Management of a Large Complex Lower Extremity Wound in a 94-Year-Old Woman with Multimorbidity: A Case Report Emphasizing Systemic Homeostasis as a Prerequisite for Local Healing

Management of a Large Complex Lower Extremity Wound in a 94-Year-Old Woman with Multimorbidity: A Case Report Emphasizing Systemic Homeostasis as a Prerequisite for Local Healing | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Management of a Large Complex Lower Extremity Wound in a 94-Year-Old Woman with Multimorbidity: A Case Report Emphasizing Systemic Homeostasis as a Prerequisite for Local Healing Zhen Li, Shui Lian Zhong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9461513/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Lower extremity wounds in super-elderly patients with multimorbidity present unique diagnostic and therapeutic challenges. The interplay among acute systemic illness, malnutrition, and local tissue breakdown often obscures the underlying pathophysiology, leading to misclassification and suboptimal management. Case Presentation: A 94-year-old woman with a history of coronary artery disease, hypertension, and chronic heart failure was admitted to the cardiac intensive care unit with progressive dyspnea and bilateral lower extremity edema. She was diagnosed with acute decompensated heart failure (NYHA Class III), sepsis (Escherichia coli bacteremia), and a tendency toward disseminated intravascular coagulation. On day 2, she developed a rapidly expanding skin defect on the right lower leg, which progressed to a maximum size of 30 cm × 15 cm with extensive necrosis and purulent exudate. Venous duplex ultrasound showed patent deep veins without reflux or thrombosis, excluding primary venous leg ulcer. The wound was therefore classified as complex lower extremity skin breakdown of mixed etiology secondary to systemic decompensation. Management consisted of systemic stabilization (antimicrobial therapy, albumin supplementation, nutritional support, and heart failure management) combined with local wound care including conservative debridement, topical povidone-iodine cream, and recombinant human epidermal growth factor (rhEGF) application. Notably, wound improvement commenced only after systemic parameters normalized—C-reactive protein declined from 105.32 mg/L to the normal range, and serum albumin increased from 26.54 g/L to 33.5 g/L. At 37-day follow-up, the wound had reduced to 20 cm × 10 cm with robust granulation tissue and marginal epithelialization, though complete closure was not achieved. Conclusions: This case demonstrates that in super-elderly patients with multimorbidity, local wound healing is contingent upon the restoration of systemic homeostasis. Clinicians should view complex wounds in this population as local manifestations of systemic illness and prioritize multidisciplinary correction of sepsis, malnutrition, and coagulopathy before expecting meaningful tissue repair from topical therapies. Findings from this single case are hypothesis-generating and warrant validation in larger observational studies. Super-elderly Multimorbidity Complex wound Systemic homeostasis Povidone-iodine Recombinant human epidermal growth factor Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Key Clinical Message In a 94-year-old woman with multimorbidity and a large lower-extremity wound, healing began only after sepsis, coagulopathy, and hypoalbuminemia were corrected. This case emphasizes that restoring systemic homeostasis—rather than relying on local dressings alone—is the essential prerequisite for tissue repair in the frail elderly. Background Chronic lower extremity wounds are highly prevalent in the aging population, with venous leg ulcers (VLU) accounting for approximately 70%–80% of all chronic lower limb ulcers [1]. The prevalence of chronic nonhealing wounds in developed countries is 1%–2% of the general population but rises to as high as 15% in Medicare beneficiaries [2]. In older adults, venous ulcers account for 85% of all leg ulcers, with incidence up to four times higher in adults older than 80 years [2,3]. Aging leads to physiological changes such as reduced skin elasticity, weakened immune responses, and slower cellular regeneration, all of which delay wound healing; frailty, marked by reduced physiological reserves, worsens these issues [4]. In super-elderly patients with acute systemic illnesses—such as sepsis, decompensated heart failure, and hypoalbuminemia—the etiology of skin breakdown is often mixed, involving a complex interplay of infection, edema, malnutrition, and background chronic venous insufficiency [5,6]. The 2025 Expert Consensus on Systematic Assessment and Treatment of Refractory Wounds in the Elderly emphasizes that diagnosis and treatment of refractory wounds in elderly patients require comprehensive consideration of primary diseases and comorbidities, systematic assessment of overall condition and local wound characteristics, and therapeutic principles including control of underlying diseases, nutritional support, infection control, and circulatory improvement [7]. In such cases, uncritical classification as “venous ulcer” may obscure the true pathophysiology and shift therapeutic focus away from urgent systemic stabilization. This case report describes a 94-year-old woman admitted with acute heart failure and sepsis who subsequently developed a large and rapidly progressing lower extremity wound. In accordance with reviewer feedback from a previous submission, we have revised the diagnostic framework: given the normal venous duplex ultrasound and the onset of skin breakdown during a period of severe systemic decompensation, the wound is better classified as secondary skin breakdown in the setting of critical illness rather than primary venous leg ulcer. This report aims to illustrate a critical clinical principle: in frail elderly patients with multimorbidity, restoration of systemic homeostasis—achieved through early, coordinated multidisciplinary intervention—is an indispensable prerequisite for local wound healing. Case Presentation Patient Information A 94-year-old woman was admitted to the cardiac intensive care unit on July 22, 2024, with a one-week history of bilateral lower extremity edema and progressive dyspnea. Her past medical history included coronary artery disease with stent implantation, hypertension (Grade 3, very high risk), and chronic heart failure. She had been prescribed aspirin (100 mg/day), atorvastatin (20 mg/day), benazepril (10 mg/day), metoprolol (47.5 mg/day), and furosemide (40 mg/day), although adherence to follow-up had been irregular in recent months. On admission, the patient was confused and orthopneic. Vital signs were as follows: temperature 37.8°C, heart rate 132 beats/min (atrial fibrillation on electrocardiogram), respiratory rate 35 breaths/min, blood pressure 105/53 mmHg. Physical examination revealed severe bilateral pitting edema of the lower extremities. The skin over the dorsal aspect of the right lower leg appeared purplish-black with increased local temperature. The right dorsalis pedis pulse was palpable but weakened; there was no toe gangrene or rest pain. Diagnostic Assessment Key laboratory findings on admission are summarized in Table 1 . Of note, inflammatory markers were markedly elevated: C-reactive protein (CRP) 105.32 mg/L, procalcitonin (PCT) 97.4 ng/mL, and interleukin-6 (IL-6) 14,350 pg/mL. Serum albumin was low at 26.54 g/L. Coagulation studies showed prolonged activated partial thromboplastin time (APTT) of 54.7 seconds and elevated D-dimer of 9.64 µg/mL, consistent with a tendency toward disseminated intravascular coagulation (DIC). N-terminal pro-B-type natriuretic peptide (NT-proBNP) was 1,304 pg/mL, indicating acute heart failure exacerbation. Table 1 Temporal Profile of Systemic Parameters and Wound Characteristics Date (2024) Clinical Events & Wound Description Laboratory Trends July 22 (D0) Right lower leg: purplish-black discoloration,intact skin, severe edema. Clinical diagnosis: soft tissue infection, sepsis CRP 105.32 mg/L PCT 97.4 ng/mL IL-6 14,350 pg/mL Alb 26.54 g/L NT-proBNP 1,304 pg/mL July 23 (D1) Skin breakdown: wound area 12 cm × 8 cm, 100% red base, copious serous exudate, surrounding skin purplish-black. D-dimer 9.64 µg/mL, APTT 54.7 s (DIC tendency) July 26 (D4) Wound expanded to 30 cm × 15 cm, mixed red and yellow base, black necrotic tissue, increased exudate. Blood culture: Escherichia coli; PCT: persistently elevated Aug 2 (D11) Wound base: 100% yellow slough, profuse purulent exudate. Daily mechanical debridement + povidone-iodine cream initiated. CRP 44.30 mg/L, PCT 0.204 ng/mL Aug 19 (D28) Wound base: 75% red granulation, 25% yellow slough; exudate significantly reduced; periwound erythema resolved Alb 31.88 g/L; coagulation parameters normalized Aug 28 (D37) Wound reduced to 20 cm × 10 cm; base robustly granulated; marginal epithelialization visible. CRP and PCT within normal range; Alb 33.5 g/L Imaging Findings Bedside ultrasound revealed moderate-to-large bilateral pleural effusions. Lower extremity venous duplex ultrasound demonstrated patent deep veins with no evidence of thrombosis or valvular reflux. Arterial ultrasound showed atherosclerotic changes with plaque formation but no hemodynamically significant stenosis. Echocardiography demonstrated mild left ventricular enlargement, biatrial dilation, and a left ventricular ejection fraction (LVEF) of 42%, with a small pericardial effusion. Vascular Assessment Due to the patient‘s critical condition and severe edema, ankle-brachial index (ABI) measurement was not performed on admission. However, the presence of a palpable dorsalis pedis pulse, the absence of rest pain, and the lack of ischemic skin changes (e.g., gangrene) clinically excluded severe limb ischemia. Non-elastic compression was applied with low tension (estimated pressure < 20 mmHg) primarily for edema control, with daily monitoring of capillary refill and distal perfusion. Wound-Specific Clinical Details · Size: Initial 12 cm × 8 cm (Day 1); maximum 30 cm × 15 cm (Day 4); final 20 cm × 10 cm (Day 37). · Depth: Partial-thickness to full-thickness skin loss, without tendon or bone exposure. · Exudate: Initially copious serous, later purulent; volume decreased markedly after Day 11. · Periwound skin: Early stage showed purplish-black discoloration with induration and hyperpigmentation; later stage demonstrated typical hemosiderin deposition (indicative of background chronic venous insufficiency). · Pain severity: Numerical Rating Scale (NRS) 7–8/10 during dressing changes; managed with topical lidocaine and oral tramadol. · Signs of venous hypertension: Bilateral edema and pigmentation were present, but venous duplex was negative for reflux, suggesting that venous hypertension was a background contributor rather than the primary driver of acute skin breakdown. Final Diagnoses Acute decompensated heart failure (NYHA Class III) Sepsis (Escherichia coli bacteremia) Tendency toward disseminated intravascular coagulation Complex right lower extremity skin breakdown (secondary to soft tissue infection with necrosis, hypoalbuminemic edema, and background chronic venous insufficiency) Hypoalbuminemia Lower extremity atherosclerosis (non-critical limb ischemia) Coronary artery disease (post-stent implantation) Hypertension Grade 3 (very high risk) Bilateral pleural effusions Reclassification of Wound Etiology The wound cannot be classified as a primary venous leg ulcer because venous duplex ultrasound showed no reflux or thrombosis, and the skin breakdown occurred in the context of acute systemic decompensation. We therefore reclassify this wound as secondary skin breakdown in the setting of critical illness—a clinical scenario wherein systemic decompensation (sepsis, hypoalbuminemia, and coagulopathy) compromises cutaneous integrity in vulnerable older adults. While the term “acute skin failure” has been proposed to describe such phenomena, it should be noted that this remains a controversial diagnostic entity. A 2025 National Pressure Injury Advisory Panel (NPIAP) think tank concluded that non-pressure-related skin failure in the critically ill currently lacks a distinct etiology, defined pathophysiology, and validated diagnostic criteria to warrant formal medical classification [8,9]. The panel emphasized that until more research is conducted, “the term has no scientific basis to be used to describe pressure injury in the critically ill” [9]. This revision does not alter local wound care principles but underscores the primacy of systemic management in achieving healing. Therapeutic Intervention Systemic Management (Foundation of Healing) · Antimicrobial therapy: Based on blood culture results (E. coli), piperacillin-tazobactam was administered for 14 days with subsequent de-escalation. · Correction of hypoalbuminemia: Repeated infusions of 20% human albumin were given, along with combined enteral and parenteral nutrition targeting 25 kcal/kg/day. · Coagulopathy management: D-dimer levels declined progressively with sepsis control; anticoagulation was not required. · Heart failure management: Diuresis and vasodilation were employed to achieve negative fluid balance and reduce peripheral edema. Local Wound Care (Adjunctive Acceleration) · Debridement strategy: Given the patient’s advanced age and thin subcutaneous tissue, a conservative sharp debridement combined with autolytic debridement was employed to avoid damage to healthy tissue and underlying fascia. · Antimicrobial dressing: From Day 11 onward, daily application of povidone-iodine cream was performed after debridement. Povidone-iodine (PVP-I) provides broad-spectrum antimicrobial activity via elemental iodine, with documented efficacy in biofilm disruption and low resistance-inducing potential [10]. The polyvinylpyrrolidone (PVP) matrix enables sustained release and maintenance of a moist wound environment. Among widely available antiseptics, PVP-I demonstrates exceptional efficacy in wound sanitation due to its broad-spectrum antimicrobial activity and minimal cytotoxicity [10]. · Growth factor application: After infection was controlled (from Day 30), recombinant human epidermal growth factor (rhEGF) gel (commercial formulation, not derived from autologous blood) was applied once daily to promote granulation and epithelialization. rhEGF has been established as a safe and effective therapeutic tool for chronic and complex ulcers, with multiple studies—including controlled trials, retrospective analyses, and systematic reviews—demonstrating consistent outcomes [11]. By stimulating cell proliferation, angiogenesis, and tissue regeneration, rhEGF reactivates essential biological processes that are typically impaired in such lesions [11]. · Regarding Yunnan Baiyao: During the early phase (Days 4–11), Yunnan Baiyao powder—a traditional Chinese medicine with local hemostatic and anti-inflammatory properties—was applied topically. However, due to crust formation that impeded drainage, it was discontinued. It should be noted that high-quality evidence supporting its use in wound care remains limited, and its application in this case was a short-term adjunctive measure. · Compression management: In the presence of a palpable dorsalis pedis pulse and no evidence of acute ischemia, low-tension short-stretch bandaging (target pressure < 20 mmHg) was applied for edema control. This was not therapeutic compression for venous disease, but rather a supportive measure for fluid management. Images The wound measured 30 cm × 15 cm. Black arrow indicates extensive black necrotic tissue; asterisk () indicates copious yellow purulent exudate. Periwound skin appears purplish-black. Following debridement and povidone-iodine cream, the wound base has become predominantly red granulation tissue (black arrow). Yellow slough is markedly reduced, and exudate is minimal. The wound has reduced to 20 cm × 10 cm. The base is dry with robust granulation tissue. White arrows indicate marginal epithelialization advancing from the wound edges. Discussion and Conclusions Systemic Homeostasis as the “Switch” for Wound Healing The most instructive observation from this case is the temporal alignment between systemic recovery and wound improvement. As illustrated in Table 1 , despite diligent local wound care (including non-adherent dressings and Yunnan Baiyao) during the first 11 days of hospitalization, the wound continued to deteriorate, expanding to its maximal dimensions of 30 cm × 15 cm. The inflection point occurred only after systemic parameters normalized—specifically, after blood cultures cleared, CRP declined to near-normal levels, and serum albumin rose above 31 g/L. This observation aligns with the “wound bed preparation” paradigm, which emphasizes that the systemic dimension (addressing infection, nutrition, and perfusion) is integral to creating a healing-competent wound environment [12]. In the persistently septic, hypoalbuminemic, and hypercatabolic state, local tissues remain in a “healing-resistant” mode, rendering any topical growth factor or advanced dressing ineffective [13]. Only through multidisciplinary collaboration—involving critical care, nutrition support, cardiology, and wound care—can systemic homeostasis be restored, thereby enabling the transition from chronic inflammatory stasis to proliferative repair. This is the core clinical message of the present case. The management strategy employed in this case aligns with the principles outlined in the 2025 Expert Consensus on Systematic Assessment and Treatment of Refractory Wounds in the Elderly, which emphasizes comprehensive evaluation of underlying diseases and comorbidities, systematic assessment of overall status and local wound characteristics, infection control, nutritional support, and circulatory improvement as core therapeutic components [7]. The ultimate treatment goal—wound closure when feasible, or palliative management when not—was reflected in our approach of prioritizing systemic stabilization over aggressive local intervention. Diagnostic Precision and Its Therapeutic Implications Misclassification of this wound as a venous leg ulcer would have directed clinical attention toward compression therapy and venoactive medications, potentially delaying urgent systemic interventions. The 2025 Canadian Consensus Statement for the Management of Venous Leg Ulcers recommends compression therapy as the cornerstone of VLU management to restore venous return and reduce ambulatory venous pressure [14]. Compression therapy remains the cornerstone of VLU management, with guidelines emphasizing early identification and correction of superficial venous incompetence [15]. Had this wound been misclassified as a VLU, the patient might have been subjected to therapeutic compression—an intervention that could have compromised arterial perfusion in the setting of weakened dorsalis pedis pulse and atherosclerotic disease [16]. The normal venous duplex ultrasound and the acute onset during systemic decompensation justified withholding compression beyond low-tension edema control. The concept of “skin failure” has been introduced in the literature to describe the deterioration of skin integrity accompanying severe illness and end-of-life decline [8,17]. However, as noted in the 2025 NPIAP think tank report, the term currently lacks a distinct etiology, defined pathophysiology, and validated diagnostic criteria [9]. Non-pressure-related skin failure in the critically ill is defined as skin injury that occurs despite standard preventive interventions and for which no other etiology has been identified [8]. The panel concluded that until the term “skin failure” has more study, it has no scientific basis to be used to describe pressure injury in the critically ill [9]. Pending further research, we consider “secondary skin breakdown in the setting of critical illness” to be a more precise and defensible description of the present case. Conservative Principles in Super-Elderly Local Wound Care In this 94-year-old patient with minimal subcutaneous tissue, aggressive surgical debridement was avoided in favor of a conservative sharp-autolytic approach, preserving the vulnerable fascial blood supply. Povidone-iodine cream demonstrated favorable tolerability and antimicrobial efficacy in this case, with its sustained-release matrix reducing dressing change frequency and associated pain. PVP-I acts by penetrating biofilm matrices, eradicating embedded microorganisms, and reducing microbial load, thereby accelerating healing in acute, chronic, and surgical wounds [10]. The application of rhEGF was timed for the proliferative phase after infection had been controlled. rhEGF has been established as a safe and effective therapeutic tool with the potential to transform the conventional management of chronic and complex ulcers, improving clinical outcomes and enhancing patients‘ quality of life [11]. By stimulating cell proliferation, angiogenesis, and tissue regeneration, rhEGF reactivates essential biological processes that are typically impaired in such lesions, thereby promoting accelerated and functional wound healing [11]. Multiple studies—including controlled trials, retrospective analyses, and systematic reviews—have demonstrated consistent outcomes across various clinical settings [11,18]. Limitations This is a single case report involving a patient of extreme age and extensive comorbidity burden. The findings are not generalizable and should be interpreted as hypothesis-generating rather than practice-changing. Specifically, the observation that systemic homeostasis is a prerequisite for local healing in the super-elderly warrants validation through larger observational studies. Additionally, due to the patient’s critical condition on admission, ABI measurement was not obtained; arterial assessment relied on clinical examination alone, which carries inherent uncertainty. The use of Yunnan Baiyao, while of cultural interest, lacks high-quality evidence and should not be construed as a recommendation for routine clinical practice outside its traditional context. Chronic wounds in older adults are further complicated by access gaps to regular caretakers, immobility, nociceptive and neuropathic pain, and frailty—factors that must be acknowledged and addressed in this population [2]. Conclusions For super-elderly patients with multimorbidity who present with complex lower extremity wounds, clinicians should view the wound as a local manifestation of systemic illness. Before deploying costly topical therapies, priority must be given to correcting sepsis, malnutrition, and hemodynamic instability through early, coordinated multidisciplinary intervention. Only when the patient transitions from a catabolic to an anabolic state can local therapies exert their intended effects. This case, through diagnostic reclassification and temporal analysis of healing milestones, provides a compelling illustration of this clinical principle. Abbreviations · ABI Ankle-brachial index · APTT Activated partial thromboplastin time · CRP C-reactive protein · DIC Disseminated intravascular coagulation · rhEGF Recombinant human epidermal growth factor · IL-6 Interleukin-6 · LVEF Left ventricular ejection fraction · NPIAP National Pressure Injury Advisory Panel · NRS Numerical Rating Scale · NT-proBNP N-terminal pro-B-type natriuretic peptide · NYHA New York Heart Association · PCT Procalcitonin · PVP-I Povidone-iodine · VLU Venous leg ulcer Declarations Ethics Approval and Consent to Participate This case report was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient‘s legal guardian for publication of this case report and accompanying images. Consent for Publication Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Availability of Data and Materials All data generated or analyzed during this study are included in this published article. Competing Interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors ’ Contributions All authors contributed to the clinical management of the patient, conception and design of the case report, data collection and interpretation, drafting and critical revision of the manuscript, and approval of the final version for submission. References O‘Donnell TF Jr, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2014;60(2 Suppl):3S-59S. Oropallo AR. 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Efficacy of intralesional recombinant human epidermal growth factor in diabetic foot ulcers in Mexican patients: a randomized double-blinded controlled trial. Wound Repair Regen. 2014;22(4):497-503. Metcalf D, Parsons D, Bowler P. Wound biofilm and therapeutic strategies. In: Wound Healing. InTech; 2016. Wounds Australia. Standards and guidelines for wound management. Wounds Australia; 2025. Wounds Canada. Best practice recommendations for skin health and wound management 2025. Wounds Canada; 2025. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 06 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers invited by journal 29 Apr, 2026 Editor invited by journal 27 Apr, 2026 Editor assigned by journal 25 Apr, 2026 Submission checks completed at journal 25 Apr, 2026 First submitted to journal 19 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9461513","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":635794572,"identity":"8b372de5-bfd0-4583-8423-b2fea8c3997e","order_by":0,"name":"Zhen Li","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Li","suffix":""},{"id":635794574,"identity":"7f16e7e4-b3aa-4e1e-8565-0b8eb9610a8e","order_by":1,"name":"Shui Lian Zhong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYBACNv7mgw8+VNjY2bcDGQkVNYS18EkcSzaccSYt2YDnWLLBgzPHCGuRY8gxk+ZtO8S4QSJHTfJhCzMRDmM4liA548wBZnOeM2wViQ1sDPzt3Qn4tTA3HzD4UHGHz7K999iNxB0yDBJnzm4gaEvijDPPmBnOnEu7kXiGjcFAIpeQlhyDw7xthxkbbuSYFSS2MROlxbAZpGUDUAsDcVqAgcwICmTJnmPJEglnjvEQ9It8f/PxH6Co5GdvPvjxR0WNHH97L34tGICHNOWjYBSMglEwCrACAGcUUz90nTTaAAAAAElFTkSuQmCC","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Shui","middleName":"Lian","lastName":"Zhong","suffix":""}],"badges":[],"createdAt":"2026-04-19 11:08:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9461513/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9461513/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108957071,"identity":"ce658bd1-a22e-42c8-bbcb-5630adbd00ab","added_by":"auto","created_at":"2026-05-11 08:16:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":284615,"visible":true,"origin":"","legend":"\u003cp\u003eDay 4 — Maximal Wound Extent\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9461513/v1/d3839666feeac28cad5529ae.png"},{"id":108956942,"identity":"01938b8f-6b75-4c90-8142-e1548d6eef1c","added_by":"auto","created_at":"2026-05-11 08:15:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":237980,"visible":true,"origin":"","legend":"\u003cp\u003eDay 28 — Granulation Phase\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9461513/v1/dd05e553a8371bf9f134ab3f.png"},{"id":108957059,"identity":"bcc08f2f-cd28-4abe-b0d6-9f9707013e1e","added_by":"auto","created_at":"2026-05-11 08:16:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":316711,"visible":true,"origin":"","legend":"\u003cp\u003eDay 37 — Epithelialization\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9461513/v1/46c8c2ec72ec2075ba5db70e.png"},{"id":108957012,"identity":"64696672-fc58-4c32-85bc-358b997f3064","added_by":"auto","created_at":"2026-05-11 08:16:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":328007,"visible":true,"origin":"","legend":"\u003cp\u003eDay 42 When the patient was discharged, the epidermis of the wound had formed.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9461513/v1/2c586aa3e1843477e38f48b0.png"},{"id":108957101,"identity":"cb1881b6-c5ee-4065-a093-b55449b50493","added_by":"auto","created_at":"2026-05-11 08:16:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1362576,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9461513/v1/7d3b39f1-27d9-4c85-895f-8be1cb8bd137.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Management of a Large Complex Lower Extremity Wound in a 94-Year-Old Woman with Multimorbidity: A Case Report Emphasizing Systemic Homeostasis as a Prerequisite for Local Healing","fulltext":[{"header":"Key Clinical Message ","content":"\u003cp\u003eIn a 94-year-old woman with multimorbidity and a large lower-extremity wound, healing began only after sepsis, coagulopathy, and hypoalbuminemia were corrected. This case emphasizes that restoring systemic homeostasis\u0026mdash;rather than relying on local dressings alone\u0026mdash;is the essential prerequisite for tissue repair in the frail elderly.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eChronic lower extremity wounds are highly prevalent in the aging population, with venous leg ulcers (VLU) accounting for approximately 70%\u0026ndash;80% of all chronic lower limb ulcers [1]. The prevalence of chronic nonhealing wounds in developed countries is 1%\u0026ndash;2% of the general population but rises to as high as 15% in Medicare beneficiaries [2]. In older adults, venous ulcers account for 85% of all leg ulcers, with incidence up to four times higher in adults older than 80 years [2,3]. Aging leads to physiological changes such as reduced skin elasticity, weakened immune responses, and slower cellular regeneration, all of which delay wound healing; frailty, marked by reduced physiological reserves, worsens these issues [4].\u003c/p\u003e \u003cp\u003eIn super-elderly patients with acute systemic illnesses\u0026mdash;such as sepsis, decompensated heart failure, and hypoalbuminemia\u0026mdash;the etiology of skin breakdown is often mixed, involving a complex interplay of infection, edema, malnutrition, and background chronic venous insufficiency [5,6]. The 2025 Expert Consensus on Systematic Assessment and Treatment of Refractory Wounds in the Elderly emphasizes that diagnosis and treatment of refractory wounds in elderly patients require comprehensive consideration of primary diseases and comorbidities, systematic assessment of overall condition and local wound characteristics, and therapeutic principles including control of underlying diseases, nutritional support, infection control, and circulatory improvement [7]. In such cases, uncritical classification as \u0026ldquo;venous ulcer\u0026rdquo; may obscure the true pathophysiology and shift therapeutic focus away from urgent systemic stabilization.\u003c/p\u003e \u003cp\u003eThis case report describes a 94-year-old woman admitted with acute heart failure and sepsis who subsequently developed a large and rapidly progressing lower extremity wound. In accordance with reviewer feedback from a previous submission, we have revised the diagnostic framework: given the normal venous duplex ultrasound and the onset of skin breakdown during a period of severe systemic decompensation, the wound is better classified as secondary skin breakdown in the setting of critical illness rather than primary venous leg ulcer. This report aims to illustrate a critical clinical principle: in frail elderly patients with multimorbidity, restoration of systemic homeostasis\u0026mdash;achieved through early, coordinated multidisciplinary intervention\u0026mdash;is an indispensable prerequisite for local wound healing.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Information\u003c/h2\u003e \u003cp\u003eA 94-year-old woman was admitted to the cardiac intensive care unit on July 22, 2024, with a one-week history of bilateral lower extremity edema and progressive dyspnea. Her past medical history included coronary artery disease with stent implantation, hypertension (Grade 3, very high risk), and chronic heart failure. She had been prescribed aspirin (100 mg/day), atorvastatin (20 mg/day), benazepril (10 mg/day), metoprolol (47.5 mg/day), and furosemide (40 mg/day), although adherence to follow-up had been irregular in recent months.\u003c/p\u003e \u003cp\u003eOn admission, the patient was confused and orthopneic. Vital signs were as follows: temperature 37.8\u0026deg;C, heart rate 132 beats/min (atrial fibrillation on electrocardiogram), respiratory rate 35 breaths/min, blood pressure 105/53 mmHg. Physical examination revealed severe bilateral pitting edema of the lower extremities. The skin over the dorsal aspect of the right lower leg appeared purplish-black with increased local temperature. The right dorsalis pedis pulse was palpable but weakened; there was no toe gangrene or rest pain.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDiagnostic Assessment\u003c/h3\u003e\n\u003cp\u003eKey laboratory findings on admission are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Of note, inflammatory markers were markedly elevated: C-reactive protein (CRP) 105.32 mg/L, procalcitonin (PCT) 97.4 ng/mL, and interleukin-6 (IL-6) 14,350 pg/mL. Serum albumin was low at 26.54 g/L. Coagulation studies showed prolonged activated partial thromboplastin time (APTT) of 54.7 seconds and elevated D-dimer of 9.64 \u0026micro;g/mL, consistent with a tendency toward disseminated intravascular coagulation (DIC). N-terminal pro-B-type natriuretic peptide (NT-proBNP) was 1,304 pg/mL, indicating acute heart failure exacerbation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTemporal Profile of Systemic Parameters and Wound Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate\u003c/p\u003e \u003cp\u003e(2024)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Events \u0026amp; Wound Description\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLaboratory Trends\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJuly 22 (D0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRight lower leg: purplish-black discoloration,intact skin, severe edema. Clinical diagnosis: soft tissue infection, sepsis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCRP 105.32 mg/L\u003c/p\u003e \u003cp\u003ePCT 97.4 ng/mL\u003c/p\u003e \u003cp\u003eIL-6 14,350 pg/mL\u003c/p\u003e \u003cp\u003eAlb 26.54 g/L\u003c/p\u003e \u003cp\u003eNT-proBNP 1,304 pg/mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJuly 23 (D1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkin breakdown: wound area 12 cm \u0026times; 8 cm, 100% red base, copious serous exudate, surrounding skin purplish-black.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eD-dimer 9.64 \u0026micro;g/mL, APTT 54.7 s (DIC tendency)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJuly 26 (D4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound expanded to 30 cm \u0026times; 15 cm, mixed red and yellow base, black necrotic tissue, increased exudate.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlood culture: Escherichia coli;\u003c/p\u003e \u003cp\u003ePCT: persistently elevated\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAug 2 (D11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound base: 100% yellow slough, profuse purulent exudate. Daily mechanical debridement\u0026thinsp;+\u0026thinsp;povidone-iodine cream initiated.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCRP 44.30 mg/L,\u003c/p\u003e \u003cp\u003ePCT 0.204 ng/mL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAug 19 (D28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound base: 75% red granulation, 25% yellow slough; exudate significantly reduced; periwound erythema resolved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlb 31.88 g/L; coagulation parameters normalized\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAug 28 (D37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWound reduced to 20 cm \u0026times; 10 cm; base robustly granulated; marginal epithelialization visible.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCRP and PCT within normal range; Alb 33.5 g/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eImaging Findings\u003c/h3\u003e\n\u003cp\u003eBedside ultrasound revealed moderate-to-large bilateral pleural effusions. Lower extremity venous duplex ultrasound demonstrated patent deep veins with no evidence of thrombosis or valvular reflux. Arterial ultrasound showed atherosclerotic changes with plaque formation but no hemodynamically significant stenosis. Echocardiography demonstrated mild left ventricular enlargement, biatrial dilation, and a left ventricular ejection fraction (LVEF) of 42%, with a small pericardial effusion.\u003c/p\u003e\n\u003ch3\u003eVascular Assessment\u003c/h3\u003e\n\u003cp\u003eDue to the patient\u0026lsquo;s critical condition and severe edema, ankle-brachial index (ABI) measurement was not performed on admission. However, the presence of a palpable dorsalis pedis pulse, the absence of rest pain, and the lack of ischemic skin changes (e.g., gangrene) clinically excluded severe limb ischemia. Non-elastic compression was applied with low tension (estimated pressure\u0026thinsp;\u0026lt;\u0026thinsp;20 mmHg) primarily for edema control, with daily monitoring of capillary refill and distal perfusion.\u003c/p\u003e \u003cp\u003eWound-Specific Clinical Details\u003c/p\u003e \u003cp\u003e\u0026middot; Size: Initial 12 cm \u0026times; 8 cm (Day 1); maximum 30 cm \u0026times; 15 cm (Day 4); final 20 cm \u0026times; 10 cm (Day 37).\u003c/p\u003e \u003cp\u003e\u0026middot; Depth: Partial-thickness to full-thickness skin loss, without tendon or bone exposure.\u003c/p\u003e \u003cp\u003e\u0026middot; Exudate: Initially copious serous, later purulent; volume decreased markedly after Day 11.\u003c/p\u003e \u003cp\u003e\u0026middot; Periwound skin: Early stage showed purplish-black discoloration with induration and hyperpigmentation; later stage demonstrated typical hemosiderin deposition (indicative of background chronic venous insufficiency).\u003c/p\u003e \u003cp\u003e\u0026middot; Pain severity: Numerical Rating Scale (NRS) 7\u0026ndash;8/10 during dressing changes; managed with topical lidocaine and oral tramadol.\u003c/p\u003e \u003cp\u003e\u0026middot; Signs of venous hypertension: Bilateral edema and pigmentation were present, but venous duplex was negative for reflux, suggesting that venous hypertension was a background contributor rather than the primary driver of acute skin breakdown.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFinal Diagnoses\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAcute decompensated heart failure (NYHA Class III)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSepsis (Escherichia coli bacteremia)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTendency toward disseminated intravascular coagulation\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eComplex right lower extremity skin breakdown (secondary to soft tissue infection with necrosis, hypoalbuminemic edema, and background chronic venous insufficiency)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHypoalbuminemia\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLower extremity atherosclerosis (non-critical limb ischemia)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCoronary artery disease (post-stent implantation)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHypertension Grade 3 (very high risk)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBilateral pleural effusions\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eReclassification of Wound Etiology\u003c/p\u003e \u003cp\u003eThe wound cannot be classified as a primary venous leg ulcer because venous duplex ultrasound showed no reflux or thrombosis, and the skin breakdown occurred in the context of acute systemic decompensation. We therefore reclassify this wound as secondary skin breakdown in the setting of critical illness\u0026mdash;a clinical scenario wherein systemic decompensation (sepsis, hypoalbuminemia, and coagulopathy) compromises cutaneous integrity in vulnerable older adults. While the term \u0026ldquo;acute skin failure\u0026rdquo; has been proposed to describe such phenomena, it should be noted that this remains a controversial diagnostic entity. A 2025 National Pressure Injury Advisory Panel (NPIAP) think tank concluded that non-pressure-related skin failure in the critically ill currently lacks a distinct etiology, defined pathophysiology, and validated diagnostic criteria to warrant formal medical classification [8,9]. The panel emphasized that until more research is conducted, \u0026ldquo;the term has no scientific basis to be used to describe pressure injury in the critically ill\u0026rdquo; [9]. This revision does not alter local wound care principles but underscores the primacy of systemic management in achieving healing.\u003c/p\u003e \u003cp\u003eTherapeutic Intervention\u003c/p\u003e \u003cp\u003eSystemic Management (Foundation of Healing)\u003c/p\u003e \u003cp\u003e\u0026middot; Antimicrobial therapy: Based on blood culture results (E. coli), piperacillin-tazobactam was administered for 14 days with subsequent de-escalation.\u003c/p\u003e \u003cp\u003e\u0026middot; Correction of hypoalbuminemia: Repeated infusions of 20% human albumin were given, along with combined enteral and parenteral nutrition targeting 25 kcal/kg/day.\u003c/p\u003e \u003cp\u003e\u0026middot; Coagulopathy management: D-dimer levels declined progressively with sepsis control; anticoagulation was not required.\u003c/p\u003e \u003cp\u003e\u0026middot; Heart failure management: Diuresis and vasodilation were employed to achieve negative fluid balance and reduce peripheral edema.\u003c/p\u003e \u003cp\u003eLocal Wound Care (Adjunctive Acceleration)\u003c/p\u003e \u003cp\u003e\u0026middot; Debridement strategy: Given the patient\u0026rsquo;s advanced age and thin subcutaneous tissue, a conservative sharp debridement combined with autolytic debridement was employed to avoid damage to healthy tissue and underlying fascia.\u003c/p\u003e \u003cp\u003e\u0026middot; Antimicrobial dressing: From Day 11 onward, daily application of povidone-iodine cream was performed after debridement. Povidone-iodine (PVP-I) provides broad-spectrum antimicrobial activity via elemental iodine, with documented efficacy in biofilm disruption and low resistance-inducing potential [10]. The polyvinylpyrrolidone (PVP) matrix enables sustained release and maintenance of a moist wound environment. Among widely available antiseptics, PVP-I demonstrates exceptional efficacy in wound sanitation due to its broad-spectrum antimicrobial activity and minimal cytotoxicity [10].\u003c/p\u003e \u003cp\u003e\u0026middot; Growth factor application: After infection was controlled (from Day 30), recombinant human epidermal growth factor (rhEGF) gel (commercial formulation, not derived from autologous blood) was applied once daily to promote granulation and epithelialization. rhEGF has been established as a safe and effective therapeutic tool for chronic and complex ulcers, with multiple studies\u0026mdash;including controlled trials, retrospective analyses, and systematic reviews\u0026mdash;demonstrating consistent outcomes [11]. By stimulating cell proliferation, angiogenesis, and tissue regeneration, rhEGF reactivates essential biological processes that are typically impaired in such lesions [11].\u003c/p\u003e \u003cp\u003e\u0026middot; Regarding Yunnan Baiyao: During the early phase (Days 4\u0026ndash;11), Yunnan Baiyao powder\u0026mdash;a traditional Chinese medicine with local hemostatic and anti-inflammatory properties\u0026mdash;was applied topically. However, due to crust formation that impeded drainage, it was discontinued. It should be noted that high-quality evidence supporting its use in wound care remains limited, and its application in this case was a short-term adjunctive measure.\u003c/p\u003e \u003cp\u003e\u0026middot; Compression management: In the presence of a palpable dorsalis pedis pulse and no evidence of acute ischemia, low-tension short-stretch bandaging (target pressure\u0026thinsp;\u0026lt;\u0026thinsp;20 mmHg) was applied for edema control. This was not therapeutic compression for venous disease, but rather a supportive measure for fluid management.\u003c/p\u003e\n\u003ch3\u003eImages\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e \u003cp\u003eThe wound measured 30 cm \u0026times; 15 cm. Black arrow indicates extensive black necrotic tissue; asterisk () indicates copious yellow purulent exudate. Periwound skin appears purplish-black.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFollowing debridement and povidone-iodine cream, the wound base has become predominantly red granulation tissue (black arrow). Yellow slough is markedly reduced, and exudate is minimal.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe wound has reduced to 20 cm \u0026times; 10 cm. The base is dry with robust granulation tissue. White arrows indicate marginal epithelialization advancing from the wound edges.\u003c/p\u003e "},{"header":"Discussion and Conclusions","content":" \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eSystemic Homeostasis as the \u0026ldquo;Switch\u0026rdquo; for Wound Healing\u003c/h2\u003e \u003cp\u003eThe most instructive observation from this case is the temporal alignment between systemic recovery and wound improvement. As illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, despite diligent local wound care (including non-adherent dressings and Yunnan Baiyao) during the first 11 days of hospitalization, the wound continued to deteriorate, expanding to its maximal dimensions of 30 cm \u0026times; 15 cm. The inflection point occurred only after systemic parameters normalized\u0026mdash;specifically, after blood cultures cleared, CRP declined to near-normal levels, and serum albumin rose above 31 g/L. This observation aligns with the \u0026ldquo;wound bed preparation\u0026rdquo; paradigm, which emphasizes that the systemic dimension (addressing infection, nutrition, and perfusion) is integral to creating a healing-competent wound environment [12]. In the persistently septic, hypoalbuminemic, and hypercatabolic state, local tissues remain in a \u0026ldquo;healing-resistant\u0026rdquo; mode, rendering any topical growth factor or advanced dressing ineffective [13]. Only through multidisciplinary collaboration\u0026mdash;involving critical care, nutrition support, cardiology, and wound care\u0026mdash;can systemic homeostasis be restored, thereby enabling the transition from chronic inflammatory stasis to proliferative repair. This is the core clinical message of the present case.\u003c/p\u003e \u003cp\u003eThe management strategy employed in this case aligns with the principles outlined in the 2025 Expert Consensus on Systematic Assessment and Treatment of Refractory Wounds in the Elderly, which emphasizes comprehensive evaluation of underlying diseases and comorbidities, systematic assessment of overall status and local wound characteristics, infection control, nutritional support, and circulatory improvement as core therapeutic components [7]. The ultimate treatment goal\u0026mdash;wound closure when feasible, or palliative management when not\u0026mdash;was reflected in our approach of prioritizing systemic stabilization over aggressive local intervention.\u003c/p\u003e \u003cp\u003eDiagnostic Precision and Its Therapeutic Implications\u003c/p\u003e \u003cp\u003eMisclassification of this wound as a venous leg ulcer would have directed clinical attention toward compression therapy and venoactive medications, potentially delaying urgent systemic interventions. The 2025 Canadian Consensus Statement for the Management of Venous Leg Ulcers recommends compression therapy as the cornerstone of VLU management to restore venous return and reduce ambulatory venous pressure [14]. Compression therapy remains the cornerstone of VLU management, with guidelines emphasizing early identification and correction of superficial venous incompetence [15]. Had this wound been misclassified as a VLU, the patient might have been subjected to therapeutic compression\u0026mdash;an intervention that could have compromised arterial perfusion in the setting of weakened dorsalis pedis pulse and atherosclerotic disease [16]. The normal venous duplex ultrasound and the acute onset during systemic decompensation justified withholding compression beyond low-tension edema control.\u003c/p\u003e \u003cp\u003eThe concept of \u0026ldquo;skin failure\u0026rdquo; has been introduced in the literature to describe the deterioration of skin integrity accompanying severe illness and end-of-life decline [8,17]. However, as noted in the 2025 NPIAP think tank report, the term currently lacks a distinct etiology, defined pathophysiology, and validated diagnostic criteria [9]. Non-pressure-related skin failure in the critically ill is defined as skin injury that occurs despite standard preventive interventions and for which no other etiology has been identified [8]. The panel concluded that until the term \u0026ldquo;skin failure\u0026rdquo; has more study, it has no scientific basis to be used to describe pressure injury in the critically ill [9]. Pending further research, we consider \u0026ldquo;secondary skin breakdown in the setting of critical illness\u0026rdquo; to be a more precise and defensible description of the present case.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eConservative Principles in Super-Elderly Local Wound Care\u003c/h3\u003e\n\u003cp\u003eIn this 94-year-old patient with minimal subcutaneous tissue, aggressive surgical debridement was avoided in favor of a conservative sharp-autolytic approach, preserving the vulnerable fascial blood supply. Povidone-iodine cream demonstrated favorable tolerability and antimicrobial efficacy in this case, with its sustained-release matrix reducing dressing change frequency and associated pain. PVP-I acts by penetrating biofilm matrices, eradicating embedded microorganisms, and reducing microbial load, thereby accelerating healing in acute, chronic, and surgical wounds [10].\u003c/p\u003e \u003cp\u003eThe application of rhEGF was timed for the proliferative phase after infection had been controlled. rhEGF has been established as a safe and effective therapeutic tool with the potential to transform the conventional management of chronic and complex ulcers, improving clinical outcomes and enhancing patients\u0026lsquo; quality of life [11]. By stimulating cell proliferation, angiogenesis, and tissue regeneration, rhEGF reactivates essential biological processes that are typically impaired in such lesions, thereby promoting accelerated and functional wound healing [11]. Multiple studies\u0026mdash;including controlled trials, retrospective analyses, and systematic reviews\u0026mdash;have demonstrated consistent outcomes across various clinical settings [11,18].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis is a single case report involving a patient of extreme age and extensive comorbidity burden. The findings are not generalizable and should be interpreted as hypothesis-generating rather than practice-changing. Specifically, the observation that systemic homeostasis is a prerequisite for local healing in the super-elderly warrants validation through larger observational studies. Additionally, due to the patient\u0026rsquo;s critical condition on admission, ABI measurement was not obtained; arterial assessment relied on clinical examination alone, which carries inherent uncertainty. The use of Yunnan Baiyao, while of cultural interest, lacks high-quality evidence and should not be construed as a recommendation for routine clinical practice outside its traditional context. Chronic wounds in older adults are further complicated by access gaps to regular caretakers, immobility, nociceptive and neuropathic pain, and frailty\u0026mdash;factors that must be acknowledged and addressed in this population [2].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFor super-elderly patients with multimorbidity who present with complex lower extremity wounds, clinicians should view the wound as a local manifestation of systemic illness. Before deploying costly topical therapies, priority must be given to correcting sepsis, malnutrition, and hemodynamic instability through early, coordinated multidisciplinary intervention. Only when the patient transitions from a catabolic to an anabolic state can local therapies exert their intended effects. This case, through diagnostic reclassification and temporal analysis of healing milestones, provides a compelling illustration of this clinical principle.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; ABI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnkle-brachial index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; APTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActivated partial thromboplastin time\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; CRP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; DIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDisseminated intravascular coagulation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; rhEGF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRecombinant human epidermal growth factor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; IL-6\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterleukin-6\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; LVEF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLeft ventricular ejection fraction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; NPIAP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Pressure Injury Advisory Panel\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; NRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNumerical Rating Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; NT-proBNP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eN-terminal pro-B-type natriuretic peptide\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; NYHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNew York Heart Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; PCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProcalcitonin\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; PVP-I\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePovidone-iodine\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u0026middot; VLU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVenous leg ulcer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from the patient\u0026lsquo;s legal guardian for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient\u0026rsquo;s legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the clinical management of the patient, conception and design of the case report, data collection and interpretation, drafting and critical revision of the manuscript, and approval of the final version for submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eO\u0026lsquo;Donnell TF Jr, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2014;60(2 Suppl):3S-59S.\u003c/li\u003e\n\u003cli\u003eOropallo AR. Assessment and management of chronic venous, arterial, and diabetic wounds in older adults. Semin Vasc Surg. 2025;38(3):281-290.\u003c/li\u003e\n\u003cli\u003eSen CK. Human wounds and its burden: updated 2022 compendium of estimates. Adv Wound Care. 2023;12(12):657-670.\u003c/li\u003e\n\u003cli\u003eChalk F, O\u0026rsquo;Connor T, Moore Z. The impact of ageing and frailty on wound healing. Br J Nurs. 2025;34(20):S27-S34.\u003c/li\u003e\n\u003cli\u003eGould LJ, Abadir PM, Brem H, Carter M, Conner-Kerr T, Davidson J, et al. Chronic wound repair and healing in older adults: current status and future research. J Am Geriatr Soc. 2015;63(3):427-438.\u003c/li\u003e\n\u003cli\u003eDelmore B, Cox J, Rolnitzky L, Chu A, Stolfi A. Differentiating acute skin failure from pressure injuries in the critically ill. Crit Care Nurse. 2022;42(1):31-39.\u003c/li\u003e\n\u003cli\u003eChinese Geriatrics Society Burn and Trauma Branch. Expert consensus on systematic assessment and treatment of refractory wounds in the elderly (2025 edition). Chin J Burns Wounds. 2025;41(5):401-416.\u003c/li\u003e\n\u003cli\u003eBlack J, Cox J, Cuddigan J, Jenkins J, Lev-Tov H, Mervis J, et al. Skin failure: results of a think tank hosted by the National Pressure Injury Advisory Panel. J Wound Ostomy Continence Nurs. 2025;52(5):369-375.\u003c/li\u003e\n\u003cli\u003eNational Pressure Injury Advisory Panel. Non-pressure skin failure in the critically ill: definition and conceptual framework [white paper]. NPIAP; 2025.\u003c/li\u003e\n\u003cli\u003eBigliardi PL, Alsagoff SAL, El-Kafrawi HY, Pyon JK, Wa CTC, Villa MA. The role of antiseptics in wound healing, wound disinfection, and biofilm management with a focus on povidone-iodine (PVP-I). In: Wound Care and Healing. Springer; 2025.\u003c/li\u003e\n\u003cli\u003eCacua S\u0026aacute;nchez MT, Carillo Bravo CA. An effective solution to accelerate the healing of complex ulcers using recombinant human epidermal growth factor (intralesional application): a review. Drug Des Devel Ther. 2025;19:5615-5631.\u003c/li\u003e\n\u003cli\u003eSibbald RG, Elliott JA, Persaud-Jaimangal R, Goodman L, Armstrong DG, Harley C, et al. Wound bed preparation 2021. Adv Skin Wound Care. 2021;34(4):183-195.\u003c/li\u003e\n\u003cli\u003eSchultz G, Bjarnsholt T, James GA, Leaper DJ, McBain AJ, Malone M, et al. Consensus guidelines for the identification and treatment of biofilms in chronic nonhealing wounds. Wound Repair Regen. 2017;25(5):744-757.\u003c/li\u003e\n\u003cli\u003eConway M, Stacey MC, Sibbald RG, Evans R, Kuhnke J, Queen D, et al. Canadian Consensus Statement for the Management of Venous Leg Ulcers. Int Wound J. 2025;22(4):e70415.\u003c/li\u003e\n\u003cli\u003eStacey MC. Practical management of venous leg ulcers: guideline-based diagnosis, compression, and venous intervention. Ann Phlebology. 2025.\u003c/li\u003e\n\u003cli\u003eSibbald RG, Elliott JA, Persaud-Jaimangal R, Goodman L, Armstrong DG, Harley C, et al. Wound bed preparation 2021. Adv Skin Wound Care. 2021;34(4):183-195.\u003c/li\u003e\n\u003cli\u003eLangemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206-211.\u003c/li\u003e\n\u003cli\u003eYang Q, Zhang Y, Yin H, Lu Y. Topical recombinant human epidermal growth factor for diabetic foot ulcers: a meta-analysis of randomized controlled clinical trials. Ann Vasc Surg. 2020;62:442-451.\u003c/li\u003e\n\u003cli\u003eNICE. Compression products for treating venous leg ulcers: late-stage assessment [HTE32]. London: National Institute for Health and Care Excellence; 2025.\u003c/li\u003e\n\u003cli\u003eChrysostomou D, Pokorn\u0026aacute; A, Cremers NAJ. Medical-grade honey is a versatile wound care product for the elderly. J Aging Res Lifestyle. 2024;13:51-59.\u003c/li\u003e\n\u003cli\u003eEspaulella-Ferrer M, Espaulella-Panicot J, Noell-Boix R, Casals-Zorita M, Ferrer-Sola M, Puigoriol-Juvanteny E, et al. Assessment of frailty in elderly patients attending a multidisciplinary wound care centre: a cohort study. BMC Geriatr. 2021;21(1):727.\u003c/li\u003e\n\u003cli\u003eNishian K, Fukunaga M, Nishimura M, Fujiwara R, Kawasaki D. The effect of clinical frailty on wound healing in patients with chronic limb-threatening ischemia. J Endovasc Ther. 2025;32(3):711-719.\u003c/li\u003e\n\u003cli\u003eGomez-Villa R, Aguilar-Rebolledo F, Lozano-Platonoff A, Teran-Soto JM, Fabian-Victoriano MR, Kresch-Tronik NS, et al. Efficacy of intralesional recombinant human epidermal growth factor in diabetic foot ulcers in Mexican patients: a randomized double-blinded controlled trial. Wound Repair Regen. 2014;22(4):497-503.\u003c/li\u003e\n\u003cli\u003eMetcalf D, Parsons D, Bowler P. Wound biofilm and therapeutic strategies. In: Wound Healing. InTech; 2016.\u003c/li\u003e\n\u003cli\u003eWounds Australia. Standards and guidelines for wound management. Wounds Australia; 2025.\u003c/li\u003e\n\u003cli\u003eWounds Canada. Best practice recommendations for skin health and wound management 2025. Wounds Canada; 2025.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Super-elderly, Multimorbidity, Complex wound, Systemic homeostasis, Povidone-iodine, Recombinant human epidermal growth factor, Case report","lastPublishedDoi":"10.21203/rs.3.rs-9461513/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9461513/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Lower extremity wounds in super-elderly patients with multimorbidity present unique diagnostic and therapeutic challenges. The interplay among acute systemic illness, malnutrition, and local tissue breakdown often obscures the underlying pathophysiology, leading to misclassification and suboptimal management.\u003c/p\u003e\n\u003cp\u003eCase Presentation: A 94-year-old woman with a history of coronary artery disease, hypertension, and chronic heart failure was admitted to the cardiac intensive care unit with progressive dyspnea and bilateral lower extremity edema. She was diagnosed with acute decompensated heart failure (NYHA Class III), sepsis (Escherichia coli bacteremia), and a tendency toward disseminated intravascular coagulation. On day 2, she developed a rapidly expanding skin defect on the right lower leg, which progressed to a maximum size of 30 cm × 15 cm with extensive necrosis and purulent exudate. Venous duplex ultrasound showed patent deep veins without reflux or thrombosis, excluding primary venous leg ulcer. The wound was therefore classified as complex lower extremity skin breakdown of mixed etiology secondary to systemic decompensation. Management consisted of systemic stabilization (antimicrobial therapy, albumin supplementation, nutritional support, and heart failure management) combined with local wound care including conservative debridement, topical povidone-iodine cream, and recombinant human epidermal growth factor (rhEGF) application. Notably, wound improvement commenced only after systemic parameters normalized—C-reactive protein declined from 105.32 mg/L to the normal range, and serum albumin increased from 26.54 g/L to 33.5 g/L. At 37-day follow-up, the wound had reduced to 20 cm × 10 cm with robust granulation tissue and marginal epithelialization, though complete closure was not achieved.\u003c/p\u003e\n\u003cp\u003eConclusions: This case demonstrates that in super-elderly patients with multimorbidity, local wound healing is contingent upon the restoration of systemic homeostasis. Clinicians should view complex wounds in this population as local manifestations of systemic illness and prioritize multidisciplinary correction of sepsis, malnutrition, and coagulopathy before expecting meaningful tissue repair from topical therapies. Findings from this single case are hypothesis-generating and warrant validation in larger observational studies.\u003c/p\u003e","manuscriptTitle":"Management of a Large Complex Lower Extremity Wound in a 94-Year-Old Woman with Multimorbidity: A Case Report Emphasizing Systemic Homeostasis as a Prerequisite for Local Healing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 08:12:58","doi":"10.21203/rs.3.rs-9461513/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:04:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337449645333285429945055742763012310303","date":"2026-05-06T10:45:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-29T09:10:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-27T07:51:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-25T06:57:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-25T06:56:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2026-04-19T11:03:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf005710-4012-4e2c-bbf7-a160128cbadc","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-06T14:04:56+00:00","index":39,"fulltext":""},{"type":"reviewerAgreed","content":"337449645333285429945055742763012310303","date":"2026-05-06T10:45:38+00:00","index":38,"fulltext":""},{"type":"reviewersInvited","content":"50","date":"2026-04-29T09:10:11+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T08:12:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 08:12:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9461513","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9461513","identity":"rs-9461513","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}