The impact of negative-pressure wound therapy with instillation on wounds requiring operative debridement: Pilot randomised, controlled trial.

Presence of bacteria in wounds can delay healing. Addition of a regularly instilled topical solution over the wound during negative-pressure wound therapy (NPWT) may reduce bioburden levels compared with standard NPWT alone. We performed a prospective, randomised, multi-centre, post-market trial to compare effects of NPWT with instillation and dwell of polyhexamethylene biguanide solution vs NPWT without instillation therapy in wounds requiring operative debridement. Results showed a significantly greater mean decrease in total bacterial counts from time of initial surgical debridement to first dressing change in NPWT plus instillation (n = 69) subjects compared with standard NPWT (n = 63) subjects (-0.18 vs 0.6 log10 CFU/g, respectively). There was no significant difference between the groups in the primary endpoint of required inpatient operating room debridements after initial debridement. Time to readiness for wound closure/coverage, proportion of wounds closed, and incidence of wound complications were similar. NPWT subjects had 3.1 times the risk of re-hospitalisation compared with NPWT plus instillation subjects. This study provides a basis for exploring research options to understand the impact of NPWT with instillation on wound healing.

Correlating pre-operative MRI measurements of metatarsal Osteomyelitis with surgical clean margins reveals the need for a one centimeter resection margin.

BACKGROUND: Due to the high incidence of forefoot ulcerations with associated osteomyelitis, there has been an increased demand for partial ray amputations. In order to ensure complete removal of infected metatarsal bone, a clean margin amount is chosen based on the surgeon's intraoperative visual subjective evaluation. The margin is resected and sent to pathology. Currently the literature shows positive proximal margin rates of 35-40%. The purpose of this study was to reduce the rate of positive proximal margins by effectively resecting all infected bone using pre-operative MRI measurements with an added resection margin. METHODS: Twenty-four osteomyelitis positive metatarsals were included in this exploratory study. The distance of proximal osteomyelitic extension within the metatarsal was measured on MRI in centimeters. Intra-operatively, the partial ray amputation cut was determined by adding an extra 0.5 cm resection margin to the MRI measurement. At the study's mid-point, bone histopathology revealed an increase in positive proximal margin rates-so the resection margin was increased to 1 cm. Descriptive outcomes included the mean distance of osteomyelitis propagation, proximal margin rates, as well as diagnostic statistics. RESULTS: After removing the specimens with false positive MRI results, the study sample included 21 metatarsals positive for osteomyelitis. A 0.5 cm resection margin proximal to the osteomyelitis resulted in a 50% positive proximal margin rate. After increasing the resection margin to 1 cm, there was found to be an improved positive proximal margin rate of 9%. Based on MRI findings, the mean distance + standard deviation of osteomyelitis propagation along the metatarsal proximally was 1.81 cm + 0.74 cm. The metatarsal specimen was processed by pathology into multiple pieces and compared to MRI, resulting in MRI sensitivity of 67%, specificity of 74%, positive predictive value of 79%, and negative predictive value of 60%. CONCLUSIONS: By performing a 1 cm resection margin proximal to the metatarsal osteomyelitis the proximal margin rate was reduced to clinically meaningful levels. These preliminary findings support using a 1 cm resection margin when performing any form of metatarsal amputation, to reduce the risk of residual osteomyelitis post-operatively. TRIAL REGISTRATION: St. Luke's Hospital, IRB National Protocol ID SLHN2015-112. Date:1-13-16.

Recent trends in the prevalence of low-dose aspirin use for primary and secondary prevention of cardiovascular disease in the United States, 2012-2015.

Aspirin therapy has been shown to be an effective prevention measure to reduce the risk of new or recurring cardiovascular events. The aim of this study was to provide an epidemiological analysis of low-dose aspirin use for primary and secondary CVD prevention from 2012 to 2015. Estimates of self-reported low-dose aspirin use for primary and secondary CVD prevention were obtained from the National Health Interview Survey for the years 2012-2015. Temporal changes in the prevalence of aspirin use for primary and secondary CVD prevention were assessed using logistic regression. During 2012-2015, 23.3% of respondents self-reported as taking aspirin for primary CVD prevention, decreasing from 23.7% in 2012 to 21.8% in 2015. Also during this period, 8.4% self-reported as taking aspirin for secondary CVD prevention, decreasing from 8.9% in 2012 to 8.2% in 2015. Overall, the prevalence of aspirin use for CVD prevention declined from 32.6% in 2012 to 30.0% in 2015. This study shows that over 30% of the adult population self-reports as taking low-dose aspirin for primary or secondary CVD prevention. Despite the decline in this prevalence over the previous four years, aspirin therapy remains a highly-utilized means of preventing CVD.

Clinical Experience and Best Practices Using Epidermal Skin Grafts on Wounds.

Over the years, autologous skin grafting has been used extensively to achieve wound closure, optimize a functional scar, and improve aesthetic outcomes for the patient. Although a vast majority of the literature is on the use of full-thickness and split-thickness skin grafts, epidermal skin grafts (ESGs) have emerged as a viable option in the reconstructive ladder when only the epidermal layer is needed. These grafts are distinct from other types of autologous skin grafts in that they can be harvested without anesthesia and leave minimal or no scarring at the donor site. In order to explore the use of ESGs in the continuum of primary wound closure, a multidisciplinary expert panel convened in October 2014, in Las Vegas, NV, to review the scientific basis and clinical uses of epidermal grafting. This publication provides an overview of epidermal grafting, recommendations for graft application, and potential roles for its use in wound care and closure.

A clinical review of infected wound treatment with Vacuum Assisted Closure (V.A.C.) therapy: experience and case series.

Over the last decade Vacuum Assisted Closure((R)) (KCI Licensing, Inc., San Antonio, TX) has been established as an effective wound care modality for managing complex acute and chronic wounds. The therapy has been widely adopted by many institutions to treat a variety of wound types. Increasingly, the therapy is being used to manage infected and critically colonized, difficult-to-treat wounds. This growing interest coupled with practitioner uncertainty in using the therapy in the presence of infection prompted the convening of an interprofessional expert advisory panel to determine appropriate use of the different modalities of negative pressure wound therapy (NPWT) as delivered by V.A.C.((R)) Therapy and V.A.C. Instill((R)) with either GranuFoam() or GranuFoam Silver() Dressings. The panel reviewed infected wound treatment methods within the context of evidence-based medicine coupled with experiential insight using V.A.C.((R)) Therapy Systems to manage a variety of infected wounds. The primary objectives of the panel were 1) to exchange state-of-practice evidence, 2) to review and evaluate the strength of existing data, and 3) to develop practice recommendations based on published evidence and clinical experience regarding use of the V.A.C.((R)) Therapy Systems in infected wounds. These recommendations are meant to identify which infected wounds will benefit from the most appropriate V.A.C.((R)) Therapy System modality and provide an infected wound treatment algorithm that may lead to a better understanding of optimal treatment strategies.

Use of negative pressure therapy on closed surgical incisions: a case series.

Multiple patient comorbidities and environmental factors increase the risk of incisional wound complications. The literature suggests that negative pressure therapy (NPT) on clean closed surgical incisions may help reduce the risk of wound infections and other complications. In this case study, NPT was applied in the operating room to clean closed surgical wounds in four high-risk patients (two men, two women) following coronary artery bypass grafting using bilateral internal mammary arteries, transmetatarsal amputation, and abdominal hysterectomy. All wounds healed well. These results and currently available information suggest that prospective, randomized, controlled clinical studies to assess the safety, efficacy, and cost-effectiveness of NPT in the prevention of postoperative wound complications are warranted. In addition, if studies confirm the validity and reliability of the proposed patient grading system discussed, it may help guide use of NPT in postsurgical patients.

 use of negative pressure therapy on closed surgical incisions: a case series.

Multiple patient comorbidities and environmental factors increase the risk of incisional wound complications. The literature suggests that negative pressure therapy (NPT) on clean closed surgical incisions may help reduce the risk of wound infections and other complications. In this case study, NPT was applied in the operating room to clean closed surgical wounds in four high-risk patients (two men, two women) following coronary artery bypass grafting using bilateral internal mammary arteries, transmetatarsal amputation, and abdominal hysterectomy. All wounds healed well. These results and currently available information suggest that prospective, randomized, controlled clinical studies to assess the safety, efficacy, and cost-effectiveness of NPT in the prevention of postoperative wound complications are warranted. In addition, if studies confirm the validity and reliability of the proposed patient grading system discussed, it may help guide use of NPT in postsurgical patients.