The aim of this case series and service evaluation was to demonstrate the beneficial clinical and economic outcomes of the utilisation of a negative pressure wound therapy (NPWT) clinical decision tree within routine practice. A total of 16 retrospective anonymised complex wound case studies were referred to the tissue viability nursing (TVN) service. Patients received NPWT as inpatients, as per routine practice. Data was reported as an aggregated cohort, with further stratification by wound type. Descriptive statistics were utilised. The most prevalent wound type was dehisced surgical wounds (n=10; 62.5%) located on the abdomen (n=9; 56.25%). Risk of contamination (43.75%) and exudate management (43.75%) were the most common rationales for choosing traditional NPWT (tNPWT). Seven patients (43.75%) were discharged from hospital still requiring NPWT, with five (71.4%) having wound criteria suitable for single use NPWT (sNPWT). Using tNPWT and sNPWT alongside a clinical decision tree can assist in optimising NPWT delivery to patients within an acute care setting.

Background Nitric oxide (NO) plays a critical role in wound healing, including stimulating vasodilation, angiogenesis and broad antimicrobial activity.

Aim To determine if acidified nitrite foam (ANF) is effective at killing microbial pathogens.

Methods A novel method to generate and deliver NO gas at the point of care was developed using acidified nitrite in a bubble foam. Using an ex vivo porcine dermal tissue model, the ANF was tested against six common microbial wound pathogens – Acinetobacter baumannii, Candida albicans, Pseudomonas aeruginosa, Proteus mirabilis, Staphylococcus aureus and Staphylococcus epidermidis. The prevention study tested the ANF against pathogens in the planktonic phenotype. The eradication study tested ANF against pathogens in the mature biofilm phenotype.

Results In the prevention study, a single 5-minute exposure of ANF prevented 4.5-log₁₀ to 8.6-log₁₀ growth of biofilms among the six tested pathogens. In the eradication study, a single 5-minute exposure of ANF generated a 1.2-log₁₀ to 2.5-log₁₀ reduction of mature biofilms among the six tested pathogens. In the same eradication study, two 5-minute topical exposures of the ANF separated by 10 minutes generated a 2.2-log₁₀ to 4.5-log₁₀ reduction.

Conclusions These study results suggest that a single treatment with ANF may be able to prevent biofilm reformation in chronic wounds and may eradicate some mature biofilms following two exposures.

Implications for clinical practice ANF is an effective antimicrobial agent against several tested biofilms and has the potential to become a preferred treatment in the fight against wound infection.

Background Nitric oxide (NO) plays critical roles in wound healing, including stimulating vasodilation, angiogenesis and broad antimicrobial activity.

Aim To measure the effect of an acidified nitrite foam (ANF) on biofilms created by six different microbes.

Methods A novel method of generating, delivering and topically applying NO gas at the point of care was developed using ANF in a mixed bubble foam and was tested in vitro against six common microbial wound pathogens.

Results A single 5-minute topical exposure of the NO bubble gas formulation generated a 5.8-log₁₀ reduction of mature biofilm of Pseudomonas aeruginosa, a 5.1-log₁₀ reduction of Staphylococcus aureus biofilm, a 4.0-log₁₀ reduction of Staphylococcus epidermidis biofilm, a 3.2-log₁₀ reduction of Proteus mirabilis biofilm, a 2.7-log₁₀ reduction of Acinetobacter baumannii biofilm, and a 1.5-log₁₀ reduction of Candida albicans biofilm.

Conclusion The efficacy of a 5-minute treatment of ANF used on biofilms of P. aeruginosa, A. baumannii, S. aureus, C. albicans, P. mirabilis and S. epidermidis was confirmed. The treatment resulted in a significant reduction in colony-forming units per square centimetre (CFU/cm²) comparable to or surpassing other methods of NO gas application, suggesting NO containing foam’s utility as a point of care solution for chronic wounds with elevated bioburden and biofilms where levels of endogenously produced NO may be insufficient for wound healing completion.

Compression therapy (CT) in venous leg ulcer (VLU) treatment has been further investigated, obtaining such favourable results – by improving chronic venous hypertension and enhancing other positive effects in its pathophysiology – that it is currently the cornerstone of its treatment. However, leg ulcers (LU) of non-venous aetiology can also benefit from CT. To date, current contraindications for CT are minimal.  Despite these benefits, only 50 - 60% of these patients receive CT as part of their treatment, resulting in lower healing rates than expected.

Inelastic bandages (IB) and short-stretch bandage (SSB) have multiple benefits in LU and VLU treatment as they provide low resting pressures and high working pressures >60mmHg in standing and walking, improving venous haemodynamics. The aim of this narrative review was to describe the benefits of IB and SSB in the treatment of LU non venous etiology.

We conducted a non-systematic review of literature guided by the Scale for the Quality Assessment of Narrative Articles (SANRA), regarding the benefits of IB and short-stretch bandage (SSB) CT systems in LU non venous etiology. IB are safety systems which can be useful in multiple LU aetiology, including chronic venous hypertension, diabetes, peripheral arterial disease (PAD) and inflammatory diseases, reducing pain, time for wound healing, oedema, exudate, inflammatory process, and sanitary costs. IB and SSB have benefits that other elastic materials are often unable to achieve and, when their knowledge and training are well established, they have been shown to improve LU patient care.

To implement the regional guidelines on the management of diabetic foot (DF) into real practice, the diabetiologists working in the public diabetologic services of the Tuscany Region Health Service launched an bottom-up initiative called Diabetic Foot Valley, aiming in creating a community of practice for DF care in Tuscany, Italy.

The project, started in 2022 with three meetings dedicated to acute, sub-acute and chronic DF, respectively. The outcomes were articulated into amelioration projects (APs) which targeted the critical issues identified by the analysis performed inside the three meetings and which will be carried on in 2023 and 2024.

The outcomes of the APs will be evaluated at the end of their development and compared to the baseline, to evaluate the progress made. The APs already in place are those related to revascularisation, surgical management, local care and networking, with the designing and building of a dedicated electronic platform; others, like those dedicated to offloading, screening and prevention, rehabilitation and follow-up will start in 2024.

The project, endorsed by Regione Toscana and European Wound Management Association (EWMA), will serve as a pilot which can be a point of referral for similar experiences in other European countries for the implementation of the international guidelines on DF.

Background Pressure injuries, commonly referred to as pressure ulcers (PUs) represent a localised damage to the skin and the underlying tissue due to the persistent application of pressure or pressure combined with shear. The aging demographic in developed countries and the rising incidence of chronic diseases calls for a concerted effort to enhance PU management. For that we need epidemiological studies to understand the magnitude of the problem, and they are scarce in the primary care settings.

Aim The study aims to characterise the patients’ suffering from PUs in our healthcare facilities, categorise the wounds based on their location, type, source of origin and duration of treatment. The information gathered will serve as a valuable reference point in devising strategies to enhance care and optimise cost saving.

Methods This observational, non-randomised, cross-sectional study enrolled 54 primary care patients with PUs in the area covered by ACeS Póvoa de Varzim/Vila do Conde (ACeS PVVC), primary healthcare facility in Northern Portugal, conducted during the month of January of 2019.

Results/ findings The study enrolled 54 patients, with a gender distribution of 35.2% males and 64.8% females. The mean age of participants was 82.63±9.92 years. Almost all 96.3% received their treatment at home, and 1.9% in the ambulatory (outpatient) setting. The mean number of pressure ulcers per patient was 1.47±0.73. A total of 29.6% presented with Stage II pressure ulcers, 29.6% with Stage III and 38.9% with Stage IV or unstageable.

Conclusions/ implications for clinical practice The findings of this study serve as a catalyst for further discussion about the effective management of pressure ulcers at the organisational level. The development of effective strategies for assessment, prevention, and intervention for homecare patients requires a comprehensive understanding of the occurrence of pressure ulcers within the community.

Background and aim The care of chronic wounds (CWs) is complex and their management is multifaceted. To manage the clinical manifestations, the performance of a multi-purpose dressing in the management of odour, exudate, pain and healing in patients with CWs attending a wound outpatient clinic was assessed.

Method A case series using descriptive statistics was conducted with 22 consecutive patients with an existing odorous CW attending a wound outpatient clinic. Participants were treated with a multi-purpose dressing.

Results All participants had a complete reduction of their wound odour between the first and the second dressing application (p<0.001). Maceration was reduced or completely eliminated in all exudative wounds (81.8%). All cases decreased in wound size during the study time (mean percentage 45.5%; SD 15.3). Pain was reduced in 55% and unchanged in 45% of wounds.

Conclusion and implication for practice Multi-purpose dressings provide a reduction of wound odour, wound area, as well as maceration area. In addition, the dressing has a more moderate impact on pain reduction.

Background Pain is a significant factor associated with wounds. Its presence can impact on every aspect of an individual, affecting their overall quality of life (QoL) including ability to function, as well as their social and psychological well-being. Holistic approaches that can help to address wound-related pain are vital to improve patient outcomes.

Aim We aimed to review the evidence for the holistic management of wound-related pain in individuals with chronic wounds in order to provide recommendations for healthcare professionals in clinical practice.

Method The L OVE platform was used for the search as wound and burn are in the same search category. L OVE collects systematic reviews retrieved from the systematic reviews database Epistemonikos and allocates them to specific L OVEs and questions. We conducted our search for reviews related to wounds and burns in November 2022. Retrieved titles and abstracts were exported into Rayyan. The search was organised within Rayyan according to the focus for each chapter to retrieve evidence on pain assessment, physical therapies, patient education, psychological approaches, and complementary and alternative approaches. A systematic approach was used by senior experts in wound and pain management for double-blind screening and application of inclusion criteria (chronic wounds and pain) to agree on articles for review. Sources related to acute wounds (including burn injuries) were excluded. The L OVE search was supplemented by narrative reviews of literature identified from the individual systematic reviews and handsearching of relevant sources.

Results Thirty-eight systematic reviews and 27 additional articles were identified providing a total of 65 individual pieces of evidence. The number of reviews and articles included: pain assessment (n=25); physical therapies (n=8); patient education (n=12); psychological approaches (n=2); complementary and alternative approaches (n=18). The literature related to pain assessment highlighted that assessment of wound-related pain is complex and multidimensional. Healthcare providers must determine the most suitable assessment tool for their patients and in doing so consider an individual’s ability to respond to the assessment, as there is no one assessment tool to measure pain, as ‘one size does not fit all’.

In terms of physical therapies, physical exercise is important, although the majority of evidence relates to individuals with venous leg ulcers (VLUs). In relation to management, clinicians need to recognize procedural-related pain, particularly in relation to debridement procedures. There may be a role for topical impregnated dressings and topical anaesthetics in this case. Equally it is important to manage moisture to prevent maceration and reduce the risk of pain from periwound skin irritation (dermatitis). For individuals with malignant fungating wounds (MFW) a combination of therapies to manage symptoms is recommended.

Specific research related to patient education and wound-related pain is lacking, however areas that should be considered include aetiology of the wound and causes of pain, non-pharmacological and pharmacological methods for pain relief, methods for assessing pain relief, as well as impact of pain on QoL. Psychological approaches need to consider the factors associated with pain (attention, cognitions, emotions and emotion regulation and overt behaviour) in order to determine the most appropriate treatment strategy. Evidence to make recommendations for wound-related pain is sparse; however, there may be a role for social models of care and motivation enhancement programmes for individuals with leg ulcers. Additionally, aromatherapy and music therapy may also be helpful. Evidence for other chronic wounds is lacking. There is some evidence to support the role of honey for the management of wound-related pain, specifically the research indicates that the analgesic action may be related to its anti-inflammatory properties. Evidence for traditional Chinese medicine (TCM), plants, low-dose topical steroids and low level-laser therapy was very weak.

Conclusion The experience of wound-related pain  is complex and needs to take into consideration the psychological and social factors that can impact on an individual’s QoL to ensure a holistic approach. Equally the assessment of wound-related pain is complex and multidimensional. Healthcare providers must determine the most suitable assessment tool for their patients and in doing so consider an individual’s ability to respond to the assessment. Management of wound-related pain may require both non-pharmacological and pharmacological approaches and can include dressings and devices. A holistic strategy should also incorporate both education (patient and healthcare professional) and psychological approaches to improve patient outcomes.

Our review has identified a lack of scientific resources on wound-related pain management to make clear recommendations for effective strategies. What is needed are further prospective studies of patients with wound-related pain and different types of non-healing wounds. Such research should be cognisant that a phenomenon as complex as pain must also be examined comprehensively. The phenomenon of pain has a high degree of subjective perception and individuals have different coping strategies, and healthcare professionals need to be mindful of this. The main determinants of wound-related pain management cannot solely be based on the wound symptomatology and the process of care (healing), but also need to consider the individuality of the patient and their current needs.