Healing Trajectory Research Articles

Faster Than Projected Healing in Chronic Venous and Diabetic Foot Ulcers When Treated with Intact Fish Skin Grafts Compared to Expected Healing Times for Standard of Care: An Outcome-Based Model from a Swiss Hospital.

Purpose: Inadequate response to wound management is defined as a reduction in the wound area of <40-50% following four weeks of standard of care (SOC) and should be managed with a skin substitute product. We set out to evaluate a novel outcome-based model focusing on the management of hard-to-heal venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs) using SOC treatment or intact fish skin grafts (FSGs) in a regional hospital. Methods: We built an outcome-based model applying surrogate markers and endpoints of wound healing for VLU and DFU to determine the healing trajectory with SOC treatment. We could predict if VLU and DFU would heal by weeks 20 and 24, respectively, after four weeks of evaluating the initial wound area reduction. 51 patients were recruited (26 VLUs and 25 DFUs) and 42 wounds were randomized. 17 wounds deemed unlikely to heal by week 8 received management with FSG as per the Swiss Society for Dermatology and Venereology (SGDV) and the Swiss Association for Woundcare (SAfW) guidelines for the use of skin replacement products, and 26 wounds continued SOC for weeks 5-8. Results/Discussion: 12 wounds managed with FSG beat the modeled SOC healing predictions, with the majority healed >50% sooner and as early as <10% of the time than was predicted. Of these 17, five wounds failed to achieve the required size reduction in Week 4-8 (over 25% improvement in wound area vs. SOC). The FSG were assigned to treatment-resistant VLU and DFUs and were still able to heal these wounds most of the time and even changed the wound's healing trajectory that increased in size in the initial four weeks. Conclusion: This pilot study showed that management with FSG results in faster healing wounds than SOC predicted, while SOC-treated wounds mostly followed model predictions.

Engrained with modernity: commodification, medicalisation, and cross-border medical travel for health care in Nepal

Biomedicine was introduced in Nepal by Christian Missionaries en route to Tibet and China. When Nepal entered the democratic era in the early 60s, a considerable influx of biomedicine was brought into Nepal by the modernizing state as part of the promise of national development. After the 60s, biomedicine expanded in Nepal mainly through private sector involvement. This had consequences in the health-care domain in Nepal including the commodification of health-care services and increasing medicalization. The practice and expansion of biomedicine is also closely associated with its social and cultural mediation. This article focuses to examine how the macro process of health development shaped the medical practices, especially the healing trajectories and cross-border medical travel of Maithili Brahmin women from Nepal’s Tarai. This article shows that the three prominent avenues of health-care services, namely, medicalization, commodification, and cross-border medical travel predominant in the study area, are thriving and intertwined in such a way that they are reciprocally strengthening each other. This article is based on primary ethnographic data generated from field research conducted in a social cluster among the women from Nepal’s Tarai.

20 Autologous Meshed Split Thickness Graft Healing in Interstice versus Grafted Sites: A Histological Characterization

IntroductionAutologous skin grafting is a common technique used in the treatment of full thickness (FT) wounds to aid in healing, wound closure, and reducing the likelihood of developing hypertrophic scarring. Meshed split thickness skin grafts (mSTSG) which contain portions of the dermis and epidermis are the gold standard for the treatment of FT wounds because they allow for expansion of skin taken from a relatively small donor site. It has largely been hypothesized that in mSTSG skin progenitor cells migrate from the edges of healthy donor tissue to aid in healing the interstices created by meshing. For this reason, meshed wound healing is not homogenous as interstice and meshed sites display distinct healing characteristics. This study aims to characterize the differences between interstice and grafted site healing.MethodsWound healing was evaluated in vivo using Duroc pigs. In this model, 4 animals had 10.16 cm by 10.16 cm full-thickness burns created on bilateral flanks for a total of 12 wounds. On day 2, the burns were excised down to subcutaneous tissue, mSTSG was harvested, meshed 4:1, and applied to the prepared wound beds. Wounds were photographed and sampled on days 5, 9 and, 15. Punch biopsies from either the grafted area or interstice area were taken at each time point, processed, and imaged. Images were used to quantify epidermal and dermal thickness, cellularity, and rete ridges.ResultsEpidermal thickness at day 5 in interstices was significantly thinner than in graft (1.73±4.33µm vs. 75.7±66.1µm, p< 0.05). By day 9, interstice epidermal thickness was comparable to graft thickness (194.9±157.7µm vs. 199.5±117.7µm). On the other hand, dermal thickness was elevated in the interstice at days 9 (1850.4±642.0µm vs. 1277.6±652.0µm, p< 0.05) and 15 (2469.9±626.14µm vs. 1660.7±674.6µm, p< 0.01) to a significant degree. Cellularity was greater at all time points in the interstice compared to the grafted sites. Similarly, rete ridge ratios (RRR) were significantly greater in the grafted areas at day 5 (0.0±0.0µm v.s. 1.0±0.7µm, p< 0.01) and day 9 (1.32±1.2µm vs. 1.9±0.45µm, p< 0.05).ConclusionsThese data show that within a grafted burn wound, healing is a dynamic and heterogenous process when looking at interstice and graft sites, respectively. Grafted sites were thinner throughout, showed decreased inflammatory cell infiltrate, and exhibited higher RRR. Thicker tissue layers and upregulated cellularity in interstices point to a wound healing trajectory that is slower than grafted sites, even by the time wounds are fully re-epithelized.

The clinical impact of hydro-responsive dressings in dynamic wound healing: Part II.

Over the course of a wound's healing trajectory, whether the wound is acute or hard-to-heal, management is likely to involve the use of several different dressing types. Minimising the complexity of treatment (in terms of dressing usage) would aid clinicians in providing effective wound care but excellent clinical outcomes must remain the primary goal. This study was an open-labelled, non-comparative study assessing the clinical effectiveness of a coordinated wound dressing treatment regimen. After an initial phase of using a hydro-responsive wound dressing (HydroClean, HRWD-1, PAUL HARTMANN AG, Germany) to cleanse and debride hard-to-heal wounds, the wounds were subsequently treated with either HydroTac (HRWD-2, PAUL HARTMANN AG, Germany) (to maintain healing progression and re-epithelialisation) or RespoSorb (a superabsorbent dressing, PAUL HARTMANN AG, Germany) (to manage moderate-to-high levels of exudate). The Pressure Ulcer Scale for Healing (PUSH) assessment tool was used to measure the wound status over the course of the treatment period and to assess several wound status parameters (for example, wound area, exudate levels and wound characteristics such as level of re-epithelialisation). The results from this study demonstrated that wounds treated with HRWD-2 showed a positive healing response when using the PUSH score assessment tool with a significant mean reduction (p<0.0001) in the PUSH score of wounds treated with HRWD-2, with >75% of wounds being closed by the end of the study. This result underlines the effectiveness of HRWD-2 in supporting healing progression. The results from this study support the coordinated use of HRWDs for the effective management and treatment of a variety of hard-to-heal wounds.

The Effect of a Biofilm-disrupting Wound Gel vs. a Broad-spectrum Antimicrobial Ointment on a Chronic Wound Microbiome: A Secondary Analysis Associating Clinical and Laboratory Findings

Advancement in wound bioburden diagnostics continues to evolve highlighting the need to link laboratory findings to clinical practice. This study aims to determine if laboratory data from a previously published study supports a correlation between use of a novel biofilm-disrupting wound gel and lower bacterial bioburden, wound size reduction, and improved healing. This is a secondary data analysis of a multicenter, prospective, randomized, open-label clinical trial performed from September 2014 through March 2016. The trial compares treatment outcomes of standard of care either with a wound gel (experimental) or triple-antibiotic maximum-strength ointment (control) looking at differences in bioburden measured at time zero (baseline) and after 4 weeks of treatment. Quantitative real-time PCR testing for bacteria and fungi, including testing for resistance factors to vancomycin and methicillin or using proprietary genetic sequencing, was used for analysis. Low or medium bacterial load at baseline correlated to an average reduction in wound size of 40% and 24%, respectively, whereas there was a 19% increase in size among wounds with a high bioburden. Reducing wound bioburden could result in a clinically relevant change in the healing trajectory. In this study, wound size reduction and increased healing percentages were superior in the experimental group.

Image-Based Artificial Intelligence in Wound Assessment: A Systematic Review.

Significance: Accurately predicting wound healing trajectories is difficult for wound care clinicians due to the complex and dynamic processes involved in wound healing. Wound care teams capture images of wounds during clinical visits generating big datasets over time. Developing novel artificial intelligence (AI) systems can help clinicians diagnose, assess the effectiveness of therapy, and predict healing outcomes. Recent Advances: Rapid developments in computer processing have enabled the development of AI-based systems that can improve the diagnosis and effectiveness of therapy in various clinical specializations. In the past decade, we have witnessed AI revolutionizing all types of medical imaging like X-ray, ultrasound, computed tomography, magnetic resonance imaging, etc., but AI-based systems remain to be developed clinically and computationally for high-quality wound care that can result in better patient outcomes. Critical Issues: In the current standard of care, collecting wound images on every clinical visit, interpreting and archiving the data are cumbersome and time consuming. Commercial platforms are developed to capture images, perform wound measurements, and provide clinicians with a workflow for diagnosis, but AI-based systems are still in their infancy. This systematic review summarizes the breadth and depth of the most recent and relevant work in intelligent image-based data analysis and system developments for wound assessment. Future Directions: With increasing availabilities of massive data (wound images, wound-specific electronic health records, etc.) as well as powerful computing resources, AI-based digital platforms will play a significant role in delivering data-driven care to people suffering from debilitating chronic wounds.

Synthesizing time-series wound prognosis factors from electronic medical records using generative adversarial networks

Wound prognostic models not only provide an estimate of wound healing time to motivate patients to follow up their treatments but also can help clinicians to decide whether to use a standard care or adjuvant therapies and to assist them with designing clinical trials. However, collecting prognosis factors from Electronic Medical Records (EMR) of patients is challenging due to privacy, sensitivity, and confidentiality. In this study, we developed time series medical generative adversarial networks (GANs) to generate synthetic wound prognosis factors using very limited information collected during routine care in a specialized wound care facility. The generated prognosis variables are used in developing a predictive model for chronic wound healing trajectory. Our novel medical GAN can produce both continuous and categorical features from EMR. Moreover, we applied temporal information to our model by considering data collected from the weekly follow-ups of patients. Conditional training strategies were utilized to enhance training and generate classified data in terms of healing or non-healing. The ability of the proposed model to generate realistic EMR data was evaluated by TSTR (test on the synthetic, train on the real), discriminative accuracy, and visualization. We utilized samples generated by our proposed GAN in training a prognosis model to demonstrate its real-life application. Using the generated samples in training predictive models improved the classification accuracy by 6.66–10.01% compared to the previous EMR-GAN. Additionally, the suggested prognosis classifier has achieved the area under the curve (AUC) of 0.875, 0.810, and 0.647 when training the network using data from the first three visits, first two visits, and first visit, respectively. These results indicate a significant improvement in wound healing prediction compared to the previous prognosis models.

Extracellular matrix and cellular senescence in venous leg ulcers

High prevalence of non-healing chronic wounds contributes to a huge healthcare burden across the world. Early treatment interventions for non-healing wounds are vital. It was previously shown that accumulation of 15% or more of senescent cells in a chronic wound edge is an indicator that the wound is unlikely to heal. However, determining the presence of senescent cells would require invasive procedures such as tissue biopsies to be taken. In this study, we found a strong correlation between decreased collagen area and presence of senescent cells in human chronic wounds i.e. venous leg ulcer (VLU), diabetic foot ulcer (DFU) and pressure ulcer (PRU). We also report that the lowest collagen levels were found in VLU patients less than 60 years of age, with a persistent wound of > 24 months. Elevated levels of senescent cells were also found in VLU of males. Second harmonic imaging of collagen at the edge of chronic wounds with a handheld multiphoton device could be used to predict the number of senescent cells, indicating if the wound is on a healing trajectory or not. Our data support the use of collagen imaging in cutaneous wound assessment for a faster and non-invasive method to predict cellular senescence and determining wound trajectory of healing.

The contemporary crisis of hallway healthcare: Implications of neoliberal health policy on the rise of emergency overcrowding.

The provision of hallway healthcare is a growing concern within contemporary healthcare systems. Hallway healthcare or hallway medicine is defined as the use of unconventional spaces, such as hallways, to provide patient care in the acute care setting. Negative effects associated with the prevalence of hallway healthcare may hinder the healing trajectory of vulnerable and ageing populations. Nurses have an intimate role in the provision of care and can offer valuable insight for the advocacy of high quality and safe patient care. Moreover, hallway healthcare is associated with the development of suboptimal working conditions that have resulted in negative impacts on the nursing profession. The authors seek to better understand the occurrence of this phenomenon by exploring the development of healthcare policies in relation to the neoliberal tenets of, individualism, free market via deregulation and privatization, and decentralization. This article provides an analysis of the historical evolution of hallway healthcare and neoliberalism. Furthermore, the authors aim to explore and demonstrate how the COVID-19 pandemic has shed light on the inefficiency of neoliberalism ideologies for healthcare. Based on the analysis, the authors shall provide suggestions for nurses and stakeholders to enact meaningful change in an international context.

Investigating the Benefits of Using 3D Camera Technology to Improve Wound Measurements in a Tissue Viability Service: Outcomes of a Pilot Implementation Study

Sub-optimal experience and outcomes for people with stalled wounds is common. Clinicians have limited methods for reliably and accurately measure wounds. Depth measurement is an important indicator of healing, and digital methods of imaging the wound may offer increased accuracy and enable clinical decision-making. This study aimed to implement a Panasonic FZ-M1 toughpad with WoundCareLite software version 1.5.0.0, to enable three-dimensional measurements in Tissue Viability (TV) service. Length, width, and depth measurement were compared with usual manual measurement using a paper ruler alongside a 2D photographic image. Statistical analysis included the comparison of wound dimension measures and a presentation of visual healing trajectories over 4 weeks using run-charts. 30 patients were recruited over five weeks (13 female and 17 male), representing 4% of the usual caseload. Manual measurement and 3D software automatic method demonstrated that the width and depth 3D auto measures were more accurate than manual measures but depth measures were often wrong thus making volumetric measures inaccurate. Consistent wound size measurement was feasible, and healing trajectories provide a useful means of continuous assessment. Technology guided measurement has potential benefits over manual measurement as a means of more accurately monitoring healing. In this case, depth measurement could not be accurately assessed in practice and further software innovation is indicated to enable outcome measurement in tissue viability services.

Medical-Grade Honey as an Alternative Treatment for Antibiotics in Non-Healing Wounds-A Prospective Case Series.

Non-healing wounds are usually colonised by various types of bacteria. An alternative to antibiotic treatment in patients with infected wounds with local signs of inflammation may be medical-grade honey (MGH), which favourably affects the healing process with its antimicrobial, antioxidant, anti-inflammatory, and immunomodulatory properties. The objective of this study was to evaluate the effect of MGH therapy on the healing process of non-healing wounds of various aetiologies and different wound colonisations. Prospective, observation–intervention case studies (n = 9) of patients with wounds of various aetiologies (venous leg ulcers, diabetic foot ulcers, surgical wound dehiscence) are presented. All wounds were treated with MGH and the healing trajectory was rigorously and objectively monitored. In all cases, pain, odour, and exudation were quickly resolved, which led to an improvement in the quality of life of patients. Despite the proven bacterial microflora in wounds, antibiotic treatment was not necessary. The effects of MGH alleviated the signs of local infection until their complete elimination. In eight out of nine cases, the non-healing wound was completely healed. MGH has antimicrobial, anti-inflammatory, and antioxidant effects in wounds of various aetiologies and forms an effective alternative for the use of antibiotics for treating locally infected wounds.

“What me is”: Insomnia Cures, Saintly Miracles, and Chaucer’s Book of the Duchess as Illness Narrative

Unlike its immediate sources, French dits amoureux by Guillaume de Machaut and Jean Froissart that privilege love adventure, Chaucer’s Book of the Duchess is centrally concerned with illness and healing and the ways that they shape embodied experience. The medicalized attention Chaucer’s poem brings to the narrator’s insomnia in particular reveals connections to both contemporary natural philosophy and hagiographic miracle collections, which sometimes included insomnia among conditions cured through saintly intervention. In the Book of the Duchess, sleeplessness is a canvas for an immersive meditation on the body, its creative processes, and problems of identity, or “what me is” (line 31). Looking beyond the French courtly register that has dominated critical interpretation, this essay reframes Chaucer’s poem in its contemporary intellectual context as an early instance of “illness narrative,” drawing methodological support from theories of intertextuality as well as the sociology and ethnography of illness. The poem’s healing trajectory, differently relevant to the dreamer, the Man in Black, and White, ultimately affirms the communicative movement from self to other and the therapeutic value of empathy as necessary conditions for the poet’s creative agency.

Thermal imaging potential and limitations to predict healing of venous leg ulcers

Area analysis of thermal images can detect delayed healing in diabetes foot ulcers, but not venous leg ulcers (VLU) assessed in the home environment. This study proposes using textural analysis of thermal images to predict the healing trajectory of venous leg ulcers assessed in home settings. Participants with VLU were followed over twelve weeks. Digital images, thermal images and planimetry of wound tracings of the ulcers of 60 older participants was recorded in their homes by nurses. Participants were labelled as healed or unhealed based on status of the wound at the 12th week follow up. The weekly change in textural features was computed and the first two principal components were obtained. 60 participants (aged 80.53 ± 11.94 years) with 72 wounds (mean area 21.32 ± 51.28cm2) were included in the study. The first PCA of the change in textural features in week 2 with respect to week 0 were statistically significant for differentiating between healed and unhealed cases. Textural analysis of thermal images is an effective method to predict in week 2 which venous leg ulcers will not heal by week 12 among older people whose wounds are being managed in their homes.

Feeling at Home in the Clinic: Therapeutic Dwelling in an Addiction Rehabilitation Center in Tehran, Iran

AbstractThis article describes community life in a free residential rehabilitation center for women in Tehran, Iran. In a social context that stigmatizes drug use, especially by women, this rehabilitation center provides poor and homeless drug users a much‐needed opportunity to engage in recovery. I argue that the treatment team's emphasis on “therapeutic dwelling” had significant ramifications on the rehabilitation outcomes of their patients. I use the term “therapeutic dwelling” to refer to a patient's ability to form mutual relations of care and concern with others in therapeutic settings. A therapeutic culture that emphasizes dwelling can have multiple effects on the healing trajectories of patients. It can create a supportive community that extends the rehabilitation process while also further marginalizing patients who are unable to properly exhibit care toward others. Ultimately, this article highlights that dwelling should be approached as a malleable—rather than a purely positive—form of sociality that has the power to both exclude and welcome, to provide and withhold personal connection and intimacy

Functional Imaging in Wounds: Imaging Modalities of Today and Tomorrow

Wound care is a multidisciplinary field with significant economic burden to our healthcare system. Not only does wound care cost the US healthcare system $20 billion annually, but wounds also remarkably impact the quality of life of patients; wounds pose significant risk of mortality, as the five-year mortality rate for diabetic foot ulcers (DFUs) and ischemic ulcers is notably higher compared to commonly encountered cancers such as breast and prostate. Although it is important to measure how wounds may or may not be improving over time, the only relative “marker” for this is wound area measurement—area measurements can help providers determine if a wound is on a healing or non-healing trajectory. Because wound area measurements are currently the only readily available “gold standard” for predicting healing outcomes, there is a pressing need to understand how other relative biomarkers may play a role in wound healing. Currently, wound care centers across the nation employ various techniques to obtain wound area measurements; length and width of a wound can be measured with a ruler, but this carries a high amount of inter- and intrapersonal error as well as uncertainty. Acetate tracings could be used to limit the amount of error but do not account for depth, thereby making them inaccurate. Here, we discuss current imaging modalities and how they can serve to accurately measure wound size and serve as useful adjuncts in wound assessment. Moreover, new imaging modalities are also discussed and how up-and-coming technologies can provide important information on “biomarkers” for wound healing.

Partners Taking Turns Leaning In and Leaning Out: Trusting in the Healing Arc of Attachment Dynamics following Betrayal

Betrayal trauma threatens pair-bond attachment relationships. Across a trajectory of repair and healing, offenders and aggrieved partners manifest distinct trajectories, with asynchronous progression and timelines. Without careful intervention, their colliding trajectories may preclude repair and healing, producing instead corrosive interaction and relationship disintegration. We focus on attachment-organized responses designed to safeguard the relationship as partners alternate “leaning in” and “leaning out” of the relationship. We specifically profile the situation of initial offending partner ambivalence. Our attachment-informed model of couple repair and healing following betrayal trauma describes four phases, key developmental tasks, and attachment dynamics related to couples’ asynchronous healing trajectories. Although betrayal trauma can lead to relationship dissolution, couples can heal (a) as both partners work together to navigate one partner’s “leaning out” with the other partner’s “leaning in” responses, (b) as offenders choose to be accountable, witness their partner’s pain, and make amends, (c) as aggrieved partners intentionally process the offense through benevolent indignation, and (d) as both address relationship deficits and needs. A clinical vignette depicts the couple experience, and we then discuss the associated relationship dynamics and suggest clinical responses related to each phase.

A pragmatic randomised controlled clinical study to evaluate the use of silicone dressings for the treatment of skin tears.

One of the most common types of skin breakdown in ageing populations is skin tears. The International Skin Tear Advisory Panel advocates for special attention to be paid to dressing selection related to skin tear management. The panel recommends choosing dressings that will promote the maintenance of moisture balance, suit the local wound environment, protect peri‐wound skin, control or manage exudate and infection, and optimise caregiver time. It is paramount that dressings protect the fragile nature of the skin associated with those who at heightened risk for skin tear development. To compare the effectiveness of soft silicone dressings (a contact layer and/or foam) for the healing of skin tears with local practices that do not include soft silicone dressings. The study was a pragmatic randomised controlled prospective study. One hundred and twenty‐six individuals from two long‐term care facilities in Ontario Canada who presented with skin tears were randomised into the treatment group using either soft silicone dressings (a contact layer and/or foam) or the control group using non‐adhesive dressings. The current study demonstrated that 96.9% (n = 63) of skin tears in the treatment group healed over a 3‐week period compared with 34.4% (n = 21) in the control group. The proportion of wound healing experienced at week 2 was 89.2% (n = 58) in the treatment group compared with 27.9% (n = 17) in the control group. There was a significantly greater reduction in wound surface area relative to baseline in the treatment group (2.9 cm2) compared with the control group (0.6 cm2) (χ 2 = 21.792 P < .0001) at week 1. Survival analysis data supported that skin tears healed 50% faster in the treatment group (11 days) compared with the control group (22 days) (χ 2 = 59.677 P < .0001). The expected healing trajectory of acute wounds, including skin tears, if proper wound bed preparation is realised and infection is controlled, is 7 to 21 days. Results of this study suggest the use of silicone dressings support wound healing and aid in wound closure within the expected healing trajectory, with faster complete wound closure and mean healing times compared with non‐silicone dressing for the treatment of STs.

A prospective clinical trial evaluating changes in the wound microenvironment in patients with chronic venous leg ulcers treated with a hypothermically stored amniotic membrane.

Amniotic tissues have been long utilised to treat chronic wounds; however, there are few studies evaluating how the wound microenvironment responds to these therapies. The goal of this study was to evaluate the changes in wounds treated with a hypothermically stored amniotic membrane (HSAM). In this prospective single‐arm study, 15 female patients with venous leg ulcers were treated with HSAM from male donors and standard of care for 12 weeks. Over the course of the study, wound exudate was collected and evaluated using proteomic microarrays. Biopsies were collected during the course of treatment to detect the presence of HSAM tissue. By 4 weeks, 60% of subjects achieved 50% or greater reduction in wound size, and by 12 weeks, 53% of subjects achieved 100% re‐epithelialization. HSAM DNA was detected in 20% of biopsies as determined by the detection TSPY4, indicating HSAM was no longer present within the wound bed approximately 7 days from the last treatment for the majority of wounds. Proteomic analysis of wound exudate found that wounds on a healing trajectory had significantly higher levels of MMP‐10, MMP‐7, and TIMP‐4 and significantly lower levels of CX3CL1, FLT‐3 L, IL‐1ra, IL‐1a, IL‐9, IL‐2, IL‐3, MCP‐1, and TNF‐b compared with other wounds.

Association of Systemic or Intravitreal Antivascular Endothelial Growth Factor (Anti-VEGF) and Impaired Wound Healing in Pediatric Patients: Collagen to the Rescue.

Bevacizumab is a humanized monoclonal antibody to vascular endothelial growth factor (VEGF) that has been used as a systemic chemotherapy treatment of various malignancies in adults since 2000. It has been used for pediatric patients over the last decade. In addition, bevacizumab is used for neonatal intravitreal administration for retinopathy of prematurity, a major complication of preterm birth, characterized by incomplete and abnormal vascularization of the retina that can lead to retinal detachment and blindness without treatment. The objective of this multiple case series is to report impaired wound healing seen in 3 adolescents and 1 premature neonate receiving bevacizumab and to propose collagen-based dermal template as a choice for the management of such wounds. The 3 adolescents were undergoing treatment of malignancies and developed wound healing complication within weeks of receiving anti-VEGF. The premature neonate experienced an extravasation and had a slow wound healing trajectory after receiving intravitreal administration of bevacizumab for retinopathy of prematurity. All wounds achieved closure following topical treatment with a collagen dermal template. Use of bevacizumab is increasing in the pediatric population. Clinicians should be aware of compromised wound healing and higher likelihood of wound dehiscence after bevacizumab administration. We recommend waiting for at least 4 to 6 weeks between anti-VEGF administration (either systemic or vitreous) and elective surgical procedures, consistent with adult literature recommendations. If patient has an existing wound, we assert that bevacizumab should not be administered until that wound is healed. If wound healing is stalled, we recommend dermal template as a safe and effective accelerator of wound healing.

Initial Experience Combining Negative Pressure Wound Therapy With Autologous Skin Cell Suspension and Meshed Autografts.

The success of autologous split-thickness skin grafts (STSGs) in the treatment of full-thickness burns is often dependent on the dressing used to secure it. Tie-over bolsters have been used traditionally; however, they can be uncomfortable for patients and preclude grafting large areas in one definitive operation. Negative pressure wound therapy (NPWT) is used as an alternative to bolster dressings and may afford additional wound healing benefits. In our center, NPWT has become the dressing of choice for securing STSGs. While the RECELL® system is being used in conjunction with STSGs, it is currently unknown whether autologous skin cell suspensions (ASCS) can be used with NPWT. This report is a retrospective chart review of nine patients treated in this manner. All wounds were almost completely re-epithelialized within 14 days, and their healing was as expected. Wound healing trajectories are shown. There were no significant complications in these patients. This dressing technique can be considered as an option when using ASCS and widely meshed STSG.