The National Institutes of Health reports that 80% of wound infections are due to biofilm.23 Biofilm is invisible to the naked eye, and detection with different techniques is currently being investigated.24 Without destruction of biofilm, wound healing can stall during the inflammatory phase.25. Viscopaste or It is often moist and may bleed easily with minimal trauma. If cellulitis or signs of systemic infection are present, oral antibiotics may also be indicated. Commence with one layer, if tolerated, then add another second layer but extending to only 2/3 of the lower leg and finally, if tolerance is maintained, then add another 1/3. Typical signs of infection such as erythema, edema, pain, and fever are not always present. These should not be used because they impede blood flow to the area and can actually worsen existing ulcers or increase the risk of developing a new ulcer.37. Many minor wounds result in damaged skin cells that lose their function and need time and simple treatment to heal. If peripheral vascular disease is also present, there is greater risk for infection and amputation may sometimes be necessary. The definition of a wound is damage to the integrity of biological tissue, including skin, mucous membranes, and organ tissues. Eschar Pictured left is an eschar from a pressure ulcer. Edmonds M, Foster AVM, Vowden P. Wound bed preparation for diabetic foot ulcers. The bacterial infection produces toxins that release gas and cause tissue death. Clean wounds have no foreign materials or debris inside, whereas contaminated wounds or infected wounds might have dirt, fragments of the causative agent, bacteria or other foreign materials. Whilst there are some being used overseas, none of these have yet been approved for use in Australia. Areas of the ulcer may turn black as the tissue dies. Slough wounds are yellow, tan, green or brown and may be moist, loose and stringy. Slough or eschar may be present. The post-surgical wound will then need to be well managed to avoid infection. Zetuvit Plus. Electrical wounds: These usually present with superficial burn-like or sting-like wounds secondary to the passage of high-voltage electrical currents through the body, and may include more severe internal damage. Flaminal Hydro or Wounds can be open or closed. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Try not to get soap on the wound. In the first of four healing stages, your body swings into action to stop the flow of blood. The first category in the updated TIMERS framework remains tissue management, which encompasses the observation of viable or non-viable tissue to identify an appropriate treatment modality. Put gentle pressure on your skin with a gauze pad or clean cloth. Most wounds go on to heal in the normal pathway of: As there are many factors to consider when trying to manage a complex, slow-to-heal wound, the following factors are not an exhaustive list, and not necessarily presented in order of priority, however it is generally considered that nutrition is paramount Major types of closed wounds include: Contusions - blunt trauma causing pressure damage to the skin and/or underlying tissues Blisters Although there are many types of leg ulcers, the most common are venous, followed by arterial, and then mixed venous arterial. This was the first step of what would be a long journey toward regaining his independence and mobility, yet Albert maintained a positive attitude throughout what was to be a nearly nine-month recovery process. One of the crucial aspects of a dressing regime is assessment and reassessment. Loss of function: Many wounds can be disabling and life threatening if a major organ, blood vessel or nerve was damaged. Minor wounds, like cuts, scrapes, bruises and scratches, are very common and usually dont require medical attention; but some, including infected wounds, require treatment to preserve function and prevent complications. Treatment is different for each type of wound. When managing a complex, slow-healing wound, it is important to remember that there are occasions when wound debridement is not appropriate, and symptom control is more suitable. ", University of Edinburgh: "Types of Wound. It typically moves through four stages: hemostasis/coagulation, inflammation, proliferation, and maturation/remodeling (Table 1).6 These phases overlap as cytokines and growth factors guide the healing process. Primapore. Adhesive foams are generally appropriate here, unless the wound is located very close to the anus, in which case a thick barrier cream is often used. A surgical wound of the latter category has a higher incidence of dehiscence or complications. Most patients with diabetic foot ulcers also have underlying peripheral arterial disease, which requires evaluation. Signs of an infected wound include soreness, redness, oozing and pus in the wound. An infection from a pressure sore can burrow into joints and bones. They are classified by etiology into four categories, each with its own typical location, depth, and appearance: arterial, diabetic, pressure, and venous ulcers7 (Table 2). The best course of action can be determined only by assessing the comprehensive needs of the patient and the characteristics of the wound itself. Moisture balance is an essential part of wound care. 3. healing process. Eschar may be dry or moist and presents as thick and sometimes . This soft, gelatinous, highly exuding tissue requires specific treatment. Full thickness tissue loss with exposed bone, tendon or muscle. If this is not possible, then dressings known to aid autolytic debridement should be selected and used according to manufacturer's instructions. Melolin, Mefix. Identification of Tissue Types The first category in the updated TIMERS framework remains tissue management, which encompasses the observation of viable or non-viable tissue to identify an appropriate treatment modality. ", Wound Care Centers: "At Home Wound Treatment.". Features: low-adherence, supportive, allows exudate to pass through, transparent. To better understand wound healing, we need to learn more about the different types of wounds and factors involved in their healing. Atrauman Ag, and The latest in wound care delivered to your inbox every Friday. They are common and are often incorrectly treated. Granulation tissue (firm, beefy red tissue) requires some exudate management and protection. As their names suggest, they result from insufficient blood flow in the veins and arteries, respectively. Stage three injuries involve damage through to the subcutaneous tissue, with the presence of slough and soft, tenacious necrotic tissue, which will require debridement. Venous and arterial ulcers are vascular wounds caused by problems with the circulatory system. Click through below to explore: All layers of skin are intact, with no redness, blemishes or maceration. They are typically shallow and located on the medial supramalleolar aspect of the lower extremity (Figure 1). 2005 - 2023 WebMD LLC, an Internet Brands company. Accessed April 16, 2020. After vascular intervention, the TIME principle should be used. The combined effects result in structural deformities of the foot; dry, poorly hydrated integument; and an inability to detect pain and repetitive injury. The words 'cleansing' and 'debridement' are often used interchangeably, however, they are two distinct terms to describe different management processes: The application of a fluid that is then wiped across the wound area with gentle strokes to aid in the removal of any loose, unwanted product or agent. Slough may be present in other types of wounds such as vascular, diabetic, among others. Allevyn Life. Now your body's healing process kicks into gear. These must be applied from toes to knee after selecting the appropriate size according to the manufacturer's guide. Clean the wound: Wash the area with soap and water. Both require further vascular assessment, which may include arterial Doppler/duplex ultrasonography, segmental limb pressures, pulse volume recording, skin perfusion pressure, or transcutaneous oximetry.10 Referral to a specialist should be considered if vascular test results suggest poor perfusion. Zetuvit. 4. Another consideration if colonisation is of concern, is to use generalised body skin-antiseptic cleansers to reduce the possibility of bacteria colonising from one area to another. An ABI less than 0.8 may be a sign of arterial disease, and an ABI greater than 1.2 is consistent with noncompressible vessels. Suspected deep tissue injury (depth unknown): purple/maroon localised area of discolouration of intact skin or blood-filled blister. The exact cellular implication of this is not known but it is believed that people who are depressed fail to consume a healthy diet or engage in other Do not culture or treat clinically uninfected lower extremity wounds with systemic antibiotics. Uses: surgical, cuts, abrasions, lacerations. Assessment at each dressing change involves looking for changes in tissue type and exudate volume and type, any reduction in odour, changes in wound size, and reduction of pain. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies. Wound edges must be free from undermining. Some wounds may need flushing with medical syringes, while others may need surgical debridement to remove foreign materials or dead tissue. Generally, the rule is: if the tissue is dry and ischaemic, then keep it dry. Peripheral neuropathy interferes with the ability to sense injuries, leading patients unknowingly placing stress on a limbs pressure points until an ulcer develops. The issue here however, is that this type of healing is slow and can result in an unacceptable scar. Depending on the cause, site and depth, a wound can range from simple to life threatening. As wound care clinicians, when we see slough, we want to get rid of it so that the wound is able to heal because necrotic tissue prevents or slows healing. wound healing phase. StatPearls.com. Books about skin diseasesBooks about the skin The last stage of healing is about making the new skin stronger. Partial-thickness loss of dermis presenting as a shallow, open wound with a red/pink wound bed, without slough or bruising. A more reliable test in these patients is the toe-brachial index because the toe arteries rarely calcify. An important aspect to consider is that when debriding wounds autolytically the wound may appear deeper as the necrotic debris is removed, revealing the true depth of the wound. Despite differences in etiology, chronic wounds share certain features, including excessive levels of proinflammatory cytokines, persistent infections, formation of drug-resistant microbial biofilms, and senescent cells that do not respond to reparative stimuli.8. Implementing TIMERS: the race against hard-to-heal wounds. Data Sources: An initial PubMed search was performed using the key terms chronic wounds, diabetic foot ulcers, venous ulcers, arterial ulcers, and pressure ulcers. By performing excellent gentle wound cleansing and debridement, healthcare professionals can assist with wound healing by removing any necrotic tissue which may be impacting the treatment goals. An acronym used to guide this process step by step is HEIDIE: So, with this in mind, and having completed a thorough overall assessment, a Penetrating wounds: These result from trauma that breaks through the full thickness of skin; reaching down to the underlying tissue and organs, and includes: Stab wounds (trauma from sharp objects, such as knives), Gunshot wounds (wounds resulting from firearms), Thermal wounds: Extreme temperatures, either hot or cold, can result in thermal injuries (like, Chemical wounds: These result from contact with or inhalation of chemical materials that cause skin or lung damage. In the Z technique, the handle of a swab is rotated between the fingers in a zig-zag fashion across the wound without touching the wound edge. What is gangrene? This is. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). A chronic wound is one that fails to progress through a normal, orderly, and timely sequence of repair, or in which the repair process fails to restore anatomic and functional integrity after three months.1 In 2014, wound care for Medicare beneficiaries cost an estimated $28 billion to $96.8 billion.2 A 2012 German study found a 1% to 2% prevalence of chronic nonhealing wounds in the general population.3 Chronic wounds, typically diabetic ulcers, preceded 85% of amputations.4 Some chronic wounds can take decades to heal, thus contributing to secondary conditions such as depression, and can ultimately lead to isolation and family distress. There are other nutrients required that also play an important role, but these four are often considered vital. You can apply another layer of antibiotic ointment before you put on the new bandage. offensive smell, excess pus, spreading erythema) Assessing a dressing type There are a few things you should consider when assessing a wound dressing: What is the action of the dressing? Mechanical debridement can involve several different methods. 'Separation of the layers of a surgical wound, it may be partial or only superficial, or complete with separation of all layers and total disruption. Pressure injuries may never heal if the patient is failing to consume adequate food and fluids to maintain body functions and assist tissue growth. There are a few enzyme products available around the world but the only one currently available in Australia is Once the necrotic tissue has been removed and healthy granulation tissue is present, the aim dramatically changes to one of protection. The use of barrier agents ensures this. In many cases, these heavily colonised wounds will require daily dressing changes, with emphasis on peri-wound protection. Try not to touch the wound. This wound and dressings guide will identify some of the most common wound types and guide you in setting your aim of care and selecting the best dressing or product to achieve that aim. There are several different types of debridement: surgical, autolytic, enzymatic, and biologic. muscle interface. For women greater than 51 years of age, and all healthy adult men, the intake is recommended to be 8 mg per day. Other options include the Levine and Z techniques. The general approach is to use an antimicrobial and exudate-management dressing, reviewing blood profiles and concentrating on nutrition to help grow stronger better-quality tissue. All human beings are at risk for sustaining or developing wounds, but the risk is higher in children, elderly people, alcoholics, those with addiction to narcotics, or people with mental illness or disability. For a detailed description of wound dressings see synthetic wound dressings. Opsite Post-Op and Non-penetrating wounds: These are usually the result of blunt trauma or friction with other surfaces; the wound does not break through the skin, and may include: Abrasions (scraping of the outer skin layer), Contusions (swollen bruises due to accumulation of blood and dead cells under skin), Concussions (damage to the underlying organs and tissue on head with no significant external wound). Mechanical debridement: This form of debridement is . 7. The type of tissue at the base of the wound will provide useful information relating to expectation of total healing time and the risk of complicationsfor example, bone at the base may suggest osteomyelitis and delayed or non-healing. It then becomes the attending clinicians role to prevent infection. The most common complication from wounds is infection. A structured approach is essential, as the most common error in wound care management is rushing in to select the latest and greatest new wound dressings without actually giving thought to wound aetiology, tissue type and immediate aim. Any type of incisions caused by knives. However Not all wounds are clear cut. Closing a wound. Zetuvit. Depending on the location and type of injury, some wounds will hurt, bleed and swell more than others. ", Mayo Clinic: "Cuts and scrapes: First aid. White blood cells head to the scene. If what you're cleansing out of the wound is stringy and yellow, and the wound base appears more granular after cleansing, it is most likely slough. To boost wound healing, however, and in women who are pregnant, the RDI for iron can be as high as 30 mg per day. Abrasions due to scraping of the skin generally consist of some types of debris like gravel, sand, metal or glass, etc. (It is a given that when managing pressure injury risk and actual damage, the pressure is relieved, and attention is given to nutritional requirements.). Atkin L, Bucko Z, Conde Montero E, et al. The most common types of problem wounds include: Diabetic foot ulcers. The simple, straightforward suture line is generally treated with a dressing that will manage a small amount of anticipated, early inflammatory exudate and provide a waterproof covering. Necrotic wounds are unable to heal until the dead tissue is removed in a surgical process called debridement. The term used to describe pale, grey/brown/red granulation tissue. Depending on the type and location of the wound you may need oral or topical antibiotics to prevent infection. After a thorough assessment, a small, simple laceration is generally managed with antiseptic cleansing, The outer border of a skin ulcer is often raised and inflamed. Should the body decide to separate the eschar from the tissue below it, the eschar then usually provides a well-demarcated edge from which to work. Overview Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from the skin. For a chronic wound to progress to the healing phase, healthcare professionals must be able to clean the wound as thoroughly as possible without causing further pain to the patient. 2019;28:3a. It won't help you heal faster, but it will keep an infection away. Most surgery can be categorised into two groups: elective ('clean') and emergency (this is often referred to as 'dirty'). adequate compressionusually 30 to 40 mm Hgto improve venous return, The preferred treatment approach for diabetic foot ulcers is offloading the foot to remove pressure from the affected area, but has a greater emphasis on pressure redistribution, offloading, and microclimate control. In everyday parlance, wounds typically refer to skin injuries. Copyright 2020 by the American Academy of Family Physicians. If the wound is locally infected, the clinician may choose to manage the infective tissue with debridement and topical antimicrobials (not topical antibiotics) (Lipsky & Hoey 2009). Various types of trauma can cause these, and it is critical to ensure wounds are cleaned and appropriately dressed to limit the spread of infection and further injury. The best management of an abrasion is to stop the bleeding, give the area a good clean with an antiseptic and then apply a mesh dressing that will protect the superficial raw area and allow new tissue to form quickly without being damaged when the first dressing is attended. The process of wound healing involves three overlapping phases: The rate at which a wound heals is dependent on several factors. It is important to differentiate between wet necrotic tissue and dry necrotic tissue to formulate the best, evidenced-based wound care treatment plan. MTI, Inc. The classic signs and symptoms of each of these ulcer types can be found in the Compression therapy selection is complex and must be tailored to the patient. Mesh dressings for this purpose include: If the wound is infected, then cleansing with an antiseptic solution and rinsing this off after 2 minutes will assist in reducing bacterial load. Search date: May 2018. Those classified as acute wounds heal uneventfully (with no complications) in the predicted amount of time. 2023 Ausmed Education Pty Ltd (ABN: 33 107 354 441), 4. Whilst the autolytic process is taking place, the wound exudate will be higher in volume, so super absorbent pads will be required as the secondary dressing, for example You will be shown pictures and asked to identify the correct answer as information is shared. There may be both venous and arterial insufficiency. Arterial Ulcers. Proteins in your blood act like glue to make the platelets clump together and stick to the opening in the blood vessel. The most common symptoms of wounds are pain, swelling and bleeding. Acticoat Flex, These ulcers are managed according to guidelines from the National Pressure Ulcer Advisory Panel, which classifies them into six stages based on the extent of tissue damage. These ulcers can be shallow or deep and are usually surrounded by a thick ring of callus. Debridement can be as previously mentioned: managed by a surgeon, a skilled clinician, or using dressings to aid autolytic processes. With continued best-practice interventions, these signs indicate that the wound will most likely go on to heal. Biofilms may be present, especially in chronic wounds, but they are usually not visible to the naked eye. American Society of Hematology: "Blood Clots. Zinc paste bandages and compression bandages are the mainstay of treatment to achieve these goals. You will not see slough in a stage 2 pressure injury. Epithelial cells travel from the outward wound edges and crawl across the wound bed to wound closure. selecting the appropriate wound dressing or treatment device to meet the aim and aid the Diabetic foot ulcers are managed by offloading the foot and, if necessary, treating the underlying peripheral arterial disease. Wound Bed Preparation in Practice. Eschars also result from burns; especially thermal or electric burns. The Essential Evidence summary provided by AFP was also used, as were several landmark articles in wound care and guidelines from the major societies involved with wound care. Keep the wound dry and stable, offload the area as much as possible, and gather input from your consulting services. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. Wound Manag Prev. These types of cut wounds are usually clean-edged. This is a collection of images ranging from normal to abnormal tissue types: healthy pink granulation tissue, different types of necrotic tissue (black, dry eschar) including yellow slough on the wound bed surface and exposed underlying structures including bone and tendon. Taking a multidisciplinary approach and managing the entire patient are critical to wound healing. Accessed April 16, 2020. The five-year mortality rate after developing a diabetic ulcer is approximately 40%5; therefore, proper diagnosis and treatment of wounds and management of comorbidities are imperative. Examples: This wound care vacuum cleaner will remove excess exudate and contain it in a canister, away from the wound surface. Additional factors that may influence healing include: If the patient has declining health, then it is unlikely any amount of therapy will influence wound healing. Examples: The search included clinical trials, systematic reviews, randomized controlled trials, and meta-analyses published since 1990. There are many factors that contribute to chronic, non-healing wounds, including systemic illnesses, age and repeated trauma, as well as conditions such as: Signs of chronic, non-healing wounds are similar to infected wounds, and include pus, redness or warmth around the wound, a bad odor, increasing pain, darkening skin at the edges and fever. Slough is present only in stage 3 pressure injuries and higher. 2019. https://specialty.mims.com/topic/change-in-chronic-wound-management--ne. This tissue responds poorly to too much moisture and in most cases a dressing that protects this tissue from the effects of moisture is used. Simple debridement that can be undertaken by all healthcare professionals involves gentle circular movements over the wound with dry gauze, which may lift some debris. Offloading with a total contact cast is the optimal treatment for diabetic foot ulcers. Does your patient have signs or symptoms of infection, along with purulence? It is the first-line treatment for chronic wounds. Antimicrobial washes may also be beneficial if biofilm is suspected. Sorry, there are no matching doctors in your area, Sorry no questions were found related to this procedure, Do Not Sell or Share My Personal Information. Shear, friction and pressure will all affect the wound tissue and periwound condition. It is imperative to ensure that the correct dressing, and dressing regime, has been chosen to optimise wound healing. Kindred Hospitals take an interdisciplinary approach to creating comprehensive wound care plans based on insight from specialists and extensive wound assessments that determine all factors contributing to and affecting the wounds of each patient. Uses: Surgical wounds, cuts, abrasions, low to moderately exuding wounds. Granulating Wounds. This also reduces oedema, an important aspect to consider in all instances of wound care. Skin ulcers cause a crater-like depression in the skin, which may weep clear fluid (called serous ), blood, or, when infected, pus. Change in chronic wound management, new TIMERS guideline further improves wound care. All wounds have the potential to become chronic wounds. You can take care of most minor cuts and scrapes yourself. Wound Essentials. In many instances, removal of non-viable tissue may be achieved through various methods of debridement. The team at Kindred gave me my life back, and Ill be thankful to them for the rest of my days.. Swanson, T, Ousey, K, Haesler, E, Bjarnsholt, T, Carville, K, Idensohn, P, Keast, DH, Larsen nee Angel, D, Waters, N & Weird, D 2022. Debris will promote the risk of infection and slow the growth of epithelial cells. With the above information, it is now time to undertake She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Home treatment is OK if the wound isn't very deep and it's not in a spot where scarring is a problem, like your face. Both of these processes will affect new cellular growth and hence must be addressed. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. In many instances, removal of non-viable tissue may be achieved through various methods of debridement. Therefore having a knowledge of the characteristics of venous and arterial ulcers is imperative to ensure appropriate decision-making regarding management of these wounds. Chemical messengers direct cells to make collagen, a protein that acts like scaffolding to rebuild the damaged area. Home treatment is OK if the wound isn't very deep and it's not in a spot where. Treatment consists of exercise, which lowers venous pressures28; elevation of lower extremities; and adequate compressionusually 30 to 40 mm Hgto improve venous return29 after vascular status has been proven adequate(Table 4).29,30 Patients may benefit from statin therapy for its vasoactive and anti-inflammatory effects.30 Early endovenous ablation may also be beneficial.31. Patients with arterial ulcers should be immediately referred to a vascular surgeon for appropriate intervention. There are now six classifications of pressure injury. To appropriately treat a chronic wound, an understanding of the pathophysiology of the wound is critical. Tubigrip or Fascia: Connective tissue that covers muscle and found throughout the body. 3. WOUND CARE TERMINILOGY ORGANIZATION FOR WOUND CARE NURSES | WWW.WOUNDCARENURSES.ORG 3 Exudate: Fluid from the wound that can be serous, sanguineous or purulent. The first stage of wound healing is to stop the bleeding. pain. About the Author Open wounds are wounds with exposed underlying tissue and/or organs that are open to the outside environment (like penetrating wounds). Adams, R. Foundations of Health and Social Care, Palgrave Macmillan, 2007. Yellow (sloughy/granulation phase) Black (necrotic tissue/eschar) Wounds with signs of infection (e.g. Other wounds that often require medical care are those that: Surgical wounds are cuts or incisions in the skin by a scalpel or drain placed during surgery. Risk-assessment tools such as the Braden scale 15 can help minimize pressure ulcers by identifying high-risk patients. She has a passion for education, teaching, and our veterans. Uses: fixing primary dressings, catheters and tubes. Common lower extremity wounds include arterial, diabetic, pressure, and venous ulcers. The first step in the management of arterial ulcers is treating the underlying cause, which may include vascular bypass, stents, or dilation by a vascular surgeon (Table 5). Cytokines and growth factors released; vasodilation; phagocytosis (i.e., white blood cells engulf bacteria and debris); neutrophils release reactive oxygen species and proteases, Collagen (type III) synthesis, granulation formation, epithelialization, angiogenesis, contraction, Scar strength increases to approximately 80% of original tissue, Deep; eschar; punched-out, well-demarcated borders; deep structures may be exposed, Ankle-brachial index or toe-brachial index, Lower extremity arterial duplex ultrasonography, Located on plantar aspect of foot, extensive callus formation, superficial to deep, Magnetic resonance imaging if concern for osteomyelitis, Located over bony prominences, superficial to deep, Shallow, no eschar; located over medial aspect of lower extremity (gaiter region), Lower extremity venous duplex ultrasonography with reflux, Hydrocolloid (for mild to moderate drainage), Honey impregnated (autolytic debridement), After vascular evaluation, compress 30 to 40 mm Hg as tolerated (contraindicated if ankle-brachial index < 0.6), Zinc oxide compression bandage (Unna Boot), Elevation above level of the heart at rest, Vasoactive and anti-inflammatory properties in addition to lipid-lowering properties, Clinically significant improvement in healing time and healing rates, TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound, Compress 30 to 40 mm Hg as tolerated if edema is present and perfusion, Significantly improves healing rate and quality of life, Roll-on total contact cast (similar to fiberglass), Wash with pH-balanced skin cleanser and water, Increase protein intake to 1.5 g per kg body weight, Change positions every one to two hours to limit pressure on affected area, TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound based on wound stage.

Children's Park In Qatar, Sawyer On Lincoln Columbia, Sc, Articles W