Background: Pain is among the most problematic aspects of chronic wounds. It adversely affects not only physical function but also social and psychological aspects of life. In concert, these effects can seriously impinge on quality of life. Despite affecting up to 80% of patients with leg ulcers, pain is reported to be under-treated. Methods: A secondary, within-subject controlled study design comparing wound pain intensity using a visual analogue scale of venous leg ulcer patients over 4 weeks receiving different interventions. In total, 29 patients received multi-layer compression over 4 weeks, followed by neuromuscular stimulation (NMES) of the leg muscle pump in addition to compression for a further 4 weeks. Paired comparison was then made of the pain gradient (rate of change in pain) between the two phases. A second cohort of 22 patients received only multi-layer compression throughout both 4-week phases. The trial was reported following the CONSORT guidelines. Results: Introduction of NMES at week 4 was accompanied by a significant increase in the rate of pain reduction over the following 4 weeks. Patients receiving standard care for the second 4-week phase experienced no change in the pain trajectory. Conclusions: 1 Hz NMES of the common peroneal nerve to activate the leg muscle pump is accompanied by an improved pain trajectory in patients with chronic venous leg ulcers. This mirrors the improvement in the rate of reduction in wound size previously reported in the same cohort. Pain is a common feature of chronic wounds and mitigation of pain is likely to have a profound impact on the quality of life of individuals with chronic venous leg ulcers.

ABSTRACTBackground and AimsNeuro‐ischemic ulcers (NIU) present a substantial clinical and economic burden on the healthcare systems. This study aims to evaluate their healing rate, associated healthcare resource utilization, and prognostic factors influencing healing.MethodsConsecutive patients attended specialist clinics or admitted to wards in three tertiary hospitals for new or existing NIUs from November 2019 to November 2021 were eligible for this study. Each participant was followed up three times (1‐month, 3‐month and 6‐month after enrollment), with ulcer healing as the primary outcome of interest. Cox regression analysis was performed to identify independent predictors of NIU healing.ResultsIn total, 439 patients were recruited. Six months after they seek care in the tertiary healthcare setting, 36.0% of the participants had their ulcer fully healed. Male gender (adjusted HR: 0.71, 95% CI: 0.53–0.93), history of coronary intervention (adjusted HR: 0.62; 95% CI: 0.41–0.93), requirement of lower extremity revascularization (adjusted HR: 0.72; 95% CI: 0.54–0.98) and offloading (adjusted HR: 0.61; 95% CI: 0.46–0.81) were found to be associated with failure to heal. Ulcers located over the toes (adjusted HR: 1.64; 95% CI: 1.17–2.32) was associated with better healing. Dependent activity of daily living (adjusted HR: 0.74; 95% CI: 0.55–1.01) was also potentially a risk factor for slow healing with borderline significance.Nonhealed group of patients incurred higher requirement of revascularization (42.3% vs. 25.3%, p < 0.001), negative pressure wound therapy (40.6% vs. 29.7%, p = 0.03), off‐loading (57.3% vs. 46.8%, p = 0.04) and antibiotic treatment (45.2% vs. 26.6%, p < 0.001), compared to those in the healed group.ConclusionNIU imposes a significant burden on both patients and the healthcare system in Singapore, with low healing rates even after 6 months of tertiary‐level care. Early identification and risk stratification of high‐risk patients may help improve outcomes.

OBJECTIVE To determine if intermittent neuromuscular electrostimulation (NMES) of the common peroneal nerve increases microvascular flow and pulsatility in and around the wound bed of patients with combined venous and arterial etiology. METHODS Seven consenting participants presenting with mixed etiology leg ulcers participated in this study. Microvascular flow and pulsatility was measured in the wound bed and in the skin surrounding the wound using laser speckle contrast imaging. Measurements were made at baseline and when the venous pumps of the leg were activated by 1 Hz intermittent neuromuscular stimulation of the common peroneal nerve. The nerve was stimulated transdermally at the head of the fibula. RESULTS When activated by NMES, wound bed flux increased by 38% (95% CI, 11%-73%; P = .023), and periwound flux increased by 19% (95% CI, 9%-32%; P = .009). Pulsatility increased in the wound bed by 214% (95% CI, 51%-985%; P = .017) and in the periwound by 122% (95% CI, 38%-299%; P = .014). CONCLUSIONS The results indicate that NMES is effective in augmenting microvascular flow in leg ulcers with combined venous and arterial etiology.

Objective To measure the effect of neuromuscular stimulation of the common peroneal nerve on the microvascular blood flow within the wound bed of diabetic foot ulcers. Research Design and Methods 13 patients with diabetic foot ulcers (11 neuropathic, 2 neuroischemic) were recruited. Microvascular flux and pulsatility were measured in real time in the wound bed, and at the wound edge, using Laser Speckle Contrast Imaging (Moor FLPI-2; Moor Instruments Ltd, Axminster, United Kingdom). Changes from baseline were measured when the leg muscle pump was activated by 1 Hz neuromuscular stimulation of the common peroneal nerve, using a wearable device (geko, Firstkind Ltd Daresbury, United Kingdom). Results In the 11 neuropathic ulcers, significant increases were seen in all microvascular parameters. Wound bed flux increased by 36% (95%CI 11%-68%, P = .002), and peri-wound flux increased by 92% (95%CI 46%-160%, P = .001). Pulsatility in the wound bed increased by 183% (95%CI 61%-517%, P = .005), while pulsatility in the peri-wound increases by 359% (95%CI 264%-455%, P = .001). Additionally, an increase in flux and pulsatility was observed in the neuroischemic ulcers. Conclusions Neuromuscular stimulation of the common peroneal nerve presents a mode of activating the leg muscle pump without additional pressure insult to the foot and has potential to support the microcirculation during wound-healing, effectively emulating exercise without any of the attendant risks of exercise to the neuropathic or neuroischemic foot.

Chronic wounds pose an increasing burden on the healthcare system and data on wound outcomes and are needed to evaluate and address disparities and reform healthcare policies. In Singapore, data on chronic wounds are fragmented and to address this, we established a Chronic Wounds Registry (CWR) to collect harmonised data on chronic wounds and their outcomes over 6 months. This is a multi-centre prospective cohort study from Nov 2019 to Nov 2021. Patients with chronic wounds were enrolled at multi-speciality acute care hospitals and data were prospectively collected on baseline characteristics, including subject demographics, clinical data, wound images, interventions/treatment, cost burden and patient reported health-related quality of life (HRQOL). Patients were followed up for 6 months and wound outcomes recorded at Month 1, Month 3 and Month 6 time points. Despite the onset of COVID pandemic, a total of 812 patients were recruited in our study. Mean age was 63.5 ± 11.6 years with 66% men and 59% of Chinese ethnicity. Twenty percent of all the wounds were recurrent and patients with venous leg ulcers (VLU) (32%) had the highest recurrence. At 6 months, 225 (46%) of the neuro-ischemic ulcers (NIU), 152 (60%) of the VLUs and 29 (46%) of the pressure injuries (PI) had healed. Major (5%) amputations were highest in patients with NIUs. All-cause mortality was highest (30%) and HRQOL was lowest for patients with PIs (-0.18). Development of a national wound registry is both feasible and essential to consolidate key data elements on chronic wounds. The CWR in its current state captured the local epidemiology, patient journey in acute care hospitals, which will benefit in healthcare policymaking and harmonise care across different levels of healthcare system. The next phase of the CWR aims to track patients in all settings and collect data on the entire patient journey following an episode of wounding.

This study evaluates the cost-effectiveness of the geko device a neuromuscular electro-stimulator technology with standard of care (SoC) versus SoC alone for venous leg ulcer (VLU) treatment, from the UK National Health Service (NHS) perspective over 12 months. Research was conducted across NHS UK facilities, primarily within community services and outpatient leg ulcer clinics, encompassing a total of 51 patients. A partitioned survival model, based on a two-arm randomised controlled trial, assessed wound healing rates using Kaplan-Meier curves and parametric extrapolations over a 12-month time horizon. Costs were derived from UK reference costs the British National Formulary, and the Personal Social Services Research Unit (2021/22). The primary outcome measured was the incremental cost per quality-adjusted life-year gained. The geko device provides additional benefits by stimulating the lateral popliteal nerve, augmenting venous, arterial, and microvascular flow. The addition of the geko device to SoC significantly enhanced outcomes, increasing healing probability by 68% compared to SoC. This integration would result in a cost saving of £774.14 per patient when compared to the SoC alone across the NHS. Economic analyses indicate that integrating the geko device into SoC protocols would reduce the overall NHS expenditure on VLU wound management by as much as 15%. The approach also positively impacted health-related quality of life. The geko™ device when used adjunctively with SoC would be a cost-effective method for managing chronic VLUs within the NHS, improving healing rates and offering economic benefits.

Background: Randomized controlled trials using complete healing as an endpoint suffer from poor statistical power, owing to the heterogeneity of wounds and their healing trajectories. The Food and Drug Administration (FDA) has recently consulted with expert groups to consider percentage area reduction (PAR) of the wound over a 4-week period as a valid intermediate endpoint, creating the opportunity for more powerful study designs. Methods: A within-subject controlled study design comparing the PAR of venous leg ulcers (VLU) in patients over 4 weeks receiving different interventions. Twenty-nine patients received multilayer compression over 4 weeks, followed by neuromuscular electrostimulation (NMES) of the leg muscle pump in addition to compression for a further 4 weeks. Paired comparison was then made of PAR between the two phases. A second cohort of 22 patients received only multilayer compression throughout both 4-week phases. Results: Patients randomized to NMES saw a significant increase in healing rate compared with compression alone, whereas patients receiving compression only saw no significant change in healing rate throughout the course of the study. Conclusions: Intermittent NMES of the common peroneal nerve significantly accelerates the healing of VLU. It is well tolerated by patients and deserves serious consideration as an adjuvant to compression therapy. PAR is a useful metric for comparing the performance of wound healing interventions, and the self-controlled trial design allows sensitive discrimination with a relatively small number of subjects over a reasonably short trial period. The study is reported according to the CONSORT reporting guidelines. Clinical Trial Registration: NCT03396731 (ClinicalTrials.gov).

Following our recent editorials regarding the estimation of the costs of wound care both globally and nationally,1 we published a few regional specific analyses.2, 3 To supplement this further, we carried out a similar analysis in the remaining top 10 highest spenders and updated their national costs to the most recent government data published. The regional analysis may vary by country depending on the collective statistics available for the regions. The recent editorial introduced the approach to estimate the possible costs of wound care using freely available governmental health data, population statistics, and the research findings of many national groups.1 Using this methodology, an estimate, the costs of wounds nationally as a whole, and the individual regional elements of which the countries are comprised was carried out for those countries within the top 10 spenders, globally. The previous analysis1 focused on 2019 to permit a direct comparison between countries. The subsequent analyses focused on updating these figures to the most recently available estimate, based on the availability of regional governmental statistics. Also, in this analysis, we present the estimates in local currency, rather than international common currency. This will enable a broader understanding and provide an increased utility for researchers. This will be particularly useful for regional analysis within nations. As with our previous analyses, the 'accuracy' of the estimate is dependent on what governmental information is available. One weakness is in some geographies that there is a lack of the availability of per capita healthcare spend on a regional basis. Perhaps within some geographies, the per capita healthcare spend is universal across all regions. To further our analysis, we made that assumption to permit a calculation of regional healthcare spend based on population statistics. Irrespective of any inaccuracies in our estimation model, the data provides an indication of the likely regional spend across a geography, giving benchmark data for improvement initiative or governmental investment. The following table provides a snapshot of the possible costs of wound care within these geographies in the year 2022. Compared to our previous analysis,1 not unsurprisingly, the costs increased across all geographies. Interestingly, some minor changes in ranking within the top 10 did change. Further analysis was carried out to provide a regional picture country by country. The results of this regional analysis are presented below. The United States spends the most on healthcare globally.4 A national analysis (Table 1) suggests this is true for wound are also.1 The most recent governmental figures only permitted a regional analysis for 2020. Previous studies within the USA had provided an estimate of the likely costs,5-9 which are not outdated. None of these studies provided a regional analysis giving a picture of wound care spend state by state. The data presented in Figure 1 provide a crucial estimate of the likely costs of wounds across the United States. The costs are significant across all states, with some being more than many nations. These figures can provide a vital benchmark with regards to governmental/payor impacts both regionally and nationally. China may have lost the number one slot for total population recently, but our analysis estimates significant costs for wound care. A literature search highlighted a few studies with regards to wound care and its costs within China.10-13 A regional analysis shows for most of China's regions that their wound care costs equal that of many countries. This is not surprising since the estimation model is population based and China is developing economically with ongoing significant increases in per capita healthcare spend (Figure 2). Japan is one of the countries globally with a disproportionate elderly population. Since wound care is a problem for the elderly, then it should come as no surprise that Japan spends significantly in the wound care arena. Previous studies have shown this to be the case, especially in the pressure injury area.14, 15 Figure 3 presents the national and regional estimates of the wound care spend across Japan and its regions. Germany has a well-structured healthcare system and a good handle on its healthcare costs. Several authors have published some costing studies within German.16-19 Figure 4 provides a 2022 national estimate of cost, while providing a regional picture of the likely spend in the wound care area. France like Germany has a well-developed and tracked healthcare system. A literature search shows there are few studies within France regarding the estimation of wound care costs.20 An analysis across France and its regions shows significant spend across the country (Figure 5). Brazil is a quickly developing nation, with its healthcare systems becoming more and more sophisticated. With a large population its national healthcare spend is significant,21 and this includes wounds (Table 1). A literature search shows several studies have been carried out to highlight the cost of wounds within Brazil.22, 23 None, however, have provided a complete national cost nor indeed regional component. A regional analysis (Figure 6) demonstrates significant costs particularly in the east and south of the country. Italy has one of the lower per capita healthcare spends within Europe.24 However, its estimated wound care spend is still significant as seen in Table 1 and supported by a previous study. A regional analysis presented in Figure 7 shows how this is broken down regionally. Australia efficiently tracks its healthcare spending state by state. Several research groups have published cost related studies,25, 26 which includes a national estimate of wound care costs.27 None of these studies provided a regional picture of wound care expenditure. A regional analysis using our estimation model (Figure 8), presents how this is broken down across the country. Comprehending the economic impact of wound care offers valuable insights to policymakers and healthcare leaders, shedding light on the broader economic implications of wound management and its costs to the payors. This knowledge serves as a foundation for informed decision-making and the development of policies and research direction that support effective wound prevention and care practices. The impact can be both regionally or nationally influenced so a deeper understanding of regional spend can provide more directive guidance versus a national picture of costs.

The hierarchy of clinical evidence in support of medical devices ranges from case studies to randomised controlled trials (RCTs), systematic reviews and meta-analyses. While RCTs are seen as the gold standard for medicinal products, case studies provide some real-world insight as to the usefulness of medical devices, especially within the management of wounds. As wound carers/healers, we understand the complexity of these patients, with a variety of wound types, co-morbidities and a range of potential clinical outcomes. In wound patients however, like many other clinical conditions, patients are individual with their own unique challenges and outcomes. This is where clinical case studies can provide insight into the intricacies of the individual rather than the collective outcomes of a pooled population in a RCT: a real-world, personalised view. This could be a useful stage in supporting interventions and supplement the data derived from RCTs. In the two articles within this supplement, the authors present a review of the previously published clinical support for a unique hyaluronic acid and amino acids combination product (Vulnamin®). It also presents additional clinical evidence obtained through a consensus meeting of an international group of experts regarding their clinical experience with the use of the combination product in difficult-to-treat wounds. Their objective was to reach a consensus on how and when to utilise such products to provide a cost-effective, convenient option in all healthcare settings to improve outcomes for patients. Members of the Expert Panel presented their clinical experience with the product range. The case reports presented were obtained in Italy, Poland, Turkey and the United Kingdom, with data collection in accordance with the principles of Good Clinical Practice. From this real-world information, the panel of experts presented recommendations for the use of the product range in clinical practice. The 14 case studies presented demonstrate successful use of this hyaluronic acid and amino acids combination to be effective in the management of acute and chronic wounds. While the experts provide guidance on the use of such an approach in a variety of clinical situations, they do recommend that future, large-scale, randomised, controlled clinical trials are required in different clinical settings. In addition, the experts recommend further health economic data and reimbursement studies are carried out. The information provided gives a real-world picture on the flexibility of this combination product in the management of difficult to heal wounds, while recognising the need for further data. From this case series and supportive clinical review, the expert clinicians recommend considering the use of a combination product of hyaluronic acids and amino acids in several clinical situations. No interest is declared by both authors in the sponsor of the articles in this supplement.

ObjectiveTo estimate the ‘cost of illness’ arising from chronic wounds in Singapore.DesignIncidence-based cost of illness study using evidence from a range of sources.SettingSingapore health services.ParticipantsWe consider 3.49 million Singapore citizens and permanent residents. There are 16 752 new individuals with a chronic wound in 2017, with 598 venous ulcers, 2206 arterial insufficiency ulcers, 6680 diabetic ulcers and 7268 pressure injuries.Primary outcome measures expressed in monetary terms are the value of all hospital bed days lost for the population; monetary value of quality-adjusted life years (QALYs) lost in the population; costs of all outpatient visits; and costs of all poly clinic, use of Community Health Assist Scheme (CHAS) and emergency departments (EDs) visits. Intermediate outcomes that inform the primary outcomes are also estimated.ResultsTotal annual cost of illness was $350 million (range $72–$1779 million). With 168 503 acute bed days taken up annually (range 141 966–196 032) that incurred costs of $139 million (range 117–161 million). Total costs to health services were $184 million (range $120–$1179 million). Total annual costs of lost health outcomes were 2077 QALYs (range −2657 to 29 029) valued at $166 million (range −212 to 2399 million).ConclusionsThe costs of chronic wounds are large to Singapore. Costs can be reduced by making positive investments for comprehensive wound prevention and treatment programmes.

My son's interpretation of ‘MAC Attack’ differs drastically from mine. His comes from a ravenous urge for two all-beef patties on a sesame seed bun, whereas I am referring to one of the endless limitations placed on my practice by Medicare administrative contractors (MACs). The most recent ‘MAC Attack’ by Novitas, First Coast Service Options and CGS, representing 14 US states, restricted the use of Cellular and/or Tissue-Based Products (CTPs), also known as ‘skin substitutes’, to four applications per diabetic foot or venous leg ulcer.1 These new local coverage determinations (LCDs) are effective as of 17th September 2023. Failure to achieve success after four CTP applications will result in the loss of patient access to this therapy—both ‘MAC Attacks’ have potential adverse health effects. But before villainizing the MAC medical directors for their decision, a review of the literature is warranted. In truth, CTPs used without proper wound bed preparation often fail. In fact, the results are worse than if a wound was never treated with a CTP.2 The key to success in healing wounds with CTPs is wound bed preparation: debridement, control of bacterial burden, maintaining an appropriate moisture balance, off-loading for diabetic foot ulcers and compression for venous leg ulcers. Reduction of bacterial load is crucial prior to the application of CTPs; however, wound care specialists often rely solely on clinical signs and symptoms to detect bacterial load. The ability to detect clinically significant levels of bacteria using examination is poor (sensitivity less than 15%).3 Wound cultures are equally inaccurate,4 and it takes days for the results to return. The national and local coverage determinations for CTP use have required control of bacterial burden as a condition for reimbursement for years; however, clinicians have used and continue to use inaccurate and unreliable methods for determining bacterial load. The decision on when to apply a CTP is at best haphazard. The fault of this ‘MAC Attack’ lies with the wound care community and the slow adoption of diagnostics. The most studied diagnostic in the detection of bacteria in acute and chronic wounds is fluorescence imaging—a point-of-care, non-invasive, modality that safe uses violet light to detect bacterial loads greater than 104 CFU/g.3 At this level, bacteria elicit changes at the cellular level that result in tissue damage and healing arrest, often without exhibiting signs of overt infection. This number of bacteria was recently termed chronic inhibitory bacterial load (CIBL).5 Clinical signs and symptoms of bacterial load are inaccurate in non-healing wounds and are often completely absent in immunocompromised patients.3 The ability to detect a clinically significant level of bacteria, CIBL, prior to the application of a CTP using only signs and symptoms of infection is poor; however, fluorescence imaging can improve the detection of bacteria by fourfold to sevenfold3 irrespective of clinical expression and throughout all skin tones. Despite being an accurate, bedside method of bacterial detection, the adoption of fluorescence imaging has been slow. Real-time fluorescence imaging has been reported to improve both CTP and autologous skin grafting outcomes based on the presence or absence of bacterial fluorescence prior to application.6, 7 Further, fluorescence imaging improves reduction of bacterial burden, as demonstrated in numerous publications, by accurately identifying and localising high bacterial loads and guiding clinicians in the process of removing bacteria in real time.8, 9 A randomised control trial found that the most common intervention prompted by fluorescence imaging was debridement, and patients who received the imaging intervention showed improved healing (twice as many DFUs healed at 12 weeks than the standard of care).10 Wound specialists must expand their toolkit to optimise wound bed preparation prior to the application of CTPs or face stricter and broader restrictions. Fluorescence imaging in combination with physical examination enhances the identification of bacteria, which in turn improves wound healing outcomes with CTPs. Finally, as the wound care community builds a robust body of evidence on the optimisation of CTPs, the evidence garnered can be used to assuage the next ‘MAC attack.’

(1) Background: Chronic wounds represent a major burden to patients and healthcare systems and identifying new therapeutic targets to encourage wound healing is a significant challenge. This study evaluated nWASP as a new therapeutic target in human wound healing and determined how this can be regulated. (2) Methods: Clinical cohorts from patients with chronic wounds were tested for the expression of nWASP and cell models were employed to evaluate the influence of nWASP on cellular functions that are key to the healing process following knockdown and/or the use of nWASP-specific inhibitors. (3) Results: nWASP was significantly elevated at transcript levels in human non-healing chronic wounds versus healing tissues. nWASP inhibitors, wiskostatin and 187-1, along with the knockdown of nWASP, modified both HaCaT and HECV cell behaviour. We then identified two signalling pathways affected by nWASP inhibition: TrkB signalling and downstream PLCγ1 phosphorylation were impaired by nWASP inhibition in HaCaT cells. The healing of wounds in a diabetic murine model was significantly improved with an nWASP inhibitor treatment. (4) Conclusions: This study showed that nWASP activity was related to the non-healing behaviour of chronic wounds and together with the findings in the in vivo models, it strongly suggested nWASP as a therapeutic target in non-healing wounds that are regulated via TrkB and PLCγ1 signalling.

The IWJ family were saddened to learn of the passing of a wound care legend Dr. Barbara Braden after a 2-year battle with cancer. While many of us may not have personally met Barbara, her name is known universally. Barbara J. Braden, PhD, FAAN, was the Dean of University College at Creighton University in Omaha, Nebraska. She received her bachelor's degree from Creighton University in 1973, her master's from the University of California at San Francisco in 1975 and her doctoral degree from the University of Texas at Austin in 1988. She is best known for her work in the development of the Braden Scale for Predicting Pressure Sore Risk, which has been translated into many languages and is used on all continents. Dr. Braden is a Fellow of the American Academy of Nursing, and a past member of the NPUAP board of directors. In her own words in an interview with Wounds Canada in 2007, she explained her surprising journey. ‘I authored the tool out of my expertise in clinical nursing but working with Dr. Nancy Bergstrom to test it convinced me to get my PhD. It has propelled me from being known locally and regionally to being known nationally and internationally. It has resulted in opportunities to speak to multidisciplinary audiences around the world. Because of it, I have received awards for achievement from the Creighton University, University of California at San Francisco and the University of Texas at Austin. It took me from faculty to administration and directly resulted in my appointment as Graduate Dean at Creighton University. Many people read this and interpret it as meaning I was in charge of graduate programs in nursing. But because of my international reputation for research in the field, the faculty of the university had sufficient respect for my expertise to make me Dean of the entire Graduate School, which included 21 master's programs and three doctoral programs across five different schools. In short, it turned a nice and moderately successful career into an unbelievably fabulous career!’1 It may have been surprising to her but not to those who knew her. Being the namesake of the most widely used pressure injury risk assessment globally changed her career. Dr. Braden had a major impact in nursing research and alongside her colleague Dr. Nancy Bergstrom changed pressure ulcer care forever. She was a leader in supporting nursing research and a strong advocate for nursing science and evidenced based care. Her passing while sad, reminds us all of the extensive influence of Barbara Braden in the wound-care area and she will leave a legacy in this area for other clinicians and researcher to benefit from. Her legacy will live on through the continued work of many others, using the Braden Scale. We all know she made the world a better place. Let us face it we all know that nurses make the world a better place. Plain and simple, they are the engine of healthcare. A legacy like the Braden Scale is testament to this impact being an excellent reminder of the difference nurses can make. Dr. Braden, we thank you for all you contributed to our world of wound care. We thank you for making a difference in the lives of clinicians caring for those with wounds. But most of all we thank you for your impact in reducing the pain and suffering of those with or having the potential for pressure injuries. The world has Superman and Superwoman but has sadly lost its Supernurse! Rest In Peace, and make sure those in heaven know how to use the Braden Scale effectively!

As long-standingwound researchers, wewere sad to hear of the passing of a wound-care legend, Professor Hugo Partsch. Hugo for many is regarded as the grandfather of compression science. As an Austrian dermatologist, he contributed significantly to the research in phlebology and compression. Here is his contribution to our journal in the 20 years of its existence and as a co-author with our Editor-in-Chief:

International Wound JournalVolume 20, Issue 2 p. 235-237 EDITORIALOpen Access Importance of imaging to wound care practice Douglas Queen, Corresponding Author Douglas Queen [email protected] Correspondence Douglas Queen Email: [email protected]Search for more papers by this authorKeith Gordon Harding, Keith Gordon HardingSearch for more papers by this author Douglas Queen, Corresponding Author Douglas Queen [email protected] Correspondence Douglas Queen Email: [email protected]Search for more papers by this authorKeith Gordon Harding, Keith Gordon HardingSearch for more papers by this author First published: 30 January 2023 https://doi.org/10.1111/iwj.14082AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Medical imaging has greatly advanced health care in the past three decades. Its use has allowed clinicians to identify injuries, conditions, and diseases. From broken bones to compromised organs to cancer detection, early and/or accurate diagnosis can save limbs and lives. Medical imaging offers quicker and more reliable information, and has drastically improved patient outcomes and helped doctors achieve better results. For example, medical imaging guides doctors in surgery for improved precision and accuracy. Imaging permits doctors to assess disease progression or severity of an injury. This information helps doctors choose the right approach and treatments. What is regarded as medical imaging? The FDA defines it as, "Medical imaging refers to several different technologies that are used to view the human body in order to diagnose, monitor, or treat medical conditions. Each type of technology gives different information about the area of the body being studied or treated, related to possible disease, injury, or the effectiveness of medical treatment." Imaging is familiar to most clinicians regarding X-rays, ultrasound, and MRI as examples. Some are becoming familiar to those providing wound care. Imaging has become an essential part of the clinical record for wound care patients by using photography.1 However, the area of imaging technology is just evolving within wound care, providing more new diagnostic tools,2 some of which will be highlighted below. Medical imaging has been an important tool for many years throughout all aspects of medicine. Historically, wound care clinicians do not access such technology within wound care centres. This appears to be changing. There are new, small, portable, point-of-care devices being developed that can easily fit into the wound care algorithm. The future of wound care3 will include the adoption and implementation of these new diagnostic approaches, helping prevent, diagnose, treat, and monitor wound progress.4 Wound assessment, for the most part, relies on visual evaluation by clinicians, both expert and non-expert.5 Such assessment is largely subjective and presents the opportunity for development of new technologies to remove subjectivity from the assessment process. Advanced solutions have, therefore, been developed where digital photography, usually using smart phones, is supported by advanced machine learning software. Such approaches, however, continue to be confounded by several factors such as variable lighting conditions, distance to the objects, and quality of images. Therefore, further development and evolution are required. Visual evaluation of wounds, the current gold standard, has served clinicians well but is clearly not the future of imaging in wound care.6 1 ULTRASOUND IMAGING While the area measurements are essentially surface measurements, other technologies provide a more in-depth insight into the wound and its underlying tissue. Advances in ultrasound technology have led to portable ultrasound solutions. Consequently, portable ultrasounds provide high-quality imaging that was once limited to bulkier devices. Furthermore, ultrasound machines are becoming increasingly smaller, ranging from laptop-based ultrasound machines to a variety of hand-held scanners (e.g., Clarius7). Portable ultrasounds can be used for 2D, 3D, or 4D imaging and are powered with advanced imaging capabilities for high-contrast resolution and image optimisation. Visualisation of tissue 3D structures up to a depth of several inches is possible making ultrasound imaging a powerful tool to study full-thickness wounds. The portability of today's handheld devices makes it practical for use in wound care settings. Cloud storage and artificial intelligence analysis make this diagnostic approach more readily suited for the expert/non-expert wound care world. 2 PERFUSION IMAGING Wound physiology is complex, with the assessment and diagnosis of wounds being difficult. Vascular assessment is a critical in wound care to assess tissue health status and healability. Adequate tissue perfusion is recognised as a predictor of wound healing. Tissue oxygen saturation is a surrogate marker of wound perfusion. Ankle brachial index and transcutaneous oxygen measurement are the two clinically common methods used to measure vascular supply of wound tissue. However, both only provide a point measurement and are less suitable to assess the perfusion status over the entire wound area. Non-invasive vascular assessments provide an adequate screening test, but their output is often limited and requires significant clinical interpretation. New emerging sophisticated imaging technologies (e.g., MIMOSA Pro8) allow clinicians to obtain more information about the wounds they are treating and enable a better understanding of tissue microenvironments. These new imaging devices can assess tissue oxygenation, microvasculature, tissue health status, and wound microbiome. Use of these new diagnostic approaches will aid clinicians in making more informed treatment decisions. Near-infrared spectroscopy (NIRS) is an emerging imaging technology that can be used to evaluate functional tissue health status in the management of chronic wounds. This non-contact device is hand-held, mobile, and offers repeatable immediate images that can be used to determine site-specific quantifiable levels of tissue oxygenation in and around the wound. This diagnostic tool uses differing optical signals based on the proportion of oxygenated haemoglobin found within the tissue capillary bed. The images obtained provide sufficient information for clinical assessment of tissue health. Near-infrared imaging modalities can serve as an additional diagnostic assessment of wounds in which adequate perfusion is a concern. Correct interpretation of near-infrared images obtained is critical. 3 FLUORESCENCE IMAGING Increased wound bacteria loads can hinder healing and cause infection. Bacteria and biofilm may persist in the wounds even with good wound care practices. Elevated levels of tissue bioburden can further prolong wound chronicity. Although swabs and wound biopsies can be used to confirm presence of bacterial burden in wounds, but their use varies widely and results are often prolonged. An essential component of wound care is debridement of devitalised or bacteria-laden tissue that acts as a barrier to healing and can prevent the effectiveness of topical antimicrobial agents. Determining how much debridement is needed can be a challenge and can be over aggressive to ensure total removal. The immediate information on the presence and location of bacteria was essentially a guessing game until the development of fluorescence imaging. This technology shows bacterial-loading of tissues providing a target for debridement. The immediate diagnostic information and feedback on treatment efficacy clinicians receive through the fluorescence imaging of bacteria is useful. Fluorescence imaging helps clinicians to understand the infection status of wounds and helps to monitor the effectiveness of clinical interventions. Handheld fluorescence imaging devices (e.g., MolecuLight i:X9), are easy to use, non-invasive and portable. This technology visualises potentially harmful bacteria on the wound surface and surrounding tissues not otherwise visible with the naked eye. The device emits a violet light that illuminates the wound and surrounding area, exciting the wound tissues and bacteria and resulting in fluorescence signals. The signals produced are tissue specific: endogenous tissue components such as collagen will fluoresce green, while pathologic bacteria fluoresce red, and pseudomonas will fluoresce cyan. The information captured in the images can aid in more targeted and thorough wound debridement, support clinical decisions and dressing selection, and aid in determining the need for antimicrobial therapy to improve clinical outcomes. 4 THERMAL IMAGING Thermography provides significant diagnostic value and prognostic insight to a range of clinical problems. Thermal imaging devices (e.g., FLIR10) can potentially be used to provide information on systemic or local temperature abnormalities in tissue caused by ischemia, inflammation, or infection prior to clinical manifestations. The technique consists of comparing images obtained on both limbs and performing an asymmetrical analysis by subtracting mean temperature of the nonulcerated limb from the corresponding value of the ulcerated one. Long-wave infrared thermography can measure radiant heat from a body surface and has been accepted as a valuable adjunct to standard investigations in the early detection of inflammation and infection. Research has shown that a temperature difference between a chronically infected wound and normal tissue has a specific elevated thermal gradient range of 3°C to 4°C. The utility of thermography has been investigated in many clinical applications. The clinical utility can be split into two primary scenarios: Inflammation based (Increased flow) Infection–powerful predictor of early Surgical Site Infection (SSI). Infection–adjunctive predictor of Diabetic Foot Infection (DFI). Autoimmune–Charcot Foot (diabetes). Autoimmune–Hidradenitis Suppurativa, Lupus Erythematosus, Calciphylaxis, etc. Perfusion based (Decreased flow) Ischemic Diabetic Foot Ulcer (DFU). Surgical Free and Rotational Flaps. Angioplasty Surveillance. Pressure-Induced including Deep Tissue Injury. Trauma-Induced. 5 EMERGING LANDSCAPE Current and emerging imaging technologies offer a deeper insight into both the wound and its underlying physiology. By visualising and obtaining this deeper insight the information provided offers higher clinical relevance of the assessment. While being in the early stages of implementation within wound care many have gained experience and relevance in other clinical and non-clinical areas. The major benefit for wound care is as they become more and more integrated into wound care practice, they are fast becoming part of routine clinical workflow. This is especially true of the more portable and easier to use devices. While the interpretation of diagnostic output maybe be more complex this is often simplified via artificial intelligence and machine learning to present a diagnostic output. The use of new diagnostic imaging technologies has started to change the clinical management of all types of wounds. Specifically, it has improved both the assessment and management of wounds and provides visual documentation that enhances patient engagement and facilitates better treatment compliance. REFERENCES 1Queen D, Harding K. Is wound photography becoming sloppy? Int Wound J. 2020; 17(1): 5- 6. 2Wound Diagnostics' Arrive at Last. Int Wound J. 2010; 7: 207- 209. 3Harding KG, Queen D. A 25-year wound care journey within the evolution of wound care. Adv Skin Wound Care. 2012; 25(2): 66- 70. 4Queen D. A personal perspective. Int Wound J. 2006; 3: 3. 5Harding K, Queen D. Can 2015 be a transformative year for diagnostics in wound care? Int Wound J. 2015; 12(1): 1. 6Queen D. Wound care 2010–a scientist's perspective! Int Wound J. 2007; 4(3): 194. 7www.clarius.com 8www.mimosadiagnostics.com 9www.moleculight.com 10www.flir.com Volume20, Issue2February 2023Pages 235-237 ReferencesRelatedInformation

Background Little is known about stage 1 and 2 pressure injuries that are health care‐acquired. We report incidence rates of health care‐acquired stage 1 and stage 2 pressure injuries, and, estimate the excess length of stay using four competing analytic methods. We discuss the merits of the different approaches. Methods We calculated monthly incidence rates for stage 1 and 2 health care‐acquired pressure injuries occurring in a large Singapore acute care hospital. To estimate excess stay, we conducted unadjusted comparisons with a control cohort, performed linear regression and then generalized linear regression with a gamma distribution. Finally, we fitted a simple state‐based model. The design for the cost attribution work was a retrospective matched cohort study. Results Incidence rates in 2016 were 0.553% (95% confidence interval [CI] 0.55, 0.557) and 0.469% (95% CI 0.466, 0.472) in 2017. For data censored at 60 days’ maximum stay, the unadjusted comparisons showed the highest excess stay at 17.68 (16.43‐18.93) days and multi‐state models showed the lowest at 1.22 (0.19, 2.23) days. Conclusions Poor‐quality methods for attribution of excess length of stay to pressure injury generate inflated estimates that could mislead decision makers. The findings from the multi‐state model, which is an appropriate method, are plausible and illustrate the likely bed‐days saved from lowering the risk of these events. Stage 1 and 2 pressure injuries are common and increase costs by prolonging the length of stay. There will be economic value investing in prevention. Using biased estimates of excess length of stay will overstate the potential value of prevention.

In 2023 the IWJ has a lot to celebrate. Firstly, it is our 20th birthday and secondly our performance metrics have continued to improve year on year. Our impact factor has marginally increased again in 2022. As editors, we are very pleased to confirm that IWJ's impact factor has jumped slightly to 3.1. It has also risen 7 places in the Dermatology category ranking, now 22nd of 70 journals, and 24 places in Surgery, now 49th of 212 journals. Other important journal metrics also increased in 2022 over 2021 (Table 1) and a glossary of terms is presented in Table 2 to help with understanding of importance of each. While many of the metrics presented in Table 2 represent differing ways of presenting a journal's impact, it is humbling for our editorial and production teams, and our publisher Wiley Inc, to see these increasing metrics across the board. These solidify the IWJ as a valuable resource to the scientists and clinicians researching wounds around the world. A fantastic result, and we thank all involved in this achievement. As a reader of or a contributor to our journal, you are probably aware of the continued success of the IWJ, but here are some updated facts that prove its continued evolution towards the number one international resource for those involved in both the science and practice of wound healing. All in all, the IWJ continues to achieve the international profile and status we desired and is now recognised as the premier international, high-quality, peer-reviewed resource in wound care. As the editorial team, we would like to thank all contributors to this success to date and to also encourage bigger and better things by asking for your continued and increased participation in growing this valuable resource.

Venous leg ulceration results in significant morbidity. However, the majority of studies conducted are on Western populations. This study aims to evaluate the wound healing and quality of life for patients with venous leg ulcers (VLUs) in a Southeast Asian population. This is a multi-centre prospective cohort study from Nov 2019 to Nov 2021. All patients were started on 2- or 4-layer compression bandage and were reviewed weekly or fortnightly. Our outcomes were wound healing, factors predictive of wound healing and the EuroQol 5-dimensional 5-level (EQ-5D-5L) health states. Within our cohort, there were 255 patients with VLU. Mean age was 65.2 ± 11.6 years. Incidence of diabetes mellitus was 42.0%. Median duration of ulcer at baseline was 0.30 years (interquartile range 0.136-0.834). Overall, the median time to wound healing was 4.5 months (95% confidence interval [CI]: 3.77-5.43). The incidence of complete wound healing at 3- and 6-month was 47.0% and 60.9%, respectively. The duration of the wound at baseline was independently associated with worse wound healing (Hazard ratio 0.94, 95% CI: 0.89-0.99, P = .014). Patients with healed VLU had a significantly higher incidence of perfect EQ-5D-5L health states at 6 months (57.8% vs 13.8%, P < .001). We intend to present longer term results in subsequent publications.