A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types

Cannabinoids in Integumentary Wound Care: A Systematic Review of Emerging Preclinical and Clinical Evidence

This systematic review critically evaluates preclinical and clinical data on the antibacterial and wound healing properties of cannabinoids in integument wounds. Comprehensive searches were conducted across multiple databases, including CINAHL, Cochrane library, Medline, Embase, PubMed, Web of Science, and LILACS, encompassing records up to May 22, 2024. Eighteen studies met the inclusion criteria. Eleven were animal studies, predominantly utilizing murine models (n = 10) and one equine model, involving 437 animals. The seven human studies ranged from case reports to randomized controlled trials, encompassing 92 participants aged six months to ninety years, with sample sizes varying from 1 to 69 patients. The studies examined the effects of various cannabinoid formulations, including combinations with other plant extracts, crude extracts, and purified and synthetic cannabis-based medications administered topically, intraperitoneally, orally, or sublingually. Four animal and three human studies reported complete wound closure. Hemp fruit oil extract, cannabidiol (CBD), and GP1a resulted in complete wound closure in twenty-three (range: 5-84) days with a healing rate of 66-86% within ten days in animal studies. One human study documented a wound healing rate of 3.3 cm2 over 30 days, while three studies on chronic, non-healing wounds reported an average healing time of 54 (21-150) days for 17 patients by oral oils with tetrahydrocannabinol (THC) and CBD and topical gels with THC, CBD, and terpenes. CBD and tetrahydrocannabidiol demonstrated significant potential in reducing bacterial loads in murine models. However, further high-quality research is imperative to fully elucidate the therapeutic potential of cannabinoids in the treatment of bacterial skin infections and wounds. Additionally, it is crucial to delineate the impact of medicinal cannabis on the various phases of wound healing. This study was registered in PROSPERO (CRD42021255413).

MOFs and MOF-Based Composites as Next-Generation Materials for Wound Healing and Dressings

In recent years, there has been growing interest in developing innovative materials and therapeutic strategies to enhance wound healing outcomes, especially for chronic wounds and antimicrobial resistance. Metal-organic frameworks (MOFs) represent a promising class of materials for next-generation wound healing and dressings. Their high surface area, pore structures, stimuli-responsiveness, antibacterial properties, biocompatibility, and potential for combination therapies make them suitable for complex wound care challenges. MOF-based composites promote cell proliferation, angiogenesis, and matrix synthesis, acting as carriers for bioactive molecules and promoting tissue regeneration. They also have stimuli-responsivity, enabling photothermal therapies for skin cancer and infections. Herein, a critical analysis of the current state of research on MOFs and MOF-based composites for wound healing and dressings is provided, offering valuable insights into the potential applications, challenges, and future directions in this field. This literature review has targeted the multifunctionality nature of MOFs in wound-disease therapy and healing from different aspects and discussed the most recent advancements made in the field. In this context, the potential reader will find how the MOFs contributed to this field to yield more effective, functional, and innovative dressings and how they lead to the next generation of biomaterials for skin therapy and regeneration.

Challenges around quantifying uncertainty in a holistic approach to hard-to-heal wound management: Health economic perspective

Treatment of hard-to-heal wounds involves a holistic approach for choosing between available treatment options. However, evidence for informing these choices is sparse, introducing uncertainty into decisions about the optimum treatment pathways that reflect the vast heterogeneity in this patient population. This paper discusses the existing clinical and health economic literature in order to provide insight into sources of uncertainty in the evaluation of the holistic approach to management of the hard-to-heal wounds, and how this uncertainty can be appropriately reflected in research. We identified three key sources of uncertainty in the evaluation of chronic wound treatments, namely heterogeneity in aetiology and patient populations, heterogeneity in treatment pathways, and challenges around capturing all relevant outcomes. Reflecting these complexities requires sophisticated modelling of treatment sequencing and long-term outcomes. The paper discusses how the scope specification, scenario analyses, and sensitivity analyses can be used to fully characterise analytical uncertainty.

Application of Alginate-Based Hydrogels in Hemostasis

Hemorrhage, as a common trauma injury and clinical postoperative complication, may cause serious damage to the body, especially for patients with huge blood loss and coagulation dysfunction. Timely and effective hemostasis and avoidance of bleeding are of great significance for reducing body damage and improving the survival rate and quality of life of patients. Alginate is considered to be an excellent hemostatic polymer-based biomaterial due to its excellent biocompatibility, biodegradability, non-toxicity, non-immunogenicity, easy gelation and easy availability. In recent years, alginate hydrogels have been more and more widely used in the medical field, and a series of hemostatic related products have been developed such as medical dressings, hemostatic needles, transcatheter interventional embolization preparations, microneedles, injectable hydrogels, and hemostatic powders. The development and application prospects are extremely broad. This manuscript reviews the structure, properties and history of alginate, as well as the research progress of alginate hydrogels in clinical applications related to hemostasis. This review also discusses the current limitations and possible future development prospects of alginate hydrogels in hemostatic applications.

Topically administered purified clinoptilolite-tuff for the treatment of cutaneous wounds: a prospective, randomized phase I clinical trial

In an ageing society, chronic ulcers pose an increasingly relevant healthcare issue associated with significant morbidity and an increasing financial burden. Hence, there is an unmet medical need for novel, cost‐effective therapies that improve healing of chronic cutaneous wounds. This prospective, randomised, open‐label, phase I trial investigated the safety and tolerability of topically administered purified clinoptilolite‐tuff (PCT), mainly consisting of the naturally occurring zeolite‐mineral clinoptilolite, in artificial wounds in healthy male volunteers compared to the standard of care (SoC). We found that topically administered PCT was safe for therapeutic application in acute wounds in healthy male volunteers. No significant differences in wound healing or wound conditions were observed compared to SoC‐treated wounds. However, we found a significantly higher proportion of CD68‐positive cells and a significantly lower proportion of α‐smooth muscle actin‐positive cells in PCT‐treated wounds. Scanning electron microscopy revealed PCT particles in the restored dermis in some cases. However, these did not impede wound healing or clinical symptoms. Hence, purified PCT could represent an attractive, cost‐effective wound treatment promoting the process of healing.

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.

Cost-effectiveness analysis of domiciliary topical sevoflurane for painful leg ulcers

Objectives

The general anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. We conducted a Bayesian cost-effectiveness analysis (CEA) comparing the addition of domiciliary topical sevoflurane to conventional analgesics (SEVOFLURANE, n = 38) versus conventional analgesics alone (CONVENTIONAL, n = 26) for the treatment of nonrevascularizable painful leg ulcers in an outpatient Pain Clinic of a Spanish tertiary hospital.

Methods

We used real-world data collected from charts to conduct this CEA from a public healthcare perspective and with a one-year time horizon. Costs of analgesics, visits and admissions were considered, expressed in €2016. Analgesic effectiveness was measured with SPID (Sum of Pain Intensity Difference). A Bayesian regression model was constructed, including “treatment” and baseline characteristics for patients (“arterial hypertension”) and ulcers (“duration”, “number”, “depth”, “pain”) as covariates. The findings were summarized as a cost-effectiveness plane and a cost-effectiveness acceptability curve. One-way sensitivity analyses, a re-analysis excluding those patients who died or suffered from leg amputation, and an extreme scenario analysis were conducted to reduce uncertainty.

Results

Compared to CONVENTIONAL, SEVOFLURANE was associated with a 46% reduction in costs, and the mean incremental effectiveness (28.15±3.70 effectiveness units) was favorable to SEVOFLURANE. The estimated probability for SEVOFLURANE being dominant was 99%. The regression model showed that costs were barely influenced by any covariate, whereas effectiveness was noticeably influenced by “treatment”. All sensitivity analyses showed the robustness of the model, even in the extreme scenario analysis against SEVOFLURANE.

Conclusions

SEVOFLURANE was dominant over CONVENTIONAL as it was less expensive and much more effective.

Accelerated burn wound healing with photobiomodulation therapy involves activation of endogenous latent TGF-β1

The severity of tissue injury in burn wounds from associated inflammatory and immune sequelae presents a significant clinical management challenge. Among various biophysical wound management approaches, low dose biophotonics treatments, termed Photobiomodulation (PBM) therapy, has gained recent attention. One of the PBM molecular mechanisms of PBM treatments involves photoactivation of latent TGF-β1 that is capable of promoting tissue healing and regeneration. This work examined the efficacy of PBM treatments in a full-thickness burn wound healing in C57BL/6 mice. We first optimized the PBM protocol by monitoring tissue surface temperature and histology. We noted this dynamic irradiance surface temperature-monitored PBM protocol improved burn wound healing in mice with elevated TGF-β signaling (phospho-Smad2) and reduced inflammation-associated gene expression. Next, we investigated the roles of individual cell types involved in burn wound healing following PBM treatments and noted discrete effects on epithelieum, fibroblasts, and macrophage functions. These responses appear to be mediated via both TGF-β dependent and independent signaling pathways. Finally, to investigate specific contributions of TGF-β1 signaling in these PBM-burn wound healing, we utilized a chimeric TGF-β1/β3 knock-in (TGF-β1^Lβ3/Lβ3) mice. PBM treatments failed to activate the chimeric TGF-β1^Lβ3/Lβ3 complex and failed to improve burn wound healing in these mice. These results suggest activation of endogenous latent TGF-β1 following PBM treatments plays a key role in burn wound healing. These mechanistic insights can improve the safety and efficacy of clinical translation of PBM treatments for tissue healing and regeneration.

Biofilm-Innate Immune Interface: Contribution to Chronic Wound Formation

Delayed wound healing can cause significant issues for immobile and ageing individuals as well as those living with co-morbid conditions such as diabetes, cardiovascular disease, and cancer. These delays increase a patient’s risk for infection and, in severe cases, can result in the formation of chronic, non-healing ulcers (e.g., diabetic foot ulcers, surgical site infections, pressure ulcers and venous leg ulcers). Chronic wounds are very difficult and expensive to treat and there is an urgent need to develop more effective therapeutics that restore healing processes. Sustained innate immune activation and inflammation are common features observed across most chronic wound types. However, the factors driving this activation remain incompletely understood. Emerging evidence suggests that the composition and structure of the wound microbiome may play a central role in driving this dysregulated activation but the cellular and molecular mechanisms underlying these processes require further investigation. In this review, we will discuss the current literature on: 1) how bacterial populations and biofilms contribute to chronic wound formation, 2) the role of bacteria and biofilms in driving dysfunctional innate immune responses in chronic wounds, and 3) therapeutics currently available (or underdevelopment) that target bacteria-innate immune interactions to improve healing. We will also discuss potential issues in studying the complexity of immune-biofilm interactions in chronic wounds and explore future areas of investigation for the field.

Knockdown of Dual Oxidase 1 (DUOX1) Promotes Wound Healing by Regulating Reactive Oxygen Species (ROS) by Activation of Nuclear Kactor kappa B (NF-κB) Signaling

Background

The aim of this study was to evaluate the potential role of dual oxidase 1 (DUOX1) in wound healing.

Material/Methods

Primary fibroblasts were isolated from wound granulation tissue. Fibroblasts cell lines were established using DUOX1 overexpression and interference. Cell proliferation and reactive oxygen species (ROS) production were measured and compared among the groups.

Results

DUOX1 expression was highest in the slow-healing tissues (P<0.05). Knockdown of DUOX1 significantly increased cell proliferation and inhibited ROS production and cell apoptosis (P<0.01). Moreover, expression of malondialdehyde (MDA) was significantly reduced, while expression of superoxide dismutase (SOD) expression was significantly increased (P<0.01). In addition, DUOX1 silencing significantly upregulated collagen I, collagen III, and NF-κB protein levels in the cytoplasm, and inhibited the protein levels of P21, P16, and NF-κB in the nucleus (P<0.01). Overexpression of DUOX1 caused a reverse reaction mediated by knockdown of DUOX1. When DUOX1-overexpressing cells were treated with the ROS inhibitor N-acetyl-L-cysteine (NAC), the protein levels that were increased by DUOX1 overexpression were reversed.

Conclusions

These results suggest that knockdown of DUOX1 significantly benefits wound healing, likely by the regulation of oxidative stress via NF-κB pathway activation.

Development of Bacterial Cellulose Biocomposites Combined with Starch and Collagen and Evaluation of Their Properties

One of the major benefits of biomedicine is the use of biocomposites as wound dressings to help improve the treatment of injuries. Therefore, the main objective of this study was to develop and characterize biocomposites based on bacterial cellulose (BC) with different concentrations of collagen and starch and characterize their thermal, morphological, mechanical, physical, and barrier properties. In total, nine samples were produced with fixed amounts of glycerol and BC and variations in the amount of collagen and starch. The water activity (0.400–0.480), water solubility (12.94–69.7%), moisture (10.75–20.60%), thickness (0.04–0.11 mm), water vapor permeability (5.59–14.06 × 10⁻⁸ g·mm/m²·h·Pa), grammage (8.91–39.58 g·cm⁻²), opacity (8.37–36.67 Abs 600 nm·mm⁻¹), elongation (4.81–169.54%), and tensile strength (0.99–16.32 MPa) were evaluated and defined. In addition, scanning electron microscopy showed that adding biopolymers in the cellulose matrix made the surface compact, which also influenced the visual appearance. Thus, the performance of the biocomposites was directly influenced by their composition. The performance of the different samples obtained resulted in them having different potentials for application considering the injury type. This provides a solution for the ineffectiveness of traditional dressings, which is one of the great problems of the biomedical sector.

Prevalence, incidence and risk factors for foot pressure ulcers in hospitalized elderly patients. An observational and prospective study

BACKGROUND

Incidence and clinical characteristics of foot pressure ulcers (FPU) in hospitalized elderly patients are not well known. The aim of the study was to determine the incidence of FPU during hospitalization, to describe main FPU characteristics and to assess main risk factors for FPU in hospitalised elderly subjects.

METHODOLOGY

An observational prospective study was performed in which patients 65 years or older admitted to Vascular Surgery, Orthopaedic or Geriatric departments were followed from admission to discharge. Trained nurses evaluated all recruited patients on a daily basis for possible FPU. Main characteristics of the patient (age, sex and co-morbidities) and the ulcer (location, grade) were registered.

RESULTS

299 patients were recruited (62.2% women, mean age 82.3 years, mean number of co-morbidities 2.8). Prevalence of FPU was 30.1% at admission and 73.9% at discharge. Incidence of FPU during hospitalization was 9.5 new FPU/100 person-day. 97.0% of the new FPU were grade 1 (erythema) and the most common locations were in the heel (57.6%), the external lateral part of the foot (13.1%), and the hallux of the fist toe (11.8%). Apart from immobility, main risk factors for FPU are age, geriatric residence origin and not able to outdoor life.

CONCLUSIONS

FPU has a high incidence among hospitalised elderly patients; most of them are grade 1 and located in the heel. More attention must be paid in the prevention of pressure ulcers in hospitalized frail subjects.

An economic evaluation examining the cost-effectiveness of continuous diffusion of oxygen therapy for individuals with diabetic foot ulcers

Continuous delivery of oxygen therapy has been observed to improve healing for individuals with an advanced diabetic foot ulcer (DFU). However, this intervention requires the purchasing of an oxygen delivery device and moist dressings. It is unknown whether this upfront financial investment represents good value for money. Thus the aim of this project is to evaluate the cost-effectiveness of treating advanced DFU using continuous delivery of oxygen compared with negative pressure wound therapy from the perspective of the public health care payer in Ontario, Canada. A microsimulation model was constructed with inputs from peer-reviewed journal publications and publicly available reports. The 5-year costs and quality-adjusted life-years were compared between treatment and comparator. Sensitivity analyses were conducted to evaluate the robustness of results. The model predicted that continuous delivery of oxygen would cost $4800 less compared with negative pressure wound therapy and increased quality-adjusted life years by 0.025. Lower cost and improved outcomes were observed in most scenario analyses. The results of this economic evaluation suggest that CDO therapy may reduce health care economic burden with a modest increase in quality of life outcomes. Health care decision-makers should consider the inclusion of CDO for the treatment of DFU.

Research and Policy Impact of Trials Published by the UK National Institute of Health Research (2006-2015)

OBJECTIVES

Health technology assessment aims to inform and support healthcare decision making, and trials are part of that process. The purpose of this study was to measure the impact of a sample of trials in a meaningful but robust fashion.

METHODS

All randomized controlled trials funded and published by the UK National Institute of Health Research in the Health Technology Assessment journal series and other peer-reviewed journals were identified for 2006 to 2015. Citation analysis was performed for all trials, and quantitative content analysis was undertaken on a purposive sample to determine whether impact could be categorized as "instrumental" (ie, having a clear influence on key research and policy publications).

RESULTS

The search identified 133 relevant trials. The citation rate per trial was 102.97. Of the 133 trials, 129 (98%) were cited in 1 or more systematic reviews or meta-analyses (mean per trial = 7.18, range = 0-44). Where they were cited, the trials were used in some form of synthesis 63% of the time. Ninety-one of the 133 (68%) trials were found to be cited in 1 or more guidance or policy document (mean per trial = 2.75, range = 0-26) and had an instrumental influence 41% of the time. The publication of these trials' results in journals other than the Health Technology Assessment journal appears to enhance the discoverability of the trial data. Altmetric.com proved to be very useful in identifying unique policy and guidance documents.

CONCLUSION

These trials have impressive citation rates, and a sizeable proportion are certainly being used in key publications in a genuinely instrumental manner.

Bayesian Regression Model for a Cost-Utility and Cost-Effectiveness Analysis Comparing Punch Grafting Versus Usual Care for the Treatment of Chronic Wounds

Punch grafting is a traditional technique used to promote epithelialization of hard-to-heal wounds. The main purpose of this observational study was to conduct a cost-utility analysis (CUA) and a cost-effectiveness analysis (CEA) comparing punch grafting (n = 46) with usual care (n = 34) for the treatment of chronic wounds in an outpatient specialized wound clinic from a public healthcare system perspective (Spanish National Health system) with a three-month time horizon. CUA outcome was quality-adjusted life years (QALYs) calculated from EuroQoL-5D, whereas CEA outcome was wound-free period. One-way sensitivity analyses, extreme scenario analysis, and re-analysis by subgroups were conducted to fight against uncertainty. Bayesian regression models were built to explore whether differences between groups in costs, wound-free period, and QALYs could be explained by other variables different to treatment. As main results, punch grafting was associated with a reduction of 37% in costs compared to usual care, whereas mean incremental utility (0.02 ± 0.03 QALYs) and mean incremental effectiveness (7.18 ± 5.30 days free of wound) were favorable to punch grafting. All sensitivity analyses proved the robustness of our models. To conclude, punch grafting is the dominant alternative over usual care because it is cheaper and its utility and effectiveness are greater.

Physical activity trails in an urban setting and cardiovascular disease morbidity and mortality in Winnipeg, Manitoba, Canada: a study protocol for a natural experiment

INTRODUCTION

Aspects of the built environment that support physical activity are associated with better population health outcomes. Few experimental data exist to support these observations. This protocol describes the study of the creation of urban trials on cardiovascular disease (CVD)-related morbidity and mortality in a large urban centre.

METHODS AND ANALYSIS

Between 2008 and 2010, the city of Winnipeg, Canada, built four, paved, multiuse (eg, cycling, walking and running), two-lane trails that are 5-8 km long and span ~60 neighbourhoods. Linking a population-based health data with census and environmental data, we will perform an interrupted time series analysis to assess the impact of this natural experiment on CVD-related morbidity and mortality among individuals 30-65 years of age residing within 400-1200 m of the trail. The primary outcome of interest is a composite measure of incident major adverse CVD events (ie, CVD-related mortality, ischaemic heart disease, stroke and congestive heart failure). The secondary outcome of interest is a composite measure of incident CVD-related risk factors (ie, diabetes, hypertension and dyslipidaemia). Outcomes will be assessed quarterly in the 10 years before the intervention and 5 years following the intervention, with a 4-year interruption. We will adjust analyses for differences in age, sex, ethnicity, immigration status, income, gentrification and other aspects of the built environment (ie, greenspace, fitness/recreation centres and walkability). We will also assess trail use and trail user profiles using field data collection methods.

ETHICS AND DISSEMINATION

Ethical approvals for the study have been granted by the Health Research Ethics Board at the University of Manitoba and the Health Information Privacy Committee within the Winnipeg Regional Health Authority. We have adopted an integrated knowledge translation approach. Information will be disseminated with public and government partners.

TRIAL REGISTRATION NUMBER

NCT04057417.

Can supernatant from immortalized adipose tissue MSC replace cell therapy? An in vitro study in chronic wounds model

Background

Mesenchymal stem cells (MSCs) secrete a cocktail of growth factors and cytokines, which could promote tissue regeneration and wound healing. Therefore, in clinical practice, post-culture MSC supernatant treatment could be a more attractive alternative to autologous stem cell transplantation. In this study, we compared the regenerative properties of supernatants harvested from four newly established human adipose tissue mesenchymal stem cell lines (HATMSCs) derived from chronic wound patients or healthy donors.

Methods

HATMSC supernatants were produced in a serum-free medium under hypoxia and their content was analyzed by a human angiogenesis antibody array. The regenerative effect of HATMSCs supernatants was investigated in an in vitro model of chronic wound, where cells originating from human skin, such as microvascular endothelial cells (HSkMEC.2), keratinocytes (HaCaT), and fibroblasts (MSU-1.1), were cultured in serum-free and oxygen-reduced conditions. The effect of supernatant treatment was evaluated using an MTT assay and light microscopy. In addition, fibroblasts and HATMSCs were labeled with PKH67 and PKH26 dye, respectively, and the effect of supernatant treatment was compared to that obtained when fibroblasts and HATMSCs were co-cultured, using flow cytometry and fluorescent microscopy.

Results

A wide panel of angiogenesis-associated cytokines such as angiogenin, growth-regulated oncogene (GRO), interleukin-6 and 8 (IL-6, IL-8), vascular endothelial growth factor (VEGF), insulin growth factor 1 (IGF-1), and matrix metalloproteinase (MMP) were found in all tested HATMSCs supernatants. Moreover, supernatant treatment significantly enhanced the survival of fibroblasts, endothelial cells, and keratinocytes in our chronic wound model in vitro. Importantly, we have shown that in in vitro settings, HATMSC supernatant treatment results in superior fibroblast proliferation than in the case of co-culture with HATMSCs.

Conclusions

Our results suggest that therapy based on bioactive factors released by the immortalized atMSC into supernatant has important effect on skin-derived cell proliferation and might preclude the need for a more expensive and difficult cell therapy approach to improve chronic wound healing.

Regeneration and Repair of Skin Wounds: Various Strategies for Treatment

Skin as a mechanical barrier between the inner and outer environment of our body protects us against infection and electrolyte loss. This organ consists of 3 layers: the epidermis, dermis, and hypodermis. Any disruption in the integrity of skin leads to the formation of wounds, which are divided into 2 main categories: acute wounds and chronic wounds. Generally, acute wounds heal relatively faster. In contrast to acute wounds, closure of chronic wounds is delayed by 3 months after the initial insult. Treatment of chronic wounds has been one of the most challenging issues in the field of regenerative medicine, promoting scientists to develop various therapeutic strategies for a fast, qualified, and most cost-effective treatment modality. Here, we reviewed more recent approaches, including the development of stem cell therapy, tissue-engineered skin substitutes, and skin equivalents, for the healing of complex wounds.

[Research progress in adipose tissue promoted wound healing]

OBJECTIVE

To summarize recent progress in adipose tissue acting as a more efficient and ideal therapy to facilitate wound repair and evaluate the therapeutic values of adipose tissue.

METHODS

The related literature about adipose tissue for wound healing in recent years was reviewed and analyzed.

RESULTS

Enormous studies focus on the capacity of adipose tissue to accelerate wound healing including cellular components, extracellular matrix, and paracrine signaling have been investigated.

CONCLUSION

Adipose tissue has generated great interest in recent years because of unique advantages such as abundant and accessible source, thriven potential to enhance the regeneration and repair of damaged tissue. However, there is still a need to explore the mechanism that adipose tissue regulates cellular function and tissue regeneration in order to facilitate clinical application of adipose tissue in wound healing.

Complex Lower Extremity Wound in the Complex Host: Results From a Multicenter Registry

Background:

The complex diabetic lower extremity wound has not been well studied. There are a variety of new technologies now being applied with a paucity of evidence in evaluating their outcomes. The aim of this study is to describe clinical outcomes in the complex lower extremity wound in the comorbid host. We hypothesized that treatment choice would have minimal impact on healing outcomes in this compromised population.

Methods:

A multicenter retrospective registry of patients with diabetes and lower extremity wounds was created to compare treatment modalities of collagen–glycosaminoglycan scaffold, negative-pressure wound therapy, local tissue flap, and free tissue transfer. Statistical analyses included descriptive, proportional comparisons and Cox regression.

Results:

There were no statistical differences in age, hemoglobin A1c, or body mass index between groups. Study patients had a history of amputation (40.5%), peripheral vascular disease (54.6%), peripheral neuropathy (64.8%), end-stage renal disease (13.9%), renal/hepatic disease (40.4%), and hypertension (85%). The most common wound etiologies were surgical dehiscence (69%), diabetic neuropathic wounds (39%), and ischemic wounds (28%), most commonly located on the foot or at a prior amputation site (30%). Mean wound area was 57.9 cm² and almost half with exposed bone. There were no statistical differences between treatment groups in proportion or time to healing, recurrence, or time to return to baseline function.

Conclusions:

Commonly used treatment modalities employed for this population of patients resulted in similar outcomes. This is the first study to describe the complex diabetic lower extremity wound in a complex host.

Prevalence of pressure injury among Chinese community-dwelling older people and its risk factors: A national survey based on Chinese Longitudinal Healthy Longevity Survey

AIM

To investigate the distribution of pressure injuries among older adults in China and to identify the associated risk factors.

DESIGN

Cross-sectional study.

METHODS

The identified subjects were collected from 2012 wave of a national Chinese Longitudinal Healthy Longevity Survey. Older people were defined as being 65 years of age or older. We used chi-square test and binary logistic regression to investigate the risk factors of pressure injury development.

RESULTS

A total of 55 older people were documented as suffering from pressure injuries among 6,961 older Chinese adults, with a prevalence of 0.8%. In the group of disability, the prevalence of pressure injuries from high to low was 3.6% in the highly limited group, 0.4% in the moderately limited group, and 0.3% in the not limited group. The prevalence of pressure injury among older people with stroke, cancer, and dementia were 2%, 4.2%, and 6.6%, respectively. According to the final binary logistic regression analysis, age, disability, incontinence, cancer, and dementia emerged as important risk factors for pressure injury development.

CONCLUSION

Pressure injury among Chinese community-dwelling aged people was shown to be associated with age, disability, incontinence, cancer, and dementia. As the development of pressure injury may distinctly increase the burden on individuals and healthcare systems, the social and related institutions should actively prevent and control the disease.

IMPACT

The results of this study will improve the identification of pressure injury among older Chinese people and contribute to the development of effective pressure injury risk management interventions.

Cost-Effectiveness of Wound Care: A concept analysis

This review aimed to analyse the concept of cost-effectiveness within the context of chronic wound care using Walker and Avant's approach. The Cumulative Index to Nursing and Allied Health Literature^® (EBSCO Information Services, Ipswich, Massachusetts, USA), MEDLINE^® (National Library of Medicine, Bethesda, Maryland, USA) and Nursing & Allied Health^® (ProQuest LLC, Ann Arbor, Michigan, USA) databases were searched using a combination of keywords. A total of 18 peer-reviewed articles were identified. In wound care, defining attributes for the concept of cost-effectiveness encompassed treatments which were both effective and economical. Four antecedents were identified, including the type of wound, care setting, type of dressing and patient-related characteristics. The consequences of cost-effective wound care were patient prognosis, quality of life, the economic burden on the patient and healthcare system and cost-savings. These findings will hopefully help to standardise cost-effectiveness terminology among nursing professionals in various healthcare settings.

Cost-effectiveness analysis of a randomized clinical trial of early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration

BACKGROUND

Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers.

METHODS

This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol.

RESULTS

After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective.

CONCLUSION

Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

Novel trends in application of stem cells in skin wound healing

The latest findings indicate the huge therapeutic potential of stem cells in regenerative medicine, including the healing of chronic wounds. Main stem cell types involved in wound healing process are: epidermal and dermal stem cells, mesenchymal stem cells (MSCs), endothelial progenitor cells (EPCs) and hematopoietic stem cells (HSCs). In the therapy of chronic wounds, they can be administrated either topically or using different matrix like hydrogels, scaffolds, dermal substitutes and extracellular matrix (ECM) derivatives. Stem cells are proven to positively influence wound healing by different direct and indirect mechanisms including residing cells stimulation, biomolecules release, inflammation control and ECM remodelling. MSCs are especially worth mentioning as they can be easily derived from bone-marrow or adipose tissue. Apart from traditional approach of administering living stem cells to wounds, new trends have emerged in recent years. Good healing results are obtained using stem cell secretome alone, for example exosomes or conditioned media. There are also attempts to improve healing potential of stem cells by their co-culture with other cell types as well as by their genetic modifications or pretreatment using different chemicals or cell media. Moreover, stem cells have been tested for novel therapeutic purposes like for example acute burns and have been used in experiments on large animal models including pigs and sheep. In this review we discuss the role of stem cells in skin wound healing acceleration. In addition, we analyse possible new strategies of stem cells application in treatment of chronic wounds.

An improvement in acute wound healing in mice by the combined application of photobiomodulation and curcumin-loaded iron particles

Here, we examined the combined effect of pulse wave photobiomodulation (PBM) with curcumin-loaded superparamagnetic iron oxide (Fe₃O₄) nanoparticles (curcumin), in an experimental mouse model of acute skin wound. Thirty male adult mice were randomly allocated into 5 groups. Group 1 was served as the control group. Group 2 was a placebo and received distilled water, as a carrier of curcumin. Group 3 received laser (890 nm, 80 Hz, 0.2 J/cm²). Group 4 received curcumin by taking four injections around the wound. Group 5 received laser + curcumin. One full-thickness excisional round wound was made on the back of all the mice. On days 0, 4, 7, and 14, bacterial flora, wound surface area, and tensile strength were examined and microbiological examinations were performed. In case of wound closure, the two-way ANOVA shows that wound surface area of entire groups decreased progressively. However, the decrease in laser + curcumin and laser groups, and especially data from laser + curcumin group were statistically more significant, in comparison with the other groups (F statistics = 2.28, sig = 0.019). In terms of microbiology, the two-way ANOVA showed that laser, and laser + curcumin groups have statistically a lower bacterial count than the curcumin, control, and carrier groups (F statistics = 35, sig = 0 = 000). Finally, the one-way ANOVA showed that laser + curcumin, curcumin, and curcumin significantly increased wound strength, compared to the control and carrier groups. Furthermore, laser + curcumin significantly increased wound strength, compared to the control, laser, and curcumin groups (LSD test, p = 0.003, p = 0.002, and p = 0.005, respectively). In conclusion, curcumin nanoparticles, pulse wave laser, and pulse wave laser + curcumin nanoparticles accelerate wound healing, through a significant increase in wound closure rate, as well as wound strength, and a significant decrease in Staphylococcus aureus counts. Furthermore, the statistical analysis of our data suggests that the combined treatment of pulse wave laser + curcumin nanoparticles enhances the wound closure rate, and wound strength, compared to the laser and curcumin nanoparticles alone.

REAL-WORLD CLINICAL EVALUATION AND COSTS OF TELEMEDICINE FOR CHRONIC WOUND MANAGEMENT

BACKGROUND

Chronic wounds are frequent, affect quality of life, and increase care costs. Telemedicine provides potential for effective wound care management, especially for the monitoring of complex wounds at home.

OBJECTIVES

The objective of the present study was to determine the clinical effects and costs of telemedicine for the follow-up of complex chronic wounds from the perspective of the public health insurance. The study ran over a period of 9 months.

METHODS

We conducted a prospective, pragmatic, open-label, observational study and carried out a cost-effectiveness analysis. A total of 116 patients with chronic wounds were assigned to their choice of two groups: telemedicine (N = 77) and traditional follow-up (control; N = 39). The primary outcome was the time to healing. Secondary outcomes included percentage of wounds reaching target objective, percentage of wounds healed completely, outpatient care costs, travel costs, and hospitalizations.

RESULTS

Time to healing was shorter in the telemedicine group than in the control group (137 versus 174 days; p .05). Outpatient care and hospitalization costs were not significantly different. The main results in terms of economic savings were medical transport costs reimbursed by the French public health insurance, which were significantly lower in the telemedicine group. Telemedicine costs were found to be €4,583 less per patient compared with standard practice over 9 months.

CONCLUSIONS

This trial suggests that telemedicine saves travel costs and results in a shorter healing time than traditional follow-up.

Update: Topical Antimicrobial Agents for Chronic Wounds

GENERAL PURPOSE

To provide information on the use of topical antimicrobial agents for the treatment of chronic wounds.

TARGET AUDIENCE

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

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Examine features of wounds and wound healing as well as the purpose of specific antimicrobial agents.2. Identify potential therapeutic and adverse effects of specific topical antimicrobial agents for the treatment of chronic wounds.

ABSTRACT

Bacteria can delay or prevent healing in the surface compartment of a chronic wound or invade the deep and surrounding structures. This article focuses on the superficial compartment and the appropriate use of topical antimicrobial therapies. The authors have reviewed the published evidence for the last 5 years (2012-2017) and extrapolated findings to clinical practice with critical appraisal and synthesis of the recent literature with expert opinion, patient-centered concerns, and healthcare systems perspectives. Summary evidence tables for commonly used topical antimicrobials are included.

Cost-effectiveness of treatments for superficial venous reflux in patients with chronic venous ulceration

Background

Venous leg ulcers impair quality of life significantly, with substantial costs to health services. The aim of this study was to estimate the cost‐effectiveness of interventional procedures alongside compression therapy versus compression therapy alone for the treatment of chronic venous leg ulceration.

Methods

A Markov decision analytical model was developed. The main outcome measures were quality‐adjusted life‐years (QALYs) and lifetime costs per patient, from the perspective of the UK National Health Service at 2015 prices. Resource use included the initial procedures, compression therapy, primary care and outpatient consultations. The interventional procedures included superficial venous surgery, endothermal ablation and ultrasound‐guided foam sclerotherapy (UGFS). The study population was patients with a chronic venous ulcer who were eligible for either compression therapy or an interventional procedure. Data were obtained from systematic review and meta‐analysis of RCTs.

Results

Surgery gained 0·112 (95 per cent c.i. −0·011 to 0·213) QALYs compared with compression therapy alone, with a difference in lifetime costs of €−1330 (−3570 to 1262). Given the expected savings in community care, the procedure would pay for itself within 4 years. There was insufficient evidence regarding endothermal ablation and UGFS to draw conclusions.

Discussion

This modelling study found surgery to be more effective and less costly than compression therapy alone. Further RCT evidence is required for both endothermal ablation and UGFS.

Health-related quality of life in patients with venous leg ulcer treated in primary care in Brazil and Portugal

BACKGROUND

Venous ulcers constitute an important public health problem as they can cause disability with consequences for multiple dimensions of quality of life.

OBJECTIVE

To describe the quality of life in patients with venous leg ulcer treated in primary care in two cities from Brazil and Portugal.

METHODS

This was a cross-sectional comparative study with a non-probabilistic sample of 171 patients with venous leg ulcers who were treated in primary care in two cities from Brazil and Portugal, namely, Natal and Évora. A form covering sociodemographic and health data and the Medical Outcomes Study 36-Item Short-Form Health Survey were used, and descriptive and inferential analyses were performed.

RESULTS

Significant differences in age and income were observed between the two samples. Patients with venous leg ulcer from Brazil had lower income and were younger than those from Portugal. Quality of life scores were significantly higher in Portugal for the physical aspects, pain, and social functioning, among domains, and for the physical health dimension and total score of QOL.

CONCLUSION

The quality of life was better in Portugal than in Brazil and the differences between the countries need further investigation.

Extracellular vesicles as modulators of wound healing

Impaired healing of cutaneous wounds and ulcers continues to have a major impact on the quality of life of millions of people. In recent years, the capacity for stem and progenitor cells to promote wound repair has been investigated with evidence that secreted factors are responsible for the observed therapeutic benefits. This review addresses current evidence in support of stem/progenitor cell-derived extracellular vesicles (EVs) as a regenerative therapy for acceleration of wound healing. Encouraging results for local or systemic administration of EVs have been reported in a range of clinically-relevant animal models of cutaneous wounds. Furthermore, a number of plausible mechanisms involving EV-mediated transfer of proteins and RNAs that trigger pro-repair pathways in target cells have been demonstrated experimentally. However, for successful clinical translation in the coming years, further emphasis on standardized experimental protocols, detailed methodological reporting and clear definition of EV-based therapeutic products will be required.

Bioprinting of skin constructs for wound healing

Extensive burns and full-thickness skin wounds are difficult to repair. Autologous split-thickness skin graft (ASSG) is still used as the gold standard in the clinic. However, the shortage of donor skin tissues is a serious problem. A potential solution to this problem is to fabricate skin constructs using biomaterial scaffolds with or without cells. Bioprinting is being applied to address the need for skin tissues suitable for transplantation, and can lead to the development of skin equivalents for wound healing therapy. Here, we summarize strategies of bioprinting and review current advances of bioprinting of skin constructs. There will be challenges on the way of 3D bioprinting for skin regeneration, but we still believe bioprinting will be potential skills for wounds healing in the foreseeable future.

Oxidized Regenerated Cellulose/Collagen Dressings: Review of Evidence and Recommendations

OBJECTIVE

Healthcare systems are being challenged to manage increasing numbers of nonhealing wounds. Wound dressings are one of the first lines of defense in wound management, and numerous options exist. The oxidized regenerated cellulose (ORC)/collagen dressing may offer healthcare providers a robust and cost-effective tool for use in a variety of wounds.

DESIGN

A multidisciplinary panel meeting was convened to discuss the use of ORC/collagen dressings in wound care and provide practice recommendations. A literature search was conducted to provide a brief review of the peer-reviewed studies published between January 2000 and March 2016 to inform the meeting.

SETTING

A 2-day panel meeting convened in February 2017.

PARTICIPANTS

Healthcare providers with experience using ORC/collagen dressings. This multidisciplinary panel of 15 experts in wound healing included podiatrists, wound care specialists (doctors, certified wound care nurses, and research scientists), and an orthopedist.

RESULTS

The literature search identified 58 articles, a majority of which were low levels of evidence (69.3% were level 3 or lower). Panel members identified wound types, such as abrasions, burns, stalled wounds, diabetic foot ulcers, and pressure injuries, where ORC/collagen dressing use could be beneficial. Panel members then provided recommendations and technical pearls for the use of ORC/collagen dressings in practice. Barriers to ORC/collagen dressing use were discussed, and potential resolutions were offered.

CONCLUSIONS

An ORC/collagen dressing can be a critical tool for clinicians to help manage a variety of wounds. Clinical and economic studies comparing standard-of-care dressings and plain collagen dressings to ORC/collagen dressings are needed.

Medications affecting healing: an evidence-based analysis

The purpose of this arm of the study was to investigate the impact of medication on healing times of the various wound types, including acute wounds and leg ulcers. A prospective longitudinal study design was used, with de-identified data collected using an electronic mobile wound care database system. Three main categories of data were collected, including patients' demographics, wounds types and treatment characteristics. For acute wounds, there was a total of 1732 patients with 2089 acute wounds. The average healing time was about 35 days. The only significant association was with chemotherapy, which increased healing time by 21 days (P = 0·048). There were non-significant trends towards reduced healing times with antibiotics (0·5 days; P = 0·853), anticoagulants (1·7 days, P = 0·673) and corticosteroids (4·98 days, P = 0·303). Non-steroidal anti-inflammatory drugs (NSAIDs) were associated with a non-significant increase in healing time (2·17 days, P = 0·707). For leg ulcers, there was a total of 264 patients with 370 leg ulcers. We only examined the impact of antibiotics, anticoagulants, corticosteroids and NSAIDs on healing times as they had an adequate number of wounds to analyse. The average healing times of leg ulcers were found to be 73 days. None of the classes of medications had any significant impact on healing time. Both anticoagulants and NSAIDs increased healing time by (22·5 days, P = 0·08) and (12·5 days, P = 0·03), respectively. On the other hand, antibiotics and corticosteroids decreased healing times non-significantly by (9·1 days, P = 0·33) and (21·6 days, P = 0·84), respectively.

Pressure injuries in elderly with acute myocardial infarction

Objectives

To assess pressure injury (PI) incidence among patients hospitalized for acute myocardial infarction (AMI) in an intensive coronary care unit (ICCU) and to detect the impact of specific risk factors on the development of PI in this clinical setting.

Patients and methods

Prospective cohort study in ICCU setting. Patients admitted for AMI: patients mean age 67.5±11.5 years (n=165). Norton Scale, Mini Nutritional Assessment (MNA), demographic, clinical and biochemical data collected at the time of ICCU admission have been tested in a logistic model to assess the odds ratios (ORs) of PI risk development. The jackknifed area under the receiver operating characteristic curve (AUC) and the decision curve analysis have been employed to assess the additive predictive value of a factor.

Results

Twenty-seven (16.3%) patients developed PIs. An increased PI risk was associated with advanced age (OR =2.5 every 10-year increase; 95% CI =1.1–5.7), while probability of PI development was reduced in patients with higher left ventricular ejection fraction (LVEF) (OR =0.4 every 5% increase; 95% CI =0.24–0.66), MNA score (OR =0.65 every unit change; 95% CI =0.44–0.95) and Norton Scale score (OR =0.7 every unit change; 95% CI =0.57–0.88). The AUC and the decision curve analysis showed that LVEF inclusion improved the discrimination power and the clinical net benefit of the final model.

Conclusion

Age, LVEF, Norton Scale and MNA scores have a strong and independent clinical value as predictors of in-hospital PI development in patients with AMI. This finding has the potential to improve the clinical management of patients admitted in ICCU.

A prospective analysis of pinch grafting of chronic leg ulcers in a series of elderly patients in rural Cameroon

BACKGROUND

Chronic leg ulcers (CLUs) pose serious public health concerns worldwide. They mainly affect the elderly population. Pinch grafting (PG) could be used to treat a variety of CLUs. However, in Cameroon, there is scarce data on the outcome of PG of CLUs in elderly patients in rural hospitals where most of these patients seek for medical attention and where clinicians rely on unconventional wound dressing methods to treat CLUs. Our objective was to describe the outcome of PG of CLUs in elderly patients in rural Cameroon.

METHODS

This was a prospective study conducted in a rural hospital of North West Cameroon. From February 2015 to January 2016, comprehensive historical and clinical data were collected per elderly patient who presented with a chronic leg ulcer necessitating PG. PG was done using a simple procedure and each patient followed up for 8 months. Outcome was described in terms of ulcer healing and pain and donor site complications.

RESULTS

Our series included 13 patients: 8 males (61.54%; 95% CI: 31.58-86.14) and 5 females (38.46%; 95% CI: 13.86-68.42) aged from 69 to 88 years (mean: 77.54 ± 5.70 years). Three patients (23.08%; 95% CI: 5.04-53.81) had associated co-morbidities. All the ulcers were unilateral with durations ranging from 7 to 41 months (mean: 19.46 ± 11.03 months). The ulcers ranged in size from 9.0 to 38.1 cm2 (mean: 17.66 ± 8.35 cm 2). We registered one (7.69%; 95% CI: 0.19-36.03) graft rejection. Concerning the other ulcers, ten (83.33%; 95% CI: 51.59-97.91) had healed after 12 postoperative weeks while 2 (16.67%; 95% CI: 2.09%-48.41) had healed after 14 postoperative weeks and the mean healing time was 12.33 ± 0.78 weeks. Patients with healed ulcers had reduced ulcer site pain from the immediate postoperative period but there was no significant difference in the mean pain scores before and after graft (6.77 against 4.23, p = 0.13). These ulcers remained healed after 8 postoperative months. Each donor site had healed 2 weeks after PG. Donor site problems were minimal and included hypopigmentation.

CONCLUSION

The outcome of PG of CLUs in our series of older patients was satisfactory. This finding does not discount the role of conservative therapy, but we encourage clinicians in rural Cameroon to consider PG over long-term unconventional conservative therapy in the elderly.

Janus films with stretchable and waterproof properties for wound care and drug delivery applications

Janus PDMS films with porous/nonporous structures are fabricated for wound care. The film has good stretchability, waterproof and breathable surfaces and non-stick properties, which enhance its performance compared to traditional wound bandages.

Evaluating the Expected Costs and Budget Impact of Interventional Therapies for the Treatment of Chronic Venous Disease

BACKGROUND

Chronic venous disease is a common disorder in the United States. The manifestations of chronic venous disease include varicosities and related sequelae that are frequent contributors to the morbidity and high costs associated with the disease. The interventional treatment options for chronic venous disease have expanded greatly in recent years and include various surgical and vein ablation techniques. Polidocanol injectable foam (also known as polidocanol endovenous microfoam 1%), a chemical ablation agent, is the most recent entrant to the market.

OBJECTIVE

To evaluate the expected patient-level total treatment costs and health plan-level budgetary impact of polidocanol injectable foam compared with the currently available interventional treatment options from a third-party US payer perspective.

METHODS

A Microsoft Excel-based budget impact model was designed to compare the costs of polidocanol injectable foam with other interventional treatments (ie, laser ablation, radiofrequency ablation, surgery, and multimodality treatment). The model included drug acquisition, medical procedure, administration, additional treatment, and disease progression costs. The treatment patterns and rates of additional treatment were incorporated from a recent retrospective claims analysis for established treatment modalities and from the clinical trials for polidocanol injectable foam. The model estimates the 1-year total estimated costs and the health plan budget impact assuming an 8-week treatment time frame.

RESULTS

The total expected 8-week treatment costs were $2165 for polidocanol injectable foam, $1827 for endovenous laser ablation, $2106 for radiofrequency ablation, $2374 for surgery, and $2844 for multimodality treatment. The initial treatment costs were higher for surgery and multimodality treatment compared with polidocanol injectable foam and were lower for endovenous laser ablation and radiofrequency ablation treatments. Polidocanol injectable foam is projected to have a relatively small budget impact ($0.01 per member per month) at an initial 5% market share.

CONCLUSION

Polidocanol injectable foam offers an alternative to other interventional options for the treatment of varicose veins and is projected to have a relatively small budget impact. From a health plan perspective, this drug is likely to have a relatively low budget impact as it becomes more widely used.