EWMA Journal May 2011 by EWMA European Wound Management Association

Volume 11 Number 2 May 2011 Published by European Wound Management Association

Working together to ensure better patient outcomes Danish Wound Healing Society

The EWMA Journal ISSN number: 1609-2759 Volume 11, No 2, May, 2011 Electronic Supplement May 2011 www.ewma.org

EWMA Council

The Journal of the European Wound Management Association Published three times a year

Jan Apelqvist

Zena Moore

Marco Romanelli

President Elect

President

Immediate Past President

Editorial Board Carol Dealey, Editor Sue Bale Finn Gottrup Martin Koschnick Zena Moore Marco Romanelli Zbigniew Rybak José Verdú Soriano Rita Gaspar Videira Peter Vowden

Sue Bale

Patricia Price

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 Layout: Birgitte Clematide

Paulo Alves

Barbara E. den Boogert-Ruimschotel

EWMA Journal Editor

Carol Dealey

Corrado M. Durante

Luc Gryson

Dubravko Huljev

Gerrolt Jukema

Martin Koschnick

Severin Läuchli

Eskild Winther Henneberg

Treasurer

Printed by: Kailow Graphic A/S, Denmark Copies printed: 14,000 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 2011. Prospective material for publication must be with the editors as soon as possible and no later than 15 July 2011. The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. Copyright of all published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement and printed, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval.

Maarten J. Lubbers

Sylvie Meaume

Rytis Rimdeika

Robert Strohal

CO-OPERATING ORGANISATIONS’ BOARD Christian Thyse, AFISCeP.be Andrea Bellingeri, AISLeC Elia Ricci, AIUC Aníbal Justiniano, APTFeridas Gerald Zöch, AWA Luc Gryson, BFW Vladislav Hristov, BWA Els Jonckheere, CNC Milada Francu, CSLR Dubravko Huljev, CWA Hans Martin Seipp, DGfW Eskild Winther Henneberg, DSFS Anna Hjerppe, FWCS Pedro Pacheco, GAIF J. Javier Soldevilla, GNEAUPP Editorial Board Members Sue Bale, UK Carol Dealey, UK (Editor) Finn Gottrup, Denmark Martin Koschnik, Portugal Zena Moore, Ireland Marco Romanelli, Italy Zbigniew Rybak, Poland José Verdú Soriano, Spain Rita Gaspar Videira, Portugal Peter Vowden, UK

Christian Münter, ICW Aleksandra Kuspelo, LBAA Mark Collier, LUF Kestutis Maslauskas, LWMA Corinne Ward, MASC Hunyadi János, MSKT Suzana Nikolovska, MWMA Alison Johnstone, NATVNS Kristin Bergersen, NIFS Louk van Doorn, NOVW Arkadiusz Jawień, PWMA Rodica Crutescu, ROWMA Severin Läuchli, SAfW (DE) Hubert Vuagnat, SAfW (FR) Goran D. Lazovic, SAWMA

Mária Hok, SEBINKO Sylvie Meaume, SFFPC Christina Lindholm, SSIS Jozefa Košková, SSOOR Guðbjörg Pálsdóttir, SUMS Javorca Delic, SWHS Magnus Löndahl, SWHS Andrea Nelson, TVS Jasmina Begić-Rahić, URuBiH Barbara E. den Boogert-Ruimschotel, V&VN Skender Zatriqi, WMAK Georgina Gethin, WMAOI Nada Kecelj Leskovec, WMAS Bülent Erdogan, WMAT Leonid Rubanov, WMS (Belarus)

EWMA Journal Scientific Review Panel Paulo Jorge Pereira Alves, Portugal Caroline Amery, UK Michelle Briggs, UK Mark Collier, UK Bulent Erdogan, Turkey Madeleine Flanagan, UK Milada Franců, Czech Republic Peter Franks, UK Francisco P. García-Fernández, Spain Luc Gryson, Belgium Alison Hopkins, UK Gabriela Hösl, Austria

For contact information, see www.ewma.org

Klaus Kirketerp-Møller, Denmark Zoltán Kökény, Hungary Christian Münter, Germany Andrea Nelson, UK Pedro L. Pancorbo-Hidalgo, Spain Hugo Partsch, Austria Patricia Price, UK Rytis Rimdeika, Lithuania Salla Seppänen, Finland Carolyn Wyndham-White, Switzerland Gerald Zöch, Austria

5 Editorial

Carol Dealey

Science, Practice and Education

7 The fight against biofilm infections: Do we have the knowledge and means?

ELECTRONIC SUPPLEMENT MAY 2011

Klaus Kirketerp-Møller, Thomas Bjarnsholt, Trine Rolighed Thomsen

10 Biofilms in wounds: An unsolved problem? António Pedro Fonseca

25 Diabetic foot ulcer pain: The hidden burden Sarah E Bradbury, Patricia E Price

38 Topical negative pressure in the treatment of deep sternal infection following cardiac surgery: Five year results of first-line application protocol Martin Šimek

Scientific Communication

43 Wounds Research for Patient Benefit: A five year programme of research in wound care Karen Lamb, Nikki Stubbs, Jo Dumville, Nicky Cullum

EWMA

48 EWMA Journal Previous Issues and Other Journals 50 Introducing the Belgian Federation of Woundcare Brigitte Crispin, Luc Gryson

52 EWMA Patient Outcome Group Patricia Price

55 1st EWMA Health Economics Course organised by the EWMA Patient Outcome Group Finn Gottrup

56 Advanced Wound Care Sector (AWCS) Status Report Hans Lundgren

60 EWMA Wound Surveys – Resource consumption for wound care Finn Gottrup

62 National collaboration for the Leg Ulcer & Compression Seminars 2011 Hugo Partsch, Finn Gottrup

64 EWMA Corporate Sponsors Contact Data Organisations

66 Conference Calendar 69 Conference Report: EWMA Session, 20th Annual European Tissue Repair Society Congress Gerrolt N. Jukema

70 FWCS: The 14th national wound healing congress in Helsinki, Finland Anna Hjerppe

The May 2011 edition of the EWMA Journal Electronic Supplement consist of all the accepted abstracts for the EWMA 2011 Conference in Brussels. It is divided into 150 Oral presentations and 358 Poster presentations and it is possible to download individual abstracts as well as the entire supplement (including all the abstracts) at www.ewma.org/english/ewma-journal/ electronic-supplement.html

72 Wound Treatment Organisation established in Ukraine Rytis Rimdeika

74 EWMA Cooperating Organisations 75 International Partner Organisations 75 Associated Organisations EWMA Journal

2011 vol 11 no 2

WWW.EWMA.ORG 3

HQ024571104

Welcome to Mölnlycke Health Care Satellite Symposium Investigating the Impact of Topical Antimicrobials in Wound Care 2011 EWMABe ium Brussels · lg May 26, 2011 at 11.15-12.15 11.org

www.ewma20

Wound infection is the most concerning of all wound complications. Topical antimicrobials play an important role in preventing and managing local wound infections however there are some outstanding questions regarding the usage of these agents that need to be answered. The aim of this Symposium is to support the appropriate use of topical antimicrobial agents and to promote clinical decision-making that ensures their prescription only when clinically indicated. Chairmen: Assoc Prof Bill McGuiness & Lt Col Steven Jeffery Speakers: Professor Kevin Chipman, Dr Paul Silverstein & Dr Jean-Charles Kerihuel

We look forward to seeing you there!

You said:

“It’s time to change NPWT ” So we did. Discover easy-to-use, less painful1 Avance® Avance NPWT system can help prevent some of the unnecessary pain often experienced in NPWT. Thanks to two unique products with Safetac® technology: Avance film with Safetac and Mepiseal® sealant with Safetac, patients experience less blistering2, less damaging maceration to the periwound area3 and more comfortable dressing changes1. The properties of Safetac also means you can quickly and easily reposition the film during application with no pain to the patient and no loss of effectiveness. Avance NPWT is easy to learn for patients and professionals alike, and the same pump can be used in the hospital or at home. To see all the ways Avance is delivering NPWT the way you want it, visit our stand. 1. White R. A Multinational survey of the assessment of pain when removing dressings. Wounds UK 2008;Vol 4, No 1. 2. Submitted to International Journal of Orthopaedic and Trauma Nursing, 2011. 3. Meaume S et al. A study to compare a new self adherent soft silicone dressing with a self adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Management 2003;49(9):44-51.

The Mölnlycke Health Care name and logo, Avance®, Mepiseal® and Safetac® are registered trademarks of Mölnlycke Health Care AB. © Copyright (2011) Mölnlycke Health Care. All rights reserved. Mölnlycke Health Care AB, Box 13080, SE-402 52 Göteborg, Sweden. Phone + 46 31 722 30 00. www.molnlycke.com

Dear Readers

elcome to the Spring Issue of the EWMA Journal, sometimes known as the ‘Conference Issue’ as its publication coincides with our annual conference. It is a great pleasure to know that conference delegates will all receive a copy of this issue, as I imagine that there may be a number who have not come across the EWMA Journal before. If this is you, please be aware that the Journal is freely available on-line via the EWMA website and also via Ebsco Host (free for NHS UK employees). As ever we have a number of interesting papers for you as well as all the news of EWMA activities and updates from a number of our Co-operating Organisations. I would like to draw your attention to some in particular. We have two papers about biofilms, one an opinion piece from a Danish group led by Dr Klaus Kirketerp-Møller which highlights some of the problems surrounding biofilms; the other from Assistant Professor Pedro Fonseca which gives us really detailed information about biofilms and their effects. I would also recommend to you a quite different paper which looks at the impact of pain on the quality of life with patients with diabetic foot ulcers. This is the second of two papers by Bradbury and Price on this subject and they both make interesting reading. In this issue we have what I hope is the start of a long series – the showcasing of large funded programmes of research relating to wound healing and tissue viability. Professor Nicky Cullum provides us with details of an interesting programme of Research for Patient Benefit funded by the English National Institute for Health Research (NIHR). The NIHR provides funding for programme grants lasting 4-5 years and it is very encouraging that two such programmes are wound management/tissue viability related. The other programme grant called PURPOSE will be showcased in the next issue. We would be delighted to hear from other successful research teams about their projects and showcase them in the same way.

EWMA Journal

2011 vol 11 no 2

am writing about something completely different in the final part of my editorial – and it could be called my farewell speech. At the Annual General Meeting this month I will be retiring from EWMA Council and I have decided it is also appropriate to step down as editor of the Journal. This will not be a shock to Council as we have been discussing this for some time and the Journal editorship is being passed over into the very capable hands of Sue Bale. Sue has been on the Editorial Board for a while, so she has a very good insight into the workings of the Journal. I would like to take this opportunity to thank all the members of the Editorial Board and of the Scientific Review Panel as well as the ‘Two Katja’s’ of EWMA Secretariat for their support over the last few years. The Editorial Board and the Scientific Review Panel have been very gracious about undertaking rapid reviews for me at short notice from time to time and I have depended on them all for their considered reviews of the papers we receive. As for the ‘Two Katja’s’ – they have had the thankless task of trying to keep me to deadlines and prompting me when I forget things! I wish them all well and I am sure the Journal will continue to go from strength to strength. As for me, well it will seem strange as I have been involved with EWMA since before it was officially established and a member of Council all of that time as well. I have thoroughly enjoyed being part of EWMA and have friends in many countries in Europe through the meetings I have attended. On a very personal note I especially appreciated these friendships and the love and support I received when my husband died. So now, I am officially winding down towards my retirement in 2012 when I have many plans which include having more time to spend with friends and family, especially my little grandson who loves to help me with my digging in my vegetable garden.

Carol Dealey, Editor

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ConvaTec researchers used an in vitro bacteria-seeded agar overlay model simulating a colonized wound surface to investigate the antimicrobial activity of selected silver wound dressings. The dressings were separately applied to agar surfaces seeded with S. aureus and P. aeruginosa. After 48 hours, the dressings were removed from the agar surfaces. These photographs are representative of the visually observed results with S. aureus. 1. The Antimicrobial Activity of Silver-Containing Wound Dressings on a Simulated Colonised Wound Surface. Scientific Background Report. WHRI3415 MA162. 2011 Data on File, ConvaTec. 2. Jones S, Bowler PG, Walker M. Antimicrobial activity of silver-containing dressings is influenced by dressing conformability with a wound surface. WOUNDS. 2005;17(9):263-270. 3. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber dressing. Wound Repair Regen. 2004;12(3):288-294. AQUACEL and Hydrofiber are registered trademarks of ConvaTec Inc. All other trademarks are the property of their respective owners. © 2011 ConvaTec Inc. AP-011145-MM [AM/EM]

Science, Practice and Education

Opinion Piece

The fight against biofilm infections:

Do we have the knowledge and means?

hen a ship arrives on the shores of an unknown territory with scarce or no information of what is beyond the horizon, it is only confidence in the capacity and the skills of the crew and hardware that will convince the commander that the land can be taken. Intelligence is of outmost importance. Do we have the intelligence in the battle against biofilm infections to win? In the present paper we will list what we believe is the key knowledge today and identify what science lacks, in order to suggest research strategies to resolve biofilm infections.

A Paradox: How wonderful that we have met with a paradox. Now we have some hope of making progress. Niels Bohr (1885-1962)

It is more or less accepted that chronic wounds harbour bacterial biofilm. As illustrated later in this paper, bacterial biofilm has the ability to interfere with the human immune system in numerous ways and to prevent healing. Despite that, the majority of chronic wounds will heal if the cause or predisposing factors are treated; the venous leg ulcer will heal with compression therapy, the diabetic ulcer will heal by off-loading and the cancer ulcer will heal after radiation. The residual group, the non-healing ulcers of mixed origin, could heal if unrecognized and untreated factors are treated well. One of these factors is bacterial biofilm. But what is the difference between the biofilm in the healing group and in the non-healing group? To stay with the military metaphors, we have reports of some battles we have won, but does that give us knowledge of the bacteria’s full weaponry?

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2011 vol 11 no 2

Communication and virulence factors Communication between bacteria is pointed out to be a target for intervention. Quorum Sensing (QS) in general and between Pseudomonas aeruginosa specifically is only a fragment of the communication between the bacteria. The Nacyl homoserine lactone QS signal molecule in P. aeruginosa will trigger the production of virulence factors such as rhamnolipids that, in vitro, can eliminate Neutrophils1. Blocking or modification of QS, in theory, will enable the immune system to eradicate the bacteria even in mature biofilms. However the QS molecules differ between Gram-positive and Gram-negative bacteria and even within these. A single drug to regulate all the harmful effects of QS is hardly imaginable. We have only a little overview of the communication in multi-species biofilm and of the communication between different mono-species biofilms. To interfere with the bacteria we need to decode their communication under different conditions. For instance: does antibiotic treatment alter the communication? Does surgical debridement? Insight into this will help us develop treatment strategies for different conditions. Resistance Antibiotic resistance and tolerance in bacterial biofilm is a major problem in the treatment of infections. The resistance is regulated in many different ways beside the resistance carried by the resistance genes, as in the mecA in Staphyloccocus aureus. Tolerance is partly QS controlled, partly influenced by different phenotypes within the biofilm e.g., different growth rates, efflux pumps etc, and by numerous other factors like the matrix components2;3. The response from the clinician has been newer drugs, higher dosages and polydrug treatment. Understanding the mechanisms of resistance and tolerance in biofilms can help us develop new treatment strategies and hopefully stop the rising curve of antibiotic usage and of antibiotic resistance.

1Klaus Kirketerp-Møller MD

2,3Thomas Bjarnsholt, Phd

4 Trine

Rolighed Thomsen,

Phd 1Orthopedic Department Hvidovre University Hospital Denmark 2University

of Copenhagen Faculty Of Health Sciences Department of International Health, Immunology and Microbiology Denmark

3Rigshospitalet Department for Clinical Microbiology, afsnit 9301, Denmark 4Department of Biotechnology Chemistry and Environmental Engineering Denmark

Correspondence: Klaus Kirketerp-Møller kkm@dadlnet.dk Conflict of interest: None

Science, Practice and Education

Mono or multispecies biofilm Chronic wounds are shown to be polymicrobial with no single bacterium exclusively colonizing the wounds4-7. The microbial community is highly variable, and it has been recently published that some primary populations exist in each wound, but there can also be hundreds of different species present, many of which are in trace amounts8. Using FISH, it has been illustrated that some individual microcolonies in chronic wounds only consist of a single species9. Mono and polyspecies biofilms probably exist in the same ulcer, but the importance or relevance of this is not yet established10. The uneven distribution The appearance of improved sampling techniques and molecular biology methods have illustrated that the traditional culture-dependent methods often underestimate the micro-organisms present and that a non-random distribution pattern of bacteria exists in the wounds. Differences in bacterial populations across the surface and also deep inside the wounds were found in several studies. S.aureus was primarily located close to the wound surface and P. aeruginosa was primarily located deeper in the wound5;11. This is highly relevant for the clinician. How and when is the sample taken? In an ideal world, the whole wound would be taken out to identify every single pathogen, but this is not possible nor does it provide us with the full answer. Which bacterial strain or even subgroup is important? The newer culture-independent methods such as 16S rRNA gene-based pyrosequencing, 16S rDNA cycle, PCR, real time PCR and fingerprinting techniques like denaturant gradient gel electrophoresis are identifying bacteria never before associated with chronic wounds. The problem for the clinician to evaluate the result of a culture-independent method is paramount. Which bacteria is truly a pathogen and which is merely passing by in search of a friendlier environment? How about a cut-off limit that indicates that this bacterium is abundant enough to be a pathogen? Well, the pathogenecity between different strains and phenotypes differs and probably differs over time within the same phenotype. Adding detection of known virulence genes to the molecular methods would be helpful in the process of interpretation. The role of revision before sampling Neither the traditional culturing technique nor the culture-independent methods can compensate for the threedimensional uneven distribution of micro-organisms in chronic ulcers. When designing a protocol for sampling, we think the following should be considered: 1. Revise the ulcer before sampling. The surface is likely to host commensal flora, and it is more likely that an in-depth residing bacteria is pathogenic than a superficial one. 2: Swab a large area or take a big biopsy. 8

The introduction of a stringent protocol for sampling in diabetic foot ulcers reduced the frequency of MRSA by almost two-thirds in the ulcer and reduced the number of bacteria believed to be colonizers by three-fourths12.

Are the predominant bacteria the villain? Well they probably are, but some strains are highly virulent and co-exist very well with other species. The betahaemolytic Streptococcus and the Staphylococcus aureus are an example. Yet we do not know whether the virulence of a certain strain is dependent upon another. The most abundant bacteria found by traditional methods could just be the one easiest to grow. The paradigm shift in research: Instead of only finding the bacteria, look for what they are doing. The questions we, both researchers and clinician, should ask are: What role does every single bacterial and fungal species have in the ulcer? What role does the biofilm formation play and is it the same for all species? Which virulence factors are the most important, and does QS play a role etc. Only by having thorough knowledge of this, will we be able to develop sufficient treatment strategies for each individual ulcer. Until then we have to rely on “Best-Practice Principles”. m

References 1 van Gennip M, Christensen LD, Alhede M, Phipps R, Jensen PO, Christophersen L, et al. Inactivation of the rhlA gene in Pseudomonas aeruginosa prevents rhamnolipid production, disabling the protection against polymorphonuclear leukocytes. APMIS 2009 Jul;117(7):537-46. 2 Percival SL, Hill KE, Malic S, Thomas DW, Williams DW. Antimicrobial tolerance and the significance of persister cells in recalcitrant chronic wound biofilms. Wound Repair Regen 2011 Jan;19(1):1-9. 3 Lewis K. Persister cells, dormancy and infectious disease. Nat Rev Microbiol 2007 Jan;5(1):48-56. 4 Wolcott RD, Gontcharova V, Sun Y, Dowd SE. Evaluation of the bacterial diversity among and within individual venous leg ulcers using bacterial tag-encoded FLX and titanium amplicon pyrosequencing and metagenomic approaches. BMC Microbiol 2009;9:226. 5 Thomsen TR, Aasholm MS, Rudkjobing VB, Saunders AM, Bjarnsholt T, Givskov M, et al. The bacteriology of chronic venous leg ulcer examined by culture-independent molecular methods. Wound Repair Regen 2010 Jan;18(1):38-49. 6 Dowd SE, Sun Y, Secor PR, Rhoads DD, Wolcott BM, James GA, et al. Survey of bacterial diversity in chronic wounds using pyrosequencing, DGGE, and full ribosome shotgun sequencing. BMC Microbiol 2008;8:43. 7 Gjodsbol K, Christensen JJ, Karlsmark T, Jorgensen B, Klein BM, Krogfelt KA. Multiple bacterial species reside in chronic wounds: a longitudinal study. Int Wound J 2006 Sep;3(3):225-31. 8 Smith DM, Snow DE, Rees E, Zischkau AM, Hanson JD, Wolcott RD, et al. Evaluation of the bacterial diversity of pressure ulcers using bTEFAP pyrosequencing. BMC Med Genomics 2010;3:41. 9 Kirketerp-Moller K, Jensen PO, Fazli M, Madsen KG, Pedersen J, Moser C, et al. Distribution, organization, and ecology of bacteria in chronic wounds. J Clin Microbiol 2008 Aug;46(8):2717-22. 10 Burmolle M, Thomsen TR, Fazli M, Dige I, Christensen L, Homoe P, et al. Biofilms in chronic infections – a matter of opportunity – monospecies biofilms in multispecies infections. FEMS Immunol Med Microbiol 2010 Aug;59(3):324-36. 11 Fazli M, Bjarnsholt T, Kirketerp-Moller K, Jorgensen B, Andersen AS, Krogfelt KA, et al. Nonrandom distribution of Pseudomonas aeruginosa and Staphylococcus aureus in chronic wounds. J Clin Microbiol 2009 Dec;47(12):4084-9. 12 Sotto A, Richard JL, Combescure C, Jourdan N, Schuldiner S, Bouziges N, et al. Beneficial effects of implementing guidelines on microbiology and costs of infected diabetic foot ulcers. Diabetologia 2010 Oct;53(10):2249-55.

EWMA Journal

2011 vol 11 no 2

Lohmann & Rauscher

“Simplifying wound management by means of new technology and new definitions.” A symposium - (60 min, Thursday 26.05.11, 11:15 - 12:15h) “Wounds at risk – a new definition (Chair: Thomas Eberlein, Sa Cabaneta/E, Andrew Kingsley, Devon/UK)” ■

Wound at risk and its new definition by the W.A.R. Score – Thomas Eberlein, Sa Cabaneta/E (15 min)

■

Sign Checker – symptoms, diagnosis, therapy – Andrew Kingsley, Devon/UK (15 min)

■

Reduction of SSI in a paediatric population: using a new postoperative polihexanide containing dressing regimen in a paediatric cardiology unit – Thomas Witter (RN Child) & Dr. Aaron Bell, London/UK (15 min)

■

Randomised controlled single center study comparing a polihexanide containing bio-cellulose dressing with silver sulfadiazine cream in partial thickness dermal burns – Andrzej Piatkowski de Grzymala, Aachen/DE (15 min)

B symposium - (60 min, Wednesday 25.05.11, 15:30 - 16:30h) “Gentle Debridement – rapid and effective (Chair: Trudie Young, Aneurin Bevan Health Board, Bangor/UK)” ■

Consensus guidance for the use of debridement techniques in the UK – Trudie Young (Aneurin Bevan Health Board), Bangor/UK (30 min)

■

The wound debrider – a new fibre technology for debridement: results on 60 patients – Michael Schmitz, Rengsdorf/DE (15 min)

■

Gentle debridement: first clinical experience in UK – Sylvie Hampton (Tissue Viability Consultancy Services), Eastbourne/UK (15 min) Meet us at the EWMA 2011, stand 26!

Suprasorb® X + PHMB specifically for wounds at risk of infection or infected wounds. quick and effective pain reduction wide antimicrobial spectrum good tissue compatibility

EWMA Journal

2011 vol 11 no 2

www.Lohmann-Rauscher.com

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Biofilms in wounds:

An unsolved problem?

António Pedro Fonseca PhD, Assistant Professor1,2 1Faculdade

de Medicina, Universidade do Porto,

2 REQUIMTE, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal

Correspondance: António Pedro Fonseca, Alameda Prof. Hernâni apfonseca09@gmail.com

Abstract Chronically infected wounds are very costly to health care institutions and a significant cause of suffering. The major failure associated to chronic wounds is a delayed healing process due to the presence of single or polymicrobial communities that give protection to antimicrobials and host defenses. These biofilm communities can be healthy or pathogenic according to the predominant microorganism so all the prophylactic and therapeutic measures should consider the wound healing process as a window of opportunity, ideally after a sharp and regular debridement. The aim of this review is to give an additional insight to health practitioners of the importance of the biofilm paradigm in explaining the delay in wound healing and its relation to a diagnostic, prophylactic and therapeutic management.

Conflict of interest: None

1. Biofilms a. Introduction The ability of a microorganism to establish an infection is dependent on several factors, namely those of the host and the pathogen. There is a balance between the pathogen and the host concerning the numbers of pathogens that are needed to start colonization and advance an infection. This balance is dependent on the host defense system and the presence and expression of pathogenic factors associated to the microorganism1,2.

References 1. Gardner SE, Frantz RA, Saltzman CL, Dodgson KJ. Staphylococcus aureus is associated with high microbial load in chronic wounds. Wounds 2004: 16(8):251-7. 2. Jensen PØ, Bjarnsholt T, Phipps R, Rasmussen TB, Calum H, Christoffersen L, Moser C, Williams P, Pressler T, Givskov M,, Høiby N. Rapid necrotic killing of polymorphonuclear leukocytes is caused by quorumsensing-controlled production of rhamnolipid by Pseudomonas aeruginosa. Microbiology 2007: 153:1329-38. 3. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science 1999: 284:1318-22. 4. Donlan RM, Costerton JW. Biofilms: Survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 2002: 15(2):167-93. 5. Hall-Stoodley L, Costerton JW, Stoodley P. Bacterial biofilms: From the natural environment to infectious diseases. Nat Rev Microbiol 2004: 2:95-108. 6. Jefferson KK. What drives bacteria to produce a biofilm? FEMS Microbiol Lett 2004: 236(2):163-73.

b. Biofilm formation Biofilm is a community of single or multiple microorganisms that are surface attached and encased within an extracellular matrix3. This community is found attached to abiotic surfaces like industrial waters systems and indwelling medical devices4 or biotic like mucosal surfaces5.Biofilm formation in the host is a strategy of the microorganism to survive the host defenses and also to optimize the use of the nutrient rich environment and the cooperative work between the biofilm organisms6. Biofilms can have either a positive effect such as the biodegradation7 in sewage treatment8 or a negative effect such as corrosion of pipes, infection of indwelling medical devices and the persistent infections in cystic fibrosis and chronic wounds9,10. Bacteria can grow in a free-living planktonic state or in a sessile form, a complex process that requires a sequence of coordinated activities11. This complex sequence starts with the adhesion of the microorganism. This adhesion can be reversible at first and then becomes irreversible. Following this there is the formation of microcolonies with the intervention of the quorum sensing (QS) molecules and afterwards the segregation of mucopolyssacharides (the matrix that encase the microcolonies in a biofilm)10.

7. Mor R, Sivan A. Biofilm formation and partial biodegradation of polystyrene by the actinomycete Rhodococcus rubber. Biodegradation 2008: 19(6):851-8. 8. Oliver R, May E, Williams J. Microcosm investigations of phthalate behaviour in sewage treatment biofilms. Sci Total Environ 2007: 372(2-3):605-14. 9. James GA, Swogger E, Wolcott R, Pulcini E, Secor P, Sestrich J, Costerton JW, Stewart PS. Biofilms in chronic wounds. Wound Repair Regener 2008: 16(1):37-44. 10. Fonseca AP, Sousa JC, Tenreiro R. Pseudomonas aeruginosa as a nosocomial pathogen: Epidemiology, virulence, biofilm formation and antimicrobial therapy. In: Pandalai SG, editor. Recent Research Developments in Microbiology. Kerala, India: Research Signpost; 2006. Volume 10. p. 97-132. 11. Davey ME, O’Toole GA. Microbial biofilms: from ecology to molecular genetics. Microbiol Mol Biol Rev 2000: 64(4):847-67. 12. Oliveira DR, Azeredo J, Teixeira P, Fonseca AP. The role of hydrophobicity in bacterial adhesion. In: Gilbert P, Allison D, Brading M, Verran J, Walker J, editors. Biofilm Community Interactions: Chance or Necessity? Cardiff: Bioline; 2001. p. 11-22.

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2011 vol 11 no 2

Science, Practice and Education

Figure 1. Biofilm development in P seudomonas aeruginosa. This flowchart divides biofilm formation in different steps involving specific events and bacterial properties. Firstly, planktonic b acteria migrate to the surface and adhere (A, B). Once adhered, bacteria divide and twitch to form microcolonies (C). Then alginate production begins that helps to cement the biofilm matrix in a three d imensional structure (D). Some of singular or aggregate cells (also referred as “planktonic biofilms”) are released from the biofilm and adhere to the surface in a cyclic pathway (E). LW-Lifshitz-Van der Waals forces; EL: electrostatic forces; AB: acid-base interactions; OMP: outer membrane protein; LPS: lipopolysaccharide (Adapted from Fonseca et al 2006) (10).

i. Adhesion Planktonic motile and non motile bacteria can become sessile as they start the adhesion process to an abiotic or biotic surface. For this initial step the presence and functionality of several adhesins such as flagella and fimbrae are needed10,12. There are two possible stages, namely the reversible adhesion in which bacteria can revert to the planktonic state and the irreversible adhesion that is a really step to microcolony development and biofilm formation (Figure 1).

ii. Microcolonies and biofilm formation After the initial irreversible adhesion, the cells start to divide and form cell clusters called microcolonies. The dividing cells produce quorum sensing molecules that allow the aggregation of the microcolonies. These structures are thus able to produce a matrix of extracellular polymeric substances (EPS) that encases the aggregating cells in a biofilm. These cells can have a flagellum-drive movement within the biofilm thus they are not evenly distributed in the biofilm13 and in this particular case they demand the existence of interstitial water channels that also facilitate the exchange of nutrients and wastes10,14. Expression of genes was found to be different in several steps of biofilm formation; in fact the av

13. Malic S, Hill KE, Hayes A, Percival SL, Thomas DW, Williams DW. Detection and identification of specific bacteria in wound biofilms using peptide nucleic acid fluorescent in situ hybridization (PNA FISH). Microbiology 2009: 155:2603-11. 14. Liu YC, Post JC. Biofilms in pediatric respiratory and related infections. Curr Allergy Asthma Rep 2009: 9(6):449-55. 15. Sauer K, Camper AK, Ehrlich GD, Costerton JW, Davies DG. Pseudomonas aeruginosa displays multiple phenotypes during development as a biofilm. J Bacteriol 2002: 184(4):1140-54. 16. Fux CA, Stoodley P, Hall-Stoodley L, Costerton JW. Bacterial biofilms: a diagnostic and therapeutic challenge. Expert Rev Anti-infect Ther 2003: 1(4):667-83. 17. Flemming HC, Wingender J. Relevance of microbial extracellular polymeric substances (EPSs)- Part I: Structural and ecological aspects. Water Sci Technol 2001: 43(6):1-8. 18. Barraud N, Hassett DJ, Hwang S, Rice RA, Kjelleberg S, Webb JS. Involvement of nitric oxide in biofilm dispersal of Pseudomonas aeruginosa. J Bacteriol 2006: 188(21):7344-53. 19. Davis SC, Ricotti C, Cazzaniga A, Welsh E, Eaglstein WH, Mertz PM. Microscopic and physiologic evidence for biofilm-associated wound colonization in vivo. Wound Repair Regen 2008: 16(1):23-9.

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20. Wu J, Xi C. Evaluation of different methods for extracting extracellular DNA from the biofilm matrix. Appl Environ Microbiol 2009: 75(16):5390-5. 21. De Beer D, Stoodley P. Relation between the structure of an aerobic biofilm and transport phenomena. Water Sci Technol 1995: 32(8):11-18. 22. Barrett JF, Hoch JA. Two – component signal transduction as a target for microbial anti-infective therapy. Antimicrob Agents Chemother 1998: 42:1529–36. 23. Yao W, Yue D, Yong Z, YangBo H, BaoYu Y, ShiYun C. Effects of quorum sensing autoinducer degradation gene on virulence and biofilm formation of Pseudomonas aeruginosa. Sci China C Life Sci 2007: 50(3):385-91. 24. Kaplan JB. Biofilm dispersal: mechanisms, clinical implications, and potential therapeutic uses. J Dent Res 2010: 89(3):205-18. 25. Schaber JA,Triffo WJ, Suh SJ, Oliver JW, Hastert MC, Griswold JA, Auer M, Hamood AN, Rumbaugh KP. Pseudomonas aeruginosa forms biofilms in acute infection independent of cell-to-cell signaling. Infect Immun 2007: 75(8):3715-21. 26. Bjarnsholt T, Givskov M. Quorum-sensing blockade as a strategy for enhancing host defences against bacterial pathogens. Philos Trans R Soc 2007: 362(1483):1213-22. 27. Rasmussen TB, Bjarnsholt T, Skindersoe ME, et al (2005) Screening for quorum sensing inhibitors (QSI) by use of a novel genetic system, the QSI selector. J Bact 187(5): 1799–1814.

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erage difference in protein regulation was 35%15. If planktonic cells are compared with biofilm cells, 800 proteins can be upregulated which demonstrates an expression level over 50% of the proteome15. The microcolonies and biofilm formation is a complex process that involves multiple factors and a variety of interactions, namely the adaptive responses of the sessile microorganisms. In fact the eventual presence of optimal amount of nutrients can be an inducing factor for biofilm dispersal due to increased growth of the microorganisms16. Some of the biofilm cells can switch to a planktonic free-swimming phenothype or can detach as aggregates (“planktonic biofilms”)17 and this process aids the spread of the infection by the restarting of the biofilm formation in other locations18.

iii. Biofilm physiology The knowledge of biofilm physiology is of utmost importance to understand the activities of the microorganisms within the biofilm. This information is essential for any approach in order to control biofilm formation. There are several methods that can give some insights into biofilm morphophysiology such as the use of light, epifluorescence, electron and confocal laser microscopy19. Biofilm architecture is an important factor that influences the detachment process and is affected by the amount of extracellular polymeric substances (EPS) produced. EPS is often composed of polysaccharides, lipids, proteins, nucleic acids and enzymes, and is an aid to the bacterial adhesion process20. The bulk of the biofilm is 75-90% of EPS with only 10-25% being made up of cells. Additionally it is known that biofilms from different species have their singular cellular and non cellular arrangements. An example of this are the water channels that are often dependent on the degree of hydration of the biofilm and are of utmost importance in the intake of the nutrients and excretion of the wastes, and are thus essential for bio-

film survival21. There are also several differences in a biofilm’s architecture due to the mono or poly specific character of the biofilm. The microbial ecology can also influence the production of virulence factors and have an effect in the biofilm phenotype as a collective virulence parameter and this may be caused by the communication between the cells. The ability to adapt and have adequate responses to the series of changes in the environment is dependent on cell-cell signal transduction systems22,23. Microorganisms can monitor and respond to the presence of others by the production of signaling molecules and this process is called quorum sensing. It is known that this process controls biofilm formation through the secretion of autoinducers, thus representing a key role in the regulation of biofilm architecture, the expression of virulence factors and in the dispersion of organisms24. Nevertheless, there are some strains of Pseudomonas aeruginosa that can form biofilm independently of quorum sensing25. The inhibition of cell communication has been shown lately as a new treatment strategy, in particular in the prevention of biofilm infections such as in the case of garlic that inhibits quorum sensing in P. aeruginosa26,27.

c. Factors that interfere in Biofilm formation The formation of biofilm is influenced by various factors that range from the morphophysiology of the microorganisms to the complexity of the environment in terms of nutrients or the presence of chemical and physical agents. The ability of the microorganisms to adhere to abiotic or biotic surfaces as well as the adherence rate is known to influence the formation of the biofilm28. Bacterial adhesins such as flagella or type IV fimbrae29 and the overall hydrophobicity of the bacterial surface can determine if the attachment to the surface is reversible or irreversible. The availability of nutrients is another important factor for the production of quorum sensing molecules, enzymes or amino acids that are essential for adhesion and biofilm  formation16.

28. Lasaro MA, Salinger N, Zhang J, Wang Y, Zhong Z, Goulian M, Zhu J. F1C fimbriae play an important role in biofilm formation and intestinal colonization by the Escherichia coli commensal strain Nissle 1917. Appl Environ Microbiol 2009: 75(1):246-51.

35. Bryers JD. Medical Biofilms. Biotechnol Bioeng 2008: 100(1):1–18.

29. O’Toole GA, Kolter R. Flagellar and twitching motility are necessary for Pseudomonas aeruginosa biofilm development. Mol Microbiol 1998: 30:295-304.

37. Oh YJ, Lee NR, Jo W, Jung WK, Lim JS. Effects of substrates on biofilm formation observed by atomic force microscopy. Ultramicroscopy 2009: 109(8):874-80.

30. Ammons MCB, Ward LS, Fisher ST, Wolcott RD, James GA. In vitro susceptibility of established biofilms composed of a clinical wound isolate of Pseudomonas aeruginosa treated with Lactoferrin and xylitol. Int J Antimicrob Agents 2009: 33(3):230-6. 31. Lee J, Jayaraman A, Wood TK. Indole is an inter-species biofilm signal mediated by SdiA. BMC Microbiol 2007: 18(7):42. 32. Giladi M, Porat Y, Blatt A, Shmueli E, Wasserman Y, Kirson ED, Palti Y. Microbial growth inhibition by alternating electric fields in mice with Pseudomonas aeruginosa lung infection. Antimicrob Agents Chemother 2010: 54(8):3212-18. 33. Percival SL, Thomas JG, Williams DW. Biofilms and bacterial imbalances in chronic wounds: anti-Koch. Int Wound J 2010: 7(3): 169-175. 34. Rusconi R, Lecuyer S, Guglielmini L, Stone HA. Laminar flow around corners triggers the formation of biofilm streamers. J R Soc Interface 2010: 7:1293-9.

36. Kirketerp-Møller K, Jensen PØ, Fazli M, Madsen KG, Pedersen J, Moser C, Tolker-Nielsen T, Høiby N, Givskov M, Bjarnsholt T. Distribution, organization and ecology of bacteria in chronic wounds. J Clin Microbiol 2008: 46(8):2717-22.

38. Leid JG, Shirtliff ME, Costerton JW, Stoodley AP. Human leukocytes adhere to, penetrate, and respond to Staphylococcus aureus biofilms. Infect Immun 2002: 70(11):6339-45. 39. Burmølle M, Webb JS, Rao D, Hansen LH, Sørensen SJ, Kjelleberg S. Enhanced biofilm formation and increased resistance to antimicrobial agents and bacterial invasion are caused by synergistic interactions in multispecies biofilms. Appl Environ Microbiol 2006: 72(6):3916-23. 40. Wenzel RP. Health care-associated infections: major issues in the early years of the 21st century. Clin Infect Dis 2007: 15(45 Suppl 1):S85-8. 41. Fonseca AP, Granja PL, Nogueira JA, Oliveira DR, Barbosa MA. Staphylococcus epidermidis RP62A adhesion to chemically modified cellulose derivatives. J Mat Sci: Mat Med 2001: 12:543-8.

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i. Effect of chemical and physical agents on biofilm The presence of specific substances during biofilm growth can affect it either stimulating or inhibiting formation. It is known that certain substances have a chelating effect for iron, which is important in low concentrations for sessile growth30. Another substance, indole, which is secreted by several gram negative microorganisms, such as Escherichia coli, increases biofilm formation in Pseudomonas aeruginosa31. The application of electric currents, however, can inhibit biofilm development and have a synergetic activity with the antimicrobials in the attack on biofilms32. This synergistic activity may provide a competitive advantage to the microorganisms and a real increase in the pathogenic effect of a biofilm in several diseases and infections, namely in chronic wounds, resulting in enhanced tissue degradation or impairment of the host immune response33. Another factor is the shear stress that affects the adhesion and biofilm formation process. In fact, the hydrodynamic conditions in which the biofilm occurs can influence the architecture and strength of the biofilm4. Additionally, biofilm formation can occur not only in laminar but also in turbulent flow, although it is known that for this case quorum sensing is less effective34. d. Biofilm detection methods The early or even late detection of biofilms is of utmost importance. There are several methods to determine the presence of the biofilm in vitro and in vivo in wounds isolated or in combination. Shape and size of the microorganisms in a singular or mixed culture and the eventual presence of polymorphonuclear neutrophils (PMN) in a tissue can be assessed by light microscopy35. If the microscope also has a fluorescent light it is possible to use fluorophores as stains, which absorb light emitted at a specific wavelength. If the fluorescence technique is used to stain specific components such as the DNA using peptide nucleic acids it is called Fluorescent in situ hybridization (FISH)36. It is possible, with the use of confocal laser scanning microscopy, which 42. Extremina CI, Aguiar AI, Costa L, Peixe L, Fonseca AP. Optimization of processing conditions for the quantification of enterococci biofilms using microtitre-plates. J Microbiol Methods (in press). 43. Fonseca AP, Extremina C, Fonseca AF, Sousa JC. Effect of subinhibitory concentration of piperacillin/tazobactam on Pseudomonas aeruginosa. J Med Microbiol 2004: 53:903-10. 44. Fonseca AP, Correia P, Sousa JC, Tenreiro R. Association patterns of Pseudomonas aeruginosa clinical isolates as revealed by virulence traits, antibiotic resistance, serotype and genotype. FEMS Immunol Med Microbiol 2007: 51:505-16. 45. Fonseca AP, Sousa JC. Effect of antibiotic-induced morphological changes on surface properties, motility and adhesion of nosocomial Pseudomonas aeruginosa strains under different physiological states. J Appl Microbiol 2007: 103:1828-37. 46. Fonseca AP, Sousa JC. Effect of shear stress on growth, adhesion and biofilm formation of Pseudomonas aeruginosa with antibiotic-induced morphological changes. Int J Antimicrob Agents 2007: 30:236-41. 47. Gaetti-Jardim Jr E, Nakano V, Wahasugui TC, Cabral FC, Gamba R, Avila-Campos MJ. Occurrence of yeasts, enterococci and other enteric bacteria in subgingival biofilm of HIV-positive patients with chronic gingivitis and necrotizing periodontitis. Braz J Microbiol 2008: 39(2):257-61. 48. Douglas LJ. Candida biofilms and their role in infection. Trends Microbiol 2003: 11(1):30-6.

allows a 3D visualization of the biological sample, and if coupled with a live/dead stain, to see the composition and distribution of living cells within the biofilm structure in vivo and in real time35. If necessary it is possible to have detailed information in the arrangement of the biofilm structures such as the type of adherence to the matrix or to a specific matrix through assessment using scanning electron microscopy (SEM), but, if available, it is also possible to have the levels of resolution of the SEM using “in vivo” conditions and studying real time effects of the antimicrobials, using atomic force microscopy (AFM)37. There is always the possibility to obtain the percentage of colony forming units, but, in the main, planktonic cells grow rather than biofilm cells. In this case special care must be taken if the biofilm is polymicrobial such in the case of wounds and if there is the possibility of the presence of anaerobic bacteria.

e. Medical importance of Biofilms Biofilms are resistance phenotypes for microorganisms that give protection to the antimicrobials35 and to the immune system38, namely through the effect of EPS and the slow growth rate of the microorganism within the biofilm. This biofilm ability often results in chronic infections. The close proximity of microorganisms within the biofilm creates conditions for a better transference and acquisition of resistance and virulence genes35. These biofilm resistance strategies result in a huge resistance to antimicrobials as compared to their planktonic counterparts39 and under certain circumstances the detached biofilm can lead to an embolism when transported through the veins and this is definitely life threatening40. Biofilms are often the cause of indwelling medical device associated infections. These devices, such as catheters, prosthesis, contact lenses4 etc serve as reservoirs for the microorganisms and are a source of nosocomial infections. Several species of bacteria can be biofilm forming microorganisms such as Staphylococcus species41, Enterococcus spe

49. Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappin-Scott HM. Microbial biofilms. Annu Rev Microbiol 1995: 49:711-45. 50. Thomas JG, Nakaishi LA. Managing the complexity of a dynamic biofilm. J Am Dent Assoc 2006: 137(3):10S-15S. 51. Dowd SE, Sun Y, Secor PR, Rhoads DD, Wolcott BM, James GA, Wolcott RD. Survey of bacterial diversity in chronic wounds using pyrosequencing, DGGE, and full ribosome shotgun sequencing. BMC Microbiol 2008: 8:43. 52. Anderson GG, O’Toole GA. Innate and induced resistance mechanisms of bacterial biofilms. Curr Top Microbiol Immunol 2008; 322:85-105.53. Borriello G, Werner E, Roe F, Kim AM, Ehrlich GD, Stewart PS. Oxygen limitation contributes to antibiotic tolerance of Pseudomonas aeruginosa in biofilms. Antimicrob Agents Chemother 2004: 48(4):2659-64. 54. Driffield K, Miller K, Bostock JM, O’Neill AJ, Chopra I. Increased mutability of Pseudomonas aeruginosa in biofilms. J Antimicrob Chemother 2008: 61(5):1053-6. 55. Phillips P, Sampson E, Yang Q, Antonelli P, Progulske-Fox A, Schultz G. Bacterial biofilms in wounds. Wound Healing Southern Africa 2008: 1(2):10-2. 56. Karatuna O, Yagci A. Analysis of the quorum sensing-dependent virulence factor production and its relationship with antimicrobial susceptibility in Pseudomonas aeruginosa respiratory isolates. Clin Microbiol Infect 2010 (Epub ahead of print).

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cies42, Pseudomonas aeruginosa10,41,43-46, Enteric bacteria47 and Candida albicans48, but most biofilms in wounds are often polymicrobial and several synergistic or antagonistic effects can occur between the virulence factors of the present microorganisms. For example, the Candida species produces a chemical substance that is inhibitory to quorum sensing in Pseudomonas aeruginosa. It is known that over 60% of chronic infections are biofilm related49. In fact biofilms are implicated in several microbial infections such as catheter infections16, ear and dental infections50, cystic fibrosis and human wounds13,51. Biofilm composition and architecture represent key roles in resistance to antimicrobials52. Besides the singular resistance of each cell, the biofilm can be seen as a community that has a resistance phenotype and this starts in the beginning when adhesion occurs and increases with the biofilm development35. There are several mechanisms that allow the biofilm to work as a resistance phenotype: a) the oxygen tension, the pH and the chemical substances within can alter the activity of the antimicrobials53, b) the slow growth as a result of the low oxygen tension makes the microorganisms less susceptible to the antimicrobials that are exponential growing cells, like the ß-lactams, c) the biotic or abiotic surface and the hydrodynamics (shear stress) of the biofilm formation process can select subpopulations resulting in different architectures and compositions of the biofilm, d) the close proximity of the microorganism within the biofilm creates the perfect conditions to the transfer/acquisition of genes. Additionally the microorganisms seem to increase their ability to mutate and this can affect the antimicrobial resistance54, e) quorum sensing molecules can regulate resistance genes but their absence does not necessarily mean a reduction in the susceptibility to the antimicrobials55,56, and f) extracellular matrices (EPS) work as a physical barrier that restricts the diffusion of the antimicrobial agents into the biofilm.

2. Biofilms in wounds – Why they are a problem? a. Wound formation In the human body the frontier to the external environment is the skin. This multi-layered structure is an anatomical barrier that also helps in the homeostatic preservation, thermoregulation and protection against infection57. An additional condition of the skin is its dryness, and the ability to secrete antibodies and inhibitory substances. The skin is also the surface for the proliferation for microbial normal flora that has the function of preventing the adhesion of pathogenic microorganisms58. A wound is a discontinuity of the skin that can be in more than a tissue or organ and have accidental or deliberate causes55. b. Effect of Biofilm on wound healing – the biofilm paradigm The pathogenicity of the microorganisms is dependent on their virulence ability within the wound. This capability of most microorganisms results from their production of toxins and enzymes, or from their biofilm production abilities. In the case of a slow reaction of the host to the biofilm, and in the particular case of an immunodeficient host, it increases the possibility of the development of chronic infections9,59. The PMN have little reaction against the “community resistance phenotype” called biofilm which in the case of wounds can be polymicrobial and thus quite recalcitrant. Virulent organisms, such as Pseudomonas aeruginosa and Staphylococcus aureus, when forming biofilms in vivo, show less susceptibility to antimicrobials compared to the planktonic culture60. There are two main wound microbial biofilm hypotheses that can explain why biofilms delay wound healing. The first suggests that there are specific bacterial species, despite the complexity of microbial populations within the biofilm, which are responsible for the delay in wound healing and in the overall infection process. The second argues that there is no specific bacterial species but that all the microbial community is responsible and the biofilm works as a 

57. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn Wound Infections. Clin Microbiol Rev 2006: 19(2):403-34. 58. Gariboldi S, Palazzo M, Zanobbio L, Selleri S, Sommariva M, Sfondrini L, Cavicchini S, Balsari A, Rimui C. Low molecular weight hyaluronic acid increases the selfdefence of skin epithelium by induction of β-Defensin 2 via TLR2 and TLR4. J Immunol 2008: 181(3):2103-10. 59. Cooper R. Using honey to inhibit wound pathogens. Nurs Times 2008: 104(3): 46-9. 60. Davies CE, Hill KE, Newcombe RG, Stephens P, Wilson MJ, Harding KG, Thomas DW. A prospective study of the microbiology of chronic venous ulcers to reevaluate the clinical predictive value of tissue biopsies and swabs. Wound Repair Regen 2007: 15:17-22. 61. Bjarnsholt T, Kirketerp-Møller K, Jensen PØ, Madsen KG, Phipps R, Krogfelt K, Høiby N, Givskov M. Why chronic wounds fail to heal: a new hypothesis. Wound Repair Regen 2008: 16(1):2-10. 62. Burmølle M, Thomsen TR, Fazli M, Dige I, Christensen L, Homøe P, Tvede M, Nyvad B, Tolker-Nielsen T, Givskov M, Moser C, Kirketerp-Møller K, Johansen HK, Høiby N, Jensen PØ, Sørensen SJ, Bjarnsholt T. Biofilms in chronic infections – a matter of opportunity – monospecies biofilms in multispecies infections. FEMS Immunol Med Microbiol 2010: 59:324-36.

63. Thomsen TR, Aasholm MS, Rudkjøbing VB, Saunders AM, Bjarnsholt T, Givskov M, Kirketerp-Møller K, Nielsen PH. The bacteriology of chronic venous leg ulcer examined by culture-independent molecular methods. Wound Repair Regen 2010: 18(1):38-49. 64. Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic. J Wound Care 2009: 18(2):54-6. 65. Leake JL, Dowd SE, Wolcott RD, Zischkau AM. Identification of yeast in chronic wounds using new pathogen-detection technologies. J Wound Care 2009: 18(3):103-4, 106, 108. 66. Fazli M, Bjarnsholt T, Kirketerp-Møller K, Jørgensen B, Andersen AS, Krogfelt KA, Givskov M, Tolker-Nielsen T. Non-random distribution of Pseudomonas aeruginosa and Staphylococcus aureus in chronic wounds. J Clin Microbiol 2009: 47(12):4084-9. 67. Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A, Ragnarson-Tennvall G, Reike H, Spraul M, Van Acker K, Van Baal J, Van Merode F, Ferreira I, Huijberts M. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE study. Diabetologia 2008: 51(5):747-55.

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unit. Both theories are important to explain the wound healing process and need to be proven, so both may be taken into account by practitioners considering wound management strategies33. The biofilm in the chronic wound is composed of a community of microorganisms in which the overall effect in the community unit is greater than the sum of its singular or specific parts33, thus an important approach to promote wound healing could be to enable an “ecological shift” that increases growth of non-problematic bacteria. This could be a prevention approach with the development of techniques to continuously avoid the predominance of pathogenic bacteria within the biofilm. This could involve the use of probiotics and the idea of helpful biofilm in wound healing33. It is therefore of utmost importance to control the microbial progression during wound healing and to maintain “healthy” biofilms, thus avoiding the development of pathogenic biofilms. If the biofilm community pathogenic effect exceeds host immune response, there is a compromised wound healing process33,61.

3. How can biofilms be treated? a. Diagnosis of biofilms in wounds The diagnosis of wound infection is mainly done on the basis of clinical symptoms but it was demonstrated that the microbial load of wound samples can be higher than 1 x 105 microorganisms/g of tissue with no signs of clinical infection, thus showing an urgent need for revision of the established guidelines for wound infections diagnosis. There are cases of chronic wound infections that progress to septicemia or even death because they fail to show clinical symptoms55. Recently, it has been shown that using culture-dependent methods in the wound microorganisms enable the isolation and identification of only 5% of the bacterial species, thus biopsy samples are a better option to have accurate information on the microbial diversity in the biofilms13. Besides an improved sampling technique,

there is the emergence of molecular biology methods9,62, but the best option is perhaps the combination of cultivation/molecular methods63. There are several microorganisms that are predominant in the biofilms that cause chronic wounds and these include fastidious or anaerobic biofilm growing bacteria such as Staphylococcus, Pseudomonas, Serratia, Bacteroides, and Corynebacterium64. The identification of the biofilm bacteria in wounds can be assessed using several molecular methods such as fingerprinting, using 16S rRNA, fluorescence in situ hybridization (FISH), pyrosequencing and quantitative PCR (Q-PCR)51,64. This last method enables a characterization within a few hours of the microorganisms present in wounds and has already been used to demonstrate that the numbers of certain bacteria such as P. aeruginosa and S. aureus varies between samples which are taken in different locations in the same wound63. But if detection of the relative contribution of the bacteria or yeast is needed in a chronic wound sample, pyrosequencing methods are recommended, although they only give return results in 24 hours65. The use of rRNA gene based PCR techniques, that is using Q-PCR and pyrosequencing, gives information regarding presence of viable and nonviable bacteria, prevalence and type of bacterial species, but there is no information concerning the structural organization and spatial distribution of the bacteria in the biofilm nor even any information on the relative contribution of each bacteria to the disease pathogenesis. This can be obtained by visualization of the bacterial communities that exist in the wound biofilms by using FISH with species-specific peptide nucleic acid-PNA DNA probe plus a PNA probe for all eubacterial species. Burmølle et al (2010)62 describe the use of a combination of PNA-FISH and confocal laser scanning microscopy (CLSM) to assess the spatial distribution and structural organization of biofilm bacteria in chronic wounds62,66. The combined method demonstrated that the microbial communities in chronic wounds 

68. Yasuhara H, Hattori T, Shigeta O. Significance of phlebosclerosis in non-healing ischaemic foot ulcers of end-stage renal disease. Eur J Vasc Endovasc Surg 2008: 36(3):346-52.

76. Andersen AS, Jøergensen B, Bjarnsholt T, Johansen H, Karlsmark T, Givskov M, Krogfelt KA. Quorum-sensing-regulated virulence factors in Pseudomonas aeruginosa are toxic to Lucilia sericata maggots. Microbiology 2009; 156:400-7.

69. Hunt TK. Hyperbaric Oxygen and Wounds: A tale of two enzymes. EWMA J 2010: 10(2):7-9.

77. Marazzi M, Stefani A, Chiaratti A, Ordanini MN, Falcone L, Rapisarda V. Effect of enzymatic debridement with collagenase on acute and chronic hard-to-heal wounds. J Wound Care 2006: 15(5):222-7.

70. Rhoads DD, Wolcott RD, Percival SL. Biofilms in wounds: management strategies. J Wound Care 2008: 17(11):502-8. 71. Wolcott RD, Ehrlich GD. Biofilms and chronic infections. J Am Med Assoc 2008: 299(22):2682-4. 72. Schultz GS, Barillo DJ, Mozingo DW, Chin GA. Wound bed preparation and a brief history of TIME. Int Wound J 2004: 1(1):19-32. 73. Wolcott RD, Rumbaugh KP, James G, Schultz G, Phillips P, Yang Q, Watters C, Stewart PS, Dowd SE. Biofilm maturity studies indicate sharp debridement opens a time-dependent therapeutic window. J Wound Care 2010: 19(8):320-8. 74. Hofman D. The autolytic debridement of venous leg ulcers. Wound Essentials 2007: 2:68-73. 75. Armstrong DG, Salas P, Short B, Martin BR, Kimbriel HR, Nixon BP, Boulton AJM. Maggot therapy in “lower-extremity hospice” wound care; fewer amputations and more antibiotic-free days. J Am Podiatr Med Assoc 2005; 95(3):254-7.

78. Cowan T. Biofilms and their management: implications for the future of wound care. J Wound Care 2010: 19(3):117-20. 79. Bratzler DW, Houck PM, Richards C, Steele L, Dellinger EP, Fry DE, Wright C, Ma A, Carr K, Red L. Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project. Arch Surg 2005: 140(2): 174-82. 80. Lipp C, Kirker K, Agostinho A, James G, Stewart P. Testing wound dressings using an in vitro wound model. J Wound Care 2010: 19(6):220-6. 81. Presterl E, Suchomel M, Eder M, Reichmann S, Lassnigg A, Graninger W, Rotter M. Effects of alcohols, povidone-iodine and hydrogen peroxide on biofilms of Staphylococcus epidermidis. J Antimicrob Chemother 2007: 60:417-20. 82. Demling RH, Burrell RE. The beneficial effects of nanocrystalline silver as a topical antimicrobial agent. Leadership Medica 2002: 16(7).

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Reducing the human and economic cost of wounds Part I

Reducing the human and economic cost of wounds Part II

Speakers: Prof John Posnett Prof Christine Moffatt Prof Donald Hudson

Speakers Prof John Posnett Prof Patricia Price Dr Roland Becker Dr John Lantis Date: Thursday, 26th May Time: 16.00 - 17.00 Venue: Silver Hall

Date: Wednesday, 25th May Time: 12.30 - 13.30 Venue: Gold Hall

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Science, Practice and Education

are often polymicrobial but the bacterial aggregates are mainly composed of a single bacterial species62. Fazli et al (2009)66 showed by using PNA- FISH and CLSM there is a nonrandom distribution of the bacteria in wounds, for example P. aeruginosa is primarily at the deepest part and S. aureus is often near the surface. Dowd et al (2008)51 described some repeated patterns of coaggregation that have the ability to work in synergy to produce chronic infection as “functional equivalent pathogroups” (FEPs).The above referred techniques are complex and limited to research laboratories, thus there is a need to develop simpler means of detecting biofilms in a routine microbiology diagnostic.

b. Biofilm Treatments for chronic wounds Patient quality of life can be affected by a delayed wound healing process, thus the wound treatment aims to achieve its goal within a reasonable time frame. This is possible if appropriate care is taken and attention paid to the condition of the wound and of the patient55. Some predisposing factors such as underlying diseases67,68 and microbial infection with biofilm forming organisms51 can influence the healing process of infected and chronic wounds. There are several strategies targeted towards promoting wound healing in chronic wounds and they must take into account the factors that are responsible for the delay in the healing process. These factors should be identified as soon as possible to prevent complications. Nevertheless, if complications occur there are treatment strategies that range from using ultrasounds, debridement, negative pressure, hyperbaric oxygen69, and others70. First of all, foreign bodies should be removed from the wound because their presence interferes with the healing process, thus a physical intervention is of utmost importance for the management of biofilms71. This cleansing can be done by mechanical, chemical or biological methods. Additionally the presence of devitalized tissue serves as a nutritional matrix for microbial development and proliferation, thus removal of foreign bodies and devitalized tissue must be done and the process is called debridement. This technique cannot avoid the ability of the bio-

film to reconstitute itself, thus topical antimicrobial and antibiofilm strategies should be considered72, but during this recovery process the biofilm is more vulnerable to antimicrobials because it needs to reform its extracellular polymeric substances, increase cell division and colony activity64. Wolcott et al (2010)73 showed that debridement or post-debridement opens a time-dependent therapeutic window of increased antibiotic sensitivity which is 24-48 hours for P. aeruginosa. In the wounds there is an autolytic debridement when the healing process is developing in the right timeframe and this process only functions when the wound is moist and the patient’s own enzymes can be used74. Debridement can also be done by larvae which feed on the dead tissues and excrete bactericidal products that help to reduce the wound’s bioburden75, although Andersen et al (2009)76 did describe the death of the larvae by P. aeruginosa quorum sensing molecules. There is also the possibility of a more selective debridement by using enzymes for the digestion of the slough of a wound and they can be obtained from microorganisms such as collagenase or fibrinolysin or from urea and papain or even plants77. In particular cases there is a need for removal of large amounts of necrotic tissue and this demands a more extreme course of action such as a surgical procedure78. Treatment of biofilms in wounds often needs the use of antimicrobials in a systemic and/or topical therapy. Antimicrobials can also be used for prophylactics especially in immunocompromised patients79, but the correct procedure is to identify the microorganisms involved and to determine antimicrobial susceptibility, although the information is always reduced because they are determined with planktonic, not sessile populations. Antimicrobials can be administered topically as wound dressings80, orally, or injected intravenously or subcutaneously and the main objective is to reduce or even completely remove the microbial load of wounds78. Several 

83. Russell AD, Hugo WB. Antimicrobial activity and action of silver. Prog Med Chem 1994: 31:351-70.

90. Pietschmann S, Hoffmann K, Voget M, Pison U. Synergistic effects of Miconazole and Polymyxin B on microbial pathogens. Vet Res Commun 2009: 33:489-505.

84. Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS, Gully NJ. Inability to form a biofilm of Streptococcus mutans on silver fluoride- and potassium iodide-treated demineralised dentin. Quintessence Int 2009: 40(2):155-61.

91. Stewart PS, Costerton JW. Antibiotic resistance of bacteria in biofilms. Lancet 2001: 358(9276):135-8.

85. Okhiria OA, Henriques AFM, Burton NF, Peters A, Cooper RA. Honey modulates biofilms of Pseudomonas aeruginosa in a time and dose dependent manner. J ApiProduct & ApiMedical Sci 2009: 1(1):6-10. 86. Molan PC. The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 2006: 5(1):40-54. 87. Merckoll P, Jonassen TØ, Vad ME, Jeansson SL, Melby KK. Bacteria, biofilm and honey: A study of the effects of honey on ‘planktonic’ and biofilm-embedded chronic wound bacteria. Scand J Infect Dis 2009: 41:341-7 88. Extremina CI, Freitas da Fonseca A, Granja PL, Fonseca AP. Anti-adhesion and anti-proliferative cellulose triacetate membrane for prevention of biomaterial centered infections associated to Staphylococcus epidermidis. Int J Antimicrob Agents 2010: 35:164-8. 89. Thomas S, McCubbin P. A comparison of the antimicrobial effects of four silvercontaining dressings on three organisms. J Wound Care 2003: 12(3):101-7.

92. Katsuyama M, Kobayashi Y, Ichikawa H, Mizuno A, Miyachi Y, Matsunaga K, Kawashima M. A novel method to control the balance of skin microflora Part 2. A study to assess the effect of a cream containing farnesol and xylitol on atopic dry skin. J Dermatol Sci 2005: 38(3):207-13. 93. Kaneko Y, Thoendel M, Olakanmi O, Britigan BE, Singh PK. The transition metal gallium disrupts Pseudomonas aeruginosa iron metabolism and has antimicrobial and antibiofilm activity. J Clin Invest 2007: 117(4):877-88. 94. Martineau L, Dosch H-M. Biofilm reduction by a new burn gel that targets nociception. J Appl Microbiol 2007: 103:297-304. 95. Itoh Y, Wang X, Hinnebusch BJ, Preston JF 3rd, Romeo T. Depolymerization of beta-1,6-N-acetyl-D-glucosamine disrupts the integrity of diverse bacterial biofilms. J Bacteriol 2005: 187(1):382-7. 96. Gill AL, Bell CNA. Hyperbaric oxygen: its uses, mechanisms of action and outcomes. Q J Med 2004: 97:385-95.

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Science, Practice and Education

antiseptics, such as Povidone iodine, can be used alone or in combination with the antibiotics in order to achieve increased antimicrobial activities81. In fact one of the possible advantages of using antiseptics is the reduced probability of developing bacterial resistance since they have several targets in the bacteria. The use of silver as part of dressings has also proved to be successful, and this is due to the bactericidal properties of silver82, as already reported for silver catheters83. Silver lethal activity works at much higher concentrations for sessile bacteria as compared to planktonic bacteria84. Another known antiseptic is honey, which is claimed to have antibacterial activity through the action of its phytochemicals and the ability to promote healing85-87. Several works have demonstrated the importance of drug release in the prevention of biofilm formation88 and it is known that the rate of antimicrobial release from a dressing or catheter determines its efficacy89. Combinations of antimicrobials with synergistic activity can be used as in the case of bacitracin-polymyxin90 because there are major difficulties in having an effect on dormant cells within the biofilm91. Another issue is that systematic antibiotics have only 25-32% efficacy against biofilms70 because they only suppress rapidly growing cells at the outermost active edges of the biofilm91. It is of utmost importance to combine strategies, i.e. combining the use of debridement and antibiotics, and especially those with antibiofilm abilities. There are a number of well-known antibiofilm agents, some of which have already been referred to during this review, like Lactoferrin and the use of phages and pulsed electric fields, but there are others such as Xylitol, Gallium, EDTA, Dispersin B, as well.92. Gallium can disrupt Fe-dependent processes because many biological systems cannot distinguish Ga3+ from Fe3+ and this is particularly important for P. aeruginosa biofilm development93. Martineau and Dosch (2007)94 have recently described that EDTA in a wound gel can have some efficacy against P. aeruginosa biofilms. Dispersin B targets the EPS and degrades the community structure of the biofilm95.

As a conclusion, in order to suppress and eliminate biofilms, a triple strategy should be used incorporating topical antiseptics and systemic antibiotics for damaging of cell metabolism and integrity, using antibiofilm antimicrobials that act in the biofilm as a microbial community that works together in a “resistance phenotype”70 and using a strategy that augments the host’s defenses95. Alongside the triangle of antimicrobial – pathogenic agent – host, we must consider the environment in which all three work together and this can be also used to enhance wound healing. An example of this is the use of topical oxygen therapy that involves the use of supersaturated oxygen delivered to the wound over a certain time period which increases protein production and cell homeostasis60. Another example is the use of hyperbaric oxygen therapy that supplies adequate tissue oxygenation96. Prevention of biofilm should be the first and important aim of any strategy for infection control. Nevertheless with biofilm therapeutic measures, care should be taken in order to reduce the quantity of the microorganisms as well as the virulent factors they express allowing a better and facilitated work for the immune system97. Several studies show that there are pathogens that can form biofilms within 10-16 h of culture45 and this ability has been reported in vivo in animal for 48-72 hours35. This ability of some pathogens to easily form biofilm in wounds should be stopped in the early step of the initial adhesion, and this is particularly important in immunocompromised hosts. In this case the use of natural substances that stimulate cellular growth may promote enhancement of regenerative process as is the case in the use of bone marrow-derived cells98 or stem cells99. Another strategy to control biofilms is the use of phages to which particularly the young biofilms seem to be more susceptible100. Lactoferrin is a protein present in the gingival fluids and in saliva that has iron-binding properties. This ability is particularly important in the case of Pseudomonas aeruginosa wound biofilms, since they need iron for their stability. The use of Lactoferrin can interfere with normal biofilm formation

97. Percival SL, Cutting KF. Biofilms: possible strategies for suppression in chronic wounds. Nurs Stand 2009: 23(32):64-72.

103. Alipour M, Suntres ZE, Lafrenie RM, Omri A. Attenuation of Pseudomonas aeruginosa virulence factors and biofilms by co-encapsulation of bismuth–ethanedithiol with tobramycin in liposomes. J Antimicrob Chemother 2010; 0:dkq036v1dkq036.

98. Badiavas EV, Falanga V. Treatment of chronic wounds with bone marrow -derived cells. Arch Dermatol 2003; 139:510-6. 99. Branski LK, Gauglitz GG, Herndon DN, Jeschke MG. A review of gene and stem cell therapy in cutaneous wound healing. Burns 2009: 35(2):171-80. 100. Sillankorva S, Neubauer P, Azeredo J. Pseudomonas fluorescens biofilms subjected to phage phiIBB-PF7A. BMC Biotechnol 2008: 8:79. 101. Wakabayashi H, Yamauchi K, Kobayashi T, Yaeshima T, Iwatsuki K, Yoshie H. Inhibitory effects of Lactoferrin on growth and biofilm formation of Porphyromonas gingivalis and Prevotella intermedia. Antimicrob Agents Chemother 2009: 53(8):3308-16. 102. Bjarnsholt T, Jensen PØ, Rasmussen TB, Christophersen L, Calum H, Hentzer M, Hougen H, Rygaard J, Moser C, Eberl L, Høiby N, Givskov M. Garlic blocks quorum sensing and promotes rapid clearing of pulmonary Pseudomonas aeruginosa infections. Microbiology 2005: 151:3873-80.

104. Cooper RA, Okhiria O. Biofilms, wound infection and the issue of control. Wounds UK 2006: 2(3):52-61. 105. Uhlemann C, Heinig B, Wollina U. Therapeutic ultrasound in lower extremity wound management. Int J Low Extrem Wounds 2003: 2(3):152-7. 106. Petrofsky JS, Lawson D, Berk L, Suh H. Enhanced healing of diabetic foot ulcers using local heat and electrical stimulation for 30 min three times per week. J Diabetes 2010: 2:41-6. 107. Charles CA, Ricotti CA, Davis SC, Mertz PM, Kirsner RS. Use of tissue-engineered skin to study in vitro biofilms. Dermatol Surg 2009: 35(9):1334-41. 108. Kanno E, Toriyabe S, Zhang L, Imai Y, Tachi M. Biofilm formation on rat skin wounds by Pseudomonas aeruginosa carrying the green fluorescent protein gene. Exp Dermatol 2010: 19(2):154-6.

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Silent. Gentle. Powerful. allowing improved efficacy in the antimicrobial action101. Another biofilm control measure is to use substances that can interfere in the cell to cell communication, namely by quorum sensing attenuation26. Garlic has been used for the rapid clearance of P. aeruginosa from the lungs of mice models102. Synergistic activity has been reported between tobramycin and bismuth against P. aeruginosa quorum sensing, virulence factors and biofilm formation ability103. Several studies have demonstrated in vitro that the use of honey can influence biofilm formation85 thereby having the possibility of topical application in wound management104. Another strategy is to disrupt the biofilm in wounds by using ultrasound105, electric stimulation or electromagnetic therapy106. In order to evaluate potential biofilm interventions there is a need for the development of biofilm models13,107,108, however before effective anti-biofilm interventions are accepted there is a need for clinical evidence of biofilm associated infections.

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Conclusion remarks and future work The increased number of chronic wounds in ageing populations is a major problem. The knowledge of the relation between the concepts of wound chronicity and biofilm is of utmost importance. It is therefore crucial to develop means to diagnose biofilm infections, and there is a strong need for effective treatment strategies. However it should be stated that there are no routine biofilm detection methods available yet and effective interventions depend on the quality of the diagnosis. It is certainly possible to explain, under a biofilm paradigm, the delay in chronic wound healing, therefore the biofilm communities must be identified as soon as possible as well as their distribution within the biofilm, but more information regarding their specific contribution to the pathogenesis is fundamental for the selection of adequate therapeutic methods. The debridement or postdebridement of chronic wounds can induce a restart in the biofilm formation and this can create a window of opportunity that should be exploited using a combination of methods, within an antibiofilm strategy. The relative predominance of pathogens in the biofilm community can also be avoided by promoting the shift to healthy biofilm that can be an easier target for host defenses. m

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2011 vol 11 no 2

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Science, Practice and Education

Diabetic foot ulcer pain:

The hidden burden ABSTRACT Background: Diabetic foot ulcers (DFU) are often considered painless due to sensory peripheral neuropathy, with pain only occurring with infection or other complications (Sibbald et al., 2006). Recent research suggests DFU pain is more prevalent than expected and severely impacts on quality of life (Ribu et al., 2006; Bengtsson et al., 2007). Aim: To explore the effect of specific DFU pain on life quality from the patient’s perspective. Methods: Purposive sampling identified three patients from a specialist DFU clinic. Data was collected using semi-structured interviews. Interviews were recorded, transcribed and analysed using thematic content analysis. Results: Four themes emerged: Experience of Pain; Physical Effects of Pain; Coping, Support and Social Impact; and Psychological Impact. Results indicated that DFU pain affected patients physically and psychologically, especially with regards to sleep, mobility and social roles. Feelings of depression, isolation and loss of independence were expressed. Pressure from footwear and dressing changes caused or worsened DFU pain. Conclusions: DFU pain is an under-recognised phenomenon which can be both severe and debilitating, and also negatively impact on life quality across physical and psychosocial domains. Further qualitative work into the patients’ lived experiences of DFU pain is needed to help clinicians understand the relevance to holistic diabetic foot care and service provision. Introduction Diabetic Foot Ulcer (DFU) pain is a phenomenon which has been both under-estimated and underresearched. The exploratory study published in part one of this article on the presence and characteristics of DFU pain found that patients can experience specific DFU pain despite the presence of neuropathy, and not always related to Decorrelated complications. This supported the findings of previous works1,2. A second phase was therefore conducted within the same study

(Part two)

to investigate the impact of specific DFU pain on quality of life (QoL). Previous research has indicated that DFUs negatively impact on QoL3,4,5, as does pain from various causes6,7,8,9. DFU can significantly decrease QoL for a variety of reasons, including decreased mobility, diminished independence, loss of employment, increased risk of amputation and repetitive trips to clinicians for care10. Despite this, there is relatively little research in this area. Although pain is often raised as an issue in studies on DFU and QoL, none have looked specifically at DFU pain and QoL from the patient’s perspective. Ribu et al.1 evaluated health-related quality of life (HRQoL) as part of their research into DFU pain using generic and disease-specific measurement tools. Results found that patients experiencing DFU pain had consistently low scores in both physical and psychological domains. A qualitative study on the patient’s perspective of living with a DFU identified pain as one of six commonly experienced problems11. Almost all patients experienced pain at some time, with most reporting ulcer pain woke them at night and having to lie in certain positions to avoid pressure on the ulcer. Pain was reported when walking even short distances. Three patients avoided taking analgesia due to fear of reliance. Pain was mainly discussed in relation to painful neuropathy, although direct relationship with the ulcer or other causes was not considered. The effect of the pain in causing sleep deprivation and fatigue affecting overall QoL was highlighted.

Sarah E Bradbury, MSc Research Nurse, Cardiff University

Patricia E Price, PhD Professor and Dean of Healthcare Studies, Cardiff University Department of Dermatology and Wound Healing, Cardiff University Correspondence: Sarah Bradbury Research Nurse Dept. of Dermatology and Wound Healing Room 13 Upper Ground Floor School of Medicine Heath Park Cardiff Conflict of interest: None

Pain was raised as a significant factor in a phenomenological study12 to determine the QoL issues of 21 patients with DFUs. Just under half of the patients complained of ulcer pain impairing their ability to walk, discomfort on lying down and during dressing changes. The authors felt unable 

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Science, Practice and Education Table 1 Inclusion criteria

Exclusion criteria

Over eighteen years of age

Dementia or learning/communication difficulties

Experience of specific DFU pain Willing to participate in an interview Able to fully understand and give informed consent

to confirm that pain was definitely originating from the ulcer rather than an underlying pathology, but it suggests that patients feel they are experiencing ulcer pain which is impairing their QoL. A comparable study by WatsonMiller13 yielded similar results. Other studies also found patients with DFU experienced pain, but did not further explore the nature of that pain or its specific impact on QoL4,14,15. Despite providing useful information on the effect of DFU on HRQoL, studies generally have small sample sizes and the subject would still benefit from further research. The difficulty with measuring HRQoL with specific regard to foot ulcers in diabetic patients is that they often do not experience only one complication of the disease in isolation. This can make it difficult to determine with certainty that it is the ulcer that is affecting QoL, especially in studies which do not exclude patients with other diabetic complications. The lack of disease-specific tools for DFU until relatively recently may also have hindered progress within this field – as Vileikyte16 stated, the effects of DFU on HRQoL are distinct from those associated with the disease itself and need to be addressed separately. Overall, it is clear from the qualitative work undertaken, which allows the patients to voice their individual difficulties and experiences, that pain is an important contributor to reduced QoL for patients with DFU. Unfortunately, QoL studies related to DFU generally do not provide enough detail on the effect of pain as this is not their primary aim. Substantial conclusions cannot be drawn from their results with relation to pain, but they do provide a useful overview and some insight into the nature and degree of the problem, thereby justifying the need for more specific work. The need for further research on the subject of pain from DFU and QoL was thus identified to determine the extent to which the problem needs consideration in clinical practice.

Methods An exploratory research design was continued in this phase using qualitative methods. Participants were chosen using purposive sampling from the same local specialist diabetic foot clinic as in

phase one. Basic inclusion/exclusion criteria were used to assess if a participant was suitable (Table 1). Face-to-face semi-structured interviews were considered an appropriate method to collect qualitative data on the effect of DFU pain on everyday life. An interview schedule was developed to guide the conversation onto relevant topics based on the study aims and issues identified within the literature, but with a particular focus on pain. The first interview acted as a pilot of the schedule to determine if the questions were valid and easy to understand, and to gain insight into how the questions were interpreted by patients to try to improve reliability. Following this the interview schedule was shortened and revised to include broader topic areas. The interviews were recorded and manually transcribed. Reflective notes were also made shortly after completing the interview recording any non-verbal communication, the researcher’s thoughts on the topics covered and the response of the participant to ensure the best quality information was assembled for analysis. The study protocol was approved by the Local Research Ethics Committee. Confidentiality and anonymity were maintained throughout the research process, and written informed consent was taken. Identification of suitable participants and completion of the interviews occurred over a six month period. All participants chose to be interviewed at home, and each interview lasted approximately 30 minutes. The taped conversations were transcribed by the researcher and then verified by a second researcher not involved with the interviews. A copy was sent to the appropriate participant for verification and to make any required changes or additions. These processes were performed to improve reliability and minimise bias within the study findings. The transcribed and verified data was then analysed using thematic content analysis, guided by elements of the method published by Burnand 17. In an effort to demonstrate methodological rigour and reduce researcher bias, the identified data categories were checked by a second researcher to ensure the primary interpretation fairly represented the data. The themes were then examined to identify any associated relationships which  were discussed and compared.

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2011 vol 11 no 2

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Science, Practice and Education Table 2: Sample Demographics Study number

Gender

Age

Type of Diabetes

Duration of Diabetes (Years)

DFU Aetiology

Duration of DFU (Months)

No. of Diabetes Related Complications

RESULTS Three patients were recruited between September 2007 and January 2008. The intended sample was five patients but, mainly due to the time delay while waiting for ethics approval, a number of patients achieved ulcer healing and were discharged, or no longer had pain in their ulcer. Some patients refused to participate. The study sample, again although small, presented views from a male and female perspective (Table 2). The type and duration of diabetes and ulcer aetiology and duration were similar across the group. All the patients had complex medical histories consisting of independent diseases and diabetes-related complications, which could impact on QoL. The interview data will be presented using the four themes generated during analysis.

Experience of Pain This theme was generated from the patient’s descriptions of their pain, when it occurred, the factors that caused it or made it worse and how they managed it. Participants described their pain in various ways – sharp, unexpected, variable in occurrence but of severe intensity, intermittent, spontaneous, continuous and unrelenting. One described it “...as if my foot were in a bed of stinging nettles”, while another stated it was the worst he’d ever had. None of the patients seemed surprised to be experiencing pain, despite having peripheral neuropathy. One felt that pain could even be a good sign, while another was more surprised at its severity. The main issue consistently raised relating to factors that increased or worsened pain was application of pressure on the wound, especially during dressing changes and from footwear. All patients described pain occurring in bed due to pressure from bedclothes or moving to lie on the ulcer: “…I can’t sleep in bed, I can’t stand blankets or anything on the foot”. Two patients having dressings changed by family members stated it was not terribly painful, except during cleansing and if the dressing had ‘dried out’.

The patient having dressings changed by District Nurses remarked that cleansing could be painful, but felt the pain at was more dependent on the individual performing it, describing some as ‘rough-handed’. He also experienced pain during dressing application and for some time afterwards: “If anybody touches it, it’s hell”. Difficulty finding footwear that did not exert pressure and cause pain was expressed by two patients. Both had bought their own shoes or found solutions, but not always ideal ones, such as wearing sandals throughout the winter. One was particularly frustrated with the service provided by the hospital: “The shoes they make are too heavy and are no good to me, but I can’t make them understand that”; “…they bruised all my feet and aggravated the toe”. Analgesia was used by all three participants for pain management. Two took a codeine-based preparation which helped decrease their pain most of the time, although one felt the pain never went away entirely. This patient was reluctant to take increased or further analgesia due to polypharmacy. The third patient was taking multiple forms of analgesia, including Morphine tablets and liquid, an anti-epileptic for neuropathic pain and Paracetamol, but still experienced uncontrolled ulcer pain: “…the medicine I’m taking is not touching me…”; “… If I could find a tablet or a medicine that could take it away just for a few hours, I’d be more than happy”. He had previously overdosed on Oramorph in desperation to get rid of the pain, leaving him feeling ill for several days. When discussing a previous possibility of having the leg amputated due to a back condition and reduced circulation, he felt that at times amputation would be preferable to continuing in such pain from his ulcer: “I suppose that’s the worst I can look forward to, but if it can get rid of that [pointing at the ulcer]…I know it sounds stupid…”. He described restlessness at not getting any relief from the pain, describing himself as like ‘an animal in a cage’, stating he’d try anything to decrease the pain. 

EWMA Journal

2011 vol 11 no 2

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Science, Practice and Education

Physical Effects of Pain This theme was identified from patient comments regarding the effects of DFU pain on physical aspects of their daily life. Problems with mobility due to pain were discussed by all participants, leading to feelings of loss of independence. One felt his pain was improving as his ulcer was beginning to heal – he was using a walking stick rather than a Zimmer frame, and commented that feelings of loss of control in his life had diminished as his mobility improved. Another felt decreased mobility had the biggest effect on QoL. Already experiencing limited mobility, the ulcer pain now forced her to use a wheelchair. Footwear problems highlighted previously also had adverse effects. Another participant identified walking as a dominant factor in increasing his ulcer pain, requiring an electric scooter outside the house and leaving him unable to drive. Sleep was also altered due to DFU pain, particularly for one. He slept in a chair as he couldn’t tolerate the pressure of the duvet on his foot while in bed, but was awake for long periods during the night. Sleeping tablets were ineffective: “I just move my foot like everybody else does in bed…and that’s it, bang, it wakes me up”; “…about half hour and I wake…”; “I’ve gone through the roof with smoking... every time I wake up I’ve got to have something to do…”. He thought lack of sleep made him feel much worse, feeling he could cope much better generally if his sleep improved. Another commented that pain affected her sleep, finding she needed daytime naps due to tiredness, but felt that analgesia taken at night helped. One participant felt ulcer pain did not specifically wake him during the night, but took sleeping tablets with his bedtime analgesia. Pain had also led to the loss of a previously healthy appetite for one participant: “Well, I’m not living, it’s as simple as that. I’ve got no appetite, I eat like a pigeon. I used to love my Sunday dinners, but the look of them makes me feel ill now”.

Coping, Support and Social Impact This theme was derived from the patients’ accounts of the impact ulcer pain had on their relationship with family, friends and healthcare professionals, including the support they received and coping strategies they adopted. All participants remarked they were unable to perform all their activities of daily living independently. This was also due to other medical conditions which affected their general health, such as cardiovascular disease, haemolytic anaemia and previous back surgery, in addition to the pain. 30

Help and support from family members also enabled them to cope. One felt the support received from her daughter made a big difference to her daily life and with coping with the pain. She performed dressing changes, reminded her to take analgesia and performed housework. This, however, made the patient feel she was putting pressure on her daughter’s time. Feeling a burden on their family was also identified by the other participants, with one commenting he and his wife had no retirement. Another also depended greatly on his wife, feeling that DFU pain and the limitations it placed on his mobility was impacting on his family relationships: “I’ve got a daughter nearby… I hardly see her..”; “I’ve got to the stage where I don’t want anybody…I mean I love having the grandkids up here but they can be noisy, and it makes me irritable”; “…as kids are, they don’t realise. I’m frightened when one of them is behind me. All I need is a tap on that and I’m up in the air”; “…it has changed my life, without a doubt”. He also felt unable to perform any household maintenance or previously enjoyed social activities, especially as there were steep steps outside his house: “…I’m not in the mood, I just can’t be bothered. I’m sick of being in but I don’t want to do anything else”. Another participant stated: “I’ve just been like a zombie. With no interest. Now I’m beginning to get out a bit, I feel better. I want to go out more”. All participants commented on the care received from various clinicians for their DFU and related pain. Two felt that healthcare professionals had provided them with good care and support, which helped them cope. “…There was one nurse… she sat with me and gave me comfort. Now that is something that you cannot get with swallowing a pill”. One felt psychological support wouldn’t have helped, as she felt she had adapted to living with pain. Neither felt there was anything clinicians could have done better. Conversely, one participant was unhappy with the support he had received from his general practitioner and district nurses, in particular, feeling there was no encouragement with progress of the wound and they were always in a rush to leave. He did feel more supported by the DFU clinic that had referred him to a Pain Specialist whose interventions had provided some relief for a short while. He was, however, frustrated with delays in treatment. 

EWMA Journal

2011 vol 11 no 2

HQ022571104

Investigating the Impact of Topical Antimicrobials in Wound Care EWMA2011 ium Brussels · Belg .org 11

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Welcome to the Mölnlycke Health Care Satellite Symposium, May 26, 2011 at 11.15-12.15 in Gold hall Wound infection is the most concerning of all wound complications. Topical antimicrobials play an important role in preventing and managing local wound infections however there are some outstanding questions regarding the usage of these agents that need to be answered. The aim of this Symposium is to support the appropriate use of topical antimicrobial agents and to promote clinical decision-making that ensures their prescription only when clinically indicated. The Chairmen Assoc Prof Bill McGuiness, Acting Head of School, Nursing and Midwifery, La Trobe University and AWMA President Australia, and Lt Col Steven Jeffery, Consultant Plastic Surgeon, The Royal Centre for Defence Medicine UK, will open and close the seminar by discussing commonly raised questions regarding using topical antimicrobials. Professor Kevin Chipman, Professor of Cell Toxicology, University of Birmingham, UK, will give an overview of published safety data on topical antimicrobials. Dr Paul Silverstein, Clinical Professor Plastic Surgery, University of Oklahoma, USA will discuss the importance of considering the health economic aspect in clinical studies in burn care. Dr Jean-Charles Kerihuel, Medical Director and Consultant Physician & Methodologist, France, will reveal results from a large observational study using topical antimicrobial dressings in different wound types.

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Science, Practice and Education

Psychological Impact This theme concerns the patient’s emotions, including feelings of depression, isolation and loss of independence, which overlapped considerably with the other themes due to the wide impact of the pain overall. Loss of motivation and feelings of depression due to ulcer pain were expressed by two participants: “…the worst time I’ve got at the moment is getting out of bed in the morning. I need real willpower to go into the bathroom and dress”. “I look out there now and think spring is coming, but what can I do? Nothing.”. Feelings of isolation and loss of independence were also raised. One participant felt frustrated with the lack of relief from the pain and that the ulcer controlled his life. Two participants did however express trying to cope with things by thinking more positively, especially one whose pain was slowly improving: “There’s a light at the end of the tunnel now”.

DISCUSSION A larger, more diverse sample would have provided a richer data set and increased expression of views, but time constraints made it difficult to address this issue. It would have been interesting to learn the experience of patients with purely neuropathic ulceration to determine any differences in QoL issues. Data saturation was not achieved so the collected data may be lacking in diversity or consistency. However, the main aim was not to generate theory but to gain information and perspective of the lived experience of DFU pain. Experience of Pain The reported descriptions of pain are varied and intense in nature, similar to the results of the Short-Form McGill Pain Questionnaire18 used in phase one. Despite the common perception that neuropathy leads to painless ulcers, the patients were not surprised to be experiencing pain. Preconceptions often held by patients and clinicians regarding the pain experience need addressing if DFU pain is to be understood and adequately managed. The causes of pain were similar to that reported by qualitative studies relating to DFU as a whole11,12, with pressure from footwear or bedding being recurrent themes. Pain at dressing change has been noted by other QoL studies into DFU12, and is a common finding with studies related to wound pain19,20,21. As with one patient here, leg ulcer studies have reported how individual clinicians’ technique and basic understanding can impact on the experience, with patients feeling that they are not listened to or cared about22. VLU were once considered painless 32

or not as painful as arterial ulcers which potentially caused increased pain at dressing change due to a poor knowledge base – a similar situation could occur with DFU due to the preconception that the pain sensation is compromised. Although pain at dressing change is becoming a more prominent and researched area, more consideration needs to be given to treatment of DFU with the awareness that they can be painful. Problems with footwear are commonly cited within the QoL research relating to both DFU and VLU, although not always necessarily related to pain. The dissatisfaction or difficulties expressed by two patients regarding finding appropriate footwear could be an important issue for future care. Appropriate footwear for patients with DFU is paramount due to the requirement for offloading to improve healing23,24,25. Use of appropriate orthoses can improve physical and mental functioning in diabetic patients26, reinforcing the requirements for an efficient and effective orthotic service within diabetic foot clinics to not only improve healing but also QoL. The adverse effect of footwear on DFU pain is a significant issue for any healthcare professional (HCP) involved in the management of DFU, which again requires raised awareness and consideration within service provision. Participants reported varying efficacy of analgesia for controlling DFU pain. Whereas previous literature is mainly concerned with the under-use of analgesia or the fear of dependence by patients11,27, some findings here suggest DFU pain can be so severe and multi-factorial that oral analgesia alone may not be sufficient. The only temporary relief one patient experienced was following referral to a chronic pain specialist, yet until clinicians acknowledge that specific ulcer pain exists and is not necessarily of neuropathic origin, there may be minimal referrals to specialist services. Management of some DFU pain may require treatment such as nerve blocks, psychological support or complementary therapies. Further research into this area alone is necessary if DFU pain assessment and management is to become even adequate.

Physical Effects of Pain The majority of research into chronic wounds and QoL suggests they impact significantly on physical aspects of daily life4,11,12,22,28,29,30. Qualitative work consistently highlights issues with mobility and sleep, the consequences of which appear far-reaching in terms of fatigue, loss of independence and social isolation. Similar reports were found here, particularly with regard to mobility. Standing and walking even short distances was found to increase pain, which concurred with previous findings in both quantitative and qualitative  EWMA Journal

2011 vol 11 no 2

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studies1,2,11,12. Some patients with DFU report frustration at the enforced decrease in mobility due to the need to offload the foot, and state they would rather adopt risktaking behaviours and accept the possible consequences to their physical health for an increase in their QoL11,12,30. If pain, however, is the cause of reduced mobility, then this option may not be available, leaving patients feeling completely restricted and isolated and with few coping mechanisms on which to depend. Achieving ulcer healing may be the only way of returning to a more normal physical functioning, as described by one participant. Sleep was an important issue for patients both in this study and previous works, leading to extreme fatigue and changes in mood4,28. The patients seem to become trapped in a vicious circle whereby the consequence of one problem exacerbates another. Increased fatigue due to sleep deprivation leads to further decreased mobility, which increases fatigue further due to patients becoming lonely, isolated and lacking in energy and motivation. The results reinforce the idea that the impact of physical restrictions from DFU pain has the same widespread effect on psychosocial well-being as other types of chronic wound. This emphasises the need for a holistic approach in order to facilitate a better understanding of patients’ needs.

Coping, Support and Social Impact The accounts of DFU pain causing increased dependence on others for assistance with simple daily activities is in accordance with general QOL studies into patients with DFU and VLU11,13,30. This causes feelings of loss of control and loss of self, which can leave patients anxious, depressed and vulnerable. While supportive families are a common theme within this study and others, and recognised as invaluable by patients, it is common for patients to feel burdensome and guilty, placing unwanted restrictions on their loved ones, especially if partners are elderly and may not be in perfect health. These issues can affect relationships whereby patients feel a loss of their previous life and a change in their social role, as reflected by the comments of one subject regarding not being able to play with his grandchildren or wanting to socialise with other family and friends. These comments are again a recurring theme in other QoL literature on patients with chronic wounds, where fear of others knocking their wound and causing pain led to the avoidance of social or public situations12,19,29,30,31,32. Again, a perpetual cycle may develop where decreased mobility and increased dependence leads to social isolation, leaving patients depressed and not wanting contact with others. One patient alluded to such feelings, mentioning he could not perform tasks related to the upkeep of his home, a restriction which may have left him with feelings of low self-worth due to his 34

change of role within the family. These issues highlight the extent to which DFU pain can restrict individuals and compromise lives, so clinicians need to be aware of these feelings if they are to address all the needs of the patient. Varying positive and negative relationships with HCPs were reported by participants. The literature suggests many patients with chronic wounds become disillusioned with their HCPs, feeling their personal experience is not being recognised, thus inhibiting freedom of expression13, and that they are not provided with enough education or involvement in decision-making regarding their care31. Others get frustrated with the inconsistency of treatment and develop a lack of confidence in their HCP’s32. It has been suggested that clinicians become focused on treating illnesses rather than people, or on curing rather than helping patients to live and cope with chronic illness29,33 – this may be the case with the patient who felt ignored and that his clinicians never offered him encouragement or reassurance, but seemed only concerned with completing the task in hand (redressing the ulcer) as quickly as possible. The ulcer and its healing can become the sole focus of all interventions, and the clinician loses sight of the personal experience and caring perspective. This underlines the need for clinicians to develop effective interpersonal skills and consider psychosocial aspects to recognise individual needs. The aim should be to prevent or lessen the psychosocial implications of DFU pain in the same way as physical treatment. Support in the form of allowing patients to talk, providing comfort and information-giving were the factors which participants felt fostered good relationships with their HCPs and helped them to cope.

Psychological Impact The psychological impact of DFU pain is a common thread running through all the themes already discussed – the experience of pain, physical restrictions and changes in relationships all led to feelings which created a change in psychosocial well-being. Several comments dealt solely with feelings of depression, loss of motivation and resignation at their situation and the effect it was having on their lives. Increased anxiety and depression in patients with diabetes and foot ulcers has been documented3,414,34. These feelings can be enhanced due to concern that ulcers will never heal and a fear for the future at the loss of hope over regaining any control over their lives. One patient commented that the ulcer and pain controlled him, leaving him without positive thoughts. Another expressed a loss of motivation to even get up and wash and dress, yet was concerned about being a burden on his carer and frustrated at his lack of independence. Fear of amputation and its link to  EWMA Journal

2011 vol 11 no 2

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Science, Practice and Education

depression is often mentioned within the literature11,13, yet the desperation and anxiety felt by one patient regarding the lack of relief from his DFU pain had led him to question if amputation would be the more preferable option. These issues underline the importance for clinicians to pay more than lip service to holistic and psychological care, especially with regard to patients experiencing DFU pain, if prevention and management of such severe emotions is to be achieved. Some patients coped with the feelings surrounding their DFU pain and its impact on their lives by either resigning themselves to its existence and their need to adapt to it, or by trying to think positively rather than succumbing to negative feelings. Husband29 suggested after a period of adaptation and endurance of long-term ulceration patients may learn to shift the focus of their life away from the ulcer in order to cope with it. Small improvements in one patient’s ulcer pain may have enabled him to see a future without pain and a return to his old feelings of self. Either way, clinicians need to consider helping the patient to cope and adapt to potentially chronic conditions while also trying to address physical needs and ulcer healing. Limitations to the study are acknowledged, such as the potential for poor external validity. Smaller than expected sample sizes were obtained, and were chosen from a specialist environment dealing with complex and chronically ill patients. Therefore, similar findings may not occur with a larger, less complex population, and it is possible observed effects were not independent of natural variation within the clinic. However, the study was purely exploratory and filled a void by providing interesting and valuable information on an under-researched area. The results act References 1. Ribu L, Rustoen T, Birkeland K, Hanestad BR, Paul SM, Miaskowski C (2006) The Prevalence and Occurrence of Diabetic Foot Ulcer Pain and its Impact on HealthRelated Quality of Life The Journal of Pain 7 (4) 290-299 2. Bengtsson L, Jonsson M, Apelqvist J (2008) Wound-Related Pain is Underestimated in Patients with Diabetic foot Ulcers Journal of Wound Care 17 (10) 433 3. Carrington AL, Mawdsley SKV, Morley M, Kincey J, Boulton AJM (1996) Psychological Status of Diabetic People with or without Lower Limb Disability Diabetes Research and Clinical Practice 32: 19-25 4. Brod M (1998) Quality of Life Issues in Patients with Diabetes and Lower Extremity Ulcers: Patients and Care Givers Quality of Life Research 7: 365 – 372 5. Meijer JWG, Trip J, Jaegers SMHJ, Links TP, Smits AJ, Groothoff JW, Eisma WH (2001) Quality of Life in Patients with Diabetic Foot Ulcers Disability and Rehabilitation 23 (8) 336-340 6. Paul SM, Zelman DC, Smith M, Miaskowski C (2005) Categorizing the Severity of Cancer Pain: Further Exploration of the Establishments of Cutpoints Pain 113: 37-44

as a basis for future research and highlight the requirement for this work to be performed. The presence of complications related to diabetes and other medical conditions within the sample could also raise the question as to the extent to which the views and experiences expressed were solely attributable to DFU pain. They could also incorporate the difficulties of living with foot ulcers or diabetes itself, or even just general ill-health. Attempts were made to overcome this through reading of a statement at the commencement of each interview reiterating the specific subject matter and study aims.

CONCLUSION Overall, the results of the qualitative component of this study into DFU pain have confirmed that this underrecognised phenomenon can have detrimental physical and psychosocial effects. This has major implications for clinical practice in that it challenges current assessment practices and accentuates the need for clinicians to improve their understanding of DFU pain and its consequences in order to increase quality of care provision and ensure the holistic needs of patients are met. Lloyd and Orchard35 considered that improvements in QoL have become a more accepted goal of medical care, in addition to the alleviation of physical symptoms, but it is still evident that advancements can be made with regard to psychosocial issues. External pressures such as limited time and resources within diabetic foot clinics may lead to QoL issues related to pain and other aspects of living with a foot ulcer being overlooked, as the physical challenge of the ulcer itself is prioritised. Clinicians need to consider 12. Ashford RL, McGee P, Kinmond K (2000) Perception of Quality Of Life by Patients with Diabetic Foot Ulcers the Diabetic Foot 3 (4) 150-155 13. Watson-Miller S (2006) Living with a Diabetic Foot Ulcer: A Phenomenological Study Journal of Clinical Nursing 15: 1336-1337 14. Tennvall GR, Apelqvist, J (2000) Health-Related Quality of Life in Patients with Diabetes Mellitus and Foot Ulcers Journal of Diabetes and Its Complications 14: 235-241 15. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T (2007) A Comparison of the Health-Related Quality of Life in Patients with Diabetic Foot Ulcers, with a Diabetes Group and a Nondiabetes Group from the General Population Quality of Life Research 16: 179-189 16. Vileikyte L (2001) Diabetic Foot Ulcers: A Quality of Life Issue Diabetes/Metabolism Research and Reviews 17: 246-249 17. Burnand P (1991) A Method of Analysing Interview Transcripts in Qualitative Research Nurse Education Today 11: 461-466 18. Melzack R (1987) The Short-Form McGill Pain Questionnaire Pain 30: 191-197

7. Zelman DC, Dukes E, Brandenburg N, Bostrom A, Gore M (2005) Identification of Cut-points for Mild, Moderate and Severe Pain due to Diabetic Peripheral Neuropathy Pain 115: 29-36

19. Mudge E, Holloway S, Simmonds W, Price P (2006) Living with Venous Leg Ulceration: Issues Concerning Adherence British Journal of Nursing 15 (21) 1166-1171

8. Benbow M (2006) Holistic Assessment of Pain and Chronic Wounds Journal of Community Nursing 20 (5) 24-28

20. White R (2008) A Multinational Survey of the Assessment of Pain when Removing Dressings Wounds UK 4 (1) 14-24

9. Flanagan M (2006) Managing Chronic Wound Pain in Primary Care Practice Nurse 31 (2) 34-37

21. Price P, Fagervik-Morton H, Mudge EJ, Beele H, Ruiz JC, Nystrom TH, Lindholm C, Maume S, Melby-Ostergaard B, Peter Y, Romanelli M, Seppanen S, Serena TE, Sibbald G, Soriano JV, White W, Wollina U, Woo KY, Wyndham-White C, Harding KG (2008) Dressing-Related Pain in Patients with Chronic Wounds: An International Perspective International Wound Journal 5 (2) 159-171

10. Goodridge D, Trepman E, Embil, JM (2005) Health-Related Quality of Life in Diabetic Patients with Foot Ulcers Journal of Wound, Ostomy and Continence Nursing 32 (6) 368-377 11. Ribu L, Wahl A (2004) Living with Diabetic Foot Ulcers: a Life of Fear, Restrictions, and Pain Ostomy/Wound Management 50 (2) 57-67

22. Charles H (1995) The Impact of Leg Ulcers on Patients’ Quality of Life Professional Nurse 10 (9) 571-574

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increased QoL as a measure of success as well as objective physical outcome measures, because while these are important, dealing with a chronic and progressive disease such as diabetes may mean that patients have to cope with such problems for long periods of time. More work into the effect of DFU pain on QoL may help to raise awareness and aid clinicians in the provision of holistic care that facilitates both physical and psychological well-being.

Implications for clinical practice n Clinicians need to be more aware of the importance of providing psychosocial care in addition to focusing on ulcer healing. n Collaborative working between diabetic foot specialists, wound care specialists, pain specialists and primary care teams could promote better assessment and management of DFU pain and its impact on QoL. n Patients should be involved in decision-making regarding their treatment. Further research n Further qualitative work into the patient’s perspective on DFU pain could help clinicians to understand the relevance to diabetic foot care and to their own practice, and aid in meeting patient needs more completely. n Quantitative work using formal HRQoL tools could provide interesting information and comparative data with other patient populations. n The development of a tool incorporating the physical assessment of DFU pain in conjunction with a review of psychosocial issues might be a useful method of increasing awareness and improving dissemination of information. m 23. Krasner D (1998) Diabetic Ulcers of the Lower Extremity: A Review of Comprehensive Management Ostomy/Wound Management 44 (4) 56-75 24. Frykberg RG (2002) Diabetic Foot Ulcers: Pathogenesis and Management American Family Physician 66 (9) 1655-1662 25. Jeffcoate WJ, Harding KG (2003) Diabetic Foot Ulcers The Lancet 361: 1545-1551 26 Davies S, Gibby O, Phillips C, Price P, Tyrrell W (2000) The Health Status of Diabetic Patients Receiving Orthotic Therapy Quality of Life Research 9: 233-240 27. Persoon A, Heinen MM, van der Vleuten CJM, de Rooij MJ, van de Kerkhof PCM, van Achterberg T (2004) Leg Ulcers: A Review of their Impact on Daily Life Journal of Clinical Nursing 13: 341-354 28. Douglas V (2001) Living with a Chronic Leg Ulcer: An Insight into Patients’ Experiences and Feelings Journal of Wound Care 10 (9) 355-360

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29. Husband LL (2001) Shaping the Trajectory of Patients with Venous Ulceration in Primary Care Health Expectations 4: 189-198 30. Kinmond K, McGee P, Gough S, Ashford R (2003) ‘Loss of Self’: A Psychosocial Study of the Quality of Life of Adults with Diabetic Foot Ulceration Journal of Tissue Viability 13 (1) 6-16 31. McPherson MV, Binning J (2002) Chronic Foot Ulcers Associated with Diabetes: Patient’s Views The Diabetic Foot 5: 198-204

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33. Pott E (1992) Health Promotion and Chronic Illness: Discovering a New Quality of Health Geneva: World Health Organisation 34. Anderson RJ, Clouse RE, Freedland KE, Lustman PJ (2001) The Prevalence of Comorbid Depression in Adults with Diabetes: A Meta Analysis Diabetes Care 24 (6) 1069-1078 35. Lloyd CE, Orchard TJ (1999) Physical and Psychological Well-Being in Adults with Type 1 Diabetes Diabetes Research and Clinical Practice 44: 9-19

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Topical negative pressure in the treatment of deep sternal infection following cardiac surgery: Five year results of first-line application protocol

1 Martin

Šimek, MD,PhD

1Martin

Kaláb, MD, Molitor, MD,PhD 1Roman Hájek, MD,PhD 1Jana Grulichová 1Patrick Tobbia, MD 2Bohumil Zálešák, MD, PhD 1Vladimír Lonský, MD,PhD 2Martin

Short paper of Cardiac Surgery 2Department of Plastic and Aesthetic Surgery University Hospital and Palacky University Faculty of Medicine, Olomouc, Czech Republic 1Department

Correspondence: Martin Šimek martin.simek@c-mail.cz The authors have no nancial relationship fi with KCI Company San Antonio, TX, USA

Abstract Aim: We sought to evaluate a five year single centre experience for the application of topical negative pressure therapy (TNP) as the first-line therapy in the treatment of deep sternal wound infection (DSWI) following cardiac surgery. Methods: Prospective analysis of 50 consecutive patients (27 men, 23 women, mean age 67.8±9.2 years) who underwent first-line application of topical negative pressure for the treatment of deep sternal wound infection within a five year period (from September 2004 to September 2009). Clinical and wound care outcomes were evaluated, therapeutic failure rates, in-hospital and as well as the one year mortality of unified application protocol. Results: During follow-up 4% of 30-day mortality, 8% of in-hospital mortality, and 14% of one year mortality (10% DSWI-related complication adjusted) were observed. The mean length of overall therapy reached 12.6±8.0 days including the mean of 5.4±2.5 revision/dressing changes within 38.1±14.6 days of the mean in-hospital stay. The sternal bone was stabilized in 94% of cases; various flaps were employed in covering of the residual soft tissue defect in 70% of patients. Treatment failed in 6% of all cases, 4% due to DSWI recurrence, and 2% due to necrosis of the advanced muscle flap. The risk of wire-related fistula was 14% during whole follow-up period. Conclusion: TNP therapy is a reliable method for the treatment of DSWI following cardiac surgery. The primary application of TNP demonstrated a low risk of failure and a significant decrease in short- and mid-term mortality was observed.

Presented at the 20th Conference of the European Wound Management Association, 26-28 May, Geneva, Switzerland.

Introduction Deep sternal wound infection (DSWI) is one of the most serious complications of cardiac surgery performed through median sternotomy with predicted mortality ranging between 5 to 30%1. Despite welldescribed risk-related factors, improved antibiotic prophylaxis and aseptic methods, the incidence remains unchanged, varying from 1% to 5%2. The treatment strategies of DSWI is still challenging; it differs from one country to another, from one institution to another and even from one surgeon to another at the same department2. Methods Between March 2002 to September 2009, 6009 median sternotomies were performed at our department as a primary access for heart surgery. DSWIs were diagnosed according to the guidelines of the Centre for Disease Control and Prevention (CDC, 3), DSWI occurred in 84 patients which represented an incidence rate of 1.39%. Fifty consecutive patients (59%) were primarily scheduled for the first-line application of topical negative pressure therapy (TNP) between September 2004 and September 2009. The detailed unified therapeutic protocol has been described previously4,5,6. The median sternotomy was completely released and all suture material removed during primary revision. After bacterial sampling, when two to three swabs were taken (subticular, and mediastinal tissue, sternal bone), the wound was repeatedly flushed out with tepid saline solution. Inherent surgical debridement included removing only clearly necrotic tissue and was performed with aid of a scalpel, surgical spoon, and low-voltage electrocautery. Hydrosurgical debridement using saline jet-powered device (Versajet™, Smith and Nephew, UK) has not been employed. Moreover, debridement on the mediastinal structures was done extremely gently to avoid the risk of severe bleeding from grafts or the right ventriEWMA Journal

2011 vol 11 no 2

Science, Practice and Education Table 1. Perioperative characteristics

Figure 1. Therapeutic protocol

cle. If the bone mass was affected with osteomyelitis, it was removed with adherent sternocostal joints and costal cartilages. Emphasis was put on meticulous haemostasis throughout each debridement. Bleeding from the bone marrow was controlled with temporally placed bone wax, which was removed within next dressing changes. Surgical debridement with repetitive application of TNP (Vacuumassisted closure™, KCI San Antonio, Tx, USA) was carried out every 48 hours until the wound bed was found to be free of infection, then the wound was covered by wellvascularised granulation tissue. When C-reactive protein levels dropped below 30 mg/l, then the chest was reclosed (Figure 1). Peri-procedural, wound care characteristics and clinical outcomes were recorded in a prospective manner. All patients had a one year follow-up for the evaluation of long-term morbidity and mortality, Kaplan-Meier actuarial analysis of survival was plotted. Approval of the local ethics committee was obtained for the protocol of the application of TNP to the open chest wound in 2004.

Results There were 27 males (54%) and 23 females (47%) with an average age 67.8±9.2, and BMI 29.9±5.3 kg/m2. Detailed peri-operative characteristics including co-morbidities, surgical procedures and post-operative complications related to DSWI are summarized in Table 1. A total of 45 patients underwent coronary artery bypass grafting either as single procedure or in combination with valve surgery. In this subgroup of patients, 28 (63%) had diabetes and the internal thoracic artery (IMA) was taken down in 40 (89%). Unilateral IMA harvesting (80%) was done in pedicled fashion, whereas bilateral IMA harvesting (20%) was always performed without surrounding tissue as a skeletonized graft with maximal effort to spare the chest bone blood supply. The presentation of DSWI was delayed in average 16.1±14.2 days after the primary surgery, and twenty-three (46%) patients were re-admitted to the hospital due to DSWI despite an uneventful wound healing progress at the time of discharge. Gram positive strains EWMA Journal

2011 vol 11 no 2

TNP (n=50)

Age (years) BMI (kg/m2 ) Male/female ration (%) DM (%) COPD (%) Immunosuppressive therapy (%) Renal impairment (kreatinin>120 mmol/l) (%) LVEF (%) EuroSCORE log

67.8±9.2 29.9±5.3 54.0/46.0 58.0 34.0 18.0 28.0 40.8±13.6 6.9±6.2

CABG/valve/combined procedure (%) Mean operation time (min) Mean XC time (min) Mean ECC time (min) Emergency surgery (%) Postoperative blood loss (ml) Mean artificial pulmonary ventilation (hours) Mean ICU stay (hours)

60/10/30 230.5±44.8 62.8±45.6 90.7±40.1 24.0 910±540.3 19.4±28.1 61.1±34.8

Revision for bleeding/tamponade (%) 18.0 Revision for sternal instability (%) 40.0 Prolonged mechanical ventilation/tracheostomy (%) 8.0 BMI – body mass index DM – diabetes mellitus COPD – chronic obstructive pulmonary disease LVEF – left ventricle ejection fraction

CABG – coronary artery bypass grafting XC – cross clamp ECC – extracorporeal circulation ICU – intensive care unit

were dominantly cultivated from swabs obtained from the infected wound site, particularly staphylococcal aureus and coagulase-negative staphylococcus (Graph 1). There was no significant difference in outcome based on etiological causative agent. Based on the protocol, mean length of primary therapy reached 10.8±7.9 days including mean of 5.0±2.1 number of dressing changes in average until the wound bed was free of infection. All dressing changes were performed in the operating theatre, every patient was given a general anaesthetic and relaxed to avoid right ventricle or graft injury caused by the sternal lamella margins. The cost of each surgical debridement and dressing changes were analysed. The expenditure was approximately 2000 CZK (77 €) for general anaesthesia, 900 CZK (35 €) for surgical debridement, and 2500 CZK (96 €) for dressing material and collecting canister. A calculated total cost per one dressing change reached 5400 CZK (208 €).Changes in laboratory inflammatory parameters characteristics 

Graph 1. Predominant wound microorganisms

Graph 2. Laboratory inflammatory parameters characteristics

(C-reactive protein, white blood count) throughout the therapy are displayed in Graph 2. The sternum was approximated in 47 patients (94%), and residual soft tissue defect needed to be covered with local flaps in 45 patients (70%). Detail of employed flaps is showed in Graph 3. Primary treatment failed in three patients (6%); in two patients (4%) due to DSWI recurrence, and in one (2%) due to necrosis of bipedicle muscle flap owing to the technical failure. All those patients underwent TNP therapy according to the therapeutic protocol similar to primary application (rescue therapy), and the necrotic flap was removed. Furthermore, superficial sternal wound infection (SSWI) or soft tissue dehiscence occurred in four patients (8%) which was treated with moist healing therapy and/or was surgically closed. Mean overall length of TNP therapy reached 12.6±8.0 days including 5.4±2.5 dressing changes on average, mean in-hospital time was 38.1±14.6 days. Focusing on the mortality, 4% of 30-day mortality (two patients), and 8% of in-hospital mortality (four patients) was recorded ranging between the 9th-94th post-operative day. Three patients (6%) died of multiple organ failure and one (2%) of intractable bleeding from a right ventricle rupture that occurred shortly after the primary revision. Detailed therapy characteristics and clinical outcomes are recorded in table 2. During the one year follow-up, a total of seven patients (14%) were lost, five of whom (10%) were an immediate consequence of DSWI (DSWI adjusted mortality), another seven patients (14%) underwent treatment for wire-related fistula. The one year plotted survival analysis using Kaplan-Meier analysis is displayed in Figure 2.

Discussion The treatment of DSWI poses an ongoing challenge for cardiac surgeons; thus far there is no consensus about the standard of care covering this issue2. TNP therapy has been used in cardiac surgery since 1997. Despite growing and encouraging experience, evidence that TNP is better than conventional therapy is still lacking4. Several studies comparing TNP versus conventional therapy showed superiority of TNP in terms of reduction of primary therapy failure, short- and long-term mortality and morbidity, and 40

Graph 3. Flap employment

better quality of life, however, all had retrospective design and were conducted on a limited number of patients5,6,7,8. Recently initial data showed the cost-effectiveness of this therapy9. Even though the cost of TNP was comparable with other treatment strategies of DSWI, this treatment brought a significant reduction in mortality and in-hospital stay9. Thus, there is still essential need for further investigations including larger prospective multi-centre study, and randomized trials4. From a surgical point of view, TNP combines advantages of the open therapy which enables repetitive debridement and wound drainage with the closed therapy, because even in the absence of sternal closure, applied negative pressure of 125 mm Hg effectively stabilizes the chest. It allows immediate postoperative extubation and mobilization of the patient. Moreover, sealing the sternal wound minimizes the risk of secondary contamination and facilitates handling with patients, particularly if they need to be hospitalized in the ICU10. The exact mechanism of TNP action on wound healing has not been fully explained as yet10. It has been shown to accelerate granulation tissue building, reduce wound surface area, decrease local and interstitial tissue oedema, and increase perfusion of the peri- and wound area10,11,12 even when the left internal mammary artery has been harvested for bypass grafting13. Moreover, diminished bacterial load or modulation of bacterial species together with the reduction of the amount of metalloproteinase detected in the wound bed strongly suggest that the effect of TNP on wound healing processes is rather more fundamental than adjunct14,15. A new negative pressure therapy (V.A.C – Instillation™, KCI, San Antonio, TX, USA) has been recently introduced. It combines the positive effect of sub atmospheric pressure with intermittent instillation of antiseptic solution. This therapy demonstrated its effectiveness in the treatment of chronic-infected wounds such as pelvic and leg post-traumatic osteomyelitis. Applied negative pressures together with intermittent instillation of polyhexanide solution significantly reduced total in-hospital stay (36 vs. 73 days, p<0.0001) and recurrence of infection (3 vs.59%, p<0.0001) compared with conventional treatment16. EWMA Journal

2011 vol 11 no 2

Science, Practice and Education Table 2. Therapy characteristics and outcomes TNP (n=50) Primary therapy No. of revisions/dressing changes Length of primary therapy (days) Failure of primary therapy (%)

5.0±2.1 10.8±7.9 6.0

Complications after the chest closure DSWI (%) Flap necrosis (%) SSWI/dehiscence (%) Fistula (%)

4.0 2.0 8.0 14.0

Overall therapy Overall length of therapy (days) Overall No. of revision/dressing changes In-ICU stay (hours) In-hospital stay (days)

12.6±8.0 5.4±2.5 204.4±320.1 38.1±14.6

Mortality 30-day mortality (%) In-hospital mortality (%) Multiple organ failure (%) Intractable bleeding (%) 1-year mortality (%)

4.0 8.0 6.0 2.0 14.0

ICU – intensive care unit

Although the manufacturer’s recommended negative pressure setting is 125 mmHg for polyurethane foam, and 150 mmHg for polyvinyl alcohol foam, some of the studies that focused on cutaneous blood flow suggested that further increase in sub atmospheric pressure, even up to 300 mmHg, leads to a three times increase of cutaneous blood flow for polyvinyl alcohol and five times for polyurethane foam17. The aim of this prospective study was to evaluate the clinical outcome of first-line application of TNP for DSWI as a standard of care. The results suggested that TNP therapy is associated with low rates of therapy failure, and reduction in short- and mid-term mortality. Uniform treatment protocol allowed for equivalent outcomes to be achieved among all surgeons at one unit. Literature 1. Lepelletier D, Perron S, Bizouarn P, et al. Surgicalsite infection after cardiac surgery: Incidence, microbiology, and risk factors. Infect Control Hosp Epidemiol 2005;26:466-72. 2. Schimmer C, Sommer P, Bensch M, Elert M, Leyh R. Management of poststernotomy mediastinitis: experience and results of different therapy modalities. Thorac Cardiovasc Surg 2008;56:200-4. 3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. The hospital infection control practise advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol 2002;20:247-78. 4. Raja SG, Berg GA. Should vacuum-assisted closure therapy be routinely used for management of deep sternal wound infection after cardiac surgery. Interactive Cardiovasc Thorac Surg 2007;6:523–27. 5. Sjögren J, Gustafsson R, Nilsson J, Malmsjö M, Ingemansson R. Clinical outcome after poststernotomy mediastinitis: Vacuum-assisted closure versus conventional treatment. Ann Thorac Surg 2005;79:2049-55. 6. Simek M, Hajek R, Fluger I, et al. Topical negative pressure versus conventional treatment of deep sternal infection in cardiac surgery. EWMA Journal 2008;8:19-22.

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Figure 2. Kaplan-Meier survival analysis

Conclusion TNP therapy is a safe method for the treatment of DSWI following cardiac surgery. The first-line application protocol of TNP demonstrated a low risk of failure and a significant decrease in short- and mid-term mortality was observed. Implications for Clinical Practice n TNP is an effective treatment for deep sternal infection after cardiac surgery n TNP is associated with low failure rate, and reduced short- and mid-term mortality n TNP should be widely accepted as a first-line treatment strategy for DSWI in cardiac surgery Further Research n Multi-centre prospective randomized trials comparing TNP with the conventional therapy need to be undertaken n Influences of individual wound-healing risk factors and microbiological agents on the effectiveness of TNP therapy need to be examined m

7. De Feo M, Vicchio M, Nappi G, Contrufo M. Role of Vacuum in Meticillin-Resistant Deep Sternal Wound Infection. Asian Cardiovasc Thorac Ann 2010;18:360-363. 8. Petzina R, Hoffman J, Navasardyan A, Mamsjoe S, Ubenhaun A, Hetzer R. Negative pressure wound therapy for post-sternotomy mediastinitis reduces mortality rate and sternal re-infection rate compared to conventional treatment. Eur J Cadiothoracic Surg 2010;38:110-113 9. Mokhari A, Sjögren J, Nilsson J, Gustafsson R, Malmsjö M, Ingemansson R. The cost of vacuumassisted closure in treatment of deep sternal wound infection. Scand Cardiovasc J 2007;42:85-89. 10. Banwell PE, Musgrave M. Topical negative pressure therapy: mechanisms and indications. Int Wound J 2004;1:95-106. 11. Ubbink DT, Westerbos SJ, Nelson EA, Vermeulen H. A systematic review of topical negative pressure therapy for acute and chronic wounds. Brit J Surg 2008;95:685-692. 12. Argenta LC, Morykvas MJ, Marks MW, DeFranzo AJ, Molnar JA, David LR. Vacuum-assisted closure: State of art. Plast Reconstruct Surg 2006;117: 127-42S.

13. Petzina R, Gustafsson L, Mokhtari A, Ingemansson R, Malmsjö M. Effect of vacuum-assisted closure on blood flow in the peristernal thoracic wall after internal mammary artery harvesting. Eur J Cardiothorac Surg 2006;30:85-9. 14. Mouës CM, Vos MC, van den Bemd GJ, Stijnen T, Hovius SE. Bacterial load in relation to vacuumassisted closure wound therapy: a prospective randomized trial. Wound Repair Regen 2004;12:117. 15. Mouës CM, van Toorenenbergen AW, Heule F, Hop WC, Hovius SE. The role of topical negative pressure in wound repair: expression of biochemical markers in wound fluid during wound healing. Wound Repair Regen 2008;6:488-94. 16. Timmers MS, Steenvoorde P, Bernards AT, van Dissel JT, Jukema GN. Negative pressure wound treatment with polyvinyl alcohol foam and polyhexanide antiseptic solution instillation in posttraumatic osteomyelitis.Wound Repair Regen. 2009;17:27886. 17. Timmers MS, Le Cessie S, Banwell P, Jukema GN: The effects of varying degrees of pressure delivered by negative pressure wound therapy on skin/tissue perfusion. Ann Plast Surg 2005:55:665-671.

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Scientific Communication

Wounds Research for Patient Benefit:

A five year programme of research in wound care Background The Wounds Research for Patient Benefit (WRPB) programme commenced in 2008 and will receive £1.75 million of funding from the Programme Grants for Applied Research funding stream of the National Institute for Health Research (NIHR), over five years. The research programme is a multidisciplinary collaboration between NHS Leeds Community Healthcare and the University of York. The large and diverse population of Leeds offers an ideal laboratory for research, ensuring the delivery of useful and valid information regarding complex wound care and the University of York is home to the Wounds Research Group which has an international reputation for its expertise in a range of research methodologies applied to wound care. The WRPB programme is specifically focused on researching complex wounds which we define as wounds which involve superficial, partial or full thickness skin loss and which are healing by secondary intention. They are wounds with an underlying cause or which occur in patients where underlying disease may impact upon healing e.g. pressure ulcers, leg ulcers and dehisced surgical wounds. Currently good information regarding the nature, treatment, costs and outcomes for people with complex wounds is very limited and this research programme will plug some of these knowledge gaps, reduce clinical uncertainty and enable decision makers to prioritise future research and areas for service development. We wanted to take this opportunity to provide an overview of the work that is being carried out as part of this programme and to invite you to share your clinical uncertainties with us. The research programme is split into three distinct, but integrated workstreams which we will describe in turn.

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2011 vol 11 no 2

Workstream 1: Data capture and epidemiology Workstream 1 is focused on collecting high quality information about complex wounds and their care. There is a real lack of basic, yet important, information about the treatment of complex wounds in the UK; a fact we have confirmed in a recently completed literature review of wound prevalence surveys/audits. Whilst we included fifty studies in the review, problems of study design meant that many of these studies were at high risk of bias and likely to under- or over-estimate wound prevalence. These biases result in large differences in the published estimates of complex wound prevalence. Our literature review helped inform the design of a new large and comprehensive survey of people with complex wounds in Leeds. The survey took place over a two-week period in March 2011 and included all settings in which people with complex wounds are treated including health clinics for people with no fixed abode and prisons. This comprehensive data collection and the inclusion of hard-to-reach groups such as IV drug users mean that we are confident in the results and the estimate of wound prevalence this study will bring. This survey also recorded who is delivering health care, how often and what treatments are being provided so we will have important new insights into the impact of wounds on all health care services. Data are currently being analysed and  will be published late 2011.

Karen Lamb1 Nikki Stubbs1 Jo Dumville2 Nicky Cullum2 Dr Susan O’Meara2 1NHS Leeds Community Healthcare, St. Marys Hospital, Leeds, LS12 3QE 2Department

of Health ciences, S University of York, York, YO10 5DD Conflict of interest: None

Scientific Communication

Finally, within this workstream we are exploring whether we can routinely collect high quality data about people with complex wounds, for use in both service planning and research. Such a system, a type of register, would record the number of patients affected; the ongoing impact of wounds on quality of life; actual treatments received and healing rates achieved. Additionally, such a system could facilitate on-going assessment of costs and benefits, as well as monitoring the diffusion of new-to-market medical devices into practice. Such data will contribute to health technology assessment via the tentative application of advance methodologies that may generate information on the clinical and cost effectiveness of wound treatments. This work is on-going and more information about this and all aspects of workstream 1 can be found at: www. york.ac.uk/healthsciences/wounds-patientbenefit/wone/

Workstream 2: Understanding what matters most to patients, carers and health professionals in complex wound care Workstream two acknowledges that those researching and delivering wound care should fully understand what outcomes matters most to patients and carers. Wound healing is frequently reported in trials, whilst some have argued for alternative outcomes1, so we are asking patients and clinicians. Other possible outcomes of interest could include debridement, the number of dressing changes, resource use, exudate, odour, pain, dressing comfort and product durability. To find out we are undertaking indepth interviews with patients, carers and healthcare staff about the relative importance of different wound treat-

ment outcomes to them. The study includes patients who have leg ulcers, diabetic foot ulcers, pressure ulcers and dehisced surgical wounds and the findings will provide missing information for researchers and health care staff on what matters most to different patients experiencing wound care. Additionally, in collaboration with the James Lind alliance (JLA)2, we are convening groups of patients, carers and citizens who are interested in helping to set the research agenda for the treatment specific wounds. The JLA was established in 2004 to encourage patients, carers and clinicians to work together to identify and prioritise important healthcare uncertainties that can be translated into research priorities. Where there is no clear evidence about the effectiveness of treatments, clinicians and patients are left with uncertainty and are reliant on the opinions of health care professionals which can be flawed. In our experience public involvement in, and awareness of, wounds research is minimal. Given the lack of patient involvement in research agenda setting and the limited evidence-base informing clinical decisions in wound care3‑5, the JLA is supporting the development of a partnership of patients, carers and clinicians to identify research priorities in the prevention and management of pressure ulcers. The objective is to discover the research questions that matter most to stakeholders. The initial meeting of the James Lind Alliance Pressure Ulcer Partnership (JLAPUP) took place in York in Spring 2011 and was participated in with much enthusiasm by delegates. Further information on the JLAPUP can be found at www.york.ac.uk/healthsciences/ wounds-patientbenefit/jla-pressureulcerpartnership/ 

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 send directly to you three times a year n EWMA news and statements send directly to you n A discount on your registration fee for EWMA Conferences EWMA Secretariat Nordre Fasanvej 113, Right to apply for EWMA travel grants n 2000 Frederiksberg, n Yearly membership fee € 25 Denmark Tel: +45 7020 0305 Yearly membership fee for members of cooperating organisations € 10 n

Please register as a EWMA member at WWW.EWMA.ORG 44

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EWMA Journal

2011 vol 11 no 2

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Workstream 3: Evidence synthesis Workstream 3 brings together existing research to answer questions about which wound treatments work best. In order that our reviews tackle questions of high priority to the NHS, we consulted with clinicians, including nurses and podiatrists and compiled a list of 27 potential questions which can be viewed on our website (www.york.ac.uk/ healthsciences/wounds-patientbenefit/wthree ). Questions included: What is the relationship between debridement and healing in foot ulcers and other complex/chronic wounds? and What is the best way to diagnose osteomyelitis? For each topic we have scoped the literature in order to identify existing summaries of research and we have noted those topics that seem ‘ripe’ for further investigation. It is important to note that this list is not closed and we welcome further suggestions from readers of this journal (please submit suggestions via our Programme website or by contacting Susan O’Meara, susan.omeara@york.ac.uk). The main focus here is clinical effectiveness questions (i.e., those that explore how well an intervention works) or what the most accurate method of diagnosis is. Our consultation with clinicians has resulted in us initiating a new review on dressings for healing diabetic foot ulcers where we are using a more sophisticated method of evidence synthesis (mixed treatment comparison) to make the most of existing published data.6‑8 We are also working on updating existing Cochrane reviews in wound care. We have completed one update (Antibiotics and antiseptics for venous leg ulcers9) and another (Compression for venous leg ulcers) is underway. We also have a new review in progress which explores the influence of the type of research funding on the quality of wound treatment trials. Additional new reviews and review updates will be undertaken as the research programme progresses. A further component of this Workstream will investigate how we might best present the results of evidence synthesis, including quantitative information and uncertainty, to make them most useful for health professionals.

Conclusions Good clinical management of complex wounds promotes positive outcomes and reduces wound recurrence. The lack of good quality research evidence for wound treatments should concern us all — only approximately 10% of recommendations in National institute of Health and Clinical Excellence and the Royal Collage of Nursing wound care guidelines are supported by Level 1 evidence. The Wound Research for Patient Benefit research programme is encouraging the production of more relevant and better quality research evidence on the effectiveness and costeffectiveness of wound prevention and treatment. This evidence has the potential to improve the quality of care, patient outcomes and reduce costs. If you wish to contribute to discussion on treatment uncertainties or have any other wound care-related research questions please contact us via our website: www.york.ac.uk/healthsciences/ wounds-patientbenefit/research-question/ m Disclaimer All authors receive funding from the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG-0407-10428). The views expressed in this review are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. References 1. Gottrup F. Debridement: another evidence problem in wound healing. Wound Repair and Regeneration 2009; 17:294-95. 2. The James Lind Alliance. www.lindalliance.org/ Accessed 19th April 2011 3. NICE (2005) The management of pressure ulcers in primary and secondary care: A Clinical Practice Guideline. Available at http://guidance.nice.org.uk/CG29/Guidance/ pdf/English . (Accessed 06/01/2010). 4. NPUAP-EPUAP Guidelines for Pressure Ulcer Prevention and Treatment (2009). Available at www.npuap.org (accessed 20 April 2011). 5. Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA (2008) Treatment of Pressure Ulcers: A Systematic Review JAMA 300 22: 2647-2662 6. Sutton A, Ades AE, Cooper N, Abrams K. Use of indirect and mixed treatment comparisons for technology assessment. Pharmacoeconomics. 2008;26(9):753-67. 7. Lu G, Ades AE. Combination of direct and indirect evidence in mixed treatment comparisons. Stat Med. 2004 Oct 30;23(20):3105-24 8. Glenny AM, Altman DG, Song F, Sakarovitch C, Deeks JJ, D’Amico R, Bradburn M, Eastwood AJ; International Stroke Trial Collaborative Group. Indirect comparisonsof competing interventions. Health Technol Assess. 2005 Jul;9(26):1-134, iii-iv. 9. O’Meara S, Al-Kurdi D, Ologun Y, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD003557. DOI: 10.1002/14651858.CD003557.pub3. Available from www.mrw. interscience.wiley.com/cochrane/clsysrev/articles/CD003557/frame.html

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EWMA Journal

2011 vol 11 no 2

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EWMA Journal

Previous Issues

Volume 1, no 1, January 2011 Who will take on Ali Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi Diabetic foot ulcer pain: The hidden burden Sarah E Bradbury, Patricia E Price The reconstructive clockwork as a 21st c entury concept in wound surgery Karsten Knobloch, Peter M. Vogt Anaemia in patients with chronic wounds Lotte M. Vestergaard, Isa Jensen, Knud Yderstraede A survey of the provision of e ducation in wound management to undergraduate nursing students Zena Moore, Eric Clarke Caring for Patients with Hard-to-Heal Wounds – Homecare Nurses’ Narratives Camilla Eskilsson

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

Daptomycin in the disinfection of complicated infected skin ulcers of the lower limbs in geriatric patients and candidates for reconstructive and/or regenerative surgery Campitiello F., et al. Foam adhesive dressing in the treatment of leg skin ulcers Bucalossi M., et al. Classification of peristomal skin changes: multicentric observational study Pisani F., et al. Chronic infected skin lesions, micro-organisms and bacterial resistance Nebbioso G., et al. Chronic skin ulcers in elderly patients: What are the outcomes? Peruzza S., et al.

Volume 10, no 3, October 2010 Rationale for compression in leg ulcers with mixed, arterial and venous aetiology Hugo Partsch Pressure ulcers in Belgian hospitals: What do nurses know and how do they feel about prevention? D. Beeckman, T. Defloor, L. Schoonhoven, K. Vanderwee Nutritional Supplement is Associated with a Reduction in Healing Time and Improvement of Fat Free Body Mass in Patients with Diabetic Foot Ulcers P. Tatti, A.E. Barber, P. di Mauro, L. Masselli Chronic wounds, non-healing wounds or a p ossible alternative? M. Briggs Silver-impregnated dressings reduce wound c losure time in marsupialized pilonidal sinus A. Koyuncu, H. Karadaˇ, A. Kurt, C. Aydin, O. Topcu Venous leg ulcer patients with low ABPIs: How much pressure is safe and tolerable? J. Schuren, A. Vos, J.O. Allen, Adherence to leg ulcer treatment: Changes associated with a nursing intervention for c ommunity care settings A. Van Hecke, M. Grypdonck, H. Beele, K. Vanderwee, T. Defloor A Social Model for Lower Limb Care: The Lindsay Leg Club Model M. Clark

English

Finnish

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

Haava, no. 4, 2010 www.shhy.fi Thema: Burns Burns – Classification and treatment Leena Berg Operative treatment of burns Heli Kukko Electricity damages – What they are? Leena Berg Treatment of burns in history and today in HYK burn center Sari Ilmarinen Paavo’s 1. day in intensive care unit Liisa Sikkilä

Spanish

Helcos, vol. 22, no. 1, 2011 Pressure ulcers risk assessment scales for children FP García-Fernandez, PL Pancorbo-Hidalgo, JJ Soldevilla-Agreda Measue healing in perssure ulcers. What do we have? JC Restrepo-Medrano, J Verdú The skin has a symbolic characteristic because it is where the body and the spirit unite JA Marina

Volume 10, no 1, January 2010 Systematic review of R epositioning for the Treatment of Pressure Ulcers Zena Moore, Seamus Cowman Analysis of wound care in n ursing care homes as part of a district-wide wound care audit Peter Vowden, Kathryn Vowden Chronic leg ulcers among the Icelandic population Guðbjörg Pálsdóttir, Ásta Thoroddsen Cross-sectional Survey of the O ccurrence of Chronic Wounds within Capital Region in Finland Anita Mäkelä The EWMA Teach the Teacher Project Zena Moore

Advances in Skin & Woundcare, vol. 24, no 5, 2011 www.aswcjournal.com A Morphological and Biochemical Analysis Comparative Study of Collagen Products Jeffrey C. Karr, Anna Rita Taddei, Simona Picchietti, Gabriella Gambellini, Anna Maria Fausto, Franco Giorgi A Case of Refractory Pyoderma Gangrenosum Treated with a Combination of Apligraf and Systemic Immunosuppressive Agents Giacomo Duchini, Peter Itin, Andreas Arnold Overcoming Lower-Extremity Wound Defects Using Hydrocolloid Framing Bruce M. Goldstein

Volume 10, no 2, May 2010 Hyperbaric Oxygen and Wounds: A tale of two enzymes Thomas K. Hunt HBOT in evidence-based wound healing Maarten J. Lubbers Comparative analysis of two types of gelatin microcarrier beads Mohamed A Eldardiri et al. Evidence based guidelines – how to channel relevant k nowledge into the hands of nurses and c arers Susan F. Jørgensen, Rie Nygaard Lack of due diligence in the prophylaxis of pressure ulcers? Dr. Beate Weber, Hans-Joachim Castrup Six prevalence studies for pressure ulcers – Snapshots from Danish Hospitals Susan Bermark et al. The Ransart Boot – An offloading device for every type of Diabetic Foot Ulcer? I.J.Dumont et al. The Haitian Earthquake, January 2010 John M Macdonald

Acta Vulnologica, vol. 9, no 1, 2011 www.vulnologia.it

English

Journal of Wound Care, vol. 20, no 4, 2011 www.journalofwoundcare.com A clinical evaluation of the efficacy and safety of singlet oxygen in cleansing and disinfecting stagnating wounds G. Kammerlander, O. Assadian, T. Eberlein, P. Zweimeller, S. Luchsinger, A. Andriessen Role of oxygen in wound healing: A review of the evidence A.C. Chambers, D.J. Leaper Wound healing following combined radiation and cetuximab therapy in head and neck cancer patients N.R. Dean, L. Sweeny, P.M. Harari, J.A. Bonner, V. Jones, L. Clemons, H. Geye, E.L. Rosenthal

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2011 vol 11 no 2

EWMA

English

Int. Journal of Lower Extremity Wounds vol. 10, no, 3, 2011 http://ijlew.sagepub.com Diabetic Foot Amputations in Greece: Where Do We Go From Here? N. Papanas,M.K. Lazarides Impact of Diabetic Foot Related Complications on the Health Related Quality of Life (HRQol) of Patients – A Regional Study in Spain E. García-Morales, et al. A Chronic, Destructive Mycetoma Infection in a Diabetic Foot in Saudi Arabia M. Malone, Al Gannass, F. Bowling Review: The Diabetic Bone: A Cellular and Molecular Perspective Robert Blakytny, Maximilian Spraul, Edward B. Jude Seminar Review: A Review of the Basis of Surgical Treatment of Diabetic Foot Infections Javier Aragón-Sánchez

English

Leczenie Ran, Issue 1, Volume 8, 2011 Osteoprotegerin – a new marker of atherosclerosis helpful in selecting patients at amputation risk? Aleksandra Rumianowska, et al. The Doreen Norton scale for assessing risk of pressure ulcers Katarzyna Cierzniakowska, et al. Risk factors of lower limb amputation in diabetic foot syndrome Beata Mrozikiewicz-Rakowska, et al. The efficacy of selected antiseptics against CNS isolated from chronic wound infections examined in in vitro conditions and in conditions imitating the wound environment Marzenna Bartoszewicz, et al.

English

Time course of the angiogenic response during normotrophic and hypertrophic scar formation in humans Willem M. van der Veer, et al. Formulated collagen gel accelerates healing rate immediately after application in patients with diabetic neuropathic foot ulcers Peter Blume, et al. Development of the DESIGN-R with an observational study: An absolute evaluation tool for monitoring pressure ulcer wound healing Yuko Matsui, et.al How to assess scar hypertrophy – A comparison of subjective scales and Spectrocutometry: A new objective method Ilkka S. Kaartinen, et al. A novel noncontact method to assess the biomechanical properties of wound tissue Clare Y. L. Chao, et al. Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial) Takehiko Ohura, et al.

Lietuvos chirurgija, vol. 8, no 4, 2010 www.chirurgija.lt Anal fistula plug for the treatment of complex fistula-in-ano Palubinskas E, Samalavicius NE, Gudelyte L Aloplasty in inguinal hernia repair in Lithuania Narmontas D, Gradauskas A Comparative analysis of chronic hemorrhoids surgical treatment Denisenko VL Injection of methylene blue solution into the inferior mesenteric artery of resected rectal specimens for rectal cancer as a method to increase lymph node harvest Klepsyte E, Samalavicius NE Early results of incarcerated abdominal wall hernia repair Stanaitis J, Saltanavicius R, Povilavicius J, Stasinskas A Acute mesenteric ischemia following cardiac surgery Andrejaitiene J Incarcerated obturator hernia in 49 year old women: A case report and review of the literature Markevicius M, Lunevicius R, Markovas V, Stanaitis J German

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Phlebologie, no 2, 2011 www.schattauer.de Outpatient varicose vein surgery Neller 5-year results for 980 nm endovenous laser obliteration of Beinvarizen. First comparisons with 1470 nm laser and laser radial probe. Pinzetta et al. Caliber reduction of the great saphenous vein and the femoral artery after CHIVA Mendoza et al. Analgesic effect of topical sevoflurane on venous leg ulcer with intractable pain Geronimo-Pardo et al. The CALISTO-study Bauersachs Differential diagnoses of venous leg ulcers Gallenkemper, Schimmelpfennig, Dissemond

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.

Wound Repair and Regeneration, vol. 19, no 3, 2011 www.wiley.com

Wund Management, vol. 5, no 2, 2011 English abstracts are available from www.mhp-verlag.de Classification of wounds at risk (W.A.R. score) and their antimicrobial treatment with polihexanide ó A practice-oriented expert recommendation J. Dissemond, O. Assadian, V. Gerber, A. Kingsley, A. Kramer, D. J. Leaper, G. Mosti, A. Piatkowski, G. Riepe, A. Risse, M. Romanelli, R. Strohal, J. Traber, A. Vasel-Biergans,T. Wild, T. Eberlein Electrotherapy of chronic wounds: Evidence of clinical effectiveness and benefit K. Herberger, T. Kornek, E. S. Debus, H. Diener, M. Augustin

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Wounds (SÅR) vol. 19, no 1, 2011 www.saar.dk Will systematic actions for improvement of wound bed preparation, edema control and treatment of malnutrition lead to a better wound healing? A review of 33 treatment cases Arne Langøen, Tove Sandvoll Vee Dressings: Super absorbents in the treatment of wounds Anne Hindhede Soap is not recommended in the treatment of wounds Jette Skiveren, Britta ÿstergaard Melby, Lis Kirkedal Bunder, Heidi Nordahl Larsen, Katja Safin Gudmundsen, Susan Bermark Wound Management for Diabetic Patients: a Holistic Approach Sanne Wichmann

Please contact the Journal Secretariat at ewma@ewma.org

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INTRODUCING

The Belgian Federation

Brigitte Crispin President of AfiScep and Befewo

Luc Gryson President of C.N.C. and Befewo

The Belgian Federation of Woundcare (BEFEWO) was established in 2004 as the umbrella organisation of two major wound management associations in Belgium. Belgium is a bilingual country where both French and Flemish (Dutch) are spoken. The two wound management associations existing at that time were CNC Wound Management Association and AFISCeP. An outcome of this joint partnership was the Belgian National Bilingual wound management conference in 2006 in Brussels. The success of this initiative has now resulted in an annual BEFEWO conference with over 450 participants each year. In 2011 the BEFEWO conference will be held during the EWMA conference at the SQUARE in Brussels. It is a great privilege in 2011 for BEFEWO to host EWMA’s conference in Brussels, the European Capital, as it is also the fifth anniversary of the Belgian Bilingual National Conference. The organisations not only collaborate with conferences but also in relation to liaising with the Belgian Government. Here the organisations undertake common initiatives and represent each other as BEFEWO members in diverse international organisations as EWMA, ECET, EPUAP and ETRS. BEFEWO is a joint organisation representing the strength, multilingualism and unity of Belgium and its wound management associations. Besides the interest in wound management both organisations have a specific interest in ostomy care which is closely combined with wound management in Belgium.

CNC Wound Management Association (CNC WMA) Fifteen years ago CNC WMA was established as a charity. The founding members of CNC WMA were Jan Vandeputte and Luc Gryson, both masters in Nursing Sciences and still active in wound management. Today CNC WMA has a board of managers, a council and an executive to fulfil all activities now delivered by CNC WMA. CNC WMA started as a very small specialised wound care nurses’ association but gradually healthcare professionals of different specialities also became interested in membership. Nowadays the healthcare professionals offer a valuable contribution in the society’s activities and nurses of all specialities with an interest in wound management are becoming members. The main purpose of CNC WMA is to promote education in wound care among doctors, nurses and other health care professionals. To this end, CNC WMA has a strong and firm collaboration with several University colleges making it possible to organise more than six basic wound management courses and two postgraduate courses for nurses each year. As a result of this CNC WMA has contributed to the education of over 3,000 nurses in modern wound care. In addition, CNC WMA, together with partners, offers over 25 different educational specialised programs in wound management for nurses and doctors in Flanders. Since 1999 CNC WMA, together with The HUB University College of Brussels, has organised the post graduate course in wound management. In 2004 the same collaboration was set up with the KATHO University College. Another joint activity with HUB University College Brussels will be the master class being launched in

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of Woundcare

EWMA2011 25-27 May Brussels · Belgium

April 2011. This is a new initiative on which there hopefully will be a lot of focus in the future. Since 2000 an annual Flemish wound symposium has been organised and in 2008 the symposium became the Flemish Wound Management Conference. Held in Kortrijk with its mirror symposium in Hasselt –Genk the conference annually attracts over 700 doctors and nurses to attend. Besides education and promotion of wound management, CNC WMA believes in collaboration between organisations to promote wound care issues. CNC WMA collaborates with NVKVV (Nationaal Verbond van Katholieke Vlaamse Verpleegkundigen) Flanders, a major Nurses organisation, regarding a joint membership at reduced annual fee opportunity; with VLAS, the Flemish ostomy organisation, regarding educational activities and also with a steering committee of 21 local wound management companies to establish better education and awareness towards wound-care in Belgium.

AFISCeP.be – Association Francophone d’Infirmiers(ères) en Stomathérapie, Cicatrisation et Plaies Belgique Nearly twenty years ago an association named ARIAS was established. This association handled the distribution of information regarding ostomised patients to nurses and attending doctors etc. for the more professional treatment of ostomised patients. Five years later ABISCEP was established with the intention to train stoma therapy nurses in Belgium. Over time, this association expanded into wound care and healing. In 2007, these two francophone associations joined together under one name: AFISCeP.be.

In 2001, CNC WMA started a preliminary UCM (University Conference Model) concept at the EWMA conference for its postgraduate students. Since then CNC WMA has been proud to be able to send students to the conference each year.

This association is very active. It organizes an annual conference and roundtable meeting. In addition, some members are responsible for informing home care providers and future nurses in schools. It participates in the INAMI (Institut National Assurance Maladie Invalidité – National Institute for Disability Health Insurance) work group and defends patients for the reimbursement of equipment used in stoma care. The association works for the recognition of stoma therapy nurses and nurses specializing in wound care. In addition, AFISCeP. be also organises supplementary training events for certified stoma therapy nurses. An additional project was a 900 hour stoma therapy and wound care training course that was organised to meet the Belgian legislation in the field. Our association works with CNC WMA to organise the BEFEWO conference which bring together the French and Flemish communities.

In 2011 the updated website, www.woundcare. be, will be launched which is a reference for Flemish students and nurses seeking comprehensive and accessible information concerning wound management. Together with the paper version wondzorg.be this is the major reference source for the Flemish nurses and doctors.

To support and complement its activities the AFISCeP.be publishes a quality journal twice a year that is respected and valued by all professionals. Its website, www.afiscep.be, also keeps members up-to-date on the latest news in the field. These projects all contribute to the dissemination of information and training to maintain a high skill level of caregivers in patient support and care. m

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atient Outcome Group (POG) is currently working on disseminating the messages formulated in the POG document “Outcomes in controlled and comparative studies on non-healing wounds – Recommendations to improve quality of evidence in wound management”. Patricia Price PhD, CHPsychol, Chair of the EWMA Patient Outcome Group Dean and Head of School of Healthcare Studies

POG is currently initiating several projects to meet the general objectives: 1. Identify barriers: n With a starting point in the current debate on evidence in wound healing and the Cochrane levels of evidence, the group will define the primary barriers (as experienced by clinicians and companies) related to the creation and implementation of evidence-based guidelines in wound healing. 2. Propose guidelines for clinical data collection: n The objective will be to define how existing guidelines for clinical trials (e.g. RCTs or more “practical” studies (real life studies etc.)) can be adapted to wound management, by including, for example, other end points such as number of dressing changes, health economics, QOL, education of staff and structure of treatment. 3. Participate in the public debate / policy making: n The working group should present a common viewpoint on clinical trials of wound management products in relation to the debate on both national and European levels. A primary goal will be to influence the decision making processes concerning approval and reimbursement of wound management products. EWMA will act as shareholder and work to influence the national agendas in order to put chronic wounds on the agenda. n A central European HTA unit is assumed to be established. The working group should approach involved institutions in order to present the work and conclusions of the group in relation to evidence in HTA of wound management products.

4. Create and implement consensus: Other interested parties (clinicians, companies, reimbursement authorities, European collaborative groups and institutions) should be involved in order to establish consensus within the area. A pan-European consensus with a national implementation strategy has been proposed.

POG conducted a Health Economics Course in Copenhagen which can be read about elsewhere in this Journal edition. Furthermore, the group is currently preparing EWMA Industry Course to be held on October 13-14th, 2011 in Budapest. The group is also working on translating the essential document into German and French in order to spread the messages of the work. Currently there is a Polish translation of the document, which is available on the website. Furthermore, the group is continuing to disseminate the messages of the POG document by addressing relevant concerns to the authorities in the EU and member states in order to enhance research in wound care and, in turn, create a better treatment of wounds for patients all over Europe. POG currently consists of: Clinical: Patricia Price, Chair (EWMA Council) Jan Apelqvist (EWMA Council) Finn Gottrup Luc Gryson (EWMA Council) Hugo Partsch Robert Strohal (EWMA Council) Industry: Abbott Nutrition, B Braun, Convatec Lohmann and Rauscher, Mölnlycke For further information about EWMA Patient Outcome Group, please visit ewma.org/english/ patient-outcome-group.html. Any questions concerning Patient Outcome Group or the document can be sent to EWMA Secretariat: ewma@ewma.org m

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Bionect Start ®

Start well, faster heal!

Hyaluronic acid + Collagenase

BIONECT® START is the bioactive solution for necrotic and fibrinous wounds. Fidia’s collagenase, developed from Vibrio Alginolitycus (non pathogenic bacterial strain), has a high purity grade to assure the respect of periwound skin. Hyaluronic acid provides an ideal wound environment and promotes wound healing.

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EWMA INDUSTRY COURSES 13 -14 October 2011 · Budapest, Hungary

EWMA and the EWMA Patient Outcome Group introduce the EWMA Industry Courses 2011. The two courses are held over two days. One course focuses on Evidence and Outcome and the other focuses on Health Economics. The courses are primarily targeted at industry representatives, but will also be of relevance to clinicians and others interested in research and wound care economics.

13-14 October 2011 Generating Evidence in wound care

13-14 October 2011 Health Economics

The course aims to give an introduction to clinical trials in addition to the use of alternative end points and outcomes in wound care. The course will provide the participants with an understanding of what the essential considerations and limitations are when conducting research in wound care. Furthermore, the participants will be provided with the necessary information on how to conduct evidence based research in wound care, taking the right measures into consideration.

This course aims to give an introduction to health economics and evaluation as applied to wound care. The course will provide the participants with an understanding of how to evaluate the economic benefits and challenges in prevention, diagnosis and treatment. The participants will aquire basic knowledge about economic analysis and training in the tools of how to conduct economic evaluation. The entry point is wound care, but the principles are general.

For more information and registration please visit www.ewma.org/industrycourse

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acilitated by the internationally recognised health economist John Posnett, the course took place on 7-8 April 2011 in Copenhagen, Denmark. The course was considered a pilot for future similar courses with the next EWMA Health Economics Course scheduled to take place in Budapest on 13-14 October 2011. The main objective of the course is to provide training in health economics principles and health economics analysis applied in wound care. Participants are, among other things, introduced to methods of how to elaborate and present arguments on modern wound care products and the organization of the treatment.

Learning objectives: n To understand why an economic approach to wound care is essential for both clinicians and for the industry in the face of demographic and technological trends; n To understand how to demonstrate the value of good treatment to senior managers and other decision-makers, through audit and other forms of observational research; n To learn how to undertake or to interpret the results of economic evaluations of healthcare interventions. Feedback and evaluation by course participants The course attracted a mixed group of 30 participants including international clinicians (physicians and nurses), industry representatives and EWMA Council members. The following feedback is based on the responses to an online evaluation questionnaire after the course. n 100% of the respondents expressed that the course had met their expectations n 100% of the respondents would recommend the course to others. n The social & networking aspects of participation in the course were considered relevant by all participants.

Background for the course and content The EWMA Health Economics Course is a new activity under the auspices of the EWMA Patient Outcome Group (POG). Meeting the objectives of EWMA POG, focus on the need for knowledge about health economics is increasing due to the changing demographics and the continuing rise in the cost of health care provision across Europe. Health Economics is based on the concept of scarcity, which suggests that there will never be sufficient resources to meet the ever growing need for health care by society. Thus, the underlying premise is that the delivery of health care should be founded on equity and efficiency; in other words, making the best use of the resources available (Phillips 2005).

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Finn Gottrup MD, DMSci Professor of Surgery, Former Chair of the EWMA Patient Outcome Group

EWMA wants to contribute to maintain focus on the severe costs of wounds, thereby strengthening the importance of wound care investments in order to improve conditions for patients. Further information about the next EWMA Health Economy Course is available at: www.ewma.org/industrycourse m References Phillips CJ (2005); Introduction; In Health Economics an Introduction for Health Professionals (Phillips CJ ed.). British Medical Journal, Oxford, pp. 1-17.

Participants at the 1st EWMA Health Economics Course in Copenhagen, April 2011.

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2011 vol 11 no 2

Advanced Wound Care Sector (AWCS) Status Report

Hans Lundgren Chair of the Eucomed Advanced Wound Care Sector Group

Introduction The Eucomed AWCS group (www.eucomed.org) was founded back in June 2007, and since then we have had sixteen regular meetings. At present there are eight companies in the group: B. Braun, Covidien, ConvaTec, KCI, Mölnlycke Health Care, Paul Hartmann, Smith & Nephew and 3M. In addition, we also work in active partnership with EWMA and Policy Action. The purpose of this paper is to give an update of our activities during the latest nine months, from July 2010 to March 2011. Status report Questionnaire about Patient Safety sent out by the European Commission to the Member States With short notice, the AWCS group together with EWMA was offered an opportunity to contribute to a questionnaire that was being finalized by the European Commission. This questionnaire, about Patient Safety, was sent by the Commission to the Member States by the end of March 2011. The purpose of the exercise was to support the European Commission in its review of the Council Recommendation on Patient Safety (approved June 2009). Our recommendation ended up in

Patient Safety in the EU By Zena Moore I am happy to announce that EWMA and the Eucomed based Advanced Wound Care Sector Group (AWCS) got a unique opportunity to be heard prior the European Commission Questionnaire to be send to all Member States on P atient safety. EWMA recommended together with AWCS to the European Commission that the following questions be in corporated into the planned questionnaire sent to member states.

EC Patient Safety Questionnaire to Member States The European Wound Management Association (EWMA) and the Eucomed based Advanced Wound Care Sector Group (AWCS) recommends to the European Commission that the following questions be incorporated into the planned questionnaire sent to member states on Patient safety. 1. Does the member state have in place guidelines for diagnosis and effective treatment of chronic/non-healing wounds? Yes/no: ___ If yes, which programmes/policies/performance parameters/quality measures are in place (homecare or hospital targeted)? ___

nine distinct questions. Please see below for a list of the questions posed. While it is not certain that any questions submitted to the EC will in fact be used in the questionnaire for the Member States, the engagement alerts the Commission to AWCS/EWMA’s interest in this dossier and provides an avenue for future discussions with the Commission – particularly regarding the use of adequate wound care treatment to increase the patient safety.

Eucomed AWCS (Advanced Wound Care Sector) The 16th Eucomed AWCS meeting took place on 17-18 January 2011 at the B.Braun offices in Paris, commensurate with the CPC. This was a 1½ day session with a goal & strategy meeting followed by a normal meeting. The budget for the year 2011 will be €30,000 which means €5,000 per company. The priorities of the group during 2011 will be: n The European Commission AHAIP (Active and Healthy Ageing Innovation Partnership), knowing that diabetes is a chronic disease with a hidden potential for DFUs and thus a public health issue.

2. Do national targets exist for the prevention of wounds? Yes/no: ___ • Pressure ulcers (tic x): __ • Leg ulcers: __ • Diabetic foot ulcers: __ • Healthcare associated infections in wounds: __ If yes, which programmes/policies/performance parameters/ quality measures are in place? (please elaborate below): homecare or hospital targeted? ___ 3. Do national targets exist for education and training specific to wound care and prevention with regards to adverse events, hereunder health care workers specialisation in wound prevention and treatment? Yes/no: ___ • Pressure ulcers (tic x): __ • Leg ulcers: __ • Diabetic foot ulcers: __ • Healthcare associated infections in wounds: __ If yes, which programmes/policies/performance parameters/ quality measures are in place? (please elaborate below): homecare or hospital targeted? ___

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“Patient Safety”, continue to be involved with this campaign through the risk of wound infections. n “Continue the dialogue with national associations: SDMA and ABHI (UK), BvMed (Germany), Appamed (France), Assobiomedica (Italy) and Fenin (Spain). n Work in active partnership with Policy Action and EWMA including the POG (Patient Outcomes Group).

Wound Care contribution to the European Commission campaign on ‘Active and Healthy Ageing’ Based on the EU2020 strategy for a smart, sustainable and inclusive Europe, the European Commission (EC) in October 2010 launched the Innovation Union Strategy. A key pillar of that strategy is the pilot Innovation Partnership on Active and Healthy Ageing. Eucomed answered to the EU public consultation by providing four proposals to the ‘Active and Healthy Ageing Partnership’ which revolve around: 1. Developing procurement systems that focus on procuring innovation. The UK and Sweden have developed new approaches around this objective. 2. Facilitating research on the parameters that influence national and local procurement decisions. 3. Reducing risks and hospitalisation of people with cardiac problems. Raising awareness of the benefits of remote monitoring of cardiac devices and develop appropriate funding schemes. 4. Avoiding hospitalisation of people through effective community care in the areas of stoma, wounds and incontinence, conditions that have high prevalence in people with any chronic conditions.

to contribute to a smart, sustainable and inclusive economy, ranging from limited end-user involvement, through patchy adoption of novel technology, to a lack of harmonisation in funding and reimbursement practices across the member states. Eucomed is of the opinion that, in partnership with other stakeholders, these innovation barriers can be overcome, thus contributing to the three goals the EC has set out for itself with this pilot partnership: 1. Enabling EU citizens to lead healthy, active and independent lives while ageing; 2. Improving the sustainability and efficiency of social and health care systems; 3. Boosting and improving the competitiveness of the markets for innovative products and services, responding to the ageing challenge at both EU and global level, thus creating new opportunities for businesses.

Today, the medical technology industry is faced with a number of innovation hurdles which limit its potential

Eucomed MedTech Forum On 12-14 October 2010, the annual Eucomed MedTech Forum, organized under the patronage of Mr John Dalli, EU Health Commissionaire, took place in Brussels. The theme this year was “Europe 2020: Driving the innovation agenda” and the highlight of the event was a CEO Summit. The forum attracted over 350 leaders from policy and scientific communities, along with the medical technology industry. The mission of Eucomed (www.eucomed. be) is to improve patient and clinician access to modern, innovative and reliable medical technology. The CEO Summit welcomed representatives from both global and European industry leaders. In the first panel we saw: n Alex Gorski, Worldwide Chairman, Medical Devices and Diagnostics Group, Johnson & Johnson n Pierre Guyot, CEO Mölnlycke Health Care n Srini Seshadri, President, Smiths Medical 

4. Do national targets exist for the multidisciplinary approach to treatment and prevention of wounds? Yes/no: ___ • Pressure ulcers (tic x): __ • Leg ulcers: __ • Diabetic foot ulcers: __ • Healthcare associated infections in wounds: __ If yes, which programmes/policies/performance parameters/quality measures are in place? (please elaborate below): homecare or hospital targeted? ___

6. Does national standardisation exist for wound care, hereunder national quality measures? Yes/no: ___ • Pressure ulcers (tic x): __ • Leg ulcers: __ • Diabetic foot ulcers: __ • Healthcare associated infections in wounds: __ If yes, which programmes/policies/performance parameters/quality measures are in place? (please elaborate below): h omecare or hospital targeted? ___

5. Does national targets/procedures/regulation exist for avoiding delay for patient treatment, hereunder organisation of treatments (e.g. clinical pathways)? Yes/no: ___ • Pressure ulcers (tic x): __ • Leg ulcers: __ • Diabetic foot ulcers: __ • Healthcare associated infections in wounds: __ If yes, which programmes/policies/performance parameters/quality measures are in place? (please elaborate below): homecare or hospital targeted? ___

7a. If data collection on wounds are in place which is collected and how is it reported? • Incidence: __ • Prevalence: __ • Costs: __ If yes, how is it reported? Which measures for exhaustive c ollection has been taken and how is it reported (e.g. clinical and/or research based collection, national/local)? 

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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.

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9. Does national targets/procedures/regulation exist for patient rights to choose between treatment regimes, hereunder reimbursement of services (e.g. prevention tools)? Yes/no: ___ • Pressure ulcers (tic x): __ • Leg ulcers: __ • Diabetic foot ulcers: __ • Healthcare associated infections in wounds: __ If yes, which programmes/policies/performance parameters/quality measures are in place? (please elaborate below): homecare or hospital targeted? ___

This 4 day theoretical course & practical training gives participants a thorough introduction to all aspects of diagnosis, management and treatment of the diabetic foot.

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8. Do national targets exist for research support on chronic/ non-healing wounds? Yes/no: ___ • Pressure ulcers (tic x): __ • Leg ulcers: __ • Diabetic foot ulcers: __ • Healthcare associated infections in wounds: __ If yes, which programmes/policies/performance parameters/quality measures are in place? (please elaborate below): homecare or hospital targeted? ___

Theory & Practice 4 Day Course, 3 - 6 October 2011 Pisa, Italy

Everyone agreed that innovations are necessary for society to grow and develop, but still public payers (government, county councils and municipalities) are reluctant to buy new innovative products. The reason for that is the care providers’ conservative idea of seeing their main goal as the care of patients and not as bringing in innovations in the healthcare process. Therefore we must apply a holistic view of health and social care. In the end it is all about customer benefits, in terms of utility for the patients, caregivers and relatives, but also in services and efficiency in the process and organization around the patient. m

Management of the Diabetic Foot

IHE Forum (Swedish Institute of Health Economics) This year’s annual conference took place in Lund on 2-3 September 2010, with the theme “How can we promote innovations in healthcare? ”. There were many interesting speeches from different angles including “Innovation – what is that and how does it influence economic growth?”, “Purchase of innovations”, and “Value Based Pricing – To set the price on value or cost?”

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The speakers gave a description of what they think the world will look like in five years and what it means for the industry and for its customers in terms of change. In his speech, Pierre Guyot started with an introduction of Mölnlycke Health Care, then continued with describing today’s challenges for the medtech industry in general, and finally asked how Europe can help to create a more innovative industry climate. The focal point of his presentation was on the coming shift from hospital care to community & homecare, and how government policy could help or hinder this change. The complete presentations from the MedTech Forum can be found here, (www.eucomed.be/Home/portal/mtf2010_presentations/mtf_presentations.aspx)

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EWMA Wound Surveys Resource consumption for wound care

Finn Gottrup MD, DMSci Professor of Surgery, Former Chair of the EWMA Patient Outcome Group

Background Research within wound care is fragmented and it is difficult to find validated data on the prevalence and costs of wounds. The EWMA Patient Outcome Group has for some time been working for creating better evidence in wound care and spreading the understanding of the complex approach to wound care research. The purpose of the EWMA Wound Survey is to uncover the true resource costs of wounds to hospital and community care health care providers in different countries in Europe. Uncovering the prevalence of wounds, the hours and time consumption of health care professionals, and the costs of treatment materials and wound-related hospitalisation in specific health care providers’ organisations, serves to raise awareness of the true significance of good wound care. Specifically the surveys will focus on: 1) The prevalence of all types of wounds, in both hospitals and in municipalities/community service. 2) The costs of wound treatment in hospitals and in municipalities/community care. 3) Convey publications and discussion papers/ arguments that can serve as a political tool to increase awareness among politicians of the actual prevalence of wounds and to reveal the actual resources being used to treat the wounds.

Methods The studies are part of a EWMA project, which will cover several European countries. The first study using this methodology was done in Hull in the UK, published in the International Wound Journal, 20081 and this methodology has been adapted for the EWMA studies. The study is intended to be made as a “point prevalence” study. For practical reasons, data will

be was collected over 2 days in hospitals and over 1 week in communities. Data are collected by going through all patient files in all hospital wards and in all community nursing centres as well as in all nursing homes. The researchers all take an active role in gathering the data and in obtaining approval for the study with the hospital management and with the community nursing service. The data are collected for each patient are categorised and represent some of the following: n Number of wounds n Condition of the wound n Type of wound n Place of origin The nursing staff collecting the data will access the wounds and record the time consumption for each patient per dressing change, for travelling time and for documentation. Combining the time consumption with the average cost of a nursing hour, and extrapolating the data to the entire country, the total cost for the nursing time consumption for wound treatment can be calculated. Similarly, the total cost for dressings and wound-related hospitalisation can be calculated, and adding these two costs together a total cost of wound care can be measured. The data collected in a database from where the statistical analysis is taken from and thus calculated the costs of the wound treatment.

Results The results of the survey are presented in tables with written analysis and the following is essential to prospects of the idea behind the survey.

1 ”Drew P, Posnett J, Rusling L. The Costs of wound Care for a local population in England. International Wound Journal 2007; 4(2): 149-155

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Conclusion The purpose of the surveys is to present the costs in the individual country of wound care. The results of the survey will convey the ability to hospital and municipalities/ community care givers to view their actual cost. This will facilitate a dialogue with policy makers and other administrators and result in saved money and improvement of the quality of life for the patients.

The prevalence of the wound collected in both hospital and municipalities/community care is presented, hereunder the following parameters are covered: n No. of Citizens covered (population) n Percentage of inhabitants n No. of Patients with wound(s) n Prevalence per 1000 population n Percentage of hospital patients with wounds n Calculated total no. of patients with wound(s)

Currently the surveys of this kind have been conducted in England and Denmark and the results are presently being processed in Denmark. Further surveys are planned in Germany, Italy and Portugal and later in France and Spain. m

The different types of wounds are presented: n Acute/surgical wound n Pressure Ulcers n Leg Ulcers n Diabetic Foot Ulcers n Other n Total no

The Danish Wound Survey Nina Bækmark, MSc Finn Gottrup, Professor, MD, DMSci. Eskild W. Henneberg, MD John Posnett, BA (Hons), DPhil (Econ). Heron Health Jan Sørensen, MD Rikke Trangbæk, MSc

Furthermore, the types of wounds are correlated with the resource consumption of the treatment of the wound. The results presented are: n Nursing time (minutes) per dressing change n Travelling time Documentation time (minutes) n Total, cost of nursing time n Total cost of dressings n Total cost nursing time and dressings n Total cost of wound-related hospitalisation

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volume 19. number 11. november 2010

Using electrical stimulation to treat scars Effect of elasticity on sub-bandage pressure in two bandaging systems: a RCT Why do wound dressings have a potential analgesic effect? Predicting which organisms might cause infection in a resource-poor setting Potential effects of honey on angiogenesis: an animal study

Pilonidal sinus disease: a review

A bizarre presentation of necrotising fasciitis in the cervicofacial region Severe hidradenitis suppurativa: a case report Psychological profile of patients with neglected malignant wounds Marjolin’s ulcer in the natal cleft mimics anal canal carcinoma Reconstruction of a chronic late post-nephrectomy wound

JWC_19_10_frontcover.indd 1

07/10/2010 16:18

Clinical and cost effectiveness evaluation of low friction and shear garments International organisations update Venous reflux in delayed leg ulcer healing A review of pilonidal sinus disease: part one Clinical report: a new negative pressure wound therapy system

NPWT: a systematic review

COVER.indd 1

03/12/2010 12:25

Can thermography predict delayed healing in pressure ulcers?

EWMA

National collaboration for the Leg Ulcer & Compression Seminars 2011

T Hugo Partsch ICC President

Finn Gottrup Former chair of the EWMA Patient Outcome Group

ogether with the wound management associations in the Slovak Republic, Austria and Hungary, the International Compression Club (ICC) and EWMA arrange a sequence of 3 Leg Ulcer & Compression seminars in Bratislava, Vienna and Budapest on the 10th, 11th and 13th of October 2011. The national wound management associations involved are the Austrian Wound Association (AWA), the Slovak Wound Care Association (SSOOR), the Hungarian Association for the Improvement in Care of Chronic Wounds and Incontinence (SEBINKO) and the Hungarian Wound Care Society (MSKT). The program draws on the existing ICC consensus documents on compression therapy as well as results and experiences gained through the implementation of the EWMA Central & Eastern European Leg Ulcer Project (LUP) carried out by the wound associations and project teams in Slovenia, Poland and the Czech Republic. The overall objective of the Leg Ulcer & Compression seminars is to discuss and plan for the establishment of national consensus on prevention and treatment of leg ulceration using compression therapy. In each country the seminar program is

based on the current national situation with regards to the treatment of leg ulceration. Further information and preliminary programme for the Leg Ulcer & Compression seminars is available at www.ewma.org/icc-ewmaseminar/ The role of the national wound associations In order to achieve the objectives of the Leg Ulcer & Compression seminars a close collaboration between the local wound associations, the ICC and EWMA is essential. Apart from chairing the Leg Ulcer & Compression seminars together, the national associations play a key role in facilitating the involvement of national stakeholders in the seminars and the follow-up activities which may prove to be the most important result of the seminars. In Hungary, the annual meetings of MSKT and SEBINKO will take place in connection with the Leg Ulcer & Compression seminars. The two Hungarian associations will hold their meetings with a joint exhibition on 12 October at the same venue where the seminars will take place on 13 October. For more information about the national wound associations please see below. m

AWA

MSKT

SEBINKO

SSOOR

Austrian Wound Association

Hungarian Wound Care Society

Slovak Wound Care Association

www.a-w-a.at

www.euuzlet.hu/mskt/ President: Dr. Hunyadi János

Hungarian Association for the Improvement in Care of Chronic Wounds and Incontinence

No. of members: 240 President: Franz Trautinger Activities: – Annual Congress – Foster education and research in wound care

Activities: – Annual congress every year in October – Publishes the journal S ebkezelés Sebgyógyulás – Aims at spreading of practical and scientific knowledge regarding wound healing between MD’s and health care workers.

www.sebinko.hu No. of members: 198 President: Fokiné Karap Zsuzsanna Activities: – Annual congress every year in October – Publishes the SEBINKO Journal twice a year

www.ssoor.sk No. of members: 31 President: Jozefa Košková Activities: – Cooperation with teaching institutions and wound care specialists – Review the wound situation in Slovakia EWMA Journal

2011 vol 11 no 2

BRATISLAVA 10 OCTOBER VIENNA 11 OCTOBER BUDAPEST 13 OCTOBER For information about the programme, registration etc. please visit the website www.ewma.org/icc-ewma-seminar The seminars will be held in local languages and English with simultaneous translation.

LEG ULCER & COMPRESSION SEMINARS 2011 SEMINARS 2011 COMPRESSION LEG ULCER &

Organised by: EWMA & International Compression Club (ICC)

Corporate Sponsor Contact Data Corporate A

Abbott Nutrition 200 Abbott Park Road Abbott Park Illinois 60064 USA Tel: +1 (614) 624-7485 Fax: +1 (614) 624-7899 www.abbottnutrition.com

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

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

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

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

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

Mölnlycke Health Care Ab Box 13080 402 52 Göteborg, Sweden Tel: +46 31 722 30 00 Fax: +46 31 722 34 01 www.molnlycke.com

Ferris Mfg. Corp. 16W300 83rd Street Burr Ridge, Illinois 60527-5848 U.S.A. Tel: +1 (630) 887-9797 Toll-Free: +1 (630) 800 765-9636 Fax: +1 (630) 887-1008 www.PolyMem.eu

Wound Management Smith & Nephew Medical Ltd 101 Hessle Road Hull, HU3 2BN United Kingdom Tel: +44 (0) 1482 225181 Fax: +44 (0) 1482 328326 www.smith-nephew.com/wound

Sorbion AG Im Suedfeld 11 48308 Senden Germany Tel.: +49 (0) 2536 34 400 400 Fax: +49 (0) 2536 34 400 410 www.sorbion.com

Systagenix Wound Management Gargrave North Yorkshire BD23 3RX United Kingdom Tel: +44 1756 747200 Fax: +44 1756 747590 www.systagenix.com

Use the EWMA Journal to profile your company Deadline for advertising in the October 2011 issue is 1 September 2011

EWMA Journal

2011 vol 11 no 2

EWMA

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

Advanced BioHealing, Inc. 10933 N. Torrey Pines Road, Suite 200 La Jolla, CA 92037 Tel: 858.754.3705 Fax: 858.754.3710 www.AdvancedBioHealing.com

AOTI Ltd. Qualtech House Parkmore Business Park West Galway, Ireland Tel: +353 91 660 310 Fax: +353 1 684 9936 www.aotinc.net

ArjoHuntleigh 310-312 Dallow Road Luton LU1 1TD United Kingdom Tel: +44 1582 413104 Fax: +44 1582 745778 www.ArjoHuntleigh.com

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

BSN medical GmbH Quickbornstrasse 24 20253 Hamburg Tel: +49 40/4909-909 Fax: +49 40/4909-6666 www.bsnmedical.com www.cutimed.com

Curea Medical GmbH Münsterstraße 61-65 48565 Steinfurt Germany Tel: +49 36071 9009500 Fax: +49 36071 9009599 www.curea-medical.de

Flen pharma NV Blauwesteenstraat 87 2550 Kontich Belgium Tel.: +32 3 825 70 63 Fax: +32 3 226 46 58 www.flenpharma.com

HILL-ROM 83, Boulevard du Montparnasse 75006 Paris France Tel: +33 (0) 1 53 63 53 73 Fax: +33 (0) 1 53 63 53 70 www.hill-rom.com EWMA Journal

2011 vol 11 no 2

Life Wave 9 Hashiloach St. P.O.B. 7242 Petach Tikvah 49514 Israel Tel: +972-3-6095630 Fax: +972-3-6095640 www.life-wave.com

Nutricia Advanced Medical Nutrition Schiphol Boulevard 105 1118 BG Schiphol Airport The Netherlands www.nutricia.com

Organogenesis Switzerland GmbH Baarerstrasse 2 CH-6304 Zug Switzerland Tel: +41 41 727 67 89 www.organogenesis.com

Phytoceuticals Zollikerstrasse 44 8008 Zurich Switzerland Tel: +41 58 800 58 58 www.1wound.info

Argentum Medical LLC Silver Antimicrobial Dressings 2571 Kaneville Court Geneva, Illinois 60134 U.S.A. Tel: +1 630-232-2507 Fax: +1 630-232-8005 www.silverlon.com

TEVA 5 Basel St. Petach Tikva 49131 Israel Tel: +972 8 932 4000 Fax: +972 8 932 4001 www.polyheal.co.il

Laboratoires Urgo 42 rue de Longvic B.P. 157 21304 Chenôve France Tel: +33 3 80 54 50 00 Fax: +33 3 80 44 74 52 www.urgo.com

Welcare Industries SPA Via dei Falegnami, 7 05010 Orvieto ( TR ) Italia Tel: +39 0763-316353 Fax +39 0763-315210 www.welcaremedical.com

Organisations

Conference Calendar 2011 Days City

Country

Annual Meeting of the Chronic Wounds Initiative (ICW)

Conferences

May 11-12 Bremen

Germany

Annual Meeting of the Italian Nurses’ Cutaneous Wounds Association (AISLeC)

May 12-14 Bologna

Italy

May 25-27 Brussels

Belgium

Jun

Denmark

21st Conference of the European Wound Management Association

Theme

Common Voice – Common Rights

12th EFORT Congress

1-4

Copenhagen

International Lymphoedema Framework Conference

Towards Global implementation of Best Practice – Opportunities and Challenges

Jun

16-18 Toronto

Canada

Annual Meeting of German Society of Wound Healing and Wound Treatment (DGfW)

Guidelines and quality standards of Fascinating Biotechnology

Jun

23-25 Hannover

Germany

14th Annual European Pressure Ulcer Meeting (EPUAP) Pressure Ulcer Research Achievements Translated Aug to Clinial Guidelines Sep

31-2 Oporto

Portugal

30th Annual meeting of the European Bone and Joint Infection Society

Sep

15-17 Copenhagen

Denmark

Sep

21-24 Ancona

Italy

Biofilm and Health Economics in Bone and Joint Infections

Annual meeting of Italian Association for the Study of Cutaneous Ulcers (AIUC) Pisa International Diabetic Foot Courses

Oct

3-6

Pisa

Italy

Bi-Annual Conference of the Wound Management Association of Ireland

Oct

4-5

Galway

Ireland

21st Annual European Tissue Repair Society

Oct

5-7

Amsterdam

Netherlands

EWMA Leg Ulcer and Compression Seminars

Oct

Bratislava

Slovakia

EWMA Leg Ulcer and Compression Seminars

Oct

Vienna

Austria

EWMA Leg Ulcer and Compression Seminars

Oct

Budapest

Hungary

4th Latin American Conference on Ulcers

Oct

11-14 Rio de Janeiro Brazil

EWMA Master Course 2011

Is Oedema a Challenge in Wound Healing?

Oct

13-14 Budapest

Hungary

EWMA Industry Course 2011

Health Economics and Generating Evidence in wound healing – clinical trials, alternative end points and outcome

Oct

13-14 Budapest

Hungary

The Annual Fall Symposium on Advanced Wound care (SAWC/WHS)

Oct

13-15 Las Vegas

USA

First International Pediatric Wound Care Symposium

Oct

27-29 Rome

Italy

Biannual meeting of the Woundcare Consultant Society

Nov 22-23 Utrecht

Netherlands

Annual Meeting of the Danish Wound Healing Society

Nov 24-25 Kolding

Denmark

2012 16th National Conference of wound healing of CPC

Jan

10th National Australian Wound Management Association Conference

Mar 18-22 Sydney

Australia

World Council of Enterostomal Therapists Conference

Apr

Australia

22nd Conference of the European Wound Management Association

May 23-25 Vienna

Austria

Sep

7-12 Yokohama

Japan

Sep

28-30 Potsdam

Germany

4th Congress of the World Union of Wound Healing Societies 10th Scientific Meeting of Diabetic Foot Study Group (DFSG)

Better care – Better Life

15-17 Paris

France

19-23 Adelaide

For web addresses please visit www.ewma.org

EWMA Journal

2011 vol 11 no 2

FUNDRAISING CAMPAIGN DURING THE EWMA BRUSSELS CONFERENCE

EWMA2011 25-27 May Brussels · Belgium

Support the WAWLC Podoconiosis Eradication Project in Ethiopia AIMS OF THE WAWLC INITIATIVE: n Training

for 200 health care providers from 50 different hospitals, clinics and organisations n Training to Health Extension Workers and local non-medical community agents, especially women n Provision of kit (education material and supplies) for each participant to teach & treat patients n Meeting with Ethiopian Ministry of Health in August 2011 Donations are welcomed at the EWMA Conference or at http://wawlc.org/donation.html

About Podoconiosis: n An

endemic non-filarial elephantiasis,

commonly known as “Mossy Foot”. n Affects n Listed

> 1 million people in rural villages of Ethiopia.

by WHO as neglected tropical disease in 2010.

EWMA has since 2009 been part of the WAWLC initiative.

22nd Conference of the European Wound Management Association 22. Kongress der European Wound Management Association

EWMA 2012 23 -25 May / Mai · 2012 WOUND HEALING – DIFFERENT PERSPECTIVES, ONE GOAL WUNDHEILUNG – UNTERSCHIEDLICHE PERSPEKTIVEN, EIN ZIEL

gual: Bilin German sh & g: Engli rachi tsch p s i e Zw & Deu sch n E gli

ienna · Austria · Österreich Organised by the European Wound Management Association in cooperation with Die Österreichische Gesellschaft für Wundbehandlung AWA (Austrian Wound Association) Organisiert von: der Europäischen Wound Management Organisation in Zusammenarbeit mit der Österreichische Gesellschaft für Wundbehandlung, AWA

WWW.EWMA.ORG / EWMA2012

Organisations

Conference Report ETRS

EWMA Session, 20th Annual European Tissue Repair Society Congress

ETRS

European Tissue Repair Society

Gent, 15-17 September 2010 Building on the long standing tradition and the relationship between EWMA and the European Tissue Repair Society, the interaction between both societies has become even more intense during the last two years. To continue their established relationship and develop an even closer collaboration, a combined session was scheduled during the 20th European Tissue Repair Society Congress in Gent Belgium, 15-17 September 2010.

Prof.dr. Gerrolt N. Jukema

The local host of the meeting was the University of Gent. The congress venue was an historical building of the University (‘het Pand’) in the historical part of the old city. The congress was attended by numerous delegates from all over Europe and the United States of America.

Member of the EWMA council, board member of the ETRS

The topic of the combined EWMA / ETRS session was ‘Management of Acute Wounds.’ This session was chaired by Finn Gottrup and Gerrolt Jukema (a member of the EWMA council and a board member of the ETRS). Martin Koschnik highlighted in his presentation the clinical relevance of antiseptic treatment of contaminated and infected wounds with polyhexanid (PHMB) solution.

Gerrolt Jukema presented experimental clinical data on infected trauma and orthopedic wounds. In addition, new modalities for treatment of acute and infected wounds were presented, including topical negative wound therapy and the installation technique with polyhexanid solution. Maggot therapy for treatment of infected wounds, including data from his experimental research, was also presented. Finn Gottrup, as the current chair of the EWMA Patient Outcome Group, shared his thoughts with the audience about problems with evidence and outcomes in wound healing studies. This session was very well attended by congress participants and featured an interactive discussion with the presenters, reflecting the close relationship between the lab and the clinician. Experimental research, based on clinical problems studied in relation with patients’ carerelated infections, can be a map guiding us to improved and quality-related patient care. A new combined, clinical-orientated session of both societies is scheduled at the 21st Annual European Tissue Repair Society Congress in Amsterdam, The Netherlands, on October 5th-7th 2011. It is sure to be both interesting and informative, and further develop the close relations between these two wound societies. m

16 Billions Approx. Health Care Budget for the year 2011 An invitation to expand and invest in the biggest market among Gulf Region Comate Ltd., is fully equipped with all necessary infrastructure to launch your product in Saudi Arabia. Comate Ltd., is successfully representing many world renowned manufacturers. Comate Ltd., is one of the leading companies in the field of Medical Equipments, Wound Care Management & Dental materials in Kingdom of Saudi Arabia dealing with more than 100 potential customers in Governmental & Private Sectors since 1989. Head Office : Riyadh P.O Box 88552 Zip Code 11672 Kingdom of Saudi Arabia

eyjarrar@comate.com info@comate.com

Organisations

The 14th national wound healing congress in Helsinki, Finland FWCS Finnish Wound Care Society

Anna Hjerppe MD, Clinical teacher, President Department of Dermatology, Tampere University Hospital, Finland www.suomenhaavan hoitoyhdistys.fi

In February this year, The Finnish Wound Care Society organized its fourteenth, national, two day congress on wound healing. The theme was:

Challenging and uncommon wounds The theme was selected according to suggestions from the field. Although these wounds are rare and more seldom diagnosed than wounds such as venous leg ulcers, they pose real challenges both for the patient and for the health care system. The theme was split into four main sessions. The first session focused on malignant fungating wounds. We had a leading Finnish dermato pathologist to give an introductory lecture on the different manifestations of skin cancers and cancer metastasis to the skin. This was followed by the different treatments and finally there was a nurse-led lecture on the special wound care of these extremely hard-to-heal or non-healing wounds. Caring for a patient with a malignant fungating wound is a challenge for any nurse or doctor regardless of their years of experience in wound care. The wounds cause huge distress for the patient including pain, malodour, haemorrhage, excessive exudate and infection, altered body image and social isolation. Neglect may also play its role with patients with advanced malignant wounds. The patient and his family may fail to seek medical help even if the wound is clearly visible. The stories about the patients with malignant fungating wounds were listened to attentively by our audience. The informative lecture improved both their knowledge and clinical understanding of patients with malignant fungating wounds. The second session focused on acute traumatic wounds, especially on wounds in fragile elderly skin or traumatic amputations. This lecture was very appropriate as, at the same time as our conference, the Fair Centre was also hosting a big motorcycle event and many of those traumatic amputations discussed seemed to have happened to motorcyclists!

The third session about pressure ulcers (PU) was held the next morning. This theme was chosen to cover the new EPUAP and NPUAP Guidelines. The session included the presentation of the new Guidelines which the Finnish Wound Care Society has had translated into Finnish to enable healthcare professionals in Finland to fully understand them; no more excuses for not preventing PUs! Our fourth session concentrated on various types of skin vasculitis, from the diagnosis to the treatment and to local wound care. Along with the main sessions, we had organised practical workshops. The workshops focussed on five common wound care themes: debridement, ABI- measuring, compression therapy, how to choose a right wound care product and how to dress a difficult wound. There were 96 participants at these workshops (fully booked). And the participants had a chance to learn “hands on” about the themes. Each workshop included about 20 minutes introduction and 20 minutes of practical experience. Organizing workshops requires strenuous efforts from our organizing committee and is not financially profitable, but we included them as they offer a very beneficial way of learning. The venue was in the Helsinki Fair Centre, in the congress area. We have chosen this same venue for four years now, because it is very easy to get there from all over Finland. Also the personnel of the Fair Centre are very professional and have become almost “friends” to us which made the hard work of organizing such an event easier for us all. On the first night of the congress we always have a ‘get together’ evening party which also takes place in the Fair Centre. The event is free of charge and has a free buffet for participants. This year’s theme was “TexMex” and featured not only a buffet of food chosen to go with the theme, but also some Tequila girls who danced and served tequila for those who wanted to enjoy tequila slammers; some participants had quite a headache the next morning!

EWMA Journal

2011 vol 11 no 2

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM) The objective of the evening party is to make social contacts with other delegates and to meet friends. The company members can also attend, so it is also a good marketing possibility for them. The party has always been very successful and popular with the participants; this year we had there almost 300 partygoers! Over all we had around 650 participants at this year’s congress. This was only about 100 fewer than the year before, so our fears about the theme were unnecessary. We had a marketing area of 280m2 for wound care companies and 37 companies attended. We are very strict about what kinds of companies are allowed to participate; only those companies that are genuinely involved in wound care are welcomed. This is because we want to preserve our status as professionals. We also reward our lecturers well for presenting the lectures; that way we can ensure very high standard specialist lectures and we can be sure the knowledge is always up to date and evidence based. In all, our congress was, once again, a very successful event: the lectures were brilliant and kept to schedule, the food was good, the exhibition looked very impressive and the feedback that we had was mainly positive. Next year is our 15th national congress. The planning and organizing has already started, the theme has been chosen and marketing has begun. The congress will be built around the theme of acute wounds, so that it can serve as many healthcare professionals as possible. This theme was last presented six years ago and the event was the biggest success we’ve ever had. That time there were over 1100 participants and we are hoping to have the same amount of participants next year or even more; that will be a really huge challenge for us! However, with a good program, top lecturers and the good reputation that we have gained over the years, the challenge will not be an impossible one! m

in Brussels Since 2007, EWMA has successfully offered students of wound management from institutes of higher education across Europe the opportunity to take part of academic studies whilst participating in the EWMA Conference. In 2011 it is expected that students from the institutes listed below will participate in the EWMA UCM in Brussels. The opportunity of participating in the EWMA UCM is available to all teaching institutions with wound management courses for health professionals.

EWMA2011 25-27 May Brussels · Belgium

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 EWMA Education Committee, EWMA President Participating institutions:

Haute École de Santé Geneva, Switzerland

HUB Brussels Belgium

KATHO university college Roeselare Belgium

Escola Superior de Enfermagem de Lisboa Portugal

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

2011 vol 11 no 2

Organisations

Wound Treatment Organisation established in Ukraine On November 25-26th, 2010, in Kiev, the capital of Ukraine, the conference “Wounds, Wound Infections and Wound Closure” was organised by the newly established Ukrainian Wound Treatment Organization (UWTO).

Rytis Rimdeika Member of EWMA Council, President of LWMA

This association is the first in the Ukraine that focuses on wound treatment. The instigators of UWTO have worked tremendously hard establishing local sections in 15 regions of the Ukraine. In the beginning the Ukrainian association was mainly based on the initiative of doctors from various specialties but there is a clear determination for the association to become open to healthcare professionals from multiple disciplines. UWTO has a very strong council of well-known Ukrainian physicians who have been elected to the main positions. The council is represented by Professor B. M. Datsenko as President, and Professors E.J. Fistal, G. P. Kozynets and T. Tamm as vice presidents. During the process of establishment, several consultations took place with EWMA Council and EWMA Secretariat. The close co-operation with EWMA is due to the fact that EWMA supports local initiatives of establishment of national wound management societies in countries across Eastern Europe. To date Ukrainian delegates have visited the annual EWMA conference in Geneva and have also participated in national meetings in Lithuania and Belarus. The exchange of experiences with neighbouring countries regarding the establishment of their own associations greatly helped the Ukrainian founders during the organising process

Chairing persons at the opening ceremony, from the left UWTO President Prof. B. M. Datsenko, chairman of the organizing committee Prof. G. P. Kozynets, and EWMA representative Prof. R. Rimdeika

for UWTO. More information about UWTO can be found on their web-site www.uwto.org.ua. The conference “Wounds, Wound Infections and Wound Closure” was organised in the Academy for Postgraduate Studies of Ukraine. The procedure of registration was finalised in the late autumn after a long arrangement process. The conference program included three thematic sessions: Wound Care and Debridement, Surgical Wound Reconstruction, and Modern Trends in Management of Wound and Wound Infections. EWMA was represented by the Council Member Rytis Rimdeika, who had the privilege of opening the conference with an introductory presentation on EWMA. The conference attracted more than 200 participants from various regions of the Ukraine, and neighbouring Belarus and Russia. Participants from numerous regions of the Ukraine presented papers and case reports from their clinical practices. In addition, round table discussions on diabetic foot issues were held by prominent lecturers from the Ukraine. The conference also featured separate poster sessions which were held in the exhibition area. During the conference there were exhibitions of wound dressings, wound care equipment, medical devices and pharmaceutical products. Representatives of well-known international medical companies as well as local manufacturers participated actively in the exhibition and also organised concurrent sessions and workshops. The conference was followed by a welcome party for all participants. m

The Exhibition

EWMA Journal

2011 vol 11 no 2

· EW

IA T I O N

E U R OP EA

E· RS

MASTER COU MA

· M A NA GE M E

·A

EWMA Master Course Advanced theoretical and practical sessions related to oedema and wound healing.

13-14 October 2011 · Budapest, Hungary

Is Oedema a Challenge in Wound Healing? Through a mixture of lectures, workshops and interactive sessions the course will bridge theory and practice, addressing a broad range of topics including: n n n n n n n n

Oedema as a problem in different types of wounds and what impact it has The pathophysiology of oedema Psycho-social impact of oedema Methods for diagnosing different types of oedema Prevention and management Development of evidence based outcome measurement of oedema in wound healing Infection Associated skin complications

Credits for Continuing Medical Education (CME) will be awarded by the European Union of Medical Specialists.

For more information about the programme, registration etc. please visit

www.ewma.org/woundcourse

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

AISLeC Italian Nurses’ Association for the Study of Cutaneous Wounds www.aislec.it

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

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

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

BEFEWO Belgian Federation of Woundcare www.befewo.org

BWA Bulgarian Wound Association www.woundbulgaria.org

GNEAUPP National Advisory Group for the Study of Pressure Ulcers and Chronic Wounds www.gneaupp.org

ICW Chronic Wounds Initiative www.ic-wunden.de

LBAA Latvian Wound Treating Organisation

LUF The Leg Ulcer Forum www.legulcerforum.org

LWMA Lithuanian Wound Management Association www.lzga.lt

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

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

CNC Clinical Nursing Consulting – Wondzorg www.wondzorg.be

MWMA

CSLR

Macedonian Wound Management Association

Czech Wound Management Society www.cslr.cz

NATVNS

CWA

National Association of Tissue Viability Nurses, Scotland

Croatian Wound Association www.huzr.hr

NIFS

DGfW

NOVW

German Wound Healing Society www.dgfw.de

DSFS

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

FWCS Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

GAIF

Norwegian Wound Healing Association www.nifs-saar.no

Dutch Organisation of Wound Care Nurses www.novw.org

PWMA Polish Wound Management Association www.ptlr.pl

ROWMA Romanian Wound M anagement Association www.artmp.ro

Associated Group of Research in Wounds www.gaif.net

EWMA Journal

2011 vol 11 no 2

Organisations

SAfW

SWHS

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

Serbian Wound Healing Society www.lecenjerana.com

SWHS

SAfW

Swedish Wound Healing Society www.sarlakning.se

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

TVS

SAWMA

Tissue Viability Society www.tvs.org.uk

Serbian Advanced Wound Management Association www.serbiawound.org

URuBiH

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

SFFPC

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

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

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

WMAK

SSiS

WMAOI

Wound Management Association of Kosova

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

Wound Management A ssociation of Ireland www.wmaoi.ie

SSOOR

WMAS

Slovak Wound Care Association www.ssoor.sk

Wound Management Association Slovenia www.dors.si

WMAT

SUMS

Wound Management A ssociation Turkey www.yaradernegi.net

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

WMS (Belarus) Wound Management Society

International Partner Organisations AWMA

Debra International www.debra-international.org

NZWCS

AAWC

ILF

SOBENFeE

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

International Lymphoedema Framework www.lympho.org

Brazilian Wound Management Association www.sobenfee.org.br

Australian Wound Management Association www.awma.com.au

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

Associated Organisations

EWMA Journal

Leg Club

LSN

Lindsay Leg Club Foundation www.legclub.org

The Lymphoedema Support Network www.lymphoedema.org/lsn

2011 vol 11 no 2

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

5 Editorial

Carol Dealey

Science, Practice and Education

7 The fight against biofilm infections: Do we have the knowledge and means? Klaus Kirketerp-Møller, Thomas Bjarnsholt, Trine Rolighed Thomsen

10 Biofilms in wounds: An unsolved problem? António Pedro Fonseca

25 Diabetic foot ulcer pain: The hidden burden Sarah E Bradbury, Patricia E Price

38 Topical negative pressure in the treatment of deep sternal infection following cardiac surgery: Five year results of first-line application protocol Martin Šimek

Scientific Communication

43 Wounds Research for Patient Benefit: A five year programme of research in wound care Karen Lamb, Nikki Stubbs, Jo Dumville, Nicky Cullum

EWMA

48 EWMA Journal Previous Issues and Other Journals 50 Introducing the Belgian Federation of Woundcare Brigitte Crispin, Luc Gryson

52 EWMA Patient Outcome Group Patricia Price

55 1st EWMA Health Economics Course organised by the EWMA Patient Outcome Group Finn Gottrup

56 Advanced Wound Care Sector (AWCS) Status Report Hans Lundgren

60 EWMA Wound Surveys – Resource consumption for wound care Finn Gottrup

62 National collaboration for the Leg Ulcer & Compression Seminars 2011 Hugo Partsch, Finn Gottrup

64 EWMA Corporate Sponsors Contact Data

Organisations

66 Conference Calendar 69 Conference Report: EWMA Session, 20th Annual European Tissue Repair Society Congress Gerrolt N. Jukema

70 FWCS: The 14th national wound healing congress in Helsinki, Finland Anna Hjerppe

72 Wound Treatment Organisation established in Ukraine Rytis Rimdeika

74 EWMA Cooperating Organisations 75 International Partner Organisations 75 Associated Organisations