Wound Scoring Research Articles

Radial pressure waves mediate apoptosis and functional angiogenesis during wound repair in ApoE deficient mice

This study aims to quantify by intravital microscopy and histological wound scoring the effect of radial pressure wave treatment (RPWT) on murine incisional wound healing. The dorsal skinfold chamber in mice was used for intravital microscopy, whereby an incisional wound was created within the chamber. RPWT to the wound was carried out using a ballistic pressure wave source (EMS Swiss DolorClast). Animals received a dose of 500 pulses at an energy flux rate of 0.1mJ/mm2 and a frequency of 3Hz at day 1, 3, 5, 7, 9, and 11 post wounding. RPW treated and untreated ApoE depleted mice (ApoE−/−) were compared to normal healing wild type animals (WT). The microcirculation of the wound was analyzed quantitatively in vivo using epi-illumination intravital fluorescence microscopy. Tissue samples were examined ex vivo for wound scoring and immunohistochemistry. Upon RPWT total wound score in ApoE−/− mice was increased by 13% (not significant) on day 3, by 37% on day 7 (P<0.05), and by 39% on day 13 (P<0.05) when compared to untreated ApoE−/− mice. Improved wound healing was associated with an increase of functional angiogenetic density by 23% (not significant) on day 5, by 36% on day 7 (P<0.05), and by 41% on day 9 (P<0.05). Following RPWT, on day three we observed enhanced expression of capase-3 (2-fold), proliferating cell nuclear antibody (PCNA, 1,6-fold), and endothelial nitric oxide synthase (eNOS, 2.6-fold), all P<0.05. In conclusion repetitive RPWT accelerated wound healing in ApoE−/− mice by increasing functional neovascular density. In addition our findings strongly suggest that RPW may facilitate the linear progression of wound healing phases by fostering apoptosis.

Sutures versus Sterile Strips for Closure of Ankle Arthroscopy Portals: Prospective Crossover Trial

Either a nylon single suture or adhesive tape in the form of Steri strip are commonly used for the closure of portals in ankle arthroscopy. The purpose of this study was to compare the two methods with regards to their safety, complications and cosmetic result. This was a prospective cross over study of 100 patients who underwent ankle arthroscopy. Materials used for wound closure were either a 3-0 nylon suture or a single Steri strip. Portals were reviewed according to a validated wound scoring system. Parameters such as the age and gender of the patients, the duration of tourniquet use and the use of an intraarticular corticosteroid injection at wound closure were also studied. Ninety-five patients were included in the statistical analysis. No technique was found to be superior in terms of the wound description (p = 0.164), infection grade (p = 0.232), infection treatment (p = 0.557) and the cosmetic appearance (p = 0.371). Seventy-two percent of patients had a good to excellent cosmetic result. There were two cases of infection requiring administration of antibiotics, one from each method of closure. Of the independent parameters, the use of cortisone was related to a lower infection treatment score (p = 0.013). Patients with signs of infection had a shorter total tourniquet time compared to the patients with no infection (p = 0.002). The use of either a single suture or Steri strip in the closure of ankle arthoscopy portals has equivalent results. Both methods were safe with equivalent cosmesis and low infection rates.

A systematic review of scoring systems for diabetic foot ulcers

Foot ulcers are a common and important complication of diabetes. Variation in the clinical presentation of this disease has resulted in a paucity of evidence from comparable studies to guide optimal clinical management. A validated scoring system might help clinicians and researchers in everyday assessment and management of patients or the development and assessment of new therapies. The aim of the present review was to critically appraise the published literature of wound scoring systems for diabetic foot ulcers. An electronic search was performed using the EMBASE and MEDLINE databases from 1966 until 2009 for scoring systems for diabetic foot ulcers. The literature review conformed to PRISMA statement standards. The literature search identified 197 articles, of which 180 were excluded. Eleven scoring systems and six validation or comparative studies are described. Many scoring systems exist for classification of the diabetic foot, few of which have been validated. Detailed scoring systems offer a valuable method for the comparison of data from different diabetic foot centres. Simplistic scoring systems may be used in clinical practice and the choice of scoring system should be determined by the population under study.

Häufigkeit von Wundinfektionen bei Verwendung eines Glycogelverbandes nach PEG-Anlage: Ergebnisse einer kontrollierten Studie

Percutaneous endoscopic gastrostomy (PEG) is the method of choice for long- term artificial enteral feeding. Standardized wound management such as daily dressing changes and local disinfection of the exit site helps to keep complication rates low. New bacteriostatic glycogel wound dressing has not yet been tested. We compared glycogel dressing to the usual method of wound aftercare with regard to wound infections. The standard wound management was compared to glycogel dressing. 100 consecutive patients were investigated in a prospective randomized trial from Aug. 2004 to Jan. 2006 regarding wound infections. We also compared indications for PEG placement, complications other than wound infection, and mortality. The exit site was examined and scored daily using a specific wound scoring system. After 30 days, the patients were followed up by phone calls to determine if any infection had occurred after discharge. During our study, 98 out of 100 patients had a successful PEG procedure performed. Out of these 98 patients, 48 patients received standard wound dressing care and 50 patients used glycogel dressing. The indications for PEG placement were not significantly different between the two groups. A total of 88% of patients (n = 42) with standard wound care had no relevant infection (50%, n = 24 with score 0 or 1; 38%, n = 18 had score 2), 10% (n = 5) presented with serious local infection (score 3) and one patient (2%) had severe infection necessitating PEG removal (score 4). In the group using glycogel dressing, 88% of the patients (n = 44) did not show any relevant sign of infection (54%, n = 27 with score 0 or 1; 34%, n = 17 had score 2), 8% (n = 4) had serious local infection (score 3), 2% (n = 1) had severe infection (score 4) and 2% (n = 1) were lost to follow up. Regarding wound infection rates after PEG placement, glycogel wound dressing was found to be as effective as standard wound dressing. Thus, omitting daily changes of regular wound dressings by using glycogel dressing instead may be advantageous for patients and generally help to decrease overall cost.

Reduction in wound infection rates by wound surveillance with postdischarge follow-up and feedback

Surgical wound surveillance with postdischarge follow-up is rarely done in the UK as it is seen as expensive. The aim of this study was to determine whether employing a dedicated team was effective and reduced costs. Infection data were collected prospectively with postdischarge follow-up at 2-3 months, and fed back to surgeons. Wound infection was defined using both ASEPSIS wound scoring and criteria of the US Centers for Disease Control (CDC) definitions. Over 4 years, 15 548 patient episodes were included. Postdischarge surveillance data were available for 79.9 per cent of the 15 154 records of patients who survived. There was a significant reduction in the rate of wound infection between the first and fourth years by ASEPSIS and CDC definitions: odds ratio 0.77 (95 per cent confidence interval (c.i.) 0.64 to 0.92) and 0.69 (95 per cent c.i. 0.57 to 0.83), respectively. The proportion of infections fell significantly in orthopaedic, cardiac and thoracic surgery. The annual budget for wound surveillance was pound 91,600. Changes in infection rates contributed pound 347,491 to the reduction in cost among the patients surveyed. Wound surveillance was associated with a reduction in rates of wound infection within 4 years. The cost reduction as a result of fewer infections exceeded the cost of surveillance after 2 years.

A clinical model of dermal wound angiogenesis.

Full-thickness dermal biopsies were performed in healthy volunteers to establish the range of angiogenic responses in wound healing in a normal population. Four-millimeter punch biopsies were made in the forearms of 15 healthy volunteers. Each wound was evaluated microscopically 4-5 times per week for 2 weeks. A semiquantitative wound scoring system to evaluate the neovasculature at the wound periphery was investigated. A vascular score was calculated for each wound at each observation. Two independent observers analyzed the microscopic wound images using the scoring system. At the end of the 14-day period, repeat biopsies were performed on some of the volunteers, and the granulation tissue was stained with anti-CD31. The Kaplan-Meier method was used to estimate the distribution of the time to reach predetermined target average vascular scores. A mixed-effects regression model indicated that time, age, and observer were predictors for the average vascular score outcome. The pattern and time course for wound neovascularization was highly reproducible in this group of healthy volunteers, and the assay was feasible and well tolerated. This wound angiogenesis model may be useful for monitoring the effects of antiangiogenic agents on normal wound neovascularization.

Preoperative core needle biopsy as an independent risk factor for wound infection after breast surgery

Objective Diverging findings concerning the rate of postoperative wound infections in patients undergoing breast surgery have been reported, and little is known regarding the possible risk factors for these infections and their relative importance. We assessed risk factors for wound infection, placing particular emphasis on the influence of preoperative procedures such as core needle biopsy. Methods In a prospective evaluation of 326 patients undergoing breast surgery, we identified risk factors for wound infections by univariate analysis and subsequent step-wise multiple logistic regression. Assessment of wound infection was based on a simple wound scoring system. Results Of the 326 patients, 50 (15.3%) developed wound infections. As expected, after univariate analysis a higher proportion of postsurgical infections was observed in patients with diabetes (33.3% versus 14.3%; odds ratio [OR] = 3.00, 95% confidence interval [CI] 1.109, 8.157; P = .03) and malignant tumors (21.2% versus 6.8%; OR = 3.716, 95% CI 1.762, 7.849; P < .001). Patients with wound infections were significantly older than those without (mean age 63.73 versus 51.44 years, P < .001). Surprisingly, patients who underwent core needle biopsy, which in most cases was performed within 1–3 days before breast surgery, were also at significantly higher risk for developing a wound infection (22.3% versus 9.6%; OR = 2.718, 95% CI 1.454, 5.076; P = .001). This effect remained unchanged when controlled for potential confounders by step-wise multiple logistic regression. Conclusion In breast surgery, the independent risk factors for wound infections are older age and preoperative core needle biopsy.

Preoperative Core Needle Biopsy as an Independent Risk Factor for Wound Infection After Breast Surgery

In Brief OBJECTIVE Diverging findings concerning the rate of postoperative wound infections in patients undergoing breast surgery have been reported, and little is known regarding the possible risk factors for these infections and their relative importance. We assessed risk factors for wound infection, placing particular emphasis on the influence of preoperative procedures such as core needle biopsy. METHODS In a prospective evaluation of 326 patients undergoing breast surgery, we identified risk factors for wound infections by univariate analysis and subsequent step-wise multiple logistic regression. Assessment of wound infection was based on a simple wound scoring system. RESULTS Of the 326 patients, 50 (15.3%) developed wound infections. As expected, after univariate analysis a higher proportion of postsurgical infections was observed in patients with diabetes (33.3% versus 14.3%; odds ratio [OR] = 3.00, 95% confidence interval [CI] 1.109, 8.157; P = .03) and malignant tumors (21.2% versus 6.8%; OR = 3.716, 95% CI 1.762, 7.849; P < .001). Patients with wound infections were significantly older than those without (mean age 63.73 versus 51.44 years, P < .001). Surprisingly, patients who underwent core needle biopsy, which in most cases was performed within 1–3 days before breast surgery, were also at significantly higher risk for developing a wound infection (22.3% versus 9.6%; OR = 2.718, 95% CI 1.454, 5.076; P = .001). This effect remained unchanged when controlled for potential confounders by step-wise multiple logistic regression. CONCLUSION In breast surgery, the independent risk factors for wound infections are older age and preoperative core needle biopsy. In breast surgery, the independent risk factors for wound infections are older age and preoperative core needle biopsy.

Effects of an Augmented Postoperative Fluid Protocol on Wound Healing in Cardiac Surgery Patients

Cardiac surgery patients are vulnerable to hypoperfusion postoperatively and often have subcutaneous tissue oxygen tension less than 50 mm Hg. Hypovolemia most likely contributes to this hypoperfusion and may lead to impaired wound healing. To determine if a modified postoperative fluid replacement protocol would result in improved tissue oxygen tension, blood flow, and healing in cardiothoracic surgery patients. A total of 166 cardiac surgery patients, 18 to 90 years old, participated in a randomized, 2-group, repeated-measures study. The experimental group received fluid augmentation during the first 36 hours after surgery; the control group received standard postoperative replacement fluids. Subcutaneous tissue oxygen tension and temperature were measured 8, 18, and 36 hours after surgery. Tissue cellularity and accumulation of hydroxyproline were evaluated in tissue obtained from subcutaneous expanded polytetrafluoroethylene tubes. Wound complications were evaluated by using the ASEPSIS Wound Scoring System. Tissue oxygen levels, tissue cellularity, and accumulation of hydroxyproline were similar in the 2 groups. A negative correlation (P = .01) existed between higher tissue oxygen values and lower (better) ASEPSIS leg wound scores. More than 80% of the patients had tissue oxygen levels of 50 mm Hg or less at each time of measure. Many values were 30 to 40 mm Hg less than the ideal for control of bacteria and healing. The frequency of low oxygen levels is consistent with data from earlier studies. Determination of other interventions to improve subcutaneous tissue perfusion in cardiac surgery patients is needed.

Wound Infections after Cardiac Surgery - a Wound Scoring System may Improve Early Detection

Objective - This study was aimed at describing the early development of wound infections after cardiac surgery to identify markers for upcoming infections. Design - We followed a cohort of 200 patients for 3 months after cardiac surgery to establish the incidence of all types of postoperative infections. Wound healing and C-reactive protein (CRP) were followed for the first 2 weeks. Results - A total of 175 patients out of 200 could be followed up. Using a broad definition of wound infection a total of 30% of the patients had some kind of wound infection. The diagnosis of most infections occurred after the patients had left the cardiac surgery unit (median 12 d after surgery). Our wound scoring method shows significant differences at an early stage between infected and non-infected wounds. At the time of diagnoses CRP was elevated in patients with deep sternal infection. Conclusion - A long follow-up period is needed to establish the true incidence of infection. Wound scoring can give an early indication of wound infections and CRP can help in the diagnoses of deep infections.

Indications for Optical Shape Measurements in Orthopaedics and Dermatology

Summary This paper provides some basic ideas and results concerning the use of optical 3D-shape measurement techniques for medical problems. We focus herein on the structured light technique which seems to be the best method for delivering quantitative results without encumbering the patients. Image acquisition and sophisticated image processing algorithms gain insights into wound healing processes in orthopaedics or into the laser-tissue interaction in dermatology. Finally, an improved therapy or wound scoring, resp. an approved laser treatment might be evaluated from full-field 3D-measurements.

Contact-Free Spectroscopy of Leg Ulcers: Principle, Technique, and Calculation of Spectroscopic Wound Scores

Objective wound monitoring is an essential tool for evidence-based medicine in leg ulcers and other chronic wounds. Non-invasive and contact-free optical remittance spectroscopy seems to be a useful approach as it can provide additional information with respect to more traditional techniques of wound scoring. Twenty-three patients with chronic venous, arterial, and mixed leg ulcers were enrolled in this study. The clinical state of the ulcers was documented by a clinical wound score (quantity, color, and consistency of granulation tissue). The spectroscopic readings were performed with a novel diode-array spectrometer system in the visible and near-infrared range of the spectrum (400-1600 nm) with a resolution of 5 nm. The wound spectra mainly depend on the absorption of hemoglobin and water. The maximum correlation coefficients of mean remittance spectra with the clinical wound scores did not exceed +/- 0.5. Discriminant and cluster analysis were applied for spectral classification of wound scores. By using cross-validation the percentage of correct predicted wound scores was about 69%. Our results indicate that the application of optical visible and near-infrared spectroscopy could be a valuable remedy for the clinician.

The evaluation of wound infection after arterial surgery.

Many of the wound infections that occur after arterial surgery require prolonged attention with frequent changes of dressings. However, the traditional way of reporting wound infections is to only declare the overall incidence of this adverse event. In this study, we have evaluated 302 patients undergoing arterial surgery to determine the relationship between the incidence of wound infection, the length of time that wounds were dressed, and the results of a modified ASEPSIS wound scoring system. The overall incidence of wound infection was 14% (43/302). It was noted that patients with high wound scores had a correspondingly high incidence of conventionally defined wound infections; and, in addition, such patients required dressing changes over prolonged periods. It is concluded that the documentation of both the duration of wound dressings and a wound scoring system are useful tools when evaluating the outcome of patients after arterial surgery.

A prospective study of wound infection in coronary artery surgery

The incidence of wound infection in coronary artery surgery is low, but there is an appreciable mortality associated with sternal infection. In other fields of surgery there is evidence that an all disposable paper gown and drape system has protective advantages over a fabric system. Using an established wound scoring system (ASEPSIS), we investigated this in a prospective, randomised trial of patients undergoing cardiac surgery. 505 patients undergoing isolated coronary artery surgery in a single hospital over an 18 month period were randomised to either a disposable, paper drape system or re-usable fabric drapes. Allocation was stratified according to whether or not the patient had had previous coronary artery surgery. Patients were followed for 3 months. Total infection scores for each wound were calculated from daily scores collected in hospital together with the scores at six weeks and three months. The two randomised groups were otherwise well matched. Full follow-up information was available for 464 (92%) patients. There was no evidence of any difference in rates of sternal or leg wound infection between the two groups (P = 0.87 and 0.62, respectively). Women were more likely to have infected sternal wounds (P = 0.17) and significantly more likely to have infected leg wounds (P = 0.04). Patients with sternal wound infections had a significantly higher body mass index (P = 0.001). High Parsonnet scores and increased time on ventilation were significantly associated with leg wound but not sternal infections. For both wound sites, patients with infections had spent longer in the operating theatre. In a randomised controlled study of patients undergoing coronary artery surgery we found that the use of paper drapes and gowns conferred no benefit over a reusable fabric in terms of post-operative wound infection. Although females and diabetics are more likely to experience this complication, an important additional risk factor is an extended operating time.

Comparison of wound scoring methods for use in audit

Accurate information on the prevalence of surgical wound infection is difficult to obtain; outpatient follow-up is often inadequate. For two months in 1993 and again in 1995, surgical wounds throughout one hospital were examined by the same observer with the intention of comparing different methods for assessing wound infection. Two standard definitions [Centers for Disease Control (CDC), USA and National Prevalence Survey (NFS), UK] were compared with ASEPSIS and the Southampton method. In 1993, 325 wounds in 230 patients were examined with follow-up of 203 (88%) patients. In 1995, 559 wounds were surveyed in 375 patients with follow-up in 364 (97%). Patient groups in the two years were similar. ASEPSIS identified 92 (13%) wounds as having scored over 20 points indicating infection, and another 16·5% having disturbance of healing. There was no significant difference between the two surveys. The two scoring methods were more sensitive than the standard definitions but CDC and NPS did not differ significantly from each other. Between 44 and 47% of clean wounds identified as infected by standard definitions were classed as disturbance of healing by ASEPSIS. All methods were labour-intensive and to implement any one of them on a regular basis would require a full-time investigator. The first surveillance program with feedback of results to the surgeons did not significantly affect the rates two years later.

Evaluation of a wound scoring method for patients undergoing cardiac surgery

The main endpoint of studies evaluating antimicrobial prophylaxis in surgical patients is wound morbidity. This should consist of more than the solitary declaration of the rate of wound infection. In this study, a modified version of ASEPSIS (a wound scoring system) has been prospectively evaluated in 1000 patients undergoing cardiac surgery. Twentyone patients (2·1%) had an infected sternal wound. The components of ASEPSIS most significantly associated with a sternal wound infection were: the presence of a purulent exudate, a postoperative stay >14 days, the identification of pathogenic organisms, and the use of antibiotics ( P < 0·0001). Although ASEPSIS is a useful mechanism for conveying information about wounds, it does ignore bleeding into wounds and the extent that troublesome wounds need to be dressed after surgery.

Surveillance of wound infections

Demands are increasing for accurate rates of wound infection in surgical units. However, definitions vary widely and resources are limited. Wound scoring methods improve objectivity and have the power to show changes with time, but they can be laborious. Without community surveillance, inpatient rates can also be misleading.

The use of the wound scoring method ‘ASEPSIS’ in postoperative wound surveillance

For the purposes of wound surveillance programmes and clinical trials, a wound scoring method, ASEPSIS, makes assessment of wound sepsis more objective and reproducible by allotting points both for the appearance of the wound in the first week and for the clinical consequences of infection. ASEPSIS was compared with other definitions of wound infection in 1029 surgical patients and its suitability for surveillance and detection of risk factors were examined. Satisfactory healing was recorded in 867 patients, disturbance of healing in 74 and minor, moderate and severe wound infection in 41, 24 and 23 patients respectively. An ASEPSIS score over 20 points was more sensitive and as specific as the presence of pus as an indicator of changes in management resulting from infection. Multiple regression analysis of ASEPSIS scores indicated that operation type, ward, degree of contamination, age, body mass index, and preoperative stay in hospital were significant risk factors. In matching 52 infected patients with uninfected controls, any wound score over 10 points was associated with a significant delay in discharge from hospital (median 3 days, P < 0·0005).

Postoperative wound scoring

Assessing postoperative wound sepsis rates is important from both an economic and an audit point of view. Most definitions of wound sepsis are too narrow and too subjective and wound scoring systems that have been developed to counteract these deficiencies suffer from a lack of objectivity, making valid comparisons between wound sepsis rates in different institutions impossible. The ASEPSIS scoring system is a definite advance in this area and its proven reproducibility makes it invaluable in multicentre trials assessing wound sepsis. However, it has limitations, mainly associated with the underlying assumption regarding the linearity of the ASEPSIS index. It is felt that by closely examining ASEPSIS wound scores from a large number of patients it may be possible to improve this scoring system. surgical wound infection/postoperative sepsis (wound)/scoring system

Factors predisposing to wound infection in cardiac surgery. A prospective study of 517 patients.

Postoperative wound infection can greatly prolong hospital stay after cardiac surgery, so the identification of predisposing factors may help in prevention or early institution of treatment. Transfer of organisms from the leg to the sternum during coronary artery surgery has been proposed as a major additional cause of sepsis. The definition of wound infection is not standardised and therefore makes comparison between centres difficult. In a prospective study of 517 patients, a wound scoring method (ASEPSIS) has been used to register all abnormal wounds to maximise the chances of identifying factors predisposing to infection. Abnormal healing was noted in 99 (19%) sternal wounds and 29 (8%) leg wounds. Obesity was the principal risk factor (P less than 0.005). Diabetes, reoperation, length of preoperative hospital stay, age, sex, or previous cardiac surgery had little effect on wound healing. The range of bacteria isolated from chest wounds after coronary artery surgery was similar to that after valvular surgery, but the rate of isolation was significantly greater. With careful attention to technique, leg wound infection rarely presented a clinical problem and did not appear to be a source of bacteria infecting the chest wound.