Staying Ahead of the Curve at SAWC Spring

Each year, the Symposium on Advanced Wound Care (SAWC) Spring/Wound Healing Society (WHS) Annual Meeting provides attendees with valuable, up-to-date, evidence-based education and resources in the form of session lectures by thought leaders, posters presenting clinical cases/research, and an exhibit hall packed full of industry sharing their latest products to help wound care patients. The 4-day meeting is filled with more than 50 sessions focused on topics pertinent to today’s wound care clinician, such as diabetic wounds, reimbursement, debridement, wound infection, and biofilm. Herein, we highlight 2 sessions and 2 posters relevant to the Wounds readership in order to share more wound care education beyond the journal’s monthly written and multimedia content.

To access more material from past SAWC meetings, visit the Wound Care Learning Network.

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It’s no secret that stress plays a huge impact on the human body and brain (eg, headaches, anxiety, nausea, depression, sleep problems), with chronic stress even changing certain areas of the brain.¹ Stress-induced impaired wound healing has been linked to behavioral and physiological factors.² For instance, poor health care decisions can lead to delayed cell migration and collagen deposition at the wounded area from heavy alcohol use.³ In a session titled “‘The No Stress Zone’: Stress, Pain, and Their Impact on Wound Healing” from the SAWC Spring 2019, Loretta Vileikyte, MD, PhD, discussed the potential variables involved in the relationship between stress and wound healing. Dr. Vileikyte reviewed a wide range of human and animal studies on the physiological and psychological impacts of stress. Regarding the emotional states and immune modulation, she referred to a study by Dickerson et al⁴ that reported shame and guilt modulated tumor necrosis factor alpha expression independently of depression. In addition, a prospective study of 48 postmenopausal women (aged 54-82 years) reported that anger was related to interleukin 6 stress reactivity among women with low social support.⁵ 

Matthew Hardman, PhD, considered the biology of stress in wound healing later in the same lecture. Stressful situations impacting wound healing that Dr. Hardman mentioned included dental students healing mucosal punch biopsy wounds 40% slower in duration during a brief examination period (eg, college midterm exam) as compared with a vacation and chronic stress in female caregivers taking 24% longer to heal a small standardized punch biopsy wound than well-matched controls.⁶ Further, Dr. Hardman spoke about the hypothalamic pituitary adrenal (HPA; ie, central stress response system) axis and chronic stress. In a normal HPA axis, according to Dr. Hardman, the perceived stress causes cortisol to release into circulation, which then travels to the brain and activates the hippocampus and is then shut down. For chronic stress, cortisol is elevated chronically; the excess causes tissue changes and leads to hippocampal degradation. 

To learn more about the impact of chronic stress on wound healing progression, as well as the wound pain cycle, visit www.woundcarelearningnetwork.com/on-demand/sawc to watch full sessions from past SAWC meetings.

When talking about pain management, opioid prescriptions may be a potential treatment option for clinicians to consider. However, in today’s world, the opioid crisis is a very real and catastrophic epidemic. The Centers for Disease Control and Prevention estimates that an average of 130 Americans die from an opioid overdose daily and about 68% of the 70 200 drug overdoses in 2017 involved an opioid.⁷ To address this growing concern in relation to wound pain management, Daniel Tobin, MD, FACP, and Daniel Federman, MD, shared pertinent information in a session, titled “Managing Pain in the Wound Care Patient in an Era of an Opioid Crisis,” at SAWC Spring 2019. 

Dr. Federman stressed the importance of an evidence-based approach in all aspects of wound care, including pain management. In chronic pain treatment, he said there are multiple factors to consider, 2 of which are self-management and self-efficacy. Clinicians should address the patient’s pain in a patient-specific context, meaning that not all treatments will work for chronic pain; promote healthy behaviors and quality of life; and address comorbidities so as to diminish their need for polypharmacy, invasive procedures, and unproven alternative therapies.⁸ Dr. Federman also reminded attendees that treating and optimizing co-occurring conditions is part of pain treatment, such as major depression/anxiety, diabetes mellitus, and substance abuse. When determining the appropriate course of pain management treatment, non-pharmacologic methods also should be considered. These can involve physical activity (low-intensity exercise, physical therapy, yoga), behavioral treatments (cognitive behavioral therapy, meditation, guided imagery), and others with proven impacts on pain relief (massage, acupuncture, nerve blocks).^8,9 Clinicians, according to Dr. Federman, need to plan multimodal treatment courses, communicate the steps with the whole treatment team (including the patient), motivate the patient to pursue multimodal treatment, monitor the safety and efficacy of the treatment, and always modify the treatment plan if/when problems arise.

The second half of the lecture by Dr. Tobin focused on safe opioid prescriptions to explore opioid use (pros and cons) in chronic pain management; review opioid prescribing principles; learn to prevent, screen for, and recognize evidence of opioid harm; and consider when and how to discontinue opioid use. The potential benefits of opioids include pain and suffering reduction, well-being promotion, and function and quality of life improvements. However, the harms consist of the known side effects of opioids; endocrinopathy; diversion, misuse, and addition; and overdose/death. Dr. Tobin said the benefits of opioids do not seem to outweigh the risks, as there is an inadequacy of studies on their efficacy (ie, brief duration rather than long term, few randomized controlled trials, small sample size, pharmaceutical-sponsored studies) and underwhelming outcomes reported (mixed reports on function, modest pain relief usually not sustained); Kreb et al¹⁰ even reported that opioids were not superior to nonopioids for improving musculoskeletal pain-related function over a 12-month period in a randomized study. 

When considering whether to prescribe opioids for pain management, clinicians should be aware of the side effects associated with opioids (pruritus, urinary retention, hyperalgesia) and how these can impact their wound healing. At the end of the day, nonopioid treatment plans may be the best course of action to avoid increasing the number of opioid-related deaths⁷ and adding to the epidemic. Nonpharmacologic care plans show promise, as Dr. Federman pointed out, with Hassett⁹ advising the “ExPRESS” (exercise, psychologic distress, regaining function, emotional well-being, sleep hygiene, and stress management) approach to chronic pain. Regardless of whether the clinician chooses the opioid or nonopioid treatment for wound pain management, the patient’s overall well-being must always be at the forefront of the clinician’s mind.

Visit www.woundcarelearningnetwork.com/sawc-demand/managing-pain-wound-care-patient-era-opioid-crisis to watch the full session from SAWC Spring 2019.

Exhibited at SAWC Spring, Dr. Fernandez and coauthors presented their findings of a case series on 19 patients with complex wounds that were treated with reticulated open-cell foam dressings with through holes (ROCF-CC; V.A.C. VERAFLO CLEANSE CHOICE Dressing; KCI, an Acelity Company, San Antonio, TX) in conjunction with negative pressure wound therapy with instillation and dwell time (NPWTi-d; V.A.C. VERAFLO Therapy; KCI, an Acelity Company). Their poster, “Use of Reticulated Open Cell Foam Dressings With Through Holes During Negative Pressure Wound Therapy With Instillation: A Large Case Study,”¹¹ reported their experience of utilizing NPWTi-d with ROCF-CC dressings on these patients, showcasing the development of healthy granulation tissue in the wound bed following NPWTi-d in all patients with an average length of NPWTi-d use at 9.5 ± 4.1 days. 

All patients in this study received NPWTi-d using ROCF-CC with instillation of quarter-strength Dakin’s solution, hypochlorous solution, or saline with a dwell time of 5 to 10 minutes followed by 2 to 3.5 hours of continuous negative pressure at -125 mm Hg. The dressings were changed every 2 to 3 days. The wounds seen in their study were predominantly pressure injuries (37%) followed by traumatic wounds (26%), surgical wounds (16%), soft tissue infections (11%), chronic wounds (5%), and infections at the hardware site (5%).

To demonstrate their positive results, the authors provided 2 example cases, one of which was of a 33-year-old man with an infection of his above-the-knee amputation stump resulting from a fall (Figure 1). In Figure 1A, the wound at presentation prior to conservative sharp debridement and oral antibiotics is shown. The patient was started on NPWTi-d, instilling 80 mL to 100 mL of hypochlorous solution with a 10-minute dwell time, followed by 2 hours of negative pressure. After 9 days of NPWTi-d, the therapy was discontinued and standard NPWT (V.A.C. Therapy; KCI, an Acelity Company) was initiated (Figure 1B).

From their clinical practice with these 19 patients, the authors determined NPWTi-d with ROCF-CC dressings provided effective and rapid removal of thick exudate and infectious materials and aided the development of healthy granulation tissue.

Click here to view the full poster and PDF on the Wound Care Learning Network.

Chronic wounds are described as any wound that does not progress through the normal healing process and remains open for more than 1 month.¹² Diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs) are an increasing burden on the health care system and affected populations, with a global DFU prevalence of 6.3% (US: 13%)¹³ and a global VLU prevalence of 1% (among those aged 18-64 years).¹⁴ With an increasing number of patients presenting with these wounds and the increasing expenditure associated with their care, clinicians look to find inexpensive, quicker, and more effective treatments to help their patients – one of which may be an autologous homologous skin construct (AHSC).

The poster “Closure of Refractory Diabetic Foot Ulcers and Venous Stasis Leg Ulcers Using a Single Application of an Autologous Homologous Skin Construct in the Clinic Setting” by Armstrong et al¹⁵ reported the outcomes of a pilot study on DFUs and VLUs treated with AHSC (SkinTE; PolarityTE, Salt Lake City, UT) that were refractory to at least 1 month of conservative care. Their study included 11 DFUs (Wagner grades 1 and 2) and 5 VLUs treated with an AHSC product derived from the patient’s own skin to regenerate full-thickness, functionally polarized skin with all of its layers. A 1.5-cm² piece of full-thickness skin was harvested from each patient’s proximal calf, sent to the laboratory for processing, and returned to the clinician within 48 hours. Following debridement, AHSC was applied evenly, dressed with a silicone dressing, secured by adherent tape strips, and supported by an absorbent foam covered by a triple-layer compression. Dressing changes were performed weekly along with recording wound healing progress via digital photography.

The reported results showed that a single application of AHSC promoted granulation tissue formation, progressive epithelialization, and wound closure 12 weeks after application in 10 of 11 (91%) DFUs and 5 of 5 (100%) VLUs. One patient with a DFU developed a hardware infection unrelated to the AHSC-treated wound. No adverse related events were reported.

One case presented was of a patient with a VLU of the left proximal ankle measuring 12.2 cm²(Figure 2A). Photographic evidence of rapid epithelization and closure are shown at days 14, 28, and 60, with closure documented on day 94 (Figure 2B-2E). This VLU demonstrated a durable response to AHSC treatment upon final observation 115 days post application (Figure 2F).

From these 16 patients, the authors found AHSC closed the DFUs and VLUs refractory to dressing care in a single application, which one can postulate would reduce health care costs and stress on the patient. Further evaluation with RCTs should be conducted to validate its efficacy for treatment of chronic lower extremity wounds.

Click here to view the full poster and abstract on the Wound Care Learning Network; in addition, the poster presentation by David Armstrong, DPM, MD, PhD, is available here.

Content disseminated at the SAWC Spring 2019 offered a breadth of information to attendees. This information extends far beyond the sessions and posters highlighted herein. With 6 poster abstract categories (clinical research, laboratory research, case series/study, practice innovations, health economics, and evidence-based practice) and 5 tracks (leading edge, lower extremity wounds, outpatient care of wounds, science and technology, and wound care 360 view), attendees are exposed to educational resources beyond the capabilities of Wounds and other wound care publications. If interested in viewing more content from the SAWC Spring 2019 as well as past SAWC sessions, visit the Wound Care Learning Network, the official resource of SAWC, at www.woundcarelearningnetwork.com. 

Author: Jaclyn Gaydos

Affiliation: Managing Editor, Wounds

This article was not subject to the WOUNDS peer-review process.