Bridge Building
Howard L. Enfiejian, PhD.D.
Director of Research and Medical Communication
Derma Sciences Inc., Old Forge, PA
It's happened too often and in too many places to be coincidental. Whether I'm at a
scientific meeting or clinical conference, I often hear people observe how the stunning
advances in our understanding of wound healing and tissue remodeling have yet to translate
into corresponding advances in day-to-day wound care. This is certainly not a criticism,
given the fact that care givers and researchers alike are dealing with an unfathomably
complex biological process. However, in the case of indolent wounds, some of the high
science may be used in a disarmingly simple way. A review of the literature suggests how.
Within the well-healing wound, many events are intricately orchestrated, such as
macrophage function, fibroblast proliferation, lymphocyte proliferation and activation,
collagen synthesis, the appearance of actin within fibroblasts, and the activity of growth
factors. Some of these coincide with specific events within wound fluid, such as
time-dependent declines in arginine concentrations, or with more complex phenomena, such
as amino acid profiles. Other events occur, to all appearances, simply as a function of
time, with other contributing factors not yet being understood. It is also very telling
that the activity and proliferation of wound cells depends more on the concentration of
trophic factors within the wound fluid than upon their concentration within the serum.
This observation exemplifies the biological priority of the healing wound and the
importance of an optimum wound environment.
In an indolent wound, however, things become deranged. Major differences in the
concentration of many components of the cellular environment appear in fluids taken from
healing and nonhealing wounds. These components include bicarbonate, glucose, total
protein, albumin, -globulin and cholesterol, as well as abnormal levels of epidermal
growth factor, transforming growth factors alpha and beta, and insulin-like growth
factor-I. Ultimately, these kind of derangements result in functional deficits ranging
from altered collagen metabolism, delayed healing, and premature leukocyte activation, to
exaggerated fibronectin and vitronectin degradation. It is also crucial to know that
fluids drawn from acute and chronic wounds have radically different effects on healing.
Fluids drawn from acute wounds typically stimulate the elements of wound repair in various
test systems, whereas fluids drawn from chronic wounds profoundly inhibit these elements.
These observations lead to the simple but powerful supposition that the body's innate
capacity for healing can only proceed in the proper cellular micro-environment.
Unfortunately, given the daily pressures of patient care, such environments can be
difficult to create and maintain. Indolent wounds, once formed, can persist for years in
the absence of a proper cellular micro-environment. What is intriguing, however, is that
care givers can manipulate many of the factors that cause indolent wounds to begin with
and in so doing abort the cascade of events that leads to the formation of chronic wound
fluid. Given the proper resources, education, and cooperation, things like humidity,
infection, nutrition, pH, and oxygen tension can be controlled. To some extent,
catastrophic illnesses such as malnutrition, pulmonary and cardiac disease, neurologic
problems, and diabetes can either be controlled or compensated. In effect, the expenditure
of time and resources up front will reduce risk factors, abort complex metabolic
deterioration, and prevent expensive complications down the line.
These goals will require extensive education, cooperation, and respect among care
givers, managed care organizations, and HMOs. On the one hand, people who control budgets
must allot care givers the resources necessary to undertake comprehensive preventive care.
Care givers on the other hand, must realize that their ongoing commitment to the
insightful use of these resources will ultimately save incalculable amounts of money and
enhance the dignity of their patients' lives.
