A prospective, randomized, controlled, crossover study comparing three multilayered foam dressings for the management of chronic wounds.

Aim: Compare foam dressings - Mepilex Border Flex (MxBF), Allevyn Life (AL) and Optifoam Gentle EX (OGEX) - in treatment of chronic wounds. Materials & methods: Prospective, randomized, controlled trial (crossover design). Subjects received one dressing for 2 weeks, then comparator dressing for following 2 weeks. Wound/periwound characteristics evaluated weekly at dressing change. Primary end point: dressing durability (incidence of exudate strikethrough). Results: Higher incidence of intact dressings (no strikethrough) at Day 7 (Week 1) with MxBF (6/17; 35.3%) compared with AL (1/18; 5.6%), and with MxBF (7/16; 43.8%) compared with OGEX (2/16; 12.5%; p < 0.05). No significant differences between groups regarding wound size reduction. Conclusion: MxBF had statistically greater durability than AL/OGEX during first critical week of treatment.

Faster Healing and a Lower Rate of Recurrence of Venous Ulcers Treated With Intermittent Pneumatic Compression: Results of a Randomized Controlled Trial.

Objective: Fifty-two subjects with chronic venous insufficiency and hard-to-heal lower leg ulceration (>1-year-old and >20-cm2 surface area) were treated with either intermittent, gradient, pneumatic compression (n = 27) plus standard compression therapy or compression therapy alone (control). Methods: Compression therapy consisted of a nonadherent primary wound dressing plus a 4-layer compression bandage (n = 25). The mean age and size of the ulcers were 1.4 years and 31 cm2, respectively, and did not differ significantly between groups. Intermittent pneumatic compression was performed using a 4-chamber pneumatic leg sleeve and gradient, sequential pump. All pumps were calibrated to a pressure setting of 50 mm Hg on each subject, and treatments were for 1 hour twice daily. Evaluations were performed weekly to measure edema, local pain, granulation, and wound healing. Results: The median time to wound closure by 9 months was 141 days for the intermittent pneumatic compression-treated group and 211 days for the control group (P = .031). The rate of healing was 0.8 ± 0.4 mm/d for the control group and 2.1 ± 0.8 mm/d for the group treated with intermittent pneumatic compression (P < .05). When compared with subjects treated with standard care, the group treated with intermittent pneumatic compression reported less pain at each evaluation point for the first 6 weeks of the trial. At weeks 1, 2, and 3, the visual analog pain scores were significantly lower for the intermittent pneumatic compression-treated group (P < .05). Conclusion: These results suggest that intermittent pneumatic compression is a valuable adjunct to compression therapy in the management of large or painful venous ulcers.

Latest Advances in Wound Debridement Techniques.

The surgical surgical debridement of wounds has evolved over the past 250 years. At that time, the amputation of extremities was recognized as a life-saving procedure to treat major wounds suffered in combat. This continued until after World War I. As the survival of patients with diabetes and other chronic conditions improved, and as advanced therapies were developed to meet the needs of an increasing number of patients with chronic wounds, debridement became a focal point of surgical wound care. It is now well-established that debridement enhances wound-healing and improves the efficacy of advanced therapies and surgical closure. Up until the last two decades, sharp excision with "cold steel" was the only option for debridement. In the early 2000's, a high-power waterjet was introduced, and provided a more precise debridement of wound surfaces. As our understanding of biofilms increased, so came the realization that biofilms are stratified within the wound, with anaerobic species preferentially developing deeper within the wound. The latest surgical instrument for wound debridement, the direct contact low frequency ultrasound device (DCLFU), has recently been introduced. A vacuum sheath was added to the active tip to contain spray dispersion. The device is capable of removing all of the wound tissue including biofilm down to a healthy base. This allows for optimal preparation of the wound prior to deployment of an advanced therapy, graft, or flap. This instrumentation is designed specifically for use in the operating room. However, the manufacturer has recently introduced a less powerful, but still effective, version for use in the outpatient clinic. These advances in surgical debridement technology have paved the way for more effective subsequent interventions for treating chronic wounds.

Human-derived Acellular Dermal Matrix Grafts for Treatment of Diabetic Foot Ulcers: A Systematic Review and Meta-analysis.

BACKGROUND: Treating diabetic foot ulcers (DFUs) requires thorough understanding of available surgical tools. OBJECTIVE: This meta-analysis compares human-derived acellular dermal matrices (H-ADMs) with standard of care (SOC) to evaluate the number of healed ulcers at 12 and 16 weeks and number of days to complete healing. As a secondary outcome, the efficacy of 3 H-ADM subtypes are studied. METHODS: Two researchers searched PubMed, EMBASE, and The Cochrane Central Register of Controlled Trials for relevant titles from inception through July 2018. Inclusion criteria indicated articles be randomized controlled trials investigating the effects on neuropathic, nonischemic DFUs. RESULTS: Data from 312 DFUs in total were included in the meta-analysis. The results show H-ADMs are more effective in healing patients within a 12-week (3.14; range, 2.04-4.83) and 16-week period (2.35; range, 1.25-4.43) in comparison with SOC. Further, the mean time to complete healing was shorter in the H-ADM group (-2.31 days; range, -2.67 to -1.95 days) in comparison with SOC. Within the subgroups, 2 H-ADMs were associated with a higher likelihood of complete healing within 12 weeks when compared with SOC. The third H-ADM had a point estimate, which suggested superiority over SOC. CONCLUSIONS: This study shows H-ADMs are associated with a higher likelihood of complete healing and fewer days to complete healing within a 12-week and 16-week periods when compared with SOC. Also, the commercial products performed similarly.

Wound Conforming Matrix Containing Purified Homogenate of Dermal Collagen Promotes Healing of Diabetic Neuropathic Foot Ulcers: Comparative Analysis Versus Standard of Care.

Objective: To compare outcomes of diabetic foot ulcers (DFUs) treated with a collagen Wound Conforming Matrix (WCM) or standard of care (SOC). Approach: WCM, a highly purified homogenate of 2.6% fibrillar bovine dermal collagen that conforms to the wound surface, was evaluated in comparison to daily saline-moistened gauze dressing changes (SOC) as part of a retrospective subset analysis of a randomized controlled trial in DFU. Following a 2-week run-in period during which patients received SOC, patients whose wounds did not reduce in area by >30% during run-in were randomly assigned to receive WCM (one or two applications) or SOC. Results: Statistically significant acceleration of early healing rates was observed following a single application of WCM with weekly outer dressing changes compared with daily saline-moistened gauze dressing changes (SOC). Over a 4-week period, 50% of patients receiving a single application of WCM achieved ≥75% reduction in wound area compared with 13% for SOC. WCM appeared to be safe and well tolerated, with no adverse events related to treatment and no evidence of an immunologic reaction to bovine collagen. Innovation: WCM is unique in its intimate contact with the wound bed and its ability to progress a wound toward healing with a single application. Conclusion: WCM is a treatment modality to accelerate DFU healing rates, with the potential to reduce the likelihood of infection and other complications, and cost of care.

Swift Downregulation of Gelatinases (MMP-2, MMP-9) in Neuropathic Diabetic Foot Ulcers Treated With Total Contact Cast.

OBJECTIVE: The aim of this study is to evaluate how treatment with total contact cast (TCC) affects the balance of proteases in diabetic foot ulcers (DFUs) as they heal. MATERIALS AND METHODS: This was a prospective observational study of 22 eligible patients with neuropathic plantar DFUs in a hospital-based wound care center. All patients treated with TCC had adequate arterial circulation (ankle-brachial index > 0.75), no sign of infection, and all DFUs were grade 1A according to the University of Texas Diabetic Wound Classification System. Patients had weekly follow-up visits for wound evaluation and reapplication of the TCC. Wound tissues were obtained at baseline (week 0 prior to initial treatment), week 3, week 6, and week 12. Tissue homogenates were analyzed for matrix metalloprotease (MMP) 2, MMP-9, tissue inhibitor matrix metalloproteinase (TIMP) 1, and TIMP-2. Wound measurements were obtained at weekly follow-up visits, and healing rates were calculated by photodigital planimetry. RESULTS: Treatment with TCC for 3 weeks resulted in a 20% decrease in MMP-2 (P = .031) and 44% decrease in MMP-9 (P = .018). By week 6, MMP-2 and MMP-9 levels were reduced by 37% and 55%, respectively. Tissue inhibitor matrix metalloproteinase 1 increased by 42% (P = .033) and TIMP-2 by 44% (P = .04) after 6 weeks of therapy with TCC. CONCLUSIONS: This significant and rapid drop of both MMP-2 and MMP-9 strongly suggests a decline of the inflammatory phase and initiation of the proliferation phase.

Evaluación económica de sistemas de riego para plantaciones de palma aceitera en la Zona Norte de Colombia / Economic Assessment of Irrigation Systems for Oil Palm Plantations at the Colombian Northern Zone

El déficit de agua es uno de los factores más limitantes para la obtención de altos rendimientos en los cultivos. Junto con esto, se debe mencionar que el agua se está convirtiendo en un ecurso escaso debido a condiciones relacionadas con el cambio climático, lo cual implica que cuando un productor decide regar sus cultivos, la eficiencia del sistema para el uso de agua debe ser un factor a considerar. Este artículo presenta los resultados de una investigación que pretende evaluar desde un punto de vista económico dos sistemas de riego empleados en plantaciones de palma de aceite de Colombia: el sistema de riego por aspersión (ra) y el sistema de riego por inundación (ri). Además, dentro del análisis se consideró un escenario en el que el productor no utiliza ningún sistema de riego (sr). Con respecto a los métodos de evaluación económica se utilizaron: la tasa interna de retorno, el costo unitario, el ingreso neto y el periodo de recuperación de la inversión. Los resultados indican que, a un precio de $ 365.000 por tonelada de rff, 70 Revista Palmas. Bogotá (Colombia) vol. 39 (1) 69 - 85, enero - marzo 2018 Introducción El rendimiento potencial de la palma de aceite se ve limitado, entre otros factores, por el déficit de agua. Esta situación se traduce en una brecha entre el potencial que ofrecen los materiales genéticos desarrollados y el rendimiento que en realidad obtienen los productores de sus cultivos. En ese sentido, la oferta hídrica determina el potencial de producción de un cultivo (Van Ittersum et al., 2013). En el caso de la palma de aceite, Corley & Tinker (2014) refieren que el déficit de agua es el factor climático que probablemente más afecta los rendimientos de este cultivo. A partir de lo anterior, se podría afirmar que el rendimiento esperado de un cultivo en regiones con déficit de este recurso, estará principalmente en función de las soluciones que se adopten para superar esta condición limitante. Entre estas se encuentran la adopción de materiales genéticos con tolerancia a la sequía, la implementación de sistemas de riego que permitan suplir el déficit (Lobell, Cassman & Field, 2009), y/o la adopción de otras prácticas que contribuyan a mitigar el efecto de la sequía en el suelo y que a su vez favorezcan la retención de la humedad existente, tal como el uso de residuos orgánicos (Beltrán, Pulver, Guerrero & Mosquera, 2015). De acuerdo con Woittiez et al. (2017), el rendimiento de la palma de aceite se reduce con precipitaciones inferiores a 2.000 mm/año, o si se presentan meses con precipitaciones inferiores a 100 mm. En el caso de las regiones palmeras de Colombia ambas condiciones son ciertas. Por ejemplo, en la Figura 1 se puede ver la precipitación mensual de cuatro plantaciones de la Zona Norte durante cuatro años. Es posible observar que al menos durante cuatro meses del año se registran precipitaciones que no superan los 100 mm. Establecer cultivos de palma aceitera con un sistema de riego por aspersión es la mejor alternativa desde el punto de vista económico. De esta manera, la tir resulta ser 4 % mayor con ra comparado con ri, y un 8 % superior en comparación con sr. Así mismo, el costo unitario es 7 % menor con ra comparado con ri, y 9 % más bajo en comparación con sr. Por su parte, los ingresos netos son 20 % más altos en ra comparado con ri, y 63 % superiores en comparación con sr. Por último, la amortización llega antes en ra en comparación con ri y sr. Este trabajo presenta además resultados para el análisis de sensibilidad que se llevó a cabo sobre el precio del agua y el precio pagado por rff

Water deficit is among the most limiting factors for obtaining high yields in agricultural crops. Along with this, water is becoming a scarce resource due to climate change, which implies that whenever a grower de-cides to irrigate their crops, the efficiency of the system for water usage must be a factor to be considered. This paper presents the results of a research undertaken in order to assess two irrigation systems used at oil palm plantations in Colombia from an economic perspective, they were: sprinklers irrigation (-*) and, f lood irrigation (2*). A scenario in which the grower does not use any irrigation system (K*) was also con-sidered. Regarding the economic assessment methods we used: internal rate of return (*&&), unit cost, net income, net present value (OQS), and payback period (QU). Results indicate that at a price of XYQ 365.000 per ton of 22U, establishing oil palm crops with sprinklers irrigation systems is the best alternative from an economic angle. With this method, the *&& is 4% higher at -* compared to 2*, and 8% higher compared to K*. The unit cost is 7% lower at -* compared to 2*, and 9% lower compared to K*. Besides, net income is 20% higher at -* than at 2*, and 63% higher compared to K*. Finally, the payback period comes earlier at -*, compared to 2* and K*. This study also provides results for sensitivity analyses carried out for the price of water and for the price paid for 22U.

Venous Ulcers Treated With a Hyaluronic Acid Extracellular Matrix and Compression Therapy: Interim Analysis of a Randomized Controlled Trial.

Diabetic foot ulcers (DFUs) are a severe and costly complication of diabetes and may result in foot amputation. CASE REPORT: A 69-year-old man with a 10-year history of type 2 diabetes, who was undergoing routine care for diabetes in the authors' clinic, developed a DFU of his right foot of 4 years' duration. The wound did not respond to conventional treatments, and imaging studies were normal. His 2 biopsies tested negative for malignancy. The DFU was fully removed surgically. Following surgical removal, squamous cell carcinoma (SCC) was diagnosed in the histologic study of the wound. CONCLUSION: Clinicians should consider a diagnosis of SCC in any chronic, nonhealing DFU. Early surgical resection of a chronic, nonhealing DFU may prevent development of SCC in an ulcer.

The VCU Pressure Ulcer Summit: The Search for a Clearer Understanding and More Precise Clinical Definition of the Unavoidable Pressure Injury.

This article reports the findings of the Unavoidable Pressure Ulcer Committee (of the VCU Pressure Ulcer Summit) that was tasked with addressing key issues associated with pressure injuries that are unavoidable or unpreventable. Our goals were (1) to clarify nomenclature and descriptions surrounding "terminal ulceration," (2) to describe the medical complications and comorbid conditions that can lead to skin failure and/or terminal ulceration, (3) to describe the variable possible causes of unavoidable pressure injuries, and (4) to present clinical cases to exemplify pressure injuries considered to be unavoidable.

Effect of High-pressure, Intermittent Pneumatic Compression for the Treatment of Peripheral Arterial Disease and Critical Limb Ischemia in Patients Without a Surgical Option.

UNLABELLED: Thirty-four subjects with symptomatic peripheral arterial disease (PAD) or critical limb ischmeia (CLI) who were experiencing claudication pain, chronic resting pain, numbness, and ischemic lower leg/foot ulceration were randomized into 2 treatment groups. MATERIALS AND METHODS: Eighteen of these patients received treatment with high-pressure, intermittent pneumatic compression (HPIPC) 60 minutes twice daily for 16 weeks, and 16 subjects received standard care consisting of an exercise regimen of walking for 20 minutes twice daily for 16 weeks. The HPIPC device delivers bilateral pressures of 120 mm Hg. Cycle times provide sequential compression for 4 seconds (+/- 0.5 seconds) followed by a 16-second rest period (+/- 3.0 seconds), resulting in a 20-second cycle or 3 cycles per minute. The study was designed to measure patient-centered outcomes. The primary endpoint was peak walking time (PWT), defined as time to maximally tolerated claudication pain. Secondary endpoints included change in resting ankle brachial index, ulcer healing, relief of resting/wound pain, and quality of life (QoL) index. Age (73.7 years vs 72.7 years), baseline PWTs (1-6 minutes), and risk factors were similar in both treatment groups. RESULTS: At 4 weeks, the percent change from baseline in PWT did not vary significantly between treatment groups (17.8% for HPIPC and 17% for standard care). After 8 weeks, the percent change in PWT for the HPIPC group was 41% compared to 32% for the group receiving standard care (P = 0.062). At the 16-week time point the percent change from baseline in PWT was significantly different between treatment arms (35.5% for the standard care group and 54.7% for the group receiving HPIPC [P = 0.043]). The mean reduction in wound surface area was 57% and 71% at 12 weeks and 16 weeks, respectively, for the HPIPC group, compared to 45% and 56% for the control group. The HPIPC group reported significantly greater pain relief at the 12-week (P = 0.044) and 16- week (P = 0.038) time points. Compared to the control group, the HPIPC group reported improvement in patient-centered outcomes such as physical function and bodily pain. These differences were statistically significant (P less than 0.05) at the 16- week evaluation period. CONCLUSION: Therapy consisting of HPIPC for 2 hours daily for a period of 16 weeks significantly improved PWT, reduced resting pain, and improved healing rates, physical function, and bodily pain. There were no devicerelated complications, allowing for long-term use. This study further supports that HPIPC is safe and effective and should be considered for patients who are not candidates for endovascular or surgical procedures. Furthermore, HPIPC offers an excellent alternative for the palliative care of patients with PAD and CLI symptoms.

Low-frequency ultrasound (20-40 kHz) as an adjunctive therapy for chronic wound healing: a systematic review of the literature and meta-analysis of eight randomized controlled trials.

Ultrasound as a therapeutic agent in chronic wound healing has been studied extensively. This systematic review and meta-analysis specifically examines low-frequency (20-30 kHz) ultrasound delivered at either low or high intensity. The objective of this review was to determine whether low-frequency ultrasound used as an adjunctive therapy improves the outcomes of complete healing and reduction of size of chronic lower limb wounds. PubMed, Cochrane/CENTRAL, technical assessment, relevant wound-related journals, and clinical guidelines were searched along with contacting manufacturers and authors of relevant randomized controlled trials were completed. Searches focused on the use of low-frequency ultrasound in randomized controlled trials. Data were collected via a data collection form and was adjudicated independently via coauthors. Meta-analyses and heterogeneity checks were performed using Mantel-Haenszel and inverse variance (fixed and random effects) statistical methods on studies with similar outcomes (complete healing and percent wound area reduction) over similar time periods. Single study results were reported via the statistical methods used in the study. Eight randomized controlled trials were identified. Results demonstrated that early healing (at ≤5 months) in patients with venous stasis and diabetic foot ulcers was favorably influenced by both high- and low-intensity ultrasound delivered at a low frequency-either via contact or noncontact techniques. However, the quality of the data may be suspect, especially for low-frequency low-intensity noncontact ultrasound because of significant biases. In patients presenting with either venous stasis or diabetic foot ulcers (Wagner classification 1-3), early healing appears to be facilitated by either low-frequency low-intensity noncontact ultrasound or low-frequency high-intensity contact ultrasound.

Wounds measured from digital photographs using photodigital planimetry software: validation and rater reliability.

UNLABELLED:  Traditional wound tracing technique consists of tracing the perimeter of the wound on clear acetate with a fine-tip marker, then placing the tracing on graph paper and counting the grids to calculate the surface area. Standard wound measurement technique for calcu- lating wound surface area (wound tracing) was compared to a new wound measurement method using digital photo-planimetry software ([DPPS], PictZar® Digital Planimetry). METHODS: Two hundred wounds of varying etiologies were measured and traced by experienced exam- iners (raters). Simultaneously, digital photographs were also taken of each wound. The digital photographs were downloaded onto a PC, and using DPPS software, the wounds were measured and traced by the same examiners. Accuracy, intra- and interrater reliability of wound measurements obtained from tracings and from DPPS were studied and compared. Both accuracy and rater variability were directly related to wound size when wounds were measured and traced in the tradi- tional manner. RESULTS: In small (< 4 cm2), regularly shaped (round or oval) wounds, both accuracy and rater reliability was 98% and 95%, respectively. However, in larger, irregularly shaped wounds or wounds with epithelial islands, DPPS was more accurate than traditional mea- suring (3.9% vs. 16.2% [average error]). The mean inter-rater reliabil- ity score was 94% for DPPS and 84% for traditional measuring. The mean intrarater reliability score was 98.3% for DPPS and 89.3% for traditional measuring. In contrast to traditional measurements, DPPS may provide a more objective assessment since it can be done by a technician who is blinded to the treatment plan. Planimetry of digital photographs allows for a closer examination (zoom) of the wound and better visibility of advancing epithelium. CONCLUSION: Measurements of wounds performed on digital photographs using planimetry software were simple and convenient. It was more accurate, more objective, and resulted in better correlation within and between examiners. .

Incorporating wound healing strategies to improve palliation (symptom management) in patients with chronic wounds.

BACKGROUND: Palliative wound care should be centered on symptom management and is a viable option for patients whose chronic wounds do not respond to standard interventions, or when the demands of treatment are beyond the patient's tolerance or stamina. Palliative wound care is the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing (total closure). Palliative wound care strategies must also work in conjunction with curative treatment objectives as wounds often heal completely in spite of serious illness and advanced disease. Palliative wound care is much more than pain, exudate and odor management. Common curative treatment goals such as physical correction of the underlying pathology, addressing nutrition and other supportive aspects of care, and sensible (nonharmful) local wound treatments should never be ignored. OBJECTIVE: (1) To provide a fresh and effective approach to palliative wound care by integrating individual clinical expertise with clinical and laboratory evidence from the (curative) wound healing literature and (2) to share our (Calvary Hospital) experience and approach to palliative wound care in an inpatient, home, and outpatient setting. This approach can be summarized with the mnemonic S-P-E-C-I-A-L (S = stabilizing the wound, P = preventing new wounds, E = eliminate odor, C = control pain, I = infection prophylaxis, A = advanced, absorbent wound dressings, L = lessen dressing changes). Throughout this paper we will offer rationale, principles and recipes, for each of the steps of the "SPECIAL" approach in an effort to facilitate the caring for chronic wounds in palliative medicine. CONCLUSIONS: A practical marriage of wound palliation (symptom management) with current wound healing concepts to provide options for the palliative care provider and improve the practice of palliative medicine.

Effect of noncontact normothermic wound therapy on the healing of neuropathic (diabetic) foot ulcers: an interim analysis of 20 patients.

This is the interim analysis of a prospective, randomized, controlled study comparing diabetic foot ulcer healing in patients being treated with either noncontact normothermic wound therapy (Warm-UP; Augustine Medical Inc. Eden Prairie, MN) applied for 1 hour 3 times daily until healing or 12 weeks, or standard care (saline-moistened gauze applied once a day). Surgical debridement and adequate foot off-loading was provided to both groups. Evaluations were performed weekly and consisted of acetate tracings, wound assessment, and serial photography. Twenty patients have completed the trial and both treatment groups were distributed evenly (N = 10). Ulcers treated with noncontact normothermic wound therapy had a greater mean percent wound closure than control-treated ulcers at each evaluation point (weeks 1-12). After 12 weeks, 70% of the wounds treated with noncontact normothermic wound therapy were healed compared with 40% for the control group. In this subset of patients there have been no adverse events associated with noncontact normothermic wound therapy.