The annual cost to the NHS of managing 3.8 million patients with a wound was estimated in 2020 to be £8.3 billion, of which £5.6 billion was spent on the 30% of wounds that did not heal and £2.7 billion on the 70% of wounds that healed (Guest, 2020). One of the main symptoms associated with chronic \'hard-to-heal\' wounds is the production of excess exudate (Atkin et al, 2019). This is due to a prolonged chronic inflammatory response stimulated by a physiological cause. This article describes what exudate is and its importance in the wound healing process, highlighting the consequences of too little or excessive wound exudate associated with any wound. The article goes on to describe a case series observational study involving a range of patients (n=47; 33 male/14 female), aged between 33 and 91 years (mean 67.4 years), with a variety of acute (n=11) and chronic exuding wounds (n=44). In total, 55 wounds of various aetiologies were managed with DryMax Super (a dressing whose design includes superabsorbent polymers) in order to evaluate and report on the absorption and fluid-handling properties of the product.

Chronic wounds pose a significant threat to human health, particularly for the elderly, and require extensive healthcare resources globally. Autophagy, a key molecular player in wound healing, not only offers a defense against infections but also contributes to the deposition of the extracellular matrix during the proliferative phase. Additionally, it promotes the proliferation and differentiation of endothelial cells, fibroblasts, and keratinocytes. We have recently shown that applying magnetized saline water topically can trigger autophagy in intact skin. In this case series, we document the successful management of five non-infected, difficult-to-heal wounds in elderly patients using a topical autophagy-stimulating gel containing 95% magnetized saline water. The treated wounds included pressure ulcers, venous ulcers, and trauma-related injuries that had shown minimal or no improvement with standard wound therapies over a prolonged period. Application of the autophagy-stimulating gel promoted wound healing, as indicated by reduced fibrous and necrotic tissue, granulation tissue formation, re-epithelialization, and partial or complete wound closure. These preliminary case studies suggest that a topical gel containing magnetized saline water, which promotes autophagy, may aid healing of chronic wounds in elderly patients. Further investigation is warranted to explore the potential of this novel approach, as it may offer a valuable addition to the existing arsenal of wound care treatments for the aging population, particularly in addressing difficult-to-heal wounds.

Spinal cord injury (SCI) where the lower motor neuron is compromised leads to atrophy and degenerative changes in the respective muscle. This type of lesion becomes especially critical when the gluteal muscles and/or the hamstrings are affected as they usually offer a cushioning effect to protect from skin injuries. Previous research conducted over the past 30 years has made advancements in the development of parameters for the optimal application of long pulse stimulation with the aim to restore muscle structure and trophic aspects in people with chronic SCI (<20 years post-injury). This work provides an overview of previous achievements in the field through a narrative literature review before presenting preliminary results in the form of a case series from an ongoing study investigating the acute effects of six months of long pulse stimulation on the tissue composition of the gluteal muscles in five people with chronic SCI (>20 years post-injury). Participants underwent a 33-min home-based long pulse stimulation program five times a week, and their muscle and adipose tissue thicknesses were assessed at baseline, after three and six months, respectively, using magnetic resonance imaging. The results show that the largest increase in muscle thickness occurred at the level of the height of the acetabulum (+44.37%; χ2(2) = 0.5; p = 0.779), whereas the most important decrease in adipose tissue occurred at the level of the sacroiliac joint (SIJ) reference (−11.43%; χ2(2) = 1.6; p = 0.449) within only six months of regular stimulation despite the preceding long denervation period. The underlying mechanism and physiology of muscular resuscitation from myofibrillar debris as presented in chronic denervation to functional contractile entities remain to be investigated further.

UNASSIGNED: To forecast the monetary impact by using Return on Investment (ROI) when integrating the World Health Organization (WHO) patient safety curriculum within the two years of an active diploma duration for 2019 and 2021 classes based on reported Hospital-Acquired Pressure Ulcers (HAPU) events.
UNASSIGNED: During this cross-sectional study, we compared the financial impact of integrating the WHO Patient Safety Curriculum in one 2-year diploma program in Saudi Hospital for class 2019 and 2021. All 51 qualified students were identified and included in this study. Demographic and patient safety perceptions for all students in both categories were analyzed and supported by historical data and students\' feedback.
UNASSIGNED: The whole revenue estimation for unaffiliated students\' fees during one program was found higher than the total estimated benefits from forecasting. The total monetary cost estimation was higher than the integrated Diploma\'s cost during the program that was paid once. The ROI is (-7.73%). The HAPU percentage was lower than the MOH benchmark. The highest mean was for the personal attitude to patient safety, and the lowest was for knowledge of error and patient safety (4.05 ± 0.66 and 3.33 ± 0.74, respectively).
UNASSIGNED: The study indicated a negative value from business perspectives; however, the projected multiple intangible benefits on education and training of the health sector are significant.
UNASSIGNED: تهدف الدراسة إلى التنبؤ بالأثر المالي باستخدام \"عائد الاستثمار\" عند دمج منهج منظمة الصحة العالمية لسلامة المرضى على أحد برامج الدبلوم والذي يمتد لمدة سنتين استنادا على التقارير المقدمة من عدد المرضى المصابين بتقرحات الفراش أثناء إقامتهم في المستشفى.
UNASSIGNED: في هذه الدراسة المقطعية، قمنا بمقارنة الأثر المالي لدمج منهج منظمة الصحة العالمية لسلامة المرضى في أحد برامج الدبلوم في التمريض بإحدى مستشفيات السعودية، وأظهرت نتائج مشاركة 51 طالب في السنتين المتوالية للدبلوم 2019 و 2021 معلوماتهم الديموغرافية وتصورهم عن سلامة المرضى ومقارنة المجموعتين، حيث استندت جميع التحليلات على البيانات التاريخية وتعليقات الطلاب.
UNASSIGNED: كان تقدير الإيرادات الإجمالية لرسوم الطلاب غير المنتسبين خلال برنامج واحد أعلى من إجمالي الفوائد المقدرة من التنبؤ. من خلال البرنامج، كان إجمالي تقدير التكلفة المالية أعلى من تكلفة دراسة الدبلوم والتي يتم دفعها مرة واحدة. بلغ قيمة العائد على الاستثمار (-7.73%). كانت نسبة تقرحات الفراش أقل من معيار وزارة الصحة. كان أعلى متوسط للموقف الشخصي من سلامة المرضى، وأقلها كان للمعرفة بالخطأ وسلامة المريض (4.05 ± 0.66 و3.33 ± 0.77) على التوالي.
UNASSIGNED: تشير الدراسة إلى أن عوائد الاستثمار ذات قيمة سلبية، وبالرغم من ذلك فإن الفوائد المتعددة والمتوقعة على التعليم والتدريب في قطاع الصحة كبير.

BACKGROUND: The identification of professional liability profiles related to the development of pressure injuries is a very thorny issue from a medico-legal perspective. This is because no matter how strict the applied prevention protocols applied may be, the development of such injuries is largely dependent on endogenous factors. This paper aims to investigate the medico-legal issues related to this topic through the exposition of one case of medico-legal litigation and a traditional review of the literature.
METHODS: We performed a literature search using three databases (Pubmed, Scopus, and Web Of Science), restricting the search to the period between 2001 and 2021. We used \"pressure ulcers\" and \"jurisprudence\" as the main keywords. From an initial library of 236 articles, our selection resulted in 12 articles, which were included in the review.
RESULTS: We identified the ever-increasing expectations of patients and the concept of automatic attribution of responsibility when a pressure ulcer develops as the primary reasons for the increase in litigation over the past 20 years. The related corrective measures are numerous: a strict adherence to guidelines, an adequate documentation of preventive measures, a risk assessment, family involvement, and a successful collaboration between physicians and government institutions.
CONCLUSIONS: The biological complexity of the pathogenetic development of pressure ulcers makes the subject very delicate from the medico-legal point of view. In principle, it is possible to state that a very large proportion of such injuries are preventable, but that there remains a percentage of them that cannot be prevented. In such cases, only a proper documentary demonstration of the adequacy of preventive measures can exclude liability profiles.

A continuous positive airway pressure (CPAP) mask is a respiratory ventilation method used for treating breathing disorders including respiratory failure and obstructive sleep apnoea (OSA). The forces applied by a CPAP mask may affect facial development and lead to pressure ulcers. In an experimental setting, the magnitude and the distribution of the contact pressures developed by a CPAP mask on the face were investigated for providing information aiming at optimizing the design of the device.
A nasal CPAP mask with forehead support was placed via its headgear straps on a rigid phantom head and then a controlled load was incrementally applied via a mechanical testing system (5848 Micro Tester, Instron), up to 4 maximum levels of exerted force, namely 5 N, 10 N, 15 N, and 20 N. Real-time pressure mapping was realized by means of sensor matrixes (I-Scan System, Tekscan) applied on the facial surface in four regions (forehead, nasal bridge, zygoma, and maxilla). The data were then transferred on a virtual model created by 3D scans of both the CPAP mask and the phantom head used in the experiments.
At increasing applied force, increases in average contact pressure were present at the zygomatic region (1-8 kPa), nasal bridge (12-14 kPa), and forehead (13-29 kPa), while the maxillary region showed relatively stable values (9 kPa). Despite the overall increase in average contact pressure with increasing applied force, no direct proportionality was present. Contact areas did not show clear increments, despite force may redistribute on a larger area, as sensors did not cover the entire mask perimeter. Peak contact pressure values were somehow affected by pressure concentrations that led to saturation in some areas of the sensors (up to 2% of the sensels).
The CPAP mask exerts pressures that may be not uniformly distributed on the face of a subject. This information underlines the clinical importance of assessing both the pressure exerted and the areas that are interested by the mask contact, so as to optimise the CPAP masks design for obtaining a good compromise between ventilation performance and reduction of possible side effects on living tissues.

UNASSIGNED: The most common complication of pelvic organ prolapse is stress urinary incontinence, whereas hydronephrosis or stasis ulcers are quite rare and typical of severe stages. The best treatment for this unusual presentation is still controversial. Here we present our approach.
METHODS: Here we present the case of a 70-year-old White/Caucasian woman who presented to our hospital with genital procidentia lasting for 10 years that was associated with both hydronephrosis and stasis ulcers.
UNASSIGNED: The Pelvic Organ Prolapse Quantitation system was used to assess the severity of the prolapse, being evaluated as stage IV with the apical compartment leading. A thorough search of the literature was conducted to find any similar cases and evaluate the best evidence treatment.
RESULTS: A no-mesh procedure comprising vaginal hysterectomy, axial apex suspension, and anterior and posterior repair with ulcerated skin removal resulted in complete resolution of both mechanical and functional symptoms. At 3- and 6-month follow-up visits, a satisfying vaginal profile without hydronephrosis was seen. The Pelvic Organ Prolapse Quantitation at 6 months follow-up was as follows: Aa -3, Ba -3, C -7; gh 2, pb 3, tvt 9; Ap -3, Bp -3.
UNASSIGNED: Pelvic organ prolapse involves many organs and causes further complications, leading seldom to renal insufficiency and stasis ulcers. A temporary solution to the obstruction can be achieved by utilizing a pessary, but this device cannot be applied when a stasis ulcer has been previously established. The use of mesh for pelvic floor repair is controversial, but a previous vaginal ulcer may represent a contraindication. A complete evaluation and a challenging surgery may allow the recovery of complicated and severe pelvic organ prolapse. Native tissue pelvic repair gives no erosion postsurgical risk, which is the typical complication of the prosthesis.

UNASSIGNED: Approximately three million people in the US have hard-to-heal pressure ulcers (PUs), including 10% of hospitalised patients. Healing depends on ulcer stage and patient comorbidities. Despite advances in nutrition and wound care, PUs can take months or years to reach complete closure. To date, clinical studies have focused on single modality therapy. However, there is no one therapy that can address all of the deficits in these complex, hard-to-heal wounds. A commonly used treatment for PUs, negative pressure wound therapy (NPWT), has demonstrated improved healing in Stage 3 and 4 PUs. NPWT entails applying suction to a porous sponge fitted into the wound cavity and sealed with an occlusive dressing. Negative pressure facilitates wound healing by removing wound fluid containing harmful proteases, stimulating the formation of granulation tissue and promoting wound contracture. However, it does not affect biofilm formation. We hypothesised that adding an antibiofilm agent might increase the effectiveness of NPWT in recalcitrant PUs.
UNASSIGNED: A prospective case series was conducted in outpatient wound care centres and a skilled nursing facility to examine the combination of a biofilm-disrupting antimicrobial agent (Blast-X, Next Science, US) in combination with NPWT (VAC, 3M, US) in healing and reducing bacterial burden in treatment-resistant pressure ulcers. Patients consented to application of the antibiofilm agent and NPWT three times per week for four weeks. The wounds were measured, imaged for bacteria and tested for host and bacterial protease activity weekly.
UNASSIGNED: Of the 10 patients, four dropped out of the study before the end of the four weeks. Of the remaining six, four patients experienced a reduction in wound surface area and volume, reduced protease activity and lower bacterial levels.
UNASSIGNED: The results of this study showed that multimodal therapy, including NPWT and biofilm disruption, may restart the healing of stagnant treatment-resistant PUs.

OBJECTIVE: Impaired wound healing can lead to hard-to-heal wounds, which impact on patients, clinicians and healthcare systems. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) was developed to manage wounds through early-stage cleansing. This study describes the use of NPWTi-d to help manage hard-to-heal wounds in patients with risk factors for impaired wound healing.
METHODS: In this case series, patients were treated between October 2015 and March 2018 at a community hospital in western France. Normal saline solution was instilled into wounds with a dwell time of 10 minutes, followed by the application of negative pressure at -75 mmHg to -125 mmHg for 2-3 hours. If needed, patients were given appropriate oral or intravenous antibiotic treatment in conjunction with NPWTi-d and subsequent wound therapies.
RESULTS: A total of 15 patients participated in the study. Mean age was 81±13 years, and 12 (80%) patients were malnourished with blood albumin levels of 30.1±5.7g/l, and 12 (80%) patients were given antibiotic therapy. The mean duration of NPWTi-d was 19.4±20.8 days, with a mean number of dressing changes of 6.6±6.8; the duration of NPWTi-d and the number of dressing changes for pressure ulcers was three times that of the other wound types. The mean cost of NPWTi-d in this study was €1643.40±€1709.13. Overall, NPWTi-d provided early-stage wound cleansing and helped achieve adequate granulation tissue formation and progression to the next phase of wound healing.
CONCLUSIONS: In these cases, NPWTi-d was a beneficial and effective method of treating hard-to-heal wounds that were resistant to traditional treatments, yielding favourable clinical outcomes.

One of the biggest challenges faced by healthcare providers is the treatment of chronic, non-healing wounds. This paper reports for the first time in the UK the results of five case studies in which a novel regenerating matrix-based therapy, CACIPLIQ20, was used. CACIPLIQ20 is a heparan sulphate mimetic designed to replace the destroyed heparan sulphate in the extracellular matrix of wound cells. All five patients in this case series had chronic, non-healing ulcers that had not improved with conventional care. Treatment included two applications of CACIPLIQ20 per week, for a maximum of 12 weeks. Three of the five wounds healed completely, and the remaining two showed significant improvements in size and quality. The treatment was well tolerated by the patients and also led to a significant reduction in pain. Moreover, CACIPLIQ20 treatment was found to be highly cost-effective when compared to conventional care, with the potential to save healthcare systems significant resources. Further studies are needed to build a strong evidence base on the use of this product, but these preliminary findings are certainly promising.