EWMA Journal January 2007 by EWMA European Wound Management Association

Volume 7 Number 1 January 2007 Published by European Wound Management Association

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EWMA Council

The EWMA Journal ISSN number: 1609-2759 Volume 7, No. 1. January, 2007 The Journal of the European Wound Management Association Published three times a year Editorial Board Carol Dealey, Editor E. Andrea Nelson Finn Gottrup Michelle Briggs Peter Franks Peter Vowden Sue Bale Zbigniew Rybak

Marco Romanelli President Elect & Treasurer

Peter Franks President

Peter Vowden Immediate Past President

Finn Gottrup Recorder

EWMA web site www.ewma.org For membership application, correspondence, prospective publications and advertising please contact: EWMA Business Office Congress Consultants Martensens Allé 8 1828 Frederiksberg C · Denmark. Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org Layout: Birgitte Clematide

Sue Bale

Judith Darózcy

The next issue will be published May 2007. Prospective material for publication must be with the editors as soon as possible and no later than 15 March 2007 The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. Copyright of all published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction obtained from both the Author and EWMA via the Editorial Board of the Journal, and proper acknowledgement and printed, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval.

Katia Furtado

Luc Gryson

Zena Moore

E. Andrea Nelson

Deborah Hofman

Christina Lindholm

Christine Moffatt Position Document Editor

Printed by: Kailow Graphic A/S, Denmark Copies printed: 13,000 Prices: Distributed free of charge to members of the European Wound Management Association and members of co-operating associations. Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€

Carol Dealey EWMA Journal Editor

Patricia Price

Zbigniew Rybak

Salla Seppänen

Javier Soldevilla

Carolyn Wyndham-White

Panel Members Editorial Board Members Dr. E. Andrea Nelson, UK Dr. Carol Dealey, UK Professor Finn Gottrup, Denmark Dr. Michelle Briggs, UK Professor Peter Franks, UK Professor Peter Vowden, UK Dr. Sue Bale, UK Dr. Zbigniew Rybak, Poland Educational Panel Madeleine Flanagan, UK Co-operating Organisations’ Board Rokas Bagdonas Pauline Beldon Claudia Caula Mark Collier Rodica Crutescu Bülent Erdogăn Milada Francu Marie Gamlem Sheila Gilmartin Peter Hanga Mária Hok Lydia Jack

Aníbal Justiniano Aleksandra Kuspelo M.A. Lassing-Kroonenberg Guðbjörg Pálsdóttir Martin Koschnik Helena Peric Vivianne Schubert Maciej Sopata José Verdú Soriano Luc Tèot Deborah Thompson Gerald Zöch

Scientific Review Panel Luc Gryson, Belgium Zena Moore, Ireland Marco Romanelli, Italy José verdu Soriano, Spain Carolyn Windham-White, Switzerland Professor Peter Franks, UK Deborah Hofman, UK Dr. E. Andrea Nelson, UK Professor Patricia Price, UK Madeleine Flanagan, UK Ass. Professor Gerald Zöch, Austria M.D. Milada Franc˚u, Czech Republic Professor Ralf-Uwe Peter, Germany Salla Seppänen, Finland Ass. Professor Rytis Rimdeika, Lithuania Dr. Caroline Amery, UK Senior Lecturer Mark Collier, UK

For contact information, see www.ewma.org

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Journal 2007 vol 7 no 1

Editorial

3 Editorial

Carol Dealey

Scientific Articles 5 Self-care activities of venous leg ulcer patients in Finland Salla Seppänen

17 Smoking is not contra-indicated in maggot debridement therapy in the chronic wound Pascal Steenvoorde

23 Effectiveness of non-alcohol film forming skin protector on the skins isles inside the ulcers and the healing rate of venous leg ulcers Tanja Planinsek Rucigaj

26 Wound measurement: the contribution to practice Georgina T. Gethin

31 Improving education in wound care: crossing he boundaries of interprofessional learning Caroline McIntosh

32 Waterjet debridement of deep and indeterminate depth thermal injuries Mayer Tenenhaus

EBWM 34 Abstracts of recent Cochrane reviews

elcome to the first issue of the EWMA Journal for 2007.

As you will have seen from the cover, the focus for some of the background articles in this issue is on the UK, in anticipation of the EWMA Conference being held in Glasgow this year. We saw it as an opportunity to ‘showcase’ the activities of some of the organisations who are partnering EWMA in planning the conference. I would also draw your attention to the Call for Abstracts and the details of the EWMA Awards, especially the First Time Presenter Award to be found on pages 40-41. More details about the conference can be found on the EWMA website: www.ewma.org/ewma2007. We look forward to an exciting event in what looks to be stunning venue.

Sally Bell-Syer

EWMA 35 Brian Gilchrist: thank you Peter J Franks

36 EWMA Education Development Project: what is it and what does it do? Zena Moore

38 EWMA 2007 Glasgow, United Kingdom 40 EWMA 2007 Abstract Submission 41 EWMA 2007 Awards 42 LUF, The Leg Ulcer Forum 43 National Association of Tissue Viability Nurses (Scotland) 44 TVNA, Tissue Viability Nurses Association 45 TVS, Tissue Viability Society 46 EWMA Journal previous issues 46 International Journals 48 EWMA Corporate Sponsors Contact Data 50 EWMA welcomes new Corporate B Sponsors

Conferences 52 EPUAP conference in Berlin, 2006

However, the whole of the journal does not focus on activities in the UK and the scientific papers and abstracts reflect the fact that the EWMA Journal is a European journal and draws upon readers from many countries. There is also a growing recognition across Europe of the impact that chronic wounds have upon the lives of individuals and importance of providing them with effective wound care services. There is still much to understand about all aspects of wound healing and management and great opportunities for research, particularly collaborative research across Europe. Sadly, although there are now opportunities for funded studies on a national level in many countries, there is still a lack of interest at a European level. There is no mention of chronic wounds within the topics listed in the Health Theme for the FP7 Research Programme funded by the European Commission, despite lobbying from the European Pressure Ulcer Advisory Panel. Maybe we all need to get political and lobby our relevant local representatives to the EU in order to get their attention

54 6th scientific meeting of the DFSG 54 The 1st national congress of WMAT

Carol Dealey, Editor

55 Conference calendar

Organisations 56 HWMS/MSKT, Hungarian Lymphoedema and Wound Managing Society 57 The hungarian SEBINKO association 58 Co-operating organisations

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Journal 2007 vol 7 no 1

Making the Choice Clear AQUACEL® Ag dressing is the only antimicrobial with all the benefits of Hydrofiber® ConvaTec Technology

• Gels on contact with exudate—absorbs and retains fluid 1 and locks away harmful components contained within exudate*,2-4 as demonstrated in in vitro testing • Effective antimicrobial—low concentration of ionic silver kills a broad range of wound pathogens in the dressing including MRSA 5 as demonstrated in in vitro testing • Enhances patient comfort—soft and conformable for ease of application • Allows for non-traumatic removal—without damaging newly formed tissue • Supports healing—by providing a moist environment *AQUACEL® dressing has the same composition and Hydrofiber® Technology as AQUACEL® Ag dressing. References: 1. Parsons D, Bowler PG, Myles V, Jones S. Silver antimicrobial dressings in wound management: a comparison of antibacterial, physical, and chemical characteristics. Wounds. 2005;17(8):222-232. 2. Walker M, Hobot JA, Newman GR, Bowler PG. Scanning electron microscopic examination of bacterial immobilisation in a carboxymethyl cellulose (AQUACEL®) and alginate dressings. Biomaterials. 2003;24:883-890. 3. Bowler PG, Jones SA, Davies BJ, Coyle E. Infection control properties of some wound dressings. J Wound Care. 1999;8(10):499-502. 4. Walker M, Cochrane CA. Protease sequestration studies: a comparison between AQUACEL® and PROMOGRAN® in their ability to sequester proteolytic enzymes. WHRI 2494 WA139. May 27, 2003. Data on file, ConvaTec. 5. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber® dressing. Wound Rep Reg. 2004;12:288-294. ®/TM The following are trademarks of E.R. Squibb & Sons, L.L.C.: AQUACEL Ag and Hydrofiber. ConvaTec is an authorised user. ©2006 E.R. Squibb & Sons, L.L.C. July 2006 GO-06-1047.1

www.aquacelag.com

Scientific Article

Self-care activities of venous leg ulcer patients in Finland Abstract The aim of the study was to describe the healthdeviation of self-care activities of venous leg ulcer patients in Finland. The self-care activities were studied using WAS-VOB© (Panfil/Evers), which is a catalogue containing propositions for self-care activities for venous leg ulcer patients. It includes 59 propositions of self-care activities describing them in eight sections: general compression, wearing compression bandages, wearing compression hosiery, mobility, temperature, overloading of the venous system, prevention of skin damage and wound healing. For this study the WAS-VOB© was translated in to Finnish and culturally modified. The background information of patients concerned 1) independency and social aspects, 2) medical and wound history and 3) current situation of wound. The data were collected in the years 2003-2004 and analysed by SPSS 11.0. The study involved 88 venous leg ulcer patients, 75% of whom were female. Most of the patients (80%) were over 65 years old. All the patients had a medical diagnosis of venous leg ulcer and 74 of them had an ulcer or ulcers at the time of study. The general compression treatment was implemented every day by 72% of the patients either using compression bandages or hosiery. One third of patients (29) applied compression therapy on themselves. The three best implemented self-care activities were skin care, avoidance of venous system overload and avoidance of high temperatures. The least implemented self-care activities were mobility, wound healing and implementation of compression therapy. Only 35.4% of the patients reported that they implemented compression therapy even when a wound was not present. Health-care professionals need to motivate venous leg ulcer patients to continue compression therapy after the wound is healed. In addition, mobility activities and asepsis in wound treatment need more at-

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tention in supervision of self-care. WAS-VOB© assesses the self-care deficits of venous leg ulcer patients and it can also be recommended for use as a tool for health professionals in the area of preventive care.

Background of the study It is estimated that in Finland there are about 15,000 people who suffer from venous leg ulcers and 400,000 people who suffer from venous insufficiency, which it is estimated, for 12-14% of them, will turn into leg ulcers.1 The incidence of venous leg ulcers among the Finnish population is very much the same as in other European countries, 0.12-0.19%.2,3,4,5,6 When those leg ulcer patients who are not involved in professional health care are included within the incidence of venous leg ulcer patients, the numbers are estimated to be around 2%. In the future the number of venous leg ulcer patients will increase in all European countries, because of the aging population. The incidence of venous leg ulcers in the over 65s age group is 1.0-3.3%.8

Salla Seppänen, RGN, Specialist in MedicalSurgical Nursing, MNSc, Principal Lecturer, Oulu University of Applied Sciences, Oulainen Department of Health Care Finland salla.seppanen@pp.inet.fi

Poor rates of healing and high rates of re-ulceration are typical characteristics of these chronic wounds. The statistics show that around 50-72% of venous leg ulcer patients have had an ulcer for at least one year and 12-29% of patients have had an ulcer for over 2 years. Venous leg ulcers recur in 67-80% of patients, and 25% of venous leg ulcer patients have had at least four wound episodes.7 The cooperation of patients is very important for the successful treatment and prevention of venous leg ulcers. Within the framework of the Theory of Self-Care Deficit, venous leg ulcer patients have self-care requisites caused by the medical diagnosis and its treatment. Also the pain, discomfort and frustration of the slow healing of ulcers create requisites for self-care to bring relief. The self-care deficit refers to the relationship between self-care



agency and therapeutic self-care demands of individuals in which capabilities for self-care because of existent limitations are not equal to meeting some or all components of their therapeutic self-care demands.9 The special healthdeviation self-care propositions in the case of venous leg ulcer patients are maintaining and supporting the venous system, promoting wound healing and preventing re-ulceration.10 The implementation or knowledge of self-care activities among venous leg ulcer patients is not much studied, so we can just assume that the self-care is not all that well implemented.

Implementation of the study The aim of this study was to describe the health-deviation self-care activities of venous leg ulcer patients in Finland. The study was carried out through structured interviewing of leg ulcer patients and structured assessment of patients’ ulcers by professional nurses. The patients for the study were selected by the nurses. Criteria for inclusion were that a patient had a medical diagnosis of venous leg ulcer and a patient was able to communicate reliably. Also patients with a history of leg ulcers were accepted in to the study, even if they did not have an ulcer at the time of the study. Also, the self-care activities among the leg ulcer patients were continued as normal in a preventive perspective. The study proposal was accepted by the ethical committee of Helsinki University Hospital. All the hospitals, health care centres and nursing homes where the data were collected accepted the study proposal and gave permission for the implementation of study. Also each patient was individually informed of the study and he/she decided on his/her participation in the study. The self-care activities were studied by WAS-VOB© (Panfil/Evers), which is a catalogue containing propositions of self-care activities for venous leg ulcer patients.11 The measurement was developed by professors E-M Panfil and GCM Evers and tested in the German population with 234 venous leg ulcer patients. The test and retest-coefficient were between 0.53 and 0.67. Cronbach’s alpha was between 0.63 and 0.82.12 WAS-VOB© includes 59 propositions of self-care activities describing them in eight sections; general compression, wearing compression bandages, wearing compression hosiery, mobility, temperature, overloading of the venous system, prevention of skin damage and wound healing. The propositions are assessed by patients with a four point Likert scale; definitely yes, possibly yes, possibly no, definitely no.11

Table 1. The Sections of WAS-VOB© (Panfil/ Evers) PART 1. General compression • 1a Activities for implementation of compression (7 propositions) • 1 b Wearing compression bandages (6 propositions) • 1 c Wearing compression hosiery (4 propositions) PART 2. I. Self care activities • 2. Mobility (13 propositions) • 3. Temperature (5 propositions) • 4. Overloading of the venous system (10 propositions) II Self-care activities to avoid skin damages (6 propositions) III Self-care activities in wound management (8 propositions)

For this study the WAS-VOB© was translated in to Finnish and culturally modified; at the end of WAS-VOB© four propositions concerning of self-care activities related to sauna were included. Table 2. The self-care activities related to sauna SELF-CARE ACTIVITIES RELATED TO SAUNA (4 propositions) • ’I bathe weekly in sauna. • ’I do not bathe in hot sauna.’ • ’I do not raise my legs up in sauna.’ • ’I put wet and cool towels on the wound to keep it cooler in sauna.’

The background histories of patients were collected by questionnaire, which included three items: 1) independency and social aspects, 2) medical and wound history and 3) current situation in leg ulceration. The wound assessment was done by the nurses with special charts that included the size of wound, tissue type, amount, colour and smell of exudation and assessment of peri-wound. Because the pain is a problem with leg ulcer patients13,14,15 the patients’ experience of pain was also measured on a numeric scale (0-10). The data was collected in the years 2003-2004 by registered nurses who were specialists in wound management in Oulu and Mikkeli Polytechnics. The nurses assessed the wound, amount of oedema in legs and filled patients’ charts with the medical information that was needed. The self-care activities of venous leg ulcer patients were studied using the WAS-VOB© proposition catalogue and by interviewing the patients. The data was analysed by SPSS 13.0 for statistics.

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Scientific Article

Background information of venous leg ulcer patients The study involved 88 venous leg ulcer patients, of whom 75% were female. Most of the patients (80%) were over 65 years old.

Current situation in leg ulceration Of the patients, 74 (84%) had an ulcer or ulcers at the time of study and 24 (32.4%) of those had more than one ulcer. The total number of ulcers was 112. While the ulcers were mainly superficial, five wounds extended into muscle. The size of wounds varied a lot, ranging between height 2mm-379 mm and length 2 mm-170 mm. All wounds had granulation and fibrin tissue and two wounds displayed necrotic tissue. At the time of study, 55 patients had oedema in one or both legs and 47 patients reported pain. The patients assessed the pain on a numeric scale 0-10. (See Table 3) Table 3. Numeric value of venous leg ulcer patients’ experience of pain

Picture 1. The age of venous leg ulcer patients (N= 88)

Most of the patients 75.8% (86) lived at home or in nursing homes and 54.6% (47) of them lived with family or spouse. Two patients were cared for in a geriatric ward of a health care centre. 73% of patients (64) coped independently or with minor help with their daily activities. 43.2% of patients (38) used some aid for mobility. Most of the patients (85.2%, n= 75) were mentally active. Only 9.1% (8) of patients had some problems with memory and 5.7% (5) had more serious memory problems concerning difficulties in coping with daily activities For most of the patients (69.3%, n=61) the wound management was implemented at home either by health visitors (25 patients) or by non-professional persons, such as the patients themselves or a relative (36 patients). For some of the patients the wound management was implemented in primary health care, in a ward 6.8% (6 patients) or in an outpatient clinic10.2% (9 patients). Ten patients (11.4%) had their wounds managed in specialised hospital units. Two of the patients lived in a home for the elderly and their wound management was done by the nurses who worked there. The wound history of 86 patients was described. Of those, 37.6% (32) had just one episode of leg ulcers, while 42.4% (36) had 2-3 episodes and 20% of the patients (17) had had more than three wound episodes. Also the time period that a patient has suffered venous leg ulcers was long. The longest history of wounds was 60 years while 14 patients (16.3%) reported that they had had venous leg ulcers for over 20 years and 48 patients (55.8%) reported suffering venous leg ulcers for five years or less.

Numeric value of pain 0 1-3 4-7 8

Number of venous leg ulcer patients 10 patients 23 patients 29 patients 5 patients

Self-care activities of venous leg ulcer patients The self-care activities of venous leg ulcer patients are described in two main categories -compression therapy and other self-care activities. The first main category, compression therapy, is divided in to sub-categories – general activities in the implementation of compression therapy, wearing compression bandages and wearing compression hosiery. The second category, other self-care activities, is divided in to six sub-categories: mobility, temperature, overloading of the venous system, preventing skin damages, wound management and activities related to sauna. Compression therapy Patients’ activities for applying the compression therapy were studied by 17 propositions of which seven concerned general activities for compression therapy and six propositions related to wearing compression bandages and four to wearing hosiery. However, 41.8% of patients reported that they do not implement compression therapy if there is no wound. Only 35.4% of patients said that they definitely would implement the compression therapy while the skin is intact and the rest, 32.8%, said possibly yes or possibly no. (table 2). While implementing compression therapy 72.2% of the patients said that they did it daily, but only 53.2% of the patients said definitely yes that they put compression bandages or hosiery immediately when they wake up. Most 

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Journal 2007 vol 7 no 1

Contreet / Biatain - Ag Sustained silver release and absorption in one dressing

• Contreet / Biatain - Ag reduces the ulcer area by 45-56% within 4 weeks1-3 • Contreet / Biatain - Ag kills MRSA faster than other silver dressings4 • Contreet / Biatain - Ag provides excellent exudate management1-3 • Contreet / Biatain - Ag is a cost-effective treatment5

Contreet / Biatain - Ag Sustained silver release and absorption in one dressing Visit 1 Münter K-C et al. Effect of a sustained silver-releasing dressing on ulcers with delayed healing: the CONTOP study. Journal of Wound Care 2006, 15(5), 199-206. 2 Jørgensen B et al. The silver-releasing foam dressing, Contreet Foam, promotes faster healing of critically colonised venous leg ulcers: a randomised, controlled trial. International Wound Journal 2005, 2(1), 64-73. 3 Rayman et al. Sustained silver-releasing dressing in the treatment of diabetic foot ulcers. British Journal of Nursing 2005, 14(2), 109-114. 4 Ip M et al. Antimicrobial activities of silver dressings: an in vitro comparison. Journal of Medical Microbiology 2006, 55, 59-63 5 Scanlon E et al. Cost-effective faster wound healing with a sustained silver-releasing foam dressing in delayed healing leg ulcers - a healtheconomic analysis. International Wound Journal 2005, 2(2), 150-160.

www.woundcare.evidence.coloplast.com to find all peer-reviewed clinical, laboratory and health-economic evidence for Coloplast wound dressings.

Faster wound healing – by reducing the barriers to wound healing

Scientific Article

of the patients (59%) reported that they wear compression only in the daytime. The other self care-activities related to general compression were not so well implemented; only 19.7% of patients reported that they definitely yes raised the swollen foot, just 16.9% of patients said definitely yes to exercise after putting on compression and only 27.8% of the patients replied definitely yes to keeping the leg raised several times during the day. WAS-VOB©

Table 4. Venous leg ulcer patients’ answers for propositions concern on the general activities of implementation of compression therapy Proposition

Likert scale

Valid %

of patients reported definitely yes to the use of padding under the bandage and 54.9% of patients reported definitely yes to taking care that the pressure is strongest in the ankle. Only 43.4% of patients reported definitely yes to confirming that the bandages will stay up and only 29.4% of patients reported definitely yes to re-doing bandaging when the bandages loosen. (See table 5). Table 5: The venous leg ulcer patient answers for WAS-VOB© propositions concern on wearing of compression bandages Proposition

Likert scale

Valid %

I put on the compression bandages by myself. (n=54)

- definitely yes - possibly yes - possibly no - definitely no

22.2 11.1 1.9 64.8

I wear compression bandages or hosiery even when I have NO wound. (n=79)

- definitely yes - possibly yes - possibly no - definitely no

35.4 6.3 16.5 41.8

I use two bandages for the compression. (n= 53)

The first thing what I do when I wake up is that I put on hosiery or compression bandages. (n=77)

- definitely yes - possibly yes - possibly no - definitely no

53.2 13.0 10.4 23.4

- definitely yes - possibly yes - possibly no - definitely no

41.5 7.5 11.3 39.6

I use the padding under the bandage. (n=54)

I wear compression bandages or hosiery everyday. (n=79)

- definitely yes - possibly yes - possibly no - definitely no

72.2 10.2 3.8 13.9

- definitely yes - possibly yes - possibly no - definitely no

42.6 7.4 9.3 40.7

I take care that the pressure is strongest in the ankle.(n=51)

- definitely yes - possibly yes - possibly no - definitely no

59.0 10.3 3.8 26.9

- definitely yes - possibly yes - possibly no - definitely no

54.9 15.7 11.8 17.6

I confirm that the bandages will stay up. (n=53)

- definitely yes - possibly yes - possibly no - definitely no

19.7 17.2 19.7 43.4

- definitely yes - possibly yes - possibly no - definitely no

43.4 26.4 18.9 11.3

I do exercise for at least 20 minute after putting on the compression bandages or hosiery. (n=77)

- definitely yes - possibly yes - possibly no - definitely no

16.9 19.5 23.4 40.3

When the bandages loosen/slacken off, I take it off and do the bandaging again. (n=51)

- definitely yes - possibly yes - possibly no - definitely no

29.4 23.5 15.7 31.4

I raise up my legs several times during the day. (n=79)

- definitely yes - possibly yes - possibly no - definitely no

27.8 29.1 24.1 19.0

I wear compression only in daytime. (n=78)

I raise up the swollen foot. (n=76)

The second sub-category under the main category ‘compression therapy’ was wearing compression bandages. While 22.2% of patients who wear compression bandages reported that they definitely yes did the bandaging themselves, 64.8% of patients reported that they definitely no put on the compression bandages themselves. The answers to the other propositions of this item showed that the technique of bandaging is not that good when done by professionals or non professionals; only 41.5% of patients reported definitely yes for using two bandages, just 42.5%

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Reasons the patients reported for not using the compression bandages were pain, discomfort and family tradition. • I feel unwell when I wear the compression bandages. • Bandages hurt; I feel pain while wearing them. • My brother and sisters have also had a history of venous leg ulcers and they never used compression bandages and everything went OK for them. The third sub-category under the main category compression therapy was ‘wearing compression hosiery’. The answers show that the implementation of compression therapy by hosiery was not too good: only 42.6% of the patients who wear hosiery reported that they definitely yes do change to clean hosiery every second day. Also the condition of hosiery was not inspected nor was new hosiery bought every 6 months as recommended. (table 6). 

Table 6. The venous leg ulcer patients’ answers for WAS-VOB© propositions concerning the wearing of compression hosiery. Proposition

Likert scale

Valid %

Table 7. The venous leg ulcer patients’ answers for WAS-VOB© propositions concerning mobility Proposition

Likert scale

Valid %

I change to clean compression - definitely yes hosiery every second day. (n= 54) - possibly yes - possibly no - definitely no

42.6 22.2 11.1 24.1

I avoid standing for a long time period. (n= 88)

- definitely yes - possibly yes - possibly no - definitely no

55.7 27.3 13.6 3.4

I do not wear loose hosiery (without stretch). (n= 53)

- definitely yes - possibly yes - possibly no - definitely no

32.1 26.3 20.8 20.8

I avoid sitting down for a long time period. (n=88)

- definitely yes - possibly yes - possibly no - definitely no

29.5 30.7 26.1 13.6

I inspect my hosiery every 6 months. (n= 50)

- definitely yes - possibly yes - possibly no - definitely no

22.0 8.0 12.0 58.0

I walk often. (n=84)

- definitely yes - possibly yes - possibly no - definitely no

44.0 23.8 22.6 9.5

I buy new hosiery after 6 months. (n = 50)

- definitely yes - possibly yes - possibly no - definitely no

30.0 14.0 10.0 46.0

I raise my feet during the daytime, as often as possible.(n=86)

- definitely yes - possibly yes - possibly no - definitely no

30.2 32.6 24.4 12.8

I raise my feet during the evening as often as possible. (n=85)

- definitely yes - possibly yes - possibly no - definitely no

36.5 25.9 24.7 12.9

I raise my feet above the heart level. (n=86)

- definitely yes - possibly yes - possibly no - definitely no

22.1 17.4 30.2 30.2

I have raised up the foot of my bed. (n= 87)

- definitely yes - possibly yes - possibly no - definitely no

25.3 5.7 20.7 48.3

I stretch and twist my feet several times a day. (n=86)

- definitely yes - possibly yes - possibly no - definitely no

27.9 30.2 27.9 14.0

I stretch and twist my toes several times a day. (n=86)

- definitely yes - possibly yes - possibly no - definitely no

19.8 37.2 25.6 17.4

I exercise my calf muscles, at least 15 minutes per day. (n=86)

- definitely yes - possibly yes - possibly no - definitely no

12.8 15.1 29.1 43.0

Before falling asleep I exercise my feet so that the venous circulation is supported. (n=85)

- definitely yes - possibly yes - possibly no - definitely no

16.5 10.6 25.9 47.1

I walk at least 30 minutes a day. (n=86)

- definitely yes - possibly yes - possibly no - definitely no

23.3 11.6 29.1 36.0

I buy new shoes in the afternoon or evening. (n=82)

- definitely yes - possibly yes - possibly no - definitely no

6.1 13.4 31.7 48.8

The patients’ comments relating to not wearing compression hosiery were that the hosiery was too expensive. • “The hosiery are so expensive – I do not have extra money for them! Other Self-Care Activities The other self-care activities of venous leg ulcer patients were studied in sub-categories: mobility; temperature; overloading of the venous system; preventing skin damage; wound management; and activities related to sauna. The sub-category ‘mobility’ included 13 propositions related to physical exercise, sitting down, raising the legs, sleeping position and type of shoes (table 7). About half of the patients reported that they walk often. However, only 22.7% of the patients reported that that they definitely yes walk at least half an hour everyday. Over half of the patients reported that they do avoid standing for a long time and 30% of the patients said that they definitely yes avoid sitting down for a long time. The other physical activities were not so well implemented; only 12.8% of the patients reported that they definitely yes do daily gymnastic exercises for 15 minutes (see table 7).

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Scientific Article

The section ‘temperature’ included five propositions concerning the temperature inside the house, tap water while washing feet and wearing socks and shoes (table 8). Just 32.6% of the patients said definitely no they do not wash their feet in very warm water and 65% of patients reported that they definitely no use socks or shoes that make their feet sweat.

Likert scale

Proposition

Likert scale

Valid %

I wear stockings and socks that are tight. (n=76)

- definitely yes - possibly yes - possibly no - definitely no

0.0 3.4 10.2 86.4

I wear a tight girdle. (n=84)

- definitely yes - possibly yes - possibly no - definitely no

0.0 0.0 2.4 97.6

Valid %

I wear tight underpants or pants. (n=81)

- definitely yes - possibly yes - possibly no - definitely no

3.4 3.4 1.1 92.0

I prefer sitting so that my legs are crossed. (n=87)

- definitely yes - possibly yes - possibly no - definitely no

10.3 6.9 23.0 59.8

I carry heavy things like firewood and water from the well. (n=88)

- definitely yes - possibly yes - possibly no - definitely no

9.1 2.3 12.5 76.1

I carry heavy shopping bags. (n=86)

- definitely yes - possibly yes - possibly no - definitely no

10.5 3.5 24.4 61.6

Table 8. The venous leg ulcer patients’ answers for WAS-VOB© propositions concerning temperature Proposition

Table 9. The venous leg ulcer patients’ answers for WAS-VOB© propositions concern on avoiding overloading the venous system

In the winter I usually keep my room temperature very warm. (n=87)

- definitely yes - possibly yes - possibly no - definitely no

28.7 25.3 16.1 29.9

I wash my feet with very warm water. (n=86)

- definitely yes - possibly yes - possibly no - definitely no

25.6 25.6 16.3 32.6

- definitely yes - possibly yes - possibly no - definitely no

2.3 8.1 23.3 66.3

- definitely yes - possibly yes - possibly no - definitely no

2.3 4.7 27.9 65.1

I carry heavy laundry baskets. (n=87)

- definitely yes - possibly yes - possibly no - definitely no

21.6 21.6 13.6 43.2

- definitely yes - possibly yes - possibly no - definitely no

3.4 4.6 18.4 73.6

I carry heavy things in my work. (n=83)

- definitely yes - possibly yes - possibly no - definitely no

6.0 2.4 8.4 83.1

I lift up heavy items. (n=85)

- definitely yes - possibly yes - possibly no - definitely no

5.9 2.4 16.5 75.3

For physically heavy tasks I ask for - definitely yes help from other people. (n=85) - possibly yes - possibly no - definitely no

60.0 16.5 11.8 11.8

I wear socks that make my feet sweat. (n=86)

I wear shoes that make my feet sweat. (n=86)

While I sleep I prefer a very warm blanket. (n=88)

The section ‘overloading the venous system’ included 10 propositions concerning socks, sitting position, carrying heavy bags and other heavy items (table 9). Many patients reported definitely no to wearing tight socks (86.4%) or trousers (92.0%) and do not cross their legs when sitting down. (59.1%). They definitely do not carry heavy bags or other heavy items; 60% of the patients also reported that they definitely yes ask for help with physically heavy tasks.

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The section ‘avoiding skin damage’ included six propositions concerning self-protection of intact skin (table 10). Only 63.6% of the patients reported that they definitely yes try to avoid hurting themselves, 55.7% of patients said that they definitely yes cream their feet regularly and 43.2% of patients said that they definitely yes protect the skin of their feet and legs against grazes and cuts. In addition, 46.6% of the patients said that they definitely yes inspected their feet daily and 25.3% of them said that that they definitely use padding on the bone prominence  under the compression bandages.

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Scientific Article

Table 10. The venous leg ulcer patients’ answers for WAS-VOB© propositions concerning avoiding skin damages Proposition

Likert scale

Table 11. The venous leg ulcer patients’ answers for WAS-VOB© propositions concern on wound management

Valid %

Proposition

Likert scale

Valid %

I pay attention to avoid hurting myself. (n=88)

- definitely yes - possibly yes - possibly no - definitely no

63.6 29.5 4.5 2.3

I inspect a wound every time the bandages are changed to be sure that there are no signs of infection (n=83)

- definitely yes - possibly yes - possibly no - definitely no

56.6 12.0 9.6 21.7

I cream my feet regularly. (n=88)

- definitely yes - possibly yes - possibly no - definitely no

55.7 23.9 12.9 8.0

I regularly measure the length and the width of the wound (n=80)

- definitely yes - possibly yes - possibly no - definitely no

11.3 7.5 8.8 72.5

I protect my skin under hosiery or compression bandages. (n=81)

- definitely yes - possibly yes - possibly no - definitely no

43.2 28.4 9.9 18.5

I wash my hands every time before changing the dressing (n=78)

- definitely yes - possibly yes - possibly no - definitely no

59.0 12.8 5.1 23.1

I inspect my feet every day to be sure that there is no skin damage (n=88)

- definitely yes - possibly yes - possibly no - definitely no

46.6 20.5 19.3 13.6

When I remove the dressing I take care not to damage surrounding skin or new tissue in the wound (n=77)

- definitely yes - possibly yes - possibly no - definitely no

55.8 16.9 2.6 24.7

I use padding on the bone prominence under the compression bandages (n=83)

- definitely yes - possibly yes - possibly no - definitely no

25.3 15.7 20.5 38.6

I take care to ensure the wound has enough humidity (n=76)

- definitely yes - possibly yes - possibly no - definitely no

34.2 27.6 10.5 27.6

If I feel unwell I check if my feet are swollen or if there are any signs of ulcers (n=87)

- definitely yes - possibly yes - possibly no - definitely no

32.2 21.8 26.4 19.5

I go to see my GP immediately if I see any signs of wound infection (n=76)

- definitely yes - possibly yes - possibly no - definitely no

73.3 9.3 10.7 6.7

I use a clean towel every day for drying my feet (n=77)

- definitely yes - possibly yes - possibly no - definitely no

36.4 18.2 20.8 24.7

I always have wound care products and dressings with me (n=75)

- definitely yes - possibly yes - possibly no - definitely no

34.7 21.3 13.3 30.7

The section ‘wound management’ included eight propositions concerning asepsis and assessment and treatment of ulcer (table 11). Only 56.6% of the patients reported that they definitely yes inspected the wound every time the wound was treated. Also, while 59% of the patients reported that they definitely yes wash their hands before treating the wound and 55.8% of the patients said that they are definitely careful while taking off a dressing to avoid causing damage to a wound, only 34.2% of patients reported that they definitely take care that the wound has enough humidity and just 34.7% of the patients reported that they definitely yes always carried with them dressings and wound management products. Self-care activities related to sauna Almost half of the patients reported that they go to sauna once a week and 13.3% of the patients had sauna often but seldom more than once a week. For 32.5% of the patients it was not possible to go to sauna at all because of their physical condition or because there was not sauna available. For example, “I live in a home for the elderly and there is no sauna.” The patients were very well aware of that they should avoid very hot sauna and not keep their legs raised in sauna because the hot sauna will enlarge veins and cause extra oedema. Only 24.7% of patients protected the wound from heat with a cold and wet towel (table 12).

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Table 12. The venous leg ulcer patient responses to the propositions concern on the self-care activities related to sauna Proposition

Likert scale

Valid %

I do not bath in hot sauna (n= 82)

- definitely yes - possibly yes - possibly no - definitely no

43.9 29.3 7.3 19.5

I do not raise my legs up in sauna (not over heart) (n= 78)

- definitely yes - possibly yes - possibly no - definitely no

65.4 10.3 3.8 20.5

I protect the wound with a wet and cool towel while I am in sauna (n= 73)

- definitely yes - possibly yes - possibly no - definitely no

24.7 11.0 9.6 54.7

The patients also reported extra information on self-care activities related to sauna. • While I have an open wound I do not go to sauna. • I put cool water on my wound while I am in sauna • I keep my foot in cool water while I sit down in sauna and throw water on the rocks  • I do not cover the wound, while I am in sauna.

Scientific Article

Conclusions The deficits in the self-care activities of venous leg ulcer patients were very strongly related to prevention of oedema and implementing of compression therapy. According to the study, general compression was implemented daily by 72% of the patients but 13.9% of the patients said that they definitely do not use compression therapy daily. There are some patients who are not cooperative enough with the implementation of compression therapy, this is especially a problem when the wound is healed and skin is intact. Only 35.4% of the patients reported that they continue to implement compression therapy when a wound does not exist. Similar results were reported in Panfil’s and Ever’s study.12 Also the techniques of bandaging and wearing of hosiery were not carried out according to the recommendations: apply compression on the morning before getting out of bed, use the padding on the ulcer as well on the bone prominence of leg under the compression bandages and use two bandages. In addition, the checking of the fitting of hosiery and buying new after 6 months’ wear were not implemented well. Also, only one third of the patients applied the bandages themselves, this presents a challenge to nurses to supervise relatives and non-professional caregivers, who are implementing the compression therapy for the patient more carefully to ensure it is carried out efficiently and effectively. The best implemented self-care activities reported by patients were avoiding of overloading the venous system, skin care and avoiding of very high temperatures. The less well implemented self-care activity was mobility. The physical exercises recommended to support venous circulation and muscles in the legs were not well implemented. The reason for this might be that patients are not aware of the importance of physical exercise, and they do not know what to do or how to do it. According to the results of the study the most demanding challenge for health professionals is to motivate venous leg ulcer patients to apply compression therapy. To achieve this it will be necessary to develop community-based care models for venous leg ulcer patients and offer education for health professionals. According to the previous studies, these two activities can significantly improve the healing of the ulcers as well as the cost-effectiveness of care of venous leg ulcer patients.16, 17. In the Harrison study the implementation of new community-based approach to the treatment of leg ulcer patients led to better healing rates and improved the efficiency of care. The proportion of patients receiving the appropriate treatment (compres-

sion bandages) nearly doubled, the average number of care visits per person declined, and the healing rates nearly tripled.17. I do believe that the specialist nurse-led care model is likely to be a key issue in the promotion of selfcare activities of venous leg ulcer patients while the wound exists and also when the wound is healed and skin is intact. In Finland there is a deficit in the health care system; while a patient does not have a wound episode the supervision of venous leg ulcer patients is minimal. Preventative care should be included as an integral part of the care of venous leg ulcer patients. This study also gave an opportunity to test WAS-VOB© in a clinical situation. The results of the study as well as the experience of the nurses who interviewed the patients for the study showed that WAS-VOB© is a suitable tool for the assessment of self-care deficits of venous leg ulcer patients and it can be recommended for use as a tool for health professionals caring for venous leg ulcer patients. WAS-VOB© helps nurses to identify the key issues of selfcare. The limit of WAS-VOB© is that it does not take into consideration weight and nutrition, which also are part of the self-care activities of venous leg ulcer patients. m References 1. Lehtola A, Hietanen H, Säärihaava. In book Hietanen H, Iivanainen A, Seppänen S, Juutilainen V. Haava. 2003. WSOY. Porvoo: 136-157. 2 Baker S, Stacey M, Singh G et. al. 1992. Aetiology of chronic leg ulcers. Eur J Vasc Surg 6:245-51. 3 Fowkes F, Evans C, Lee A. 2001. Prevalence and risk factors of chronic venous insufficiency. Angiology 52:5-15. 4 Malanin G, Jansen C. 1990. Säärihaavat I. Kuka sairastaa, kuka hoitaa, mitä maksaa? Suomen Lääkärilehti 45:11-13. 5 O’Brien, Perry I, Burke P.2000. Prevalence and aetiology of leg ulcers in Ireland. Irish Journal of Medical Science 169:110-112. 6. Öien R, Håkansson A, Hansen B. 2000. Leg ulcer epidemiology and care in a well-defined population in southern Sweden. Scandinavian Journal of Primary Health Care 18:220-225. 7. Leach M. J. 2004. Making sense of the venous leg ulcer debate: a literature review. Journal of Wound Care. 13 (2): 52-56. 8. Margolis D, Bilker W, Santanna J et al. 2002. Venous leg ulcer: Incidence and prevalence in the elderly. Journal of American Academic Dermatology 3:381-6. 9. Orem D. Nursing concepts of practice. 1985. McGraw-Hill Book Company. USA. 10. Panfil E-M. Health-deviation self-care of people with venous leg ulcer. Paper presented at the 7th International Self-Care Deficit Nursing Theory Conference in Atlanta/ USA. November 1-3, 2002. 11. Panfil E-M, Evers GCM. Krankheitsbedingte Selbstpflege von menschen mit einem venös bedingten offenen Bein. WAS VOB© (Panfil Evers). Private Universität Witten/ Herdecke gGmbH, Instiut für Klinische Plflegeforschung, Stockumer STR 12, D-58453 Witten. 12. Panfil E-M. 2002. Health-deviation self-care of people with venous leg ulcer. Paper presented at 7th International Self-Care Deficit Nursing Theory Conference in Atlanta/USA. November 1-3.2002. 13. Charles, H. Does leg ulcer treatment improve patients’ quality of life? Journal of Wound Care 2004, 13 (6): 209-213. 14. Clay, C.S. & Chen W.Y.J 2005. Wound pain: the need for a more understanding approach. Journal of Wound Care 2005, 143 (4):181-184 15. Hareendran ym 2005 Measuring the impact of venous leg ulcers on quality of life. Journal of Wound Care 2005 154(2):53-57 16. Moffat C, Franks P. 2004. Implementation of a leg ulcer strategy. British Journal Dermatology 151:857-867. 17. Harrison M, Graham I, Lorimer K et al. 2005. Leg-ulcer care in the community, before and after implementation of an evidence-based service. CMAJ 172 (11):1447-52.

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Journal 2007 vol 7 no 1

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Scientific Article

Smoking is not contra-indicated in maggot debridement therapy in the chronic wound Based on a study of 125 wounds in 109 patients Abstract Smoking has demonstrated negative effects on acute wound healing. However, the effect on healing of chronic sloughy or necrotic wounds is less clear. Patients that were treated with Maggot Debridement Therapy (MDT) from 1 August 2002, and who were finished with MDT on the first of March 2006 were included in the present study. The patient group consisted of a total of 109 patients, who were treated with MDT for 125 infected chronic wounds. In the current study there were 37 smokers and 72 non-smokers. The overall results of MDT were comparable in both groups (success rate of MDT is 67.7% in smokers versus 70.8% in non-smokers; a statistically nonsignificant difference). In our opinion, although smoking has been proven to have negative effects on acute wound healing, it does not seem to influence healing in the chronic sloughy or necrotic wound. Smoking should therefore not be regarded as a (relative) contra-indication for MDT. Keywords: Maggot debridement – smoking – outcome

Introduction The negative effects of smoking on acute wound healing were first reported in 1977, in a smoker with impaired healing of a hand-wound.1 Cigarette smoke contains over 4000 different components with different effects on a variety of tissues in the body.2;3 There is a vast amount of literature describing the negative effects of smoking on acute wound healing.4 There is also evidence that5 6-9 smoking cessation programs improve healing rates, compared to patients that continue to smoke.10 These effects are, however, less clear in the chronic wound.3 Maggot debridement therapy (MDT) is effective in the debridement of chronic sloughy or necrotic wounds, with success percentages of around 80%.11 Patients with cutaneous ulcers should be instructed to refrain EWMA

Journal 2007 vol 7 no 1

from smoking12, but this is not always feasible in a chronic wound population. Also, there are many other factors besides smoking that influence the healing of chronic wounds.13 We questioned ourselves whether MDT-healing rates were influenced by smoking, because smoking is considered as a (relative) contra-indication for MDT in another hospital in the Netherlands. We believe this could be important in traumatic acute wounds, but believe this should be reconsidered in the chronic wound care group in whom amputation sometimes seems to be the only alternative. We believed MDT in smokers would be a better alternative to the standard surgical debridement that was performed in our clinic before the introduction of MDT. Here we report MDT-results on 125 wounds in 109 patients, with special emphasis on the possible detrimental effects of smoking.

Methods In the period August 2002 to March 2006, patients who presented with chronic wounds with signs of gangrenous or necrotic tissue at our surgical department and seemed suited to MDT were treated with MDT. This is a descriptive consecutive caseseries. Chronic wounds were arbitrarily defined as wounds existing for more than four weeks. The accepted definition of a chronic wound relates to any wound that fails to heal within a reasonable period. There is no clear-cut definition that points to how chronic a wound is.12 Three physicians, three nurses and one nurse practitioner were involved in the actual maggot therapy. Patients were not eligible for the study if the treating surgeon believed an urgent amputation could not be postponed (for example in case of severe sepsis) or if life expectancy was shorter than a few weeks. All patients gave informed consent for MDT. Patient characteristics like age and sex were also reported. The patient was recorded as a non-smoker if they had never smoked or had been non-smoking for  more than three months.

Pascal Steenvoorde MD MSc*1,2, Catharina E. Jacobi Phd3, Louk P. van Doorn MA2, Jacques Oskam MD Phd1,2 From the department of Surgery1 Rijnland Hospital Leiderdorp, the Rijnland Wound Clinic Leiderdorp2 and the department of Medical Decision Making3, Leiden University Medical Center, all in the Netherlands Corresponding author*: P. Steenvoorde, MD MSc. Rijnland Hospital Leiderdorp, Simon Smitweg 1. Postbus 2300 RC Leiderdorp, The Netherlands Phone: 0031-715828282 psteenvoorde@zonnet.nl and/or p.steenvoorde@rijnland.nl

Maggot debridement therapy At the start of this study, maggots were not commercially available. We were able, however, to get them at the nearest university medical center. Currently, maggots can be ordered up to 24 hours before start of the clinic (BiologiQTM, Apeldoorn, The Netherlands). The maggot applications are performed in our outpatient department twice a week. MDT was performed until thorough debridement was achieved. Each maggot application remained on the wound for three to four days. The free-range technique is more effective14 and is our preferred technique. However, with reference to patient preference15, painful wounds16, coagulation problems in the patient17 and problems with ensuring an adequate barrier for preventing maggot escape the contained technique was chosen. In total 65/125 (52%) wounds were treated with the contained technique. Outcome Maggots are debriding agents; if the wound is clean from bacteria, necrosis and slough maggots are no longer useful in the wound, and other wound-treatments must be followed in order to close the wound. In this study we defined eight different outcomes of MDT, based on outcome definition in the literature.11;18-21 and our own experience14;16;22;23 Effect of MDT observed (beneficial outcome) 1) Wound fully closed by second intervention (for example split skin graft); 2) Wound spontaneously fully closed; 3) Wound free from infection and <1/3 of original wound size; 4) Clean wound (free from infection/necrosis/slough), but same as initial size or up to 1/3 smaller. No effect of MDT observed (unsuccessful outcome) 5) No difference observed between the pre- and post-MDT-treated wound; 6) The wound is worse; 7) Minor amputation (for example partial toe amputation); 8) Major amputation (for example below knee amputation). 9) Unknown outcome.

In this study outcomes 1-4 are arbitrarily determined beneficial outcomes and outcomes 5-9 are determined unsuccessful outcomes. They are arbitrary because in some patients a fully debrided wound does not offer any advantages for the patient (for example he/she still needs wound care) and for another patient only a partial toe amputation (which is defined as non-successful) could mean the difference between being in a wheelchair and being fully ambulatory. Statistical analyses To study the impact of smoking on the outcome of MDT, a univariate analysis using Chi-square statistics was performed.

Results From August 2002 until March 2006, 109 patients with 125 wounds were treated with MDT in our hospital. In total 110 patients were offered MDT, one alcoholic patient, with a psychiatric history refused. For one patient the outcome was not known, due to the patientâ&#x20AC;&#x2122;s death during maggot treatment. The patient died in another hospital, due to a myocardial infarction, which was unrelated to the MDT. There were 59 male (54.1%) and 50 female patients treated. The average age was 71 years (range: 2593 years). The wounds existed on average seven months before starting with MDT (range 1 week-11 years). Of the 125 wounds treated with MDT, 76 (69.7%) had beneficial outcomes (Table 1). MDT resulted in complete debridement and epithelialization, leading to a stable and pain-free scar with no subsequent breakdown in 64 of the 125 wounds (51.2%), while 14 wounds (11.3%) were free from necrosis, slough and infection and the wound dimensions were less than one third of original wound size. A major amputation was needed in 28 patients (22.4%). In the current study there were 37 smokers and 72 non-

The woundteam, from left to right: Louk van doorn, nurse practioner Geertje Abrahamse, woundcare nurse Pascal Steenvoorde, resident surgery Nicolette hof, nurse practioner Franca Hallebeek, woundcare nurse Jacques Oskam, vascular surgeon

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Scientific Article Table 1. Results of MDT in 109 patients with 125 wounds, divided by smokers and non-smokers

N (%) 125 (100)

Total Beneficial outcome 1. Wound fully closed by second intervention (for example split skin graft) 2. Wound spontaneously fully closed 3. Wound free from infection and <1/3 of original wound size 4. Clean wound (free from infection/necrosis/slough), but same as initial size or up to 1/3 smaller Unsuccessful outcome 5. There is no difference between before and after MDT 6. The wound is worse 7. Minor amputation (for example toe) 8. Major amputation (below knee amputation or above knee amputation) 9. Unknown result

All wounds* Smokers Non-smokers N (%) N (%) 41 (32.8) 84 (67.2)

All patients** Smokers Non-smokers N (%) N (%) N (%) 109 (100) 37 (33.9) 72 (66.1)

85 (68.0) 23 (18.4)

29 (70.7) 9 (22.0)

56 (66.7) 14 (16.7)

76 (69.7) 23 (21.1)

25 (32.9) 9 (24.3)

51 (67.1) 14 (19.4)

41 (32.8) 14 (11.2)

16 (39.0) 2 (4.9)

25 (29.8) 12 (14.3)

34 (31.2) 13 (11.9)

13 (35.1) 2 (5.4)

21 (29.2) 11 (15.3)

7 (5.6)

2 (4.9)

5 (6.0)

6 (5.5)

1 (2.7)

5 (6.9)

40 (32.0) 5 (4.0) 1 (0.8) 5 (4.0) 28 (22.4)

12 (29.3) 2 (4.9) 0 (0.0) 2 (4.9) 8 (19.5)

28 (33.3) 3 (3.6) 1 (1.2) 3 (3.6) 20 (23.8)

33 ((30.3) 3 (2.8) 1 (0.9) 5 (4.6) 23 (21.1)

12 (36.4) 2 (5.4) 0 (0.0) 2 (5.4) 8 (21.6)

21 (63.6) 1 (1.4) 1 (1.4) 3 (4.2) 15 (20.8)

1 (0.8)

0 (0.0)

1 (1.2)

1 (0.9)

0 (0.0)

1 (1.4)

X2=0.209

* Chi-square: smokerâ&#x20AC;&#x2122;s/non-smokerâ&#x20AC;&#x2122;s wounds vs. 2-group outcome: (df=1), P-value=0.647 (via Fishers Exact correction: P-value=0.688) ** Chi-square: smoking/non-smoking patients vs. 2-group outcome: X2=0.123 (df=1), P-value=0.725 (via Fishers Exact correction: P-value=0.826)

smokers. Of the smokers 25 (67.7%) had a good result, compared to 51 (70.8%) in the non-smokers group. This difference was non-significant (Table 1). The same result was true if success was defined only as a closed wound (outcome 1 or 2). Nor did smokers have a higher chance of amputation (outcome 7 and 8).

Discussion Smoking is a risk factor for complicated wound healing; it is a systemic risk factor in line with diabetes and malnutrition. It seems to be one of the most important (preventable) risk factors for impaired healing, considering more than 25% of the adult population smokes.3 Smoking causes damage to blood vessels, there is decreased collagen production24, increased aging of collagen25 and keratinocytes show impaired migration.26 Nicotine has been shown to impair wound contraction from the sixth to the tenth day in a rabbit-ear model.27 Tobacco smoke contains over 4000 different compounds of particles or gases. There are many toxic components like nicotine, carbon monoxide, cyanide, heavy metals, additives and numerous different chemical compounds known as condenate.3 The effect of the cigarette smoke is a thrombogenic state through an effect on the blood constituents, vasoconstricting prostaglandins and an effect on the dermal microvasculature.28 Eventually all these factors lead to tissue hypoxia. There is a vast amount of literature describing the negative effects of smoking on acute wound healing. Sternal woundhealing4, hip and knee arthroplasty5, ankle arthrodesis29, spinal fusion6, intra-oral implant placement7, skin flaps8, incisional hernia30, leg amputation31 and breast reducEWMA

Journal 2007 vol 7 no 1

tion9 are all examples of acute wounds that have delayed healing in smokers. For example, delayed healing after breast reduction was significantly associated with smoking. In a study on 179 patients undergoing breast reduction surgery; 22% had delayed healing in the smoking group versus 7.7% in the non-smoking group (p=0.03)9; thus demonstrating a relatively strong effect. Evidence of the negative effect of smoking is not only seen in (skin-)wound healing, there is also evidence, in the fields of (for example) fracture healing32 and bowel anastomosis33 where it has been shown that smoking negatively affects healing. There is a dose-response association in heavy smokers with all cause higher morbidity, however it is not clear if this is also the case for wound healing.34 One study found that high-level smokers (> 1 pack per day) had developed tissue necrosis three times more frequently compared to low-level smokers (<1 pack per day).35 In literature we could find no reports describing the differences between cigarette and cigar smokers, nor on passive smoke. Almost all smokers in the current study were cigarette smokers, there was one cigar smoker. In patients undergoing elective hip or knee replacement, a smoking intervention study (with smoking cessation or at least a 50% reduction in smoking) led, in a randomised controlled trial (n=120), to a reduction in the wound-related complications from 31% to 5% (p=0.001).10 This effect was found if the patients had been subject to a sixeight week program. In experimental rat studies, Kaufman and others found that exposure to tobacco smoke seven days prior to the flap procedure affected flap survival more î&#x201A;Š

Scientific Article

adversely than did smoking postoperatively. They, however, did not find cessation of smoking to greatly improve flap survival.36 Others found a critical time period of seven to 14 days of preoperative cessation of smoking before this increase in flap survival occurred.37 It seems therefore that pre-operative smoking is more important than post-operative smoking. However, all these reports relate to acute wound healing, and we are dealing with patients with chronic wounds. In our study many patients claimed they would stop smoking during the MDT, but we classified them as smokers, because the duration of MDT is shorter than the time needed before healing rates would be comparable to non-smokers. In this type of study, with relatively small sample sizes, one should always be careful interpreting the results. In this study we found no indications that smoking should be considered a contra-indication in MDT of chronic wounds. It is always possible that there is an effect, but one not shown by the statistics. Regarding our study, however, it is not very likely a negative effect of smoking in chronic wound therapy was missed as even a somewhat larger percentage of smokers had beneficial outcomes as compared to non-smokers. References 1. Mosley LH, Finseth F. Cigarette smoking: Impairment of digital blood flow and wound healing in the hand. Hand. 1977;9:97-101. 2. Peto R, Lopez AD, Borehain J. Mortality from tobacco in developed countries: indirect estimation from national statistics. Lancet. 1992;339:1268-1278. 3. Sorensen LT. Smoking and wound healing. EWMA Journal. 2003;3:13-15. 4. Golosow LM, Wagner JD, Feeley M et al. Risk factors for predicting surgical salvage of sternal wound-healing complications. Ann Plast Surg. 1999;43:30-35. 5. Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br. 2003;85:178-181. 6. Glassman SD, Anagnost SC, Parker A, Burke D, Johnson JR, Dimar JR. The effect of cigarette smoking and smoking cessation on spinal fusion. Spine. 2000;25:26082615. 7. Jones JK, Triplett RG. The relationship of cigarette smoking to impaired intraoral wound healing: a review of evidence and implications for patient care. J Oral Maxillofac Surg. 1992;50:237-239. 8. Nolan J, Jenkins RA, Kurihara K, Schultz RC. The acute effects of cigarette smoke exposure on experimental skin flaps. Plast Reconstr Surg. 1985;75:544-551. 9. Cunningham BL, Gear AJL, Kerrigan CL, Collins ED. Analysis of breast reduction complications derived from the Bravo study. Plast Reconstr Surg. 2005;115:15971604.

In this study on maggot debridement therapy on chronic wounds, we could not observe any statistically significant difference between smokers and non-smokers in outcome. Tissue hypoxia is the end-result of the detrimental effects of smoking, which occurs through different pathways.28 It has been shown in the acute wound that smoking has negative effects, and we hypothesize that this is due to tissue hypoxia in the smokers group. The patients in our study were a selection of many worst-case scenarios. We could postulate that all these wounds had tissue hypoxia at presentation, caused by different mechanisms, such as arterial insufficiency, diabetes mellitus or smoking. It could be that, because all wounds were in some sort of tissue hypoxia at the start of MDT, that is the reason why we didn’t observe any difference between the smokers and the non-smokers in outcome.

Conclusion Smoking has an adverse effect on acute wound healing, but in chronic wound care this effect has been less proven. In this study, smoking was not found to affect the results of maggot debridement therapy in chronic wounds, and smoking should, therefore, not be a contra-indication for maggot debridement therapy in these wounds. m 20. Courtenay M, Church JC, Ryan TJ. Larva therapy in wound management. J R Soc Med. 2000;93:72-74. 21. Mumcuoglu KY, Ingber A, Gilead L et al. Maggot therapy for the treatment of intractable wounds. Int J Dermatol. 1999;38:623-627. 22. Steenvoorde P, Budding TJ, Engeland Av, Oskam J. Maggot therapy and the ’YUK factor’; an issue for the patient? Wound Repair Regen. 2005;13:350-352. 23. Steenvoorde P, Jacobi CE, Doorn Lv, Oskam J. Maggot Debridement Therapy of infected ulcers: patient and wound factors influencing outcome. Ann Royal Coll Surg Eng accepted for publication. 2006. 24. Jorgensen LN, Kallehave F, Christensen E, Siana JE, Gottrup F. Less collagen production in smokers. Surgery. 1998;123:450-455. 25. Rickert WS, Forbes WF. Changes in collagen with age- II Modification of collagen structure by exposure to gaseous phase of tobacco smoke. Exp Geront. 1972;7:99. 26. Zia S, Ndoye A, Lee TX, Webber RJ, Grando SA. Receptor-mediated inhibition of keratinocyte migration by nicotine involves modulations of calcium influx and intracellular concentration. J Pharmacol Exp Ther. 2000;293:973-981. 27. Mosely LH, Finseth F, Goody M. Nicotine and its effect on wound healing. Plast Reconstr Surg. 1978;61:570-575. 28. Chang LD, Buncke G, Slezak S, Buncke HJ. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg. 1996;12:467-474. 29. Cobb TK, Gabrielsen TA, Campbell DC, Wallrichs SL, Ilstrup DM. Cigarette smoking and non-union after ankle arthrodesis. Foot Ankle Int. 1994;15:64-67.

10. Moller AM, Villebro N, Pedersen A, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359:114-117.

30. Sorensen LT, Hemmingsen UB, Kirkeby LT, Kallehave F, Jorgensen LN. Smoking is a risk factor for incisional hernia. Arch Surg. 2005;140:119-123.

11. Wolff.H., Hansson C. Larval therapy - an effective method for ulcer debridement. Clin Exp Dermat. 2003;28:137.

31. Lind J, Kramhoft M, Bodtker S. The influence of smoking on complications after primary amputations of the lower extremity. Clin Orthop Relat Res. 1991;211-217.

12. Shai A, Maibach HI. Wound Healing and Ulcers of the Skin. Diagnosis and Therapy - The practical approach. Heidelberg: Springer-Verlag; 2005:1-268.

32. Schmitz MA, Finnegan M, Natarajan R, Champine J. Effect of smoking on tibial shaft fracture healing. Clin Orthop Relat Res. 1999;184-200.

13. Hunt TK, Hopf H, Hussain Z. Physiology of wound healing. Adv Skin Wound Care. 2000;13:6-11.

33. Sorensen LT, Jorgensen T, Kirkeby LT, Skovdal J, Vennits B, Wille JP. Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg. 1999;86:927-931.

14. Steenvoorde P, Jacobi CE, Oskam J. Maggot Debridement Therapy: Free-range or contained? An In-vivo study. Adv Skin Wound Care. 2005;18:430-435. 15. Steenvoorde P, Oskam J. Use of larval therapy to combat infection after breast-conserving surgery. J Wound Care. 2005;14:212-213. 16. Steenvoorde P, Budding TJ, Oskam J. Pain levels in patients treated with maggot debridement therapy. J Wound Care . 2005;14:485-488. 17. Steenvoorde P, Oskam J. Bleeding complications in patients treated with Maggot Debridement Therapy (MDT). Letter to the editor. IJLEW. 2005;4:57-58. 18. Wollina U, Liebold K, Schmidt W-D, Hartmann M, Fassler D. Biosurgery supports granulation and debridement in chronic wounds - clinical data and remittance spectroscopy measurement. Int J Dermatol. 2002;41:635-639.

34. Sorensen LT, Horby J, Friis E, Pilsgaard B, Jorgensen T. Smoking as a risk factor for wound healing and infection in breast cancer surgery. Eur J Surg Oncol. 2002;28:815-820. 35. Goldminz D, Bennet RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol. 1991;127:1012. 36. Kaufman T, Eicheulaub EH, Levin M. Tobacco smoking: impairment of experimental flap survival. Ann Plast Surg. 1984;13:468. 37. Hardesty R.A., West SS, Schmidt S. Preoperative cessation of cigarette smoking and its relationship to flap survival. Presented at the 69th Annual Meeting, American Association of Plastic Surgeons, Hot Springs, VA, USA. 1990.

19. Church JCT, Courtenay M. Maggot debridement therapy for chronic wounds. Lower extremity Wounds. 2002;1:129-134.

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H087510701

Secure ﬁxation when you and your patients need it most

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1 Jørgensen, B.; Friis, G. J.; Gottrup, F. Pain and quality of life for patients with venous leg ulcers: Proof of concept of the efﬁcacy of Biatain - Ibu, a new pain reducing wound dressing. Wound repair and regeneration 2006, 14 (3), 333-339. 2 Steffansen, Bente and Herping, Soﬁe Paarup Kirkeby. Novel wound models for characterizing the effects of exudates levels on the controlled release of ibuprofen from foam dressings. Poster, EWMA 2006, Czech Republic. 3 Sibbald, R. G., Coutts, Patricia, and Fierheller, Marjorie. Improved Persistent Wound Pain With A Novel Sustained Release Ibuprofen Foam Dressing. Poster, Symposium for Advanced Wound Care, San Antonio, Texas, USA, 2006. 4 Flanagan, M.; Vogensen, H.; Haase, L. Case series investigating the experience of pain in patients with chronic venous leg ulcers treated with a foam dressing releasing ibuprofen. World Wide Wounds 2006, April. and Biatain are registered trademarks of Coloplast A/S. © 2006-09. All rights reserved Coloplast A/S, 3050 Humlebæk, Denmark.

Extended Abstract Âˇ PragUE 2006

Scientific Article

Effectiveness of non-alcohol film forming skin protector on the skins isles inside the ulcers and the healing rate of venous leg ulcers Randomized clinical study

Abstract: The tender islands of epithelium inside venous leg ulcers are exposed to copious moisture from ulcers and tape trauma from frequent adhesive dressing changes. Protecting them with non-alcohol film forming skin protector will entail a faster healing rate of venous leg ulcers.

INTRODUCTION Epithelialization is the migration of new cells and begins from wound edges and hair follicles1. The main reason for delayed healing is copious exudates at the chronic wound maceration and skin breakdown of peri-wound surface. At the same time the chronic exudates cause the breakdown of extracellularmatrix proteins and growth factors, inhibit cell proliferation and lead to poor angiogenesis. In addition the exudates cause the degradation of tissue matrix and non-migration of epithelial cells from wound margin2,3. However, the presence of islands of epithelium originating from hair follicles is an indicator of healing4. To protect the skin isles and aid healing, film forming skin protectors are applied to the skin. These leave a protective polymer behind on the skin when the carrier solvent evaporates off. The film forming skin protector has to be: 1. non-cyto-toxic: because it is used near wounds and must not interfere with wound healing; like alcohol free skin protectors; 2. moisture barrier effective, and 3. have the ability to protect vulnerable skin from frequent adhesive dressing changes that can cause tape trauma5, 6. The protector which has all those abilities is a nonalcohol film forming skin protector Cavilon* from 3 M â&#x20AC;&#x201C; a protective polymer (Acrylates Copolymer) dissolved into a fast drying carrier solvent (Hex methyl Disiloxane)3.

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Journal 2007 vol 7 no 1

AIM In a randomized clinical study we compared the speed of formation of skin isles inside the ulcers when using and not using non-alcohol film forming skin protector. METHODS Adult patients older than 18 years with venous leg ulcers C6s, Ep, As/Ad/Ap, Pr on CEAP classification7, ABPI > 0,8, with skin isles inside the ulcers, in bed stage B 1-2 by the V. Fallanga classification of wound bed8 were included in a precise randomized clinical study. Additional inclusion criteria were: no recidive ulcer, ulcer duration of less than 10 years, and the maximum size of ulcer 300 cm2. Acute wound contamination was an excluding criterion. Other exclusion criteria were severe disease like insulin dependent diabetes mellitus, rheumatoid arthritis, carcinoma, cardiac decompensation, uncontrollable hypertension and immobility. Patients were selected and placed into one of two groups by closed numbered envelopes. The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and received hospital permission. The ulcer area and skin isles were drawn onto film and then measured by using a digital planimeter*. This was carried out both before and at the end of the study. Each ulcer was measured three times and the investigator calculated the average value of the ulcer area and isles. The study was run for three months and all the patients were in hospital. At first assessment patients were placed into two groups, the ulcus was measured and photos taken. The same nurse and doctor-investigator carried out the dressing changes and compression. The control was assessed after 17 days when the study was closed.

Tanja Planinsek Rucigaj MD, dermatovenerologist Dermatovenerological clinic, Clinical centre, Ljubljana, Slovenia Correspondance to: Tanja Planinsek Rucigaj C. na Brod 20 b 1231 Ljubljana Slovenia Tel: 0038641511806 Fax: 0038615612295 rucigaj.janko@siol.net

î&#x201A;Š

Before study Patient no.1

Sprinkle with film-forming skin protector. Patient no.1

End of study Patient no.1

Table 1

Table 2

Twenty-seven venous leg ulcers were included in the study: group 1: 14 patients, duration of ulcers average 9.7 years; average 16.6 days of therapy and group 2: 13 patients, duration of ulcers average four years; average 18.7 days of therapy. In the first group we treated the ulcers with non-alcohol film forming skin protector over the whole area of the ulcers (including isles, wound bed and peri-wound skin) at every change of dressing and then we covered the ulcers with hydrocolloid dressings. The hydrocolloid dressings were changed every two to five days, depending on secretion from the ulcers. In Slovenia, hydrocolloid dressings are usually applied on wounds when granulation tissue starts to grow2. The selection of those dressings simulated the tape trauma of adhesive dressings. The compression therapy was performed with long-stretch bandages. In the second group we used the hydrocolloid dressings only along with the long-stretch bandages. There were no adverse events and all patients completed the study.

RESULTS Group 1: At the beginning â&#x20AC;&#x201C; the ulcers with skin isles, treated with non-alcohol film forming skin protector measured an average of 151.8 cm2, and an average of 128.2 cm2 at the end. The skin isles averaged 7.6 cm2 at the beginning, and 14.9 cm2 at the end of the study. Group 2: At the beginning â&#x20AC;&#x201C; the ulcers with skin isles, which were treated without non-alcohol film forming skin protector, were on average 186.7 cm2, and at the end of the study averaged 188.8 cm2. The skin isles measured an average of 14.5 cm2 at the beginning, and 12.5 cm2 at the end (Table 1, 2).

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DISCUSSION The whole ulcer area was reduced by an average of 15.55% of the ulcers treated with non-alcohol film forming skin protector and on average enlarged by 1.12% on those other ulcers where skin protectors were not used. The isles were on average approximately two times larger with the use of non-alcohol film forming skin protector therapy and reduced by nearly an average of 13.8% on the ulcers without skin protectors. It seems that non-alcohol film forming skin protector saves skin isles from the harm of different traumas inside venous leg ulcers. In our case faster growing isles were already seen after two days in those ulcers where we used non-alcohol film forming skin protector. CONCLUSIONS 1. In our cases the prevalence of skin isles treated with non-alcohol film forming skin protector increased significantly and the ulcers healed faster than skin isles and ulcers treated without non-alcohol film forming skin protector. 2. It seems that non-alcohol film forming skin protector is not cyto-toxic, is moisture barrier effective and has the ability to protect vulnerable skin from DMS 1205-6 Intern.PressMap.EWMAad

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frequent adhesive dressing changes which can cause tape trauma. However, larger studies including cellular level studies are needed to evaluate the effectiveness of this non-alcohol film forming skin protector. m

References 1. Shai A, Maibach HI. Wound Healing and Ulcers of the Skin. Springer-Verlag Berlin Heidelberg 2005.p.10-12. 2. Auböck J. Synthetic Dressings. In: Hafner J, Ramelet AA, Schmeller W, Brunner UV (eds). Current problems in dermatology.Management of Leg Ulcers. Basel: Kager. 1999; p.28-32. 3. Hampton S, Stephen-Haynes J. Skin Maceration: Assessment, Prevention and treatment. In: White R. Skin Care in Wound Management: Assessment, Prevention and treatment. Aberdeen: Wounds UK limited, 2005. p. 87-106. 4. Moffatt C, Morison MJ, Pina E.Wound bed preparation for venous leg ulcers. In EWMA Position document: Wound bed preparation in practice. London: MEP Ltd, 2004.p. 14-5. 5. Lutz JB, et al. Comparison of the barrier properties of four film forming skin protectants. Abstract/poster The Symp. On Adv. Wound Care. April 30-May 4,1995. 6. Wallace J.et al.Film forming skin protectant products: preventing skin breakdown. Abstract/poster The Symp. On Adv. Wound Care. April 28-30,1994. 7. Ramelet AA, Kern P, Perrin M. Varicose veins and teleangiectasias. Elsevier SAS 2004, p. 6-8. 8. Falanga V.Classification for Wound Bed Preparation and Stimulation of chronic Wounds. Wound repair and Regeneration; 8(5):347-52.

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Moorings Mediquip

Extended Abstract · PragUE 2006

Georgina T. Gethin RGN, HE Dip Wound Care (PhD student) HRB-Research Fellow Faculty of Nursing Royal College of Surgeons, Dublin, Ireland Prof. Seamus Cowman, PhD, MSc, FFNMRCSI, RGN, RNT, PGCEA, Dip N. Head of Department Faculty of Nursing Royal College of Surgeons Dublin, Ireland Corresponding Author: ggethin@eircom.net Tel: 00 353 86 8560053

Wound Measurement: the contribution to practice

Abstract The routine assessment of a wound is limited to what is visible to the naked eye and is both knowledge and skill based process dependent on objective and subjective interpretation. Wound measurement represents a simple, objective contribution to this process. However, clinicians should be aware of the reliability and validity of various methods used. Studies, which have compared methods, have reported a high degree of intra-rater reliability for each method but ruler based method over estimates size and should only be used as an estimate of wound size compared to acetate or planimetry. Acetate tracing and digital planimetry are well suited to routine clinical practice and no statistically significant differences in size are seen for wounds less than 10 cm2 when both methods are used. For wounds > 10 cm2 a statistically significant difference has been reported. Studies have concluded that acetate provides accurate measurement but planimetry is deemed more precise. Monitoring of wound size over a 4 week period and calculation of percentage change from baseline can aid in prediction of healing. In addition, it may indicate the need for further investigation, provide objective information, and can improve cost justification, communication and patient care.

Introduction The progress or deterioration in the condition of a wound represents a complex physiological process occurring at a molecular and cellular level with the end result only visible to the naked eye. It is reasonable to suggest that often wounds are visualized as a ‘one time event’ represented in an assessment of what is seen at a point in time rather than as changes over time. The fundamental question posed when assessing a wound is whether the wound is the same, better or worse than before?’ One method of answering this question

is by measuring the wound. This paper reviews various approaches to wound measurement and examines the benefits of each.

Advantages of measuring wounds Wound measurement serves a numbers of purposes: it provides an objective component of assessment and re-evaluation; lack of change in size or unusual patterns in wound size may indicate the need for further investigation; provides reassurance to both patient and clinician; aids cost justification; enhances communication; slow progress with standard treatment could aid selection of more advanced treatment modalities.1,2 While many methods are available to determine wound size they vary in terms of contact or non-contact methods; cost; availability; skill required and ease of use. For most clinicians the ruler technique and acetate methods are the most commonly used .3 In addition, digital planimetry is easy to use and relatively low in cost.4 Given the range of approaches to wound measurement a vital aspect in the determination of the suitability of an individual approach for use in practice is whether inter-rater reliability and validity has been established. Ruler method The ruler method requires measuring the greatest length of the wound by the greatest perpendicular width and is deemed to be the most reliable of ruler methods.5 However, this method requires subjective interpretation and lacks clarity as to the exact points to be measured.4 In addition, this method can overestimate the size of the wound by up to 44% compared to other methods.6,7,8 As Majeske argues one is applying the area of a rectangle that is length x breath to an irregular shape such as a wound.6 Indeed when this method is used the length and width of the wound may not change but new areas of epithelization may develop in the wound bed which cannot be accounted for. Therefore length x width should be EWMA

Journal 2007 vol 7 no 1

Scientific Article

regarded as an estimation of size rather than true reflection of size and thus the contribution of the ruler method for wound assessment and evaluation is questionable.9 Acetate method The acetate method involves tracing the circumference of the wound onto a two layered 1 cm2 preprinted acetate tracing (single layer may still be available in certain areas). The contact layer is discarded and the area of the wound is calculated by counting each square that is more than half within the border of the wound as 1 cm2.10 Acetates are still available in mm2 but less commonly used than the 1 cm2 and are more time consuming to count. The acetate method of wound measurement requires subjective interpretation, as each square within the border of the wound margin must be interpreted for inclusion or not. Acetates have the advantage of being easily stored within patient notes, can be dated and areas of epithelization or slough can be marked on the tracing. This method has high inter-rater reliability.6,11 However, when this method is used it is important to have the patient in the same position at each measurement as the main source of error is the ability of observers to define precisely the edge of the wound.12 Digital planimetry Digital planimetry for wound measurement requires placing the acetate tracing on a digital tablet, retracing the border using a stylus and the underlying sensor calculates area. This method is more objective and precise and has high inter-rater and intra-rater reliability but still depends on the accuracy of the initial wound tracing.4,6,11 Other methods include structured light technique, colour reflective analyzer, ultrasound and magnetic resonance imaging but are more suited to specialized centers and do not lend themselves to routine use within the clinical environment.12,13

Comparing methods of wound measurement A recent study compared the area of 50 superficial wounds using acetate tracing and square counting with digital planimetry (Visitrak, Smith & Nephew).4 25 wounds less than 10 cm2 and 25 wounds greater than 10 cm2 were measured. They reported for wounds less than 10 cm2 no statistically significant difference (p = 0.330) but for the larger wounds a statistically significant difference was demonstrated (p=0.008).4 The results of this study support the finding of Oien et al (2000) where the differences in methods increased with the increased size of the wound.11 The authors attempted to determine if any difference existed in % change in wound size after 4 weeks using both methods but insufficient tracings were available for mean-

ingful statistical analysis, however for the 13 tracings that were available the results were very similar.4 A comparison of 4 methods of wound measurement including diameter, square counting, digital and mechanical planimetry of 50 wounds of 20 patients reported a high degree of agreement with each other at least for wounds with an area up to 10 cm2.11 This supports the findings of Majeske.6 In addition it should be noted that different measurement methods cannot be used interchangeably, as studies report different wound size with each method.4,6,11 Measuring cavity wounds is difficult as even some advanced measurement techniques such as structured light are inaccurate as these technologically advanced techniques cannot precisely account for the 3D aspect of the wound and thus are unsuitable for undermined or very deep and very large wounds.12,14 Melhuish suggested that the circumference of a wound can be used to monitor progress of healing in cavity wounds.15 A study by Melhuish et al (1994) of 14 surgical wounds over 10 weeks or until healing demonstrated a direct correlation between area and wound circumference (0.90, p <0.001) and volume and circumference (0.70, p < 0.001).15 The authors conclude that circumference could be used to follow the progress towards healing when measurement devices cannot probe the depths of the cavity.15 Clinical application The clinical impact of measuring wounds over time is demonstrated in studies which used change in wound area as a prognostic indicator to healing.2,16,17 Sheehan et al (2003) monitored percentage change in Wagner grade 1 and 2 diabetic foot ulcers of 203 patients over 12 weeks as part of a randomised controlled trial. This study reported that the mean percentage reduction in wound area was 82% in those DFU that healed by week 12, versus 25% of those that did not heal.17 The results were statistically significant (p<0.02) and were independent of the wound treatment the patient received and concluded that % change at 4 weeks was a robust predictor of healing. 17 A further study of 104 venous leg ulcer patients receiving optimum care and in whom wound area was measured over a 4 week period as a prognostic indicator to healing at 24 weeks was conducted.16 The percentage change in area at week 2, 3, 4 and between weeks 1 and 2, and weeks 3 and 4 all distinguished between wounds that healed at 24 weeks and those that did not.16 This was in contrast to the rate of healing (area healed per week) which did not differentiate between the healed and non-healed groups.16 The ‘instability’ in wound healing over time has been reported and chronic wounds have been described as becom

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Scientifi c Article

ing ‘inert’ or ‘static’ at any stage along the healing process.2,18 However, in reviewing studies of wound healing and wound measuring ‘rate of healing’ appears less reliable than ‘percentage change in area’ over a defi ned period of time as a useful predictor to healing.16 However, a ‘mean adjusted healing rate’ formulae by Tallman et al (1997) reported that for venous ulcers early negative healing rates indicate a poor prognosis for healing and that this method accurately predicts healing as early as the third week of treatment.2 A review by Flanagan (2003) further supports the use of percentage reduction in wound size as a means of effective wound monitoring.19 It concluded that a percentage reduction at 2-4 weeks of between 20-40% is a good predictor of healing.19 Indeed Margolis et al (2000) uses wound size as one of two parameters to predict healing of venous ulcers when fi rst line management such as compression therapy is used, wound duration is the second parameter.20 In their study patients received one point for wounds larger than 5 cm2 and one point for duration longer than 6 months.20 93% of those with a score of 0 healed at 24 weeks compared with 13-37% of those with a score of 2.20 The authors state as an advantage of this scoring system that patients can be selected for more advanced treatment modalities and further investigation at an early stage of management. In this regard ruler measurements are unsuited to wound monitoring, as they consistently overestimate size. 6,7,11 The time frame of 4 weeks from the commencement of a treatment regime is useful for clinicians during which effi cacy of treatment can be monitored objectively. Wound measuring can further aid planning of appropriate treatment strategies and avoid shifts in treatment regimes.2 Such regular reassessments using wound measuring are currently the only way to determine treatment effi cacy, quantify and document progress and guide further treatment decisions and aid early identifi cation of factors delaying healing.5,9,19 In addition validated predictors of healing could serve as surrogate end points in the evaluation of new treatment and allow more effi cient design of clinical trials.17

CONCLUSION Wound measurement is essential in ensuring best practice approaches to wound management. There are multiple approaches to measuring wounds and some are more reliable and valid than others such as acetate and planimetry. Healthcare practitioners must at all times adopt the most appropriate and validated methods of measurement in the management of patients/clients wounds. It is the case that many elements of wound management require subjective interpretation based on varying levels of

knowledge and skill. The use of accurate yet simple wound measurement such as acetate and planimetry supports the use of objective information which can aid wound monitoring. The pace of change in wound management is placing an emphasis on the development of more objective tools by which to assess and evaluate wound healing, measuring can contribute to this. Whereas it is diffi cult to make strong pronouncements on individual approaches it is clear that the inter-rater reliability of many methods such as acetate and planimetry is high, and other methods need to be used with caution for example ruler based methods have been shown to overestimate size and should only be regarded as an estimate. Monitoring of wound size over a 4 week period and calculation of percentage change in area can assist in prediction of healing and provides objective, factual information on which to base treatment decisions. m

References 1. Vowden, K. Common problems in wound care: wound and ulcer measurement. British Journal of Nursing, (1995) 4(13), 775-779. 2. Tallman, P., Muscare, E., Carson, P., Eaglstein, H. and Falanga, V. Initial rate of healing predicts complete healing of venous ulcers. Arch Dermatology, (1997) 133, 1231-1234. 3. Charles, H. wound assessment: measuring the area of a leg ulcer. British Journal of Nursing, (1998), 7(13), 765-772. 4. Gethin, G. and Cowman, S. Wound measurement comparing the use of acetate tracings and VisitrakTM digital planimetry. Journal of clinical Nursing, (2006), 15, 422-427. 5. Keast, D., Bowering, C., Evans, A, Mackean, G., Burrows, C. and D’Souza, L. MEASURE a proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair and Regeneration, (2004) 12(3), S1-S17. 6. Majeske, C. Reliability of wound surface area measurements. Physical Therapy, (1992) 72(2), 138-141. 7. Brown, D. Comparing different ulcer measurement techniques: a pilot study. Primary Intention, (2003), 11(3), 125-134. 8. Schultz, G., Mozingo, D., Romanelli, M. and Claxton, K. Wound healing and TIME: new concepts and scientific applications. Wound Repair and Regeneration, (2005) 13(4), S1-S11. 9. Gethin, G. The importance of continuous wound measuring. Wounds UK, (2006), 2(2), 60-68. 10. Harding, K. Methods for assessing change in ulcer status. Advanced wound care, (1995), 8, 28-42. 11. Oien, R., Hakansson, A., Hansen, B. and Bjellerup, M. Measuring the size of ulcers by planimetry: a useful method in the clinical setting. Journal of Wound Care, (2002) 11(5), 165-168. 12. Plassmann, P. Measuring wounds. Journal of Wound Care, (1995) 4(6), 269-272. 13. Romanelli, M. Technological advances in wound bed measurements. Wounds (2002), 14(2): 58-66. 14. Mani, R. and Ross, J. Morphometry and other measurements In: Mani, R., Falanga, V., Sherman, CP., Sandeman, D. eds. Chronic Wound Healing, WB Saunders, London, (1999) 81-98. 15. Melhuish, J., Plassman, P. and Harding, K. Circumference, area and volume of the healing wound. Journal of Wound Care, (1994) 3(8), 380-384. 16. Kantor, J. and Margolis, D. A multicentre study of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks. British Journal of Dermatology, (2000), 142(5), 960-964. 17. Sheehan, P., Jones, P., Caselli, A., Giurini, J., Veves, A. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes care, (2003) 26(6), 1879-1882. 18. Enoch, S. and Price, P. Should alternative endpoints be considered to evaluate outcomes in chronic recalcitrant wounds? World Wide Wounds, www.worldwidewounds.com (2004) October. 19. Flanagan, M. wound measurement: can it help us to monitor progression to healing? Journal of Wound Care, (2003), 12(5), 189-194. 20. Margolis D., Berlin, J. and Strom, B. Which venous leg ulcers will heal with limb compression bandages? American Journal of Medicine, (2000) 109(1), 15-19.

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H086040701

Improved

Neither patients nor nurses need to suffer from poor fluid handling. Mepilex® Border with improved fluid handling is even better than before as it reduces the risk of leakage and maceration. Thanks to its unique and patented Safetac® soft silicone adhesive technology, Mepilex Border minimises trauma to the wound, the surrounding skin and pain to the patient. Try new Mepilex Border with Safetac technology – an improvement almost as important as the double straw. Mölnlycke Health Care AB (publ), Box 13080, SE-402 52 Göteborg, Sweden, Phone + 46 31 722 30 00, www.molnlycke.com, www.safetac.com The symbol and the word mark are both registered trademarks or trademark pendings of Mölnlycke Health Care

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Extended Abstract Âˇ PragUE 2006

Scientific Article

Improving education in wound care: crossing the boundaries of interprofessional learning

Introduction Despite a plethora of evidence and clinical guidelines the management of complex chronic wounds is a challenging area of clinical practice for all practitioners involved in tissue viability. Nurses and podiatrists are frequently involved in the assessment and management of complex wounds on the lower extremities. Despite evidence demonstrating the benefits of inter-professional team working, the reality remains there is often little collaboration between nurses and podiatrists in the care of patients with chronic wounds on the lower extremity. This partly stems from a lack of awareness of each others roles and inconsistent educational strategies at pre-registration and postregistration levels. The University of Huddersfield, United Kingdom, has begun to address this issue by developing an inter-professional strand to undergraduate/ pre-registration wound care education. Aim To develop an IT-based learning resource to convey evidence-based concepts and best practice in wound care to undergraduate/ pre-registration nursing and podiatry students. Methods A CD-Rom has been developed utilising a problem based learning format bringing â&#x20AC;&#x153;theory to lifeâ&#x20AC;? with the use of real life case scenarios centred on the assessment and management of common wound types; diabetic foot ulcers, pressure ulcers, leg ulcers and infected wounds. This format allows students to select care options in a virtual environment and receive generated feedback based

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on current best evidence and research. Users will be encouraged to interpret findings from clinical investigations, test their knowledge at the start of the quiz and again at the end of the CD, additionally students will be encouraged to consider the role of different professions in the virtual case. Qualitative statements from experienced nurses and podiatrists are included that highlight perceived perceptions on the benefits and barriers to interprofessional collaboration in wound care.

Purpose The CD-Rom will provide an innovative approach to wound care education that will bridge the theory to practice gap, highlight the importance of interdisciplinary working and raise awareness of each others roles. Conclusion This initiative aims to introduce an IT resource to undergraduate nursing and podiatry students to encourage students to embrace evidence based concepts, appreciate the importance on an interprofessional approach and better prepare students for independent practice. The CD-Rom will be formally evaluated after 12 months to assess whether the anticipated learning outcomes have been achieved by students of both disciplines. m

Caroline McIntosh MSc BSc (Hons) MChS Senior Lecturer in Podiatry Centre for Health & Social Care Research, University of Huddersfield, Queensgate, Huddersfield, West Yorkshire, HD1 3DH, UK Tel: 01484 473224, Fax 01484 472380 c.mcintosh@hud.ac.uk Karen Ousey RGN, ONC, DPPN, PGDE, BA, MA, Principal Lecturer, Department of Nursing, Centre for Health & Social Care Research, University of Huddersfield, Queensgate, Huddersfield, West Yorkshire, UK

Funding: This project was funded, following a successful bid for School of Human and Health Sciences, University of Huddersfield innovation funding. Declaration of interest: None

Scientific Article

ABSTRACT STUTTGART · GERMANY · 2005

1Mayer

Tenenhaus, M.D.,

2Oliver

Rennekampff, M.D., Bhavsar, M.D., 3Bruce Potenza, M.D.

1Dhaval

1Division

of Plastic Surgery, UCSD, San Diego, CA

2Division

of Plastic Surgery, Tübingen University, Tübingen, Germany

3Division of Trauma and Burn Surgery, UCSD Medical Center, San Diego, CA

rennekampff@ bgu-tuebingen.de Please note: Dr. Rennekampff and Dr. Tenenhaus contributed equally to this work.

Waterjet debridement of deep and indeterminate depth thermal injuries

ABSTRACT Deeper and indeterminate depth thermal injuries often prove to be particularly challenging and difficult to manage. Protracted management strategies can lead to prolongation of the inflammatory phase of wound healing and result in compromised aesthetic and functional results. Conversely, overaggressive attempts at excisional debridement might condemn the site to skin graft closure or flap reconstruction with its resultant stigmata. Recently, a waterjet debriding tool has been advocated for surgical wound debridement and wound bed preparation and has shown particular promise in the field. The benefits of this therapeutic modality include controlled depth precision, rapid debridement, evacuation of debris as well as the elimination of an additional sharp cutting edge from the surgical field. In this abstract we describe our clinical experience with the use of the Versajet SystemTM, a fluid jet technology in the treatment of deep and indeterminate depth burns. A high pressure jet stream of saline is oriented parallel to the working plane and tangential to the tissue. In traversing the working aperture, this stream creates--by Venturi effect--a vacuum which evacuates debris. A vertical orientation to the working head promotes cutting while a more tangential or oblique application facilitates debridement. Increasing the power setting both increases its cutting and debriding abilities and augments the evacuation of debris. The Versajet SystemTM employs disposable hand-pieces in varied angulations and debriding apertures facilitating the treatment of areas like the fingers and nose, which are often difficult to contour or reach with traditional excisional modalities.

to precisely debride these wounds for immediate closure with either skin grafts or biosynthetic dressings. All grafted wounds demonstrated successful take and all sites treated in biosynthetic dressings epithelialized within 5 to 16 days post application. Pseudoeschar, the proteinacious exudative collection that develops on thermal injury surfaces treated with topical antimicrobials, has been shown to inhibit epithelialization as well as skin graft or biosynthetic biointegration. The waterjet rapidly removes this layer affording accurate assessment of the depth of injury. Deeper thermal injuries are successfully debrided of nonvital tissue and debris. Limitations to the present form of this technology include the difficulty of addressing full thickness eschars, particularly when overlying superficially located fatty collections as seen in the malar regions of the face. This is a cutting and debriding tool and judicious application and care in use as with all surgical instruments must be employed. Ex-vivo experiments on discarded abdominoplasty skin demonstrate that the adjustable power settings of the Versajet SystemTM allow for precise and controlled debridement of the surgical planes of skin while preserving adnexa, critical for epithelialization. Concomitant application of biosynthetics like Transcyte and Biobrane complement this approach. As opposed to conventional excisional surgical knives like the Goulian, Braithwaite, and scalpel, the absence of additional sharp cutting edges on the surgical field yields an additional extra measure of protection to both patient and staff. m

To date, at our institutions, twenty patients with burns to the face, neck, extremities, and torso have undergone debridement using the water jet powered surgical tool. The Versajet SystemTM was able

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97 different instruments. 1 cutting-edge technology. VERSAJET significantly expands your surgical debridement and excision options. The VERSAJET Hydrosurgery System enables surgeons to simultaneously grasp, cut and remove damaged tissue and contaminants precisely-without the collateral tissue trauma associated with current surgical modalities. EU Authorised Representative: Wound Management, Smith & Nephew Medical Ltd, 101 Hessle Road, Hull HU3 2BN T 44 (0) 1482 225181 F 44 (0) 1482 673106

Debridement of traumatic wounds, chronic wounds, burns and other soft tissue lesions is achieved in a single step, with a single instrument, and single-handedly. Call us today for a demonstration. Manufactured for: Smith & Nephew, Inc. 11775 Starkey Road, Largo, FL 33773 USA T (1) 800 876 1261

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EBWM

ABSTRACTS OF RECENT COCHRANE REVIEWS Wound drains after incisional hernia repair Gurusamy KS, Samraj K The Cochrane Database of Systematic Reviews Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.2007 Issue1.

Sally Bell-Syer, MSc Review Group Co-ordinator Cochrane Wounds Group Department of Health Sciences Area 4 Seebohm Rowntree Building University of York York, United Kingdom sembs1@york.ac.uk

ABSTRACT Background: Incisional hernias are caused by the failure of the wall of the abdomen to close after abdominal surgery, leaving a hole through which the viscera protrude. Incisional hernias are repaired by further surgery. Surgical drains are frequently inserted during hernia repair with the aim of facilitating fluid drainage and preventing complications. Traditional teaching has recommended the use of drains after incisional hernia repair other than for laparoscopic ventral hernia repair. More than 50% of open mesh repairs of ventral hernias have drains inserted. However, there is uncertainty as to whether drains are associated with benefits or harms to the patient. Objectives: To determine the effects on wound infection and other outcomes, of inserting a wound drain during surgery to repair incisional hernias, and, if possible, to determine the comparative effects of different types of wound drain after incisional hernia repair. Search strategy: We searched the Cochrane Wounds Group Specialised Register (last searched March 2006), the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 1, 2006), EMBASE (1974 to March 2006), PubMed (1951 to March 2006), and Science Citation Index Expanded (1974 to March 2006). We also searched the meta-register of controlled trials. Selection criteria: We considered all randomised trials performed in adult patients who underwent incisional hernia repair and that compared using a drain with no drain. We also considered trials that compared different types of drain. Data collection and analysis: We extracted data on the characteristics of the trial, methodological quality of the trials, outcomes (e.g. infection and other wound complications) from each trial. For each outcome we calculated the risk ratio (RR) with 95% confidence intervals (CI) and based on intention-to-treat analysis. Main results: Only one trial was eligible for inclusion in the review with a total of 24 patients randomised to an electrified drain (12 patients) compared with a corrugated drain (12 patients). There were no statistically significant differences between the groups for any of the outcomes (a variety of measures of infection).

Authors’ conclusions: There is insufficient evidence to determine whether wound drains after incisional hernia repair are associated with better or worse outcomes than no drains. ________ Plain language summary: No recommendations can be made about whether drains should be used after incisional hernia repair because of a lack of trial evidence. Incisional hernias are caused by the failure of the wall of the abdomen to close after abdominal surgery. This leaves a hole through which the viscera (guts) protrude. Hernias are repaired with further surgery, during which the insertion of a drain to remove excess fluid is common practice. It is not known whether or not these drains help the wounds to heal. Drains may produce undesired results such as an increased risk of infection, pain, and an increased length of hospital stay after surgery. We reviewed all the available trial evidence to see whether drains help or hinder recovery after operations for incisional hernia repair. We found that no trials that compared people who had drains inserted for this type of surgery against those who didn’t. One trial compared two types of drain against each other, and both models of drain performed similarly well. Further trials need to be carried out before being able to answer the question about the benefits, or otherwise, of drains inserted during repair of incisional hernias.

Topical silver for treating infected wounds Vermeulen H, van Hattem JM, Storm-Versloot MN, Ubbink DT The Cochrane Database of Systematic Reviews Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2007 Issue1 ABSTRACT Background: Topical silver treatments and silver dressings are increasingly used for the local treatment of contaminated or infected wounds, however, there is a lack of clarity regarding the evidence for their effectiveness. Objectives: To evaluate the effects on wound healing of topical silver and silver dressings in the treatment of contaminated and infected acute or chronic wounds. Search strategy: We sought relevant trials from the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Wounds Group Specialised Register in March 2006 and in MEDLINE, EMBASE, CINAHL, and digital dissertations databases up to Sep-

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EWMA

tember 2006. In addition, we contacted companies, manufacturers and distributors for information to identify relevant trials. Selection criteria: Randomised controlled trials (RCTs) assessing the effectiveness of topical silver in the treatment of contaminated and infected acute or chronic wounds. Data collection and analysis: Eligibility of trials, assessment of trial quality and data extraction were undertaken by two authors independently. Disagreements were referred to a third author. Main results: Three RCTs were identified, comprising a total of 847 participants. One trial compared silver-containing foam (Contreet®) with hydrocellular foam (Allevyn®) in patients with leg ulcers. The second trial compared a silver-containing alginate (Silvercel®) with an alginate alone (Algosteril®). The third trial compared a silver-containing foam dressing (Contreet®) with best local practice in patients with chronic wounds. The data from these trials show that silver-containing foam dressings did not significantly increase complete ulcer healing as compared with standard foam dressings or best local practice after up to four weeks of follow-up, although a greater reduction of ulcer size was observed with the silver-containing foam. The use of antibiotics was assessed in two trials, but no significant differences were found. Data on pain, patient satisfaction, length of hospital stay, and costs were limited and showed no differences. Leakage occurred significantly less frequently in patients with leg ulcers and chronic wounds treated with a silver dressing than with a standard foam dressing or best local practice in one trial. Authors’ conclusions: Only three trials with a short followup duration were found. There is insufficient evidence to recommend the use of silver-containing dressings or topical agents for treatment of infected or contaminated chronic wounds. ________ Plain language summary: Using dressings and topical agents which contain silver for treating infected wounds.

Brian Gilchrist: Thank you Many of you will know Brian Gilchrist who has been Secretary of EWMA since its inception in 1991. Originally a native of New Zealand, Brian has worked for many years in the Nightingale School of Nursing at Kings College in London where he has just resigned as Head of Pre-Registration Education. Brian has left the UK (and Europe) to return to his native New Zealand where he has recently taken up an appointment as Director of Nursing Education at the Universal College of Learning in Palmerston North. Because of this move he is no longer able to act as the EWMA Secretary. However, all is not lost as there is a flourishing wound care society in New Zealand which Brian has already been invited to join. Although not part of Europe, the New Zealand Wound Care Society is one of our unofficial Co-operating Organisations and as members receive copies of the EWMA Journal, I am sure we will not lose touch. Brian has been a stalwart of the EWMA Council, and as Secretary has dealt with membership issues, organized the agendas for all Council meetings and Annual General Meetings. Much of his time working for EWMA has been taken up liaising with the UK Charity Commission on points of procedure when the EWMA Constitution has had to be amended. As president of EWMA I would like to thank Brian for all his hard work over the last 16 years. I hope that his new appointment will offer him plenty of new challenges that I am sure he will relish. Peter J Franks, EWMA President

People with chronic wounds such as foot ulcers and leg ulcers and acute wounds such as surgical wounds often find their wound becomes infected. Healing the wound can be delayed by the amount of bacteria on the wound surface. Wound care involves frequent dressing changes. Silver is an antimicrobial and dressings which contain silver have been developed. The authors of this Cochrane review wanted to find evidence on whether silver based dressings reduced infection and encouraged wound healing. Three studies looking at people with chronic wounds were included in the review and found that silver-containing foam dressings did not result in faster wound healing after up to four weeks of follow-up. One study did find that the overall size of the ulcer reduced more quickly when dressed with a silver-containing foam. There is no enough evidence to recommend the use of silver-containing dressings or topical agents for treating infected or contaminated chronic wounds.

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Are you interested in submitting an article or paper for EWMA Journal? Read our author guidelines at www.ewma.org/english/authorguide

EWMA

EWMA Education Development Project: what is it and what does it do?

EWMA Educational Panel

Zena Moore RGN, MSc, FFNMRCSI Lecturer, Faculty of Nursing & Midwifery, RCSI, Dublin 2, Ireland zmoore@rcsi.ie

Background In order to meet EWMA’s education goal, the educational development project was established in October 2000. The broad aims of this project are to increase the knowledge and skills of health care professionals’ involved in the management of individuals with wounds of varying aetiologies, thereby enabling them to provide optimum wound care. In order to achieve this goal, the project aims to provide quality standards against which other organisations can evaluate existing wound management programmes. For those groups who do not have existing education, the project aims to provide contemporary interdisciplinary wound management education that is endorsed by organisations affiliated to EWMA. The project group have worked hard at achieving their aims. Thus far, two very successful aspects of the work of the project group have been: • The development of curricula exploring a variety of wound aetiologies • The establishment of an endorsement process for existing education programmes

Wound Management Modules A modular curricula framework has been designed that incorporates various aspects of wound management, for example Diabetic Foot Ulcers, Management of Oncology Wounds and Principles of Wound Care. Modules on Wound Assessment and Infection are due for completion in early 2007. A full list of modules is available on the EWMA web site. All of the modules are available for members of EWMA through the EWMA office. Endorsement Process The project group acknowledged that there are a large number of existing programmes of education on different aspects of wound management currently available. Many of the groups or organisations who have developed those programmes expressed an interest in having EWMA endorsement of their programmes. To this end, the project group developed an endorsement process in order to work collaboratively with colleges

and universities and other groups or institutions. EWMA approval for existing wound education programmes provides a large number of advantages, for example, having the course added to the EWMA approved course list makes the institution more visible and thereby improves the marketing of courses to potential students. Furthermore, through the endorsement of the speciality wound healing content of courses, educational excellence is demonstrated. The interest in this endorsement process has been enormous, and to date, there are 50 courses approved by EWMA. Further information about the endorsement process is available from the EWMA web site (www.ewma.org).

New developments The members of the project group have been aware for some time that health professionals are seeking alternative approaches to professional development and have created a unique model that combines attendance at the annual EWMA Conference with academic study at a university of their own choice. This model is called the University Conference Model (UCM) and is headed up by Madeline Flanagan, past chair of the Education Development Project. The module is due to be piloted at the EWMA meeting in Glasgow in May 2007. Further information is available from Madeleine Flanagan at m.flanagan@herts.ac.uk. Other work underway is a “Teach the Teachers” education programme, aimed at standardising the training of those who teach wound care across Europe. The project group will continue with the development of further modules on other aspects of wound care and the development of an endorsement process for other teaching resources. The education group are committed to achieving their project aims and we are grateful to all those who have worked with us to date. We look forward to further collaboration from those interested in the work of the group so that together we may assist in the development of high quality, easily accessible, wound management education across Europe. m

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COPA™

Ultra-soft foam wound dressing

• Super absorbency • Ultra Softness and superior feel • Maximum protection Fluid capacity (cc/cm2) 1.5 1.25

1.24

0.74

0.75

0.43

0.5 0.25 0

COPA

Allevyn®

Polymem®

COPA’s fluid capacity outperforms the leading competition

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Allevyn is a trademark of Smith & Nephew. Polymem is a trademark of Fleming Medical Limited. ™ Trademark of Tyco Healthcare Group LP or its affiliate © 2006 Tyco Healthcare Group LP. All rights reserved.

P-WC-A-Copa/GB

Evidence, Consensus and Driving the Agenda forward

EWMA 2007

EWMA2007 · GLASGOW 2-4 MAY · 2007 WWW.EWMA.ORG/EWMA2007

17th Conference of the European Wound Management Association 2-4 May 2007

GLASGOW United Kingdom

EWMA was founded in 1991 at a conference in Cardiff with the aim of addressing clinical and scientific issues associated with wound healing and representeding medical, nursing, scientific and pharmaceutical interests. One of the objectives of this meeting was to draw on expertise from professionals throughout Europe and a council was formed with members from the UK and mainland Europe, so that EWMA would be able to have direct links with the wound healing societies in these countries. Initially, EWMA had its annual conference in the UK, but in 1994, EWMA had its first conference outside the UK in Copenhagen, Denmark. From 1994-1998 EWMA maintained its position in the UK with an annual conference in Harrogate, UK, but also had conferences in different European countries.

From 1999, EWMA decided to have only one main conference every year and as the need for EWMA to become truly pan-European was evident, the conferences have since then been held in a variety of countries across Europe. Over the years, since the last time EWMA was in the UK in 1999, it has been a standing wish from many council members to “return” to UK and now is the time. With the EWMA 2007 Conference being held in Glasgow, EWMA is very pleased to be “back” in the UK, where “it all started”. The conference is organised in cooperation with the Leg Ulcer Forum (LUF), the National Association of Tissue Viability Nurses (NATVNS), the Tissue Viability Nurse Association (TVNA) and the Tissue Viability Society (TVS).

EWMA Conference History Year City Next conferences 2007 Glasgow 2008 Lisbon 2009 Helsinki

Country

Theme

United Kingdom Portugal Finland

Evidence, Consensus and Driving the Agenda forward

Previous conferences 2006 Prague 2005 Stuttgart

Czech Republic Germany

2003 2002 2001 2000 1999 1998 1998 1997 1997 1996

Pisa Grenada Dublin Stockholm Harrogate Madrid Harrogate Milano Harrogate Amsterdam

Italy Spain Ireland Sweden United Kingdom Spain United Kingdom Italy United Kingdom Holland

1995 1994 1993 1992 1991

Harrogate Copenhagen Harrogate Harrogate Cardiff

United Kingdom Denmark United Kingdom United Kingdom United Kingdom

Innovation, Education, Implementation From the Laboratory to the Patient: Future Organisation and Care of Problem Wounds Team-work in Wound Care – The Art of Healing Chronic Wounds and Quality of Life Back to the Future Advances in Wound Management Taking Wound Care into the 21st Century Acute and Chronic Wounds: Is there a Difference? Patient Centred Wound Care New Approaches to the Advancement of Chronic Wounds Improving Clinical Outcomes through Education Wound Healing Therapy: a critique of current practice and opportunities for improvement Advances in Wound Management Advances in Wound Management Advances in Wound Management Advances in Wound Management Advances in Wound Management

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EWMA

The Scottish Exhibition and Conference Centre (SECC) is designed by Norman Foster, who named it the Armadillo.

The theme of the conference is:

Evidence, Consensus and Driving the Agenda forward

How did the Thistle become a National Emblem? The prickly purple thistle was adopted as the Emblem of Scotland during the reign of Alexander III (1249 -1286). Legend has it that an Army of King Haakon of Norway, intent on conquering the Scots landed at the Coast of Largs at night to surprise the sleeping Scottish Clansmen. In order to move more stealthily under the cover of darkness the Norsemen removed their footwear. As they drew near to the Scots it wasn’t the only thing hiding under the cover of darkness. One of Haakon’s men unfortunately stood on one of these spiny little defenders and shrieked out in pain, alerting the Clansmen of the advancing Norsemen. Needless to say the Scots won the day. From that day, the thistle has been adopted as Scotland’s National Emblem. Nowadays, the Thistle is widely used to signify the “Scottishness” of countless products, services, organisations, etc., and can be seen everywhere. www.scotshistoryonline.co.uk/thistle/thistle.html

The venue for the conference is the Scottish Exhibition and Conference Centre (SECC), which is located on the banks of the River Clyde in Glasgow, There are many good reasons for choosing Glasgow and the SECC. Glasgow has been transformed in recent years and has become one of Europe’s most cosmo politan, culturally dynamic and exciting conference destinations. As Glasgow is a city in the midst of a cultural and economic renaissance, participants at EWMA 2007 will not only benefit from an interesting scientific programme, but also from the beautiful city of Glasgow. The conference venue, the SECC, is Britain’s largest integrated exhibition and conference centre, which can host specialist events for up to 25,000 people. It opened in 1997 and is designed by Norman Foster, who named it the Armadillo – very appropriate looking at its shape. Throughout the complex, the style is light and airy, the mood professional and the atmosphere dynamic. The 64 acre site is a ten minute walk from Glasgow city and only 11 miles from the city’s international airport. The SECC even has its own railway station, bus terminus and heliport. The EWMA 2007 Conference Evening will be at the Glasgow Science Centre. It is located directly opposite the SECC and with its three landmark titanium-clad buildings and several exciting attractions, it offers a  variety of exhilarating and unusual experiences. For more information, please go to: www.ewma.org/ewma2007 · www.secc.co.uk www.glasgowsciencecentre.org · www.seeglasgow.com

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Evidence, Consensus and Driving the Agenda forward EWMA2007 · GLASGOW 2-4 MAY · 2007

EWMA 2007 Abstract Submission

WWW.EWMA.ORG/EWMA2007

Submit an Abstract 1. To submit an abstract for EWMA 2007 please go to www.ewma.org/ewma2007. Detailed information on how to submit the abstract will be provided online. 2. If you wish to submit an abstract and have no access to the internet, please contact the Conference Secretariat:

EWMA Business Office Congress Consultants Martensens Allé 8 DK-1828 Frederiksberg C Denmark ewma2007@ewma.org Tel: +45 70 20 03 05 Fax: +45 70 20 03 15

For further information, please visit the website: www.ewma.org/ewma2007 Practical information 1. Abstracts are required for all oral presentations and posters 2. Abstracts must be submitted in English 3. Abstracts must be submitted before 24.00 GMT 15 February 2007 4. The title should be as brief as possible but long enough to clearly indicate the nature of the study. Write the abstract title in CAPITAL LETTERS. No full stop at the end. 5. A “blind” selection process will be used. No identifying features such as names of authors and hospitals, medical schools, clinics or cities may be listed in the title or abstract text. You will be asked to enter the names of authors and their institutions, when you submit your abstract online.

WWW.EWMA.ORG/EWMA2007 40

Contents of your Abstract 1. Abstracts should briefly and clearly state the purpose, method, results, and conclusion of the work: Aim: Clearly state the purpose of the abstract Methods: Describe your selection of observations or experimental subjects clearly. Results: Present your results in a logical sequence in text, table and illustrations. Discussion: Emphasize new and important aspects of the study and conclusions that are drawn from them. 2. All abbreviations must be defined in first use. 3. Use generic drug names. 4. Statements such as “results will be discussed” or “data will be presented” cannot be accepted. 5. Papers will not be accepted if previously presented at a EWMA meeting unless there is a substantial increase in data. Reviewing 1. The scientific committee will review the abstract. 2. Notification can be expected two months prior to the conference. 3. It is the responsibility of all investigators that all studies are performed with respect to both national and international legislations and ethical guidelines both with regards to humans and animals. The EWMA 2007 Scientific Committee reserves the right to reject any submitted abstract, which is believed to violate these principles. Conditions 1. The presenting author must register as an active participant at the Conference. EWMA 2007 reserves the right to not publish any abstracts that are not followed by a participant registration a minimum of one month prior to the conference. 2. Abstracts will be published on the web site and in the final programme for the conference. By submitting an abstract you consent to giving EWMA 2007 permission to publish your abstract. 3. If you wish to withdraw an abstract, please contact the Conference Secretariat in writing, and await confirmation of your withdrawal.

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EWMA Membership

EWMA 2007 Awards Poster Prizes These awards are designed to reward the considerable work that goes into preparing a poster for presentation at the conference. To be eligible for consideration you must have a paper accepted for poster presentation at the EWMA 2007 conference. Posters that have been submitted/presented elsewhere are not eligible for a poster prize. A panel of judges will attend the poster session, and authors are strongly encouraged to be present at these sessions in order to answer questions concerning their work. The panel will award 3-5 poster prizes.

Become a member of the European Wound Management Association and you will receive EWMA position documents annually and EWMA Journal three times a year. In addition, you will also have the benefit of obtaining the membership discount, which is normally 15%, when registering for the EWMA Conferences. The most important aspect of becoming a member of EWMA is the influence this membership can give you. As a EWMA member you can vote and even stand for election for the EWMA Council, which will give you direct influence on future developments within European woundhealing. Please register as a ewma member at www.ewma.org. A membership only costs 25 EUR a year. You can pay by credit card as well as bank transfer. Existing members of EWMA can also renew their membership online.

Value of poster prizes: The value of each oster prize will be E 200. p

EWMA Business Office Danske Bank, London Cash Management 75 King William Street, London EC4N 7DT, UK Account No: 93406336. IBAN: GB69DABA30128193406336 BIC/SWIFT: DABAGB2L. Sort code 301281

How to apply: Your accepted poster will automatically be considered for this award, provided that it has not previously been submitted elsewhere.

EWMA Membership application Please use CAPITAL letters

First Time Presenter Prize This award is designed to encourage people who have not previously presented their work at an international conference. To be eligible for this prize you must have submitted your abstract to EWMA and you must be a “novice presenter”. That is, you should not have presented previously at an international conference. Posters that have been submitted elsewhere are not eligible for this prize. A panel of judges will attend the presentation sessions.

Surname: First name(s): Profession:

Physician

How to apply: Please confirm that you are applying for this award when submitting your abstract online. Furthermore, you should send a letter to the Scientific Secretariat stating that this is your first presentation at an international conference, and you should enclose a letter from your employer/supervisor/manager confirming that you have not presented previously at an international conference. m

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Dietician

Nurse

Pharmacist

Other

Work Address:

Address for Correspondence (if different from above):

Tel:

Value of prize: The value of the First Time Presenter prize will be E 450.

Surgeon

Fax:

E-mail: I enclose a cheque of 25e. Please indicate cheque no.: ___________________________________ Please make cheques payable to: European Wound Management Association Or: Please debit my account by 25e: Credit Card type: (Delta, Master Card or Visa). Credit card no:

Expiry Date: Exact name and initials on the credit card:

_____________________________________ Please return form and enclose cheque to: EWMA Business Office, Congress Consultants Martensens allé 8, DK-1828 Frederiksberg C, Denmark

THE LEG ULCER FORUM The Leg Ulcer Forum (LUF) aims to support health care professionals who care for people with leg ulcers and related conditions. The LUF has been in existence for 13 years and is committed to facilitating discussion, debate, reflective practice and the dissemination of new evidence and research. The LUF also has a political voice particularly in relation to DoH and PASA initiatives in compression therapies and dressings. The LUF is equally concerned with the continuing professional development of those new to leg ulcer management as well as the specialist practitioner. The benefits of membership (which costs £15 annually) includes a welcome pack with LUF resources, mailings of educational material produced by the LUF and the Wound Care supplements from Nursing Times. In addition you will be entitled to a discounted delegate fee at LUF educational events.

The LUF has affiliations in Ireland and Scotland and the Executive members of all 3 teams are committed to offering members support and encouragement to advance the care of patients and development of staff working in this field. Events this year include a summer conference on the 12th July in the South of England, events and workshops in Ireland and an August conference in Scotland. This year we are pleased to be a co-operating society for the EWMA conference in may 2007 and look forward to meeting as many of you as possible there. Please contact us via our administrative address if you have any queries and if you are interested in becoming a member or a commercial sponsor. Irene Anderson (Chair) legulcer.forum@btopenworld.com or telephone: 01480 494842 www.legulcerforum.org

17TH CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION

Evidence, Consensus and Driving the Agenda forward EWMA2007 · GLASGOW 2-4 MAY · 2007

WWW.EWMA.ORG/EWMA2007

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NATIONAL ASSOCIATION OF TISSUE VIABILITY NURSES (SCOTLAND) The National Association of Tissue Viability Nurses (Scotland) was established in the early 1990’s by the first couple of Tissue Viability Nurses who were appointed in Scotland. Since then the number of members has steadily increased. The group meets four times a year and provides an opportunity for members to network, to share ideas and to discuss ways to improve patient care. The group is very pro-active and have created various documents such as the Tissue Viability Competency Framework, Skin Excoriation tool and a Wound Assessment Chart. All these documents can be downloaded from our website www.natvns.com The National Association of Tissue Viability Nurse Specialists (Scotland) continues to be a proactive group and the past year has seen our members involved in several projects. The work of the wound debridement subgroup, in collaboration with Stirling University, has resulted in the first Scottish wound debridement course which will be held in Stirling University during January 2007. The wound assessment form will be included in a development from the Scottish Executive. It is their intention to publish the form as a clinical template, which will allow all areas of Scotland to have access to it. Work on the mentorship framework is progressing with a sub group working on the implementation of the competency framework.

The Best Purchasing Initiative has evolved over the past year into National Procurement (NP). Our members are working closely with National Procurement in relation to specialist equipment and wound management products. The next year will be a challenge for the association as the work on projects continues. Our involvement with National Procurement will include many of our members who will work tirelessly to ensure the products which are in the final selection allow clinicians across Scotland to be able to choose the care that individual patients require. An exciting opportunity has arisen to collaborate with the European Wound Management Association (EWMA) during the next year to help organize their conference to be held in Glasgow in May 2007. Ultimately the work of the NATVNS is about establishing and maintaining high standards of patient care. I am sure our members will continue to work together to achieve this aim. Liz McMath, Chair person (Amended chair persons report) Committee Chair – Lydia Jack Vice Chair – Anne Ballard Wilson Secretary – Joy Bell Secretary – Fiona Russell www.natvns.com

Production of the best practice statement on the treatment of pressure ulcers and review of the best practice statement on prevention of pressure ulcers.

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TISSUE VIABILITY NURSES ASSOCIATION Tissue Viability Nurses (TVNs) in the UK are facing their biggest challenge yet as we move into 2007. The current UK population is 59.8 million, 16% of which are aged 65 years and older, within which the proportion of those aged 85 years and older is now 12% (Office for National Statistics, 2004). By the year 2007 there will be more of the population aged over 65 years than under 18 years (NSF Older People, 2006). These statistics no doubt reflect the wider picture within Europe, although not all countries are as densely populated as the UK. This steep rise in the elderly population is accompanied by changes with the NHS with the emphasis of care moving primarily to the community setting. While this might be logical, many primary care trusts have not yet organised themselves to be able to accommodate this shift in care. As a consequence many Tissue Viability Nurses (TVNs) are being urged to spread their service with reduced resources.

The TVNA is the only UK association within wound care that is exclusive to nurses. Full membership is reserved for registered nurses in post whose primary responsibility is the provision of tissue viability services or who have the lead responsibility for tissue viability issues within a trust or other care-giving organisation. Associate membership is open to any registered nurse with a specialist interest in tissue viability. The primary objective of the TVNA is to provide its members with professional and political representation by acting as the primary point of contact for government and other agencies. An increasingly significant objective is that of promoting the integration of quality assurance into tissue viability and supporting the clinical governance agenda. Pauline Beldon, Chair TVNA pauline.beldon@epsom-sthelier.nhs.uk www.tvna.org

The Tissue Viability Nurses Association (TVNA), believes it is time that government and the Department of Health realised the extent of the problem and the worth of TVNs. A submission has been made to the Health Care Committee in Parliament by Jacqui Fletcher (TVN, University of Hertfordshire) containing information gathered from TVNs across the UK with the aim of raising the government’s awareness of the issues involved within the speciality of Tissue Viability.

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ABOUT TVS The Tissue Viability Society (TVS) is probably the world's oldest society dedi cated to all tissue viability issues. Formed in 1981 and a UK registered charity since 1996 the Society attracts members from all health care professions involved with tissue viability. Our mission statement includes our goals – to disseminate information, promote research and increase awareness of all aspects of good clinical practice in wound prevention and management – essentially we want to provide expertise in wound management. What is tissue viability? This is a growing speciality that primarily considers all aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration. However tissue viability is not just wound management for it also covers a wide range of organisational, political and socioeconomic issues as well as professional relationships and education. The Tissue Viability Society has over 1500 members drawn from the various professions involved in tissue viability; primarily nurses but with many doctors, engineers, scientists, pharmacists, podiatrists and other professions also represented. There is a Council elected by members who serve to guide the strategic direction of the Society and a Business Office and Professional Adviser to conduct the day-to-day actions of the Society. Please visit www.tvs.org.uk to find out more details of the Society and its activities.

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There was considerable disappointment among Tissue Viability Society members and supporters that the one-day symposium on wound inflammation scheduled for late October 2006 had to be cancelled due to the low number of delegates who booked places! The shortage of delegates was probably a direct consequence of the low profile of the meeting where the event organizers did not reach out to non-TVS members. The Trustees of the TVS would like to thank all those who did book places and especially note the support given by the companies who booked exhibition space. In 2007 there will be no separate Tissue Viability Society conference with the TVS partnering with the European Wound Management Association at the EWMA conference to be held in early May in Glasgow. The AGM of the TVS will be held during the Glasgow meeting and we look forward to welcoming members at the TVS stand during the EWMA event. There will be a TVS conference in the spring of 2008 and future society news will bring details of this forthcoming event. The TVS will be issuing monthly updates of its activities through an electronic newsletter. Members and non-members alike can sign up to receive this communication at the TVS web-site www.tvs.org.uk Michael Clark Tissue Viability Society, 1 Lancaster Place, London WC2E 7HR tvs@mcmslondon.co.uk www.tvs.org.uk

EWMA Journal

International Journals

Previous Issues Volume 6, no 2, Fall 2006 The number of leg ulcers increases – a 20-year-questionnaire study in Pirkanmaa Health Care in Finland Anna L Hjerppe An ex-vivo model to evaluate dressings & drugs for wound healing Johanna M. Brandner, Pia Houdek, Thomas Quitschau, Ute Siemann-Harms, Ulrich Ohnemus, Ingo Willhardt, Ingrid Moll Compression therapy of venous ulcers Hugo Partsch Seasonal variation of onset of venous leg ulcers Marian Simka Determinants and estimation of wound healing achievement after minor amputation in patients with diabetic foot Robert Bém, A. Jirkovská, V. Fejfarová, J. Skibová, B. Sixta, P. Herdegen Leg ulcer prevalence in the Czech Republic: Omnibus survey results 2006 Zdenek Kucera

Volume 6, no 1, Spring 2006 Focus on silver Jean-Yves Maillard, Stephen P Denyer Factors that influence the frequency of rebandaging Una Adderley Microengineered hydrogel as a vehicle for grafting human skin cells Stephen Britland, Annie Smith Wound Care in Anatolia Ali Barutcu Implementation of a Leg Ulcer Strategy in Central & Eastern Europe Peter J. Franks Post Graduate Wound Healing Course Modena, Italy Deborah Hofman From The Laboratory to the Patient: Future Organisation and Care of Problem Wounds. A New Experience Finn Gottrup

Volume 5, no 2, Fall 2005 Retrospective analysis of topical application of factor XIII in patients with chronic leg ulcers Mirjana Ziemer, Claudia Scheumann, Martin Kaatz, Johannes Norgauer An overview of surgical site infections: aetiology, incidence and risk factors Finn Gottrup, Andrew Melling, Dirk A. Hollander Regulating research and associated activity in the UK Sue Bale Article Review – The effectiveness of a hyperoxygenated fatty acid compound in preventing pressure ulcers Joan-Enric Torra i Bou, T. Segovia Gómez, J. Verdú Soriano, A. Nolasco Bonmatí, J. Rueda López, M. Arboix i Perejamo Article Review – Extended commentary on a trial E. Andrea Nelson UK Lymphoedema Framework Project Philip A. Morgan, Christine J. Moffatt, Debra C. Doherty, Peter J. Franks German Wound Surgeons 1450-1750 Carol Dealey

Volume 5, no 1, Spring 2005 Wound Healing and Wound Treatment 2004 – the current state Stephan Coerper Vascularized Bone Replacement for the Treatment of Chronic Bone Defects – Initial Results of Microsurgical Solid Matrix Vascularization Ulrich Kneser The Importance of Family and Domiciliary Treatment of Immobile Patients with Chronic Wounds F. Petrella After TIME: wound bed preparation for pressure ulcers Marco Romanelli, Madeleine Flanagan Selected abstracts from 2nd World Union of Wound Healing Societies meeting

The section on International Journals is part of EWMA’s attempt to exchange information on wound healing in a broad perspective. Italian

Acta Vulnologica, vol. 4, no 3, 2006 Reconstructive surgery in chronic ulcers of the lower limbs with the use of Integra Derma Regeneration Template Campitiello F., Della Corte A., Fattopace A., Mancone M. Assessment of the use of “Prontosan”, a detergent solution, as an adjuvant in the treatment of ulcers Forma O. Efficacy of hyperbaric oxygen therapy in the healing of ulcers Brustia P., Crespi A., Renghi A., Fassiola A., Villaraggia A. Vacuum-assisted sternal closure after a “depression induced ischaemic test” in a case of severe mediastinitis Cappuccio G., Patanè F., Comoglio C., Zingarelli E., Sansone F., Ceresa F. Clinical methodology in wound care. The scientific basis for the correct local therapy Somà K., Furlini S.

English

Advances in Skin & Wound Care, vol. 20 January 2007 www.aswcjournal.com Certification and Education: Do They Affect Pressure Ulcer Knowledge in Nursing? Karen Zulkowski, Elizabeth A. Ayello, Sharon Wexler The Role of Moisture Balance in Wound Healing Denis Okan, Kevin Woo, Elizabeth A. Ayello, R. Gary Sibbald Determining Differential Diagnosis by Practical Observation Cynthia A. Fleck Wound Care Challenges Faced in Iran Afsaneh Alavi Update Charge Encounter Sheets and Charge Description Masters Kathleen D. Schaum The Role of Nutritional Therapy in Palliative Care Mary Ellen Posthauer

English

The International Journal of Lower Extremity Wounds vol. 5, no 4, 2006 http://ijlew.sagepub.com Achieving Goals in Wound Healing Raj Mani What Price Wound Care? Paul Trueman and John Posnett Role of Hyperbaric Oxygen Therapy in the Management of Lower Extremity Wounds D. Mathieu Do Clinical and Social Factors Predict Quality of Life in Leg Ulceration? Peter J. Franks and Christine J. Moffatt An Assessment of the Disease Burden of Foot Ulcers in Patients With Diabetes Mellitus Attending a Teaching Hospital in Lagos, Nigeria A. O. Ogbera, O. Fasanmade, A. E. Ohwovoriole, O. Adediran Thermography and Thermometry in the Assessment of Diabetic Neuropathic Foot: A Case for Furthering the Role of Thermal Techniques M. Bharara, J. E. Cobb, and D. J. Claremont Is There Evidence-Based Guidance for Timing of Soft Tissue Coverage of Grade III B Tibia Fractures? Corstiaan C. Breugem and Simon D. Strackee Necrotizing Fasciitis: A Common Problem in Darwin Jennifer M. Byrnes

The EWMA Journals can be downloaded free of charge from www.ewma.org

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Spanish

Helcos 2006, vol 17, no 4

English

Legal aspects related to pressure ulcers J.Javier Soldevilla Agreda, Sonia Navarro Rodriguez Assesment of the satisfaction and effectiveness of the hydrocoloid dressing Sureskin II in the treatment of acute and chronic wounds J.C. Modenes ; J.M. Porras; M. Pelet; S. Cámara; E. Jovet; I. Santaló; J.L. Palacio

Finnish

English

EWMA

Antiseptics, iodine, povidone iodine and traumatic wound cleansing MN Khan, AH Naqvi Optical assessment of skin blood content and oxygenation JC Barbanel, F Gibson, F Turnbull The effect of pressure loading on the blood flow rate in human skin CH Daly, JE Chimoskey, GA Holloway, D Kennedy Optimal method for isolation of human peritoneal mesothelial cells from clinical samples of omentum M Riera, P McCulloch, L Pazmany, T Jagoe

Haava, vol. no 4, 2006 www.suomenhaavanhoitoyhdistys.fi Knowledge of Wound Management in Journals and Internet Helvi Hietanen Wound Surgery under Unwanted Conditions Erkki Tukianen, Virve Koljonen Working in the Kingdom of Saudi Arabia Marja Sirkeinen International Experience of Wound Marianne Olander Wound Management in Switzerland Christina Falk Wound Management in England, Ireland and Norway Minna Tikkanen A Survey of Wound Care in Ireland Zena Moore, Seamus Cowman EWMA, European Wound Management Conference in Prague Ansa Iivanainen, Tiina Pukki, Salla Seppänen, Nina Pulkkinen Pressure Ulcer – Know-how in Practice Tiina Pukki Learning Wound Management in France Niina Tasaranta European Pressure Ulcer Advisory Panel ( EPUAP) Helvi Hietanen EWMA – European Wound Management Association Salla Seppänen The Nordic Burn Conference in Kuopio Päivi Mäntyvaara, Päivi Virkki Pressure Ulcer Prevention Protocol – adult Marja-Leena Isoaho Guide for A Novice Visitor in Wound Management Conference Tiina Pukki

International Wound Journal, Dec. 2006, vol. 3, Issue 4 www.blackwellpublishing.com Negative-pressure wound therapy: a snapshot of the evidence Derick A Mendonca, Remo Papini, Patricia E Price The management of deep sternal wound infections using vacuum assisted closure (V.A.C.®) therapy Tatjana Fleck et al. Silver dressings: their role in wound management David J Leaper Reimbursement of dressings: a WUWHS statement Luc Téot et al. Does dermal thermometry predict clinical outcome in diabetic foot infection? Analysis of data from the SIDESTEP* trial David G Armstrong, Benjamin A Lipsky, Adam B Polis, Murray A Abramson In vitro diffusion bed, 3-day repeat challenge 'capacity' test for antimicrobial wound dressings John Greenman, Robin MS Thorn, Saliah Saad, Andrew J Austin Inflammatory inert poly(ethylene glycol)protein wound dressing improves healing responses in partial- and full-thickness wounds Kirill I Shingel, Liliana Di Stabile, Jean-Paul Marty, Marie-Pierre Faure Estimating the risk of pressure ulcer development: is it truly evidence based? Catherine A Sharp, Mary-Louise McLaws Prognosis of stage I pressure ulcers and related factors Miwa Sato, Hiromi Sanada, Chizuko Konya, Junko Sugama, Gojiro Nakagami The potential of microscopic sterile sponge particles to induce foreign body reaction Alper Sari, Yavuz Basterzi, Tuba Karabacak, Bahar Tasdelen, Ferit Demirkan

Journal 2007 vol 7 no 1

Journal of Tissue Viability, Nov 2006, vol. 16 no 4 www.tvs.org.uk/standard.asp?id=104

English

Journal of Wound Care, July issue, vol. 16, no 1, 2007 www.journalofwoundcare.com; jwc@emap.com Economics of pressure-ulcer care: review of the literature on modern versus traditional dressings L. San Miguel, J-E. Torra i Bou, J. Verdú Soriano Dressing remedies: a concept for improving access to and use of dressings in nursing homes A. Clarkson Bacterial resistance to silver in wound care and medical devices A. Lansdown Our motivation to improve patient care wills us to succeed A. Brown, H. Middleton, C. Curry, J. Geraghty, C. Rivers Venous leg ulcer treatment and practice — part 1: the causes and diagnosis of venous leg ulcers S. Rajendran, A.J. Rigby, S.C. Anand An educational intervention for district nurses: use of electronic records in leg ulcer management A. Lagerin, G. Nilsson, L. Törnkvist Role of topical negative pressure in pressure ulcer management A. Mandal Use of porcine dermal collagen graft and topical negative pressure on infected open abdominal wounds K.S. Jehle, A. Rohatgi, M.K. Baig A review of the effect of tap water versus normal saline on infection rates in acute traumatic wounds S. Hall The successful management of a dehisced surgical wound with TNP following femoropopliteal bypass A. Dee

English

Touch Briefing: European Dermatology Review www.touchbriefings.com/cdps/cditem.cfm?nid=2003&cid=5 European Dermatology Review 2006 brings together leading industry experts in each specialized sector within the dermatological field, in order to create a market-leading platform to provide the most comprehensive information on the latest innovations and developments within dermatology.

Scandinavian

Wounds (SÅR) vol. 14, no 4, 2006 www.saar.dk Testing of Sorbion Sachet in the primary sector Susan F. Jørgensen New treatment of dry skin on the diabetic foot Marita Jonsson, Anett Chramer, Jan Apelqvist, Christel Nelson Zimdal Amelogenin (Xelma®), Norwegian experiences after using it for 9 years Theis Huldt-Nystrøm, Jon Helge Bonesrønning, Øystein Vatne, Ada Steen, Nathalie Dufour, Kirsti Espeseth, Runbjørg Buner, Kirsten M Nilsen, Erlend Tolaas, Malene Johnsrud, Marcus Gürgen, Anne Lise Westmo

EWMA Corporate Sponsor Contact Data Corporate B

Corporate A

Coloplast Holtedam 1-3 DK-3050 Humlebæk Denmark Tel: +45 49 11 15 88 Fax: +45 49 11 15 80 www.coloplast.com

ConvaTec Europe Harrington House Milton Road Ickenham, Uxbridge UB10 8PU United Kingdom Tel: +44 (0) 1895 62 8300 Fax: +44 (0) 1895 62 8362 www.convatec.com

Ethicon GmbH Johnson & Johnson Wound Management Oststraße 1 22844 Norderstedt Germany Tel: +49 40 52207 230 Fax: +49 40 52207 823 www.jnjgateway.com

KCI Europe Holding B.V. Parktoren, 6th floor van Heuven Goedhartlaan 11 1181 LE Amstelveen The Netherlands. Tel: +31 - (0) 20 - 426 0000 Fax: +31 (0)20 426 0097 www.kci-medical.com

Lohmann & Rauscher P.O. BOX 23 43 Neuwied D-56513 Germany Tel: +49 (0) 2634 99-6205 Fax: +49 (0) 2634 99-1205 www.lohmann-rauscher.com

Mölnlycke Health Care Ab Box 13080 402 52 Göteborg, Sweden Tel: +46 31 722 30 00 Fax: +46 31 722 34 08 www.molnlycke.com

Smith & Nephew Po Box 81, Hessle Road HU3 2BN Hull, United Kingdom Tel: +44 (0) 1482 225 181 Fax: +44 (0) 1482 328 326 www.smith-nephew.com

Tyco Healthcare 154, Fareham Road PO13 0AS Gosport United Kingdom Tel: +44 1329 224479 Fax: +44 1329 224107 www.tycohealthcare.com

3M Health Care Morley Street, Loughborough LE11 1EP Leicestershire United Kingdom Tel: +44 1509 260 869 Fax: +44 1 509 613326 www.mmm.com

Activa Healthcare Ltd 1 Lancaster Park Newborough Road Needwood Burton on Trent Staffordshire DE13 9PD Tel: +44 (0) 8450 606 707 Fax: +44 (0) 1283 576808 www.activahealthcare.co.uk

B. Braun Medical 204 avenue du Maréchal Juin 92107 Boulogne Billancourt France Tel: +33 1 41 10 75 66 Fax: +33 1 41 10 75 69 www.bbraun.com

Comvita UK Ltd Unit 3, 55-57 Park Royal Road London NW10 7LP United Kingdom Tel: +44 208 961 4410 Fax: +44 208 961 9420 www.comvita.co.uk

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EWMA Position Document 2006 Management of wound infection The 2006 European Wound Management Association (EWMA) position document on ‘Management of wound infection’ continues last year’s exploration of the criteria for wound infection by tackling the complex clinical challenges healthcare professionals face when making decisions about how to treat wound infection.

Ferris Mfg. Corp. 16W300 83rd Street Burr Ridge, Illinois 60527-5848 U.S.A. Tel: +1 (630) 887-9797 Toll-Free: +1 (630) 800 765-9636 Fax: +1 (630) 887-1008 www.polymem.com EWMA Position Document Editor: Christine Moffatt

Paul Hartman AG Paul-Hartmann Strasse D-89522 Heidenheim Germany Tel: +49 (0) 7321 / 36-0 Fax: +49 (0) 7321 / 36-3636 www.hartmann.info

Sorbion AG Hobackestraße 91 D-45899 Gelsenkirchen Tel: +49 (0)2 09-95 71 88-0 Fax: +49 (0)2 09-95 71 88-20 www.sorbion.com

Laboratoires Urgo 42 rue de Longvic B.P. 157 21300 Chenôve France Tel: (+33) 3 80 44 70 00 Fax: (+33) 3 80 44 71 30 www.urgo.com

The document is available from www.ewma.org as a downloadable pdf. For further details contact MEP Ltd, 53 Hargrave Road, London N19 5SH. www.mepltd.co.uk or EWMA Business Office, Congress Consultants, Martensens Allé 8, 1828 Frederiksberg, Denmark. ewma@ewma.org Tel: +45 7020 0305 Fax: +45 7020 0315

With the recent escalating prevalence of bacterial resistance there has been renewed interest in the use of topical antimicrobials particularly silver, iodine, honey and maggot therapy. However, injudicious use and the limited clinical evidence to support their use has led to further problems and controversies. In producing this position document, EWMA pays particular attention to the appropriate use of topical antimicrobials and provides practical recommendations for clinicians. This position document, the fifth in the series, was launched at Prague, 18-20 May 2006. The document comprises four seminal papers: • An integrated approach to managing wound infection P Vowden and RA Cooper • Demystifying silver J-Y Maillard and SP Denyer • Topical management of infected grade 3 and 4 pressure ulcers Z Moore and M Romanelli • Topical antimicrobials and surgical site infection A Melling, FK Gould and F Gottrup ‘Management of wound infection’ has been supported by an unrestricted educational grant from ConvaTec and is available in English, French, German, Italian, Spanish and Japanese.

Previous Position Documents:

Use the EWMA Journal to profi le your company Deadline for advertising in the next issue is 26 March 2007

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EWMA welcomes new Corporate B Sponsors B. Braun

he B. Braun Group stands for competence in healthcare. For more than 165 years, the company has been developing, producing and distributing products and services for medicine, and it has developed into a worldwide group of companies. In 2005, almost 31,000 B. Braun employees in 50 countries achieved a turnover of EUR 3.03bn.

The product spectrum ranges from infusion solutions, injection pumps and accessories for infusion therapy, intensive medicine and anesthesia to surgical instruments, sterile containers and sutures, hip and knee endoprostheses, power systems and accessories for extra corporeal blood treatment and products for wound care and infection control. The complete range encompasses more than 160,000 different products.

B. Braun Wound Excellence Center

B. Braun Centers of Excellence in Wound Care. B. Braun has focused its know-how in wound care through specialized, dedicated Centers of Excellence (CoE) and offers a range of products under brand names likes Askina, Calgitrol Ag and Prontosan. The wound care centers of excellence have close relationships with other CoEs, leading to innovative synergies and development of new products aimed at bringing significant patient benefits.

Ferris Mfg. Corp.

erris Mfg. Corp., with head office in Burr Ridge (Chicago), USA, was founded by Robert W. Sessions, a former director of biomedical research at Chicago’s Rush-Presbyterian St. Luke’s Medical Center. In his craving to add science to the art of wound care Sessions had realized that traditional therapies discourage, even inhibit, healing. Responding to this problem, he began his quest for a truly wound-friendly dressing. After researching thousands of different formulations, he discovered a drug-free and irritant-free blend that creates an ideal warm, moist healing environment and in 1988, his PolyMem® formulation was patented and introduced to the professional wound care market. What was truly unique with this formulation was that it contained three wound-friendly components each providing patient benefits; a cleanser (F68), a moisturizer (glycerol), and a super- absorber. PolyMem dressings now belong to an innovative class of adaptable wound care dressings called QuadraFoam™ that effectively cleanse, fill, absorb, and moisten wounds throughout the healing continuum. Even if Ferris Mfg. Corp. is most known for PolyMem wound dressings, Sessions is also responsible for numerous other inventions, including: one of the first implantable cardiac pacemakers; disposable electrocardiogram electrodes; a disposable bone marrow aspiration needle; a suture-less cannula for open heart surgery; the HunterSessions Vena Cava Occluder (an implant to prevent blood clots in the lungs); BabySmooth™ diaper rash pads, and RhinoPak™ nasal surgery dressings. Sessions died in April of 2005 and Ferris Mfg. Corp. is now led by his nephew, Dr. Roger Sessions.

The full range of products offered respond to basic needs for moist treatment, but complex wounds and non healing wounds require novel approaches for wound repair. B. Braun is actively involved in providing better solutions for local care of the wound and thereby aims at bridging the gap between clinical use and basic research.

Due to the work of Bob Sessions, the company has received numerous awards and recognitions for excellence in medical product design and contributions to the medical profession. These awards include the Illinois Governor’s Export Award (1998 and 1999), the Medical Device and Diagnostic Industry’s Medical Design Excellence Awards® (2000), the WOCN Case Study Merit Award (2006), and the Frost & Sullivan 2006 North-American Product Differentiation Innovation Award. This latest reward was won for its’ its most recent line, Shapes™ by PolyMem – a large range of pre-cut, easy-to-use dressings that reduce the need to manually cut dressings to size.

For more information, please go to www.bbraun.com

For more information, please go to www.polymem.com

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Journal 2007 vol 7 no 1

Conferences

A stimulating and successful conference for the EPUAP in Berlin With over 500 delegates and more than 35 speakers, this conference provided ample opportunity for networking and to hear about developments in pressure ulcer care.

elegates from Europe, the US (boosted by a delegation from the National Pressure Ulcer Advisory Board Panel, NPUAPD), Australia, Japan, Korea and China met together in september 2006 in Berlin at the ninth European Pressure Ulcer Advisory Panel (EPUAP) open meeting. The conference theme was â&#x20AC;&#x2DC;Pressure Ulcers: putting knowledge into practiceâ&#x20AC;&#x2122;, and included a host of stimulating presentations with topics such as technological advances in pressure ulcer prevention, microbiology, the patientâ&#x20AC;&#x2122;s experience of living with a leg ulcer, tissue refl ectance spectroscopy and the development of test methods for support surfaces. Given the large number of presentations it would be impossible to describe them all here, but I would like to focus on a few that caught my eye. Papers Dan Bader highlighted the need for objective monitoring to identify at-risk individuals and the conditions, such as the patient-support interface, that can lead to tissue breakdown. New technologies being developed can image the entire soft-tissue composition down to the underlying bony prominences, evaluate damage at the cellular level and predict the local mechanical environment within the tissue. Such techniques may have the potential to provide new monitoring systems for practitioners. Dr Bader reminded us that a better understanding of the physiology of pressure ulceration is the key to prevention and management. Jane Nixon reported on the PRESSURE trial: a randomised controlled trial (RCT) that compared alternating pressure mattresses and overlays in 11 hospitals (including six NHS trusts). Its objective was to determine whether there are any differences between the two, with a primary end point of the development of a grade 11 or above pressure ulcer. The sample consisted of 1972 patients aged 55 or over admitted in the previous 24 hours to vascular, orthopaedic, medical or elderly acute care wards, either as acute or elective admissions. Of the sample, 990 were randomised to overlays and 982 to mattresses. Intentionto-treat analysis found no difference in the proportion of patients who developed new pressures ulcers in either

group. However, the mattresses were associated with lower overall costs. Jeannie Donnelly announced the results of a RCT comparing leg elevation with therapy mattresses in the prevention of pressure ulcers on the heels of people with fractured hips. She set out to further investigate the theory that offl oading is an effective measure in preventing heel pressure ulcers. All patients with a hip fracture admitted to the Royal Hospitals Trust, Belfast, were recruited if they had a fractured hip, were aged 65 or over, and gave informed consent. Patients whose fractures had occurred 48 hours previously or had existing heel damage were excluded. Patients were randomised to receive one of two treatment options: heels elevated or heels down. The primary outcome was development of a grade I or above pressure ulcer. Assessments were verifi ed by an experienced tissue viability nurse blinded to the intervention. Patients in the control group developed more pressure damage than those in the intervention group. The results were so pronounced that the study was stopped half way through on ethical grounds. Other events The EPUAP also announced the formation of the Shear Force Initiative Group, comprising the EPUAP, the NPUAP and the Japanese Pressure Ulcer Society. The group has two goals: to identify the clinical signifi cance of shear force (and agree on a defi nition), and explore how best to monitor shear. The group fi rst met in Aberdeen at EPUAP open meeting 2005, and held a follow-up meeting in Berlin. Industry were represented both in the exhibition, and by sponsored symposia, with KCI supporting a session on a holistic approach to pressure ulcer management, Nutricia a symposium on nutrition and healing, Smith & Nephew a session on adapting to the complexity in wound management, Gaymar one on deep tissue injury and Gerromed one on electrical stimulation in healing. EPUAP will celebrate its tenth anniversary open meeting in Oxford from 30 August to 1 September 2007. m Tracy Cowan, Deputy Editor/Production Editor, Journal of Wound Care

EWMA

Journal 2007 vol 7 no 1

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www.PolyMem.eu PolyMem and QuadraFoam are trademarks of Ferris Mfg. Corp., registered or pending in the US Patent and Trademark Office and in other countries. © 2006 Ferris Mfg. Corp. All rights reserved. 16W300 83rd St., Burr Ridge, IL 60527 MKL-218,0706

6th Scientific Meeting of the

The 1st National Wound Care Congress

Diabetic Foot Study Group

of WMAT

(of the EASD) 10-13 September 2006, Elsinore, Denmark

rom 10 September to 13 September 2006 the Scientific Meeting of the Diabetic Foot Study Group (DFSG) of the European Association for the Study of Diabetes (EASD) took place in Elsinore (close to Copenhagen), Denmark. The 13th of September was dedicated to the Diabetic Foot Symposium with the theme “Treatment and Organisation”, which was mainly for local participants and was held in Danish. The DFSG meeting supports an interdisciplinary collaboration between diabetologists, podiatrists, specialist nurses, orthopaedic and vascular surgeons and all other specialists with an interest in caring for diabetic patients with foot problems. The main themes of the conference were: Diabetic foot infection – Diagnosis and management  Biomechanics of the Diabetic Foot  Charcot Osteoarthropathy  Standard and adjunctive therapies  Surgical management  Structures of Diabetic Foot Care  Extra sessions covered the following topics:  The Eurodiale project  21st Century Wound Care – Making the DFU disappear (KCI Symposium)  Improving Diabetic Foot Care in the Developing World (Novo Nordisk Symposium) 

Future meetings The 5th International Symposium on The Diabetic Foot will be held 9-12 May 2007 in Noordwijkerhout, the Netherlands. It is a 4-day symposium and the meeting aims at providing up-to-date information on prevention and management of the diabetic foot. For more information please go to www.diabeticfoot.nl

Board members of WMAT with EWMA Council members Finn Gottrup, Sue Bale and Brian Gilchrist.

he 1st National Wound Care Congress was held 15-18 November 2006 at Silence Beach Resort Hotel, Side-ANTALYA, Turkey.

EWMA council members Sue Bale, Brian Gilchrist and Finn Gottrup attended this conference and found that WMAT, the Turkish Wound Management Association had arranged a very interesting scientific programme. m Link to the scientic programme: www.yarabakimikongresi.com/eng/kongreprogrami. php

The next Scientific Meeting of the Diabetic Foot Study Group (DFSG) of the European Association for the Study of Diabetes (EASD) will be held in September 2008 in Pisa, Italy. For more information please go to www.dfsg.org m 54

EWMA

Journal 2007 vol 7 no 1

Conferences

Conference Calendar International Conferences

Theme

17th Conference of the European Wound Management Association (EWMA 2007)

Evidence, Consensus and Driving the Agenda forward

May

2007

EADV 16th Congress

European Dermatology and Venereology – Strong Past, Stronger Future

May

EPUAP 10th European Meeting

Aug/Sep

ETRS 17th Annual Meeting

Measurements in wound healing – the conduit between the laboratory and the clinic

Sep

ILDS 21st World Congress of Dermatology

Global Dermatology for a globalized world

Oct

2-4

Glasgow

16-20 Vienna

Austria

30-1

Oxford

26 -28 Southampton 1-5

Buenos Aires

Argentina

Lisbon

Portugal

Toronto

Canada

Pisa

Italy

2008 18th Conference of the European Wound Management Association (EWMA 2008)

May

WUWHS – 3rd Congress of the World Union of Wound Healing Societies

Jun Sep

Diabetic Foot Study Group (DFSG) of the EASD Theme

National Conferences

4-8

2007

Finnish Wound Care Meeting

Feb

1-2

Helsinki

Finland

DGfW 10th Annual Congress

Wundbehandlung – in der Schräglage?!

Mar

9-10

Berlin

Germany

Seminar and annual meeting in NIFS

Diabetic Foot

Mar

15-16 Oslo

17th Annual Meeting of WHS and SAWC

Apr/May 28-01 Tampa

5th international symposium on the Diabetic Foot

May

SAfW 4th Congress

May

12th Congress of the ESDaP

Jun

9-12 24

Jun

SiSS National Congress

Sep

APTFeridas 2007 Congress

Nov

7-9

Wounds UK

Nov

Noordwijkerhout The Netherlands Morges

14-17 Wroclaw

Wounds UK summerconference

Norway

Warwickshire

Switzerland Poland UK Sweden

Porto

Portugal

For web link please visit www.ewma.org

17TH CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION

Evidence, Consensus and Driving the Agenda forward EWMA2007 · GLASGOW 2-4 MAY · 2007

WWW.EWMA.ORG/EWMA2007

Activity of the Hungarian Lymphoedema and Wound Managing Society HWMS/MSKT

Hungarian Lymphoedema and Wound Managing Society Prof. Dr. Judit Daróczy Department of Dermatology and Lymphology Saint Stephan Hospital Budapest H-1096, Nagyvárad tér 1. Tel/Fax: 36-1-280-1368 daroczy@istvankorhaz.hu judit@daroczy.net

Background: In Hungary chronic wound assessment and treatment is carried out by general practitioners, dermatologists and surgeons. There are no standards of care and there is no consensus within the levels of professional care providers – general practice, hospital, rehabilitation, etc. – concerning their participation in that care. The only professional center for the treatment of chronic peripheral lymphoedema in Hungary is in the department of Dermatology and Lymphology of the Saint Stephan Hospital, Budapest. In Hungary dermatologists provide treatment for chronic lymphoedema. The medical staff of Saint Stephan Hospital has established the accepted and published guideline for complex oedema relief. As skin lesions of lymphoedema patients (especially those with complications) need dermatological care, it seems to be a good idea to link the care of lymphoe dema, wounds and dermatological diseases. Goals: – to acquaint GPs and specialists with the established standards of care; – to stress the importance of the levels of care (each patient should receive the appropriate treatment according to his status) otherwise the care can be too expensive; – to educate wound care nurses and establish provision of a recognized training programme with diploma; – to establish provision of information and support for patients and their relatives; – to establish a specialized nursing unit for chronic wound treatment. In 2007 basic changes will happen because of the reform of the national healthcare system in Hungary. Parallel to the diminution of the number of active hospital beds the number of rehabilitation and chronic beds will increase. With this in mind, the Hungarian Wound Managing Society (MSKT) submitted an application for a specialized nursing unit for chronic wound treatment with 40 beds that could be set up in Saint Stephan Hospital. Methods and activities: 1. Every year the Hungarian Wound Managing Society (MSKT) organizes a congress on a current topic. In 2006 the topic was the guideline of chronic wound treatment. This guideline was handed in to the Ministry of Health. We also discussed the competency and training of wound care nurses.

2. Involvement of nursing directors: In Hungary there are no centers for wound treatment; care of chronic wounds is performed in dermatology and surgery outpatient clinics and departments. For this reason, wound care presents a problem for those hospital departments (internal medicine, diabetology, gastroenterological surgery) where patients with chronic wounds are usually treated. In 2006 we organized a national meeting for the nursing directors of hospitals and the decision was made that the training of nurses in wound treatment will be supplemented and supported with a license exam. 3. Institute of Nursing Postgraduate Diploma: Twice a year we organize a 54-hour long training programme for nurses in chronic wound treatment incorporating both theory and practice. Until now this training did not give a license for the nurses to work independently (only a diploma). 4. Nurses working in chronic wound treatment would need a license to be able to independently treat patients referred to the communal centers by doctors. To address this, the first half of 2007 is to be spent defining the competencies of the nurses’ role. This is going to be done in cooperation with representatives of different specialties: surgery, infectology, hygiene, diabetology, traumatology, dermatology, internal medicine, angiology, and vascular surgery to ensure an ‘all disciplines’ approach to wound care. 5. Specialized nursing unit for chronic wound treatment: we have started to establish the operational conditions and the quality assurances required for the activity/operation of a specialized nursing unit. Within the healthcare reform programme, the opening of the unit is planned for the second half of 2007. Summary and problems: 1. The guideline for chronic wound treatment appropriate for the Hungarian healthcare, hospital and insurance system has been accepted by a professional board and has been officially published. 2. The guideline has to be accepted by other medical specialties and the drain on the resources of the other levels of care has to be monitored. 3. The treatment of lymphoedema and chronic wounds has to be integrated with the dermatological care system. 4. For training and education we need financial support.

EWMA

Journal 2007 vol 7 no 1

Organisations

Moments = Years The Life Of The 10 Year Old Hungarian SEBINKO Association

SEBINKO

Hungarian Association for the Improvement of Care of Chronic Wounds and Incontinentia Dr. Maria Hok Independent consultant Nursing education, Nursing research, Nursing management and Quality of Nursing Care Hungary Budapest 1085 Maria Street 5. SEBINKO Association Hungary hokmaria42@t-online.hu www.sebinko.hu

In Glasgow 2007 at the EWMA – Evidence, Consensus and Driving the Agenda Congress, we hope that by sharing our experiences we will learn a lot of interesting information and will be able to count this congress as one of our great moments to come. EWMA

Journal 2007 vol 7 no 1

The Hungarian SEBINKO Association was e stablished in 1996 to improve the care of incontinent people and patients with chronic or problem wounds. At the beginning its members were nurses, today it includes doctors and whole institutions amongst its members. In the first years the main challenges were those of finding the way forward; we used the first three years to establish the aims and the mission of our organisation, and to ensure our values became known and accepted. Our mission statement is as follows: “The aim of the SEBINKO Association is to develop a wide scope, nationwide co-operation and consensus in the fields of chronic wound prevention and treatment and the improvement of the treatment of incontinence. This we support by developing, teaching and training scientific methods”. We are striving to reach our goals by continuous information flow through the SEBINKO publications, conferences, correspondence, training programmes, tenders etc. We are achieving our goals through wide-scale co operation and support from professional care givers including doctors, nurses, scientists and the medical industry who work in the field of chronic wounds and incontinence. We support the wound treatment and incontinence treatment programmes developed by medical institutes and the development of responsible, reliable nursing care in the fields of wound treatment and healing. We place special emphasis on the importance of unified documentation and data processing and the training of institutional coordinators for decubitus and incontinence. Our association is actively supporting the following values of professional help and care: – preservation or reestablishment of the selfcare of the patients, – security – minimising pain, – infection-free surroundings, – cost effectiveness in wound treatment. Since 1999, when these values were introduced at our first consensus conference, these values have also been supported by our associates. A ’big moment’ for us was in 2003 when we accepted, by consensus, the management principles of the client-oriented wound treatment process. At the heart of this consensus were unified documentation, data collection and processing, with an emphasis on decubitus.

The most important details of the consensus were the competencies of the members of the multidisciplinary team, the details and documentation of the continuous wound, and patient observation. In 2006 these were accepted by the National Health Financial Institute and made compulsory – another three years and another great moment for us! Of the resources necessary for effective wound treatment, we find evidence, knowledge and use of different techniques, and product information and presentation by medical industry sales people as important as the training of the wound treatment team, the patients, their relatives and their involvement in the treatment. Not forgetting treatment cost-effectiveness. Since 2003 we have built a strong relationship with the founders and acceptors of the nationwide consensus. Amongst them one can find professional politicians, members of Parliament, members of medical and nursing colleges, leaders of professional and civil organisations, health industry organisations, universities, practitioners and practicing teams. Of our ’Big Moments’ we mustn’t forget our annual conferences that take place in October every year. At our 10th Anniversary Conference in 2006 we identified ’The development of clinical validity and best practices requirements’ as the professional task facing our members and us for the following year. In this the most important areas will be the development of everyday best practice, continuous evaluation, renewal of nursing research methods, and the development of training and evidence research. All the details of this work may take up to three years each before they also become some of our ’Big Moments’! One of the greatest moments came in 2006 with the acceptance of our organisation in to the cooperating bodies of EWMA. We believe that our organisation, upon developing its solid national base, will be able to share our experiences and learn from the international experience offered by EWMA. Based on the above it is understandable that, for us, the 2006 EWMA Congress: Innovation, Education, Implementation was very important, and, therefore, it was also one of our great moments.

Co-operating Organisations ABUSCEP

Wound Management Association in Belgium

AISLeC

Associazione Infermieristica per lo Studio Lesioni Cutanee Italian Nurse Association for the Study of Cutaneous Wounds www.aislec.it

AIUC

Associazione Italiana Ulcere Cutanee. Italian Association for Cutaneous Ulcers www.aiuc.it

APTFeridas

Portuguese Wound Management Association www.aptferidas.com

AWA

Austrian Wound Association www.a-w-a.at

CNC/BFW

Wound Management Organisation www.befewo.org www.wondzorg.be

CSLR

Czech Wound Management Society www.cslr.cz

DGfW

Deutsche Gesellschaft für Wundheilung www.dgfw.de Danish Wound Healing Society

DWHS

Danish Wound Healing Society www.dsfs.org

FWCS

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

GAIF

Grupo Associativo de Investigacão em Feridas www.gaif.net

GNEAUPP

Grupo Nacional para el Estudio y Asesoramiente en Ulceras por Presión y Heridas Crónicas www.gneaupp.org

GWMA

Greek Wound Management Association

HWMS/MSKT

Hungarian Lymphoedema and Wound Managing Society

IWHS

Iceland Wound Healing Society www.sums-is.org

LBAA

Latvian Wound Treating Organisation

Lymphoedema Framework www.lymphoedemaframework.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

LUF

The Leg Ulcer Forum www.legulcerforum.org

LWMS

Lithuanian Wound Management Society

EWMA

Journal 2007 vol 7 no 1

Organisations

NATVNS

National Association of Viability Nurse Specialists (Scotland) www.natvns.com

NIFS

Norwegian Wound Healing Association www.nifs-saar.no

NOVW

Dutch Organisation of Wound Care Nurses www.novw.org

PWMA

Polish Wound Management Association

Qualitäts Netzwerk

TVNA

Tissue Viability Nurses Association www.tvna.org

TVS

Tissue Viability Society www.tvs.org.uk

WMAI

Wound Management Association of Ireland www.wmaoi.org

WMAS

Slovenian Wound Management Association

WMAT

Wound Management Association Turkey

ROWMA

Romanian Wound Management Association

SAfW

Swiss Association for Wound Care www.safw.ch

SEBINKO

Hungarian Association for the Improvement of Care of Chronic Wounds and Incontinentia www.sebinko.hu

SFFPC

La Société Française et Francophone de Plaies et Cicatrisations www.sffpc.org

SISS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

SWHS

Present your national wound management organisation or write a report about your organisation’s latest meeting. ewma@ewma.org

Deadline for incoming material for the next issue is 15 March 2007.

Svenskt Sårläkningssällskap www.sarlakning.com

EWMA

Journal 2007 vol 7 no 1

3 Editorial

Carol Dealey

Scientific Articles 5 Self-care activities of venous leg ulcer patients in Finland Salla Seppänen

17 Smoking is not contra-indicated in maggot debridement therapy in the chronic wound Pascal Steenvoorde

23 Effectiveness of non-alcohol film forming skin protector on the skins isles inside the ulcers and the healing rate of venous leg ulcers Tanja Planinsek Rucigaj

26 Wound measurement: the contribution to practice Georgina T. Gethin

31 Improving education in wound care: crossing he boundaries of interprofessional learning Caroline McIntosh

32 Waterjet debridement of deep and indeterminate depth thermal injuries Mayer Tenenhaus

EBWM 34 Abstracts of recent Cochrane reviews Sally Bell-Syer

EWMA 35 Brian Gilchrist: thank you Peter J Franks

36 EWMA Education Development Project: what is it and what does it do? Zena Moore

Conferences 52 EPUAP conference in Berlin, 2006 54 6th scientific meeting of the DFSG 54 The 1st national congress of WMAT 55 Conference calendar

Organisations 56 HWMS/MSKT, Hungarian Lymphoedema and Wound Managing Society 57 The hungarian SEBINKO association 58 Co-operating organisations