Therapeutic effect of continuous diffusion of oxygen therapy combined with traditional moist wound dressing therapy in the treatment of diabetic foot ulcers.

AIMS: To investigate the therapeutic effect of continuous diffusion of oxygen (CDO) combined with traditional moist wound dressing (MWD) on the diabetic foot ulcers (DFUs) inpatients. METHODS: The inpatients from May 2016 to April 2018 were enrolled and randomly divided into MWD, CDO and combination treatment groups (n = 40 each group). The moist dressing was used in the MWD group while a micro-oxygen supply device was used in the CDO group. The combination treatment group was given both MWD and CDO. All patients were treated for 8 weeks. The wound healing, amputation rate, and inflammatory control were evaluated. RESULTS: Compared with MWD and CDO groups, the combination group showed a higher wound healing rate (P < 0.05), lower white blood cell count (P < 0.05) and lower high-sensitivity C-reactive protein level (P < 0.05). During 1-year follow-up, the amputation rate was 0% in combination group, which was significantly lower than that in other two groups (P < 0.05). CONCLUSIONS: The combination of MWD and CDO was effective in promoting healing and preventing infection of DFUs, which holds a potential to be a new strategy for the treatment of this critical clinical condition.

The Estimation of Blood Paramagnetic Center Changes during Burns Management with Biodegradable Propolis-Nanofiber Dressing.

The evolution of the paramagnetic center system in blood during the healing of skin burn wounds dressed with a biodegradable apitherapeutic nanofiber dressing was examined. The aim of this study was to determine the changes in paramagnetic centers in blood during the influence of apitherapeutic nanofiber dressings on the healing process. The blood samples were tested before burn infliction (day 0) and, respectively, on the 10th and 21st days of the experiment. Paramagnetic centers in the blood of the pig used as the model animal were examined with an X-band (9.3 GHz) electron paramagnetic resonance spectroscopy. The EPR spectra were measured with Bruker spectrometer at 230 K with a modulation frequency of 100 kHz. The EPR lines of the high spin Fe3+ in methemoglobin, high spin Fe3+ in transferrin, Cu2+ in ceruloplasmin, and free radicals were observed in the multicomponent spectra of blood. For the application of the apitherapeutic nanofiber dressing, the amplitudes of the EPR signals of Fe3+ in methemoglobin were similar up to 10 days. For the experiment with the apitherapeutic formulation, the heights of EPR signals of Fe3+ in transferrin were lower after 10 days and 21 days of therapy, compared to day 0. For the application of the apitherapeutic formulation the signals of Cu2+ in ceruloplasmin and free radicals, strongly decreased after 10 days of therapy, and after 21 days it increased to the initial values characteristic for day 0. The apitherapeutic formulation caused that after 21 days the EPR spectrum of Cu2+ in ceruloplasmin and free radicals was considerably high. The apitherapeutic formulation interaction after 10 days and after 21 days of therapy resulted in the low EPR lines of Fe3+ in methemoglobin. EPR spectra of blood may be useful for presentation of the changes in its paramagnetic centers during the healing process of the burn wounds.

Improving the Quality of Chronic Wound Care Using an Advanced Wound Management Program and Gentian Violet/Methylene Blue-Impregnated Antibacterial (GV/MB) Dressings: A Retrospective Study.

INTRODUCTION: Comprehensive wound management programs that employ a standardized integrated care bundle (ICB) and advanced wound dressings are generally recognized to decrease healing times and treatment costs. The purpose of this study was to compare wound healing rates and cost efficiencies as measured by nursing-care requirements for patients not on an ICB versus patients on an ICB and using a gentian violet/methylene blue-impregnated (GV/MB) antimicrobial advanced wound dressing. MATERIALS AND METHODS: The comprehensive wound management programs enabled continuous, standardized measurement of each patient's wound episode from admission with a wound to healing and discharge. Data was recorded over 24 months from 2016 to 2018. The variables recorded for each patient included: wound healing time (number of weeks), wound acuity based on the Bates-Jensen Wound Assessment Tool (BWAT), a comorbidity index (using the Charlson Comorbidity Index), and the number of wound dressing changes. The wound dressing changes required a visit by a registered nurse and, therefore, served as an indicator of care delivery costs where the dressing change visit cost was $68 (CAD). RESULTS: A total of 6300 patients (25% of the total study population) were identified as using GV/MB dressings within the context of an ICB. The mean healing time for these patients was accelerated more than 50% versus patients not on an ICB. The average total cost of patient care was reduced by more than 75% from diagnosis to wound healing when patients were on an ICB with GV/MB dressings. These results compared well to patients on ICBs that had other types of advanced dressings. CONCLUSION: The study demonstrates that a comprehensive wound management program based on integrated care bundles in conjunction with GV/MB dressings can be a highly-effective clinical option. The benefits showed significant reductions in healing times and treatment costs.

Burns Due to Application of Raw Garlic to the Feet as a Home Remedy for Fever.

We present an illustrative case of unintentional burns to the feet of a 15-month-old child following the application of raw garlic as a home remedy for fever. We provide an overview of the historical medicinal uses of garlic as well as its unintended adverse effects. This case underscores the importance of clinicians' ability to recognize unusual presentations of injury due to culturally based practices that require care in emergency settings. This is particularly important in patient populations for whom abusive etiology would be considered.

Comparison of antimicrobial activity of selected, commercially available wound dressing materials.

OBJECTIVE: The aim of our study was to examine the antimicrobial potential of eight selected, commercially available wound dressings containing different antimicrobial agents: silver, chlorhexidine acetate, povidone-iodine, and manuka honey. METHOD: The materials were tested against four reference strains of bacteria: Staphylococcus aureus (PCM 2051), Staphylococcus epidermidis (PCM 2118), Pseudomonas aeruginosa (ATCC 27853), and Escherichia coli (K12), using the disc diffusion-like method and a time-killing assay. RESULTS: For both experiments, the highest activity against all four tested strains of bacteria was observed in the case of Mepilex Ag, which contains silver as an antibacterial agent. Incubation for four hours of a 10x10mm2 piece of this material in 10ml cells suspension (concentration: 109-1010CFU/ml) resulted in complete elimination of bacteria of all four strains tested. The same results were obtained for a povidone-iodine containing dressing, Inadine, though its activity was lower in the disc diffusion assay. Silvercel, Aquacel Ag and Melgisorb Ag, which also contain silver, also exhibited a satisfactory level of activity. In the case of Aquacel Ag, 24 hours' incubation resulted in complete elimination of the cells of both Gram-negative bacteria, Escherichia coli and Pseudomonas aeruginosa.The Escherichia coli cells were killed after only four hours' treatment. High effectiveness against Escherichia coli was also demonstrated for Silvercel. However, 24 hours' includation was required for complete elimination of the cells of this bacteria strain. High activity against all tested bacteria, but only in the disc diffusion assay, was observed for Algivon, which contains manuka honey. The Medisorb Silver Pad, containing silver, and Bactigras, which contains chlorhexidine acetate, revealed much lower antimicrobial activity, particularly noticeable in the time-killing assay. In addition, we also tested the anti-staphylococcal activity of a biopolymer material impregnated with lysostaphin. Results revealed that its activity against Staphylococcus aureus was comparable to the most active wound dressings impregnated with silver or inadine. CONCLUSION: Some important differences in the antimicrobial potential of investigated materials have been found. The presented results could be of interest to clinicians managing wounds.

A Novel Peptide-Based Antimicrobial Wound Treatment is Effective Against Biofilms of Multi-Drug Resistant Wound Pathogens.

Wound infections are a common complication of combat-related injuries that significantly increase morbidity and mortality. Multi-drug resistant (MDR) organisms and their associated biofilms play a significant role in the pathogenicity and chronicity of wound infections. A critical barrier to progress in the treatment of traumatic wounds is the need for broad spectrum antimicrobials that are effective against biofilms and compatible with topical delivery. In this study, we present the in vitro efficacy of two de novo designed cationic, antimicrobial peptides and related topical formulations against single species and polymicrobial biofilms of MDR bacteria. Minimum biofilm eradication concentrations for peptides ranged from 0.7 µM for Staphylococcus aureus to 13.2 µM for Pseudomonas aeruginosa. Varying pH did not adversely impact peptide activity, however, in the presence of albumin, minimum biofilm eradication concentrations generally increased. When formulated into gels or dressings, both peptides eradicated mono- and polymicrobial biofilms of MDR pathogens. The biocompatibility index (BI) was found to be greater than one for both ASP-1 and ASP-2, with a slightly greater (more favorable) BI for ASP-2. The BIs for both peptides were greater than BIs previously reported for commonly used topical antimicrobial agents. The antimicrobial peptides and related formulations presented provide a promising platform for treatment of wound biofilms to improve outcomes for those injured in combat.

Warm Water Compress as an Alternative for Decreasing the Degree of Phlebitis.

Intravenous fluid therapy is an invasive procedure which may increase the risk of patient complications. One of the most common of these is phlebitis, which may cause discomfort and tissue damage. Therefore, a nursing intervention is needed to effectively treat phlebitis. The purpose of this study was to investigate the effectiveness of applying a warm compression intervention to reduce the degree of phlebitis. A quasi-experimental pre-test and post-test design was used, with a non-equivalent control group. The total sample size was 32 patients with degrees of phlebitis ranging from 1 to 4. The total sample was divided into 2 interventional groups: those patients that were given 0.9% NaCl compresses and those given warm water compresses. The results showed that both compresses were effective in reducing the degree of phlebitis, with similar p values (p = .000). However, there was no difference in the average reduction score between the two groups (p = .18). Therefore, a warm water compress is valuable in the treatment of phlebitis, and could decrease the degree of phlebitis both effectively and inexpensively.

Flammability of topical preparations and surgical dressings in cutaneous and laser surgery: a controlled simulation study.

BACKGROUND: Surgical fires are a rare, but serious complication of dermatologic procedures involving electrosurgical and laser devices. Given the lack of data regarding basic fire safety principles, many dermatologists remain unaware of this potential risk. OBJECTIVE: We evaluated the flammability of topical preparations and surgical drapes commonly encountered in the immediate operative field during cutaneous and laser surgery. METHODS: Surgical dressings, drapes, and pork belly skin were examined for fire risk upon exposure to isopropyl alcohol, chlorhexidine gluconate, and aluminum chloride under dry, saturated, and damp conditions. Both electrosurgery and a carbon-dioxide laser were used as ignition sources. RESULTS: At least some char was observed in 86 of 126 simulated conditions (68%). Flames occurred in 2 test conditions: dry underpad drapes and cotton balls exposed to the carbon-dioxide laser. In general, drapes and dressings dampened or saturated with isopropyl alcohol failed to ignite with electrofulguration or electrodessication, although sparks and moderate char developed on pork belly skin and the underpad drape. Materials dampened or saturated with chlorhexidine gluconate, which contains isopropyl alcohol, generated less smoke and char compared with materials exposed to aluminum chloride, which does not contain alcohol. LIMITATIONS: Future studies may assess the flammability of materials in the setting of oxygen supplementation. CONCLUSION: In common cutaneous surgical environments, electrosurgery or ablative laser may lead to char and rarely to fire. Char may be seen in up to two thirds of simulated conditions, and in a minute proportion of conditions, fire is observed.

[Dressings for local treatment of leg ulcers]. / Pansements utilisés dans le traitement local des ulcères de jambe.

The beneficial effect of a moist wound environment has been well established for healing rate of acute wounds, pain relief and debridement of chronic wounds. Modern dressings are occlusive or semi occlusive, classified according to their physical composition and to their performances such as absorbent capacity, hydrating ability, adhesive components and debridement capacity. They are used to control the exudates and to maintain the wound in a moist environment. Published systematic reviews of the value of different types of dressings in the management of chronic wounds provide only weak levels of evidence of their clinical efficacy, in terms of healing rate. Nevertheless, the indications of modern dressings were recently determined according to a systematic review of the literature and to a formal consensus process. Despite the lack of appropriate studies, modern dressings remains a part of the standard of care and are widely used according to the experience of the clinicians, in larger indications than what may be recommended by evidence-based medicine.

Are biopolymers potential deodourising agents in wound management?

OBJECTIVE: To investigate the odour-adsorbing properties of biopolymers, with a view to using the findings to develop a novel dressing with odour-adsorbing properties. METHOD: The odour-adsorbing properties of a selection of biopolymers (aloe vera, tea tree oil, neem oil and manuka honey) and three commercially available dressings containing activated charcoal cloth (ACC) were quantitatively assessed using laboratory test equipment. An aloe vera-containing composite dressing, designed and developed by the authors, was also compared with the ACC dressings. RESULTS: Aloe vera was the most adsorbent of the biopolymers and a 40% dilution had comparable values to those of the ACC dressings. Furthermore, values for the novel composite dressing were similar to those of the ACC dressings. CONCLUSION: The novel composite dressing may be a potential alternative to ACC dressings, and has the added advantages of having antimicrobial properties as well as the ability to promote a moist wound environment. However, more research is needed.

Wound dressing components degrade proteins detrimental to wound healing.

Excessive levels of matrix metalloproteinases (MMPs) are present in chronic wounds preventing wound closure. Reducing detrimental components may be key in healing chronic wounds. Elta Protease-containing wound dressings have been observed clinically to resolve inflammation and appear to aid healing in acute and chronic recalcitrant wounds. To investigate possible mechanisms of action, in vitro tests, zymography, collagenase assays and enzyme-linked immunosorbent assays (ELISAs), were performed to evaluate the effect of the dressing proteases on detrimental and beneficial wound healing components such as MMPs, Tissue Inhibitor of Matrix Metalloproteinases (TIMPs), cytokines and growth factors. Standards of pro- and active MMP-2, MMP-9 and chronic wound fluid (CWF) were prepared. Degradation of target proteins was enhanced by increased Elta Protease concentration, temperature and incubation time. Incubation with serial dilutions of the Elta Proteases resulted in nearly complete degradation of all MMP standards. After a 30-minute incubation, twofold diluted Elta Proteases degraded >90% of the gelatinases in CWF. ELISAs showed that Elta Proteases effectively degraded MMP-9 and tumour necrosis factor (TNF-alpha). In contrast, Platelet Derived Growth Factor (PDGF) and interleukin 1 beta were resistant to degradation by Elta Proteases. These results suggest that Elta Protease dressings appear to deactivate detrimental components in CWF, which may reduce wound bed contact with harmful proteins.

Prevalence of silver resistance in bacteria isolated from diabetic foot ulcers and efficacy of silver-containing wound dressings.

Silver dressings are used to manage wounds at risk of infection or locally infected. This in vitro study was conducted to assess the prevalence of silver resistance genes in 112 bacterial isolates obtained from the diabetic foot ulcers of patients attending the Diabetic Foot Clinic at Tameside General Hospital, UK. Using polymerase chain reaction to screen for three silver-resistance transcriptional units--silE, silS and silP--two silver-resistant bacteria were identified; both are strains of Enterobacter cloacae, an organism rarely implicated as a primary pathogen in chronic wounds. No recognized wound pathogens (Staphylococcus aureus-24 isolates and Pseudomonas aeruginosa-nine isolates) were found to contain silver-resistant genes. Analysis of the efficacy of silver-containing dressings on the silver-resistant strains of Enterobacter cloacae using confocal laser microscopy showed that, despite evidence of genetic resistance to silver, all strains were killed following a maximum of 48 hours of exposure to the dressings. Results suggest that presence of silver resistance genes is rare and that genetic resistance does not necessarily translate to phenotypic resistance to silver. While silver resistance in wound care should be monitored, the threat of widespread resistance is low and silver-containing dressings remain an extremely important tool in managing wound infection.

Study of the adhesiveness of medical tapes when wet, dry or following application of Friars' balsam.

BACKGROUND: Adhesive tapes are routinely used during anesthesia for vital roles such as securing tracheal tubes or intravascular access devices. There are currently very few experimental data available to guide the choice of tape for a particular indication. METHODS: The performance of four medical adhesive tapes (Sleek, Elastoplast, Mefix and Leukoplast zinc oxide) was evaluated under three different conditions (wet, dry and following prior application of Friars' balsam). A strain gauge was used to determine the force required to detach each tape from the skin of the inner forearm. The test was repeated 20 times under each standardized condition. Statistical analysis was performed using two way anova and the Scheffe posthoc test. RESULTS: Leukoplast was the most adhesive tape overall (P < 0.001); Sleek was more adhesive than Mefix and Elastoplast (P < 0.001); and Mefix was more adhesive than Elastoplast (P = 0.018). Under wet conditions, Elastoplast and Mefix were less adhesive than when dry (P < 0.001), whereas the adhesiveness of Sleek and zinc oxide was unchanged. Friars' balsam significantly increased the adhesiveness of Elastoplast and Sleek (P = 0.02 for both). CONCLUSIONS: There is a dramatic variation in performance between different adhesive tapes and between different conditions, which has implications for the choice of tape for a particular clinical application.

The selection of skin care products for use in hyperbaric chamber may depend on flammability acceptability indices score.

PURPOSE: Current protocols call for stopping adjunctive skin care treatments during hyperbaric oxygen therapy (HBOT) because the hyperbaric environment is considered unsafe for skin care products. The elevated oxygen fraction and the increased pressure in the hyperbaric chamber dramatically increase the flammability potential of materials, leading to the need for rigorous standards to prevent flame ignition. A scientific method of evaluating the flammability risks associated with skin care products would be helpful. Several skin care products were tested, using established industrial techniques for determining flammability potential with some modification. The information obtained from these tests can help clinicians make more rational decisions about which topical products can be used safely on patients undergoing HBOT. METHODS AND MATERIALS: Wendell Hull & Associates conducted independent studies, comparing the oxygen compatibility for leading skin care products. Oxygen compatibility was determined using autogenous ignition temperature (AIT), oxygen index (OI), and heat of combustion (HoC) testing. AIT, a relative indication of a material's propensity for ignition, is the minimum temperature needed to cause a sample to self-ignite at a given pressure and oxygen concentration. OI, a relative indication of a material's flammability, is the minimum oxygen percentage that, when mixed with nitrogen, will sustain burning. HoC is the absolute value of a material's energy release when burning, if ignition occurs. Products with a high AIT, a high OI, and a low HoC are more compatible in an oxygen-enriched atmosphere (OEA). An acceptability index (AI) based on these 3 factors was calculated for the products, so the testers could rank overall material compatibility in OEAs (Lapin A. Oxygen Compatibility of Materials. International Institute of Refrigeration Commission Meeting; Brighton, England; 1973). RESULTS: Test results for the skin products varied widely. The AIT, OI, HoC, and AI were determined for each product under described circumstances. The AIT results indicate that all products in 99.5% oxygen concentration under pressure will ignite and that a pattern based on the absence or presence of petroleum-based ingredients does not seem to exist. Products containing petrolatum, mineral oil, paraffin, and paraffin wax had a HoC that equaled or exceeded the HoC of gasoline, whereas products without petroleum-based ingredients had a significantly lower HoC. The OI of skin products not containing petrolateum-based ingredients was significantly higher than the OI of products containing it. The AI values the OI as the most important value: the higher the AI, the more acceptable the product is for use with oxygen. The silicone-containing, petroleum-free products received an AI up to 25 times higher than the petrolatum-based products. These findings suggest a wide variation in the safety profiles of skin products. Skin products being considered for use in an OEA should be screened for flammability risks. This screening will allow informed decisions about the fire safety of the products. Further research is indicated.

In vitro studies to show sequestration of matrix metalloproteinases by silver-containing wound care products.

Excess or "uncontrolled" proteinase activity in the wound bed has been implicated as one factor that may delay or compromise wound healing. One proteinase group--matrix metalloproteinases--includes collagenases, elastase, and gelatinases and can be endogenous (cell) or exogenous (bacterial) in origin. A study was conducted to assess the ability of five silver-containing wound care products to reduce a known matrix metalloproteinase supernatant concentration in vitro. Four silver-containing wound dressings (a carboxy-methyl cellulose, a nanocrystalline, a hydro-alginate, and a collagen/oxidized regenerated cellulose composite dressing), along with a 0.5% aqueous silver nitrate [w/v] solution and controls for matrix metalloproteinase-2 and matrix metalloproteinase-9 sourced from ex vivo dermal tissue and blood monocytes, respectively, were used. Extracts were separated and purified using gelatine-Sepharose column chromatography and dialysis and polyacrylamide gel electrophoretic zymography was used to analyze specific matrix metalloproteinase activity. All dressings and the solution were shown to sequester both matrix metalloproteinases. The silver-containing carboxy-methyl cellulose dressing showed significantly greater sequestration for matrix metalloproteinase-2 at 6 and 24 hours (P< 0.001) compared to the other treatments. For matrix metalloproteinase-9, both the carboxy-methyl cellulose dressing and the oxidized regenerated cellulose dressing achieved significant sequestration when compared to the other treatments at 24 hours (P <0.001), which was maintained to 48 hours (P < 0.001). Results from this study show that silver-containing dressings are effective in sequestering matrix metalloproteinase-2 and -9 and that this can be achieved without a sacrificial protein (eg, collagen). Although the varying ability of wound dressings to sequester matrix metalloproteinases has been shown in vitro, further in vivo evidence is required to confirm these findings.

Understanding wound dressings: alginates.

A variety of wound dressing groups is currently available on prescription. In a series of six articles, Jacqui Fletcher looks at the different groups of dressings, their composition, and indications for use. This first article looks at alginates. The second article in the series discusses foam dressings, and will appear in the Wound Care Supplement of 7 June.

The release of zinc ions from and cytocompatibility of two zinc oxide dressings.

OBJECTIVE: These in vitro studies examined the release of zinc ions from and the response of human dermal fibroblasts to two zinc oxide-medicated dressings: one with zinc oxide in an ointment base and one using polyvinylpyrrolidone (PVP), a hydrophilic polymer for the binding of zinc oxide particles. METHOD: Zinc release from the dressings in buffered-saline (pH 7.4) was studied through a high-pore-density membrane (pore size, 0.40 microm) in a two-compartment model at 37 degrees C for three hours. Cytocompatibility of the dressings and 500 micromol/l of zinc ions was assessed using the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay after exposure to monolayers of confluent normal human dermal fibroblasts to the dressing extracts for four hours. RESULTS: The zinc release rate from PVP-bound zinc oxide was more than two-fold higher than from zinc oxide in the ointment. Extract of the zinc oxide ointment, containing 150 micromol/l solubilised zinc, elicited a cytotoxic reaction, while the zinc oxide-PVP extract, containing 410 micromol/l solubilised zinc, and 500 micromol/l zinc chloride were non-cytotoxic to the fibroblasts. CONCLUSION: Zinc release in a simulated wound milieu appears to be inhibited when zinc oxide is incorporated in a lipophilic vehicle. It is hypothesised that the ointment vehicle induced cytotoxicity rather then the solubilised zinc oxide. DECLARATION OF INTEREST: None.