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Caring for patients with hard-to-heal (chronic) wounds requires a multifaceted approach that addresses their diverse needs, which can contribute to the complexity of care. Wound care providers must have a comprehensive understanding of the patient's comorbid conditions and psychosocial issues to provide personalised and effective treatment. Key quality indicators for effective wound care involves not only selecting appropriate local wound care products, such as foam dressings, but also addressing individual patient experiences of wound-related pain, odour, itch, excessive wound drainage, and self-care needs. The purpose of this review is to inculcate the wound care practice community, research scientists and healthcare industry with a sense of accountability in order to work collaboratively in addressing these unmet care needs.

Objective: Complications from diabetic foot wounds, including bacterial infection, ulceration and gangrene, are major causes of hospitalisation and are responsible for 85% of amputations in patients with diabetes. Given that orally administered investigational therapeutic Cytoreg (Cytorex de Venezuela SA, Venezuela), a defined aqueous mixture of hydrofluoric, hydrochloric, sulfuric, phosphoric, citric and oxalic acids, has been shown to increase levels of arterial blood oxygen in a Wistar rat model, oral and oral+topical Cytoreg were tested on patients with diabetic foot ulcers (DFUs) under a humanitarian, compassionate-use protocol., Method: All patients received oral Cytoreg (5.0 ml concentrate in fruit juice) for 30 days; half also received weekly wound washing with Cytoreg concentrate in isotonic saline (1:50 volume/volume) (oral+topical group). In addition to standard clinical observations, wounds were monitored against the Saint Elian checklist system for the diabetic foot., Results: A total of 10 patients took part in the study. Complete wound closure was observed in 4/5 patients in the oral+topical group; in the remaining patient, necrotic and fibrin tissues on the wound edges were eliminated. Half (2/4) of the patients receiving oral-only Cytoreg experienced complete wound closure; one patient in this group was removed prematurely because of an unrelated illness and was not replaced. During the study, no significant differences were observed between groups in either the oxygen saturation of the affected tissues or in insulin and glycaemia levels (p<0.05). Significant increases in arterial haemoglobin and arterial oxygen partial pressure (p<0.05) were observed, and significant decreases were measured in the levels of glycosylated haemoglobin, aspartate aminotransferase, glutamic-pyruvic transaminase, creatine and urea (p<0.05)., Conclusion: The results of this study justify an expanded clinical study for the treatment of DFUs with Cytoreg.

Objective: Diabetic foot ulcers (DFUs) are a common downstream consequence of diabetes and pose significant concern to the health of affected individuals. There are currently limited data available that detail the epidemiology and inpatient burden of DFUs in Canada. This study aims to provide updated data on the epidemiological and economic burden of DFUs in Canada between 2015 and 2019., Method: Using the Canadian Institute for Health Information Patient Cost Estimator the authors estimated, as the primary outcome, the number of DFU inpatient cases in Canada, the associated financial burden of these admissions on the Canadian healthcare system, physician compensation, and average patient length of hospitalisation. This analysis covered 12 Canadian jurisdictions and was stratified by age, sex, province and geographical region. The secondary outcome was to highlight temporal trends in the public health burden of DFUs by computing the average annual percentage change (AAPC; the weighted average of several annual percentage changes over multiple years) using Joinpoint (Surveillance Research Program National Cancer Institute, US) regression analysis., Results: The total number of cases, average length of hospitalisation and physician costs across Canada were highest for patients over ≥60 years of age. By region, the total number of cases and standardised physician costs were highest in Central Canada, followed by Western Canada, and subsequently Eastern and Northern Canada. In 2019, there were >1800 patients with DFUs admitted to Canadian acute care hospitals. Despite having the lowest number of inpatient admissions, Northern Canada had the highest associated inpatient costs, followed by Central, then Western and, lastly, Eastern Canada. Overall, mean inpatient costs remained stable over time across all age groups (AAPC 0.61; 95% confidence interval: -1.87-3.15), with an average cost of >$10,000 CAD per case. Average physician cost across all jurisdictions was approximately $1000 CAD per case, with the mean hospitalisation time being nine days., Conclusion: The findings of this study emphasise the dynamic nature of the economic and epidemiological DFU burden in Canada, underscoring the need for targeted interventions, multidisciplinary care and evidence-based resource allocation for the optimal management of diabetes and DFUs.

Objective: Wound care is an important component of nursing care, consuming a significant amount of working hours. Literature reports the existence of many barriers to evidence-based wound care and that nursing students have an increasing need for education in this field. While blended learning activities have shown some benefits in learning outcomes, dedicated wound care modules within baccalaureate nursing courses occur infrequently. The aim of this study was to facilitate an increase in confidence and knowledge of evidence-based wound care in third-year baccalaureate nursing students., Method: In this descriptive pre-post research design, a dedicated wound care module within a baccalaureate nursing course (using a constructivist learning approach) was offered to students in a university in Australia. Pre- and post-implementation surveys were completed (2018-2020). Due to a small number of matching participants, only descriptive statistics were calculated for all variables., Results: A total of 276 students were invited to respond to the survey and 41 responded initially, 35 responded post the wound care module, and 26 responded to the survey after six months. Positive outcomes were noted in increased levels of confidence in the student nurses' ability to assess, manage and prevent wounds; as well as to apply evidence-based practice and change management following the educational wound care module within the baccalaureate nursing course., Conclusion: Implementation of a dedicated wound care module within a baccalaureate nursing course in this sample of third-year students fostered a positive change in the knowledge of evidence-based wound management, assessment and prevention. Education of the next generation of registered nurses in this valuable area of practice is an important part of baccalaureate nursing education.

Objective: The aim of this study was to observe the surgical wound healing process in patients with multiple myeloma who had undergone surgery., Method: We collected clinical data on patients with multiple myeloma and observed wound healing following surgical therapy. Additionally, we compared the expression of angiogenesis markers in patients with and without multiple myeloma (undergoing surgical excision of other tumour tissues). In patients who had multiple myeloma bone disease, we examined several clinical features: haemoglobin levels; albumin levels; blood glucose levels; and surgery programme. We then compared expression levels of the angiogenesis markers CD31, CD34 and vascular endothelial growth factor (VEGF) in samples scraped from the skin margin of the surgical incision in 12 patients without multiple myeloma (control) and nine patients with multiple myeloma., Results: All 61 patients with multiple myeloma observed showed no disunion, no delayed union and no infection in their wound healing. CD31 and VEGF expression was higher in the nine patients with multiple myeloma compared with the 12 control patients without. We observed no difference in CD34 expression between control and experimental groups., Conclusion: The results of this study suggest that patients with multiple myeloma who have undergone surgery recover well and produce higher quantities of new vessels compared with patients without multiple myeloma. This occurs through increased expression of CD31 and VEGF, angiogenic factors which promote wound healing. We did not observe higher expression of these factors contributing to increased incisional implantation metastasis.

Objective: Currently there is limited real-world research on the adhesion qualities, pain and clinical performance of specific silicone adhesives products, and their role in maintaining skin integrity and preventing medical adhesive-related skin injuries (MARSI). This paper presents a clinical evaluation of performance and safety parameters of two silicone adhesive dressings on lacerations or surgical wounds and the surrounding skin in daily practice on fragile skin., Method: An observational, prospective, multicentre, uncontrolled post-market clinical observational study with Leukomed T skin sensitive and Leukomed T plus skin sensitive (both BSN medical GmbH, Essity Group) was undertaken at three sites across Germany between June 2021 to November 2022. Inclusion parameters were acute wounds (surgical or laceration) in patients with at least one fragile skin condition. Endpoints included: the percentage of adhered dressing area seven days after application of the dressings; and evaluation of any signs of skin damage and erythema following dressing removal. Furthermore, self-reported patient pain, comfort during dressing wear, and the health professionals' ease of dressing handling with gloves were assessed., Results: A total of 42 patients with fragile skin and surgical wounds (35 patients) or lacerations (7 patients) were recruited. Mean age was 78 years. There were no signs of erythema following dressing removal and no MARSI (skin stripping, blister, skin tears, maceration, irritant contact dermatitis or allergic dermatitis) occurred at removal after seven days of wear time. Data demonstrated a reliable wound coverage with sufficient adhesion without negatively affecting the periwound skin and wound improvement was observed in 94% of patients. The vast majority of patients reported minimal pain at removal, reduced wound pain and high satisfaction with wearing comfort. Health professionals found the dressings easy to apply and remove, even with gloved hands., Conclusion: The results of this real-world evidence showed effective and well-tolerated use of transparent dressings with silicone adhesive in patients with fragile skin. The dressings may reduce the risk of skin damage including MARSI, while providing patients a high wearing comfort and allowing an almost pain-free dressing change.

Objective: Venous leg ulcers (VLUs) are often large and complicated wounds that, despite combinations of advanced wound care techniques and systemic treatment of underlying vascular issues, take many months to heal and have high rates of recurrence. In this study, we investigated the efficacy of a novel wound care solution-human keratin matrix (HKM)., Method: A case series of VLUs were treated with HKM in conjunction with indicated vascular intervention and standard of care (SoC) procedures. For analysis, these wounds were divided into very large (>200 cm 2 ) and smaller (<35 cm 2 ) wounds., Results: The cohort comprised 16 VLUs (very large=7; smaller=9). Very large VLUs were reduced in size by an average of 71% within 10 weeks, and showed a 50% size reduction within four applications of HKM. Smaller VLUs reduced by 50% in size within the first three weeks of treatment, and 88.9% of these wounds healed completely with an average of 4.5 HKM applications over an average of 6.5 weeks., Conclusion: The results of this series highlight the potential of HKM, in combination with indicated systemic interventions and SoC, as an effective treatment for hard-to-heal (chronic) VLUs, even in very large wounds.

Background: Pressure injuries (PIs) are among the most common skin and soft tissue wounds occurring in patients who are bedbound and/or immobile. PI management hinges on their prevention; however, reoccurrence poses a challenge to their management and requires a multidisciplinary approach. Here, the authors describe a lumbosacral rotation flap (LSRF) for the coverage of sacral PIs., Method: A single-centre, retrospective analysis of prospectively collected data was carried out. All patients undergoing LSRF for sacral PIs were included. Patients with active systemic sepsis, immune compromise, hepatic or renal dysfunction were excluded. All patients underwent preoperative optimisation and wound cultures to direct antibiotic therapy after surgery., Results: A total of nine patients underwent the procedure (seven male and two female). Mean age was 47.6 years with a mean ulcer size of 92.9 cm 2 . Bone biopsy indicated the presence of osteomyelitis in three patients. Of the LSRFs, two flaps showed minimal local complications in the form of marginal flap necrosis which was managed conservatively. All flaps healed well with no cases of flap loss or the need for secondary procedures., Conclusion: The results of this analysis showed that LSRF can be considered a first line of treatment of sacral PIs. They can be used to cover large defects. Due to their large base and flap size, readvancement in cases of recurrence is also possible.

Objective: Closed surgical incision sites at high risk of complications, and with exudate or leakage, are increasingly being managed with closed incision negative pressure wound therapy (ciNPWT) to reduce tissue stress and increase the force necessary to disrupt the incision. This study was undertaken to investigate the performance and safety of a canister-based, single-use NPWT (suNPWT) system when used on closed surgical incision sites., Method: The investigation was designed as a prospective, open, non-comparative, multicentre study aimed at confirming the safety and performance attributes of the suNPWT system when applied to low-to-moderately exuding closed surgical incisions. The primary performance measure was the wound remaining closed from baseline to the last follow-up visit on day 14. Secondary performance measures included: wound and periwound condition; wear time of the system; product consumption; adherence to therapy; and patients' pain progress. Details of adverse events were also collected., Results: Some 35 patients were recruited. The closed surgical incisions responded well to treatment with the tested suNPWT system. All wounds remained closed throughout the investigation. Consistent with other studies of ciNPWT reporting low infection rates, the current study observed either no or low exudation in 90.4% of wounds at the final visit, together with absence of surgical site infection. Pain severity levels were low, both at dressing change and during delivery of negative pressure. No serious adverse device events were reported., Conclusion: In this study, the suNPWT system supported the healing of closed surgical incisions with no safety concerns relating to its use.

Objective: Innovation in wound healing, particularly regarding diabetic foot ulcers (DFUs), is needed to reverse the number of diabetes-related amputations. This study evaluated a novel approach and performance of a multimodal wound matrix in converting stalled DFUs into a healing trajectory., Method: Patients with either type 1 or 2 diabetes and with foot ulcers (Wagner grade 1 and 2), were screened to determine eligibility for treatment. Ulcers improving >30% in area during a two-week screening phase were not eligible for the study treatment phase. The study was an open-label trial conducted in three phases: screening, treatment and healing confirmation. Patients enrolled in the study received a treatment protocol that included application of a wound matrix to the ulcer and offloading., Results: A total of 19 patients (15 males, four females) with a median age of 60 years, and a median ulcer duration of 36 weeks took part in the study. Patients showed an average four-week percentage area reduction (PAR) of 62%, a 12-week PAR of 94%, and a 12-week healing rate of 57% (8/14)., Conclusion: Results of this study support the viability and potential of a novel approach to treating DFUs that includes use of a multimodal wound matrix.

Objective: Maggot debridement therapy (MDT) is increasingly being used in clinical practice as an alternative treatment for hard-to-heal (chronic) wounds. Among the many benefits of using MDT is its antimicrobial effect. Maggots secrete substances that are known to have antibacterial properties against both Gram-negative and Gram-positive bacteria. Clinically, this results in the effective eradication of pathogenic species and consequently, a faster healing process. The aim of this study was to evaluate the effect MDT has on the bacterial flora of hard-to-heal ulcers., Method: Patients with venous, mixed arteriovenous, decubitus, diabetic and neuropathic wounds were treated with larvae of Lucilia sericata enclosed in bags. Dressings were applied to the wounds for 72 hours. Before and after the therapy, a swab was taken from the wound, and bacterial diversity and bacterial growth scores were assessed. While 16 patients were treated only once, the treatment had to be repeated in four cases until the wounds were fully debrided., Results: Bacteria of the species Pseudomonas aeruginosa, Proteus mirabilis, Staphylococcus aureus and Enterococcus faecalis were the most common strains observed. Of the 20 patients treated, the total number of bacterial strains decreased in eight wounds, but increased in five wounds, while no difference was observed in nine wounds. The average number of bacterial strains in wounds decreased after MDT. A lower incidence of alarm pathogens was also reported. In cases where multiple applications of larvae were administered, greater decreases in bacterial growth scores were observed than in cases with a single application of dressing (37.5% vs 18.1%, respectively). In 18 cases, after disinfection of the wound by larvae, it was reinfected by strains not detected before. Wounds healed completely after MDT in two patients., Conclusion: In this study, MDT changed the bacterial diversity of hard-to-heal wounds. The larvae reduced overall bacterial growth scores and acted on both Gram-positive and Gram-negative bacteria as well as on alarm pathogens. Cleaned wounds appeared to become vulnerable to infection by opportunistic bacteria. The bacterial burden decreased as the number of applications of biological dressings increased.

Objective: To learn about the experiences of people who seek treatment for hard-to-heal wounds, we distributed a nationwide pilot survey, asking questions about the nature of their wound, how it shaped their daily lives, pathways to receiving care and experiences with treatment. The long-term objective is to quantify the journey of patients with hard-to-heal wounds to identify ideal intervention points that will lead to the best outcomes. This article summarises the findings, implications, limitations and suggestions for future research., Method: Qualitative data were self-reported from patients with hard-to-heal wounds (open for ≥4 weeks) in a pilot chatbot survey, (Wound Expert Survey (WES)) provided online in the US on Meta platforms (Facebook and Instagram) between 2021 and 2022., Results: The US national pilot survey attracted responses from 780 patients, 27 of whom provided a video testimonial. Some 57% of patients delayed treatment because they believed their wound would heal on its own, and only 4% saw a wound care specialist. Respondents reported the cost of care as the most frequent reason for not following all of a doctor's treatment recommendations. Queries regarding quality of life (QoL) revealed that more than half (65%) said they have negative thoughts associated with their wound at least every few days. Some 19% of respondents said their wound had an odour and, of them, 34% said odour had a major or severe negative impact on their self-confidence. Economically, nearly one-quarter of respondents said having a wound led to a drop in their total household income and 17% said their wound led to a change in their employment status., Conclusion: A national pilot survey of patients with hard-to-heal wounds revealed that many delay seeking professional assistance and only a small minority see a wound care specialist. Experiencing an ulcer, even for a few months, can have significant negative effects on a patient's QoL. Patients frequently had negative thoughts associated with their wound, and odour compounded these negative effects, leading to major or severe negative impacts on self-confidence. Households experienced a decline in income, due to both the direct reduction or loss of patient employment and the additional time spent by family members assisting in patient recovery. Thus, a variety of factors contribute to poor outcomes for patients with hard-to-heal wounds. To validate and extend these preliminary results, future surveys of patients with hard-to-heal wounds should focus on additional reasons patients do not seek professional help sooner. To improve health outcomes and QoL, assessment of patient socioeconomic variables should occur whenever wound closure stalls.

Objective: Several national and international guidelines recommend lipidocolloid technology with a nano-oligosaccharide factor (TLC-NOSF) dressings (UrgoStart dressing range, Laboratoires Urgo, France) for treating patients with chronic wounds. However, these dressings are still often reported as second-line options, potentially leading to loss of opportunity for patients and additional costs for payers. This review aimed to explore the reported wound healing and patient outcomes as well as the related costs when the dressings were used as first-line treatment in patients with different types of chronic wounds., Method: A systematic review of the literature was conducted. Databases (MEDLINE, Embase, Emcare, and Google Scholar) were searched up to 1 February 2024, without any language or time period limitations. Studies were eligible if the evaluated dressings had been used as a first-line treatment for chronic wounds, that is, as an integral part of the standard of care (SoC) at the patient's first presentation and/or in recent wounds. The main evaluation criteria included: wound healing rate; time to reach wound closure; change in patients' quality of life (QoL); and associated costs. The quality of evidence of the included studies was appraised using well-recognised risk-of-bias tools suitable for different study designs. A narrative synthesis describes the findings in three sections depending on the type of comparison. This report followed the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Results: A total of 17 studies published between 2017 and 2024 met the eligibility criteria. A comparative analysis between TLC-NOSF dressings and standard dressings, both of which were used as first-line treatment, was reported in nine studies. A comparative analysis between the use of TLC-NOSF dressings as first-line and second-line treatments was reported in eight studies, and five studies reported a systematic use of the TLC-NOSF dressing as first-line treatment without a control group. Overall, the included studies had a relatively low risk of bias for the respective types of evidence. Data of 10,191 patients of both sexes and different age groups with a total of 10,203 wounds (diabetic foot ulcers, leg ulcers, pressure injuries, and other types of chronic wounds) were included in the analysis: 7775 treated with the evaluated dressing and 2428 treated with a comparator dressing. The data suggested that using TLC-NOSF as a first-line treatment for chronic wounds consistently resulted in significantly higher healing rates, shorter healing times, and cost savings compared with standard dressings used under similar conditions. Real-life evidence confirmed the results obtained in clinical trials and economic models, within similar ranges, regardless of the settings involved or of the characteristics of the patients and wounds treated. The wound healing rates ranged around 70-80% by week 20/24 and time-to-heal was reported on average around seven weeks, with slightly longer times reported in wounds with a more severe prognosis. Furthermore, the dressings were shown to improve patient QoL, and were well tolerated and accepted, supporting a wider adoption approach., Conclusion: The results of this review are aligned with the current guidelines recommending the use of TLC-NOSF dressings in the treatment of patients with chronic wounds. They support its wider implementation as a first-line treatment and as an integral part of SoC for these wounds in the daily practice of all centres involved in their management.

Objective: This study examined the effectiveness of a combination of hyperbaric oxygen therapy (HBOT) and topical haemoglobin spray in treating hard-to-heal, sloughy diabetic foot ulcers (DFUs)., Method: Patients with hard-to-heal DFUs at least 25% sloughy or necrotic were included in the study. We compared the results of patients who received standard of care and HBOT with topical haemoglobin spray (oxygen group) to an equal number of patients who only received standard personalised wound care (control group). The initial values of haemoglobin A1C and C-reactive protein, wound culture results and SINBAD (site, ischaemia, neuropathy, bacterial infection, area, depth) scores were documented. Wounds were considered healed when completely closed within 16 weeks., Results: The oxygen group (n=21) had a mean SINBAD score of 5.00±0.89, while the control group (n=21) had a mean score of 4.62±0.80 (p=0.155). After 16 weeks, 85.7% of wounds in the oxygen group showed complete recovery, compared with 52.4% in the control group (p=0.02)., Conclusion: In this study, a greater number of wounds in the oxygen group healed. Combining HBOT with topical haemoglobin spray provides oxygenation to the wound for longer, primarily because patients can receive 90 minutes of HBOT daily. This ensures that patients benefit from both systemic and local oxygen. This combination therapy may effectively address the problem of hypoxia and promote healing in hard-to-heal wounds.

Objective: Delayed or stalled healing in open wounds can result from persisting chronic inflammation related to infection and/or persistent bacterial colonisation and biofilm. Treatment of hard-to-heal wounds focuses on debridement and exudate management, but also on infection prevention and control. Silver dressings have been evaluated in randomised clinical trials (RCTs); this meta-analysis evaluated the efficacy and safety of a silver ion-releasing foam dressing (Biatain Ag; Coloplast A/S, Denmark) to treat hard-to-heal wounds., Method: Literature databases (PubMed and Cochrane Library) were searched for studies on silver ion-releasing foam dressings in the treatment of hard-to-heal wounds. Individual patient data from four RCTs were obtained and included in the meta-analysis., Results: Findings showed that treatment with the silver ion-releasing foam dressing was associated with a significantly higher relative reduction in wound area after four (least squares-mean difference (LS-MD): -12.55%, 95% confidence interval (CI): (-15.95, -9.16); p<0.01) and six weeks of treatment (LS-MD: -11.94%, 95%CI: (-17.21, -6.68); p<0.01) compared with controls. Significant benefits were also observed for time to disappearance of odour (hazard ratio: 1.61, 95%CI: (1.31, 1.98); p<0.01), relative reduction of exudate (LS-MD: -5.15, 95%CI: (-7.36, -2.94); p<0.01), proportion of patients with periwound erythema (relative risk (RR): 0.81, 95%CI: (0.69; 0.94); p<0.01), and less pain at dressing removal (LS-MD: -0.35, 95%CI: (-0.63, -0.06); p=0.02). No differences regarding safety outcomes were identified., Conclusion: This meta-analysis has demonstrated beneficial outcomes and a good tolerability profile for silver ion-releasing foam dressings in the treatment of moderate-to-highly exuding wounds with delayed healing compared with control dressings.

Radiation-induced skin ulcer following cancer and/or tumour is well-documented in the literature. However, radiation-induced skin ulcer following the excision of keloid is yet to be reported. Here, we report the case of a 33-year-old female patient with a suprapubic skin ulcer of five months' duration following keloid treatment with electron beam therapy at recommended dosage. Various examinations, including a skin biopsy, metagenomic sequencing, magnetic resonance imaging and immunochemistry, indicated that the skin ulcer was induced by radiotherapy. While postoperative radiotherapy has been recommended immediately following keloid excision to reduce the risk of recurrence, the present case highlights the risk of skin refractory ulcer following keloid radiotherapy.

Background: Hospital-acquired pressure ulcer (HAPU) is a significant problem in healthcare settings and is associated with negative impacts on patient health. Although monitoring of pressure ulcers (PUs) among hospitalised patients was started more than a decade ago in Oman, no previous studies have been completed to estimate the prevalence and risk factors of HAPUs among patients in the intensive care unit (ICU). The aim of this study was to estimate the prevalence and identify risk factors for HAPUs among adult ICU patients in selected tertiary hospitals in Oman., Method: A retrospective, cross-sectional, nested, case-control design was used to identify the prevalence rate of HAPUs and risk factors for a cohort of adult ICU patients over one calendar year (1 January-31 December 2019) in two tertiary hospitals in Oman., Results: The prevalence rate for HAPU among ICU patients in Oman was 36.4%. However, when excluding cases of stage 1 ulcer, the rate was 30.37%. The most prevalent location was the sacrum (64.1%), and the most common stage was stage 2 (73.1%). The risk factors for HAPU included male sex (odds ratio (OR): 0.37; p=0.023), organ failure (OR: 3.2; p=0.033), cancer (OR: 3.41; p=0.049), cerebrovascular accident (OR: 12.33; p=0.001), mechanical ventilator (OR: 9.64; p=0.025) and ICU length of stay (OR: 1.24; p<0.001)., Conclusion: HAPUs among ICU patients constitute a significant problem associated with severe clinical consequences and result in substantial adverse healthcare outcomes worldwide, including in Oman. Identifying the risk factors and the impact on the healthcare system is the foundation for preventing and managing HAPUs.

Objective: Person-centred care (PCC) is an important approach as it positively affects disease management. Guiding studies are needed on the use and development of PCC in hard-to-heal (chronic) wound management. This study aimed to determine attitudes and approaches of nurses and physicians working in hard-to-heal wound management towards PCC, and obtain their views and suggestions for its scope and improvement., Method: Participants of this descriptive survey study consisted of nurses and physicians responsible for hard-to-heal wound care and treatment in healthcare institutions at all levels in Turkey. Data were collected through a structured online survey shared with members of professional associations via social media platforms between March-November 2020. Descriptive statistics and qualitative inductive content analysis were used to analyse data., Results: Participants (n=418) included physicians (84.2%) and nurses (15.8%). Mean participant-graded their person-centred behaviour level was 8.18±1.80 (out of 10 points). The majority of participants reported that they informed patients about care, treatment processes and options (87.3%) as well as including them in the decision-making process (74.6%). Responses of the participants regarding the scope of PCC were classified into five main categories, the most prominent being: 'individual', 'care', 'professional development' and healthcare system'. Suggestions for the improvement of PCC were classified into seven main categories, with 'personalised care', 'disease-specific care', 'continued training of healthcare professionals should be ensured' and 'home care system should be developed for the continuity of care' among the prominent subcategories., Conclusion: The findings of this study suggests that education on PCC is an important approach. Institutional protocols and guidelines can support person-centred hard-to-heal wound management. In this study, the level of person-centred behaviour of the participants was determined to be good. Although the results of the study cannot be generalised to all health professionals-the majority of the participants were physicians-it is recommended to develop and disseminate the PCC model in hard-to-heal wound management using the findings.

Objective: Pressure ulcers (PUs) severely impact health outcomes in neonatal intensive care, with up to 28% prevalence and doubled mortality rates. Due to their only partially developed stratum corneum, neonates are highly susceptible to PUs because of a lack of adequate support surfaces. The occipital region of the head and hip are the main risk areas due to immobility and newborn body proportions. The main goal of the study was to investigate the impact of reduction in local pressure in these body areas by two air mattress designs and different filling states., Method: Two innovative air-filled mattress prototypes (prototype 1 and prototype 2), consisting of three different segments (head, trunk and feet regions), were developed to reduce local interface pressures by optimising pressure distribution, and were assessed with three air pressure filling states (0.2kPa, 0.4kPa and 0.6kPa). A baby doll was used to investigate pressure distribution and local pressure impact. It measured 51cm and the weight was modified to be 1.3kg, 2.3kg and 3.3kg, representing premature to term newborn weights, respectively. A specialised foam mattress and an unsupported surface were considered as controls., Results: The interface pressures at the hip region for newborn models could be reduced by up to 41% with mattress prototype 1 and 49% with prototype 2 when filled with 0.2kPa air pressure. It was found that the size and the pressure inside air segments was crucial for interface pressure., Conclusion: Our results demonstrated that air mattresses achieved lower interface pressures compared to conventional support surfaces, and that the benefit of the air mattresses depended on their filling status. The importance of using innovative, segmented designs that were tailored to meet the specific needs of highly vulnerable paediatric patients was demonstrated.

Objective: Diabetic foot ulcers (DFUs) present a significant global health challenge, resulting in high morbidity and economic costs. Current available treatments often fail to achieve satisfactory healing rates, highlighting the need for novel therapies. This study evaluated the safety and efficacy of a novel autologous whole blood clot (AWBC)-a blood-based, biodegradable provisional matrix-in conjunction with standard of care (SoC) when compared to SoC alone in the treatment of hard-to-heal DFUs., Method: A multicentre, prospective, blinded assessor, randomised controlled trial was conducted at 16 sites across the US, South Africa and Turkey. A cohort of patients with hard-to-heal DFUs was enrolled and randomised to either the AWBC group or the control group. The primary endpoint was complete wound closure at 12 weeks, while secondary endpoints included time to heal and percentage area reduction (PAR) at four and eight weeks. Data were analysed using both intention-to-treat (ITT) and per-protocol (PP) populations., Results: The cohort included 119 patients. AWBC treatment resulted in a significantly higher healing rate compared to the control in both ITT (41% versus 15%, respectively; p=0.002) and PP populations (51% versus 18%, respectively; p=0.0075). AWBC treatment also resulted in a shorter mean time to heal and higher durability of wound closure. Safety analysis showed a similar incidence of adverse events (AEs) between groups, with no device-related AEs., Conclusion: The AWBC system, by modulating the wound microenvironment and providing a functional extracellular matrix, offered a promising new approach to treating hard-to-heal DFUs, demonstrating superior healing outcomes compared to SoC alone in this study.

Pressure ulcers (PU) are a globally recognised healthcare concern, with their largely preventable development prompting the implementation of targeted preventive strategies. Risk assessment is the first step to planning individualised preventive measures. However, despite the long use of risk assessment, and the >70 risk assessment tools currently available, PUs remain a significant concern. Various technological advancements, including artificial intelligence, subepidermal moisture measurement, cytokine measurement, thermography and ultrasound are emerging as promising tools for PU detection, and subsequent prevention of more serious PU damage. Given the rise in availability of these technologies, this advances the question of whether our current approaches to PU prevention can be enhanced with the use of technology. This article delves into these technologies, suggesting that they could lead healthcare in the right direction, toward optimal assessment and adoption of focused prevention strategies.

Objective: The aim of this in vitro experimental series was to explore the mode of action of a hydrocellular polyurethane foam dressing (HPFD) and how its advanced features support beneficial interactions with the wound bed to address common barriers to wound healing, thus supporting improved clinical outcomes., Method: Multiple in vitro microbiological tests were performed, assessing prevention of bacterial ingress, surface removal of bacteria, bacterial sequestration and retention into the dressing in a clinically relevant environment. Odour molecule concentrations were measured using gas chromatography and further assays explored matrix metalloproteinase (MMP)-9 retention in the dressing using enzyme linked immunosorbent assay., Results: The HPFD demonstrated marked reductions in bioburden levels across multiple tests. These included prevention of bacterial ingress for seven days, removal of surface bacteria and absorption into the dressing. Further tests identified that most bacteria were sequestered into the hyperabsorbent layer (90.5% for Pseudomonas aeruginosa and 89.6% for meticillin-resistant Staphylococcus aureus ). Moreover, the majority of bacteria (99.99% for both test organisms) were retained within the dressing, even upon compression. Additional tests demonstrated a marked reduction of odour molecules following incubation with HPFD and total retention of protease MMP-9 within the dressing., Conclusions: Proactive management of the wound environment with an appropriate advanced wound dressing, such as the HPFD examined in these in vitro investigations, can not only help to minimise the barriers to healing, as observed across this test series by direct interaction with the wound bed, but may, as a result, provide an ideal environment for wound progression with minimal disturbance.

Objective: The most recent edition of the International Clinical Practice Guideline for the Prevention and Treatment of Pressure Ulcers/Injuries was released in 2019. Shortly after, in 2020, the first edition of the SECURE Prevention expert panel report, focusing on device-related pressure ulcers/injuries, was published as a special issue in the Journal of Wound Care . A second edition followed in 2022. This article presents a comprehensive summary of the current understanding of the causes of pressure ulcers/injuries (PU/Is) as detailed in these globally recognised consensus documents., Method: The literature reviewed in this summary specifically addresses the impact of prolonged soft tissue deformations on the viability of cells and tissues in the context of PU/Is related to bodyweight or medical devices., Results: Prolonged soft tissue deformations initially result in cell death and tissue damage on a microscopic scale, potentially leading to development of clinical PU/Is over time. That is, localised high tissue deformations or mechanical stress concentrations can cause microscopic damage within minutes, but it may take several hours of continued mechanical loading for this initial cell and tissue damage to become visible and clinically noticeable. Superficial tissue damage primarily stems from excessive shear loading on fragile or vulnerable skin. In contrast, deeper PU/Is, known as deep tissue injuries, typically arise from stress concentrations in soft tissues at body regions over sharp or curved bony prominences, or under stiff medical devices in prolonged contact with the skin., Conclusion: This review promotes deeper understanding of the pathophysiology of PU/Is, indicating that their primary prevention should focus on alleviating the exposure of cells and tissues to stress concentrations. This goal can be achieved either by reducing the intensity of stress concentrations in soft tissues, or by decreasing the exposure time of soft tissues to such stress concentrations.

Objective: This study sought to determine the risk-adjusted (controlled for patient characteristics) trend in pressure injury (PI) incidence in Switzerland., Method: A secondary data analysis was conducted. The data originated from the national PI quality measurement based on a multicentre cross-sectional design with repeated annual measurements. Descriptive statistics, a Cochran-Armitage trend test and logistic (multilevel) regression modelling were applied., Results: The analysis sample comprised 123,715 patients from 230 hospitals over 10 survey years (2011-2019 and 2022). The incidence of descriptive PI varied in Switzerland between 3.7% and 5.6% over the survey years. No linear trend could be found when patient characteristics were not considered. A non-linear trend was detected when controlling for patient characteristics and the time effect (repeated measurement). This was also reflected in the plotted risk-adjusted incidence, which revealed a decrease followed by a levelling off. When only considering the incidence of PIs rated category 2 and higher, there was also a non-linear decreasing trend when controlling for patient characteristics and time effects. If the incidence per survey year were estimated on the basis of patient characteristics, an increase in the incidence would have been expected., Conclusion: Although patients' risk of developing a PI increased between 2011-2022, the incidence of PIs in Switzerland first decreased and then levelled off. The results indicated that care quality in Swiss hospitals has improved regarding PIs. Nevertheless, in view of demographic trends and increasing staff shortages, it is important to continue to monitor PI incidence and to invest in PI prevention.

Objective: Multicomponent bandages (MCBs) are recommended by the French Authority for Health (Haute Autorité de Santé) as first-line treatment for venous leg ulcers (VLUs). A first analysis of the data collected from the French administrative healthcare database (Système National des Données de Santé (SNDS)) on 25,255 patients with a VLU supported superiority of MCBs versus short stretch bandages when considering the healing outcomes and costs associated with closure of these wounds. The aim of this study was to assess how beneficial the primary dressing (technology lipido-colloid nano-oligosaccharide factor (TLC NOSF) or control dressing group (CDG)) could be, when used in combination with MCBs in the treatment of VLUs., Method: Data from the SNDS were collected for patients meeting the following inclusion criteria: treatment for a VLU with MCBs and with the same dressing type (TLC-NOSF or CDG) during the whole treatment period. Healing outcomes were documented on the global cohorts and propensity score-matched cohorts. The mean healthcare cost and the ecological impact were calculated for those patients healed within the study period., Results: In total, 12,507 patients met the criteria for treatment with both MCBs and TLC-NOSF dressings (n=1134) versus MCBs and CDG (n=11,373); with 1134 and 2268 patients per group following propensity score matching. Healing outcomes were favourable for the TLC-NOSF group in the global cohort and were enhanced in the propensity score-matched cohorts. At every point of the analysis, the adjusted healing rates were significantly higher in the TLC-NOSF group than in the CDG group (p<0.001). In the propensity score-matched cohorts (n=3402), the healing rate at three months was 52% in the TLC-NOSF group versus 37% in the CDG group (p<0.001). The median healing time was 87 days versus 125.5 days in the TLC-NOSF and CDG groups, respectively (p<0.0001). TLC-NOSF dressings significantly reduced the average treatment cost per healed ulcer (€2099) by 23.7% compared with dressings without TLC-NOSF (€2751) (p<0.001), as well as the resources used., Conclusion: This SNDS analysis confirms, in the largest real-life study performed in VLU management, the superiority of the TLC-NOSF dressings versus those not impregnated with the NOSF compound. Better clinical outcomes associated with cost savings and a positive ecological impact support the combination of MCBs and TLC-NOSF dressings and should be considered as an optimal standard of care for the global management of VLUs. These outcomes reinforce the current positions of the international guidelines on the use of NOSF impregnated dressings (UrgoStart range; Laboratoires Urgo, France) in this pathology.

Pressure ulcers/injuries (PU/Is) are a burden on healthcare systems worldwide. They are costly and have a negative impact on the quality of life of patients. PU/Is cause discomfort, prolong hospital stays and can even lead to death. Data on the incidence and prevalence of PU/Is are used to implement effective, tailored prevention practices. The aim of this paper is to highlight the importance and value of collecting epidemiological data in terms of its practical use in Slovakia. The prevalence of PU/Is was found to be low compared to global data. Shortcomings in the collection of epidemiological data are highlighted; however, the use of those available data in amending national standards, such as the mandatory reporting of PU/Is, is summarised. Several steps and activities related to the prevention and care of PU/Is have been carried out in Slovakia. It is important to know not only the prevalence in terms of field of care, time and provider, but also, more specifically, the risk characteristics and/or presence of PU/I in order to initiate more individualised and tailored patient care.

This commentary considers the similarities which exist between pressure ulcers (PUs) and diabetic foot ulcers (DFUs). It aims to describe what is known to be shared-both in theory and practice-by these wound types. It goes on to detail the literature surrounding the role of inflammation in both wound types. PUs occur following prolonged exposure to pressure or pressure in conjunction with shear, either due to impaired mobility or medical devices. As a result, inflammation occurs, causing cell damage. While DFUs are not associated with immobility, they are associated with altered mobility occurring as a result of complications of diabetes. The incidence and prevalence of both types of lesions are increased in the presence of multimorbidity. The prediction of either type of ulceration is challenging. Current risk assessment practices are reported to be ineffective at predicting when ulceration will occur. While systemic inflammation is easily measured, the presence of local or subclinical inflammation is harder to discern. In patients at risk of either DFUs or PUs, clinical signs and symptoms of inflammation may be masked, and systemic biomarkers of inflammation may not be elevated sufficiently to predict imminent damage until ulceration appears. The current literature suggests that the use of local biomarkers of inflammation at the skin's surface, namely oedema and temperature, may identify early tissue damage.

Objective: The effect of continuous topical oxygen therapy (cTOT) on Pseudomonas aeruginosa biofilm gene transcription profiles following inoculation onto porcine skin, using a customised molecular assay was determined., Method: Sterilised porcine skin explants were inoculated with Pseudomonas aeruginosa in triplicate: 0 hours as negative control; 24 hours cTOT device on; 24 hours cTOT device off. The oxygen delivery system of the cTOT device was applied to the inoculated tissue and covered with a semi-occlusive dressing. All samples were incubated at 37±2°C for 24 hours, with the 0 hours negative control inoculated porcine skin samples recovered immediately. Planktonic suspensions and porcine skin biopsy samples were taken at 0 hours and 24 hours. Samples were processed and quantifiably assessed using gene specific reverse transcription-quantitative polymerase chain reaction assays for a panel of eight Pseudomonas aeruginosa genes (16S, pelA, pslA, rsaL, pcrV, pscQ, acpP, cbrA) associated with biofilm formation, quorum sensing, protein secretion/translocation and metabolism., Results: Transcriptional upregulation of pelA, pcrV and acpP, responsible for intracellular adhesion, needletip protein production for type-3 secretion systems and fatty acid synthesis during proliferation, respectively, was observed when the cTOT device was switched on compared to when the device was switched off. Data suggest increased metabolic activity within bacterial cells following cTOT treatment., Conclusion: cTOT is an adjunctive therapy that supports faster healing and pain reduction in non-healing hypoxic wounds. Oxygen has previously been shown to increase susceptibility of biofilms to antibiotics through enhancing metabolism. Observed gene expression changes highlighted the impact of cTOT on biofilms, potentially influencing antimicrobial treatment success in wounds. Further in vitro and clinical investigations are warranted.

Objective: Despite the development of microscopic reconstructive techniques for lower limb salvage, major limb amputation is still required for critical, unsalvageable lower leg wounds, with steadily increasing estimates of major limb amputations. In this study, the authors highlight a surgical technique for below-knee (BK) amputation using an ultrasonic scalpel, and evaluate its safety and effectiveness compared with the conventional method of using surgical blades., Method: A retrospective chart review was conducted at the Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, Republic of Korea, on patients who underwent BK amputation between October 2012 and January 2021. Patients were assigned to two groups: amputation using classical methods, such as surgical blades and electrocautery (group A); and amputation using an ultrasonic scalpel (group B). Numerous perioperative factors, such as operation time, intraoperative blood loss, postoperative complications and recovery time were examined. The present study adhered to the STROBE guidelines., Results: A total of 41 patients (16 in group A and 25 in group B) were included in this study. Operation time was significantly shorter in group B (p=0.001) and intraoperative blood loss was lower (p=0.011). Wound healing time did not vary between groups., Conclusion: In this study, the use of an ultrasonic scalpel for lower limb amputation was effective in reducing operation time and blood loss, which may be helpful in improving outcomes for patients with comorbidities.

Catatrophic antiphospholipid syndrome (CAPS), a rare variant of antiphospholipid syndrome (APS), is associated with rapid multiorgan failure. While APS is associated with single medium-to-large blood vessel occlusions, CAPS is most often associated with several, concurrent vascular occlusions of small vessels, commonly of the kidneys, heart, skin and brain. We present a case of a 21-year-old female patient with a history of immune thrombocytopenia purpura and APS, who eventually developed concurrent cerebral venous sinus thrombosis, diffuse alveolar haemorrhage, renal thrombotic microangiopathy, and a necrotic, vasculitic wound on her forearm. Despite hospitalisation and treatment, her condition worsened and the patient eventually died after succumbing to suspected CAPS.

Early indicators of healing provide valuable information on the potential benefit of treatment. In patients with hard-to-heal (chronic) diabetic foot ulcers (DFUs), timely intervention is critical. Ulcers that fail to show measurable progress within four weeks of treatment are considered recalcitrant. These ulcers increase the risk of soft tissue infection, osteomyelitis and lower extremity amputation. A prognostic indicator or surrogate marker allows for rapid evaluation of treatment efficacy and safety. An inverse correlation between a percentage area reduction (PAR) of ≤50% at week 4 and complete healing by week 12 has been previously established; however, the data were derived from a standard of care (SoC) arm of clinical trials that are over a decade old. In this post hoc analysis, data from a large multicentre prospective randomised controlled trial were reviewed to assess PAR at week 4 as a prognostic indicator in patients treated with SoC. Overall, 65.4% (17/26) of patients with PAR >50% at week 4 achieved complete closure at week 12. The receiver operating characteristic (ROC) curve for area reduction by week 4 showed strong discrimination for predicting non-healing (area under the ROC curve: 0.92; p<0.001; positive predictive value: 70.6%; negative predictive value: 87.2%). These findings are consistent with previous studies and support the use of four-week PAR as a prognostic indicator.

Objective: While most xenograft wound matrices are flat sheets not designed for deep or tunnelling wounds, three-dimensional acellular collagen matrices (3D-ACM) can fill deep wound beds and enable full wound wall apposition. This case series examines the use of 3D-ACM in treating diabetic foot ulcers (DFUs) that are deep, tunnelling, undermining, or irregularly shaped. We report outcomes of cases where 3D-ACM was applied to deep or tunnelling DFUs present for at least four weeks., Method: In this retrospective case series, 3D-ACM was applied, healing was monitored and measurements were collected. Additional 3D-ACM was applied as needed., Results: In total, 11 patients with 13 wounds were treated. Improved wound appearance and reduced size were observed at most follow-ups. Mean initial wound depth was 1.6cm, and several wounds showed significant depth reductions shortly after therapy initiation. In total, 62% of wounds (8/13) reached 50% closure by four weeks. Additionally, 54% (7/13) were fully closed by 12 weeks. The remaining 46% (6/13) took between 12-22.3 weeks to heal. Overall mean therapy time was 13.1 weeks (range: 2.0-22.3 weeks). Deeper wounds generally took longer to close., Conclusion: The findings of this case series showed that 3D-ACM could offer a protective microenvironment for wound management for deep or tunnelling DFUs. While some took >12 weeks to close, this may be attributable to large initial depths and volumes, rather than a failure to respond to the treatment modality. Other wounds that require a conforming 3D matrix, enabling full wound wall apposition, may benefit from 3D-ACM. Further investigations would be beneficial to understand the capabilities of this treatment modality.

Due to an ageing population and prolonged lifespan, pressure injury (PI) incidence is increasing. Patients with a PI typically endure longer hospital stays, which create a significant burden on healthcare resources and costs. With appropriate preventive interventions, most PIs can be avoided; however, skin failure may become inevitable in particular instances. These are classified as unavoidable PIs. Patients in a critical condition are exposed to a unique set of therapies, medications and bodily states. Oftentimes, these instances decrease tissue tolerance, which may promote PI formation. Patients who are critically ill, especially those with extended stays in the intensive care unit, are susceptible to skin failure due to: prolonged immobility; mechanical ventilation; acute respiratory distress syndrome; COVID-19; sepsis; multiorgan system dysfunction; vasopressor use; and treatment with extracorporeal membrane oxygenation. Poor perfusion leading to skin breakdown results from the compounding factors of circulatory collapse, build-up of metabolites, compromised lymphatic drainage, patient comorbidities, and ischaemia via capillary blockage in patients who are critically ill. In addition, similar physiology is present during end-of-life multisystem organ failure, which creates unavoidable skin deterioration. The aim of this review is to provide an overview of circumstances which decrease tissue tolerance and ultimately lead to PI development, despite adequate preventive measures in patients who are critically ill.

Objective: This case series examines the use of a multimodal wound matrix (MWM) trialled in a selection of clinical practice settings and on a variety of hard-to-heal wounds. The objective was to evaluate the effects of MWM and its performance in managing such wounds, regardless of clinical setting and ulcer type., Method: Treatment of the MWM was conducted by independent wound care practitioners on wounds that were of >4 weeks duration. Treatment was once a week. Assessment was taken after four weeks and at week 12 of the study to assess percentage area reduction (PAR) compared to baseline measurements taken at the first treatment visit. Complete (100%) re-epithelialisation was also recorded., Results: A total of 63 wounds were treated with MWM, and ulcer types were grouped as: diabetic foot ulcers (n=21); venous leg ulcers (n=18); pressure injuries (n=10); and others (n=14). Of the wounds, 78% had 100% re-epithelialisation, with an average PAR of 57% at four weeks and 86% at 12 weeks. The average time to resolution for those wounds that closed was 7.9 weeks., Conclusion: Results from this series of independent case studies support the application of MWM to potentially benefit healing in hard-to-heal wounds of different aetiologies of any duration and in a variety of clinical settings.

Objective: The objective of the scoping review will be to understand and describe risk factors associated with surgical site infection (SSI) in an orthopaedic surgery population in Sub-Saharan Africa and South Africa. This paper describes the protocol that will be used for the scoping review., Method: A comprehensive literature search will be conducted using MEDLINE (PubMed), CINAHL (EBSCO), Embase and Cochrane Libraries to identify articles meeting the inclusion criteria, including both published and grey literature, in order to provide a broad overview of the reported risk factors associated with patients who have undergone an orthopaedic surgery with an outcome of SSI within 90 days of a procedure. Additional studies will be sourced by exploring the reference list of included eligible studies. By using a combination of the Population, Exposure, Outcome framework, terms and synonyms related to each category, in different variations, along with Boolean operators (AND, OR, NOT) in the search strategy, identified comprehensive and relevant literature for the scoping review., Results: It is anticipated the results will provide a baseline of risk factors that will inform the development of a risk assessment tool for clinical use., Conclusion: This protocol will inform the development of a scoping review to describe factors associated with SSIs following orthopaedic surgery in Sub-Saharan Africa and South Africa.

Objective: Managing the gap between the dressing and the wound bed can facilitate the healing of exuding wounds. A silicone foam dressing (Biatain Silicone; Coloplast A/S, Denmark) was developed for application to exuding wounds. A sub-analysis of the real-world, prospective, observational VIPES (Observatoire en Ville des Plaies ExSudatives) study was conducted to investigate the use and performance of the silicone foam dressing in a community nursing setting in France., Method: The sub-analysis included patients from the VIPES study who received the silicone foam dressing as a primary dressing for an acute or hard-to-heal (chronic) wound. Epidemiological and wound healing outcomes were reported via a smartphone application., Results: Overall, 64 patients were included in the sub-analysis. At baseline, most wounds (n=33/40; 82.5%) were in treatment failure (i.e., were stagnant, non-healing or had poor exudate management). At the last follow-up visit, a median of 22.5 (range: 3-151) days post baseline, 48.4% of wounds had healed and 25.0% were progressing towards healing. From baseline to the last follow-up visit, significant reductions in exudate level (p<0.0001) and exudate pooling (p<0.0001), and significant improvements in wound edges (p≤0.0001) and periwound skin (p<0.01) were observed. A total of 62.3% of patients had re-epithelialising wounds at the last follow-up visit. The majority of nurses (88.3%) and patients (85.0%) reported that the wound had improved and, at most dressing removals (93.5%), nurses reported that the dressing conformed closely to the wound bed., Conclusion: Overall, the data suggest that use of the silicone foam dressing in community practice supported the healing of wounds, illustrating the importance of exudate and gap management.

There are several reasons for skin damage, including genetic factors, disorders, acute trauma, hard-to-heal wounds, or surgical interventions. Whatever the cause, wounds have a substantial impact on people who experience them, their caregivers and the healthcare system. Advanced wound care products have been researched and developed, providing an opportunity for faster and more complete healing. Tissue engineering (TE) is a promising strategy that can overcome limitations when choosing a graft for a wound. Amniotic membrane is a highly abundant, readily available, and inexpensive biological tissue that does not raise ethical concerns, with many applications in different fields of TE and regenerative medicine. It has attractive physical characteristics, such as elasticity, rigidity and mechanical strength, among others. The effects can also be potentiated by association with other substances, such as hyaluronic acid and growth factors. This paper describes new perspectives involving the use of amniotic membranes.

Objective: Acute laceration wound (ALW) is one of the most common injuries in Indonesia with potential significant morbidities. In rural areas, povidone-iodine and honey are commonly used as wound dressings. This study aimed to identify the effectiveness of honey compared to paraffin gauze and the commonly used povidone-iodine in improving ALW healing time., Method: This study was a single-blind, pilot randomised controlled trial (RCT) with three intervention groups (honey, povidone-iodine, and paraffin). The outcomes were wound healing time, slow healing, secondary healing, signs of infection, wound dehiscence, oedema, maceration, necrosis, exudate and cost., Results: A total of 35 patients (male to female ratio: 4:1), with a mean age of 22.5 (range: 6-47) years, were included and randomised to treatment groups using predetermined randomisation according to wound location and wound dressing selection: honey group, n=12; povidone-iodine group, n=11; paraffin group, n=12 with one patient lost to follow-up. All groups achieved timely healing, with a mean healing time of 9.45±5.31 days and 11.09±5.14 days for the povidone-iodine and paraffin groups, respectively, and a median healing time of 10 (3-19) days for the honey group (p>0.05). More wounds in the honey group achieved healing in ≤10 days compared with the other groups. Both povidone-iodine and honey groups had fewer adverse events, with the latter having the lowest cost., Conclusion: In this study, honey was clinically effective in accelerating healing time with a lower cost compared to paraffin, and was comparable to povidone-iodine. Future RCTs with a larger sample size should be pursued to determine honey's role in ALW treatment.

Objective: Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the hair follicle. Its treatment often requires a surgical approach. The aim of our study was to evaluate the occurrence of post-surgical complications following a new standard of surgical management. This included presurgical lesion mapping by ultra-high frequency ultrasound (UHFUS) with a 70MHz probe. Postoperative management was based on the principles of HS-TIME (time, inflammation/infection, moisture, edges)., Method: A single-centre, retrospective study was conducted by the Department of Dermatology of the University of Pisa. Patients with moderate and severe HS, refractory to previous medical and surgical therapies, were enrolled. All of the patients were treated with wide surgical excision of lesions, previously explored through a UHFUS evaluation with VEVO MD (Fujifilm VisualSonics, Inc., Canada) using a 48MHz and a 70MHz ultrasound probe. Following surgery, all patients were treated with secondary intention healing following the principles of HS-TIME. For each patient, we assessed the occurrence of post-surgical complications at follow-up visit six months after surgery. For each patient we assessed the occurrence of early post-surgical complications at every follow-up visit after surgery until complete wound healing. The occurrence of delayed complications was then assessed in all patients with an observation time after complete healing of >3 months (n=23)., Results: A total of 26 patients were enrolled in the study. There were no reported cases of post-surgical bleeding or haematoma occurrence, while three (11.5%) patients developed minor surgical site infection. The average severity of pain decreased from a numerical rating scale of 5.3 immediately after surgery to 1.3 after four weeks. The average healing time was 33.3±16.8 days, and only five (19.2%) patients reported a complete wound healing time of >6 weeks. Focusing on delayed complications: 1/23 (4.3%) patient had hypertrophic scarring; 2/23 (8.7%) patients reported dysaesthesia; and 2/23 (8.7%) cases of clinical relapse were reported. No cases of limited mobility at the surgery site were registered., Conclusion: The findings of the study demonstrated the efficacy of a novel surgical protocol, including a preoperative ultrasound evaluation and appropriate postoperative wound management. Further prospective studies are needed to validate the observed results; however, we conclude that the low recurrence rates and post-surgical complications confirmed that our proposed protocol would represent an effective strategy for the management of patients with HS eligible for surgical therapy.

Objective: This work explores concurrent optical and magnetic stimulation (COMS) effects on hard-to-heal wounds in real-world settings., Method: In this case series, participants received COMS 1-3 times per week for up to 12 weeks alongside standard wound care., Results: A total of 27 patients (18 female and nine male) were included. Mean age was 72 years. Participants' wounds that were unresponsive to standard wound care included: venous leg ulcers (VLUs, n=13); mixed leg ulcers (MLUs, n=4); diabetic foot ulcers (DFUs, n=1); pressure ulcers (PUs, n=5); and traumatic wounds (TWs, n=4). On average, COMS was applied twice a week, resulting in an overall mean wound area reduction of 69%. In 24 participants, COMS was used primarily to achieve wound closure by the end of the 12-week period, of which: 12 were classified as complete wound closure (50%; VLUs=8, PUs=3 and TW=1); four as likely-to-heal (17%; VLUs=2 and MLUs=2); four as 'improved' (17%; MLU=1, DFU=1 and TWs=2); and four as 'non-responding' (17%; VLUs=3 and MLU=1). The best results were achieved in PUs and VLUs (respectively 100% and 62% categorised as completely healed). When used in participants where its purpose was other than that of achieving wound closure, COMS was successfully used to debride two PUs, and for wound bed preparation in one TW., Conclusion: In this case series, COMS showed positive effects and appeared to be beneficial in healing different types of hard-to-heal wounds in community health and homecare settings. Novel COMS therapy aspects emerged: (1) positive outcomes for PU and VLU treatment; (2) COMS as a potential debridement tool when sharp debridement is unfeasible; and (3) COMS as a promising method to prepare wound beds for subsequent skin grafting or skin replacement procedures.

Objective: The aim was to evaluate the effectiveness of a marine omega fatty acid-containing multimodal wound matrix (MWM) in reducing bacterial contamination and supporting wound area reduction (WAR) in patients with hard-to-heal wounds of varying aetiologies., Method: A prospective, single-site, pilot case series of patients with hard-to-heal wounds. All wounds were considered non-healing prior to inclusion as they had failed to achieve at least 50% WAR after at least four weeks of standard of care (SoC) treatments. Patients were seen once weekly for wound assessments, matrix application and dressing changes. Baseline and weekly fluorescence images, standard wound images and wound measurements were obtained., Results: A total of three patients, two with venous leg ulcers (VLUs) and one with a diabetic foot ulcer (DFU) were enrolled in this pilot study. The mean baseline wound age prior to study enrolment was 24 weeks, with a mean baseline wound size of 8.61cm 2 . The two VLUs went on to complete closure. The DFU displayed a total WAR of 53% by six weeks, when the patient was lost to follow-up due to a geographical relocation. The mean percentage area reduction of all wounds combined was 82% upon study completion., Conclusion: The use of MWM proved to be effective and safe in this patient cohort. The wounds included in this case series failed to enter a healing trajectory with SoC wound therapies. The MWM supported wound closure and reduced bacterial loads in this patient cohort.

Objective: Compared with standard excision with a two-dimensional histological examination, Mohs micrographic surgery offers a lower recurrence rate and a greater extent of healthy tissue sparing for the treatment of high-risk basal cell carcinoma (BCC). The aims of this study were to first quantify the healthy tissue spared through the micrographic technique compared to traditional surgery for high-risk tumours. Then, to speculate, through the analysis of the distal micrographic resection margin, the adequate width of safety margins for standard excision., Method: A cohort of patients with high-risk BCC was treated with Mohs surgery. Safety margins, tumours residual final breach and hypothetical standard excision safety margins areas were recorded., Results: A total of 96 patients were included. A reduction of 27.96% (95% Confidence Interval (CI): 17.90-38.02) of healthy skin removed was observed using a micrographic method compared to the standard approach. Standard excision with a 6mm safety margin was associated with 86.46% (95% CI: 79.62-93.30) of complete excision. Greater margins were not associated with a statistically significant improvement of complete excision., Conclusion: Mohs surgery should be considered the gold standard operative treatment for high-risk BCC. However, if micrographic techniques are not feasible, the standard excision with a predetermined margin of 6 mm, should be considered as the best option.

Objective: To explore the experience of patients with incontinence and incontinence-associated dermatitis (IAD) in acute care hospitals and their family caregivers, including their perceptions and management, as well as the impact on their wellbeing., Method: A qualitative exploratory study design was employed in 18 wards across six acute/subacute hospitals in New South Wales, Australia. Patients with incontinence (with or without IAD) were invited to participate. Where interviews were not possible with the patient, their family caregiver was invited to participate. Semi-structured interviews were conducted., Results: There were 45 interviewees in the study; 41 were patients with incontinence (11 of whom had IAD) and four were family caregivers. The experience of incontinence was captured by three themes: 'incontinence interrupts every aspect of my life'; 'actively concealing and cloaking'; and 'perceived as irreversible'. Incontinence was expected by the patients at their age and did not come as a surprise. It was normalised and approached with stoicism. As such, patients self-managed their incontinence by developing strategies to ensure they avoided episodes of incontinence during their stay. Incontinence left patients feeling anxious, embarrassed and with a sense of shame, and they did not communicate these feelings, or engage with health professionals about their incontinence, nor did health professionals discuss their incontinence with them. There was a strong sense of resignation that incontinence was irreversible and nothing could be done to improve it. All participants displayed little knowledge of IAD. The experience of having IAD was characterised by the theme 'debilitating and desperate for relief' and was experienced as a particularly painful, itching and burning condition that left patients distressed and irritable., Conclusion: Patients with incontinence in acute settings required further education from health professionals to reduce the stigma of incontinence, and provide further support to manage their incontinence. Health professionals can also play a key role in educating patients about the risks of developing IAD and how it can be prevented.

Objective: Surgical site complications (SSCs) are the leading cause of unplanned emergency department visits and readmissions following total joint arthroplasty (TJA). The use of closed-incision negative pressure therapy (ciNPT) has shown promise in reducing SSC occurrence. However, no study has evaluated the cost-effectiveness of ciNPT in primary TJA. The purpose of this study was to calculate the break-even absolute risk reduction (ARR) of SSCs, the break-even treatment cost of SSCs, and the break-even cost-of-use for ciNPT, based on existing literature to assess the cost-effectiveness of ciNPT in primary TJA., Method: Relevant values for ARR, infection treatment cost and intervention cost were obtained via literature review. A break-even analysis was conducted to investigate the cost-effectiveness of ciNPT use in primary TJA, as well as to derive the ARR, infection treatment cost (C t ) and intervention protocol cost (C p ) values at which ciNPT use becomes cost-effective., Results: The values derived from the literature review were as follows: C p =$160.76 USD; C t =$5348.78 USD; ARR=0.0375. The break-even ARR was calculated to be 3.0%, the break-even C p was calculated to be $200.58 USD, and the break-even C t was calculated to be $4286.93 USD. The ARR of ciNPT use was greater than the calculated break-even ARR., Conclusion: This analysis demonstrated that ciNPT use in primary TJA was cost-effective. By examining the difference between the calculated break-even C p and the C p reported in the literature, the cost saved per patient treated with ciNPT can be calculated to be $39.82 USD.

Alternative 3-dimensional (3D) skin models that replicate in vivo human skin are required to investigate important events during wound healing, such as collective cell migration, epidermal layer formation, dermal substrate formation, re-epithelialisation and collagen production. In this study, a matched human 3D skin equivalent model (3D-SEM) was developed from human skin cells (fibroblast and keratinocytes), characterised using haematoxylin and eosin, immunofluorescence staining and microRNA profiling. The 3D-SEM was then functionally tested for its use in wound healing studies. Mesenchymal stem cells (MSCs) were isolated and characterised according to the criteria stipulated by the International Society for Cell Therapy. Cytokine and growth factor secretions were analysed by enzyme-linked immunosorbent assay. MSC-conditioned medium (MSC-CM) was then tested for wound healing capacity using the developed 3D-SEM at different timepoints i.e., at one, two and four weeks. The constructed 3D-SEM showed consistent development of skin-like structures composed of dermal layers and epidermal layers, with the ability to express epidermal differentiation markers and full stratification. They also showed prolonged longevity in culture media, retaining full differentiation and stratification within the four weeks. MicroRNA profiling revealed a strong correlation in microRNA expression between the developed 3D-SEM and the original native skin (p<0.001; R=0.64). Additionally, MSC-CM significantly enhanced migration, proliferation and differentiation of epidermal cells in the wounded models compared to control models at the different timepoints. In conclusion, in this study, the developed 3D-SEM mimicked native skin at the cellular and molecular levels, and clearly showed the important stages of skin regeneration during the healing process. MSC secretome contains growth factors that play a pivotal role in the healing process and could be used as a therapeutic option to accelerate skin healing.

Objective: To evaluate the healing outcome of a platelet-rich plasma (PRP) gel prepared using TKKT01 (a wound care device to prepare the PRP gel) in patients with hard-to-heal diabetic foot ulcers (DFUs) and who showed an inadequate response to ≥4 weeks of standard of care (SoC)., Method: This open-label, single-arm, multicentre study was conducted in 15 centres in Japan. Eligible patients received PRP gel treatment twice a week for eight weeks, followed by a final evaluation after the completion of week 8 (day 57). The primary endpoint was the percentage of patients who achieved ≥50% reduction in wound radius at the final evaluation (achievement criterion, ≥60% of patients). Secondary endpoints included: wound area and volume reduction rates; time to possible wound closure by secondary intention; time to possible wound closure using a relatively simple procedure (e.g., skin graft and suture); and safety at the final evaluation., Results: A total of 54 patients were included in the full analysis set, with 47 patients included in the per protocol set; the primary endpoint was met in 38/47 (80.9%) (95% confidence interval: 66.7-90.9%) patients who achieved ≥50% wound radius reduction at the final evaluation. High rates of wound area (72.8%) and volume (92.7%) reduction were observed at the final evaluation. The median time to possible wound closure by secondary intention and by use of a relatively simple procedure was 57 and 43 days, respectively. Complete wound closure at the final evaluation was achieved in 27 (57.4%) patients. No safety concerns were raised., Conclusion: In this study, the efficacy and safety of PRP gel treatment with TKKT01 in patients with hard-to-heal DFUs in Japan were confirmed by our findings., Declaration of Interest: This study was funded by Rohto Pharmaceutical Co., Ltd., Japan. NO has been paid a consulting fee by Rohto Pharmaceutical Co., Ltd. KH is the Chief Medical Officer of Rohto Pharmaceutical. Co., Ltd. The other authors have no conflict of interest to declare.

Objective: Medical adhesive-related skin injuries (MARSI), defined as skin damage associated with the use of medical adhesive products or devices, are a common and under-reported condition that compromises skin integrity. The prevention and management of MARSI that can occur around the needle insertion site of a chest wall implantable port in hospitalised patients with a tumour remain challenging issues. The aim of this study was to explore whether the incidence of MARSI could be reduced by changing the body position during dressing changes., Method: Participants were recruited between May 2019 and November 2020 in the oncology department of a tertiary hospital. Patients were randomly assigned to Group AB (supine followed by semi-recumbent position) and Group BA (semi-recumbent followed by supine position) with a standard intervening recovery interval of 21-28 days. Assessments for typical MARSI included itching, the combination of erythema and oedema, and blisters in the port area, and were graded according to the level of severity., Results: The itch intensity was significantly lower in phase B (semi-recumbent) compared to phase A (supine) (2.35±1.985 versus 5.31±1.332, respectively; p<0.01). Similarly, the severity of erythema and oedema was less severe when comparing phase B to phase A: grade 0 (64.9% versus 10.5%, respectively); grade 1 (28.1% versus 19.3%, respectively); grade 2 (3.5% versus 7.0%, respectively); grade 3 (1.8% versus 45.6%, respectively); and grade 4 (1.8% versus 17.5%, respectively) (Z=5.703; p<0.01). Blisters were found far less frequently in phase B than phase A (1.8% versus 56.1%, respectively; p<0.01)., Conclusion: The study provided statistically significant evidence that patients in a semi-recumbent position receiving dressing at a chest wall implantable port had fewer and less severe injection site MARSI than when in a supine position., Declaration of Interest: The authors have no conflicts of interest to declare.

Objective: A hard-to-heal wound is defined as a wound that failed to proceed through the normal phases of wound healing in an orderly and timely manner. The purpose of this article is to describe the impact of hard-to-heal wounds on the wellbeing, quality of life (QoL) and satisfaction with QoL of patients in Oman with hard-to-heal wounds., Method: A descriptive cross-sectional study of patients with hard-to-heal wounds attending three tertiary care hospitals using a self-reported questionnaire was conducted., Results: A total of 275 patients took part in the study. Patients reported a low wellbeing score (67.06±19.72), moderate QoL score (52.18±25.07) and moderate satisfaction scores (68.91±23.88). Significant mean differences were reported with age, sex, educational level, monthly income and type of wound all at p<0.05., Conclusion: The findings of this study demonstrated that hard-to-heal wounds could influence the wellbeing, QoL and overall satisfaction with QoL of patients., Declaration of Interest: Funding was received through an internal grant of the Sultan Qaboos University to conduct the research conducting the research (IG/CON/FACN/20/01). The authors have no conflicts of interest to declare.

Objective: To evaluate the use and performance of a gelling fibre dressing (Biatain Fiber; Coloplast A/S, Denmark) in the management of wounds in community nursing practice., Method: A sub-analysis of the prospective, observational, real-world VIPES (Observatoire en Ville des Plaies ExSudatives) study was conducted. Patients with exuding wounds, for which nurses chose to apply the gelling fibre as a primary dressing, were included. Outcomes included assessments of wound condition and patient/nurse opinion., Results: Overall, 149 patients with acute (n=52; 34.9%) or hard-to-heal (chronic) (n=97; 65.1%) wounds were included. At baseline, mean±standard deviation wound age was 351.5±998.2 days, 108 (72.5%) wounds were moderately-to-highly exuding, and 126 (84.6%) showed exudate pooling in the wound bed. At the last follow-up visit, 29 (19.5%) wounds had healed, within a median of 36 days, and 64 (43.0%) were progressing towards healing. From baseline to the last follow-up visit, significant reductions in wound surface area (p<0.05), depth (p<0.01), exudate level (p<0.0001), and in the proportion of wounds with sloughy tissue (p<0.0001) were observed. Most wounds had no (n=86; 58.5% (two missing values)) or low exudate pooling (n=45; 30.6% (two missing values)) at the last visit and proportions of patients with healthy wound edges/periwound skin increased from baseline. At the last visit, wounds were considered improved by nurses in 71.4% (n=105) of cases, and by patients in 66.7% (n=98) of cases (two patients missing)., Conclusion: Patients who received treatment with the gelling fibre experienced improvements in the condition of a range of complex wounds. This analysis highlights the importance of adequate exudate management, and indicates how the selection of an appropriate wound dressing can encourage healing progression., Declaration of Interest: This study was financially supported by Laboratoires Coloplast SAS, Paris, France. Coloplast A/S funded the writing and editing of the article and contributed to its content. Coloplast A/S and Laboratoires Coloplast SAS reviewed the article for scientific accuracy. Nurses received financial compensation for their participation in the study. NA is a full-time employee of Coloplast A/S. APJ was an employee of Coloplast A/S when this article was written. FA was a full-time employee of Laboratoires Coloplast SAS at the time of publication development. RS and CJ are full-time employees of CEN Biotech. AK received an educational grant from Coloplast A/S to provide scientific input to the publication. The authors have no other conflicts of interest to declare.