In this issue of Wound Repair and Regeneration (WRR), I am pleased to present the updated Wound Healing Society (WHS) Treatment Guidelines for Pressure, Arterial, Venous, and Diabetic Ulcers, which reflect a modified perspective. The original guidelines were published in December 2006, with the goal of enhancing the quality of care of patients suffering from chronic wounds.1-5 This effort became, in a short time, a standard reference for the most comprehensive and up-to-date, state of the art scientific exposé. In 2006, the WHS set out to create documents that clinicians could use to intelligently care for patients. While not algorithmic, a practitioner can pragmatically follow guideline recommendations to perform conceptually sound wound care. However, to succeed in that undertaking, the 2006 guidelines adopted a novel approach to interpreting evidence: highest levels of evidence included laboratory or animal data supported by clinical experience; lower levels of evidence allowed experimental data without significant human experience. This interpretation of evidence differs from what has evolved in guideline development.6, 7 This approach was utilized in part to avoid conclusions that too little evidence was available to make recommendations and, in part, because of the basic science interests of the Society. Furthermore, evidence acceptable for one wound type was adopted for all wound types. The levels of evidence used are listed below: Level I: Meta-analysis of multiple randomized clinical trials (RCTs) or at least two RCTs supporting the intervention of the guideline. Another route would be multiple laboratory or animal experiments with at least two significant clinical series supporting the laboratory results. Level II: Less than Level I, but at least one RCT and at least significant clinical series or expert opinion papers with literature reviews supporting the intervention. Experimental evidence that is quite convincing but not yet supported by adequate human experience is included. Level III: Suggestive data of proof-of-principle, but lacking sufficient evidence such as meta-analysis, RCT, or multiple clinical series. At the outset, hearty congratulations should be given to the WHS, the guideline organizers and the individual committees that worked on those original guidelines. The guidelines succeeded. At the completion of that project, all recognized that medicine evolves and the need to update the guidelines on a regular basis was implicit from the beginning. The wound healing world was quite different in 2006, and the field has matured from its infancy to its adolescence. Over the past decade, a greater appreciation of the seriousness of the disease state has arisen.8-10 We have begun to appreciate the real costs of the disease to patients, their families, caregivers, payers, and society.11, 12 Novel diagnostic and therapeutic tools have emerged and/or been more widely adopted. Centers of wound healing excellence have become commonplace and more clinicians recognize wound care as their specialty.13 Wound healing meetings have proliferated, and didactic and experiential, fellowship-like training has been envisioned. The field has started to unify, with opportunities for greater, collective policy input from related organizations. Outside of wound care, many guidelines have emerged over the past decade.14, 15 Most of these guidelines have adhered to similar set rules of evidence, different than the WHS used, which generally excluded the use of laboratory data as a basis for recommendations. However, this wound care organization had something special in these guidelines: they were respected, clinicians used them and they improved patient care. In planning to update these recommendations, we did not want to lose this important feature of the WHS guidelines. At the same time, we wanted to respect the need to base care on current clinical data and experience. As a compromise, we authors agreed to begin to align with the majority of guidelines that rely on human data, by basing any changes to the WHS guidelines on clinical data from the specific wound type addressed by guideline. By doing so, we would not eliminate prior recommendations in the absence of new, wound type specific clinical data. Using literature from 2006 forward, each guideline group reviewed the findings. Guidelines were formulated, underlying principle(s) enumerated, and evidence references listed and coded. The code abbreviations for evidence citations are as follows: STAT: Statistical analysis, meta-analysis, consensus statement by commissioned panel of experts RCT: Randomized clinical trial CLIN S: Clinical series LIT REV: Literature review RETRO S: Retrospective series review TECH: Technique or methodology description PATH S: Pathological series review I want to thank the tremendous work of all members of the guideline committees and specifically mention Drs. Lawrence Lavery, William Marston, Gayle Gordillo, and Daniel Federman who served as chairs for the Diabetic Foot Ulcer, Venous Ulcer, Pressure Ulcer, and Arterial Ulcer guideline committees, respectively. All guideline committee members should be applauded for their hard work and excellent efforts. Respecting the past and building toward the future is a difficulty balance. The first drafts of the guidelines were posted in 2014 for public comment. Each committee reviewed the comments and adjusted the guidelines accordingly. The guidelines also went through the WRR peer review process. Therefore, I also offer my sincerest thanks to all panel members who have worked so hard to produce these remarkable documents. These guidelines are not the culmination of work but the beginning. They serve to highlight what we know and what we do not know. Adrian Barbul, MD, who helped lead the guidelines effort, let the original guidelines serve as “a call to action to all scientists, clinicians, health care providers, industry members involved in this field and government funding agencies: the need for more hard data is clear and these data cannot be acquired unless all interested groups lock arms and work toward this goal.”16 His words were prescient. Join the WHS now in improving patient care by following evidenced based care and in the future by generating high quality research.
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Robert S. Kirsner (2015) studied this question.