1. Salcido, Richard MD, EdD

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This month's continuing medical education activity on page 376 recognizes the sustained effort of the New York-based team of authors in driving the effort to incorporate the histopathologic determinants of diagnosing and selecting treatment options for chronic wounds including pressure ulcers (PrUs). According to the authors, there remains a paucity of work linking wound biopsies to the classification, diagnosis, and treatment of tissue damage. This is with 1 nuance, however; biopsies harvested after wound debridement are retrospective owing to the temporal nature of debridement itself, because the goal of debridement is revitalizing the wound edges to stimulate wound healing.1

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Therefore, in clinical practice, biopsies collected from the debrided tissue are retrospective (see recommended reading). This observation is supported by the authors who state, "A more detailed analysis of the wound edge histopathology is needed to suggest optimal therapeutic interventions for a given wound." Without engaging tautology, it is my informed observation that to accomplish the above laudable goals, serial biopsies should be obtained and analyzed throughout the epochs of a nonhealing chronic wound. Similarly, the trajectory of a healing wound should also be sequentially histologically examined.2


Furthermore, these analyses could be matched with clinical findings or wound stages and particular histologic staging schemas. As it was alluded to in a previous article by the authors, there are not enough scientific studies to influence effective prevention or treatment through current evidence-based medicine criteria.1 Many of the clinical studies on PrUs remain difficult to evaluate because the studies are anecdotal, based on random observation, or are uncontrolled. Thus, reproducible fundamental research needs to be conducted on topics related to patient outcomes. For example, research on the basic histologic, pathological, and biochemical markers found in an evolving PrU needs to be studied. Such knowledge of the changing PrU could significantly influence patient care. Because of patient-related variables or ethical considerations, however, this research often cannot be conducted on humans, and therefore animal models have been used to achieve these goals.1,2


In 1993, an animal model of sequential mechanically induced histologic grading scale was validated for the purpose of evaluating the depth of the wound, tissue damage, muscle infarction, and apoptotic cellular damage through an ischemia-reperfusion injury hypothesis. Still, animal models are only homologs to the human condition and remain at the lower rung of the evidence rating scale.2


To rectify this long-standing research gap, the authors of this continuing education activity are leading interprofessional collaborations with pathology, surgery, and others to develop human sequential histopathology models aimed at understanding the pathology of nonhealing wounds. This practice is similar to the long-standing tradition of evaluating pathologic specimens after surgery for the purpose of diagnosis and classification guiding treatment options.




1. Golinko MS, Joffe R, de Vinck D, et al. Surgical pathology to describe the clinical margin of debridement of chronic wounds using a wound electronic medical record. J Am Coll Surg 2009;209:254-60e1. [Context Link]


2. Salcido R, Donofrio JC, Fisher SB, et al. Histopathology of pressure ulcers as a result of sequential computer-controlled pressure sessions in a fuzzy rat model. Adv Wound Care 1994;7(5):23-6. [Context Link]

Recommended Reading


Vassar M, Holzmann M. The retrospective chart review: important methodological considerations. J Educ Eval Health Prof 2013;10:12.