The healing process in acute wounds has been extensively studied and the knowledge derived from these studies has often been extrapolated to the care of chronic wounds, on the assumption that nonhealing chronic wounds were simply aberrations of the normal tissue repair process. However, this approach is less than satisfactory, as the chronic wound healing process differs in many important respects from that seen in acute wounds. In chronic wounds, the orderly sequence of events seen in acute wounds becomes disrupted or "stuck" at one or more of the different stages of wound healing. For the normal repair process to resume, the barrier to healing must be identified and removed through application of the correct techniques. It is important, therefore, to understand the molecular events that are involved in the wound healing process in order to select the most appropriate intervention. Wound bed preparation is the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures. Experts in wound management consider that wound bed preparation is an important concept with significant potential as an educational tool in wound management. This article was developed after a meeting of wound healing experts in June 2002 and is intended to provide an overview of the current status, role, and key elements of wound bed preparation. Readers will be able to examine the following issues; the current status of wound bed preparation; an analysis of the acute and chronic wound environments; how wound healing can take place in these environments; the role of wound bed preparation in the clinic; the clinical and cellular components of the wound bed preparation concept; a detailed analysis of the components of wound bed preparation.

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An appreciation of the factors affecting the progression from colonization to infection can help clinicians with the interpretation of clinical findings and microbiological investigations in patients with chronic wounds. An understanding of the physiology and interactions within multi-species biofilms may aid the development of more effective methods of treating infected and poorly healing wounds. The emergence of consensus guidelines has helped to optimize clinical management.

Greater interest in wound healing is needed to ensure higher standards of basic care. Precise identification of the systemic, local, and molecular factors underlying the wound healing problem in individual patients should allow better tailored treatment. Allogeneic skin grafting and bioengineered skin equivalents are being used successfully in patients with venous leg ulcers and diabetic patients with foot ulcers.

OBJECTIVE -Foot-related disease is the most common cause for hospital admission among the diabetic population. Lower-limb peripheral arterial occlusive disease (PAOD) is a major risk factor in diabetic foot disease. Screening for PAOD commonly includes foot pulses and the ankle-brachial pressure index (ABPI) and/or the toe-brachial pressure index (TBI), but concerns persist regarding their accuracy. We evaluated the efficacy of several commonly used screening methods in different subject populations.RESEARCH DESIGN AND METHODS -We studied 130 limbs in 68 individuals with no critical ischemia over 8 months. Limbs were grouped on the basis of the presence or absence of diabetes, clinically detectable peripheral neuropathy, and PAOD identified on color duplex imaging. Comparative analyses of foot pulses, the ABPI, the TBI, and distal Doppler waveform analysis were performed.RESULTS -Foot pulses, the TBI, and qualitative waveform analyses were highly sensitive screening methods in individuals with and without diabetes. However, detectable peripheral neuropathy was associated with a reduced sensitivity and poor specificity of foot pulses, a reduction in sensitivity of the ABPI (71 to 38%), and a reduction in specificity of the TBI (81 to 61%) and qualitative waveform analysis (96 to 66%). Quantitative analysis failed to detect disease with severely damped and low-intensity signals.CONCLUSIONS -Screening tools that are effective in screening for lower-limb PAOD in the nondiabetic population are less efficacious in diabetes, particularly in the presence of detectable peripheral neuropathy. Qualitative waveform analysis and the TBI were demonstrated to be more effective screening methods than the ABPI and foot pulses particularly in high-risk limbs with detectable peripheral neuropathy. Diabetes Care 28:2206 -2210, 2005F oot-related disease is the most common cause for hospital admission among the diabetic population and is recognized as the most common cause of nontraumatic lower-limb amputation in the western world. People with diabetes are Ͼ20 times more likely to undergo an amputation than the rest of the population (1). The main risk factors for the development of diabetic foot disease are peripheral neuropathy and peripheral arterial occlusive disease (PAOD). The detection of significant arterial disease is vital to the prevention and treatment of foot disease. The unreliable nature of the symptoms and signs of lower-limb arterial insufficiency in diabetes means that noninvasive tests are essential to achieve effective screening (2,3). The European Working Group on Critical Leg Ischaemia recommends an additional, noninvasive vascular assessment for patients with diabetes and foot ulceration (4).Screening techniques commonly used in assessing lower-limb perfusion are the palpation of foot pulses and calculation of the ankle-brachial pressure index (ABPI) and/or the toe-brachial pressure index (TBI). There is continued debate regarding the influence of peripheral neuropathy and arterial calcification on the reliabil...

The efficient healing of a skin wound is something that most of us take for granted but is essential for surviving day-to-day knocks and cuts, and is absolutely relied on clinically whenever a patient receives surgical intervention. However, the management of a chronic wound – defined as a barrier defect that has not healed in 3 months – has become a major therapeutic challenge throughout the Western world, and it is a problem that will only escalate with the increasing incidence of conditions that impede wound healing, such as diabetes, obesity and vascular disorders. Despite being clinically and molecularly heterogeneous, all chronic wounds are generally assigned to one of three major clinical categories: leg ulcers, diabetic foot ulcers or pressure ulcers. Although we have gleaned much knowledge about the fundamental cellular and molecular mechanisms that underpin healthy, acute wound healing from various animal models, we have learned much less about chronic wound repair pathology from these models. This might largely be because the animal models being used in this field of research have failed to recapitulate the clinical features of chronic wounds. In this Clinical Puzzle article, we discuss the clinical complexity of chronic wounds and describe the best currently available models for investigating chronic wound pathology. We also assess how such models could be optimised to become more useful tools for uncovering pathological mechanisms and potential therapeutic treatments.

Aims: To determine the sensitivity to honey of Gram‐positive cocci of clinical significance in wounds and demonstrate that inhibition is not exclusively due to osmotic effects. Methods and Results: Eighteen strains of methicillin‐resistant Staphylococcus aureus and seven strains of vancomycin‐sensitive enterococci were isolated from infected wounds and 20 strains of vancomycin‐resistant enterococci were isolated from hospital environmental surfaces. Using an agar incorporation technique to determine the minimum inhibitory concentration (MIC), their sensitivity to two natural honeys of median levels of antibacterial activity was established and compared with an artificial honey solution. For all of the strains tested, the MIC values against manuka and pasture honey were below 10% (v/v), but concentrations of artificial honey at least three times higher were required to achieve equivalent inhibition in vitro. Comparison of the MIC values of antibiotic‐sensitive strains with their respective antibiotic‐resistant strains demonstrated no marked differences in their susceptibilities to honey. Conclusions: The inhibition of bacteria by honey is not exclusively due to osmolarity. For the Gram‐positive cocci tested, antibiotic‐sensitive and ‐resistant strains showed similar sensitivity to honey. Significance and Impact of the Study: A possible role for honey in the treatment of wounds colonized by antibiotic‐resistant bacteria is indicated.

Traditionally wet-to-dry gauze has been used to dress wounds. Dressings that create and maintain a moist environment, however, are now considered to provide the optimal conditions for wound healing. Moisture under occlusive dressings not only increases the rate of epithelialisation but also promotes healing through moisture itself and the presence initially of a low oxygen tension (promoting the inflammatory phase). Gauze does not exhibit these properties; it may be disruptive to the healing wound as it dries and cause tissue damage when it is removed. It is not now widely used in the United Kingdom. Occlusive dressings are thought to increase cell proliferation and activity by retaining an optimum level of wound exudate, which contains vital proteins and cytokines produced in response to injury. These facilitate autolytic debridement of the wound and promote healing. Concerns of increased risk of infection under occlusive dressings have not been substantiated in clinical trials. This article describes wound dressings currently available in the UK. Low adherent dressings Low adherent dressings are cheap and widely available. Their major function is to allow exudate to pass through into a secondary dressing while maintaining a moist wound bed. Most are manufactured in the form of tulles, which are open weave cloth soaked in soft paraffin or chlorhexidine; textiles; or multilayered or perforated plastic films. They are designed to reduce adherence at the wound bed and are particularly useful for patients with sensitive or fragile skin.