Biomarkers in rosacea: A systematic review.

Rosacea is a chronic and psychologically ladened disease affecting 1%-3% of people worldwide. The identification and validation of biomarkers in rosacea patients has the potential to improve disease progression, support diagnosis, provide objective measures for clinical trials and aid in management. The objective of this review is to systematically identify all rosacea biomarkers, categorize them by type and identify trends to improve disease expression. Eligibility criteria for this review (PROSPERO CRD42023397510) include randomized controlled trials, case-control studies, cohort studies and other observational studies. No restrictions were placed on patient demographics (age, sex, ethnicity) or language of publication until February 2023. Quality of studies was assessed using the National Institute of Health quality assessment tool. The literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A total of 805 unique articles were screened based on the applied inclusion and exclusion criteria. After the articles were screened based on title/abstract and full-text, a total of 38 studies were included, reporting on a total of 119 unique biomarkers. The results of this review and current rosacea pathogenic mechanisms provide the greatest support for the innate cathelicidin and inflammasome, Th 1 and Th 17 pathways. The most commonly reported biomarkers include IL-1ß, TNF-α, IL-37, IFN-γ and MMP-9. Biomarkers identified in this study support current theories of rosacea pathogenesis and provide direction for research to further our knowledge. However, more research is needed to identify biomarkers panels that can provide diagnostic utility. This may be difficult due to the heterogeneity of the disease and potential differences between rosacea subtypes.

Prevention and treatment of pressure ulcers.

Pressure ulcer prevention and treatment remains a challenge for interprofessional teams in all health care sectors. Evidencebased pressure ulcer guidelines can be simplified with a bedside enabler utilizing the wound bed preparation paradigm. Key steps involve treatment of the cause, addressing patient-centered concerns, and administering local wound care (debridement, infection/ inflammation control, and moisture balance before considering advanced therapies with the edge effect). Optimal outcomes are achievable with a multi-disciplinary approach that supports patients and their circle of care, which is central to every evaluation and course of treatment decisions.

Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool.

BACKGROUND: Peristomal skin problems are common and are treated by a variety of health professionals. Clear and consistent communication among these professionals is therefore particularly important. The Ostomy Skin Tool (OST) is a new assessment instrument for the extent and severity of peristomal skin conditions. Formal tests of reliability and validity are necessary for its use in clinical practice, research, and education. OBJECTIVES: To estimate inter- and intra nurse assessment variability of the OST and validity by comparison to a 'gold standard' (GS) defined by an expert panel. METHODS: Thirty photographs of peristomal skin were presented twice to 20 ostomy care nurses--10 from Denmark (DK) and 10 from Spain (ES)--to determine intra- and inter nurse assessment variability. The same photographs were presented to an international group of experts (dermatologist and ostomy care nurses), to establish a GS for comparison and validation of the results. RESULTS: A high intra-nurse assessment agreement, κ=0·84, was found with no differences in the intra-nurse assessments from the two groups of nurses (DK and ES). The inter-nurse assessment agreement was 'moderate to good', κ=0·54, with the agreement between the experts higher, κ=0·70. A high correlation between the scores from the nurses and the GS were seen in the lower part of the two scales [Discoloration, Erosion, Tissue overgrowth (DET) score<7)]. CONCLUSION: The study supported the validity of the OST. It is suggested that a categorical scale can be used to illustrate the severity of the DET scores.

Common foot examination features of 247 Iranian patients with diabetes.

BACKGROUND: Iran is a Middle Eastern country with a 70 million population. There are 3 million Iranians with diabetes mellitus (DM) and there is a high incidence of non traumatic amputation in this population. Amputation is often preceded by foot deformity or ulceration. We evaluated the routine foot examination of persons with diabetes (PWD) attending an outpatient Diabetic Clinic to identify the clinical characteristics that might be early warning signs of individuals at a high risk of developing a foot ulcer or having a subsequent non traumatic amputation. METHODS: A prospective, descriptive, clinic-based study was conducted on 247 patients with diabetes mellitus in 2005. The objectives of the study were to define the abnormal features of the foot examination in PWD which could be risk factors for ulceration or amputation. RESULTS: The mean age of patients with diabetes was 52 +/- 12. The prevalence of callus in the enrolled patients was 12% and heel fissures were noted in 50%. There was a significant relationship between callus formation and the absence of tibialis posterior pulse (odds ratio 5), the presence of the hammer toe deformity (odds ratio 4), and foot ulceration (odds ratio 3). The prevalence of foot ulcers in PWD was 4%. CONCLUSION: A diabetic screening program identifying callus formation, absent pulses, and hammer toe are important early signs of individuals at an increased risk for foot ulcers. This program will facilitate early treatment to decrease the loss of limbs.

The improvement of wound-associated pain and healing trajectory with a comprehensive foot and leg ulcer care model.

PURPOSE: Pain is a major concern for subjects with chronic wounds, but its optimal management remains elusive. The aim of this study was to validate an organized pain management approach using the Wound Associated Pain model in subjects with chronic leg and foot ulcers. DESIGN: We completed a prospective cohort study that documented pain in chronic wound subjects over a 4-week period. SUBJECTS AND SETTING: A total of 111 subjects with chronic leg and foot ulcers were recruited from the community and ambulatory wound care clinics. RESULTS: Using a systematic approach based on the Wound Associated Pain model, we demonstrated improved overall wound healing outcomes in 111 subjects with chronic leg and foot ulcers. Using an 11-point numerical rating scale, the average level of pain was reduced from 6.3 at week 0 to 2.8 at week 4 (P < .001). The average healing rate was 0.39 cm per week and the average relative reduction in size was 59.36% (t = 2.31; P = .023). To examine the relationship between pain and wound healing, pain levels were compared in subjects who achieved wound closure and those who did not. The mean pain score was 1.67 for the healed subjects in contrast to 3.21 for those who did not achieve complete wound closure (P < .041). CONCLUSIONS: A comprehensive patient assessment can improve chronic leg and foot ulcer wound-related pain and healing rates. The mean pain scores are lower for patients with healed ulcers than for those who do not obtain complete wound closure.

Combined use of an ibuprofen-releasing foam dressing and silver dressing on infected leg ulcers.

OBJECTIVE: To investigate the effect and safety of an ibuprofen-releasing foam (Biatain-Ibu, Coloplast A/S) combined with an ionised silver-releasing wound contact layer (Physiotulle Ag, Coloplast A/S) on painful, infected venous leg ulcers. METHOD: This open non-comparative study involved 24 patients with painful, exuding, locally infected, and stalled venous leg ulcers. Persistent pain and pain at dressing change were monitored using a 11-point numerical box scale (NBS). The composition of the wound bed, the dressing combination's ability to absorb exudate and minimise leakage, ibuprofen content in the exudate, reduction in wound area and adverse effects were also recorded. RESULTS: Persistent wound pain decreased from a mean of 6.3 +/- 2.2 to 3.0 +/- 1.7 after 12 hours and remained low thereafter. Pain at dressing change also decreased and remained low. Forty-eight hours after the first dressing application, the mean concentration of ibuprofen in the wound exudate reached a constant level of 35 +/- 21 microg/ml. After 31 days, the relative wound area had reduced by 42%, with an associated decrease in fibrin and an increase in granulation tissue. The number of patients with wound malodour decreased from 37% to 4%. No serious adverse events were reported. CONCLUSION: The combined use of the ibuprofen-releasing foam dressing and silver-releasing contact layer reduced wound pain and promoted healing without compromising safety.

Evaluation of a new composite dressing for the management of chronic leg ulcer wounds.

OBJECTIVES: A new composite dressing (Versiva, ConvaTec) combines three technologies: hydrocolloid, hydrofibre and a foam-film layer. This study aimed to assess the safety of the dressing in the management of patients with venous leg ulcers. Clinical performance was also assessed. METHOD: This multicentre, non-randomised, open-label, phase II study assessed the safety (via adverse-effect reporting) and performance, including weartime, absorption, dressing integrity, ease of use and wound progression, of Versiva. Up to 10 dressing changes were assessed within a five-week study period. RESULTS: In 75 dressing changes of 11 ulcers, the mean wear time was approximately five days. No or minimal leakage was observed in 81% of changes. In 93%, the dressing was 'very easy' to remove, with no trauma to surrounding skin. Most changes (77%) were painless. CONCLUSION: Versiva met or exceeded the investigators' expectations for exudate absorption, protection of peri-wound skin and reduction in wound pain and ulcer area. Healing or marked improvement was observed in 82% of leg ulcers within the five-week study. The relatively long wear-time of five days represents a cost-effective advantage for this dressing compared with other available adhesive foams for the management of chronic wounds.

The use of portfolios for assessment of the competence and performance of doctors in practice.

BACKGROUND: The use of portfolios can potentially provide flexibility in the summative assessment of doctors in practice. An assessment system should reflect and reinforce the active and planned professional development goals of individual doctors. This paper discusses some of the issues involved in developing such a system. RESULTS: To provide a complete picture of an individual doctor's practice, we suggest that a portfolio should encompass: (1) evidence covering all three domains of patient care, personal development and context management; (2) evidence that the person continuously undertakes critical assessment of their own performance, identifies and prioritises areas requiring enhanced performance and takes action to improve them as appropriate; (3) evidence that has been generated by assessments that are acceptably reliable, and (4) evidence which, taken in its entirety, is sufficient, valid, current and authentic. We include a suggested outline of the components of such a portfolio and suggest some criteria to determine the effectiveness of learning cycles. Portfolio reliability and validity requires sufficient evidence on which to base a judgement combined with reliable processes. CONCLUSION: Carefully specified portfolios can contribute to a system that ensures all doctors take an active part in identifying and meeting their own learning needs. Such a system, if properly implemented, would have a greatly beneficial impact on continuous quality improvement for the profession in general.

Best practices for the prevention and treatment of venous leg ulcers.

Chronic venous insufficiency is the most common cause of leg ulcers. Its incidence increases as the population ages. Managing venous leg ulcers involves treating the cause, optimizing local wound care, and addressing patient-centered concerns. The cornerstone of the diagnosis of chronic venous insufficiency includes demonstrating venous disease. The clinician must rule out significant coexisting arterial disease by performing a thorough clinical assessment and obtaining an ankle brachial pressure index. The most important aspect of treatment is resolving edema through high compression therapy for those individuals with an ankle brachial pressure index greater than or equal to 0.8. Other components of successful chronic venous insufficiency management include increasing mobility and medical management. Selected patients may respond to surgery, biologicals, adjunctive therapies, and lifestyle enhancements. Twelve recommendations are made incorporating current best clinical practices and expert opinion with available research. The approach to venous disease is best accomplished through a multidisciplinary team that revolves around the active participation of patients and their families. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to provide best clinical practices.

Cost-effectiveness of Apligraf in the treatment of venous leg ulcers.

Venous ulcers are the most common chronic wounds of the lower leg. Skin substitutes recently have been introduced to stimulate nonhealing wounds. To conduct an incremental cost-effectiveness analysis, a model was developed to compare the four-layer bandage system, with and without one application of skin substitute, for the outpatient treatment of venous leg ulcers. The model estimated the costs and consequences of treatment with and without the skin substitute application. Two analytic horizons were explored: 3 months and 6 months. Determined by seven physicians, data and assumptions for the 3-month model were based on information from a clinical trial, published studies, and clinical experience. Data for the 6-month model were extrapolated from the shorter model. The model results indicate that over 3 months, the use of the skin substitute provided a benefit of 22 ulcer days averted per patient at an incremental cost of $304 (societal). The incremental cost-effectiveness ratio was $14 per ulcer day averted. Over 6 months, the incremental cost-effectiveness ratio was less than $5 per ulcer-day averted. The skin substitute plus a four-layer bandage was more costly and more effective than the four-layer bandage alone. The skin substitute is increasingly cost-effective over a longer analytic horizon and in a subgroup of patients with ulcers of long duration (greater than 1-year duration at baseline). The results come from a model that is based on a series of estimates and assumptions, and accordingly, confirmation of this finding in a prospective study is encouraged.

Screening evaluation of an ionized nanocrystalline silver dressing in chronic wound care.

The successful topical treatment of chronic wounds requires adequate debridement, bacterial balance, and moisture balance. An ionized nanocrystalline silver dressing was evaluated through an uncontrolled, prospective study of a case series of 29 patients with a variety of chronic nonhealing wounds. The four arms of the study included nine patients with foot ulcers, six patients with venous stasis ulcers, two patients with pressure ulcers, and 12 patients with miscellaneous wounds. All wounds were assessed for the usual signs of clinical infection, with most of these parameters being measured and recorded. Microbiologically, bacterial load was determined via quantitative biopsies and semi-quantitative swabs. In general, the results showed a marked clinical improvement for the majority of wounds treated with the dressing. Among improved parameters included decreased exudate and decreased purulence. The quantitative bacterial biopsies did not show any decrease in organism numbers, although the semi-quantitative swabs indicated a decrease in the wound surface bacterial loading. This was indicative of the dressing's ability to reduce surface bacteria and achieve an element of bacterial balance in the superficial dermal compartment. The proposed mechanism of action for this ionized nanocrystalline based dressing is through bacterial and moisture balance within the superficial wound space compartment.

High bacterial load in asymptomatic diabetic patients with neurotrophic ulcers retards wound healing after application of Dermagraft.

Diabetic neuropathic foot ulcers are a major healthcare burden. These chronic wounds always have a bacterial load, and although normal flora is not harmful, increased tissue burden may impede healing before clinical signs of infection are evident. In this study, chronic noninfected diabetic neuropathic foot ulcers (those with adequate blood supply and pressure offloading) were assessed for bacterial burden immediately before the application of a skin substitute. Eight patients with diabetic neuropathic foot ulcers greater than 1 cm2 and free of necrotic tissue had 3-mm tissue biopsies taken from the ulcer base for quantitative bacteriology. Five of the eight patients (75%) had greater or equal to 10(5) colony forming units/gram organisms present despite the absence of clinical signs of infection. Wound healing rates were linked to bacterial load as determined from quantitative biopsy--no growth was associated with a wound healing rate of 0.2 cm per week, 10(5) to 10(6) colony forming units/gram was associated with a healing rate of 0.15 cm per week, and greater than 10(6) colony forming units/gram was associated with 0.05 cm/per week healing rate. High bacterial burden impeded healing both before and after the application of the skin substitute. The authors will change their clinical practice to assess all diabetic neuropathic foot ulcers using quantitative skin biopsies before applying skin substitutes. All patients will be treated with combination antibiotics and repeat biopsies obtained with decreased bacterial burden (< 10(6) colony forming units/gram) prior to using any bioengineered skin substitute or growth factor treatment.

Preparing the wound bed--debridement, bacterial balance, and moisture balance.

Successful diagnosis and treatment of patients with chronic wounds involve holistic care and a team approach. The integration of the work of an interdisciplinary care team that includes doctors, nurses, and allied health professionals with the patient, family, significant others, and caregivers offers an optimal formula for achieving wound resolution. Such an approach challenges practitioners and everyone participating in wound care to integrate data and information that arise from a number of sources and mitigating factors. In this article, the authors define the changing paradigm that links treatment of the cause and focuses on three components of local wound care: debridement, wound-friendly moist interactive dressings, and bacterial balance. The authors demonstrate that the treatment of chronic wounds can be accomplished through a series of recommendations and rationales based on the literature and their experience. These recommendations lay the groundwork for thorough assessment and evaluation of the wound.

Best practices for the prevention, diagnosis, and treatment of diabetic foot ulcers.

Although the prevention, assessment, and treatment of diabetic foot ulcers has improved in recent years, care is often fragmented and does not always meet best clinical practice. This article incorporates current best clinical practices and expert opinion with available research to arrive at 11 recommendations. These recommendations include adequate vascular supply, infection control, pressure offloading, and an optimal local wound environment. This approach is best accomplished through a multidisciplinary team and revolves around the active participation of the person with diabetes. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to establish and empower a team to provide best clinical practices.

Nursing management of chronic wounds: best practices across the continuum of care.

This article highlights the nurse's role within a holistic, interdisciplinary approach to chronic wound management. Best practices for chronic wound care are discussed, drawing on evidence-based science when it is available. The fundamentals of chronic wound care, including cleansing, irrigation, débridement, infection control, and topical treatment are addressed. New devices and technologies are briefly reviewed. Implementing these best practices across the continuum of care will result in greater advances in the management of chronic wounds.