Recherche de publication

Aim:

Complex case management in a fragile elderly patient to achieve an optimal outcome.

Method:

The 96 year-old female had a deep wound infection after osteosynthesis of her left ankle. In the hospital she was treated with negative pressure wound therapy (NPWT). Upon arrival on March 2, 2017 in the rehabilitation centre the wound surface was 8 x 3 cm, the wound bed contained 10% yellow and 90% granulation tissue with some hyper-granulation present. The wound edges were non vital and there was oedema in her left ankle. The surrounding skin was slightly red.

Results:

The patient received nutritional supplements twice daily. NPWT was discontinued and the treatment regime now comprised: Debridement using a monofilament1 pad, followed by cleansing with water and disinfection with an antiseptic. The peri-wound skin was protected with a spray on film, a collagen2 and an alginate3 dressing were covered with a superabsorbent pad fixed with an adhesive film dressing.4 Dressing changes were on average twice weekly. For compression 2 layers (20 mmHg) of a tubular compression5 system were applied during the day and reduced to one layer at night. Wound closure was achieved after 41 days of treatment. The patient continued with the compression system for another 6 weeks to protect the fragile area and to prevent oedema from reoccurring.

Conclusion:

Complex wound closure was achieved in a comfortable fashion that suited the individual needs of this elderly fragile patient.

Aim:

Although hosiery is the golden standard in the maintenance phase for treating lymphedema or venous leg ulcers, clinical challenges exist where hosiery may not be suitable due to unresolved edema or practical application issues. In this study a practical solution for this group of patients was implemented using a Leg Ulcer Hosiery Treatment System.*

Method:

9 patients, 5 males, 4 females aged between 45 – 87 years old. 7/9 edema, I erysipelas and I DVT. Previous treatment: 6/7 no treatment, 2 Tubigrip, 1 ill-fitting hosiery Referrals from the General Practitioner or Medical Specialists to the bandager Medical Stockings measurement. In all cases edema persisted and an alternative solutions was chosen using the new system for 4 – 6 weeks for treatment of the edema.

Results / Discussion:

After evaluation, there was an immediate effect reduction in edema, from 6 to 14%. Comfort and Donning was good to very good. Doffing was average to good. Patients were able to wear their own shoes, stay active and in some cases, continue working. They were measured for follow on Medical Stockings. The system was simple, effective, promoted self-care and was available off the shelf. Costs of bandager and community nurse time were reduced.

Conclusion:

Simple solutions such as the 2 layer Leg Ulcer System can help patients and caregivers for the treatment of edema with or without a wound. Benefits are self-management and cost efficiency instead of 2 – 3 x week bandaging. All patients could fit into their own shoes, and this motivates mobility.

Aim:

The study compared clinical efficacy and cost of autolitic, enzymatic and mechanical debridement using a monofillament pad* and a pad with a handle.

Method:

A monofilament debrider was proposed for its efficacy, safety, tolerability and ease of use. Eighty community patients with complex wounds containing sloughy tissue were allocated to the treatment groups at random, after they consented. They were followed for 15 days. At baseline medical history, wound characteristics and privious treatment was recorded. During visits wound condition, patient reported pain during debridement, time required for the procedure and product handling, were scored. Costs calculation took into account clinical efficacy, time to debridement, number of home visits, nursing costs, costs

per product used.

Results / Discussion:

Debridement was effective and comfortable using all evaluated methods (on a 5-point Likert scale, the 2 monofilament products scored a mean of 4,9 and 4,8, enzymatic sored a mean of 4,6 and autolytic debridement a mean of 3,6). The total costs for debridement using the monofilament pad* and product with handle was Euro 58,67 and Euro 72,47 respectively. For enzymatic debridement the total costs were Euro 213,35 and for autolytic debridement Euro 98,67. Cost was significantly lower in the monofilament group due to a reduction in debridement time, number of visits and nursing time.

Conclusion:

The addition of the monofilament products to our debridement portfolio use for wound management in the community represents an added value in the treatment available for patients with complex wounds with appropriate use of tight resources.

Aim:

To evaluate the performance of Monofilament Fibre Debridement Technology compared to a cleaning cloth in the removal of bacteria and biofilm using a wound intelligence device which leverages the principles of fluorescence.

Method:

Patients were selected with chronic wounds who demonstrated signs that biofilm was the primary cause of the wound being static or slow to heal. A monofilament fibre debridement pad was used to mechanically debride the chronic wounds and expedite wound bed preparation. The same procedure was repeated using a cleaning cloth with poloxamer following manufacturer’s instructions for use. A wound intelligence device was used to take images of fluoresce in bacteria ≥ 10⁴ CFU/g on the surface of the wound bed before and after using the monofilament fibre debridement pad and compared with the before and after images using the cleaning cloth.

Results / Discussion:

To date, eight patients have been recruited into the evaluation, four using the monofilament fibre debridement pad and four using the cleaning cloth. In all cases, images demonstrate that the monofilament fibre debridement technology has superior ability to removal bacteria and biofilm when compared to the cleaning cloth with poloxamer. Data collection continues.

Conclusion:

To date, the monofilament fibre debridement technology has shown better removal of bacteria and biofilm when compared with a cleaning cloth using fluoresce imaging in the evaluation.

Aim:

Increased bacterial loads on the wound surface amplify and/or perpetuate a proinflammatory environment. It was suggested that lower probability of healing is seen when ≥4 pathogens are present. Biofilm formation further lowers the probability of healing. Hence, it was postulated that it is necessary to create conditions that are unfavourable to microorganisms and favourable for host repair mechanisms. Dressings featuring active antimicrobial agents or a passive antimicrobial mechanism may help in the treatment of chronic wounds.

Method:

DACC-coated1, SAP2, activated-charcoal/Ag3, and biocellulose/PHMB4 dressings were investigated. Antibacterial activity against P.aeruginosa was tested according to JISL1902:2002. S.aureus biofilm was cultivated on glass plates, covered with dressings, and incubated for 24h at 37°C. Biomass was evaluated directly after dressing removal and following 48h regrowth period using the alamar blue assay.

Results / Discussion:

All dressings displayed complete inhibition of P.aeruginosa, rated as strong antibacterial activity according to JISL1902:2002 (log-reduction>3). Treatment of S.aureus biofilm with the dressings efficiently reduced biomass and significantly less viable bacteria were observed. However, only the biocellulose/PHMB4 dressing exhibited a remanescent effect and was able to inhibit biofilm regrowth over 48h.

Conclusion:

Antimicrobial dressings can decrease multiplication of bacteria by passive mechanisms based on securely binding microbes in or to the dressing as observed for DACC-coated1 or SAP2 dressing. Dressings actively releasing agents like Ag+ or PHMB have additional effects reaching bacteria beyond direct dressing contact. Here, PHMB was found to be superior to Ag+ demonstrating a remanescent effect and preventing biofilm regrowth.

Aim:

Chronic wounds are often colonized by different microorganisms, the most prominent being Staphylococcus aureus and Pseudomonas aeruginosa. PHMB-containing dressings have been shown to effectively inhibit bacterial progeny. However, bacteria do not act alone and the concept of biofilm formation and presence is now widely accepted. Therefore, current research targets antibiofilm strategies to restore an optimal wound-healing environment. A combined treatment approach involving debridement and the addition of antibacterial agents may then provide the highest success rates. Here, the efficacy of the new PHMB-containing PU foam* against a Staphylococcus aureus biofilm was evaluated in vitro. Moreover, antibacterial activity was evaluated in a direct contact method against Staphylococcus aureus and Pseusomonas aeruginosa.

Method:

Antibacterial activity against S. aureus and P.aeruginosa was tested according to JISL1902:2002. S.aureus biofilm was cultivated on glass plates, covered with dressings, and incubated for 24h at 37°C. Biomass was evaluated directly after dressing removal and following 48h regrowth period using the alamar blue assay.

Results / Discussion:

The new PHMB-containing PU foam* displayed complete inhibition of S.aureus and P.aeruginosa in the direct contact test, rated as strong antibacterial activity according to JISL1902:2002 (log-reduction>3). Treatment of S.aureus biofilm with the new PHMBcontaining PU foam* efficiently reduced biomass and significantly less viable bacteria were observed.

Conclusion:

It was found that the new PHMB-containing PU foam* exhibits a strong antibacterial activity against prominent microorganisms in chronic wounds. Moreover, it could be shown to reduce biofilm. Hence, it can be expected to exert beneficial effects in stagnating wounds and promote healing.

Aim:

Debridement is key to management of both slough and biofilm, and a number of methods are available to achieve this including surgical and mechanical debridement. Recent developments have led to new products indicated for debridement of wounds, including a unique sterile pad consisting of monofilament fibres. The purpose of this project was to examine wound related pain during mechanical debridement using monofilament debridement pad (WDP).

Method:

This is a case series of 10 patients with acute or chronic wounds that had slough required debridement. All wounds were debridement weekly for four weeks. Pain at baseline and during the debridement procedure (procedural pain) was evaluated using a verbal analogue scale (VAS) on which 0 was no pain and 10 was the worst pain imaginable.

Results / Discussion:

The wounds treated (number) were surgical wounds (3); pressure injury (3); venous leg ulcer (2); diabetic foot ulcer (1); trauma wound (1). The mean surface area covered by slough in the 10 wounds at week 0 was 79%. In every case the surface area of the wound covered by slough at week 0 reduced by week 4 to a mean of 8%. The average pain score at baseline was 6 in comparison to the mean pain of 7 during the debridement procedure using monofilament pads.

Conclusion:

WDP provides an effective solution to the goal of removing loose slough, deeply cleaning wounds and removing exudate. WDP does not induce high levels of procedural pain and any such pain subsided once debridement was complete.

Aim:

Non-healing wounds contain elevated levels of neutrophil elastase and matrix metalloproteinases (MMPs) which are responsible for degradation of extracellular matrix and growth factors. These destructive processes prevent wound closure and lead to persisting wounds. Binding of these proteases contributes to the treatment of chronic wounds. The aim of this study was to compare the binding capacity of two polyacrylatesuperabsorber dressings* for elastase and MMP-2 in vitro.

Method:

Samples of SAP* and SAP Pro** were cut (0.5 cm2), taken in a final volume of 1mL of protease solution (PMN elastase: 250ng/mL; MMP-2: 4000pg/mL), and incubated up to 24h at 37°C. Concentrations of unbound protein were determined by specific immunoassays for PMN elastase and MMP-2. In addition, it was checked if proteases can be eluted from the dressing samples subsequently.

Results / Discussion:

SAP* exhibited high binding capacity for both proteases. After 24h elastase concentrations were significantly reduced about 95% (p<0.001) and MMP-2 amounts completely abolished (100%, p<0.001). Only marginal amounts of elastase andMMP-2 could be eluted from the samples after incubation. SAP Pro** demonstrated a comparable high binding of elastase and MMP-2. No distinct differences in the performance of the dressings were noted.

Conclusion:

The polyacrylate superabsorber dressings SAP* and SAP Pro** are able to shortly bind large amounts of elastase and MMP-2 in vitro. Elution of the dressing samples revealed a strong, possibly irreversible binding of both proteases. Decrease of these matrix degrading proteases should aid establishment of a physiological wound milieu in vivo and thus support the healing process.

Aim:

To review the evidence supporting the use of Monofilament fibre debridement technology (MFDT) in dermatological conditions.

Method:

MFDT has been successfully used for 7 years in the debridement and management of chronic wounds¹ and hyperkeratosis². In recent years clinicians have been utilizing the MFT in specific dermatological skin conditions.

Results / Discussion:

MFDT has been shown in case studies and case series to be a useful emerging treatment, especially when self-care is a priority, in the management of dermatological conditions resulting in:

 Varicose eczema

 Epidermolysis bullosa

 Chronic wounds in dermatological patients

 Dry, scaly and flaky skin conditions

 Hyperkeratosis associated with venous disease

 Secondary skin changes associated with chronic oedema and lymphoedema

 Actinic keratosis

 Prior to photodynamic therapy

 Acne vulgaris

The 18 million special monofilament fibres which have angled tips to reach uneven areas of the skin or wound bed are able to remove unwanted tissue, materials and skin, allowing other concurrent treatment to reach their target area without the barriers imposed by for e.g. devitilised tissue, dry, scaly and flaky skin and other debris and materials. This technology has received positive NICE guidance¹⁷ for use in acute and chronic wounds. MFDT is very soft, comfortable and gentle on patients. It is safe and easy to use and can also be used by patients for self-care.

Conclusion:

A review of the supporting evidence clearly supports the continued research and interest in MFDT related to dermatological conditions.

Aim:

Compression remains the gold standard for long-term management of chronic edema. Reviews have shown that the benefits of compression diminish according to levels of non-adherence. Reasons commonly stated for nonadherence to compression include inconvenience, heat, cost, and pain. We hypothesize that offering compression options will have positive impact on patients’ compliance and concordance to compression regimens.

Method:

Observational study performed at 2 different edema management clinics. Ten patients presenting with lower extremity swelling and history of non-compliance with previous compression regiments were observed. Objective data measured included limb volume, range of motion (ROM), functional activity status using the Timed Up and Go(TUG), and assessment of quality of life (QOL) using the Lymphoedema QOL Tool (LYMQOL-LEG). Measurements were taken at four different intervals over a minimum of 3 months. Compression options were individualized to patient's physical presentation and lifestyle for long term management of their edema.

Results / Discussion:

Compression therapy had a positive impact on all outcomes measured during the intensive phase of therapy. Follow-up outside the intensive phase of therapy demonstrated further volume loss in 6/10 subjects; Volume remained constant 3/10, increased slightly 1/10. LYMQOL scores and functional performance level maintained stable during the follow-up period.

Conclusion:

Offering multiple compression options including custom and ready-to-wear flat knit stockings*, an adjustable wrap ** and nighttime compression options*** had a positive impact on patients’ adherence to compression regimens during the study period compared to single compression modalities offered previously. Individualizing the compression regimen to each patient’s lifestyle improved their adherence to chronic edema management.