Ewma Journal April 2013 by EWMA European Wound Management Association

Volume 13 Number 1 April 2013 Published by European Wound Management Association

EWMA FOCUS ON ANTIMICROBIALS AND DEBRIDEMENT

The EWMA Journal ISSN number: 1609-2759 Volume 13, No 1, April, 2013 The Journal of the European Wound Management Association Published twice a year

EWMA Council Jan Apelqvist President

Salla Seppänen

Zena Moore

President Elect

Immediate Past President

Gerrolt Jukema

Dubravko Huljev

Editorial Board Sue Bale, UK, Editor Jan Apelqvist, Sweden Georgina Gethin, Ireland Martin Koschnick, Germany Marco Romanelli, Italy Rytis Rimdeika, Lithuania José Verdú Soriano, Spain Rita Gaspar Videira, Portugal Salla Seppänen, Finland

Corrado M. Durante Treasurer

Scientific Recorder

Secretary

EWMA web site www.ewma.org Editorial Office please contact: EWMA Secretariat Nordre Fasanvej 113 2000 Frederiksberg, Denmark Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org

Paulo Alves

Sue Bale

Barbara E. den Boogert-Ruimschotel

Mark Collier

Javorka Delic

Georgina Gethin

Magdalena Annersten Gershater

Nada Kecelj-Leskovec

Martin Koschnick

EWMA Journal Editor

Ann-Mari Fagerdahl

Layout: Birgitte Clematide Printed by: CS Grafisk A/S, Denmark Copies printed: 13.000 Prices: The EWMA Journal is distributed in hard copies to members as part of their EWMA membership. EWMA also shares the vision of an “open access” philosophy, which means that the journal is freely available online. Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published in October 2013. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than August 1st 2013. The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. All scientific articles are peer reviewed by EWMA Scientific Review Panel. Copyright of published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement, 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. All issues of EWMA Journal are CINAHL listed.

Sebastian Probst

Elia Ricci

Rytis Rimdeika

José Verdú Soriano

Robert Strohal

CO-OPERATING ORGANISATIONS’ BOARD Esther Armans Moreno, AEEVH Christian Thyse, AFISCeP.be Tommaso Bianchi, AISLeC Roberto Cassino, AIUC Aníbal Justiniano, APTFeridas Gilbert Hämmerle, AWA Jan Vandeputte, BEFEWO Vladislav Hristov, BWA Els Jonckheere, CNC Lenka Veverková, CSLR Ivana Vranjkovic, CWA Arne Buss, DGfW Bo Jørgensen, DSFS Heidi Castrén, FWCS Pedro Pacheco, GAIF J. Javier Soldevilla, GNEAUPP

Christian Münter, ICW Aleksandra Kuspelo, LBAA Susan Knight, LUF Loreta Pilipaityte, LWMA Corinne Ward, MASC Hunyadi János, MSKT Suzana Nikolovska, MWMA Anne Wilson, NATVNS Kristin Bergersen, NIFS Louk van Doorn, NOVW Arkadiusz Jawie´n, PWMA Severin Läuchli, SAfW (DE) Hubert Vuagnat, SAfW (FR) Goran D. Lazovic, SAWMA Mária Hok, SEBINKO F. Xavier Santos Heredero, SEHER

Sylvie Meaume, SFFPC Susanne Dufva, SSIS Jozefa Košková, SSOOR Leonid Rubanov, STW (Belarus) Guðbjörg Pálsdóttir, SUMS Cedomir Vucetic, SWHS Serbia Magnus Löndahl, SWHS Sweden Alison Hopkins, TVS Jasmina Begi´c-Rahi´c, URuBiH Zoya Ishkova, UWTO Barbara E. den Boogert-Ruimschotel, V&VN Julie Jordan O’Brien, WMAI Skender Zatriqi, WMAK Nada Kecelj Leskovec, WMAS Mustafa Deveci, WMAT

EWMA JOURNAL SCIENTIFIC REVIEW PANEL Paulo Jorge Pereira Alves, Portugal Caroline Amery, UK Jan Apelqvist, Sweden Sue Bale, UK Michelle Briggs, UK Stephen Britland, UK Mark Collier, UK Rose Cooper, UK Javorka Delic, Serbia Corrado Maria Durante, Italy Bulent Erdogan, Turkey Ann-Mari Fagerdahl, Sweden Madeleine Flanagan, UK Milada Francu ˚, Czech Republic Peter Franks, UK Francisco P. García-Fernández, Spain

Magdalena Annersten Gershater, Sweden Georgina Gethin, Ireland Luc Gryson, Belgium Eskild W. Henneberg, Denmark Alison Hopkins, UK Gabriela Hösl, Austria Dubravko Huljev, Croatia Gerrolt Jukema, Netherlands Nada Kecelj, Slovenia Klaus Kirketerp-Møller, Denmark Zoltán Kökény, Hungary Martin Koschnick, Germany Severin Läuchli, Schwitzerland Maarten J. Lubbers, Netherlands Sylvie Meaume, France Zena Moore, UK

Christian Münter, Germany Andrea Nelson, UK Pedro L. Pancorbo-Hidalgo, Spain Hugo Partsch, Austria Patricia Price, UK Sebastian Probst, Schwitzerland Elia Ricci, Italy Rytis Rimdeika, Lithuania Zbigniew Rybak, Poland Salla Seppänen, Finland José Verdú Soriano, Spain Robert Strohal, Austria Richard White, UK Carolyn Wyndham-White, Switzerland Gerald Zöch, Austria

4 Editorial

Science, Practice and Education 7 The Biofilm-forming capacity of s taphylococcus aureus from chronic wounds can be useful for determining Wound-Bed Preparation methods Yuliya Yarets, L. Rubanov, I. Novikova, N. Shevchenko

15 In vitro efficacy of various topical antimicrobial agents against multidrug-resistant bacteria

ELECTR ONIC S UPPLEM ENT

Marianna Hajská, L. Slobodníková, H. Hupková, J. Koller

20 The mTOR inhibitors and the skin wound healing Farida Benhadou, V. del Marmol

24 A Review of Evidence for Negative Pressure Wound Therapy (NPWT) use Post Spinal Surgery Ross A. Atkinson, K. J. Ousey, S. Lui, J. B. Williamson

27 A randomized study on the effectiveness of a new pressurerelieving mattress overlay for the prevention of pressure ulcers in elderly patients at risk Elia Ricci, C. Roberto, A. Ippolito, A. Bianco, M. T. Scalise

35 Motorcycle ride position, venous return, and symptoms of chronic venous insufficiency Ellie Lindsay, P. Vowden, K. Vowden, J. Megson

38 Archagathus – History’s first wound expert Elia Ricci

Cochrane Reviews 40 Abstracts of Recent Cochrane Reviews Sally Bell-Syer

EWMA

The April 2013 edition of the EWMA Journal Electronic Supplement consist of all the accepted abstracts for the EWMA 2013 Conference in Copenhagen. The Electronic Supplement is divided into Oral presentations and Poster presentations and it is possible to download individual abstracts as well as the entire supplement (including all the abstracts) at:

46 EWMA Journal Previous Issues and Other Journals 49 EWMA Antimicrobial Document Finn Gottrup

52 Finn Gottrup – Honorary lecturer of the EWMA Conference 2013

http://ewma.org/english/publications/ ewma-journal/electronic-supplement.html

Jan Apelqvist

55 EWMA Document: Résumé: Debridement – An updated overview and clarification of the principle role of debridement Robert Strohal, Dissemond, J., O’Brien, J., Piaggesi, A., Rimdeika R., Young, T., Apelqvist, J

63 EWMA policy paper: Patient Safety & Pressure Ulcers Zena Moore

66 E-Health Symposium at EWMA 2013, Copenhagen Claus Duedal Pedersen, Jan Apelqvist

68 The Diabetic Foot Symposium: A Nordic Perspective Karel Bakker, Jan Apelqvist

Organisations 74 Conference Calendar 75 Report from the 4th Pisa International Diabetic Foot Course Alberto Piaggesi

76 Report from the 1st Charcot Foot Course Maximillian Spraul

77 Russian Wound Conference In Norgorod Alexey Baindurashvili, Vladimir Kenis

78 WAWLC Symposium at EWMA 2013 David Keast

80 AAWC News

Robert J. Snyder

82 AEEVH: Spanish Association of Vascular Nursing and Wounds Esther Armans

84 AWMA: Australian Wound Management Association in 2012 Bill McGuiness

86 Review of the 5th Symposium on Chronic Wounds with International Participation: Atypical Wounds Nastja Kucišec-Tepeš

88 SWHS: Report from First Congress for treatment of chronic wounds Javorka Delic, Simon Pandjatijan

90 EWMA Cooperating Organisations

* At smith&nephew our products promote wellbeing which helps to reduce the human and economic cost of wounds. Join us for our symposia on the 15th May 2013 which will be held at EWMA 2013 in Copenhagen

Wound Management Smith & Nephew, Medical Ltd, 101 Hessle Road, Hull, HU3 2BN, UK T +44 (0)1482 225181 - F +44 (0)1482 328326 - www.smith-nephew.com/wound

ÂŠ Smith & Nephew January 2013 40823

Editorial

Presenting In-depth Wound Care Topics

he European Wound Management Association (EWMA) has a track record of presenting in-depth investigations of selected wound management topics. During the past year, EWMA has focused on debridement and the use of antimicrobials in infected wounds. The EWMA document “Debridement – An updated overview and clarification of the principal role of debridement” was published in the Journal of Wound Care last January. EWMA now looks forward to presenting the ”EWMA Antimicrobial Document” at EWMA 2013 in Copenhagen from May 15 to 17. Further information about these two documents is available on pages 49 and 55 of this issue of the EWMA Journal. EWMA has grown in significance in recent years due to its participation in a wide and growing variety of activities. The EWMA documents play a central role by incorporating the objectives of our association in practice, bringing specific topics into focus to advocate for policy change at the national or European level, and improving the work and education of health care professionals. The documents are interdisciplinary where EWMA recruit and involve specialists and co-workers from various disciplines to be able to present and analyse each topic from a broad perspective.

The EWMA documents aim to: n Present in-depth investigations of specific treatment strategies and methodologies. n Provide an overview of the best available evidence and/or how this evidence may be achieved. n Highlight a particular topic that has not yet been sufficiently described in the existing literature. n Bring specific topics into focus to advocate for policy change at the national and European levels. n Ensure that the documents are edited by editors appointed by the EWMA Council. n Include authors that represent the views and expertise of both EWMA as well as other stakeholders. n Present information from a clinical and scientific viewpoint and with a focus on benefits to the patient. During 2013, EWMA will produce two new documents. The first document will focus on wound care in home care settings across Europe; a working group has been established and is meeting to assemble this document. The second document will outline multidisciplinary approaches with a specific focus on organisational and political aspects of wound care. We welcome participants who plan to attend the EWMA 2013 conference in Copenhagen to also attend the sessions that present the documents on debridement and the use of antimicrobials in wound care. Sue Bale, EWMA Journal Editor and Jan Apelqvist, EWMA President

EWMA Journal

2013 vol 13 no 1

Venous Leg Ulcer Therapy

nc a v d

un o dW

re p m

e r a C

n o i s s

ap r e h

h ea l i n g success*

85%

Teaming up for more success. A European case study of BSN medical showed that the combination of Advanced Wound Care and Compression Therapy significantly improved 85 % of venous leg ulcers and completely healed 53 % of all cases within 12 weeks.* With its products Cutimed ® Sorbact ®, Cutimed ® Siltec, JOBST ® Comprifore and JOBST ® UlcerCARE TM, BSN medical enables effective management of venous leg ulcers while offering ease of use for doctors and patients – the perfect combination for optimal wound healing and high patient compliance. *Currently in preparation: A European Approach for Successful Venous Leg Ulcer Healing (VERUM).

BSN medical GmbH · Quickbornstraße 24 · 20253 Hamburg · www.bsnmedical.com

Cutimed ® Sorbact ® Cutimed ® Siltec JOBST ® Comprifore JOBST ® UlcerCARE TM

Science, Practice and Education

ienna

EWMA 2012

The Biofilm-forming capacity of s taphylococcus aureus from chronic wounds can be useful for determining Wound-Bed Preparation methods

Abstract Introduction: Staphylococcus aureus is frequently found in chronic wounds. Bacterial biofilms within chronic wounds impact on the surgical closure of the wounds with skin grafting. Methods of wound bed preparation (WBP) influence the microorganisms within the biofilm. We used in vitro monitoring to analyse the possible influence of WBP methods on the in vivo formation of biofilms. Aim: To conduct a comparative analysis of the impact of WBP treatment methods on the capacity of S. aureus isolated from chronic wounds to form biofilms in vitro. Methods: We modeled S. aureus biofilm formation in 96-well plates. We assayed the capacity of bacteria isolated from chronic wounds to form biofilms at the time of patient admission and after treatment with either ultrasound debridement (UD) and topical negative pressure (TNP; Main Group) or standard dressings (Control Group). We also compared biofilm formation by bacteria from patients with different grafting outcomes. Results: The treatment of chronic wounds with UD and TNP reduced the capacity of S. aureus to synthesise a major biofilm substance. S. aureus isolates from patients with favourable skin-grafting results had a lower capacity to form biofilms in vitro compared with isolates from patients with poor skin-grafting results. The use of UD and TNP for surgical closure reduced the length of the skin-graft healing process compared with the use of standard bandages. Conclusion: The isolation from chronic wounds of significant titers of S. aureus strains with a high capacity to form biofilms within 2 to 6 hours of incubation in vitro highlights the advantage of using hardware methods (UD and TNP) for WBP for surgical closure.

EWMA Journal

2013 vol 13 no 1

Introduction All chronic wounds harbor a diverse microflora that contributes directly and indirectly to their non-healing phenotype[1,2]. Exposed and devitalised tissue in chronic wounds provides a favourable environment for colonisation by a wide variety of microorganisms[3,4]. Frequently, chronic wounds harbor aerobic gram-positive cocci (Staphylococcus aureus is reported to be present in frequencies varying from 43% to 88% of the ulcers)[5,6]. Biofilms are a significant factor that differentiates chronic wound infections from acute wound infections[3]. The key characteristics of biofilm-forming bacteria are their resistance to host defenses and their tolerance of antimicrobials[7,8]. Bacterial biofilms are a complex microenvironment consisting of single or mixed species that are attached to one another or to surfaces and encased within extracellular polymeric substances (EPSs)[9]. The EPS generally consists of polysaccharides, and the bacteria within the EPS induce chronic inflammation that delays healing[10,11]. The polysaccharide components of S. aureus cell walls facilitate adherence to extracellular matrix components such as fibronectin or collagen in wounded tissues[1,2]. Different methods of treating pathogenic biofilms in chronic wounds can improve patient outcomes[3,7,11]. Sibbald et al. (2000) and Falanga (2000) first described the concept of wound bed preparation (WBP)[12,13]. The approach stresses that the successful diagnosis and treatment of chronic wounds require holistic care and a team approach[14,15]. The three main objectives of care in the WBP model are debridement, bacterial balance, and exudate management. The achievement of the key objectives should lead to a well-stabilised wound supported by a sufficiently vascularised  wound bed.

Yuliya Yarets1, MD, PhD Leonid Rubanov2, MD Iryna Novikova1, MD, PhD, Professor Natalia Shevchenko3, MSc 1Clinical Laboratory Diagnostic Department, Gomel State Medical University (Gomel, Belarus) 2Regional

Centre for Thermal Injury, Wounds, Wounds Infection, and Reconstructive Surgery and President of Gomel Wound Management Society (Gomel, Belarus)

3Bacteriologist, ClinicalDiagnostic Laboratory Department, Republican Centre of Radiation Medicine and Human Ecology (Gomel, Belarus)

Correspondence: artyut@mail.ru Conflict of interest: none

Debridement promotes healing by removing non-viable tissue and biofilms that shield bacterial colonies[16]. Ultrasonic assisted debridement (UD) is a relatively painless method of removing non-viable tissue. UD allows a rapid transition to secondary procedures, and its effectiveness in biofilm disruption is supported by in vitro studies and a decreased bioburden in patients[17,18]. Topical negative pressure (TNP) is reported by clinical and experimental studies to decrease bacterial colonisation. The seal created by the foam and drape used to apply TNP reduces the risk of bacterial colonisation; and TNP causes improved blood perfusion that may increase resistance to infections[19]. The complex use of UD and TNP methods in WBP prior to skin transplant may impact on biofilm formation following the transplant and thus reduce the frequency of post-surgery complications. Our study aimed to conduct a comparative analysis of the in vitro biofilm-forming capacity of S. aureus isolated from chronic wounds before and after wound treatment with various WBP treatment methods (standard bandages or UD/TNP) prior to skin transplant. Materials We enrolled 55 patients (20 females and 35 males, aged 25 to 70 years) who sought treatment for chronic wounds at the Gomel Regional Centre for Thermal Injury, Wound, Wounds Infection, and Reconstructive Surgery (Gomel City Clinical Hospital No1, Belarus) during 2011. The chronic wounds consisted of venous leg ulcers (n=16), pressure ulcers (n=6), traumatic ulcers (n=10), and inflammatory ulcers (n=13). In each case, the duration of the ulcers was more than 4 weeks prior to the patient’s enrollment in the study. Because UD and TNP are already used in the Gomel Regional Centre to treat chronic wounds, approval from the local ethical committee was not necessary. All patients gave written informed consent before being admitted to the study. In all cases, prior treatments, including domiciliary outpatient treatment with local remedial therapy and empirical antibiotic therapy, were unsuccessful. At the time of admission to the Gomel Regional Centre, each patient had wounds with clinical signs of inflammation. Methods We divided the patients into two groups, depending on the treatment methods. The pre-procedural wound-treatment protocol for the Control Group (n=30) included antiseptic bandages, chlorhexidine, povidone iodine, and polyethylene glycol-based ointments (e.g., Levomecol). We performed WBP 7-10 days after starting the pre-proce-

dural treatment. We changed the patients’ bandages once each day. After the pre-procedural treatment and WBP, the patients received skin grafts. The pre-procedural wound-treatment protocol for the Test Group (n=25) included UD and TNP. We applied UD at 25 kH using a «Sonoca-185» (Soring Inc., Germany) apparatus. Each patient underwent two UD treatments. We conducted the first UD treatment on the 2nd or 3rd day after beginning the pre-procedural wound-treatment protocol. We performed TNP each day for 5 to 7 days using the Visma-Planar (Belarus) negative pressure-therapy system. The optimal target pressure was 75-125 mmHg; the pressure was dependent on the patient’s tolerance. We changed the wound dressings for the patients in the Test Group every 48 hours. After receiving TNP, the patients in the Test Group underwent a second UD procedure and concomitant skin grafting. We performed wound closure for the patients in both groups using a split-thickness (0.4 mm) skin graft. None of the patients had intra-procedural complications. We changed the wound dressings for the patients in both groups once per day during the post-procedural period. Outcome assessment We collected data characterising the clinical efficacies of the pre-procedural treatments via detailed visual assessment of the regeneration process. Our data included the amount of wound effluent, the condition of the tissue surrounding the wound, the degree of granulation, the wound size and surface condition, and the appearance of edge epithelialisation. To assess the effectiveness of the skin grafts, we considered the recommended clinical signs of wound readiness: absence of inflammation, expressed exudation, purulent discharge, wound adhesiveness, mature red or bright pink granulations, and the presence of edged epithelialisation[12]. We assessed the process of graft healing by considering not only the terms and signs of the fixation, but also the complete graft healing, including the colour and degree of fixation of the graft and the degree of exudation after surgical wound closure. We defined the grafting procedure as successful when graft fixation occurred on the 3rd or 4th day after surgery and complete graft healing occurred within 7 to 9 days after surgery. We determined the presence of graft instability based on paleness and graft failure. We defined graft failure as rejection or dissolution of the graft in the immediate post-procedural period (day 8, ±3 days, on average). If a graft failed, then the patient required future repetition of the procedure.

EWMA Journal

2013 vol 13 no 1

Science, Practice and Education

Results By 7 to 10 days after the pre-procedural treatment, all of the patients in the Control Group exhibited decreased clinical signs of inflammation such as erythema, edema of peri-wound tissues, exudate volume, and release-fromwound detritus. In addition, the growth of friable granulation tissue began after the patients received the standarddressing treatment. After we performed the standard-dressing treatment, the wounds of all of the Control Group patients were ready for plastic closure, and the patients received skin grafts.

Fig. 1. Complete graft healing terms of the patients with different WBP treatment methods.

Bacterial strains We isolated S. aureus from chronic wounds. Previous work by our group demonstrated that Staphylococcus species predominate in cultures isolated from chronic wounds [20]. Biofilm assay We modeled biofilm formation in sterile 96-well polysterene microtiter plates[21]. We used Congo red and crystal violet stains to visualise both the matrix and the bacterial cells [22, 23]. We used 95% ethanol to extract the stain connected to the biofilm. We measured the optical density (OD) of each sample at a wavelength of 540 nm (for crystal violet/ethanol solution) and 490 nm (for Congo red/ethanol solution) using a Sirio microplate reader (Seac Radium Group, Italy). We isolated S. aureus from the patients’ wounds before and after WBP and compared the biofilm formation capacities of the isolates from patients with different skin-grafting outcomes. We performed all of our experiments in the Clinical-Diagnostic Laboratory of the Republican Centre of Radiation Medicine and Human Ecology and at the Clinical Laboratory Diagnostic Department of Gomel State Medical University (Gomel, Belarus). We presented the results as medians with lower and upper quartiles (M [25-75%]). We used a non-parametric Mann-Whitney U-test to compare the two study groups the Wilcoxon test to compare dependent samples (variables). We considered results to be statistically significant when p<0.05.

After the first application of UD to the patients in the Test Group, all of the necrotic areas were successfully debrided. The application of TNP resulted in the purification of the wound, the activation of reparative processes, and the covering of the bottom of the wound with granulation tissue. As a result, the patients in the Test Group experienced more noticeable clinical improvement following the skin grafting (7th-10th day of treatment) than the patients in the Control Group. The patients in the Test Group exhibited no signs of inflammation and no wound discharges. In addition, we observed signs of active reparation in the patients in the Test Group immediately following the grafting procedure. Differences in the graft healing dynamics of the patients depended on the pre-procedural treatment. All of the patients in the Test Group experienced successful wound closure: skin graft fixation occurred by the 3rd day with complete healing by the 9th (6th; 10th) day. The results were different for the patients of the Control Group. In the Control Group, 80% of the patients (n=24) had complete graft healing. The patients in the Control Group, however, exhibited several signs of instability during the post-procedural treatment; such as weak fixation, paleness, and exudation from under the grafts within 4 to 5 days; resulting in additional interventions. As a result, complete graft healing occurred significantly later in the Control Group than in the Test Group (12th [10th; 15th] day [p=0.015]) (Fig. 1). Twenty percent of the grafts in the Control Group did not take during days 2 to 5 of the post-procedural period. Some of the patients in the Control Group developed graft loss that required supplementary conservative treatment and repeated skin-grafting procedures. The patients in both groups received a dynamic bacteriological examination. In total, we detected 45 strains of S. aureus at a diagnostically significant titer (>105 c.f.u.). We isolated 20 strains from patients in the Control Group and 15 strains from patients in the Test Group. We considered bacterial contamination to be significant at a titer 

EWMA Journal

2013 vol 13 no 1

Fig. 2. Biofilm formation by S. aureus strains isolated from patient chronic wounds.

of 103-105 c.f.u. At the first bacteriological examination, all of the isolates had titers >105 c.f.u. After treatment with UD and TNP, the titers decreased up to 103-105c.f.u. In all of the patients in the Control Croup, the titers remained high, more than 105 c.f.u., prior to surgery. During the post-procedural period, we identified 14 strains of S. aureus with titers of 103105 c.f.u. in the patients in the Control Group. During the same period, we identified nine such strains in the patients in the Test Group. Figure 2 shows the in vitro biofilm-forming capacity of the S. aureus strains isolated during the first bacteriological examination (Fig. 2). We noted an increase in the OD of the crystal violet-stained eluate from 0,171 (0,057; 0,308) units at 2 hours to 0,568 (0,281; 0,611) units by 4 hours (p=0.015). This change reflects the active reproduction of S. aureus. During the remaining incubation time (from 4 to 48 hours), the biomass of the S. aureus isolates in the model biofilms was stable. An increase in the OD of Congo red-stained eluate (p=0.03) indicated a change in the dynamics of the synthesis of the exopolysaccharide (Fig. 2). The absorption parameters did not change during the incubation period from 6 to 24 hours, and we observed simultaneous decreases in EPS accumulation and the OD of Congo red staining (p=0.015). We observed changes in the dynamics of biofilm formation by the S. aureus strains isolated from the wounds of the Test Group patients after WBP but prior to surgery. After 4 and 6 hours of incubation, the OD values of the Congo red-stained eluates from the samples obtained after WBP were lower than those obtained prior to treatment (p=0.003). This finding indicates a decrease in biofilm polysaccharide production after complex WBP. The in vitro biomass production of the postWBP isolates from the Test Group decreased 18 hours after

Fig. 3. Biofilm formation by S. aureus strains isolated from chronic wounds during the first examination and after WBP with UD and TNP.

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

Science, Practice and Education

Fig. 4. Biofilm formation dynamics in vitro by S. aureus strains isolated from patient wounds after standard treatment.

the reduction in polysaccharide production (p=0.013; Fig. 3). The biofilm formation at 18 to 24 hours among the strains isolated immediately prior to surgery did not differ from that among the strains isolated at the time of hospital admission. The exopolysaccharide synthesis by the strains isolated after WBP, however, decreased. In addition, the Congo red OD values were lower after 48 hours of incubation than they were initially (p=0.038; Fig. 3). The dynamics of biofilm formation among the S. aureus strains isolated from the patients in the Control Group following WBP did not differ from those among the strains isolated from the same patients at the time of admission (Fig. 4). We examined the differences in the dynamics of the grafthealing process and the frequency of graft loss during the post-procedural period (Figs. 5 and 6) by measuring biofilm formation among the strains isolated from loss grafts (Control Group) and at the moment of skin-graft healing (Test Group). The Congo red-absorption parameters of the isolates from the wounds that experienced graft loss were greater than those of the isolates obtained after complete graft healing (p=0.037, p=0.004). This result indicates that graft loss is accompanied by a higher capacity for S. aureus to form biofilms. The S. aureus isolates from the wounds that experienced graft loss demonstrated a lower capacity for biomass formation and an increased capacity for exopolysaccharide accumulation at the beginning of the incubation period (2-4 hours). This finding was confirmed by lower crystal violet-extinction parameters for isolates from the wounds that experienced graft loss (Fig. 6). We observed higher biomass (p=0.01) after 6 hours of incubation, although the OD values for crystal violet staining did not differ between the groups during the rest of the î&#x201A;Š incubation time.

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

Fig. 5. Differences in the capacity for exopolysaccharide synthesis of the biofilm from patients depending on the results of wound closure outcome. Results are shown for patients with favourable skin grafting outcome from the Test Group and for patients with graft failure from the Control Group.

Discussion Experimental studies describe biofilm formation by different bacteria, including Staphylococcus species[23,24]. Bacteria attach to one another within several minutes and begin to develop the initial EPS within 2 to 4 hours. After beginning to form the EPS, the bacteria become increasingly tolerant to biocides within 6 to 12 hours. Within 24 hours, the bacteria develop mature biofilm colonies that are extremely resistant to biocides and shed planktonic bacteria. Therefore, the application of appropriate treatment at the early stages of biofilm formation is critical for biofilm management in chronic wounds. UD treatment involves the removal of contaminated tissue and disrupts the formation of the biofilm in the wound by destroying the EPS[17,18]. The use of TNP, which involves the removal of wound exudates and the reduction of bacteria during WBP, prevents bacterial attachment[19]. The complex use of UD and TNP facilitates the formation of granulation tissue and further helps to promote the wound-healing process[13,14,15]. Our experience is that the combination of UD and TNP is an excellent method for WBP prior to skin grafting, in contrast to other standard treatment methods.

Fig. 6. The formation of the cellular biomass of S. aureus isolated from wounds of patients with different skin graft healing outcomes. Results are shown for patients from the Test Group with favourable skin grafting outcomes and for patients from the Control Group with graft failure.

The results of our in vitro studies of biofilm formation by S. aureus strains isolated from chronic wounds support the hypothesis that the complex use of UD and TNP prior to skin grafting has a significant, positive effect on treatment outcomes. Treatment with UD and TNP resulted in a decreased capacity for S. aureus to form biofilms in vitro. The reduced capacity to from biofilms was a predictor of skin-grafting outcome; and the result was confirmed by the differences in OD values for Congo red staining measured at 2 to 18 hours in the Test Group and the Control Group. We detected higher crystal violet-absorbance parameters during the early stages of incubation (2-4 hours) in the patients with favourable skingrafting outcomes compared with those in the patients with graft loss. The isolates from patients with favourable outcomes exhibited increased proliferation and decreased biofilm-forming capacity (Fig. 6). The absence of a thick layer of ESP did not prevent the influence of local factors for wound protection, and thus, S.aureus contamination in wounds treated with UD and TNP did not cause infection or prevent healing. Therefore, we propose that the presence of S. aureus strains with a low biofilm-forming capacity will not influence the process of graft fixation. On the other hand, the presence of S. aureus strains that quickly form biofilms will affect the contact characteristics of the wound bed and impede the process of graft fixation, resulting in graft rejection. Hence, the influence of S. aureus biofilm formation should be taken into consideration when choosing the methods for WBP. The application of standard treatment methods did not alter the capacity of S. aureus to form biofilms. As a result, the

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

Science, Practice and Education

standard treatment methods did not achieve more favourable results in graft healing; in the Control Group, 20% of the patients experienced graft failure. Also, patients in the Control Group that had successful graft healing during the post-procedural period exhibited unstable graft signs; as a result, healing took longer in the Control Group than in the Test Group. Therefore, the conventional treatment of chronic wounds appears to be of little use in improving the outcome of skin grafts, and this notion is supported by other studies[24,25]. The complex use of UD and TNP did not influence the key stages of biofilm formation in vitro; these methods, however, directly influenced the pathophysiological mechanisms of chronic wounds. UD removes non-viable tissues and reduces bacterial load[17,18]. TNP promotes healing via the removal of soluble healing inhibitors from the wound and thus increases tissue perfusion, inactivates capillary autoregulation, allows the proliferating cells to rest between cycles of cell division and produce new cellular components, stimulates angiogenesis and epithelialisation, and draws the wound edges closer together[19]. Overall, our isolation of etiologically significant S. aureus strains from chronic wounds and our determination of their capacity to form biofilms with 2 to 6 hours of incubation support the complex use of UD and TNP for WBP before surgical closure.

Implications for Clinical Practice Studies of the capacity of S. aureus isolates to form a biofilms in vitro can influence the choice of methods for WBP prior to skin grafting. If S. aureus strains with an active capacity to form biofilms in vitro within 2 hours of incubation are isolated from a chronic wound during an initial bacteriological examination, then the patient is a good candidate for UD and TNP, because the bacterial strains in their wounds are likely to influence the healing of the graft. The influence of the thick layer of the main biofilm substance on the process of graft fixation should also be taken into account. Because S. aureus strains with a low capacity for biofilm formation, evidenced by EPS accumulation after 6 hours of incubation in vitro, do not influence graft fixation and healing, conservative methods of standard wound dressing will be effective for WBP in wounds harbouring those strains. Further research In the future, we will repeat these studies with increased numbers of patients in the experimental group and confirm the results in a practical setting. We are also studying the influence of different methods of wound treatment on biofilm formation by other etiologically important strains of bacteria, such as Enterobacteriaceae, Enterococcus faecalis, and non-fermenting gram-negative rod bacteria. Conclusion The biofilm-formation capacity of bacteria from chronic wounds can be used for choosing the best treatment method for WBP prior to skin grafting. m

References 1. Stephens P. Anaerobic cocci populating the deep tissues of chronic wounds impair cellular wound healing responses in vitro. Brit J Dermatol 2003:148:1-11. 2. Wall I, [et al]. Potential role of anaerobic cocci in impaired human wound healing. Wound Repair Regen 2002:10:346-53. 3. James G.A, [et al]. Biofilms in chronic wounds. Wound Rep Regen 2008:16:37-44. 4. Bowler P.G, [et al]. Wound microbiology and associated approaches to wound management. Clin Microbiol Rev 2001:141:247-269. 5. Brook I., Frazier, E. H. Aerobic and anaerobic microbiology of chronic venous ulcers. International Journal of Dermatology 1998:37:426-8. 6. Hansson C, [et al]. The microbial flora in venous leg ulcers without clinical signs of infection. Acta Dermato-Venereologica 1995:75:24-30. 7. Bjarnsholt T, [et al]. Why chronic wounds will not heal: a novel hypothesis. Wound Repair Regen 2008:16:2-10. 8. Potera C. Forging a link between biofilm and disease. Science 1999:283:1837-1839. 9. Davis D.G, [et al]. The involvement of cell-to cell signals in the development of a bacterial biofilm. Science 1998:280:295-298.

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

10. Mack D, [et al]. The intercellular adhesin involved in biofilm accumulation of Staphylococcus epidermidis is a linear b-1,6-linked glucosaminoglycan: purification and structural analysis. J Bacteriol 1996:178:175-183. 11. Davis S.C, [et al]. Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair Regen 2008:16:23-29.

18. Breuing K.H, [et al]. Early experience using low-frequency ultrasonic in chronic wounds. Annals of plastic surgery 2005:2(55):183-187. 19. European Wound Management Association (EWMA). Position Document: Topical negative pressure in wound management. London: MEP Ltd, 2007. 17 P.

12. Falanga V. Classifications for wound-bed preparation and stimulation of chronic wounds. Wound Repair Regeneration 2000:8:347-352.

20. Yarets Y.I, Shevchenco N.I, Rubanov L.N. Monitoring of strains and antibiotic sensitivity in Gomel regional centre of thermal injury, wound, wounds infection and reconstructive surgery. Infections in Surgery 2011:3:8-11.

13. Sibbald R.G, [et al]. Preparing the wound bed: debridement, bacterial balance, and moisture balance Ostomy/Wound Management 2000:11(46):14-35.

21. Judith H, [et al]. Growing and Analyzing Static Biofilms. In: Current Protocols in Microbiology. John Wiley & Sons, Inc; 2005. Supplement 22. Units 1B.1.1-1B.1.17.

14. Sibbald R.G, [et al]. Best practice recommendations for preparing the wound bed: Update 2006. Wound Care Canada 2006:1(4): 15-29.

22. Christensen G.D, [et al]. Adherence of slime-producing strains of Staphylococcus epidermidis to smooth surfaces. Infect Immun 1982:37:318-326.

15. Schultz G.S, [et al]. Wound bed preparation: a systematic approach to wound management. Wound Repair and Regeneration 2003:1(11):1-28.

23. Deighton M.A, [et al]. Methods for studying biofilms produced by Staphylococcus epidermidis. Methods Enzymol 2001:336:177-195.

16. Allan N, [et al]. The impact of VERSAJET hydrosurgical debridement on wounds containing bacteria biofilms. Wound Rep Reg 2010:18:A 88.

24. Bester E, [et al]. Metabolic differentiation in biofilms as indicated by carbon dioxide production rates. Appl Environ Microbiol 2010:76(4):215-233.

17. Ensing G.T, [et.al] The combination of ultrasound with antibiotics released from bone cement decreases the viability of planktonic and biofilm bacteria: an in vitro study with clinical strains. J Antimicrob Chemother 2006:58:6:1287-1290.

25. Rhoads 26. D.D, [et al]. Evidence of biofilms in wounds and potential ramifications. In: Gilbert P, [et al], editors. Biofilms: Coming of Age. Manchester, UK: The Biofilm Club, Manchester University; 2007. p. 131-143.

Flaminal

- a new generation in wound care

4 in 1 Enzyme Alginogels ®

Continuous debridement Antimicrobial Moist wound healing Wound edge protection / Not cytotoxic

Enzyme Alginogels ® - a new generation in wound care Flen Pharma introduces a new class in wound healing: Enzyme Alginogels ® Enzyme Alginogels ® can be applied to any type of chronic or acute wounds at any stage, whether they are contaminated or infected. Enzyme Alginogels ® provide simply better wound care.

info@flenpharma.com www.flenpharma.com

Science, Practice and Education

In vitro efficacy of various topical antimicrobial agents against multidrug-resistant bacteria ABSTRACT Aim: To evaluate the in vitro efficacy of nine topical antimicrobial agents frequently used in our burn centre against five multidrugresistant bacterial strains isolated from burn wounds of our patients. Material and methods: A simple and reproducible in vitro model was used to evaluate the effects of the following topical antimicrobials: 1% silver sulfadiazine, neomycin with bacitracin, 1% acetic acid, 0,2% nitrofurazone, 1% acetic acid with 1% silver sulfadiazine, Acticoat®, Aquacel®Ag, Atrauman®Ag, and Ialugen®Plus. Survival of five bacteria planktonic forms (Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, Staphylococcus haemolyticus, Enterococcus faecalis, and Escherichia coli) was evaluated 24-hours after application. Results: The highest efficacies against all strains were found with 1% silver sulfadiazine, 1% silver sulfadiazine + 1% acetic acid, Acticoat®, Aquacel®Ag and Ialugen®Plus. The combination of neomycin with bacitracin in ointment form and Atrauman®Ag were absolutely ineffective. Conclusions: Topical antimicrobial agents play an important role in the treatment of burns, but they should be used according to the efficacy against bacterial strains in wounds. Thanks to our results we can modify the spectrum of topical antimicrobials used in our burn centre. In the future, we would like to examine the efficacy of the topical agents using an in vitro biofilm model.

EWMA Journal

2013 vol 13 no 1

INTRODUCTION Improvements in burn wound care have led to longer survival and potentially an extended hospital stay. The most likely cause of death is an infectious complication after surviving the initial burn insult and resuscitation period[1]. It is now estimated that approximately 75% of the mortality following thermal injuries is directly related to infection[2,3,4]. Burn patients are at high risk for infections caused by nosocomially-acquired multidrugresistant organisms because of generalised humoral and cellular immunodeficiency, gastrointestinal translocation of microorganisms, prolonged hospital stay, and invasive diagnostic and therapeutic procedures[2,5]. The standard of care at specialised burn centres worldwide is early excision of necrotic tissues and grafting, which results in decreased mortality. However, the benefit of topical antimicrobial agents is that they can be used at all levels of care. Another benefit of topical antimicrobials is that they can be applied directly to the site of colonisation or infection and can be used for both prophylaxis and treatment of burn wound infections[6]. According to 43% of burn specialists worldwide, the antimicrobial activity in a burn dressing is considered to be essential[7]. Bacteria with resistance to multiple systemic antimicrobials are increasing in prevalence, which raises the concern for a subsequent increase in resistance to topical antimicrobial agents[6,8,9]. In the last decades, one of the most commonly applied topical agents for partial-thickness burns has been silver sulfadiazine[10,11]. Despite the possible but uncommon side effects attributed to silver sulfadiazine[9,12], this agent is also a reference standard therapy in many studies. The most frequently used topical agent in our burn centre is a combination of 1% silver sulfadiazine cream and 1% acetic acid solution. In addition to our own clinical experience, several studies have affirmed the efficacy of this solution[13-17]. According to the European Wound Management Association position document [Management of wound infection (2006)], the selection of antimicrobial agents to reduce or eradicate micro-organisms must be influenced by the specificity and efficacy of the agent. However, the decision for

Marianna Hajská1 M.D., PhD Student Lívia Slobodníková2 PhD., Clinical Micro biologist Helena Hupková2 Assoc. Prof. – Head of the Department Ján Koller1 Assoc. Prof. – Head of the Department 1 Teaching

Department of Burns and Reconstructive Surgery, Medical Faculty of Comenius University and University Hospital, Bratislava, Slovakia

2 Institute

of Microbiology, Medical Faculty of Comenius University and University Hospital, Bratislava, Slovakia Corresponding author: mariannahajska@ gmail.com Conflict of interest: none



Table 1: List of the tested topical antimicrobial agents Solutions

1% Acetic Acid

Prepared by hospital pharmacy

0,2% Nitrofurazone

Prepared by hospital pharmacy

1% Silver Sulfadiazine

Dermazin®1% crm, Sandoz Pharmaceuticals

Neomycin with Bacitracin

Framykoin® ung, Zentiva

Combination

1% Silver Sulfadiazine with 1% Acetic Acid

Dermazin®1% crm, Sandoz Pharmaceuticals with 1% Acetic acid prepared by hospital pharmacy

Impregnated dressings

Acticoat® Smith and Nephew

Consists of three layers: an absorbent rayon/polyester inner core sandwiched between outer layers of a nanocrystalline silver-coated low-adherent polyethylene net

Aquacel®Ag Convatec

Non-woven pad or ribbon dressing composed of sodium carboxymethylcellulose and 1.2% ionic silver

Atrauman®Ag Hartmann

Polyamide fibres coated with elemental silver; the impregnation contains Caprylic/Capric/Stearic Triglyceride;Bis-diglyceryl-polyacyladipate-2 and Macrogol 2000

Ialugen®Plus IBSA

1% silver sulfadiazine, 0,2% natrii hyaluronas

Creams / Ointments

selection of a particular topical antimicrobial agent in our burn centre has so far been mostly empiric. The common standard is to take a swab from the burn wound at admission and at least once per week, after which the sample is sent to the microbiological laboratory for evaluation of wound flora and susceptibility testing. The results inform us of bacterial susceptibility to most of the systemic antibiotics, but not to topical ones. From the high variety of topical antimicrobials only the minimal inhibition concentration of nitrofurazone and bacitracin are routinely tested in our laboratory so far. AIM The aim of this study was to evaluate and compare the efficacy of nine topical antimicrobials and investigate whether the multidrug-resistant bacteria isolated from burns of our hospitalised patients are still susceptible against the most frequently applied agents in our burn centre. MATERIAL AND METHODS Multidrug-resistant bacteria isolated in the year 2011 from burn wounds of patients hospitalised in the Bratislava Burn Centre were used to create a bacterial collection stored in the research laboratory of the Institute of Microbiology. We tested the susceptibility of five bacterial strains [Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), Staphylococcus haemolyticus, Enterococcus faecalis, and Escherichia coli] in planktonic form against nine topical antimicrobials (Table 1) using the modified quantitative method originally introduced by Hammond A. et al.[18]. In comparison with the original method, solutions and impregnated dressings were also tested in addition to ointments. We placed three sterile 6-mm cellulose disks on a petri dish with Luria Bertani agar (LB-agar), and 10 µl bacterial suspension containing 10²-10³ colony forming units 16

(CFU) was dropped on each disk (Figure 1). The surface of the dish was covered with a sterile gauze square (5 × 5 cm) saturated with topical antimicrobials, or with one of the commercially produced impregnated dressings. From each cream/ointment, 1 g was uniformly spread on the gauze. From solutions, 2-ml aliquots were dropped to saturate the gauze. A sterile gauze square without topical antimicrobials was used as a control. A sterile small glass petri dish was placed on the gauze to maintain direct contact between the agent and the inoculated disks (Figure 2). The dishes were incubated at 37°C for 24 hours, after which the gauze squares were removed and each disk transferred into a sterile tube containing 1 ml phosphate buffered saline (PBS). The tubes were vigorously vortexed three times for 2 minutes to detach bacteria from the disks. Suspended cells were serially diluted four times (a 10-fold dilution was used) in PBS and 10-µl aliquots of each dilution were inoculated on LB agar plates. These plates were incubated at 37°C for 16 hours and the numbers of CFU were counted (Figure 3). The final result recorded represented ³ 108 CFU/disk if the bacterial growth was so massive that the number of CFU obtained was uncountable even in the highest dilution. RESULTS Using five multidrug-resistant bacterial strains in planktonic form our results demonstrated strong bactericidal action of five topical antimicrobial agents: 1% silver sulfadiazine, 1% silver sulfadiazine with 1% acetic acid, Acticoat®, Aquacel®Ag, and Ialugen®Plus. In all of these samples tested no bacterial growth was detected 24 hours after their application. The same bactericidal effect against MRSA, S. haemolyticus, and P. aeruginosa was found with the application of 1% acetic acid. On the other hand, this agent had only a bacteriostatic effect against E. coli and E. faecalis. Nitrofurazone in a 0,2 % concentration EWMA Journal

2013 vol 13 no 1

Science, Practice and Education

Figure 1: Three sterile 6-mm cellulose disks with bacterial suspension placed on the surface of an LB-agar plate.

Figure 2: Sterile gauze square placed on top of disks and covered by a small sterile glass petri dish.

was highly effective as well, with the exception against P. aeruginosa where no effect was observed. On the other hand, neomycin with bacitracin and Atrauman®Ag were found ineffective against all of the bacteria tested, as we observed the same bacterial growth using these agents as in the control samples with sterile gauze only. The results are shown in Figure 4. DISCUSSION Bacterial resistance belongs to the most severe problems in modern medicine. Some authors suggest that resistance against topical antimicrobials increases similar to resistance seen against systemic antibiotics[19]. Animal and clinical studies are performed to determine the efficacy of topical antimicrobials in vitro. While studies on patients are focused on comparisons between new agents and standard therapy[12,20,21], in vitro models are designed to test more agents[1,19,22,23]. To show the efficacy of topical antimiFigure 4: Bacteria counts (CFU/disk) after 24 hours of action of the tested topical antimicrobials (bacterial count 108 CFU per disk corresponds to ³108 CFU per disk) (1% AA: 1% acetic acid; 1% SS: 1% silver sulfadiazine; neo+bac: combination of neomycin and bacitracin)

EWMA Journal

2013 vol 13 no 1

Figure 3: Bacterial growth in 10-μl aliquots of the serial dilutions of bacteria detached from the testing disk after 24 hours of incubation with the tested agent.

crobials against bacterial flora from the wounds of patients it is necessary to establish a standard in vitro model. This is important to test and compare the efficacy of different forms (solutions, ointments, etc.) of agents. We proved that a modification of the method introduced by Hammond A. et al. (2011) provides this possibility. Our in vitro method for testing and comparing antimicrobial efficacy is simple and reproducible, and the quantitative analysis of the surviving microbial inoculum is fully sufficient to demonstrate the efficacy of the tested agents. The majority of results obtained in our study are in concordance with results of other already published studies. For instance, we demonstrated resistance of P. aeruginosa to 0,2% nitrofurazone, which, on the other hand, had a bactericidal effect on the rest of the bacterial strains tested. These findings are similar to those of Conly et al.[24]. We also found high efficacy of 1% silver sulfadiazine, despite it having been the most frequently used topical antimicrobial in our burn centre for many years and that evidence for bacterial resistance to silver has been reported[25-27]. Similarly high efficacy of this agent was demonstrated by Koo et al.[28]. In addition to our results, the findings of Ryssel et al.[13-16] have shown a bacterio

Science, Practice and Education

static and even a bactericidal effect of acetic acid on various bacterial strains. The clinical efficacy of dressings combining hyaluronic acid and silver sulfadiazine (Ialugen®Plus) was previously shown in a clinical study[29] and has been realised in our burn centre. Now its high antibacterial efficacy was demonstrated in the in vitro model presented in this study. Acticoat® and Aquacel®Ag exhibited similarly excellent antimicrobial activity in our study too, which is in concordance with results published by other groups. [30-34]. We demonstrated excellent efficacy of five topical antimicrobials in preventing wound infection; however, all of our tests were performed in vitro on planktonic bacteria only, and further research on bacterial biofilms and in the clinical setting will be necessary. CONCLUSIONS We demonstrated that the topical antimicrobial agents most frequently used in our burn centre (1% silver sulfadiazine and 1% acetic acid) have high efficacy against

multidrug-resistant bacteria isolated from burn wounds of our patients. Implication for clinical practice The use of topical antimicrobials is very important not only according to usual practice but also according to the establishment of their efficacy in vitro. Even if we were not able to test all varieties of bacteria from wounds of our patients, our having tested the efficacy of the most regularly used agents against resistant strains of bacteria can help burn specialists to prevent and treat burn wound infection more effectively. Further research We are currently performing tests on bacteria in a biofilm form of growth to find out the efficacy of the tested agents in burns treated several hours/days after injury. This testing will also be expanded to a larger number of clinical bacterial strains. m

References [1] Glasser JS, Guymon CH, Mende K, Wolf SE, Hospenthal DR, Murray CK. Activity of topical antimicrobial agents against multidrug-resistant bacteria recovered from burn patients. Burns 2010: 36 (8): 1172-84. [2] Guggenheim M, Thurnheer T, Gmür R, Giovanoli P, Guggenheim B. Validation of the Zürich burn-biofilm model. Burns 2011: 37 (7): 1125-33. [3] Koller J, Boca R, Langšádl L. Changing pattern of infection in the Bratislava burn center. Acta chirurgicae plasticae 1999: 41 (4): 112-116. [4] Königova R, Bláha J a kol. Komplexní lécba papáleninového traumatu. Praha: Karolinum; 2010. p. 305. [5] Gomez R, Murray CK, Hospenthal DR, Cancio LC, Renz EM, Holcomb JB, et al. Causes of mortality by autopsy findings of combat casualties and civilian patients admitted to a burn unit. J Am Coll Surg 2009: 208:348-54 [6] Davis SC, Pisanni F, Montero RB. Effects of commonly used topical antimicrobial agents on Acinetobacter baumannii: an in vitro study. Mil Med 2008: 173:74-8 [7] Selig HF, Lumenta DB, Giretzlehner M, Jeschke MG, Upton D, Kamolz LP. The properties of “ideal” burn wound dressing – What we need in daily clinical practice? Results of a worldwide online survey among burn care specialists. Burns 2012: 38 (7): 960-966. [8] Schuenck RP, Dadalti P, Silva MG, Fonseca LS, Santos KR. Oxacilin- and mupirocin-resistant Staphylococcus aureus: in vitro activity of silver sulphadiazine and cerium nitrate in hospital strains. J Chemother 2004: 16:453-8 [9] Fuller FW. The side effects of silver sulfadiazine. Journal of Burn Care and Rehabilitation. 2009: 30:464-70 [10] Hermans MH. Results of an internet survey on the treatment of partial-thickness burns, full thickness burns and donor sites. Journal of Burn Care and Rehabilitation. 2007: 28:835-47 [11] Hermans MH. Results of a survey of the use of different treatment options for partial and full thickness burns. Burns 1998: 24:539-51 [12] Daryabeigi R et al.: Comparison of healing time of the 2 degree burn wounds with two dressing methods of fundermolherbal ointment and 1% silver sulfadiazine cream., Iran J Nurs Midwifery Res. 2010 Summer: 15(3): 97-101. [13] Ryssel H, Kloeters O, Germann G, Schäfer T, Wiedemann G, Oehlbauer M. The antimicrobial effect of acetic acid – an alternative or common local antiseptics?. Burns 2009: 35(5): 695-700

[14] Ryssel H, Gazyakan E, Germann G, Hellmich S, Riedel K, Reichenberger MA, Radu CA. Antiseptic therapy with a polylactacid-acetic acid matrix in burns. Wound Repair Regen. 2010: 18 (5): 439-444.

[25] Wenzel RP, Hunting KJ, Osterman CA, et al. Providencia stuartii, a hospital pathogen: potential factors for its emergence and transmission. Am J Epidemiol 1976; 104(2): 170-80.

[15] Ryssel H, Germann G, Riedel K, Reichenberger M, Hellmich S, Kloeters O. Suprathel-acetic acid matrix versus acticoat and aquacel as an antiseptic dressing in vitro study. Ann Plast Surg. 2010: 65 (4): 391-395.

[26] Bridges K, Lowbury EJ. Drug resistance in relation to use of silver sulphadiazine cream in a burns unit. J Clin Pathol 1977; 30(2): 160-74.

[16] Ryssel H, Andreas Radu C, Germann G, Kloeters O, Riedel K, Otte M, Kremer T. Suprathel antiseptic matrix: in vitro model of local antiseptic treatment?. Adv Skin Wound Care 2011: 24 (2): 64-67. [17] Fraise A. Acetic acid; a cost effective burn dressing for all nations. 16 th Congress of the International Society for Burn Injuries; 9.-13.Sept 2012; Edinburgh, United Kingdom: ISBI; 2012. Paper No: 184 [18] Hammond AA, Miller KG, Kruczek CJ, Dertien J, Colmer-Hamood JA, Griswold JA, Horswill AR, Hamood AN. An in vitro biofilm model to examine the effect of antibiotic ointments on biofilms produced by burn wound bacterial isolates. Burns 2011: 37 (2): 304-313 [19] Neely AN, Gardner J, Durkee P, Warden GD, Greenhalgh DG, Gallagher JJ, Herndon DN, Tompkins RG, Kagan RJ. Are topical antimicrobials effective against bacteria that are highly resistant to systemic antibiotics? Burn Care Res. 2009: 30 (1): 19-29. [20] Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazene dressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. 2011: 4 (3): 183-7. [21] Strand O, San Miguel L, Rowan S, Sahlqvist A. Retrospective comparison of two years in a paediatric burns unit, with and without acticoat as a standard dressing. Ann Burns Fire Disasters. 2010: 23 (4): 182-5. [22] Ge SD, Hu ZL, Cheng YL, Fang ZY, Tu SZ, Xu BR, Jiang XT. Experimental study on topical antimicrobial agents in burns. Burns Incl Therm Inj. 1987: 13 (4): 277-80. [23] Taddonio TE, Thomson PD, Smith DJ Jr, Prasad JK. Topical antimicrobial testing of burn wound microorganisms: evaluation of a new technique. Burns 1990: 16 (1): 64-66. [24] Conly JM, Byrne S, McLeod J, Hoban S, Robertson G, Ronald AR. Antimicrobial cream susceptibility testing. Burns Incl Therm Inj. 1985: 12 (2): 91-6.

[27] Silver S. Bacterial silver resistance: molecular biology and uses and misuse of silver compounds. FEMS Microbiol Rev 2003; 27: 341-53. [28] Koo DS, Zhen S, Zhen ZD, Shi XW, Xiang SJ. Assessment of topical therapy of the burn wound with silver sulphadiazine after its use for 15 years in a burn unit. Burns. 1989: 15 (3): 193-6. [29] Koller J. Topical treatment of partial thickness burns by silver sulfadiazine plus hyaluronic acid compared to silver sulfadiazine alone: a double-blind, clinical study. Drugs Exp Clin Res. 2004:30(5-6):183-90. [30] Ulkür E, Oncul O, Karagoz H, Yeniz E, Celiköz B. Comparison of silver-coated dressing (Acticoat), chlorhexidine acetate 0.5% (Bactigrass), and fusidic acid 2% (Fucidin) for topical antibacterial effect in methicillin-resistant Staphylococci-contaminated, full-skin thickness rat burn wounds. Burns. 2005 Nov: 31(7):874-7. [31] Selçuk CT, Durgun M, Ozalp B, Tekin A, Tekin R, Akçay C, Alabalık U. Comparison of the antibacterial effect of silver sulfadiazine 1%, mupirocin 2%, Acticoat and octenidine dihydrochloride in a full-thickness rat burn model contaminated with multi drug resistant Acinetobacter baumannii. Burns. 2012 Dec: 38(8):1204-9. [32] Acar A, Uygur F, Diktas H, Evinç R, Ulkür E, Oncül O, Görenek L. Comparison of silver-coated dressing (Acticoat®), chlorhexidine acetate 0.5% (Bactigrass®) and nystatin for topical antifungal effect in Candida albicans-contaminated, full-skin-thickness rat burn wounds. Burns. 2011 Aug: 37(5):882-5. [33] Nasir NA, Halim AS, Singh KK, Dorai AA, Haneef MN. Antibacterial properties of tualang honey and its effect in burn wound management: a comparative study. Nasir NA, Halim AS, Singh KK, Dorai AA, Haneef MN. BMC Complement Altern Med. 2010 Jun 24:10:31. [34] Mabrouk A, Boughdadi NS, Helal HA, Zaki BM, Maher A. Moist occlusive dressing (Aquacel(®) Ag) versus moist open dressing (MEBO(®)) in the management of partial-thickness facial burns: a comparative study in Ain Shams University. Burns. 2012 May: 38(3):396-403.

EWMA Journal

2013 vol 13 no 1

ienna

EWMA 2012

Farida Benhadou, MD

Veronique del Marmol, MD, PhD

Dermatology department, ULB Erasme Hospital, Brussels, Belgium Correspondence: Farida.Benhadou@ ulb.ac.be Conflict of interest: none

The mTOR inhibitors and the skin wound healing Abstract Background: The wound healing process is divided into four phases: haemostasis/coagulation, inflammation, proliferation, and wound remodelling. The wound closure needs a perfect control of these phases thus wound management is always a challenge. Numerous factors, like medications, can markedly affect most aspects of the wound healing process. Aim: We want to focus our attention on the mammalian target of rapamycin (mTOR). Deregulation of the mTOR signalling pathway occurs frequently in human malignancies. The pharmacological inhibition of mTOR with rapamycin and its analogs is used in organ transplantation to prevent rejection and to slow skin carcinogenesis in organ recipients. Methods: This article reviews the recent literature on the mTOR inhibitors and the potential cellular and/or molecular mechanisms involved in the wound healing process. Results and conclusions: The mTOR inhibitors can affect all steps of the healing process by decreasing the inflammatory cell number, angiogenesis, and myofibroblast proliferation. The frequent association, among organ recipients treated by mTOR inhibitors, with other immunosuppressive therapies and comorbidities exacerbate the risk of wound healing complications. The complexity of the mTOR pathway is not completely understood but its role in the wound healing process is crucial. The indication for the mTOR therapy has to be discussed carefully for each patient. Introduction The mTOR inhibitors are new immunosuppressive agents mainly used in transplant medicine and in oncology. The first agent developed was the rapamycin or rapamune and was initially isolated in the soil of Easter Island and was used as a fungicide(1).

The discovery of the immunosuppressant properties of rapamycin led to the understanding of the mammalian target of rapamycin (mTOR) pathway. The mTOR pathway is a complex network playing a key role in the synthesis of cellular proteins important for angiogenesis, metabolism and cell proliferation(2). Many clinical trials have shown the effectiveness of rapamycin in decreasing the incidence of malignancy and skin cancers in solid organ transplant recipients(3,4). The development of rapamycin and its analogs is a promising therapeutic option but important adverse events have been described such as hyperlipidemia, anaemia, leukopenia, and thrombocytopenia(5). Their cutaneous side effects and especially their effect on the wound healing process will be discussed in this article. Mechanisms of action The mTOR is an important kinase necessary for physiological cellular activities acting by forming two complexes; the mTOR complex 1 and the mTOR complex 2. The result of the activation of complex 1 is the promotion of cell proliferation, the angiogenesis process and protein synthesis. The mTOR complex 2 activity is essential for the transformation and vitality of a number of cancer cell types, but in many normal cells, mTOR complex 2 activity is less essential. The rapamycin can inhibit the activation of the mTOR complex 1 by binding to an intracellular receptor FKBP12, but how this interaction antagonises the mTOR complex 1 is not well understood. In that way, rapamycin is able to cause an immunosuppression by inhibiting the signal transduction pathway required for the progression of cytokine-stimulated T-cells from G1 into S phase. In addition, many enzymes along the signalling pathway that are inhibited by the rapamycin play

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

Science, Practice and Education

a role in the development and progression of different cancers and metabolic disorders such as diabetes or atherosclerosis. The mTOR pathway is upregulated in many other conditions such as in polycystic kidney disease and neurofibromatosis. The mTOR pathway is a complex network with a variety of positive and negative regulators but all these mechanisms are not completely explained(6,7,8). Side effects Despite their attractive pharmacological properties, side effects are associated with mTOR use in 20-40%(9) of patients. Some side effects are easily manageable, whereas others lead to discontinuation of the drug. The anaemia, thrombocytopenia, neutropenia, proteinuria, lymphedema and hyperlipidemia are the most reported dose dependent side effects(10,11). Cutaneous side effects have also been reported such as wound healing impairment. Such skin side effects have also been reported with the use of anti-vascular endothelial growth factor (VEGF) therapy and could therefore be a limiting factor for their use(12). Cutaneous side effects Pruritic follicular papulo-pustular eruption represents a typical side effect occurring early after the initiation of the mTOR inhibitors therapy. This effect is mostly temporary and usually improves within a few weeks(13). Pruritus and xerosis are frequently reported by the patients receiving mTOR inhibitors therapy(13). Cases of angioedema have been reported but all the patients were simultaneously treated with angiotensinconverting enzyme inhibitors. The resolution of the angioedema was observed after the withdrawal of the angiotensin-converting enzyme inhibitors(14). The development of buccal ulcerations and stomatitis are a common and potentially dose limiting toxicity associated with the use of mTOR inhibitors in cancer treatment(13). The interactions of the mTOR inhibitors on the healing process are important cutaneous side effects. Wound infections, incisional hernias and wound dehiscence have also been reported(15). Wound healing impairment A normal healing process can be divided in four steps: haemostasis and coagulation, inflammation, proliferation and remodelling. A perfect control on each step is necessary for a correct healing(16).

EWMA Journal

2013 vol 13 no 1

The mTOR inhibitors can directly interfere with each step of the healing process but more specifically on the inflammation and proliferation stages. They are able to inhibit the angiogenesis process by decreasing the level of the VEGF, they can also decrease the activity of the intraepithelial gd T cells and cause an inhibition of the smooth muscle cells, fibroblast proliferation and matrix deposition. This would decrease the formation of scar tissue and compromise blood flow to the defect. The crucial role played by the mTOR in the healing process has yet to be examined in detail(17). The mTOR inhibitors can also indirectly interfere with the repair process. Their immunosuppressant properties increase the risk of infection. The anaemia, hypoproteinemia and lymphedema secondary to the mTOR inhibitors therapy are also risk factors for healing complication and delayed healing(18,19). Management The management of wound healing complications in patients treated by mTOR therapy is difficult. The clinicians have to be aware of the potential healing impairment caused by mTOR therapy. We have reviewed the recent literature concerning mTOR therapy and its impact on the wound healing process. There is no standardised guideline concerning the management of healing complications. We have found some recommendations; with a level three of evidence based medicine, proposed for the use of the mTOR inhibitors in the transplantation medicine(20). We have summarised the important points: n Before starting the mTOR inhibitors therapy, it is recommended that the risk factors for wound healing complications are checked. Factors like the use of concomitant immunosuppressive therapy, obesity, and smoking are modifiable risk factors. The patient’s age, sex and ethnic origin are non–modifiable risk factors. Any modifiable risk factor should be addressed. If a non-modifiable risk factor is identified, a risk–benefit analysis should be performed and, if appropriate, an alternative treatment to mTOR inhibitors should be considered. n Some clinicians are narrowing or even discontinuing the use of steroids in the early post-transplant period. It is also recommended to avoid the use of the mTOR inhibitors during the first week posttransplantation. n The impaired healing is a dose-dependent side effect. A cumulative rapamycin dose of more than 35 mg during the first four days post-transplantation is a risk factor for impaired healing. It is highly recom-



Science, Practice and Education

mended to avoid the loading doses and to initiate and maintain rapamycin at a dose of 2–4 mg/day, with an increase in dose above this level only if target levels are not reached by day seven. Recommended target levels are between 5 and 10 ng/ml, depending on concomitant immunosuppressant therapy. n It is also important to know that some medications can increase the blood level of the rapamycin like the inhibitors of CYP3A4 (verapamil, ketoconazole, erythromycin…) and their concomitant use with the mTOR inhibitors therapy can be a risk factor for impaired healing. n Concerning the risk for surgery, it is important to identify the type of surgery. For major surgery, the mTOR inhibitors have to be stopped five to 10 days before the surgery and restarted one to three months after the surgery. n Regarding non-surgical wounds such as traumatic wounds and vascular ulcers, the recommended attitude is classical wound care management. The risk factors for a wound healing complication have to be checked and corrected if possible. The diagnosis and treatment of infections are important steps for helping the correct healing. The withdrawal or the decreasing of the dose of the mTOR inhibitors therapy has to be considered only for complicated wounds where there is an inability to correct the risk factors(20).

Conclusions: The development of the mTOR inhibitors is an interesting therapeutic option thanks to their different immunosuppressive properties. They are mainly used in transplant medicine and oncology. The involvement of the mTOR pathway in many disorders such as neurofibromatosis and polycystic kidney disease has enlarged their indications. One of the major benefits of rapamycin is that it is an immunosuppressant that inhibits carcinogenesis, whereas other immunosuppressants are thought to increase carcinogenesis like the calcineurin inhibitors. The effect of the mTOR inhibitors on carcinoma is likely inhibition of angiogenesis and an associated decrease in vascular endothelial growth factor. Unfortunately the use of the mTOR inhibitors is associated with many side-effects. Some of these are manageable, whereas others could be limiting factors for mTOR use. This article gives you a general overview of the effects of mTOR inhibitor therapy. Our article sought to point out their important impact on the skin healing process. The management of this side effect is based on a number of recommendations with a level three of evidence based medicine. Control of the risk factors for wound complication is a crucial step before starting such therapy. The complexity of the mTOR pathway is not completely understood but its role in the wound healing process is crucial. The indication for the mTOR therapy has to be fully discussed and the risk-benefits balance must be considered carefully for each patient. It would also be interesting in the future to develop guidelines regarding their use in the oncology field. m

References:

10 Kim M et al. Marked erythrocyte microcytosis under primary immunosuppression with sirolimus. Transpl Int.2006:19 :12-18.

1 Sharp ZD, Strong Rather role of mTOR signaling in controlling mammalian life span: what a fungicide teaches us about longevity. J Gerontol A Biol Sci Med Sci 2010: 65:580–589.

11 Kasiske B et al. Mammalian target of rapamycin inhibitor dyslipidemia in kidney transplant recipients. Am J Transplant.2008:8 : 1384-1392.

2 Karar J, Maity A.J PI3K/AKT/mTOR pathway in angiogenesis. Front Mol Neurosc 2011:4:51-64.

12 Kamba T et al. Mechanisms of adverse effects of anti-VEGF therapy for cancer. Br J Cancer. 2007 :96(12): 1788–1795.

3 Tee A, Blenis J. mTOR, translational control and human disease. Seminars in Cell & Developmental Biology 2005:16:29–37.

13 Mahe E et al. Cutaneous adverse events in renal transplant recipients receiving sirolimus-based therapy. Transplantation 2005:79 :476-482.

4 Hofbauer G et al. Swiss clinical practice guidelines for skin cancer in organ transplant recipients. Swiss med Wkly2009 :139(29_30) :407- 415.

14 Zuckermann A et al. Clinical experience with Certican in maintenance heart transplant patients at the medical University of Vienna. J. Heart Lung Transpl 2005:24 : 206-209.

5 Brewer J et al. The effects of sirolimus on wound healing in dermatologic surgery. Dermatol Surg 2008:34:216-223. 6 Hara K et al. Raptor, a binding partner of target of rapamycin, mediates TOR action. Cell 2002:110:177-189. 7 Kim D et al. G betaL, a positive regulator of the rapamycin-sensitive pathway required for the nutrient-sensitive interaction between raptor and mTOR. Mol Cell 2003:11:895-904. 8 Suryawan A et al. Differential regulation of protein synthesis in skeletal muscle and liver of neonatal pigs by leucine through an mTORC1-dependent pathway J Anim Sci Biotechnol.2012 : 3(3). 9 Rostaing L et al. mTOR inhibitor/proliferation signal inhibitors: entering or leaving the field. J nephrol .2010:23 (02) : 133-142.

15 Brewer J et al. The effects of sirolimus on wound healing in dermatologic surgery. Dermatol Surg 2008:34:216-223. 16 Di Pietro L A, Guo. Factors affecting wound healing. J Dent Res. 2010 ;89(3):21929 17 Squarize C et al. Accelerated Wound Healing by mTOR Activation in Genetically Defined Mouse Models. Plos One 2010:5 (5) :10643. 18 Mills R et al. Defects in skin T cell function contribute to delayed wound repair in rapamycin-treated mice .J Immunol 2008 :181(6): 3974-3983. 19 Schäffer M et al. Sirolimus impairs wound healing. Langenbecks Arch Surg 2007: 392:297-303. 20 Campistol JM et al. European Society for Organ Transplantation 2009: 22(7) : 681-687.

EWMA Journal

2013 vol 13 no 1

Visit us at EWMA 2013

Are you ready to enjoy the freedom of superior absorption?

Coloplast Wound Care will soon increase its superior absorption for faster healing offering with the launch of a new foam product. Visit us at EWMA on stand 9 for more information and join our A-symposium Wednesday 15th of May from 12.30–13.30

Science, Practice and Education

A Review of Evidence for Negative Pressure Wound Therapy (NPWT) use Post Spinal Surgery Extended Abstract

Ross A. Atkinson1 PhD, Spinal Research Coordinator Karen J. Ousey2 PhD, RGN, Reader, Steve Lui2 MSc, Senior Lecturer, John Bradley Williamson3 MBChB, FRCS, Consultant in Spinal Surgery 1Greater Manchester Neurosciences Centre; and Honorary Research Associate – The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, C235 Clinical Sciences Building, Stott Lane, Salford, M6 8HD. 2School

of Human and Health Sciences, Centre for Health and Social Care Research, University of Huddersfield, Queensgate, Huddersfield, West Yorkshire, HD1 3DH. 3Salford

Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD

Correspondence: ross.atkinson@nhs.net Conflict of interest: none

Aims To systematically search, critically appraise and summarise randomised controlled trials (RCTs) and non-RCTs assessing the effectiveness of negative pressure wound therapy (NPWT) in patients with a surgical spinal wound. Methods A systematic review based on search strategies recommended by the Cochrane Back and Wounds Review Groups was undertaken using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases. Any publications between 1950 and 2011 were included. Funding to undertake this systematic review was received from the University of Huddersfield Collaborative Venture Fund and KCI Medical. Results Nine retrospective studies(1-9) and five case studies(10-14) of patients with spinal wound complication were included in this systematic review. No RCTs were found. Only one study described more than 50 patients(4). Generally, a pressure of -100 to -125 mmHg was used in adult patients(1,8,12).

References 1. Jones GA, Butler J, Lieberman I, Schlenk R. Negative-pressure wound therapy in the treatment of complex postoperative spinal wound infections: complications and lessons learned using vacuum-assisted closure. J Neurosurg Spine 2007: 6(5):407-411. 2. Labler L, Keel M, Trentz O, Heinzelmann M. Wound conditioning by vacuum assisted closure (V.A.C.) in postoperative infections after dorsal spine surgery. Eur Spine J 2006: 15(9):388-396. 3. Mehbod AA, Ogilvie JW, Pinto MR, Schwender JD, Transfeldt EE, Wood KB et al. Postoperative deep wound infections in adults after spinal fusion: management with vacuum-assisted wound closure. J Spinal Disord Tech 2005: 18(1):14-17. 4. Ploumis A, Mehbod AA, Dressel TD, Dykes DC, Transfeldt EE, Lonstein JE. Therapy of spinal wound infections using vacuum-assisted wound closure: risk factors leading to resistance to treatment. J Spinal Disord Tech 2008: 21(5):320-323. 5. Antony S, Terrazas S. A retrospective study: clinical experience using vacuum-assisted closure in the treatment of wounds. J Natl Med Assoc 2004: 96(8):1073-1077. 6. Canavese F, Gupta S, Krajbich JI, Emara KM. Vacuum-assisted closure for deep infection after spinal instrumentation for scoliosis. J Bone Joint Surg Br 2008: 90(3):377-381.

Duration of NPWT in situ ranged from three to 186 days(2,5,6,8,13). Wound healing was assessed every two to three days and generally completed between seven days and 16 months(1-5,9-14). NPWT is contraindicated in the presence of active cerebrospinal fluid leak(1), metastatic or neoplastic disease in the wound(9,10), in patients with an allergy to the NPWT dressing(9), and in those with a bleeding diathesis(1). Discussion We identified no RCTs discussing the use of NPWT in the management of surgical spinal wounds, and limited low quality evidence demonstrating that NPWT can be used effectively in this type of patient. In an RCT in obese patients undergoing total knee arthroplasty, no difference in the time taken to achieve a dry wound with NPWT as compared with a sterile gauze has been reported(15). Importantly, that study was terminated early due to the presence of skin blisters associated with the NPWT dressing; an adverse effect which has not been reported in the spine literature. Furthermore, Dorafshar and colleagues(16) concluded that NPWT did not provide superior

7. Canavese F, Gupta S, Emara KM, Krajbich JI. Use of the vacuum assisted closure in instrumented spinal deformities for children with neuromuscular scoliosis who developed post-operative deep spinal infection. Developmental Medicine and Child Neurology 2009: 51(5):50. 8. Horn PL, Ruth B, Kean JR. Use of wound V.A.C. therapy in pediatric patients with infected spinal wounds: a retrospective review. Orthop Nurs 2007: 26(5):317-322: quiz 323-324. 9. Zehnder SW, Place HM. Vacuum-assisted wound closure in postoperative spinal wound infection. Orthopedics 2007: 30(4):267-272. 10. Yuan-Innes MJ, Temple CL, Lacey MS. Vacuum-assisted wound closure: a new approach to spinal wounds with exposed hardware. Spine (Phila Pa 1976) 2001: 26(3):E30-33. 11. Adams J, Hakim EM. A critical analysis of existing evidence on the management of a wound with Malignant Desmoplastic Melanoma and Neurofibromatosis: a caser report. Rehabilitation Oncology 2009: 27(1):26-27. 12. van Rhee MA, de Klerk LW, Verhaar JA. Vacuum-assisted wound closure of deep infections after instrumented spinal fusion in six children with neuromuscular scoliosis. Spine J 2007: 7(5):596-600. 13. Vicario C, de Juan J, Esclarin A, Alcobendas M. Treatment of deep wound infections after spinal fusion with a vacuum-assisted device in patients with spinal cord injury. Acta Orthop Belg 2007: 73(1):102-106.

EWMA Journal

2013 vol 13 no 1

ienna

EWMA 2012

outcomes with regards to wound volume and surface area over wall suction applied to a sealed gauze dressing in patients with acute wounds resulting from trauma, dehiscence or surgery. However, a further study in knee arthroplasty patients found that NPWT was associated with a reduction in post-operative development of seromas and improved healing(17). Conclusions The evidence for NPWT use in orthopaedic surgery is ambiguous, and at best low quality in spine patients. Published reports are limited to small retrospective and case studies, with no reports of NPWT being used as a prophylactic treatment in spinal patients. Larger, prospective RCTs of NPWT are needed to support the current evidence that it is effective in treating spinal wound complications. In addition, future studies should investigate the use of NPWT as a prophylactic treatment to promote wound healing and prevent infection, and report data relating to safety and health economics. m

14. Hwang JH, Modi HN, Suh SW, Hong JY, Yang JH, Park JH. Maggot debridement therapy for postsurgical wound infection in scoliosis: a case series in five patients. Spine (Phila Pa 1976) 2011: 36(4):313319.

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM)

EWMA 2013 COPENHAGEN 15 -17 May · 2013

in Copenhagen

The EWMA UCM programme offers students of wound management from institutes of higher education across Europe the opportunity to take part of their academic studies whilst participating in the EWMA Conference. The opportunity of participating in the EWMA UCM is available to all teaching institutions with wound management courses for health professionals. The UCM programme at the EWMA 2013 Conference in Copenhagen will offer networking opportunities between the students from various UCM groups, UCM Lectures as well as assignments and workshops arranged specifically for the UCM students. EWMA strongly encourages teaching institutions and students from all countries to benefit from the possibilities of international networking and access to lectures by many of the most experienced wound management experts in the world. Yours sincerely

Zena Moore, Chair of the Education Committee, Immediate Past President Participating institutions:

Donau Universität Krems Austria

HUB Brussels Belgium

Haute École de Santé Geneva, Switzerland

Lithuanian University of Health Sciences Lithuania

15. Howell RD, Hadley S, Strauss E, Pelham FR. Blister formation with negative pressure dressings after total knee arthroplasty. Current Orthopaedic Practice 2011: 22(2):176–179. 16. Dorafshar AH, Franczyk M, Gottlieb LJ, Wroblewski KE, Lohman RF. A prospective randomized trial comparing subatmospheric wound therapy with a sealed gauze dressing and the standard vacuum-assisted closure device. Annals of Plastic Surgery 2011: 69(1):79-84.

Metropolitan University College Denmark

17. Pachowsky M, Gusinde J, Klein A, Lehrl S, Schulz-Drost S, Schlechtweg P, et al. Negative pressure wound therapy to prevent seromas and treat surgical incisions after total hip arthroplasty. International Orthopaedics 2011: 36(4):719-722.

University of Hertfordshire United Kingdom

Universidade Católica Portuguesa Porto, Portugal

For further information about the EWMA UCM, please visit the Education section of the EWMA website www.ewma.org or contact the EWMA Secretariat at ewma@ewma.org EWMA Journal

2013 vol 13 no 1

Puts you in control of wet wounds!

ยง ยง ยง ยง ยง

Superabsorbs and retains large amounts of exudate Minimizes the risk of maceration and skin damage Convenient and safe single-use wound dressing Works well under compression Reduced dressing changes = patient comfort and cost efficiency

For availability in your country, please contact: info@absorbest.se

Manufacturer: Absorbest AB Kisa, Sweden www.absorbest.se www.drymax.se info@absorbest.se

Science, Practice and Education

A randomized study on the effectiveness of

A NEW PRESSURE-RELIEVING MATTRESS OVERLAY for the prevention of pressure ulcers in elderly patients at risk ABSTRACT Aim: This is a two-arm prospective study with random assignment to assess the efficacy of Aiartex®, a new CE-marked three-dimensional anti-decubitus mattress overlay made from flame retardant Polyester compared with Akton® a commercially available viscoelastic mattress overlay for the prevention of pressure ulcers development in aged patients at moderate/high risk. Methods Fifty patients (aged 65 years or older) admitted in long-term units, who were at moderate/high risk (Braden scale score 8-14) or medium-high risk (Norton1 scale score 6-12) of developing pressure ulcers, were randomly assigned to either three-dimensional (study group) or viscoelastic (control group) mattress overlay placed on top of a standard foam mattress. The observational period was 4 weeks. Results Neither patients using three-dimensional nor those using the control overlay developed a pressure ulcer during the entire study. Both overlays were well tolerated, and no patient experienced adverse events or allergic reactions. No patient experienced skin maceration or cutaneous irritation. Conclusions The results obtained with threedimensional were comparable to those obtained with the control mattress overlay. This suggests that a new comfortable, easy-to-use, and safe mattress overlay can be used for the prevention of pressure ulcers.

INTRODUCTION Pressure ulcers, also known as pressure sores or decubitus, are wounds, usually accompanied by an inflammatory reaction, that develops as the result of sustained, externally applied pressure, often over a bony prominence1. Pressure ulcers may penetrate into the subcutaneous tissue in rather short time2 but require many weeks of conservative treatment to heal or, alternatively, may need surgical coverage3. Pressure ulcers are an emerging entity 4,5 and have huge impact on quality of life6. The growth of the elderly population and the longer survival of other frail persons, have led to a remarkable increase of acute and long-term hospitalization7-9, with augmented care and economic burdens for the healthcare system in the developed countries10-13. Today, pressure-reducing equipments are widely used in the daily practice of pressure ulcer prevention.14,15 However, the limited amount of clinical evidences can make selection of appropriate equipment difficult.14,15 The Norton17 and Braden18 scales are among the most widely recognized pressure ulcer risk assessment and grading tools that illustrate the main principles for appropriate prevention.16 According to Braden scale, reduction of skin maceration is one of primary factors in the pressure ulcer prevention.18 Humidity and friction are also contributing risk factors for pressure ulcers development. In the literature, several studies described the efficacy of different types of mattresses and mattress overlays in the treatment and prevention of pressure ulcer formation; however, many reviews8,9,19 highlighted the need for further randomized studies. We decided to avoid a direct comparison between a standard mattress and a mattress overlay, as this

Elia Ricci, M.D.1 Cassino Roberto, M.D.2 Annamaria Ippolito, S.S.O.2 Andrea Bianco, M.D.3 Maria Teresa Scalise, H.D.3 1Operative

Unit of Vulnology, San Luca Clinic, Pecetto Torinese, Italy 2Vulnera

Italian Vulnological Center, Turin, Italy

3Long Term Care RPO, Turin, Italy

Correspondence: ericcisegreteria@alice.it Conflict of interest: This study was sponsored by Herniamesh® Srl

 References 1. Norton D. “Calculating the risk: reflections on the Norton scale”. Decubitus 1989; 2(3): 24-31.

4. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992;89:272-8.

2. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009

5. Brandeis GH, Morris JN, Nash DJ, Lipsitz LA. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990;264:2905:9.

3. Harris AG, Leiderer R, Peer F, Messmer K. Skeletal muscle microvascular and tissue injury after varying durations of ischemia. Am J Physiol 1996;271:2388–98.

6. Vangilder c, Macfarlane GD, Meyer S. results of nine international pressure ulcer prevalence survey: 1898 to 2005. Ostomy Wound Manage 2008;54:40-54.

EWMA Journal

2013 vol 13 no 1

Table 1. Cases at enrollment

N of patients evaluated N of patients admitted

Males

Females

93 8

167 42

Age

(mean, years)

81.5 84.7

would not have added any important information to our current knowledge: thus, we decided to compare the new mattress overlay with a largely used mattress overlay with proven efficacy.

operators. The other two meetings discussed the study design and case report forms. For each unit, one medical operator was responsible for enrolling the patients, who were then assessed at T=0 by an external physician responsible for conducting the study. Patients of both genders aged 65 years old or more, who had an anticipated hospitalization period in the same unit lasting at least 28 days after assignment to the study groups, were included in the study if they presented with all inclusion criteria (and in presence of none of the exclusion criteria) listed in Table 2, patients with pressure sores stage 1 was also eligible. After informed consent was given, eligible patients were medically assessed on the day of the screening; patient demographic data were collected, blood samples for hematocrit and albumin tests were taken, if appropriate, and BMI values were calculated (as kg/m2). Assessment of patient vital signs and accurate evaluation of pressure ulcer, if present (including evaluation by digital planimetry, photography and WBP score), was to be performed (however, as described later in the text, no development of pressure ulcers was observed during the study). Patients were randomized according to a computer generated pre-defined assignment list in sealed envelopes to use a standard mattress plus either three-dimensional or viscoelastic overlay. The observational period was 4 weeks.

MATERIALS AND METHODS The study was conducted from May 9, 2011 to September 5, 2011. This prospective, two-arm study with random assignment was designed taking into account the current version of the EPUAP-NPUAP guidance for chronic cutaneous ulcer, and was conducted in compliance with ICH GCP Guidelines, National regulatory requirements, the Declaration of Helsinki, recommendations of the Ethics Committee, and local regulatory and administrative requirements. All eligible patients were fully informed of the benefits and risks of participation in this study. From each patient a written informed consent was obtained prior to the subject entering the study. Patients were repositioned every 2 hours, alternating lateral (30Â°) and supine position. The study was Table 2. inclusion / exclusion criteria conducted in two long-term care units, with a Criteria total of 150 beds. A total of 260 patients from Braden scale score >8 to < 14 these two units were evaluated for participaNorton scale score >6 to < 12 tion into the study. We only selected patients Pressure ulcer stage 0 (EPUAP-NPUAP) who (according to their clinical status) were Pressure ulcer stage 1 (EPUAP-NPUAP) candidates for mattress overlays available Expected hospital stay > 28 days at the care units. The characteristics of the Pressure ulcer stage 2 (EPUAP-NPUAP) general population screened and enrolled are Pressure ulcer stage 3 (EPUAP-NPUAP) summarized in Table 1. Pressure ulcer stage 4 (EPUAP-NPUAP) After study design and preparation of case Terminal or severely compromising illness report forms, 4 meetings with all investigators AIDS or hepatitis C from both units took place. During the first Ongoing systemic corticosteroid therapy, two meetings, the guidelines for prevention immuno-suppressant therapy or chemotherapy and treatment were established. All protocols Enrollment within the past 3 months in any study were based on the EPUAP-NPUAP guiderelated to wound healing lines2; a copy of these guidelines, translated Allergy to mattress overlay components into the Italian language, was provided to all

7. Langemo DK. Quality of life and pressure ulcers: what the impact? Wounds 2005;17:3-7. 8. Reddy M, Sudeep GS, Rochon PA. Preventing Pressure Ulcers: A Systematic Review. JAMA 2006; 296(8): 974-984. 9. Cullum N, McInnes E, Bell-Sayer SEM, Legood R. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews 2004, Issue 3.

Inclusion

Exclusion

YES

10. Langer G, Schloemer G, Knerr A, Kuss O, et al. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews 2003, Issue 4. 11. Essex HN, Clark M, Sims J, Warriner A, Cullum N. Health-related quality of life in hospital inpatients with pressure ulceration: assessment using generic health-related quality of life measures. Wound Repair Regen 2009;17:797-805. 12. Gorecki C, Brown JM, Nelson EA, Briggs M, et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc 2009;57:1175-83.

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

Science, Practice and Education Figure 1. The Aiartex® mattress overlay.

B. The mattress overlay alone

C. The mattress overlay applied over a standard mattress. A. Detail of the innovative three dimensional structure

Patient’s conditions (any presence of skin lesions, pressure ulcers, erythema, area of skin maceration) were then re-assessed at days 7, 14, 21, and day 28 (the last visit). The occurrence of any adverse event or allergic reaction was evaluated at each visit. Risk assessment according to Norton and Braden scales was performed at the first visit and at the end of the study. Patient’s conditions (any presence of skin lesions, pressure ulcers, erythema, area of skin maceration) were then re-assessed at days 7, 14, 21, and day 28 (the last visit). The occurrence of any adverse event or allergic reaction was evaluated at each visit. Risk assessment according to Norton and Braden scales was performed at the first visit and at the end of the study. The presence of pain (as assessed by the patient using a 10 cm visual analogue scale, VAS) was also evaluated at the first visit and at the end of the study: the evaluation was conducted by the external investigator. Global safety and tolerability of the 2 overlays were assessed by the investigators during the last visit using a non-validated 4-point scale (1 = poor, 2 = fair, 3 = good, 4 = excellent).

Aiartex® mattress overlay (Herniamesh® Srl, Chivasso, Turin, Italy) The Aiartex® mattress overlay is a CE-marked class 1 medical device that is used in the treatment and prevention of pressure ulcers. This 3D mattress overlay is a macro-porous three-dimensional material (9 mm thick) entirely made in Polyester flame retardant.20 It consists of two parallel and superimposed layers connected by transversal suspensory monofilaments (see Figure 1). It is highly porous (with pores larger than one millimeter) and elastic, with complete return to its original shape after decompression (this latter data comes from the indications of the manufacturer and was confirmed by the studies conducted with this mattress overlay). Small, interconnected air spaces are originated, which provide continuous ventilation of the skin while improving load distribution with a reduction of pressure peaks. The upper layer, soft, 

13. Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing 2004;33:230-5.

16. McInnes E, Cullum NA, Bell-Syer SEM, Dumville JC. Support surfaces for pressure ulcer prevention (review). Chocrane Database of Systematic Review 2008, Issue 4.

14. Pompeo MQ. The role of “wound burden” in determining the costs associated with wound care. Ostomy Wound Manage 2001;47(3):65–71.

17. Norton D, Exton-Smith AN, McLaren R. An investigation of geriatric nursing problems in hospitals. London: Churchill Livingstone. National Corporation for Care of Old People, 1975.

15. Bell J. The role of pressure-redistributing equipment in the prevention and management of pressure ulcers. J Wound Care 2005;14(4):185-8.

EWMA Journal

2013 vol 13 no 1

18. Braden B. Bergstrom N. Clinical utility of the Braden Scale for Predicting Pressure Sore Risk. Decubitus. 1989:2:44-51.

Table 3. Baseline demographic and clinical characteristics of study population. Variable

viscoelastic

P Value

Mean ± SD (n)

83.6 ± 6.9 (25)

85.8 ± 8.4 (25)

0.317

Males (n)

Females (n)

Mean ± SD (n)

164.6 ± 7.1 (25)

163.3 ± 7.6 (25)

Body weight (kg)

Mean ± SD (n)

58.6 ± 12.2 (25)

60.1 ± 11.8 (25)

0.661

BMI (kg/m2)

Mean ± SD (n)

21.6 ± 4.0 (25)

22.6 ± 4.4 (25)

0.405

Hematocrit (%)

Mean ± SD (n)

38.1 ± 4.2 (21)

36.4 ± 4.0 (20)

0.193

Albumin (g/dl)

Mean ± SD (n)

3.3 ± 0.6 (21)

3.2 ± 0.6 (20)

0.597

Systolic blood pressure (mmHg)

Mean ± SD (n)

121.0 ± 12.2 (25)

120.4 ± 12.7 (25)

0.865

Systolic blood pressure (mmHg)

Mean ± SD (n)

68.2 ± 6.3 (25)

69.4 ± 8.3 (25)

0.567

Heart rate (bpm)

Mean ± SD (n)

73.3 ± 7.8 (25)

73.3 ± 7.3 (25)

n.a.

Age (years) Gender Height (cm)

0.247 0.535

Anova test, or Yates’ chi-squared test

made of multi-filament, drains any exudates and conveys them to the lower layer by capillarity and gravity through the transversal mono-filaments, thus maintaining the skin dry and aerated and preventing maceration. The intermediate transversal layer and the lowest one are both made of monofilament. The mattress overlay weights 850 g. The main mechanism of action of this elastically deformable mattress overlay is based on its innovative 3D structure, in which the creation of small interconnected air spaces allows weight distribution, thus reducing the peak pressure, and also allows for drainage of exudates; moreover, the device minimizes frictional stress. Preliminary results on the performance of Aiartex® as a pressure-relieving device21-24, were obtained in recent studies.25,26 These studies, which were published in non-indexed journals, provided results that were indicative only, and served as the basis for the present study.

Akton® Viscoelastic mattress overlay (Action Products, 954 Sweeney Drive, Hagerstow, MD, USA) Viscoelastic mattress overlay (15.9 mm thick) was selected as the control mattress overlay being one of the most widely used pressure relieving device for the prevention of pressure ulcers, especially in the United States of America: the FDA recommendation for its use was graded as “strong”.27,28 The mattress overlay is made of 100% Akton viscoelastic polymer.27 It has been on the market for almost 40 years. It is a vulcanized cross-linked rubber material with ability to maintain its shape, stretch, deflect an applied load and absorb shock. For these properties it is used for the treatment and prevention of decubitus ulcers within the medical industry. Some models are available with a hook and loop hitch used to secure one end of the mattress overlay to the head of the bed. The mattress overlay weights 35 kg.

Table 4. Norton and Braden scale scores evaluated at the admission (Day 0) and at the end of the study (Day 28) Day 0

Norton scale

viscoelastic (n = 25)

3D (n = 25)

Viscoelastic (n = 25)

Mean ± SD

9.6 ± 1.4

10.4 ± 1.3

9.6 ± 1.4

10.4 ± 1.3

Mean ± SD

11.9 ± 1.5

12.4 ± 1.2

11.9 ± 1.5

P value Braden scale P value

Day 28

3D (n = 25) 0.042* 0.199

0.042* 12.5 ± 1.2 0.125

*P < 0.05, Anova test

19. Madhuri R, Sudeep S, Paula A. Preventing Pressure Ulcers: a systematic review. JAMA. 2006;296(8):974-984

22. Ippolto AM, Cassino R, Ricci E. Come migliorare le prestazioni delle superfici antidecubito. Acta Vulnologica 2011;9:S1-S3 (Italian).

20. Aiartex technical information (ww.herniamesh.com/en/incont_TrattamentoFerite. html).

23. Ricci E, Cassino R, Trabucco R. Overlay in tessuto tridimensionale, performance sui picchi di pressione. Acta Vulnologica 2011;9(S1-S3):124-6 (Italian).

21. Cassino R, Ricci E. Caratteristiche di impiego di un sovramaterasso in materiale tridimensionale per la prevenzione di decubiti. Acta Vulnologica 2010;8:S1-S3 (Italian).

24. Ricci E, Cassino R. Inner tube overlay: an added value? EWMA Journal 2011;11:2S.

EWMA Journal

2013 vol 13 no 1

Science, Practice and Education

patients assigned to the control mattress overlay (10.4 ± 1.3). Our analysis revealed Score that these average score values in the two 1 – poor 2 – fair 3 – good 4 – excellent groups of patients, although moderately, 3D (n) 0 0 20 5 were significantly different (P = 0.042). Viscoelastic (n) 0 0 24 1 Interestingly, the score values in the two P value n.a. n.a. 0.192 groups of patients remained unchanged during the clinical trial, thus maintaining Yates’ chi-squared test such a slightly significant difference at the end of the study (Table 4). However, no statistically significant difference was found in the average Braden scale scores Study objectives and statistical analyses evaluated at Day 0 or Day 28 between the two groups of The primary objective of the study was the comparison in patients (11.9 ± 1.5 and 12.4 ± 1.2 for patients assigned the two study groups of the incidence of pressure ulcers at to use 3D and viscoelastic mattress overlays, respectively, P day 28. The secondary objectives included the compari> 0.05). Thus, we considered that such a small difference son of the following: change of the ulcer size (if present), in the Norton score values did not jeopardize the validity incidence of new ulcers involving sacrum and heels as of the clinical trial and the results could be interpreted well as the other exposed anatomic areas (such as spinous in a descriptive manner. At the day of study enrollment, process, trochanter, lateral and medial malleolus, ischium, none of the 50 patients presented with a pressure ulcer at elbow); patient’s subjective safety, tolerability and evaluathe sacrum, heel, or other anatomical regions (see Table tions (comfort and satisfaction); safety (including assess3); interestingly, none of the patients developed pressure ment of wound) and tolerability. It should be pointed ulcers during the entire study period. The presence of pain out that, as described later , no development of pressure associated with staying in bed was evaluated in less than a ulcers was observed during the study. No formal power half of patients; however, no statistically significant differcalculation was performed to address the determination of ence was found between the two groups of patients. The the sample size. P values of less than 0.05 were considered average Norton score evaluated at the day of the enrollto be statistically significant. ment into study (Day 0) in the group of patients assigned to use the 3D mattress overlay (40.8 ± 23.4) resulted in moderately lower scores than in patients assigned to the RESULTS control group (59.4 ± 16.1); however, no statistically sigA total of 50 patients, who were admitted in different nificance was found between groups. At the end of the long-term care units in Italy, were enrolled in the study, 25 study, Norton scores remained stable. Both study and pts per group. Table 3 summarizes the demographic and control mattress overlays were well tolerated and none of some of the clinical characteristics of the study population. the patients experienced adverse events during the entire The mean age of the patients using the 3D overlay was duration of the study; skin health was optimal in patients 83.6 ± 6.9 years, and the mean age of patients using the of both groups, and no patient experienced skin maceracontrol mattress overlay was 85.8 ± 8.4 years. Statistical tion or irritation. Table 5 summarizes the results on global analyses revealed that all patients enrolled in the study safety and tolerability scores as assessed by the investigators were homogeneous in terms of age, gender and other deduring the last visit using a 4-point scale. Such scores fell in mographic and clinical characteristics, with no significant the good-excellent classes for all patients. In particular, the difference between the two groups of patients. global safety and tolerability was classified as “excellent” in However, when analyzing the distribution of the vala slightly larger number of patients assigned to 3D overlay ues of pressure ulcer risk assessment, the average Norton (5 patients vs. only one patient in the control group); score evaluated at the day of the enrollment into study however, such difference was not statistically significant. (Day 0) in patients assigned to the study group resulted in slightly lower scores (9.6 ± 1.4) than in the group of  Table 5. Comfort assessment at the end of the study (day 28), as evaluated by the investigators in patients using study and control mattress overlay.

25. Mastrangelo D, Farina E, Di Donna V, Gallicchio V, et al. Analisi iniziale di studio prospettico randomizzato su coprimaterasso antidecubito. Acta Vulnologica 2009;7:S1-S3 (Italian). 26. Mastrangelo D, Farina E, Gallicchio V, De Anna D, et al. Studio osservazionale su coprimaterasso nella prevenzione e cura dei decubiti. Acta Vulnologica 2010;8(2):87-92 (Italian).

28. U.S. Food and Drug Administration (FDA). Guidance for industry: Chronic cutaneous ulcer and burn wounds – Developing products for treatment. U.S. Department of Health and Human Services, Food and Drug Administration, Center for Biologicals Evaluation and Research (CBER), Center for Devices and Radiologic Health (CDRH), and Center for Drug Evaluation and Research (CDER). June 2006.

27. Akton technical information (www.akton.com/akton.html).

EWMA Journal

2013 vol 13 no 1

Science, Practice and Education

DISCUSSION The original three-dimensional mattress overlay structure, which combines properties of pressure relieving device with the additional properties of low friction device, good ventilation, and moisture absorbing capacity, laid the groundwork for the rationale of our study. We were expecting the device to be potentially capable to prevent and/or slow progression of pressure ulcers in patients at risk. As a matter of fact, this new mattress overlay has already gained some attention as promising pressure-reducing equipment. The ability of this mattress overlay as a reliever of the peak sacral interface pressure when applied over different types of mattresses (such as standard, foam, silicone fiber, low alternating pressure, interactive automatic compensation, and air loss) had already been demonstrated in recent studies.21,24 Some evidence on the effectiveness of 3D mattress overlay in preventing ulcer formation in low-risk bedridden patients was also provided in recent observational studies conducted by Mastrangelo et al.25,26 The aim of our study was to evaluate the effectiveness of 3D mattress overlay in preventing pressure ulcer formation in aged patients at high/moderate risk, as well as its safety and comfort, as compared with a commercially available viscoelastic mattress overlay that has been clinically proven to be effective in pressure ulcer prevention in a good quality randomized controlled trial.29,30 As a general outcome, the results of this study indicate that the two mattress overlays were equally effective, well-tolerated and safe tools when used as anti-decubitus ulcer devices. The target anatomic areas (sacrum and heels) adopted for the primary endpoint were identified taking into account the most common location of pressure ulcers in patients hospitalized in long term care units.31,32 Our population study was composed of patients at moderate/high risk of pressure ulcer development who, at the enrollment in the study, did not have any pressure ulcer in the sacrum or heel (in accordance with inclusion criteria, patients must have either grade 0 or 1 ulcer); interestingly, none of the patients developed pressure ulcers in these or other anatomical areas during the entire study duration. These results on the good performance of 3D mattress overlay as anti-decubitus mattress overlay are in agreement with the findings of Mastrangelo et al.23,24 Both at the initial visit and at the end of the study, the scores evaluated in 3D mattress overlay, using patients according to the Norton

classification system, were slightly but significantly lower than those observed in patients using the control mattress overlay; the scores registered using the Braden scale also revealed a small difference, which however lacked any statistical significance. According to the finding of Mastrangelo et al., in patients presenting with superficial ulcers at the beginning of the study and assigned to use 3D mattress overlay, the complete healing was attained one week earlier than in patients who were not using the mattress overlay.23,24 In our study, the lack of patients presenting with ulcers prevented the evaluation of whether 3D mattress overlay could help improve the healing of pressure sores. We acknowledge that a study extended to patients presenting with ulcers of varying severity might have provided a more comprehensive overview into the potential benefits of the use of 3D mattressoverlay, as it could have allowed to investigate in details the ability to improve wound healing in terms of ulcer size reduction, management of exudates, and acceleration of wound healing. As a matter of fact, the results of our study certainly indicate that this is an issue that needs to be addressed, and that further accurate analyses in this respect are desirable.

29. Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomised controlled trial comparing a dry visco-elastic polymer pad and standard operating table mattress in the prevention of postoperative pressure sores. International Journal of Nursing Studies 1998;35(4):193â&#x20AC;&#x201C;203.

31. Schue RM, Langemo DK. Pressure ulcer prevalence and incidence and a modification of the Braden Scale for a rehabilitation unit. J Wound Ostomy Continence Nurs. 1998;25(1):36-43.

30. Cullum N, Nelson EA, Fleming K, Sheldon T. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy Health technology Assessment 2001;5(9).

CONCLUSIONS The 3D mattress overlay provided a good performance in terms of pressure ulcer prevention in patients at high/ moderate risk, thus confirming that its particular structure allowed an optimal load distribution and a reduced support pressure that helped in reducing the risk of capillary occlusion in patients with limited mobility. Moreover, the capability of draining and conveying humidity allowed preserving good conditions of the skin layer, as no maceration was noticed. It is also important to notice that 3D mattress overlay weighted only 850 g in favour of a much better handling if compared to the viscoelastic overlay whose weight was 35 kg. In conclusion, although further evaluations of the beneficial effect of this new device in the management of pressure ulcers might be advisable in order to provide a more comprehensive overview, we believe that our results obtained with AiartexÂŽ mattress overlay, which were comparable to those obtained with a widely used polymer mattress overlay, support the proposal that a new comfortable, easy-to-use, and safe opportunity is available for the prevention of pressure ulcers. m

32. Lahmann NA, Halfens RJ, Dassen T. Pressure ulcers in German nursing homes and acute care hospitals: prevalence, frequency, and ulcer characteristics. Ostomy Wound Manage. 2006 Feb;52(2):20-33.

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

Allround expertise

Sizes: Ă¸ 11 cm and Ă¸ 17 cm

rbion o s w e the n r e v o c s Di tar* at hagen s i t l u sana m 13 in Copen 20 EWMA

sorbion sana multi star*

Primary dressing for low to moderate exuding wounds

NEW

available from Main Germany rch 2013

High flexibility Tissue protection Less pain during dressing change Locks in bacteria and toxins Hypoallergenic

* sorbion sana multi star is currently available in Germany only.

www.sorbion.com

Vivano Safety. And Simplicity. 速

16/5 posium on .m.! m y s r u o Visit :15 p a.m. to 12 5 :1 1 1 m o fr

The VivanoTec negative pressure unit by HARTMANN is the central component of the Vivano system for successful negative pressure treatment of wounds. Its low weight means it can be used either on the move or in hospitals. Thanks to its intuitive menu navigation, the VivanoTec negative pressure unit combines easy usage with highly precise treatment settings and the necessary reliability, thus guaranteeing a high level of safety and user-friendly handling.

Science, Practice and Education

ienna

EWMA 2012

Motorcycle ride position, venous return, and symptoms of chronic venous insufficiency

oth immobility and venous compression, whether due to clothing, build, pregnancy, or body position, affect venous return from the lower limb. Krijnen et al.(1) reported that standing professions increase the incidence of venous insufficiency in male workers, confirming the importance of hydrostatic pressure in the development of venous disease. Bjellerup(2) coined the term “hydrostatic leg ulcers” to describe leg ulcerations not associated with prior deep venous thrombosis or superficial or deep venous reflux. Similar duplex ultrasonography findings affecting up to 10% of subjects have been noted in other studies of lower limb venous ulceration(3). Motorcycle design requires many bikers to adopt a riding position that results in acute flexion at both knee and hip, and to maintain this position for prolonged periods with little or no calf muscle pump activity. This position, combined with tight-fitting protective clothing on the lower limbs, increases the risk of popliteal vein compression, which compromises venous return(4).

We therefore conducted a questionnaire survey to assess bikers’ lower limb symptoms and their attitudes toward health and safety. Over a period of 4 years, motorcyclists were invited to complete a questionnaire regarding motorcycle usage, demographics, attitudes towards risk, and lower limb health. Of the 767 respondents, 332 (43%) reported experiencing leg cramps during or immediately after motorcycling. Data analysis to determine correlations with factors such as rider age, journey time, and class of motorcycle is on-going and will be reported elsewhere. Our survey results reveal that many bike riders experience typical symptoms of chronic venous insufficiency, suggesting that the bike ride position may contribute to the development of lower limb venous disease. These observations have lead to the publication of general advice on maintenance of healthy legs for bikers and their passengers (www.legclub.org/ downloads/motorcyclists.pdf ). These findings by themselves do not provide convincing evidence that ride position and reduced 

Figure 1

Ellie Lindsay1 Independent Specialist Practitioner Visiting Fellow, Queensland University of Technology

Peter Vowden2 Consultant Vascular Surgeon, Bradford Teaching Hospitals Visiting Professor of Wound Healing Research, University of Bradford K. Vowden2 J. Megson2 1The Lindsay Leg Club Foundation 2Bradford

Teaching ospitals NHS FoundaH tion Trust, Bradford UK Correspondence: ellie@legclub.org Conflict of interest: none

EWMA Journal

2013 vol 13 no 1

Science, Practice and Education Figure 2 Results obtained in bike ride position showing a normal result for the left leg (A), and poor emptying and obstructed pattern for the right leg (B). RT, refilling time; Vp, venous pump.

calf muscle pump effective activity is a causative factor in bikers’ low limb symptoms. Designing a non-invasive assessment of venous function suitable for use in the bike ride position was difficult, but we concluded that a modified photoplethysmography (PPG) venous testing protocol offered the best solution. The standard method for PPG assessment of venous function is well documented(5). Kelechi and Bonham(6) described this method as a simple but underused tool for venous function assessment. In addition, Sam et al.(7) concluded that PPG assessment is a reproducible non-invasive method for assessing venous function. Methods In an attempt to quantify the effect of bike ride position on venous function, each subject was tested in two different positions. A conventional PPG test was conducted while the subject was seated with the hip and knee flexed at approximately 110° (see Figure 1). A similar test was conducted with the subject seated in a typical sports bike riding position with an acutely flexed knee and hip and dorsiflexed ankle. In both tests, 10 ankle flexion extension exercises were performed while light absorption of skin illuminated by a light-emitting diode was recorded by a photo-receiver. Changes in light absorption were used to determine the efficiency of the calf muscle pump in emptying blood from the lower limb. Continued observation as the PPG reading returns to baseline during the resting phase indicates refilling time, a measure of valvular competency. Standard patterns of emptying and refilling have been defined, with a refilling time of <20 s considered abnormal (indicating venous incompetence). Failure to References 1. Krijnen RM, de Boer EM, Ader HJ, Bruynzeel DP. Venous insufficiency in male workers with a standing profession. Part 1: epidemiology. Dermatology. 1997;194(2):111-20. 2. Bjellerup M. Hydrostatic leg ulcers: a new classification. J Wound Care. 1997;6(9):408-10. 3. Vowden KR, Barker A, Vowden P. Leg ulcer management in a nurse-led, hospitalbased clinic. Journal of Wound Care. 1997;6(5):233-6. 4. Lane RJ, Cuzzilla ML, Harris RA, Phillips MN. Popliteal vein compression syndrome: obesity, venous disease and the popliteal connection. Phlebology. 2009 Oct;24(5):201-7.

empty indicates abnormal calf muscle pump activity or venous outflow obstruction. To ensure as much consistency in the testing as possible, all subjects were trained in how to exercise during the initial phase of the test. All tests were conducted by a single observer using a Rheo Dopplex II PPG system (Huntleigh Healthcare Ltd). Results A total of 15 biker subjects were tested (30 limbs). For each subject, the venous refilling times were similar whether the test was performed in a sitting or riding position. Abnormal or equivocal refill times recorded for 50% of subjects. In contrast, the exercise phase results of each subject differed markedly between the two testing positions. In the sitting position, four of the 30 limbs showed abnormal emptying with a partially obstructive pattern. However, in the sports bike riding position, 16 of the 30 limbs tested showed decreased emptying compared with the standard sitting results (Figure 2), with seven limbs showing marked obstruction. Conclusion This initial pilot study demonstrates that a standard PPG testing protocol can be modified to enable testing of a motorcyclist sitting in a typical sport bike riding position. A PPG pattern of venous obstruction was noted in some subjects, indicating that popliteal vein obstruction may occur in this position. Ethical approval for further research is currently being sought to confirm these findings and evaluate venous function in a wider biker population. m 5. King BM. Using photoplethysmography to assess for venous insufficiency and screen for deep vein thrombosis (DVT): A review of the literature on the use of photoplethysmography (PPG) as an assessment tool to identify the presence of venous insufficiency and in screening for DVT Available from: www.huntleigh.co.uk/diagnostics/Admin/ files/20081027112959.pdf. Huntleigh Healthcare Ltd; 2004. 6. Kelechi TJ, Bonham PA. Measuring venous insufficiency objectively in the clinical setting. Journal of vascular nursing : official publication of the Society for Peripheral Vascular Nursing. 2008 Sep;26(3):67-73. 7. Sam RC, Darvall KA, Adam DJ, Silverman SH, Bradbury AW. Digital venous photoplethysmography in the seated position is a reproducible noninvasive measure of lower limb venous function in patients with isolated superficial venous reflux. J Vasc Surg. 2006 Feb;43(2):335-41.

EWMA Journal

2013 vol 13 no 1

“An integrated part of wound management.”

Visit us in hall C.2, stand number 10.

Debrisoft® removes debris effectively in a quick and easy way stimulates wound healing by protecting newly formed tissue

2000083 0313 e

improves quality of life being almost painless

Scientific Communication

ARCHAGATHUS History’s first wound expert Considered a failure in medicine, attacked by his political rivals, and eventually expelled from Rome, Archagathus’s competence and professionalism has been historically d enied; however, evidence shows that he might be considered the first medical expert of wounds.

Elia Ricci, M.D. Operative Unit of Vulnology, San Luca Clinic, Pecetto Torinese, Italy Correspondence: ericcisegreteria@alice.it Conflict of interest: none

rchagathus, a surgeon of Greek origin, was born in the Peloponnese, in Sparta, but his precise birthdate is unknown. He was said to have fled the wars in Greece to advance his profession in Rome. Thanks to the efforts of Caesar in helping the Greek medical class by favouring its establishment in Rome, Archagathus was granted Roman citizenship in 219 B.C. as one of the first doctors from abroad.

This dispute demonstrates how difficult it can be for pioneers of emerging sciences to achieve acceptance by their contemporaries. Archagathus appears to have introduced sophisticated operating techniques to Rome, previously unknown to the Romans of that time1, evoking fear and repulsion of his talents. His biography provides some interesting insights into the society in which he lived.

Archagathus was considered an expert in wounds, given the title of Vulnarius or “wound curer” and was granted a “Medical Taberna” acquired with the Acilio task (public funds collected at the Acilia crossroads, where he worked to cure public illnesses). This was essentially the first public operating room and public medical clinic described in history.

The medical profession in 3rd-century B.C. Rome was mainly performed by servile foreigners and commoners, and successively by independent doctors, hardly any of whom were of Roman origin. It is unclear if this was because the medicinal arts, which did not fall under the “liberal arts,” did not respond to “Roman gravitas,” or because Greek doctors, no longer considered unreliable, opportunistic, unprejudiced, or venal charlatans (as in the past) affirmed themselves in Rome due to their renewed knowledge, the critical review of more ancient medicine, and an ethical and moral re-equilibrium.

A negative legacy in history However, Plinius the Elder, author of one of largest single works to survive from the Roman Empire, Naturalis Historia, wrote about Archagathus’s reputation some 150 years later: “…He obtained Roman citizenship and was extraordinarily popular on his arrival, but very soon, gained the nickname of the “executioner” [“Carnifax” in Latin] because of his savage use of the scalpel and cautery and generated aversion towards his profession and towards other doctors...” (Nat. Hist. XXIX, 12-13). This narrative was derived from another historian, Cassio Emina, a 2nd-century B.C. Roman annalist of noted xenophobic sentiment. The immediate negative legacy of Archagathus may originate from the ongoing dispute between him and Cato (234–149 B.C.), the Roman statesman often referred to as Censorius (the Censor), known for his conservatism and opposition to Hellenization. 38

Cato argued that for 600 years, the Romans had managed without doctors but not without medicine. Despite not being a medic himself, he wrote a great deal on medical topics such as domestic medicine, raising the credibility of empirical medicine. In this conception, even health was in the hands of the Paterfamilias, the head of the Roman family, the absolute and final sovereign. The household father passed down the essential indications of cures to his own sons and set aside a room in his home to cure family illnesses. Cato therefore did not disregard magic rituals and the obsessive recourse to cabbages, which was almost a panacea suitable for curing any illness. 1

See G.Penso, La medicina romana. L’arte di Esculapio nell’antica Roma, Saronno 1985, pages 82-84.

EWMA Journal

2013 vol 13 no 1

Adding insult to injury Archagathus, who definitely did not pass through the school of philosophers and operated technically and mentally with the aim and hope of achieving tangible results, seems to have had the opposite opinion. At that time, he could not easily go against public opinion and disagree with the prejudice of famous men, whose opinions were listened to and valued by virtue of their inclination to writing. In addition, Archagathus did not undertake the most prudent internal medicine, leaving that specialty, with all good peace, to Cato and to the spells and amulets suggested by the oracles. Cato’s opposition to Archagathus also reveals the concept of dignity among the Romans, who were themselves viewed as barbarians by the Greeks. His views on the medical profession are explained by Plinius as follows: “The ancients did not condemn medicine per se, but as a career; they especially did not accept the idea of the benefit of compensation obtained on human life...” (Nat. Hist. XXIX, 8, 16). The attitude toward a Greek doctor among Romans, especially one who had been granted citizenship and allowed to work in a taberna acquired with public money, probably paid by the state in full autonomy, would have been very poor. We can imagine with how much haughty self-satisfaction Archagathus’s detractors learned of his carefree use of the scalpel and cautery, from which failures were inevitable (and in the eyes of the public, too numerous). Eventually, this was used as a justification for Archagathus’s expulsion from Rome. Reputation re-established after 2000 years Archagathus’s sharp fall is difficult to understand, as he must have worked in Rome for several years. Was he a failure or were his methods cruel? Perhaps not. Like today, the most formidable wound complication is infection, and in antiquity, without antibiotics, infection probably meant certain death. To combat infection, Archagathus’s aggressive interventions were frequent and focused toward saving human lives. According to current mainstream opinion, this is fully justifiable. Perhaps in antiquity, the treatment was less well-received and seemed too destructive. Nonetheless, Archagathus’s knowledge and methods lived on despite the lack of appreciation among the Roman establishment. In a Greek papyrus restored from the Egyptian sands, cicatrizants (amongst other things) linked to the name of Archagathus cast a different light on this doctor who has been maltreated by history: he was a conscientious professional who was clearly also interested in post-operational events. Even 250 years after Archagathus’s arrival in Rome, his remedies were being prescribed by doctors during the Imperial Period. In addition, Aulus Cornelius Celso, an influential author in the medical field, praises Archagathus in his book De Medicina, indicating that even 1st-century B.C., Celso continued to prescribe “Archagathus’s plaster”, made of red lead, burned branches, white lead, turpentine, and litharge (a mineral form of lead oxide), for curing wounds, which suggests a definitive knowledge of empirical medicine.

Visit EWMA on our Social Media platforms Follow us and get the latest updates about the EWMA 2013 Conference as well as other EWMA activities:

www.facebook.com/ EWMA.Wound

www.linkedin.com/company/ european-wound-managementassociation

Twitter: @ewmatweet

Archagathus was probably not the first surgeon to arrive in Rome, but today he is considered the Roman public health surgeon par excellence based on the historical evidence. He was a capable surgeon and a doctor of undisputed quality. Archagathus even became a point of reference for his innovation in dedicating himself to curing wounds as a Vulnarius. Not until 200 years later did people begin to refer explicitly to the specialty of curing wounds and skin ulcers. m

EWMA Journal

2013 vol 13 no 1

ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 10, 2012

Autologous platelet-rich plasma for treating chronic wounds Maria José Martinez-Zapata, Arturo J Martí-Carvajal, Ivan Solà, José Angel Expósito, Ignasi Bolíbar, Luciano Rodríguez, Joan Garcia Sally Bell-Syer, MSc Managing Editor Cochrane Wounds Group Department of Health Sciences University of York United Kingdom Correspondence: sally.bell-syer@york.ac.uk Conflict of interest: none

Citation example: Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L, Garcia J. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database of Systematic Reviews 2008 , Issue 1. Art. No.: CD006899. DOI: 10.1002/14651858.CD006899. Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Autologous platelet-rich plasma (PRP) is a treatment that contains fibrin and high concentrations of growth factors and has the potential to aid wound healing. Objectives: To determine whether autologous PRP promotes the healing of chronic wounds. Search methods: We searched the Cochrane Wounds Group Specialised Register (searched 15 August 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 8); Ovid MEDLINE (1950 to August Week 1 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, August 14, 2012); Ovid EMBASE (1980 to 2012 Week 32); EBSCO CINAHL (1982 to 10 August 2012) and International Clinical Trials Registry Platform (ICTRP)(accessed 22 August 2012). No date or language restrictions were applied. Selection criteria: We included randomised controlled trials (RCTs) that compared autologous PRP with placebo or alternative treatments for any type of chronic wound in adults. Data collection and analysis: Two review authors independently assessed each study against the inclusion criteria, extracted data and assessed risk of bias for all included trials. We calculated the risk ratio (RR) or the mean difference (MD) and time to wound healing was analysed as survival data using the hazard ratio (HR). We considered heterogeneity as significant when I2 was >75%.

Main results: Nine eligible RCTs were included, with a total of 325 participants of whom 44% were women. The median number of participants per RCT was 26 (range 10 to 86). Four RCTs recruited people with mixed chronic wounds (there were participants with wounds caused by more than one aetiology and participants who had wounds of several aetiologies in the same trial), three RCTs recruited people with venous leg ulcers and two RCTs considered foot ulcers in people with diabetes. The median length of treatment was 12 weeks (range eight to 40 weeks). One study was at low risk of bias, three studies were at high risk of bias with the remainder being at overall unclear risk of bias. The proportion of completely healed chronic wounds was reported in seven RCTs that compared PRP with standard treatment or placebo, with no statistically significant difference between the groups, in diabetic foot ulcers (RR 1.16; 95% CI 0.57 to 2.35), in venous leg ulcers (pooled RR 1.02; 95% CI 0.81 to 1.27; I2=0% ) and in mixed chronic wounds (pooled RR 1.85; 95% CI 0.76 to 4.51; I2=42%). The total area epithelialised at the end of the intervention was reported in three RCTs of mixed chronic wounds, there was no statistically significant difference between the groups (pooled MD -1.94 cm2; 95% CI -4.74 to 0.86; I2=47%). The percentage of wound area healed was reported in two RCTs of mixed chronic wounds, and results were statistically significant in favour of the PRP group (RR 51.78%; 95% CI 32.70 to 70.86; I2= 0%). Wound complications like infection or necrosis were reported by three RCTs, and there was no statistically significant difference between groups (RR 1.08; 95% CI 0.31 to 3.73). Adverse effects were reported by three studies and there was no statistically significant difference between people treated with PRP and those not given PRP (pooled RR 1.07; 95% CI 0.32 to 3.58; I2=0%). Authors’ conclusions: There is currently no evidence to suggest that autologous PRP is of value for treating chronic wounds. However, current evidence is based on a small number of RCTs, most of which are either at high or unclear risk of bias. Well-designed and adequately powered clinical trials are needed. Plain language summary: Autologous platelet-rich plasma (PRP) for chronic wounds Chronic wounds include pressure ulcers, venous leg ulcers, arterial ulcers, neurotrophic ulcers and foot ulcers in people with diabetes. Autologous platelet-rich

EWMA Journal

2013 vol 13 no 1

Cochrane Reviews

plasma (PRP) is a potential wound-healing treatment because it contains fibrin and high concentrations of growth factors that are thought to help healing. This review evaluated the effectiveness and safety of PRP and included nine randomised clinical trials, with a total of 325 participants. There were no differences between the autologous PRP and the control groups in terms of healing. However, these results require confirmation in adequately powered, well conducted RCTs.

Publication in The Cochrane Library Issue 11, 2012

Compression for venous leg ulcers Susan O’Meara, Nicky Cullum, E Andrea Nelson, Jo C Dumville Citation example: O’Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews 2009 , Issue 1. Art. No.: CD000265. DOI: 10.1002/14651858.CD000265.pub2 Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Up to one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (or varicose or stasis) ulcers. The main treatment is the application of a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it was unclear whether they are effective in treating venous ulcers and, if so, which method of compression is the most effective. Objectives: To undertake a systematic review of all randomised controlled trials (RCTs) evaluating the effects on venous ulcer healing of compression bandages and stockings. Specific questions addressed by the review are: 1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective? Search methods: For this second update we searched: the Cochrane Wounds Group Specialised Register (31 May 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 5, 2012); Ovid MEDLINE (1950 to May Week 4 2012); Ovid MEDLINE (In-Process & Other NonIndexed Citations 30 May 2012); Ovid EMBASE (1980 to 2012 Week 21); and EBSCO CINAHL (1982 to 30 May 2012). No date or language restrictions were applied. Selection criteria: RCTs recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression stockings were eligible for inclusion. Eligible comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. RCTs had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). Secondary outcomes of the review included ulcer recurrence, costs,

EWMA Journal

2013 vol 13 no 1

quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of RCTs. Data collection and analysis: Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author. Main results: Forty-eight RCTs reporting 59 comparisons were included (4321 participants in total). Most RCTs were small, and most were at unclear or high risk of bias. Duration of follow-up varied across RCTs. Risk ratio (RR) and other estimates are shown below where RCTs were pooled; otherwise findings refer to a single RCT. There was evidence from eight RCTs (unpooled) that healing outcomes (including time to healing) are better when patients receive compression compared with no compression. Single-component compression bandage systems are less effective than multi-component compression for complete healing at six months (one large RCT). A two-component system containing an elastic bandage healed more ulcers at one year than one without an elastic component (one small RCT). Three-component systems containing an elastic component healed more ulcers than those without elastic at three to four months (two RCTs pooled), RR 1.83 (95% CI 1.26 to 2.67), but another RCT showed no difference between groups at six months. An individual patient data meta-analysis of five RCTs suggested significantly faster healing with the four-layer bandage (4LB) than the short stretch bandage (SSB): median days to healing estimated at 90 and 99 respectively; hazard ratio 1.31 (95% CI 1.09 to 1.58). High-compression stockings are associated with better healing outcomes than SSB at two to four months: RR 1.62 (95% CI 1.26 to 2.10), estimate from four pooled RCTs. One RCT suggested better healing outcomes at 16 months with the addition of a tubular device plus single elastic bandage to a base system of gauze and crepe bandages when compared with two added elastic bandages. Another RCT had three arms; when one or two elastic bandages were added to a base threecomponent system that included an outer tubular layer, healing outcomes were better at six months for the two groups receiving elastic bandages. There is currently no evidence of a statistically significant difference for the following comparisons: n alternative single-component compression bandages (two RCTs, unpooled); n two-component bandages compared with the 4LB at three months (three RCTs pooled); n alternative versions of the 4LB for complete healing at times up to and including six months (three RCTs, unpooled); n 4LB compared with paste bandage for complete healing at three months (two RCTs, pooled), six months or one year (one RCT for each time point); n adjustable compression boots compared with paste bandages for the outcome of change in ulcer area at three months (one small RCT); n adjustable compression boots compared with the 4LB with respect to complete healing at three months (one small  RCT);

single-layer compression stocking compared with paste bandages for outcome of complete healing at four months (one small RCT) and 18 months (another small RCT); n low compression stocking compared with SSB for complete healing at three and six months (one small RCT); n compression stockings compared with a two-component bandage system and the 4LB for the outcome of complete healing at three months (one small, three-armed RCT); and, n tubular compression compared with SSB (one small RCT) for complete healing at three months. Secondary outcomes: 4LB was more cost-effective than SSB. It was not possible to draw firm conclusions regarding other secondary outcomes including recurrence, adverse events and health-related quality of life. Authors’ conclusions: Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear to be more effective than those composed mainly of inelastic constituents. Twocomponent bandage systems appear to perform as well as the 4LB. Patients receiving the 4LB heal faster than those allocated the SSB. More patients heal on high-compression stocking systems than with the SSB. Further data are required before the difference between high-compression stockings and the 4LB can be established. Plain language summary: Compression bandages and stockings to help the healing of venous leg ulcers Venous leg ulcers can occur when blood returning from veins in the legs to the heart is slow or obstructed. These ulcers can take a long time to heal (weeks or months) and can cause distress to patients, as well as being very costly to the health service. Compression bandages help blood to return to the heart from the legs, and there are a variety of types of bandage systems available; some are just a single bandage, while others require the application of several different types of bandages to the leg. Compression stockings are sometimes used as an alternative to compression bandages. This review examined the effectiveness of compression bandages versus no compression, and compared different types of compression bandages and stockings. We looked at how well these different treatments work in terms of ulcer healing. We found that applying compression was better than not using compression, and that multi-component bandages worked better than single-component systems. Multi-component systems (bandages or stockings) appear to perform better when one part is an elastic (stretchy) bandage. A very detailed analysis showed that a system called the ‘four-layer bandage’ or ‘4LB’ (i.e. four different bandages applied to the leg, including an elastic one) heals ulcers faster than the ‘shortstretch bandage’ or ‘SSB’ (a type of bandage with very minimal stretch).

Publication in The Cochrane Library Issue 12, 2012

Recombinant human growth hormone for treating burns and donor sites Roelf S Breederveld, Wim E Tuinebreijer Citation exampl : Breederveld RS, Tuinebreijer WE. Recombinant human growth hormone for treating burns and donor sites. Cochrane Database of Systematic Reviews 2011 , Issue 2. Art. No.: CD008990. DOI: 10.1002/14651858.CD008990. Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Recombinant human growth hormone (rhGH) increases protein synthesis, therefore it is used in burns with a total body surface area (TBSA) greater than 40%, where there is frequently an increase in protein breakdown and a decrease in protein synthesis. This change in protein metabolism correlates with poor wound healing of the burn and donor sites. Objectives: To determine the effects of rhGH on the healing rate of burn wounds and donor sites in people with burns. Search methods: We searched the Cochrane Wounds Group Specialised Register (searched 28 June 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 6); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to June Week 3 2012); Ovid MEDLINE (InProcess & Other Non-Indexed Citations June 27, 2012); Ovid EMBASE (1980 to 2012 Week 25); and EBSCO CINAHL (1982 to 21 June 2012). Selection criteria: Randomised controlled trials (RCTs) comparing rhGH with any comparator intervention, e.g. oxandrolone or placebo, in adults or children with burns. Data collection and analysis: Two review authors independently selected studies, assessed trial quality and extracted data. The primary outcomes were the healing of the burn wound and donor sites and the occurrence of wound infections. The secondary outcomes were mortality rate, length of hospital stay, scar assessment, and adverse events: hyperglycaemia and septicaemia. Main results: We included 13 RCTs (701 people). Six of the RCTs included only children aged 1 to 18 years and seven involved only adults (from 18 to 65 years of age). The mean TBSA of the included participants was greater than 49%. Twelve studies compared rhGH with placebo and one study compared rhGH with oxandrolone. Two trials found that compared with placebo, burn wounds in adults treated with rhGH healed more quickly (by 9.07 days; 95% confidence interval (CI) 4.39 to 13.76, I² = 0%). The donor site healing time was significantly shorter in rhGH-treated adults compared with placebo-treated participants (by 3.15 days; 95% CI 1.54 to 4.75, I² = 0%). Two studies in children with the outcome of donor site healing time could be pooled and the donor site healing time was shorter in the rhGH-treated children (by 1.70 days; 95% CI 0.87 to 2.53, I² = 0%). No studies reporting the outcome of wound infection

EWMA Journal

2013 vol 13 no 1

Cochrane Reviews

were found. The incidence of hyperglycaemia was higher in adults during rhGH treatment compared with placebo (risk ratio (RR) 2.43; 95% CI 1.54 to 3.85), but not in children. Pooling the studies of adults and children yielded a significantly higher incidence of hyperglycaemia in the rhGH-treated participants (RR 2.65; 95% CI 1.68 to 4.16). Authors’ conclusions: There is some evidence that using rhGH in people with large burns (more than 40% of the total body surface area) could result in more rapid healing of the burn wound and donor sites in adults and children, and in reduced length of hospital stay, without increased mortality or scarring, but with an increased risk of hyperglycaemia. This evidence is based on studies with small sample sizes and risk of bias and requires confirmation in higher quality, adequately powered trials. Plain language summary: Human growth hormone for treating burns and skin graft donor sites Growth hormone is produced by the pituitary gland. For decades, it could only be obtained by extraction from pituitary glands but more recently it has been produced through genetic engineering and made available for therapy as recombinant human growth hormone (rhGH). The aim of this review was to determine the effects of rhGH when used to treat burns and skin graft donor sites and to determine its safety compared with other treatments. A burn that affects more than 40% of total body surface area affects the entire body. In people with such large burns, metabolism increases, as represented by a higher heart rate. This state of increased metabolism is called hypermetabolism. Hypermetabolism consumes high levels of energy Part of this energy is obtained through the breakdown of the patient’s own muscles, which leads to wasting. This breaking down of tissues into smaller molecules to release energy is called catabolism. However, such catabolism does not provide sufficient energy for the hypermetabolic state. This shortage of energy and building molecules leads to prolonged burn wound and donor site healing. In children, this shortage also leads to growth retardation. This catabolic state can be treated with anabolic agents that reverse the protein breakdown. One of the anabolic agents recommended for such a treatment approach is recombinant growth hormone. We found 13 eligible randomised controlled trials (RCTs) involving 701 people for inclusion in this review. There is some evidence that recombinant growth hormone therapy in people with burns covering more than 40% of the total body surface area helps burn wounds and donor sites heal more rapidly and reduce the length of hospital stay, without increased mortality or increased scarring. We found it difficult to assess the quality of these studies due to poor reporting therefore we cannot be completely confident in their results.

Issue 4. Art. No.: CD008058. DOI: 10.1002/14651858. CD008058.. Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Burn injuries are an important health problem. They occur frequently in the head and neck region - the area central to a person’s identity, that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of partial-thickness burns to the face. Objectives: To assess the effects of topical interventions on wound healing in people with facial burns of any depth. Search methods: We searched the Cochrane Wounds Group Specialised Register (searched 12 November 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to November Week 1 2012); Ovid MEDLINE - In-process & Other Non-Indexed Citations (searched November 12, 2012); Ovid EMBASE (1980 to 2012 Week 45); and EBSCO CINAHL (1982 to 9 November 2012) for relevant trials. We did not apply date or language restrictions. Selection criteria: Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review. Data collection and analysis: Two review authors independently assessed and included the references identified by the search strategy. Included trials were assessed using a risk of bias form, and data were extracted using a standardised data extraction sheet. For dichotomous and continuous outcomes, we calculated risk ratios and mean differences, respectively, both with 95% confidence intervals (CI). Main results: We included five RCTs, comprising a total of 119 participants. Two studies compared two different antimicrobial agents and three compared a biological or bioengineered skin substitute with an antimicrobial agent. All studies had small sample sizes and were at high risk of bias. Heterogeneity of interventions and outcomes prevented pooling of data. In three studies time to complete wound healing was significantly shorter for those using a skin substitute than for those using an antibacterial agent, but the quality of the evidence was low. Pain was significantly reduced with the use of skin substitutes in both studies that reported this outcome in all groups, range mean differences -2.00 (95% CI -3.82 to -0.18) to -4.00 (95% CI -5.05 to -2.95) on a 10-point scale. Authors’ conclusions: There is insufficient high quality research and evidence to enable conclusions to be drawn about the effects of topical interventions on wound healing in people with facial burns.

Publication in The Cochrane Library Issue 1, 2013

Topical treatment for facial burns Cornelis J Hoogewerf, Margriet E Van Baar, M Jenda Hop, Marianne K Nieuwenhuis, Irma MMH Oen, Esther Middelkoop Citation example: Hoogewerf CJ, Van Baar ME, Hop MJ, Nieuwenhuis MK, Oen IMMH, Middelkoop E. Topical treatment for facial burns. Cochrane Database of Systematic Reviews 2009 , EWMA Journal

2013 vol 13 no 1

Plain language summary: Topical treatment for facial burns Burn injuries are an important health problem. Burns frequently occur on the head or neck. These areas are central to a person’s identity and play a vital role in communication. Other basic abilities such as hearing, smelling and breathing may become affected as a direct result of a facial burn. The authors of this 

Cochrane Reviews

Cochrane review wanted to assess the effects of topical (surface) treatments for wound healing in facial burns. Examples of topical treatments are antimicrobial creams and ointments and biological, or bioengineered (artificial), skin substitutes. Five small studies were included in the review. Two studies compared two different antimicrobials whilst three compared antimicrobials with skin substitutes. All studies were small and at high risk of bias therefore we cannot be confident in the results and the overall evidence is of low quality. There is insufficient reliable evidence as to whether topical treatments improve outcomes for people with facial burns including improved wound healing, rates of infection, the need for surgery, improved appearance of scars, reduced pain, improved overall patient satisfaction, reduced adverse effects, improved quality of life or reduced the length of the hospital stay. More research is needed.

Pressure-relieving interventions for treating diabetic foot ulcers Jane Lewis, Allyson Lipp Citation example: Lewis J, Lipp A. Pressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2000 , Issue 3. Art. No.: CD002302. DOI: 10.1002/14651858.CD002302.. Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Diabetes-related foot ulceration is a major contributor to morbidity in diabetes. Diabetic foot ulcers are partly a consequence of abnormal foot pressures and pressure relief is a widely used treatment for healing diabetes-related plantar foot ulcers, but the most effective method for healing is unclear. Objectives: To determine the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes. Search methods: For this update we searched the Cochrane Wounds Group Specialised Register (searched 2 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to October Week 4 2012); Ovid MEDLINE (InProcess & Other Non-Indexed Citations, October 31, 2012); Ovid EMBASE (1980 to 2012 Week 43); and EBSCO CINAHL (1982 to 1 November 2012). There were no restrictions based on language or publication status. Selection criteria: Randomised controlled trials evaluating the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes. Data collection and analysis: Data from eligible trials were extracted, and summarised using a data extraction sheet, by two review authors independently. Main results: Fourteen trials (709 participants) met the inclusion criteria for the review. One study compared two different types of non-removable casts with no discernable difference between the groups. Seven studies (366 participants) compared non-removable casts with removable pressure-relieving devices. In five of those studies non-removable casts were associated with a statis44

tically significant increase in the number of ulcers healed compared with the removable device (RR 1.17 95% CI 1.01 to 1.36: P value = 0.04). Two studies (98 participants) found that significantly more ulcers healed with non-removable casts than with dressings alone. Achilles tendon lengthening combined with a non-removable cast in one study resulted in significantly more healed ulcers at 7 months than non-removable cast alone (RR 2.23; 95% CI 1.32 to 3.76). More ulcers remained healed at two years in this group (RR 3.41; 95% CI 1.42 to 8.18). Other comparisons included surgical debridement of ulcers; felt fitted to the foot; felted foam dressings and none of these showed a statistically significant treatment effect in favour of the intervention. Authors’ conclusions: Non-removable, pressure-relieving casts are more effective in healing diabetes related plantar foot ulcers than removable casts, or dressings alone. Non-removable devices, when combined with Achilles tendon lengthening were more successful in one forefoot ulcer study than the use of a non-removable cast alone. Plain language summary: Non-removable pressure-relieving interventions help to heal foot ulcers in people with diabetes Foot ulceration is a complication of diabetes and can lead to amputation. Ulcers can occur due, in part, to abnormal pressures on the sole of the foot. The studies included in this review compared non-removable pressure-relieving interventions (foot casts) with other ways of relieving pressure on the ulcer site to improve healing. The comparisons included dressings alone, temporary therapeutic shoes, removable pressure-relieving devices and surgical intervention. The review found that the nonremovable interventions were more effective than any of the other external pressure-relieving methods. Non-removable casts used with Achilles tendon lengthening were more successful in one forefoot ulcer study than using a non-removable cast alone.

Skin grafting for venous leg ulcers June E Jones, E Andrea Nelson, Aws Al-Hity Citation example: Jones JE, Nelson EA, Al-Hity A. Skin grafting for venous leg ulcers. Cochrane Database of Systematic Reviews 2007 , Issue 2. Art. No.: CD001737. DOI: 10.1002/14651858. CD001737.pub3. Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Venous leg ulceration is a recurrent, chronic, disabling condition. It affects up to one in 100 people at some time in their lives. Standard treatments are simple dressings and compression bandages or stockings. Sometimes, despite treatment, ulcers remain open for months or years. Sometimes skin grafts are used to stimulate healing. These may be taken, or grown into a dressing, from the patient’s own uninjured skin (autografts), or applied as a sheet of bioengineered skin grown from donor cells (allograft). Preserved skin from other animals, such as pigs, has also been used (xenografts). Objectives: To assess the effect of skin grafts for treating venous leg ulcers. EWMA Journal

2013 vol 13 no 1

Search methods: For this update we modified the search strategies and conducted searches of The Cochrane Wounds Group Specialised Register (searched 27 July 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (2008 to July Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 26, 2012); Ovid EMBASE (2008 to 2012 Week 29); and EBSCO CINAHL (2008 to 26 July 2012). We did not apply date or language restrictions.

Are you a health care professional involved in wound care assessment, treatment and management?

Selection criteria: Randomised controlled trials (RCTs) of skin grafts in the treatment of venous leg ulcers. Data collection and analysis: Two review authors independently undertook data extraction and assessment of study quality. Main results: For this update of the review, we identified one new trial, bringing the total to 17 trials (1034 participants) - all of which were generally at moderate or high risk of bias. In 12 trials participants also received compression bandaging. Eleven trials compared a graft with standard care in which no graft was used. Two of these trials (102 participants) compared a dressing with an autograft; three trials (80 participants) compared frozen allografts with dressings, and two trials (45 participants) compared fresh allografts with dressings. Two trials (345 participants) compared tissue-engineered skin (bilayer artificial skin) with a dressing. In two trials (97 participants) a single-layer dermal replacement was compared with standard care. Six trials compared alternative skin grafting techniques. The first trial (92 participants) compared autografts with frozen allograft, a second (51 participants) compared a pinch graft (autograft) with porcine dermis (xenograft), the third (110 participants) compared growth-arrested human keratinocytes and fibroblasts with placebo, the fourth (10 participants) compared an autograft delivered on porcine pads with an autograft delivered on porcine gelatin microbeads, the fifth trial (92 participants) compared a meshed graft with a cultured keratinocyte autograft, and the sixth trial (50 participants) compared a frozen keratinocyte allograft with a lyophilised (freeze-dried) keratinocyte allografts. Significantly more ulcers healed when treated with bilayer artificial skin than with dressings. There was insufficient evidence from the other trials to determine whether other types of skin grafting increased the healing of venous ulcers. Authors’ conclusions: Bilayer artificial skin, used in conjunction with compression bandaging, increases venous ulcer healing compared with a simple dressing plus compression. Further research is needed to assess whether other forms of skin grafts increase ulcer healing. Plain language summary: Skin grafts to improve leg ulcer healing Approximately 1% of people in industrialised countries have a leg ulcer at some time, mainly caused by poor blood flow back from the legs towards the heart. Skin grafts, either using the patient’s own skin, artificial skin or donor skin/cells, have been evaluated to see whether they improve the healing of ulcers. The review of trials found evidence that tissue-engineered skin composed of two layers increases the chance of healing. There was not enough evidence to recommend any other type of graft, and further research is required. m

Could you spare 15 minutes to share your expertise in wound care? As part of my PhD studies at Cardiff Metropolitan University I am currently undertaking a study to examine the health practitioners’ knowledge, attitudes and behaviour of wound assessment and antimicrobial treatment in wound care management with a particular emphasis on the application of honey. To participate in this questionnaire anonymously please use the link below. https://www.surveymonkey.com/s/ woundhealingsurvey

Thank you for your assistance in advance Mr. Abdul M. Seckam BSc (Hons), AMIBiol, MSc, MPH. Cardiff Metropolitan University, UK abseckam@cardiffmet.ac.uk

EWMA Journal

2013 vol 13 no 1

EWMA Journal

Previous Issues

Volume 12, no 3, October 2012 Therapeutic strategies for diabetic foot ulceration RJ Hinchliffe, JRW Brownrigg Offloading the diabetic foot: Evidence and clinical decision making S.A. Bus Soft-tissue complications during treatment of children with congenital clubfoot A. Baindurashvili, V. Kenis, Y. Stepanova An evolution in Medical Tapes: From Latex to Acrylic L. Gryson Bacteria and fungus binding mesh in negative pressure wound therapy – A review of the biological effects in the wound bed M. Malmsjö, S. Lindstedt, R. Ingemansson, L. Gustafsson

Other Journals EWMA wishes to facilitate the exchange of information on wound healing in a broad perspective with this section on International Journals. English

Cultural Considerations in Advanced Wound Care Donna Boyer The Safety and Efficacy of Topical Retapamulin Ointment Versus Placebo Ointment in the Treatment of Secondarily Infected Traumatic Lesions: A Randomized, Double-blind Superiority Study John F. Tomayko, Gang Li, John J. Breton; Nicole Scangarella-Oman, MaryBeth Dalessandro, Michael Martin Construct Validity of the Moisture Subscale of the Braden Scale for Predicting Pressure Sore Risk Tolulope Omolayo, Kilty Brown, Mary Pat Rapp, Jing Li, Ryan Barrett, Susan Horn, Nancy Bergstrom

Volume 12, no 2, May 2012 A structured approach to s urgical treatment in deep infection in diabetic foot Cedomir S Vucetic, et.al. Endothelial progenitor cells, a unipotent stem cell, involved in neovascularization of wound healing in diabetic foot ulcer Jacqueline Chor Wing Tama, et.al. Bacteriophages for the treatment of severe infections: – a ‘new’ option for the future? Daniel De Vos, et.al. Developing evidence-based ways of working: – Employing interdisciplinary team w orking to improve patient outcomes in diabetic foot ulceration – our experience Kristien Van Acker Exploring the characteristics of a v enous leg ulcer that contribute to the emotional distress experienced by patients Jessica Walburn, et.al. Development of a wound healing index for chronic wounds Juan Carlos Restrepo-Medrano, et.al.

Finnish

Volume 11, no 3, October 2011 Challenges facing district nurses in the prevention of pressure ulcers Lynne Watret Clinical application of stem cells in wound h ealing: A near future? Benoit I Hendrickx Understanding the Patient Experience: Does empowerment link to clinical practice? Patricia Price The Influence of Egyptian Propolis on Induced Burn Wound Healing in Diabetic Rats – Antibacterial Mechanism Emad T. Ahmed, Osama M. Abo-Salem, Ali Osman PURSUN UK: The Pressure Ulcer Research Service User Network for the UK Delia Muir Perspective of the European Patients’ Forum Developing Collaboration Nicola Bedlington

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

Haava, no. 1, 2013 www.shhy.fi Good Care of Diabetes is the active involvement Pirjo Ilanne-Parikka Diabetes – disease with various pathophysiology Hannu Järveläinen Prolonged wound healing of diabetic Ansa Iivanainen, Esa Soppi Diabetic’s nutrition and wound Eliina Aro Obesity, challenge that predispose to many diseases Esa Soppi Diabetic and operation Johanna Katomaa Skin care of diabetic’s feet Ulla Dunder, Tiina Pukki Removing of callus from a diabetic’s foot Hanneli Saarikoski

Volume 12, no 1, January 2012 How to rate the wound d ebridement trauma? Jan Stryja Ensuring equitable wound management education within the Australian context Jan Rice Low wound prevalence and cost burden: The impact of a multidisciplinary wound specialist team Alison Hopkins, Fran Worboys, John Posnett The results of a comprehensive wound audit in a UK primary care trust Alison Hopkins, Fran Worboys Pressure ulcer programme of research – PURPOSE Nixon J, Wilson L.M, Coleman S, Gorecki C, Muir D, Pinkney L, Keen J, Briggs M, McGinnis E, Stubbs N, Dealey C, Nelson A The skin’s own bacteria may a ggravate inflammatory and occlusive changes in atherosclerotic arteries of lower limbs Waldemar L. Olszewski, Piotr Andziak, M. Moscicka-Wesolowska, Bozenna Interewicz, Ewa Swoboda, Ewa Stelmach Problem with the post burn wound pain: Chronic profiles Laima Juozapaviciene, Rytis Rimdeika, Aurika Karbonskiene

Advances in Skin & Wound Care, vol. 26, no 39, 2013 www.aswcjournal.com

Spanish

Helcos, vol. 23, no. 4, 2012 “Professional’s knowledge of the departement of urgencies on the prevention and treatment of pressure ulcers” Hinojosa-Caballero, D. “Colour therapy in venous ulcers healing. The chromo terapy” Alexandre S; Arola N; Jové M; Blanco J

English

International Wound Journal, vol. 10, no 1, 2013 www.wiley.com Keratinocytes in the treatment of severe burn injury: an update L Lootens, N Brusselaers, H Beele, S Monstrey Negative pressure wound therapy in acute, contaminated wounds: documenting its safety and efficacy to support current global practice E Shweiki, KE Gallagher Characteristics of hospitalised US veterans with nosocomial pressure ulcers TT Goodell, Z Moskovitz Expenditure of chronic venous leg ulcer management in German primary care: results from a population-based study U Müller-Bühl, R Leutgeb, J Bungartz, J Szecsenyi, G Laux Healing process of venous ulcers: the role of microcirculation E Ambrózy, et al. Effects of non contact low-frequency ultrasound on healing of suspected deep tissue injury: a retrospective analysis JS Honaker, MR Forston, EA Davis, MM Wiesner, JA Morgan Non traumatic lower extremity amputations in younger patients: an 11-year retrospective study JWS Chin, L Teague, A-M McLaren, JL Mahoney Wound infection, dressings and pain, is there a relationship in the chronic wound? KF Cutting, RJ White, P Mahoney A case series of skin necrosis following use of non invasive ventilation pressure masks Z Ahmad, M Venus, W Kisku, SS Rayatt EWMA Journal

2013 vol 13 no 1

EWMA English

Int. Journal of Lower Extremity Wounds vol. 13, no 1, 2013 http://ijlew.sagepub.com Increased Skin Inflammation and Blood Vessel Density in Human and Experimental Diabetes Ana Tellechea, et al. Interobserver and Intraobserver Reproducibility of Plain X-Rays in the Diagnosis of Diabetic Foot Osteomyelitis Francisco J. Álvaro-Afonso, et al. PICO: A Revelation In Topical Negative Pressure Therapy? Zeeshan Ahmad, Marcus Davis, Rana Das-Gupta Wireless Electrical Stimulation: An Innovative Powerful Tool for the Treatment of a Complicated Chronic Ulcer Ourania Castana, et al. Evaluation of the Effects of Homologous Platelet Gel on Healing Lower Extremity Wounds in Patients With Diabetes Guiqiu Shan, et.al. A Chronic Leg Ulcer Presenting With Charcot-Marie-Tooth Disease and Type 2 Diabetes: A CaseReport Haitao Ren, Chuangang You, Chunmao Han

English

Dutch

Interview Monique Verdier, Board of Directors: Wound Expert Center gets anual price “Compliments of the Board” Groen Hart Hospital, Gouda, The Netherlands FHI Platform chrinic and complex wounds: Companies also want to be involved in negotiations Wound Infection Summit 2013. Background and registration Research: Faster woundhealing is the best way to reduce costs

German

Journal of Tissue Viability, vol. 22, no 1, 2013 www.journaloftissueviability.com

Journal of Wound Care, vol. 22, no 3, 2013 www.journalofwoundcare.com

Scandinavian

Wounds (SÅR) vol. 21, no 1, 2013 www.saar.dk The Importance of Moist Wound Healing Britta Østergaard Melby Pressure Ulcer Prevention: HELP – We can’t cope with it yet!! Helle Dreier Randomized, controlled intra-patient test of Mepilex Lite foam dressings versus water-based cream for the treatment of skin reactions in radiotherapy after mastectomy Paterson, D.B., Poonam, P., Bennett, N.C., Peszynski, R.I., Van Beekhuizen, M.J., Jasperse, M.L., Herst, P.M. “Grey wounds” – when wounds are in a grey area Omong Mortensen Pressure ulcers are potentially fatal! Maria Plaschke Wound App – Mobile learning – easy and straightforward EWMA – more than wounds – Visit at the EWMA Secretariat What kind of work does the executive committee do? – Interview with Eskild Henneberg Jens Fonnesbech

German

Wund Management, vol. 7, no 1, 2013 English abstracts are available from www.mhp-verlag.de

Clinical and cost effectiveness of absorbent dressings in the treatment of highly exuding VLUs. M. Panca, K. Cutting, J.F. Guest SAP-containing dressings exhibit sustained antimicrobial effects over 7 days in vitro C. Wiegand, M. Abel, J. Muldoon, P. Ruth, U.C. Hipler Clinical outcomes of WF10 adjunct to standard treatment of diabetic foot ulcers to standard treatment for diabetic foot ulcers N. Yingsakmongkol Orthopaedic nurses’ knowledge about pressure ulcers in Iran: a cross-sectional study S. Iranmanesh, A Abdoli Tafti, H. Rafiei, M. Dehghan, F. Razban Wound ‘dechronification’ with negatively charged polystyrene microspheres: a double-blind RCT Y. Shoham, et al. Leczenie Ran Issue 2, vol. 9, 2012

Polish

Modern rules of pressure ulcers conservative treatment M. Sopata, E. Tomaszewska, A. Kotlinska-Lemieszek Principles and techniques of peripheral nerve surgery A. Chrapusta Pressure ulcers – physiotherapy in the treatment process E. Mikotajewska Retrospective analysis and evaluation of risk factors connected with wound infection occurrence of elderly patients who underwent surgery between 2006-2008 in the Department of Thoracic Surgery of Hospital of Lung Diseases and Tuberculosis in Bystra P. Rogozinski, K. Brulinski, E. Malinowski, M. Kucharzewski Breast reconstruction – the women’s motivation and the level of satisfaction with surgery E. Mazurek English

Wound Repair and Regeneration, vol. 21, no 2, 2013 www.wiley.com Historical foundations of wound healing and its potential for acceleration: dose-response considerations Edward J. Calabrese The role of skin substitutes in the management of chronic cutaneous wounds Nicholas S. Greaves, et al. Empiric evidence for a genetic contribution to predisposition to surgical site infection James P. Lee, Harriet W. Hopf, Lisa A. Cannon-Albright Randomized controlled trial on collagen/oxidized regenerated cellulose/silver treatment Finn Gottrup, et al. Microfluidic wound bandage: Localized oxygen modulation of collagen maturation Joe F. Lo, et al.

EWMA Journal

2013 vol 13 no 1

Phlebologie, no 1, 2013 www.schattauer.de Endovenous laser therapy vs. high ligation/stripping I. Flessenkämper; D. Stenger; M. Hartmann; S. Roll Endocrine mechanisms in the pathogenesis of primary varicosis* Ch. Busch; S. Schnabl; A. Strölin Effects of medical compression stockings on venous haemodynamics M. Marshall; V. Wienert Recommendations for hygiene in sclerotherapy M. Hahn; F.X. Breu; H. Gerlach; M. Stücker; E. Meyer; M. Dettenkofer Transient ischaemic attack after sclerotherapy of the Vena saphena parva J. Noppeney, M. Winkle; A. Brunner; T. Noppeney Foam Sclerotherapy S. Reich-Schupke; M. Stücker

Pressure ulcer prevention and treatment knowledge of Jordanian nurses M.Y.N. Saleh, M. Al-Hussami, D. Anthony 3-dimensional buttocks response to sitting: A case report S.E. Sonenblum, S.H. Sprigle, J.M. Cathcart, R.J. Winder New wound care HTC launches P. Vowden

English

NTVW vol. 8, no 2, 2013 www.ntvw.nl

Bakterielle Biofilme, Teil 2: Besiedlung des Menschen Erfahrungen bei der Anwendung von Octenisept® zur Wundantisepsis Versorgungsstrategien im häuslichen Bereich bei einem „Wundpatienten“ mit Adipositas per magna Positive Erfahrungen mit dem Einsatz von Hydrokolloiden bei der postoperativen orthopädischen Wundversorgung Silberhaltige Therapeutika zur Wundbehandlung – Eine Übersicht German

Zeitschrift für Wundheilung, vol. 17, December, 2012 www.dgfw.de Impact of Albumin on Antiseptic Agents T. Hirsch, A. Lahmer, H.-M. Seipp Interface pressure measurement as a quality control step in compression therapy – current state of the art T. Ott, K. Waldvogel-Röcker, P. Melinic, B. Nink-Grebe, W. Jungkunz, H.-M. Seipp The pedal bypass is one option in treatment of the neuro-ischemic diabetic foot syndrome D. Ipsen, U. Brune Improvement of wound healing by CO2-treatment – organisation and management of the therapy H. Sorg, A. Limbourg, A. H. Roushan, G. Küther, D. Braunschweig, C. Gutenbrunner, P. M. Vogt, H.-O. Rennekampff Pressure Ulcer Assessment – based on NANDA -I Nursing Diagnosis S. Strupeit, G. Bauernfeind

Everything you love about foam dressings and more

Protective top layer Soft FOAM pad AQUACEL™ layer

Gentle silicone border

Now only one dressing offers the comfort and simplicity of FOAM plus the healing benefits of an AQUACEL layer ™

Gentle silicone border designed to adhere to surrounding skin, not the wound bed

™

NeW

Available in a range of adhesive and non-adhesive sizes AQUACEL, the AQUACEL logo, ConvaTec, the ConvaTec logo, Hydrofiber and the Hydrofiber logo are trademarks of ConvaTec Inc., and are registered trademarks in the U.S. © 2012 ConvaTec Inc. AP-011757-MM

wered by

AQUACEL™ Dressings TRIED. TRUE. TRUSTED.™

To find out more about AQUACEL™ foam dressing or to arrange a visit from your ConvaTec representative, please visit www.convatec.com.

EWMA

EWMA ANTIMICROBIAL DOCUMENT

he European Wound Management A ssociation (EWMA) antimicrobial document will be published soon. The document results will be presented at the EWMA Conference in Copenhagen in May 2013 during a key session at Thursday, May 16 at 08:00-09.30.

The author group is: n Finn Gottrup, Surgery, Bispebjerg Hospital, Denmark (Chair) n Jan Apelqvist, Endocrinology (health economy), University Hospital of Malmö, Sweden (Co-Chair) n Zena Moore, Nursing, Royal College of Surgeons in Ireland, Ireland n Sebastian Probst, Nursing, Zurich University of Applied Sciences, Switzerland n Rose Cooper, Microbiology, Cardiff School of Health Sciences, Wales n Thomas Bjarnsholt, Microbiology/biofilm, Copenhagen University, Denmark n Edgar Peters, Infection, University Medical Center, Utrecht, The Netherlands Infection is one of the most frequent complications of non-healing wounds. Infection can jeopardize progress toward healing, result in longer treatment times, and increase the use of resources. In the worst cases, infection can result in a major amputation or a life-threatening condition. Wounds are especially disposed to infection because the exposure of subcutaneous tissue after a loss of skin integrity provides a moist, warm, and nutritious environment that is conducive to microbial colonization and proliferation. Consequently, the use of antimicrobial agents is vital in wound management. There is increasing focus on the use of antimicrobials and potential adverse consequences of the current use of such products. When treating with antibiotics, all sensitive bacteria are normally killed except the bacteria with resistance. After

EWMA Journal

2013 vol 13 no 1

the removal of non-resistant bacteria, resistant strains of bacteria will have fewer constraints to develop and thus free access to grow rapidly, with the potential consequence of jeopardising patients’ health statuses. Inappropriate use of antimicrobials (especially antibiotics) creates an environment for the selection of resistance against currently available products. Development of ‘superbugs’, which represent a substantial threat to public health, is inevitable. This is the background for the European Union’s and the United States’ increased focus on antimicrobial resistance. Resistance to antibiotics considerably decreases possibilities for effectively treating infections and increases the risk of complications and death. Within the European Union alone, it is estimated that 2 million patients acquire nosocomial (hospital acquired) infections each year, of which more than half are drug-resistant. Infections based on resistant bacteria are associated with up to a 2-fold increase in mortality compared to susceptible in fections.

Finn Gottrup Chair of the EWMA Antimicrobial Document Author Group ewma@ewma.org www.ewma.org Conflict of interest: None

Procedure for translations of EWMA documents: A EWMA Cooperating Organisation must be responsible for the translation. If the content of the document is suggested changed in the translated version, these changes must be approved by EWMA prior to publication. A reference to the original article must be included on the inside of the front cover (colophon) A disclaimer must be inserted stating that EWMA and the publishing journal hold no responsibility for possible variations from the original document, with reference to the article published in JWC. The EWMA Logo and name must be included on the front page of the document. The Organisation responsible for the translation (Must be a EWMA Cooperating Organisation) is allowed to place its logo on the front page together with a reference to its responsibility for the translation. The translated document must be sent to the EWMA Secretariat (ewma@ewma.org) for approval prior to publication.

EWMA

EWMA wants to address the controversies related to the use of antimicrobials in wound management and hopes to raise debate about how to solve the problem. Therefore, EWMA established a working group that prepared the EWMA antimicrobial document. Objectives of the EWMA Antimicrobial Document 1. Producing an update, including statements as to which items are shown to be evidence-based at the highest level. 2. Uncover controversies and issues related to the use of antimicrobials in wound management and describe possible solutions and the pros and cons of such. 3. Summarise the presented information and produce perspectives for further work. The document is intended to cover viewpoints for all health care staff, policy makers and politicians, industry, hospitals administrators, and patients with wounds. However, the text will be targeted for readers with basic knowledge of wounds and wound management. References European Academies Science Advisory Council (2007). Tackling antibiotic resistance in Europe. London, The Royal Society (www.knaw.nl/pdf/EASAC_Antibacterial_resistance. pdf, accessed 23 February 2009). Vicente M et al. (2006). The fallacies of hope: will we discover new antibiotics to combat pathogenic bacteria in time? FEMS Microbiology Reviews, 30:841-852. Cosgrove S, Carmeli S (2003). The impact of antimicrobial resistance on health and economic outcomes. Clinical Infectious Diseases, 36:1433-1437.

Structure and Content of the EWMA Antimicrobial Document The document structure includes different aspects of health care perspectives surrounding the theme of antimicrobials in wounds. Each chapter begins with an introduction to current knowledge and status of the specific theme called “Where are we today.” This section of each chapter also covers an assessment of the current literature and evidence for the current consensus. The evidence assessment builds upon EWMAs previous work with outcomes (Gottrup et al. 2010) and the method of assessment derives from the recommendations made in this article. The second section of each chapter will answer the “Controversies” relevant to the chapter’s theme. Each controversy has its own subtitle and the author group’s oneline statement of answer to the controversy. Following the author group’s statement, the controversy is discussed and a short conclusion is made. m

Supporting Companies · Bbraun · BSN · Convatec · Eucomed Advanced Wound Care Sector Group · Ferris/Polymem

· FlenPharma · Lohmann & Rauscher · Mölnlycke · Schülke & Mayr · Smith & Nephew · Sorbion

Make a difference in clinical practice Become a Member of EWMA

Benefits of your EWMA Membership: n You make a difference in clinical practice within wound management in Europe n Right to vote and stand for EWMA Council n EWMA Journal sent directly to you two times a year EWMA Secretariat Nordre Fasanvej 113, EWMA news and statements sent directly to you n 2000 Frederiksberg, n A discount on your registration fee for EWMA Conferences Denmark Tel: +45 7020 0305 n Right to apply for EWMA travel grants Fax: +45 7020 0315 n Yearly membership fee € 25 ewma@ewma.org www.ewma.org n Yearly membership fee for members of cooperating organisations € 10

Please register as a EWMA member at WWW.EWMA.ORG 50

EWMA Journal

2013 vol 13 no 1

With PolyMem, finger and toe injuries don’t have to slow you down. ®

Save time with PolyMem Finger/Toe dressings, which are easy to apply – even for patients themselves – and often require fewer dressing changes thanks to their unique design. Simply roll the dressing onto the injured digit and let PolyMem do the work. PolyMem dressings help reduce edema, bruising, pain and inﬂammation when applied to open or closed injuries. THE IDEAL CHOICE FOR MANAGING: • Lacerations • Sprains • Burns • Strains • Contusions • Ulcers • Matricectomies • Abrasions

Please visit our stand at EWMA 2013 to try the new and bigger sizes (ideal for large toes).

Ferris Mfg. Corp. 5133 Northeast Parkway, Fort Worth, TX 76106 USA • +1 817-900-1301 • www.polymem.com Unless otherwise indicated, all trademarks are owned by or licensed to Ferris. © 2013, Ferris Mfg. Corp., Fort Worth, TX 76106 USA MKL-619, REV-0, 1212

EWMA

Finn Gottrup Honorary lecturer of the EWMA Conference 2013 in Copenhagen

Finn Gottrup: Professor in Surgery, Mentor, DMSci, MD, Specialist in Anatomy, General Surgery and Surgical Gastroenterology is a man with many titles and even more appreciation from colleagues, students, and others who work with him. This year, Finn Gottrup is awarded honorary lecturer of EWMA 2013 in Copenhagen.

Jan Apelqvist EWMA President ewma@ewma.org www.ewma.org

EWMA 2013 Conference Honorary Lecture Thursday 16th May, 14:30-15:00

Prof. Gottrup is the author of more than 400 publications, and has lectured extensively on clinical and experimental wound healing, wound infections, tissue perfusion, and oxygenation, within EWMA and to provide education in wound healing and treatment. He is recognised by a wide range of professions as Denmark’s leading expert on wounds. Prof. Gottrup is member of several national and international boards, committees, and editorial boards, an energetic lecturer for all of Denmark’s medical educations, and a regular speaker at international conferences, where he is appreciated for his high-quality presentations and broad knowledge of wound healing. In 1991, Prof. Gottrup was awarded the world’s first professorship in wound healing and he became professor of Surgery at University of Southern Denmark in 2003. Finn is what you could call a fireball. His many commitments deliver sufficient evidence for this, but there is much more to the person than his impressive merits. Passion is what propels the life work of Finn Gottrup, and passion is what makes this year’s acknowledgement extraordinarily well deserved. It is therefore my personal honour to welcome Finn Gottrup as honorary lecturer of the EWMA 2013Conference.

Honorary Lecturer Finn Gottrup has earned this distinction due to his committed life work within wound healing. This includes his greatly appreciated involvement in the EWMA Council as past president, recorder, and Council member and his capacity as founder and long-serving president for this year’s local organiser, the Danish Wound Healing Society, one of oldest national wound management organisations in the world. This is the fourth time an honorary lecturer has been appointed by EWMA.

Finn Gottrup started the Copenhagen Wound Healing Center in 1996, and in 2003 he was involved in establishing the University Center for Wound Healing in Odense, Denmark. These wound healing centres have been a prime force behind Denmark’s status among the world leaders in wound management. Prof. Gottrup was head of the centres from 1996-2003 and 20032007, respectively. Presently, he is professor in surgery and consultant at Copenhagen Wound Healing Center.

A lot has happened since EWMA was founded in 1991. As one of the founders, Finn’s efforts were among the driving forces behind the rapid development of our association. As past president and recorder, he has been a hard-working representative of EWMA’s multidisciplinary base, which could not have been better personalised than in Finn. Finn has always guaranteed a tireless effort to include nurses, physiotherapists, foot therapists, and physicians from other areas of specialisation into the field of wound healing. Perhaps the ability to work hard and stay focused derives from being born in Jutland the western part of Denmark. It is a place well known for its honest, sympathetic, loyal, sincere, and dependable people and their interaction with the enormous North Sea. This is a place where you are bound to develop a certain perspective of yourself and the world surrounding you. Finn has realised that although he is engaged in widespread activities, they all come down to one thing in the end: the good of the patient. When you ask people close to Finn to describe him, they usually attribute typical traits of the West Coast people to his personality and career. To quote the EWMA’s immediate past president, Zena Moore: “Finn epitomises Evidence Based Practice as he always endeavours to ‘do the right thing right’”. I could not have said it more precisely myself. m EWMA Journal

2013 vol 13 no 1

It’s time to see NPWT in a whole new light Avance® NPWT system with Safetac® is designed to minimise the pain and stress proven to delay healing1. Contact your Mölnlycke Health Care representative for a no-obligation demonstration at your clinic or hospital. For more information go to www.molnlycke.com References: 1. Upton D. et al. Pain and stress as contributors to delayed wound healing. Wound Practice and Research, 2010. 18 (3):114-122. Mölnlycke Health Care AB, Box 13080, SE-402 52 Göteborg, Sweden. Phone + 46 31 722 30 00. www.molnlycke.com. The Mölnlycke Health Care, Avance® and Safetac® names and respective logos are registered globally to one or more of Mölnlycke Health Care Group of companies. © 2013 Mölnlycke Health Care. All rights reserved.

HEAL WITH CONFIDENCE You are in the business of caring, and so are we. Like you, patient wellbeing is foremost in what we do. We all know the presence of EPA (Elevated Protease Activity) means a wound is unlikely to heal, without appropriate intervention1. And that’s not all EPA does. If undetected it also puts a burden on costs through the need for extensive and long-term clinician care as well as delaying healing and causing distress to patients through ongoing discomfort. We recognise it’s difficult to reconcile your need to cut costs in cases where there is also a need for increased care. However, we believe we’ve now made it possible. We know, as you do, that by reducing healing time there can be a significant reduction in the costs associated with clinician time and care provision. A recent study showed that 100% of the wounds tested with WOUNDCHEK™ Protease Status and found to have EPA, and then treated with PROMOGRAN®, either healed or improved* at 12 weeks2.

Not currently cleared by FDA for sale within the US market.

This outcome underlines that using a test and treat approach can make a significant difference to you, your patients, and your budgets.

Check for EPA, target treatment, and see first-hand the benefits.

Part of the

family

www.systagenix.com/woundchek Email: epa@systagenix.com Don’t miss our symposium on Wednesday 15th May 2013 at the EWMA conference. Or visit us at Stand 12 and ask to speak to Paolo, Louise or Chris. References: 1. Serena T. et al. Protease activity levels associated with healing status of chronic wounds. Poster, Wounds UK 2011. *Healing (wound closed in 12 weeks of treatment). Improvement (wound reduced in area by 50% in 12 weeks of treatment) 2. Tedeschi A. et al. The role of EPA detection in the management of chronic diabetic wounds. Oral Presentation by Anichini R, DFSG 2012.

EWMA

EWMA Document: Résumé

DEBRIDEMENT – An updated overview and clarification of the principle role of debridement Introduction The routine care of non-healing acute and chronic wounds often includes either the cleansing or debridement of the wound. Debridement induces the functional process of tissue repair and is a central medical intervention in the management of acute and chronic non-healing wounds. Many new debridement techniques have been introduced in recent years. These techniques primarily apply physical principles and forces to promote tissue repair from the acute inflammatory phase. Despite the central role of debridement in the field of wound healing, no document exists to summarize the different debridement techniques. With the “EWMA Document: Debridement - An updated overview and clarification of the principle role of debridement”, EWMA aims to provide an overview of the various options. This European Wound Management Association (EWMA) Document on Debridement comprises a general literature review and additional clinical expertise from the authors. The objective of this document is to provide an updated overview of debridement and recommend an overall clinical algorithm that defines the why, when, and how of debridement. Debridement refers to a process that removes adherent, dead, or contaminated tissue from a wound. Debridement is a separate process from the act of cleansing, which is defined as the removal of dirt (e.g., loose metabolic waste or foreign material) from a wound. We define debridement as the act of removing necrotic material, eschar, devitalised tissue, serocrusts, infected tissue, hyperkeratosis, slough, pus, haematomas, foreign bodies, debris, bone fragments, or any other type of bioburden from a wound to promote wound healing. Debridement is sometimes referred to as a form of wound bed preparation; however, from a global perspective, treatment of the wound edges and the peri-wound skin are as important as the wound EWMA Journal

2013 vol 13 no 1

bed for successful healing. This global perspective supports a definition of debridement that refers to the removal of bioburden from the wound bed as well as the liberation of wound edges and periwound skin. The purpose of this document is to show that this broader view of debridement opens new possibilities and perspectives within the field of wound healing. Debridement must be understood as a process that is used in conjunction with other treatment approaches when applying a global approach to wound healing. Debridement represents a central step in the management of wounds; therefore, this process can be applied to many types of wounds irrespective of their diagnoses and origins. A clear indication for debridement can be determined from the diagnosis of the tissue type, the type of bioburden that covers the wound bed, the state of the wound edges, and the state of the peri-wound skin. A definition of debridement that relates to the tissue type allows a clinician to define the appropriate time to apply the treatment as well as identify the most appropriate debridement method. Therefore, an appropriate diagnosis must first define the problem (e.g., necrosis, eschar, slough, source of infection) and define the exudate levels of the wound bed, which range from dry to wet. Many additional parameters influence both the decision to treat a wound with debridement and the technique that is chosen, including the amount of pain from the procedure, the patient’s environment, the patient’s choice, the patient’s age, the skill and resources of the caregiver, the patient’s quality of life, and regulations and guidelines.

Robert Strohal EWMA Council Member Other members of the group: Dissemond, J. O’Brien, J. Piaggesi, A. Rimdeika R. Young, T. Apelqvist, J ewma@ewma.org www.ewma.org The full document was published by the Journal of Wound Care in January 2013 (Strohal, R., Apelqvist, J., Dissemond, J. et al. EWMA Document: Debridement. J Wound Care. 2013; 22 (Suppl.1): S1–S52)

Mechanical debridement Mechanical wound debridement involves the use of dry gauze dressings, wet-to-dry gauze dressings, impregnated gauze/tulle dressings, or a monofilament fibre pad to remove non-viable tissue from  the wound bed. 55

Wet-to-dry debridement is a method of mechanical debridement that is used mainly in the United States. A moist gauze pad is applied to the wound. As the devitalised tissue dries, the tissue re-hardens and becomes attached to the gauze. When the dressing is changed, the adhered material is pulled free from the wound. This method is reported to be painful and therefore results in a lack of compliance with the treatment. Remnants of the gauze can become embedded within the tissue and act as a focus for infection. This method can also damage healthy tissue. Although the gauze is inexpensive, the application technique is time consuming and costly. Similar limitations apply when either paraffin tulle or gauze is used as a debriding agent. The monofilament fibre pad is designed to mechanically remove slough and devitalised cells from the wound bed. This product type contains no pharmacologically toxicologically potentially irritants and has been used successfully to debride a variety of wound types. This product has also been used to remove peri-ulcer hyperkeratosis and may be able to disrupt biofilms. For wounds that include thick tenacious slough or hard necrosis, the tissue should be softened prior to the application of the monofilament fibre pad. There is little support for the use of wet-to-dry gauze, dry gauze, and paraffin tulle as effective debriding agents. The limitations of these products should preclude their use in clinical practice. The monofilament fibre pad shows the potential to advance mechanical debridement as a viable technique. Further research and clinical use of the monofilament fibre pad is needed to determine its effects on a variety of acute and chronic wound types. Autolytic dressings, enzymatic dressings, absorptive dressings, and honey Autolytic debridement Autolytic debridement is a natural process that can be supported by a moist wound treatment strategy, such as hydrogel-based dressings. Indications are different kinds of acute and chronic wounds with necrotic tissue or fibrin coatings to rehydrate, soften and liquefy hard eschar and slough. It should be used in wounds with moderate or no exudate only. E.g. hydrogels can donate water to dry wounds or absorb fluids from moderate exudating wounds. Autolytic debridement is a selective debridement that promotes the release of endogenous proteolytic enzymes and activates phagocytes. These enzymes will soften, break down, and dissolve necrotic or sloughy tissue, which can then be digested by macrophages. Therefore, autolytic debridement is indicated for a number of acute

and chronic wounds, including wounds with necrotic tissue or fibrin coatings. Autolytic debridement should be used on wounds with no exudate or moderate exudate only. For these wounds, hydrogel-based dressings can donate water to dry wounds or absorb fluids from wounds with a moderate amount of exudate. However, autolytic debridement should not be used on bleeding wounds, fistula, body cavities, or highly exudative wounds. Autolytic debridement is contraindicated for infected wounds and wounds with a high potential for anaerobic infections. Moreover, autolytic debridement should not be used in patients that have a known contact sensitisation to any of the ingredients of the dressing components such as propylene glycol, which is often used as a preserving agent. Autolytic debridement dressings are usually changed once a day. Autolytic debridement products are easy to use, painless, and safe. However, these produces should only be used in patients in whom other options, such as surgical debridement, are not available or contraindicated. Autolytic debridement can also be used to soften and rehydrate eschar prior to the use of other debridement methods. Enzymatic debridement Enzymatic debridement is a specific wound debridement option that uses proteolytic enzymes that work synergistically with endogenous enzymes. These proteolytic enzymes are used to hydrolyze peptide bonds in wounds that are covered with non-viable tissue. Enzymatic debridement can be useful for patients with non-infected wounds in whom mechanical debridement options are not available or are contraindicated, such as in patients with bleeding problems. The most widely used products for enzymatic debridement contain collagenases, streptokinase, streptodornase, papain, and/or krill enzymes. For enzymatic debridement to be fully effective, the wounds must always have enough moisture from the environment. The application of enzymatic dressings should be performed once or twice a day. Enzymatic debridement is an easy and safe option as a conservative debridement approach. However, treatment with enzymatic debridement prolongs the time to achieve a complete removal of necrotic tissue. Therefore, enzymatic debridement should be chosen only for patients in whom other options, such as surgical debridement, are not available or contraindicated. Absorptive dressings Absorptive dressings such as dextranomer are recommended for the treatment of exudative wounds with yellow sloughy surfaces. These absorptive dressings are highly EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

EWMA

hydrophilic and rapidly absorb exudate from the necrotic sloughy mass. Absorptive dressing should be replaced after 1 to 3 days; the exact time depends on the extent of the exudation. Absorptive dressings are easy products to apply and can be used even with very exudative wounds. Therefore, absorptive dressings are an appropriate choice for the management of exudate. The most significant adverse effect that is associated with absorptive dressings is the pain that occurs during the removal of the saturated dressing, which results from the adherence effects. Honey Wound dressings that contain honey can be used to treat wounds with necrotic tissue or slough. Honey is also indicated for local wound infections, including infections that are caused by methicillin-resistant staphylococcus aureus (MRSA). Honey is effective for both its antibacterial properties as well as its use as an autolytic substance. Honey draws fluid from the surrounding tissue to reduce wound edema and is supported by the increased formation of exudate that washes debris and bacteria from the wound. Wound dressings that use honey are usually changed once a day. Larvae therapy Larvae therapy, which is also known as Maggot Debridement therapy (MDT) or Bio-surgery, is a form of mechanical debridement in which live sterile maggots such as lucilia sericata (green bottle variety) are placed on necrotic/sloughy wounds. Larvae therapy has been in use for the past four hundred years as an alternate treatment for wound healing when traditional methods of debridement (e.g., autolytic, mechanical, or surgical) have been unsuccessful. In recent years, the use of larvae therapy has re-emerged due to the rise in both chronic wounds and antibiotic-resistant strains of bacteria such as MRSA. In addition to debridement, the larvae also have antimicrobial properties and stimulate healing. As a debridement technique, larvae therapy is selective and rapid, and can be performed easily and quickly to eradicate the discomforts of infection, malodour, and necrosis in a safe and effective way. Larvae therapy is not suitable for all wounds debridement; therefore, patients should undergo a holistic assessment before treatment is initiated. Larvae are contraindicated for use near the eyes, in the upper gastrointestinal and upper respiratory tracts, and in patients with a reported allergy to fly larvae, brewerâ&#x20AC;&#x2122;s yeast, or soybean protein. Larvae therapy is also not suitable for wounds with exposed blood vessels that may potentially connect to deep vital organs. In addition, caution must be taken to ensure that wounds are never allowed to heal over the larvae. Care should also be EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

taken in patients with a known risk of a bleeding disorder; for these patients, the use of antibiotics in conjunction with the larvae therapy may be necessary, particularly if pseudomonas aeruginosa is present. Larvae therapy should not be used on areas of the body that are subject to pressure because the larvae may become squashed or suffocate due to pressure. The benefits of larvae therapy include the efficiency in debridement and disinfection as well as the stimulation of healing in chronic wounds. Patient interest in larvae therapy is growing due to the potential benefits. In addition, health care staff are becoming more familiar with the innovations of this treatment. However, the choice to use larvae therapy for debridement requires active participation from the patient in decisions about their own health. Technical solutions Jet lavage (direct debridement technique) The principle of Jet Lavage debridement evolves from the lavage of wounds, which is a technique that has been used since ancient times to treat acute wounds. Lavage has also been used more recently to treat chronic wounds. Many different lavage devices have been produced. Some lavage devices are gentle and simple to use and others are complex and comparable to surgical tools. Due to the precision and versatility of existing lavage devices, such devices are so flexible that they may be applied to many different conditions and clinical models, ranging from venous leg ulcers to post-surgical ulcers of the diabetic foot. An interesting possibility related to this device is to use the jet lavage technique in combination with antiseptic solutions may maximize antimicrobial activity, which is an important aspect of debridement. A limitation of the jet lavage technique is that this technique may be painful to some patients. Therefore, jet lavage should only be used when adequate pain management strategies are available. There is also speculation that the jet lavage technique may disseminate bacteria in the environment because of the formation of an aerosol during the application. This effect needs to be tested, but may contribute to the contamination of the setting in which the procedure is conducted. Ultrasound (direct debridement technique) Due to impressive upgrades in technology, ultrasound (US) equipment now populates the clinical environment with a variety of instruments, which have been applied to almost all of the clinical models of chronic ulceration with satisfying results. The cost of US devices is high in terms î&#x201A;Š

of absolute costs relative to the purchase of the instrument, but low when one considers that most of the devices use sterilisable probes instead of disposable consumables. One positive feature of the US approach is that US can be used on many different types of tissue, ranging from loose connective tissue to tendon or bones. However, the nebulization of material from the wound bed may be massive if not properly managed. Due to this issue, the setting in which the US procedure is conducted is of crucial importance to ensure the safety of both the patient and the US operator. Negative pressure (indirect debridement technique) Negative pressure interacts with the wound environment at many different levels, including the micro- and macrostructure of the lesion. These effects are integrated in a complex activity that results in the promotion of wound healing during all phases of negative-pressure wound therapy (NPWT) development. NPWT can be integrated with an antiseptic application, by either instilling antiseptics within the system to periodically rinse the wound area or ensuring the absorption of antiseptic into the material that is used to fill the lesion. A number of studies with NPWT have been conducted on virtually all clinical conditions that are related to wound management. The efficiency of NPWT has been confirmed for most of the conditions on which it has been tested. However, NPWT should not be applied on wounds in which infected and necrotic tissue or local ischaemia or active bleeding is present, or when deep structures such as vessels, tendons, muscles, joints, or bones are exposed. Low-frequency ultrasound (indirect debridement technique) The known mechanisms of action of low-frequency ultrasound (LFUS) varies according to the physical and biological modifications that they induce at the cellular level. These modifications occur more frequently in the KHz rather than in the MHz frequency range. One known action of LFUS is cavitation, which results from the formation of micro-bubbles. These micro-bubbles concentrate the acoustic energy and produce a shearing of the cellular structures. Micro-streaming, which consists of the linear movement of macromolecules and ions around the stationary structure of cells, may be a consequence of cavitation. The combination of cavitation and micro-streaming can interfere with cellular activity. Frequency resonance is a possible alternative mechanism of action of LFUS. Frequency resonance is related to a modification in the structure of proteins and the activation of a signal transduction at the nuclear level. These modifications would lead to a range of effects at the cellular level that can impact wound healing, such as leukocyte 58

adhesion, increased angiogenesis, or increased nitric oxide (NO) production. As in the case of NPWT, these effects may indirectly promote the debridement of chronic lesions by shifting cellular tissue towards the reparative phase. Clinical studies have demonstrated an improvement in the healing process and positive effects on the microcirculation in many different types of chronic wounds. The actions of LFUS are mediated by a saline solution that is vaporized by the US probe to transmit mechanical energy to the wound bed. This vaporization is probably the most relevant limitation of this technology. Vaporization can be managed by applying the same protection that has been adopted for the high-frequency US equipment. Another limitation of this technique is the expertise that is needed to effectively manage this technology. Surgical and sharp debridement Surgical and sharp debridement are rapid methods for removing dead tissue, including devitalised necrotic tissue or fibrin, from the wound and peri-wound skin. The main benefit of surgical and sharp debridement is the speed of dead tissue removal: these procedures are fast and effective, which allows the healing process to start quickly. The low cost of sharp excision is another benefit. Surgical and sharp debridement are non-selective methods; alternative methods should be considered if either the dead tissue does not extend further than the deep dermal layer or the wound bed is covered by fibrin or slough. However, a solid layer of necrotic tissue with a clear demarcation between viable and dead tissue are absolute indications for surgical and sharp debridement are solid layer of necrotic tissue and the clear demarcation line between viable and inevitable tissue. Surgical debridement is also indicated for wounds that contain necrotic tissue in which excision and immediate grafting are superior to other methods of reconstruction. Surgical debridement may be limited to the removal of dead tissue only or may be extended to include viable tissue to obtain the vital tissue bed that is essential for a graft if immediate reconstruction is performed. Sharp debridement may be performed by any kind of medical specialist without a surgical background, including nurses, family doctors, and other medical personnel. Surgical debridement is a more invasive action that is performed mostly by surgeons in an operation theatre. Surgical debridement might be limited to dead tissue removal or excision might be extended to viable tissue level to obtain vital tissue bed essential for graft take if immediate reconstruction is performed. Both surgical and sharp debridement should be performed under sterile conditions irrespective of the extent of the invasion. Special procedure EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

EWMA

packs that contain drapes, gauzes, and disposable instruments have been designed for sharp excision or surgical debridement and are available on the market by various suppliers. Pain is a very important issue in both surgical and sharp debridement. Steps should be taken to ensure that the patient is able to verbalize their pain both during and following the procedure. Sharp debridement may be performed without significant anaesthesia, but oral or systemic painkillers should be administered before the procedure. Other possible complications related to these methods are usually associated with over-excision. Over-excised wounds may heal with scarring, may be significantly delayed in healing, or may result in the damage of deeper structures.

time to heal, and the quality of life of the patient. From a resource utilisation standpoint, an analysis of debridement as an integrated part of wound management to achieve a specific endpoint, such as healing, is essential. The resource utilisation aspects of the currently available debridement techniques have not been thoroughly examined. For example, in patients with hard to heal diabetic foot ulcers, including patients with deep foot infections, the dominant contributing factors to the high cost of care include the number of surgical procedures, the length of the hospital stay, and the length of time to heal. Figure 1 provides an overview of resource use related to debridement. Fig 1: Resource utilisation and debridement

There are few contraindications for surgical and sharp debridement. The most important contraindications include a poor general status of the patient and the disturbance of blood coagulation. However, these contraindications are relatively safe for sharp debridement because this method is a minor intervention that drastically improves the status of the patient in the majority of cases, decreases the intoxication of the wound, and releases cytokines and other mediators of the inflammation.

Surgical procedures (theatre time, clinician time, disposables) Debridement (material, number of procedures, time, category of staff) Inpatient stay (bed days, clinic) Diagnostic and laboratory tests Facility time and visits (clinic or outpatient setting, category of staff) Frequency of dressing changes and by whom (staff, patient, family) Dressings, drugs, and other disposables and appliances Antibiotics and other drugs (duration, dosage) Complications and adverse reactions Outcome (time to clean, time to heal, healing rate)

Health economics – Wound management and debridement Several recent positive examples have illustrated possible ways to reduce both resource utilisation and costs while simultaneously improving the health-related quality of life of affected patients. Successful projects are often associated with a broader perspective that includes not only the costs of dressings and other material but also the costs of staff, the frequency of dressing changes, the length of Fig 7. Debridement process cycle Fig 7. Debridement process cycle

Goal achieved = Continued treatment

However, health economic data that is specific to debridement techniques is limited. This evidence will become increasingly important as the impact of non-healing wounds on society as well as the individual is clarified, and the resources in the health care system become scarcer. These data may become mandatory in many countries to approve new treatment strategies. However, differences in reimbursement procedures, health care organisation, salaries of staff, and the availability of facilities in various European countries make it difficult to define clear-cut recommendations about health economics.

DIAGNOSIS Goal not achieved

Necessity & proability

GOAL ACHIEVED ?

DECISION

Outcome & technique

REVIEW

ADD ONS Locally & systematically

Debridement algorithm The algorithm included in this document reflects the consensus opinion of the authors based on their personal experience. The aim of this algorithm is to provide a clear description of the general pathway of debridement as well as a proposal for a structured approach to choosing the appropriate techniques. The suggested pathway of debridement is illustrated in the process cycle that is shown in Figure 7. Figure 8 illustrates a possible pathway to direct the choice of a debridement technique. As a starting point, we have chosen the time 

Terminology

EWMA Diagnosis:Journal

2013 vol 13 no 1

Diagnosis of bioburden, tissue type and factors influencing debridement. Decision: Decision on the outcome that should be achieved, the time

Review: Review whether the outcome has been successfully achieved and whether the chosen debridement technique had proven to be valid in the specific treatment case. Goal:

EWMA

needed for treatment and the availability of the technology in the various treatment settings and situations. Our objective with these choices is to provide a simple model that is suitable for daily clinical use. However, for any choice of debridement technique, the following parameters may influence the decision: pain, the patient’s environment, the patient’s choice and consent, the patient’s biological age and comorbidities, quality of life aspects, the skill and resources of the caregiver, and regulations and existing guidelines.

and suitable for the patient can be made. These parameters are described in detail throughout the document; a short list of the most important aspects that are related to each of the techniques is included in Figure 8. Finally, it should be emphasised that any of the listed technologies may be the most suitable option for debridement with regard to a specific patient or treatment situation. m All references can be found in the full document.

In addition, a consideration of the cost efficiency of the various techniques should be included when a choice between two or more options that may be clinically relevant

The document is available for download, free of charge, at www.journalofwoundcare.com or www.ewma.org

Fig 8. Choice of techniques: Benefi ts and disadvantages related to various techniques ts and disadvantages related to various techniques Fig 8. Choice of techniques: Benefi

Least time consuming

YES

MECHANICAL DEBRIDEMENT

BENEFItS

DISADVANtAGES

Very fast method

Traditional wet-to-dry debridement may result in increased risk of infection and risk of damage to healthy tissue and pain

No special expertise needed (easy to use) Modern mechanical debridement products are claimed to cause little to no pain No damage to healthy tissue (selective debridement).

Not effi cient in cases of thick, tenacious slough and hard necrosis (demand prior softening).

Fast method

YES

SHARP DEBRIDEMENT ?

Risk of infection, if sterile conditions are not ensured.

Cost and resources: few resources needed with regard to staff and materials Effi cient in wounds with a solid layer of necrotic tissue Suitable for exudative wounds and, in some cases, infected wounds.

YES

LARVE THERAPY ?

YES

AUTOLYTIC OR ENZYMATIC DEBRIDEMENT ?

Reduce pain, bacteria and malodour

May be painful

Cost and resources: few resources needed

Contraindicated for some parts of the body, for patients with decreased perfusion, wounds with exposed blood vessels connecting to deep vital organs, and in cancer wounds.

Separate necrotic tissue from living tissue.

Easy to use Cost and resources: may be cost saving due to fewer dressing changes (decrease in staff hours) Little or no pain No damage to healthy tissue (selective debridement) Autolytic: may provide exudation management (if dressing has absorptive properties).

YES

JET LAVAGE OR ULTRASOUND ?

Risk of allergic reactions to ingredients of the dressings and risk of infl ammation Some dressings are not suitable for highly exudative wounds (enzymatic, hydrogels, occlusive dressings) Enzymatic: Need a moist environment to work effectively; may lead to excessive production of exudate (not suitable for highly exudative wounds) Autolytic: The debridement process is time consuming; contraindicated for infected wounds.

Jet lavage: Flexible modes of action (in various types of products) suitable for different wound conditions

Equipment is not generally available in the various types of treatment settings

Ultrasound: Can interfere with many different structures and has a range of effects, varying from destruction to dislocation and physical modifi cation.

Cost effectiveness: cost of equipment is high For hydrosurgery especially, skilled staff, treatment room and anaesthesia are additional costs May be painful (if no pain control).

Effi cient in wounds with a solid layer of necrotic tissue

SURGICAL DEBRIDEMENT

Suitable for exudative wounds and, in some cases, infected wounds.

Cost and resources: need for skilled staff, anaesthesia, treatment room/operation room etc May be very time consuming to provide resources needed Risk of removing healthy tissue Risk of infection, if sterile conditions are not secured Not suitable for patients with decreased perfusion Special precautions must be taken into account when treating functionally and cosmetically important areas.

Most time consuming

J O U R N A L O F WO U N D C A R E V o l 2 2 . N o 1 . E W M A D o c u M E N t 2 0 1 3

EWMA Journal S41

2013 vol 13 no 1

EWMA DOCUMENTS EWMA publications in 2013: EWMA D Debride ocument: ment An u

EWMA document on Debridement The document was published in January 2013 and is currently being translated into five languages. It offers a clarification of the principal role of debridement and defines the possibilities and limitations for standard and new debridement options.

pdat of the ed overview principl a e role o nd clarifi cati on f debrid ement

A EWMA

JWC EWM

A_final.indd

Docume

07/02/2013

EWMA Document on Antimicrobials This document will meet the on-going discussion across Europe concerning the issues and controversies of the use of antimicrobials in wound treatment. The document will be launched at the EWMA 2013 Conference.

11:02

Clinical study guidelines on non healing wounds The guidelines will include a checklist with relevant research questions, frequent mistakes and links to other relevant sources of information. With these guidelines the POG group aims to support the recommendations included in the 2010 POG document on evidence and outcomes: Outcomes in controlled and comparative studies on non healing wounds – Recommendations to improve quality of evidence in wound management

Upcoming projects in 2014: Home Care – Wound Care and Multidisciplinary Treatment Home Care – Wound Care will outline a list of recommendations for the treatment of patients with wounds in their own homes. The project is an attempt to anticipate the future challenges of different European health care systems due to demographic and public health developments.

The Multidisciplinary Treatment project will promote the use of the multidisciplinary approach to wound care as well as identified any current challenges and barriers in the use of multidisciplinary teams.

Both projects are expected to be launched at the EWMA 2014 Conference in Madrid.

All EWMA Documents can be downloaded from www.ewma.org For further details contact: EWMA Secretariat, Nordre Fasanvej 113, 2000 Frederiksberg, Denmark · Tel: +45 7020 0305 · Fax: +45 7020 0315 · ewma@ewma.org

The organisation for Wound Professionals with a multidisciplinary approach

Multidisciplinary cooperation: A nessecity and a challenge to achieve

EWMA

EWMA policy paper

PATIENT SAFETY & PRESSURE ULCERS Good clinical practices for pressure ulcers Patient safety has been a high political priority of the European Commission for many years. Recently, the Commission launched the Joint Action on Patient Safety and Quality of Care initiative. Dedicated to implementing the 2009 Council Recommendations on Patient Safety, including “the prevention and control of health care-associated infections (HCAIs)”, the initiative is designed to exchange best practices in patient safety throughout the Member States and encourage greater safety and quality in health care delivery for patients in all health care settings. Ensuring patient safety in health care settings is of great importance. The European Centre for Disease Prevention and Control (ECDC) estimates that between 8 and 12% of patients experience an adverse event during hospitalisation. European figures suggest that up to 23% of all hospital inpatients develop a pressure ulcer. Furthermore, most pressure ulcers occur during hospitalisation for an acute episode of illness or injury (EPUAP, 2002). The message of this document from the European Wound Management Association (EWMA) is that a pressure ulcer is a preventable adverse event. The incidence of pressure ulcers can be significantly reduced across Europe with good preventative strategies. As part of the Joint Action on Patient Safety and Quality of Care, the EWMA believes that clinical guidelines for the prevention and treatment of hospital-acquired pressure ulcers must be validated and implemented into clinical practice through the creation of an exchange mechanism as part of Work Package 4 on Safe Clinical Practices to protect patients from this common but mostly avoidable type of wound.

Pressure ulcers – an adverse event An often overlooked area of patient safety is wounds, and particularly pressure ulcers. Pressure ulcers are often preventable yet frequently

EWMA Journal

2013 vol 13 no 1

acquired by patients during their hospital stay as they receive treatment for other conditions (EPUAP, 2002). Despite advances in technology, preventative aid, and increased financial expenditure, pressure ulcers remain a common and debilitating concern (Moore, 2012). The impact of pressure ulcers on the individual is profound and affects all daily functions and activities (Gorecki et al. 2009). The costs associated with the prevention and management of pressure ulcers are considerable and one of the most significant costs is the cost of nursing care (Posnett and Franks, 2008). The economic drain on health care systems is compounded by the fact that health care professionals and clinicians are often not trained in wound prevention and treatment and/ or remain in systems where multidisciplinary and integrated care processes are not in place. Without proper clinical guidelines, wound treatment may take weeks or months, and patients may need to undergo additional treatment (including surgery) to recover from a wound that could have been prevented.

Zena Moore Chair of the EWMA Education Committee ewma@ewma.org www.ewma.org

Pressure ulcers commonly occur in patients who cannot reposition themselves to relieve the pressure on their bony prominences (Moore 2011). The ability to reposition is often diminished in the elderly, the malnourished, and patients with an acute illness (Moore 2011). Pressure ulcers can be prevented by identifying those patients who are most at risk and implementing effective prevention strategies. Nevertheless, the incidence of pressure ulcers is rising. Therefore, prevention and management strategies need to become core components of the strategic planning of health care services. Indeed, the presence of a pressure ulcer is considered to be an indicator of the quality of care (DOH 2012), and incidence figures reduce society’s confidence in the ability of the health care system to deliver care that is timely, appropriate, and effective (Davis and Caseby, 2001). 

EWMA

The reduction in the incidence of pressure ulcers is important for both hospital settings and primary care settings, particularly because of the considerable costs of treatment. Relatively little effort is needed to implement guidelines that will benefit patients across primary care, secondary care, home care, and long-stay settings.

Costs of pressure ulcers Bennett et al (2004) suggest that the total annual cost for pressure ulcer management in the UK is £1.4 to £2.1 billion annually, or 4% of the total UK health care expenditure. In Spain, the proportion is almost 5% (20022003 data) (Posnett et al. 2009). The overall cost for the management of pressure ulcers has been estimated at e250,000,000 in Ireland (Gethin et al. 2005). In the Netherlands, pressure ulcers have been found to be the third most expensive disease (Haalboom, 2000). These costs are not due to medication or surgical interventions, but to the prolonged hospitalisation and the intensive nursing care that is required for treatment. Posnett and Franks (2008) estimate that the cost of pressure ulcer management is £1.8 to £2.6 billion annually in the UK, with nursing care accounting for up to 41% of total costs. Estimated costs of pressure ulcers in Ireland: n Total cost for one patient = €119,094 n 129 days in the hospital at a daily cost of € 923 n All care settings in Ireland = € 205 million

The length of a hospital stay for a patient who develops a pressure ulcer is estimated to be 2 to 3 times greater (i.e. 30.4 days compared to 12.8 days) than a typical patient that does not develop a pressure ulcer (Allman et al. 1999). In a cohort of 2,000 patients, the presence of a pressure ulcer was associated with a median excess length of stay of 4.31 days (Graves et al. 2005a). Pressure ulcers are also associated with significantly higher mean unadjusted hospital costs (US$37,288 versus US$13,924) (Allman et al. 1999). As the demographics of the European population changes, including a rise in the elderly population, these costs are likely to rise proportionately (Moore & Cowman 2009).

References 1. European Pressure Ulcer Advisory Panel (2002): Summary report on the prevalence of pressure ulcers. EPUAP Review 4, 49-57. 2. Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, Defloor T, Nixon J & on behalf of the European Quality of Life Pressure Ulcer Project group (2009): Impact of pressure ulcers on quality of life in older patients: a systematic review. Journal of the American Geriatrics Society 57, 1175-1183. 3. Posnett J & Franks PJ (2008): The burden of chronic wounds in the UK. Nursing Times 104, 44-45. 4. Haalboom JRE (2000): Some remarks about overlays in the prevention and treatment of pressure ulcers. EPUAP Review 2, 67-70.

Pressure ulcers can be avoided with appropriate knowledge and use of prevention measures by health care staff. Pressure ulcers cost European health care systems up to e25 billion a year*, a cost that equates to almost onesixth (~17 %) of the total EU budget. Now is the time to adopt interventions that are effective not only in delivering a high quality of care but also in reducing costs.

Clinical guidelines for pressure ulcer prevention and treatment The EU can play a significant role in sharing the best practices for pressure ulcer prevention and treatment in health care settings, particularly through the Joint Action on Patient Safety and Quality of Care. Different wounds require different treatment. Although evidence-based guidelines for health care professionals are available for treatment, these guidelines are often not implemented in many health care settings. The incidence of wounds can be considerably reduced in every Member State of the EU by following basic clinical guidelines. The EWMA endorses the clinical guidelines developed by the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) and believes that the Joint Action Work Package 4 should take action toward ensuring that these clinical guidelines for the prevention and treatment of pressure ulcers are shared and implemented in clinical settings throughout the EU.

Studies have shown that a reduction of up to 73% of pressure ulcers is possible with effective preventative strategies. Indeed, a recent study (Moore et al 2011) demonstrated that the use of an alternate method of repositioning reduced the incidence of pressure ulceration by 8 per 100 patients (11%-3%). The study reiterates that the repositioning of individuals who are the most at risk to develop pressure ulcers (one component of pressure ulcer prevention strategies) is effective both economically and clinically, in support of the EPUAP/NPUAP 2009 guidelines. m

5. Allman RM, Goode PS, Burst N, Bartolucci AA & Thomas DR (1999): Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Advances in Wound Care 12, 22-30.

9. Moore Z., Cowman S., Conroy RM. (2011) A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. Journal of Clinical Nursing 20: 17-18. 2633-2644

6. Graves N, Birrell FA & Whitby M (2005): Modelling the economic losses from pressure ulcers among hospitalized patients in Australia. Wound Repair and Regeneration 13, 462-467.

10. Pressure Ulcer Prevention: Quick Reference Guide. European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP). 1 January 2010.; www.epuap.org/ guidelines/Final_Quick_Prevention.pdf

7. Moore ZEH & Cowman S (2009): Repositioning for treating pressure ulcers. Cochrane Database of Systematic reviews Issue 2. Art. No.: CD006898. DOI: 10.1002/14651858.CD006898.pub2. 8. Davis CM & Caseby NG (2001): Prevalence and incidence studies of pressure ulcers in two long-term care facilities in Canada. Ostomy and Wound Management 47, 28-34.

11. Gethin, G. et al. Estimating costs of pressure area management based on a survey of ulcer care in one Irish hospital. Journal of Wound Care 2005, 14:4, 162-165 *Estimates are calculated from the figures above.

EWMA Journal

2013 vol 13 no 1

23rd Conference of the European Wound Management Association

EWMA 2013 15 -17 May · 2013 · Copenhagen · Denmark

Organised by the European Wound Management Association in cooperation with the Danish Wound Healing Society · www.saar.dk

WWW.EWMA.ORG / EWMA2013

E-Health Symposium at EWMA 2013

T Claus Duedal Pedersen Head of Unit, OUH Centre of Clinical Innovation

Jan Apelqvist EWMA President

ewma@ewma.org www.ewma.org

he European Wound Management Association (EWMA) is proud to announce its first E-health symposium hosted in collaboration with the Odense University Hospital (OUH) and the Region of Southern Denmark. The symposium will take place on Friday, 17 May from 8.00 to 14.45 as part of the EWMA 2013 Conference in Copenhagen. The symposium’s title is: Transforming health care delivery with new technology: The case of wound care The aim of this E-health symposium is to bring the development and use of E-health and information and communication technology (ICT) in wound care into focus. The E-health symposium is part of the EU supported project United4Health, which is currently being implemented by more than 30 consortium partners from across Europe.. The E-health symposium is part of the United4Health project, which is currently being implemented by more than 30 consortium partners from across Europe. Both the Region of Southern Denmark and EWMA are partners in this consortium, which aims to exploit and further deploy innovative telemedicine services that have already been implemented in trials across Europe. The United4Health project also aims to develop a dissemination model to communicate E-health messages to clinical communities. The symposium and the full EWMA conference offers participants the opportunity to visit the E-Health Pavilion in the exhibition hall. Here, guided workshops will introduce participants to current and future ICTs that will help support the redesign of health care delivery.

Symposium programme Key Session: E-health and the future of the health care system: Leading international experts within the field of E-health will give an overview of where we are now and discuss how the ever-increasing use of ICT can be expected to affect the way health care is delivered in the future. The session will include discussion of how telemedicine has moved from 66

EWMA 2013 COPENHAGEN 15 -17 May · 2013

local pilot projects to large-scale implementation and how E-health is evaluated in practice using evidence-based methods. n Where are we now and where are we going: Present reality and future potential (Kevin Dean) n People Process and Technology: Integrating IT into Care Delivery (Hal Wolf ) n An evidence-generating implementation process: The telemedicine solution for diabetic foot ulcers in the Region of Southern Denmark (Knud Yderstræde) n Case for Scotland – Technology Part of Normal Service (Anne Reoch) n Mobile wound healing center using telemedecine: Analysis of a database including 5795 patients and perspectives (Luc Téot)

Introduction of new technologies will transform the organisation of care: New patient and provider roles This session focuses on how the introduction of telemedicine in routine care can affect organisational structures in terms of the way care is delivered. This kind of change is not merely the introduction of a new working tool; it changes workflows and creates new roles and responsibilities for everyone involved. Using wound care as a case, the session will discuss the most central changes occurring in the multidisciplinary collaboration and cross-sectoral patient care. n Telemedicine: A communication tool to improve integrated care and multi disciplinary collaboration (Rolf Jelnes) n Changing roles and responsibilities in cross-sectoral collaboration (Anne Sorknæs) n New roles for the patient: Possibilities and responsibilities (Jane Clemensen) n Telemedicine as a tool to upgrade competences across the continuum of care: An educational perspective (Kian Zarchi) Understanding the user perspective: Real-life experience with using telemedicine in wound care Join this session to learn about the perspectives and experiences of those who already integrated telemedicine in routine wound care. The session EWMA Journal

2013 vol 13 no 1

EWMA

5th Pisa International Diabetic Foot Course, 2 - 5 October 2013 Pisa, Italy This 4 day theoretical course & practical training gives participants a thorough introduction to all aspects of diagnosis, management and treatment of the diabetic foot. Lectures will be combined with practical sessions held in the afternoon at the diabetic foot clinic at the Pisa University Hospital. Lectures will be in agreement with the International Consensus on the Diabetic Foot & Practical Guideline on the Management and Prevention on the Diabetic Foot.

· BY

NDORS SE E ED UR

IAT IO N

E U R OP EA

Background E-health is defined as the transfer of health resources and health care by electronic means. E-health encompasses three main areas: n Delivery of health information for health professionals and health consumers through the Internet and telecommunications. n Use of IT and E-commerce to improve public health services, for example, through health worker education and training. n Use of E-commerce and E-business practices in health systems management.

Management of the Diabetic Foot

Key Session: What is good evidence in wound care and how do we generate it? This session will cover a range of topics related to applying an evidence-based approach to research in wound care and E-health. The emphasis will be on understanding the importance of choosing the most appropriate clinical and economic outcome measures when designing studies. The speakers will examine the difficulties associated with selecting and measuring appropriate outcomes to provide robust evidence which can be used for informing practice in wound care and for investments in large scale national telemedicine programmes. The session introduces you to an evaluation model developed specifically to evaluate complex E-health interventions simultaneously affecting multiple aspects of care delivery. Recommendations for achieving study results that can be transferred and applied to other contexts will be discussed. n Evidence (Patricia Price) n Update on evidence based practise - where are we now (Andrea Nelson) n The importance of evidence: What kind of evidence do we need for investment in E-health for telemedicine? (Kristian Kidholm) n How to assess the transferability of evidence from studies in E-health (Anne-Kristine Dyrvig)

quality services, all within the context of finite available resources. The hope is that E-health will result in higher quality health care that improves safety and responsiveness to patient needs at lower costs. In some countries, the use of E-health has already transitioned from local isolated pilot projects to large-scale national implementation plans. The use of new technologies is here to stay and will forever affect the way that health care is delivered. m

· CO

offers real user stories from stakeholders representing different spectrums of the care continuum and gives you a unique opportunity to learn about successes and challenges in introducing these new ways of collaborating and communicating. After brief testimonials by each individual stakeholder, an interactive Q&A session will invite the audience to share their hopes and concerns in terms of implementing telemedicine in daily practice.

· M A NA GE M E

·A

(WHO, http://www.who.int/trade/glossary/story021/en/)

This course is endorsed by EWMA.

E-health and ICT have been appointed a key role in developing and optimising health care to face the challenges of aging populations, the increase in people living with chronic conditions, and the growing demand for high

www.diabeticfootcourses.org

EWMA Journal

2013 vol 13 no 1

EWMA

The Diabetic Foot Symposium:

A NORDIC PERSPECTIVE We know what works – why don’t we do it everywhere?

Karel Bakker Chairman of the International Working Group on the Diabetic Foot

Jan Apelqvist EWMA President

ewma@ewma.org www.ewma.org

Although the same general principles and policy recommendations are governed everywhere, a large degree of decentralization means that the local implementation of clinical best practices is often fragmented and incomplete. You will find textbook examples of multidisciplinary diabetic foot care in rural and remote communities. However, you will also find urban regions where the orchestration and implementation of recommended management regimens are challenged. Consequently these geographic variations in provision of high quality care, challenges the fundamental goal for Nordic Health care systems, of ensuring equal access to care for all its citizens. Nordic Diabetic Foot Symposium at EWMA 2013 in Copenhagen This discrepancy in care is one of the key issues that will be addressed on Thursday, 16 May 2013 at the Nordic Diabetic Foot Symposium. This symposium will run as a full-day parallel session at the European Wound Management Association (EWMA) 2013 conference in Copenhagen. The aim of this symposium is to share examples with Nordic countries about the implementation of international diabetic foot guidelines for best practices in diabetic foot care. Furthermore, a key focus of the agenda is a discussion about how a systematic and widespread implementation of these best practices can be achieved in Nordic countries.

International Working Group on the Diabetic Foot Guest Session The day will open with a guest session hosted by the International Working Group on the Diabetic Foot (IWGDF). Since 1999, the IWGDF has produced practical and specific consensus guidelines on the management and prevention of diabetic

foot. The guidelines have been translated into many languages and constitute an international gold standard for the management of diabetic foot. At this session, IWGDF representatives will discuss global perspectives on diabetic foot management.

Status on diabetic foot care in the Nordic countries The opening session will be followed by a session that reviews the implementation of guidelines on the management and prevention of diabetic foot in Nordic counties. Leading diabetic foot specialists from Norway, Finland, Sweden, and Denmark will each provide a brief overview of the organisation of diabetic foot care in their country. An official from the Danish Health and Medicine Authority will provide a recent example of the development of a national clinical guideline on diabetic foot care in Denmark. This presentation will also include examples of how guideline implementation can be supported by authorities at the national level. EWMA President Jan Apelqvist will end the session with a look toward the future and present his view on the most urgent steps that are needed to push the agenda of diabetic foot care forward. Monitoring and quality control: How can we prove the impact? The mid-morning session will review the importance of data on quality indicators and how this data can significantly improve care. The first part of the session will review the basic requirements for data collection and the organisational challenges associated with adequate health care delivery. The second part of the session will showcase examples of how systematic and thorough data collection can be used to guide policy changes. The chair will conclude the session by highlighting current trends and future opportunities for Nordic benchmarking.

EWMA Journal

2013 vol 13 no 1

11th Scientific Meeting of the EWMA 2013 COPENHAGEN 15 -17 May · 2013

International perspectives on implementation The afternoon session will focus on the various organisational aspects of care and how the optimisation of health care administration can improve the quality of care. Examples from selected countries around Europe will be used to illustrate how every step counts to move the agenda forward. The session will conclude with a panel debate to discuss what Nordic countries can learn from other European countries that have successfully implemented adequate care management strategies. This panel will be composed of clinical representatives from the Nordic countries as well as international experts. Keynote Session: Vascularisation and amputation The day will conclude with a scientific session in which leading researchers from the areas of vascularisation and amputation will present and discuss their recent findings. Next Steps: The Nordic Diabetic Foot Project Our vision is that this symposium will serve as a launch pad for the Nordic Diabetic Foot project. The general aim of the Nordic Diabetic Foot project is to actively advocate for the systematic implementation of best practice diabetic foot care guidelines in the Nordic countries. This aim will be accomplished by promoting various advocacy activities that highlight the gap between the recommendations set forth by international consensus guidelines and actual practice. This project will be forged by a coalition with EWMA and IWGDF representatives, national wound management associations and/or national endocrinology societies and national diabetes associations. m

Diabetic Foot Study Group of the EASD

20-22 September 2013 Sitges, Spain

Conference theme Advancement of knowledge on all aspects of diabetic foot care Main subjects during conference:  Epidemiology  Basic and clinical science  Diagnostics  Classification  Foot clinics  Biomechanics, Osteoarthropathy  Orthopaedic surgery  Infection  Revascularisation  Uraemia 

Wound healing/outcome

www.dfsg.org

EWMA NEWS

Collaboration with Danish nurses’ organisations and education institutions during EWMA 2013

In connection with the European Wound Management Association (EWMA) 2013 Conference in Copenhagen, 15-17 May, EWMA has taken the initiative to increase collaboration with nurses’ organisations in Denmark. The primary objective is to promote wound management as a focus area for nurses. Therefore, undergraduate nurse students from universities across Denmark have been invited to attend a short introduction to wound management, focusing on wound management as a specialty and career opportunities within the field. By invitation from EWMA, the Danish umbrella organisation for the nurse specialties (Danish Nursing Society, DASYS) will also be present with a stand in the exhibition area. In the same area of the exhibition hall, participants will have the opportunity to meet representatives from Danish universities offering post-graduate courses in wound management. These representatives will provide information and guidance about educational opportunities within the field. m

Russian Spoken Symposium

EWMA 2013 COPENHAGEN 15 -17 May · 2013

The European Wound Management Association (EWMA) presents the 3th Russian Speaking Symposium, to be held during the annual EWMA Conference. As in 2012, the 2013 symposium will be offered with simultaneous Russian and English translations. Activities during EWMA 2013 In 2013, the Russian Speaking Symposium will include presentations on organisational aspects of modern wound care. In addition, the symposium will offer high-level clinical scientific presentations, roundtable discussions, and networking opportunities to exchange experiences and evaluate practices. The programme in 2013 is divided into two half-day events to allow participants better opportunities to meet and share knowledge with other Russian-speaking physicians, specialist nurses, and health care managers who are interested in wound care. The programme will start on Wednesday, 15 May, and will end at approximately noon on Thursday, 16 May. Registration for the symposium is open through the www.ewma2013.org website. The final programme of the EWMA Conference and the Russian Spoken Symposium will also be published at this site. Commitment to support wound care associations To further strengthen the involvement and collaboration with clinicians, key decision-makers in health care, and other stakeholders, EWMA is launching an advocacy project in Russia to address barriers related to the best treatment practices for patients with wounds. This initiative will kick off with a focus group meeting during the EWMA 2013 conference. The goal of this project is to support implementation of current international guidelines and help establish research projects and education programmes in selected wound care centres in Russia over the next 3 years. This project is part of EWMA’s continuing effort to support emerging wound associations in Russia, Belarus, and Ukraine. The objective of this project is to raise aware-

EWMA Journal

2013 vol 13 no 1

EWMA

ness about chronic wounds and available treatment practices with physicians, nurses, key decision-makers in health care, and the general population in all three countries. Preliminary programme for the Russian Speaking Symposium at EWMA 2013 in Copenhagen Day 1: Wednesday, 15 May 13:45-15:00 Opening of the Russian Speaking Symposium with a briefing on the current status of care in Belarus, Ukraine, and Russia

ienna

EWMA 2012

In the October 2012 issue of EWMA Journal we showed the winning posters from the Poster Prize competition. However we apologies that the picture of the poster was not of the winning poster by Kyle Turton.

15:30-16:45 Organisation of care and implementation barriers (public health focus) including a panel discussion

Translated into both Russian and English

17:00-18:00 EWMA scientific presentations with a focus on EWMA documents: debridement and antimicrobial

Translated into Russian

Please see the correct winning paper poster here.

Day 2: Thursday, 16 May 08:00-09:30 Free paper presentations (nine papers selected) 10:00-11:00

Free paper presentations (six papers selected)

Background information Since 2009, EWMA has actively supported the establishment of wound care societies in Russia, as well as neighbouring countries Belarus and Ukraine. As a result of the activities during the Russian Speaking Symposia over the past 3 years, wound care associations have been established in Belarus and Ukraine. Both associations are now registered as EWMA Cooperating Organisations and, as such, have access to organisational support and advice from EWMA, whose representatives maintain continuous contact with key clinical stakeholders. m

Welcome to our new Corporate A Sponsors:

Welcome to our new Corporate B Sponsors:

EWMA Journal

2013 vol 13 no 1

EWMA

Corporate Sponsors Corporate A BSN medical GmbH www.bsnmedical.com www.cutimed.com

Coloplast www.coloplast.com

ConvaTec Europe www.convatec.com

Ferris Mfg. Corp. www.PolyMem.eu

Paul Hartmann AG www.hartmann.info

Wound Management Smith & Nephew Medical Ltd www.smith-nephew.com/wound

KCI Europe Holding B.V. www.kci-medical.com

Lohmann & Rauscher www.lohmann-rauscher.com

Flen Pharma NV www.flenpharma.com

Mölnlycke Health Care Ab www.molnlycke.com

Sorbion AG www.sorbion.com

Systagenix Wound Management www.systagenix.com

Corporate B ArjoHuntleigh www.ArjoHuntleigh.com

DryMax www.absorbest.se/ drymax-woundcare

SastoMed www.sastomed.com

3M Health Care www.mmm.com B. Braun Medical www.bbraun.com Abbott Nutrition www.abbottnutrition.com

Advanced BioHealing, Inc. www.AdvancedBioHealing.com

ABIGO Medical AB www.abigo.se

AOTI Ltd. www.aotinc.net

Chemviron www.chemvironcarbon.com

Curea Medical GmbH www.curea-medical.de

MediWound Ltd. www.mediwound.com

Nutricia Advanced Medical Nutrition www.nutricia.com

Söring Gmb www.soering.com

Stryker www.stryker.com

Laboratoires Urgo www.urgo.com Organogenesis Switzerland GmbH www.organogenesis.com

Welcare Industries SPA www.welcaremedical.com Drawtex www.drawtex.com

Phytoceuticals www.1wound.info EWMA Journal

2013 vol 13 no 1

SPECIAL EWMA MEMBERS OFFER

journal of wound care

The journal is internationally renowned for its cutting edge and state-of-the-art research and clinical articles, as well as its coverage of management, education and novel therapies.

Journal of Wound Care (JWC) is the leading source of tissue viability research and information. JWC is essential reading for all specialists who wish to enhance their practice and stay ahead of developments in wound management and tissue viability.

?? ?? ?

volume 22. number 3. march 2013

JWC is indexed on Medline, Scopus, CINAHL and the Thomson Reuters’ Science Citation Index-Expanded and Current Contents/ Clinical Medicine and will be receiving an Impact Factor in June 2013.

“The Journal of Wound Care is an extremely valuable resource that contains a wealth of peer-reviewed papers detailing the latest advances in wound care research. A must read for clinicians, academics and researchers who want to advance their own knowledge/practice and keep abreast of the wound care literature.” Caroline McIntosh, Head of Podiatry, National University of Ireland

Clinical and cost-effectiveness of different superabsorbent dressings for VLUs Clinical outcomes of WF10 adjunct to standard treatment of diabetic foot ulcers Wound ‘dechronification’ with negatively charged polystyrene microspheres SAP-containing dressings exhibit sustained antimicrobial effects over 7 days in vitro Use of 3D photography in complex-wound assessment Orthopedic nurses’ knowledge about pressure ulcers in Iran: A cross-sectional study

cover.indd 1

22/02/2013 10:09

SAVE 10% – SUBSCRIBE TODAY Obtain access to the online archive containing all content published in JWC since 1999 with an online subscription. EWMA members quote EWMA2013 to receive your discount* *Promotional code required

Visit: www.journalofwoundcare.com/EWMA13 or call us on: +44 (0) 1722 716 997 Join us for debate and discussion:

Journal of Wound Care

Conference Calendar Conferences

Theme

2013

Days

City

Country

Annual Conference of the Swedish Wound Care Nurses Association (SSiS)

Apr

15-16 Stockholm

Sweden

Annual Conference of the Tissue Viability Society (TVS)

Apr

17-18 Kettering

United Kingdom

Spring Symposium on Advanced Wound Care and Wound Healing Society (SAWC)

May

ICW (Chronic Wounds Initiative) annual congress

May

15-16 Bremen

Germany

May

15-17 Copenhagen

Denmark

May

23-26 Cracow

Poland

23rd Conference of the European Wound Management Association (EWMA)

Organisation ad cooperation in Copenhagen

10th European Academy of Dermatology and Venereology (EADV) Spring Symposium Annual Conference of the Swiss Association for Wound Care (SAfW Romande)

Stomatherapy & Pediatric Wounds

May

1-5

Denver, Colorado

Morges

30-31 Girona

USA

Switzerland

XXV National Congress of Vascular Nursing and Wounds (AEEVH)

May

14th European Federation of National Associations of Orthopaedics and Traumatology (EFORT) Congress 2013

Jun

VIII National Congress of the Italian Nurses’ Cutaneous Wounds Association (AISLeC)

Jun

12-14 Pero

Italy

16. Jahreskongress (DGfW)

Jun

13-15 Bielefeld

Germany

Annual Conference of European Pressure Ulcer Advisory Panel (EPUAP)

Aug

28-30 Vienna

Austria

15th European Burns Association Congress (EBA)

Aug

28-31 Vienna

Austria

2nd Conference of ‘EB-CLINET – Clinical Network of EB Centres and Experts’

Sep

17-18 Salzburg

Germany

Pie Diabetico

Sep

18-19 Sitges

Spain

Annual Conference of Italian Association for the Study of Cutaneous Ulcers (AIUC)

Sep

19-21 Milano

Italy

5-8

Istanbul

Spain Turkey

Diabetic Foot Study Group (DFSG) 2013

Sep

20-22 Barcelona

Spain

Dystrophic Epidermolysis Bullosa Research Association (DEBRA) International annual congress

Sep

20-22 Rome

Italy

SAWC+WHS Fall symposium

Sep

26-28 Las Vegas

USA

12th National Wound Management Conference of The Wound Management Association of Ireland (WMAI)

Oct

1-2

Cork

Ireland

Pisa International Diabetic Foot Courses 2013

Management of the Diabetic Foot

Oct

2-5

Pisa

Italy

Annual Conference of the Dutch Organisation of Woundprofessionals (NOVW)

Players in Wound Care

Oct

7-8

Ede

The Netherlands

11th School of Wounds by the Associative Group of Research in Wounds (GAIF)

Oct

9-12

Peniche

Portugal

WundD•A•CH Kongress 2013 (AWA, ICW & SAfW)

Oct

10-12 Friedrichshafen Germany

VI Ibero-Latin American Congress about Ulcers and Wounds (SILAUHE)

Oct

23-25 Santiago

Chile

IV Congresso Brasileiro de Tratamento de Feridas (SOBENFeE)

Nov

12-15

Brazil

III Congress of the Spanish Society of Wounds (SEHER)

Nov

22-24 Madrid

Spain

14th Congress of the Woundcare Consultant Society (WCS)

Nov

26-27

Netherlands

Jan

19-21 Paris

France

Apr

10-12 Rheine

Germany

May

14-16 Madrid

Spain

2014 18ème Conférence Nationale des Plaies et Cicatrisations SFFPC 2nd International Course on The Neuropathic Osteoarthropathic Foot (Charcot Foot Course) 24rd Conference of the European Wound Management Association (EWMA)

Advanced Postgraduate Course

For web addresses please visit www.ewma.org

EWMA Journal

2013 vol 13 no 1

Organisations

Report from the 4th Pisa International Diabetic Foot Course 2012

he fourth International Diabetic Foot Course, Management of the Diabetic Foot, took place in Pisa, Italy on October 8 to 11, 2012. A total of 30 participants from 16 different countries, including 10 international faculty members and 13 national faculty members, took part in the 2012 course. The course combines theory with practical training. Theoretical lectures were held in the mornings and practical workshops were held in the after-

noons at the specialised diabetic foot clinic at the University Hospital of Pisa. The course finished with a 2-hour direct transmission from the operating room, where Alberto Piaggesi and his staff did two operations with commentary and discussion provided live by two faculty members. An evaluation survey and general comments from participants during the course suggest great satisfaction with the outcome of the course, especially in terms of emphasising the combination of practice and theory.

Prof. Alberto Piaggesi Director Diabetic Foot Section University Hospital of Pisa www.diabeticfoot courses.org

The participants commented that sharing this experience and interacting with the most recognised international experts in the field was very valuable. The 5th International Diabetic Foot Course will be held in Pisa on October 2 to 5, 2013. Further information is available at www.diabeticfootcourses.org or by contacting the Course Secretariat at info@diabeticfootcourses.org. m

Practical Session

Prof. Karel Bakker and Brigitte Hochegger

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

Participants and faculty members of the 2012 course

Report from the 1st Charcot Foot Course

Prof. Maximillian Spraul Diabetologist Mathias-Spital Rheine Germany www.charcotfootcourses.org

ourse on ational C rn te In st 1 ropathic Foot The Neu ic hropath rt a o Oste t) (Charco se, ur

aduate Co d Postgr Advance y German , ne ei Rh

r, ovembe 15 -17 N

2012

Practical session

g urses.or

co rcotfoot

www.cha

he first International Course on the Neuropathic Osteoarthropathic Foot (Charcot Foot) was held in Rheine, ermany, November 15 to 17, 2012. G A total of 33 participants and faculty members from 12 different countries took part in the Charcot Foot course. The 2½-day course gave participants a rare opportunity to train skills and discuss treatment, diagnosis, and management of the Charcot Foot with highly recognised international experts and local specialists. The course consisted of a combination of theoretical lectures, participant/faculty member debates, and practical sessions/workshops in the specialised foot clinic at Mathias-Spital in Rheine. During the practical sessions, participants were

divided in small groups to train and develop the diagnostic and treatment skills necessary for interdisciplinary treatment of Charcot patients. The course also offered participants and faculty members plenty of opportunities to network and exchange knowledge during the optional social events held every evening during the course. The next Charcot Foot course will be held in Rheine, April 10 to 12, 2014. Further information is available at www.charcotfootcourses.org or by contacting the Course Secretariat at info@ cap-partner.eu. The Charcot Foot course is open to anyone involved in the treatment or management of Neuropathic Osteoarthropathic Foot patients, but the primary participant groups are surgeons, orthopaedic surgeons, podiatrists, and diabetologists working in a multidisciplinary foot clinic, as well as specialised nurses, orthopaedic shoemakers and orthotists. m

EWMA Journal

2013 vol 13 no 1

Organisations

RUSSIAN WOUND CONFERENCE IN NORGOROD The scientific conference “Wounds: Contemporary approaches to pathogenesys and treatment” took place November 15 and 16, 2012, in Nizhny Novgorod. Leading specialists from different regions of Russia and other countries took part in the event. More than 300 surgeons attended the conference and received much useful information concerning up-to-date methods for wound treatment. One of the organisers was Russian association “Clean Wound” and its president, Prof. A. Baindurashvili, who presented on the status of the problem in Russia and abroad. This association incorporates surgeons who specialise in different branches including traumatology, combustiology, vascular surgery, peripheral arterial disease, and diabetic angiopathy, for whom the problem of wound healing is one of the most crucial.

Alexey Baindurashvili MD PhD, Professor Saint-Petersburg, Russia Vladimir Kenis, MD Saint-Petersburg, Russia

The scientific program included sessions on systemic therapy of patients with sepsis, wound healing, diabetic foot, inflammatory lesions of locomotorium, tip and tricks, and complications in the treatment of orthopedic patients. Presentations were given by recognised specialists including Prof. A. Alekseev and Prof. N. Karyakin. Experiences in wound treatment were revealed by foreign reporters including Prof. R. Rimdeika (Lithuania), Prof. T. Tamm (Ukraine), Dr. A. Karlbauer and Dr. T. Vild (Austria), and Dr. V. Pishot, Dr. Mikhalik, and Dr. Radoshevich (Slovenia). The results of introducing innovative approaches to wound healing into daily practice, including vacuum assisted closure therapy, were presented. Good results of application of this technique in the treatment of peritonitis were revealed by Dr. Zakharchenko from Emergency Institute by Dzhanelidze (Saint Petersburg). Leading manufacturers of wound care products also presented at the exhibition. m

Participants and faculty members of the 2012 course. EWMA Journal

2013 vol 13 no 1

Organisations

WAWLC Symposium at EWMA 2013 WAWLC World Alliance for Wound and Lymphoedema Care

Over the past few years, the World Alliance for Wound and Lymphoedema Care (WAWLC) has modelled itself as a global leader in wound and lymphoedema management. The working design of the WAWLC is proving to be a realistic and successful formula for supporting countries as they develop the capacity to provide effective care for wound and lymphedema patients. The annual executive board meeting of the WAWLC took place in Geneva in November 2012. One key issue on the agenda focused on the organisation and coordination of future WAWLC initiatives and activities.

David Keast President of WAWLC www.WAWLC.org

ANNUAL WAWLC SYMPOSIUM One significant outcome from the executive board meeting was the decision to establish an annual WAWLC symposium. The objective of this symposium is to provide other wound care associations with practical examples of wound and lymphoedema care in resource-poor settings. This symposium will be a permanent annual event that will be held in conjunction with one of the major international wound or lymphoedema care conferences as a hosting partner. WAWLC Symposium at EWMA 2013 The WAWLC will play a prominent role at the European Wound Management Association (EWMA) 2013 conference in Copenhagen. On Thursday, May 16, the WAWLC Symposium will run as a fullday parallel session entitled Wound Care in Resource-Poor Settings: Experiences from the Field.

EWMA international Partner Organisation

We are proud to announce that this symposium will be held in association with Médecins Sans Frontières (MSF). The symposium will include an MSF guest session in which MSF representatives will present their hands-on experiences in adapting modern wound management techniques in the humanitarian setting. A WAWLC/MSF workshop will close the day with an open dialogue meeting that centres on a discussion of the use of the Standard Wound Kit in resource-poor settings. The symposium will also include a guest session about Step by Step, the International Diabetes Foundation’s diabetic foot care programme in the developing world. The full programme for the WAWLC/MSF symposium 2013 can be found at www.ewma2013.org

In 2014, the annual WAWLC Symposium will be held in Canada and hosted by the Canadian Association of Wound Care. ABOUT WAWLC World Health Organization White Paper on Wound and Lymphoedema Management A cornerstone of the WAWLC activities is the “Wound and Lymphoedema Management” white paper, which was published by the World Health Organization (WHO) in association with the WAWLC in 2010. This document outlines wound management strategies with a specific focus on wound care in resource-poor settings where low cost wound management is a necessity. The WHO white paper has been well received by health care professionals worldwide, and further derivative publications will be made available to the public. The WAWLC is currently exploring the potential to provide various translations of the fulltext document as well as an abridged version and a DVD that outlines basic wound care. Update on WAWLC Projects The WAWLC works in partnership with resourcepoor communities worldwide. Please visit WAWLC. org/projects to view an overview of current projects as well as captivating personal field reports from volunteer health care professionals. General Information The WAWLC is a global consortium of health organizations, non-governmental organizations, health professional associations, academic and research institutions, industry, and individuals who share an interest in advancing wound care and lymphoedema management worldwide. The WAWLC’s mission is to work in partnership with resource-poor communities worldwide to advance sustainable prevention and care of wounds and lymphoedema. The WAWLC started as a working group in 2007 and was officially launched as a global partnership in 2009. m

EWMA Journal

2013 vol 13 no 1

Call for Papers Journal of Tissue Viability Journal of Tissue Viability is a quarterly journal concerned with all aspects of the occurrence and treatment of wounds, ulcers and pressure sores including patient care, pain, nutrition, wound healing, research, prevention, mobility, social problems and management. The Journal particularly encourages papers covering skin and skin wounds but will consider articles that discuss injury in any tissue. Articles that stress the multi-professional nature of tissue viability are especially welcome. We seek to encourage new authors as well as well-established contributors to the fi eld - one aim of the journal is to enable all participants in tissue viability to share information with colleagues. We are excited to invite you to publish in Journal of Tissue Viability, an international, peer reviewed journal.

ISSN: 0965-206X

Official Journal of the Tissue Viability Society.

For more information visit: www.journaloftissueviability.com

Editor in Chief: D. Bader, Southampton, UK

TYPES OF PAPERS

International editorial board:

• Clinical Study • Basic Research Study • Case Report • Review Articles • Letters to the Editor

ABSTRACTED & INDEXED IN: • BioInfoBank Library • Medline • PubMed • Science Direct • Scopus

C. Dealey, UK L. Edsberg, USA A. Gefen, Israel S. Hagisawa, Japan A. Nelson, UK J. Nixon, UK H. Partsch, Austria M. Romanello, Italy L. Schoonhoven, Netherlands L. Stockton, UK J. Swaine, Australia T. Young, UK

Submit your paper online now! http://ees.elsevier.com/jtv

Organisations

AAWC NEWS AAWC Association for the Advancement of Wound Care

Robert J. Snyder DPM, MSc, CWS President, AAWC www.aawconline.org

AAWC is the leader in interdisciplinary wound healing and tissue preservation. Be sure to join AAWC on Facebook and Linked In.

EWMA international Partner Organisation

It is my pleasure to update the readers of the European Wound Management Association Journal on the recent affairs of the Association for the Advancement of Wound Care (AAWC). AAWC continues to focus on diabetic foot and limb preservation, among our many goals as an interprofessional society. We are preparing new guidelines for wound infection and diabetic foot ulcers based on the latest evidence-based literature. AAWC will also launch a new educational image CD with a set of pictures dedicated to diabetic foot wounds. Other current objectives include our concentration on the AAWC Global Volunteers program via partnership with Health Volunteers Overseas and formation of our United States-focused component of the program. AAWC is currently exploring how we may work with those in India through collaboration with Indian Health Services. AAWC looks forward to being a resource to help with challenges facing those in India regarding wound care, education, and available resources. AAWC strives to understand the ever-changing policy and payment rules that impact our members and the patients we serve. Through our Regulatory Committee, we monitor the proposed rules issued by the Centers for Medicare and Medicaid Services on an annual basis for the Medicare and Medicaid systems that effect payment and coverage. We review technology assessments conducted by the Agency for Healthcare Research and Quality that may affect wound care and lead to new or revised coverage decisions. In addition, we identify developing national and local Medicare coverage policies related to wound care procedures, technologies, and devices to ensure ongoing access to

wound care specialists and evidence-based wound care treatments. When appropriate, the AAWC provides clinical feedback and/or recommendations to the policy makers and regulators to address concerns or issues for payment and coverage decisions. We alert our members of pending policy or payment changes and encourage members to engage directly with decision makers to share their clinical experience. Our Quality Measures Committee is further involved with the National Quality Forum to better understand and help guide the process of developing wound care-related measures for ongoing quality reporting initiatives in the United States. The Symposium on Advanced Wound Care (SAWC) Spring is fast approaching and will be held in Denver, Colorado from May 1 to 5, 2013. In line with our strategic objectives, several sessions regarding diabetic foot and limb preservation will be available. Additionally, AAWC is proud to host several sessions, including the interactive AAWC Poster Grand Rounds, the informative AAWC Speaker Training, and the popular AAWC Global Volunteers program. AAWC also has a unique Membership Celebration and Auction planned. AAWC members will receive a 20% discount on SAWC registration. AAWC membership has increased by 20% over the last year and dues are currently available at a 20% discount (only US$115 per year). AAWC has a variety of benefits for members to explore and enjoy. Please accept our invitation to join our organisation and enhance your networking ability with colleagues in the United States. Visit www.aawconline.org to learn more. m

EWMA values your opinion and would like to invite all readers to participate in shaping the organisation. Please submit possible topics for future conference sessions. EWMA is also interested in receiving book reviews, articles etc. Please contact the EWMA Secretariat at ewma@ewma.org

EWMA Journal

2013 vol 13 no 1

ANNUAL CONFERENCE AND EXHIBITION 14-16 NOVEMBER 2013 ACC LIVERPOOL

we hope to see you in Liverpool in 2013 The Society and Conference committee would like to wholeheartedly thank all participants for making the 2012 Centenary Society conference in Glasgow the best yet. The 2013 conference will be held at the ACC in Liverpool on 14-16 November 2013. The conference committee are already working hard on producing a first class programme and are looking forward to the many attractions Liverpool has to offer.

Call for Papers Presenting your work at Europe's largest podiatry conference not only raises the profile of yourself, colleagues and your employing organisation, it also highlights new research and developments and provides a platform for sharing new ideas and initiatives with your peers. Accepted presentations can help shape the conference agenda by bringing new topics and ways of working to the forefront and stimulating debate. Submissions are welcome from podiatrists of all levels and areas of the profession that demonstrate new and existing innovative research or practice initiatives in diabetes, rheumatology, management, surgery, biomechanics, dermatology, footwear, orthotics and general practice.

For further information please visit www.scpconference.com or call 020 8832 7311

Submission deadlines: Oral presentations – 28 April 2013 • Poster presentations – 8 September 2013

Organisations

Spanish Association of Vascular Nursing and Wounds AEEVH Asociación Española Enfermería Vasculas y Heridas

Esther Armans, RN President of AEEVH www.aeev.net

The Association for Vascular Nursing (AEEV) is the leading professional organisation in its field in Spain. AEEV was founded and registered in 1988 with the Ministry of National Affairs and accepted as a member organisation in the European Wound Management Association (EWMA) with the new name Asociación Española Enfermería Vasculas y Heridas (AEEVH) on October 2012. AEEVH has 310 members and is a non-profit scientific association.

In 2006, the working group developed a national consensus about leg ulcers, which was turned into a national reference guide on leg ulcers in 2009. A register for leg ulcers (RUNEI) was created by the same associations in 2010.

The primary objectives of AEEVH are as follows: n Promote and foster excellence in care related to vascular wounds, angiology, and vascular surgery. n Provide guidance and advice to nurses on issues related to the prevention and treatment of all vascular wounds. n Provide training and education for vascular nurses within the area of wound care. n Provide and promote health education quality using evidence-based clinical guidelines to manage the care of patients with vascular disease and wounds. n Cooperate and exchange with other national associations whose objectives are to improve the quality of wound management. n Promote and support research in nursing.

CONGRESS AEEVH has organised an annual national conference since 1988 (Congreso Nacional de Enfermeria Vascular), which is conducted in Spanish. Normal attendance is approximately 200-300 participants.

ACTIVITIES AEEVH has a working group on vascular ulcers and diabetic foot. This working group drew up the national guideline Consenso sobre Ulceras Vasculares y Pie Diabético de la AEEV, Guía de Práctica Clínica in March 2004. EWMA Cooperating Organisation

Together with Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas (GNEAUPP) and Spanish Society of Angiology and Vascular Surgery (SEACV), the working group drew up the national guideline Conferencia Nacional de Consenso sobre Ulceras de la Extremidad Inferior (CONUEI).

AEEVH specialist members are updating the new association web-site, which will include patient educational material and sections for the different areas of the association.

The national conference areas of interest are as follows: n Vascular wounds. n Diabetic foot. n Surgical wounds. n Wounds in primary care. n Nursing care for surgical vascular techniques. The next national conference will be held May 30 and 31, 2013, in Girona, Spain. The scientific program will cover the following topics: Three roundtables: n Negative pressure therapy (one case). n Education and health through a continuous care program. n Ethics of care in a budget cuts scenario. Two workshops: n Quality training in the care of vascular ulcers. n Basic principles of compression therapy. In addition, the AEEVH national conference includes an exhibition of oral presentations and poster discussions. The program is available at www.aeevh.net. Our working group is designing a specific guideline for clinical research using different interventions to assess impact on patients with vascular ulcers. The aims are to improve the management of this particular issue with special attention on enhancing patient quality of life.

EWMA Journal

2013 vol 13 no 1

bolog e l h P o t er

xt pap

r ne u o y t i m ub

er.de

ttau a h c s @ e is.weich

Organisations

AWMA

Australian Wound Management Association

Dr. Bill McGuiness President of AWMA www.awma.com.au

Australian Wound Management Association in 2012 INTERNATIONAL INITIATIVES In 2012 AWMA was represented at three significant international events. The first was the European Wound Management Association national conference held in Vienna in May. A substantial number of our members were invited to present findings from a variety of Australian activities. We also used the event to promote the AWMA bid to host the 2016 World Union of Wound Healing Societies (WUWHS) conference. The second international event started with an invitation from the U.S. National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel to collaborate in the next revision of the pressure injury prevention and treatment guidelines. The offer to participate is in recognition of the alliance formed in our region to author the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Professor Keryln Carville and the other members of the Australian Pressure Injury Advisory Panel will oversee this exciting initiative in 2013/14. The third international event was AWMA attendance at the 2012 WUWHS and our bid to host the 2016 WUWHS. The bid was unsuccessful, but a number of our members were able to showcase the excellent wound management research and practice being undertaken in our region. The bid also provided a forum to strengthen our relationships with wound healing groups in the southern hemisphere.

EWMA international Partner Organisation

NATIONAL INITIATIVES Wound awareness campaign Since the national conference, the FAME subcommittee have been actively pursuing the Wound Awareness Agenda. As in 2011, the focus for 2012 continues to be subsidised compression for patient with venous leg ulcers. In 2011, AWMA established a single identifiable brand, met with state ministers of health, and held a number of awareness-increasing stunts. It became obvious during the 2011 campaign that we would not be able to progress our arguments unless supporting data was available. In 2012, the following wound awareness activities were undertaken with the intent of developing evidence-based arguments to pursue our aim. n

Commissioning of KPMG to develop a cost benefit analysis of subsidising compression therapy. The KPMG consultants were asked to estimate the health care cost of assisting clients with venous leg ulceration at both the federal and state government levels, and potential cost

reduction if compression therapy was subsidised. The report will be officially released on March 21, 2013 during wound awareness week. n

Holding meetings with every Senator who is a member of the Senate committee for community affairs. The brief of this committee is to investigate issues of importance to the community and make recommendations to the Senate. There was unanimous agreement amongst the senators that the case for compression subsidy is, to quote one senator, a “no brainer”. We have received a commitment that AWMA will be invited to present to the committee in 2013.

To help allay fears of a cost increase if compression therapy was subsidized, the Education subcommittee is designing a credentialing process that would endorse general practitioners, nurse practitioners, and community nurse consultants to prescribe subsidised compression therapy.

New AWMA structure During 2012, the final stages of phase one in the AWMA structure change were completed. All state and territory web sites were migrated into one national web site. National membership categories were agreed and a national membership database established. In preparation for the next evolution of the AWMA structure, a discussion paper was sent to the committee of each state and territory in mid-2012. The paper has been revised to incorporate the comments received and circulated to the state and territory groups for final comments. After the structure has been agreed, professional assistance will be sought to help AWMA move to the new structure. Development of additional national resources In 2012, the Venous Leg Ulcer subcommittee released a patient information booklet to be used in conjunction with the AWMA venous leg ulcer guidelines. This is a free resource available on the AWMA website. LOCAL INITIATIVES The introduction of Medicare locals is providing a number of our local members with the opportunity to influence delivery of wound care at the primary health level. Assistance to develop practice guidelines, care trajectories, and educational materials has been heavily influenced by our local members. m

EWMA Journal

2013 vol 13 no 1

October 24-27, 2013 See complete details online including continuing education statements, learning objectives, session descriptions, faculty credentials, information for submitting poster and oral abstracts, and registration information at

SymposiumOnWoundCare.com

Presented by

In Collaboration with

Organisations

Review of the 5th Symposium on Chronic Wounds with International Participation:

CWA

Croatian Wound Association Nastja Kucˇišec-Tepeš MD, PhD President of the Croatian Wound Association www.huzr.hr

Atypical Wounds In accordance with the basic aim of the Croatian Wound Association (CWA), which is education of health personnel of all profiles and specialities on all levels of health care, we organised the 5th Symposium on Chronic Wounds under the title Atypical Wounds. The topic of the Symposium was chosen with the aim of rounding off knowledge in the area of chronic wounds, with regard to the fact that previous Symposia discussed Decubitus, Lower Leg Ulcers, Diabetic Foot and Chronic Wounds: Local Treatment as a Challenge for Clinicians. All the Symposia had international participation. The Symposium on Atypical Wounds was organised by the CWA and the Wound Management Association of Slovenia (WMAS), both members of the European Wound Management Association. The Symposium was held in Primošten, a beautiful venue in central Dalmatia on the Adriatic Sea, from October 24 to 26, 2012. We chose the topic of Atypical Wounds for our 5th Symposium because such have a very complex pathophysiological aetiology, are difficult to recognise and diagnose correctly, and have complex treatment. With regard to the exceptional complexity of atypical wounds, an interdisciplinary approach to the management of such conditions is imperative for good clinical practice. This requires a precise examination and supervision of the patient, determination of pathogenesis, establishing of differential diagnosis in the shortest possible time, and optimal targeted treatment.

EWMA Cooperating Organisation

The Symposium included invited professional and scientific lectures by eminent experts from Croatia, Slovenia, Austria, Sweden, and countries of the region. In addition, eight workshops including practical work took place. The total number of participants was 180; of these, 120 were health personnel, most of who participated in our earlier Symposia. The knowledge participants gained is important in clinical practice with patients suffering from chronic wounds. There were 30 invited lecturers and the Symposium included plenary lectures, patient presentations, workshops, and above all, a lively and fruitful discussion. Contrary to earlier years, the presentations of sponsors were also well attended.

The topics of the Symposium on Atypical Wounds were as follows: Definition and classification of atypical wounds: Autoimmune diseases n Wounds in autoimmune bullous dermatoses and systemic connective tissue diseases n Vasculitis and vasculopathy n Pyoderma gangrenosum – case report Dermatological diseases n Wounds and dermatoses n Current wound care in patients with elephanthiasis – third-stage lymphedema n Pemphigus chronicum vulgaris – case report Rare atypical wounds n Wounds in vascular and metabolic diseases n Wounds in hematology patients n Malignant wounds n Wounds in genital and oral regions n Wounds in children and epidermolysis bullosa n Squamous cell carcinoma – case report Other atypical wounds n Calciphylaxis n Dermatitis artifacta – psychiatric causes n Self-mutilation – artifacts – case report n Surgical approach to atypical wounds (clinical cases) n Subcutaneous ischemic arteriosclerosis (Martorell ulcer, calciphylaxis, eutrophication) The importance of compressive therapy The workshops were lively and well attended, with up to 20 participants each. Every Symposium participant could choose the workshops according to individual interests and take part in one to four of the workshops. The topics of the workshops were as follows: n The role of short-stretch bandage in lymphedema therapy n Complications of inappropriate compression therapy n Role of negative pressure therapy in the treatment of chronic wounds n Application of modern dressings in the treatment of chronic wounds

EWMA Journal

2013 vol 13 no 1

Atypical agents of wound infection and targeted samples n Role of debridement in treatment of chronic wounds n Treatment of skin surrounding wounds n Measurement of the ankle-brachial pressure index (ABPI) Sponsors’ presentations were as follows: n Application of Physiotulle Ag compresses in the management of atypical wounds n Relation of silver release and antimicrobial effect of silver-containing wound dressings in vitro n Hartman’s solutions for wound treatment n Nutritive support to the healing of chronic wounds

2nd International Course on The Neuropathic Osteoarthropathic Foot (Charcot Foot Course) Advanced Postgraduate Course, Rheine, Germany

10 -12 April, 2014

The lectures were published in full as a supplement of the indexed journal Acta Medica Croatia, the official journal of the Academy of Medical Sciences of Croatia. After five Symposia on chronic wounds in 5 years, we have covered, at least theoretically, the issues of chronic wounds and wrote usable publications for clinical practice. Much effort was invested to provide the participants of the Symposia with a quality fundamental knowledge in the area of chronic wounds. m

The international course will be based on the expertise gathered from 12 consecutive years of providing national courses on the Diabetic Foot. The main focus are practical sessions in small groups to train the diagnostic and treatment skills necessary for the interdisciplinary treatment of Charcot patients. The course will be held at the Mathias-Spital in Rheine.

Are you interested in submitting an article or paper for EWMA Journal?

The courses are open to anyone involved in the treatment or management of Neuropathic Osteoarthropathic Foot patients. Number of participants: 25-50 Language: English

Read our author guidelines at www.ewma.org

EWMA Journal

2013 vol 13 no 1

www.charcotfootcourses.org 87

Report from First Congress for treatment of chronic wounds with international participation:

SWHS

Serbian Wound Healing Society

Prim Dr. Javorka Delic President of SWHS

Dr. Simon Pandjatijan member of Council SWHS www.lecenjerana.com

EWMA Cooperating Organisation

Chronic wounds, modern therapy-answers The First Congress for treatment of chronic wounds in Serbia was held September 23 and 24, 2012, in Belgrade. Belgrade, a city at the confluence of the Sava and Danube rivers, received 400 Congress participants. Invited teachers were from Denmark, Italy, Germany, Lithuania, Austria, Serbia, Croatia, and Slovenia and included experts for the treatment of chronic wounds (CWs), professors Finn Gottrup, Elia Ricci, Dubravko Huljev, Rytis Rimdeika, Harald Daum, and Sarah Rowan. Participants were from Serbia, Macedonia, Montenegro, and Albania. The Congress was accredited (given a Certificate) from the City Health Council and the Serbian Medical Chamber. The aim of the Congress was the definition, incidences, prevalence, and etiology of distribution of CWs in Serbia, the degree of application of advances in diagnosis and therapy, standard documentation, and the results of treatment. The ultimate goal was laying the groundwork for establishing a centre for the treatment of CWs in Serbia. The scientific programme of the Congress including multiple sessions: Plenary Programme (definition of chronic wounds, cause distribution), chronic venous ulcers, pressure sores ulcer, chronic ulcers of nonvascular origins, chronic wounds in dermatology, acute wounds, diabetic foot, organisation of the Centre for Wound Healing, innovations in the treatment of chronic wounds, burns and injuries of children, and the roles of nurses in the treatment of CWs. There were three symposiums: antiseptics in the prevention and treatment of wounds and the prevention of intrahospital infections, application of topical negative pressure, and application of alginate compress with honey. The Congress had three courses: compression therapy in the treatment of CWs, application of modern local therapy and application of topical negative pressure. In addition, the Congress included two roundtables: Centre for treatment of CWs and procedures in the treatment of infectious CWs. There were four poster sessions, two for doctors and two for nurses. For the first time, the Congress held a panel of patients of members of the Serbian Wound Healing Society (SWHS) and diabetic patients in Belgrade. Patients are partners in the treatment of wounds.

The Congress included a European Wound Management Association (EWMA) stand with examples of EWMA Journal No. 12, Vol. 3, October 2012 as well as notices for the 23rd EWMA Congress, May 15 to 17, 2013 in Copenhagen. We are honored that six EWMA Council members participated in the Congress and made a significant contribution to the Congress, including Secretary Dubravko Huljev and members Elia Ricci, Rytis Rimdeika, Nada Kecelj -Leskovšek, and Delic Javorka. In the education programme for nurses working in home care, basic help was provided by Dr. Sebastian Probst, a member of the EWMA Council. The Scientific Committee selected 40 expert presentations that were published in a supplement of the magazine Wounds. The Congress was supported by 12 pharmaceutical companies. The main conclusion of the roundtables at the Congress, in which invited speakers from several countries participated, was the need for further education and regional/international cooperation in forming basic guidance for the treatment of wounds, education of experts to treat CWs regardless of specialty, formation of a primary team for the treatment of wounds, and an increase in home care treatment for CWs. The Congress materials and conclusions with regard to organisation of treatment centres for healing wounds, which needs the support of relevant state factors, will be sent to the State Ministry of Health. The second Congress for the treatment of CWs will be held in 2014 in Belgrade, so this is a notice and a call for participation for all colleagues from our country and abroad. Report from Panel of the patients: The relations between professional staff and patients with CWs; Home care, the relation of the confidence between the patients and nurses “I have the great honour to report that the first Congress for chronic wounds management was held, and was the first congress where the patients were included!” said Dr, Simon Pandjiatjan, chairman of the Panel of the patients, plastic and reconstructive surgeon and a member of the SWHS Council. The topics about patients presented information about issues including what and where the patients were treated; financial burden of the patients and

EWMA Journal

2013 vol 13 no 1

Organisations

health system; quality of life of the patients; home care; TeleUlcus; the possibility for the best diagnostic procedures and current dressing; risk factors and commorbidities; and information about CWs. The conference room included plenty of patients from a club for patients with CWs, diabetic foot, and others, doctors, nurses, and industry respresentatives. The discussions were very intense and emotional, and included discussion of many individual problems in CW management. Patient: M.I., 55 years, from Belgrade. He had participated in the discussion about personal experience: â&#x20AC;&#x153;After posttraumatic injuries of the bones on the leg (25 years ago) and osteomyelitis, deep veins thrombosis, arthrosis, I had many chronic wounds, last persisted 5 years. I had 5 operations and my doctors were: ortopedists, plastic and vascular surgeons, internists, microbiologists, physiatrics, dermatologist, and general practicioners. I have been in many hospi-

In early June 2013, the VIII School for the treatment of wounds will be held in Belgrade. The school is the first dedicated to the education of doctors and nurses who work in the service of healing chronic wounds. The school includes international participation, with invited lecturers and participants. The school will have 15 lectures and three workshops. The lectures are devoted to topics as follows: n Problem of arterial, venous, decubitus, diabetic, post-traumatic, post-surgical, and other chronic wounds n Modern diagnostics and therapy (echo, compression therapy, topical negative pressure, use of lasers, hyperbaric oxygen, use of antibiotics, types of debridement, early pediatric home healing, and modern lining) n Problems of skin care, home care, and prevention methods (comorbidities and risk factors) The club of patients with chronic wounds of nonvascular and vascular origins are involved with the school, which is organised under SWHS. School participants include pharmaceutical companies, who present drugs and devices for diagnosis and therapy. The main goal of the school is education, organisation of a centre for healing wounds, improving home treatment, and cooperation with colleagues from the region and other European countries, the EWMA, and other reference organisations in this area medicine. Lectures and workshop presentations will be published in the magazine Wounds, which SWHS has issued since 2007. The school is accredited with the Medical Council, and 50 students will receive certificates.

EWMA Journalâ&#x20AC;&#x201A;

2013 vol 13 no 1

tals, and that means many expenses. Now, I have chronic wound and oedema. For dressing I used more than 20 different materials and medical treatments. My financial costs are e100 for 1 month. I think that the government must pay for the medical treatments for wounds dressing, and organise one centre for wound management.â&#x20AC;? The conclusions of this meeting were that the patients are partners in the treatment of CWs. In Serbia, there are more than 60,000 patients with CWs. The inclusion of the patients in all processes for CW management is very important for amelioration the treatment. Home care services participate in under 5% of CWs management. Demographic data shows an increase in the population older than 65 years, and in Serbia, this is 20% of the total population. This is a source of potential patients for home care. More than 50% of the patients with CWs are older than 70 years. In this group, 53% suffered from total or partial immobility. Many patients have two or more comorbidities: cardiovascular disease (50%), degenerative disease (30%), metabolic disease (5%), and mental disturbance (10%). Approximately 75% have risk factors for developing CWs. Analysis of the home care service in the Angiology Department, Belgrade (Delic J, Mikulic V, 2009) showed that 85% of patients were older than 70 years, and 56% of them have CWs of vascular or non-vascular origins. These data showed that we need better organisation of the home care service, greater numbers of professional staff (especially nurses), and a programme for constant education. We need support to help us organise the programme of education. We need guidelines for CW care, standard documentation, and programmes for prevention. In Belgrade, we have two services for home care. The first is the Gerontological Centre, which takes care of the population older than 65 years, but this is general care for patients who have total or partial immobility. Wound care is included in 8.2% of all visits (a total of 370,000 per year). The most frequent wounds were pressure wounds: oncological, post-traumatic, and venous. Approximately 96% of all wounds were in patients older than 70 years, with an average age of 85 years. The second home care service is part of Primary health services (15 in Belgrade). This is also general home care service, but participation in wound care management is greater: wound care represents 20% of all visits. Despite these two home care services that provide wound care, Serbia does not have an organised home care service exclusively for CW management. Our activities for 2013 include organisation of the VIII school for wound management and many workshops for nurses who work in home care services. m

Cooperating Organisations

DGfW German Wound Healing Society www.dgfw.de

AEEVH Spanish Association of Vascular Nursing and Wounds www.aeevh.es

Danish Wound DSFS Healing Society Danish Wound Healing Society www.saar.dk

FWCS

AFIScep.be French Nurses’ Association in Stoma Therapy, Wound Healing and Wounds www.afiscep.be

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

AISLeC

GAIF Associated Group of Research in Wounds www.gaif.net

Italian Nurses’ Cutaneous Wounds A ssociation www.aislec.it

GNEAUPP

AIUC Italian Association for the study of Cutaneous Ulcers www.aiuc.it

National Advisory Group for the Study of P ressure Ulcers and Chronic Wounds www.gneaupp.org

ICW

APTFeridas Portuguese Association for the Treatment of Wounds www.aptferidas.com

Chronic Wounds Initiative www.ic-wunden.de

LBAA

AWA

Latvian Wound Treating O rganisation

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

BEFEWO

LUF

Belgian Federation of Woundcare www.befewo.org

The Leg Ulcer Forum www.legulcerforum.org

BWA

LWMA

Bulgarian Wound Association www.woundbulgaria.org

Lithuanian Wound Management Association www.lzga.lt

CNC

MASC

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

Maltese Association of Skin and Wound Care www.mwcf.madv.org.mt/

CSLR

MSKT

Czech Wound Management Society www.cslr.cz

Hungarian Wound Care Society www.euuzlet.hu/mskt/

CWA Croatian Wound Association www.huzr.hr

MWMA Macedonian Wound Management Association

Associated Organisations

International Partner Organisations AWMA

ILF

Lindsay Leg Club Foundation www.legclub.org

Australian Wound Management Association www.awma.com.au

International Lymphoedema Framework www.lympho.org

LSN

AAWC

NZWCS

The Lymphoedema Support Network www.lymphoedema.org/lsn

Association for the Advancement of Wound Care www.aawconline.org

New Zealand Wound Care Society www.nzwcs.org.nz

Debra International

SILAUHE

Leg Club

Dystrophic Epidermolysis Bullosa Research Association www.debra.org.uk

For more information about EWMA’s Cooperating Organisations please visit www.ewma.org

EFORT European Federation of National Associations of O rthopaedics and Traumatology www.efort.org

Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

SOBENFeE Brazilian Wound Management Association www.sobenfee.org.br EWMA Journal

2013 vol 13 no 1

Organisations

NATVNS

STW Belarus

National Association of Tissue Viability Nurses, Scotland

Society for the Treatment of Wounds (Gomel, Belarus) www.burnplast.gomel.by

NIFS Norwegian Wound Healing Association www.nifs-saar.no

NOVW Dutch Organisation of Wound Care Nurses www.novw.org

PWMA Polish Wound Management Association www.ptlr.pl

SAfW Swiss Association for Wound Care (German section) www.safw.ch

SAfW Swiss Association for Wound Care (French section) www.safw-romande.ch

SAWMA Serbian Advanced Wound Management Association www.lecenjerana.com

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

SUMS Icelandic Wound Healing S ociety www.sums-is.org

SWHS Serbian Wound Healing Society www.lecenjerana.com

SWHS Swedish Wound Healing Society www.sarlakning.se

TVS Tissue Viability Society www.tvs.org.uk

URuBiH Association for Wound Management of Bosnia and Herzegovina www.urubih.ba

UWTO Ukrainian Wound Treatment Organisation www.uwto.org.ua

V&VN Decubitus and Wound Consultants, N etherlands www.venvn.nl

SEHER The Spanish Society of Wounds www.sociedadespanolaheridas.es

SFFPC

WMAI Wound Management A ssociation of Ireland www.wmai.ie

The French and Francophone Society f Wounds and Wound Healing www.sffpc.org

WMAK

SSiS

WMAS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

SSOOR Slovak Wound Care Association www.ssoor.sk

Wound Management Association of Kosova

Wound Management Association Slovenia www.dors.si

WMAT Wound Management A ssociation Turkey www.yaradernegi.net

Other Collaborators DFSG

Eucomed

Diabetic Foot Study Group www.dfsg.org

Eucomed Advanced Wound Care Sector Group www.eucomed.org

EADV

ICC

European Academy of Dermatology and Venereology www.eadv.org

EBA European Burns Association www.euroburn.org

EPUAP European Pressure Ulcer Advisory Panel www.epuap.org ETRS

ETRS European Tissue Repair Society www.etrs.org

EWMA Journal

2013 vol 13 no 1

International Compression Club www.icc-compressionclub.com

MSF Médecins Sans Frontières www.msf.org

WAWLC World Alliance for Wound and Lymphedema Care www.wawlc.org

WUWHS The World Union of Wound Healing Societies www.wuwhs.org

4 Editorial

15 In vitro efficacy of various topical antimicrobial agents against multidrug-resistant bacteria Marianna Hajská, L. Slobodníková, H. Hupková, J. Koller

20 The mTOR inhibitors and the skin wound healing Farida Benhadou, V. del Marmol

24 A Review of Evidence for Negative Pressure Wound Therapy (NPWT) use Post Spinal Surgery Ross A. Atkinson, K. J. Ousey, S. Lui, J. B. Williamson

27 A randomized study on the effectiveness of a new pressure-relieving mattress overlay for the prevention of pressure ulcers in elderly patients at risk Elia Ricci, C. Roberto, A. Ippolito, A. Bianco, M. T. Scalise

35 Motorcycle ride position, venous return, and symptoms of c hronic venous insufficiency Ellie Lindsay, P. Vowden, K. Vowden, J. Megson

38 Archagathus – History’s first wound expert Elia Ricci

Cochrane Reviews 40 Abstracts of Recent C ochrane Reviews Sally Bell-Syer

EWMA 46 EWMA Journal Previous Issues and Other Journals 49 EWMA Antimicrobial Document Finn Gottrup

52 Finn Gottrup – Honorary lecturer of the EWMA 2013 Jan Apelqvist

55 EWMA Document: Debridement – An updated overview and clarification of the principle role of debridement

Robert Strohal, Dissemond, J., O’Brien, J., Piaggesi, A., Rimdeika R., Young, T., Apelqvist, J

63 EWMA policy paper: Patient Safety & Pressure Ulcers Zena Moore

66 E-Health Symposium at EWMA 2013, Copenhagen Claus Duedal Pedersen, Jan Apelqvist

68 The Diabetic Foot Symposium: A Nordic Perspective Karel Bakker, Jan Apelqvist

Organisations 74 Conference Calendar 75 The 4th Pisa International Diabetic Foot Course Alberto Piaggesi

76 Report from the 1st Charcot Foot Course Maximillian Spraul

77 Russian Wound Conference In Norgorod Alexey Baindurashvili, Vladimir Kenis

78 WAWLC Symposium at EWMA 2013 David Keast

80 AAWC News

Robert J. Snyder

82 AEEVH: Spanish Association of Vascular Nursing and Wounds Esther Armans

84 AWMA: Australian Wound Management Association Bill McGuiness

86 Review of the 5th Symposium on Chronic Wounds with International Participation: Atypical Wounds Nastja Kucišec-Tepeš

88 SWHS: Report from First Congress for treatment of chronic wounds Javorka Delic, Simon Pandjatijan

90 EWMA Cooperating Organisations