EWMA Journal April 2017 (1) by EWMA European Wound Management Association

Volume 17 Number 1 2017 April 2016 Published Published by by European Wound Wound Management Management Association

THE CRITICAL IMPORTANCE OF HAND HYGIENE IN

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5 Editorial. Sebastian Probst, Editor of EWMA Journal

Science, Practice and Education 7 Debridement method optimisation for treatment of deep dermal burns of the forearm and hand Zacharevskij E, Baranauskas G, Varkalys K, Kubilius D, Rimdeika R 15 Lived experiences of life with a leg ulcer - a life in hell Lernevall LSD, Fogh K, Nielsen CB, Dam W, Dreyer PS 23 Illness, Normality, and Self-management: Diabetic Foot Ulcers and the Logic of Choice Andersen SL, Pedersen M, Steffen V 34 Essential microbiology for wound care. Pina E

Cochrane Reviews 37 Abstracts of Recent Cochrane Reviews. Rizello G

EWMA 46 EWMA Journal Previous Issues and Other Journals 49 EWMA 2017 Conference in Amsterdam, The Netherlands 57 World Hand Hygiene Day – joint EWMA & ICN campaign programme 57 New EWMA Document: Negative Pressure Wound Therapy – Overview, Challenges and perspectives Apelqvist J 61 New EWMA document: Use of oxygen therapies in wound healing: Focus on topical and hyperbaric oxygen treatment Gottrup F, Dissemond J 65 Wound curriculum for nurses – post-registration qualification wound management Holloway S, Pokorná A, Verheyen-Cronau I, Strohal R 70 New Corporate sponsors 74 EWMA News

Organisations 82 Recent Publications of the Korean Wound Management Society Han S 84 AAWC News Bohn G 87 Wounds Australia News Sandy-Hodgetts K 88 Experiences from Roundtable: The system of prevention, monitoring and treatment of pressure ulcers in the Czech Republic Pokorná A 90 Corporate Sponsors 92 Conference Calendar 94 Cooperating Organisations

KRAKOW, POLAND 9-11 MAY 2018

The EWMA Journal ISSN number: 1609-2759 Volume 17, No 1, November, 2017 The Journal of the European Wound Management Association Published twice a year

EWMA Council Severin Läuchli

Sue Bale

Salla Seppänen

President

President Elect

Immediate Past President

Luc Gryson

Alberto Piaggesi

José Verdú Soriano

Editorial Board Sebastian Probst, Switzerland, Editor Sue Bale, UK Vickie R. Driver, USA Georgina Gethin, Ireland Salla Seppänen, Finland Hubert Vuagnat, Switzerland

Treasurer

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

Secretary

Scientific Recorder

Selcuk Baktiroglu

Gregory Bohn

Barbara den Boogert-Ruimschotel

Mark Collier

Georgina Gethin

Magdalena Annersten Gershater

Kirsi Isoherranen

Edward Jude

Christian Münther

Julie Jordan O’Brien

Andrea Pokorná

Sebastian Probst

Layout: Nils Hartmann, Open design/advertising Printed by: Kailow Graphic, Denmark Copies printed: 9.500 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 2017. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than August 15th 2017. The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. All scientific articles are peer reviewed by EWMA Scientific Review Panel. Copyright of published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval. All issues of EWMA Journal are CINAHL listed.

Sara Rowan

Kylie SandyHodgetts

Robert Strohal

Jan Stryja

Hubert Vuagnat

COOPERATING ORGANISATIONS’ BOARD Esther Armans Moreno, AEEVH Christian Thyse, AFISCeP.be Valentina Vanzi, AISLeC Corrado Maria Durante, AIUC Ana-Maria Iuonut, AMP Romania Aníbal Justiniano, APTFeridas Gilbert Hämmerle, AWA Kirsty Mahoney, AWTVNF Jan Vandeputte, BEFEWO Vladislav Hristov, BWA Els Jonckheere, CNC Lenka Veverková, CSLR Mirela Bulic, CWA Arne Buss, DGfW Susan Bermark, DSFS Heli Kallio, FWCS Rosa Nascimento, GAIF J. Javier Soldevilla, GNEAUPP

Georgios Vasilopoulos, HSWH Björn Jäger, ICW Aleksandra Kuspelo, LBAA Susan Knight, LUF Loreta Pilipaityte, LWMA Corinne Ward, MASC Hunyadi János, MSKT Suzana Nikolovska, MWMA Linda Primmer, NATVNS Øystein Karlsen, NIFS Louk van Doorn, NOVW Arkadiusz Jawie´n, PWMA Sebastian Probst, SAfW (DE) Maria Iakova, SAfW (FR) Goran D. Lazovic, SAWMA Tânia Santos, ELCOS Ján Koller, SSPLR Mária Hok, SEBINKO

F. Xavier Santos Heredero, SEHER Sylvie Meaume, SFFPC Susanne Dufva, SSIS Jozefa Košková, SSOOR Leonid Rubanov, STW (Belarus) Guðbjörg Pálsdóttir, SUMS Saša Milievic, SWHS Serbia Magnus Löndahl, SWHS Sweden Tina Chambers, TVS Jasmina Begi´c-Rahi´c, URuBiH Natalia Vasylenko, UWTO Ellie Lenselink, V&VN Peter Quataert, WCS Caroline McIntosh, WMAI Skender Zatriqi, WMAK Dragica Tomc, WMAS Mustafa Deveci, WMAT

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

Georgina Gethin, Ireland Luc Gryson, Belgium Marcus Gürgen, Norway Eskild W. Henneberg, Denmark Alison Hopkins, UK Gabriela Hösl, Austria Dubravko Huljev, Croatia Arkadiusz Jawien, Poland Gerrolt Jukema, Netherlands Nada Kecelj, Slovenia Klaus Kirketerp-Møller, Denmark Zoltán Kökény, Hungary Martin Koschnick, Germany Knut Kröger, Germany Severin Läuchli, Schwitzerland David Tequh, Netherlands Sylvie Meaume, France

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

EWMA Journal editorial

It is a pleasure to present to you the April edition of the EWMA journal The EWMA journal was founded in 2001 and has published two issues every year with the aim of providing EWMA members with the highlights of wound care within Europe as well from Australia and the United States. Professor Sue Bale, EWMA-president elect, has been editor of the Journal from 2010-2016 and has handed over the position to Professor Sebastian Probst, EWMA council member. The entire EWMA editorial team, as well as the EWMA Council, thank Professor Bale for her work and great collaboration through the years.

Dear readers

efore I present you this issue I would like to introduce myself. I am a professor of tissue viability and wound care at the School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland. My research and teaching activity is in self-efficacy, quality of life and treatment interventions in patients with a venous leg ulcer as well as patients with a palliative wound. My goal as journal editor is two-fold: firstly I would like to increase the collaboration with the cooperating organisations so we can provide you with useful information about wound care from Europe and from our international partner organisations. Secondly we want to deliver high quality research articles as well as original articles from UCM- , Bachelor- and Master-theses. We therefore ask all our readers to submit their latest work as well their news within their organisation. Three papers are published in this issue. One outlines the results of a qualitative study investigating how patients suffering from arterial or mixed leg ulcers experience their everyday life and life in general with a leg ulcer. Another study presents how the perception of diabetes as a disease

that can be relatively easily controlled has consequences for the diagnosis and treatment of foot ulcers. Finally, this issue of the EWMA Journal includes the presentation of a randomised, controlled, parallel-group clinical trial designed to compare enzymatic, mechanical and autolytic debridement methods for the treatment of the forearm and hand deep dermal burns. In this issue we have also decided to highlight the annual WHO Hand Hygiene Campaign, which this year falls on the last day of the EWMA 2017 Conference, Friday 5 May. Due to the high relevance of hand hygiene in relation to several current EWMA focus topics, such as antimicrobial stewardship and surgical site infection, EWMA has decided to support the campaign with a joint programme developed in collaboration with the International Council of Nurses. The programme will include distribution of relevant materials as well as a workshop on hand hygiene during the EWMA 2017 Conference in Amsterdam to be held 3-5 May. In this issue you will find more information about this campaign as well as the EWMA 2017 Conference. I hope you all enjoy this issue. Sebastian Probst, Council member Professor in Wound Care, DClinPrac, RN University of Applied Sciences Western Switzerland Geneva, Switzerland

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2017 vol 17 no 1

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Science, Practice and Education

Debridement method optimisation for treatment of deep dermal burns of the forearm and hand

Ernest Zacharevskij1,2,3

Gytis Baranauskas2,3

ABSTRACT Introduction Surgical debridement of marginal deep dermal burns of the forearm and hand frequently is too aggressive to residual healthy skin. Additional operation is needed - split thickness skin grafting. Donor site complications should be taken in consideration, also transplanted skin rejection and ulceration. Therefore, clinical trials should be targeted to assess effectiveness of alternative debridement methods.

Materials and Methods Our team performed a randomised, controlled, parallel-group clinical trial designed to compare enzymatic, mechanical, and autolytic debridement methods for the treatment of deep dermal burns of the forearm and hand. Laser Doppler Imaging (LDI) performed on the third day post-burn, was used to predict burn wound healing time. Patients who LDI predicted burn wound healing time of no more than three weeks, were included in the study. For the first (control) group received standard treatment - dressings with 1% silver sulphadiazine cream. The second patient group was treated with hydrocolloid dressings to promote autolytic debridement. The third patient group received a combination treatment dressings with silver sulphadiazine and mechanical debridement using special single-use monofilament polyester fibre pads. The fourth group was treated with application of enzymatic dressings. The treatment period for each patient was 3 weeks, which was followed by assessment at 6 months to evaluate post-burn scars.

Results There were 82 patients with deep dermal burns of the forearm and hand included in the trial, with a minimum of 20 patients in each treatment group. EWMA Journal

2017 vol 17 no 1

The fastest burn wound healing was observed in the patient group treated with hydrocolloid dressings. Furthermore, the quality of scars according to the Vancouver Scare Scale (VSS) and return of function of the injured extremity according to Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) also were the best for the hydrocolloid dressings group.

Karolis Varkalys2,3

Conclusion Accelerated autolytic debridement is an effective method for treatment of deep dermal burns of the forearm and hand and hypertrophic scar prevention in patients with LDI prediction of burn wound healing of less than 3 weeks.

INTRODUCTION There is concrete scientific evidence that nonviable, necrotic cells and tissue debris should be removed from the surface of burn wounds to promote healing, because biochemical changes in the damaged tissues may affect the process of wound healing, leading to systemic complications, which in turn, can become chronic1,2. Timing of debridement is also very important in burn wound management. Several clinical trials demonstrated the advantage of early debridement after 3–5 days post-burn and grafting compared to conservative management after 2–3 weeks and final skin grafting3-6. Early debridement could reduce the average length of stay in the hospital and even the mortality rate of burn patients4-7. However, surgical excision of partial thickness burns should be performed qualitatively. If the wound bed has the potential for fast epitheliali

Darius Kubilius2,3

Rytis Rimdeika1,2,3 1Department of Plastic and Reconstructive Surgery, Lithuanian University of Health Sciences Hospital Kaunas Clinics 2Lithuanian

University of Health Sciences, Medical Academy

3Lithuanian Wound Management Association, www.lzga.lt

Correspondence to: ernest.zacharevskij@ gmail.com Conflicts of interest: None

sation, conservative wound management can reduce the overall need for skin grafting in selected patients and the associated hospital costs8-11. The acceptable time limit for burn wound self-epithelialisation is approximately 3 weeks. Several scientific reviews have reported that burn wounds that took longer than 21 days to heal posed a high risk of hypertrophic scar development of nearly 80%12,13. Traditional treatment of burns capable of healing within 2–3 weeks, such as superficial and partial thickness burns, is to manage the burn with non-operative local wound care including debridement and dressing changes, and aggressive range of motion exercises14,15. Partial thickness burns can be tangentially excised and covered with a temporary skin substitute16,17. However, there is no strong consensus on which topical antimicrobial agent or dressing is optimal for burn wound coverage to prevent or control infection 18-20. If wound healing cannot be achieved within 21 days, additional necrectomy and skin grafting should be performed, especially in cases of burns of the forearm, hand, and face. Surgical debridement of burns of the forearm and hand is specific because important and delicate structures are encased within a relatively limited space in the dorsal aspect and covered by skin without a thick subcutaneous layer. The challenging shape of the hand and fingers and excellent blood supply of upper extremity tissues should also be taken into consideration16. Surgical debridement reduces the chance of burn wound self-epithelialisation but has a high probability of serious complications, such as massive bleeding, and microvascular and neurological damage21. Therefore, clinical trials should be targeted to alternative selective debridement methods for the treatment of deep dermal burns of the forearm and hand22. Laser Doppler Imaging Proper initial burn treatment requires accurate burn degree evaluation and healing time prediction. Burn severity classifications are marked by characteristic changes in vasculature and blood flow23. A perfect instrument for burn severity evaluation is Laser Doppler Imaging (LDI), which produces a colour-coded image of dermal blood ﬂow to quantify the inﬂamatory response in a burn and predict burn wound outcomes and healing times with high accuracy23-25. An LDI result is described by perfusion units (PU) and is defined by ranges for the three categories of healing potential (HP): HP 14 days: colour-coded pink and red, >600 PU; HP 14–21 days: green and yellow, 260–600 PU; HP >21 days: blue and dark blue, <260 PU. 8

Several studies have compared LDI and clinical assessment to predict healing outcomes. These studies confirmed the utility of LDI for assessing burn wound depth and showed superior accuracy over clinical assessment26-30. The accuracy of LDI for the assessment of burn depth was 95% on the third day post-burn and 97% on the fifth day, compared to 60–80% for established clinical methods28,30. Materials and Methods Our team performed a randomised, controlled, parallel-group clinical trial designed to compare enzymatic, mechanical, and autolytic debridement methods for the treatment of partial thickness deep dermal burns of the forearm and hand. The main inclusion criterion was LDI predictiona on the third day post-burn of no more than 3 weeks for burn wound healing (Figure 1).

Figure 1: LDI color imaging hand on the third day post-burn, 378PU.

The study took place in the Department of Plastic and Reconstructive Surgery, Lithuanian University of Health Sciences Kaunas Clinics, Lithuania. The clinical trial was approved by the Lithuanianan Biomedical Studies Ethical Committee and Lithuanian State Data Protection Inspection. The trial was registered in the ISRCTN registry (ID: ISRCTN84005357). There were four groups to which patients were randomly assigned. The first (control) group received standard treatment - dressings with 1% silver sulphadiazine creamb applied once daily. The second patient group was treated with hydrocolloid dressingsc changed every 3 days to promote autolytic debridement (Figure 2-4). The third patient group received a treatment combination - dressings with 1% silver sulphadiazine once daily and mechanical debridement with special single-use monofilaEWMA Journal

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Science, Practice and Education

Figure 2: Left hand 2B° burn, 94cm2, 378 PU (hydrocolloid). 6 days post burn.

Figure 5: Mechanical debridement with single-use monofilament fiber pad: before after.

Figure 3: Left hand 2B° burn, 94cm2, 378 PU (hydrocolloid) 6 days post burn.

Figure 4: Left hand 2B° burn, (hydrocolloid) 6 months post burn.

ment polyester fiber padsd for first 4–5 days once daily (Figure 5). The fourth group was treated with application of a proteolytic enzyme complexe on gauze dressings once daily.

Patients were treated for 3 weeks and assessed at 6 months to evaluate the quality of post-burn scars according to the Vancouver Scar Scale (VSS) and functional recovery according to The Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH; official Lithuanian 

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translation). The VSS data for scar appearance and DASH data for hand functionality provided a complementary objective evaluation of post-burn scars. We included in our study patients from 18 to 65 years with deep (2°) partial thickness burns of the forearms and hands. All participants agreed to participate in the trial protocol and signed the consent form. Patients with superficial and full thickness burns (according to clinical and LDI burn wound prediction), patients with known pregnancy (pregnancy test was performed for all female patients), and vulnerable persons (psychiatric diagnosis, confounding diseases) were excluded from the study. Finally, 82 patients were selected and randomised into four trial groups, each including a minimum of 20 patients. Patients’ clinical condition and burn wounds were evaluated after 3, 7, 14 and 21 days post-burn according to the study wound assessment protocol. Burn wound size was estimated by covering the wound with transparent film and using a ruler to measure square centimetres. Pain feeling was evaluated after 10 minutes according to the pain Visual Analog Scale (VAS) after dressings were changed. Clinical wound conditions, such as exudation, erythema, fluctuation, local heat in the wound, sensibility on palpation, swelling, necrosis persistence, amount of fibrin, appearance of granulation tissue, epithelialisation process, were evaluated for all wounds by the same physician according to the study protocol measurement parameters (percentage of whole wound area). During the first evaluation, patients also were asked to complete the DASH with the researcher’s assistance, because this time was closer to the incident and it was easier for patients to remember how much hand function they had before the burn accident. Swabs were taken to identify wound contamination after 3, 7, and 14 days post-burn using the Levine method31,32. Autolytic debridement with hydrocolloid dressings Autolytic debridement describes the biochemical process by which the wound naturally clears necrotic tissue in the presence of endogenous phagocyte cells and proteolytic enzymes. This process is promoted and strengthened by maintaining a moist wound environment33,34. Autolytic debridement is the most selective compared to other methods of wound debridement35. Hydrocolloid dressings are used mostly to treat partial thickness and full thickness skin wounds. They consist of a moulded gel agent and a waterproof outer layer. The gel layer forms an adhesion matrix that consists of an absorbent material like pectin, gelatine, or carboxymethylcellulose36. The inner layer of the dressing absorbs exudate 10

and turns into a gel. When the dressing’s moisture absorption increases, it becomes more permeable to water. This feature shows the moisture transfer ability of the dressing to control exudate in the wound37. The most important functions of hydrocolloid dressings are the maintenance of a natural environment for wound healing, promotion of autolytic debridement, control of exudate, insulation and a barrier against microorganisms, and pain control. Hydrocolloid dressings should be changed every 3–5 days. The dressing may be kept on a maximum of 7 days for best results38. However, these bandages are not suitable for highly exudative or infected wounds because they are impermeable to oxygen, which could lead to development of an anaerobic infection in the wound. In addition, the adhesive component of the dressing can be allergenic39. Mechanical debridement with monofilament polyester fibre pads Special single-use padsc are intended for the debridement of devitalised tissue, debris, and hyperkeratosis caused by chronic and acute wounds. There is no need for analgesia, and the process takes, on average, 2–4 minutes. The product’s instructions recommend that emollients be washed from the skin before treatment with this device. A new pad is required for each separate area of skin being treated and for large areas, more than one pad may be required40,41. There is still need for more evidence, but a number of smaller, prospective, pilot, non-comparative studies and case studies have suggested that using the debridement pad on appropriate wounds will permit full debridement more quickly, compared to other debridement methods. In addition, the pad is convenient and easy to use, and is well tolerated by patients. This product is estimated to be a cost saving for complete debridement compared to other methods such as hydrogel, gauze, and bagged larvae40,41, although some pain responses following debridement have been reported42. Burn wound treatment with silver sulphadiazine leads to pseudoeschar formation, mostly during first week postburn; thus, the combination of silver sulphadiazine with mechanical debridement can improve the ability to examine the wound surface, remove debris more quickly, and promote epithelialisation. Enzymatic debridement During process of enzymatic debridement proteolytic enzymes hydrolyse peptide conjoins of collagen molecules EWMA Journal

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Science, Practice and Education

HEALING TIME

PAIN

4,5 18,8

19,8

3,5

Time (Days)

15,9 15

Hydrocolloids (n = 20) Enzyma:c (n = 21)

Combined treat. (n = 20)

VAS (score)

19,5

Control group (n = 21)

3 2,5

Hydrocolloids (n = 20)

Enzyma:c (n = 21) Combined treat. (n = 20)

1,5

Control group (n = 21)

0,5 0

0-3d.

Hydrocolloids (n = Enzyma:c (n = 21) Combined treat. Control group (n = 20) (n = 20) 21)

7d.

Figure 6

21d.

Figure 7

NECROSIS

FIBRINE

Hydrocolloids (n = 20) Enzyma:c (n = 21)

Combined treat. (n = 20)

Grade (%)

25 Grade(%)

14d.

Days a2er burn

40 Hydrocolloids (n = 20)

Enzyma:c (n = 21) Combined treat. (n = 20)

Control group (n = 21)

Control group (n = 21) 10

5 0

0 0-3d.

7d.

14d.

21d.

0-3d.

Days a2er burn

7d.

14d.

21d.

Days a2er burn

Figure 8

Figure 9

and other proteins; therefore, dead tissue loses attachment to the wound and is removed from the wound environment. Enzymatic debridement has a highly-selective mode of action, is quite safe for the surrounding healthy tissues, and therefore can be used in long-term care facilities and even in outpatient departments43,44.

Patient demographics were similar between groups with respect to the patients’ age, total burn wound area, spread of burn cause, burn size, LDI burn depth evaluation, and primary DASH score(p>0.05) .

In our study of burn wound debridement methods, we used a local enzymatic producte. This proteolytic enzyme complex was applied using gauze dressings to cover the wound, and was performed once daily. The enzyme complex is obtained from Streptomyces flavus. Characteristics of the enzyme complex included: proteolytic activity, no less than 5 u/cm3 and collagenase activity, no less than 1500 u/cm3. The preparation was stabilised with glycerine (ratio 1:1). Streptomyces flavus is a non-pathogenic microorganism, assigned to Biosafety Risk Group I. There is no evidence of illness in humans from using this preparation45. Upon contact with healthy skin, the enzymatic collagenase preparation does not produce any irritation46. Results We included 82 patients with deep dermal burns of the distal forearm and hand in the trial, with a minimum of 20 patients in each of the four groups to permit statistical analysis.

The fastest rate of burn wound healing was observed in the patient group treated with hydrocolloid dressings (n=20) 15.9 ± 2.6 days compared to the control group (n=21) 19.8 ± 2.9 days, the treatment combination group (n=20) 19.3 ± 2.5 days, and the enzymatic dressings group (n=21) 19.5 ± 2.3 days (p<0.05) (Figure 6). No difference was detected in pain VAS between groups at 10 minutes after the dressing change procedure during evaluations at 3, 7, 14, and 21 days post-burn [Figure 7]. Burn wound contamination was more common in the hydrocolloid dressings group, but no significant difference was found between groups and none of the patients was excluded from the study because of burn wound infection. The most common microorganism, detected by swabs, was Staphylococcus aureus (methicillin-sensitive strains). Necrotic tissue and wound debris were significantly reduced in the hydrocolloid dressings group because of the induced autolytic debridement process (p<0.05) (Figure 8-9). The amount of fibrin in burn wounds during evaluation after 7 days post-burn was statistically higher in the 

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2017 vol 17 no 1

EPITELISATION

VANCUVER SCAR SCALE

100

4,85

Hydrocolloids (n = 20) Enzyma:c (n = 21)

Combined treat. (n = 20) Control group (n = 21)

VSS (Score)

Grade (%)

4,19 60

Hydrocolloids (n = 20)

2,55

Enzyma:c (n = 21) Combined treat. (n = 20)

1,36

Control group (n = 21)

0 0-3d.

7d.

14d.

21d.

Hydrocolloids (n Enzyma:c (n = Combined treat. Control group (n = 20) 21) (n = 20) = 21)

Days a2er burn

Figure 10

Figure 11

DASH ALTERATION 18 16

DASH (score)

14 12 10

Hydrocolloids (n = 20) Enzyma:c (n = 21)

Conclusion Comparison of enzymatic, mechanical, and autolytic debridement in our clinical trial revealed that burn wound healing was significantly faster, and scarring and limb functional recovery were better in the hydrocolloid dressing group.

Combined treat. (n = 20)

Control group (n = 21)

4 2 0 Before burn

6 months aKer burn Time

Figure 12

control and treatment combination groups, most likely due to silver sulphadiazine-induced pseudoeschar formation (p<0.05) (Figure 9). Mechanical debridement with monofilament polyester fibre pads did not have a good fibrin layer clearance effect, as we had prognosticated in our study.

Accelerated autolytic debridement with hydrocolloid dressings was the most effective method for the treatment of deep dermal burns of the distal forearm and hand and prevention of hypertrophic scarring in patients with an LDI healing prediction of less than 3 weeks. All debridement methods we evaluated in our study had positive effect on necrosis elimination from the wound surface and promotion of burn wound epithelialisation. During ordinary burn treatment, it is useful to change debridement methods, if clinical examination shows that debridement efficacy is insufficient or even harmful for burn wound epithelialisation.

The epithelialisation process was statistically slower at 14 days for the enzymatic group (p<0.05); however, all wounds had healed by 21 days (Figure 10). The quality of scars evaluated at 6 months post-burn according to the VSS and extremity function according to the DASH mean scores were lowest (best scar outcome and least disability, respectively) for the hydrocolloid dressings group (1.36 and 1.6, respectively) compared to the control group (4.19 and 16.3, respectively), the treatment combination group (3.0 and 9.8, respectively), and the enzymatic dressing group (4.85 and 11.0, respectively) (Figure 11-12). The difference in means of wound healing speed and VSS between groups was statistically significant as determined by ANOVA p<0.05. Moderate correlations were found between fastest wound healing time and best VSS values (R=0.51; p<0.01) and fastest wound healing time and change in DASH at 6 months post-burn (R=0.5; p<0.01).

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FOOTNOTES a. All Laser Doppler images were captured with the MoorLDLS2 Laser Doppler Line Scanner (Moor Instruments, Devon, UK) b. “Sulfargin”, Grindeks AS, Riga, Latvia c. GranuFlex®, ConvaTec, Greensboro, NC, USA d. “Debrisoft” Lohmann&Rauscher GmbH & Co, Vienna, Austria e. “Streptomyces flavus 197 Ferment”, Biocentras, LTU, Vilnius, Lithuania REFERENCES 1. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg 1996 Jul; 183(1):61–64. 2. Hansbrough JF, Zapata-Sirvent RL, Peterson VM, Bender E, Claman H, Boswick JA. Characterization of the immunosuppressive effect of burned tissue in an animal model. J Surg Res 1984 Nov; 37(5):383–393. 3. Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma 1970 Dec; 10(12):1103–1108. 4. Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston S. A comparison of conservative versus early excision. Therapies in severely burned patients. Ann Surg 1989 May; 209(5):547–552. 5. Sorensen B, Fisker NP, Steensen JP, Kalaja E. Acute excision or exposure treatment? Scand J Plast Reconstr Surg 1984; 18:87–93 6. Maslauskas K, Rimdeika R, Saladžinskas Z, Ramanauskas T. The epidemiology and treatment of adult patients with hand burns in Kaunas University of Medicine Hospital in 1985, 1995, 2001 and 2002. Medicina 2004; 40(7):620-626. 7. Thompson P, Herndon DN, Abston S, Rutan T. Effect of early excision on patients with major thermal injury. J Trauma 1987 Feb; 27(2):205–207. 8. Palmieri TL, Greenhalgh DG. Topical treatment of pediatric patients with burns: a practical Guide. Am J Clin Dermatol 2002; 3(8):529–534. 9. Cuttle L, Naidu S, Mill J, Hoskins W, Das K, Kimble R. A retrospective cohort study of Acticoat® versus Silvazine in pediatric population. Burns 2007 Sep; 33(6):701–707. 10. Jeffrey SLA. Debridement of pediatric burns. In: Granick MS, Gamelli RL. Surgical wound healing and management. Informa Health Care, USA, 2007; 53–56. 11. Venclauskienė A, Basevičius A, Zacharevskij E, Vaičekauskas V, Lukoševičius S, Rimdeika R. Lazerinės doplerografijos vertė vertinat nudegimo žaizdų savaiminės epitelizacijos tikimybę. Lietuvos bendrosios praktikos gydytojas; Kaunas: Vitae Litera. 2013; 17(6):374-378. 12. Davis SC, Mertz PM, Bilevich ED, Cazzaniga AL, Eaglstein WH. Early debridement of second degree burn wounds enhances the rate of reepithelialization – an animal model to evaluate burn wound therapies. J Burn Care Rehabil 1996 Nov-Dec; 17(6 Pt 1):558–561. 13. Deitch EA, Wheelahan TM, Rose MP, Clothier J, Cotter J. Hypertrophic burn scars: analysis of variables. J Trauma 1983 Oct; 23(10):895–898.

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14. Samuel P Mandell, Matthew B Klein. Primary operative management of hand burns. In: UpToDate, Marc G Jeschke & Kathryn A Collins (Eds.), UpToDate; 2016.

30. Pape SA, Skouras CA, Byrne PO. An audit of the use of laser Doppler imaging (LDI) in the assessment of burns of intermediate depth. Burns 2001 May; 27(3):233–9.

15. Goodwin CW, Maguire MS, McManus WF, Pruitt BA Jr. Prospective study of burn wound excision of the hands. J Trauma 1983 Jun; 23(6):510-7.

31. Bonham PA. Swab cultures for diagnosing wound infections. J Wound Ostomy Continence nurs. 2009 Jul-Aug; 36(4):389-95.

16. Hyakusoku H, Orgill PD, Teot L, Pribaz JJ, Ogawa R. Color Atlas of Burn Reconstructive Surgery. ISBN: 978-3-642-05069-5. Springer-Verlag Berlin Heidelberg 2010. p. 22-25.

32. Gardner SE, Frantz rA. Wound bioburden. In: Baranoski S, Ayello EA, editors. Wound Care Essentials Practice Principles. New York, NY: Lippincott, Williams & Wilkins; 2004, p. 91-116.

17. Uhlig C, Rapp M, Hartmann B, Hierlemann H, Planck H, Dittel KK. Suprathel – an innovative, resorbable skin substitute for the treatment of burn victims. Burns 2007 Mar; 33(2):221-9.

33. Dissemond J, Goos M. Optionen des Debridements in der Therapie chronischer Wunden. J Dtsch Dermatol Ges 2004; 2(9):743–751.

18. Mayer Tenenhaus, Hans-Oliver Rennekampff. Local treatment of burns: Topical antimicrobial agents and dressings. In: UpToDate, Marc G Jeschke & Kathryn A Collins (Eds.), UpToDate, 2016. 19. Hoogewerf CJ, Van Baar ME, Hop MJ, et al. Topical treatment for facial burns. Cochrane Database Syst Rev 2013. 20. Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev 2013. 21. Singer AJ, McClain SA, Taira BR. Rapid and selective enzymatic debridement of porcine comb-burns with bromelain derived Debrase: acute phase preservation of non-injured tissue and zone of stasis. J Burn Care Res 2010 Mar-Apr; 31(2):304–309. 22. Gong C, Lyu K, Wang G, Wang G, Zhu S, Xia Z. Debridement of burn wounds using a hydrosurgery system. Zhonghua Shao Shang Za Zhi 2015 Dec; 31(6):470-2. 23. Droog EJ, Steenbergen W, Sjoberg F. Measurement of depth of burns by laser Doppler perfusion imaging. Burns 2001 Sep; 27(6):561–8. 24. Pape SA, Baker RD, Wilson D, Hoeksema H, Jeng JC, Spence RJ, Monstrey S. Burn wound healing time assessed by laser Doppler imaging (LDI). Part 1: Derivation of a dedicated colour code for image interpretation. Burns 2012 Mar; 38(2):187-194. 25. Hoeksema H, Van de Sijpe K, Tondu T, Hamdi M, Van Landuyt K, Blondeel P et al. Accuracy of early burn depth assessment by laser Doppler imaging on different days post burn. Burns 2009 Feb; 35(1):36– 45. 26. Holland AJ, Martin HC, Cass DT. Laser Doppler imaging prediction of burn wound outcome in children. Burns 2002 Feb; 28(1):11–7. 27. Jeng JC, Bridgeman A, Shivnan L, Thornton PM, Alam H, Clarke TJ et al. Laser Doppler imaging determines need for excision and grafting in advance of clinical judgment: a prospective blinded trial. Burns 2003 Nov; 29(7):665–70. 28. La Hei ER, Holland AJ, Martin HC. Laser Doppler imaging of paediatric burns: burn wound outcome can be predicted independent of clinical examination. Burns 2006 Aug; 32(5): 550–3.

34. Eaglstein WH. Moist wound healing with occlusive dress¬ings: a clinical focus. Dermatol Surg 2001 Feb; 27(2):175–181. 35. Kramera A, Lademannb J, Bendera C, Sckellc A. Suit¬ability of tissue tolerable plasmas (TTP) for the management of chronic wounds. Clinical Plasma Medicine 2013. 36. Fletcher J, Moore Z, Anderson I, Matsuzaki K. Hydrocol¬loids and pressure ulcers Made Easy. Wounds International 2011; 2:1-5. 37. Kannon GA, Garrett AB. Moist wound healing with occlusive dressings. A clinical review. Dermatol Surg 1995; 21(7):583–590. 38. Ousey K, Cook L, Young T, Fowler A. Hydrocolloids in practice. Wounds UK 2012. 39. Arnold TE, Stanley JC, Fellows EP, Fellows EP, Moncada GA, Allen R et al. Prospective, multicenter study of managing lower extremity venous ulcers. Ann Vasc Surg 1994 Jul; 8(4):356–362. 40. Meads C, Lovato E, Longworth L. The Debrisoft monofilament debridement pad for use in acute or chronic wounds. Appl Health Econ Health Policy 2015 Dec; 13(6):583–594. 41. Haemmerle G, Duelli H, Abel M., Strohal R. The wound debrider: a new monofilament fibre technology. Br J Nurs 2011 Mar 24 – Apr 14; 20(6):S35-6, S38, S40-2. 42. Bahr S, Mustafi N, Hättig P, Piatkowski A, Mosti G, Reimann K et al. Clinical efficacy of a new monofilament fibre-containing wound debridement product. J Wound Care. 2011 May; 20(5):242–248. 43. Strohal R, Dissemond J, Jordan O‘Brien J, Piaggesi A, Rimdeika R, Young T et al. EWMA Document: Debridement. J Wound Care 2013; 22 (Suppl. 1): S1–S52 44. Dissemond J. Modern wound dressings for the therapy of chronic wounds. Hautarzt. 2006 Oct; 57(10):881–887. 45. “Regulations for worker protection from the influence of biological agents in the”, “National news” No. 56-1999, 2001. 46. Medical methodic M 2.1: 1995 “Determination methodic of acute skin irritation (erosion) for chemical agents and preparations”.

29. Nguyen K, Ward D, Lam L, Holland AJ. Laser Doppler Imaging prediction of burn wound outcome in children: is it possible before 48 h? Burns 2010 Sep; 36(6):793–8.

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Science, Practice and Education

Lived experiences of life with a leg ulcer - a life in hell ABSTRACT Background Little is known about patient lived experience with arterial or mixed leg ulcers. Due to the lack of knowledge and the increasing focus on implementation of patient perspectives, this study was conducted.

Aim This study investigates how patients suffering from arterial or mixed leg ulcers experience their everyday.

Methods Six qualitative life-interviews were conducted: one focus group interview and five semi structured interviews. Data was analysed with Pia Dreyer’s Paul Ricoeur-inspired method, following three steps: naïve reading, structural analysis and critical analysis and discussion.

Results Following themes are discussed in the manuscript. The essence of the lived experience is captured in the overall theme: a life with a leg ulcer – a life in hell. This overall finding derived from four themes describing the influence on everyday life: constant pain – without the possibility of relief, an eternal battle against the ulcer – to survive, a state between despair and hope and the ulcer controlled everyday life.

STUDENT S E C T I O N

Lina S. D. Lernevall1,2 *

INTRODUCTION Chronic and slow-healing wounds are terms used for ulcers that do not heal within 8-12 weeks, assuming optimal local wound treatment1. The prevalence of chronic wounds is uncertain, but is estimated to be about 0.12 to 0.4 %. Early diagnosing and treatment of these patients is therefore of great importance, as chronic wounds have a great impact on patient quality of life2,3. Patients with arterial insufficiency or mixed arterial and venous insufficiency are a special subgroup of leg ulcer patients, and little is known about their lived experience. These patients experience pain due to the compromised blood supply to the extremities, which negatively affects their quality of life. Patient experience of pain related to the wound is different depending on the aetiology4. As a consequence, it is important to focus in detail on these patients with respect to pain, quality of life, and the experience of living with painful wounds. Therefore, the aim of this article is to investigate how patients suffering from arterial or mixed leg ulcers experience their everyday life.

Conclusion

METHODS Through a qualitative study design and a phenomenological-hermeneutical approach5,6, we conducted five semi-structured interviews and one focus group interview to gain insight into patient lived experiences from their perspective. All ethical guidelines of nursing science and by the University of Aarhus were ensured.

Patients consider living with an arterial or mixed leg ulcer as living a life in hell. Patients are in an existential crisis and would rather die than live the rest of their lives with a leg ulcer. Given their low quality of life and general unhappiness, more needs to be done to help these patients.

Research setting All patients included in this study received wound treatment at The Wound Care Centre (WCC), a specialist patient facility within the Department of Dermatology and Venereology of 

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Karsten Fogh2

Camilla B. Nielsen2

Wilja Dam2

Pia S. Dreyer1,3. 1 University

of Aarhus, The Faculty of Health Sciences, Dept. of Nursing Science. Denmark.

2 Department

of Dermatology, Aarhus University Hospital, Aarhus, Denmark. 3 Department

of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark. *Department of Plastic Surgery and Burn Centre, Haukeland University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway.

Correspondence: lina.lernevall@helse-bergen.no Conflicts of interest: None

Aarhus University Hospital in Denmark; the centre treats 65 patients per week. The patients are involved as partners in their treatment and helped to gaining knowledge and insight about their condition, as well as how to cope with it. The WCC followed the patients within the clinic and worked with patients at home closely by telemedicine with homecare nurses. Patient selection Two nurses from the WCC searched telemedicine, a photo-based information technology for wound-assessment and identified 11 patients that fulfilled the given inclusion and exclusion criteria.

FIGURE 1. PATIENT SELECTION INCLUSION CRITERIA: Patients with arterial or mixed leg ulcer with a known ABPI (Ankle-Brachial Pressure Index)- or toe pressure.

EXCLUSION CRITERIA: Patients with venous leg ulcers, with diabetes, psychic or mentally unstable, with healed ulcers or patients who had had amputation.

The same nurses phoned all patients, informed them about the study, and invited them to participate. Seven patients gave their consent. Four patients were excluded: two due to amputation, one to diabetes and one due to hospitalisation. The first author contacted the patients, and they were again given oral and written information about the project. One patient could not participate due to acute hospitalisation; therefore, six patients were enrolled in this study. (Figure 2) Data collection, setting and locations One focus group interview was conducted at the WCC with four patients. Present at the interview were the first author and a nurse from another speciality to take notes and ask questions if the first author overlooked anything. Five semi-structured interviews were conducted after the focus group interview, two at the WCC and three in the patient’s private homes, by the choice of the patient. The single interviews were conducted to give the patients a setting where they could speak more privately. The first author was present at all interviews. The same open-ended interview guide that had been pilot-tested was used at all interviews. All interviews were tape-recorded, lasted between 35-90 min and were then verbatim transcribed by the first author. Data analysis The gathered data was analysed with Dreyer’s Ricoeurinspired method7. The analysis followed three steps: naïve reading, structural analysis and critical analysis and discussion. For naïve reading, the text is read as a whole.

FIGURE 2. PATIENT DEMOGRAPHICS GENDER AGE DIAGNOSE

ABPI PRESSURE

TOE PRESSURE

WOUND LOCATION

DURATION OF WOUND

Lateral side of the left lower leg.

1 year and 3 months

Female 65 Mixed leg ulcer Right ankle = 0,57 Right = 53 mmhg Left ankle = 0,91 Left = 29 mmhg (may 2014) → 53 mmhg (6/2-15 after blood vessel operation) Female 74 Mixed leg ulcer Right ankle=0,39 Not measured (Blood vessel Left ankle = 0,42 operation not possible. Right leg was amputated) Male 61 Arterial leg ulcer Right ankle = 0,22 Right = 24 mmhg Left ankle = 0,66 Left = 100 mmhg

Right lower leg. Small superficial ulcer on the left leg.

5 years

Lateral side of right foot.

4 years

Male 69 Mixed leg ulcer Left ankle = 0,59 Not measured

Lateral malleoli on the left foot.

1 year and 5 months

Male 69 Mixed leg ulcer

Lateral malleoli on the right foot.

1 year and 9 months

Lateral malleoli left foot and 1. toe on the left foot.

4 years

Right ankle= 0,70 Left ankle = 1,00

Right = 25 mmhg Left = 62 mmhg

Male 77 Mixed leg ulcer Not found in the Right = 127 mmhg patients journal Left = 80 mmhg 16

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FIGURE 3. STRUCTURAL ANALYSIS MEANING-BEARING UNITS: WHAT IS SAID IN THE TEXT?

SIGNIFICANCE-BEARING UNITS: WHAT DO THE TEXT “TALK” ABOUT?

THEME:

“Something more painful than a leg ulcer is hard to find”, “It is terrible”, These wounds, the pain is like hell. – I think we all can agree on that”, “Because I had pain, it was so horrible, and I didn’t get anything to ease it”, …because it has been so excruciating”, “I can sometime come to tears, you saw it yourself before when I was telling you about it, the tears come, yes they do, because it’s been so awful”, “…and the pain was so bad that I was crying when I left the outpatient clinic. I went outside and I cried. I’ve been …”

“Something more painful than a leg ulcer is hard to find”. All patients live with terrible pain, it is there all the time, and it is so terrible that the patients have difficulties in the describing it fully. “Yes it’s hard to describe, the pain, because it’s something you have to try to really understand what it is”. The wounds ache “like hell” and the pain is horrible, foul, terrible and excruciating at the same time. The leg ulcer is so painful, they wound not wish it on anyone else. “I wouldn’t wish it on my worst enemy. Not at all”.

Constant pain – without the possibility of relief:

Two patients explain how they sat crying after wound treatment …

The text was then read again, focusing on smaller parts of the text to gain a deeper understanding8, whereupon the first author wrote a summary of the overall meaning of the interviews. Structural analysis is a dialectic process consisting of three levels, where one looks at the meaningbearing units and the significance-bearing units, and ends up with a number of themes. The structural analysis was conducted multiple times by the first and last authors, until changes became minimal7,9. (Figure 3) Finally, we performed the critical analysis and discussion. The given themes were discussed with existing knowledge and there was a movement from the specific interpretation level to a more general interpretation, resulting in a superior overview over the comprehensive understanding of the text. RESULTS After the analyses, four themes emerged: constant pain – without the possibility of relief, an eternal battle against the ulcer – to survive, a state between despair and hope and the ulcer controlled everyday life. (Figure 4)

The four themes show how the leg ulcer inflicts on the patient’s life. When describing life, the patients used words like dreadful, terrible, horrible, painful and expressions like “It’s been like hell… like a living hell”. These words combined with the four themes, create an overall finding: “A life with a leg ulcer is a living hell”, which is the essence of the lived experience. One could argue that patients are in an existential crisis because they experience their lives with a leg ulcer as though a living hell. These words are the patients own very strong expressions. Constant pain – without the possibility of relief All patients lived with a constant and horrible pain and would not wish it on their worst enemy, stating, “It’s hard to find something more painful than a leg ulcer”. The leg ulcer pain made it difficult to walk, and the patients were forced to use crutches, walkers or swivel chairs, making it close to impossible to move around. Sitting down a whole evening was also difficult, and during the night, the leg ulcer pain was at its worst. Every patient complained about lack of sleep: “I never sleep more than two hours in a row. 

FIGURE 4. ILLUSTRATION OF THE RESULTS

A LIFE WITH A LEG ULCER

• Constant pain – without the possibility of relief • An eternal battle against the ulcer – to survive • A state between despair and hope • The ulcer controlled everyday life IS A LIFE IN HELL

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It’s every night”. Despite taking painkillers before bedtime, they could not find total relief, and were happy when they got two hours of coherent sleep. Analgesics did not have any significant effect. The only thing that could ease the pain a little was to move the leg in a vertical position. Every night, the patients wished to sleep a whole night. The patients could not escape the pain completely, and they were stuck in the present, because the ulcer was hurting all the time. The ulcer was even painful when it was healing. Together, the patients’ statements showed how they lived life in constant pain without the possibility of total relief. An eternal battle against the ulcer – to survive If their leg ulcer would not heal, the leg had to amputated. That was their biggest fear for patients, and they would rather die than let it happen. One said, “I will not accept it! Then I wouldn’t like to be here anymore. It’s what I fear the most”. The patients fought hard to keep their legs. The patients always talked about their leg ulcer in third person, as “it” instead of “my (leg) ulcer”: “It’s become a strange thing for me, and it’s hurting me”. This indicated that they distanced themselves, making it something that was outside their body, something they fought against. When the leg ulcer progressed unrestrained without healing, the patients’ attitude towards amputation changed. The patients had a feeling of rotting; they were disgusted, shuddered and shaken by the sight and smell of the ulcer. Their lives was threatened, and the earlier fear for amputation changed for a fear of death. All patients said that there was nothing positive in having a leg ulcer, that life with a leg ulcer was not a life worth living. For one patient amputation was a reality, because “there is no chance that it’ll get better at all”! The fight against the leg ulcers began to be lost and the earlier hope for healing turned to a hope for a quick amputation, for peace and absence from the pain. The other patients had successful blood vessel operations, and that, together with the consistent wound treatment, made the ulcer starting to heal. Seeing the ulcers decreasing in size, they started to believe in victory against the leg ulcer, that it would eventually heal and allowing them a new life. Living with a leg ulcer was a point of no return and changed everything. Patients would live in fear for reoccurring ulcers and be marked by their experience for the rest of their lives: “It’ll always be a part of you. It’ll always be there”. The fight against the leg ulcer could only end with a healed ulcer or an amputation. No matter the outcome, there was a battle against the leg ulcer – to survive. A state between despair and hope When first developing a leg ulcer, patients immediately had some negative thoughts, stating, “…you think gangrene, you think cancer, you think a lot of things. Why 18

won’t it heal”? After four months without healing, it was not possible for them to be positive, and they became scared and vulnerable, and doubted that they would survive. The wound dressings and bandaged reminded them of their situation and they felt sick to death. The patients all blamed themselves for their leg ulcer, because of smoking, alcohol, unhealthy food habits, and stressful jobs: “It’s my own fault that I’ve calcified”. They had all seen their ulcer progress in size, even though specialists treated them. This made them depressed and fearful, and they lost hope. Experiencing this, the patients grew sceptical of health professionals, a feeling that would only truly disappear when the ulcer was almost healed, or healing was not possible at all. Despite the distrust, they needed the support from the nurses, which they got throughout the treatment. The nurses never gave up on hope for healing: “The nurses always say, ““It’s going the right way”, and they’re optimistic. They are like that for years”. This encouragement and support was described as priceless and vital to the patients. One stated, “Without them I don’t think I would be here today”. The nurses awakened a little hope that the despair could not destroy, causing the patients to live in a state between despair and hope. The ulcer controlled everyday life The leg ulcer affected them in every possible way. Daily activities like taking a shower, getting dressed, grocery shopping, and gardening were complicated by the leg ulcer. The patients used to be active with hobbies, but stopped with the leg ulcer. “It stops my swimming, it stops my bowling and it stops our travelling. I can’t ride a bike anymore and things like that”. The patients grew inactive and lost mobility and fitness, which affected them negatively. The ulcers were treated regularly, some on a daily basis, twice/trice a week and some weekly. The strict treatment schedule made them feel trapped and imprisoned. The process of healing the leg ulcer was very slow, and they needed to be patient. One stated, “I thought it’d take 14 days, but now it’s been three years”. One patient was particularly tired of waiting, “This little one, it’s been 18 months now. It isn’t bigger that the tip of that ballpoint pen. It won’t close.….. But what am I to do? Wait! I’m waiting for Godot”. The ulcers even controlled the purchase of shoes, due to the many layers of compression bandage on the foot and leg, which enlarged the foot. All patients found they needed bigger shoes, and had difficulty finding some that would fit and that they liked. They solved the problem by not wearing shoes or wearing sandals, no matter the season. The patients were offered special footwear from EWMA Journal

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the WCC, but they refused to use them and put them in the closet. The look of the shoes was a daily irritation and had a huge impact on how the patients saw themselves. One stated, “I can’t come like the fine gentleman, I used to be”. Therefore, the leg ulcer overtook their life, options and doings, in other words; the leg ulcers controlled everyday life.

worse, despite operation, when is then the right time for amputation? The patients depend on support from the health professionals and if healing is not possible, when should the support change from healing to amputation? And should amputation be executed much earlier? These questions need to be further studied to help bring better care to these patients.

DISCUSSION Constant pain – without the possibility of relief Pain caused by the leg ulcer affected the patients’ everyday life and existence, which is also mentioned in other articles as the worst symptom when living with a leg ulcer10-20. As found in many studies, patients are so severely affected by the pain that their sleep is reduced for many years4,10,13,15,18,19,21-24. Is constant pain – without the possibility of relief a consequence to the arterial disease or the ulcer? It is known that great pain is associated with arterial disease in the legs4. For patients with an arterial component in their leg ulcer, the pain is connected to both the ulcer and minimized blood supply, making it even more painful.

A state between despair and hope Self-reproach and guilt were central feelings and affected the patients, but were also a way to comprehend their situation. These feelings have not been described previously. Furthermore, the patients had all been smokers, and some still were. As smoking is one of the biggest factors that contribute to reduced wound healing27, the guilt and the negative thoughts the patients have may give them psychological stress. This was found to cause significant delayed wound healing, a weakened immune system, increase anxiety and depression, and lower quality of sleep28. Having a low mood is reported in other studies10,12,14,15,17-20; therefore, it is of great importance that the health professionals detect how the patients are affected mentally. Wound treatment is not only the physical treatment, but also a holistic treatment, involving the physical, psychological, social and existential state of the patient, and therefore, nurses need to apply holistic need-orienting nurse intervention.

Analgesic medication is known to have a poor impact on leg pain where intermittent claudication (claudicatio intermittens) occurs25. Insufficient pain-regulated patients are a known problem14,15,18,22,24, and despite taking analgesic medication, the patients from this study found incomplete relief from the pain. These patients continue to have pain, despite medications and the existing knowledge of the phenomenon. Could ultrasound-applied nerve block against pain be an option in the future, or is it too expensive? Should the healthcare system aim at helping through therapy, where total pain relief is not promised as the goal, for instance, through acceptance and commitment therapy26. We need some new ways to pain-regulate these patients, or we need to change our promises of complete pain elimination. An eternal battle against the ulcer – to survive The patients fought to keep their leg, which is also found in three other studies13,15,17. The patients interviewed were disgusted with their leg and rejected it, which has not been described earlier for these types of wounds. For one patient, amputation was a reality, and the earlier fear for amputation changed to a hope for a life after amputation without pain. Therefore, as describes earlier18,23,24 amputation can be the patients’ biggest fear, but also a relief when healing is not possible. When dealing with these types of wounds, blood vessel operation should always be conducted when possible. However, if the wound is progressing from bad to EWMA Journal

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The ulcer controlled everyday life We found that the patients’ world become smaller, they cannot move around, attend their hobbies, or live their normal everyday life – the leg ulcers take over and control everything. Other studies have even reported on decreased activity10,13-20. The patients feel punished and imprisoned because they cannot be away from their home for too long, due to scheduled wound treatments. This situation can be compared to criminals wearing an ankle bracelet with electronic tracking. The difference between the patients and the criminals is that the patients do not know when or if the leg ulcer will heal, whereas the criminals only have to wear the ankle bracelet for maximum six month before they are free. The patients wait to heal, and one patient describe it as waiting on Godot, making a parallel to the French play, En attendant Godot, by Samuel Beckett from 195329, where to characters are waiting endlessly and in vain for the person Godot. Are we doing enough to help these patients? In England, there are Lindsay’s leg ulcer clubs30 that offer leg ulcer treatment and social activities. Instead of being isolated at home, the patients go out to get their treatment and meet others in the same situation. In Denmark, there are no associations for these patients, so maybe the concept in England needs to be adopted by other countries.  19

Science, Practice and Education

The leg ulcer takes ovrer everything, including the choice of buying shoes, which is also reported in other studies13,15,17-19. This has been reported since 1999, and is still a problem today, indicating that the optimal solution is still out there somewhere to be discovered.

Further research: n These patients have problems with footwear. A new study could look at the special needs of the patients and work closely with shoe manufacturers to develop new shoe models.

Limitations of the study There were only six patients â&#x20AC;&#x201C; one with arterial leg ulcer and five with mixed leg ulcers. If there had been the same number of patients with one of the two diagnoses, statements could have been analysed against each other. It is uncertain if interviewing more patients would have created other themes.

n Further

research could enlighten the patient perspective before and after amputation. Had they preferred it earlier or later? n When and what makes a patient change thoughts and attitude towards leg amputation? n Living

CONCLUSIONS The findings from this study give a deeper understanding into how arterial or mixed leg ulcers affect the everyday life of the patients, which is felt like living in a living hell. Patients experience an existential crisis and would rather die than live the rest of their lives with a leg ulcer. These patients are in great pain, feel guilt or self-reproach in relation to how they got their wounds, and they are fighting to keep their leg and to maintain hope. Therefore, it will not be sufficient only to treat the wound. Health professionals need to give individual holistic treatment to each patient, involving the physical, psychological, social and existential state of the patient. We need to treat the wound and the person living with the wound. Even though many interventions have been developed to help these patients (e.g. pain management and specialised wound dressings), this study indicates that there is more to be done.

with a leg ulcer is a life-changing event, and further studies could look at life after healing or am putation in relation to the patients becoming themselves again. Author contributions L. Lernevall performed this study; it is a presentation of her Danish master thesis (June 2015). She was in charge of the design, data collection, data analyses, and drafting and writing of the manuscript. K. Fogh, W. Dam and C. B. Nielsen enabled the recruitment of the patients for this study and gave substantial input to the writing. P. Dreyer was the supervisor, gave substantial input to the design, supervised the creation of this article and commented on and made critical revisions of the manuscript.

Implications for clinical practice n

Healthcare systems need to apply a holistic need orienting nurse intervention for these patients.

n Healthcare professionals should aim at helping patients live with the pain, for instance through therapy, instead of promising total absence of pain during the ulcer period. n Healthcare professionals should discuss the possibility of amputation sooner. If blood vessel operation is not possible and healing is not progressing, one should consider amputation. We cannot let the patients live in living hell for many years.

In many countries, there are no organisations dedicated to help these patients, no places these patients can meet. Could the successful Lindsayâ&#x20AC;&#x2122;s Leg Club organisation from England be adopted31? n

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REFERENCES 1. Caspersen F, Gottrup F, Mathiesen D, Brockdorff A. Sårteam - Organisering af et behandlingstilbud til patienter med problemsår - en medicinsk teknologivurdering. 1st ed. Sundhedsstyrelsen: Sundhedsstyrelsen, Center for Evaluering og Medicinsk Teknologivurdering; 2006. 2. Moffatt C, Vowden K, Price P, Vowden P. Psychosocial factors and delayed healing. In: Moffatt C, Vowden P, Augustin M, Justiniano A, Lindholm C, Margolis D, et al, editors. European Wound Management Association (EWMA). Position Document: Hard-to-heal wounds a holistic approach London: EWMA, MEP Ltd.; 2008. p. 10-14. 3. Faria E, Blanes L, Hochman B, Mesquita Filho M, Ferreira L. Health-related quality of life, self-esteem, and functional status of patients with leg ulcers. WOUNDS 2011;23(1):4-10. 4. Closs SJ, Nelson EA, Briggs M. Can venous and arterial leg ulcers be differentiated by the characteristics of the pain they produce? J Clin Nurs 2008 03;17(5):637-645. 5. Thisted J. Den humanvidenskabelige tradition. In: Thisted J, editor. Forskningsmetode i praksis: projektorienteret videnskabsteori og forskningsmetodik Kbh.: Munksgaard Danmark; 2010. p. 48-64. 6. Martinsen B, Norlyk A, Dreyer PS. Patientperspektivet : en kilde til viden. Kbh.: Munksgaard; 2013. 7. Dreyer PS, Pedersen BD. Distanciation in Ricoeur’s theory of interpretation: narrations in a study of life experiences of living with chronic illness and home mechanical ventilation. Nurs Inq 2009;16(1):6473. 8. Ricoeur P. Interpretation theory : discourse and the surplus of meaning. 6. print. ed. Fort Worth, Tex.: Texas Christian University Press; 1976. 9. Ricoeur P. Hvad er en tekst? Forklare og forstå (1970). In: Ricœur P, editor. Filosofiens kilder Stjernebøgernes kulturbibliotek: Vinten; 1973. p. 101-130. 10. Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. Quality of life in chronic leg ulcer patients. An assessment according to the Nottingham Health Profile. Acta Derm Venereol 1993 Dec;73(6):440443. 11. Hamer C, Cullum NA, Roe BH. Patients’ perceptions of chronic leg ulcers. J Wound Care 1994 03;3(2):99-101. 12. Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications. J Am Acad Dermatol 1994 Jul;31(1):4953. 13. Hyde C, Ward B, Horsfall J, Winder G. Older women’s experience of living with chronic leg ulceration. Int J Nurs Pract 1999 12;5(4):189-198. 14. Wissing U, Ek A, Unosson M. Life situation and function in elderly people with and without leg ulcers. Scand J Caring Sci 2002 03;16(1):59-65.

16. Wilson AB. Quality of life and leg ulceration from the patient’s perspective. Br J Nurs 2004 06/10;13(11):17-20. 17. Briggs M, Flemming K. Living with leg ulceration: a synthesis of qualitative research. Journal of advanced nursing 2007 08/15;59(4):319-328. 18. Herber OR, Schnepp W, Rieger MA. A systematic review on the impact of leg ulceration on patients’ quality of life. Health Qual Life Outcomes 2007 Jul 25;5:44. 19. Slonkova V, Vasku V. Quality of life in the patients with chronic leg ulcers -- a preliminary report. EWMA J 2008 10;8(3):23-23. 20. Parker K. Psychosocial effects of living with a leg ulcer. Nurs Stand 2012 07/11;26(45):52-62. 21. Mudge E, Spanou C, Price P. A focus group study into patients’ perception of chronic wound pain. Wounds UK 2008;4(2):21-28.

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22. Taverner T, Closs J, Briggs M. A meta-synthesis of research on leg ulceration and neuropathic pain. Br J Nurs 2011 11/09;20:18-27. 23. Cwajda-Bialasik J, Szewczyk M, T., Moscicka P, Cierzniakowska K. The locus of pain control in patients with lower limb ulcerations. J Clin Nurs 2012 12;21(23):3346-3351. 24. Taverner T, Closs S,J., Briggs M. The Journey to Chronic Pain: A Grounded Theory of Older Adults’ Experiences of Pain Associated with Leg Ulceration. PAIN MANAGE NURS 2014 03;15(1):186-198. 25. Lindholm C. Sår. Kbh.: Gad; 2005. 26. Wikipedia tfe. Acceptance and commitment therapy. 2016; Available at: https://en.wikipedia.org/ wiki/Acceptance_and_commitment_ therapy?. Accessed 06/10, 2016. 27. Anderson K, Hamm RL. Factors That Impair Wound Healing. The Journal of the American College of Clinical Wound Specialists 2012;4(4):84-91. 28. Guo S, DiPietro LA. Factors Affecting Wound Healing. Journal of Dental Research 2010;89(3):219-229. 29. Beckett S. Waiting for Godot. 2016; Available at: https://en.wikipedia.org/ wiki/Waiting_for_Godot. 30. Lindsay E. Lindsay Leg Club Foundation. Br J Community Nurs 2014 09/02:49-50. 31. The Lindsay Leg Club Foundation. The Lindsay Leg Club Foundation. 2015; Available at: http://www. legclub.org/. Accessed 17 maj, 2015.

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15. Haram RB, Nåden D. Hvordan pasienter opplever å leve med leggsår. Vård i Norden 2003 Årg. 23, pub. 68, nr. 2 (2003):16-21.

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Science, Practice and Education

Illness, Normality, and Self-management:

Diabetic Foot Ulcers and the Logic of Choice

Signe Lindgård Andersen1

Maja Pedersen1

Abstract The accounts of three individuals with diabetes, and their experiences with diabetic foot ulcers, are presented in this article. We discuss how the issues of illness, normality, and self-management appeared to each of the affected individuals. Our aim is to show how the perception of diabetes as a disease that can be relatively easily controlled, has consequences for the diagnosis and treatment of foot ulcers. The analysis was partly inspired by anthropological studies of diabetes patients that revealed a discourse of normality in the sense that treatment allows the individual to live a life not necessarily associated with illness. The analysis was also based on the Dutch philosopher and social scientist Annemarie Mol’s concepts of the logic of choice and the logic of care that question whether it is appropriate to assign more responsibility to the individual for his or her own illness.

INTRODUCTION Foot ulcers occur most frequently among patients with type 2 diabetes. The risk of ulcer development increases as the number of years with diabetes increases1. Diabetic foot ulcers occur primarily among the elderly population. Men have a higher prevalence of foot ulcers compared with women. Overall, it is characteristic for people suffering from diabetic foot ulcers to have reduced physical, emotional, and social functioning1–3. International studies reveal that social isolation, poor education, and low social and economic status increases the vulnerability of these patients and restricts access to care4. Diabetic foot ulcers have consequences for the individual patient and his family in the form of long-term morbidity and disability1. The ulcers cause physical discomfort EWMA Journal

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and reduce mobility and, ultimately, reduced quality of life and loss of self-esteem5,6. There are strong humanitarian and socio-economic reasons to implement more effective prevention and treatment strategies for diabetic foot ulcers. In general, qualitative diabetes research has received more attention in recent years, but research on sequelae (e.g. diabetic foot ulcers) is sparse; several researchers have indicated the need for more studies within this field7,8. However, it is welldocumented that the lack of knowledge about patients’ perceptions of illness in general and more specifically of foot ulcers causes treatment delays and increases the long-term risk of ulceration and amputation4. Authors often present these problems as a result of the patients’ lack of ability and willingness to comply with health care providers’ instructions9. Qualitative studies identify a complex interaction of factors; differences in illness perception, communication, and responsibilities between patients and health care providers have key roles10–12. The aim of this study was to reveal how the perception of diabetes as a disease that can be relatively easily controlled, and therefore allows the person with diabetes to live a nearly normal life, has consequences for the diagnosis and treatment of foot ulcers. We address this issue in a Danish context using three patient narratives. The three illness narratives illustrate the patients’ different strategies for assuming responsibility for their own health. They also reveal how the choices taken by individuals are often systematically inappropriate 

Vibeke Steffen2 1Clinical Research Centre Amager and Hvidovre Hospital Kettegaard Allé 30 2650 Hvidovre Denmark 2Institute

of Anthropology University of Copenhagen Øster Farimagsgade 5, Building 9 1353 Copenhagen Denmark

Correspondence: signe.lindgaard.andersen@ regionh.dk Conflicts of interest: None

and misguided, and in conflict with the medical diagnosis and treatment of foot ulcers. METHODS Our study was based on data collected during a Health Technology Assessment (HTA) initiated by the Danish National Board of Health in 20113. The HTA included a part on patients’ perspectives that examined how people with diabetes perceived the disease and its symptoms in relation to foot ulcers. The study included a systematic literature review (see note 3) and was supplemented with 16 patient interviews. These interviews deserved a more thorough analysis than that provided by the HTA report; our analysis examined these interviews in more detail. The HTA board-affiliated physicians and wound care nurses assisted in recruitment of study participants. The qualitative interviews were conducted in hospital wards and in the meeting and teaching rooms at hospitals and clinics in three regions of Denmark. The interviews followed a semi-structured interview guide and were typically 1 to 2 hours in length. Cognitive impairment and mental instability were primary reasons for exclusion. The participants were ten men and six women (age range, 37–79 years). Some of the participants had foot ulcers for a few months; others had contended with foot ulcers for many years. Several patients had undergone amputation surgery. The patients also had other diabetes complications (e.g. eye disease, kidney failure). The three case studies of the key participants analysed in this paper were selected from the group of 16 interviewees across gender, age, and social status. We chose these participants because they highlighted the challenges people with diabetic foot ulcers encounter when selecting the correct choices and finding the correct balance between normality, freedom of choice, and self-management. Before each interview, each participant was given information about its purpose and was reminded that his or her responses were voluntary and anonymous. A physician provided information about the study to each participant and verbal consent was given to the researcher before the interview began. The participants could withdraw from the study at any time. ANALYSIS “Normal” with diabetes The conversations with the diabetic foot ulcer patients revealed a conspicuous lack of disease perception among the group. A number of significant contributions to medical anthropology have demonstrated the perception of illness as a gateway to understanding disease management13,14. However, this approach seemed inadequate for patients 24

with diabetic foot ulcers. They often insisted on living, and strived to live, as normally as possible despite serious foot ulcers. The published literature’s emphasis on “compliance” as a key factor in the treatment of foot ulcers also seemed inadequate. There is a long tradition of studying the variation in the interpretation of disease over time and across societies and cultures within the anthropology of health15. Perceptions of illness in different clinical contexts, and in relationship to different diagnoses, have been analysed13,16. The perceptions and expectations of health and disease have key roles in prevention and treatment. However, when examining perceptions of illness among people with diabetes, the most significant finding is the very strong emphasis on normality. The Danish anthropologist Regnar Kristensen has shown how the Danish Diabetes Association’s language changed around 1980. Instead of having diabetes, affected individuals were referred to as being a person with diabetes17. This change also affected perception (i.e. from being diabetic patients to being diabetics). The change in language reflected a change in health educational efforts. The emphasis shifted from considering diabetes as only a metabolic dysfunction, to including the physical and mental being of the whole person. The diagnosis was thus expanded to an identity in which the disease aspects and patient roles were reduced in scale in favour of a health discourse that identified the diabetic as a responsible manager of his own health. As a result, the patient (and significant others) can be inclined to conclude that if a diabetic complies with the requirements of the triune treatment (i.e. insulin, diet, and exercise), it is paradoxically now considered “not normal” to be ill as a diabetic17. The Norwegian anthropologist, Per Kristian Hilden18, has emphasised that technological and organisational developments in diabetes treatment are key factors contributing to normalisation of the disease. He shows how patient education and biomedical regulations for people with diabetes have an almost exaggerated focus on normality that tends to reduce the effects of the disease on the cultural and social understanding of the self18. Diabetes treatment mostly emphasises self-management and the diabetic’s ability to self-care. A crucial component of self-management is the claim that the knowledge, technology, and practical aspects of treatment available to people with diabetes make it possible to control, and reduce the severity of, the disease. In particular, technological development of treatments incorporating blood glucose testing (e.g. HbA1c tests) simplifies the meaning of to “be in control of the life with diabetes”. The consequence of the increased focus on normality EWMA Journal

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via instrumental regulation and self-management is that successful treatment increasingly becomes the patient’s responsibility. The social scientist and philosopher, Annemarie Mol, describes two fundamentally different ways of viewing and managing the relationship between the patient and the health care system19; the two views are “the logic of choice” and “the logic of care”, respectively. “The logic of choice” includes the idea and the ideal of free personal choice. Since the 1970s, personal choice has assumed an increasingly important role in the health care system. For example, emphasis on patients’ rights and informed consent is a counterweight to the paternalism that characterised the relationship between the patient and the health care system19. Introduction of the “logic of choice” results in radical changes; the physician increasingly assumes the role of manager and provider of solutions and the patient is redefined as the consumer of these services, writes Mol. Considering this general trend in the health care system allows understanding of the increased focus on self-management, freedom of choice, and personal responsibility in diabetes care and the efforts to live a normal life. Mol proposes “the logic of care” as an alternative to “the logic of choice”. “The logic of care” is a pragmatic approach to therapy that focuses on how to live with the disease. The question becomes not who is responsible, but what must be done. The development of the disease over time does not occur in a linear sequence. It involves a tortuous path with unexpected twists and turns, so there is no direct correlation between personal choice and health condition19. Patients act as individuals who make choices and as individuals who are part of a network of countless other activities and assessments beyond the clinical context of the disease. The patient and the health care providers contribute with solutions to, and act in relationship to, the problems, changes, and unforeseen events that occur in a life with diabetes19. Case 1: “Normally, I don’t have foot ulcers” The study participant, Jytte, was 62 years of age. She was diagnosed with type 2 diabetes 17 years previously. The interview revealed a very committed, independent, and active woman with an academic background. In many ways, she had lived her life unaffected by her diabetes until 1 year ago, when she developed a foot ulcer. After a run, Jytte found a blister under her big toe that quickly developed into a wound. She thought it was harmless and over the next three months she tried to encourage healing by changing her footwear and cleaning the lesion. She decided she would not trouble her physician with such a small wound. Eventually, the wound developed a severe infection. Jytte visited the hospital and surgery was performed. The interview with Jytte revealed her efforts towards normality and her pragmatic approach to disease. She basiEWMA Journal

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cally regarded herself as healthy. When asked how the foot ulcers affected her life, she exclaimed, “Normally, I don’t have foot ulcers”, which indicated that she viewed the foot ulcer as a temporary problem. She distanced herself from this chronic disease. She explained her attitude:

“I want to live as close to normal as possible. I’d rather not be made sick. Sometimes there is also someone out here at the centre (The Diabetes Health Care Centre), who asks why I don’t make some more blood glucose tests. And I say it is because it makes me feel medicalised. There are those that measure their blood sugar every day and measure blood pressure constantly. I don’t think that is necessary for me. If I did, I would feel sick constantly. I don’t think I am.” Generally, technological management of diabetes plays a major role in a patient’s health beliefs and lack of experience with illness. A person with a well-regulated and uncomplicated diabetes does not feel the presence of the disease; it remains an abstraction (i.e. Wittrup’s “shadow disease”)20. The sense of disease was absent for Jytte. She preferred to talk about her educational background, career choices, and grandchildren, and not her life with diabetes. As Hilden points out, the technological management of diabetes allows the patient to live a normal life – which is what Jytte made a virtue of – and to maintain the freedom to prioritise and choose one’s own lifestyle (18). Hilden writes:

“The promotion of self-management serves to link choice to the general understanding of living a normal life. The implication is that diabetes should no longer be considered an impediment to the free choosing of what life to live, which in the cultural context is taken to characterise normal life”18. Thus, it is the responsibility of the individual with diabetes to self-manage the illness and to control the extent to which the illness should affect daily life. 

The positive message about the well-controlled diabetic partly explains why people with diabetes are generally not as concerned about understanding or explaining their illness as people with other chronic diseases such as cancer21. There was no clear illness perception in Jytte’s responses or in the responses of other study participants. Instead, they often referred to doctors when asked about their condition. Diabetes is a complex disease because several conditions occur simultaneously in the same patient. Many patients act in ways that differ significantly from what is expected by healthcare providers. Jytte felt she could self-manage the wound, so she implemented footwear changes and used foot baths:

“I thought I had to be careful and change to some other shoes, and then I could probably make the wound go away. But you cannot. (…) I simply could not make it heal. Now I have learned that you should not just postpone it and think that you can handle it yourself. Usually you cannot. (…) But you don’t like to be any trouble”. Because she had many years of experience with diabetes and self-management, Jytte concluded that she could handle her own wound. But, by trivialising it as a small impairment, she unintentionally prevented the healing of her foot ulcer. In Jytte’s case, the abstract perception of illness and the effort to live life as normally as possible had the serious consequence of development of a severe foot ulcer. “Homework” and strategic risk assessment Grøn et al. uses the concept of ‘homework’, which refers to the activities that the health care system instructs chronic disease patients to perform at home for care of their condition22. These multi-faceted tasks require adaptation to, and modification of, family routines and everyday situations22. Homework implies a context of social complexity in which the patient is confronted by a number of ambivalent situations characterised by tension between sociality and treatment considerations22. This tension often results in Campbell et al.’s ‘strategic non-compliance’; the patient deliberately defies the health care provider’s instructions in an attempt to achieve a balance between being a patient and live an acceptable life7. The concepts of ‘homework’ and ‘strategic non-compliance’ are useful for understanding the circumstances of patients with diabetic foot ulcers. As they attempt to lead normal lives, they are confronted 26

with dilemmas that they try to solve pragmatically and based on their personal experiences. In general, individuals with diabetes have practised active homework for years because the disease is managed through daily blood glucose measurements, insulin injections, and regulation of diet. The life of patients with diabetic foot ulcers however is characterised by great physical discomfort, which includes long periods of time not walking or putting weight on the foot so that the ulcer can heal. The patient’s homework is then paradoxically reformulated into a passive waiting. This quest to behave perfectly at rest is an almost impossible task, which prevents the patient from accomplishing normal social roles. This results in a reduced quality of life (e.g. physically, socially, emotionally, and economically) in all aspects of being for the patients and their relatives23. Their homework must be adapted to a reality in which they are aware that agency is likely to worsen the wound, while passive waiting reduces their social contacts and participation in society. Preben’s responses illustrate this dilemma. Compared with the other participants, Preben was a relatively more experienced diabetic foot ulcer patient. He had recently completed his first period of hospitalisation for foot ulcer treatment. After treatment at the hospital, patients like Preben often find themselves in a contradictory situation at home. Previous experience with life as an active diabetic corresponds poorly with the treatment requirements of passive waiting; the requirements of wound healing often lose ground for normality.Case 2: “I have a son and he gets no food then” Preben was 53 years of age. He was a trained chef who lived alone with his son. He chose to stay for the weekend at the hotel that was affiliated with the hospital. Preben was characteristically easy-going; he loved to use his high spirits and good cooking to please others. Preben had many years of experience managing type 2 diabetes, while the foot ulcer first appeared less than 6 months ago. His district nurse discovered the ulcer and immediately referred him to the hospital. Shortly after hospitalisation, he underwent surgery and had a challenging recovery period because he was instructed not to walk or lean on his foot. He stayed at home for a short period, but it was difficult for him to comply with the instructions. He expressed frustration that he would not be able to purchase groceries and cook for his son. He was unable to cope with the circumstances at home, so he returned to the hospital because he felt safer and more cared for in that environment. The wound was in remission at the time of the interview, but Preben was concerned about how he would cope after he was discharged from the hospital.

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Like Jytte, Preben lacked a concrete sense of the serious nature of foot ulcers. He referred to the condition as a “luxury problem” that he should not complain about. This perception affected his approach to the management of the ulcer at home. In that environment, he had to confront his inability to prepare food for his son if he complied with the health care providers’ recommendations to avoid walking. The patient’s strategic risk assessment emerges especially in relationship to reliance on other people for assistance with everyday practical tasks and personal care. The patient experiences humiliation when compelled to request help. To maintain autonomy and dignity in social relationships many patients chose mobility instead of ulcer healing24. Preben commented: “I had no wheelchair. I had a pair of crutches, and then I had to make some food and … (shrugs) … I have a son, and he will not get any food then. (…) Then you want to use the toilet. Ah, it doesn’t matter if I just stomp on my toes, I thought. And then it goes wrong, of course. You want to be independent, you know, and I prefer to do things by myself. I will not ask for help, though I have to. I get home care now. But to stop me from cooking, that, I will not do. I will cook no matter how old I get”. Preben experienced the consequences of long-term treatments and learned from his negative experiences. Eventually, he understood the importance and the need to accept assistance from others. Later in the interview, he said, “Now I don’t bother anymore.” However, he was still affected by the dilemma of managing self-care and continuing to cook even though the activity would have negative effects on ulcer healing. Preben might have understood the seriousness of his condition and the consequences of walking on the ulcerated foot. In practice, however, the patient confronts other stand-alone and competing issues, so other solutions are selected to achieve a balance between a desirable life and ulcer healing. The article on homework22 indicated that consideration of social relationships is often included in the circumstances during which the patient acts inappropriately. In particular, fear of social isolation and of being a burden to others combined with the effort to maintain a normal everyday life causes the patient with diabetic foot ulcers to act inappropriately in relation to ulcer healing. For Preben, it was the utmost pleasure of cooking for his son. For other patients, assuming responsibility for their personal hygiene may provide a minimal sense of personal empowerment and autonomy. Passive waiting as homework complicates the patient’s role and the efforts to be a “good patient”. Diabetes treatment generally encourages self-management based on the principles of

freedom and normality. It thus defines the independent and active patient as the good patient. However, foot ulcer treatment requires the opposite response of passivity and relinquishment of normality. It is difficult to navigate in the gap between the hospital and the home environments. The interviews with Preben suggested that he was concerned about returning home and reassuming responsibility for self-care. He chose to remain at the patient hotel for a week although from a therapeutic perspective he was ready to go home. Preben is a good example of how the transition from the hospital’s safe environment to the challenging situation at home mirrors a shift from the logic of care to the logic of freedom. In the hospital context, he understood that he could receive support for his personal care and that he would be cared for without having to manage the foot ulcers. As he said: “Out here (at the hospital) I am carried on my hands and feet. It’s great”. Preben and the other patients experienced the health care system as primarily a caring environment. Problems arise when the logic of care is limited to the hospital context, and personal responsibility for the illness is returned to the patient at the time of discharge from the hospital. Personal responsibility, guilt, and the logic of choice In the previous sections, we illustrated how patients experience physical and practical burdens in relation to the development of foot ulcers. The psychological consequences (e.g. guilt and self-blame) that often accompany strategic non-compliance can be a heavy burden for patients with diabetic foot ulcers. As previously discussed, the linguistic shift from having diabetes to being a diabetic has expanded the concept of diabetes from referring to a metabolic dysfunction to including the patient’s personal identity. Kristensen problematises this change and suggests that people with diabetes are more vulnerable because their entire identity becomes threatened by the disease17. When the diabetes patient did not comply with the treatment requirements, he ‘sinned’ against the doctor and against the object of the doctor’s interest (i.e. the body). But, as the emphasis shifted to self-management the responsibility for, and control of, treatment was partly transferred to the patient17. The diabetic now sins against himself. Emotions such as guilt, anger, and frustration are now directed towards the self. The less successful diabetic may now confront the burden of both illness and failure as a person, and this change in sense of responsibility has caused more people with diabetes to experience psychological problems17. In Hilden’s view, the emphasis on self-management and personal responsibility becomes problematic with the appearance of complications: 

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“I would like to argue that, to the extent that one attempts to attribute the long-term complications from which one suffers to type 1 diabetes, the logic of self-management “backfires”. This logic effectively attributes long-term complications, not to diabetes mellitus as such, but to its management and, hence, to the person in charge of that management”18. The responsibility for the development of sequelae is placed on the person with diabetes; several of the patients with foot ulcers blamed themselves for their current circumstances. This is illustrated by the responses of the participant, Mathias, who had struggled with diabetic foot ulcers for years. Case 3: “If only I had listened properly” Mathias was 37 years of age at the time of the interview. He used to work as a slaughterhouse worker, when he was diagnosed with diabetes in 1992. His first foot ulcer developed 5 years before the interview. When the foot ulcer first appeared, Mathias was preoccupied with earning an income. Despite warnings from others, he ignored what appeared to be a minor scratch. The diabetes education provided by the hospital had informed him about possible sequelae. However, because the ulcer was not painful he did not visit a physician until he detected an odour. His response was too late, and the fourth and fifth toes and part of the foot were amputated. During the year following surgery, he was readmitted to the hospital many times for problems related to the healing process, for new emerging ulcers, and for surgery. The disease gradually affected all aspects of his life. He took early retirement, gave up playing football, lost his friends, and felt physically, socially, and psychologically crippled. Frustration, depression, and self-blame emerged concurrently with the lack of progress during healing. Severely depressed, Mathias attempted suicide a year before our interview. The poor healing response and need for amputation forced Mathias to understand the severity of his foot ulcers and triggered guilt, anger, and depression. These emotional responses were supported by the rhetoric that emphasised personal responsibility; Mathias developed low self-esteem. During the interview he repeatedly commented that his present condition might have been avoided if he had listened to the doctors’ advice, “If only I had listened properly, it might never have happened. Then you blame yourself ”.

Annemarie Mol explains that “the logic of choice” goes along with guilt and self-blame. When one makes a personal choice, one is also responsible for the consequences of that choice; there is only one to blame for negative outcomes19. A patient’s sense of logic informs him that the circumstances that emerge after a choice has been taken must be the consequences of that choice. Although individuals recognise that they constitute a large part of everyday experiences, coincidence and unforeseen incidents are not part of this framework. The logic of choice has a chronological time line that moves from information (neutral) to selection (value-laden), then to action (technical) and evaluation19. The following statement indicated that Mathias assessed his current condition as a direct consequence of the choices he selected: “It all goes back to the fact that I was too stubborn and stupid when I got the foot ulcer. So it all goes back to the foot ulcer”. This view retrospectively reduces the complex interactions between daily incidents and events to a single determinant and to individual choice between well-defined options. The consequence of placing the emphasis on personal responsibility and apparently free choice rather than on caring and professional advice is that the disease becomes a psychological burden for patients. Mol argues for the logic of care as an alternative to the logic of choice. The logic of choice attributes the responsibility for illness to lack of control and to poor choices. Within the logic of care framework, illness is viewed as basically uncontrollable and unpredictable. Mol writes that in spite of what we would like to believe, the disease cannot be controlled19. From the logic of care perspective, Mathias’ choice to continue working despite the presence of serious foot ulcers was only one choice among other choices and actions that could not be ascribed unambiguous consequences, including that he was now confined to a wheelchair and received state-funded social security payments. This process is interactive; the need to choose, claim responsibility, and assume guilt constantly shifts positions. This process is referred to as “shared doctoring” by Mol. Unlike the discourse of normality in diabetes treatment, life with diabetes cannot be subjected to a higher level of control19. By contrast, she describes life with diabetes as a life of continuous adaptation. The logic of care represents a more pragmatic approach to disease and treatment. Compared with the discourse of choice, the logic of care is more harmonious with most of the experiences of patients with diabetic foot ulcers. Analysis of the experiences of Jytte, Preben, and Mathias revealed that life with diabetic foot ulcers includes tension between illness, normality, and self-management. Managing life with diabetes is much more complex than making correct

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and informed choices. The conflicting demands between social responsibility and an active life versus ideal wound care and passive waiting result in a difficult balancing act between different considerations rather than a straight forward road with rational choices and correct solutions. CONCLUSION Analysis of these three empirical cases revealed a group of patients negatively affected by a discourse of normality, self-management, and the logic of choice. Patients with diabetic foot ulcers experience sudden changes. They move from normality to illness, from care during hospitalisation to self-management at home, and from the role of the active diabetic to the passive patient with diabetic foot ulcers. These changes make them particularly vulnerable and expose them to negative consequences that are greater than those attributable to the disease itself.

Synthesis of the normality discourse within diabetes treatment with Annemarie Mol’s concepts of the logic of choice and the logic of care in the treatment of diabetic foot ulcers clarifies understanding of the contradictory situations that patients experience. Both the resourceful and active patients and the disadvantaged and passive patients behave inappropriately when they attempt to select the correct choices during management of their health problems. Paradoxically, total passivity is often the main requirement for the patient with diabetic foot ulcers. Close collaboration between the clinical reality and the patient’s everyday life, and the correct balance between logic of care and logic of choice are crucial for a successful treatment outcome.

Clinical recommendations Based on the findings of this study, we propose some recommendations for clinical practice. First, it is important that the clinician understands important aspects of the patient’s everyday life (e.g. social and work commitments). Lack of this information may challenge the patient´s ability to follow treatment instructions for care of the foot ulcer. Second, the clinician should emphasise to the patient that compared with a normal ulcer, a diabetic foot ulcer has different characteristics and is a much more severe lesion. Finally, the patient must be reminded that his new circumstances require total passivity and that this requirement conflicts with the general recommendations about exercise and activity that are given during the treatment of diabetes.

NOTES 1. This manuscript is a revised and translated version of an original article published in the Danish peer-reviewed journal: Tidsskrift for Sygdom og Samfund in 2013, volume 19, pp. 121-140. In 2013, the paper was reprinted in the Danish magazine, Sår. The journal and the magazine have been informed about, and have agreed to, publication of the edited reprint of the article. 2. The patient survey included in the Health Technology Assessment on diabetic foot ulcers was conducted by the author. Parts of it have been published in the National Board of Health Report (2011). We thank the Danish Board of Health and the entire project team for their cooperation. We especially thank Niels Ejskjær for encouragement and for assisting us with contact with the patients. We also thank the patients who kindly participated in the interviews. 3. A literature search of seven databases (Medline, Embase, CINAHL, Psych Info, and International Biography of Social Science (IBSS)) was performed. The search terms were: diabetic foot ulcer, diabetes and patient experience, diabetes and adherence, diabetes and patient care, diabetes and anthropology. We also performed a general literature search on people with diabetes and their experiences with diabetes and foot ulcers in REX (The Royal Library) and in the Literature Database (DSI library). Thirty out of the 130 studies that the search revealed were included in the patient perspectives section of this report.

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Science, Practice and Education

REFERENCES 1. Boulton AJM, Vileikyte L, RagnarsonTennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet Lond Engl. 12. november 2005;366(9498):1719–24.

15. Steffen V, Meldgaard M. Om fortolkninger og sundhedsopfattelser. I: Steffen, V (red): Sundhedens veje: grundbog i sundhedsantropologi. Kbh.: Hans Reitzel; 2006.

2. Molvær AK, Graue M, Espehaug B, Østbye T, Midthjell K, Iversen MM. Diabetes-related foot ulcers and associated factors: results from the Nord-Trøndelag Health Survey (HUNT3) (2006-2008). J Diabetes Complications. april 2014;28(2):156–61.

16. Eisenberg L, Kleinman A, redaktører. The Relevance of social science for medicine. Dordrecht ; Boston : Hingham, MA: D. Reidel Pub. Co. ; distributed in the U.S.A. and Canada by Kluwer Boston; 1981. 422 s. (Culture, illness, and healing).

9. Delamater AM. Improving Patient Adherence. Clin Diabetes. 1. april 2006;24(2):71–7. 10. Cohen MZ, Tripp-Reimer T, Smith C, Sorofman B, Lively S. Explanatory models of diabetes: Patient practitioner variation. Soc Sci Med. 1. januar 1994;38(1):59–66. 11. Gale L, Vedhara K, Searle A, Kemple T, Campbell R. Patients’ perspectives on foot complications in type 2 diabetes: a qualitative study. Br J Gen Pr. 1. august 2008;58(553):555–63. 12. Petersson P, Springett J, Blomqvist K. The triumph of hope over experience: using peoples’ experiences to inform leg ulcer care through participatory action research. J Nurs Healthc Chronic Illn. 1. marts 2009;1(1):96– 104. 13. Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. 8. [print]. Berkeley: University of California Press; 2003. 427 s. (Comparative studies of health systems and medical care). 14. Helman C. Culture, health and illness: an introduction for health professionals. Bristol: Wright; 1984. 242 s.

21. Skov Jensen SF, Kræftens Bekæmpelse (forening). Hvad er meningen med kræft?: en antropologisk undersøgelse blandt danske patienter og behandlere. Kbh.: Kræftens Bekæmpelse : [Eksp. Fællesekspeditionen; 1987.

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8. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T. 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. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. marts 2007;16(2):179–89.

20. Wittrup I. Læring og mestring, patientuddannelse på deltagernes præmisser, kvalitiv evaluering. 1. oplag. Århus: Region Midtjylland, Center for Folkesundhed og Kvalitetsudvikling; 2011.

7. Campbell R, Pound P, Pope C, Britten N, Pill R, Morgan M, m.fl. Evaluating meta-ethnography: a synthesis of qualitative research on lay experiences of diabetes and diabetes care. Soc Sci Med. februar 2003;56(4):671–84.

19. Mol A. The logic of care, health and the problem of patient choice. Abingdon, Oxon: Routledge; 2008. xii+129.

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6. Sutton M, McGrath C, Brady L, Ward J. Diabetic foot care: assessing the impact of care on the whole patient. Pract Diabetes Int. 1. juli 2000;17(5):147–51.

18. Hilden PK. Risk and late modern health: socialities of a crossed-out pancreas. [Oslo]: Faculty of Medicine, University of Oslo; 2003.

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5. Goodrigde D, Trepman E, Embil JM, Doughty D. Ovid: Health-Related Quality of Life in Diabetic Patients With Foot Ulcers: Literature Review. [Internet]. [henvist 28. september 2016]. T

17. Kristensen R. At være eller ikke være diabetiker? En antropologisk undersøgelse af sundhedspædagogikken inden for diabetesbehandlingen og blandt diabetikere. Tidsskr Forsk Sygd Og Samf [Internet]. 2008 [henvist 28. september 2016];5(9). Tilgængelig hos: http://ojs.statsbiblioteket.dk/index.php/sygdomogsamfund/article/viewArticle/1327

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4. Apelqvist J. The foot in perspective. Diabetes Metab Res Rev. juni 2008;24 Suppl 1:S110-115.

13th Conference of the European Council of Enterostomal Therapists

3. Diabetiske fordsår - En Medicinsk Teknologivurdering. [Internet]. Sundhedsstyrelsen. [henvist 28. september 2016]. Tilgængelig hos: http://sundhedsstyrelsen.dk/~/media/ B2F4C74504034E878304BF259EA8D46B.ashx

ECET2017

22. Grøn L, Mattingly C, Meinert L. Kronisk hjemmearbejde. Sociale håb, dilemmaer og konflikter i hjemmearbejdsnarrativer i Uganda, Danmark og USA. Tidsskr Forsk Sygd Og Samf [Internet]. 18. september 2008 [henvist 29. september 2016];5(9). Tilgængelig hos: http://ojs.statsbiblioteket.dk/index.php/sygdomogsamfund/article/view/1328 23. Kinmond K, McGee P, Gough S, Ashford R. “Loss of self”: a psychosocial study of the quality of life of adults with diabetic foot ulceration. J Tissue Viability. 1. januar 2003;13(1):6–16. 24. Livskvalitet hos diabetikere med fodsår indlagt i Videncenter for Sårheling. Britta Østergaard Melby [Internet]. [henvist 29. september 2016]. Tilgængelig hos: http:// docplayer.dk/2215442-Livskvalitethos-diabetikere-med-fodsaar-indlagti-videncenter-for-saarheling-brittaoestergaard-melby.html

www.ecet2017.org Building bridges – from west to east, from south to north Ostomy – Continence – Wound European Nurses with academic nature and good clinical experience for ostomy, incontinence and wound care

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End IAD today, prevent it tomorrow Thursday 4th May 16:00 – 17:00 in Forum Preventing and treating skin breakdown due to the devastating influences of incontinence, leading to IAD, remains a clinical challenge. Attend the IAD symposium to learn more. Key speakers include Prof. Lisette Schoonhoven, Prof. Dimitri Beeckman, Dr. Jan Kottner, Mary Brennan rn mba cwon faacws and Debra Thayer Msc.

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Cochrane Reviews

ABSTRACTS OF RECENT COCHRANE REVIEWS Internal dressings for healing perianal abscess cavities

Selection criteria: Published or unpublished randomised controlled trials (RCTs) comparing any type of internal dressing (packing) used in the post-operative management of perianal abscess cavities with alternative treatments or different types of internal dressing.

Stella R Smith, Katy Newton, Jennifer A Smith, Jo C Dumville, Zipporah Iheozor-Ejiofor, Lyndsay E Pearce, Paul J Barrow, Laura Hancock, James Hill

Data collection and analysis: Two review authors independently performed study selection, risk of bias assessment, and data extraction.

Smith SR, Newton K, Smith JA, Dumville JC, IheozorEjiofor Z, Pearce LE, Barrow PJ, Hancock L, Hill J. Internal dressings for healing perianal abscess cavities. Cochrane Database of Systematic Reviews 2016, Issue 8 . Art. No.: CD011193. DOI: 10.1002/14651858. CD011193.pub2.

Main results: We included two studies, with a total of 64 randomised participants (50 and 14 participants) aged 18 years or over, with a perianal abscess. In both studies, participants were enrolled on the first postoperative day and randomised to continued packing by community district nursing teams or to no packing. Participants in the non-packing group managed their own wounds in the community and used absorbant dressings to cover the area. Fortnightly follow-up was undertaken until the cavity closed and the skin re-epithelialised, which constituted healing. For non-attenders, telephone follow-up was conducted.

Publication in The Cochrane Library Issue 8, 2016

ABSTRACT Background: A perianal abscess is a collection of pus under the skin, around the anus. It usually occurs due to an infection of an anal gland. In the UK, the annual incidence is 40 per 100,000 of the adult population, and the standard treatment is admission to hospital for incision and drainage under general anaesthetic. Following drainage of the pus, an internal dressing (pack) is placed into the cavity to stop bleeding. Common practice is for community nursing teams to change the pack regularly until the cavity heals. Some practitioners in the USA and Australia make a small stab incision under local anaesthetic and place a catheter into the cavity which drains into an external dressing. It is removed when it stops draining. Elsewhere in the USA, simple drainage is performed in an outpatient setting under local anaesthetic. Objectives: To assess the effects of internal dressings in healing wound cavities resulting from drainage of perianal abscesses. Search methods: In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (InProcess & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries to identify ongoing and unpublished studies, and searched reference lists of relevant reports to identify additional studies. We did not restrict studies with respect to language, date of publication, or study setting. EWMA Journal

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Gill Rizzello Managing editor Cochrane Wounds, School of Nursing, Midwifery and Social Work, University of Manchester.

Both studies were at high risk of bias due to risk of attrition, performance and detection bias. It was not possible to pool the two studies for the outcome of time to healing. It is unclear whether continued post-operative packing of the cavity of perianal abscesses affects time to complete healing. One study reported a mean time to wound healing of 26.8 days (95% confidence interval (CI) 22.7 to 30.7) in the packing group and 19.5 days (95% CI 13.6 to 25.4) in the non-packing group (it was not clear if all participants healed). We re-analysed the data and found no clear difference in the time to healing (7.30 days longer in the packing group, 95% CI -2.24 to 16.84; 14 participants). This was assessed as very low quality evidence (downgraded three levels for very serious imprecision and serious risk of bias). The second study reported a median time to complete wound healing of 24.5 days (range 10 to 150 days) in the packing group and 21 days (range 8 to 90 days) in the non-packed group. There was insufficient information to be able to recreate the analysis and the original analysis was inappropriate (did not account for censoring). This second study also provided very low quality evidence (downgraded four levels for serious risk of bias, serious indirectness and very serious imprecision).

Correspondence: gill.rizzello@ manchester.ac.uk More information: www.wounds.cochrane.org Conflicts of interest: None

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There was very low quality evidence (downgraded for risk of bias, indirectness and imprecision) of no difference in wound pain scores at the initial dressing change. Both studies also reported patients’ retrospective judgement of wound pain over the preceding two weeks (visual analogue scale, VAS) as lower for the non-packed group (2; both studies) compared with the packed group (0; both studies); (very low quality evidence) but we have been unable to reproduce these analyses as no variance data were published.

ies, we found only two randomised controlled trials (RCTs) that were eligible for this review (RCTs provide more robust results than other trial types). The studies were small with a total of 64 participants randomised, all over 18 years of age, with a perianal abscess. In the studies, participants received either packing by community nursing teams or no packing. Participants in the non-packing group managed their own wounds by using absorbant dressings to cover the area with no internal dressing. Participants were seen fortnightly until the cavity had healed.

There was no clear evidence of a difference in the number of post-operative fistulae detected between the packed and nonpacked groups (risk ratio (RR) 2.31, 95% CIs 0.56 to 9.45, I2 = 0%) (very low quality evidence downgraded three levels for very serious imprecision and serious risk of bias).

It is not clear whether time to complete wound healing is affected by packing of cavity (and what evidence exists is very low quality). There was very low quality evidence that packing made no difference to wound pain at the first dressing change. There was very low quality evidence that on judging the wound pain over the preceding two weeks, participants in the packing group had experienced more pain that those in the non-packing group.

There was no clear evidence of a difference in the number of abscess recurrences between the packed and non-packed groups over the variable follow-up periods (RR 0.72, 95% CI 0.22 to 2.37, I2 = 0%) (very low quality evidence downgraded three levels for serious risk of bias and very serious imprecision). No study reported participant health-related quality of life/health status, incontinence rates, time to return to work or normal function, resource use in terms of number of dressing changes or visits to a nurse, or change in wound size. Authors’ conclusions: It is unclear whether using internal dressings (packing) for the healing of perianal abscess cavities influences time to healing, wound pain, development of fistulae, abscess recurrence or other outcomes. Despite this absence of evidence, the practice of packing abscess cavities is commonplace. Given the lack of high quality evidence, decisions to pack may be based on local practices or patient preferences. Further clinical research is needed to assess the effects and patient experience of packing.

Plain language summary Internal dressings for healing perianal abscess cavities What are perianal abscesses and how are they treated? A perianal abscess is a collection of pus under the skin around the anus (back passage); perianal abscesses are common, and usually due to an infection in an anal gland. In the UK, the standard treatment is to have an operation under anaesthetic to cut the skin and drain the pus. This prevents the infection spreading and relieves pain in the affected area. An internal dressing (otherwise known as a “pack”) is placed inside the abscess cavity, initially to stop bleeding. The pack is changed by nurses in the community regularly until the cavity has healed. It is thought that packing the cavity reduces the chance of the abscess recurring. Some patients go on to develop a fistula after a perianal abscess. A fistula is an abnormal communication between the anus and the skin next to it and a small hole next to the anus discharges pus intermittently. Fistulae can take many months and several operations to heal. This review aims to assess the effects of packs on healing perianal abscess cavities, particularly the time it took for the cavities to heal, and the amount of pain patients experienced. What we found: After extensive searching to find relevant stud36

It is not clear whether packing or not affects the number of postoperative fistulae or abscess recurrences. We did not find any RCTs that compared participant healthrelated quality of life/health status, incontinence rates, time to return to work or normal function, resource use in terms of number of dressing changes or visits to a nurse, or change in wound size. There is no high quality evidence for the use of packing for healing perianal abscess cavities. Assessed as up to date 17th May 2016.

Publication in The Cochrane Library Issue 11, 2016

Topical antibiotics for preventing surgical site infection in wounds healing by primary intention Clare F Heal, Jennifer L Banks, Phoebe D Lepper, Evangelos Kontopantelis, Mieke L van Driel Citation example: Heal CF, Banks JL, Lepper PD, Kontopantelis E, van Driel ML. Topical antibiotics for preventing surgical site infection in wounds healing by primary intention. Cochrane Database of Systematic Reviews 2016, Issue 11 . Art. No.: CD011426. DOI: 10.1002/14651858.CD011426.pub2. ABSTRACT Background: Surgical site infections (SSI) can delay wound healing, impair cosmetic outcome and increase healthcare costs. Topical antibiotics are sometimes used to reduce microbial contaminant exposure following surgical procedures, with the aim of reducing SSIs. Objectives: The primary objective of this review was to determine whether the application of topical antibiotics to surgical wounds that are healing by primary intention reduces the incidence of SSI and whether it increases the incidence of adverse outcomes (allergic contact dermatitis, infections with patterns of

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antibiotic resistance and anaphylaxis). Search methods: In May 2015 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL. We also searched clinical trial registries for ongoing studies, and bibliographies of relevant publications to identify further eligible trials. There was no restriction of language, date of study or setting. The search was repeated in May 2016 to ensure currency of included studies. Selection criteria: All randomized controlled trials (RCTs) and quasi-randomised trials that assessed the effects of topical antibiotics (any formulation, including impregnated dressings) in people with surgical wounds healing by primary intention were eligible for inclusion. Data collection and analysis: Two review authors independently selected studies and independently extracted data. Two authors then assessed the studies for risk of bias. Risk ratios were calculated for dichotomous variables, and when a sufficient number of comparable trials were available, trials were pooled in a metaanalysis. Main results: A total of 10 RCTs and four quasi-randomised trials with 6466 participants met the inclusion criteria. Six studies involved minor procedures conducted in an outpatient or emergency department setting; eight studies involved major surgery conducted in theatre. Nine different topical antibiotics were included. We included two three-arm trials, two four-arm trials and 10 two-arm trials. The control groups comprised; an alternative topical antibiotic (two studies), topical antiseptic (six studies) and no topical antibiotic (10 studies), which comprised inert ointment (five studies) no treatment (four studies) and one study with one arm of each. The risk of bias of the 14 studies varied. Seven studies were at high risk of bias, five at unclear risk of bias and two at low risk of bias. Most risk of bias concerned risk of selection bias. Twelve of the studies (6259 participants) reported infection rates, although we could not extract the data for this outcome from one study. Four studies (3334 participants) measured allergic contact dermatitis as an outcome. Four studies measured positive wound swabs for patterns of antimicrobial resistance, for which there were no outcomes reported. No episodes of anaphylaxis were reported. Topical antibiotic versus no topical antibiotic: We pooled the results of eight trials (5427 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with no topical antibiotic (RR 0.61, 95% CI 0.42 to 0.87; moderatequality evidence downgraded once for risk of bias). This equates to 20 fewer SSIs per 1000 patients treated with topical antibiotics (95% CI 7 to 29) and a number needed to treat for one additional beneficial outcome (NNTB) (i.e. prevention of one SSI) of 50.

We pooled the results of three trials (3012 participants) for the outcome of allergic contact dermatitis, however this comparison was underpowered, and it is unclear whether topical antibiotics affect the risk of allergic contact dermatitis (RR 3.94, 95% CI 0.46 to 34.00; very low-quality evidence, downgraded twice for risk of bias, once for imprecision). Topical antibiotic versus antiseptic: We pooled the results of five trials (1299 participants) for the outcome of SSI. Topical antibiotics probably reduce the risk of SSI in people with surgical wounds healing by primary intention compared with using topical antiseptics (RR 0.49, 95% CI 0.30 to 0.80; moderate-quality evidence downgraded once for risk of bias). This equates to 43 fewer SSIs per 1000 patients treated with topical antibiotics instead of antiseptics (95% CI 17 to 59) and an NNTB of 24. We pooled the results of two trials (541 participants) for the outcome of allergic contact dermatitis; there was no clear difference in the risk of dermatitis between topical antibiotics and antiseptics, however this comparison was underpowered and a difference cannot be ruled out (RR 0.97, 95% CI 0.52 to 1.82; very low-quality evidence, downgraded twice for risk of bias and once for imprecision). Topical antibiotic versus topical antibiotic: One study (99 participants) compared mupirocin ointment with a combination ointment of neomycin/polymyxin B/bacitracin zinc for the outcome of SSI. There was no clear difference in the risk of SSI, however this comparison was underpowered (very low-quality evidence downgraded twice for risk of bias, once for imprecision). A four-arm trial involved two antibiotic arms (neomycin sulfate/ bacitracin zinc/polymyxin B sulphate combination ointment versus bacitracin zinc, 219 participants). There was no clear difference in risk of SSI between the combination ointment and the bacitracin zinc ointment. The quality of evidence for this outcome was low, downgraded once for risk of bias, and once for imprecision. Authors’ conclusions: Topical antibiotics applied to surgical wounds healing by primary intention probably reduce the risk of SSI relative to no antibiotic, and relative to topical antiseptics (moderate quality evidence). We are unable to draw conclusions regarding the effects of topical antibiotics on adverse outcomes such as allergic contact dermatitis due to lack of statistical power (small sample sizes). We are also unable to draw conclusions regarding the impact of increasing topical antibiotic use on antibiotic resistance. The relative effects of different topical antibiotics are unclear.

Plain language summary Topical antibiotics (applied to the skin) for preventing surgical site infection in wounds that are stitched or held together another way Background: The presence of micro-organisms, such as bacteria, at wound sites following surgery can result in surgical site infections for patients. Surgical site infections can result in increased healthcare costs, delays in wound healing and pain. Antibiotics are medicines that kill bacteria or prevent them from 

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developing. Antibiotics can be taken by mouth (orally), directly into veins (intravenously), or applied directly to the skin (topically). Topical antibiotics are often applied to wounds after surgery because it is thought that they prevent surgical site infection. There are thought to be benefits in using antibiotics topically rather than orally or intravenously. As topical antibiotics act only on the area of the body where they are applied, there is less likelihood of unwanted effects that affect the whole body, such as nausea and diarrhoea. Topical antibiotics are also thought to reduce the chances of bacterial resistance (bacteria changing to become resistant to medication). However topical antibiotics can also have unwanted effects, the most common being an allergic reaction on the skin (contact dermatitis), which can cause redness, itching and pain at the site where the topical antibiotic was applied. Review question: We reviewed the evidence about how effective topical antibiotics are in preventing surgical site infection if applied directly to wounds after surgery. We focused on the effect of topical antibiotics on the type of surgical wound where the edges are held closely together so that the wound heals more easily (known as healing by primary intention). The edges of these wounds can be held together with stitches, staples, clips or glue.

Jason KF Wong, Kavit Amin, Jo C Dumville Citation example: Wong JKF, Amin K, Dumville JC. Reconstructive surgery for treating pressure ulcers. Cochrane Database of Systematic Reviews 2016, Issue 12 . Art. No.: CD012032. DOI: 10.1002/14651858.CD012032.pub2. ABSTRACT Background: The management of pressure ulcers involves several interventions ranging from pressure-relieving measures such as repositioning, to treatments that can include reconstructive surgery. Such surgery may be considered for recalcitrant wounds when full thickness skin loss arises and deeper structures such as muscle fascia and even bone are exposed. The surgery commonly involves wound debridement followed by the addition of new tissue into the wound. Whilst reconstructive surgery is an accepted means of ulcer management, the benefits and harms of surgery compared with non-surgical treatments, or alternative surgical approaches are not clear. Objectives: To assess the effects of reconstructive surgery for healing pressure ulcers (stage II or above), comparing surgery with no surgery or comparing alternative forms of surgery in any care setting.

What we found: In May 2016 we searched for as many relevant studies as we could find that investigated the use of topical antibiotics on surgical wounds healing by primary intention. We managed to identify 14 studies which compared topical antibiotics with no treatment, or with antiseptics (i.e. other treatments applied to the skin to prevent bacterial infection), and with other topical antibiotics. Eight of these trials involved general surgery and six involved dermatological surgery (surgery involving only the skin). Many of the studies were small, and of low quality or at risk of bias. After examining them all, the authors concluded that the risk of having a surgical site infection was probably reduced by the use of topical antibiotics applied to wounds after surgery, whether the antibiotics were compared with an antiseptic, or to no treatment. As infection is a relatively rare event after surgery, the actual reduction in the rate of infection was 4.3% on average when the use of topical antibiotic was compared with antiseptic, and 2% when use of the topical antibiotic was compared with no treatment. It would require 24 patients on average to be treated with topical antibiotics instead of antiseptic, and 50 patients to be treated with topical antibiotic compared to no treatment in order to prevent one wound infection. Four studies reported on allergic contact dermatitis, but there was insufficient evidence to determine whether allergic contact dermatitis occurred any more frequently with topical antibiotics than with antiseptics or no treatment, and this should also be considered before deciding to use them.

Search methods: We searched the following electronic databases to identify reports of relevant randomised clinical trials (searched 26 September 2016): the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL. We also searched three clinical trials registers and reference lists of relevant systematic reviews, meta-analyses and health technology assessment reports.

This plain language summary is up to date as of May 2016.

Reconstructive surgery for treating pressure ulcers Review question

Publication in The Cochrane Library Issue 12, 2016

Reconstructive surgery for treating pressure ulcers 38

Selection criteria: Published or unpublished randomised controlled trials that assessed reconstructive surgery in the treatment of pressure ulcers. Data collection and analysis: Two review authors independently performed study selection. We planned that two review authors would also assess the risk of bias and extract study data. Main results: We did not identify any studies that met the review eligibility criteria nor any registered studies investigating the role of reconstructive surgery in the management of pressure ulcers. Authorsâ&#x20AC;&#x2122; conclusions: Currently there is no randomised evidence that supports or refutes the role of reconstructive surgery in pressure ulcer management. This is a priority area and there is a need to explore this intervention with more rigorous and robust research.

Plain language summary

We aimed to review the evidence as to whether reconstructive surgery is an effective treatment for healing pressure ulcers. We were unable to find any randomised controlled trials investigating this question. Background: Pressure ulcers are areas of skin and tissue damEWMA Journalâ&#x20AC;&#x201A;

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age that result largely from people remaining in the same position for long periods of time. When parts of the body, especially those that have less fat such as the lower back and heel, have constant external pressure applied (for example sitting on the same area of the body without changing position) this restricts blood flow to the skin and underlying tissues which can lead them to break down. People at risk of developing pressure ulcers include the elderly and those with mobility problems such as wheelchair users and long-term hospital patients. Pressure ulcers can be classified using a staging system where stage I ulcers still have intact skin, stage II ulcers involve partial skin and tissue loss and are often shallow wounds and stage III and IV ulcers are open wounds with deeper tissue damage. Pressure ulcers are serious wounds that are costly to treat, so care is focused on their prevention. When ulcers do occur, treatment options include wound dressings, and antibiotics and antiseptics. Reconstructive surgery is often reserved for deep or hard to heal pressure ulcers, or both. There are different types of surgeries that can be conducted: most involve removal of dead tissue from the wound and then use of fat, muscle and/or skin from other parts of the patient’s body to fill the wound cavity. Study Characteristics: In September 2016 we searched for randomised controlled trials studying the use of surgery for treating pressure ulcers. However, whilst reconstructive surgery for pressure ulcers is practised widely, we found no randomised controlled trials that investigated the potential benefits and harms associated with surgery or that could guide the optimal choice of surgical technique. Many studies excluded from this review reported data from groups of people undergoing reconstructive surgery without a comparison of outcomes for similar groups of people who did not have surgery, or who had different types of surgery. This means that it is not possible to weigh up the benefits and harms of surgery, or different surgical techniques. Key results: We found no randomised controlled trials investigating reconstructive surgery for pressure ulcers. Certainty of the evidence: The benefits and harms of reconstructive surgery for the treatment of pressure ulcers are uncertain and more rigorous research in this area is needed, especially as this question has been prioritised by patients, carers and health professionals. This plain language summary is up to date as of September 2016.

Protease-modulating matrix treatments for healing venous leg ulcers Maggie J Westby, Gill Norman, Jo C Dumville, Nikki Stubbs, Nicky Cullum Citation example: Westby MJ, Norman G, Dumville JC, Stubbs N, Cullum N. Protease-modulating matrix treatments for healing venous leg ulcers. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD011918. DOI: 10.1002/14651858. CD011918.pub2. EWMA Journal

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ABSTRACT Background: Venous leg ulcers (VLUs) are open skin wounds on the lower leg that occur because of poor blood flow in the veins of the leg; leg ulcers can last from weeks to years, and are both painful and costly. Prevalence in the UK is about 2.9 cases per 10,000 people. First-line treatment for VLUs is compression therapy, but around 60% of people have unhealed ulcers after 12 weeks’ treatment and about 40% after 24 weeks; therefore, there is scope for further improvement. Limited evidence suggests non-healing leg ulcers may have persisting elevated levels of proteases, which is thought to deter the later stages of healing; thus, timely protease-modulating matrix (PMM) treatments may improve healing by physically removing proteases from the wound fluid. Objectives: To determine the effects of protease-modulating matrix (PMM) treatments on the healing of venous leg ulcers, in people managed in any care setting. Search methods: In September 2016 we searched: the Cochrane Wounds Specialised Register; CENTRAL; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: We searched for published or unpublished randomised controlled trials (RCTs) that evaluated PMM treatments for VLUs. We defined PMM treatments as those with a purposeful intent of reducing proteases. Wound healing was the primary endpoint. Data collection and analysis: Two review authors independently performed study selection, risk of bias assessment and data extraction. Main results: We included 12 studies (784 participants) in this review; sample sizes ranged from 10 to 187 participants (median 56.5). One study had three arms that were all relevant to this review and all the other studies had two arms. One study was a within-participant comparison. All studies were industry funded. Two studies provided unpublished data for healing. Nine of the included studies compared PMM treatments with other treatments and reported results for the primary outcomes. All treatments were dressings. All studies also gave the participants compression bandaging. Seven of these studies were in participants described as having ‘non-responsive’ or ‘hard-toheal’ ulcers. Results, reported at short, medium and long durations and as time-to-event data, are summarised for the comparison of any dressing regimen incorporating PMM versus any other dressing regimen. The majority of the evidence was of low or very low certainty, and was mainly downgraded for risk of bias and imprecision. It is uncertain whether PMM dressing regimens heal VLUs quicker than non-PMM dressing regimens (low-certainty evi

dence from 1 trial with 100 participants) (HR 1.21, 95% CI 0.74 to 1.97). In the short term (four to eight weeks) it is unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (very low-certainty evidence, 2 trials involving 207 participants). In the medium term (12 weeks), it is unclear whether PMM dressing regimens increase the probability of healing compared with non-PMM dressing regimens (low-certainty evidence from 4 trials with 192 participants) (RR 1.28, 95% CI 0.95 to 1.71). Over the longer term (6 months), it is also unclear whether there is a difference between PMM dressing regimens and non-PMM dressing regimens in the probability of healing (low certainty evidence, 1 trial, 100 participants) (RR 1.06, 95% CI 0.80 to 1.41). It is uncertain whether there is a difference in adverse events between PMM dressing regimens and non-PMM dressing regimens (low-certainty evidence from 5 trials, 363 participants) (RR 1.03, 95% CI 0.75 to 1.42). It is also unclear whether resource use is lower for PMM dressing regimens (low-certainty evidence, 1 trial involving 73 participants), or whether mean total costs in a German healthcare setting are different (low-certainty evidence, 1 trial in 187 participants). One cost-effectiveness analysis was not included because effectiveness was not based on complete healing. Authors’ conclusions: The evidence is generally of low certainty, particularly because of risk of bias and imprecision of effects. Within these limitations, we are unclear whether PMM dressing regimens influence venous ulcer healing relative to dressing regimens without PMM activity. It is also unclear whether there is a difference in rates of adverse events between PMM and nonPMM treatments. It is uncertain whether either resource use (products and staff time) or total costs associated with PMM dressing regimens are different from those for non-PMM dressing regimens. More research is needed to clarify the impact of PMM treatments on venous ulcer healing.

Plain language summary Protease-modulating matrix treatments for healing venous leg ulcers Review question We reviewed the evidence about the effects of treatments designed to lower the levels of protease in venous leg ulcers. Protease is an enzyme, a chemical produced by the body. High levels of protease in a wound are thought to slow down wound healing. We wanted to find out if treatments that remove protease from wounds could help venous leg ulcers to heal more quickly, and if these treatments were harmful in any way. Background: Venous leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Leg ulcers can be painful, may become infected, and may affect mobility and quality of life. In 2012 in the UK, it cost about GBP 1700 per year to treat each person with an open venous leg ulcer. The usual treatment for venous leg ulcers is compression therapy (for example, compression bandages), but even this does not work for everyone (about a third of people still have wounds 40

that have not healed after six months). Therefore, we need to try additional treatments, and various dressings have been used alongside compression therapy. One of these is a ‘proteasemodulating matrix’ (PMM) type of dressing. Research suggests that wounds are slow to heal when there are high levels of a substance called ‘protease’. The PMM dressing is designed to remove these proteases from wound fluid, and this is expected to help the wound heal. In this study, we investigated whether there is any evidence that PMM dressings heal leg ulcers more quickly than other types of dressings. Study characteristics: In September 2016 we searched for as many relevant studies as we could find that had a reliable design (randomised controlled trials) and had compared PMM treatments with other treatments for venous leg ulcers. We found 12 studies involving a total of 784 people. Ten studies gave results we could use and all treatments were dressings. All these studies gave all the participants compression therapy as well as the dressings. Most of the people in the trials had wounds that were not getting better or had been there a long time. Key results: Findings from four trials are unclear as to whether there is a benefit of PMM dressings on venous ulcer healing compared with other dressings. Five trials reported on wound side effects and their results are unclear as to whether there is a difference in rates of side effects between PMM dressings and other dressings. It is also unclear whether PMM dressings result in decreases in the amount of saline used and the time taken during dressing changes, and whether there is an effect on total costs. Certainty of the evidence: Overall, the certainty of the evidence was judged to be low: most studies we found were small and could have been better conducted, so it was difficult to be sure how meaningful the results were. The next step would be to do more research of better quality to see whether PMM dressings do heal venous ulcers more quickly than other dressings. This plain language summary is up to date as of September 2016.

Dressings for the prevention of surgical site infection Jo C Dumville, Trish A Gray, Catherine J Walter, Catherine A Sharp, Tamara Page, Rhiannon Macefield, Natalie Blencowe, Thomas KG Milne, Barnaby C Reeves, Jane Blazeby Citation example: Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, Blencowe N, Milne TKG, Reeves BC, Blazeby J. Dressings for the prevention of surgical site infection. Cochrane Database of Systematic Reviews 2016, Issue 12 . Art. No.: CD003091. DOI: 10.1002/14651858.CD003091.pub4. Abstract Background: Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured,

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often with sutures, staples, or clips. Wound dressings applied after wound closure may provide physical support, protection and absorb exudate. There are many different types of wound dressings available and wounds can also be left uncovered (exposed). Surgical site infection (SSI) is a common complication of wounds and this may be associated with using (or not using) dressings, or different types of dressing. Objectives: To assess the effects of wound dressings compared with no wound dressings, and the effects of alternative wound dressings, in preventing SSIs in surgical wounds healing by primary intention. Search methods: We searched the following databases: the Cochrane Wounds Specialised Register (searched 19 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 8); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations, MEDLINE Daily and Epub Ahead of Print; 1946 to 19 September 2016); Ovid Embase (1974 to 19 September 2016); EBSCO CINAHL Plus (1937 to 19 September 2016). There were no restrictions based on language, date of publication or study setting. Selection criteria: Randomised controlled trials (RCTs) comparing wound dressings with wound exposure (no dressing) or alternative wound dressings for the postoperative management of surgical wounds healing by primary intention. Data collection and analysis: Two review authors performed study selection, ‘Risk of bias’ assessment and data extraction independently. Main results: We included 29 trials (5718 participants). All studies except one were at an unclear or high risk of bias. Studies were small, reported low numbers of SSI events and were often not clearly reported. There were 16 trials that included people with wounds resulting from surgical procedures with a ‘clean’ classification, five trials that included people undergoing what was considered ‘clean/contaminated’ surgery, with the remaining studies including people undergoing a variety of surgical procedures with different contamination classifications. Four trials compared wound dressings with no wound dressing (wound exposure); the remaining 25 studies compared alternative dressing types, with the majority comparing a basic wound contact dressing with film dressings, silver dressings or hydrocolloid dressings. The review contains 11 comparisons in total. Primary outcome: SSI: It is uncertain whether wound exposure or any dressing reduces or increases the risk of SSI compared with alternative options investigated: we assessed the certainty of evidence as very low for most comparisons (and low for others), with downgrading (according to GRADE criteria) largely due to risk of bias and imprecision. We summarise the results of comparisons with meta-analysed data below: - film dressings compared with basic wound contact dressings following clean surgery (RR 1.34, 95% CI 0.70 to 2.55), very low certainty evidence downgraded once for risk of bias and twice for imprecision. EWMA Journal

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- hydrocolloid dressings compared with basic wound contact dressings following clean surgery (RR 0.91, 95% CI 0.30 to 2.78),very low certainty evidence downgraded once for risk of bias and twice for imprecision. - hydrocolloid dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.57, 95% CI 0.22 to 1.51), very low certainty evidence downgraded twice for risk of bias and twice for imprecision. - silver-containing dressings compared with basic wound contact dressings following clean surgery (RR 1.11, 95% CI 0.47 to 2.62),very low certainty evidence downgraded once for risk of bias and twice for imprecision. - silver-containing dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.83, 95% CI 0.51 to 1.37), very low certainty evidence downgraded twice for risk of bias and twice for imprecision. Secondary outcomes: There was limited and low or very low certainty evidence on secondary outcomes such as scarring, acceptability of dressing and ease of removal, and uncertainty whether wound dressings influenced these outcomes. Authors’ conclusions: It is uncertain whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI, or whether any particular wound dressing is more effective than others in reducing the risk of SSI, improving scarring, reducing pain, improving acceptability to patients, or is easier to remove. Most studies in this review were small and at a high or unclear risk of bias. Based on the current evidence, decision makers may wish to base decisions about how to dress a wound following surgery on dressing costs as well as patient preference.

Plain language summary Dressings for the prevention of surgical site infection Review question This review aimed to assess whether use of different wound dressings (or leaving a wound exposed without a dressing) has an impact on the number of people who get wound infections following surgery where the wound is closed with stitches, staples, clips or glue. We also investigated whether different dressings resulted in less pain, less scarring or were more acceptable to patients and health professionals. Background: Millions of surgical procedures are conducted globally each year. The majority of procedures result in wounds in which the edges are brought together to heal using stitches, staples, clips or glue; this is called ‘healing by primary intention’. Afterwards, wounds are often covered with a dressing that acts as a barrier between it and the outside environment. One possible advantage of a dressing may be to protect the wound from infection (surgical site infection). Many different dressing types are available for use on surgical wounds. However, it is not clear whether one type of dressing is better than any other in preventing surgical site infection, or, indeed, whether it is better not to use a dressing at all. 

Study characteristics: We conducted a review of all available, relevant evidence about the impact of dressings on the prevention of surgical site infections in surgical wounds healing by primary intention. This review examined data from 29 randomised controlled trials (which provide the most reliable evidence). These investigated the use of dressings in surgery that had a low risk of surgical site infection (clean surgery) and surgery with a higher risk (potentially contaminated surgery). Key results: We found no clear evidence to suggest that one dressing type was better than any other at reducing the risk of surgical site infection, nor that covering wounds with any dressing at all reduced the risk of surgical site infection. Additionally, there was no clear evidence that any dressing type improves scarring, pain control, patient acceptability or ease of removal. Currently decision makers may opt to make decisions about whether and how to dress a wound based on patient and clinician preferences and dressing costs. Certainty of the evidence: It is important to note that many trials in this review were small and the evidence was of low or very low certainty meaning that current information is uncertain. Assessed as up to date September 2016.

Publication in The Cochrane Library Issue 1, 2017

Fibrin glue for pilonidal sinus disease Jon Lund, Samson Tou, Brett Doleman, John P Williams 1Division of Health Sciences, School of Medicine, University of Nottingham, Derby, UK 2Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK 3Department of Surgery and Anaesthesia, Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Derby, UK Citation example: Lund J, Tou S, Doleman B, Williams JP. Fibrin glue for pilonidal sinus disease. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD011923. DOI: 10.1002/14651858.CD011923.pub2. ABSTRACT Background: Pilonidal sinus disease is a common condition that mainly affects young adults. This condition can cause significant pain and impairment of normal activities. No consensus currently exists on the optimum treatment for pilonidal sinus and current therapies have various advantages and disadvantages. Fibrin glue has emerged as a potential treatment as both monotherapy and an adjunct to surgery. Objectives: To assess the effects of fibrin glue alone or in combination with surgery compared with surgery alone in the treatment of pilonidal sinus disease.

Search methods: In December 2016 we searched: the Cochrane Wounds Specialised Register; CENTRAL; MEDLINE; Embase and CINAHL Plus. We also searched clinical trials registries and conference proceedings for ongoing and unpublished studies and scanned reference lists to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: We included randomised controlled trials (RCTs) only. We included studies involving participants of all ages and studies conducted in any setting. We considered studies involving people with both new and recurrent pilonidal sinus. We included studies which evaluated fibrin glue monotherapy or as an adjunct to surgery. Data collection and analysis: Two study authors independently extracted data and assessed risk of bias. We used standard methods expected by Cochrane. Main results: We included four RCTs with 253 participants, all were at risk of bias. One unpublished study evaluated fibrin glue monotherapy compared with Bascom’s procedure, two studies evaluated fibrin glue as an adjunct to Limberg flap and one study evaluated fibrin glue as an adjunct to Karydakis flap. For fibrin glue monotherapy compared with Bascom’s procedure, there were no data available for the primary outcomes of time to healing and adverse events. There was low-quality evidence of less pain on day one after the procedure with fibrin glue monotherapy compared with Bascom’s procedure (mean difference (MD) -2.50, 95% confidence interval (CI) -4.03 to -0.97) (evidence downgraded twice for risk of performance and detection bias). Fibrin glue may reduce the time taken to return to normal activities compared with Bascom’s procedure (mean time 42 days with surgery and 7 days with glue, MD -34.80 days, 95% CI -66.82 days to -2.78 days) (very low-quality evidence, downgraded as above and for imprecision). Fibrin glue as an adjunct to the Limberg flap may reduce the healing time from 22 to 8 days compared with the Limberg flap alone (MD -13.95 days, 95% CI -16.76 days to -11.14 days) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and imprecision). It is uncertain whether use of fibrin glue affects the incidence of postoperative seroma (an adverse event) (risk ratio (RR) 0.27, 95% CI 0.05 to 1.61; very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and imprecision). There was low-quality evidence that fibrin glue, as an adjunct to Limberg flap, may reduce postoperative pain (median 2 versus 4; P < 0.001) and time to return to normal activities (median 8 days versus 17 days; P < 0.001). The addition of fibrin glue to the Limberg flap may reduce the length of hospital stay (MD -1.69 days, 95% CI -2.08 days to -1.29 days) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and for unexplained heterogeneity). A single RCT evaluating fibrin glue as an adjunct to the Karydakis flap did not report data for the primary outcome of time to healing. It is uncertain whether fibrin glue with the Karydakis flap affects the incidence of postoperative seroma (adverse EWMA Journal

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event) (RR 3.00, 95% CI 0.67 to 13.46) (very low-quality evidence, downgraded twice for risk of selection, performance and detection bias and for imprecision). Fibrin glue as an adjunct to Karydakis flap may reduce length of stay but this is highly uncertain (mean 2 days versus 3.7 days; P < 0.001, low-quality evidence downgraded twice for risk of selection, performance and detection bias). Authors’ conclusions: Current evidence is uncertain regarding any benefits associated with fibrin glue either as monotherapy or as an adjunct to surgery for people with pilonidal sinus disease. We identified only four RCTs and each was small and at risk of bias resulting in very low-quality evidence for the primary outcomes of time to healing and adverse events. Future studies should enrol many more participants, ensure adequate randomisation and blinding, whilst measuring clinically relevant outcomes.

Plain language summary Fibrin glue for pilonidal sinus disease Review question We reviewed the evidence regarding the effectiveness of fibrin glue, used on its own or with surgery, in the treatment of pilonidal sinus disease. Background: Pilonidal sinus disease is a common condition mainly affecting young adults. The condition develops following an infection in the groove between the buttocks. The infection can cause fluid collections or a sinus (a channel under the skin) to form. Young men are more likely to be affected, and other risk factors include obesity, poor hygiene and prolonged sitting. Extensive body hair is also a factor as ingrowing hair follicles are thought to make the condition worse. The condition causes pain and often requires time off work. This affects patients’ quality of life and may cause loss of earnings.

the first day after the procedure compared with Bascom’s procedure. When fibrin glue is used alongside a type of surgery called the Limberg flap it may reduce the healing time by approximately 14 days compared with the surgery on its own, however this finding is highly uncertain as the evidence is very low-quality. It is uncertain whether using the fibrin glue alongside the Limberg flap affects the incidence of a complication called seroma (a collection of fluid) but it may reduce postoperative pain (this evidence is low-quality and therefore quite uncertain) and may reduce time to return to normal activities (low-quality evidence) and length of hospital stay (this was very low-quality evidence and therefore very uncertain). One study evaluated the effect of adding fibrin glue to a type of surgery called the Karydakis flap. It is not clear from this study whether using the glue affects time to healing or the incidence of seroma. Using the fibrin glue with the Karydakis flap may reduce length of hospital stay compared with surgery alone but again this is low-quality evidence. Quality of the evidence: The quality of evidence for all outcomes was low or very low, mainly due to problems with the ways the studies were conducted and also the uncertainty in the results because of the small numbers of participants in the studies. This means we cannot be confident of the effects of fibrin glue on any of these outcomes and more, better quality and larger studies are required. This plain language summary is up to date as of December 2016.

Pilonidal sinus disease is normally treated with a small operation. Fibrin glue, a naturally-occurring glue-like gel, can also be used as an alternative to, or in addition to surgery. We looked for evidence as to whether fibrin glue can speed up the healing time for this type of wound. We also wanted to find out if the treatment affected other outcomes such as pain, infection and return of the pilonidal sinus following the procedure, and whether it had any side effects (fluid collections or allergic reactions). Study characteristics: In December 2016 we searched for randomised controlled trials involving participants of any age or sex, whose pilonidal sinus had been treated with fibrin glue, either on its own or with surgery. We found four studies that included 253 participants, the majority of whom were male. Fibrin glue on its own was compared with surgery in one study. In three studies fibrin glue was applied during surgery and compared with surgery on its own. There were problems with the design and conduct of all four studies which mean that their results are very uncertain. Key results: It is not known whether fibrin glue on its own affects time to healing and adverse events compared with a type of surgery (Bascom’s procedure). Fibrin glue may result in less pain on EWMA Journal

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Exufiber® – the fibre dressing you would design Easier removal1 | Superior fluid retention2

We discovered that fibre dressings could perform even better From speaking with our customers, we understand how much a fibre dressing that can balance four equally important demands can help you and your patients. Conformability

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Exufiber® is the highly absorbent gelling fibre dressing you and your patients deserve. It is used to manage moderately to highly exuding wounds.

REFERENCES: 1. Chadwick P, McCardle J. Exudate management using a gelling fibre dressing. The Diabetic Foot Journal 2015; 18(1): 43-48. 2. Data-on-file report Mölnlycke Health Care. 3. Mölnlycke Health Care data: Veeva Survey undertaken in UK, Sweden, Denmark, Finland, Norway and Latvia between September 2014 and July 2015.

Find out more at www.molnlycke.com Mölnlycke Health Care AB, Box 13080, Gamlestadsvägen 3C, SE-402 52 Göteborg, Sweden. Phone +46317223000. The Mölnlycke, Exufiber and Hydrolock trademarks, names and logo types are registered globally to one or more of the Mölnlycke Health Care Group of Companies. © 2017 Mölnlycke Health Care AB. All rights reserved. HQWC0098

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CLOSER TO ZERO EWMA 03 May – 05 May 2017 RAI Congress Centre Amsterdam

At Smith & Nephew we’re dedicated to reducing the human and economic cost of wounds. We keep an ambitious objective in mind: ZERO. Zero pressure ulcer incidence. Zero surgical site complications. Zero diabetic amputations. Zero delay in wound healing. Zero chronic wound recurrence. Zero wound-related readmissions. Zero waste of healthcare resources. It is never simple. It is not always achievable. We do however believe it is the objective we should help you get closer to every day.*

Join us at our sponsored satellite symposia: Learn how Smith & Nephew can help you reduce the burden of challenging wounds for patients, practitioners and providers. Date: Wednesday 3rd May Time: 12.30h – 13.30h Place: Forum meeting room We look forward to welcoming you in Amsterdam!

We’re here to help you reduce the human and economic cost of wounds, and at the EWMA Congress this year we look forward to demonstrating how ALLEVYN™ LIFE and ALLEVYN Gentle Border wound dressing, ACTICOAT™ Antimicrobial Silver Dressing, as well as Negative Pressure Wound Therapy devices; PICO™ and RENASYS™ TOUCH improve patient outcomes, and at the same time conserve resources for health care systems. We have also invited a number of international key opinion leaders to present at our stand 3 C 01.

*smith&nephew Supporting healthcare professionals for over 150 years

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*The decision to use Smith & Nephew should be made by a healthcare professional, in line with applicable local protocols. Smith & Nephew products should always be used for the indications set out in the applicable instructions for use. ™Trademark of Smith & Nephew [tm]All trademarks acknowledged ©January 2017 Smith & Nephew 80600

EWMA Journal

Previous Issues

Volume 16, no 2, October 2016 Efficiency in wound care: The impact of introducing a new foam dressing in community practice Kronert GT, Roth H, Searle RJ

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

Negative pressure wound therapy in the treatment of acute pyoinflammatory diseases of soft tissues Obolensky VN, Ermolov AA, Rodoman GV V OL . 14 - N O . 1 - MARCH 2016

The use of clinical guidelines during the treatment of diabetic footulcers in four Nordic countries Annersten M The WAWLC Wound Care Kit for less resourced countries: a key tool for modern adapted wound care Vuagnat H, Comte E

Volume 16, no 1, April 2016 Development of an Evidence-Based Global Consensus for Diabetic Van Netten JJ, Bakker K, Apelqvist J, Lipsky BA, Schaper NC, Clinical challenges of differentiating skin tears from pressure ulcers LeBlanc K, Alam T, Langemo D, Baranoski S, Campbell K, Woo K Primary Care Patient Safety (PISA) Research Group Samuriwo R, Evans HP, Carson-Stevens A, Rees P, Hibbert P,

English

Acta Vulnologica, vol. 14, no 1, 2016 www.vulnologia.it Application of Ortodermina ointment (lidocaine 5%) when preparing ulcers for ultrasonic debridement Giacinto F., Germano M., Giacinto E., et al Retrospective study on the use of negative pressure wound therapy in the treatment of pilonidal cysts (sinus pilonidalis) opera-ted on using an open technique or complicated by dehiscence of the surgery site through sepsis Carnali M., Ronchi R., Finocchi L., et al Epidemiology of antibiotic resistance and MBL genes among Pseudomonas aeruginosa and Acinetobacter baumannii clinical strains isolated from burnt patients in Iran: a systematic review Hashemi A., Tarashi S., Erfanimanesh S.

Advances in Skin & Wound Care, vol. 30, no 1, 2017 www.aswcjournal.com Educating Nurses in the United States about Pressure Injuries Ayello EA, Zulkowski K, Capezuti E, et al Survey Results from Canada and Some Latin America Countries: 2016 National Pressure Ulcer Advisory Panel Changes in Terminology and Definitions Ayello EA, Lobo Cordero GM, Sibbald RG Skin Tears: Finally Recognized LeBlanc K, Baranoski S Top 10 Medicare Reimbursement Regulations Currently Impacting Wound Care Practices Schaum KD

Challenges faced by healthcare professionals in the provision of compression hosiery to enhance compliance in the prevention of venous leg ulceration Tandler SF Pressure Ulcer Incidence: Do patients retain information? Vowden K, Warner V, Collins J.

Volume 15, no 2, October 2015 Of youth and Age - What are the Differences regarding skin structure and function ? Kottner J The Development and Benefits of 10 year ́s Experience with an Electronic Monitoring Tool (PUNT) in a UK Hospital Trust. Collier M Preparing student Nurses for the future of Wound Management: Telemedicine in a simulated Learning Environment. Christiansen S, Rethmeier A The Psychological Effect of Malignant fungating Wounds on the Patient. Reynolds H, Gethin G The Pressure Ulcer Guidance (PUG) Tool. Barnard J, Copson D

Finnish

Pyoderma gangrenosum –Is it rare wound or more general than known? Kirsi Isoherranen Chronic leg ulcer – the reason might be malignancy? Anne Keinonen Necrobioisis lipoidica – rare and difficult to treat Johanna Mandelin Nursing care of patient with a rare wound Ulla Väänänen

Spanish Volume 15, no 1, April 2015 Efficacy of magnetic resonance imaging in deciding the appropriate surgical margin in diabetic foot osteomyelitis. Fujii M, Armstrong DG, Terashi H Ex vivo platelet activation with extended duration pulse electric fields for autologous platelet gel applications - A new, potential clinical standard for platelet activation and perspectives for a more widespread adoption and improved wound healing with platelet gels. Neculaes VB, Torres A, Morton C, Larriera A, Klopman S, Conway K, Garner AL Pressure ulcer reduction: the role of unregistered healthcare support workers in validation and prevention. Ellis MB, Price J Measuring change in limb volume to evaluate lymphoedema treatment outcome. Williams AF, Whitaker J

Haava, no. 4, 2016 www.shhy.fi

Helcos, vol. 26, no. 4, 2016 Pressure ulcers as a safety patient problem JE Torra-Bou, J. Verdú-Soriano; R. Sarabia-Lavín Incontinence-associated dermatitis: knowledge of nursing students and clinical nurses in Jaén S. Chiquero, A. Cruz-Lendinez, FP García-Fernández Prevalence of pressure ulcers in a third level hospital in Mexico City JE Barrera, MC Pedraza, G. Pérez-Jimenez Healing of skin ulcers: an anlysis of professional nursing practice D. Nogueira, FA Araújo, J. Souza

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

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2017 vol 17 no 1

EWMA Journal of Tissue Viability, vol. 25, no 4, 2016 www.journaloftissueviability.com

Scandinavian ÅRGANG 25 NR 4

English

december 2016

Systematic mapping review about costs and economic evaluations of skin conditions and diseases in the aged

MEDLEMSBLAD FOR DANSK SELSKAB FOR SÅRHELING OG FOR NORSK INTERESSEFAGGRUPPE FOR SÅRHELING

Andrea Lichterfeld-Kottner, Elisabeth Hahnel, Ulrike BlumePeytavi et al Cost-effectiveness analysis alongside a pilot study of prophylactic negative pressure wound therapy. Christopher Heard, Wendy Chaboyer, Vinah Anderson et al A decade of research on Incontinence-Associated Dermatitis (IAD): Evidence, knowledge gaps and next steps. Dimitri Beeckman Device-related pressure ulcers from a biomechanical perspective. Ayelet Levy, Kara Kopplin, Amit Gefen

ÅRSMØDET 2016 – SÅRINFEKTIONER – HVOR ER VI I DAG? AMBROISE PARÉ – DEN SKÅNSOMME KIRURG NYT LÆRINGSREDSKAB I SÅRBEHANDLING: FILM FDA – GÆSTEFORELÆSNING VED PANELMØDE INFLAMASJON VED KRONISKE SÅR – BETA-GLUKAN

Scandinavian

SÅRmagasinet no 3, 2016 www.swenurse.se NPortrait of Dr Guido Ciprandi - a giant in childrens´wounds Christina Lindholm Unusual wounds Nina Åkesson New method to treat piloniodal sinus Roland Andersson Pressue ulcer risk and risk assessment in intensive care unit Maarit Ahtila

Scandinavian

Sår (Wounds), no. 3 September 2016 www.saar.dk LEUCOPATCH – A patch of the patient’s own blood Jens Fonnesbech SKIN TEARS - Skin lesions with flap Jette Skiveren & Susan Bermark REAL WOUNDS - A journey of discovery into the clinic Ole E. Sørensen LEUCOPATCH 34 - A medico-technical stroke of genius Jens Fonnesbech

English

Wound Repair and Regeneration, vol. 25, no. 4, 2017

Journal of Wound Care, vol. 26, no 2, 2016 www.journalofwoundcare.com

English volume 26. number 2. february 2017

Official journal of the World Union of Wound Healing Societies

MEDLINE LISTED

IMPACT FACTOR

The effects of Tarantula cubensis venom on wound healing in an animal model A coverlet device on skin management: a pilot study in critical care patients Indicators of prognosis for admissions from a specialist diabetic foot clinic Inter-rater and intra-rater reliability of a rapid bacteria counting system Healing of an arterial leg ulcer by compression bandaging: a case report

Polish

Prevalence of skin tears in the extremities among elderly residents at a nursing home in Denmark J. Skiveren, B. Wahlers, S. Bermark Healing of an arterial leg ulcer by compression bandaging: a case report C. Sanchez, H. Partsch. Prevention of postsurgical wound dehiscence after abdominal surgery with NPWT: a multicentre randomised controlled trial protocol K. Sandy-Hodgetts, G.D. Leslie, R. Parsons, et al . Efficacy and safety of a new coverlet device on skin microclimate management: a pilot study in critical care patients O. Forriez, J. Masseline, D. Coadic, et al.

Leczenie Ran vol. 13, no 4, 2016 www.journalofwoundcare.com

Volume 24

Number 1 Pages 1-158 January/February 2017

Lithuanian

Lietuvos chirurgija, vol. 15, no 2-3, 2016 www.chirurgija.lt

mtfwoundcare.org

Phlebologie, vol. 1, 2017 www.schattauer.de Treatment of chronic ulcers S. Reich-Schupke Chronic venous insufficiency Ch. Busch et al. Recurrent vein thrombosis with agenesis of the inferior vena cava and AT III deficiency J. Lukaseder et al.

EWMA Journal

2017 vol 17 no 1

Unphosphorylated PTEN Inhibits TGF-β Mediated β-Catenin Translocation

WOUND REPAIR AND REGENERATION THE INTERNATIONAL JOURNAL OF TISSUE REPAIR AND REGENERATION

The Wound Healing Society

The European Tissue Repair Society

The Japanese Society for Wound Healing

The Australian Wound Management Association

WRR_C1-C4.indd 1

Diagnostic peculiarities and difficulties of parapharyngeal space tumours Senkus L, Gibavicienė J, Cepulis V Oligometastatic breast cancer: a case report and literature review Ostapenko V, Cicenas S, Briediene R, et al. Giant breast malignant phyllodes tumor: a case report and literature review Ostapenko V, Ostapenko A, Dasevicius D, et.al. Radiation-associated angiosarcoma after breast cancer: a case report and literature review Ostapenko V, Ostapenko A, Petroska D, et.al.

German

Volume 25 Number 1 January/February 2017

ISSN 1067-1927

WOUND REPAIR AND REGENERATION

A comparison study of steroid ointment treatment with and without active hydrocolloid dressing (Granuflex® Extra Thin) occlusion in mild plaque psoriasis disease Rajzer L, Budynek M Analysis of epidemiological factors and results of burns treatment in children in the own material Pastuszka A, Smyczek D, Koszutski T et al. INTRODUCING Pressure ulcers in the terminally ill patients Kempa S, Klich D, Zaporowska-Stachowiak I et al. Selected problems of local healing of a pressure ulcer – Making wound care better, cases report for everyone. Bazaliński D, Więch P, Barańska B et al.

Wounds (SÅR) no 4, 2016 www.saar.dk ANNUAL MEETING in Kolding 2016 - Summary Jens Fonnesbech & Maria Plasche Inflammation in chronic wounds Ingrid Skjæveland and Dag Grønvoll New learning tool in wound treatment - Common learning module in Region Zealand Esther Krejberg, Liselotte Bostrup Jensen & Ida Charlotte Rothmann Hjalager Ambroise Paré - The gentle surgeon Adam Bencard

06/03/17 4:18 PM

German

Cadexomer iodine provides superior efficacy against bacterial wound biofilms in vitro and in vivo DJ Fitzgerald, PJ Renick,EC Forrest, et al. Relationship between Opioid Treatment and Rate of Healing in Chronic Wounds. VK Shanmugam, KS Couch, Sean McNish, et al. Biofilm detection by wound blotting can predict slough development in pressure ulcers: a prospective observational study G Nakagami, G Schultz, DJ Gibson, et al. Evidence of invasive and non-invasive treatment modalities for hypertrophic scars: a systematic review M Kafka, V Collins, Lars-Peter Kamolz, et al.

Wund Management, no 1, 2017 Age as a limiting factor in therapeutic options – ethical aspects M. Mäder Special aspects in dermatology and basics in topical skin care in elderly patients T. Eberlein Effective debridement with micro-water-jet-technology (MWT): A retrospective clinical application observation with 90 patients with acute and chronic wounds M. Reber, P. Nussbaumer

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EWMA

EWMA 2017 AMSTERDAM, THE NETHERLANDS

3-5 MAY 2017

EWMA 2017 Conference in Amsterdam, The Netherlands The 27th conference of European Wound Management Association will be a great event in many ways. The scientific programme has expanded significantly and will consist of various key sessions, workshops, focus sessions, full-day streams, and satellite symposia. It will involve scientists from Europe and other countries in the world. The 2017 conference is organised in cooperation with the Dutch Knowledge Centre Wound Care, WCS. The conference offers almost 1,000 scientific presentations by international key speakers, free paper presenters, poster presenters, workshop facilitators, focus session speakers and satellite symposium speakers.

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2017 vol 17 no 1

THE CONFERENCE THEME IS:

CHANGE, OPPORTUNITIES AND CHALLENGES -WOUND MANAGEMENT IN CHANGING HEALTHCARE SYSTEMS

National healthcare systems in Europe are continuously changing, reorganising and adapting to respond to changing demographics and budget restrictions. This sets the context in which wound healing and wound carers must navigate to provide the best possible treatment for the individual patient. At the same time technology is rapidly developing, providing new methods and means of treatment and organisation. The 27th EWMA conference will have its focus on the changes, opportunities and challenges provided by these continuous processes for wound management across Europe and beyond. The 2017 programme will offer guest sessions from several organisations that are active in thematic issues related to wound healing and management. The organisations 50

include Dystrophic Epidermolysis Bullosa Research Association (DEBRA), European Burns Association (EBA), The European Council of Enterostomal Therapy (ECET), European Pressure Ulcer Advisory Panel (EPUAP), The European Society for Clinical Nutrition and Metabolism (ESPEN), European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS), European Society for Vascular Surgery (ESVS), European Tissue Repair Society (ETRS), International Compression Club (ICC), International Lymphoedema Framework (ILF) and Association of Diabetic Foot Surgeons (A-DFS), JA-CHRODIS, V&VN Wound Expertise, World Alliance for Wound & Lymphedema Care (WAWLC), Wound Platform Netherlands and Wounds Australia. EWMA Journalâ&#x20AC;&#x201A;

2017 vol 17 no 1

EWMA

An International Partner Session will be hosted by EWMA’s Korean partner KWMS Thursday 4th May, 10.0011.00.

PROGRAMME HIGHLIGHTS

KEY SESSIONS The topics highlighted at EWMA 2017 cover the advancement of research in relation to epidemiology, pathology, diagnosis, prevention and wound management. Additional guest sessions will be held to discuss wound healing and management, and promote cooperation and networking. KEY SESSIONS INCLUDE: n Opening plenary key session: Change, opportunities and challenges - wound management in changing healthcare systems

Use of oxygen therapies in wound healing, with special focus on topical and hyperbaric oxygen treatment n

n Chronic Wounds In The Fragile Aging Patient - Joint key session of EWMA and ISTAP n Negative Pressure Wound Therapy - overview, chal lenges and perspectives n

Quality of care and cost effectiveness

Microbiology of wounds. From basic to clinical Science

n Advanced therapies in Wound management - A look into the future of wound management n Healing wounds, saving limbs - Management of arterial ulcers n

Prevention and treatment of scars

n Psychological impact of chronic illness or chronic wounds? n

Diabetic Foot

Surgical Site Infections across sectors – what can be done to improve prevention? n

 EWMA Journal

2017 vol 17 no 1

EWMA

WORKSHOPS EWMA 2017 will also run a variety of interactive workshops, giving participants an opportunity to address and elaborate on particular aspects of the session themes.

FOCUS SESSIONS EWMA focus sessions foster more in-depth discussions than the workshops allow. Focus session include: n

Hidradenitis suppurativa

Allergology

Oncological wounds and breast cancer

WORKSHOPS INCLUDE: n

Clean hands – clean wounds

n Audio-Visual workshop: Making compression therapy for ulcer treatment easier n

n Larval debridement therapy: modern breakthroughs in an ancient solution

Diabetic Foot Screening How to measure success in wound healing – from a dermatologists perspective n

Cooperating organisations workshop

Positioning patients with pressure ulcers

Care of burns patients that are not hospitalized

How to identify atypical wounds

Eczema in leg ulcer patients

Infection and wound care

How do maggots operate?

How to read a paper. Understanding basic statistics

Diabetic foot – assessments, offloading and footwear

Wound Debridement

A number of abstracts will also be presented in high-level free paper sessions, and as e-posters on display throughout the event.

Stay informed by visiting the conference website, www.ewma2017.org information about the programme. You can also get your updates on EWMA’s social media platforms.

n Core Outcome Set for Reporting of Trials in Venous Leg Ulceration

EWMA Journal

2017 vol 17 no 1

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EWMA NEWS

WORLD HAND HYGIENE DAY – JOINT EWMA & ICN CAMPAIGN PROGRAMME The International Council of Nurses (ICN) and the European Wound Management Association (EWMA) have joined their forces to relay the World Health Organization’s (WHO) campaign aimed to raising awareness among healthcare professionals and of the critical importance of hand hygiene in improving patient outcomes and strengthening healthcare systems. WHY FOCUS ON HAND HYGIENE Annually, hundreds of millions of individuals globally are affected by health care-associated infections (HCAIs). Systematic reviews of the literature from both developed and developing countries indicate that HCAI is the most frequent adverse event in healthcare. HCAI leads to prolonged hospital stays, long-term disability, increased resistance to antimicrobial medicines, high costs for patients and families, a high financial burden for health systems, and avoidable deaths. Most health care-associated infections are preventable through good hand hygiene – cleaning hands at the right times and in the right way. The WHO’s global campaign SAVE LIVES: Clean Your Hands campaign and its May 5th World Hand Hygiene Day (WHHD) aim to galvanize action at the point of care to demonstrate that hand hygiene is entrance for reducing HCAI and increasing patient safety. ICN – EWMA JOINT CAMPAIGN Nurses are in a strong position to influence and enhance a culture that supports and enhances patient safety and infection prevention and control. ICN and the EWMA will be launching a campaign at their respective congresses to populate the WHO call for action. This campaign will raise awareness about the importance of hand hygiene and will support nurses to lead the way in this critical intervention. The campaign will be headed by Dr Frances Hughes, CEO of ICN and Dr. Severin Läuchli, President of EWMA. The campaign will include a workshop on hand hygiene during the EWMA 2017 Conference in Amsterdam, held 3-5 May, and the ICN 2017 Conference in Barcelona, held 27 May – 2 June.

CAMPAIGN ACTIVITIES DURING THE EWMA 2017 CONFERENCE n Hand Hygiene workshop at the EWMA 2017 Conference: Friday 5 may 10.15 -11.15

Visit the Hand Hygiene booth in the EWMA 2017 Exhibition area. Booking no. 3D 10 n

EWMA Journal

2017 vol 17 no 1

International Lymphoedema Framework Conference

www.ebjis2017.org

36th annual meeting of the Co-hosted by the Italian Lymphoedema Framework

21-24 June 2017 Siracusa · Italy

European Bone and Joint Infection Society

Venue: Teatro Massimo Comunale

www.2017ILFconference.org

Save the date

7 - 9 September 2017 Nantes · France · La Cité Nantes Events Center Important deadlines Abstract Submission 8 May 2017 Early Registration 1 July 2017

There will be simultaneous translation to Italian.

All sessions will have simultaneous translation to French

L&R – providing solutions for wound care.

Meet us at EWMA 2017, Hall 2, Booth 2 C 01!

Our point of interest. We place the well-being of our employees, customers, medical professionals and patients at the heart of everything we do.

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We are looking forward to discuss your daily challenges in wound care. Join our symposia and meet us at the booth! Let us provide you with product and service solutions in the fields of: Debridement (Debrisoft) ■ Local Wound Management (Suprasorb, Vliwasorb) ■ Negative Pressure Wound Therapy (CNP) ■ Compression (Rosidal, Actico, ReadyWrap) ■

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Science, Practice and Education

Negative Pressure Wound Therapy

Overview, challenges and perspectives

Learn more about NPWT and the document at the on EWMA keysession m fro ay M 4 Thursday 0 :3 15 0:3 14

Jan Apelqvist Physician at Diabetes and Endocrinology, Lund University, Sweden

The EWMA document on negative pressure wound therapy (NPWT) has now been published as an online supplement to the Journal of Wound Care. This article introduces the document. diac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11

On behalf of co-editor Christian Willy and the author group, whose other members include: Ann-Mari Fagerdahl, Marco Fraccalvieri, Malin Malmsjö, Alberto Piaggesi, Astrid Probst, Peter Vowden.

While the potential of NPWT is promising and the clinical use of the treatment is widespread, high-level evidence of its effectiveness and economic benefits remain sparse.12–14

Introduction Since its introduction in clinical practice in the early 1990’s negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4–6 dehisced sternal wounds following carEWMA Journal

2017 vol 17 no 1

The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, 

Correspondence: ewma@ewma.org The document is supported by unrestricted educational grants from: Acelity, BSN medical, Genadyne, Mölnlycke Health Care, Schülke & Mayr GmbH, Smith & Nephew and Spiracur.

which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents (15–19) with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients n

n Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research n The nature and extent of the problem for wound management: from the policy maker and health-care system perspectives

The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuumassisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery.

Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system’s points of view—particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: 1. Present the rational and scientific support for each delivered statement 2. Uncover controversies and issues related to the use of NPWT in wound management 3. Implications of implementing NPWT as a treatment strategy in the health-care system 4. Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital admini strators who are indirectly or directly involved in wound management. The document has been published as an online supplement to the Journal of Wound Care and can be downloaded via www.ewma.org

REFERENCES 1 Bobkiewicz, A., Banasiewicz, T., Ledwosinski, W., Drews, M. Medical terminology associated with Negative Pressure Wound Therapy (NPWT). Understanding and misunderstanding in the field of NPWT. Negative Pressure Wound Therapy. 2014; 1: 2, 69–73. 2 Hampton, J. Providing cost-effective treatment of hard-to-heal wounds in the community through use of NPWT. Br J Community Nurs 2015; 20: Suppl 6, S14–S20. 3 Apelqvist, J., Armstrong, D.G., Lavery, L.A., Boulton, A.J. Resource utilization and economic costs of care based on a randomized trial of vacuum-assisted closure therapy in the treatment of diabetic foot wounds. Am J Surg 2008; 195: 6, 782–788. 4 Acosta, S., Bjarnason, T., Petersson, U. et al. Multicentre prospective study of fascial closure rate after open abdomen with vacuum and mesh-mediated fascial traction. Br J Surg 2011; 98: 5, 735–743. 5 Kaplan, M. Negative pressure wound therapy in the management of abdominal compartment syndrome. Ostomy Wound Manage 2005; 51: 2A Suppl, 29S–35S. 6 Swan, M., Banwell, P. Topical negative pressure. Advanced management of the open abdomen. Oxford Wound Healing Society. 2003. 7 Fuchs, U., Zittermann, A., Stuettgen, B. et al. Clinical outcome of patients with deep sternal wound infection managed by vacuum-assisted closure

compared to conventional therapy with open packing: a retrospective analysis. Ann Thorac Surg 2005; 79: 2, 526–531.

8 Fleck,T., Gustafsson, R., Harding, K. et al. The management of deep sternal wound infections using vacuum assisted closure? (V.A.C.®) therapy. Int Wound J 2006; 3: 4, 273–280. 9 Armstrong, D.G., Lavery, L.A., Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005; 366: 9498, 1704–1710. 10 Blume, P.A., Walters, J., Payne, W. et al. Comparison of negative pressure wound therapy using vacuumassisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care 2008; 31:4, 631–636. 11 Trueman, P. Cost-effectiveness considerations for home health V.A.C. Therapy in the United States of America and its potential international application. Int Wound J. 2008; 5: Suppl 2, 23–26. 12 Dumville, J.C., Owens, G.L., Crosbie, E.J. et al. Negative pressure wound therapy for treating surgical wounds healing by secondary intention. Cochrane Database Syst Rev 2015; 6: 6, CD011278. 13 Dumville, J.C., Webster, J., Evans, D., Land, L. Negative pressure wound therapy for treating pressure

ulcers. Cochrane Database Syst Rev 2015; 5: 5, CD011334.

14 Dumville, J.C., Hinchliffe, R.J., Cullum, N. et al. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2013; 10: 10, CD010318. 15 Gottrup, F., Apelqvist, J., Price, P. et al. Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management. J Wound Care 2010;19: 6, 237–268. 16 Strohal, R., Apelqvist, J,. Dissemond, J. et al. EWMA document: Debridement: an updated overview and clarification of the principle role of debridement J Wound Care 2013; 22: Suppl 1, S1–S49. 17 Gottrup, F., Apelqvist, J., Bjarnsholt, T. et al. EWMA Document: Antimicrobials and Non-healing Wounds: Evidence, controversies and suggestions. J Wound Care 2013; 22: Suppl 5, S1–S89. 18 Moore, Z., Butcher, G., Corbett, L.Q, et al. EWMA Document: Home Care-Wound Care: Overview, Challenges and Perspectives. J Wound Care 2014; 23: Suppl 5: S1–S38. 19 Probst, S., Seppänen, S., Gethin, G. et al. EWMA Document: Home Care-Wound Care: Overview, Challenges and Perspectives. J Wound Care 2014; 23: Suppl 5a, S1–S41.

EWMA Journal

2017 vol 17 no 1

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1 Humbert P, Faivre B, Véran Y et al. On behalf of the CLEANSITE study group. Protease-modulating polyacrylate-based hydrogel stimulates wound bed preparation in venous leg ulcers a randomized controlled trial. Journal of the European Academy of Dermatology and Venereology 2014;28(12):1742-1750. 2 Kaspar, D (2011). Therapeutic effectiveness, compatibility and handling in the daily routine of hospitals or physicians’ practices. HARTMANN Data on file: Hydro-Responsive Wound Dressing (HRWD) and AquaClear Technology are trademarks of HARTMANN.

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1. Münter KC, Meaume S, Augustin M, Senet P, Kérihuel J.C. The reality of routine practice: a pooled data analysis on chronic wounds treated with TLC-NOSF wound dressings. Journal of Wound Care 2017; 26: WUWHS Suppl, S4–S15. 2. French Health Insurance Report to the Ministry of Health for 2014. July 2013. 3. Jünger M, et al. Comparison of interface pressures of three compression bandaging systems used on healthy volunteers. J Wound Care. 2009;18(11):474, 476-80.

EWMA

New EWMA document:

Use of oxygen therapies in wound healing: Focus on topical and hyperbaric oxygen treatment

Finn Gottrup (Editor)MD, Professor of Surgery University of Southern Denmark, Copenhagen Wound Healing Center, Department of Dermatology, D42, Bispebjerg University Hospital, 2400 Copenhagen NV, Denmark

In 2015 EWMA decided to prepare the elaboration of a document about the use of oxygen in wound healing. Although oxygen is one of the essential components in terms of the healing of wounds the EWMA Council at that time considered that the topic was not very comprehensively covered in the existing literature. This short article introduces the full document which will be available for free online download from May 2017.

Joachim Dissemond (Co-editor) MD, Professor Department of Dermatology, Venerology and Allergology, University Hospital of Essen, Hufelandstr. 55, 45147 Essen, Germany

terial occlusive disease (PAOD) and diabetic foot ulcers. In addition, there is increasing evidence that hypoxia is a central aspect for almost all types of non-healing wounds.

On behalf of the author group, whose other members include: Carol Baines, Robert Frykberg, Peter Østrup Jensen, Jacek Kot, Knut Kröger, Pasquale Longobardi.

The document is supported by an unrestricted educational grant from: ActiMaris, AOTI, Inotec AMD, OxyCare and SastoMed. More information: www.ewma.org EWMA Journal

Non-healing wounds are a significant problem in health care systems worldwide. In the industrialised world almost 1–1.5% of the population will have a non-healing wound at any one time. Furthermore, wound management is expensive; in Europe it is expected that wound management accounts for 2–4% of health-care budgets. These figures will probably rise along with an increase in the elderly and diabetic population. INTRODUCTION TO THE DOCUMENT Wounds require, amongst other things, restoration of macro- and microcirculation as essential conditions for healing. The main, or at least one of the most immediate requirements is oxygen, which is critically important for reconstruction of new vessels and connective tissue and provision of a competent resistance against infection. Sustained oxygen is therefore vital for the healing of patients with non-healing wounds. This has been proven for wounds associated with peripheral ar-

2017 vol 17 no 1

Oxygen therapy is a general term which includes amongst others Hyperbaric Oxygen Therapy (HBOT) and Topical Oxygen Therapy (TOT). HBOT has been known for many years and is well established in wound treatment regimes. Therefore, in this paper HBOT is being presented as the synopsis of mechanisms of action, clinical evidence and current recommendations of internationally recognised hyperbaric organisations. On the other hand, during recent years, 

EWMA

new therapeutic approaches based on TOT have been developed to support wound healing. Due to its relative novelty and small number of clinical studies when compared to HBOT, the description of several methods classified generally as TOT are presented in more detail with description of most, including still ongoing, studies. The imbalance in volume of description between those two treatment methods created by this approach must be carefully judged by the reader with special attention to the grade of evidence and level of recommendations. In future, the relation between TOT and HBOT, with possible synergistic action must be taken into account when planning further studies. DOCUMENT AIM, OBJECTIVES AND SCOPE The overall aim of this document is to highlight the present knowledge with regard to the use of oxygen therapies in the care and treatment of wounds of different aetiologies, which fail to progress through an orderly and timely sequence of repair. In this document, these types of wounds are defined as “non-healing”. Excluded from this document are animal and cellular models, acute wounds (e.g. surgical/trauma wounds), and burns. Furthermore, the distribution of supplementary systemic oxygen at barometric pressure in connection with surgery is not covered by this document.

STRUCTURE AND CONTENT OF THE DOCUMENT The document is presented in nine chapters: n Chapter 1: Introduction to the document including its aim, objectives and scope as well as a short presen tation of its structure n Chapter 2: Presents the methodology and terminology used in the document. n Chapter 3: Introduces and discusses the role of molecular oxygen in living tissue in general and in wound healing processes specifically. n

Chapter 4: Presents and discusses TOT

Chapter 5: Presents and discusses HBOT

n Chapter 6: Focuses on patient perspectives of oxygen treatment including Health Related Quality of Life ‘ and patient education. n Chapter 7: Presents considerations regarding economics and cost-efficiency of TOT as well as HBOT n

The document will provide an overview of treatment options, as well as assessments of the best available evidence on their respective results. In addition, the document will go into detail with specific aspects and current discussions regarding the use of oxygen in wound healing including: n The role of oxygen and hypoxia in the wound healing process n

Patient perspectives of oxygen treatment

Cost-effectiveness aspects of oxygen therapies

Discussing what is still controversial and giving suggestions for future actions. n

In line with other similar documents published by EWMA during recent years, the document structure is inspired by the different elements that are usually included in the health technology assessment (HTA) approach. Thus, it is not a traditional position document that discusses different treatment strategies, when to use which product, or assesses one product against another, but rather a holistic picture of the current practice and reality of the use of oxygen therapies in wound healing.

Chapter 8: Presents the conclusions of the document

n Chapter 9: Provides a brief look towards expected new developments over the next few years in the area of oxygen therapies and wound healing.

The document has been published as an online supplement to the Journal of Wound Care and can be downloaded via www.ewma.org

Presentation of the “Use of oxygen therapies in wound healing: Focus on topical and hyperbaric oxygen treatment” document is the main topic of a key session which is scheduled for Wednesday 3 May 16.45-18.00 in the room “Elicium 2”.

EWMA Journal

2017 vol 17 no 1

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In-depth studies of new treatment applications with research into existing treatments to guide your clinical decision-making

All the innovations in wound care from both preclinical and preliminary clinical trials of potential treatments worldwide

Visit www.magsubscriptions.com/jwc or call +44 (0)1722 716997

EWMA

Wound curriculum for nurses – post-registration qualification wound management EWMA has just finalised the first curriculum in a series of several curricula intended for use in levels 5-7 of the European Qualifications Framework (EQF)1. The aim of these is to support a common approach to postregistration qualification in wound management for nurses across Europe. EWMA hopes and will work towards a close collaboration with European nurse organisations as well as educational institutions to implement these common curricula. INTRODUCTION In recent years, the care of people with chronic wounds has made enormous progress throughout Europe. To bring existing evidence based and best practice knowledge to all professional nurses is a key objective of the European Wound Management Association (EWMA). For this reason, EWMA has developed a curriculum for nurses that aligns with the EWMA curriculum on wound healing for physicians2 which was approved by the European Union of Medical Specialists (UEMS) in April 2015. Since the vocational qualifications in Europe are not all at the same level and the pre-registration curricula may differ, three curricula referring to different EQF levels are under development. The first curriculum is intended for EQF level 5. Curricula intended for EQF levels 6 and 7 will be available in due course. Depending on the existing educational level of the undergraduate qualification of the participants the EWMA curricula can be adapted to meet the competencies expected at levels 5, 6 or 7. SCOPE, AIMS AND OBJECTIVES OF THE CURRICULUM This EWMA wound curriculum for nurses - postregistration qualification wound management takes into account that individuals with chronic wounds require very specific therapy and care needs related to their clinical presentation and the challenges related to multiple co-morbidities. EWMA Journal

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To be able to apply an holistic approach to and provide effective management of individuals with wounds, the nurse must therefore have specific knowledge, practical skills and awareness about patient safety, local wound care, the overall patient status and interdisciplinary teamwork. The nursing process provides the overarching framework for the curriculum and takes into account the outcomes of the interventions in the course of care (prevention, diagnostics and treatment). The curriculum explores a range of comprehensive nursing interventions such as the assessment, planning, interventions and evaluation related to individuals with acute and chronic wounds. It should allow students to extend their knowledge of wound care to obtain specific competencies. This constitutes explicit knowledge of the relationships between the typical underlying diseases with the onset of chronic wounds, as well as their guideline-based care in terms of causal, local and concomitant therapy. Finally, the curriculum also aims to support the development of the nurse’s ability to assess the psychosocial and behavioural aspects of patients with wounds and to promote the patient’s quality of life. The curriculum aims to provide the students with theoretical and practical skills to support appropriate decision-making (evidence 

Samantha Holloway, RN, MSc Senior Lecturer, Cardiff University School of Medicine , Centre for Medical Education, Wales Andrea Pokorna, RN, PhD, Associate professor Medical Faculty, Masaryk University, Dept. of Nursing, Brno, Czech Republic Ida Verheyen-Cronau, RN Initiative Chronische Wunde (ICW) Robert Strohal, MD Dept. of Dermatology and Venerology Federal University Teaching Hospital Feldkirch

Correspondence: ewma@ewma.org Conflicts of interest: None

EWMA

based nursing and practice, problem based learning and practical based learning). A professional Scope of Practice and Code of Conduct is considered fundamental and essential components to guide nursing practice. Clear guidance should be provided and defined in relation to professional boundaries, for example in relation to interventions such as wound debridement. These boundaries need to be defined according to national or local recommendations or legislation and have therefore not been provided within the curriculum. FORMAT The curriculum summarises the required learning goals, knowledge and skills related to the inter-professional and interdisciplinary that are suggested for inclusion in the post-registration qualification in wound management. However the curriculum may also be included or adapted in other relevant post- registration and postgraduate training programmes. The learning goals (outcomes) have been developed with reference to BloomÂ´s taxonomy3. All units include learning goals in the following categories: n

Knowledge/cognitive (K)

Pragmatic, psychomotor skills (P)

Awareness/behaviour (A)

12. Pressure ulcers 13. Diabetic foot syndrome 14. Lower leg ulcers 15. Health care delivery and health economics 16. Documentation NEXT STEPS To maximise the impact of these curricula, EWMA will seek collaboration with relevant organisations and educational institutions to disseminate the curricula and support their implementation in post-registration nurse education across Europe. Additional plans to support the adoption and use of the EWMA curricula includes an online Delphi process as well as the continued process to develop and update EWMA Education modules providing more details on the topics to cover within a specific subject. We hope that you will support this initiative to ensure common high standards for the education of the next generations of wound managers. WHERE TO FIND IT? The Curriculum can be downloaded via http://ewma.org/what-we-do/education/

The intention for the curriculum is that is it incorporated into existing programmes in different European countries4, specific details of the teaching and learning methods and assessment and evaluation methods are not included. These should follow the structure used by the education provider while incorporating the content and learning objectives provided in this curriculum according to local recommendations and procedures (legislation and accreditation processes). The curriculum includes 16 units of study: 1. The role of prevention in wound care 2. Evidence based nursing/evidence based practice 3. Patient education and promoting self-care 4. Case management (patient centred care) 5. Wounds and wound healing 6. Nutrition and wound healing 7. Microbiology and wounds 8. Antimicrobial agents, hygiene and wounds 9. Debridement and wounds 10. Moist wound healing 11. Alternative or unconventional treatment options for wounds 66

REFERENCES 1. Learning Opportunities and Qualifications in Europe, https://ec.europa.eu/ploteus/ search/site?f%5B0%5D=im_field_entity_type%3A97 2. www.ewma.org/what-we-do/education/wound-curriculum-physicians/ 3. Bloom, B. S.; Engelhart, M. D.; Furst, E. J.; Hill, W. H.; Krathwohl, D. R. (1956). Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York: David McKay Company. 4. European Union Standards for Nursing and Midwifery: Information for Accession Countries, 2nd edition, 2009, www.euro.who.int/__data/assets/pdf_file/0005/102200/ E92852.pdf

EWMA Journalâ&#x20AC;&#x201A;

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• Official organ of the German and Swiss Phlebological Society • Free online access to all articles, even to the online archive dating back to 1998! • All publications available in English too, since 2013! • Always stay up to date by signing up for the Electronic Table of Contents (eTOC) at: www.schattauer.de/etoc-EN.html Phlebologie 6 issues per volume ISSN 0939-978X www.phlebologieonline.de

• Submit your next paper to Phlebologie! Reach your audience without restrictions – free download of all articles at www.phlebologieonline.de

Founded in 1972, the journal Phlebologie has served for decades as the leading European peer-reviewed journal advancing knowledge in the field of venous disorders. As the official journal of the German and Swiss Societies of Phlebology it is the field’s most important scientific journal in the German speaking countries to date. The journal publishes original and review articles on all aspects of the field as well as theme-oriented issues on new and emerging diagnostic procedures, therapies, or preventative medicine. Since 2013, all scientific articles are translated into English and published online as articles freely accessible to everyone. All scientific manuscripts are strictly peer-reviewed in a blinded fashion by international renowned experts. The journal strictly follows the ethical guidelines and recommendations provided by the International Committee of Medical Journal Editors and related organizations. Free print copy (articles mainly in German) available on request.

www.phlebologieonline.de

EWMA EWMA AMSTERDAM 2017

EWMA 2017 AMSTERDAM, THE NETHERLANDS

3-5 MAY 2017

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM) IN AMSTERDAM

The EWMA UCM programme offers students of wound management from institutes of higher education across Europe the opportunity to take part of their academic studies whilst participating in the EWMA Conference.

PARTICIPATING INSTITUTIONS:

The opportunity of participating in the EWMA UCM is available to all teaching institutions with wound management courses for health professionals. The UCM programme at the EWMA 2017 Conference in Amsterdam will offer networking opportunities between the students from variours UCM groups, UCM Levtures as well as assignments and workshops arranged specifically for the UCM students. EWMA strongly encourages teaching institutions and students from all countries to benefit from the possibilities of international networking and access to lectures by many of the most experienced wound management experts in the world. Yours sincerely Luc Gryson Chair of the Education Committee

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

www.wunddach-kongress-2017.org

2. WundD·A·CH Dreiländerkongress 2017 St. Gallen, Schweiz 28. - 30. September 2017 Abstract Deadline

Early Bird Registrierung

1. Juni 2017

15. Juli 2017

Programmthemen ■

Venöses Ulcus cruris - aus verschiedenen Blickwinkeln

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Wunden in der Palliativmedizin

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Diabetischer Fuß

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Antimikrobielle Therapie

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Amputation

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Interprofessionelles Team in der Wundbehandlung

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Lokaltherapie jenseits von Wundauflagen

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Wundbehandlung in der DACH Region

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Neues aus der Grundlagenforschung

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Allergien in der Wundbehandlung

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Inflammation in der chronischen Wunde

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Psychosoziale Aspekte beim chron. Wundpatienten

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Sicherheit in der Wundbehandlung

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Ko-Morbiditäten

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Ethik in der Wundbehandlung

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Narben

WISSEN SICHERHEIT

NEW SPONSORS

AUREALIS PHARMA

Aurealis Pharma is a Swiss-Finnish biopharmaceutical company developing a technology platform facilitating therapeutic protein combination therapy embedded in one single product. The technology platform is based on non-pathogenic lactic acid bacteria engineered to produce and secrete multiple therapeutic human proteins locally in target tissue. This technology is safe, efficient and can be manufactured in a very cost-effective way. Our lead product candidate AUP-16 is targeting chronic inflammatory wounds, such as DFU and VLU. AUP-16 is modified to express and secrete three therapeutic proteins, with the aim to re-initiate the wound healing process by addressing critical pathways in the wound healing cascade: inflammation, angiogenesis and granulation tissue formation. Aurealis technology enable efficient local delivery of multiple therapeutic proteins in a single product. The same technology can easily be applied to also other major indi-

cations with high unmet medical need, such as advanced cancer and osteoarthritis.

• Efficient. AUP-16 is secreting multiple therapeutic

proteins at the same time with continuous release avoiding frequent and high peak dosing. AUP-16 is considered as a single active ingredient producing the three human therapeutic proteins.

• Safe. AUP-16 is a topical treatment with no systemic exposure and related toxicity.

• Easy. AUP-16 is easy to use with a convenient dosing schedule. No special teams or devices needed. Freeze-dried product is reconstituted, mixed and applied once, twice or three times a week depending on the indication.

• Affordable. Manufacture and logistics are easy and

inexpensive, infrastructure exists enabling low cost of goods and significant cost advantages (biologic agent with low cost).

Fig 1: AUP-16, our front running wound healing compound.

AUP-16. DIABETIC FOOT ULCER 1. FGF-2: Growth Factor in clinical use. Supports fibroblasts and formation of new blood wessels. 2. IL-4: Anti-inflammatory cytokine in clinical trials. Supports macrophage M2 polarization and fibroblast proliferation. 3. CSF-1: Cytokine in clinical trials. Supports macrophage recruitment and M2 polarization. Prevents apoptosis of macrophages. 4. Lactic acid bacteria has immune activating anti-inflammatory and antiinfective properties. 70

Fig 2: In vivo proof-of-concept studies performed in diabetic mice demonstrate superiority of AUP-16 over standard-of-care and positive control TGFa + PDGF-BB.

Contact Dirk Weber, CMO Aurealis Pharma AG dirk.weber@aurealispharma.com ; www.aurealispharma.com T: +41 79 9441580 EWMA Journal

2017 vol 17 no 1

Visit EWMA on our Social Media platforms Follow us and get the latest updates about the EWMA 2017 Amsterdam Conference as well as other EWMA activities

www.facebook.com EWMA Wound

www.linkedin.com/company/ european-wound-management-association

Twitter: @ewmatweet

Instagram: @ewmapics

Make a difference in clinical practice Become a Member of EWMA Benefits of your EWMA Membership: n You make a difference in clinical practice within wound management in Europe n Right to vote and stand for EWMA Council n EWMA Journal sent directly to you two times a year n EWMA news and statements sent directly to you n A discount on your registration fee for EWMA Conferences n Right to apply for EWMA travel grants n Yearly membership fee € 25 n Yearly membership fee for members of cooperating organisations € 10

EWMA Journal

2017 vol 17 no 1

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Submit your paper to EWMA Journal Volume 17 16 Number 1 2016 April 2016

Volume 16 15 Number 2 2015 October 2015

Published Published by by European Wound Wound Management Management Association

on the road to better

PATIENT

sAfETy Volume 14 Number 1 May 2014

Volume 14 Number 2 October 2014

Published by European Wound Management Association

Volume 13 Number 2 October 2013 Published by European Wound Management Association

WOUND CARE A PATIENT, PROFESSIONAL, PROVIDER AND PAYER PERSPECTIVE

INNOVATION, KNOW-HOW AND TECHNOLOGY IN WOUND CARE

Published by

Editorial Board

EUROPEAN WOUND MANAGEMENT ASSOCIATION

Sebastian Probst, Editor Sue Bale, Editor in Chief Vickie R Driver

www.ewma.org

Published by European Wound Management Association

EWMA FOCUS ON ANTIMICROBIALS AND DEBRIDEMENT

– SHAPING THE FUTURE

Rf dC

Volume 13 Number 1 April 2013

Georgina Gethin Salla Seppänen Hubert Vuagnat

Management of the Diabetic Foot Management of the Diabetic Foot

9th Course · 4- 7 October 2017 · Pisa · Italy

Welcome to Pisa This 4-day theoretical course and practical training gives participants a thorough introduction to all aspects of diagnosis, management and treatment of the diabetic foot. Welcome to Pisa Lectures will be combined with practical This 4-day theoretical course and practical sessions held in the afternoon at the diabetic training gives participants a thorough introfoot clinic Pisa University Hospital. duction to at allthe aspects of diagnosis, management and treatment of the diabetic foot. Lectures will be in agreement with the International Consensus on the practical Diabetic Foot Lectures will be combined with and Practical Guideline on the Management sessions held in the afternoon at the diabetic and theUniversity Diabetic Foot. foot Prevention clinic at theon Pisa Hospital. Lectures will be in agreement with the International Consensus on the Diabetic Foot and Practical Guideline on the Management and Prevention on the Diabetic Foot.

Pisa International Diabetic Foot Course www.diabeticfootcourses.org

The course is endorsed by EWMA

EWMA News EDUCATION NEW WOUND CURRICULUM FOR NURSES – POST-REGISTRATION QUALIFICATION WOUND MANAGEMENT EWMA has just finalised the first curriculum in a series of several curricula intended for use in levels 5-7 of the European Qualifications Framework (EQF). The aim of these is to support a common approach to post-registration qualification in wound management for nurses across Europe. EWMA hopes and will work towards a close collaboration with European nurse organisations as well as educational institutions to implement these common curricula. The Wound Curriculum for Nurses as well the previously published Curriculum on Wound Healing for Physicians can be downloaded free of charge via http://ewma.org/what-we-do/ education/ EWMA TEACHER NETWORK – CURRENT ACTIVITIES The EWMA Teacher Network is a network for wound management teachers across Europe. The primary objectives of the network are to increase the collaboration on objectives, structure and content of future wound management education and training in Europe, and to explore the possibilities for establishing a sustainable life-long learning training programme for nurse teachers. Currently the network collaborates on an online survey which seeks to understand the current provision of Skin Health and Wound Management teaching as part of the current standard curriculum for undergraduate nurses across Europe. This survey is the first part of a wider European research project into Skin Health and Wound Management education for undergraduate nurses that is being undertaken by members of the network. The final phase of the project is to gather data on the experiences of student nurses in relation to Skin Health/Skin Integrity and Wound Management during their training to gauge how well prepared they feel for managing individuals with wounds. The survey is initiated and led by the EWMA Teacher Network Chair, Samantha Holloway. The EWMA Teacher Network meets annually during the EWMA Conference in May and will meet this year on 3 May at 11.45-13.15 during the EWMA 2017 Conference in Amsterdam. For more information about the EWMA Teacher Network, please visit: www.ewma.org/english/education/teacher-network.html

EWMA Journal

2017 vol 17 no 1

EWMA NEWS

EWMA News EWMA E-LEARNING MODULES ON BASIC WOUND MANAGEMENT EWMA is currently finalising an e-learning course on the basics of wound care. With this we wish to support the provision of high quality wound care by healthcare professionals without specialist knowledge in wound care in hospitals, nursing homes and home care units. The participants will become familiar with the basics of the management of acute and chronic wounds, including the following topics: Pathophysiology of Wounds, Wound Assessment, Treatment Options , Wound Infection, Debridement, Pain and Palliative Wound Care. The full course is expected to be ready in Autumn 2017.

EWMA CREATING AWARENESS It is a clear objective of EWMA to ensure that challenges in wound management are placed on the pan-European and national political agendas. For this reason, EWMA runs a number of activities aiming to create awareness about wounds and wound management among important stakeholders. Current advocacy activities include: AWARENESS EVENT IN THE NETHERLANDS, AUTUMN 2017 An awareness event targeting politicians and other key stakeholders in the Netherlands will be held in September, as a follow up activity after the EWMA 2017 Conference in Amsterdam 3-5 May. It will be organised in collaboration with the Dutch Wound Platform. Key messages of the event include: n The organisational structure within wound care is not effective, because it is based on existing organisational lines. n Patientsâ&#x20AC;&#x2122; needs and quality of life are not taken into consideration sufficiently when buying wound materials. n

EWMA Journalâ&#x20AC;&#x201A;

First line healthcare providers need to be educated more in order to provide wound care.

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EWMA News EWMA CREATING AWARENESS JOINT EPUAP & EWMA PRESSURE ULCER PREVENTION & PATIENT SAFETY ADVOCACY PROJECT This project aims to establish a joint EPUAP-EWMA focus on the pressure ulcer (PU) prevention and patient safety agendas at the European level, as well as at the national level, in selected European countries. Currently the team is working on the following main activities: n Elaboration of epidemiology overview based on existing European prevalence data. Presentation is expected at the EPUAP 2017 Conference, 20-22 September in Belfast.

Collaboration and sharing of information with the chair of the OECD Health Care Quality Indicators Expert Group (HCQI). This work is expected to contribute to improving the focus on PU as a patient safety quality indicator. n

Follow-up to the first monthly report which the project has commissioned with the aim of being kept updated about activities of the European Parliament and European Commission regarding PU / wound care. The reports will be used to target activities and decision-makers to raise awareness about patient safety and call for preventive action against the development of pressure ulcers.

The project group includes: n

EPUAP representatives: Zena Moore (chair), Lisette Schoonhoven, Jane Nixon, Jan Kottner

EWMA representatives: Andrea PokornĂĄ, Jose Verdu Soriano, Hubert Vuagnat

The project is supported by an unrestricted grant from:

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EWMA NEWS

EWMA News UPCOMING ACTIVITIES EWMA HAS DEFINED THE FOLLOWING FOCUS TOPICS FOR THE PERIOD 2018-2019: WOUNDS ACROSS THE LIFE SPAN Not all wounds are the same and not all people respond to wounds in a similar manner. And so it is with wounds across the lifespan. EWMA has therefore decided to focus on the management of individuals with wounds in the two extremities of life: n

Neonatal and paediatric wound care is under-represented in the wound care literature and within the current EWMA activities. Yet, this population poses significant challenges in the types of wounds and the bodily response to healing. Despite this, neonatal and paediatric wound care dressing and practices are often based on extrapolation of adult-based guidelines while they should be applied considering specific skin features and structures. At the other end of the life span we have an increasing ageing population with altogether complex and different wound aetiologies of a more chronic nature, and a different response to healing. Given the generally aging population, there is an increasing need to understand how age influences wound healing and the different wound aetiologies that can be encountered at different life stages.

EWMA plans to publish two documents to cover these topics: One document on neonatal/ paediatric wound management, and one on the management of geriatric wound patients. These documents will provide healthcare professionals with a resource that outlines the pathophysiology and recommended organisation of wound healing as it applies to these specific age groups. The author groups responsible for these documents will be defined in Autumn 2017. ATYPICAL WOUNDS This document will provide an overview of recent knowledge and evidence about atypical wounds, which in general terms are wounds which cannot be placed in the main wound categories. Amongst others they present a broad spectrum of conditions caused by inflammation, infection, malignancy, chronic illness or genetic disorder. Prevalence is not high (approx. 1-5 % of all wounds), but they constitute a significant proportion of wound patients especially in dermatological departments, and their considerable diagnostic delay and prolonged healing time has an enormous impact on patient Quality of Life. The objectives of the document include providing an overview on the wounds typically considered atypical, presenting the diagnostic criteria, comorbidities and diagnostic tools for these wounds as well as the available best documented treatment options including immunosuppression and other modern/advanced wound healing therapies (e.g. NPWT). Further, the document will define the challenges and recommendations related to organisation of treatment and care and health economy. The author group responsible for this document will be chaired by EWMA Council member Dr Kirsi Isoherranen, dermatologist and dermato-surgeon. The group will include members with different professional backgrounds relevant to achieving the objectives of the project. The document will be published during Spring 2019. EWMA Journalâ&#x20AC;&#x201A;

2017 vol 17 no 1

EWMA News EWMA DOCUMENTS IN PROGRESS PREVENTING AND MANAGING SURGICAL SITE INFECTIONS ACROSS HEALTH CARE SECTORS Introduction and aim While guidelines for preventing and managing surgical site infections (SSI) in hospitals are in place in many countries, there is still a need for guidance on how to deal with SSI management and prevention in community care. A set of recommendations on this topic covering primary as well as secondary care, and targeting healthcare professionals in hospital as well as community-based nurses and general practitioners (GPs), does not yet exist. EWMA has therefore decided to focus on surgical site infections and initiate a project based on broad interdisciplinary collaboration which will also link to other current EWMA initiatives such as:

The document is presented in partnership with:

The on-going EWMA Antimicrobial Stewardship Programme

The NPWT document published in Summer 2016

n The Home Care Wound Care document published in 2014, with regards to SSI prevention and management in community care

Additional information about these programmes and documents can be found at www.ewma.org/what-we-do/ewma-projects/ Objectives The main objectives of the EWMA SSI project are to: n Map the SSI incidence, prevalence and high risk areas, based on published information and data available from SSI registries. The project is supported with unrestricted grants from:

n Present the available modern techniques for prevention and treatment of surgical site infections, including assessment of cost effectiveness, patient mobility, pain etc. n Provide best practice recommendations for SSI management and prevention in hospitals and community care.

Author group Jan Stryja (Editor) Kylie Sandy-Hodgetts Claus Moser Deborah Xuereb Gregory Bohn Jennie Wilson 78

EWMA Council, Hospital Podlesi, Trinec, Czech Republic Wounds Australia, Curtin University, School of Nursing and Midwifery Dept. of Clinical Microbiology , University Hospital of Copenhagen, Rigshospitalet , Denmark Infection Prevention Society, Mater Dei Hospital, Malta West Shore Medical Center, General Surgery and Wound Care, USA Infection Prevention Society, University of West London, UK EWMA Journalâ&#x20AC;&#x201A;

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EWMA NEWS

EWMA News D

T H

ADVANCED THERAPIES IN WOUND MANAGEMENT A P I ES

E R

DVA NC

With the “Advanced Therapies in Wound Management” initiative, EWMA wish to investigate the barriers and possibilities of advanced therapies in the next generation of wound management. The project will include the publication of a focus document providing an overview of the available advanced therapies and their potential role in clinical practice. These will include the available technologies based on cellular therapies, tissue engineering and tissue substitutes, which are all technologies associated with the clinical discipline of regenerative medicine, as well as new treatments based on physical therapies and the potential of sensors and software. The overall aims of the document are to Provide healthcare professionals who are interested in investigating new treatment options with a neutral and exhaustive source of information. n

Provide a point of referral for future discussions and negotiations with healthcare providers and payers. n

Author group Alberto Piaggesi (Editor) Severin Läuchli Franco Bassetto Alexandra P. Marques Bijan Najafi Clemens Schiestl Giuseppe Turchetti

Italy, University of Pisa, EWMA Executive Committee member Switzerland, University Hospital, Zürich, EWMA President Italy, University of Padova Portugal, 3B’s Research Group US, Baylor College of Medicine Switzerland, Kinderspital Zürich Italy, Scula Superiore Sant’Anna

The project is supported with unrestricted grants from:

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Diabetic Foot Study Group of the EASD Porto · Portugal 8 - 10 September 2017 Venue Sheraton Hotel, Porto, Portugal Early registration deadline 23 May 2017

EPIDERMOLYSIS BULLOSA (EB)

4th Conference of EB-CLINET Clinical Network of EB Centres and Experts

26 – 27 September Salzburg, Austria Key sessions: • Hot topics in EB Care • Clinical trials (molecular, cell, drug, protein therapies) • Clinical cases (co-occurrence of EB and other diseases) • Clinical practice guidelines for EB • Defining outcomes in EB One shared day with the EB2017– th 5 World Conference of EB Research – ‚from lab-bench to bedside‘ For more information visit www.eb-clinet.org

Conference theme Advancement of knowledge on all aspects of diabetic foot care Main subjects during conference ●

●

Epidemiology Basic and clinical science Diagnostics Classification Foot clinics Biomechanics, Osteoarthropathy Orthopaedic surgery Infection Revascularisation Uraemia Wound healing/outcome

- Be updated on diabetic foot research happening across Europe - Understand risk factors for foot ulceration and Charcot foot - How technology can help in preventing foot ulcers and facilitate wound healing - Practice and innovation of Diabetic Foot Wound Treatment

www.dfsg.org

EWMA NEWS

EWMA Publications New publications in 2017

New EWMA document:

Negative pressure wound therapy – Overview, challenges and perspectives Published March 2017 This document provides an overview of the evidence base for the use of negative pressure wound therapy (NPWT) in wound treatment and covers all three types of NPWT: On open wounds, with instillation and over closed incisions. The document also focuses on the organisational and health economical aspects of NPWT. The document is published as an online supplement to the Journal of Wound Care. NPWT will be covered in a key session during the EWMA 2017 Conference: Thursday 4 May 14.30 -15.30

New EWMA document:

Use of oxygen therapies in wound healing – With focus on topical and hyperbaric oxygen treatment Published May 2017 The document provides practice-oriented guidance on the use of various forms of oxygen therapies for wound treatment. It will include an overview of treatment options available and an assessment of the best available evidence for use. In addition, the document will detail specific aspects and current discussions connected with the use of oxygen in wound healing. The document is published as an online supplement to the Journal of Wound Care. The document will be launched in a key session during the EWMA 2017 Conference: Wednesday 3 May 16.45 -18.00

Antimicrobial stewardship in wound care: Non-antibiotic antimicrobial interventions

Expected publication: Spring 2017 In collaboration with the British Society for Antimicrobial Chemotherapy, EWMA seeks to promote the judicious use of all antimicrobials in wound management. This paper aims to review the possible threat of the emergence of non-antimicrobial resistance and to investigate opportunities for developing alternative remedies for wound infection. The paper will be presented in the BSAC/EWMA Symposium at the EWMA 2017 Conference Friday 5 May 2017, 10.15 -12.30

For download or more information about the above publications and initiatives, please visit www.ewma.org or contact the EWMA Secretariat: ewma@ewma.org EWMA Journal

2017 vol 17 no 1

Organisations

KWMS Korean Wound Management Society

Seung-Kyu Han, MD, PhD President, KWMS More information: www.woundcare.or.kr

Recent Publications of the Korean Wound Management Society Dear EWMA Colleagues, The Korean Wound Management Society (KWMS) is a multidisciplinary society. It was founded to exchange experiences and ideas among experts with different experimental and clinical backgrounds with common interest in wound healing. Members include physicians, nurses, and researchers. Our Society has earned a nationwide reputation as the leading body with competence in wound management. The five pillars of our society are: scientific meetings, education, research, voluntary work, and interchange. In 2017, the KWMS had two big events. First, the KWMS decided to revise the Journal of KWMS to a new name, Journal of Wound Management and Research, to further enhance the academic quality of the journal. This Journal will publish papers in March and September each year. Wound specialists from around the world are warmly invited to submit original articles, review articles, case reports, ideas, and innovations to this Journal. The Journal of Wound Management and Research offers access to online manuscript submission (www.jkwms.org) for rapid peer-review and communication with authors. We sincerely hope that the Journal of Wound Management and Research will be one of the world’s leading international journals covering all basic and clinical aspects in wound healing. Second, the KWMS recently published a book entitled “Wound Healing Experts of Korea”. This book includes 29 biographical profiles of key individuals in Korea who have made significant contributions to the area of wound healing. Members of KWMS are professional, sincere, bright, and passionate about wound management who have archived a

high degree of patients’ satisfaction. There are also members who have developed new therapies and collaborated with industry in the wound healing field with excellent research results. Thanks to the great work of the members of KWMS, there have been dramatic advances in the field of wound healing in Korea. Unfortunately, most members are less well known internationally for their outstanding competence and abilities because English is not their native language. They are not active in international academic societies. Therefore, we published “Wound Healing Experts of Korea” to promote members of the KWMS who have excellent research results to leaders of international societies. In this book, you will find the profiles of leading physicians, nurses, and researchers of Korea. Although some have already gained fame in international academic societies, others have quietly made significant contributions in relative anonymity. Each profile provides critical biographical information about the member, including contact information, educational background, academic career, research interests, scientific achievements, and activities in professional societies. An Index in the back of the book was divided by subject areas to help readers find appropriate researchers. We sincerely hope that this book will be an indispensable reference tool for you in obtaining great information and better understanding about Korean leading experts in wound management. If you need a copy of the book, please contact Jae-A Jung, MD, PhD, Executive Secretary of the KWMS by email (wound@woundcare.or.kr). We will be pleased to send you a copy of the book. Seung-Kyu Han, MD, PhD President, KWMS

EWMA Cooperating Organisation

EWMA Journal

2017 vol 17 no 1

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Organisations

AAWC NEWS AAWC It’s a pleasure to update EWMA members Association for on the activities of the AAWC the Advancement of Wound Care

Dear EWMA Colleagues, The Association for the Advancement of Wound Care (AAWC) is the leading interdisciplinary organization for wound healing in the United States, and we have had tremendous success over the last several years.

Greg Bohn, MD, FACS, ABPM/ UHM, CWSP, FACHM President, Association for the Advancement of Wound Care More information: www.aawconline.org ABOUT AAWC As the leading interpro fessional organisation in the United States dedicated to advancing the care of people with and at risk for wounds, AAWC provides a whole year of valuable benefits! Be sure to join us for near daily updates and alerts on Facebook and LinkedIn.

Our Fall meeting was well attended. More than 1300 participants participated and enjoyed more than 40 sessions. Among the sessions, AAWC held an open mic Forum for our membership to discuss changes in pressure ulcer terminology. Many came to the microphone concerned how these changes may impact on patient care. Would the changes in terminology improve patient care or interfere with care in their setting? Concerns over coding confusion regarding treatment and access to needed durable medical goods were among the concerns. Many at the forum spoke to the impact that these changes may make in the US on policy and insurance coverage determinations. Implementation of the changes in the US will cost millions and yet we cannot demonstrate any benefit to patients. In addition, several members voiced concern over how these specific terms may impact providers and caregivers in the legal system of the United States. While in Europe, terminology may not have such legal ramifications; specific terms have meaning in our legal system. The term “injury” may have unforeseen implications and ramifications as many were concerned that the term itself may carry an additional burden by implying directed causation. While in some European countries there may not be a word for injury, in the US “injury” could be a loaded

term in context of medical descriptions. AAWC will continue to look for improved methodology to assess wounds and bring the best evidence to the treatment of our patients. Our collaborative effort with the Wound Healing Society to develop needed wound endpoints has made great progress. There will be a series of papers published this year outlining the process and outcomes of the end points study. We are very pleased with having been able to participate in this research. We are hopeful that this research will bring more meaningful endpoints to the field. We look forward to participating with EWMA on projects and initiatives. We feel honored to be a valued participant and hope to be able to contribute efforts aimed at betterment of patient care. AAWC does have many international members in our organization. We welcome participation in our organization and our projects. If you have an idea that would improve what we can offer members, let us know. Your contributions can make a difference. We invite our international friends to join AAWC and our mission to advance the care of people with and at risk for wounds. Please contact any board member or the office at any time; we are always happy to hear your suggestions. Visit our website to learn more about getting involved: http://aawconline.org.

Wishing you all the best. Sincerely: Greg Bohn, President, AAWC

EWMA international Partner Organisation

EWMA Journal

2017 vol 17 no 1

BIOSORB

™

Come and visit us at Stand #2B 12

GELLING FIBRE DRESSING

BIOSORB™ Gelling Fibre Dressing

43% greater absorbency than leading gelling fibre dressing. In vitro data1

Gentle on patients. Strong on removal. BIOSORB™ Gelling Fibre Dressing is a soft and conformable non-woven dressing made from sodium carboxymethyl cellulose and strengthening cellulose fibres. Designed to stay intact on removal and make dressing changes less painful.

Come and visit us at Acelity™ stand #2B 12. Ask for a demo of BIOSORB™ Gelling Fibre Dressing. See for yourself how BIOSORB™ Gelling Fibre Dressing can outperform other dressings. REFERENCE 1. Waite A, Delury C, Regan S, An in vitro evaluation of the physical properties of a new gelling fibre dressing, Presented at EWMA 2016; May 11-13, 2016; Bremen, Germany. NOTE: Specific indications, contraindications, warnings, precautions and safety information may exist for Systagenix products. Please consult a healthcare provider and product instructions for use prior to application. Copyright 2016, 2017 Systagenix Wound Management, Limited. All rights reserved. All trademarks designated herein are proprietary to Systagenix Wound Management, Limited, its affiliates and/or licensors. PRA000621-R0-EMEA, EN (04/17). M-74452.

This is how life feels to people with EB.

Association of Diabetic Foot Surgeons

Their skin is as fragile as a butterfly’s wing. They have Epidermolysis Bullosa, a painful and currently incurable skin blistering condition.

3rd Symposium 9 - 11 November 2017 Venice · Italy

www.debra-international.org

Venue Main Topics

NH Laguna Palace Hotel Venice, Italy l

What’s new on amputation prevention strategies worldwide Offloading Surgical approach of infection and osteomyelitis Prophylactic surgery Charcot foot: Medical and surgical treatment Timing of revascularization and local surgical treatment Video sessions from the operating room

Clinical cases

Poster and Communication sessions

Workshops

Important dates Abstract submission deadline 27 June 2017 Early Registration deadline 2 August 2017 Register or submit your abstract on www.a-dfs.org

International.

Organisations

WOUNDS AUSTRALIA NEWS Dear EWMA members, Wounds Australia is continuing its organisational redevelopment and we are happy to welcome the first Executive Officer, Anne Buck, who is rapidly restructuring areas of Wounds Australia operations and building the national office functions.

Kylie Sandy-Hodgetts Deputy Chair, Wounds Australia More information: www.awma.com.au

Wounds Australia held a very successful national conference with an outstanding program of international speakers in November 2016 with over 1200 participants and we were very happy to welcome Severin Lauchli and Sebastien Probst to speak at conference. We really appreciated the long journey and jetlag they endured for our benefit at conference. We are now planning the 2018 conference in Adelaide and look forward to welcoming any EWMA members who can attend. At conference Wounds Australia was pleased to announce the launch of the 3rd edition of the Australian Standards for Wound Prevention and Management following a very detailed review process. These standards are one of our core documents for wound management practice governance and completion of the review and new edition was a major milestone for 2016. Also released at our conference was the Wound infection in clinical practice update:2016 from The International Wound Infection Institute during their session. This practice update provides a valuable way to explore contemporary advances in wound infection knowledge and practice. The Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers is undergoing an extensive revision process and the revised edition will be launched during 2017 at the IWPRA conference in Brisbane. EWMA members may be aware that Wounds Australia is supporting the initial conference and formation of an Asian area alliance of wound healing organisations (IWPRA - International Wound Practice and Research Alliance) to boost regional wound management collaboration and communication in the Asian/ South Pacific region and the inaugural conference will be held in Brisbane, Australia in 2017. In 2017 we again look forward to promoting Wounds Awareness Week in October in partnership with the Wound Management Innovation CRC. This is our major population wide health promotion campaign to ‘Be Wound Aware’. Some of the Wounds Australia Board and general members will be attending EWMA conference 2017 in Amsterdam where they will be very happy to catch up their European colleagues and continue to develop fruitful conversations and cooperative relationships.

Kylie Sandy-Hodgetts Deputy Chair, Wounds Australia

EWMA international Partner Organisation

EWMA Journal

2017 vol 17 no 1

FROM RO

DTA

IENC

Experiences from Roundtable: The system of prevention, monitoring and treatment of pressure ulcers in the Czech Republic

The round table focused on the topic of the system of prevention, monitoring and treatment of pressure ulcers (hereinafter referred to as PUs) in the Czech Republic which took place on 12th November 2016 in Brno (second largest city in the Czech Republic). Andrea Pokorná EWMA Council

The roundtable was held under the patronage of the Head Nurse of Ministry of Health of the Czech Republic MSc. Alice Strnadová, MBA. It was supported by national professional societies, the Czech Association for wound management (SLR), Czech Association of Nurses (AS) as well as the European Wound Management Association (EWMA) and the European Advisory Pressure Ulcers Panel (EPUAP). The event was held to commemorate the “World STOP Pressure Ulcer Day” which is held every year on the third Thursday in November. The main aim of the event organised for multidisciplinary health professionals is to emphasise the seriousness and visibility of the problem of pressure ulcers, which are affecting not only individuals in the healthcare sector. Pressure ulcers could affect large number of hospitalised patients, but also people who stay in their own home or in other social environments (e. g. nursing or elderly homes). An equally important goal of the roundtable was to present actual information concerning the national strategy for European Pressure Ulcers (EPUAP) guidelines implementation and other national strategic interventions in pressure ulcers prevention, identification and treatment.

EWMA Cooperating Organisation

The roundtable took place in the “National Centre for Nursing and Non-Medical HealthCare Workers Education” and professionals from health and social care facilities and clinical settings, representatives from health insurance companies, health service providers, educational institutions, business and industry representatives, and journalists as well as analysts and experts from Institute of Health Information and Statistics were invited. The roundtable preceded the international symposium entitled “Pressure ulcers – the possibility to share skills, data and knowledge internationally” and organisers were very pleased that experts from several countries shared their knowledge and expert skills (Prof. Joyce Black, Ph.D. from USA,

Prof. Dimitri Beeckman, Ph.D. from Belgium and Assoc. Prof. Rut Öien, Ph.D. from Sweden). Further, domestic Czech national experts presented the latest findings in this field and particularly their potential use in clinical practice (e.g. Assoc. Prof. Lenka Veverková, Ph.D.; Doctor Jan Stryja, Ph.D. and Assoc. Prof. Andrea Pokorná). The most important information about strategies for incidence and prevalence monitoring of PUs on a national level and potential barriers in relation to the monitoring on a local level, as well as collection of data on a central level were discussed and achievements from previous years were summarised. An important milestone was undoubtedly the inclusion of pressure ulcers among ministerial safety goals, which was published in the Bulletin of the Ministry of Health no. 16/2015. Evaluation of the implementation of this ministerial safety goal in inpatient healthcare facilities was done through an electronic survey published on a special electronic portal (website): www.dekubity.eu and presented during the roundtable. Most respondents declared that high attention is paid to this safety goal implementation and most of the criteria are met. However more attention should be paid to improvements in the rules for risk reassessment in frail patients and physicians’ training in this field. In accordance with those findings it was decided to prepare the framework for a model educational programme, and in 2016 this was prepared, taking into account international recommendations and also reflecting the conditions of the Czech healthcare system (the model framework was already published in the Bulletin of the Ministry of Health in January 2017). We do hope that this will help to increase the level of knowledge in specially educated staff in management of PUs. Representatives from several healthcare facilities have EWMA Journal

2017 vol 17 no 1

Organisations

Main organiser of the Symposium with invited speakers from USA, Belgium and Sweden.

International expert’s discussion (Prof. Joyce Black and Prof. Dimitri Beeckman).

2. Education – the need for education for all health care professionals as well as educators and keeping them up to date with the newest evidence. 3. Workplace equipment – wherever are hospitalised patients at risk there must be adequate medical devices available patient’s right to adequate care is frequently influenced by the limited financial resources – it has to be emphasised and discussed on a managerial level. 4. Adequate number and structure of nursing staff – there are real staff shortages which could influence the quality of care. We recommend that consistent monitoring of staffing requirements should be related to the quality of care evaluation. Footage from the auditorium.

spoken about their activities carried out on World STOP Pressure Ulcer Day, which are also publicly accessible on the portal www.dekubity.eu. Also highlighted was information about online consulting services (dekubity@nconzo.cz) where lay carers could obtain more information. In the professional debate on supportive activities for the World STOP Pressure Ulcer Day were representatives from home care agencies involved, who pointed out how difficult it is to ensure a suitable environment in the patient’s own social surroundings and how to perform “lege artis” care. They also mentioned a low level of reimbursement of necessary dressings and lack of competence of nurses in home care. Industry representatives took the opportunity to inform roundtable participants about correct moving and handling of frail (bedbound or chair bound) individuals, expressing their willingness to support healthcare givers by disseminating information or by offering educational materials, or providing trained professionals to assist care providers and health care facilities managers in educational activities. As a result of the roundtable, the goals for year 2017 were articulated and the declaration of roundtable 2016 participants was formulated:

5. Reimbursement of effective preventive measures including patient´s education – a key aspect is the involvement of the health insurance companies and healthcare payers in to strategies for prevention and treatment of pressure ulcers. 6. Hygiene – place emphasis on ensuring hygiene measures and preventingtransmission of infection (hospital acquired infection), even in home care. Highlight need for correct hygiene procedures. 7. Industry support – industry should be accepted as a partner as they should be involved in comprehensive educational activities (for professional and also lay carers). 8. Pressure ulcer monitoring – Institute for Health Information system in collaboration with Ministry of Health will work on National Health Information system and development of adequate tools for data collection on a national level. 9. International collaboration – to utilise the special portal www.dekubity.eu for sharing information on national and international levels (PU monitoring, new prevention guidelines development and dissemination etc.), and to organise an international symposium focused on PU prevention and treatment, also in 2017.

1. Focus on PU prevention – further activities for national dissemination of the guidelines and actual position documents are supported as well as central coordination of the activities in collaboration with Ministry of Health. EWMA Journal

2017 vol 17 no 1

Organisations

Corporate Sponsors Corporate A Flen Pharma NV www.flenpharma.com

BSN medical GmbH www.bsnmedical.com www.cutimed.com

Coloplast www.coloplast.com

Ferris Mfg. Corp. www.PolyMem.eu

PAUL HARTMANN AG www.hartmann.info

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

Lohmann & Rauscher www.lohmann-rauscher.com

URGO Medical/Laboratoires Urgo www.urgomedical.com

ConvaTec Europe www.convatec.com Mölnlycke Health Care Ab www.molnlycke.com

Wacker Chemie AG www.wacker.com

Corporate B

3M Health Care www.mmm.com

DryMax www.absorbest.se/ drymax-woundcare

ABIGO Medical AB www.abigo.se

Freudenberg Vliesstoffe SE & Co. KG www.freudenberg-pm.com

Aurealis Pharma, Itd www.aurealispharma.com

KLOX Technologies Inc www.kloxtechnologies.com

B. Braun Medical www.bbraun.com

Chemviron www.chemvironcarbon.com

Medela AG www.medela.com

Medi GmbH & Co. KG www.medi.de

Mimedx Group, Inc. www.mimedx.com

Nutricia Advanced Medical Nutrition www.nutricia.com

SastoMed www.sastomed.com

Stryker www.stryker.com

Vancive Medical Technologies vancive.averydennison.com

Welcare Industries SPA www.welcaremedical.com

SOFAR S.p.A. www.sofarfarm.it

Söring Gmb www.soering.com

EWMA Journal

2017 vol 17 no 1

28th Conference of the European Wound Management Association

EWMA 2018 in cooperation with the Polish Wound Management Association

KRAKOW, POLAND 9 - 11 MAY 2018

W W W.E WM A 2018 .ORG W W W.E WM A .ORG W W W.P TLR .ORG .PL

Conference Calendar 2017/18 Conferences 2017

Theme

Month

EWMA

Change, Opportunities and May Challenges - Wound management in changing healthcare systems

For web addresses please visit www.ewma.org Days

City

Country

3-5

Amsterdam

The Netherlands

Wounds Canada Spring Conference Exploring Evidence in May 12-13 Kamloops Woundcare

B.C. , Canada

SAfW Romande

Annual Meeting

May

Morges

Switzerland

8th International Conference of New Zealand Wound Care Society

Clearing the Air – Dispelling Myths and Misconceptions in Wound Care

May

18-20

Rotorua

New Zealand

14th EADV Spring Symposium

May

25-28

Brussels

Belgium

18th

Annual Congress of the European Federation Of National Associations Of Orthopaedics And Traumatology

Annual Congress

May/June

31-2

Vienna

Austria

AEEVH

Annual Congress

June

8-9

Gijon

Spain

International Lymphoedema Framework Conference

Annual Conference

June

21-24

Siracusa, Sicily

Italy

17th European Burns Annual congress Association Congress International Wound Practice and Research conference

September

5-8

Barcelona

Spain

September

5-9

Brisbane

Australia

36th Annual meeting of the European Bone and Joint Infection Society (EBJIS)

September

7-9

Nantes

France

14th meeting of the Diabetic Foot Study Group Annual meeting September 8-10 Porto and the European Association for the Study of Diabetes European Academy of Dermatology Annual Conference September 13-17 Geneva and Venereology

Portugal

ETRS 2017

September

13-15

Brussels

Belgium

European Pressure Ulcer Advisory Panel Meeting (EPUAP)

September

20-22

Belfast

United Kingdom

EB-CLINET

4th Conference

September

24-26

Salzburg

Austria

Wound Management: Sharing Knowledge in Pursuit of Best Practice

September

25-27

Worcester

EB2017

Research Conference

September

26-27

Salzburg

Austria

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

Annual conference

September

27-30

Torino

Italy

WundD.A.CH congress

September

28-30

St. Gallen

Schweiz

Pisa International Diabetic Foot Course

October

4-7

Pisa

Italy

SAWC

November

2-4

Las Vegas

Nevada, US

3rd symposium of the A-DFS

November

9-11

Venice

Italy

DEBRA

International Conference

November

24 - 26

Wellington

New Zealand

Conferences 2018

Theme

Month

Days

City

Country

Journées Cicatrisations 2018

January

21-23

Paris

France

SAWC

Spring Symposium

April

5-9

San Diego

EWMA

Krakow: New Frontiers in Wound Management

May

9-11

Krakow

Poland

European Pressure Ulcer Advisory Panel (EPUAP) Focus Meeting 2018

Pressure Ulcers in a Pediatric and Adult ICU Population: Science and Practice United

May

21-23

Turku

Finland

The

17th

Annual Leg Club Conference

(T)issues of War & Peace

Switzerland

Fall Symposium

EWMA Journal

2017 vol 17 no 1

Medela minimizes the clinical and administrative complexity of Negative Pressure Wound Therapy (NPWT), making it easier for you to help your patients healâ&#x20AC;&#x201D;hospital to transitional care to home.

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Cooperating Organisations AEEVH

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

AFIScep.be

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

AISLeC

Italian Nurses’ Cutaneous Wounds Association www.aislec.it

AIUC

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

AMP Romania

Wound Management Association Romania www.ampromania.ro

APTFeridas

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

AWTVNF

All Wales Tissue Viability Nurse Forum www.welshwoundnetwork.org

AWA

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

BEFEWO

Belgian Federation of Woundcare www.befewo.org

BWA

Portuguese Wound Society www.sociedadeferidas.pt

FWCS

Finnish Wound Care Society www.shhy.fi

GAIF

Associated Group of Research in Wounds www.gaif.net

GNEAUPP

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

HSWH

Hellenic Society of Wound Healing and Chronic Ulcers www.hswh.gr

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

Macedonian Wound Management Association

National Association of Tissue Viability Nurses, S cotland

NIFS

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

SEHER

The Spanish Society of Wounds www.sociedadespanolaheridas. es

SFFPC

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

SSiS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

SSOOR

Slovak Wound Care Association www.ssoor.sk

SSPLR

The Slovak Wound Healing Society www.ssplr.sk/en

STW Belarus

Icelandic Wound Healing Society www.sums.is

SWHS

Serbian Wound Healing Society www.lecenjerana.com

SWHS

Swedish Wound Healing Society www.sarlakning.se

TVS

NOVW

URuBiH

Croatian Wound Association www.huzr.hr

DGfW

PWMA

German Wound Healing Society www.dgfw.de

Polish Wound Management Association www.ptlr.org.pl

DSFS

SAfW

Danish Wound Healing Society www.saar.dk

SEBINKO

Norwegian Wound Healing Association www.nifs-saar.no

Dutch Organisation of Wound Care Nurses www.novw.org

D A N I S H WO U N D HEALING S O C I E T Y

Serbian Advanced Wound Management Association www.lecenjerana.com

SUMS

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

NATVNS

CWA

SAWMA

MSKT

CNC

Czech Wound Management Society www.cslr.cz

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

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

MWMA

CSLR

SAfW

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

Bulgarian Wound Association www.woundbulgaria.org

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

ELCOS

Tissue Viability Society www.tvs.org.uk

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

UWTO

Ukrainian Wound Treatment Organisation www.uwto.org.ua

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

EWMA Journal

2016 vol 16 no 2

Organisations

Cooperating Organisations (cont.)

IWII

V&VN

ILF

Decubitus and Wound Consultants, Netherlands www.venvn.nl

International Lymphoedema Framework www.lympho.org

WCS

KWMS

Knowledge Center Woundcare www.wcs.nl

WMAI

Wound Management Association of Ireland www.wmai.ie

WMAK

Wound Management Association of Kosova

WMAS

Wound Management Association Slovenia www.dors.si

WMAT

Wound Management Association Turkey www.yaradernegi.net

Int. Wound Infection Institute www.woundinfection-institute. com

Korean Wound Management Society www.woundcare.or.kr/eng

NZWCS

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

SILAUHE

Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

Brazilian Wound M anagement Association www.sobenfee.org.br

WAWLC

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

Wounds Australia

International Partner Organisations

Other Collaborators

AAWC

DFSG

EADV

Canadian Association of Wound Care www.cawc.net

European Academy of Dermatology and Venereology www.eadv.org

Debra International

EBA

EFORT

CTRS

European Society for Vascular Surgery www.esvs.org

European Tissue Repair Society www.etrs.org

Associated Organisations Leg Club

Lindsay Leg Club Foundation www.legclub.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

Media Partner JWC

Journal of Wound Care www.magonlinelibrary.com

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

ESPEN

The European Society for Clinical Nutrition and Metabolism www.espen.org

ETRS

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

European Burns Association www.euroburn.org

European Federation of National Associations of Orthopaedics and Traumatology www.efort.org (Chinese Tissue Repair Society) www.chinese-trs.com/en

WUWHS

Diabetic Foot Study Group www.dfsg.org

CAWC

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

International Compression Club www.icc-compressionclub.com

SOBENFeE

Wounds Australia www.awma.com.au

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

ICC

ESVS

EPUAP

European Pressure Ulcer Advisory Panel www.epuap.org

FIP-IFP

Alliance of Wound Care Stakeholders International Federation of Podiatrists - Fédération Internationale des Podologues

EWMA Journal

2016 vol 16 no 2

Eucomed

Eucomed Advanced Wound Care Sector Group www.eucomed.org

5 Editorial. Sebastian Probst, Editor of EWMA Journal

Cochrane Reviews 37 Abstracts of Recent Cochrane Reviews. Rizello G

Organisations 82 Recent Publications of the Korean Wound Management Society Seung-Kyu Han 84 AAWC News Bohn G 87 Wounds Australia News Sandy-Hodgetts K 88 Experiences from Roundtable: The system of prevention, monitoring and treatment of pressure ulcers in the Czech Republic Pokorná A 90 Corporate Sponsors 92 Conference Calendar 94 Cooperating Organisations