RESUMEN
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.
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Siliconas , Cicatrización de Heridas , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Anciano , Adulto , Anciano de 80 o más Años , Heridas y Lesiones/terapia , Exudados y Transudados , Francia , VendajesRESUMEN
Non-optimal wound management and late referral to specialised units negatively impacts patient prognosis and quality of life, as well as healthcare costs. Healico is a new mobile application (app), created in the wound care field, in response to the challenges and difficulties encountered by health professionals (HPs) who deal with patients with wounds on a daily basis. This article aims to describe how this new app was developed, how it works, as well as the real-life clinical benefits and evidence supporting its use. The Healico App assists nurses, physicians and other HPs by: supporting a holistic approach to patient management; facilitating wound assessment and documentation, irrespective of where care is provided (primary, specialised or hospital services, in either public or private institutions); and supporting consistent and safe clinical practice, as well as reducing variation in care. It also provides a fast, fluid and secure communication channel, and effective coordination between HPs, supporting early interventions. The app has also been shown to improve therapeutic adherence of patients by promoting inclusive dialogue with them.
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Vendajes , Calidad de Vida , Humanos , Cicatrización de HeridasRESUMEN
Intertrigo is a common inflammatory skin disorder caused by skin-on-skin friction in skin folds, due to moisture becoming trapped because of poor air circulation. This can occur in any area of the body where two skin surfaces are in close contact with each other. The aim of this scoping review was to systematically map, review and synthesise evidence on intertrigo in adults. We identified a wide range of evidence and performed a narrative integration of this related to the diagnosis, management and prevention of intertrigo. A literature search was conducted within the following databases: Cochrane Library, MEDLINE, CINAHL, PubMed and EMBASE. After reviewing articles for duplicates and relevance, 55 articles were included. The incorporation of intertrigo in the ICD-11 provides a clear definition and should improve the accuracy of estimates. With regards to the diagnosis, prevention and management of intertrigo, the literature demonstrates consensus among health professionals in approach and this forms the basis for the recommendations of this review: identify predisposing factors and educate patient in reducing these; educate patients in skin fold management and adopt structured skin care routine; treat secondary infection with appropriate topical agent; consider using moisture-wicking textiles within skin folds to reduce skin-on-skin friction, wick away moisture and reduce secondary infection. Overall, the quality of evidence on which to determine the strength of any recommendations for practice remains low. There remains the need for well-designed studies to test proposed interventions and build a robust evidence base.
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Coinfección , Intertrigo , Enfermedades de la Piel , Humanos , Adulto , Coinfección/complicaciones , Intertrigo/diagnóstico , Intertrigo/etiología , Intertrigo/terapia , Piel , Cuidados de la PielRESUMEN
OBJECTIVE: To evaluate the healing outcomes and costs associated with the aetiological management of venous leg ulcers (VLUs) treated with recommended multicomponent bandages (MCBs) and short-stretch bandages (SSBs). METHOD: This observational study is a retrospective comparative study (Level 2b), based on the French administrative healthcare database (Système National des Données de Santé, SNDS). It includes patients treated from onset with reimbursed MCBs and SSBs for a VLU episode, between July 2018 and September 2020. Although other compression systems, such as long-stretch bandages, are commonly used for the treatment of VLUs, they are not recommended by health authorities in France and thus, were not considered for this study. A binomial regression model was performed to estimate the adjusted relative risk of wound closure rates at three months for each group, based on potential confounding factors including, notably, age, sex, key comorbidities, and wound dressing size. The mean healthcare cost was calculated for patients whose VLUs healed within the study period. RESULTS: The reimbursement data (including prescribed compression systems and nursing care) of the 25,255 selected patients were analysed in the study. There were no significant differences between the MCBs and SSBs groups when considering patient characteristics. The healing rates after three months' treatment, were 42% and 35% (p<0.001) in the MCBs and SSBs groups, respectively. When adjusting the statistical model, the chance of healing at three months was still 12% higher with MCBs compared with SSBs (p<0.0001). The median healing time was estimated at 115 (interquartile range (IQR): 60-253) days in the MCB group versus 137 (IQR: 68-300) days in the SSBs group. The average treatment cost per patient with a healed ulcer was 2875±3647 in the MCB group and 3580±5575) in the SSBs group (p=0.0179), due to lower hospital stay and nursing costs in the MCB group. Differences in wound characteristics between the two groups cannot be totally excluded, due to the limited content of the database in terms of clinical data, but should have been addressed, to some extent, through the study selection criteria and the chosen regression model. CONCLUSION: In this study, this SNDS analysis seemed to confirm that the healing outcomes achieved in real-life with MCBs were in line with those reported in clinical trials, and superior to SSBs, which reinforces the current position from the guidelines.
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Úlcera de la Pierna , Úlcera Varicosa , Humanos , Vendajes , Vendajes de Compresión , Análisis Costo-Beneficio , Úlcera de la Pierna/terapia , Estudios Retrospectivos , Úlcera Varicosa/tratamiento farmacológico , Cicatrización de HeridasRESUMEN
Skin reactions are well described complications of tattooing, usually provoked by red inks. Chemical characterizations of these inks are usually based on limited subjects and techniques. This study aimed to determine the organic and inorganic composition of inks using X-ray fluorescence spectroscopy (XRF), X-ray absorption spectroscopy (XANES) and Raman spectroscopy, in a cohort of patients with cutaneous hypersensitivity reactions to tattoo. A retrospective multicenter study was performed, including 15 patients diagnosed with skin reactions to tattoos. Almost half of these patients developed skin reactions on black inks. XRF identified known allergenic metals - titanium, chromium, manganese, nickel and copper - in almost all cases. XANES spectroscopy distinguished zinc and iron present in ink from these elements in endogenous biomolecules. Raman spectroscopy showed the presence of both reported (azo pigments, quinacridone) and unreported (carbon black, phtalocyanine) putative organic sensitizer compounds, and also defined the phase in which Ti was engaged. To the best of the authors' knowledge, this paper reports the largest cohort of skin hypersensitivity reactions analyzed by multiple complementary techniques. With almost half the patients presenting skin reaction on black tattoo, the study suggests that black modern inks should also be considered to provoke skin reactions, probably because of the common association of carbon black with potential allergenic metals within these inks. Analysis of more skin reactions to tattoos is needed to identify the relevant chemical compounds and help render tattoo ink composition safer.
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Tatuaje , Humanos , Tatuaje/efectos adversos , Tinta , Hollín , Espectrometría Raman/métodos , Espectrometría por Rayos XRESUMEN
Calcific uremic arteriolopathy (CUA) is a severely morbid disease, affecting mostly dialyzed end-stage renal disease (ESRD) patients, associated with calcium deposits in the skin. Calcifications have been identified in ESRD patients without CUA, indicating that their presence is not specific to the disease. The objective of this retrospective multicenter study was to compare elastic fiber structure and skin calcifications in ESRD patients with CUA to those without CUA using innovative structural techniques. Fourteen ESRD patients with CUA were compared to 12 ESRD patients without CUA. Analyses of elastic fiber structure and skin calcifications using multiphoton microscopy followed by machine-learning analysis and field-emission scanning electron microscopy coupled with energy dispersive X-ray were performed. Elastic fibers specifically appeared fragmented in CUA. Quantitative analyses of multiphoton images showed that they were significantly straighter in ESRD patients with CUA than without CUA. Interstitial and vascular calcifications were observed in both groups of ESRD patients, but vascular calcifications specifically appeared massive and circumferential in CUA. Unlike interstitial calcifications, massive circumferential vascular calcifications and elastic fibers straightening appeared specific to CUA. The origins of such specific elastic fiber's alteration are still to be explored and may involve relationships with ischemic vascular or inflammatory processes.
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Calcifilaxia , Fallo Renal Crónico , Calcificación Vascular , Humanos , Tejido Elástico , Fallo Renal Crónico/complicaciones , Márgenes de Escisión , Microscopía Electrónica de RastreoRESUMEN
BACKGROUND: The term dermatoporosis (DP) is used to describe the clinical signs and functional consequences of age-related extreme skin fragility. It is associated with potentially severe complications, including deep dissecting hematomas and extended skin lacerations. No studies have evaluated the prevalence and risk factors of DP in adults aged 75 and older. METHODS: The aim of our study was to assess the prevalence, complications, and risk factors of DP in a cohort of older patients hospitalized in a rehabilitation center. A case-control, single-center study was conducted between September and October 2020 in our rehabilitation ward, Rothschild Hospital, Paris, France. A senior dermatologist and a resident in geriatric medicine performed a systematic dermatological examination. The presence of DP, its stage, its location, and complications were collected, as were demographical data, comorbidities, past sun exposure, skin phototype, treatments, and biological data. RESULTS: A total of 101 patients (62 women, median age 86 years [extreme values 75-104]) were included. The overall prevalence of DP was 27%. Stage 1 was the most frequent. DP was mainly located on the upper limbs. Ten (37%) patients had a DP complication: eight (30%) skin lacerations and two (7%) deep dissecting hematomas. Multivariate analysis revealed a significant association between DP and age (odds ratio [OR] 5.82, 95% confidence interval [CI] 1.67-24.92, p = 0.009), smoking (OR 8.67, 95% CI 2.59-34.85, p = 0.001), recreational sun exposure (OR 4.23, 95% CI 1.30-15.21, p = 0.02), and anticoagulant therapy (OR 4.53, 95% CI 1.32-17.26, p = 0.02). CONCLUSION: Our study is the first to analyze the prevalence and risk factors of DP in older adults in rehabilitation. Frequency of DP makes it relevant for the geriatrician and should be described more to prevent potential severe complications. A multicentric study, with inpatients and outpatients, could evaluate the prevalence of DP in a more representative older adult population.
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Pacientes Ambulatorios , Piel , Anciano , Anciano de 80 o más Años , Femenino , Hospitales de Rehabilitación , Humanos , Prevalencia , Factores de RiesgoRESUMEN
Chronic wounds, including leg ulcers, constitute an important medical problem among older patients. Dystrophic calcifications (DC) are associated with a variety of disorders, including leg ulcers. The aim of this study was to report the clinical and biological characteristics of older patients with DC in leg ulcers and to determine the morphology and chemical composition of these calcifications. We conducted a prospective monocentric study in our Geriatric-Wound and Healing ward, Rothschild Hospital, Paris, from January 2018 to December 2019. Patients with leg ulcers were screened for DC by palpation. Patients' clinical, biological, and radiological findings were collected. DC morphology was analyzed using field-emission scanning electron microscopy and chemical composition was analyzed using µFourier transform infra-red spectroscopy and X-ray Fluorescence. Ten (7%) of the 143 patients hospitalized for leg ulcers presented DC. Older patients with DC were more likely to have leg ulcers with venous insufficiency (p = .015), colonized by Pseudomonas aeruginosa (p = .026), with a longer healing evolution (p = .0072) and hypercalcemia (p = .041). Five DC were extracted from ulcers: 2 presented 500 nm lacunar spheres and intermingled fibrils of about 10 nm in diameter, consistent with bacterial and biofilm imprints. DC were always composed of calcium-phosphate apatite and associated to the presence of zinc. Our analyses were consistent with the involvement of microorganisms and inflammatory process in DC formation. Early management of venous insufficiency, treatment of chronic bacterial colonization and use of calcium-solubilizing drugs seem to be rational strategies for calcified leg ulcer management in older patients.
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Úlcera de la Pierna , Úlcera Varicosa , Insuficiencia Venosa , Anciano , Calcio , Humanos , Estudios Prospectivos , Úlcera Varicosa/tratamiento farmacológico , Úlcera Varicosa/microbiologíaRESUMEN
Importance: Calcific uremic arteriolopathy (CUA), a rare, potentially fatal, disease with calcium deposits in skin, mostly affects patients with end-stage renal disease who are receiving dialysis. Chemical composition and structure of CUA calcifications have been poorly described. Objectives: To describe the localization and morphologic features and determine the precise chemical composition of CUA-related calcium deposits in skin, and identify any mortality-associated factors. Design, Setting, and Participants: A retrospective, multicenter cohort study was conducted at 7 French hospitals including consecutive adults diagnosed with CUA between January 1, 2006, and January 1, 2017, confirmed according to Hayashi clinical and histologic criteria. Patients with normal renal function were excluded. For comparison, 5 skin samples from patients with arteriolosclerosis and 5 others from the negative margins of skin-carcinoma resection specimens were also analyzed. Main Outcomes and Measures: Localization and morphologic features of the CUA-related cutaneous calcium deposits were assessed with optical microscopy and field-emission-scanning electron microscopy, and the chemical compositions of those deposits were evaluated with µ Fourier transform infrared spectroscopy, Raman spectroscopy, and energy dispersive radiographs. Results: Thirty-six patients (median [range] age, 64 [33-89] years; 26 [72%] female) were included, and 29 cutaneous biopsies were analyzed. Calcific uremic arteriolopathy and arteriolosclerosis skin calcifications were composed of pure calcium-phosphate apatite. Calcific uremic arteriolopathy vascular calcifications were always circumferential, found in small to medium-sized vessels, with interstitial deposits in 22 (76%) of the samples. A thrombosis, most often in noncalcified capillary lumens in the superficial dermis, was seen in 5 samples from patients with CUA. Except for calcium deposits, the vessel structure of patients with CUA appeared normal, unlike thickened arteriolosclerotic vessel walls. Twelve (33%) patients died of CUA. Conclusions and Relevance: Calcific uremic arteriolopathy-related skin calcifications were exclusively composed of pure calcium-phosphate apatite, localized circumferentially in small to medium-sized vessels and often associated with interstitial deposits, suggesting its pathogenesis differs from that of arteriolosclerosis. Although the chemical compositions of CUA and arteriolosclerosis calcifications were similar, the vessels' appearances and deposit localizations differed, suggesting different pathogenetic mechanisms.
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Calcifilaxia/fisiopatología , Piel/patología , Calcificación Vascular/patología , Adulto , Anciano , Anciano de 80 o más Años , Biopsia , Calcifilaxia/diagnóstico , Calcifilaxia/etiología , Estudios de Cohortes , Femenino , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Masculino , Microscopía , Microscopía Electrónica de Rastreo , Persona de Mediana Edad , Diálisis Renal/métodos , Estudios RetrospectivosRESUMEN
Actinic keratosis and squamous cell carcinoma in the elderly. The increase in life expectancy and the change in the habits of the population with respect to UV exposure have led to an increase in the incidence of actinic keratosis (AK) and squamous cell carcinoma (SCC). There is no specific recommendation for the "frail" elderly, but they would not differ much from the recommendations of the younger subjects. AK are common: 1 in 3 men and 1 in 5 women after 70 years. In the absence of treatment, the AK can evolve towards a SCC, justifying the interest of a systematic and early management of the AK by cryotherapy (liquid nitrogen), dynamic phototherapy, cream containing 5-fluorouracil (5(FU), imiquimod or ingenuous mebutate. Incidence of SCC is also important in the elderly and especially in mans. It can be localized on skin or mucosa. There are forms of SCC in situ or Bowen disease, cutaneous or mucosal, accessible to cryotherapy, 5-FU, imiquimod or dynamic phototherapy as an alternative to surgery. The SCC presents a mainly local evolutionary risk, with involvement of adjacent noble organs, but also regional, with significant risk of lymph node metastases, and visceral (lungs, liver in particular). The treatment must be supervised by a multidisciplinary team. If the patient has cognitive disorders, the presence of the "person of trust" is possible. At best the presence of a geriatrician or onco-geriatrician is recommended. Most often active treatment will be considered and surgical excision is the standard treatment. If general anesthesia is required, the limitation may be at this time of management because of significant co-morbidities. For inoperable SCC radiotherapy and radiochemotherapy are sometimes proposed. Metastatic SCC is complex in elderly patients because chemotherapy is poorly tolerated.
Kératose actinique et carcinomes épidermoïdes du sujet âgé. L'augmentation de l'espérance de vie et la modification des habitudes de la population vis-à-vis de l'exposition aux rayons ultraviolets ont conduit à l'augmentation d'incidence des kératoses actiniques et des carcinomes épidermoïdes cutanés. Il n'existe pas de recommandation spécifique pour le sujet très âgé « fragile ¼ mais elles ne différeraient pas beaucoup des recommandations concertant les sujets plus jeunes. Les kératoses actiniques sont fréquentes : 1 homme sur 3 et 1 femme sur 5 après 70 ans. En l'absence de traitement, les kératoses actiniques peuvent évoluer vers un carcinome épidermoïde, justifiant l'intérêt d'une prise en charge systématique et précoce des kératoses actiniques par cryothérapie (azote liquide), photothérapie dynamique, crème à base de 5-fluoro-uracile (5-FU), imiquimod ou mébutate d'ingénol. Le carcinome épidermoïde cutané est à risque de métastase, son incidence est également importante chez le sujet âgé et surtout chez l'homme. Il peut être de localisation cutanée ou muqueuse. Il existe des formes de carcinome épidermoïde in situ ou maladie de Bowen cutanée ou muqueuse accessibles à la cryothérapie, au 5-FU, à l'imiquimod ou à la photothérapie dynamique en alternative à la chirurgie. Le carcinome épidermoïde a un risque évolutif principalement local, avec atteinte des organes nobles adjacents, mais également régional, avec un risque non négligeable de métastases ganglionnaires et viscérales (poumons, foie en particulier). La prise en charge doit être encadrée par une réunion de concertation pluridisciplinaire, en présence éventuellement de la personne de confiance si le patient a des troubles cognitifs ; au mieux, la présence d'un gériatre ou oncogériatre est recommandée lors de cette réunion. Le plus souvent, un traitement actif est envisagé, et l'exérèse chirurgicale est le traitement de référence. Si une anesthésie générale est requise, des comorbidités importantes peuvent être une limitation à un geste chirurgical. Pour les carcinomes épidermoïdes inopérables, la radiothérapie externe, la curiethérapie et la radiochimiothérapie sont parfois proposées. Les carcinomes épidermoïdes métastatiques sont de traitement complexe chez le sujet âgé car les chimiothérapies sont mal supportées.
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Carcinoma de Células Escamosas , Queratosis Actínica , Neoplasias Cutáneas , Anciano , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/terapia , Femenino , Humanos , Queratosis Actínica/complicaciones , Queratosis Actínica/terapia , Masculino , Neoplasias Cutáneas/complicaciones , Neoplasias Cutáneas/terapiaRESUMEN
INTRODUCTION: Data on clinical characteristics and outcomes of infective endocarditis (IE) in the Pacific are scarce. METHODS: Retrospective hospital-based study in New Caledonia, a high-income country, on patients aged over 18â years with definite IE according to the modified Duke criteria (2005-2010). RESULTS: 51 patients were included: 31 (60.8%) men; median age of 52.4â years (IQR 33.0-70.0). Left-sided IE accounted for 47 (92.2%) patients: native valve IE in 34 (66.7%) and prosthetic valve IE in 13 (25.5%). The main underlying heart disease included: rheumatic valve disease in 19 (37.3%), degenerative heart valve disease in 12 (23.5%) and congenital heart disease in 6 (11.8%). Significant comorbidities (Charlson's score >3) were observed in 20 (38.7%) patients. Infection was community acquired in 43 (84.3%) patients. Leading pathogens included Staphylococcus aureus in 16 (31.4%) and Streptococcus spp in 15 (29.4%) patients. Complications were noted in 33 patients (64.7%) and 24 (47.1%) were admitted to the intensive care unit. Cardiac surgery was eventually performed in 22 of 40 (55.0%) patients with a theoretical indication. None underwent emergent cardiac surgery (ie, first 24â h); 2 (3.9%) were operated within 7â days; and 20 (39.2%) beyond 7â days. 11 (21.6%) patients died in hospital and 21 (42.9%) were dead after a median follow-up of 28.8â months (IQR 4.6-51.2). Two (3.9%) were lost to follow-up. CONCLUSIONS: In New Caledonia, IE afflicts relatively young patients with rheumatic heart disease, and carries high complication and mortality rates. Access to heart surgery remains relatively limited in this remote archipelago.