemic.

Results

Of the 331 Dutch pharmacy students that completed the survey, N = 42 participants reported slow healing wounds and/or wound infection and were allocated to the impaired wound healing group; the other N = 289 participants served as control group. The survey assessed mood, perceived immune fitness, and health correlates for (a) the year 2019 (the period before the lockdown), (b) the first lockdown period (March 15-May 11, 2020), (c) summer 2020 (no lockdown), and (d) the second lockdown (November 2020-April 2021). The analysis revealed that negative mood effects, reductions in quality of life, and perceived immune fitness during the two lockdowns were significantly more pronounced among individuals that reported impaired wound healing compared to the control group. The effects on mood, perceived immune fitness, and health correlates were most pronounced for the second lockdown period.

Conclusion

The COVID-19 pandemic is associated with significantly poorer mood, quality of life, and reduced perceived immune fitness. These effects are significantly more pronounced among individuals with self-reported impaired wound healing.

Inattention, Impulsivity, and Hyperactivity among Individuals with Self-Reported Impaired Wound Healing

Background: Inattention and impulsivity are common causes of accidents and injury. The aim of the current study was to examine the level of attention deficit (AD), hyperactivity, and impulsivity (HI) in individuals with and without self-reported impaired wound healing (IWH). Methods: A survey was conducted among N = 773 Dutch young adults, 18–30 years old. N = 198 were allocated to the IWH group and N = 575 to the control group. All participants completed the Attention Deficit Hyperactivity Disorder (ADHD) Rating Scale. Results: The analysis revealed that the IWH group has significantly higher scores on AD and HI, compared to the control group. Among the IWH group, 12.8% screened positive for AD (compared to 5.8% of the control group) and 14.0% screened positive for HI (compared to 7.4% of the control group). Conclusion: Clinically relevant increased inattention, impulsivity, and hyperactivity were observed among individuals with self-reported impaired wound healing.

Chronic wounds

Chronic wounds are characterized by their inability to heal within an expected time frame and have emerged as an increasingly important clinical problem over the past several decades, owing to their increasing incidence and greater recognition of associated morbidity and socio-economic burden. Even up to a few years ago, the management of chronic wounds relied on standards of care that were outdated. However, the approach to these chronic conditions has improved, with better prevention, diagnosis and treatment. Such improvements are due to major advances in understanding of cellular and molecular aspects of basic science, in innovative and technological breakthroughs in treatment modalities from biomedical engineering, and in our ability to conduct well-controlled and reliable clinical research. The evidence-based approaches resulting from these advances have become the new standard of care. At the same time, these improvements are tempered by the recognition that persistent gaps exist in scientific knowledge of impaired healing and the ability of clinicians to reduce morbidity, loss of limb and mortality. Therefore, taking stock of what is known and what is needed to improve understanding of chronic wounds and their associated failure to heal is crucial to ensuring better treatments and outcomes.

Dermatological Conditions Inducing Acute and Chronic Pain

Pain is a common condition in dermatology. The aim of this review is to analyse the characteristics of pain in dermatology. Some skin diseases are conventionally known to cause pain; e.g. ulcers, pyoderma gangrenosum and herpes zoster. Common dermatoses, such as psoriasis or atopic dermatitis, can also cause significant pain. Some conditions are characterized by neuropathic pain and/or pruritus, without visible primary lesions: e.g. the neurocutaneous diseases, including small fibre neuropathies. Patients often fear pain in skin surgery; however, surgical procedures are rather well tolerated and any pain is mainly due to administration of local anaesthetic. Some therapies may also be uncomfortable for the patient, such as photodynamic therapy or aesthetic procedures. Thus, pain in dermatology is common, and its aetiology and characteristics are very varied. Knowledge of the different situations that cause pain will enable dermatologists to propose suitable analgesic solutions.

Mental Resilience, Mood, and Quality of Life in Young Adults with Self-Reported Impaired Wound Healing

The purpose of this study was to evaluate the impact of self-reported impaired wound healing on quality of life, wellbeing, and mood. It was hypothesized that individuals with impaired wound healing report significantly poorer mood compared to healthy controls. An online survey was conducted among 2173 Dutch young adults (18-30 years old) to investigate mood, neuroticism, and mental resilience. Participants were allocated to a healthy control group (N = 1728) or impaired wound healing groups comprising a wound infection group (WI, N = 76), a slow-healing wounds group (SHW, N = 272), and a group that experienced both WI and SHW (the COMBI group, N = 97). The Kruskal-Wallis test was used to compare outcomes the groups. Compared to the healthy control group, the SHW and COMBI groups, but not the WI group, reported significantly poorer mood, increased neuroticism, reduced mental resilience, and reduced quality of life. An analysis evaluating sex differences found that negative effects on stress, mental resilience, and neuroticism were significantly more pronounced among women than among men. In conclusion, self-reported impaired wound healing is associated with poorer mood and reduced quality of life. To improve future wound care, these findings advocate for an interdisciplinary approach taking into account mood effects accompanying having impaired wound healing.

Psychological Stress on Wound Healing: A Silent Player in a Complex Background

Stress is hard to define and is further complicated by varied perceptions in the population and differing responses in different situations. Psychological stress brings about certain physiological changes through manipulation of the neural, humoral and immunological systems. Observational studies have showed that fear and anxiety before surgery can complicate normal wound healing. Two different pathways appear to be involved: one directly through hypothalamic-pituitary-adrenal axis and sympathetic-adrenomedullary axis, and another indirectly through negative psychological stressors such as anxiety, depression and social isolation. The pathogenesis includes decreased expression of pro-inflammatory cytokines, resulting in poor angiogenesis, matrix regeneration and delayed healing. Prolonged immunological activation in itself is a stressor and can precipitate a sickness behaviour syndrome manifested by disturbed sleep, anorexia, reduction in activity, increased responsiveness to pain and addiction to alcohol and tobacco. It has been observed that cortisol release suppresses pro-inflammatory cytokine release, while down-regulation of cortisol causes unabated inflammatory response. In individuals with chronic wounds, on the other hand, it is thought that physical stress has different effects such as foul odor, pain, exudate and social and familial isolation, which may act independently as psychological stressors. This article attempts to appraise the influence of psychological stress on the immunological system and its effect on wound healing.

Review on Disasters and Lower Limb Venous Disease

As per the World Health Organization, a disaster is defined as “an event that occurs in most cases suddenly and unexpectedly, causing severe disturbances to people or objects affected by it, resulting in the loss of life and harm to the health of the population.” A number of health issues are often reported following disasters, such as physical and psychological trauma, infections, malnutrition, and cardiovascular events. Among these, venous thromboembolism is deemed serious and thus should be taken into consideration. Indeed, its risk has been demonstrated to increase following earthquakes, floods, burns, and intoxications. The recent coronavirus pandemic summarizes some of the main triggering factors involved in acute and chronic venous disease development in a disaster setting: inflammation, infection, lockdown-induced reduced mobility, potential malnutrition, and overweight.

Proper venous risk assessment and guideline application have been determined to be essential in disaster management, particularly in the current time in which sheltering could lead to a potential exacerbation of the pandemic, which can only increase the risk for venous thrombotic diseases.

Global scientific teamwork is needed to make the recommendations as evidence-based and as homogeneous as possible among continents.

In this present review, we focus on how earthquakes impact venous thromboembolism, including an analysis of other disaster-related conditions, such as burns and intoxication. (This is a review article based on the informative seminar of the 40th Annual Meeting of Japanese Society of Phlebology.)

Potential predictors of quality of life in patients with venous leg ulcers: A cross-sectional study in Taiwan

Internationally, the impact of venous leg ulcers (VLUs) on the quality of life is well recognised; however, in Taiwan, the focus is only on chronic wound management. This cross‐sectional correlational study conducted at the cardiovascular and plastic surgery clinics of a regional teaching hospital between August 2019 and June 2020 investigates venous clinical severity, pain, fatigue, depression, sleep quality, quality of life, and related factors among 167 patients with VLUs. The potential predictors of the quality of life in terms of activities were venous clinical severity (P < 0.001), pain (P = 0.004), and fatigue (P < 0.001) after adjusting for covariates. The potential predictors of the quality of life in terms of the psychological domain were marital status (single/divorced) (P = 0.016), marital status (widowed) (P = 0.027), venous clinical severity (P < 0.001), pain (P = 0.001), and fatigue (P = 0.002). The potential predictors of the quality of life with regard to symptoms were venous clinical severity (P < 0.001), pain (P < 0.001), fatigue (P = 0.001), and depression (P = 0.038). These potential predictors can serve as the basis of interventions for patients with VLUs, such as those related to nutrition or training in wound dressing.

Multidimensional Pain Characteristics in Older Adults with Chronic Venous Leg Ulcers

Objective: Pain affects wound healing, treatment, and quality of life because it has significant impacts on physical, psychological, and social well-being. Despite the fact that more than half of chronic venous leg ulcer (CVLU) patients experience mild-to-moderate pain, the multidimensional characteristics of CVLU pain are not well documented. The objective of this study was to describe the multidimensional pain characteristics, including the sensory, affective, cognitive, and behavioral dimensions, of CVLU before debridement. Approach: Participants (N = 40) were recruited from a wound clinic. We conducted a descriptive analysis of clinical data, including pain, wound, and demographic characteristics, collected at the first visit. Results: The mean age of participants was 70.8 ± 9.1 years, 22 (55%) participants were female, and 35 (87.5%) were white. Participants reported mean current pain intensity (2.9 ± 2.7), least (1.2 ± 2.2) and worst (4.8 ± 3.4) pain intensity in 24 h, and tolerable pain level (4.9 ± 2.64) on a 0-10 scale. They described pain as periodic (66.7%, n = 26) with multiple pain quality descriptors (5.4 ± 2.9). Their past pain treatments provided some pain relief (65%, n = 25). For 68% (n = 27), their pain was the same as they expected. Nearly all had a tendency not to tell others about their pain (95%, n = 38). Innovation: This study is the first to describe the multidimensional pain characteristics of patients with CVLU as measured with PAINReportIt. Conclusion: Patients with CVLU reported willingness to tolerate a relatively high level of pain and experience the level of pain they anticipate. Multidimensional pain assessment will assist clinicians to select individualized therapies to manage pain and improve quality of life for these patients.

Skin-brain axis signaling mediates behavioral changes after skin wounding

Patients with chronic wounds often have associated cognitive dysfunction and depression with an as yet unknown mechanism for this association. To address the possible causality of skin wounding inducing these changes, behavior and cognitive functions of female C57BL/6 mice with an excisional skin wound were compared to unwounded animals. At six days post wounding, animals exhibited anxiety-like behaviors, impaired recognition memory, and impaired coping behavior. Wounded animals also had concomitant increased hippocampal expression of Tnfa, the pattern recognition receptor (PRR) Nod2, the glucocorticoid receptors GR/Nr3c1 and Nr3c2. Prefrontal cortex serotonin and dopamine turnover were increased on day six post-wounding. In contrast to the central nervous system (CNS) findings, day six post -wounding serum catecholamines did not differ between wounded and unwounded animals, nor did levels of the stress hormone corticosterone, TNFα, or TGFβ. Serum IL6 levels were, however elevated in the wounded animals. These findings provide evidence of skin-to-brain signaling, mediated either by elevated serum IL6 or a direct neuronal signaling from the periphery to the CNS, independent of systemic mediators. Wounding in the periphery is associated with an altered expression of inflammatory mediators and PRR genes in the hippocampus, which may be responsible for the observed behavioral deficits.

Does Social Support Moderate Wound Pain and Health-Related Quality of Life in Patients With Chronic Wounds? A Multicenter Descriptive Cross-sectional Study

PURPOSE

We sought to explore the relationships among social support, health-related quality of life (HRQOL), and wound pain, and to examine whether social support would moderate the relationship between wound pain and HRQOL.

DESIGN

A multicenter descriptive cross-sectional study.

SUBJECTS AND SETTINGS

Individuals with chronic wounds attending wound clinics affiliated with 3 public hospitals in Beijing, China.

METHODS

Sociodemographic and wound characteristics of 162 participants were retrieved from medical records. Participants completed questionnaires for wound-related pain intensity (Numerical Rating Scale), social support (Social Support Rating Scale), and HRQOL (Medical Outcome Study Short Form-36). The moderating effect analysis was examined using the PROCESS analytic tool developed by Hayes, based on the bias-corrected bootstrapping method.

RESULTS

Results revealed that higher pain intensity was significantly related to lower HRQOL (P < .01), and higher social support was associated with better HRQOL (P < .01). However, there was no significant correlation between social support and wound pain (P = .55). Importantly, the moderating effect of social support on the relationship between wound pain and HRQOL was statistically significant (P = .008).

CONCLUSIONS

We found that social support moderated the impact of wound pain on HRQOL in patients with chronic wounds. This finding suggests that support obtained from social networks may be a beneficial intervention to improve the HRQOL of patients with chronic wounds, especially those suffering from high-intensity wound pain.

Metabolomics: Impact of Comorbidities and Inflammation on Sickness Behaviors for Individuals with Chronic Wounds

Significance: Approximately 6.5 million people in the United States suffer from chronic wounds. The chronic wound population is typically older and is characterized by a number of comorbidities associated with inflammation. In addition to experiencing wound-related pain, individuals with chronic wounds commonly experience multiple concurrent psychoneurological symptoms such as fatigue and depression, which delay wound healing. However, these distressing symptoms have been relatively overlooked in this population, although their adverse effects on morbidity are well established in other chronic disease populations. Recent Advances: Inflammation is involved in multiple pathways, which activate brain endothelial and innate immune cells that release proinflammatory cytokines, which produce multiple symptoms known as sickness behaviors. Inflammation-based activation of the kynurenine (KYN) pathway and its metabolites is a mechanism associated with chronic illnesses. Critical Issues: Although putative humoral and neuronal routes have been identified, the specific metabolic variations involved in sickness behaviors in chronic wound patients remain unclear. To improve health outcomes in the chronic wound population, clinicians need to have better understanding of the mechanisms underlying sickness behaviors to provide appropriate treatments. Future Directions: This article presents a synthesis of studies investigating associations between inflammation, metabolic pathways, and sickness behaviors in multiple chronic diseases. The presentation of a theoretical framework proposes a mechanism underlying sickness behaviors in the chronic wound population. By mediating the immune system response, dysregulated metabolites in the KYN pathway may play an important role in sickness behaviors in chronic inflammatory conditions. This framework may guide researchers in developing new treatments to reduce the disease burden in the chronic wound population.

Pain and analgesics in patients with hard-to-heal ulcers: using telemedicine or standard consultations

OBJECTIVE

To compare consultations carried out via video with those performed in person for patients with painful, hard-to-heal ulcers, with a focus on ulcer pain and pain treatment. A further aim was to investigate predictors for pain and pain treatment.

METHOD

This was a register-based, quasi-experimental study based on data from the Swedish Registry of Ulcer Treatment (RUT). A total of 100 patients with hard-to-heal ulcers diagnosed via video consultation were compared with 1888 patients diagnosed in person with regard to pain assessment, intensity and treatment. Ulcer pain intensity was assessed by the visual analogue scale (VAS). Normally distributed variables (age, VAS) were compared between consultation groups using Student's t-test. Non-normally distributed variables (ulcer size, ulcer duration) were compared using the Mann-Whitney U-test, except for healing time, which was analysed with a log-rank test. Categorical variables (gender, ulcer aetiology and prescribed analgesics) were compared using Pearson's chi-square test (χ²). A p value of less than 0.05 was considered to indicate statistical significance. Predictors for pain and pain treatment were analysed in multiple regression analyses.

RESULTS

The results showed a high presence of pain; 71% of patients with pain reported severe ulcer pain. There was no significant difference in ability to assess pain by VAS in the group diagnosed via video consultation (90%) compared with the group diagnosed in person (86%) (χ², p=0.233). A significantly higher amount of prescribed analgesics was found for patients diagnosed via video (84%) compared with patients diagnosed by in-person assessment (68%) (χ², p=0.044). Predictors for high-intensity pain were female gender or ulcers due to inflammatory vessel disease, while the predictors for receiving analgesics were older age, longer healing time and being diagnosed via video consultation.

CONCLUSION

To identify, assess and treat ulcer pain is equally possible via video as by in-person consultation. The results of this study confirm that patients with hard-to-heal ulcers suffer from high-intensity ulcer pain, with a discrepancy between pain and pain relief. Further well-designed randomised controlled studies are necessary to understand how best to deploy telemedicine in ulcer pain treatment.

Role of hospital anxiety and depression on the healing of chronic leg ulcer: A prospective study

A chronic leg ulcer is a debilitating illness, owing to the local condition of the wound and a decrease in physical activity and productivity, resulting in anxiety and depression among patients. The study aimed to find any association of anxiety and depression in the healing of chronic wounds. A total of 125 patients with chronic leg ulcers were enrolled in the study. HADS questionnaire assessment followed the local wound examination in all patients. A follow-up assessment of the ulcer was done after appropriate local treatment, and data analysed with the HADS scale. In the present study, the ROC curve showed a cutoff value of 14 for the HADS score in predicting ulcer status (non-healing vs healed) after 30 days. A total of 54.4% (68) patients had a HADS score ≥ 14 and 39% (49) were true positive for the non-healing wound at a 1-month follow-up. This study revealed a sensitivity and specificity of 83.1% and 71.2%, respectively (P-value <.001), and diagnostic accuracy of 76.8%, for HADS score > 14 in the detection of non-healing ulcers. Chronic leg ulcers should be subjected to HADS assessment and if found significant corrective measures must be instituted for improving wound healing.

Pain and analgaesics in patients with hard-to-heal ulcers: using telemedicine or standard consultations

OBJECTIVE

To compare consultations carried out via video with those performed in person for patients with painful, hard-to-heal ulcers, with a focus on ulcer pain and pain treatment. A further aim was to investigate predictors for pain and pain treatment.

METHOD

This was a register-based, quasi-experimental study based on data from the Swedish Registry of Ulcer Treatment (RUT). A total of 100 patients with hard-to-heal ulcers diagnosed via video consultation were compared with 1888 patients diagnosed in person with regard to pain assessment, intensity and treatment. Ulcer pain intensity was assessed by the visual analogue scale (VAS). Normally distributed variables (age, VAS) were compared between consultation groups using Student's t-test. Non-normally distributed variables (ulcer size, ulcer duration) were compared using the Mann-Whitney U-test, except for healing time, which was analysed with a log-rank test. Categorical variables (gender, ulcer aetiology and prescribed analgesics) were compared using Pearson's chi-square test (χ²). A p value of less than 0.05 was considered to indicate statistical significance. Predictors for pain and pain treatment were analysed in multiple regression analyses.

RESULTS

The results showed a high presence of pain; 71% of patients with pain reported severe ulcer pain. There was no significant difference in ability to assess pain by VAS in the group diagnosed via video consultation (90%) compared with the group diagnosed in person (86%) (χ², p=0.233). A significantly higher amount of prescribed analgesics was found for patients diagnosed via video (84%) compared with patients diagnosed by in-person assessment (68%) (χ², p=0.044). Predictors for high-intensity pain were female gender or ulcers due to inflammatory vessel disease, while the predictors for receiving analgesics were older age, longer healing time and being diagnosed via video consultation.

CONCLUSION

To identify, assess and treat ulcer pain is equally possible via video as by in-person consultation. The results of this study confirm that patients with hard-to-heal ulcers suffer from high-intensity ulcer pain, with a discrepancy between pain and pain relief. Further well-designed randomised controlled studies are necessary to understand how best to deploy telemedicine in ulcer pain treatment.

Psychosocial factors of patients with venous leg ulcers and their association with healing

Objectives: To identify psychosocial factors present in patients with venous leg ulcers and the association that these factors have in the healing of venous leg ulcers. Methods: An integrative review of the quantitative studies in MEDLINE, Scielo and Cochrane Library databases, between 2008 and 2019, using the keywords, psychosocial factors, venous ulcer, wound healing, anxiety and depression in English, Spanish and Portuguese. Results: sixteen studies were included. The psychosocial factors present in patients with venous ulcers were depression, anxiety, feelings of helplessness, subjective well-being, self-esteem, loneliness and spirituality. Stress, a negative perception of venous ulcer, living alone and severe experience of symptoms such as pain and depression have statistically significant associations with longer periods of healing. Conclusions: Depression is one of the most frequently measured factors and present in this population. The available evidence on the association of psychosocial factors with the healing of venous ulcers is low.

Factores psicosociales en los pacientes con úlceras venosas y su asociación con la cicatrización

Objetivo: Identificar los factores psicosociales presentes en pacientes con úlceras venosas y la evidencia disponible sobre la asociación que estos factores tienen con la curación de este tipo de heridas. Métodos: Revisión integradora de la literatura de estudios cuantitativos en las bases de datos MEDLINE, Scielo y Cochrane Library entre los años 2008 y 2019, utilizando las palabras clave, factores psicosociales, úlcera venosa, cicatrización de heridas ansiedad y depresión en idioma inglés, español y portugués. Resultados: Dieciséis estudios fueron incluidos. Los factores psicosociales presentes en los pacientes con úlceras venosas fueron depresión, ansiedad, sentimientos de impotencia, bienestar subjetivo, autoestima, soledad y espiritualidad. El estrés, una percepción negativa de la úlcera venosa, vivir solo y la experiencia severa de síntomas como dolor y depresión tienen asociaciones estadísticamente significativas con periodos más prolongados de curación. Conclusión: La depresión es uno de los factores psicológicos medido y presente con mayor frecuencia en esta población. La evidencia disponible frente a la asociación de los factores psicosociales con la curación de úlceras venosas es escasa.

Relationships among economic stress, social support, age and quality of life in patients with chronic wounds: A moderated mediation model

AIMS

The aims of this study were as follows: (a) to determine if social support mediates the relationship between economic stress and quality of life; and (b) to explore whether participants' ages would moderate the indirect relationship between economic stress and quality of life through social support.

DESIGN

A questionnaire-based, cross-sectional study.

METHODS

From January 2015-June 2016, a total of 300 patients with chronic wounds were recruited from three hospitals. Data regarding economic stress, social support and quality of life were collected through survey questionnaires. The moderated mediation analysis was examined using the Hayes' PROCESS macro modelling tool, based on the bias-corrected bootstrapping method.

RESULTS

Economic stress was negatively correlated with quality of life and social support. The indirect effect of economic stress on quality of life through social support was negative. Furthermore, age moderated the relationship between economic stress and quality of life, as well as the relationship between economic stress and social support.

CONCLUSION

Reducing economic stress and improving social support are important strategies for improving quality of life in patients with chronic wounds, especially for younger patients.

IMPACT

Patients with chronic wounds experience considerable economic stress and severely impaired quality of life; however, little is known about the inner mechanisms of this relationship. This study emphasized the importance of providing social support in coping with the damage that economic stress causes to health. Clinical nurses should strengthen the comprehensive assessment of the socioeconomic status of patients and adjust nursing plans timely, to reduce the economic burden of patients based on the rational use of wound care materials. Moreover, when nursing for patients with chronic wounds, especially the elders, caregivers should strengthen the evaluation of social support and develop interventions to improve social support.

The effectiveness of stabilization appliance therapy among patients with myalgia

BACKGROUND

The efficacy of stabilization appliance therapy for masticatory muscle pain is debated. Therefore, there are currently no clear usage standards. We analyzed patient factors influencing its efficacy and characterized masticatory muscle pain subtypes to determine appropriate therapy candidates.

METHODS

This case series study recruited patients diagnosed with local myalgia or myofascial pain and used variables related to temporomandibular disorders in the analysis. We used temporary appliance to screen patients for sleep bruxism for 2 weeks. Afterwards, we initiated therapy with stabilization appliances. Efficacy was evaluated via tenderness intensity during muscle palpation and the treatment satisfaction score after 2 months of treatment.

RESULTS

We analyzed 62 (91%) patients. Tenderness upon muscle palpation was mitigated in 27 patients. Mitigated tenderness odds ratios were 0.035 for myofascial pain, 0.804 for 15-item Patient Health Questionnaire scores, and 1.915 for facet length. Thirty-nine patients expressed satisfaction; satisfaction odds ratios were 0.855 for 9-item Patient Health Questionnaire scores, 1.606 for facet length, and 4.023 for awake bruxism awareness.

CONCLUSIONS

Stabilization appliance therapy is most effective for patients with awake bruxism awareness, local myalgia, long facets, and no psychosocial risk factors.

Microbiome-skin-brain axis: A novel paradigm for cutaneous wounds

Chronic wounds cause a significant burden on society financially, medically, and psychologically. Unfortunately, patients with nonhealing wounds often suffer from comorbidities that further compound their disability. Given the high rate of depressive symptoms experienced by patients with chronic wounds, further studies are needed to investigate the potentially linked pathophysiological changes in wounds and depression in order to improve patient care. The English literature on wound healing, inflammatory and microbial changes in chronic wounds and depression, and antiinflammatory and probiotic therapy was reviewed on PubMed. Chronic wound conditions and depression were demonstrated to share common pathologic features of dysregulated inflammation and altered microbiome, indicating a possible relationship. Furthermore, alternative treatment strategies such as immune-targeted and probiotic therapy showed promising potential by addressing both pathophysiological pathways. However, many existing studies are limited to a small study population, a cross-sectional design that does not establish temporality, or a wide range of confounding variables in the context of a highly complex and multifactorial disease process. Therefore, additional preclinical studies in suitable wound models, as well as larger clinical cohort studies and trials are necessary to elucidate the relationship between wound microbiome, healing, and depression, and ultimately guide the most effective therapeutic and management plan for chronic wound patients.

Challenges and opportunities of pH in chronic wounds

Regarded as a silent epidemic, chronic wounds are a global public health issue. Wound healing is a complex, synchronized cascade of physiological processes restoring the anatomic and functional integrity of the skin; however, chronic wounds fail to proceed through the wound healing cascade. Wound pH oscillates during wound healing, usually traversing from a neutral pH to an acidic pH, while chronic wounds perpetuate in an elevated alkaline milieu. Although a neglected clinical parameter, pH has implications for relatively all pathologies of wound healing affecting oxygen release, angiogenesis, protease activity, bacterial toxicity and antimicrobial activity. Despite the array of wound healing products currently marketed, understanding the implications of pH on arresting wound healing can stimulate innovation within this vast market.