Journal of the European Wound Management Association_October 2019 by EWMA European Wound Management Association

O F T H E E U R O P E A N W O U N D M A N A G E M E N T A S S O C I AT I O N

Volume 20 · Number 2 · October 2019

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5 Editorial. Probst S

Science, Practice and Education 7 A systematic review: Topical treatment for controlling malignant wound odour. Winardi A, Irwan A M 19 Psychological factors associated with malignant fungating breast wounds. Robinson P J, Holloway S L 25 Effects of radiotherapy on wounds healing. Robinson P J, Holloway S L 31 Wounds Research Network (WReN) – a community of practice for improving wound care-related trials. Samuriwo R

Cochrane Reviews 37 Abstracts of Recent Cochrane Reviews. Rizzello G

Book Reviews 42 Pedorthic footwear; Assessment and treatment. Kirketerp K, Rasmussen A

EWMA 44 Journal of EWMA previous issues and other journals 47 EWMA focus areas for the years 2019 – 2021. Piaggesi A 50 New EWMA Council Members and EWMA Honorary Positions 51 Appreciations: Leaving Council Members 54 EWMA 2020 Conference 59 World Diabetic Foot Day 2020. Piaggesi A, Apelqvist J 60 EWMA 2019 Conference 65 EWMA Honorary Speaker 2019 Jan Apelqvist. Piaggesi A

CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION

EWMA 2020

IN COOPERATION WITH THE TISSUE VIABILIT Y SOCIET Y, TVS

VISIT EUROPE’S LEADING CONFERENCE ON WOUND MANAGEMENT

13 – 15 MAY 2020 LONDON • UK

69 EWMA Masterclass 2019. Traber J, Isoherranen K 72 EWMA 2019 Cooperating Organisations Board Meeting and Workshop. Läuchli S 74 EWMA Teacher Network. Holloway S 76 Optimising patient and health economic outcomes in Swedish wound care practice. Results of the project and reflections on the next steps. Apelqvist A, Piaggesi A, Öien R 78 The joint EPUAP – EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Projet. Achievements and lessions learned. Soriano J V, Schoonhoven L, Moore Z, Pokorna A, Vuagnat H 82 The Storytelling for Health Conference. Piaggesi A 84 EWMA Publications and Projects

Organisations 88 AAWC News. Serena T 89 CTRS News. Xie T 90 TVS News. Primmer L 92 Wounds Australia News. Sussman G, Frescos N 94 Conference Calendar 97 Cooperating Organisations, International Partner Organisations and other Collaborators 100 Corporate Sponsors

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Journal of the European Wound Management Association ISSN number: 1609-2759 Volume 20, No 2, October, 2019

EWMA Council Sue Bale

Alberto Piaggesi

Journal of the European Wound Management Association Published twice a year

Immediate Past President

President

Editorial Board Sebastian Probst, Switzerland, Editor Alberto Piaggesi, Italy Georgina Gethin, Ireland Andrea Pokorná, Czech Republic Dimitri Beeckman, Belgium Nicoletta Frescos, Australia

Georgina Gethin Scientific Recorder

Jan Stryja

Sebastian Probst

Treasurer

Honorary Secretary/ Journal Editor

EWMA website 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

Dimitri Beeckman

Nicoletta Frescos

Luc Gryson

Samantha Holloway

Kirsi Isoherranen

Edward Jude

Layout: Nils Hartmann, Open design/advertising Printed by: Kailow Graphic, Denmark Copies printed: 5.000 Prices: Journal of EWMA 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 April 2020. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than 15 January 2020 The contents of articles and letters in Journal of EWMA 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 Journal of the EWMA Editor for final approval. All issues of Journal of EWMA are CINAHL listed.

Elisabeth Lindahl

Alexandra Marques

Pedro L. Pancorbo Hidalgo

Andrea Pokorna

Tanja Planinsek Rucigaj

Thomas Serena

José Verdu Soriano

Luc Teot

Evelien Touriany

Hubert Vuagnat

COOPERATING ORGANISATIONS’ BOARD Gilbert Hämmerle, AWA Sonja Koller, AWA Leonid Rubanav, STW Belarus Christian Thyse, AFISCeP.be Jan Vandeputte, BEFEWO Els Jonckheere, CNC Jasmina Begić-Rahić, URuBiH Vladislav Hristov, BWA Marin Marinovic, CWA Lenka Veverková, CSLR Annette Høgh, DSFS Heli Kallio, FWCS Luc Téot, SFFPC Arne Buss, DGfW Christian Münter, ICW Georgios Vasilopoulos, HSWH Hunyadi János, MSKT Mária Hok, SEBINKO

Guðbjörg Pálsdóttir, SumS Caroline McIntosh, WMAI Battistino Paggi, AISLeC Ciro Falasconi, AIUC Skender Zatriqi, WMAK Aleksandra Kuspelo, LBAA Loreta Pilipaityte, LWMA Suzana Nikolovska, MWMA Corinne Scicluna, MASC Louk van Doorn, NOVW Yvonne Siebers, V&VN Peter Quataert, WCS Bodo Erhardt Günther, NIFS Arkadiusz Jawien, PWMA Aníbal Justiniano, APTF Tania Santos, ELCOS Rosa Maria Nascimento, GAIF Razvan Scurtu, AMP R

Goran D. Lazovic, SAWMA Saša Milićevic, SWHS Beata Gress Halasz, SSOOR Ján Koller, SSPLR Dragica Tomc, WMAS Esther Armans Moreno, AEEVH J. Javier Soldevilla, GNEAUPP Aranzaxu Pérez Plaza, SEHER Susanne Dufva, SSIS Sebastian Probst, SAfW German Section Maria Iakova, SAfW French Section Hubert Vuagnat, SAfW Umbrella Hakan Uncu, WMAT Susan Knight, LUF Ray Samuriwo, TVS Ruth Ropper, NATVNS Sofia Siekunova, UWTO Christine Harris, AWTVNF

JOURNAL of EWMA, 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 Javorka Delic, Serbia Corrado Durante, Italy Bulent Erdogan, Turkey Ann-Mari Fagerdahl, Sweden Madeleine Flanagan, UK Milada Franců, 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 Elia Ricci, Italy Rytis Rimdeika, Lithuania Zbigniew Rybak, Poland Salla Seppänen, Finland José Verdú Soriano, Spain Hubert Vuagnat, Switzerland Richard White, UK Marc Cornock, UK Gerald Zöch, Austria

Journal Editorial

Palliative wound care Dear readers

am happy to present you with the autumn edition of the Journal of the European Wound Management Association. This edition is dedicated to the subject of palliative wound care. Palliative wound care is derived from the philosophy and ideology of hospice care and has the purpose of relieving suffering and improving a patient’s quality of life when their condition or wound no longer responds to curative treatment.1,2 Palliative wound care takes a holistic approach, acknowledging the psychosocial impact of wounds on the individual concerned, their family and friends and their clinicians.3,4,5 It is driven by patients’ needs, desires and patient- and family-set goals, which are focussed on the management of wound-related symptoms, addressing pain control, exudate management, odour containment, controlling haemorrhage and the relief of pruritus.6,7,8 The management of such wounds and the psychosocial impact of the same will be highlighted in scientific articles. A systematic review demonstrates the possibilities of topical treatment for controlling odour in malignant fungating wounds and the psychological factors associated with malignant fungating breast wounds. Additionally, an article outlines the effects of radiotherapy on wound healing. In this issue, the hosting society of the upcoming conference — Tissue Viability Society (TVS) — gives us insight into their activities. I hope you all enjoy this issue. Sebastian Probst, Editor and EWMA Honorary Secretary Professor of Tissue Viability and Wound Care, Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, SwitzerlandI

REFERENCES 1. Beers, E. H. (2019). Palliative Wound Care: Less Is More. Surg Clin North Am, 99(5), 899–919. doi:10.1016/j.suc.2019.06.008 2. Emmons, K. R., & Lachman, V. D. (2010). Palliative wound care: a concept analysis. J Wound Ostomy Continence Nurs, 37(6), 639–644; quiz 645–636. doi:10.1097/WON.0b013e3181f90a4a 3. Probst, S., Arber, A., & Faithfull, S. (2009). Malignant fungating wounds: a survey of nurses’ clinical practice in Switzerland. Eur J Oncol Nurs, 13(4), 295–298. doi:10.1016/j.ejon.2009.03.008

4. Tilley, C., Lipson, J., & Ramos, M. (2016). Palliative wound care for malignant fungating wounds: holistic considerations at end-of-life. Nurs Clin North Am, 51(3), 513–531. doi:10.1016/j.cnur.2016.05.006

7. Alexander, S. (2009b). Malignant fungating wounds: managing pain, bleeding and psychosocial issues. J Wound Care, 18(10), 418–425. doi:10.12968/ jowc.2009.18.10.44603

5. Probst, S., Arber, A., & Faithfull, S. (2013). Malignant fungating wounds: the meaning of living in an unbounded body. Eur J Oncol Nurs, 17(1), 38–45. doi:10.1016/j.ejon.2012.02.001

8. Gethin, G., Grocott, P., Probst, S., & Clarke, E. (2014). Current practice in the management of wound odour: an international survey. Int J Nurs Stud, 51(6), 865–874. doi:10.1016/j.ijnurstu.2013.10.013

6. Alexander, S. (2009a). Malignant fungating wounds: key symptoms and psychosocial issues. J Wound Care, 18(8), 325–329. doi:10.12968/ jowc.2009.18.8.43631

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2019 vol 20 no 2

P A th EPU g n 5 i t e n e o i t a c i M n mu s m o u c d c n a Fo vention Pre : y t e f a g s Patient usmeeting2020.or c www.fo

MAIN TOPICS 



 

Patient safety: prevention and communication Quality management and patient safety "In safe hands": The Sonderborg Concept From guideline to practice Health technologies at the bedside

IMPORTANT DEADLINES Abstract submission deadline: 30 November 2019

Early registration deadline: 20 March 2020

25 – 27 May 2020 Sønderborg, Denmark

Conference secretariat EPUAP Business office c/o Codan Consulting Vodičkova 12/5, 120 00 Prague Czech Republic office@epuap.org +420 251 019 379

Science, Practice and Education

Topical treatment for controlling malignant wound odour Keywords: topical drug, odour, neoplasm, malignant, wounds and injuries

DOI: 10.35279/jewma201910.01

A systematic review

The prevalence of malignant wounds is currently unknown. However, it is estimated that around 5%–10% of breast cancer cases, sarcomas and melanomas result in malignant wounds. This article describes a study which identified and analysed the scientific evidence on the use of topical treatments for controlling odour from malignant wounds. ABSTRACT Background The prevalence of malignant wounds (MWs) is currently unknown. However, it is estimated that around 5%–10% of breast cancer cases, sarcomas and melanomas result in MWs.

Aim This study aimed to identify and analyse the scientific evidence on the use of topical treatments for controlling odour from MWs.

Methods We used a PRISMA checklist to systematically review articles in the following databases: PubMed, ProQuest, Science Direct, CINAHL, Wiley, Springer, CANCERLIT and Google Scholar, published from 2011 to 2018. We structured the research questions with the use of PICO elements. Although 111 articles were obtained from the search, only eight articles met the inclusion criteria. We analysed these articles with the aid of a CASP checklist and classified them based on the levels of evidence and recommendation grade.

Results Among the eight shortlisted articles, four were intervention studies (three RCTs and one non-controlled study), three were case studies and one was a cohort study. The MWs in these articles were predominantly located on the breast, head/neck, cervix, vulva/ vagina, groin, spine, lower limbs, penis and rectum/ anus. Wound odour was measured using the verbal rating scale (VRS). Six products were used as topical therapies to manage wound odour: Polyhexamethylene biguanide, metronidazole, green tea, Manuka honey, nanocrystalline silver nanoparticles and charcoal dressing. These were associated with journal of the european wound management association

level of evidence 2b and recommendation grade B. Further, the charcoal dressing was associated with level of evidence 4 and recommendation grade C.

Conclusions

Aswedi Winardi RN, Faculty of Nursing, Hasanuddin University, Indonesia Nurse at Wahidin Sudirohusodo Hospital Makassar, Indonesia

Andi Masyitha Irwan PhD, RN, Lecturer, Faculty of Nursing, Hasanuddin University, Indonesia

The following topical therapeutic products for control or management of MW Fodour were of recommendation grade B: polyhexamethylene biguanide, metronidazole, green tea, manuka honey and nanocrystalline silver nanoparticles.

Implications for clinical practice The topical products discussed in this review can be used for controlling MW odour. Six interventions in the form of topical therapies were identified to reduce wound odour, namely Polyhexamethylene biguanide, metronidazole, green tea, manuka honey and nanocrystalline silver nanoparticles with level of evidence 2b and recommendation grade B. The use of oral metronidazole as topical therapy in wounds is not recommended, because it shows poor results. It is better to use metronidazole gel proved to be effective and safe for reduce bad odour.

INTRODUCTION Cancer is known as one of the leading causes of death worldwide. Estimates of the global incidence of cancer obtained from the Global Burden Cancer (GLOBOCAN) database show that around 18.1 million new cancer cases and 9.6 million cancer deaths occurred in 2018.1,2 In 2017, around 1,688,780 cases of cancer were recorded in the United States (US).3 In Indonesia, the cancer prevalence in 2013 was 347,792 (1.4%).4 It is also known that cancer can metastasise to the lungs, liver, bones, brain and skin.5

Correspondence: citha_ners@med.unhas.ac.id Conflicts of Interest: None

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Malignant wounds are a form of skin metastasis.6 They often occur when cancerous cells infiltrate the skin, supporting blood vessels and lymph nodes. This in turn leads to loss of vascularisation and tissue death.10 Malignant wounds are also described as fungating wounds, ulcerative tumours, ulcerative cancer, malignant skin wounds and neoplastic lesions.7,8 These wounds are cancer-related skin lesions characterised by ulceration and necrosis.9 Currently, no accurate data exists on the prevalence of MWs worldwide. However, 5%–10% of MWs are estimated to occur in breast cancer, sarcomas and melanomas.11,12,6 About 0.6%–9% of MWs occur in patients with advanced stages of cancer who are receiving palliative care.12 Thus, MW is a serious health problem and efforts for the prevention as well as control of symptoms are required. Malignant wounds have various symptoms, such as pain, exudate, infection, bleeding and odour.6 Previous studies have found that the most disturbing symptom of MWs is unpleasant odour and pain.13 These symptoms interfere with the patients’ quality of life.14 Therefore, comprehensive palliative care is needed for the control of these symptoms. The latest publication by the European Oncology Nursing Society (EONS) recommends a number of methods and products for controlling infections and odour from MWs. These include wound cleaning and irrigation, debridement, topical application or oral intake of metronidazole, silver dressings, changing dressings (twice a day) and opiate use for pain management during wound care.15,13,16

Malignant wounds are known to be associated with the final stages of life for patients with cancer17 and eliminating or controlling MW odour remains a challenge for nurses when performing wound care. In addition, tools for measuring wound odour are subjective. Few studies have been conducted to determine the best topical treatments for controlling MW odour. The aim of this study is therefore to identify and analyse scientific evidence on the use of topical therapies for controlling MW odour. The study is based on a research design that included malignant wound type, wound odour instruments, and different types of topical therapeutics for controlling this odour. It is important to emphasise that information in the literature regarding interventions to control MW odour was minimal. For this reason, we utilised review articles that contain both study interventions (randomised and non-randomised) and cohort or case studies. METHODS We used the PRISMA 2009 checklist to assess the literature.18 We searched the following databases: PubMed, ProQuest, Science Direct, CINAHL, Wiley, Springer, CANCERLIT and Google Scholar. Research questions were structured using PICO elements (patient, intervention, comparison and outcome)19,20, as follows: P: patients with malignant wounds, I: topical treatment, C: no comparison, O: control of wound odour. Keywords were based on the databases in the MeSH Term (Figure 1). Using the PICO method, a research question was formulated as follows: “What topical treatments are used in controlling wound odour in patients with MWs?” We identified 111 articles from eight electronic databases that

Figure 1. Description of keywords used in the literature search using the PICO method (patient, intervention, comparison and outcome)

PICO COMPONENT

Fungating OR malignant OR melanoma, malignant, of soft parts OR neoplasm, malignant OR adenomas, malignant OR adenoma, malignant OR neoplasm OR neoplasm, skin OR skin cancers OR skin cancer OR cancer, skin OR Skin ulcer OR skin ulcers OR ulcer, skin OR ulcers, skin. Infection, wound OR wounds, injury OR wounds and injuries OR wounds and injury OR injury and wounds OR wound OR injury OR injuries, wounds.

Biological dressing OR biologic dressing OR dressing OR dressing, occlusive OR silver sulfadiazine OR bandage, hydrogel OR hydrogel OR alginates OR honey OR phosphorylcholine OR gels OR powders OR administration, topical drug OR administration, topical OR anti-bacterial agents. Metronidazole OR nitroimidazole OR 2 methyl 5 nitroimidazole 1 ethanol OR metrogel OR metrogyl OR metronidazole phosphate OR metronidazole hydrochloride OR metrodzhil.

No comparison in this literature review

Odour OR odours OR smell OR sense of smell OR malodorous OR malodour OR odour OR smelly tumours

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PubMed ProQuest Science CINAHL Wiley Springer CANCERLIT Google Direct Scholar 73 9 4 7 2 3 2 11

Identification

Articles identifed (n=111) Exclusion: Double publication (n=23)

Screening

Eligibility

Screening Results (n=88)

Exclusion: Not full text (13) Not according to the research question (n=57)

In accordance with the research guestion (n=18) Exclusion: Not according to the research results (n=10)

Inclusion

Articles included (n=8)

Intervention study Case study Cohort study 4 3 1 Figure 2. Flowcharts for study selection and inclusion

were published from 2011 to 2018; all these articles were studies conducted with humans as subjects. We excluded 23 articles out of the 111 because of double publications; 13 others were also excluded because they were not complete texts, and another 57 were excluded because they were not relevant to our research objectives. The criteria for inclusion in our studies were: 1) focus on interventions to control MW odour, 2) English as the language of the manuscript, and 3) published from 2011 to 2018. Of the eighteen articles that met these criteria, ten were not eligible because they not relevant to our research objectives. Thus, only eight articles fulfilled the inclusion criteria, and these were four intervention articles, three case studies and one cohort study. Figure 2 illustrates the study inclusion process. The articles that fulfilled the inclusion criteria were clas-

sified using the Critical Appraisal Skill Program (CASP) checklist21 and critical appraisal from the Center for Evidence-Based Management.22 Studies were selected according to the level of evidence, level of recommendation and quality of the study. The level of recommendation is a quality measure associated with the level of research evidence and helps in the interpretation of recommendations. In analysing the quality of clinical studies, the Oxford Centre for Evidence-Based Medicine (CEBM) was employed to classify research articles into five levels of evidence in accordance with their research designs (1, 2, 3, 4 and 5). The studies were grouped into four levels of recommendations (A, B, C and D). Grade A is a level 1 study (1a, 1b and 1c) used for systematic review of randomised clinical trials and representing a higher level of evidence. Grade B (2a, 2b, 2c, 3a and 3b) is used for systematic reviews of cohort studies, outcome î&#x201A;Š

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research, systematic reviews of case-control studies and case-control studies. Grade B represents a moderate level of evidence. Values C (4) and D (5) represent the lowest level of evidence. Grade C is used for case studies, and Grade D is for expert opinion.23 RESULTS Research design In this systematic review, eight articles were identified that fitted the objectives set for our research. These articles were mainly about clinical studies that used topical therapeutics in controlling MW odour. There were four intervention studies, which were made up of three randomised controlled trials (RCTs)8,24,25 and one non-controlled study26; further, there were three case studies27,28,29 and one cohort study.30 Malignant wound type The types of MWs varied for each study that used topical therapeutics in managing wound odour. Castro and colleagues found that MWs were predominantly located on the lower limbs (n = 12; 50.0%), followed by the head and neck (n = 6; 25.0%), breast (n = 3; 12.5%), penis (n = 2; 8.3%) and hypochondrium (upper abdomen, inferior to the thorax, and underneath the lower rib cage) (n = 1; 4.2%).8 In another study, Watanabe and colleagues examined patients with breast cancer (n = 21; 100%) and found MWs on all the patients examined.26 Lian and colleagues found MWs located on the breast (n = 24), neck (n = 2), groin (n = 2), spine (n = 1) and anus (n = 1).24 In addition, Lund-Nielsen and colleagues examined breast cancer (n = 55; 80%), head and neck cancer (n = 8; 12%) as well as other cancer-related diagnoses (n = 6; 8%).25 Results for a case study by Haynes included the following: foot vein ulcer (n = 2), pressure ulcer (n = 2), fungating tumour (n = 2), fungating breast wound (n = 1), metastasis (n = 1), squamous cell cancerous buttock (n = 1) and arterial leg ulcer (n = 1).29 In another study, Drain and Fleming examined one case of squamous cell carcinoma of the oral cavity.27 Similar to Fleming’s work, Wong and colleagues examined one case with a MW on the right arm.28 Meanwhile, a cohort study conducted by George and colleagues identified 179 patients with malodour related to necrotic cancer. The locations of these patients’ MWs were as follows: cervix (n = 80; 44.7%), head and neck (n = 71; 39.7%), breast (n = 6 3.5%, rectum/anal (n = 5; 2.8%), vulva/vagina (n = 4; 2.2%) and others (n = 13; 7.3%).30 Odour Wound Instrument With regards to the measurement of wound odour, four studies did not report how they assessed wound odour.27,28,29,30 Three studies used verbal rating scale (VRS) instruments for the measurement of wound odour. 10

Lund-Nielsen and colleagues used VRS instruments from Haughton and Young (1995)31, and reported their results in 4 categories as follows: 1 = no malodour, 2 = slight malodour, 3 = moderate malodour and 4 = strong malodour.25 Lian and colleagues, however, used a verbal numeric scale (VNS) with a range of 0–10 (0 = odourless and 10 = the worst smell imaginable).24 Another study conducted by Watanabe and colleagues used a scale range of 0–4 (0 = no smell; 1 = smell present but not offensive, slight smell close to the ulcer about 20 cm; 2 = mildly offensive smell, more pronounced smell close to the ulcer about 20 cm; 3= moderately offensive smell, at the bedside about 1 m; 4 = extremely offensive smell, at the entrance of the room).32 One study assessed odour intensity, quality and impact. To assess the intensity, 5 scales were used as follows: 0 = no odour, 1 = odour is detected only after removing the bandage, 2 = smell is felt when approaching the patient, 3 = odour detected when entering the room and 4 = odour detected before entering the room. For odour quality, 5 scales were used: 0 = no odour, 1 = smell is felt but not offensive, 2 = smell is felt and is slightly offensive, 3 = smell is felt and moderately offensive, and 4 = smell is perceived as extremely offensive. In addition, to assess the impact of odour, the respondents showed the effect of the odour by choosing 1 or more of 5 reactions: 1 = the smell is being detected, 2 = worry that other people are realising the smell, 3 = the patient is reluctant to socialise because of the smell, 4 = odour negatively affects the appetite and 5 = nausea because of the smell. Furthermore, the odour effect was assessed later on according to the number of reactions chosen by the patient: 0 score indicated all registered descriptions are selected; 1 for 4 selected descriptions; 2 for 3 selected descriptions; 3 for 2 selected descriptions; 4 for 1 selected description; and 5 if no description is selected.8 Types of topical malignant wound treatments and duration of interventions: a. Polyhexamethylene biguanide (0.2%) as well as metronidazole (0.8%) can significantly reduce the smell of malignant wounds in 4 days (p value of each intervention was <0.001 with level of evidence 2b and recommendation grade B).8 b. Metronidazole (0.75%) gel proved effective and safe for reduce bad odour in anaerobic bacteria-infected neoplastic fungating tumours during 14 days of treatment, with clinical success rates (score 0 or 1) of 95.2% (20 of 21 patients); the 90% confidence interval (exact two-tailed significance level) was 79.3%–99.8%, thus confirming the research hypothesis, which suggested that the success rate must not fall below 70% if the level of evidence was 2c and recommendation g rade was B.32 c. Green tea dressings and metronidazole topical powder

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Topical Intervention Polyhexamethylene Biguanide Metronidazole Green tea Manuka honey Nanocrystalline silver coated Charcoal

Citations in Studies

Levels of evidence

Grade of Recommendation

1 2b 4 2b 1 2b 2 2b 2 2b 1 4

B B B B B C

Table 1. Synthesis of evidence regarding topical treatment for controlling MW odour.

were effective in controlling the smell of malignant fungating wounds, and this treatment was carried out for 7 consecutive days. With level 2b of evidence and recommendation grade B24, malodour control was better when metronidazole treatment was used. Outcomes were poor during the period when only topical or intermittent oral metronidazole was used. Topical use gradually decreased (97% vs 55%) and the proportion of patients receiving maintenance oral metronidazole increased (0% in 2003–2004 vs 93% in 2011). Concurrently, there was a reduction in documented malodour (12.5% of visits per patient in 2003–2004 vs 1.5% in 2011, p<0.01).30 d. Honey-coated and silver-coated bandages were effective for treating MW odour for a period of 4 weeks, with level of evidence 2b and recommendation grade B.25 A case study conducted by Wong and colleagues used silver dressings and manuka honey to control MW odour. In this study, the level of evidence was 4 and recommendation grade was C.28 e. Activated charcoal dressings have also proven effective and comfortable in managing wound odour with level of evidence 4 and recommendation grade C.29 However, the duration of this intervention was not stated in this article. DISCUSSION Overall, six intervention products were identified as topical therapeutics for controlling MW odour: Polyhexamethylene biguanide, metronidazole, green tea, manuka honey and nanocrystalline silver nanoparticles. These products were associated with level of evidence 2b and recommendation grade B. Charcoal dressing was associated with level of evidence as 4 and recommendation grade C. Metronidazole was discussed in four studies with level of evidence 2b and recommendation grade B. Previously, researchers found that anaerobic bacteria cause malodour in fungating wounds and that metronidazole is an effective antibacterial drug in treating fungating, bad-smelling wounds.33 It is a synthetic antimicrobial drug, which is journal of the european wound management association

very effective against anaerobic bacteria and protozoa.34 Some metronidazole products, such as topical metronidazole 0.8%, metronidazole gel 0.75%, and metronidazole topical powder, were found to be effective.8,32 A 0.8% metronidazole topical solution reduced MW odour in 4 days, and the patient’s quality of life improved as their wound odour was controlled.8 In addition, using 0.75% metronidazole gel (applied 1-2 times/day for 14 days) proved to be effective and safe for reducing malodour from anaerobic bacteria-infected neoplastic fungating tumours.32 In another study, the use of metronidazole topical powder for seven days controlled the smell of malignant fungating wounds.24 However, a study that used a retrospective case note review stated that topical use of oral metronidazole showed poor results, but when metronidazole is used appropriately, it has better malodour control.30 Therefore, the use of metronidazole topical powder should be considered as a topical treatment for MW. Polyhexamethylene biguanide (PHMB) 0.2% showed no significant difference in comparison with 0.8% metronidazole topical solution in controlling MW odour for 4 days.8 In addition, green tea dressings applied for seven days can be used to control MW odour.24 Other effective interventions include manuka honey and nanocrystalline silver nanoparticles. Factors to consider when selecting a treatment for MW odour include wound size, level of cleanliness, exudation, foul odour and wound pain25 with the level of evidence was 2b and recommendation grade was B. Manuka honey is also proven to be safe and effective as a palliative treatment for reducing odour and inflammation in wounds secondary to squamous cell carcinoma of the oral cavity.27 Likewise, silver dressings can be considered in managing chronic fungating wounds; this intervention is applied with the concept of “TIME” (T-Tissue management, I-Inflammation and infection control, M-Moisture balance, E-Epithelial advancement).28

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Science, Practice and Education

Charcoal dressings contain activated carbon incorporated into a dressing, which is protected by viscose and polyamide rayon layers. However, one systematic review found that the level of evidence for activated carbon dressing was 2c while its recommendation grade was B.33 Products including charcoal consist of activated carbon. Activated carbon is usually made from natural sources such as rice, coconut shells or other types of wood; this material provides a large area for the adsorption of various types of gases, bacteria and liquids.35 Activated carbon has been used in various biomedical applications.36 These dressings contain 85%â&#x20AC;&#x201C;98% charcoal cloth active carbon.35 Some products can be used in combination with antibiotics or as primary dressings to neutralise the bacteria captured in the charcoal.37 Six interventions were identified for topical treatment to control odour in MW. Polyhexamethylene biguanide, metronidazole, green tea, manuka honey and nanocrystalline silver nanoparticles. These were associated with level of evidence 2b and recommendation grade B. Charcoal Dressing is associated with level of evidence 4 and recommendation grade C (Table 1). Our aim of identifying evidence for controlling MW odour has been achieved. However, our review has some limitations including few available RCTs, small sample sizes and absence of instruments or scales to measure odours objectively. Odour perception is induced by stimulation of chemicals sensory receptor; thus, odour perception differs from person to person.38 For this reason, an objective tool or measurement for measuring wound odour is necessary.

CONCLUSION Among the eight shortlisted articles, four were intervention studies (three RCTs and one non-controlled study), three were case studies and one was a cohort study. The MWs in these articles were predominantly located on the breast, head/neck, cervix, vulva/vagina, groin, spine, lower limbs, penis and rectum/anus. Wound odour was measured using the verbal rating scale (VRS). In the literature search, we identified eight clinical studies using topical therapies for controlling odour in MW. Six interventions in the form of topical therapies were identified for namely Polyhexamethylene biguanide, metronidazole, green tea, manuka honey and nanocrystalline silver nanoparticles with level of evidence 2b and recommendation grade B. Charcoal Dressing produces level 4 evidence and has a recommendation grade C. Some of the main limitations of our study are the limited availability of RCTs on MW odour control, small sample sizes and absence of instruments or scales to measure MW odour objectively. IMPLICATIONS FOR CLINICAL PRACTICE The topical products discussed in this review can be used for controlling MW odour. Six interventions in the form of topical therapies were identified to reduce wound odour, namely Polyhexamethylene biguanide, metronidazole, green tea, manuka honey and nanocrystalline silver nanoparticles with level of evidence 2b and recommendation grade B. The use of oral metronidazole as topical therapy in wounds is not recommended, because it shows poor results. It is better to use metronidazole gel proved to be effective and safe for reduce bad odour. m

Table 2. Description of studies on topical treatment for odour control in malignant wounds

RESEARCHER, COUNTRY

RESEARCH DESIGN

AIM

SAMPLE SIZE

Castro, Santos and Woo (2018), Brazil

RCT

To compare the effect of polyhexamethylene biguanide 0.2% with metronidazole 0.8% on malignant wound odour, quality of life and pain during application

Randomly 24 participants with malignant wounds were divided into 2 groups (12 in each group)

Watanabe et al (2016), Japan

A multicentre, open-label, noncontrolled, phase III study

To evaluate the effectiveness and safety of metronidazole gel 0.75% in reducing malodour in anaerobic infected neoplastic fungating tumours

21 participants

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

REFERENCES 1. Bray F, Ferlay J, Soerjomataram I. Global Cancer Statistics 2018 : GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. 2018;394–424.

15. Probst S, Grocott P, Graham T, Gethin G. Recommendation for the care of patients with malignant fungating wounds. London: European Oncology Nursing Society (EONS); 2015.

27. Drain J, Fleming MO. Palliative management of malodorous squamous cell carcinoma of the oral cavity with manuka honey. J Wound, Ostomy Cont Nurs. 2015;42(2):190–2.

2. WHO. Cancer. 2018; Available from: http://www. who.int/news-room/fact-sheets/detail/cancer

16. International Wound Infection Institute (IWII). Wound Infection in Clinical Practice Principles of best practice. Wounds Int. 2016;52(11):3–11.

28. Wong S, Brahim Z, Aminuddin NA, Nasirudin N. Management of malodour fungating wound with nanocrystalline silver coated dressing. Med J Malaysia. 2017;72(5):316–7.

3. American Cancer Society. Cancer Facts and Figures 2017. Genes Dev. 2017;21(20):2525–38. 4. Kemenkes RI. Infodatin, Pusat data dan Informasi Kementerian Kesehatan RI; Stop Kanker. Jakarta: Pusat data dan Informasi Kemenkes RI; 2015. 5. Elder EE, Kennedy CW, Gluch L, Carmalt HL, Janu NC, Joseph MG, et al. Patterns of breast cancer relapse. Eur J Surg Oncol. 2006 Nov;32(9):922–7. 6. Gibson S, Green J. Review of patients’ experiences with fungating wounds and associated quality of life. J Wound Care. 2013 May;22(5):265–75. 7. Adderley UJ, Holt IG. Topical agents and dressings for fungating wounds ( Review ) Topical agents and dressings for fungating wounds. 2014;(5). 8. Castro DLV, Santos VLC de G, Woo K. Polyhexanide Versus Metronidazole for Odor Management in Malignant (Fungating) Wounds . A Double-Blinded, Randomized, Clinical trial. J Wound Ostomy Cont Nurs. 2018;0(0):1–6. 9. National Cancer Institute. Definition: fungating lesion. 2015; Available from: https://www.cancer.gov/ publications/dictionaries/%0Acancerterms?cdrid=367427 10. Finlayson K, Teleni L, McCarthy A. Topical Opioids and Antimicrobials for the Management of Pain, Infection, and Infection-Related Odors in Malignant Wounds: A Systematic Review. Oncol Nurs Forum [Internet]. 2017;44(5):626–32. Available from: http:// onf.ons.org/onf/44/5/topical-opioids-and-antimicrobials-management-pain-infection-and-infection-relatedodors 11. Probst S, Arber A, Faithfull S. Coping with an exulcerated breast carcinoma: an interpretative phenomenological study. J Wound Care [Internet]. 2013;22(7):352–60. Available from: http://www. magonlinelibrary.com/doi/abs/10.12968/ jowc.2013.22.7.352 12. Castro DLV, Santos VLCG. Odor management in fungating wounds with metronidazole: A systematic review. J Hosp Palliat Nurs. 2015;17(1):73–9. 13. Lo SF, Hayter M, Hu WY, Tai CY, Hsu MY, Li YF. Symptom burden and quality of life in patients with malignant fungating wounds. J Adv Nurs. 2012;68(6):1312–21. 14. BC Cancer Agency Care and Research. Symptom Management Guidelines: Care of Malignant Wounds. Br Columbia Cancer Agency [Internet]. 2015;1–7. Available from: http://www.bccancer.bc.ca/nursingsite/documents/10. malignant wounds.pdf

17. Lin Y, Amin M, Donnelly A, Nguyen X, Amar S. Maggot Debridement Therapy of a Leg Wound From Kaposi ’ s Sarcoma : A Case. J Glob Oncol. 2015;1(2):92–8. 18. Moher D, Leberati A, Tetzlaff J, Altman DG, The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Plos Med. 2009;6(7):e1000097. 19. Frandsen TF;, Eriksen MB. The impact of PICO as a search strategy tool on literature search quality: A systematic review. J Med Libr Assoc. 2018;106(In press):420–31.

29. Haynes JS. A clinical evaluation of charcoal dressing to reduce malodour in wounds. Br J Nurs. 2018;27(6):536–42. 30. George R, Prasoona TS, Kandasamy R, Cherian R, Celine T, Jeba J, et al. Improving malodour management in advanced cancer: A 10-year retrospective study of topical, oral and maintenance metronidazole. BMJ Support Palliat Care. 2017;7(3):286–91. 31. Haughton W, Young T. Malodorous Wounds. Br J Nurs. 1995;4(16):959–63.

20. Santos CM da C, Pimenta CA de M, Nobre MRC. The PICO strategy for the research question construction and evidence search. Rev Lat Am Enfermagem [Internet]. 2007;15(3):508–11. Available from: http:// www.scielo.br/scielo.php?script=sci_ arttext&pid=S0104-11692007000300023&lng=en& tlng=en

32. Watanabe K, Shimo A, Tsugawa K, Tokuda Y, Yamauchi H, Miyai E, et al. Safe and effective deodorization of malodorous fungating tumors using topical metronidazole 0.75 % gel (GK567): a multicenter, open-label, phase III study (RDT.07. SRE.27013). Support Care Cancer [Internet]. 2016;24(6):2583–90. Available from: http://dx.doi. org/10.1007/s00520-015-3067-0

21. Critical Appraisal Skills Programme. CASP 2018: Checklist for critical appraisal of Studies. 2018; Available from: https://casp-uk.net/casp-tools-checklists/

33. Santos CM, Pimenta CA, Nobre MRC. A Systematic Review of Topical Treatments to Control the Odor of Malignant Fungating Wounds. J Pain Symptom Manage. 2010;39(6):1065–76.

22. Center for Evidence-Based Management. Critical Appraisal of a Case Study Appraisal questions. 2014;2014.

34. Clark J. Literature review. Metronidazole gel in managing malodorous fungating wounds. Br J Nurs [Internet]. 2002;11(6):S54–60 2p. Available from: http://search.ebscohost.com/login.aspx?direct=true& db=rzh&AN=106973962&lang=pt-br&site=ehostlive

23. Centre for Evidence-Based Medicine. Oxford Centre for Evidence-based Medicine-Levels of Evidence. 2009; Available from: https://www.cebm. net/2009/06/oxford-centre-evidence-based-medicinelevels-evidence-march-2009/ 24. Lian SB, Xu Y, Goh SL, Aw FC. Comparing the effectiveness of green tea versus topical metronidazole powder in malodorous control of fungating malignant wounds in a controlled randomised study. Proc Singapore Healthc. 2014;23(1):3–12. 25. Lund-nielsen B, Adamsen L, Kolmos HJ. The effect of honey-coated bandages compared with silver-coated bandages on treatment of malignant wounds — a randomized study. 2011; 26. Watanabe K, Shimo A, Tsugawa K, Tokuda Y, Yamauchi H, Miyai E, et al. Safe and effective deodorization of malodorous fungating tumors using topical metronidazole 0.75 % gel (GK567): a multicenter, open-label, phase III study (RDT.07. SRE.27013). Support Care Cancer. 2016 Jun;24(6):2583–90.

35. Bansal RC, Goyal M. Activated Carbon and Its Surface Structure. Adsorption of Activated Carbon [Internet]. 1st ed. New York: CRC Press; 2005. Available from: http://lib1.org/_ads/4AC6EEE2CB81D 2C8B2F875C6F905EDC8 36. Mikhalovsky S V., Sandeman SR, Howell CA, Phillips GJ, Nikolaev VG. Biomedical Applications of Carbon Adsorbents [Internet]. Novel Carbon Adsorbents. Elsevier Ltd; 2012. 639-669 p. Available from: http:// dx.doi.org/10.1016/B978-0-08-097744-7.00021-1 37. Akhmetova A, Saliev T, Allan IU, Illsley MJ, Nurgozhin T, Mikhalovsky S. A Comprehensive Review of Topical Odor-Controlling Treatment Options for Chronic Wounds. J Wound, Ostomy Cont Nurs. 2016;43(6):598–609. 38. Son M, Lee JY, Ko HJ, Park TH. Bioelectronic Nose: An Emerging Tool for Odor Standardization. Trends Biotechnol [Internet]. 2017;35(4):301–7. Available from: http://dx.doi.org/10.1016/j.tibtech.2016.12.007

INTERVENTION

EVALUATION OF ODOUR WITH INSTRUMENTS

OUTCOME

Intervention Group: using polyhexamethylene biguanide 0.2% Control group: using metronidazole 0.8% topical solution. Treatments were carried out for 0 days, 4 days and 8 days

Smell was measured in terms of intensity, quality and impact, which was assessed by researchers, nurses and patients

Significantly, polyhexamethylene biguanide 0.2% and metronidazole 0.8% can reduce malignant wound odour in 4 days. Thus, the patient’s quality of life increases due to controlled wound odour. Meanwhile, pain measurements between the 2 groups did not show a significant difference over time

Metronidazole gel 0.75% was applied 1-2 times / day, up to a maximum daily dose of 30 g for 14 days Fungating wounds were thoroughly cleaned and covered with dressings such as gauze, silicone gauze or wound dressing coated with topical metronidazole

The smell of wounds was assessed by researchers, nurses and patients using 5 scales (0-4)

Metronidazole gel 0.75% is an effective and safe treatment for reducing bad odour in anaerobic infected neoplastic fungating tumours

 journal of the european wound management association

2019 vol 20 no 2

Science, Practice and Education Table 2. Description of studies on topical treatment for odour control in malignant wounds

RESEARCHER, COUNTRY

RESEARCH DESIGN

AIM

SAMPLE SIZE

Lian, Xu, Goh and Aw (2014), Singapore

Prospective randomised experimental study

To compare the effectiveness of green tea with metronidazole topical powder regarding the level of malodorous score reduction using the verbal numeric scale (VNS)

Randomly 30 participants with fungating malignant wounds were divided into 2 groups (12 in each group)

Lund-Nielsen, Adamsen and KoMWos (2011), Denmark

RCT

To determine the effect of honey-coated bandages compared with silver-coated bandages in the treatment of malignant wounds, looking at the size of the wound, the cleanliness, odour, exudation and wound pain

Randomly 69 cancer patients with malignant wounds were divided into 2 groups (group A: 34, group B: 35)

Drain and Fleming, (2015), USA

Case Study

To evaluate the effectiveness of manuka honey in an 80-year-old woman suffering from malodorous squamous cell carcinoma of the mouth

An 80-year-old woman with squamous cell carcinoma in the oral cavity was treated in a nursing home. The patient was experiencing distress associated with extreme malodour

Wong, Brahim, Aminuddinand Nasirudin (2017), Malaysia

Case Study

To evaluate bad odour fungating wound management with silver coated nanocrystalline dressings

A 68-year-old woman with a four-year history of badodour related to wounds on her right arm

Haynes (2018)

Case Study

To assess the clinical effects and comfort of charcoal dressings in the management of wound odour

10 patients with: leg vein ulcer (n = 2), pressure ulcer (n = 2), fungating tumour (n = 2), fungating breast wound (n = 1), metastasis (n = 1), squamous cell cancer of the buttock ( n = 1), arterial leg ulcer (n = 1)

George et al (2017), India

Cohort study

To explore the effectiveness of topical or oral metronidazole for malodour in necrotic cancer and to propose a protocol for the use of metronidazole in MW malodour management

179 patients with malodour in necrotic cancer

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

INTERVENTION

EVALUATION OF ODOUR WITH INSTRUMENTS

OUTCOME

Each group of patients was treated for 7 consecutive days using randomised dressings Intervention Group: Using green tea solution. Meanwhile, the control group received the conventional method with metronidazole topical powder

Verbal Numeric Scale (VNS) scale 0-10

No significant difference found between green tea dressings and metronidazole topical powder in controlling the smell of malignant fungating wounds

Using modern wound care: Cleaning with water faucet and soap liquid (pH 4.5) and continued with the help of tweezers, metzenbaum scissors and non-woven pads

Verbal Numeric Scale (VNS) scale 0-10

No statistically significant differences between groups. Namely, honey-coated and silver-coated bandages were both effective for the treatment of MWs. Factors considered were wound size, cleanliness, exudation, bad odour and wound pain in malignant wounds

Not mentioned

Manuka honey is proven to be a safe and effective palliative treatment for reducing odour and inflammation in wounds secondary to squamous cell carcinoma of the oral cavity

Not mentioned

Silver dressings can be considered in managing chronic fungating wounds if other conventional methods do not lead to any improvement

The dressings used in this clinical evaluation were activated charcoal dressings, which are protected by viscose and polyamide rayon layers

Not mentioned

Charcoal dressings where effective and comfortable in managing wound odour

179 patients with malodour in necrotic cancer

Not mentioned

This study showed better malodour control when metronidazole was used. However, the results were poor during the intermittent period when using only topical oral metronidazole Topical use gradually decreased (97% vs 55%) and the proportion of patients receiving oral metronidazole treatment increased (0% in 2003–2004 vs. 93% in 2011) There was a reduction in malodour (12.5% of visits per patient in 2003-2004 vs. 1.5% in 2011, p <0.01)

Group A: Honey-coated bandages, absorbent dressings and foam bandages Group B: Nanocrystalline silver-coated bandages and foam bandages The intervention was carried out for 4 weeks

Calcium alginate infused with Manuka honey was applied to external wounds and Manuka honey paste was applied twice daily in the oral cavity using a stick Manuka honey paste was chosen for mouth sores due to its good viscosity

Wounds were assessed using the concept of “TIME” (T-Tissue management, Inflammation and infection control, M-Moisture balance, E-Epithelial advancement) The wound was cleaned with distilled water. Hydrogel was applied to soften the slough then coated with silver antimicrobial nanocrystalline. The dressing was placed at the base of the wound, detached from its side and moistened with distilled water. Then it was covered with sterile gauze

journal of the european wound management association

2019 vol 20 no 2



Science, Practice and Education Table 3. Critical Appraisal

WATANABE ET AL (2016)

LIAN ET AL (2014)

LUNDNIELSEN ET AL (2011)

Did the trial address a clearly focused issue?

Yes

Was the assignment of patients to treatments randomised?

Yes

Were all of the patients who entered the trial properly accounted for in the conclusion?

Yes

Were patients, health workers and study personnel ‘blind’ to treatment?

Yes

Were the groups similar at the start of the trial?

Yes

Aside from the experimental intervention, were the groups treated equally?

How large was the treatment effect?

Yes

How precise was the estimate of the treatment effect?

Yes

Can the results be applied to the local population, or in your own context?

Yes

Were all clinically important outcomes considered?

Yes

Are the benefits worth the harms and costs?

Yes

Level of evidence; grade of recommendation (23)

2b;B

Yes

S Yes

ATY

A L YesW O C I U P

ATY

CASTRO ET AL (2018)

EWMA MASTERCLASS 2020 ON ATYPICAL WOUNDS WITH A SPECIAL FOCUS ON SMALL VESSEL PATHOLOGY

AL WO U

CRITICAL APPRAISAL INTERVENTION STUDY (21)

CRITICAL APPRAISAL COHORT STUDY (21)

GEORGE ET AL (2017)

CRITICAL APPRAISAL CASE STUDY (22)

DRAIN AND FLEMING (2015)

WONG ET AL (2017)

HAYNES (2018)

Did the study address a clearly focused issue?

Yes

Did the study address a clearly focused question / issue?

Yes

Was the cohort recruited in an acceptable way?

Yes

Is the research method (study design) appropriate for answering the research question?

Yes

Was the exposure accurately measured and bias minimised?

Yes

Are the setting and subjects representative with regard to the populationto which the findings will be applied?

Was the outcome accurately measured to minimise bias?

Yes

Is the researcher’s perspective clearly described and taken into account?

Can’t Tell

Were any confounding factors in the design and/or analysis been taken into account?

Are the methods for collecting data clearly described?

Yes

Was the follow up of subjects complete enough?

Are the methods for analysing the data likely to be valid and reliable? Are quality control measures used?

Can’t Tell

What are the results of this study?

Yes

Are quality control measures used?

Yes

How precise are the results?

Yes

Was the analysis repeated by more than one researcher to ensure reliability?

Can’t Tell

Do you believe the results?

Yes

Are the results credible, and if so, are they relevant for practice?

Yes

Can the results be applied to the local population?

Yes

Are the conclusions drawn justified by the results?

Yes

Do the results of this study fit with other available evidence?

Yes

Are the findings of the study transferable to other settings?

Yes

Level of evidence; grade of recommendation (23)

2b;B

Level of evidence; grade of recommendation (23)

4;C

Save the date: 12 May 2020 EWMA 2020 conference venue, ExCel London, UK One day before the EWMA 2020 Conference - separate registration required. EWMA Masterclass is a special education activity which provides a unique chance for interaction between renowned experts and a smaller group of participants. In 2020, the EWMA Masterclass will be dedicated to atypical wounds with a special focus on small vessel pathology, including Martorell hypertensive ulcers, calciphylaxis and occlusive vasculopathies. This masterclass will provide a comprehensive deep dive into atypical wounds and touch upon practical advice on some of the challenges that typically arise when diagnosing and treating these types of wounds. The presentations during the masterclass will include patients’ cases, and participants will also be invited to present cases. For more information, please visit: https://ewma.org/

EWMA 2020 LONDON, UNITED KINGDOM • 13 – 15 MAY 2020

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Science, Practice and Education

Keywords: fungating wounds, psychosocial effects, body image, femininity

DOI: 10.35279/jewma201910.02

Psychological factors associated with malignant fungating breast wounds Malignant fungating wounds (MFWs) can be a distressing consequence of breast cancer. Although the true prevalence of MFWs is unknown, existing figures suggest that rates may be as high as 62%, and this figure increases with age. Multiple studies have examined the psychological consequences of MFWs in the breast. This review presents a summary of some of the research to examine the role of specialist wound advice. ABSTRACT Background Malignant fungating breast wounds, or malignant fungating wounds (MFWs) hereinafter, indicate a poor prognosis. For patients, malodour and copious exudate are the common distressing symptoms that require careful management. In addition to local wound management, patients require sensitive psychological support to improve their quality of life.

Aim To review the current evidence on the psychological effects of MFWs.

Findings In women with an MFW, feelings of anxiety associated with malodour and exudate were common, which affected their femininity and restricted their choice of clothing. In turn, this affected their body image and identity, in addition to creating a sense of social isolation, shame, and embarrassment. Moreover, the presence of an MFW served as a constant reminder of impending death, and the risk of bleeding was a major concern. Multiple studies have identified the positive influences of specialist and supportive care.

Conclusion The evidence suggests that the main psychological aspects of an MFW in the breast are associated with the symptoms and visual nature of the wound, which act as a perpetual reminder of the person’s disease and mortality. The studies reviewed herein demonstrate how an MFW affects a woman’s femininity, body image, and self-esteem, leading to feelings of embarrassment, fear, and shame, and journal of the european wound management association

consequently, social isolation. The implications for clinical practice that emerged from the review highlight the importance of the management of wound malodour and exudate and also draw attention to the importance of access to specialist wound care support as these have been shown to have a positive effect on quality of life and mitigate some of the psychosocial effects of MFW.

Pauline J Robinson RN, Year 1 Student Masters in Wound Healing and Tissue Repair Centre for Medical Education, School of Medicine, Cardiff University Wales, UK

Samantha L Holloway MSc, Reader, Programme Director. Masters in Wound Healing and Tissue Repair Centre for Medical Education, School of Medicine Cardiff University, Wales, UK

Key messages This review explored the psychological factors associated with an MFW of the breast. The results highlight that individuals with MFW experience low self-esteem the effects of which extend into many aspects of their daily lives, including their sex lives and social interactions. For many patients odour and exudate were the main contributing factors to feelings of shame and embarrassment, Furthermore for those individuals who experienced bleeding as a symptom of their wound reported being frightened of bleeding to death. A number of studies were able to show the positive effects of specialist wound care and counselling on the psychological wellbeing of the affected women.

INTRODUCTION In the UK, 54,751 cases of breast cancer in the female population were reported in 2015.1 The incidence rates of breast cancer increase progressively from the ages of 30–34 years and more remarkably from the ages of 70–74 years.1 During 2016, 11,563 deaths occurred in relation to breast cancer, accounting for 7% of all cancer-related deaths, with mortality peaking at 90 plus years of age.1  2019 vol 20 no 2

Correspondence: hollowaysl1@cf.ac.uk Conflicts of interest: None

Science, Practice and Education

Malignant fungating wounds (MFW) are a distressing complication of cancer. and have been mostly commonly reported in individuals with breast cancer.2 The prevalence of MFWs in breast cancer patients has been reported to be between 47.1%3 to 62%4 The paucity of literature on the psychological effects of MFW is evident as is the lack of knowledge pertaining to the management of these wounds among healthcare professionals.4 MFW are caused by the infiltration of malignant cells into the skin and adjacent blood and lymph vessels, and they are normally an indicator of a poor prognosis.5-7 Malignant MFW can occur as a consequence of advanced primary, secondary, or recurrent cancer, and treatment is mainly palliative.6,7 Unless the infiltration of cells is managed with adjuvant treatments, such as chemotherapy, radiotherapy, hormone therapy, or surgery, an MFW will continue to grow, causing further damage to the surrounding tissues.6 MFW can have wide-ranging effects on the physical and emotional wellbeing of the affected person, as well as those of the family members and healthcare professionals.7 Such wounds are associated with distressing symptoms such as odour, exudate, pain, bleeding, and itching, and they affect a person’s body image and self-esteem, often leading to depression and social isolation.6 According to a number of authors, knowledge and consideration among healthcare professionals of these often distressing physical and psychological symptoms will help improve the quality of life of this patient group.6,7 This review explores the psychological factors associated with an MFW of the breast. PSYCHOSOCIAL EFFECTS OF MALIGNANT FUNGATING BREAST WOUNDS Lund-Neilsen et al. undertook a prospective, exploratory intervention study to investigate the effects of MFW on femininity, sexuality, and daily life in 12 women with advanced breast cancer.8 Over a 4-week period, the women received psychological support in addition to evidencebased wound care. The authors conducted semi-structured interviews pre- and post the intervention period to enhance data capture. The responses indicated that the women expressed feelings of anxiety associated with malodour and exudate. Moreover, the women described how this affected their femininity and restricted their clothing choices, which affected their identity and created a sense of social isolation. Participants over the age of 70 years felt these were not major issues, but they acknowledged that if they were younger, the effects would be considerably stronger. With regards to sexuality, four of the women had lost their partners and lived alone. One-third of the women felt the MFW had a negative effect on their sex life, with the adverse symptoms of the MFW such as malodour and exudate being the main contributing factors. 20

Because of these factors, it was impossible for the women to be intimate with their partners, and their sexual desires faded. The study drew attention to the low self-esteem of the affected women and the effects of MFWs on their daily lives, including their sex lives and social interactions. In addition, the authors discussed the positive effects of specialist wound care and counselling on the psychological wellbeing of the affected women. The interventions were conducted in the women’s own houses, which the authors suggested probably had a positive effect because women were more likely to reveal their inner fears and anxieties in such a safe and stress-free setting. In a later qualitative study, Lo et al. investigated the experience of patients living with an MFW of the breast.4 Through semi-structured in-depth interviews, the authors identified a trajectory of five themes, namely, declining physical wellbeing, wound-related stigma, need for expert help, wound management strategies, and living positively with the wound. These themes were affected considerably by the wound care the participants received. The study participants described feeling socially isolated and ashamed, with odour and exudate being the main contributing factors. This, in turn, affected their confidence and body image. One participant mentioned keeping the wound a secret, another felt the wound influenced how others perceived them, and yet another felt the wound was a perpetual reminder of their diagnosis and impending death. A few participants attempted to self-manage their wounds to reduce the embarrassment and social stigma before seeking specialist wound management. Lo et al. reported that once a specialist assessed and advised the participants on the management of their MFW, their lived experiences were influenced positively, with enhanced emotional wellbeing, improved quality of life, and increased self-confidence. This helped them to live more positively with their MFW and become less socially isolated. The importance of specialist and supportive care has also been identified in a more recent study.9 In a prospective case series, Maida et al. collected data based on patients self-reporting of the symptoms associated with MFW (n = 67).3 Of these patients, 19.4% (n = 13) highlighted the distress caused by the aesthetics of their wounds, especially if the dressings emphasised asymmetry. In addition, the authors reported that the patients felt embarrassed by the wound odour, leading to social isolation. These findings substantiated the findings of existing studies in terms of the psychological effects of MFW on the patients’ sense of femininity and social interaction.4,8 An additional observation was that patients who experienced bleeding as a symptom of their wound reported being frightened of bleeding to death.

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In a phenomenological study, Probst et al. explored the lived experiences of nine patients with an MFW of the breast.10 The authors discussed how living with a visible cancer affects a person’s quality of life and emotional wellbeing, as well as the psychological distress it causes. Probst et al. proposed that women with advanced breast cancer who delayed seeking medical care did so because of feelings of blame and shame, ignoring the MFW developing in their breast until the symptoms became insurmountable. The findings of Probst et al. substantiated those of Lo et al., who identified that odour and exudate were the main contributing factors to feelings of shame and embarrassment, as well as the fear of looming death and effect on body image. Moreover, participants in the study of Probst et al. described being averse to taking regular prescribed analgesia owing to a fear of addiction to opioids, validating the findings of a previous case series.3 The themes of living with an MFW and feeling different emerged in the study by Probst et al..10 The authors reported how living with an MFW transformed the lives of the study participants entirely, with the graphic nature of the wound causing tremendous suffering. Some of the women found managing the distressing symptoms to be all-consuming endeavour, with one participant washing her wound every hour to eliminate the malodour and another doing the same to manage the exudate. Other participants coped by researching complementary and alternative therapies to manage the symptoms of their MFW, helping regain control of their bodies. This increased their confidence and helped them regain a sense of normality. Regaining a sense of normality was identified as a key coping mechanism, even though the women reported feel-

ing different.10 Similar themes were also identified in an earlier study.11 All the women in the study by Probst et al. mentioned that they coped by keeping their wound a secret, some even from family members. Others coped through denial and the hope of restoration of health, and they found the acceptance of a poor prognosis incomprehensible.10 The authors suggested that active coping strategies such as the ones mentioned above should be encouraged by healthcare professionals, especially with regards to complementary and alternative therapies, as well as good communication skills, to tackle the psychological effects of an MFW.10 Overall, the results of Probst et al. support the results of earlier studies.3-4,8,11 A number of the studies advocated the importance of specialist wound management4,8, and one study mentioned good communication skills.10 However, no study has offered recommendations on how to support women in mitigating the psychosocial effects of their MFWs. Subsequently this was addressed in a systematic review of the available literature.12 The authors examined 10 primary studies focusing on the quality of life of adults and proposed several recommendations (Table 1). In addition, Gibson and Green suggested the introduction of a reporting system for MFW to determine their prevalence because according to them, an understanding of the extent of the problem may help stimulate further research and the development of a national guidance.12 However, to date, the recommendation to create a registry for MFWs has seemingly not been implemented. 

Table 1. Recommendations for supporting women with MFW12

Provision of information to patients, both verbal and written Signposting to supportive services to reduce anxiety and stress Offering patients a simple and specific quality-of-life assessment tool to help stimulate expression of any anxieties to enable a problem-solving approach Training and education programmes for nurses Allowing time for care Continual assessment of pain Supplying an ‘emergency box’ with suitable dressings, medications, and dark-coloured towels in case of haemorrhage

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Science, Practice and Education

CONCLUSION Overall, the evidence reviewed indicates that the majority of the psychological aspects of an MFW of the breast are associated with the symptoms and visual nature of the wound, which acts as a perpetual reminder of the person’s disease and mortality (Lund-Neilson 2005, Lo et al. 2008, Maida 2009, Probst et al. 2013). However, other authors have described the anxiety among patients with young children and their fear of the effects of the disease on

IMPLICATIONS FOR CLINICAL PRACTICE

other people11 The literature describes how MFWs affect women’s femininity, body image, and self-esteem, leaving them with feelings of embarrassment, fear, and shame, often leading to social isolation. Malodour and exudate seem to have the most profound effects. This highlights the importance of specialist wound care support and advice, which appeared to have positive effects on women’s quality of life and mitigated some of the psychosocial effects of MFWs. m

FURTHER RESEARCH

Healthcare professionals need to be acutely aware of the low self-esteem that individuals with MFW experience.

Identification of an appropriate quality of life assessment tool for individuals with MFW to facilitate identification of patient –focussed outcome measures

Specialist and supportive care is fundamental for an individual’s well-being Allowing time to care is of paramount importance

Working with individuals with MFW to co-produce information leaflets suitable for both patients and family

Healthcare professionals need to acknowledge the real fear individuals have of leakage, odour and bleeding and provide solutions to these such as an ‘emergency care box’.

REFERENCES 1. Cancer Research. 2018. [Accessed: 2nd January 2018]. Available at: https://www.cancerresearchuk. org/health-professional/cancer-statistics/statistics-bycancer-type/breast-cancer/mortality. 2. Thomas, S. Current Practices in the Management of Fungating Lesions and Radiotherapy Damaged Skin. The Surgical Materials Testing Laboratory, Bridgend; 1992 3. Maida V, Ennis M, Kuziemsky C, Trozzolo L. Symptoms associated with malignant wounds: a prospective case series. J Pain Symptom Manage. 2009 Feb 1;37(2):206-11. 4. Lo SF, Hu WY, Hayter M, Chang SC, Hsu MY, Wu LY. Experiences of living with a malignant fungating wound: a qualitative study. Journal of Clinical Nursing. 2008 Oct;17(20):2699-2708.

5. Alexander S. Malignant fungating wounds: epidemiology, aetiology, presentation and assessment. Journal of Wound Care. 2009 Jul;18(7):273-80. 6. Merz T, Klein C, Uebach B, Kern M, Ostgathe C, Bükki J. Fungating wounds–multidimensional challenge in palliative care. Breast Care. 2011;6(1):21-4. 7. Probst S, Grocott P, Graham T, Gethin G. Recommendations for the care of patients with malignant fungating wounds. European Oncology Nursing Society (EONS). 2015.

10. Probst S, Arber A, Faithfull S. Coping with an exulcerated breast carcinoma: an interpretative phenomenological study. Journal of Wound Care. 2013 Jul;22(7):352-60. 11. Piggin C, Jones V. Malignant fungating wounds: an analysis of the lived experience. International Journal of Palliative Nursing. 2007 Aug 1;13(8):384-391. 12. Gibson S, Green J. Review of patients’ experiences with fungating wounds and associated quality of life. Journal of Wound Care. 2013 May;22(5):265-75.

8. Lund-Nielsen B, Müller K, Adamsen L. Malignant wounds in women with breast cancer: feminine and sexual perspectives. Journal of Clinical Nursing. 2005 Jan;14(1):56-64. 9. Reyonlds H, Gethin G. The psychological effects of malignant fungating wounds. EWMA Journal. 2015;15(2):29-32.

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PolyMem® wound dressings are designed to modulate inflammation to where it is needed – the wound site – while minimizing inflammation where it isn’t needed, in uninjured tissue surrounding the wound.1

more healing • less pain Modulating the inflammatory process helps reduce secondary cell damage and pain caused by the typical swelling and bruising usually observed beyond the wound site.1,2,3 PolyMem has been shown to reduce secondary cell damage by reducing the recruitment of adjacent inflammatory nerve endings (also referred to as nociceptors or free nerve endings).1 These populous nerve endings, found in the epidermis, dermis, muscle, joints and viscera, are responsible for triggering and spreading the inflammatory reaction into surrounding uninjured tissues.4,5,6,7,8

Learn more at www.polymem.com References: 1. Beitz, AJ, Newman A, Kahn AR, Ruggles T, Eikmeier L. A Polymeric Membrane Dressing with Antinociceptive Properties: Analysis with a Rodent Model of Stab Wound Secondary Hyperalgesia. The Journal of Pain. Feb 2004;5(1):38-47 2. Knight KL. Chapter 3. Inflammation and Wound Repair In Cryotherapy in Sport Injury Management. Human Kinetics. 1995. Champaign, IL 3. Merrick MA. Secondary injury after musculoskeletal trauma: a review and update. Journal of Athletic Training 2002;37(2):209-217 4. Clay CS, Chen WYJ. Wound pain: the need for a more understanding approach. Journal of Wound Care. April 2005;14(4):181-184 5. Abraham SE. Pain Management in wound care. Podiatry Management. June/July 2006:165-168 6. Wulf H, Baron R. The Theory of Pain in European Wound Management Association Position Document Pain at Wound Dressing Changes, Medical Education Partnership, London UK, 2002; page 8-11 7. Levine JD, Reichling DB. Chapter 2 Peripheral Mechanisms of Inflammatory Pain. In Wall PD, Melzak R, Editors. Textbook of Pain. 4th edition. Edinburgh, UK: Churchill Livingstone, 1999. pages 59-84. 8. Fields HL. Chapter 1 Introduction & Chapter 2 The Peripheral Pain Sensory System In Pain New York; McGraw-Hill 1987 pages 1-40 MKL-745 R5 0919

Making comfort a priority during end-of-life care

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Mölnlycke® supports the palliative wound care journey with effective solutions avoiding unnecessary and disturbing dressing changes – letting you focus on relieving pain and suffering.

Find out more about Mepilex Border Flex at www.molnlycke.com Mölnlycke Health Care AB, Box 13080, Gamlestadsvägen 3C, SE-402 52 Göteborg, Sweden. Phone +46 31 722 30 00. The Mölnlycke, Mepilex and Exufiber, names and logotypes are registered globally to one or more of the Mölnlycke Health Care group of companies. © 2019 Mölnlycke Health Care AB. All rights reserved. HQIM001123

Science, Practice and Education

Keywords: radiotherapy, wound healing, tissue injury

DOI: 10.35279/jewma201910.03

Effects of radiotherapy on wound healing Radiotherapy is widely used to treat for cancer. This therapy aims to kill cancer cells while sparing the surrounding tissue where possible. Radiotherapy can impair the normal healing process in any phase of tissue repair. This review discusses the acute and late effects of radiotherapy and relates them to wound healing.

ABSTRACT Background Radiotherapy is widely used to treat cancer, but it can influence the normal wound-healing process.

Aim To present a narrative review of the current evidence related to the effects of radiotherapy on normal wound healing.

Findings Fractionated radiotherapy treatment induces a repetitive cycle of inflammation. The acute effects of radiotherapy are mostly transient and are resolved within 4 weeks of the last dose, which correlates with the normal pathogenesis of skin regeneration. Two main theories exist with regards to the late effects of radiotherapy and the development of a chronic wound. One hypothesis is that there is a hypoxic–hypocellular–hypovascular effect. Other authors have argued that damage occurs as a result of changes to the microvasculature, in addition to the depletion of parenchymal and stromal cells. Conclusion: Recent evidence indicates that advances in treatment modalities, for example, the use of proton therapy and intensity-modulated radiotherapy, can positively influence patient outcomes in relation to tissue injury. Further advancements in our understanding of radiotherapy and its effects may lead to an improvement in the type of treatment modalities available, thereby helping prevent tissue injury altogether. Clinicians need to appreciate that healing of a radiation wound may not be realistic. Symptom-relieving treatment is of paramount importance to address the deleterious consequences of a radiotherapy related wound. journal of the european wound management association

Clinicians also need to be cognisant of the need to maintain the patient’s self-esteem and maximise their quality of life.

Key Messages This review explores the existing evidence related to the effects of radiotherapy on normal wound healing. The main observations from the studies examined indicate that ionising radiation damages cellular molecules primarily through strand breaks of deoxyribonucleic acid (DNA) or by the production of free radicals and reactive oxygen species, affecting both normal and tumour cells. Radiotherapy can impair the normal healing process in any phase of tissue repair as a result of cellular depletion, alteration in the extracellular matrix (ECM), and impairment of the microvasculature with subsequent tissue hypoxia. The acute effects of radiotherapy on the tissues range in severity from erythema to dry desquamation and hyperpigmentation. In the months or years following radiotherapy, tissue breakdown may occur leading to skin atrophy, dryness, telangiectasia, dyschromia, and dyspigmentation.

INTRODUCTION Radiotherapy has been used as a treatment modality for over a century, and currently, it is used as a standalone cancer treatment or as an adjunct to surgery or chemotherapy.1 The two main types of radiotherapy are as follows: electromagnetic radiation with x-rays and gamma rays and particulate radiation using electrons, neutrons, and protons.2 Radiation is delivered through multiple modalities, with external beam being the most commonly used modality.1,3 The treatment modality depends on the anatomical location, size, and type of  2019 vol 20 no 2

Pauline J Robinson RN, Year 1 Student Masters in Wound Healing and Tissue Repair Centre for Medical Education, School of Medicine, Cardiff University Wales, UK

Samantha L Holloway MSc, Reader, Programme Director. Masters in Wound Healing and Tissue Repair Centre for Medical Education, School of Medicine Cardiff University, Wales, UK

Correspondence: hollowaysl1@cf.ac.uk Conflicts of interest: None

Science, Practice and Education

the tumour2. The aim of the treatment is to kill the tumour cells while sparing the unaffected surrounding tissue.1,4 Nevertheless, radiotherapy causes inadvertent damage to adjacent normal tissues in up to 60% of surgical patients, especially to rapidly dividing tissues, such as skin, which are more radiosensitive.3,5 Ionising radiation acts either directly by damaging cellular molecules through energy transfer—primarily through strand breaks of deoxyribonucleic acid (DNA) or indirectly through the production of free radicals and reactive oxygen species—affecting both normal and tumour cells.3,6 Single-strand DNA breaks are thought to cause sub-lethal cellular damage which can be repaired, whereas double-strand DNA breaks are believed to cause lethal cellular damage.1 NORMAL WOUND HEALING The normal tissue-repair process involves a well-orchestrated overlapping sequence of cellular and biochemical events, including inflammation, proliferation, and remodelling.7-8 A number of intrinsic and extrinsic factors, such as poor nutrition, diabetes, infection, and the presence of a biofilm, can alter this finely tuned process.9 Radiotherapy is an extrinsic factor that can impair or modify this well-regulated and coordinated sequence of events, and it can result in the formation of a chronic or non-healing wound that fails to proceed through the normal sequence of tissue repair.4,10 Radiotherapy instigates inflammatory cell recruitment, with skin damage occurring immediately after the initial and subsequent doses.6 Radiotherapy can impair the normal healing process in any phase of tissue repair as a result of cellular depletion, alteration in the extracellular matrix (ECM), and impairment of the microvasculature with subsequent tissue hypoxia.3 Complications are contingent on the total dose, dose per fraction, treatment modality and particles used, intervals between fractions, and quantity of tissue that receives a high dose.1-2 The effects of radiotherapy on tissue repair can be classified as acute and chronic.5 ACUTE EFFECTS OF RADIOTHERAPY The acute effects of radiotherapy are observed in approximately 95% of patients.11 They range in severity from erythema to dry desquamation, hyperpigmentation, and hair loss.1,5 Acute effects usually appear within 1–4 weeks of the initial treatment, and they can last for 2–4 weeks following the final treatment.1,11 A surge of free radicals modifies the proteins, lipids, carbohydrates, complex molecules, and DNA after each subsequent exposure, resulting in a cycle of inflammatory cell recruitment and tissue injury that inhibits tissue repair.12-13 A proportion of basal keratinocytes are destroyed following the first and subsequent fractionated doses of radiotherapy, and the residual cells become cornified, shedding more rapidly; consequently, the prolif26

eration and differentiation of cells and the self-renewal of the epidermis are impaired .11 The residual keratinocytes continue to proliferate, but they are destroyed by subsequent doses of radiation.13 Furthermore, the cytokines that are present during the inflammatory phase of tissue repair, for example, transforming growth factor beta (TGFβ), vascular endothelial growth factor (VEGF), tumour necrosis factor alpha (TNFα), and interferon gamma (IFN-γ), as well as the pro-inflammatory cytokines interleukin-1 and interleukin-8, are overexpressed.13 This prolongs the inflammatory phase of tissue repair and generates a buildup of the ECM, leading to fibrosis.3,14 Liu et al. used a murine model and local soft x-ray irradiation to examine the cellular effects of irradiation on tissue repair.15 They suggested that the tissue-repair ability is dose dependent. Furthermore, they declared that all phases of wound healing are impaired by irradiation and attributed this impairment to inactive cell proliferation, apoptosis, and arrested cell cycle. They found this resulted in reduced inflammation, thinner granulation, and delayed re-epithelialisation. LATE EFFECTS OF RADIOTHERAPY In the months or years following radiotherapy, tissue breakdown may occur as a consequence of trauma, surgery, or infection, leading to the formation of chronic hard-toheal wounds.4 In addition, skin atrophy, dryness, telangiectasia, dyschromia, and dyspigmentation may occur.4 A frequent late effect of radiotherapy is fibrosis, which can lead to functional loss, body image issues, and psychosocial issues which can affect an individual’s self-esteem and their quality of life.1 Keskikuru et al. suggested that fractionated radiotherapy is linked to a reduction in the severity of fibrosis.16 Based on an in vitro study of the pathogenesis of osteoradionecrosis, Marx (1983) proposed that the late effects of radiation, resulted in hypoxic-hypocellular-hypovascular tissue, which resulted in tissue breakdown, and as a consequence a chronic non-healing wound.17 This theory is now widely accepted18 and challenged the previous propositions of Meyer (1970) who suggested that that radiotherapy-induced tissue injury is caused by radiation, trauma, and infection.19 Dion et al. (1990) undertook a pilot study of the treatment effects of pentoxifylline on 12 patients with late radiation necrosis of soft tissues.20 Although the authors supported the concept of impaired healing due to vascular injury, they suggested that the late effects of radiotherapy resulted from the depletion of parenchymal and stromal cells. In addition, they reported that 87% of the patients treated with pentoxifylline exhibited complete wound closure with a median reduction

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in healing time of 9 weeks, suggesting that pentoxifylline could be therapeutically beneficial for healing irradiated wounds. Pareek et al. developed a protocol for a Cochrane systematic review to examine the individual and combined effects of pentoxifylline and vitamin E for preventing and treating the side effects of radiation therapy and concomitant chemoradiotherapy, the results of which are yet to be published.21 More recently, Famoso et al. examined patient compliance with pentoxifylline and vitamin E treatment after breast radiation in 90 patients and found a poor compliance rate in 33 of 87 patients (38%); the main side effect was related to nausea.22 Illsley et al. examined the effect of irradiation on collagen production by fibroblasts cultured from the skin of patients undergoing radiotherapy.23 The authors found that collagen production was elevated in cells cultured from irradiated skin compared to that in cells cultured from un-irradiated skin (p = 0.016). The addition of TGFβ1 to un-irradiated skin fibroblasts increased the rate of collagen production, but the same effect was not observed with irradiated skin. In addition, it was observed that the cells from irradiated skin were larger than the control cells. They proposed that elevated collagen synthesis contributed to the development of fibrosis, and irradiation induced an altered fibroblast phenotype. Goessler et al. studied tissue samples taken from three patients with squamous-cell carcinoma treated with postoperative radiotherapy.24 The patients presented severe non-healing dermal wounds in the neck area, which was previously irradiated. Histological analysis identified that the keratinocytes in the irradiated tissue failed to proliferate compared to the control. Gene expressions of cytokeratin 1 and 10 were significantly reduced in the irradiated tissue, whereas gene expressions of cytokeratin 5 and 14 were significantly elevated. Furthermore, transforming growth factor alpha, TGFβ2, TGFβ3, keratinocyte growth factor, hepatocyte growth factor (HGF), and VEGF expression were reduced significantly. The gene expressions of fibroblast growth factors 1 and 2 and HGF were reduced marginally. Furthermore, metalloproteinases (MMP) 7, 12, and 13 were significantly elevated in the irradiated keratinocytes and fibroblasts, and the gene expression of MMP2 was elevated marginally. These findings suggest that damage to the keratinocytes during the inflammatory phase impairs angiogenesis in the proliferative phase of tissue repair. Notably, these results pertaining to the acute effects of radiotherapy have been obtained with relatively small numbers of patients with non-healing chronic wounds, which makes it difficult to judge the significance of these results.

WOUND TENSILE STRENGTH In normal wound healing, fibroblasts are attracted to the wound predominantly by platelet-derived growth factor and TGFβ during the proliferative phase of tissue repair.8 The fibroblasts then proliferate, producing fibronectin, hyaluronan, collagen, and proteoglycans, which facilitate remodelling of the ECM.8 Type III Collagen, which is predominant during proliferation, is then synthesised by the fibroblasts. During the remodelling phase of healing, Type III collagen is replaced with Type I collagen, and the fibres are then re-arranged and cross-linked.7-8 This process imparts tensile strength to the wounded tissue. Notably, the wounded tissue never regains its original strength, but it does recover approximately 80% of the original strength at 12 weeks (Broughton et al. 2006).25 Schaffer et al. investigated the tensile strength of irradiated wounds.26 They established that impaired healing was associated with diminished nitric oxide (NO) synthesis and inducible NO synthase expression (p = 0.01) and found upregulation of cell-signalling cytokine TNF-α and proinflammatory cytokine IFN-γ. Furthermore, they found diminished levels of NO synthesis and collagen deposition by fibroblasts (p = 0.01). In vitro irradiation of fibroblasts taken from non-irradiated rats led to reduced production of both NO and collagen (p = 0.01). This finding suggests that an imbalance between promoting and inhibiting factors impairs the healing of irradiated wounds. Ozbek et al. investigated the effects of preoperative conventional and hyper-fractionated radiotherapy regimes on wound healing and wound tensile strength in rats.27 The rats were randomized into three groups, with each group comprising 30 rats; sham irradiated; conventional radiotherapy with 20 daily fractions of 200 cGy, resulting in a total dose of 4000 cGy; and hyper-fractionated radiotherapy with 40 fractions of 120 cGy twice daily, resulting in a total dose of 4800 cGy. An incisional wound was made 4 weeks post radiotherapy to allow time for completion of the inflammatory and proliferative processes before onset of the maturation phase of tissue repair. Wound repair was assessed microscopically. Of the rats in the control group, 16% exhibited partial epithelisation and granulation tissue, 32% exhibited fibrosis, and 28% presented with mild or severe inflammation. By contrast, in the conventional group, 13% exhibited partial epithelisation and granulation, 35% exhibited fibrosis, and 19% presented with mild or severe inflammation. These results imply that there was no significant difference in tensile strength between the control and the conventional groups (p = 0.07). Of the rats in the hyperfractionated group, 12% exhibited partial epithelialisation, 

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18% exhibited granulation tissue, 62% exhibited fibrosis, and 31% presented with mild or severe inflammation. The results of a histopathologic analysis indicated that the occurrence of fibrosis increased significantly (p = 0.038) in the hyper-fractionated group in contrast to the other groups, and the rats in the hyper-fractionated group had significantly lower wound tensile strength than those in the control group (p = 0.03; 95% CI: 20.9647–42.6603). Although research using animal models has added considerably to our scientific knowledge, controversy remains as to how this knowledge translates to human wound healing given that rats heal through contraction, whereas humans heal through re-epithelisation.28 It is important to acknowledge the anatomical distinctions between animal models and humans, in addition to acknowledging the differences in physiological responses and pathological processes.28 PREDICTORS OF WOUND COMPLICATIONS A review by Brown and Rzucidlo discussed the patient factors associated with an increased risk of the tissue effects of radiotherapy.29 Based on a review of a series of case reports, the authors suggested an increased risk of wound complications in patients diagnosed with connective tissue disorders, such as lupus or scleroderma. Other case reports have linked patients with ataxia telangiectasia (a rare autosomal disorder) to an increased risk of the tissue effects of radiotherapy. In addition to other cellular DNA repair abnormalities or chromosomal breakage syndromes, obesity has been shown to be a factor elevating the risk of tissue effects because of the higher doses of radiotherapy required to penetrate through the body. Finally, chemotherapeutic agents, which are used to sensitise patients to radiotherapy or as an adjunct to treatment, were found to increase an individual’s susceptibility to the tissue effects of radiotherapy. Case reports add to the body of evidence by presenting the findings of clinicians in practice, but the value of such reports remains controversial because they are low on the hierarchy of evidence.30 LeBrun et al. undertook a retrospective, observational cohort study of 67 patients who underwent soft tissue sarcoma resection and radiotherapy.31 The primary outcome was the occurrence of any wound complication up to 4 months postoperatively. The authors found that 12% (n = 8) of the patients had minor wound complications and 21% (n = 14) had major wound complications documented within a median of 30 days postoperatively. In addition, diabetes was found to be associated with an increased risk of the development of major wound complications (OR 5.10; 95% CI 1.07–24.29; p = 0.4). Other predictors of wound complications included radiation dermatitis (grade 2 or above) (OR 4.82; 95% CI 1.20–19.21; p = 0.03). Interestingly, the patients who underwent proton therapy 28

did not have any wound complications. This finding may be ascribed to the increased precision of proton therapy compared to that of conventional radiotherapy, which minimises the dose to normal tissue.1 In comparison, the patients treated with three-dimensional (3D) conformal radiotherapy suffered from more wound complications compared to those treated with intensity-modulated radiotherapy (IMRT) (p = 0.04). Moreover, the authors found no statistically significant link between the patients who received radiotherapy preoperatively and those who received it postoperatively (p > .05). By contrast, in a more recent study, Stevenson et al. found a correlation between preoperative external beam radiotherapy and major wound complications (OR 2.75; 95% CI 1.21–6.26; P = 0.02).32 According to the results of a study by LeBrun et al., proton therapy and IMRT were associated with a reduced risk of wound complications in comparison to 3D conformal radiotherapy.31 However, a limitation of their study is their reliance on the accuracy of retrospective information because data may be absent or of poor quality.33 Furthermore, the follow-up time of 4 months was short. True effects of any medical treatment may not be known for some time34 therefore this is a potential limitation of the study. CONCLUSION Radiotherapy has a multifaceted cellular effect on tissue repair, involving cytokines, growth factors, fibroblasts, ECM, MMPs, and collagen synthesis, although the pathogenesis is not fully understood yet.3-4 Fractionated radiotherapy treatment induces a repetitive cycle of inflammation.3 The acute effects of radiotherapy are mostly transient and are resolved within 4 weeks of the last dose, which correlates with the normal pathogenesis of skin regeneration.3-4 Two main theories pertaining to the late effects of radiotherapy can be found in the literature. Marx proposed that a chronic wound is caused by the hypoxic-hypocellularhypovascular effects of treatment.17 Dion et al. argued that damage occurs because of changes in microvasculature, in addition to the depletion of parenchymal and stromal cells.20 Ozbek et al. found that radiotherapy reduces the tensile strength of wounds.27 This finding could explain why a few individuals who have undergone radiotherapy present with a wound following minimal trauma. More recently LeBrun et al. proposed that the treatment modality used, for example, proton therapy and IMRT, can influence patient outcomes in relation to tissue injury.31 Advancement in our understanding of radiotherapy and its effects may lead to improvement in the type of treatment modalities available, thereby preventing tissue injury altogether. It is imperative that clinicians have knowledge

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and understanding of the pathophysiology of the intrinsic and extrinsic factors that influence wound healing. This

IMPLICATIONS FOR CLINICAL PRACTICE

will enable clinicians to provide optimal and realistic treatment therapies to patients. m

FURTHER RESEARCH

Clinicians need to appreciate that healing of a radiation wound may not be realistic. Symptom-relieving treatment is of paramount importance to address the deleterious consequences of a radiotherapy related wound.

Studies examining the combined effect of pentoxyifylline and vitamin to reduce the side effects of radiotherapy are ongoing and have produced contrasting findings. Therefore, more evidence is needed to determine whether this should be implemented.

Clinicians need to be cognisant of the need to maintain the patient’s self-esteem and optimise their quality of life.

REFERENCES 1. Gieringer M, Gosepath J, Naim R. Radiotherapy and wound healing: principles, management and prospects. Oncology Reports. 2011 Aug 1;26(2):299307. 2. Gianfaldoni S, Gianfaldoni R, Wollina U, Lotti J, Tchernev G, Lotti T. An overview on radiotherapy: from its history to its current applications in dermatology. Open Access Macedonian Journal of Medical Sciences. 2017 Jul 25;5(4):521. 3. Jacobson LK, Johnson MB, Dedhia RD, Niknam-Bienia S, Wong AK. Impaired wound healing after radiation therapy: A systematic review of pathogenesis and treatment. JPRAS Open. 2017 Sep 1;13:92-105. 4. Olascoaga A, Vilar-Compte D, Poitevin-Chacón A, Contreras-Ruiz J. Wound healing in radiated skin: pathophysiology and treatment options. International Wound Journal. 2008 May;5(2):246-57. 5. Haubner F, Ohmann E, Pohl F, Strutz J, Gassner HG. Wound healing after radiation therapy: review of the literature. Radiation Oncology. 2012 Dec;7(1):162. 6. Glover D, Harmer V. Radiotherapy-induced skin reactions: assessment and management. British Journal of Nursing. 2014 Feb;23(Sup2):S28-35. 7. Enoch S, Leaper DJ. Basic science of wound healing. Surgery (Oxford). 2008 Feb 1;26(2):31-7. 8. Young A, McNaught CE. The physiology of wound healing. Surgery (Oxford). 2011 Oct 1;29(10):475-9. Flanagan M. Wound healing and skin integrity: principles and practice. John Wiley & Sons; 2013 Feb 26. 9. De Almeida SM, Cruz AD, Ferreira RI, Vizioli MR, Bóscolo FN. Effect of low-dose electron radiation on rat skin wound healing. Brazilian Dental Journal. 2007;18(3):208-14. 10. McQuestion M. Evidence-based skin care management in radiation therapy: clinical update. In Seminars in Oncology Nursing 2011 May 1 (Vol. 27, No. 2, pp. e1-e17). WB Saunders. 11. Denham JW, Hauer-Jensen M. The radiotherapeutic injury–a complex ‘wound’. Radiother Oncol. 2002 May 1;63(2):129-45. 12. Ryan JL. Ionizing radiation: the good, the bad, and the ugly. J Invest Dermatol. 2012 Mar 1;132(3):985-93.

13. Dormand EL, Banwell PE, Goodacre TE. Radiotherapy and Wound Healing. Int Wound J. 2005 Jun 2 (2): 112-27 14. Liu X, Liu JZ, Zhang E, Li P, Zhou P, Cheng TM, et al. Impaired wound healing after local soft X-ray irradiation in rat skin: time course study of pathology, proliferation, cell cycle, and apoptosis. Journal of Trauma and Acute Care Surgery. 2005 Sep 1;59(3):682-90. 15. Keskikuru R, Jukkola A, Nuutinen J, Kataja V, Risteli J, Autio P, et al. Radiation-induced changes in skin type I and III collagen synthesis during and after conventionally fractionated radiotherapy. Radiother and Oncol. 2004 Mar 1;70(3):243-48.

23. Goessler UR, Bugert P, Kassner S, Stern-Straeter J, Bran G, Sadick H, et al. In vitro analysis of radiationinduced dermal wounds. Otolaryngology—Head and Neck Surgery. 2010 Jun;142(6):845-50. 24. Broughton G II, Janis JE, Attinger CE. Wound healing: an overview. Plast Reconstr Surg. 2006 Jun 1;117(7S):1e-S. 25. Schaffer M, Weimer W, Wider S, Stülten C, Bongartz M, Budach M, Becker HD. Differential expression of inflammatory mediators in radiation-impaired wound healing. J Surg Res. 2002 Sep;107(1):93-100.

16. Marx RE. A new concept in the treatment of osteoradionecrosis. J Oral Maxillofac Surg. 1983 Jun 1;41(6):351-57.

26. Ozbek N, Guneren E, Yildiz L, Meydan D, Cakir S, Coskun M. The effect of pre-operative conventional and hyperfractionated radiotherapy schedules on wound healing and tensile strength in rats: an experimental study. Int J Oral Maxillofac Surg. 2005 Mar 1;34(2):185-92.

17. Nadella KR, Kodali RM, Guttikonda LK, Jonnalagadda A. Osteoradionecrosis of the jaws: clinico-therapeutic management: a literature review and update. J Maxillofac Oral Surg. 2015 Dec 1;14(4):891-901.

27. Nuutila K, Katayama S, Vuola J, Kankuri E. Human wound-healing research: issues and perspectives for studies using wide-scale analytic platforms. Advances in Wound Care. 2014 Mar 1;3(3):264-71.

18. Devalia HL, Mansfield L. Radiotherapy and wound healing. International Wound Journal. 2008 Mar;5(1):40-4.

28. Brown, K, R. Rzucidlo, E. Acute and chronic radiation injury. J Vasc Surg. 2011 Jan;53 (1):15S-21S.

19. Dion MW, Hussey DH, Doornbos JF, Vigliotti AP, Wen BC, Anderson B. Preliminary results of a pilot study of pentoxifylline in the treatment of late radiation soft tissue necrosis. International Journal of Radiation Oncology*Biology*Physics. 1990 Aug 1;19(2):401-7. 20. Pareek P, Samdariya S, Sharma A, Gupta N, Shekhar S, Kirubakaran R. Pentoxifylline and vitamin E alone or in combination for preventing and treating side effects of radiation therapy and concomitant chemoradiotherapy. The Cochrane Database of Systematic Reviews. 2016 Mar;2016(3). 21. Famoso JM, Laughlin B, McBride A, Gonzalez VJ. Pentoxifylline and vitamin E drug compliance after adjuvant breast radiation therapy. Advances in Radiation Oncology. 2018 Jan 1;3(1):19-24. 22. Illsley MC, Peacock JH, McAnulty RJ, Yarnold JR. Increased collagen production in fibroblasts cultured from irradiated skin and effect of TGF β 1–clinical study. British Journal of Cancer. 2000 Sep;83(5):65054.

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29. Greenhalgh, T. How to read a paper; the basics of evidence-based medicine. 5th ed. Chichester: John Wiley & Sons Ltd; 2014. 30. LeBrun DG, Guttmann DM, Shabason JE, Levin WP, Kovach SJ, Weber KL. Predictors of wound complications following radiation and surgical resection of soft tissue sarcomas. Sarcoma. 2017;2017:Article ID 5465130. 31. Stevenson MG, Ubbels JF, Slump J, Huijing MA, Bastiaannet E, Pras E, et al. Identification of predictors for wound complications following preoperative or postoperative radiotherapy in extremity soft tissue sarcoma. Eur J Surg Oncol. 2018 Jun 1;44(6):816-22. 32. Sedgwick P. Retrospective cohort studies: advantages and disadvantages. BMJ. 2014 Jan 24;348:g1072 33. Evans I, Thornton H, Chalmers I, Glasziou P. Testing treatments: better research for better healthcare. Pinter & Martin Publishers; 2011.

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Science, Practice and Education DOI: 10.35279/jewma201910.04

Wounds Research Network (WReN) - a community of practice for improving wound care-related trials Keywords: trials, wound care, community of practice, Wounds Research Network, universal health coverage

Well-designed trials that generate clinically relevant and robust knowledge are integral to improving health nationwide and achieving universal health coverage. This paper critically analyses the existing challenges associated with improving trials as well as how these challenges can be overcome through a research community of practice, such as the Wounds Research Network. ABSTRACT Poorly designed wound trials that generate knowledge that does not inform clinical practice constitute an example of research waste that undermines evidence-based healthcare. Well-designed trials that generate clinically relevant and robust knowledge are integral to improving health nationwide and achieving universal health coverage. This paper critically analyses the existing challenges associated with improving trials as well as how these challenges can be overcome through a research community of practice, such as the Wounds Research Network (WReN). Although a wide range of people have a stake in improving wound trials, they often belong to different social or professional groups that can make collaborative work challenging. In the UK, WReN demonstrates how a unifying national research community of practice can help people work together to design and conduct studies that generate knowledge that may help improve patient care.

Key Message • Communities of practice such as the WReN are a useful resource for improving wound trials to generate knowledge that informs clinical practice and contributes to the establishment of universal health coverage.

More informations: www.woundsrn.org

INTRODUCTION Poorly designed wound trials that do not generate knowledge that clinicians can utilise to inform patient care constitute an example of research waste,1-4 which undermines efforts to deliver person-centred, evidence-based healthcare to all. A lively debate has long surrounded the wound healing community regarding a trial’s ability to generate evidence that clinicians may use to inform patient care.5-9 The shortcomings and flaws associated with wound-related trials and their inability to generate knowledge that may inform patient care are well known.5,8,10 Designing trials that generate clinically relevant knowledge at a national level may be challenging because many people with wounds have other co-morbidities and because healthcare is delivered via complex adaptive systems.7,10,11 Quality improvement efforts in complex adaptive systems such as healthcare can fail with disastrous consequences and devastating outcomes.12 Poorly designed trials contribute to negative perceptions amongst clinicians, policymakers, researchers, healthcare commissioners, and funders regarding research’s ability to improve the quality of wound care and patient outcomes.5,6,10 However, the consequences of poorly designed trials extend far beyond wound healing in that they undermine efforts to promote evidence-based healthcare.2,4 

journal of the european wound management association

Ray Samuriwo PhD School of Healthcare Sciences, Cardiff University, Cardiff, United Kingdom Wales Centre for Evidence Based Care, Cardiff University, Cardiff, United Kingdom

2019 vol 20 no 2

Correspondence: samuriwor@cardiff.ac.uk Conflicts of interest: Dr Ray Samuriwo is Trustee of the Tissue Viability Society and a member of the Wounds Research Network (WReN) Scientific Committee. However, the views and opinions expressed therein are those of the author and do not necessarily reflect the views or opinions of the Tissue Viability Society or WReN.

Science, Practice and Education

Some have argued6-8 that it would be most beneficial to adopt a different approach to evidence-based wound care in which there exists less reliance on evidence from trials and clinical practice is informed by evidence from studies that employ other research methods. Adopting a broader approach to evidence-based wound care and using other research methods may generate useful insights that inform patient care. However, the global focus is on universal health coverage in which everyone has access to care that is delivered in a just, equitable, and safe manner.13 Achieving universal health coverage requires a population approach to healthcare in which the national focus is on improving the health and well-being of every citizen.13 Therefore, it is important for researchers and clinicians to consider how wound care trials can be improved to inform patient care at a national level. This paper examines key elements of the wider debate on improving healthcare-related trials before exploring how wound care trials can be improved through a research community of practice. The nature and purpose of a community of practice is summarised with an exploration into how it might contribute to improved wound trials. The Wounds Research Network (WReN) is then applied as a case study of a community of practice that was created by the Tissue Viability Society to improve wound trials in the UK. This paper concludes with a discussion of how research communities of practice such as the WReN can improve a trialsâ&#x20AC;&#x2122; ability to generate knowledge that helps achieve universal health coverage in wound care. Improving clinical trials Poor trials are not unique to wound care, as many examples exist of research waste caused by poor trials in other aspects of healthcare.2-4 Trials can be improved in a variety of ways, such as by creating more appropriate reporting standards,2,3,14 improving the methods applied,1,3 or improving regulation.15 However, the definition of what constitutes a good trial changes over time as new and innovative trial designs emerge.14 Therefore, the design and conduct of trials at any given time are socially mediated and defined. In other words, what is considered a good trial at any point in time is strongly influenced by the views of the wider research community. In the rapidly evolving world of research, the prevailing consensus within the research community concerning the most appropriate methods for the design and reporting of trials solely exists until the next methodological innovations emerge.3,14 The rapid pace of methodological innovation implies that the consensus as to the best practice regarding the design and conduct of trials in the wider research community is constantly evolving.14 The nature and pace of change in trial design can make it challenging for clinicians to understand 32

how they may most effectively apply the evidence they generate to inform patient care.14 Various groups of people are interested in improving the quality of wound trials and research. People who have a stake in improving wound trials originate from diverse professions or backgrounds, although they can be broadly be categorised as patients, informal caregivers, informal patient networks, policymakers, academics/researchers, clinicians, and industry enterprise employees. The relationships between these different groups have at times been fraught with tension due to differing perspectives and commercial interests, specifically with regard to the use of evidence to inform practice, which affects the quality of wound care that patients receive.8,10,16 From an intellectual perspective, each group of people interested in improving the quality of wound trials can be considered a community of practice.17-20 This conceptualisation is appropriate because people who belong to the research community decide what may be considered a good trial.14 Therefore, it is important to establish what a community of practice is and how it is relevant to improving wound trials. Communities of practice A community of practice is a group of people who form relationships with one another based on a shared interest in improving some aspect of their practice, who work together, and who utilise their collective expertise to achieve a shared goal.18-20 Many different groups of people are interested in improving wound care, including surgeons, doctors, nurses, physiotherapists, and patients. Consequently, each of these groups can be considered a community of practice in its own right. People who belong to a formal or informal community of practice learn from one another as they use their shared expertise to achieve their overarching goals.17,18,20 Some examples of knowledge sharing between professional and patient groups may be found in wound care centres of excellence and wound care clubs.21, 22 Over time, the people within a community of practice develop a shared identity and a set of values that can establish boundaries in collaborative work.19,20,23 Boundaries between people who belong to different professions and groups can be an impediment to the adoption of a collaborative evidence-based approach to delivering patientcentred wound care.6 8,10,16,24 The concept of a community of practice has been applied to refer to several aspects,25 and it is important that its relation to improving wound trials and research is clarified. In this paper, a community of practice refers to people who hold differing values as a result of their professions or backgrounds but nevertheless share the common interest of improving wound trials and research.

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

The Wounds Research Network A critical mass of researchers, academics clinicians, and patients in the UK have undertaken a wide range of innovative trials in pressure ulcers,26,27 leg ulcers,28-30 burns,31 and other types of wounds.32-37 The Tissue Viability Society created the WReN (https://woundsrn.org/) in 2015 to provide an interprofessional cross-speciality forum where people may share their knowledge, expertise, and insights regarding wound trials and research. The WReN offers opportunities to people from diverse backgrounds to further develop their knowledge and expertise in conducting high-quality wound trials and research regardless of their levels of expertise. Therefore, WReN is a community of practice that has helped overcome some research-related barriers to collaboration that exist between various professions and specialities in the UK. Trials in any aspect of healthcare can be improved through more efficient reporting, methods, or regulation.1-3,14,15 However, the notion of improving the design and conduct of trials through a unifying community of practice such as WReN has not been previously reported. As such, exploring the benefits of a community of practice approach to improving wound trials and research (e.g., WReN) in other nations is worthwhile. A pragmatic first step towards achieving universal health coverage in wound care may, perhaps, involve the creation of national research communities of practice that focus on improving the quality of wound trials and research. CONCLUSION This paper has considered the challenges that exist with regard to improving trials to generate knowledge that clinicians may utilise to achieve universal health coverage

in wound care. This paper has explored the case of the WReN, which functions as a community of practice that brings together people in the UK to improve wound trials and research. The WReN is an example of how a national research community of practice may facilitate interprofessional and cross-speciality collaboration as well as improvement in wound trials. National research communities of practice can help overcome the boundaries between various professions and groups of people that hinder teamwork in wound trials and research. The author hopes this paper inspires an international audience of people interested in improving wound trials to work collaboratively with others in a national research community of practice to achieve universal health coverage. IMPLICATIONS FOR FUTURE PRACTICE n Wound trials and research must be improved to generate knowledge that informs patient care at a national level. n A

national wounds research community of practice can provide a forum for shared learning and collabora tion among people from diverse backgrounds. FURTHER RESEARCH n The effectiveness of research communities of practice in improving trials’ design and conduct must be established in future research. n It is important that future research consider other approaches to improving trials that acknowledge the social and collaborative nature of research in a context with rapidly evolving methodological innovations. m

REFERENCES 1. Yordanov Y, Dechartres A, Porcher R, Boutron I, Altman DG, Ravaud P. Avoidable waste of research related to inadequate methods in clinical trials. BMJ 2015 Mar 24;350:h809. 2. Yordanov Y, Dechartres A, Atal I, Tran V-T, Boutron I, Crequit P, et al. Avoidable waste of research related to outcome planning and reporting in clinical trials. BMC Medicine 2018 Jun 11;16(1):87. 3. Dechartres A, Trinquart L, Atal I, Moher D, Dickersin K, Boutron I, et al. Evolution of poor reporting and inadequate methods over time in 20 920 randomised controlled trials included in Cochrane reviews: Research on research study. BMJ 2017 Jun 8;357:j2490. 4. Moher D, Glasziou P, Chalmers I, Nasser M, Bossuyt PMM, Korevaar DA, et al. Increasing value and reducing waste in biomedical research: Who’s listening? The Lancet 2016 Sep 27;387(10027):1573–86. 5. Webb R. Low-quality evidence from RCTs is not giving us answers. J Wound Care 2017 Sep 2;26(9):517. 6. Cutting KF, White RJ, Legerstee R. Evidence and practical wound care – An all-inclusive approach. Wound Medicine 2017 Feb 21;16(Supplement C):40–5.

7. Samuriwo R. Letters: Response to ‘Low quality evidence from RCTs is not giving us answers’. J Wound Care 2017 Nov;26(11):700–1. 8. Pagnamenta F, Lhussier M. Viewing dressing evaluation through a pragmatic lens: The application of Dewey’s experimentalism in the development of evidence for dressing selection. J Eval Clin Pract 2018 Oct;24(5):988–94.

13. World Health Organization. Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage. Geneva, Switzerland: World Health Organization; 2014. 14. Bauchner H, Golub RM, Fontanarosa PB. Reporting and Interpretation of Randomized Clinical Trials. JAMA 2019 Aug 27;322(8):732–5.

9. Lockyer S, Hodgson R, Dumville J, Cullum N. ‘Spin’ in wound care research: The reporting and interpretation of randomized controlled trials with statistically non-significant primary outcome results or unspecified primary outcomes. Trials 2013 Nov 6;14(1):371.

15. Salman RA-S, Beller E, Kagan J, Hemminki E, Phillips RS, Savulescu J, et al. Increasing value and reducing waste in biomedical research regulation and management. The Lancet 2014 Jan 11;383(9912):176–85.

10. Madden M. Alienating evidence based medicine vs. innovative medical device marketing: A report on the evidence debate at a Wounds conference. Soc Sci Med 2012 Jun;74(12):2046–52.

16. Madden M, Stark J. Understanding the development of advanced wound care in the UK: Interdisciplinary perspectives on care, cure and innovation. J Tissue Viability 2019 May;28(2):107–14.

11. Braithwaite J. Changing how we think about healthcare improvement. BMJ 2018 May 17;361:k2014.

17. Wenger E. Communities of practice and social learning systems. Organization 2000 May 1;7(2):225–46.

12. Woods DD, Branlat M. Basic patterns in how adaptive systems fail. In: Hollnagel E, Paries J, Woods D, Wreathall J, editors. Resilience engineering in practice: A guide book. Farnham: Ashgate; 2011. p. 127–44.

18. Wenger E, Snyder W. Communities of practice: The organizational frontier. Harvard Business Review. 2000 January–February:139–45.

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19. Wenger E. Knowledge management is a donut: Shaping your knowledge strategy with communities of

Science, Practice and Education

REFERENCES

practice. Ivey Business J 2004 Jan/Feb. Available from https://iveybusinessjournal.com/publication/knowledge-management-as-a-doughnut/.

20. Wenger E, Trayner B, de Laat M. Promoting and assessing value creation in communities and networks: A conceptual framework. Herleen, Netherlands: Open University of the Netherlands; 2011. 21. Lindsay E. How I got Leg Club up and running. Br J Nurs 2015 Sep 19;24:S4. 22. Government Opportunities. New £4million Welsh Wound Innovation Centre to deliver health and wealth benefits. 2013 Mar 21. Available from: http://www. govopps.co.uk/new-4m-welsh-wound-innovationcentre-to-deliver/ 23. Kislov R, Walshe K, Harvey G. Managing boundaries in primary care service improvement: A developmental approach to communities of practice. Implementation Sci 2012 Oct 15;7(1):97. 24. Samuriwo R, Hannigan B. Wounds and mental health care: System thinking. Ment Health Rev J, in press. 25. Buckley H, Steinert Y, Regehr G, Nimmon L. When I say … community of practice. Med Educ 2019 Mar 11;53(8):763–5. 26. Nixon J, Smith IL, Brown S, McGinnis E, VargasPalacios A, Nelson EA, et al. Pressure relieving support surfaces for pressure ulcer prevention (PRESSURE 2): Clinical and health economic results of a randomised controlled trial. EClinicalMedicine 2019 Sep 3;14:42–52.

27. Iglesias C, Nixon J, Cranny G, Nelson EA, Hawkins K, Phillips A, et al. Pressure relieving support surfaces (PRESSURE) trial: Cost effectiveness analysis. BMJ 2006 Aug 10;332:1416–8. 28. Gohel MS, Heatley F, Xinxue L, Bradbury A, Bulbulia R, Cullum N, et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med 2018 May 31;378(22):2105–14. 29. Ashby RL, Gabe R, Ali S, Saramago P, Chuang LH, Adderley U, et al. VenUS IV (venous leg ulcer study IV) – Compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: A randomised controlled trial, mixed-treatment comparison and decision-analytic model. Health Technol Assess 2014 Sep;18(57):1–293. 30. White J, Ivins N, Wilkes A, Carolan-Rees G, Harding KG. Non-contact low-frequency ultrasound therapy compared with UK standard of care for venous leg ulcers: A single-centre, assessor-blinded, randomised controlled trial. Int Wound J 2016 Oct;13(5):833–42. 31. Moiemen N, Mathers J, Jones L, Bishop J, Kinghorn P, Monahan M, et al. Pressure garment to prevent abnormal scarring after burn injury in adults and children: The PEGASUS feasibility RCT and mixedmethods study. Health Technol Assess 2018 Jun 29;22(36)1–162. 32. Pinkney TD, Calvert M, Bartlett DC, Gheorghe A, Redman V, Dowswell G, et al. Impact of wound edge protection devices on surgical site infection after laparotomy: Multicentre randomised controlled trial (ROSSINI Trial). BMJ 2013 July 31;347:f4305.

33. Blazeby J, Andronis L, Coast J, Donovan J, Draycott T, Gooberman-Hill R, et al. The Bluebelle Study: A feasibility study of complex, simple and absent wound dressings in elective and unplanned surgery – Phase A protocol. Bristol: University Hospitals Bristol NHS Foundation Trust; 2015. 34. Smith S, Pearce L, Newton K, Barrow P, Smith J, Hancock L. PTU-210 Packing of perianal abscess cavities (PPAC) study: A multi-centre observational feasibility study, interim analysis. Gut 2015 June;64(Suppl 1):A155.1– A155. 35. Knight R, Spoors LM, Costa ML, Dutton SJ. Wound healing in surgery for trauma (WHIST): Statistical analysis plan for a randomised controlled trial comparing standard wound management with negative pressure wound therapy. Trials 2019 Mar 28;20(1):186. 36. Costa ML, Achten J, Bruce J, Tutton E, Petrou S, Lamb SE, et al. Effect of negative pressure wound therapy vs standard wound management on 12-month disability among adults with severe open fracture of the lower limb: The WOLLF randomized clinical trial. JAMA 2018 Jun 12;319(22):2280–8. 37. Mehta S, Cro SC, Coomber B, Rolph R, Cornelius V, Farhadi J. A randomised controlled feasibility trial to evaluate local heat preconditioning on wound healing after reconstructive breast surgery: The preHEAT trial. Pilot and Feasibility Studies 2019 Jan 11;5(1):5.

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 n Please register to become a member here: www.ewma.org

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1. Bowler PG, et al. Parsons, Wound Medicine 14 (2016) 6–11. 2. Metcalf DG et al. J. Wound Care 2016; Vol25, No3. 3. Metcalf DG, et al. Int Wound J 2017; 14: 203-213. 4. Malone M et al. 2017. JWC; 20-25. AQUACEL, Hydrofiber and MORE THAN SILVER are trademarks of ConvaTec Inc. ©2019 ConvaTec Inc. AP-019908-MM * When compared to AQUACEL™ Ag Extra™ dressing and other silver-only competitor dressings: ACTICOAT™ 7 and SILVERCEL™ Non-Adherent dressings.

Cochrane Reviews

ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 3, 2019

Subfascial endoscopic perforator surgery (SEPS) for treating venous leg ulcers Zhiliang Caleb Lin, Paula M Loveland, Renea V Johnston, Michael Bruce, Carolina D Weller Example citation: Lin ZC, Loveland PM, Johnston RV, Bruce M, Weller CD. Subfascial endoscopic perforator surgery (SEPS) for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2019, Issue 3. Art. No.: CD012164. DOI: 10.1002/14651858. CD012164.pub2. ABSTRACT Background: Venous leg ulcers are complex, costly, and their prevalence is expected to increase as populations age. Venous congestion is a possible cause of venous leg ulcers, which subfascial endoscopic perforator surgery (SEPS) attempts to address by removing the connection between deep and superficial veins (perforator veins). The effectiveness of SEPS in the treatment of venous leg ulcers, however, is unclear. Objectives: To assess the benefits and harms of subfascial endoscopic perforator surgery (SEPS) for the treatment of venous leg ulcers.

322 participants. There were three different comparators: SEPS plus compression therapy versus compression therapy (two trials); SEPS versus the Linton procedure (a type of open surgery) (one trial); and SEPS plus saphenous surgery versus saphenous surgery (one trial). The age range of participants was 30 to 82, with an equal spread of male and female participants. All trials were conducted in hospital settings with varying durations of follow‐up, from 18 months to 6 years. One trial included participants who had both healed and active ulcers, with the rest including only participants with active ulcers. There was the potential for reporting bias in all trials and performance bias and detection bias in three trials. Participants in the fourth trial received one of two surgical procedures, and this study was at low risk of performance bias and detection bias. SEPS + compression therapy versus compression therapy (2 studies; 208 participants) There may be an increase in the proportion of healed ulcers at 24 months in people treated with SEPS and compression therapy compared with compression therapy alone (risk ratio (RR) 1.17, 95% confidence interval (CI) 1.03 to 1.33; 1 study; 196 participants); low-certainty evidence (downgraded twice, once for risk of bias and once for imprecision).

Search methods: In March 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including 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 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.

It is uncertain whether SEPS reduces the risk of ulcer recurrence at 24 months (RR 0.85, 95% CI 0.26 to 2.76; 2 studies; 208 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).

Selection criteria: We included randomised controlled trials (RCTs) of interventions that examined the use of SEPS independently or in combination with another intervention for the treatment of venous leg ulcers.

SEPS versus Linton approach (1 study; 39 participants) It is uncertain whether there is a difference in ulcer healing at 24 months between participants treated with SEPS and those treated with the Linton procedure (RR 0.95, 95% CI 0.83 to 1.09; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias). It is also uncertain whether there is a difference in risk of recurrence at 60 months: (RR 0.47, 95% CI  0.10 to 2.30; 1 study; 39 participants); very

Data collection and analysis: Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach. Main results: We included four RCTs with a total of journal of the european wound management association

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

The included trials did not measure or report the following outcomes; time to complete healing, health‐ related quality of life (HRQOL), adverse events, pain, duration of hospitalisation, and district nursing care requirements.

2019 vol 20 no 2

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

Cochrane Reviews

low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).

reliable evidence) to answer this question and identified four studies for inclusion.

The Linton procedure is possibly associated with more adverse events than SEPS (RR 0.04, 95% CI 0.00 to 0.60; 1 study; 39 participants); very low-certainty evidence (downgraded three times, twice for very serious imprecision and once for risk of bias).

Key messages: It is uncertain whether SEPS is beneficial or safe as a treatment for venous leg ulcers, as the certainty of the evidence collected is low or very low, and the included studies involved small numbers of participants.

The outcomes time to complete healing, HRQOL, pain, duration of hospitalisation and district nursing care requirements were either not measured, reported or data were not available for analysis. SEPS + saphenous surgery versus saphenous surgery (1 study; 75 participants): It is uncertain whether there is a difference in ulcer healing at 12 months between participants treated with SEPS and saphenous surgery versus those treated with saphenous surgery alone (RR 0.96, 95% CI 0.64 to 1.43; 1 study; 22 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias). It is also uncertain whether there is a difference in the risk of recurrence at 12 months: (RR 1.03, 95% CI 0.15 to 6.91; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias). Finally, we are uncertain whether there is an increase in adverse events in the SEPS group (RR 2.05, 95% CI 0.86 to 4.90; 1 study; 75 participants); very low certainty evidence (downgraded three times, twice for very serious imprecision and once for high risk of reporting bias). The outcomes time to complete healing, HRQOL, serious adverse events, pain, duration of hospitalisation, and district nursing care requirements were either not measured, reported or data were not available for analysis. Authorsâ&#x20AC;&#x2122; conclusions: The role of SEPS for the treatment of venous leg ulcers remains uncertain. Only low or very low-certainty evidence was available for inclusion. Due to small sample sizes and risk of bias in the included studies, we were unable to determine the potential benefits and harms of SEPS for this purpose. Only four studies met our inclusion criteria, three were very small, and one was poorly reported. Further high-quality studies addressing the use of SEPS in venous leg ulcer management are likely to change the conclusions of this review.

Plain language summary Does subfascial endoscopic perforator surgery (leg-vein surgery) help heal venous leg ulcers? What is the aim of this review?: Subfascial endoscopic perforator surgery (SEPS) involves cutting and closing off damaged perforator veins (blood vessels that link superficial and deep veins) in the leg. The aim of this review was to find out whether SEPS can help heal venous leg ulcers (slow-healing skin wounds caused by poor blood flow through leg veins). We collected and analysed all relevant randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method, which provides the most 38

What was studied in the review?: Venous leg ulcers are a common and costly health problem. These chronic wounds often take months to heal and have a high chance of recurrence after healing. Venous leg ulcers can be caused by veins that do not work properly, which results in blood flowing in the wrong direction between the superficial and deep veins in the leg. Blood that does not flow correctly causes increased pressure and inflammation, leading to skin breakdown and ulceration in the lower leg. Subfascial endoscopic perforator surgery can prevent blood from flowing in the wrong direction by cutting and tying veins that link the superficial and deep veins. It is unclear if SEPS is more effective than other treatment options such as compression bandages or stockings, which are the standard treatment for venous leg ulcers. We therefore investigated if this surgical technique can help venous leg ulcers heal more quickly. We also considered whether the surgery had any side effects, and if it impacted study participantsâ&#x20AC;&#x2122; quality of life, experience of pain, or time spent in hospital and nursing care. What are the main results of the review?: We included four studies in the review which dated from 1997 to 2011 and compared SEPS with other treatments for venous leg ulcers. The studies involved a total of 322 participants, ranging in age from 30 to 82 years, with an equal number of males and females. Two studies compared SEPS and compression stockings with compression alone; one study compared SEPS against the Linton surgical procedure (a type of open surgery on leg veins); and one study compared SEPS in addition to saphenous vein surgery (surgery on the largest superficial vein in the leg) versus saphenous vein surgery alone. We concluded that the evidence is insufficient to determine if SEPS results in better, worse, or the same outcomes as compression treatment in terms of ulcer healing. There may be a benefit of SEPS in terms of proportion of ulcers healed at 24 months, however evidence for this is of low certainty. It is also unclear due to the very low certainty of the evidence if SEPS as an addition to saphenous surgery, or as compared to the Linton approach, makes any difference in venous leg ulcer healing. No studies reported on quality of life, serious side effects or home nursing care requirements for study participants. All four studies were small in size, with the largest including 200 participants, and the other three studies reporting on 75 participants or fewer. This factor, along with poor study design methods, means that the evidence about the role of SEPS in treating venous leg ulcers is of low or very low certainty. It therefore remains unclear whether SEPS is beneficial or safe in venous leg ulcer treatment, and further high-quality studies with larger sample sizes are likely to change the conclusions of this review. How up-to-date is this review?: We searched for all studies published up to March 2018.

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

Publication in The Cochrane Library Issue 3, 2019

Negative pressure wound therapy for surgical wounds healing by primary closure Joan Webster, Zhenmi Liu, Gill Norman, Jo C Dumville, Laura Chiverton, Paul Scuffham, Monica Stankiewicz, Wendy P Chaboyer Citation example: Webster J, Liu Z, Norman G, Dumville JC, Chiverton L, Scuffham P, Stankiewicz M, Chaboyer WP. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database of Systematic Reviews 2019, Issue 3. Art. No.: CD009261. DOI: 10.1002/14651858. CD009261.pub4. ABSTRACT Background: Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). While existing evidence for the effectiveness of NPWT remains uncertain, new trials necessitated an updated review of the evidence for the effects of NPWT on postoperative wounds healing by primary closure. Objectives: To assess the effects of negative pressure wound therapy for preventing surgical site infection in wounds healing through primary closure. Search methods: We searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus in February 2018. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, metaanalyses, and health technology reports to identify additional studies. There were no restrictions on language, publication date, or setting. Selection criteria: We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT. Data collection and analysis: Four review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, ‘Risk of bias’ assessment using the Cochrane ‘Risk of bias’ tool, and quality assessment according to GRADE methodology. Main results: In this second update we added 25 intervention trials, resulting in a total of 30 intervention trials (2957 participants), and two economic studies nested in trials. Surgeries included abdominal and colorectal (n = 5); caesarean section (n = 5); knee or hip arthroplasties (n = 5); groin surgery (n = 5); fractures (n = 5); laparotomy (n = 1); vascular surgery (n = 1); sternotomy (n = 1); breast reduction mammoplasty (n = 1); and mixed (n = 1). In three key domains four studies were at low risk of bias; six studies were at high risk of bias; and 20 studies were at unclear risk of bias. We judged the evidence to be of low or very low certainty for all outcomes, downgrading the level of the evidence on the basis of risk of bias and imprecision. journal of the european wound management association

Primary outcomes: Three studies reported mortality (416 participants; follow-up 30 to 90 days or unspecified). It is uncertain whether NPWT has an impact on risk of death compared with standard dressings (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.25 to 1.56; very low-certainty evidence, downgraded once for serious risk of bias and twice for very serious imprecision). Twenty-five studies reported on SSI. The evidence from 23 studies (2533 participants; 2547 wounds; follow-up 30 days to 12 months or unspecified) showed that NPWT may reduce the rate of SSIs (RR 0.67, 95% CI 0.53 to 0.85; low-certainty evidence, downgraded twice for very serious risk of bias). Fourteen studies reported dehiscence. We combined results from 12 studies (1507 wounds; 1475 participants; follow-up 30 days to an average of 113 days or unspecified) that compared NPWT with standard dressings. It is uncertain whether NPWT reduces the risk of wound dehiscence compared with standard dressings (RR 0.80, 95% CI 0.55 to 1.18; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision). Secondary outcomes: We are uncertain whether NPWT increases or decreases reoperation rates when compared with a standard dressing (RR 1.09, 95% CI 0.73 to 1.63; 6 trials; 1021 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision) or if there is any clinical benefit associated with NPWT for reducing wound-related readmission to hospital within 30 days (RR 0.86, 95% CI 0.47 to 1.57; 7 studies; 1271 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision). It is also uncertain whether NPWT reduces incidence of seroma compared with standard dressings (RR 0.67, 95% CI 0.45 to 1.00; 6 studies; 568 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision). It is uncertain if NPWT reduces or increases the risk of haematoma when compared with a standard dressing (RR 1.05, 95% CI 0.32 to 3.42; 6 trials; 831 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision. It is uncertain if there is a higher risk of developing blisters when NPWT is compared with a standard dressing (RR 6.64, 95% CI 3.16 to 13.95; 6 studies; 597 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision). Quality of life was not reported separately by group but was used in two economic evaluations to calculate quality-adjusted life years (QALYs). There was no clear difference in incremental QALYs for NPWT relative to standard dressing when results from the two trials were combined (mean difference 0.00, 95% CI −0.00 to 0.00; moderate-certainty evidence). One trial concluded that NPWT may be more cost-effective than standard care, estimating an incremental cost-effectiveness ratio (ICER) value of GBP 20.65 per QALY gained. A second costeffectiveness study estimated that when compared with standard dressings NPWT was cost saving and improved QALYs. We rated the overall quality of the reports as very good; we did not grade the evidence beyond this as it was based on modelling assumptions.

2019 vol 20 no 2



Cochrane Reviews

Authorsâ&#x20AC;&#x2122; conclusions: Despite the addition of 25 trials, results are consistent with our earlier review, with the evidence judged to be of low or very low certainty for all outcomes. Consequently, uncertainty remains about whether NPWT compared with a standard dressing reduces or increases the incidence of important outcomes such as mortality, dehiscence, seroma, or if it increases costs. Given the cost and widespread use of NPWT for SSI prophylaxis, there is an urgent need for larger, well-designed and well-conducted trials to evaluate the effects of newer NPWT products designed for use on clean, closed surgical incisions. Such trials should initially focus on wounds that may be difficult to heal, such as sternal wounds or incisions on obese patients.

Plain language summary Negative pressure wound therapy for surgical wounds healing by primary closure Review question: We reviewed the evidence about the effectiveness of negative pressure wound therapy (NPWT) for preventing surgical site infection (SSI). Background: Surgical site infections are common wound infections that develop at the site of a surgical incision. The incidence of SSI may be as high as 40% for some types of surgery, and may also be higher for people with medical problems such as diabetes or cancer. Surgical site infections increase patient discomfort, length of hospital stay, and treatment costs. Negative pressure wound therapy involves a sealed wound dressing connected to vacuum pump that sucks up fluid from the wound, which is thought to promote wound healing and prevent infection. In an earlier 2014 version of this review, we found the effectiveness of NPWT to be unclear. This new update includes the results of new trials conducted since that time. Study characteristics: In February 2018 we searched for randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that compared NPWT with other dressings or with another type of NPWT for the prevention of SSI. We found 25 additional trials, resulting in a total of 30 trials (2957 participants), and two economic studies. The types of surgery included abdominal surgery, caesarean section, joint surgery, and others. The included trials were small, with most recruiting fewer than 100 participants. Key results: Evidence of low certainty shows that NPWT may reduce the incidence of SSI. We are uncertain if NPWT reduces the incidence of death, dehiscence (reopening of the wound), seroma (excessive fluid under a wound), haematoma (formation of blood clots), readmission to hospital, or repeat surgery. It is uncertain if NPWT results in more dressing-related blisters, or whether the treatment costs more on average than a standard dressing. Results from one trial suggest that NPWT may be more cost-effective than standard care when the impact of an SSI on length of hospital stay and other hospital costs is taken into account. Quality of the evidence: Most of our results are based on evidence of very low certainty, resulting in a high level of uncertainty in our findings. This was due to a lack of information about the methods used in the trials or a lack of adherence to 40

some of the key standards required for conducting randomised controlled trials. In addition, when a trial involves too few participants, it cannot be accurately assessed if NPWT leads to more benefit or harm. To increase confidence in our results, more high-quality, independently funded trials are needed.

Publication in The Cochrane Library Issue 6, 2019

Rigid dressings versus soft dressings for transtibial amputations Li Khim Kwah, Matthew T Webb, Lina Goh, Lisa A Harvey Citation example: Kwah LK, Webb MT, Goh L, Harvey LA. Rigid dressings versus soft dressings for transtibial amputations. Cochrane Database of Systematic Reviews 2019, Issue 6. Art. No.: CD012427. DOI: 10.1002/14651858.CD012427.pub2. ABSTRACT Background: Dressings are part of the routine postoperative management of people after transtibial amputation. Two types of dressings are commonly used; soft dressings (e.g. elastic bandages, crepe bandages) and rigid dressings (e.g. non-removable rigid dressings, removable rigid dressings, immediate postoperative protheses). Soft dressings are the conventional dressing choice as they are cheap and easy to apply, while rigid dressings are costly, more time consuming to apply and require skilled personnel to apply the dressings. However, rigid dressings have been suggested to result in faster wound healing due to the hard exterior providing a greater degree of compression to the stump. Objectives: To assess the benefits and harms of rigid dressings versus soft dressings for treating transtibial amputations. Search methods: In December 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus, Ovid AMED and PEDro to identify relevant trials. To identify further published, unpublished and ongoing studies, we also searched clinical trial registries, the grey literature, the reference lists of relevant studies and reviews identified in prior searches. We used the Cited Reference Search facility on ThomsonReuters Web of Science and contacted relevant individuals and organisations. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs that enrolled people with transtibial amputations. There were no restrictions on the age of participants and reasons for amputation. Trials that compared the effectiveness of rigid dressings with soft dressings were the main focus of this review. Data collection and analysis: Two review authors independently screened titles, abstracts and full-text publications for eligible studies. Two review authors also independently extracted data on study characteristics and outcomes, and performed risk of bias and GRADE assessments.

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

Main results: We included nine RCTs and quasi-RCTs involving 436 participants (441 limbs). All studies recruited participants from acute and/or rehabilitation hospitals from seven different countries (the USA, Australia, Indonesia, Thailand, Canada, France and the UK). In all but one study, it was clearly stated that amputations were secondary to vascular conditions. Primary outcomes Wound healing: We are uncertain whether rigid dressings decrease the time to wound healing compared with soft dressings (MD -25.60 days; 95% CI -49.08 to -2.12; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of wounds healed compared with soft dressings (RR 1.14; 95% CI 0.74 to 1.76; one study, 51 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. Adverse events: It is not clear whether rigid dressings increase the proportion of skin-related adverse events compared with soft dressings (RR 0.65; 95% CI 0.32 to 1.32; I2 = 0%; six studies, 336 participants (340 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of non skin-related adverse events compared with soft dressings (RR 1.09; 95% CI 0.60 to 1.99; I2 = 0%; six studies, 342 participants (346 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. In addition, we are uncertain whether rigid dressings decrease the time to no pain compared with soft dressings (MD -0.35 weeks; 95% CI -2.11 to 1.41; one study of 23 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. Secondary outcomes: We are uncertain whether rigid dressings decrease the time to walking compared with soft dressings (MD -3 days; 95% CI -9.96 to 3.96; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. We are also uncertain whether rigid dressings decrease the length of hospital stay compared with soft dressings (MD -30.10 days; 95% CI -49.82 to -10.38; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is also not clear whether rigid dressings decrease the time to readiness for prosthetic prescription and swelling compared with soft dressings, as results are based on very low-certainty evidence, downgraded twice for very high risk of bias and once/twice for serious/very serious imprecision. None of the studies reported outcomes on patient comfort, quality of life and cost. Authorsâ&#x20AC;&#x2122; conclusions: We are uncertain of the benefits and harms of rigid dressings compared with soft dressings for people undergoing transtibial amputation due to limited and very lowcertainty evidence. It is not clear if rigid dressings are superior to soft dressings for improving outcomes related to wound healing, adverse events, prosthetic prescription, walking function, length of hospital stay and swelling. Clinicians should exercise clinical judgement as to which type of dressing they use, and consider journal of the european wound management associationâ&#x20AC;&#x201A;

the pros and cons of each for patients (e.g. patients with high risk of falling may benefit from the protection offered by a rigid dressing, and patients with poor skin integrity may have less risk of skin breakdown from a soft dressing).

Plain language summary Rigid versus soft dressings for transtibial (below the knee) amputations What is the aim of this review?: The aim of this review was to determine whether rigid dressings are more effective than soft dressings in helping the wound to heal following transtibial (below the knee) amputations. Researchers from Cochrane searched for all relevant studies (randomised controlled trials (RCTs) and quasi-randomised controlled trials) to answer this question and found nine relevant studies. Key messages: The certainty of evidence for all outcomes was very low because the results could not rule in or rule out important benefits or harms, and because the design and reporting of the studies was not of a high standard. Therefore, we cannot be certain if the use of rigid dressings leads to better or worse patient outcomes compared with soft dressings. What was studied in the review?: We studied the effects of rigid dressings such as plaster casts or fibreglass dressings on outcomes including wound healing, adverse events, prescription of prosthetics, physical function, length of hospital stay, patient comfort, quality of life, cost and swelling in people following transtibial amputations. Rigid dressings were compared with soft dressings such as gauze or elastic bandages in all included studies. What are the main results of the review?: We included results from nine RCTs and quasi-RCTs involving 436 participants (441 limbs) in this review. Participants were recruited from acute and/ or rehabilitation hospitals from seven different countries. Sample sizes of studies ranged from 15 to 154, while the average age of participants ranged from 54 to 75. More than half of all participants had diabetes and other co-morbidities (e.g. anaemia, smoking history, hypertension, cardiac disease). Amputations were all secondary to vascular conditions (e.g. peripheral artery disease) although the cause of amputation was not always specified. We are uncertain whether rigid dressings lead to more wounds healed, fewer adverse events, faster recovery time for pain and wound healing, walking and prosthetic prescription, greater reduction in swelling, and a shorter hospital stay, compared with soft dressings. We are unsure about these results because all studies had very severe methodological limitations, and most results were based on a small number of studies (i.e. one to three studies of 21 to 65 participants). How up to date is this review?: We searched for studies that had been published up to December 2018. m

2019 vol 20 no 2

Book Reviews

Book Review Pedorthic footwear; Assessment and treatment Editors: Klaas Postema, Karl Heinz Schott, Dennis Janisse and Gerardus M. Rommers. BERJALAN, 2019

Klaus Kirketerp MD, Department of Dermatology, Bispebjerg and Frederiksberg Hospital

Anne Rasmussen Podiatrist MATT Team Leader, Foot Clinic, Steno Diabetes Center, Copenhagen

This book is comprised of 577 pages organised into 37 chapters. The book is also divided into seven sections that contain many important aspects for the clinician to use in daily clinical life. Further, each section can be read separately, if a reader wants to dig into a new subject or just refresh knowledge. This is a comprehensive book, so we have chosen to highlight a few subjects that may inspire you to read the entire book. To our knowledge, this is the first book in which footwear plays such a big role. The first section of the book contains a lot of background, which is a good intro to the functional anatomy and biomechanics of gait. There is a chapter on the changes that occur during ageing which can result in foot and walking problems. It gives a really good reflection to those of us who work with elderly patients. Clinical gait observation is an important part of the study, but as this requires some training, the book gives information on how to conduct an examination. Subsequently, there is a section on laboratory gait analysis that will probably be the method of choice in the future for evaluating insoles, shoes, pressure and gait. However, the systems require a skilled staff and generate so much data that mathematical and statistical knowledge are needed to analyse them.

Correspondence: ewma@ewma.org

The bookâ&#x20AC;&#x2122;s largest section embraces the different aspects of footwear and other offloading devices that can help people with disabilities and enhance their quality of life. The chapter provides an introduction and detailed descriptions of the various steps in journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

a protocol. It also tells readers about the whole process of building footwear and insoles, from the beginning stage to a finished product, and provides a comprehensive overview of the materials that can be used in different situations. Cosmetically appealing shoes, or maybe the lack of them, is one of the most important issues when we, as therapists, have to recommend footwear. This book devotes an entire chapter to communicating with patients, as users, on the acceptance of both illness and behaviour when we recommend footwear. Chapter 19 focuses on tips and tricks for use during a consultation. It is important to have an efficient and good consultation that gives patients realistic expectations. Therapists must pay attention to the whole body, both knees, feet and hips, and check the patient while walking, paying attention to what the wear and tear on their old footwear reveals, especially when we are prescribing new footwear.

The book also contains two sections on the foot and foot problems in children and adults. The book gives hints and ideas on how to be a little more creative and think outside the box when talk about off-loading. The book offers many good illustrations and photos; it is easy to understand and written in a way so that all healthcare professionals can gain new insight. There is also a focus on many different diseases, making the book versatile. A good feature of the book is that, for each chapter, there is a very good reference list, so readers have the opportunity to go further in depth with individual topics of their choosing. We recommend this book to all health professionals who work or want to work with foot and foot problems. m

39th Annual Meeting of the European Bone and Joint Infection Society

SAVE THE DATE 10 - 12 September 2020 Ljubljana, Slovenia

Main topics ] Optimising antibiotic treatment of bone & joint infections ] Optimal bone infection sampling and microbiological processing ] Low-grade PJI â&#x20AC;&#x201C; what is the best approach? ] Musculoskeletal infections in children ] Infections of arthroscopic implants, osteotomies and tendon reconstructions ] Chronic osteomyelitis with good function. To treat or to live with? ] Spinal infections

Important dates

www.ebjis2020.org

Abstract Submission Deadline: 10 April 2020 Early Registration Deadline: 1 July 2020

EWMA

Journal of EWMA

Other journals

Previous issues

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

Volume 20, no 1, April 2019 O F T H E E U R O P E A N W O U N D M A N A G E M E N T A S S O C I AT I O N

Volume 20 Âˇ Number 1 Âˇ May 2019

Patient-centred wound care

Finnish Nursesâ&#x20AC;&#x2122; Perception of Client-centred Wound Care SeppĂ¤nen S Optimising Wellbeing in Patients with Diabetic Foot Ulcers McIntosh C, Ivory J D, Gethin G, MacGilchrist C Taking Care of an Individualâ&#x20AC;&#x2122;s Needs at Home: Experiences of a Community Care Nursing Group Ghilardi S, Noris M, Negroni A, Paggi B, Giunni L Post-surgical Pyoderma Gangrenosum: A Retrospective Analysis of four Clinical Cases Isoherranen K A Case Report: Toxic Edipermal Necrolysis in Children Ferreira J, Santos M, Souza M, Silva G, Monteiro A, Yogui H, Santana I Factors that create Obstacles and Opportunity for Patient Participation in Orthopaedic Nursing Care StĂĽlenhag S, Sterner E

Advances in Skin & Wound Care. September 2019 www.aswcjournal.com

English Advances in

SKIN& WOUND CARE ÂŽ

The International Journal for Prevention and Healing

www.woundcarejournal.com

C M E

Volume 32 Number 9 September 2019

CLINICAL MANAGEMENT EXTRA

Pressure Injuries in the Pediatric Population: A National Pressure Ulcer Advisory Panel White Paper ORIGINAL INVESTIGATION

A Prospective, Multicenter, Single-Arm Clinical Trial for Treatment of Complex Diabetic Foot Ulcers with Deep Exposure Using Acellular Dermal Matrix Aurix Gel Is an Effective Intervention for Chronic Diabetic Foot Ulcers: A Pragmatic Randomized Controlled Trial CASE REPORT

Pyoderma Gangrenosum Associated with Sunitinib: A Case Report PLUS

Editorial Âˇ Peer Review Thank You Âˇ Payment Strategies

Finnish

Haava, no 2, 2019 www.shhy.fi

Volume 19, no 2, October 2018 The future of pressure ulcer prevention is here: Detecting and targeting inflammation early Gefen A Need for an international consensus conference on heel pressure injuries: A preliminary literature review Rivolo M, Marcadelli S Using technology to advance pressure ulcer risk assessment and self-care: Challenges and potential benefits Patton D, Moore Z, Oâ&#x20AC;&#x2122;Connor T, Shanley E, De Oliveira A L, Vitoriano A, Walsh S G, Nugent L E Prevalence of pressure injuries and other dependence-related skin lesions among paediatric patients in hospitals in Spain Pancorbo-Hidalgo P L, Torra-Bou J E, Garcia-Fernandez F P, Soldevilla-Agreda J J Survey of wound prevalence in a long-term care facility Peckford S

When the Foot Ulcer Does Not Heal- Ischemic Limb, the Potential Danger Katariina Noronen Ulcer Treatment of Ischemic Foot Tiina Pukki Aseptic Wound Treatment Mervi Niskanen New Technology in Recognition of Wound Mechanism Jorma Lahtela Helcos, vol. 30, no. 2, 2019

Spanish CONTENTS GEROKOMOS Volume 30, Number 2, June 2019

EDITORIAL 49 Gerontological vision of the Nursing Now campaign Fernando MartĂnez Cuervo

NOTEBOOK ORIGINAL ARTICLES 50 Autonomy in elderly people living in residences: relationship with gender, education level and time of institutionalization

Marta MartĂn Carbonell, Elveny Laguado Jaimes, Etilvia Campo Torregroza, Katherine del Consuelo Camargo-HernĂĄndez and Lady Johana Pereira Moreno

56 Functional capacity in home care patients over 65 years attended at Lleidaâ&#x20AC;&#x2122;s Health Region Rosa Roure Murillo, Miguel Ă ngel Escobar Bravo and Pilar JĂźrschik GimĂŠnez

61 Recognition of frailty in primary health care: A challenge for the elderly Alejandra-Ximena Araya, Evelyn Iriarte and Oslando Padilla

67 A guideline for clinical practice apply to the treatment of malnutrition in institutionalized elderly Irene Carmona FortuĂąo, MarĂa Pilar MolĂŠs Julio and Jessica Puig Zaragoza

REVIEW ARTICLE 72 Oral mucosal diseases in geriatric patients with aerosol therapy: bibliographic review Sara GonzĂĄlez MartĂn, MarĂa Josefa CĂĄmara Cuadrado and Bibiana Trevisson Redondo

Volume 19, no 1, April 2018

Grupo Nacional para el Estudio y Asesoramiento en Ă&#x161;lceras por PresiĂłn y Heridas CrĂłnicas FOTOGRAFĂ?A: â&#x20AC;&#x153;Biofilmâ&#x20AC;?. Autor: J. Javier Soldevilla Agreda

ORIGINAL ARTICLES

76 Prevalence of pressure injuries and other dependence-related skin lesions in adult patients admitted to Spanish hospitals: the fifth national study in 2017 Pedro L. Pancorbo-Hidalgo, Francisco P. GarcĂa-FernĂĄndez, Cristina PĂŠrez-LĂłpez and J. Javier Soldevilla Agreda

Opinions that matter: Patientâ&#x20AC;&#x2122;s perspective of their perioperative management during surgery for diabetic foot Piaggesi A, Bonaventura L, Giusti S, Goretti C, Menichini C Skin tears in the aging population: Remember the 5 Ws Vanzi V, LeBlanc K Recommendations to improve health care for people with chronic diseases Maggini M, Zaletel J Bioburden levels of spools of surgical tape in different healthcare settings Yu V, Deing V, Nehrdich T, Struensee B Specific risk factors for pressure ulcer development in adult critical care patients â&#x20AC;&#x201C; a retrospective cohort study Ahtiala M, Soppi E, Tallgren M Prevalence of chronic wound in different modalities of care in Germany KrĂśger K, JĂśster M

87 Impact of a training intervention in students on two acronyms for the evaluation of chronic wounds

AdriĂĄn Fuentes AgĂşndez, Gonzalo Esparza Imas, MarĂa JesĂşs Morales Pasamar, Juan Manuel Nova RodrĂguez and LucĂa Crespo VillazĂĄn

93 Risk of occurrence and prevalence of pressure injury in primary health care

Juliano Teixeira Moraes, Daniel Nogueira Cortez, GĂŠssica Cristina Souza, Larissa Oliveira and RaĂssa de Oliveira Torga

REVIEW ARTICLE 98 Tools for measuring the knowledge on pressure ulcer prevention: a literature review MarĂa Dolores LĂłpez Franco and Pedro Luis Pancorbo-Hidalgo

IJW JWC JW C Italian Journal of

WOUND CARE

www.aiuc.it

Volume 18, no 2, October 2017

Improve your ability to establish, execute and evaluate institutional research strategy

English VOLUME 28 ISSUE 1 FEBRUARY 2019 ISSN 0965-206X

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In this issue: â&#x20AC;˘ Investigating the influence of intermittent and continuous mechanical loading on skin through non-invasive sampling of IL-1Îą â&#x20AC;˘ Detection and classification methodology for movements in the bed that supports continuous pressure injury risk assessment and repositioning compliance â&#x20AC;˘ Oral mucosa pressure ulcers in intensive care unit patients: A preliminary observational study of incidence and risk factors â&#x20AC;˘ MDRPU - an uncommonly recognized common problem in ICU: A point prevalence study Official Journal of the

Prevalence of pressure injuries and other dependencerelated skin lesions in adult patients admitted to Spanish hospital: the fifth national study in 2017 Pancorbo-Hidalgo PL; Garcia-Fernandez FP; PĂŠrez-LĂłpez C Impact of training intervention in students on two acronyms for the evaluation of chronic wounds Fuentes-AgĂşndez A; Esparza-ImĂĄs Gonzalo; MoralesPasamar MJ Risk of occurrence and prevalence of pressure injury in primary health care Teixeira-Moraes J; Nogueira-Cortez D; Souza GC Italian Journal of Wound Care, Vol 2-3, 2019 www.woundcarejournal.it

Italian

Evaluation of a newly designed moisture management product for use in women giving birth at the Canberra Centenary Hospital for Women and Children. Broom M, Dunk A M, Sheridan D, McLeod M Advancing professional health care practice and the issue of accountability. Cornock M The changing US healthcare climate: What does it mean for wound care? Nusgart M Core outcome set for Venous leg ulceration â&#x20AC;&#x153;CoreVenâ&#x20AC;? Hallas S, Nelson A, Oâ&#x20AC;&#x2122;Meara S, Gethin G Negative Pressure Wound Therapy: Future Perspectives Apelqvist, J, Willy C, Fagerdahl A, Fraccalvieri M, MalmsjĂś M, Piaggesi A, Probst A, Wowden P

Pressure Injuries in the Pediatric Population: A National Pressure Ulcer Advisory Panel White Paper Delmore B, Deppisch M, Sylvia C, et al A Prospective, Multicenter, Single-Arm Clinical Trial for Treatment of Complex Diabetic Foot Ulcers with Deep Exposure Using Acellular Dermal Matrix Cazzell S, Moyer P, Samsell B, et al Aurix Gel Is an Effective Intervention for Chronic Diabetic Foot Ulcers: A Pragmatic Randomized Controlled Trial Gude W, Hagan D, Abood F, et al

Coaching in wound care. The wound care specialist nurse, facilitator for the management of skin lesions between hospital and territory in the Bologna Local Health Authority: a research project Rossana Quatrini Topical treatment with a matrix containing mesoglycan in association with hyaluronic acid in the management of chronic skin ulcers of the lower limbs Rolando Tasinato, Paolo Zangrande Negative pressure wound therapy in the acute care units of the Mendrisio Regional Hospital: results of a clinical audit Pamela Maffenini, Andrea Cavicchioli, Peter Moeller, et al.

Journal of Tissue Viability, vol. 28, no 3, 2019 www.journaloftissueviability.com The influence of incontinence pads moisture at the loaded skin interface Luciana E. Bostan, Peter R. Worsley, Shabira Abbas, Daniel L. Bader Graduated colour tape measure: Development and demonstration of this tool in a case series of neonatal skin injuries Deanne August, Ian Hitchcock, Janelle Tangney Applying honey dressings to non-healing wounds in elderly persons receiving home care RenĂĄta ZelenĂkovĂĄ, Dana VyhlĂdalovĂĄ

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

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

VOLUME 28 ISSUE 1 FEBRUARY 2019 ISSN 0965-206X

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Person-Centred Dermatology Self-care Index: a translation and validation study Jan Kottner, Oliver Ludwig, Thomas Bode et al Assessing subclinical inflammation by peroxidase detection in patients with pressure ulcers Aya Kitamura, Takeo Minematsu, Gojiro Nakagami et al Predicting diabetic foot ulcer infection using the neutrophil-to-lymphocyte ratio: a prospective study Fatma Aybala Altay, Semanur Kuzi, Mustafa Altay et al Characteristics of people with pressure ulcers using one yearâ&#x20AC;&#x2122;s routinely collected data in a defined diverse community Debra Jackson, Marie Hutchinson, Stephen Neville et al

Heridas y CicatrizaciĂłn, no 9 - 2019 Effectiveness of platelet rich plasma in compared with silver nanocrystals as a therapeutic alternative for the management of patients with soft tissue injuries. LUIS FARINGTHON REYES, OUEL SOSA VERAS, DANIEL CASTAĂ&#x2018;OS GARCĂ?A, et al. New system of classification of vascular and pressure ulcers. A different approach to unificate and simplify concepts JUAN JOSĂ&#x2030; PAGANI, SEBASTIĂ N GALEANO Sugar as local treatment for chronic infected wound: clinical case ALBA CANTELI DĂ?EZ, PAULA PĂ&#x2030;REZ RIVERA Marjolinâ&#x20AC;&#x2122;s Ulcer: Etiopathogenesis, clinic and therapeutic options. About a case JM CASARRUBIOS, m FRANCĂ&#x2030;S, V FUERTES, et al.

Phlebologie, vol. 5, 2019 www.schattauer.de

â&#x2013;ş

Phlebologie 5

The new S2k Guideline: Medical compression therapy of the extremities with medical compression stockings (MCS), phlebological compression bandages (PCB) and medically adaptive compression systems (MCS) StĂźcker Go with the (Lymph) Flow? Mortimer Negative pressure wound therapy for skin graft fixation: A reasonable option? Meissner Venous Functional Diagnostics: Hands-On Approach Part 3: Venous Occlusion Plethysmography Kahl/Bruning/Woitalla-Bruning

Kompressionstherapie

September 2019 Seite 1â&#x20AC;&#x201C;40 48. Jahrgang

â&#x2013;Ş Postinterventionelle Kompressionstherapie â&#x2013;Ş SekundĂ¤re orthopĂ¤dische Komplikationen bei angeborenen vaskulĂ¤ren Malformationen

Indexiert in â&#x2013;Ş Research Alert â&#x2013;Ş Emerging Sources Citation Index â&#x2013;Ş EMBASE â&#x2013;Ş SCOPUS

â&#x2013;Ş Operative Therapie einer ausgedehnten iliofemoralen Thrombose

Organ der Deutschen Gesellschaft fĂźr Phlebologie

CME-Fortbildung

Organ der Schweizerischen Gesellschaft fĂźr Phlebologie Bulletin de la SociĂŠtĂŠ Suisse de PhlĂŠbologie

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Organ des Berufsverbandes der Phlebologen e. V.

Scandinavian

SĂ&#x2026;Rmagasinet no 3, 2019 www.swenurse.se Vascular disease in people with diabetes Hanna Andersson National care program for prevention of foot complications in diabetes Ulrika KĂ¤llman, Linda Jervidal To suffer from malignant melanoma Madelene Stenius Diabetes foot and ulcer reception at county hospital of north Ă&#x201E;lvsborg and Uddevalla Zandra Gjers

Scandinavian

SĂĽr (Wounds), no. 2 - 2019 www.saar.dk PYODERMA GANGRĂ&#x2020;NOSUM Rikke Bech og Jens Fonnesbech SĂĽrlĂŚger fĂĽr adgang til internationalt anerkendt uddannelse Eskild W. Henneberg OVERDIAGNOSTICERING â&#x20AC;&#x201C; Vejen til sundhedsvĂŚsenets fallit Jens Fonnesbech Immunologiske sĂĽr i primĂŚr sektor? Helle Mortensen og Else SvĂŚrke Henriksen

Juni 2019

Editorial: Pasado, Presente y Futuro de la Herida â&#x20AC;˘ ArtĂculo original: Efectividad del plasma rico en plaquetas en comparaciĂłn con nanocristales de plata como alternativa terapĂŠuticapara el manejo de los pacientes con lesiones de tejido blando â&#x20AC;˘ Nuevo sistema de clasificaciĂłn de Ăşlceras por decĂşbitos y vasculares. Una propuesta diferente para unificar y simplificar conceptos â&#x20AC;˘ Caso ClĂnico: Uso de azĂşcar como tratamiento local de herida crĂłnica infectada: caso clĂnico â&#x20AC;˘ Ă&#x161;lcera de Marjolin: Etiopatogenia, clĂnica y opciones terapĂŠuticas. A propĂłsito de un caso â&#x20AC;˘ Imagen del mes: Desbridamiento enzimĂĄtico con NexobridÂŽ: EliminaciĂłn instantĂĄnea y especĂfica del tejido quemado con una pomada â&#x20AC;˘ Normas de publicaciĂłn

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Journal of Wound Care, vol. 28, 2019 www.jwc.com

Ă&#x2026;RGANG 27 NR 2

English

MEDLEMSBLAD FOR DANSK SELSKAB FOR SĂ&#x2026;RHELING OG FOR NORSK INTERESSEFAGGRUPPE FOR SĂ&#x2026;RHELING

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Wound Practice and Research, June 2019 Methods for chronic wound research â&#x20AC;&#x201C; A scoping systematic review of the recommendations, guidelines and standards CN Parker, A Francis, KJ Finlayson Ankle Brachial Pressure Index and compression application: Review summary V Team, G Gethin, JD Ivory et al Getting lower leg ulcer evidence into primary health care nursing practice: a case study S Randall, P Avramidis, N James et al The Surgical Patientsâ&#x20AC;&#x2122; Pressure Injury Incidence (SPPII) study: a cohort study of surgical patients and processes of care CM Martinez-Garduno, J Rogers, R Phillips et al

TEMA: INFLAMMATORISKE SĂ&#x2026;R

Wounds, September 2019, 2019 www.woundsresearch.com The Risk Factors of Postoperative Pressure Ulcer After Liver Resection With Long Surgical Duration: A Retrospective Study Chen HL, Jiang AG, Zhu B, et al. HS-TIME: A Modified TIME Concept in Hidradenitis Suppurativa Topical Management Oranges T, Janowska A, Chiricozzi A, et al. Efficacy and Safety of 4% Hibiscus rosa-sinensis Leaf Extract Ointment as an Adjunct Treatment to Compression Stockings on the Closure of Venous Leg Ulcers: A Pilot Study Maralit Bruan MJ, Tianco EA Wound Healing and Antimicrobial Effects of Chitosan-hydrogel/Honey Compounds in a Rat Fullthickness Wound Model Movaffagh J, Fazly-Bazzaz BS, Yazdi AT, et al.

English

Polish LECZENIE RAN, Vol .16, no. 1, 2019 Conservative treatment of the phalanx of the big toe in the course of diabetic foot Pawlowski M, Owczarczyk A, Cypryk K Use of controlled negative pressure in end-of-life wound management Bazalinski D, Wiech P, Kaczmarska D et al. Hydroterapeutic dressings in outpatients treatment traumatic injuries of the crus CybuĹ&#x201A;ka B The use of a vacuum dressing in the treatment of wounds after coronary Dyszy S, Kluszczynska M Lithuanian

Wund Management, no 4, 2019

German ISSN 1864-1121 Fachzeitschrift fĂźr das interprofessionelle Wundteam

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EWMA

New EWMA President:

EWMA focus areas for the years 2019-2021 Alberto Piaggesi MD, EWMA President

By Alberto Piagessi, EWMA President EWMA has, in recent years, gained a stronger reputation in the field of wound management, and new members, conference participants and other stakeholders have decided to join us, constantly increasing the dimension of our association and bringing in new ideas and contributions. EWMA continues a constructive and positive collaboration with industry, and this has resulted in stable sponsor engagement and support, and thus a solid financial foundation for the association. I believe that these good results, which are based on the excellent work of all those members of the council and other collaborators involved, are the result of EWMAâ&#x20AC;&#x2122;s pursuit of a consistently high quality in all the activities of the association. It is therefore crucial to me to continue work that supports scientific progress and the continuous development of good clinical practices, communication and education in wound care in the years to come. The focus areas for my time as EWMA President will, therefore, be the following: 1.Engagement of stakeholders and the pursuit of high quality in all EWMA activities n Despite the increased quality of the scientific, educational and advocacy activities organised by EWMA, there is always room for continuous improvement in each of these three main areas. Thus, the efforts to continuously increase the quality of all EWMA activities will be maintained during my time as EWMA President. will continue to invite various stakeholders to suggest projects addressing current challenges and opportunities in wound management, and to develop activities or publications based on these proposals.

n EWMA

n EWMA will continue to support new research and clinical projects in wound management via grants, exchange programs and networking, with special attention paid to the contribu tions of early-in-career scientists and clinicians.

2. Improvement of the quality of the scientific programmes at EWMA conferences n EWMA will improve and maintain the high quality of its scientific programme by carefully selecting topics and speakers, increasing the variety of lectures and rotating the speakers, with special attention paid to early-in-career scientists and professionals presenting new ideas and arguments. Close attention will be paid to the originality, novelty and neutrality of the original contributions.

n The format of the scientific programme will be maintained, but there will be an increased

number of interactive sessions, laboratories, focus groups, practical sessions, case displays and discussions, meet-the-experts sessions and debates. î&#x201A;Š journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

More information: www.ewma.org Correspondence: ewma@ewma.org

EWMA n In addition to the more traditional clinical topics, the focus on topics such as health economy, health technology assessment, biotechnologies, person-centred care and communication and the general organisation of care will be increased, to provide a wider perspective on wound management as a scientific and clinical discipline.

3. Development of the educational activities of EWMA n EWMA will continue to focus on the development of standardised wound management education in Europe. In connection with these activities, EWMA will work to develop a clear and operational strategy for supporting the implementation of standardised curricula and will conduct regular revisions of these according to recent developments in guidelines, regulations, etc.

n EWMA will consider the development of new educational activities, such as the education and training of health

care professionals in various wound aetiologies and aspects of wound management. n EWMA will work to provide more tools supporting the education of patients and private caregivers beyond the clinical and technical aspects of care (Including communication tools and psychological skills).

4. EWMA & health care politics EWMA aims to remain an independent European organisation that gathers individuals, societies and companies with an interest or involvement in wound care. In this role, it is crucial for EWMA to remain an inclusive and open organisation, collaborating with all the stakeholders engaged in wound management and operating under the same principles. Some concrete examples of activities during my time as EWMA President include EWMA’s plans to:

n Host

a World Diabetic Foot Day in London during the EWMA 2020 Conference and invite all the societies engaged in the management of the diabetic foot (DF) to participate and contribute actively to the programme.

n Continue to support the implementation of the international DF guidelines, among other things, via the EWMA

Programme for the Endorsement of Wound Centres. n Continue and further develop a close collaboration with societies outside Europe to realise activities and projects that address common challenges and promote chronic wounds as a public health problem.

n Pursue joint projects aiming for increased data collection across countries and with the involvement of various stakeholders, with the objective of providing documentation of the dimension of chronic wounds as a public health problem.

5. Person-centred care – a continued focus area of EWMA In recent years, purely evidence-based medicine (EVM) has been challenged by critics claiming that the exclusive focus on evidence-based data has contributed to separating the clinical practice from the patient. Person- or patient-centred care approaches (locally defined as ‘medical humanities’) aim to support increased patient empowerment. The philosophy behind this approach, which is not an alternative, but complementary to EVM, is to involve the patient in his or her treatment and care process with the objective of optimising the outcomes. To further support this patient-oriented approach, EWMA will: n Publish a document and instructive video material illustrating the implementation of person-centred care in the encounters between patients and wound care professionals, with the aim of increasing the use of these approaches in the field of wound management. These materials will be launched at the EWMA 2020 Conference in London.

Use the ‘Living with Chronic Wounds’ project to promote a better understanding of various patient cases among health care professionals, decision makers and other stakeholders.

a course on communication between wound care professionals and patients, focusing on the patient/ caregiver relationship. This course is planned to be available in 2021.

n Develop

journal of the european wound management association

2019 vol 20 no 2

6. Sustainability in Wound Care As one of the most important associations in wound care, EWMA has the responsibility of facing the issue of sustainability and promoting interventions, strategies and programmes in this field involving scientists, clinicians and companies. As part of these efforts, EWMA will: n Search for partnerships in the scientific field, scouting for institutions, researchers and programmes that are actively engaged in these activities, with the objective of discussing possible collaborations and engaging them in a focus session on sustainability in wound care during the EWMA 2020 Conference in London

n Start

a discussion about the notion of sustainability among EWMA members and industry partners

research projects on sustainable wound care materials, strategies and technologies as part of the EWMA Research Grant programme

n Encourage

n Promote and pursue sustainability inside EWMA through measures such as reduced travel activities, sustainable conference planning, etc.

Surely this is an ambitious program to be developed in a two-year presidential term, and I am aware of the complexity of the issues and the challenges that the pursuit of such objectives place on the shoulders of the EWMA organisation. Nevertheless, I am convinced that EWMA has not only the responsibility, but also the power, to reach these targets. I am sure that I can count on the active participation of all the members of our association in our efforts to address these challenges and further promote the health and wellbeing of our patients. m

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EWMA

New EWMA Council Members

Dimitri Beeckman

Kirsi Isoherranen

José Verdu Soriano

Tanja PlaninsekRucigaj

Hubert Vuagnat

The individual members and the Cooperating Organisations of EWMA elected five EWMA Council members during the EWMA 2019 Conference in Gothenburg, Sweden: n Dimitri

Beeckman, Belgium Isoherranen, Finland (re-elected) n Tanja Planinsek-Rucigaj, Slovenia (elected by the EWMA Cooperating Organisations Board) n Kirsi

n José

Verdu Soriano, Spain Vuagnat, Switzerland (elected by the EWMA Cooperating Organisations Board) n Hubert

The EWMA Council welcomes all new members of the EWMA Council and looks forward to a fruitful collaboration.

EWMA Honorary Positions

Alberto Piaggesi

Sue Bale

Georgina Gethin

Sebastian Probst

Jan Stryja

In May 2019, the EWMA Council elected the following members for positions in the EWMA Executive Committee: Alberto Piaggesi began his two-year term as EWMA President. Sue Bale ended her term as EWMA President and will continue her engagement with EWMA as the Immediate Past President for the next two years. Georgina Gethin took over the post of EWMA’s Scientific Recorder. Sebastian Probst took over the post of EWMA’s Honorary Secretary. Jan Stryja continues his term as EWMA Treasurer. 50

journal of the european wound management association

2019 vol 20 no 2

Appreciations: Leaving Council Members Alberto Piaggesi, EWMA President, and Sue Bale, EMWA Immediate Past President

EWMA warmly thanks the following leaving council members for their contributions and engagement in the work of EWMA: Severin Läuchli, Switzerland Severin Läuchli served as EWMA President from 2015–2017. He started his engagement in the EWMA organisation in connection with the EWMA 2010 Conference in Geneva, Switzerland, as a representative of the Swiss Wound Management Association in the Scientific Committee. During his time as EWMA President, his primary objective was to support high scientific standards through all EWMA activities, as well as generally within wound care. This increased focus led to a stronger scientific programme during the EWMA Conference and has been continued as one of EWMA’s focus areas under the following EWMA President. Severin Läuchli also made a big effort to develop the collaboration with wound management associations outside Europe, as well as other international association working within Europe, with the objective of supporting international standards, such as those within wound management education. Since then, EWMA has published curricula on wound management education for physicians (in collaboration with the UEMS) and nurses. As Immediate Past President (2017–2019) of EWMA, Severin Läuchli continued his engagement in EWMA’s European collaboration as chair of the EWMA Cooperating Organisations Board. Severin Läuchli was also a dedicated advocate for the essential role of multidisciplinary and interdisciplinary collaboration in wound management. In relation to this, he worked to increase the standardised education and engagement of physicians in wound management. Finally, Severin Läuchli was co-editor of the EWMA Document on Advanced Therapies in Wound Management (published in 2018), contributed as author to the EWMA Document on Management of Patients with Venous Leg Ulcers and co-authored a chapter in the recently published Atypical Wounds: Best Clinical Practices and Challenges Document. On the EWMA Council, Severin Läuchli was appreciated for his professionalism and dedication, and he will surely be missed. Selcuk Baktiroglu, Turkey Selcuk Baktiroglu joined the EWMA Council as a representative of the Turkish Wound Management Association. As such, he was dedicated to strengthening the ties between EWMA/European wound management and Turkish wound management professionals. As a council member elected by the Cooperating Organisations Board, he was engaged in the EWMA Cooperating Organisations Liaison Group, which is responsible for those EWMA activities involving the national organisations in Europe. Selcuk Baktiroglu was also a member of the EWMA Education Committee and generally engaged in questions related to the improvement of wound management education. During his time on the EWMA Council, Selcuk Baktiroglu represented EWMA at several conferences held by EWMA partner and cooperating organisations. Selcuk Baktiroglu is highly engaged with wound patients’ perspectives and generously shared his experiences during his term on the council. journal of the european wound management association

2019 vol 20 no 2

EWMA

Christian Münter, Germany Christian Münter became a member of the EWMA Council in May 2015 and was, even before this, an important collaboration partner from the board of the German association, Initiative Chronische Wunden e.V. (ICW). Christian Münter quickly became a key player in several different EWMA activities, as the 2016 EWMA Conference was held in Bremen, Germany. In connection with this, Christian Münter supported the scientific programme’s development and the planning of an advocacy event targeting German health care decision makers. Christian Münter was also a member and chair of the EWMA Education Committee, and in this role the committee benefitted from his experience from the educational programme run by ICW, as well as his ideas and personal engagement. Christian Münter also served as the EWMA link to the European Union of Medical Specialists (UEMS) and the newly established UEMS Thematic Federation on Wound Healing (now known as the Multidisciplinary Joint Committee - Wound Healing), which works to implement a standardised wound curriculum for physicians. Finally, Christian Münter was an important member of the Wound Centre Endorsement Committee. As such, he contributed to the development of the programme and the initial implementation of key activities related to it. Christian Münter is a kind, hard-working and diplomatic person, and we will miss him for all of this.

Julie Jordan O’Brien, Ireland Julie Jordan O’Brien is a very dedicated nurse and nurse educator, and the EWMA Council benefitted from her skills and engagement during her three-year term on the EWMA Council, 2016–2019. Before joining the EWMA Council, Julie Jordan O’Brien contributed as author to the EWMA Document on Debridement (published in 2013), and during her time on the council she was co-editor of the EWMA Document Atypical Wounds: Best Clinical Practices and Challenges (published in 2019). Julie Jordan O’Brien was also a member of the EWMA Education Committee and benefitted the work of this committee as a course reviewer and lecturer, and by offering her ideas and expertise in committee discussions. Finally, she agreed to represent EWMA as a speaker at several national conferences. As a EWMA Council member, Julie Jordan O’Brien was always ready to help, and we will miss her engagement, great sense of humour and warm personality.

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Sara Rowan, Italy Sara Rowan was a member of the EWMA Council from 2016â&#x20AC;&#x201C;2019. With a background as an educator in the wound management industry, she contributed with new perspectives and ideas. Sara Rowan is committed to the development of education in wound management, and thus became a member of the EWMA Education Committee. On this committee, she generally contributed to its many regular activities by reviewing courses for endorsement and supporting the regular updates of educational modules. She also engaged in the development of education curricula for nurses, which is a recent and very successful initiative of the Education Committee. Finally, Sara Rowan agreed to represent EWMA at several national wound management meetings and always made sure that the EWMA Council received relevant feedback about wound management development and challenges in the host countries. Sara Rowan was an engaged member of the EWMA Council who contributed to both its work and the discussions in council. We will miss her engagement and presence at our future meetings.

EWMA PODCASTS Ep.01: Understanding Diabetic Foot. Ep.02: Standardisation of the Wound Education in Europe. Ep.03: Person-centred Wound Care. Who is in Charge of the Wound?

LISTEN NOW ewma.org/what-we-do/ewma-podcasts

EWMA

EWMA 2020 LONDON · UNITED KINGDOM

13-15 MAY 2020

EWMA 2020 Conference London, United Kingdom 13-15 May 2020 In the multifaceted world of wound care, EWMA aims to support the implementation of high quality interdisciplinary and cost-effective wound care by being an educational resource, actively supporting and providing implementation of knowledge within the field of wound management.

OTHER COLLABORATORS:

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THE CONFERENCE THEME IS:

Enhancing Wound Care Quality: Global Collaboration for Local Action

In May 2020, the 30th EWMA Conference will be held in London, one of the world’s most-visited cities, and we are delighted to be partnering with the UK’s Tissue Viability Society, which will be celebrating its 40th Anniversary in 2020.

TAILOR YOUR OWN PROGRAMME Get lost in London’s rich medical history. Visit its most prominent medical museums and collections, such as the Science Museum, the Royal College of Physicians, the Florence Nightingale Museum and many more.

Safe, high-quality healthcare improves the health and wellbeing of populations and nations. Improving the quality of wound care requires shared learning, research and innovation with people from different parts of the world. The EWMA 2020 Conference will focus on how global collaboration in wound care can deliver cost-effective, high-quality wound care at a local level.

Encounter the people and places that have made this city a home of cures for more than 1000 years. Visit ewma2020.org for inspiring medical tours.

n Collaboration across professions, organisations and nations n Innovation

locally, nationally and internationally

n Local action to improve national and international wound care journal of the european wound management association

2019 vol 20 no 2

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EWMA

The EWMA 2020 Conference offers a wide variety of sessions dealing with the advancement of education and research in relation to epidemiology, pathology, diagnosis, prevention and the management of wounds. This makes it easy for delegates to tailor their own programme based on their interests and professional background.

Acute Wounds

Antimicrobials

Atypical Wounds

Basic Science

Burns

Abstract submission deadline: 2 December 2019

Devices & Intervention

Get inspired and learn more about what an EWMA Scientific Programme may look like by exploring the 2019 programme: www.ewma.org/ewma-conference/2019/scientific/programme

Diabetic Foot

Dressings

Education

e-Health

Health Economics & Outcome

Home Care

Infection

Leg Ulcer

Negative Pressure Wound Therapy

Nutrition

Pain

Pressure Ulcer

Prevention

Quality of Life

Translational Science

Wound Assessment

Case Studies (e-posters only)

ABSTRACT SUBMISSION Submit your abstract and view guidelines and conditions online. Please note that only electronic submissions are accepted.

WHY ATTEND THE EWMA CONFERENCE? LONDON: AN INTERNATIONAL CAPITAL OF MEDICINE.

The EWMA Conference offers high-level scientific presentations, networking activities and an excellent opportunity WHY ATTEND THE EWMA CONFERENCE? to The exchange knowledgeis organised and experiences withwith international EWMA Conference in cooperation TVS and offers high-level scientific presentations, networking activities and colleagues. an excellent opportunity to exchange knowledge and experience with international colleagues.

ens

95%

91%

State that the conference met their expectations or was better than expected.

Gained new knowledge, valuable information and contacts from the exhibiting companies.

Described the content of the sessions as either ‘good’ or ‘excellent’.

adline

ine

MMITTEE

SUBMISSION CATEGORIES:

97%

95%

97%

Networked with other participants during the conference.

Think the conference was relevant to their work.

Would recommend the EWMA Conference to others.

n Professional Communication (e-posters only)

*EWMA 2019 Delegate Survey

CME CREDITS (EUROPEAN CONTINUED MEDICAL EDUCATIONAL CREDITS) An application has been made to the EACCME for CME accreditation of this event.

LONDON: AN INTERNATIONAL CAPITAL OF MEDICINE Get lost in London’s rich medical history. Visit its most prominent medical museums and collections, such as the Science Museum, the Royal College of Physicians, the Florence Nightingale Museum and many more. Encounter the people and places that have made this city a home of cures for over 1000 years.

56Visit our website for inspiring medical tours, ewma2020.org (go to General Information/Guide to London).

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REGISTRATION Online registration will open in November 2019. Please visit ewma2020.org for updates. Register for the Conference from November 2019 at ewma2020.org.

Registration fees Until and incl. 11 March 2020

Category

12 March – 5 May 2020

After 6 May 2020

FULL 3 DAY CONFERENCE REGISTRATION: EWMA Members and Members of National 473 € 559 € 623 € Societies cooperating with EWMA. (394,17 € ex. VAT) (465,83 € ex. VAT) (519,17 € ex. VAT) See link below1 571 €

Non-members

(475,83 € ex. VAT)

289 €

Student registration

(240,83 € ex. VAT)

656 €

(546,67 € ex. VAT)

289 €

(240,83 € ex. VAT)

722 €

(601,67 € ex. VAT)

289 €

(240,83 € ex. VAT)

1 DAY CONFERENCE REGISTRATION FOR WEDNESDAY 13 MAY OR THURSDAY 14 MAY: EWMA members, EWMA Cooperating Organisation Members1 and non-members

309 €

(257,50 € ex. VAT)

341 €

(284,17 € ex. VAT)

407 €

(339,17 € ex. VAT)

1 DAY CONFERENCE REGISTRATION FOR FRIDAY 15 MAY ONLY: EWMA members, EWMA Cooperating Organisation Members1 and non-members

180 €

(150,00 € ex. VAT)

198 €

(165,00 € ex. VAT)

238 €

(198,33 € ex. VAT)

1 DAY REGISTRATION - EXHIBITION ACCESS ONLY: Exhibition access only (no access to sessions & workshops) 1

Same price as after 11 March

316 €

(263,33 € ex. VAT)

383 €

(319,17 € ex. VAT)

Members of EWMA Cooperating Organisations see: http://ewma.org/who-we-work-with/ ewma-cooperating-organisations/

UK VAT: 20%

IMPORTANT DATES: ENTITLEMENTS n

Registration fee includes conference bag, final programme book, abstracts available on Conference dates: 13–15 May 2020 conference app, admission to full conference programme, certificate of attendance and n CME Certificate. Registration opens: November 2019 n informed bythe visiting the conference website, The one-day-exhibition registrationStay gives access to exhibition only. Abstract submission deadline: 2 December 2019 www.ewma2020.org, for more information about n the programme. You can also find updates on Early registration deadline: March 2020 EWMA’s social media platforms.

We look forward to welcoming you to London!

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www.eafwh.org

The European Association of Fellows in Wound Healing (EAFWH) 1st Educational Programme - Austria

The first wound healing education programme organised by the EAFWH and based on the UEMS approved curriculum will be held in Innsbruck, Austria 15-16 November 2019. The programme is designed with a mix of online studies, individual preparation and face-to-face courses. Programme: 1. Course introduction: Completion of an e-learning course (Link available six weeks before face-to-face course). 2. Two face-to-face courses (each of two days duration): The first course will be held 15-16 November 2019. The second course will be held 7-8 February 2020. Location and exact dates will be announced soon. 3. Online examination: Must be completed at the latest one month after completion of 2nd course. 4. Submission of five case studies, maximum one year after successful examination. 5. Participation in two wound conferences (one of the European Wound Management Association (EWMA) and one national wound conference) at the latest one year after examinaiton. Date

Programme start from 21 October 2019

Location

Innsbruck, Austria

Language

German

Registration

Open, more information can be found here: www.eafwh.org

Information More information about the programme content can be found at www.eafwh.org Contact information For further information, please contact the EAFWH Secretariat. EAFWH Secretariat C/O CAP Partner Nordre Fasanvej 113, 2nd Floor 2000 Frederiksberg C Denmark Attention Jan Kristensen jnk@cap-partner.eu www.eafwh.org Tel: +45 70 20 03 05 Fax: +45 70 20 03 15

EWMA

World Diabetic Foot Day 2020 - open and multi-disciplinary dialogue We are pleased to introduce World Diabetic Foot Day 2020, which will be held on 15 May, during the EWMA 2020 Conference in London. From our point of view, it is a very timely initiative to unite our strengths for tackling this worldwide emergency. Diabetic foot is a serious and costly health problem that has, in recent years, grown to the dimensions of a pandemic disease. One lower limb is amputated somewhere in the world every 20 seconds because of diabetes, and 85% of the amputations are caused by a chronic ulceration.1,2 The number of patients affected by diabetic foot ulceration is increasing each year, as are the numbers of recurring cases. From a worldwide perspective, there is a dramatic underestimation of this pathology, which, because of its high mortality risk, has been defined as ‘the cancer of diabetes’; many patients also needlessly undergo amputations as a result of improper diagnostic and therapeutic approaches. It is extremely important to have an open and multi-disciplinary dialogue on improving the diagnostic techniques and interventions used to treat foot ulcers and manage the care process. That is why the former EWMA president, Jan Apelqvist, the EWMA president, Alberto Piaggesi, and the chair of the International working group on the Diabetic Foot (IWGDF), Nicolaas C. Schaper have reached out to the other associations working with Diabetic Foot Syndrome (DFS) to launch a common initiative on diabetic foot in 2020. After a successful meeting in June 2019 with other scientific associations in the field, we have decided all together to launch the first World Diabetic Foot Day. Prof Jan Apelqvist, former President of EWMA and Member of the Board of the International Working Group on Diabetic Foot (IWGDF), took on the task of chairing this initiative in 2020 and shaping, together with our partner associations, the program for World Diabetic Foot Day. The aim of this initiative is to bring together different professionals involved in the management of diabetic foot to exchange best practices and further facilitate the partnerships among them. Working together, we can further promote and facilitate the evidence-based management of diabetic foot ulcers and act against amputation.

1.International Diabetes Federation. IDF Diabetes Atlas, 8th edn. Brussels, Belgium: International Diabetes Federation, 2017.

At World Diabetic Foot Day, you can expect to:

of diabetic foot n Have

Jan Apelqvist MD, Director, Diabetes Foot Centre Department of Endocrinology University Hospital of Skåne, Division for Clinical Sciences University of Lund, Sweden

REFERENCES

EWMA is offering a platform, namely the EWMA 2020 Conference in London, for hosting World Diabetic Foot Day in 2020.

n Participate in discussions on state-of-the-art concepts and techniques related to the management

Alberto Piaggesi MD, Director, Diabetic Foot Section, Department of Medicine, University of Pisa(1), Italy EWMA President

the chance to attend talks, panel discussions, workshops and Q&A sessions organised by different renowned diabetic foot associations

2.Piaggesi et al. The organization of care for the diabetic foot syndrome: a time-dependent network. In Piaggesi A and Apelqvist J (eds), The Diabetic Foot Syndrome. Front Diabetes. Basel, Karger 2018 (36), 83–96.

n Appreciate

the complexity and different perspectives on DFS in the interpretations of the different participating organisations

n Meet

colleagues from around the world and exchange your knowledge and expertise

n Meet

key opinion leaders and follow their discussions on the future of diabetic foot.

World Diabetic Foot Day 2020 is organised by the following associations: journal of the european wound management association

Correspondence: ewma@ewma.org

2019 vol 20 no 2

EWMA

EWMA 2019 GOTHENBURG · SWEDEN

5-7 JUNE 2019

Looking back on the EWMA 2019 Conference Gothenburg, Sweden In June 2019, The EWMA Conference gathered health care professionals and industry representatives from all over the world at its 3-day wound care conference in Gothenburg.

OTHER COLLABORATORS:

Swedish Registry of Ulcer Treatment

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EWMA 2019 IN FIGURES

NATIONALITIES

419

POSTERS AND E-POSTERS

3.782

PARTICIPANTS

164

EXHIBITORS

434

PRESENTATIONS

The EWMA 2019 Conference was organised in cooperation with SSiS, the Swedish Wound Care Nurses Association, and in collaboration with RiksSår, the Swedish Registry of Ulcer Treatment. The conference had a diverse programme that included keynote sessions, focus sessions, free paper sessions, workshops, full-day streams, guest sessions and sponsored satellite symposia.

The EWMA Conference is an opportunity to meet many delegates from other countries and cultures, and the friendly conference atmosphere facilitates knowledge and expertise exchange between the delegates. SUE BALE EWMA 2019 PRESIDENT

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EWMA

FIRST TIME INTERNATIONAL PRESENTER AWARD 2019 During the conference, the chairs evaluated the first-time international presenters and selected the following speaker for the First Time International Presenter Award based on the high quality of his presentation, which was especially outstanding: Eyal Shapira; A Novel Recombinant Human Collagen-based Flowable Matrix for Chronic Lower Limb Wound Management: First Results of a Clinical Trial In the Free Paper Session: Leg Ulcer

The theme of the EWMA 2019 Conference was Personcentred Wound Care. Who is in Charge of the Wound? A multidisciplinary inter-professional team and personcentred approach to wound care supports the woundhealing process, increases patients’ quality of life and is more cost effective than other approaches. A wound is always part of someone’s body; a person has to live with it. The patient, therefore, qualifies as being an important member of the team focusing on wound healing. When all professionals, with their specific competences, work together with the patient, progress can be made and clinical knowledge and competences can be developed and shared. 62

EWMA, along with its cooperative and international partner organisations, carries out different activities to support patients and clinicians in the process of shared decisionmaking. These activities include providing educational resources, hosting scientific conferences, contributing to international projects related to wound management, actively supporting the implementation of existing knowledge and providing information on all aspects of wound management.

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Currently, EWMA is developing a document focused on patient-centred care aiming to develop materials that may help wound management practitioners improve their communication with patients and identify the most effective strategies for involving patients in the wound management processes. This document will be published in 2020. INDUSTRY It is important to stress the great contributions of the industry; these are always a big part of the EWMA conferences. The exhibition hosted more than 160 companies and organisations for EWMA participants to visit. The industry-sponsored symposia were of great value, and the Scientific Committee is grateful to all the industry partners whose cooperation contributed to the success of EWMA 2019. RELIVE EWMA 2019 Do you want to relive EWMA 2019, or maybe you missed out on a session? You can gain free access to webcasts of selected key session, all e-Posters and abstracts in our EWMA Knowledge Centre! Simply go to www.ewma.org.

Join @ewmawound

E-POSTER PRIZES The e-poster prizes are awarded to e-posters that: n Are

visually appealing

n Are

well laid out in a logical manner

n Contain n Have

relevant, interesting content

clear conclusions

PRIZES WERE AWARDED TO THE FOLLOWING FOUR E-POSTERS: Ingunn W Jolma, EP052, Devices and intervention The Effects of Pressure Redistribution of an Innovative Radle-shaped Turning Mattress, Compared to Manual Repositioning of Bed-ridden Patients Chigozie Louis Okolie and Lindsay Hawco, EP055, Devices and intervention Fabrication of Magnetic Fibres for Smart Wound Dressing Materials with Woundhealing Monitoring and Imaging Capacity Atte Kekonen, EP108, e-Health and Health Economics & Outcome A Novel Method and Measurement System for Monitoring Chronic Wounds Tabatha Rando, EP155, Dressings Simplifying Wound Dressing Selection for Residential Aged Care Nurses

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

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NOTE: Specific indications, contraindications, warnings, precautions and safety information may exist for Systagenix, Crawford and KCI (Acelity companies) products. Please consult a healthcare provider and product instructions for use prior to application. This material is intended for healthcare professionals. Copyright 2019 KCI Licensing, Inc. All rights reserved. Unless otherwise noted, all trademarks designated herein are proprietary to KCI Licensing, Inc., Systagenix Wound Management, Ltd., or Crawford Healthcare, Ltd. PRA-PM-EU-00218 (09/19)

EWMA

EWMA Honorary Speaker 2019 Jan Apelqvist It was a great pleasure to present Jan Apelqvist as the Honorary Speaker at the EWMA 2019 Conference.

Jan Apelqvist, PhD, MD is a Senior Consultant in the Department of Endocrinology at the University Hospital Malmö and Associate Professor in the Department of Clinical Science, University of Lund. Jan Apelqvist graduated as a medical specialist in Internal Medicine in 1985 and finalised his PhD in 1990 on the topic ‘Diabetic Foot Ulcer: the importance of clinical characteristics and prognostic factors for outcome’. Since then, he has contributed greatly to the development of wound management, both in Sweden and internationally, as a key player in international organisations such as the International Working Group on the Diabetic Foot (IWGDF) and EWMA. From a scientific point of view, Apelqvist’s contributions have been quite unique in the field of wound management. They include more than 200 papers, including EWMA position documents and book chapters, focused on diabetic foot ulcers and ulceration in general. These are journal of the european wound management association

Alberto Piaggesi MD, EWMA President

among the most frequently cited publications on these topics. Apelqvist’s primary focus has always been the implementation of multidisciplinary teams and evidence-based/best practice guidelines for the management of the diabetic foot. For his impressive contributions to this field, he has received a number of prestigious awards for his efforts, including, among others: n

2016: The DFSG Life Time Achievement Award, DFSG 13th Scientific Meeting. Stuttgart, Germany

2012: The Edward James Olmos Award 2012; For Achievements in the Prevention of Diabetic Foot Amputations. DFCon, LA, US

1999: The Diabetic Foot Award; For Excellent scientific contribution and pre eminent role in advanced care for diabetic patients with foot problems at the 3rd

2019 vol 20 no 2

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Correspondence: ewma@ewma.org

EWMA

International Symposium on the diabetic foot, The Netherlands 1998: Peccoraro Scientific Award (American Diabetes Association; ADA); For outstanding clinical research in the diabetic foot. Chicago, US

Chair of the EWMA Cooperating Organisations and International Partners Boards (as EWMA’s Immediate Past-President)

1995: A Clinical Achievement Award; For organisation of and implementation of a multidisciplinary foot care team. The University hospital of Lund, Sweden Apelqvist has also been an active player in the professional associations engaged in wound management. As an expert on diabetic foot ulcers (DFUs), he is a member of the IWGDF Guideline Group, responsible for the publication and updates of the IWGDF Diabetic Foot Guidelines. Based on his interest in general wound management, Apelqvist was the highly respected and cherished president of EWMA from 2011–2013. Before, during and after his presidency, Apelqvist also led or contributed to a number of key EWMA activities and projects, including: Editorship of EWMA Documents, including: Outcomes in controlled and comparative studies on non-healing wounds, Debridement and Negative Pressure Wound Therapy

Apelqvist is still involved with EWMA, and this is highly appreciated. Within Sweden and Scandinavia, Apelqvist has been a key contributor to the development of high-quality wound care. He was the founder and first president of the Swedish Wound Healing Society, in 1995, and key player in the establishment of the Nordic Diabetic Foot initiative, aiming to support the implementation of DFU guidelines across Scandinavia. The first Nordic Diabetic Foot meeting was held in Malmö in 2014. Finally, Apelqvist has, together with the Swedish health economist Gunell Ragnarson Tennvall, conducted some of the best studies on the resource utilisation and costs associated with the treatment of diabetic foot ulcers. The research papers describing these are, still today, among the most-cited on this topic. EWMA is now working to establish a new study with a similar design covering all non-healing wounds, to provide updated information.

Apelqvist encompass at the same time a clinician, a scientist, a pioneer, a navigator, a crusader and, last but not least, a human being. For all of that, we appreciate and love him very much. m

Chair of the EWMA Patient Outcome Group

EWMA

Knowledge Centre Access EWMA webcasts, e-Posters, documents and abstracts www.ewma.org

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Our new PICO 14 Single Use Negative Pressure Wound Therapy System (sNPWT) with AIRLOCK◊ Technology has a pump duration of up to 14 days,1 and is aimed for use on deep wounds (e.g. 7 centimeters deep).2 With an enhanced pump to aid use in large wounds with less user intervention.3† Turn around wound healing trajectory more effectively than standard dressings4 and tNPWT5 with PICO sNPWT.

PICO◊ 14

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For detailed product information, including indications for use, contraindications, precautions and warnings, please consult the product’s applicable Instructions for Use (IFU) prior to use. † Compared to previous versions. References: 1. Smith+Nephew December 2018. PICO 14 Service Life Testing: 14 Day Device Lifespan. Internal Report. RD/18/132. 2. Smith+Nephew 2018. The review of evidence supporting the use of PICO in wounds ≥2cmin depth. Internal report EO AWM. PCS230.001 v2. 3. Smith+Nephew 2019. Research & Development Report. PICO 14 and PICO 7 Initial Pump Down and Maintenance Pump Down Time Outs RD/19/084. 4. Dowsett C, Hampton J, Myers D, Styche T. Use of PICO to improve clinical and economic outcomes in hard-to-heal wounds. Wounds International. 2017;8, p53–58. 5. Kirsner R, Dove C, Reyzelman A, Vayser D, Jaimes H. A prospective, randomized, controlled clinical trial on the efficacy of a single-use negative pressure wound therapy system, compared to traditional negative pressure wound therapy in the treatment of chronic ulcers of the lower extremities. Wound Repair Regen. 2019 May 14. [Epub ahead of print]. Trademark of Smith+Nephew ©August 2019 Smith+Nephew. 21013 | GMC0818.

◊

EWMA

EWMA Masterclass 2019

Oxygen therapy in wound healing

Jürg Traber MD, Vascular Surgery FEBVS, Phlebology SGP Director, Venenklinik Bellevue, Switzerland Member of EWMA Education Committee

For the first time, wound experts had the opportunity to join a masterclass just before the EWMA 2019 Conference in Gothenburg, Sweden.

Kirsi Isoherranen MD, PhD, Specialist in Dermatology and Allergology, University Central Hospital of Helsinki, Wound Healing Centre, Finland EWMA Council member and member of EWMA Education and Scientific Committees

Marc Augsburger speaking at EWMA Masterclass 2019.

The EWMA Education Committee created the new approach of a masterclass. Its goal was to provide participants with more profound, highly scientific insight into the topic. Oxygen, as the basis of life, should be looked at from a scientific point of view regarding both its molecular and biological aspects. Building on scientific findings from the different treatment options of the past concerning the clinical application of oxygen were shown and discussed. Participants had the opportunity to enrich the event with their own case studies. Furthermore, they were given the chance to discuss the plausibility of oxygen therapies with experts. Responsible for the scientific programme were Kirsi Isoherranen, MD and Jürg Traber, MD, who journal of the european wound management association

engaged with the topic with great enthusiasm and commitment to make the event a success. Highly scientific presentations were given by Biochemist, Marc Augsburger, MSc; Adjunct Professor Robert Frykberg; and Jacek Kot, MD, PhD, Associate Professor. The following is a summary of their presentations. THE MOLECULAR ROLES OF OXYGEN IN WOUND HEALING Cyanobacteria were most probably the first organisms to eject oxygen into the atmosphere as a waste product. The evolution of other aerobic organisms was triggered due to this oxygenation of the atmosphere. However, life ashore was only possible once an ozonosphere (O3) had built up. 

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Correspondence: ewma@ewma.org

EWMA

of metabolic demand (energy) for regeneration, oxygen consumption by leucocytes for ROS production and the need for oxygen collagen synthesis, extracellular matrix remodelling and angiogenesis. In cases of hypoxia or hyperoxia, low levels of ROS promote regeneration. High levels of ROS cause tissue damage. Acute hypoxia triggers wound healing, whilst chronic hypoxia reduces regenerative potential.

Left to right: Kirsi Isoherranen, Marc Augsburger, Jürg Traber, Robert Frykberg and Jacek Kot.

TOPICAL OXYGEN THERAPY: MISUNDERSTOOD AND UNDERSTUDIED

This ‘protective shield’ arose approximately 700 million years ago and protected organisms from radiation injury.

Regarding the different molecular roles in wound healing, it is important to understand that oxygen is essential to healing across the continuum. During all phases of wound healing, oxygen has specific functions.

Oxygen as a molecule with covalent bonds between two oxygen atoms is called ‘molecular oxygen’. Apart from that, numerous reactive oxygen species (ROS) exist. These highly reactive molecules can be formed intermediately in many different biochemical reactions.

During the inflammatory phase, oxygen acts with n Immune response n Inflammatory mediators (interleukins, cytokines, WBCs, neutrophils – macrophages) n ROS production

Oxygen is, therefore, essential for more than just aerobic organisms; oxygen-averse single cells also had to protect themselves from the toxic properties of ROS.

During the proliferative phase, oxygen acts with n Growth factors n Angiogenesis n Fibroblasts n Collagen synthesis

Different defence mechanisms can be observed in bacteria: n Escaping (swimming away) n Joining together (forming a single mass) n Hiding within cells n Hiding behind cells (e.g., the skin acts as a barrier to oxygen) n Stabilisation through reduction The oxygen mechanisms of action are diverse and happen due to interaction with biomolecules such as the photosystem II (a part of photosynthesis in plants), haemoglobin, eNOS (endothelial nitrogen monoxide synthase), NADPH oxidase, cytochrome C oxidase, hypoxia-indicated factor I alpha (HIF-1-alpha), superoxide dismutase and prolyl-4-hydroxalase (which is essential for the biosynthesis of collagen). The necessity of oxygen for eukaryotic organisms leads back to fundamental processes such as energy production by oxidative phosphorylation, the destruction of microorganisms during phagocytosis, angiogenesis, collagen synthesis and others. Equally important is the role of ROS in redox signalling pathways and hypoxia-induced responses. In summary, the oxygenation of end organs is dependent on pulmonary gas exchange, cardiac output and the means of transport to the mentioned organs through macro – and microvascular – perfusion. Oxygen depletion is the result 70

During maturation, oxygen acts with n Remodelling n Epithelialization Whereas the arterial oxygen level (pO2) is about 100mmHg, one can find in a wound bed levels below 10mmHg, and in wound edges levels may be about 60mmHg. This imbalance of oxygen levels occurs because of disrupted or compromised vasculature and as a consequence of underlying disease, such as diabetes, arteriosclerosis, trauma-related tissue damage and oedema. By contrast, higher oxygen levels are needed to fight infection, to form collagen and to build the extracellular matrix (ECM) and achieve neovascularisation. By raising the oxygen levels in chronic wounds, the ability to fight infection is improved and enzymatic activity is maximised. Thus, topical oxygen delivery can lift the concentrations of oxygen in chronic wounds without the risk of multi-organ oxygen toxicity, and do so independently of the circulating oxygen in the vascular bed. Topical oxygen therapy remains controversial, despite 50 years of use and more than 30 clinical reports and positive reviews in the medical literature. Despite this, in the IWGDF (International Working Group on the Diabetic Foot)

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guidelines for 2019, the use of topical oxygen therapy as a primary or adjunctive intervention in diabetic foot ulcers (DFUs), including those that are difficult to heal, is not recommended. Nevertheless, since the first publication in this field (Fischer BH; Lancet 1969, ‘Topical Hyperbaric Oxygen Treatment of Pressure Sores and Skin Ulcers’), topical oxygen therapy has always been described as a promising approach to the treatment of certain wounds. Although a randomised controlled trial (Leslie, 1988, ‘Randomized Controlled Trial of Topical Hyperbaric Oxygen for Treatment of Diabetic Foot Ulcer’) did not find any statistical differences concerning the ulcer size, due to important methodological flaws, there has been on-going interest in topical oxygen therapy. Fries et al., in 2005, showed that topical oxygen promotes neovascularisation, stronger tissue and lower ulcer reoccurrence rates in a pig model. Following this animal study, some investigators looked at the effect of topical oxygen therapy in patients with chronic wounds and found promising results. Frykberg et al. investigated the effect of topical oxygen on the healing of recalcitrant DFUs by performing a double-blinded, sham controlled RCT (accepted for publication). As previously reported in abstract form (American Diabetes Association Annual Meeting, 2018), cyclical, pressurised, humidified TWO2 (Topical Wound Oxygen Therapy) significantly approved healing of DFUs at 12 weeks and 12 months. Larger wounds had significantly reduced wound area reduction, compared to sham wounds. HYPERBARIC OXYGEN THERAPY

Concerning the different effects of oxygen, the question remains on how to apply sufficient concentrations of oxygen (pO2). As analysed above, it can be administered either topically or systemically via a hyperbaric oxygen chamber (HBOT). Turhan et al. showed that HBOT is not only a useful anti-infection strategy itself, but also an adjunctive therapy when applied together with systemically administered antibiotics.

It is not just direct effects on healing processes and bacteria that are evident, but also changes in inflammatory gene expressions induced by HBOT. Thus, this gene expression could be a long-term benefit of HBOT which is not completely cleared up so far. Despite many years of research, it seems that pooled data and meta-analyses are inconclusive. However, the main problem with the data interpretation efforts is related to either poor quality or inappropriately drawn conclusions from some studies. For example, one very recent study, the DAMO2CLES multi-centre randomised clinical trial, was intended to shed light on the conflicting evidence regarding the effects of HBOT in the treatment of chronic ischemic leg ulcers. The aim of the trial was to investigate whether additional HBOT would benefit patients with diabetes and ischemic leg ulcers. The study did not show a significant improvement in complete wound healing or limb salvage in patients with diabetes and lower-limb ischemia in the Intent-To-Treat analysis, but in the analysis of sub-groups, it was clear that clinical effects of HBOT are positive in those patients who completed the full prescribed number of hyperbaric sessions. With this in mind, the challenge is to identify patients who can gain from this method and implement the complete treatment. CONCLUSION

Participants in the first EWMA Masterclass gained some profound, highly scientific insight into the role of oxygen in healing chronic wounds. They learned a lot about biological basics and the available possibilities for administering oxygen as an adjunctive therapeutic method. There was also time for highly scientific discussions. The EWMA Masterclass is a promising new form of scientific forum for discussing a medical issue with experts and should be continued at future EWMA conferences. m

EWMA MASTERCLASS 2019 ON OXYGEN THERAPIES IN WOUND HEALING Marc Augsburger (CH), MSc: The role of molecular oxygen in wound healing Jacek Kot (PL), MD, PhD: Hyperbaric oxygen therapy Robert Frykberg (USA), DPM, MPH: Topical oxygen therapy The EWMA Masterclass 2019 was based on the EWMA Document Oxygen Therapies in Wound Healing, published in 2017. It is available for free download at www.ewma.org

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EWMA

Severin Läuchli MD, Past Chair of the Cooperating Organisations Board

EWMA 2019 Cooperating Organisations Board Meeting and Workshop Facilitating and increasing the collaboration among national wound management organisations in Europe and around the world remains one of the key objectives of the EWMA conference. There, we have the opportunity to renew connections and exchange information with colleagues and representatives from the respective national wound associations.

Hubert Vuagnat and Tanja Planinsek-Rucigaj, the two new members of the EWMA Council elected by the Cooperating Organisations Board, are greated by the meeting chair.

During the conference, EWMA hosts two events to strengthen and improve the collaboration with our Cooperating Organisation representatives and International Partner Organisations. Cooperating Organisations Board meeting This year, I had the pleasure of welcoming 46 participants, including Cooperating Organisations and other partner organisation representatives, to the Cooperating Organisations Board meeting for networking, a debate session about the key topic and the exchange of knowledge and experiences.

Correspondence: ewma@ewma.org

The main topic of the 2019 presentations and table discussion was ‘Person-centred care – patient empowerment in wound management’. Alex Wolff (RN, PhD, University of Gothenburg), Selcuk Baktiroglu, Jan Stryja and Elisabeth Lindahl (all members of the EWMA Council) covered the topic in detail before the debate session opened.

It consisted of tableside discussions that were then presented in summary in plenary. Among the debated topics were barriers, strengths and weaknesses in the individual national systems’ ways of empowering patient involvement. The following debate was very profitable and led to inspirational initiatives and improvements. The final part of the board meeting was dedicated to the election of new members of the EWMA council to represent the Cooperating Organisations. This year, we had six candidates. The newly elected members, who will serve three-year terms, are Hubert Vuagnat, representing the French section of the Swiss Association for Wound Care (SAfW-RO), and Tanja Planinsek-Rucigaj, representing the Slovenian Wound Management Association (WMAS). Cooperating Organisations Workshop The workshop session took place early Friday morning,

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Discussion and sharing of experiences amongst the participants at the Cooperating Organisations Board meeting and Cooperating Organisations Workshop.

but despite that, it was well attended and the presentations led to good input and debate among the participants. Leading up to the workshop, all Cooperating Organisations were encouraged to submit an abstract about this year’s workshop theme, ‘Wound registries and use of these for research purposes’. This process led to the following presentations: Annette Høgh, Danish Wound Healing Society (DSFS): Register of Wounds in Denmark and the Use for Research

I would like to thank all the participating and contributing associations and presenters for their important efforts to ensure a successful workshop and Cooperating Organisations Board meeting. We encourage all our Cooperating Organisations to consider preparing an abstract for next year’s workshop and to send representatives to the Board meeting, in order to continue to share and discuss good practices, successes, experiences and challenges in wound care. m

Cecilia Fagerström, Swedish Wound Healing Registry (RiksSår): Presentation of the Registry of Ulcer Treatment Hakan Uncu, Turkish Wound Management Association (WMAT): Wound Registries at the Wound Care Unit of Ankara University Ciro Falasconi, AIUC, Italy: AIUC Project

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EWMA

EWMA Teacher Network

- connecting wound management educators across Europe Samantha Holloway MSc in Wound Healing and Tissue Repair Chair of the EWMA Education Committee and EWMA Teacher Network

EWMA Teacher Network 2019, Rui Pedro Gomes Pereira presents the implantation of the EQF Level 5 curriculum by the University of Minho.

What is the EWMA Teacher Network? The EWMA Education Committee established the EWMA Teacher Network in 2012 to connect wound management educators across Europe and to encourage collaboration among them. All educators involved in the training of wound management professionals can join the network and share views, experiences and ideas with peers from different teaching cultures and backgrounds. One of the main issues both the Education Committee and Teacher Network identified is the absence of a common approach to educational qualifications for wound management for both nurses and physicians across Europe. This is why one of the network’s main priorities is tackling this issue together and facilitating the implementation of a common approach to qualification in wound management.

Correspondence: ewma@ewma.org

How does the network work? The members of the EWMA Teacher Network meet annually during the EWMA Conference to discuss the latest trends and challenges within wound management education. One member from each educational institution is entitled to free conference registration if the delegate attends the Teacher Network meeting. The members of the Teacher Network are also updated 3–4 times per year via a newsletter that includes information about EWMA’s recent educational activities. Members of the Teacher Network are encouraged to contribute with their own news. Recently, our cooperating organization in Portugal, Portuguese Wound Society (ELCOS), has informed us that they have established a Portuguese Network of Wound Educators (REFE-PT). This network’s model aims to replicate and adapt to the national level the dynamics established by the EWMA Teachers Network. The EWMA Teacher Network is honoured to be a role model for our national partners, and we are pleased to be able to share this news with our Teacher Network members in our forthcoming autumn newsletter. Our future ambition is to help connect educators on both the national and European levels, as we are convinced that journal of the european wound management association

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it is only when working together that we can make a difference and bring wound management education in Europe to the highest standards. Our recent annual meeting, held during the EWMA 2019 Conference in Gothenburg This year’s Teacher Network meeting was devoted to state-of-the-art education in the European standardisation of wound education and followed the theme of the session organized by the EWMA Education Committee. Twenty-seven members from 12 countries, including Portugal, Iceland, Romania, Belgium, the UK, Sweden, Norway, Finland, Poland, Ireland, Germany and Malaysia, attended the Teacher Network meeting. During the Education session, European educators and experts in wound management shared their experience with the implementation of the EWMA levels 5 and 6 post-registration curricula for nurses and presented their national initiatives, for example, the National Wound Care Strategy for England, and a new master’s module in wound care and prevention for Nordic students. Our recent projects Last year, we undertook a project to determine the current level of wound management education in pre-registration nursing curricula. We have published an article about the preliminary results of an online survey from England, Scotland, Wales and the Republic of Ireland. You can find an article about our project in the October 2018 issue of the Journal of the European Wound Management Association.1 At the beginning of October, we released the second episode of the EWMA podcast, where I had the chance to speak to my colleagues Sebastian Probst and Ida Verheyen-Cronau about the standardisation of wound management education in Europe. Both guests of the podcast have extensive experience in their countries with the implementation of the EWMA levels 5 and 6 post-registration curricula for nurses. You can access and listen to the EWMA podcasts directly from EWMA’s website, or via SoundCloud, Stitcher and iTunes. The next meeting of the EWMA Teacher Network will take place during the EWMA 2020 conference in London. If you wish to join the Teacher Network, please contact the EWMA Secretariat: ewma@ewma.org. For further information on the EWMA Teacher Network, please visit EWMA’s website.

The EWMA Teacher Network The EWMA Teacher Network is open for all professionals engaged in wound management education. The network meets once annually during the EWMA Conference and is chaired by Samantha Holloway (EWMA Council member and Senior Lecturer, Cardiff University, Wales UK). A primary objective of the network is to increase European collaboration on objectives, structure and content of future wound management education and training in Europe.

REFERENCE 1. Holloway, S., Probst, S., Murphy, S. (2018) Determining the current level of wound management education in the pre-registration nursing curricula. EWMA Journal, 19, 83–87.

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EWMA

Jan Apelqvist MD, Chair of the EWMA Patient Outcome Group

Optimising patient and health economic outcomes in Swedish wound care practice: Results of the project and reflections on the next steps

Optimising Patient and Health Economic Outcomes in Swedish Wound Care Practice

Alberto Piaggesi MD, EWMA President

At the EWMA 2019 Conference in Gothenburg, a series of initiatives intended for documenting the present status of wound care in Sweden were presented in a number of key sessions and in a special full-day stream about home care. Optimise_2_Steffen_021019.indd 1

Rut Öien MD, Chairwoman RiksSår steering group

Correspondence: ewma@ewma.org

Leading up to the conference, a project initiative among RiksSår, the Swedish national quality Registry for Ulcer Treatment (www.rikssar.se); Malmö University Hospital; and EWMA was established to bring into focus the challenges that Swedish healthcare professionals in wound care face today. The initiative was two-pronged: First, it initiates an investigation into how evidence-based treatment strategies can improve wound care practice and present these in a call for action; second, it aims to create interest and awareness among Swedish clinicians and nurses to participate in the EWMA Conference to learn and share knowledge. EWMA wanted to use the conference to show the world’s leading wound care experts, who were gathered in Gothenburg from 5–7 June 2019, why Sweden may still be one of the best countries in the world in which to be a wound patient. Further, we wished to disseminate this knowledge as widely as possible amongst Swedish clinicians and carers engaged in wound healing, which is why we invited representatives from more than 120 Swedish medical specialty organisations, rehabilitation clinics, patient safety committees, wound care working groups and nursing organisations, along with 500 individual podiatrists, to attend. A full-day homecare stream was organised and webcast on the last day of the conference, with

active participation of more than 200 nurses from all over Sweden. Further, the project was highlighted through a Swedish press release, videos on EWMA’s YouTube channel and a Swedish national radio interview during the conference. We showed how the RiksSår model has successfully led to reductions in healing time, costs and the use of antibiotics. This has been possible because of key elements in the model, such as organising the approach to wound care in an increasingly multidisciplinary way and incorporating and developing e-health technologies. This information was distributed as a take home-message flyer in English and Swedish for the 3,800 conference participants and is available if you scan the QR code. The concurrent implementation strategy under development between the Swedish Association of Local Authorities (SALAR) and RiksSår supports the effort of getting this message across: the importance of having interdisciplinary teamwork among hospitals, the community and primary care is underpinned by the support from SALAR and interest from the highest political levels under the project Good and Near Health (God och Nära Vård). The methods to achieve this were presented in

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a call for action as part of the Swedish Outcome Project session at the EWMA Conference by, amongst others, Dr Rut Öien, of RiksSår, and Dr Jan Apelqvist, of Malmö University Hospital. In particular, one of the highlights showcased how it is possible to reduce the use of antibiotics by 50% when treating infected wounds. In light of the general antimicrobial resistance problem and the threat of MRSA in hospitals, everyone remotely involved with wound healing and/or management should be aware of this. Through the project’s collaboration efforts, the ground has been laid for carrying out an extensive health economics project to uncover the costs of having a diabetic foot ulcer, venous leg ulcer or pressure ulcer–something that has not been done in the past 20 years. Fundraising is currently on-going in Sweden to make this project a reality.

Management of the Diabetic Foot Pisa International Diabetic Foot Course

30 September - 3 October 2020 12th Course · Pisa · Italy

September

The next step is to use the lessons learned from this project and update them in a UK context for the EWMA 2020 Conference in London, learning what the typical problems and challenges are, such as the lack of liaisons between primary care and homecare/community care.

3 October

This project is supported by an unrestricted educational grant from Mölnlycke. Scan the QR code to read about the project, watch videos and download the Call for Action (in English or Swedish)

Theory & Practice 4-day theoretical course and practical training Date & Place 12th Course 30 Sep - 3 Oct 2020 Hotel San Ranieri & Pisa University Hospital Pisa · Italy

Programme includes · Neuropathy · Charcot · Infection · Ischaemia · Surgery Including a live transmission from the operating room of the Diabetic Foot Clinic

· Hands-on workshops

Members of EWMA receive a 10 % discount for the course.

www.diabeticfootcourses.org

The course is endorsed by EWMA

EWMA

Jose Verdu Soriano1 Senior Lecturer and researcher at the Faculty of Health Sciences. University of Alicante, Spain Lisette Schoonhoven1 Prof.dr. University Medical Center Utrecht Zena Moore2 Professor of Nursing and Head of the School of Nursing & Midwifery, Royal College of Surgeons in Ireland Andrea Pokorna2 Associate Professor, Department of Nursing, Faculty of Medicine, Masaryk University, Brno Hubert Vuagnat2 Head of Division of the Department of Rehabilitation and Palliative Care. University Hospitals of Geneva 1Chair

of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project 2Member

of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project

The joint EPUAP - EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project: Achievements and lessions learned The joint EPUAP–EWMA PU Prevention & Patient Safety Advocacy Project officially formed in July 2016 with the overall objective of engaging both associations in raising awareness at the European level (EU) about the role of pressure ulcer (PU) prevention from a patient safety perspective. After the planned closing of the project by the end of June 2019, the main achievements and likely next steps were presented and discussed at the EPUAP 2019 Conference in Lyon, France, 18–20 September 2019, and are presented in this article.

Collaboration Increased internal collaboration between EPUAP and EWMA, as well as externally with other Euro-pean stakeholders, has been a significant achievement of the joint project. In particular, we would like to emphasize: n Collaboration with the OECD Health Care Quality Outcomes Expert Group (HCQO)(http://www.oecd.org/els/ health-systems/health-care-quality-indicators.htm). n Project group members Prof Lisette Schoonhoven and Prof Andrea Pokorná have partici-pated in regular meetings of the OECD HCQO, focusing in particular on the objective of advocating for a future focus on the prevention of PU as a patient safety-related quality indicator and on further research into this topic. n Joint conference sessions at the EPUAP and EWMA Conferences in 2017, 2018 and 2019 with pres-entations by

the project group members as well as external presenters (e.g., Ian Brownwood from the OECD HCQO).

Seek opportunities to influence and engage in activities at the EU level n Meetings organised with EU stakeholders: n Luxembourg, June 2017: Matthias Schuppe, DG-SANTE Policy Officer for Patient Safety and Gerhard

Steffes, Policy Officer for Health Programmes and Chronic Diseases n Brussels, April 2018: MEP Karin Kadenbach and the office of MEP Alojz Peterle n UPCOMING! 7 Nov 2019: European Parliament session with participation of MEPs, com-mission representatives, patient organisations, etc. (see facts box) n Monitoring of EU institution activities related to PU and patient safety: n Monthly monitoring reports from 1 January 2017 through the end of May 2018 (elabo-rated by Brussels--

based ‘Instinctif Partners’). The monthly reports have been used to plan meetings and get new leads for PU prevention and patient safety awareness-raising promotion opportunities. n Awareness of opportunities to upload Best Practices of PU prevention to EU Commission inventory. n Elaboration of a systematic review of European PU prevalence n Presented at the EPUAP 2017 Belfast (Laura Conaty) and EPUAP 2019 Lyon conferences (‘Lessons

learned from prevalence monitoring’, by Prof Zena Moore) n Paper accepted for publication by Journal of Wound Care n Learning from PU patient experiences n Patient experience storytelling / advocacy through video-recording the case story of a patient from the

Czech Republic n Elaboration of case study format model for PU patient cases

Correspondence: ewma@ewma.org

n Publication of awareness & background articles on EPUAP and EWMA’s electronic platforms and social media accounts: n Patient safety across Europe: the perspective of pressure ulcers (May 2017) n The time to invest in patient safety and pressure ulcer prevention is now! (September 2017) n Diabetic control & pressure ulcers: fighting fatal complications and improving quality of life (December 2017) n EWMA & EPUAP added-value to OECD efforts (March 2018) n The role of pressure ulcer prevention in the fight against antimicrobial resistance (Octo-ber 2018) n Pressure ulcer monitoring: a process of evidence-based practice, data sharing and joint efforts (Jan 2019) journal of the european wound management association

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n Disability in Europe: the invisible burden of pressure ulcers (April 2019) n Publication of article ‘The Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advo-cacy Project’, Wounds UK, vol. 13, no. 3, 2017. n Social media coverage of project activities (#Europe4PUprevention) n Project activities and patient safety-related EU activities have been followed, tweeted and retweeted about under the

#Europe4PUprevention hashtag. n Elaboration of PU fact sheet n For information-sharing, in particular, at EU meetings the ‘Pressure ulcers – A Population Health Issue - A brief fact

sheet’ was elaborated.

Reflections about the scope and timeframe of the project Initially, it was the intention to work at the European (EU) level as well as at national levels. However, early in the project, the working group realised that, due to the complexity of, for example, large differences between locations and countries in terms of awareness, prevention and treatment, it would not be realistic within the timeframe of the project to pursue results at both levels. Still, the involvement of local key opinion leaders (KOLs), associations and patients in some countries has been very helpful, in the sense that it has contributed to collecting and disseminating information and implementing important activities (e.g., in the Czech Republic, a national collection of data about PU prevalence in in-patient healthcare facilities).

Conclusions, other observations and next steps n There are huge differences across and within European countries in terms of access to prevention and care for PU patients and a general lack of organised national approaches to this challenge. n Establishing and developing collaboration with the OECD HCQO expert group is an important achievement of the project, as it holds potential for involvement in the group’s future work to the benefit of the quality of the work of the group and of both associations. n Engaging with EU institutions and advocating for specific groups or topics, such as patient safety and PU prevention, is important

and possible. However, it is a task that requires continued and long-term commitment in terms of both financial and human resources. We believe that this project chose some of the right approaches in terms of: n Working with a professional agency based in Brussels n Continuously following the agendas and activities of selected EU institutions n Based on the information obtained, engaging actively through requests for face-to-face meetings n Elaborating and disseminating short position papers aimed at contributing to setting the agenda on key topics of the project n Engaging in social media-based dialogue and the continued dissemination of information However, this effort needs to have a longer perspective and financial commitment than what is possible through a two- or three-year project with a comparatively small budget. n In terms of preventing PUs, there is huge potential to learn from well-elaborated patient case stor-ies disseminated in the form of video recordings or written accounts. n EPUAP and EWMA have, as associations, benefited a lot from working together on a continuous basis in this project. n While both associations have maintained their individual focus areas and expertise, they have also shown that working

together on specific topics and tasks can generate a good use of resources and increase the respective awareness of a like-minded association. n There is an increasing interest in studying nursing, yet PU prevention does not receive a lot of at-tention in nursing curricula. We need to focus on the quality of the training and education that health care professionals receive, as this is crucial for improving the prevention of PUs and the treatment of PU patients. n Technological fixes such as increased use of telemedicine and/or e-Health can support but not replace competent health care professionals. n The trustees and councils of EPUAP and EWMA will now evaluate the learnings from the joint pro-ject. Based on this exercise, the

two associations will decide about the potential to continue some of the activities of the project together (or independently). Last, but certainly not least, the joint EPUAP–EWMA team wishes to thank everyone who has en-gaged with our joint project. A special thank you goes to our industry partners who have supported the project through unrestricted educational grants for three years (Mölnlycke Health Care, Smith & Nephew) and two years (3M, Hartmann and BBI).

UPCOMING!

7 Nov 2019 European Parliament session with participation of MEPs, commission representatives, patient organisations etc. in planning.

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EWMA

Dear Sir, Madam, On behalf of the European Wound Management Association (EWMA) & the European Pressure Ulcer Advisory Panel (EPUAP), we would like to invite you as a speaker at our roundtable debate on patient safety and wound care in Europe: “10 years after the Council recommendation on patient safety. The perspective of chronic wound and pressure ulcer prevention”. The meeting will take place on November 7th (12:30 - 14:00) at the European Parliament, Brussels (Members Salon), kindly hosted by MEP Andreas Glück (Renew Europe Group, Germany). EWMA is a European umbrella organisation, linking national wound management organisations and professionals in wound care. Central to EWMA’s objectives is to support the implementation of interdisciplinary and cost-effective wound care of high quality (Visit www.ewma.org/). EPUAP is a European organisation advocating for improved pressure ulcer prevention, care and patient safety. EPUAP is constantly looking for EU initiatives that may support pressure ulcer prevention at national level. The advisory panel also develops and updates clinical guidelines to help practitioners make informed decisions about the most appropriate interventions (Visit www.epuap.org/). The purpose of our workshop is to offer a dynamic discussion about the current situation of patient safety in Europe and suggest how national and European policymakers may shape effective strategies for safer care, specifically in wound care and pressure ulcer prevention (10 percent of our hospitalized patients suffer from pressure ulcers, increasing both their suffering and health expenditures). Our roundtable will explore the following questions: 1. What is the state of play of patient safety across Europe? 2. What are the key features needed to build patient-centred healthcare systems across the EU? 3. To what extent can pressure ulcer prevention and care of chronic wounds showcase the value of patient safety measures? Given your expertise on patient safety and public health, we believe your participation and contributions would greatly benefit the debate. We look forward to hearing from you. Warmest wishes, Prof. Dimitri Beeckman & Prof. Alberto Piaggesi On behalf of the European Pressure Ulcer Advisory Panel (EPUAP) and European Wound Management Association (EWMA)

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Lisette Schoonhoven presenting the results of the joint EPUAP & EWMA project at the EPUAP 2019 Conference.

10 years after the Council recommendation on Patient Safety The perspective of chronic wound and pressure ulcers prevention European Parliament, Brussels, 7 November 2019, 12:30-14:00 Registration Welcome and intro from EPUAP / EWMA Presidents Introductory speech from the Member of the European Parliament hosting the event Expert panel 10 years after the Council Recommendation: the burden patient harm in Europe European Commission and / or OECD Risk factors and key avenues to foster safety in healthcare settings Patientsâ&#x20AC;&#x2122; and healthcare setting representatives The case of severe wound care and pressure ulcers as widespread adverse events in the hospital EWMA Immediate Past President Prof. Sue Bale EPUAP representative (TBA) Q&A with audience and speakers Conclusion by the Member of the European Parliament or EPUAP / EWMA representative journal of the european wound management associationâ&#x20AC;&#x201A;

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EWMA

Cardiff, Swansea — 27–29 June 2019

The Storytelling for Health Conference Aurora Piaggesi Storyteller and Filmmaker

Correspondence: ewma@ewma.org

In 2018, EWMA endorsed a transmedial video project created by Raccontamiunastoria member, storyteller and filmmaker Aurora Piaggesi. The project, Living With Chronic Wounds (LWCW), was included in the programme of the second edition of the Storytelling for Health Conference, organised by South Wales University and the Swansea Health Board.

It hosted three days of lectures and various activities among storytelling, workshops and performances. The conference attracted approximately 230 delegates from various professional settings, such as medicine, the arts, research and storytelling. Most of the participants (90%) came from inside the UK, although delegates from other countries came from as far away as the U.S. and New Zealand.

perspectives of practitioners and family members, both as survivors or carers.

The speakers at the sessions introduced the audience to the projects they have developed using storytelling in healthcare contexts. The word ‘storytelling’ was used in its most various form, from written to oral, images to video. It referred, for the most part, to the retelling of patients’ experiences and emotions, but it could also include the

Sue Bale (former EWMA President) and Aurora Piaggesi presented LWCW on Saturday, 29 June alongside four other projects in a session called ‘Films for Health’ in the presence of an audience of 30–50 people. The chairperson of the session was Inga Burrows, senior lecturer in Films in the Faculty of Creative Industries, University of

Most of the projects presented were developed inside the UK on a local level, from a university environment to a city or a clinic. LWCW was the only project presented that revolved around wounds and, more importantly, was the only project developed at a European level.

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6th Symposium of the Association of Diabetic Foot Surgeons 28 August 2020 Chennai Âˇ India

South Wales, who really appreciated the work, but also mentioned privately that she would have liked to see the wounds in the trailer. The screenings were followed by an informal talk. After introducing the project to the audience, Aurora Piaggesi and Sue Bale answered questions from the audience. People were curious to know more about where the patients interviewed are now, how EWMA manages legal issues like the use of images and so on, and they were interested in learning more about what will happen next. Both Sue Bale and Aurora Piaggesi are were satisfied by the experience and intrigued by what they have learned during the conference, in terms of new possible activities and fields of research: Narration and wounds, how far can these two worlds go together? While continuing to develop the LWCW project, whose release is due at the end of the year, this might be for both EWMA and Raccontamiunastoria a new territory to explore. m

Organized in cooperation with the Diabetic Foot Society of India (DFSI) 18th Annual Conference of the Diabetic Foot Society of India DFSICON 2020 28 - 30 August 2020

EWMA

EWMA Publications P

AL WO

U ND

ATY

New and coming soon: Publications in 2019

ATYPICAL WOUNDS

New EWMA Document:

ATYPICAL WOUNDS - BEST CLINICAL PRACTICES AND CHALLENGES

BEST CLINICAL PRACTICES AND CHALLENGES

This document provides an overview of recent knowledge and evidence about atypical wounds, defined as wounds that cannot be placed in the primary categories of non-healing wounds. The document was published as an online supplement to the Journal of Wound Care in May 2019.

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28/03/2019 12.59

New EWMA Curriculum:

WOUND CURRICULUM FOR NURSES:

WOUND CURRICULUM FOR NURSES: POST-REGISTRATION QUALIFICATION WOUND MANAGEMENT – EUROPEAN QUALIFICATION FRAMEWORK LEVEL 6

POST-REGISTRATION QUALIFICATION WOUND MANAGEMENT EUROPEAN QUALIFICATION FRAMEWORK LEVEL 6

EWMA has finalised the second curriculum (EQF Level 6) in a series of curricula developed for education covering 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. The EQF Level 6 curriculum was published as an online supplement to the Journal of Wound Care in February 2019.

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15/10/2018 16.39

New EWMA Document:

SURGICAL SITE INFECTIONS A

RGIC

TIONS

PREVENTING AND MANAGING SURGICAL SITE INFECTION ACROSS HEALTH CARE SECTORS

SURGICAL SITE INFECTIONS – PREVENTING AND MANAGING SURGICAL SITE INFECTIONS ACROSS HEALTH CARE SECTORS

SITE INF

This document will provide guidance on how to deal with SSI management and prevention in hospitals and community care. The document is developed in collaboration with Wounds Australia and the Association for the Advancement of Wound Care (USA). The document will be published as an online supplement to the Journal of Wound Care in autumn 2019.

A JOINT DOCUMENT

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New E-Learning Course: BASIC WOUND MANAGEMENT

EWMA has published a set of e-learning modules on the basics of wound management, targeting health care professionals and medical students with no specialisation in wound management. The aim of the course is to support a high level of care in organisations with wound patients (hospitals, nursing homes and home care units) and provide materials that may be used in education. The course is free of charge and can be accessed via EWMA’s e-learning platform. For more information about the course and the content of each module, please visit e-learning.ewma.org.

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New E-Learning Module:

EWMA & BSAC E-LEARNING COURSE ON ANTIMICROBIAL STEWARDSHIP IN WOUND CARE This course will be available on FutureLearn.com in autumn 2019.

EWMA Publications Coming up in 2020

TED LA

EWMA Document:

OUNDS

TH R IR

BIRTH-RELATED WOUNDS

The objective of this project is to develop resources targeting health care professionals who provide care to women who have undergone childbirth (vaginally or by caesarean section). The objective will be to enhance the wound management skills of these professionals, thereby supporting the prevention and treatment of birth-related wounds and post-caesarean section infections. Chair: Charmaine Childs. Expected publication: Spring 2020.

RSO

EWMA Project:

CARE

NTR

PERSON-CENTRED CARE - PATIENT EMPOWERMENT IN WOUND MANAGEMENT With this project, EWMA aims to develop resources supporting best practice approaches to patientcentred care in wound management. The project places the patient ‘at the heart of decision making’ by helping caregivers to identify effective strategies for supporting patients in taking co-ownership in the treatment process and engaging in self-care. Chair: Georgina Gethin. Expected publication: Spring 2020.

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

journal of the european wound management association

2019 vol 20 no 2

New EWMA Projects start-up These projects will be initiated in winter 2019/2020

THERAPY

EWMA Compression Therapy Programme OGRAMME

MPRESSIO CO

EWMA is currently working on a programme aiming to investigate the use of compression therapy (CT) in venous leg ulcers (VLU) across Europe. The programme aims to address the challenges related to sub-optimal use of CT in wound management, such as when CT is not used the right way, or when it is introduced too late. This represents a potential patient safety issue. The project objectives will be to: 1) Create awareness about the current challenges related to the suboptimal use of compression and provide instructive tools supporting its optimal use (e.g., educational videos targeting health care professionals). 2) Provide an overview of the available evidence and a basis for evaluating the need for a European guideline. 3) Publish a European guideline on CT and support its implementation.

ES - TISSUE GI

New Technologies for Tissue Replacement

PLACEME RE

TECHNOLO

Chair: Alison Hopkins. The programme is planned to run over a 3â&#x20AC;&#x201C;5-year period.

This project aims to review and highlight the new technologies for the surgical management of chronic wounds that are currently on their way to the market. The primary deliverable will be an overview document targeting wound care specialists with an interest in new therapies, bridging the increasing demand for surgical solutions with the adequate indications in the complex field of wound management.

Chair: Alberto Piaggesi. Expected publication: Spring 2021.

EST YL

The Impact of Lifestyle Factors on Wound Healing

CTORS FA

PA C T O F

LIF

It is well known that the adoption of positive lifestyle factors generally contributes to wound healing and the tackling of impaired wounds. However, at present no collated publication provides an overview of the effect of all the relevant lifestyle factors and their impact in relation to specific wound aetiologies. The initial objective of this project will be to develop an up-to-date document describing the impact of lifestyle factors on wound healing. Based on the document, the responsible group will create a comprehensive guide for health care professionals and patients on how to integrate different lifestyle factors and their implications in wound management. Chair: Georgina Gethin. Expected publication: Spring 2021.

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

Online Only Subscriptions Now Available!

Make the latest research, clinical, and product information yours! Subscribe to Advances in Skin & Wound Care and you’ll receive 12 months of complete access to aswconline.com— including all archives and newly published issues during the length of your subscription. Subscribe today for as little as $39.95 with an online only subscription.

Visit shop.lww.com/aswcjournal 9-K359

Organisations

AAWC NEWS AAWC Association for the Advancement of Wound Care

As the largest inter-professional society in the US focused on the care of patients with chronic or acute wounds, the Association for the Advancement of Wound Care (AAWC) is living up to its name and mission. Its member-centric model is anchored to three pillars: Education, Public Policy and Research. Through these pillars, the AAWC is empowering the voice of its membership, enabling best practices and engaging on a global level.

Tomas Serena MD, FACS, AAWC President CEO and Medical Director, SerenaGroup

Its regional Wound Infection, Lower Extremity and Pressure Ulcer Summits enable participants to learn, do and share side by side with peers on topics crucial to the practice of wound care. The AAWC will finish 2019 having led a hands-on pre-conference at the Wild on Wounds conference, joined with Present e-Learning at the Desert Foot conference focused on limb salvage providing a full day track of educational seminars, and with DFCon, an international conference focused on the prevention and treatment of diabetic foot ulcers.

More information:

www.aawconline.org

By expanding its relationship with EWMA, the AAWC shared its operational model and highlighted its accomplishments to a global audience in Sweden. In 2020, the global perspective includes EWMA in London. Domestically, our robust member-led education initiatives continue to draw strong interest. The web-based monthly Journal Club offers new perspectives on wound care topics. These, combined with the amplified regional summits, provide on-going education for nurses, physicians, physical therapists and podiatrists. On the policy front, the AAWC is building strong key relationships with elected officials and other stakeholders to promote legislation impacting wound care. Recognised as key opinion leaders, the AAWC is working to establish wound care standards and to replace established methods of classifying pressure ulcers. Research is what keeps AAWC members advancing the science of wound healing. The AAWC is drafting a research agenda based on identified gaps in summit topics. It is developing a toolkit for clinical questions, links to the TRIP database and directions on how to create posters and presentations. The AAWC started a new chapter in 2019 organised for the future in wound care. It is designed to empower, engage and enable its membership to advance wound care in collaboration with wound care professionals in the United States and around the world. The strong voice of its membership makes it the leading organisation in US wound care.

EWMA International Partner Organisation

journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

Organisations

CTRS NEWS Professor Xiaobing Fu, President of the Chinese Tissue Repair Society (CTRS) and academician of the Chinese Engineering Academy, has been the leader in wound healing, tissue repair and regeneration medicine research in China.

CTRS

Chinese Tissue Repair Society

Ting Xie MD, PhD Consultant Surgeon and Director of Wound Healing Center at Emergency Dept., Shanghai Ninth Peopleâ&#x20AC;&#x2122;s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine The Vice President of Chinese Tissue Repair Society (CTRS) Shanghai, China

On 18 December 2018, Professor Fu was recognised as a Foreign Academician of the French Academy of Medicine at the conference of the French Academy of Medicine, held in Paris. At present, there are only 135 domestic academicians and 60 foreign academicians in the French Academy of Medicine.

More information:

www.chinese-trs.com/en

So far in his career, Professor Fu has earned a reputation for his outstanding achievements in wound healing research. In the past decade, he and his team have been working to develop basic science research and clinical practices in wound healing in China. At present, CTRS is an active and well-known global entity. His election is a major acknowledgement, not only of his own significant contributions, but also of the development of wound healing in China.

EWMA International Partner Organisation journal of the european wound management associationâ&#x20AC;&#x201A;

2019 vol 20 no 2

Organisations

TVS NEWS The Tissue Viability Society UK is proud to be celebrating their 40th anniversary at EWMA 2020! The Tissue Viability Society (TVS) is a UK independent registered charity with a multidisciplinary & professional membership that aims to improve the lives of people with a wound or at risk of developing a wound. With a 40-year heritage, the society aims to be the go-to organisation for wound care across the UK. https://tvs.org.uk/

Linda Primmer Chair, Council of Trustees. Tissue Viability Society UK Community Tissue Viability Nurse Specialist, NHS Lothian, Edinburgh, Scotland, UK

More information: https://tvs.org.uk/

TVS Objectives: n To promote best practice and support clinical care n To support innovation and research projects n To influence the national wounds agenda across the UK n To provide education and training TVS Trustees The TVS Council of Trustees is composed of 18 multi-disciplinary professionals, academics, researchers and industry partners from across the UK who have passion and expertise in wounds and their prevention https://tvs.org.uk/our-people/ Innovative TVS Projects The trustees of the TVS work hard on a wide variety of activities and projects to benefit their members and, ultimately, patients. Here are just some of the activities with which they are currently involved: n

Legs Matter Campaign: A coalition of eight healthcare charities and organisations aiming to increase awareness for people with leg and foot problems, one of the biggest healthcare challenges of our time. Learn more about this at EWMA 2020! https://legsmatter.org/

WReN (Wounds Research Network): Aims to provide a platform for shared learning and support for the design, conduct and delivery of wound prevention and treatment research throughout the UK. Founded by Professor Jane Nixon, a TVS Trustee, along with her coresearchers, with funding from the TVS since 2016 https://woundsrn.org/

Journal of Tissue Viability (Impact Factor: 2.831): Quarterly journal concerned with all aspects of the occurrence and treatment of wounds, ulcers and pressure sores, including patient care. https://www.journals.elsevier.com/journal-of-tissue-viability/

TVS – The Conference: Next year the TVS is honoured and excited to be staging its annual programme via the TVS Stream at EWMA 2020. Join the TVS stream at EWMA 2020 to learn more about TVS initiatives and more!

n Educational Grants: The TVS, with support from corporate sponsors, provides educational grants to enable its members to attend wound care conferences in the UK and Europe such as those of the TVS, EWMA & EPUAP. Visit our website for more information and to apply https://tvs.org.uk/educational-grants/

The EWMA 2020 Conference is organised in collaboration with TVS.

Regional Study Days: The TVS is expanding its programme of highly successful Tissue Viability Regional Study Days, which are FREE for healthcare professionals and carers to attend across the UK! https://tvs.org.uk/attend-a-study-day/

n Just Giving: In 2019 the TVS launched a Just Giving page to aid income generation and has raised >£600 to date. If you’d like to fundraise for our charity, please do get in touch at https:// www.justgiving.com/t-v-s

Special thanks must also go to the charity’s corporate sponsors, whose generosity and support aids the charity’s aims and objectives. EWMA Cooperating Organisation

EWMA 2020 is a time for celebration and action – join the TVS in celebrating their 40 years of providing expertise in wound management! journal of the european wound management association

2019 vol 20 no 2

CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION

EWMA 2020

IN COOPERATION WITH THE TISSUE VIABILIT Y SOCIET Y, TVS

LONDON UNITED KINGDOM 13 â&#x20AC;&#x201C; 15 MAY 2020 WWW.EWMA2020.ORG // WWW.EWMA.ORG WWW.TVS.ORG.UK

Organisations

WOUNDS AUSTRALIA NEWS It is a pleasure to update EWMA members on the activities of Wound Australia Wounds Australia had a very productive 2019, with many great accomplishments and new initiatives. A two-level credentialing programme was recently launched that recognises wound practitioners’ professional knowledge, experience and scope of practice in wound management. The programme also contributes to increasing awareness of wound care in Australia. Another initiative was the introduction of an endorsement programme for continuing professional development and resources. Geoff Sussman Chair Wounds Australia

Nicoletta Frescos Wounds Australia representative to EWMA

More information: www.woundsaustralia.au

As the country’s peak body for wound care and prevention, the Wounds Australia board continues to lobby key stakeholders for changes in health policy related to wound care services. The Australian Commonwealth government is undertaking a Royal Commission into aged care safety and quality. The aim of the commission is to investigate the problems facing age care services for residential and home care providers and looking at the sustainability of the aged care industry. Wounds Australia was invited to present a submission to the Royal Commission and subsequently required to appear before the Royal Commission to give evidence. Another invited submission was provided to the Medicare Benefits Schedule Review, which identified shortcomings in the current Medical Benefit Scheme (MBS) item numbers for the treatment of wounds. The report set out ways to reform the MBS items relating to chronic wound treatments that offer not only improved outcomes for patients but also significant long-term savings for the Australian healthcare system. In addition, we are in discussion with the Commonwealth Government for the implementation of a $2 million funding grant to undertake a national wound scoping study in primary healthcare networks. This will be done in collaboration with the Australian Medical Association and the Royal Australian College of General Practitioners. Wounds Australia is committed to increasing its research profile; in order to identify the gaps in wound care research in Australia, a scoping document was undertaken and recommendations for future directions for research focus were identified. The research priorities will be mapped into a five-year plan to support research in Australia and our neighbouring regions. The Research Committee encourages Australian research through biennial competitive research grants and awarded two $5000 and one $10,000 funding grants in 2018. Other major activities include preparation of our Journal of Wound Practice and Research to submit for PubMed listing. One of the key changes is to develop a dedicated website for the Journal. Wound Awareness Week was a very successful event, with a focus on wound issues presented to the community, politicians and health professionals. The Pan-Pacific Venous Leg Ulcer guidelines and Wounds and Pressure Injury guidelines are currently being updated, with a predicted launch in 2020.

EWMA International Partner Organisation

The 2018 Wounds Australia National Conference was held in Adelaide with 1400 delegates and has been considered as one of the best conferences to date. The next biennial conference will be held in November 2020, in sunny Brisbane, and we welcome you to attend the high-calibre scientific program and meet your Australian and Pacific region colleagues.

journal of the european wound management association

2019 vol 20 no 2

ALLEVYN™ LIFE Foam Dressing – with

EXUMASK™ Change Indicator

real needs

real results

1,2

How can a dressing make a real impact on your practice? ALLEVYN™ LIFE with its unique EXUMASK™ Change Indicator lets you and your patient know the best time to change the dressing, avoiding unnecessary changes.3 With EXUMASK™ helping to optimise patient centred care, one Welsh Health Board has reduced foam dressing use by 38,000 and spend by £48,000 in just 8 months.4 Now that’s a real result.

It’s time to discover the diﬀerence ALLEVYN LIFE can make at www.smith-nephew.com/exumask Helping you get CLOSER TO ZERO™ human and economic consequence of wounds

For detailed product information, including indications for use, contraindications, precautions and warnings, please consult the product’s applicable Instructions for Use (IFU) prior to use. 1. Kronert G, Roth H, Searle R. The impact of introducing a new foam dressing in community practice. EWMA Journal 2016; 16(2): 7–12. IMS data from May 2017 - April 2019 for EM foams. 2. Joy, H et al. A collaborative project to enhance eﬃciency through dressing change practice. Journal of Wound Care 2015;24(7):312,314-7. 3. Joy H, Bielby A, Searle R.A collaborative project to enhance eﬃciency through dressing change practice. Journal of wound care. 2015;24(7):312, 314-317. Stephen-Haynes JB, A., and Searle, R., .The clinical performance of a silicone foam in an NHS community trust. Journal of Community Nursing. 2013;27(5):50-59. Smith & Nephew February 2016 2016. Subjective comparison of masking ability of the New ALLEVYN LIFE versus Current ALLEVYN LIFE by Healthcare Professionals. Internal Report. DS/16/061/R. 4. Audit data. Betsi Cadwaladr University Health Board, 2019. ™Trademark of Smith & Nephew ©August2019 Smith & Nephew. 19984 | GMC0863C EWMA.

Organisations

Conference Calendar 2019/2020 Conferences 2019

Theme

15th National AIUC Congress

For web addresses please visit www.ewma.org

Month

Days

City

Country

October

Naples

Italy

11th Pisa International Diabetic Foot Course

Management of the Diabetic Foot October – Theory & Practice

2-5

Pisa

Italy

2019 Fall Conference of Wounds Canada

Biennial conference

3-6

Niagara Falls

Canada

28th EADV Congress

The Modern Face of Dermatology October

9-13

Madrid

Spain

Croatian Wound Association Conference (CWA)

12th Symposium with International October 10-11 participation

Trogir

Croatia

October

Icelandic Wound Healing Society (SumS)

October

Rejkjavik

Iceland

SAWC Fall

October

12-14

Las Vegas

USA

Diabetic Foot Global Conference 2019 DFCon

October

17-19

Los Angeles

USA

16th Asia Pacific Conference on Diabetic Limb Problems. 2nd Global Wound Conference

October

18-20

Kuala Lumpur

Malaysia

Leg Ulcer Forum Conference

October

Cardiff

United Kingdom

6th International Biofilm Course 2019

October

24-25

Copenhagen

Denmark

Wounds UK

November

4-6

London

United Kingdom

November

7-8

Montpellier

France

14-15

Padua

Italy

Biannual symposium

Leg Ulcers - Framing the Future

Improving Standards by Implementing clinical pathways

5th Diabetic Foot Conference Montpellier ADFS Cadaver Course

Anatomical and Surgical November Dissection of the Foot The Reconstruction of the Diabetic Foot

Would Congress of Podiatry (FIP)

November

14-16

Miami

USA

Danish Wound Healing Society (DFSF)

November

21-22

Esbjerg

Denmark

Portuguese Association for the Treatment of Wounds (APTF)

November

21-22

Gondomar

Portugal

Dutch Knowledge Centre for Wound Care (WCS) in collaboration with V&VN Wound Expertise

Wound Care Congress

November

26-27

Utrecht

The Netherlands

Desert Foot Conference (AAWC)

Best Value in Wound Care December 4-7 and Surgical

Phoenix

USA

Nuremberg

Germany

Wound Management Association of Turkey (WMAT) December 13-16

Antalya

Turkey

Conferences 2020

Annual meeting

2nd Conference of Wound Management in Nuremberg

December

Month

Days

City

Country

Czech Wound Management Society (CSLR)

January

23-24

Pardubice

Czech Republic

Conference of The French and Francophone Society of Wounds and Wound Healing (SFFPC)

January

26-28

Paris

France

28th DEBRA International Congress

January

19-23

London

United Kingdom

Conference of Finnish Wound Care Society (FWCS)

Jan/Feb

31-1

Helsinki

Finland

ESNO Congress 2020

February

Brussels

Belgium

WUWHS 2020

March

8-12

Abu Dhabi

UAE

Annual Scientific Meeting of the Korean Wound Management Society (KWMS)

April

Seoul

Korea

18th Malvern Diabetic Foot Conference

May

13-15

Worcestershire

United Kingdom

30th Conference of the European Wound Management Association 2020 (EWMA)

May

13-15

London

United Kingdom

Theme

5-7

Global Healing Changing Lives

journal of the european wound management association

2019 vol 20 no  2

Conference Calendar 2020 Conferences 2020

Theme

For web addresses please visit www.ewma.org Month

Days

City

Country

World Diabetic Foot Day

May

London

United Kingdom

5th EPUAP Focus Meeting and communication

May

25-27

Sønderborg

Denmark

GNEAUPP Symposium

May

27-29

Toledo

Spain

52th Conference of Wound Ostomy and Continence Nurses Society

June

7-10

Cleveland

USA

21st EFORT Congress

June

10-12

Vienna

Austria

39th Annual Meeting of the European Bone and Joint Infection Society

September

10 -12

Ljubljana

Slovenia

September

18-20

Bratislava

Slovakia

56th Annual Meeting of the European Association for the Study of Diabetes

September

21-25

Vienna

Austria

22nd European Pressure Ulcer Advisory Panel Annual Meeting (EPUAP)

September

23-25

Praque

Czech Rebpublic

29th EADV Congress

September

23-27

Vienna

Austria

12th Pisa International Diabetic Foot Course

Sep/Oct

30-3

Pisa

Italy

10th International Lymphoedema Framework Conference and DSFS Annual meeting

October

1-3

Copenhagen

Denmark

Patients safety: Prevention

Joining forces: optimising diagnosis and management of bone and joint infections

16th Conference of Diabetic Foot Study Group (DFSG)

EWMA ENDORSEMENT OF EDUCATIONAL ACTIVITIES WITHIN WOUND MANAGEMENT As one of the suppliers of wound management education, you can submit your education activity for EWMA endorsement. Education activities eligible for endorsement include: programme, course, e-learning module(s) within wound management education. Benefits: - The curriculum of the course/programme will be assessed by one of the EWMA Education Committee members. - You will receive recommendations on how to improve the curriculum of your course/programme. - If the course is endorsed by EWMA, it will be added to the list of endorsed courses on ewma.org - Providers of endorsed courses may use the “Course endorsed by EWMA” in their information and marketing material related to the course. Learn more at: www.ewma.org

WWW.2020ILFCONFERENCE.ORG

#ILFlympho2020

DANISH WOUND HEALING SOCIETY ANNUAL MEETING

TOPICS OF THE CONFERENCE

10 INTERNATIONAL LYMPHOEDEMA FRAMEWORK CONFERENCE

Compression across lymphoedema and wound care

1-3 OCTOBER 2020 · COPENHAGEN · DENMARK

LIMPRINT driving global improvement in care delivery Children LIMPRINT Children with lymphoedema Outcome measures for lymphoedema Lipoedema International education Patient collaboration and support Prevention of pressure ulcers Venous leg ulcers: state of the art

Dansk Netværk for Lymfødem Danish Lymphoedema Framework

Diabetic foot and lymphoedema

JOINT CONFERENCE WITH THE DANISH LYMPHOEDEMA FRAMEWORK & THE DANISH WOUND HEALING SOCIETY

Submit your manuscript to the April 2020 issue of Journal of the European Wound Management Association O F T H E E U R O P E A N W O U N D M A N A G E M E N T A S S O C I AT I O N

Volume 20 · Number 1 · May 2019

Patient-centred wound care The April 2020 issue is dedicated to Global collaboration in wound care Submission deadline for scientific papers is 15 January 2020 Journal of the European Wound Management Association Author guidelines are available at ewma.org ewma@ewma.org Published by EUROPEAN WOUND MANAGEMENT ASSOCIATION www.ewma.org

Editorial Board Sebastian Probst, Editor Alberto Piaggesi, Editor in Chief Georgina Gethin

Andrea Pokorná Dimitri Beeckman Nicoletta Frescos

Organisations

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

AWA

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

AWTVNF

All Wales Tissue Viability Nurse Forum www.welshwoundnetwork.org

ELCOS

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

BWA

MASC

Maltese Association of Skin and Wound Care

MSKT

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

NATVNS

CWA

Macedonian Wound Management Association

National Association of Tissue Viability Nurses, S cotland

NIFS

Norwegian Wound Healing Association www.nifs-saar.no

NOVW

Croatian Wound Association www.huzr.hr

Dutch Organisation of Wound Care Nurses www.novw.org

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

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

journal of the european wound management association

SAWMA

Serbian Advanced Wound Management Association www.lecenjerana.com

SEBINKO

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

SEHER

The Spanish Society of Wounds www.sociedadespanolaheridas. es

SFFPC

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

SSiS

SSOOR

Lithuanian Wound Management Association www.lzga.lt

CNC

Czech Wound Management Society www.cslr.cz

Swiss Association for Wound Care (Holding Association) www.safw.ch

LWMA

MWMA

CSLR

SAfW

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

Bulgarian Wound Association www.woundbulgaria.org

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

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

The Leg Ulcer Forum www.legulcerforum.org

BEFEWO

Belgian Federation of Woundcare www.befewo.org

SAfW

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

2019 vol 20 no 2

Slovak Wound Care Association www.ssoor.sk

SSPLR

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

STW Belarus

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

SUMS

Icelandic Wound Healing Society www.sums.is

SWHS

Serbian Wound Healing Society www.lecenjerana.com

TVS

Tissue Viability Society www.tvs.org.uk

URuBiH

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

UWTO

Ukrainian Wound Treatment Organisation www.uwto.org.ua



Organisations

Cooperating Organisations (cont.) V&VN

ETRS

European Tissue Repair Society www.etrs.org

FIP-IFP

Decubitus and Wound Consultants, Netherlands www.venvn.nl

International Federation of Podiatrists - Fédération Internationale des Podologues www.fip-ifp.org

WCS

ILF

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

International Lymphoedema Framework www.lympho.org

ISTAP

International Skin Tear Advisory Panel www.skintears.org

IWII

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

KWMS

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

MSWCP

Malaysian Society of Wound Care Professionals www.mswcp.org

NZWCS

International Partner Organisations Alliance of Wound Care Stakeholders www.woundcarestakeholders. org

AAWC

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

CTRS

Chinese Tissue Repair Society www.chinese-trs.com/en

Debra International

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

ECET

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

SILAUHE

Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

SOBENFeE

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

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

Wounds Australia

Wounds Australia www.awma.com.au

Wounds Canada

Wounds Canadia www.woundscanada.net

European Federation of National Associations of Orthopaedics and Traumatology www.efort.org

Diabetic Foot Study Group www.dfsg.org

EADV

European Academy of Dermatology and Venereology www.eadv.org

EBA

European Burns Association www.euroburn.org

ESNO

European Specialist Nurses Organisation www.esno.org

ESPEN

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

ESPRAS

The European Society of Plastic, Reconstructive and Aesthetic Surgery www.espras.org

ESVS

European Society for Vascular Surgery www.esvs.org

IWGDF

The International Working Group on the Diabetic Foot www.iwgdf.org

ICC

International Compression Club www.icc-compressionclub.com

UEMS

Multidisciplinary Joint Committee on Wound Healing www.uems.eu

Associated Organisations Leg Club

Lindsay Leg Club Foundation www.legclub.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

EFORT

European Pressure Ulcer Advisory Panel www.epuap.org

DFSG

WAWLC

European Council of Enterostomal Therapy www.ecet-stomacare.eu

EPUAP

Other Collaborators

Media Partner JWC

Journal of Wound Care www.magonlinelibrary.com

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

PPC

Practical Patient Care www.practical-patient-care.com

journal of the european wound management association

2019 vol 20 no 2

BENION. When business expansion counts.

medical device industry consulting Americas Europe Asia

For start-ups, small companies or multinationals - BENION offers comprehensive guidance and strategic advice to maximise wound care businesses. We provide the tools, methods and networks that guide brand expansion and entry into new territories with the objective of gaining market share from competitors. From our extensive clinical and commercial experience, BENION offers solutions for: Strategic affairs | To enhance a brand`s worldwide visibility we generate global growth strategies. Based on the unique characteristics of the business, we fine-tune corporate and investment strategies, including a detailed analysis of the client`s profile, brand and commercial models. Administrative affairs | Together with its network BENION covers the whole range of administrative services, including regulatory, reimbursement, compliance and legal affairs. We also offer advice on health economics, such as economic modelling, data collection and statistical analyses. Products & Sales | In line with individual requirements, BENION manages investigatory studies including, clinical trials and in-vitro or in-vivo testing - from study design and registration up to scientific publication. If required, we will construct a clinical advisory board to add external expertise to long term decision making processes. Clinical affairs | In line with individual requirements, BENION manages clinical trials for either in-vitro or

in-vivo testing - from registration up to scientific publications. If required, we build up a clinical advisory board to add external expertise to long term decision making processes. Marketing | To expand into new territories, BENION supports the placement of product portfolios and suggests culture-specific approaches to implement a sustainable marketing strategy. Our service also covers medical writing and publications, including clinical reports, manuscripts, scientific articles, brochures and promotional material. BENIONâ&#x20AC;&#x2122;s services are based on the expertise of a multidisciplinary team of experts consisting of nurses, physicians, academic and business professionals. Each team member has, at the very least, one decade of experience in the global wound care business. Our network is dedicated to the core values: integrity, commitment, objectivity and full transparency. With our key personnel in the US and Europe and close connections to Asia, we have the infrastructure to support the increase in both value and market share of wound care businesses. www.benion-medical.com

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MEDICAL DEVICE INDUSTRY CONSULTING Americas Europe Asia

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