Chronic Wounds

It is a chapter of the Book named "Feridas: Prevenção, causas e tratamento", that is about: "Wounds: prevention, causes and treatment". Health resources are finite and the health services are increasing and cannot follow the needs. So, health managers need tools to help in the analysis and decision making process. So, cost accounting provides information for determining the costs of productive sectors, allowing the control and reduction of the operating costs. (this paper can be used since the source is cited as (permitido usar desde que citada a fonte): Moreira RZ, Zuchi P. Custos Relacionados ao Tratamento de Feridas. In: Gamba MA, Petri V, Costa MTF (Orgs). Feridas: Prevenção, causas e tratamento. São Paulo: Guanabara Koogan, 2016.

Cutaneous wounds are known as the damages and injuries on the skin. Knowing the type of wound is very important before any kind of treatment or therapy being applied. Each type of wound is different from other due to the different structure, biology and pathophysiology, therefore, a kind of treatment for one wound cannot be specified for others. Considering the importance of types of wounds, these wounds are classified into different categories because of their different pathobiology. This manuscript would be a great piece of knowledge for the tissue engineer to develop specific skin substitute for specific wound which might help for the development of appropriate treatment strategies.

The current economic downturn in the UK and other countries has caused healthcare organisations to justify the costs of more advanced technologies. This is seen especially within the wound care discipline. The costs of healthcare account for a third of all UK government spend and with the prevalence of chronic wounds increasing, the cost of modern wound care is becoming more strained and open to scrutiny. Healthcare decision makers should not base their decisions on cost of dressings alone, but take into account the costs mitigated by using an advanced wound therapy. A clinical-economic assessment should be performed on a number of advanced therapies to assess if these are indeed more cost-effective long-term.

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) infection has increased precipitously over the past several decades, with far-reaching health care and societal costs. MRSA infections in the context of burn wounds lead to invasive disease that could potentially cause mortality. Chloramphenicol is a well-known broad-spectrum bacteriostatic antibiotic that has been used since 1949, but due to its hydrophobicity, poor penetration in skin, fast degradation, and toxicity, its application has been hindered. Furthermore, it has been demonstrated that old antibiotics such as chloramphenicol remained active against a large number of currently prevalent resistant bacterial isolates due to their low-level use in the past. Recently, the novel nanoparticulate drug-delivery system has been used and reported to be exceptionally useful for topical therapeutics, due to its distinctive physical characteristics such as a high surface-to-volume ratio and minuscule size. It helps to achieve better hydrophilicity, bioavailability, and controlled delivery with enhanced therapeutic index, which has resulted in decreased toxicity levels compared to the crude drug. Here, we report a novel chloramphenicol loaded with poly(ε-caprolactone) (PCL)-pluronic composite nanoparticles (CAM-PCL-P NPs), physicochemical characterizations, and its bioactivity evaluation in a MRSA-infected burn-wound animal model. CAM-PCL-P NPs could encapsulate 98.3% of the drug in the nanoparticles and release 81% of the encapsulated drug over 36 days with a time to 50% drug release of
72 hours (51%). Nanoparticle suspensions maintained the initial properties with respect to size and encapsulation efficiency, even after 6 months of storage at 4°C and 25°C, respectively (P0.05). Significant reduction in the level of toxicity was observed for CAM-PCL-P NPs compared with that of free drug as confirmed from hemolytic activity against human blood erythrocytes and cytotoxicity assay against an MCF-7 breast cancer cell line. In vitro antibacterial activities were performed by zone of inhibition, minimum inhibitory concentrations, minimum bacterial concentration, and time-kill assays, which showed that CAM-PCL-P NPs exhibited significantly enhanced anti-MRSA activity against ten clinical isolates of MRSA strains. The augmented activity of CAM-PCL-P NPs was further tested on a MRSA-infected burn-wound animal model and achieved quicker efficacy in MRSA clearance and improved the survival rate compared with free-chloramphenicol treatment. Thus, we propose CAM-PCL-P NPs as a promising novel antimicrobial candidate that may have a good potential for preclinical applications.
Keywords: chloramphenicol, PCL-pluronic, nanoparticle, methicillin-resistant Staphylococcus aureus, anti-MRSA activity, burn-wound animal model

Biofilm forms with the colonization of different microorganism resulting in a microbial community which is complex and diverse in nature. Biofilms are enclosed with different microbial colonies in a matrix known as extracellular polymeric substance. Microorganisms together in this complex structure communicate through cell signaling molecules. This process is known as quorum sensing which helps in maintaining the complexity and diversity. Biofilms are involved in causing various infections in human beings. Oral cavity and wounds are very common two sites where biofilm formation takes place. The complexity of a biofilm makes it tenacious and it’s tough to eradicate completely. There are several conventional methods such as physical, chemical, antibiotics, antiseptics and anti-biofilm agents for the eradication of dental/periodontal biofilms and biofilms associated oral wounds. Thus, various novel approaches can be proposed, one of them is Nanotechnology. Its extensive application in dentistry can be very helpful in curing various periodontal and dental diseases. Nanoparticles are one of new emerging potent system which can be really helpful in the complete eradication of complex biofilms due to their high anti-microbial properties. In this review, we have attempted to discuss dental/periodontal biofilms; oral wounds, their relation with oral biofilm microbes and their treatment as well as conventional methods of treatment available till now. With this comprehensive review, it is proposed that with the help of nanotechnology, various nanoparticles can be designed and an improvement can be done to the available methods or some new methods.

Chronic wounds represent a major public health issue, with an extremely high cost world-wide. In healthy individuals, the wound healing process takes place in different stages: inflammation, cell proliferation (fibroblasts and keratinocytes of the dermis), and finally remodeling of the extracellular matrix (equilibrium between metalloproteinases and their inhibitors). In chronic wounds, the chronic inflammation favors exudate persistence and bacterial film has a special importance in the dynamics of chronic inflammation in wounds that do not heal. Recent advances in biopolymer-based materials for wound healing highlight the performance of specific alginate forms. An ideal wound dressing should be adherent to the wound surface and not to the wound bed, it should also be non-antigenic, biocompatible, semi-permeable, biodegradable, elastic but resistant, and cost-effective. It has to give protection against bacterial, infectious, mechanical, and thermal agents, to modulate the level of...

ABSTRACT

Introduction: The proportion of the population aged over 65 years is constantly increasing and thus the emergence of various chronic diseases. Due to problems with the blood vessels in these often meet with the formation of venous ulcerations. This paper describes the case of elderly people with venous ulceration, method of treatment and care,which allows for optimal healing.
Methods: We conducted a qualitative case study, which was based on a review of documentation , interviews implementation, design and implementation of the work plan and monitoring of the patient with venous ulcers from November 2010 to March 2012. The purpose of the survey is a comprehensive treatment of the patient with venous ulcer, who lives  alone  and  is  dependent  on  foreign  aid. Research question: How  does  the comprehensive treatment of the patient, continuosly monitoring and appropriate choice of
wound dressings affect on healing the wound in elderly age of 90 years or more?
Results: Elderly patient with venous ulcers had two venous ulcerations at the beginning of treatment on left leg (first 8 x 4 cm and the other 3 x 5 cm ). We carried out for wounds every two days in the beginning, then every two to three days, using modern materials and compression bandages. Ulcers were healed after one year and four months . In the meantime, there has also been a deterioration in the healing of ulcers due to general medical condition of the patient - the elderly. The health educational work instructions (regarding diet , regular and proper medication, exercise, use of devices to facilitate movement), which patient take into account, has been achieved improved health status of the patient and faster healing of ulcers. .
Discussion and conclusion: Older organism has reduced resistance and is susceptible to pathological changes. With the aging of the body resulting in a number of anatomical and functional changes that occur in all organs and tissues, most are expressed in the cardiovascular, musculoskeletal, nervous, digestive and endocrine system. Venous leg ulcers occurs in 80 to 85 percent due to chronic venous insufficiency and is most often in the lower leg and foot. The medical - educational work can successfully prevent its occurrence and the occurrence of secondary complications. Using modern methods, approaches (TIME concept), the use of modern materials for wound care, the psychophysical comfort the elderly with venous leg ulcers is much improved, healing is faster and with less or no pain. For optimal treatment and care is important that the patient is treated comprehensive, individual and multidisciplinary.


Keywords: elderly, venous leg ulcer, ulcer assessment, preparation a bottom of the wound

Many people suffer from chronic wounds .It is a major problem in healthcare .worldwide. The treatments of chronic wounds include monitoring colour and size (area or volume) of the wound at regular intervals. This evaluation is often based on qualitative observation and manual measurements of the wound. Now a days there several researchers are developing technologies to assess the clinical improvement of chronic wounds. This paper aims to provide a study on imaging technologies applied to chronic wounds. A study on imaging technologies applied to chronic wounds is presented. Their reliability, precision, and usage are compared. The methods are divided into three categories: planimetric techniques, volumetric Technique and tissue classification.

Chronic leg ulcers (CLUs) are full thickness wounds that usually occur between the ankle and knee, fail to heal after 3 months of standard treatment, or are not entirely healed at 12 months. CLUs present a considerable burden on patients, subjecting them to severe pain and distress, while healthcare systems suffer immense costs and loss of resources. The poor healing outcome of the standard treatment of CLUs generates an urgent clinical need to find effective solutions for these wounds. Tissue Engineering and Biomaterials Science offer exciting prospects for the treatment of CLUs, using a broad range of skin substitutes or scaffolds, and dressings. In this review, we summarize and discuss the various types of scaffolds used clinically in the treatment of CLUs. Their structure and therapeutic effects are described, and for each scaffold type representative examples are discussed, supported by clinical trials. Silver dressings are also reviewed due to their reported benefits in the healing of leg ulcers, as well as recent studies on new dermal scaffolds, reporting on clinical results where available. We conclude by arguing there is a further need for tissue-engineered products specifically designed and bioengineered to treat these wounds and we propose a series of properties that a biomaterial for CLUs should possess, with the intention of focusing efforts on finding an effective treatment.

Chronic ulcers represent a major health problem in diabetic patients resulting in pain and discomfort. Conventional therapy does not guarantee adequate wound repair. In diabetes, impaired healing is partly due to poor endothelial progenitor cells mobilisation and homing, with altered levels of the chemokine stromal-derived factor-1 (SDF-1) at the wound site. Adipose tissue-associated stromal cells (AT-SCs) can provide an accessible source of progenitor cells secreting proangiogenic factors and differentiating into endothelial-like cells. We demonstrated that topical administration of AT-SCs genetically modified ex vivo to overexpress SDF-1, promotes wound healing into diabetic mice. In particular, by in vivo bioluminescent imaging analysis, we monitored biodistribution and survival after transplantation of luciferase-expressing cells. In conclusion, this study indicates the therapeutic potential of AT-SCs administration in wound healing, through cell differentiation, enhanced cellular recruitment at the wound site, and paracrine effects associated with local growth-factors production.

Chronic wounds represent a major public health issue, with an extremely high cost worldwide. In healthy individuals, the wound healing process takes place in different stages: inflammation, cell proliferation (fibroblasts and keratinocytes of the dermis), and finally remodeling of the extracellular matrix (equilibrium between metalloproteinases and their inhibitors). In chronic wounds, the chronic inflammation favors exudate persistence and bacterial film has a special importance in the dynamics of chronic inflammation in wounds that do not heal. Recent advances in biopolymer-based materials for wound healing highlight the performance of specific alginate forms. An ideal wound dressing should be adherent to the wound surface and not to the wound bed, it should also be non-antigenic, biocompatible, semi-permeable, biodegradable, elastic but resistant, and cost-effective. It has to give protection against bacterial, infectious, mechanical, and thermal agents, to modulate the level of ...

The availability of primary cells present in pathological conditions is often very limited due to stringent ethical regulation and patient consent. One such condition is chronic wounds, where dermal fibroblasts show a deficient migration. In vitro models with cellular tools that mimic the in vivo scenario would be advantageous to test new therapies for these challenging wounds. Since the availability of primary dermal fibroblasts present in chronic wounds is restricted and their “shelf‐life” limited due to increased senescence, our aim was to engineer human dermal fibroblasts with impaired migration using synthetic RGD peptides. We studied fibroblast behaviour on 3 different 2D surfaces, representative of the dermal ECM and the materials used in the development of dermal scaffolds, in addition to commercially available, collagen‐based 3D dermal scaffolds, demonstrating that the concentration of synthetic RGD peptides necessary to impair migration of dermal fibroblasts should be tailored to the particular surface/material and cell population used. The described technology could be translated to other cell types including established cell lines. A wide range of synthetic peptides exist, which differ in the amino acid sequence, thus increasing the possibilities of this technology.

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) infection has increased precipitously over the past several decades, with far-reaching health care and societal costs. MRSA infections in the context of burn wounds lead to invasive disease that could potentially cause mortality. Chloramphenicol is a well-known broad-spectrum bacteriostatic antibiotic that has been used since 1949, but due to its hydrophobicity, poor penetration in skin, fast degradation, and toxicity, its application has been hindered. Furthermore, it has been demonstrated that old antibiotics such as chloramphenicol remained active against a large number of currently prevalent resistant bacterial isolates due to their low-level use in the past. Recently, the novel nanoparticulate drug-delivery system has been used and reported to be exceptionally useful for topical therapeutics, due to its distinctive physical characteristics such as a high surface-to-volume ratio and minuscule size. It helps to a...

Offloading of the wounds in the foot is one of the most important and integral part of wound management to achieve optimal successful results. Various offloading modalities have been used for decades with each having their own merits and demerits. However, astonishingly, as far as the author knows, as an expert diabetic foot surgeon, there is no classification till date that divides offloading devices in appropriate distinct group. The Author proposes new different classifications for offloading devices/system in diabetic foot for the first time in the literature. It is a novel attempt to improvise and standardize diabetic foot practices around the world and is another component of Amit Jain's principle and practice of diabetic foot. This offloading classification can also be used for non-diabetic foot wounds.

This study evaluates clinically the effect of propolis paste on healing of cutaneous wound in dogs. Under general anesthesia and
complete aseptic conditions, two full thickness skin wounds (3 cm diameter) were created in each side of the chest in five dogs,
one dorsal and one ventral, with 10 cm between them.These wounds were randomly allocated into two groups, control group (10
wounds) and propolis group (10 wounds). Both groups were represented in each dog.The wounds were cleaned with normal saline
solution and dressed withmacrogol ointment in control group and propolis paste in propolis group, twice daily till complete wound
healing. Measurement of the wound area (cm2) was monitored planimetrically at 0, 7, 14, 21, 28, and 35 days after injury. The data
were analyzed statistically. The results revealed a significant reduction in the wound surface area in the propolis group after 14 and
21 days compared to control group.The wound reepithelization, contraction, and total wound healing were faster in propolis group
than in control group during five weeks of study. In conclusion, propolis paste has a positive impact on cutaneous wound healing
and it may be suggested for treating various types of wounds in animals.

AIMS AND OBJECTIVES To explore patient experience of chronic wound care across diverse models of outpatient wound care delivery. BACKGROUND Chronic wounds represent a significant personal, family and healthcare system burden. Evidence suggests specialist wound clinics are more effective and less expensive, however, most outpatient wound care is delivered by general community nurses. There is little understanding of how patients experience diverse models of wound care delivery, and the subsequent impact on their capacity to adapt to imbalances in their internal/external environment. DESIGN Descriptive, qualitative study. METHODS Eighteen patients with chronic wounds from three wound services were engaged in semi-structured interviews. Initial inductive analysis was refined deductively using Levine's Conservation Model. RESULTS Chronic wounds lead to imbalances and subsequent adaptions in energy conservation and personal, social and structural integrity. Nursing process and wound care system responses suggest specialist wound clinics provide access to the right person and care at the right time, with less care variation. The community nursing model is most effective with a small team of nurses, and a documented care plan, with specialist wound nurse oversight. Residential aged care facilities emerged as important sites for wound care delivery revealing higher variance in care, and less specialist wound oversight. CONCLUSIONS The application of Levine's conservation model provides a theoretical understanding and important insights into the patient experience of nurse and system elements across diverse models of wound care delivery. Specialist oversight by expert wound nurses with the capacity for medical specialist referral is the cornerstone of good wound care. A frequently reviewed wound care plan and skill development for nurses in primary, aged care, and community settings are vital. RELEVANCE TO CLINICAL PRACTICE Shared care between specialist and primary care should include evidence-based pain assessment, clear referral pathways, collaborative relationships, telehealth capacity, patient held wound plans and upskilling of frontline clinicians.

Background: Dressing materials are known to influence post-operative surgical wound healing
and scar formation (SF). A particular dressing that could promote wound hydration is
essential to ensure quick epithelialization and reduce SF. This study examined the effective-
ness of a novel Continuous Diffusion of Oxygen (CDO) dressing to reduce scar length post
cervicotomy.
Methods: A randomized controlled trial was performed in patients undergoing cervicotomy,
either for thyroid or parathyroid disease. Patients were randomized to either control (CG) or
intervention (IG) groups. The IG received a portable CDO system (TransCu O2, EO2 Concepts
Inc., TX, USA), whereas the CG received a standard dressing for a 4-week period. The primary
outcome was > 10% of scar length reduction and %change in scar length.
Results: 21 patients were recruited (Age: 53 ± 16 years; 90% female; CG = 9, IG = 12). 5 patients
were lost to follow-up. At 4 weeks, 88.8% of the IG significantly achieved > 10% of scar
reduction (versus CG = 28.5%, d = 0.48, P = 0.049), showing a 40.4% smaller scar (15.7% versus
11.2%, d = 0.13, P = 0.72) compared to the CG. However, the difference was not significant. A
sub-sample of patients undergoing thyroidectomy showed a significant scar reduction using
CDO (IG = 11.6% versus CG = 5.1%, d = 2.96, P = 0.009).
Conclusions: This is the first study to assess scar reduction using CDO adjunct therapy after cervicotomy. Advanced CDO dressings may assist wound healing showing improved outcomes for scar visualization in patients undergoing thyroidectomy. A larger sample is required to validate this observation.

Chronic wounds represent a major public health issue, with an extremely high cost world-wide. In healthy individuals, the wound healing process takes place in different stages: inflammation, cell proliferation (fibroblasts and keratinocytes of the dermis), and finally remodeling of the extracellular matrix (equilibrium between metalloproteinases and their inhibitors). In chronic wounds, the chronic inflammation favors exudate persistence and bacterial film has a special importance in the dynamics of chronic inflammation in wounds that do not heal. Recent advances in biopolymer-based materials for wound healing highlight the performance of specific alginate forms. An ideal wound dressing should be adherent to the wound surface and not to the wound bed, it should also be non-antigenic, biocompatible, semi-permeable, biodegradable, elastic but resistant, and cost-effective. It has to give protection against bacterial, infectious, mechanical, and thermal agents, to modulate the level of...

Background. Skin, the first barrier to pathogens, loses its integrity and function after an injury. The presence of an antibacterial dressing at the wound site may prevent bacterial invasion and also improve the healing process.
Objectives. The current study aimed to fabricate a biomimetic membrane with antibacterial properties for healing chronic wounds.
Material and methods. The membranes, fabricated through electrospinning, are comprised of poly(ethylene oxide) (PEO) and zinc oxide nanoparticles (ZnO-NPs) as the main biomaterial and antibacterial agent, respectively. Antibacterial activity, cell attachment and viability were tested to evaluate the biological properties of the membranes. The optimal cell compatible concentration of ZnO-NPs was determined for further studies. In vitro characterization of the membranes was performed to confirm their suitable properties for wound healing.
Results. The antibacterial PEO/ZnO-NP membrane containing 2% of nanoparticles showed no cell toxicity, and human fibroblast cells were able to adhere and proliferate on the scaffold. The in vitro results from the tensile test, wettability, porosity, and protein adsorption revealed appropriate properties of the membrane as a scaffold for skin tissue engineering.
Conclusions. Synthetic polymers have been widely used for tissue engineering applications. The proper characteristics of PEO nanofibers, including a high ratio of surface/volume, moderate hydrophilicity and good mechanical properties, make this polymer interesting for skin regeneration. The results demonstrate the potential of the antibacterial PEO/ZnO-NP membrane to be used as an engineered scaffold to improve the wound healing process.

Novel findings on fabrication techniques for bioactive materials, discovering further basic knowledge
about wound healing process, and availability of stem cells as alternative candidate for differentiated cells
have highly encouraged scientists for developing new bioengineered skin substitutes (BSS) that offer an
effective remedy for a specific wound type. However, technical, clinical, legislative and economic reasons
hamper wide-spread commercialization and clinical translation of BSS. Among the various types of
strategies that target skin repair and regeneration, tissue engineering with stem cells is most promising
route. Tissue engineering by cooperation of several disciplines forms a context on which the commercial
development of BSS is possible to provide benefits for patients who currently have limited or no cure
options. The principles of tissue engineering are to initiate cell cultures in vitro, grow them in monolayer
or on porous scaffolds and transplant the composite into a patient with a specific wound indication in vivo.
The potential for creating of custom-designed biomaterials and availability of stem cells from either
autologous or allogenic sources have helped to produce novel innovative BSS. Currently, wide range of
skin substitutes are already being fabricated for clinical use in different wound indications but not yet
definitively established. Therefore, many novel engineered constructs might be fabricated in the future.
In this review, we describe the progress that has been made to date in the field of skin substitutes and the
critical issues that are still hindering successful production and bench to bedside translation of BSS and
restricting the availability of these innovative therapeutic constructs. Integrity of the science and
technology, interdisciplinary expertise collaborations, and early interaction with regulatory entities such
as Food and Drug Administration (FDA) and European Medicines Agency (EMA), together with other
critical determinants, is vital to the successful commercialization of tissue engineering products into the
marketplace/clinic.

This communication reports preliminary data towards the development of a live ex vivo model of persistent infection that is based on the chick embryo chorioallantoic membrane (CAM), which can be used for pre-screening biomaterials with antimicrobial properties for their antimicrobial and angiogenic potential. Our results showed that it was possible to infect chicken embryos with Staphylococcus aureus, one of the main types of bacteria found in the persistent infection associated with chronic wounds, and maintain the embryos' survival for up to 48 h. Survival of the embryos varied with the dose of bacteria inoculum and with the use and time of streptomycin application after infection. In infected yet viable embryos, the blood vessels network of the CAM was maintained with minimal disruption. Microbiological tests could confirm embryo infection, but quantification was difficult. By publishing these preliminary results, we hope that not only our group but others within the scientific community further this research towards the establishment of biomimetic and reproducible ex vivo models of persistent infection.