It is important for caregivers and patients to know which wounds are at risk of prolonged wound healing to enable timely communication and treatment. Available prognostic models predict wound healing in chronic ulcers, but not in acute wounds, that is, originating after trauma or surgery. We developed a model to detect which factors can predict (prolonged) healing of complex acute wounds in patients treated in a large wound expertise centre (WEC). Using Cox and linear regression analyses, we determined which patient- and wound-related characteristics best predict time to complete wound healing and derived a prediction formula to estimate how long this may take. We selected 563 patients with acute wounds, documented in the WEC registry between 2007 and 2012. Wounds had existed for a median of 19 days (range 6-46 days). The majority of these were located on the leg (52%). Five significant independent predictors of prolonged wound healing were identified: wound location on the trunk [hazard ratio (HR) 0·565, 95% confidence interval (CI) 0·405-0·788; P = 0·001], wound infection (HR 0·728, 95% CI 0·534-0·991; P = 0·044), wound size (HR 0·993, 95% CI 0·988-0·997; P = 0·001), wound duration (HR 0·998, 95% CI 0·996-0·999; P = 0·005) and patient's age (HR 1·009, 95% CI 1·001-1·018; P = 0·020), but not diabetes. Awareness of the five factors predicting the healing of complex acute wounds, particularly wound infection and location on the trunk, may help caregivers to predict wound healing time and to detect, refer and focus on patients who need additional attention.
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Thermal injury destroys the physical skin barrier that normally prevents invasion of microorganisms. This and concomitant depression of local and systemic host cellular and humoral immune responses are important factors that contribute to colonization and infection of the burn wound. One of the most common burn wound pathogens is Staphylococcus aureus. Staphylococcus aureus is both a human commensal and a frequent cause of infections leading to mild to life-threatening diseases. Despite a variety of infection control measures, for example patient cohorting and contact precaution at burn centres, S. aureus is still frequently encountered in burn wounds. Colonization with S. aureus has been associated with delayed wound healing, increased need for surgical interventions, and prolonged length of stay at burn centres. In this minireview, we focus on S. aureus nasal carriage in relation to S. aureus burn wound colonization and subsequent infection, and its impact on strategies for infection control. © 2009 Federation of European Microbiological Societies Published by Blackwell Publishing Ltd.
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For deep partial-thickness burns no consensus on the optimal treatment has been reached due to conflicting study outcomes with low quality evidence. Treatment options in high- and middle-income countries include conservative treatment with delayed excision and grafting if needed; and early excision and grafting. The majority of timing of surgery studies focus on survival rather than on quality of life. This study protocol describes a study that aims to compare long-term scar quality, clinical outcomes, and patient-reported outcomes between the treatment options. A multicentre prospective study will be conducted in the three Dutch burn centres (Rotterdam, Beverwijk, and Groningen). All adult patients with acute deep-partial thickness burns, based on healing potential with Laser Doppler Imaging, are eligible for inclusion. During a nine-month baseline period, standard practice will be monitored. This includes conservative treatment with dressings and topical agents, and excision and grafting of residual defects if needed 14–21 days post-burn. The subsequent nine months, early surgery is advocated, involving excision and grafting in the first week to ten days post-burn. The primary outcome compared between the two groups is long-term scar quality assessed by the Patient and Observer Scar Assessment Scale 3.0 twelve months after discharge. Secondary outcomes include clinical outcomes and patient-reported outcomes like quality of life and return to work. The aim of the study is to assess long-term scar quality in deep partial-thickness burns after conservative treatment with delayed excision and grafting if needed, compared to early excision and grafting. Adding to the ongoing debate on the optimal treatment of these burns. The broad range of studied outcomes will be used for the development of a decision aid for deep partial-thickness burns, to fully inform patients at the point of consent to surgery and support optimal person-centred care.
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In recent years, the effects of the physical environment on the healing process and well-being have proved to be increasingly relevant for patients and their families (PF) as well as for healthcare staff. The discussions focus on traditional and institutionally designed healthcare facilities (HCF) relative to the actual well-being of patients as an indicator of their health and recovery. This review investigates and structures the scientific research on an evidence-based healthcare design for PF and staff outcomes. Evidence-based design has become the theoretical concept for what are called healing environments. The results show the effects on PF and staff from the perspective of various aspects and dimensions of the physical environmental factors of HFC. A total of 798 papers were identified that fitted the inclusion criteria for this study. Of these, 65 articles were selected for review: fewer than 50% of these papers were classified with a high level of evidence, and 86% were included in the group of PF outcomes. This study demonstrates that evidence of staff outcomes is scarce and insufficiently substantiated. With the development of a more customer-oriented management approach to HCF, the implications of this review are relevant to the design and construction of HCF. Some design features to consider in future design and construction of HCF are single-patient rooms, identical rooms, and lighting. For future research, the main challenge will be to explore and specify staff needs and to integrate those needs into the built environment of HCF.
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Background: The use of patient-reported outcomes to improve burn care increases. Little is known on burn patients’ views on what outcomes are most important, and about preferences regarding online Patient Reported Outcome Measures (PROMs). Therefore, this study assessed what outcomes matter most to patients, and gained insights into patient preferences towards the use of online PROMs. Methods: Adult patients (≥18 years old), 3–36 months after injury completed a survey measuring importance of outcomes, separately for three time periods: during admission, short-term (< 6 months) and long-term (6–24 months) after burn injury. Both open and closed-ended questions were used. Furthermore, preferences regarding the use of patient-reported outcome measures in burn care were queried. Results: A total of 140 patients were included (response rate: 27%). ‘Not having pain’ and ‘good wound healing’ were identified as very important outcomes. Also, ‘physical functioning at pre-injury level’, ‘being independent’ and ‘taking care of yourself’ were considered very important outcomes. The top-ten of most important outcomes largely overlapped in all three time periods. Most patients (84%) had no problems with online questionnaires, and many (67%) indicated that it should take up to 15 minutes. Patients’ opinions differed widely on the preferred frequency of follow-up. Conclusions: Not having pain and good wound healing were considered very important during the whole recovery of burns; in addition, physical functioning at pre-injury level, being independent, and taking care of yourself were deemed very important in the short and long-term. These outcomes are recommended to be used in burn care and research, although careful selection of outcomes remains crucial as patients prefer online questionnaires up to 15 minutes.
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In this chapter, we propose that the democracy we wish to see out in the world is influenced by the quality of our own “inner democracies”—that is: the quality of the democracies among and between the selves or voices in the landscape of the self. We must find ways out of the I-prisons we experience and perpetuate. With this in mind, we propose that ”writing the self,” a method whereby creative, expressive, and reflective writing is used to cultivate an internal dialogue and construct a new identity narrative (Lengelle, 2014), can assist in reshaping our stories about ”the Other and ourselves” and can contribute to personal and cultural healing and reconciliation. The inner dialogue reconciled is foundational for the external dialogue at the heart of global citizenship within education. Indeed, as Schellhammer argues, we must cultivate the self in order to become inter-culturally competent, and this includes facing shadow aspects through truthful dialogues with the self and caring for the self. https://doi.org/10.1007/978-3-319-62861-5_6 LinkedIn: https://www.linkedin.com/in/reinekke-lengelle-phd-767a4322/
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Objectives: In patients with burns an early accurate diagnosis of burn depth is essential to determine optimal treatment. The combination of Laser Doppler imaging (LDI) and clinical assessment leads to an accurate estimate of burn depth. However, the actual effects of the introduction of LDI on therapeutic decisions, clinical outcomes and costs are unknown. The aim of our study was to analyse the effectiveness and cost-effectiveness of LDI in burn care. The effects of LDI on decision-making, clinical outcomes, costs, and cost-effectiveness were assessed. Methods: A randomised controlled trial was conducted in all three Dutch burn centres, including subsequent patients with burns of indeterminate depth. In the standard care (SC) group, burn depth and treatment choices were based on clinical assessment only, in the other group (LDI) clinical assessment and LDI results were combined. Primary outcome was the effect of the introduction of LDI on wound healing time. The economic evaluation was performed from a societal perspective with a bottom up approach, following the micro-costing method. Results: Mean time to wound healing from randomisation was 14.3 days in the LDI group and 15.5 days in the SC group (p= 0.258). In the subgroup of clinical patients requiring surgery earlier decision for surgery and a shorter wound healing time were observed in the LDI group (16.0 versus 19.9 days, p= 0.029). Mean total costs per patient were € 18 549 versus € 18 896 (p= 0.837). Conclusions: LDI proved to provide guidance for therapeutic decisions with a significantly shorter wound healing time in the subgroup of clinical patients requiring surgery. When time to surgery can be reduced by 2.4 days, similar to the time to decision for surgery in our study, cost savings of € 794 per scanned patient can be achieved.
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Introduction: Patient information holds an important role in knee arthroplasty surgery regarding patients’ expectations and outcomes after surgery. The purpose of the present study was to explore the experiences and opinions of patients undergoing knee arthroplasty (KA) surgery on an information brochure provided preoperatively. Methods: A qualitative case study of 8 patients using individual semi-structured interviews was conducted to explore patients’ opinions on an information brochure in KA surgery. Results: Patients rated the brochure as good and recommended its use. Unsatisfactory information regarding wound healing, pain expectations, postoperative exercises and use of walking aids was reported. Patients stated that the table of contents was insufficient and the size of the brochure (A4-format) too large. Patients reported to have no need for additional digital sources (e.g. applications, websites). Conclusion: These opinions support the use of an information brochure. The reported opinions were used to improve the brochure. Future research should focus on the improvement of information sources by involving patients (and other users) in the development process in which the information is tailored towards patient needs.
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BACKGROUND: Hyperbaric oxygen therapy (HBOT) is used as a treatment for acute wounds (such as those arising from surgery and trauma). However, the effects of HBOT on wound healing are unclear. OBJECTIVES: To determine the effects of HBOT on the healing of acute surgical and traumatic wounds.SEARCH METHODS: We searched the Cochrane Wounds Group Specialised Register (searched 9 August 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12); Ovid MEDLINE (2010 to July Week 5 2013); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, August 08, 2013); Ovid EMBASE (2010 to 2013 Week 31); EBSCO CINAHL (2010 to 8 August 2013).SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing HBOT with other interventions such as dressings, steroids, or sham HOBT or comparisons between alternative HBOT regimens.DATA COLLECTION AND ANALYSIS: Two review authors conducted selection of trials, risk of bias assessment, data extraction and data synthesis independently. Any disagreements were referred to a third review author. MAIN RESULTS: Four trials involving 229 participants were included. The studies were clinically heterogeneous, which precluded a meta-analysis.One trial (48 participants with burn wounds undergoing split skin grafts) compared HBOT with usual care and reported a significantly higher complete graft survival associated with HBOT (95% healthy graft area risk ratio (RR) 3.50; 95% confidence interval (CI) 1.35 to 9.11). A second trial (10 participants in free flap surgery) reported no significant difference between graft survival (no data available). A third trial (36 participants with crush injuries) reported significantly more wounds healed (RR 1.70; 95% CI 1.11 to 2.61), and significantly less tissue necrosis (RR 0.13; 95% CI 0.02 to 0.90) with HBOT compared to sham HBOT. The fourth trial (135 people undergoing flap grafting) reported no significant differences in complete graft survival with HBOT compared with dexamethasone (RR 1.14; 95% CI 0.95 to 1.38) or heparin (RR 1.21; 95% CI 0.99 to 1.49).Many of the predefined secondary outcomes of the review were not reported. All four trials were at unclear or high risk of bias.AUTHORS' CONCLUSIONS: There is a lack of high quality, valid research evidence regarding the effects of HBOT on wound healing. Whilst two small trials suggested that HBOT may improve the outcomes of skin grafting and trauma, these trials were at risk of bias. Further evaluation by means of high quality RCTs is needed.
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BackgroundHyperbaric oxygen therapy (HBOT) is used to treat various wound types. However, the possible beneficial and harmful effects of HBOT for acute wounds are unclear.MethodsWe undertook a systematic review to evaluate the effectiveness of HBOT compared to other interventions on wound healing and adverse effects in patients with acute wounds. To detect all available randomized controlled trials (RCTs) we searched five relevant databases up to March 2010. Trial selection, quality assessment, data extraction, and data synthesis were conducted by two of the authors independently.ResultsWe included five trials, totaling 360 patients. These trials, with some methodologic flaws, included different kinds of wound and focused on different outcome parameters, which prohibited meta-analysis. A French trial (n = 36 patients) reported that significantly more crush wounds healed with HBOT than with sham HBOT [relative risk (RR) 1.70, 95% confidence interval (CI) 1.11–2.61]. Moreover, there were significantly fewer additional surgical procedures required with HBOT (RR 1.60, 95% CI 1.03–2.50), and there was significantly less tissue necrosis (RR 1.70, 95% CI 1.11–2.61). In one of two American trials (n = 141) burn wounds healed significantly quicker with HBOT (P < 0.005) than with routine burn care. A British trial (n = 48) compared HBOT with usual care. HBOT resulted in a significantly higher percentage of healthy graft area in split skin grafts (RR 3.50, 95% CI 1.35–9.11). In a Chinese trial (n = 145) HBOT did not significantly improve flap survival in patients with limb skin defects.ConclusionsHBOT, if readily available, appears effective for the management of acute, difficult to heal wounds.
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