Effect of nutritional supplements on wound healing in home-nursed elderly: a randomized trial

 Objective: The objective was to determine whether provision of oral nutritional supplements, delivered by community nurses, could improve nutritional status and wound healing in home-nursed elderly. Methods: This was a double-blind, randomized trial in 50 elderly patients referred for wound management. Patients received 237 mL/d of 4 or 8 kJ/mL of an oral nutritional supplement for 4 wk. Nutritional status was measured with the Subjective Global Assessment and the Mini-Mental State Examination questionnaire to determine cognitive function and wound characteristics to assess healing. Differences between variables were examined with the Mann-Whitney or Student's t test for comparing two groups, one-way analysis of variance when there was more than two groups, and chi-square analysis for comparing two categorical variables. Associations between variables were examined with Pearson's correlation and regression analysis. Results: At baseline, 34% subjects were moderately malnourished and 8% were severely malnourished. In both groups, there was significantly greater improvement in Mini-Mental State Examination scores at week 4 (95% confidence interval -2.0 to -0.001, P = 0.04) and a greater decrease in the wound effusion score (95% confidence interval -2.0 to 0.0, P = 0.045). Median length of stay did not differ between groups (P > 0.05). Conclusions: Malnutrition is common in elderly patients who are nursed at home for wound management. Provision of energy- and protein-dense oral supplements by community nurses is effective in improving some indices of wound healing and cognitive function in this group. Although further study is needed to determine the effect on length of stay, the nutritional needs of this vulnerable group should not be overlooked. © 2005 Elsevier Inc. All rights reserved.

Effect of three wound dressings on infection, healing comfort, and cost in patients with sternotomy wounds - a randomized trial

Study objective: To compare three dressing types in terms of their ability to protect against infection and promote healing, patient comfort, and cost-effectiveness.

Design: Prospective, randomized controlled trial.

Setting: Major metropolitan, academically affiliated, tertiary referral center.

Patients: Seven hundred thirty-seven patients were randomized to receive a dry absorbent dressing (n = 243) [Primapore; Smith & Nephew; Sydney, NSW, Australia], a hydrocolloid dressing (n = 267) [Duoderm Thin ConvaTec; Mulgrave, VIC, Australia], or a hydroactive dressing (n = 227) [Opsite; Smith & Nephew] in the operating theater on skin closure.

Results: There was no difference in the rate of wound infection or wound healing between treatment groups. The Primapore dressing was the most comfortable and cost-effective dressing option for the sternotomy wound. Duoderm Thin dressings were associated with increased wound exudate (p < 0.001), poor dressing integrity (p < 0.001), more frequent dressing changes (p < 0.001), more discomfort with removal (p < 0.05), and increased cost (p < 0.001).

Conclusions: In the context of no additional benefit for the prevention of wound infection or the rate of wound healing for any of the three dressing products examined, dry absorbent dressings are the most comfortable and cost-effective products for sternotomy wounds following cardiac surgery.

Effect of an arginine-containing nutritional supplement on pressure ulcer healing in community spinal patients

Objective: To determine whether or not the use of an arginine-containing nutritional supplement could result in signifi cantly shorter pressure ulcer (PU) healing times in people with spinal cord injuries living in the community, compared with a comparative historical control group. Method: Eighteen spinal-cord-injured patients (all part of a hospital spinal outreach service) received 9g of a commercial powdered arginine supplement per day until full PU healing occurred. Healing rates were compared against 17 historical control patients (as assessed by medical history audit). 
Results: Baseline characteristics (age, gender, injury level and time) were similar between groups. Mean ulcer healing times were 10.5 ± 1.3 weeks versus 21 ± 3.7 weeks (p<0.05) in the intervention and control groups respectively. Comparison of healing rates in the intervention group against expected healing rates derived from the medical literature showed that intervention patients had a signifi cantly shorter mean healing time (category 2 PU: 5.5±1.3 weeks versus 13.4 weeks; category 3 PU: 12.5 ± 1.9 weeks versus 18.2 weeks; category 4 PU: 14.4 ± 4.8 weeks versus 22.1 weeks). A diagnosis of diabetes did not significantly alter healing rates in either group. Conclusion: Results from this observational study show a promising benefit of arginine supplementation on PU healing for individuals with spinal cord injury living in the community.

Use of an arginine-enriched oral nutrition supplement in the healing of pressure ulcers in patients with spinal cord injuries : an observational study

Aim: Pressure ulcers are a serious secondary consequence of spinal cord injuries. The objective of the present study was to determine whether an arginine-containing nutritional supplement can reduce the healing time of pressure ulcers in people with spinal cord injuries compared with those not consuming the supplement until full wound healing.

Methods: Thirty-four spinal cord injured patients with a grade 2, 3 or 4 pressure ulcer were prescribed two 237 mL tetrapaks/day of a supplement containing additional protein, arginine, zinc and vitamin C. Pressure ulcer healing was assessed with the Pressure Ulcer Scale for Healing tool.

Results: Twenty patients consumed the nutritional supplement until full pressure ulcer healing had occurred, while 14 patients ceased consuming the supplement before full healing occurred because of intolerance, compliance or taste issues. A 2.5-fold greater rate of healing was observed in patients consuming the supplement until full healing compared with those who ceased taking the supplement (8.5 ± 1.1 weeks vs 20.9 ± 7.0 weeks respectively; P = 0.04). There were no significant differences in age, nutritional status, gender or reason for admission between groups. Comparison of healing rates in the group consuming the supplement to full wound healing against expected rates derived from the medical literature showed a significantly shorter time-to-healing (grade 3 pressure ulcer: 6.5 ± 0.8 weeks vs 18.2 weeks; grade 4: 11.4 ± 2.0 weeks vs 22.1 weeks; P < 0.001).

Conclusion: The present small-scale study demonstrated the potential for specialised wound healing nutritional supplements to shorten the time to pressure ulcer healing in spinal cord injured patients.

The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers

Objective: To investigate if a lower dose of arginine in the form of an oral nutritional supplement can show similar benefit in the healing rate of pressure ulcers compared with the current evidence for 9g of arginine.

Method: Twenty-three inpatients with category II, III or IV pressure ulcers were randomised to receive daily, for 3 weeks, the standard hospital diet plus 4.5 or 9g arginine in the form of a commercial supplement. Pressure ulcer size and severity was measured weekly (by PUSH tool; pressure ulcer scale for healing; 0= completely healed, 17= greatest severity). Nutritional status was determined by Subjective Global Assessment.

Results: There were no significant differences in patients’ age, gender, BMI, haemoglobin levels, albumin levels and diagnosis of diabetes between treatment groups. There was a significant decrease in pressure ulcer severity over time (p < 0.001), with no evidence of a difference in healing rate between the two arginine dosages (p=0.991). Based on expected healing time, patients in both treatment groups were estimated to achieve an almost 2-fold improvement compared with the historical control group. Patients categorised as malnourished showed clinically significant impaired healing rates compared with wellnourished patients (p=0.057), although this was unaffected by arginine dosage (p=0.727).

Conclusion: Similar clinical benefits in healing of pressure ulcers can be achieved with a lower dosage of arginine, which can translate into improved concordance and significant cost-savings for both the health-care facilities and for patients.

Low frequency ultrasound debridement (Sonoca-185) in acute wound management: a case study

There are numerous evidence-based wound debridement techniques that promote wound healing. However, some of these techniques may cause discomfort and pain for the patient and can be costly for the health care provider. A new, non-invasive wound debridement technique known as low-frequency ultrasonic debridement (LFUD) has been used for the removal of unhealthy tissue and bacterial load in wound management in the clinical setting. This paper reports the use of LFUD by a skin integrity clinical nurse consultant (CNC) as an adjuvant wound debridement and healing technique in a patient with a parastomal abscess. LFUD was found to benefit this patient in terms of expedited wound healing and increased comfort, enabling the patient to have a successful skin graft that led to complete wound closure and discharge from hospital in a timely manner.

Rigid removable cover for dorsal wound protection and tube fixation in pigs

Objective To report the design and benefits of a rigid polyethylenecover ‘shell’ for the protection of dorsal torso wounds andtube fixation in pigs.

Methods Open C-shaped polyethylene shells were designed toprotect wounds and dressings on the dorsum of pigs used inresearch into negative pressure dressing-assisted wound healing.The shells were designed to resist trauma and contamination, tobe comfortable and expansible, and to facilitate tube fixation andmanagement. Strap fixation was optimised during experimentation. Efficacy was assessed by direct observation of dressing andwound protection, tube integrity and by macroscopic and microscopicassessments of wound healing.

Results The shells effectively protected the wounds againstblunt and sharp trauma, were simple to remove and reapply, were well tolerated and allowed for growth of the pigs. Circumferentia lneck straps attached by lateral straps to the shells provedcritical. There was no wound infection or inflammation underlyingthe shells. Porting tubing via mid-dorsal holes in the shells andaffixing the tubing just cranial to these holes prevented tubedamage and traction, permitted tube management from outsidethe cages and allowed the pigs to move freely without becomingentangled.

Conclusion These shells effectively protected dorsal skinwounds and dressings, prevented tube damage and facilitatedtube management in pigs. Similar systems may be useful forother production animals for wound management and for tubemanagement with negative pressure wound healing, drain tubesor the delivery of nutrition, fluids or medications.

Zinc deficiency and its inherited disorders - A review

Zinc is an essential trace element required by all living organisms because of its critical roles both as a structural component of proteins and as a cofactor in enzyme catalysis. The importance of zinc in human metabolism is illustrated by the effects of zinc deficiency, which include a diminished immune response, reduced healing and neurological disorders. Furthermore, nutritional zinc deficiency can be fatal in newborn or growing animals. While zinc deficiency is commonly caused by dietary factors, several inherited defects of zinc deficiency have been identified. Acrodermatitis enteropathica is the most commonly described inherited condition found in humans. In several of the few cases that have been reported, this disorder is associated with mutations in the hZIP4 gene, a member of the SLC39 family, whose members encode membranebound putative zinc transporters. Mutations in other members of this family or in different genes may account for other cases of acrodermatitis in which defects in hZIP4 have not been detected. Another inherited form of zinc deficiency occurs in the lethal milk mouse, where a mutation in ZnT4 gene, a member of the SLC30 family of transmembrane proteins results in impaired secretion of zinc into milk from the mammary gland. A similar disorder to the lethal milk mouse occurs in humans. In the few cases studied, no changes in ZnT4 orthologue, hZnT4, were detected. This, and the presence of several minor phenotypic differences between the zinc deficiency in humans and mice, suggests that the human condition is caused by defects in genes that are yet to be identified. Taking into account the fact that there are no definitive tests for zinc deficiency and that this disorder can go undiagnosed, plus the recent identification of multiple members of the SCL30 and SLC39, it is likely that mutations in other genes may underlie additional inherited disorders of zinc deficiency.

Nutrition therapy in the prevention and treatment of pressure ulcers

Pressure ulcers are serious problems within hospital and aged care settings and are associated with adverse health outcomes and high treatment costs. Because of a high incidence of pressure ulcers in the health system, attention is now being directed to not just preventing, but also more effectively treating them. Nutrition plays a fundamental part in wound healing, with malnutrition, dehydration and recent weight loss identified as independent risk factors for the development of pressure ulcers. While the optimal nutrient intake to promote wound healing is unknown, increased needs for energy, protein, zinc and vitamins A, C and E have been documented. There is reasonable evidence to show that nutritional support, mostly by high-protein oral nutritional supplements, is effective in significantly reducing the incidence of pressure ulcers in at-risk patients by 25%. Intervention studies using high-protein or specialised disease-specific nutritional supplements support a trend to increased healing of established pressure ulcers. Such specialised supplements are typically based on defined amounts of arginine, vitamin C and zinc. Mechanisms by which nutritional support can aid in pressure ulcer prevention and healing are likely related to addressing macro- and/or micro-nutrient deficiencies arising from either poor oral intake or increased nutrient requirements related to the wound healing process. With much more research still to be done in this area, nutrition support appears an efficacious and costeffective adjunct to current medical and nursing approaches in the prevention and treatment of pressure ulcers.

Grafts in myringoplasty : utilizing a silk fibroin scaffold as a novel device

Chronic perforations of the eardrum or tympanic membrane represent a significant source of morbidity worldwide. Myringoplasty is the operative repair of a perforated tympanic membrane and is a procedure commonly performed by otolaryngologists. Its purpose is to close the tympanic membrane, improve hearing and limit patient susceptibility to middle ear infections. The success rates of the different surgical techniques used to perform a myringoplasty, and the optimal graft materials to achieve complete closure and restore hearing, vary significantly in the literature. A number of autologous tissues, homografts and synthetic materials are described as graft options. With the advent and development of tissue engineering in the last decade, a number of biomaterials have been studied and attempts have been made to mimic biological functions with these materials. Fibroin, a core structural protein in silk from silkworms, has been widely studied with biomedical applications in mind. Several cell types, including keratinocytes, have grown on silk biomaterials, and scaffolds manufactured from silk have successfully been used in wound healing and for tissue engineering purposes. This review focuses on the current available grafts for myringoplasty and their limitations, and examines the biomechanical properties of silk, assessing the potential benefits of a silk fibroin scaffold as a novel device for use as a graft in myringoplasty surgery.

Pulsed plasma polymerization of hexamethyldisiloxane onto wool : control of moisture vapor transmission rate and surface adhesion

A new fabric with potential in medical textiles has been developed by application of a surface coating on wool using pulsed plasma polymerization of HMDSO. This coating enabled a controllable MVTR and surface adhesion. MVTR in the range recommended for optimum wound healing was obtained by varying frequency, monomer pressure and deposition time. Lower surface adhesion was achieved. Peeling tests, contact angle measurements, SPM force curves and ATR FT-IR were used to characterize the surfaces for both wool and a PE model substrate. All these results were consistent with a decrease in surface energy after PP-HMDSO treatment. ATR FT-IR results showed a siloxane film with less organic Si(CH₃)_n groups and more SiOSi cross-links.

Docosapentaenoic acid (22:5n-3) : a review of its biological effects

This article summarizes the current knowledge available on metabolism and the biological effects of n-3 docosapentaenoic acid (DPA). n-3 DPA has not been extensively studied because of the limited availability of the pure compound. n-3 DPA is an elongated metabolite of EPA and is an intermediary product between EPA and DHA. The literature on n-3 DPA is limited, however the available data suggests it has beneficial health effects. In vitro n-3 DPA is retro-converted back to EPA, however it does not appear to be readily metabolised to DHA. In vivo studies have shown limited conversion of n-3 DPA to DHA, mainly in liver, but in addition retro-conversion to EPA is evident in a number of tissues. n-3 DPA can be metabolised by lipoxygenase, in platelets, to form ll-hydroxy-7,9,13,16,19- and 14-hydroxy-7,10,12,16,19-DPA. It has also been reported that n-3 DPA is effective (more so than EPA and DHA) in inhibition of aggregation in platelets obtained from rabbit blood. In addition, there is evidence that n-3 DPA possesses 10-fold greater endothelial cell migration ability than EPA, which is important in wound-healing processes. An in vivo study has reported that n-3 DPA reduces the fatty acid synthase and malic enzyme activity levels in n-3 DPA-supplemented mice and these effects were stronger than the EPA-supplemented mice. Another recent in vivo study has reported that n-3 DPA may have a role in attenuating age-related decrease in spatial learning and long-term potentiation. However, more research remains to be done to further investigate the biological effects of this n-3 VLCPUFA.

Hospital malnutrition : prevalence, identification and impact on patients and the healthcare system

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.