EWMA Journal January 2011 by EWMA European Wound Management Association

Volume 11 Number 1 January 2011 Published by European Wound Management Association

FOCUS ON

THE BELGIAN WOUND HEALING SOCIETIES

The EWMA Journal ISSN number: 1609-2759 Volume 11, No 1, January, 2011 Electronic Supplement Januaryr 2011 www.ewma.org

EWMA Council

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

Jan Apelqvist

Zena Moore

Marco Romanelli

President Elect

President

Immediate Past President

Editorial Board Carol Dealey, Editor Deborah Hofman, Editor Electronic Supplement Sue Bale Finn Gottrup Martin Koschnick Zena Moore Marco Romanelli Zbigniew Rybak José Verdú Soriano Rita Gaspar Videira Peter Vowden EWMA web site www.ewma.org Editorial Office please contact: EWMA Secretariat Martensens Allé 8 1828 Frederiksberg C, Denmark. Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org

Sue Bale

Patricia Price

Recorder

Paulo Alves

Secretary

Barbara E. den Boogert-Ruimschotel

EWMA Journal Editor

Carol Dealey

Corrado M. Durante

Luc Gryson

Dubravko Huljev

Gerrolt Jukema

Martin Koschnick

Severin Läuchli

Eskild Winther Henneberg

Treasurer

Layout: Birgitte Clematide Printed by: Kailow Graphic A/S, Denmark Copies printed: 13,000 Prices: The EWMA Journal is distributed in hard copies to members as part of their EWMA membership. EWMA also shares the vision of an “open access” philosophy, which means that the journal is freely available online. Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published in May 2011. Prospective material for publication must be with the editors as soon as possible and no later than 15 March 2011. The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. Copyright of all published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement and printed, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval.

Sylvie Meaume

Maarten J. Lubbers

Rytis Rimdeika

Robert Strohal

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

Aleksandra Kuspelo, LBAA Mark Collier, LUF Kestutis Maslauskas, LWMA Corinne Ward, MASC Hunyadi János, MST Suzana Nikolovska, MWMA Alison Johnstone, NATVNS Marcus Gürgen, NIFS Louk van Doorn, NOVW Arkadiusz Jawień, PWMA Rodica Crutescu, ROWMA Severin Läuchli, SAfW Hubert Vuagnat, SAfW Goran D. Lazovic, SAWMA Mária Hok, SEBINKO

Sylvie Meaume, SFFPC Christina Lindholm, SSIS Jozefa Košková, SSOOR Guðbjörg Pálsdóttir, SUMS Saša Borović, SWHS Magnus Löndahl, SWHS Michael Clark, TVS Jasmina Begić-Rahić, URuBiH Barbara E. den Boogert-Ruimschotel, V&VN Skender Zatriqi, WMAK Georgina Gethin, WMAOI Sandi Luft, WMAS Bülent Erdogan, WMAT Leonid Rubanov, WMS (Belarus)

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

For contact information, see www.ewma.org

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

Science, Practice and Education

6 Who will take on

Ali Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi,

ELECTRONIC SUPPLEMENT JANUARY 2011

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

25 The reconstructive clockwork as a 21st century concept in wound surgery Karsten Knobloch, Peter M. Vogt

29 Anaemia in patients with chronic wounds

Lotte M. Vestergaard, Isa Jensen, Knud Yderstraede

35 A survey of the provision of education in wound management to undergraduate nursing students Zena Moore, Eric Clarke

40 Caring for Patients with Hard-to-Heal Wounds – Homecare Nurses’ Narratives Camilla Eskilsson

EBWM

42 Abstracts of Recent Cochrane Reviews Sally Bell-Syer

EWMA

The January edition of the EWMA Journal Electronic Supplement includes articles with news from EWMA Cooperating Organisations. All organisations have been invited to contribute with information about their organisation, its recent activities, research projects and meetings, as well as their political and scientific involvement in wound care on a national level.

46 International Journals Previous Issues 51 Microbiology of Wounds – a Review José Verdú Soriano

53 Pisa International Diabetic Foot Course 2010 Alberto Piaggesi

54 Leg Ulcer & Compression Seminars 2011 Finn Gottrup, Hugo Partsch

56 EWMA Activities Update 58 Corporate Sponsor Contact Data Organisations

60 Conference Calendar 62 The annual meeting of GAIF – a Step Forward João Gouveia

63 The International Lymphoedema Framework Agnès Carrot

64 News from WAWLC John M Macdonald

66 Cooperating Organisations 67 International Partner Organisations 67 Associated Organisations

Contents 1. Francophone Nurses Association in Stoma Therapy, Healing and Wounds (AFISCeP) 2. Italian Association for the study of Cutaneous Ulcers (AIUC) 3. Portuguese Association for the Treatment of Wounds (APTFeridas) 4. Croation Wound Association (CWA) 5. European Pressure Ulcer Advisory Panel (EPUAP) 6. Lithuanian Wound Management Association (LWMA) 7. National Association of Tissue Viability Nurses in Scotland (NATVNS) 8. Norwegian Wound Healing Association (NIFS) 9. Dutch Organisation for Wound Care Nurses (NOVW) 10. Polish Wound Management Association (PWMA) 11. Icelandic Wound Healing Society (SUMS) 12. Serbian Wound Healing Society (SWHS) 13. Wound Management Association of Turkey (WMAT) 14. Danish Wound Healing Society (DWHS)

www.ewma.org/english/ewma-journal/ electronic-supplement.html

WWW.EWMA.ORG EWMA Journal

2011 vol 11 no 1

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1. White R., Wounds UK 2008; Vol 4, No 1 2. Dykes PJ et al. Journal of Wound Care 2001: 10: 7-10 3. White R. Evidence for atraumatic soft silicone wound dressing use. Wounds UK 2005; 1 (3): 104-109. 3. White R. Evidence for atraumatic soft silicone wound dressing use. Wounds UK 2005; 1 (3): 104-109.

Dear Readers

s we start 2011 may I wish all the readers of EWMA Journal a very Happy and Peaceful New Year. One thing I have noticed as I get older is that the years go by ever faster and 2010 was no exception. Sadly, we also lose friends as time goes by and in 2010 João Gouveia died too soon after a valiant struggle against illness. He was an important person in helping to establish wound care activity in Portugal and more can be read about his contribution on page 62. Our thoughts are very much with his wife and family at this difficult time. Despite all the problems of the world economy, EWMA had a very successful conference in 2010 in Geneva. Conferences are always a great opportunity to hear about new research and developments, but unfortunately, not everyone can attend them all. This edition of the journal showcases some of the papers presented at the conference and allows those of you who were not able to attend to learn more about the work currently being undertaken. I think you will find several thought-provoking papers in this issue on areas not generally considered such as pain in diabetic foot ulcers and anaemia found in patients with chronic wounds. However, we also have to look forward to what is ahead in 2011. One thing that is very obvious is that there is much activity in wound healing in the form of national and international societies. Some are very new such as the Ukranian Wound Treatment Organisation (UWTO) and others are more established such as Associated Group for Research in Wounds (GAIF) a Portuguese society. Some are really flourishing in the international arena such as the International Lymphoedema Framework. It is very encouraging to see so much activity and dedication being given to improving the way we manage wounds and organise the delivery of care. I would encourage you to look at the Electronic Supplement as well as the later pages in the Journal to see how much is happening in Europe and elsewhere. EWMA currently has 46 Cooperating Organisations from 35 European countries as well as 6 International Partner Organisations and 2 Associated Organisations (patient groups). Compared to when EWMA was first founded this is a massive increase, for which EWMA may take some credit as we have given assistance in the form of advice and provision of speakers for conferences to a number of different societies. I know that Council Members who have represented EWMA at national conferences have found it exciting to be present at the launch of a new society and enjoyed the opportunity to meet those involved. This month we are especially highlighting wound management in Belgium in preparation for our conference in Brussels in May. This year our theme is “Common voice – common rights”. I hope you will agree that this is a very appropriate theme for a conference held in the city so closely associated with the European Union. So put the dates: 25-27 May in your diary and plan to be there.

Carol Dealey, Editor

EWMA Journal

2011 vol 11 no 1

Who will take on

Ali Barutcu, Professor Dr Dokuz Eylul University Medical Faculty Department of Plastic Reconstructive and Aesthetic Surgery, Izmir, Turkey Aydin O. Enver, Associate Professor Dr Ataturk University Medical Faculty Department of Plastic Reconstructive and Aesthetic Surgery, Erzurum, Turkey Top Husamettin, Associate Professor Dr Trakya University Medical Faculty Department of Plastic Reconstructive and Aesthetic Surgery, Edirne, Turkey Violeta Zatrigi, Professor Dr Pristine University Medical Faculty Department of Plastic Reconstructive and Aesthetic Surgery, Pristine, Kosovo Correspondence: bapras@alibarutcu.com Conflict of interest: none

Introduction Chronic wounds cause great trouble for society. They are usually related to some chronic systemic disease or age. In developed countries with aging populations these chronic wounds are a real burden. Health care specialists worldwide have worked hard to solve the issue of chronic wounds. On the other hand, acute wounds are mostly related to trauma and post-surgical complications. For instance, 74% of deaths by traffic accidents in the 1990s were seen in developing countries.1 In addition, work-related accidents and post-surgical wound complications are also frequently seen in developing countries which have low quality labour security precautions and less efficient health care facilities. These figures all add up to a large total. Severity of the trauma and any underlying chronic disease, as in chronic wounds, worsen the case. Wound care specialists sometimes encounter acute wounds that many are reluctant to treat. Some may be even life threatening. This group of patients is trapped in between clinics. Sometimes they have to stay in an emergency clinic for days. No particular clinic takes the responsibility. There are some factors that make some physicians reluctant to take care of this group. These patients occupy hospital beds and qualified personnel for a long time. Complications to which they are prone increase the mortality rate of the clinic. This is the usual case in many centres. This paper addresses the problem presenting four cases from three different clinics to illustrate the situation.

Fig 1-a. Wound infection had caused flap necrosis and the subsequent debridement resulted in a large wound.

Fig 1-b,c. Two weeks after admittance the wound wasÂ closed using split thickness skin grafts.

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Science, Practice and Education

Fig 2-a. Bone and soft tissue microbial cultures revealed E. coli and P. aeruginosa. Scintigraphy supported ischia osteomyelitis.

Fig 2-b. The defect was closed with a fasciocutaneous flap.

1. Case This case is from Dokuz Eylul University, Izmir (not his real name), a 54 year old male had presented with haemorrhagic shock after a traffic accident in another centre. Multiple femur and tibia fractures, pelvis fracture and external iliac artery injury had been detected and hip disarticulation was made by orthopaedics. During postoperative care in the intensive care unit, wound infection had caused flap necrosis and the subsequent debridement resulted in a large wound in his pelvic area (Fig 1-a). He was transferred to a plastic surgery clinic.

2. Case A 48 years old male, diabetic patient had been admitted with pelvic pain and fever. He was diagnosed with Fournier gangrene. The history revealed that he had a spinal cord injury 30 years ago and a distal femoral amputation due to a chronic wound 12 years ago. Aggressive debridement, sigmoid loop colostomy, left orchiectomy urethra repair and urinary diversion was made by general surgery and urology departments. Bone and soft tissue microbial cultures revealed E. coli and P. aeruginosa. Scintigraphy supported ischia osteomyelitis (Fig 2-a). After systemic antibiotics, sequential debridement and vacuum assisted closure for 20 days the defect was closed with a fasciocutaneous flap (Fig 2-b).

During admittance the patient presented with severe infection and massive areas of necrotic tissue and tunnels reaching the retroperitoneal area. Systemic antibiotics, sequential debridement and vacuum assisted closure prepared the wound for grafting. Two weeks after admittance the wound was closed using split thickness skin grafts. He has since started physical therapy (Fig 1-b,c).

Fig-3. After 10 days of vacuum there was no sign of improvement and the sepsis was evident.

3. Case A 52 years old male, had a right leg above knee amputation and consequent hip disarticulation due to Burger disease and wound dehiscence. He had a history of diabetes and heavy smoking. He was given systemic antibiotics and serial debridement was performed. During debridement by general surgery, the peritoneum cavity was exposed and plastic surgeons transposed internal oblique muscle flap to the defect. Vacuum assisted closure was used to prepare the wound for definitive closure. After 10 days of vacuum there was no sign of improvement and the sepsis was evident. The patient died of septic shock due to peritonitis (Fig-3). 4. Case A 42 years old male had a crush injury of the left leg and Gustillo type IIIA open proximal tibial fracture. The orthopaedics department reduced the fracture and used steel plates for fixation. After the operation wound dehiscence complicated the wound. The patient did not have diabetes or any other metabolic disease that could hamper wound healing. The defect medial gastrocnemius î&#x201A;Š

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Fig-4a,b. Sartorius muscle was transposed to the defect, while the infected plates were removed. However the flap failed and the defect persisted. The patient was suggested and scheduled for amputation.

muscle flap was closed. However, resistant osteomyelitis and severe infection lead to flap detachment. Some autonomic dysfunction was evident with increased sweating, oedema of the entire lower limb, severe intractable pain and desquamation of the entire limb. Alpha adrenergic blockers were initiated, and while he was already having antidepressants and analgesics, medical treatment for complex regional pain syndrome was started. Extensive “Zone of injury” and complex regional pain syndrome implied relative contraindication for free flap surgery. Sartorius muscle was transposed to the defect, while the infected plates were removed. However the flap failed and the defect persisted. The patient was suggested and scheduled for amputation (Fig-4a,b).

Discussion As trauma is the main reason for acute wounds, trauma management should be a priority in the emergency room. Vital organ injuries and haemodynamic instabilities are the main concerns for the trauma team. Postoperative wound dehiscence is another reason for acute wounds. In this case systemic diseases gain more importance. Metabolic disorders like diabetes, renal failure, and cardiovascular diseases are usually the complicating factors in such patients. Treatment of complicating factors during the management of these patients may delay wound care. All cases had acute wounds which were resistant to treatment related to systemic diseases or infection. They were managed by more than one discipline but not by a team. However this does not imply that anyone takes the responsibility. Severity of the trauma and wound engage these patients to an unfavourable group. Like chronic wound care, acute wound care also needs the efforts of a united team.2 This team should have some regular and vital members like nursing and nutrition specialists. Underlying diseases and injury location should define other

members of the team. For example, an orthopaedist and a plastic surgeon in case 1; an endocrinologist, a plastic surgeon, a general surgeon and an urologist for case 2; an orthopaedist, an endocrinologist and a plastic surgeon in case 3. Where needed specialists may be recruited for the team. One of the members should take the responsibility to make the definitive treatment according to the injury type and location. In this unfavourable group of patients, wound bed preparation should be the goal of treatment until definitive intervention. Vacuum assisted wound closure has been the main means of treatment for the given patients. 3,4 Early onset of vacuum treatment, even immediately after the haemostasis in the emergency room, may be considered. Vacuum treatment may be beneficial during treatment of vital problems; this gains the wound management team valuable time for treatment. EWMA lectures have provided consensus on many problems and widely accepted guidelines on chronic wounds.5,6 However, such a protocol is not available for these unfavourable acute wounds. Societies should delineate the guidelines for acute wound management with EWMA taking the lead. m References 1 Odero, W., Garner, P. and Zwi, A., Road traffic injuries in developing countries: a comprehensive review of epidemiological studies. Tropical Medicine & International Health, 2: 445–460, 1997. 2 Gottrup F., Nix D. P., Bryant R. A. The Multidisciplinary Team Approach to Wound Management. In: Bryant R. A., Nix D. P. editors. Acute & Chronic Wounds: Current Management Concepts, Third edition, USA: Mosby; 2007. P.23-38 3 Nelson E.A., “Vacuum Assisted closure for chronic wounds: A review of the evidence”, EWMA Journal 2007 vol. 7, no.3 pp 5-11 4 Vigs et.al., “A systematic review of topical negative pressure therapy for acute and chronic wounds.”, Br. J. Surg 2008; 95: 685-692 5 Janssen H. J.,”Integrated system of chronic wound care healing- creating, managing and cost reduction”, EWMA Journal 2007 vol. 7, no.3 pp19-21 6 Karel Bakker, “The Importance of International Consensus Guidelines on the Management of the Diabetic Foot” EWMA Journal 2009, vol. 9 no:3, pp 40-41

EWMA Journal

2011 vol 11 no 1

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Science, Practice and Education

Diabetic foot ulcer pain:

The hidden burden ABSTRACT Background – Diabetic Foot Ulcers (DFU) are often considered painless due to peripheral neuropathy, with pain only occurring with complications (Sibbald et al., 2006). Recent research suggests DFU pain is more prevalent than expected (Ribu et al., 2006; Bengtsson et al., 2007). Aim: To explore the presence and characteristics of DFU pain Methods: Patients with diabetes and a foot ulcer below the malleoli attending a specialist DFU clinic over eight weeks were audited cross-sectionally. DFU pain was assessed using a modified Short-Form McGill Pain Questionnaire. Results: Twenty-eight patients were recruited and of those, 86% (n=24) reported DFU pain. The mean visual analogue scale (VAS) score was 26.36 (sd 24.29). Patients with neuro-ischaemic ulceration (n=13) reported a higher mean score than neuropathic ulceration (n=14) (mean = 32.2 (sd:24.6) v mean = 21.6 (sd=24.6) ns). Mean VAS scores for patients with DFU complications was 26.01 (sd 24.4) versus 26.9 (sd 25.4) without complications. Sixteen patients were taking regular analgesia, although not always for DFU pain alone. Conclusions: Specific DFU pain occurs more frequently than previously anticipated. Concomitant analgesic use may lead to underestimation of DFU pain. The presence of DFU pain is not limited to patients experiencing infection or other complications. Further research is required to explore this phenomenon in clinical practice.

EWMA Journal

2011 vol 11 no 1

(Part one)

Introduction There is growing awareness that pain is a prevalent problem amongst patients with many types of wounds 1,2,3,4, yet wound pain is often ignored, inappropriately assessed and badly managed 5. Whilst position documents from EWMA 6 and WUWHS 7 acknowledged that wound pain is an area of concern requiring more consideration, a lack of suitable robust studies means there remains an insufficient evidence base from which to formulate decisions regarding patient care. There is limited evidence addressing pain from wounds of aetiologies other than VLU, or at times other than dressing changes. Pain from diabetic foot ulcers (DFU) is a particularly under-researched area, possibly due to the assumption that patients experience little pain from DFU due to peripheral sensory neuropathy. There is limited knowledge of the prevalence of diabetic patients experiencing specific ulcer-related pain, their perception of it, resulting limitations, or how it should be managed. Neuropathic pain is often assumed to be the only type of pain experienced by DFU patients 8,9,10, which fails to acknowledge that pain may be specifically associated with ulceration. UK clinical guidelines 11 and advisory literature offered by the International Diabetes Federation (IDF) for the assessment and management of DFU does not consider pain at all, except as an indicator of infection. Abraham 12 declared the specific challenge with pain from diabetic wounds is the potential for multiple aetiologies of that pain, each requiring thorough consideration to manage patients appropriately. Pain may result from infection, Charcot Arthropathy or Osteomyelitis 13,14,15, as well as painful neuropathy. Some research also suggests entrapment of the tibial nerve, or Tarsal Tunnel Syndrome, may be a cause of neuropathic pain in DFU, especially when pain is worse at night 16. Sibbald et al. 17 consider pain in the DFU itself uncommon except as a symptom of these complications. Although it is well-documented that these factors often cause pain in an insensate

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



Science, Practice and Education Table 1: Inclusion/Exclusion Criteria foot, there still appears to be no eviInclusion criteria Exclusion criteria dence to suggest patients with DFU Over eighteen years of age Dementia or learning / communication do not experience nociceptive pain, difficulties procedural pain or other experiences Diagnosis of Diabetes Mellitus Problems with vision making questionof non-cyclic or cyclic acute pain as denaire completion difficult One or more foot ulcers below the malleolus Surgical or amputation wounds scribed by Krasner’s Chronic Wound Willing and able to complete a simple pain Pain Model 18. questionnaire 19 Ribu et al. found that 75% of 127 patients with DFU reported pain on walking/standing and/or pain at Table 2: Diabetes Characteristics by Aetiology night. No statistical difference was N (n=14) NI (n=13) I (n=1) Total (n=28) found for pain in the presence of inType of Diabetes: fection and Osteomyelitis. Results inType I 2 0 0 2 Type 2 12 13 1 26 dicated a high percentage of patients Mean Duration of Diabetes (years) 14.3 24.6 5 18.8 with peripheral neuropathy still expeNo. of Diabetes-Related Complications: rienced pain, although a significantly 0 3 0 0 3 higher percentage of patients who re1 6 0 0 6 ported pain most or all of the time had 2 5 6 1 12 evidence of significant ischaemia com3 0 3 0 3 pared with patients without pain. A 4 0 3 0 3 negative effect on QoL was also found 5 0 1 0 1 for patients experiencing pain. Type of Diabetes-Related Complications: Bengtsson et al. 20 found 53% of Cardiovascular Disease 6 11 1 18 101 patients reported wound-related Peripheral Vascular Disease 0 13 1 14 pain either occasionally or continuRetinopathy 5 7 0 12 ously. The presence of pain did not Nephropathy 2 4 0 6 Minor Amputation 2 3 0 5 vary between aetiologies, and patients with clinical signs of infection were (N=Neuropathic, NI=Neuro-Ischaemic, I=Ischaemic) excluded, highlighting the error of assuming that pain only occurs in the METHODS presence of such complications. The issues highlighted within the literature search A quantitative exploratory cross-sectional design using a prompted the performance of a cross-sectional, exploralocal audit to collect data at a single time point provided tory study to investigate the presence and characteristics a ‘snap-shot’ of occurrences within the sample 21. of DFU pain and the potential effect on QoL. The study Consecutive patients attending over an eight week aimed to gain information on the number of patients atperiod were assessed for inclusion (See Table 1 for inclutending one specialist diabetic foot clinic who experienced sion/exclusion criteria). This time period was decided on DFU pain; determine if a relationship existed between with consideration to the average number of patients seen ulcer pain and specific aetiologies of DFU; explore the type within the clinic that could provide an idea of the scope of and intensity of pain experienced, and examine current the problem from which to draw reasonable conclusions. management strategies being utilised. The final aim was Patients with active infection, Osteomyelitis or Charcot to investigate how ulcer pain impacts on QoL. Arthropathy were included to determine if a specific corThe study’s aims defined the need to collect quantitarelation between DFU pain and these complications extive data on the presence and characteristics of DFU pain isted. This provided a more representative sample as large and qualitative information regarding patients’ views on numbers of patients seen in specialist diabetic foot clinics QoL issues. The study was therefore conducted in two regularly encounter these problems, thus reflecting the phases. As the first phase determined that DFU pain was realities of clinical practice. a problem, the second stage regarding QoL was deemed A clinical assessment tool was devised to facilitate data necessary. As the subject area was so new, it could not collection of simple demographics and take a thorough initially be assumed that enough patients would identify clinical history of patients’ diabetes and foot ulcer(s). The DFU pain to warrant further study. The first phase of the tool was positively reviewed by colleagues prior to comstudy is presented here. mencing the audit to obtain feedback on its ease of use in the clinic setting.

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Diagnosis of aetiology was made following full vascular and neurological assessment and foot inspection, guided by the recommendations of the International Working Group on the Diabetic Foot 22. A wound assessment was performed using standardised criteria, and the ulcer(s) were assessed for the presence of infection, Osteomyelitis and Charcot Arthropathy. Following the assessment, the wounds were classified using the University of Texas Classification System (UTCS) 23. Type of footwear, frequency of podiatry visits and referrals made to a specialist pain practitioner were also recorded. Pain was assessed using a modified version of the ShortForm McGill Pain Questionnaire (SF-MPQ) 24 which captures the nature and intensity of pain, thus assisting in identifying if certain pain characteristics are associated with DFU. The patient was asked to give specific consideration to any pain in, or immediately surrounding, the ulcer only. The aim was to ascertain if the pain was specifically ulcer-related and not primarily of neuropathic origin. Verbal informed consent was obtained from each patient prior to completion of the SF-MPQ. As the information being gathered was for audit purposes and within the realms of normal clinical practice, formal ethical approval was not required. The audit data was summarised and classified according to ulcer aetiology. The VAS scores were measured on a 0-100mm scale and analysed using an independent t-test to compare the pain scores by type of DFU, as this was the primary outcome. The other comparisons are presented descriptively to avoid over analysis of the same outcome due to the relatively small sample number included in the study. The results of the SF-MPQ were analysed as outlined in the original articles on the full MPQ and the SF-MPQ by Melzack 25,24.

RESULTS Twenty-eight patients were recruited into the audit from March-May 2007. The majority of the patients were male (n=22). The overall sample was aged 43-92 years (mean 67.5, sd 13.56). Table 2 indicates the diabetes history. DFU History Fifty percent of patients presented with an ulcer(s) of neuropathic aetiology (n=14), and 46% with neuro-ischaemic aetiology (n=13). Only one patient had a purely ischaemic ulcer. Mean ulcer duration of 48 weeks (sd 66.21, range 1–234 weeks). Ulcers were classified using UTCS and indicated a range of scores from A1 to D3, the most common being A1 (29%). Some problems with clinician understanding of the UTCS were identified when results were compiled, making analysis of any correlation between DFU pain and increasing DFU severity using the Texas  scores unreliable.

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Figure 1: Reported SF-MPQ pain descriptors

Analgesia Sixteen patients (57%) were taking regular oral analgesia, including drugs for neuropathic pain while 43% (n=6) of patients with neuropathic ulceration were taking some form of analgesia compared with 69% (n=9) of neuroischaemic patients. The type of analgesia used by patients suffering with DFU pain ranged from simple analgesics to opiate analgesia (See Table 3). The main types of analgesia used were mild opiates in the form of Tramadol or Codeine-based preparations, which are normally used to manage mild to moderate pain. In addition to this, three neuropathic patients were taking Gabapentin, an anticonvulsant often used to manage neuropathic pain. Analgesia was not always taken specifically for ulcerrelated pain. In patients reporting some degree of DFU pain, 63% (n=15) were taking analgesia, while nine patients (38%) who recorded DFU pain took no analgesia. Two patients had previously been seen by a Pain Specialist due to pain related to their diabetic foot problems.

Presence of DFU Pain Eighty-six percent of patients (n=24) reported some degree of DFU pain on the SF-MPQ. The overall possible score obtainable using the descriptors and VAS components of the SF-MPQ is 142. Higher scores indicate higher pain levels. The range of scores obtained across the sample was 0-91. Of the patients reporting DFU pain, 39% (n=11) had neuropathic foot ulcers (NFU) and 50% (n=12) had neuro-ischaemic ulcers (NIU). The patient with a purely ischaemic ulcer also reported pain. For comparative purposes only the neuropathic and neuro-ischaemic groups will be used. The results of the ischaemic patient will be considered as part of the overall group. Fourteen percent of patients (n=4) reported no ulcer pain on the SF-MPQ, scoring 0 on both the pain descriptors and VAS elements. Of these, three had NFU and one had NIU. A further six patients (25%) reported pain in the bottom 10% of overall recorded scores (=9), four with NFU and two with NIU.

Table 3: Analgesia taken by Aetiology Analgesia Co-Dydramol

No. Of patients Neuropathic Neuro-ischaemic 2 0 1

Ischaemic 1

Co-Codamol

Tramadol

Paracetamol

Gabapentin

Diclofenac

Oxycontin

Characteristics of DFU Pain Figure 1 shows all types of pain on the SF-MPQ recorded by the sample. The first ten descriptors indicate the sensory component of the pain sensation, and the final four, the affective component. Aching was the most commonly reported sensory type of DFU pain (n=14), with tiring/exhausting the most common affective descriptor (n=10). Figure 2 compares pain descriptors used by patients with neuropathic and neuro-ischaemic

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2011 vol 11 no 1

Science, Practice and Education

Figure 2: Comparison of reported SF-MPQ pain descriptors with aetiology

aetiology. Despite reporting similar types of pain, there tended to be a higher frequency for the neuro-ischaemic patients across both the sensory and affective components. Pain Intensity VAS Scores obtained across the whole sample were from 0-73, with an average score of 26.4 (sd 24.3). Of those who recorded pain, 46% (n=13) recorded pain levels >40mm using the VAS, a level indicating moderate to severe pain intensity requiring immediate review and intervention 7. For the neuropathic group, the mean VAS score was 21.6 (sd 24.6, range 0–73). Seven patients recorded scores in the bottom 10% (=7). For the neuro-ischaemic group, the mean score was 32.2 (sd 24.6, range 0–67). Three patients recorded scores in the bottom 10%. The patient

with an ischaemic ulcer recorded a VAS score of 27. There was no statistically significant difference between the groups (t=-1.1, df = 1, p=0.27). Figures 3 and 4 indicate the reported pain intensity for each pain descriptor using the SF-MPQ by aetiology. Across the sample mild pain was reported 84 times, moderate pain 44 times and severe pain 12 times. Pain and DFU-Related Complications Of the patients included in the study, 64% (n=18) presented with one or more DFU-related complications (Table 4). Eight patients with clinical signs of ulcer infection were taking systemic antibiotics, five patients with suspected Osteomyelitis were referred for further investigations, and five had confirmed Osteomyelitis, three of whom were 

Figure 3: Reported SF-MPQ pain intensity for neuropathic ulcer aetiology

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2011 vol 11 no 1

Figure 4: Reported SF-MPQ pain intensity for neuro-ischaemic ulcer aetiology

chronic. One patient of the eight with Charcot Arthropathy had an active Charcot during assessment. Fourteen of these patients reported some degree of DFU pain, and four recorded an overall score of zero on the SF-MPQ. The mean VAS score for patients with one or more DFU-related complications was 26.1 (sd 24.4), compared with 26.9 (sd 25.4) for the comparative group with no DFU-related complications. For the overall SFMPQ score, the group with complications had a mean score of 31.9 (sd 28.5), compared with 33.3 (sd 31.9) for those without. Figure 5 compares the pain descriptors used by patients with and without DFU-related complications and Figures 6 & 7 compare pain intensity.

Pain and Pressure-Relieving Footwear Eighteen patients (64%) wore some form of pressurerelieving footwear, resulting in an average VAS score of 26.9 (sd 23.9) versus 25.4 (sd 26.3) for those who wore normal shop-bought footwear. The average overall SFMPQ score for these groups was 33.2 (sd 28.2) versus 31.0 (sd 32.3) respectively. Pain and Podiatry Input Twenty patients (71%) regularly attended a podiatrist for DFU assessment, review and management. The average VAS score for these patients was 25.0 (sd 23.8), with an average overall SF-MPQ score of 31.1 (sd 28.4), versus 29.9 (sd 26.9) and 35.9 (sd 33.0) for those who received no regular podiatric input.

Table 4: DFU-Related Complications DFU-related complication Infection Infection + Osteomyelitis Infection + Non-Active Charcot Infection + Osteomyelitis + Non-Active Charcot Osteomyelitis Non-Active Charcot Active Charcot

No. Of patients 2 (Neuro-Ischaemic = 2) 4 (Neuropathic = 1, Neuro-Ischaemic = 3) 3 (Neuropathic = 2, Neuro-Ischaemic = 1) 2 (Neuropathic = 1, Neuro-Ischaemic = 1) 4 (Neuropathic = 1, Neuro-Ischaemic = 3) 2 (Neuropathic = 1, Ischaemic = 1) 1 (Neuropathic = 1)

DISCUSSION Fewer patients were recruited than estimated as a result of the inclusion criteria. This small sample number makes it difficult to generalise the findings. This is also true due to the specialist, complex patient population from which they were chosen, but the sample did reflect the documented epidemiology for people with diabetic foot disease 26. More positively, such complex patients may be representative of many populations with diabetic foot disease due to the complex nature of the disease itself. There were similar numbers with NFU and NIU, concurring with previous work estimating 25-50% of DFU are neuro-ischaemic 27,28,29. Ischaemic aetiology is grossly un-

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2011 vol 11 no 1

Science, Practice and Education

Figure 5: Comparison of pain descriptors used by patients with and without DFU-related complications

der-represented within the sample – therefore no analysis was made of pain experienced by these patients. The increased duration of diabetes and number of complications experienced by the neuro-ischaemic group compared with the neuropathic group could suggest they were generally in poorer health. PVD in a neuropathic patient leads to an increased risk of ulceration, difficulty in healing, and poorer overall outcomes 30,31 suggesting the neuro-ischaemic group is more complex. One aim of this audit was to see if this led to an increase in DFU pain levels or a difference in the type of pain experienced. The UTCS would have assisted in determining this as it categorizes wounds by severity, but due to classification errors the collected data was unsuitable for analysis.

Presence of DFU Pain These results support the findings of Ribu et al. 19 and Bengtsson et al. 20 in that DFU pain is a problem, as well as supporting the qualitative work on HRQoL of patients with DFU, where pain was often raised as an issue 32,33,34,35. More patients with NIU reported pain than NFU, although it should be noted that this was not statistically significant. Laing 14 suggests that ischaemic ulcers are usually painful to the touch, so the presence of ischaemia and associated increase in ulcer severity may contribute to the sensation of specific ulcer pain. Conversely, Bengtsson et al. 20 found no difference between the presence of pain  and aetiology.

Figure 6: Reported SF-MPQ pain intensity for patients with DFU-related complications

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2011 vol 11 no 1

Science, Practice and Education

Figure 7: SF-MPQ pain intensity for patients without DFU-related complications

Eleven patients with NFU reported pain, contrasting with previous opinion that most NFU are painless. Furthermore, neuro-ischaemic patients also have an essentially insensate foot, albeit with added ischaemia, yet still appear to experience DFU pain. One neuro-ischaemic patient reported no pain, suggesting ischaemia does not always lead to ulcer pain, although there is danger in inferring too much from a single case. More certainty of the effect of ischaemia on the experience of DFU pain could be determined by a larger study with a comparable group of patients with purely ischaemic ulceration. Ribu et al. 19 had similar results with the majority of patients with no pain being those with an insensate foot, although this was also the case for many with pain. They also concluded that ischaemia was more common in those who reported pain, although a direct relationship between the two variables again cannot be assumed. Characteristics of DFU Pain Analysis of terms used to describe the nature of DFU pain should be interpreted with caution due to the small sample size and the purely exploratory nature of the study. The results obtained are also difficult to place into context as there is little previous research into the issue, and none at all using a tool like the SF-MPQ. The most frequently used descriptors for DFU pain had elements common to both nociceptive and neuropathic pain, as is often the case for patients with chronic wounds 36. When determining the best method for assessing DFU pain, one concern was that patients would be unable to isolate the DFU pain from other sources of pain, such as neuropathy or ischaemia. Subjects often described nociceptive pain using descriptors such as aching and throbbing, which are typically related to tissue damage, giving some indication that this isolation occurred. 18

Some descriptors are commonly associated with particular types of pain, but none consistently or reliably. The SF-MPQ is not designed to assess neuropathic pain specifically and so may not include descriptors for all types of associated pain. However, those descriptors reported most frequently are not those most specific to pure neuropathic pain, i.e. shooting or stabbing. This is again opposed to the common view of DFU as being painless or only associated with neuropathic pain 8,9,10,14. The neuropathic and neuro-ischaemic groups reported similar types of pain. Patients with NIU reported pain that was more frequent, severe, and varied in type than patients with purely NFU, contrasting to Bengtsson et al. 20, who reported little difference in pain intensity between aetiologies. Affective descriptors of DFU pain assess the emotional aspects of the pain experience. The neuro-ischaemic group was more likely to use affective descriptors, suggesting DFU pain associated with neuro-ischaemia can be more emotionally or psychologically challenging. This is an important factor impacting on QoL. There is inconsistency in the results of some SF-MPQs, possibly bearing upon its internal validity. Two patients reported no pain for any descriptors on the questionnaire but scored 2 out of 100 on the VAS scale – this is certainly due to the accepted margin of error which occurs when using VAS scales. Their scores could not be discounted, but could have led to a slightly larger number being reported as experiencing DFU pain than is actually the case, but also an underestimate of pain on a mean basis. Another patient reported severe pain for two descriptors, and moderate for two descriptors, yet recorded a VAS score of 1, suggesting a lack of understanding by the patient and/or a poor explanation from the clinician on VAS completion.  EWMA Journal

2011 vol 11 no 1

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Science, Practice and Education

Although the SF-MPQ has been demonstrated as valid, reliable and easy to use 24,37,38, it has never been used for assessment of DFU pain and therefore its validity cannot be absolutely certain. Pain and DFU-Related Complications When considering the impact of DFU-related complications on pain, it should be noted that there being more patients with complications than without could potentially skew results. It proved beyond the scope of this audit to detect any correlation between specific complications and DFU pain as they rarely occurred independently and the group numbers were too small. It should be acknowledged that five patients only had a suspected diagnosis of Osteomyelitis. Despite a high specificity and sensitivity for the probing to bone test used for diagnosis of Osteomyelitis 39,40, the results of further investigations would have been preferential when determining in which comparative group the patient was to be included for analysis. This highlights a problem with the audit’s cross-sectional methodology as collecting data at a single time point meant there was no follow-up of the patients to determine if Osteomyelitis was confirmed. Interestingly, the four patients in the sample who reported no pain all had one or more DFU-related complication(s), indicating that the absence of DFU pain was not associated with an absence of complications. It also highlights the complexity of assessing DFU as normal clinical signs, such as pain and tenderness due to wound infection, are often absent 41. There is little difference in the mean VAS scores between those with and without complications, contrasting with commonly presented views within the literature which indicate DFU pain is only associated with complications 11,17. This supports the work of Ribu et al. 19 and Bengtsson et al. 20, as the latter study excluded patients with complications. There was no difference in the number of times severe pain was reported by each group, although patients with complications reported moderate and mild intensity more often. When considering overall SF-MPQ scores, patients without complications actually recorded slightly higher mean scores than those with complications, again contrary to previous views. It is therefore clinically inappropriate to assume DFU pain does not exist except in the presence of complications or advancing disease, although the intensity of the pain might differ. Patients with complications used more affective descriptors for their pain than those without pain, indicating that the emotional effect of pain and complications combined is more intense. This could be due to the anxiety such patients may feel when told that they have an infection, Osteomyelitis or Charcot Arthropathy. These issues are an added complication to the existing DFU, presenting

a further risk of future problems, such as foot deformity, reduced mobility or amputation. Management of DFU Pain Findings regarding analgesic use are similar to those of Ribu et al. 19 showing a higher percentage of patients reporting DFU pain were taking analgesia than those without. It is difficult to draw implications for analgesic use in DFU pain here as many patients were taking analgesia for other problems. As 57% were taking analgesia at assessment, it is possible that concomitant analgesic use could lead to underestimation of DFU pain. As found with studies looking at VLU and use of analgesics, there were patients experiencing DFU pain that took no form of pain relief – as with the Ribu et al. 19 study, this suggests DFU pain management requires the same attention as other types of wound pain. More patients with NIU taking analgesia than those with NFU could indicate that presence of ischaemia in the neuro-ischaemic foot is the main factor for the increase in severity of DFU pain, therefore requiring more treatment with analgesics. It could, however, be a coincidence due to the large number within the sample requiring analgesia for other problems. The pilot study by Bengtsson et al. 20 found little difference between analgesic use for the two groups, and, as that study was using much larger numbers than this audit, this suggests any results should be interpreted with caution. Callus build-up causing raised foot pressures 42 could potentially cause DFU pain. The average VAS and overall SF-MPQ scores were less for those who attended regular podiatry appointments, suggesting regular debridement could contribute to decreasing pain levels. The groups were however not comparable in terms of size. Pressure-relieving footwear could provide pain relief due to decreased pressure and contact with the ulcer surface. The results did not support this theory as average VAS and overall SF-MPQ scores for patients wearing some form of pressure-relieving footwear were slightly higher than for those wearing normal shop-bought footwear. However, the difference was very small and again, the groups were not entirely comparable in size. Identifying or excluding other factors such as painful neuropathy caused by tibial nerve entrapment which could be causing pain is also useful when formulating an appropriate management plan. Although not common, surgery involving neurolysis of the tibial nerve may be helpful in this group (Dellon, 1988), and so exclusion of this as a root cause of any ulcer pain, perhaps by elicitation of Tinel’s sign with percussion behind the medial malleolus, may be useful during any further investigations of this topic. 

EWMA Journal

2011 vol 11 no 1

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Science, Practice and Education

CONCLUSION Overall, the first phase of the study reinforced previous study findings that specific DFU pain is an underestimated phenomenon experienced by patients, it can be severe and variable in nature despite the presence of peripheral neuropathy, and is not necessarily related to DFU complications. The results also emphasised the need for the second phase to be performed to further explore the pain experience and its impact on QoL. The need for more accurate and responsive pain assessment is accentuated as nearly half the patients audited reported pain >40mm on a VAS, which WUWHS 7 guidelines state requires immediate at-

tention. As with other types of wound pain, inadequate use of analgesia is a problem warranting more investigation. The small sample numbers and consequent lack of generalisability of these study findings are acknowledged. Further research is required to ascertain the prevalence of DFU pain on a wider scale, and once this has been established, advice for clinicians on the assessment and management of DFU pain would be a welcome addition to clinical guidelines on the diabetic foot, such as those offered by NICE and the IDF. m

References 1. Dallam L, Smyth C, Jackson BS, Krinsky R, O’Dell C, Rooney J, Badillo C, Amelia E, Ferrara L, Freeman K (1995) Pressure Ulcer Pain: Assessment and Quantification Journal of Wound, Ostomy and Continence Nursing 22: 211-218 2. Hofman D, Ryan TJ, Arnold F, Cherry GW, Lindholm C, Bjellerup M, Glynn C (1997) Pain in Venous Leg Ulcers Journal of Wound Care 6 (5) 222-224 3. Lindholm C, Bergsten A, Berglund E (1999) Chronic Wounds and Nursing Care Journal of Wound Care 8 (1) 5-10

22. International Working Group on the Diabetic Foot (2007) International Consensus on the Diabetic Foot & Practical Guidelines on the Management and the Prevention of the Diabetic Foot Interactive DVD launched at the 5th International Symposium on the Diabetic Foot May 2007. Available at www.idf.org/bookshop 23. Lavery LA, Armstrong DG, Harkless LB (1996) Classification of Diabetic Foot Wounds The Journal of Foot and Ankle Surgery 35 (6) 528-531 24. Melzack R (1987) The Short-Form McGill Pain Questionnaire Pain 30: 191-197

4. Charles H (2002) Venous Leg Ulcer Pain and its Characteristics Journal of Tissue Viability 12 (4) 154-158

25. Melzack R (1975) The McGill Pain Questionnaire: Major Properties and Scoring Methods Pain 1: 277-299

5. Hollinworth H, Collier M (2000) Nurses’ Views about Pain and Trauma at Dressing Changes: Results of a National Survey Journal of Wound Care 9 (8) 369-373

26. Boulton AJM (2002) The Diabetic Foot Medicine 30 (2) 36-40

6. European Wound Management Association (2002) Pain at Wound Dressing Changes London: Medical Education Partnerships Ltd

27. Edmonds ME (1987) Experience in a Multi-disciplinary Diabetic Foot Clinic In: Connor H, Boulton AJM, Ward JD (Eds.) The Foot in Diabetes Chichester: Wiley, pp. 121-133

7. World Union of Wound Healing Societies (2004) Principles of Best Practice: Minimising Pain at Wound Dressing-Related Procedures. A Consensus Document London: Medical Education Partnership

28. Thomson FJ, Veves A, Ashe H, Knowles EA, Gem J, Walker MG, Hirst P, Boulton AJM (1991) A Team Approach to Diabetic Foot Care: The Manchester Experience The Foot 1: 75-82

8. Dallam LE, Barkauskas C, Ayello EA, Baranoski S (2004) Pain Management and Wounds In: Baranoski S, Ayello EA (Eds.) Wound Care Essentials: Practice and Principles Philadelphia: Lippincott Williams and Wilkins, pp. 217-237

29. Oyibo SO, Jude EB, Voyatzoglou D, Boulton AJM (2002) Clinical Characteristics of Patients with Diabetic Foot Problems: Changing Patterns of Foot Ulcer Presentation Practical Diabetes International 19 (1) 10-12

9. Freedman G, Entero H, Brem H (2004) Practical Treatment of Pain in Patients with Chronic Wounds: Pathogenesis-guided Management The American Journal of Surgery 188 (Suppl): 31S-35S

30. Boulton AJ, Meneses P, Ennis WJ (1999) Diabetic Foot Ulcers: A Framework for Prevention and Care Wound Repair and Regeneration 7 (1) 7-16

10. Driver VR, Landowski MA, Madsen JL (2007) Neuropathic Wounds: The Diabetic Wound In: Bryant RA, Nix DP (Eds.) Acute and Chronic Wounds: Current Management Concepts 3rd Edn St. Louis: Mosby, pp 307-335 11. National Institute of Clinical Excellence (2004) Type 2 Diabetes: Prevention and Management of Foot Problems Retrieved July 12th 2008 from NICE website: http:// www.nice.org.uk/nicemedia/pdf/CG010NICE guideline.pdf 12. Abraham SE (2006) Pain Management in Wound Care Podiatry Management June/ July 165-168 13. Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR (1997) The Natural History of Acute Charcot’s Arthropathy in a Diabetic Foot Specialty Clinic Diabetic Medicine 14: 357-363 14. Laing P (1998) The Development and Complications of Diabetic Foot Ulcers American Journal of Surgery 176: 11S-19S 15. Freedman G, Cean C, Duron V, Tarnovskaya A, Brem H (2003) Pathogenesis and Treatment of Pain in Patients with Chronic Wounds Surgical Technology International 11: 168-179 16. Dellon L (1988) A Cause for Optimism in Diabetic Neuropathy Annals of Plastic Surgery 20 (2) 103-105 17. Sibbald RG, Katchky A, Queen D (2006) Medical Management of Chronic Wound Pain Wounds UK 2 (4) 74-89 18. Krasner D (1995) The Chronic Wound Pain Experience: A Conceptual Model Ostomy/Wound Management 41 (3) 20-25 19. Ribu L, Rustoen T, Birkeland K, Hanestad BR, Paul SM, Miaskowski C (2006) The Prevalence and Occurrence of Diabetic Foot Ulcer Pain and its Impact on HealthRelated Quality of Life The Journal of Pain 7 (4) 290-299 20. Bengtsson L, Jonsson M, Apelqvist J (2008) Wound-Related Pain is Underestimated in Patients with Diabetic foot Ulcers Journal of Wound Care 17 (10) 433 21. Greenhalgh T (2001) How to Read a Paper: The Basics of Evidence Based Medicine 2nd Edn. London: BMJ Books

31. Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJM (2001) Comparison of Two Diabetic Foot Ulcer Classification Systems: The Wagner and the University of Texas System Diabetes Care 24: 84-88 32. Brod M (1998) Quality of Life Issues in Patients with Diabetes and Lower Extremity Ulcers: Patients and Care Givers Quality of Life Research 7: 365 – 372 33. Ashford RL, McGee P, Kinmond K (2000) Perception of Quality Of Life by Patients with Diabetic Foot Ulcers The Diabetic Foot 3 (4) 150-155 34. Ribu L, Wahl A (2004) Living with Diabetic Foot Ulcers: a Life of Fear, Restrictions, and Pain Ostomy/Wound Management 50 (2) 57-67 35. Watson-Miller S (2006) Living with a Diabetic Foot Ulcer: A Phenomenological Study Journal of Clinical Nursing 15: 1336-1337 36. Doughty DB (2006) Strategies for Minimizing Chronic Wound Pain Advances in Skin and Wound Care 19 (2) 82-85 37. Helme RD, Katz B, Gibson S, Corran T (1989) Can Psychometric Tools be used to Analyse Pain in a Geriatric Population? Clinical Experimental Neurology 26: 113-117 38. McDonald DD, Weiskopf CS (2001) Adult Patients’ Postoperative Pain Descriptions and Responses to the Short-Form McGill Pain Questionnaire Clinical Nursing Research 10 (4) 442-452 39. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW (1995) Probing to Bone in Infected Pedal Ulcers: A Clinical Sign of Underlying Osteomyelitis in Diabetic Patients Journal of the American Medical Association 273: 721-723 40. Lavery LA, Peters EJG, Armstrong DG, Lipsky BA (2007) Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis: Reliable or Relic? Diabetes Care 30 (2) 270-274 41. Edmonds ME, Foster A (2004) The Use of Antibiotics in the Diabetic Foot American Journal of Surgery 187 (5, Supplement 1) 25S – 28S 42. Young MJ, Cavanagh PR, Thomas G, Johnson MN, Murray HJ, Boulton AJM (1992) Effect of Callus Removed on Dynamic Foot Pressures in Diabetic Patients Diabetic Medicine 9:75-77

EWMA Journal

2011 vol 11 no 1

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Science, Practice and Education

The reconstructive clockwork as a 21st century concept in wound surgery

ound surgery involves both comprehensive wound bed preparation and wound closure. There is no doubt that radical early debridement of a given wound will provide the best fundament for a proper soft tissue reconstruction. It enables the wound to go through the normal wound healing phases. All chronic wounds lasting longer than three months should be considered for surgical evaluation with biopsies taken to determine bacterial count/invasiveness. The surgical goal of debridement is to reach a level of normal, well-vascularized tissue with removal of non-vital tissue remnants. There are a number of variations of debridement procedures – surgical, mechanical, enzymatical, autolytic or biological. However, the focus of the following presentation is the reconstruction of a debrided wound by surgical means, when conservative measures have failed or are deemed inappropriate.

Stephen Mathes and Foad Nahai introduced the reconstructive ladder in 1982 in their book “Clinical applications for muscle and musculocutaneous flaps”. It was thought to guide the reconstructive surgeon in the management of a surgical defect or chronic wound progressing from simple to more complex procedures. The conventional reconstructive ladder addressing tissue defects begins with primary and secondary closure of wounds followed by autologous skin grafting, regional and local pedicled flaps, tissue expansion and free tissue transfer1. Selection of an appropriate technique is based on its ability to satisfy the particular reconstructive requirements of the defect. Success in reconstructive surgery requires coverage and restoration of form, contour and function. Depending on local capillary circulation, direct closure or skin grafts as well as local flaps often provide sufficient coverage. However, as soon as local circulation is

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2011 vol 11 no 1

Karsten Knobloch, FACS, MD, PhD Peter M. Vogt, MD, PhD Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Germany

Figure 1. Reconstructive ladder according to Mathes and Nahai in 1982.

Correspondence: knobloch.karsten@ mh-hannover.de Conflict of interest: none

impaired in a given local wound, such as in case of radiation vasculitis, local random-pattern flaps generally have the very same vascular impairment as the nearby wound. Thus, a flap with a distant vascular pedicle should be selected in this regard. Besides coverage, form and contour should be considered to obtain the best reconstructive result. While shallow wounds might be covered by splitthickness skin grafts, deeper soft tissue defects might necessitate muscle or musculocutaneous flaps to improve contour in addition to coverage. In order to overcome the step-wise approach of the aforementioned reconstructive ladder, the reconstructive elevator has been introduced. It is thought to allow ascending directly to the chosen level of reconstructive complexity by Gottlieb and Krieger2. They believed that to think sequentially, as is the case with the reconstructive ladder, is no longer sufficient. In their opinion, reconstructive surgery calls for parallel rather than simple sequential thinking in terms of reconstructive goals. They quote the following case: “Consider the case



Figure 2. Reconstructive elevator to directly approach the level of reconstructive choice for a given soft tissue defect proposed by Gottlieb and Krieger.

of a paraplegic who has a clean, granulating pressure sore. If the only goal were to close the wound, one might do so with a split-thickness skin graft. But if the goal were to provide stable coverage that best tolerates shear forces, then it would be appropriate to skip the skin-graft option and proceed with a flap.” Another PRS commentary reads: “Why climb a ladder when you can take the elevator?”3. In order to overcome the shortcomings of the reconstructive ladder, Mathes and Nahai proposed a new paradigm, “the reconstructive triangle”4.

plantation medicine with encouraging early and mid-term clinical results5. Notably, plastic reconstructive surgeons have a long tradition in transplantation medicine6. Padgett7 and Brown and McDowell8 were among the first to perform human skin transplantation in monozygotic twins. In 1942, failure of skin allografts as a potential “allergic response or immunity three weeks after grafting” was hypothesized. Rejection was studied on skin homografts by plastic surgeons. Murray, a plastic surgeon, performed the first successful human kidney transplantation in 19559 and reported the use of azathioprine for immunosuppression eight years later10. In case of recent composite tissue allotransplantation, however, short and long term problems such as potential tumour induction by immunosuppression and chronic rejection are to be considered. Given the fact that patients receiving CTA have already undergone various reconstructive procedures, the patients often gain tremendous improvement in quality of life. Following the European Union (EU) directive 2004/23/ EC, which came into effect in German law by August 1, 2007, the question arises whether hand, arm or face transplantations are tissue or organ transplantations11. Given the current allocation procedures and procurement issues in CTA we believe that CTA has much more in common with organ than mere tissue transplantation. Nonetheless, CTA might develop as an important adjunct in the reconstructive armamentarium of modern reconstructive surgeons in the not too distant future.

Robotics A further evolving field is robotics like the Da Vinci system for surgeons and the Penelope assistant robot which found their way into the clinical Operating Room. While even microsurgical anastomosis has been performed using the Da Vinci system, the total amount of time and resources spent is beyond being practical today. The role of the robot in the operating theatre is increasing, such as in robotassisted radical prostatectomies12, for primary or recurrent oropharnygeal carcinoma13, in right hemicolectomy14 or nephrectomy15. Figure 3. The reconstructive triangle with the three corners flaps, microsurgery, and tissue expansion suggested by Mathes and Nahai.

Composite tissue allotransplantation (CTA) Despite enormous achievements and refinements in the aforementioned reconstructive techniques, clinical situations and problems occur beyond the scope of these conventional reconstructive measures. As such, composite tissue allotransplantation (CTA) of partial faces or uni- or bilateral has been introduced as a juvenile part of trans-

Tissue Engineering and Regeneration Regeneration and Tissue Engineering are of distinct and genuine interest in reconstructive surgery. Free fat transfer as lipofilling has attracted significant attention in the very last years16. Adipose-derived stem cell transfer is able not only to improve contour, but also improve overlying skin17 with potential widespread future application in reconstructive surgery. A combination therapy using fat grafting and platelet-rich plasma has been applied to 20 patients suffering chronic lower-extremity ulcers18. Using the combined approach,

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Science, Practice and Education

nature of the procedures, we would propose the term “a reconstructive clockwork” for reconstructive surgery of the 21st century22. The idea of the “reconstructive clockwork” is to mirror the integral parts of various reconstructive procedures serving the one goal to address the defect, the function, the deformity or all of them in combination. The reconstructive clockwork metaphor bears the precision of microsurgical procedures and complexity of reconstructive approaches in a natural fashion. m

References 1 Mathes S, Nahai F. Clinical application for muscle and musculocutaneous flaps. Mosby, St. Louis, 1982; 3.

Figure 4. Reconstructive clockwork of the 21st century.

2 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994;93(7):1503-4. 3 Bennett N, Choudhary S. Why climb a ladder when you can take the elevator? Plast Reconstr Surg 2000;105(6):2266.

re-epithelisation was achieved within 10 weeks. Another combination therapy merges platelet gel, skin grafts, and fibrin glue to treat recalcitrant lower extremity ulcers, where the platelet gel functions as a delivery system of powerful mitogenic and chemostatic factors and the fibrin glue as a haemostatic tissue sealant avoiding staples or sutures19. The aforementioned platelet-rich plasma fibrin matrix appears to be encouraging as a therapeutic option in lower-extremity ulceration in preliminary prospective clinical trials20. However, as far as donor-site re-epithelisation after split-thickness skin autografts is concerned, platelet-rich plasma did not speed-up epithelisation of donor wounds in a randomised-controlled trial21.

Reconstructive clockwork Comprehensive care is usually achieved at best in a team approach. A given reconstructive problem is reasonably addressed by a combination of various reconstructive techniques if one alone is not able to fully succeed. Having said that the combination of reconstructive procedures is feasible and clinically relevant, the aforementioned evolving fields of composite tissue allotransplantation (CTA), robotics and regeneration/tissue engineering will be, and sometimes are already, an integral part of daily reconstructive procedures. While the abovementioned metaphors of the reconstructive ladder as well as the reconstructive elevator do not allow intuitively combining various reconstructive measures from different echelons, we would like to propose a novel thought on this issue. We consider these novel techniques, CTA, robotics and regeneration/tissue engineering as potential future integral parts of a reconstructive sequence, which is not necessarily consecutive but simultaneous. Given the integral

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4 Mathes SJ, Nahai F. Reconstructive surgery: Principles, anatomy and technique. London: Churchill Livingstone, 1997, 11-12. 5 Brandacher G, Ninkovic M, Piza-Katzer H, Gabl M, Hussl H, Rieger M, Schocke M, Egger K, Loescher W, Zelger B, Ninkovic M, Bonatti H, Boesmueller C, Mark W, Margreiter R, Schneeberger S. The Innsbruck hand transplant program: update at 8 years after the first transplant. Transplant Proc 2009;41(2):491-4. 6 Knobloch K, Vogt PM. Plastic surgeons’ tradition in transplantation medicine in light of composite tissue allotransplantation. J Am Coll Surg 2009;209(5):674. 7 Padgett EC. Is iso-skin grafting practicable?, South Med J 1932;25:895. 8 Brown JB, and McDowell F. Epithelial healing and the transplantation of skin. Ann Surg 1942;115:1166–1177. 9 Murray JE, Merrill JP, Harrison JH. Renal homotransplantations in identical twins. Surg Forum1955; 6:432. 10 Murray JE, Merrill JP, Harrison JH, Wilson RE, Dammin GJ. Prolonged survival of human-kidney homografts by immunosuppressive drug therapy. N Engl J Med 1963;269:126–129. 11 Knobloch K, Vogt PM, Rennekampff HO. Composite tissue allotransplantation (CTA): organ or tissue transplantation? Handchir Mikrochir Plast Chir 2009;41(4):205-9. 12 Carlsson S, Nilsson AE, Schumacher MC, Jonsson MN, Volz DS, Steineck G, Wiklund PN. Surgery-related complications in 1253 robot-assisted and 485 open retropubic radical prostatectomies at the Karolinska University Hospital, Sweden. Urology 2010;75(5):1092-7. 13 Dean NR, Rosenthal EL, Carroll WR, Kostrzewa JP, Jones VL, Desmon RA, Clemons L, Magnuson JS. Robotic-assisted surgery for primary or recurrent oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 2010;136(4):380-4. 14 De Souza AL, Prasad LM, Park JJ, Marecik SJ, Blumetti J, Abcarian H. Robotic assistance in right hemicolectomy: is there a role? Dis Colon Rectum 2010;53(7):1000-6. 15 Rogers C, Laungani R, Krane LS, Bhandari A, Bhandari M, Menon M. Robotic nephrectomy for the treatment of benign and malignant disease. BJU Int 2008;102(11):1660-5. 16 Rennekampff HO, Reimers K, Gabka CJ, Germann C, Giunta RE, Knobloch K, Machens HG, Pallua N, Überreiter K, Heimburg D, Vogt PM. Current perspective and limitations of autologous fat transplantation – “consensus meeting” of the German Society of Plastic, Reconstructive and Aesthetic Surgeons at Hannover, September 2009. Handchir Mikrochir Plast Chir 2010;42(2):137-42. 17 Mojallal A, Lequeux C, Shipkow C, Breton P, Foyatier JL, Braye F, Damour O. Improvement of skin quality after fat grafting : clinical observation and an animal study. Plast Reconstr Surg 2009;124:765-74. 18 Cervelli V, Gentile P, Grimaldi M. Regenerative surgery: use of fat grafting combined with platelet-rich plasma for chronic lower-extremity ulcers. Aesthetic Plast Surg 2009;33(3):340-5. 19 Chen TM, Tsai JC, Burnouf T. A novel technique combining platelet gel, skin graft, and fibrin glue for healing recalcitrant lower extremity ulcers. Dermatol Surg 2010;36(4):453-60. 20 O’Connell SM, Impeduglia T, Hessler K, Wang XJ, Carroll RJ, Dardik H. Autologous platelet-rich fibrin matrix as cell therapy in the healing of chronic lower-extremity ulcers. Wound Repair Regen 2008;16(6):749-56. 21 Danielsen P, Jörgensen B, Karlsmark T, Jorgensen LN, Agren MS. Effect of topical autologous platelet-rich fibrin versus no intervention on epithelisation of donor sites and meshed split-thickness skin autografts: a randomized clinical trial. Plast Reconstr Surg 2008;122(5):1431-40. 22 Knobloch K, Vogt PM. The reconstructive sequence in the 21st century. A reconstructive clockwork. Chirurg 2010;81(5):441-6.

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Science, Practice and Education

Anaemia in patients with chronic wounds Abstract Background: The clinical observation was made that a number of patients with reduced haemoglobin levels were admitted to the Centre for Wound Healing, Odense University Hospital, but the real prevalence was not known. Objective: This retrospective study was designed to quantify the prevalence of anaemia in patients admitted for the first time at the University Centre for Wound Healing, Odense University Hospital, for a period of 15 months. Methods: Sex, age, diabetes status, haemoglobin, C-reactive protein, creatinine, albumin, mean corpuscular volume, mean corpuscular haemoglobin and weight were registered. The renal function was estimated. Haemoglobin was differentiated according to sex. Results: Two hundred and thirteen patients participated in total - 57 % being male. Fifty five percent had anaemia. Patients with anaemia had a significantly higher C-reactive protein and lower albumin (p<0.0001). Conclusion: Anaemia was found to be related to chronic disease, renal insufficiency or a combination of these. All patients having a complicated wound in combination with anaemia should be more thoroughly investigated on admission and further blood analyses taken in order to classify the anaemia. Introduction The objective of this work was to clarify the prevalence of anaemia in patients admitted to a large University Centre dedicated to the treatment of complicated wounds (Centre for Wound Healing Odense University Hospital [WH-OUH]). A retrospective study for a period of 15 months was carried out. Outcome variables included the number of patients with anaemia and whether some subgroups of patients had a significantly lower haemoglobin level (i.e. diabetes, renal insufficiency). Also, different variables (e.g. C-reactive protein [CRP], creatinine level) were analyzed for association with anaemia. EWMA Journal

2011 vol 11 no 1

Methods All patients admitted to WH-OUH for the first time over a period of 15 months were registered. Re-admissions were not included. Variables recorded were: gender, age, diabetic status, renal function, MCV (mean corpuscular volume), MCH (mean corpuscular haemoglobin), CRP, haemoglobin, serum creatinine, albumin, and weight. The renal function was estimated using the Cockcroft and Gault formula: Creatinine clearance (CrCl)=([140-age] x weight[kg]) x constant/serum creatinine[µmol/L]), constant = 1.23 in men, and 1.04 in women. All data were collected from admission notations via the electronic patient charts. The weight was collected from data in anaesthetic chart formulas in about 50 % of the patients as only three patients had their weight determined on admission. Anaemia was defined as a value of ≤ 7.0 mmol/l (11.5 g/dl) in women and a value ≤ 8.0 mmol/l (13 g/dl) in men according to local reference values. A literature search was performed using the PubMed/Medline database, search terms being: “anaemia and chronic wounds”, “anaemia and chronic ulcers”, “anaemia and wound healing”, “anaemia and diabetes”, “anaemia and nutrition”, “albumin and inflammation”, “gastrointestinal bleeding and chronic disease” and “nutrition and healing”.

Lotte M. Vestergaard, M.D. Roskilde University H ospital, Department of Anaesthes iology. Isa Jensen, M.D. Odense University Hospital, University Centre for Wound Healing Knud Yderstraede, M.D., PhD Odense University Hospital, Department of Endocrinology Work is attributed to Centre for Wound Healing, Odense University Hospital, Odense, Denmark. Correspondence: lotte.m.vestergaard@ gmail.com Conflict of interest: none

Statistics Data were evaluated statistically using SPSS 11.5. Outcome variables were defined as mean ± 95 % confidence interval. A p-value < 0.05 was considered significant. All data were tested with histograms and Q-Q plots for deviation from a normal distribution. For all sample means the standard deviations are stated. Comparison between sample means was made by a one sample test, and if the groups did not have comparable variances, the test for different variance was used. Comparison of qualitative variables was made by cross tables,  and tested with Fisher’s exact test. 29

Table 1: Anaemia, age, CRP, albumin and creatinine. Age (mean, ± SD) CRP (mean, ± SD) Albumin (mean, ± SD) Creatinine (mean, ± SD)

Results A total of 213 individuals were admitted during the period (57 % male). Fifty five percent of the patients were diagnosed with anaemia on admission. The mean value of haemoglobin for men was 7.63 ± 1.25 mmol/l (12.29 ± 2.01 g/dl) and the mean haemoglobin for anaemic men was 6.77 ± 1.15 mmol/l (10.91 ± 1.85 g/dl). The mean haemoglobin for women was 7.16 ± 1.10 mmol/l (11.53 ± 1.77 g/dl) and the mean haemoglobin for anaemic women was 6.62 ± 1.06 mmol/l (10.66 ± 1.71 g/dl). The age span was 27 to 98 years, with a mean value of 65 years. The age average in the anaemic patients was significantly higher (p = 0.007) compared to the age average in the non-anaemic patients (68 ± 16 years versus 61 ± 17 years – see table 1). Anaemia and CRP The mean value of CRP in patients with anaemia was 98 ± 84 mg/l, while in patients without anaemia it was 41 ± 53 mg/l (p<0.0001), see Table 1. The mean value of CRP in diabetic patients was 74 ± 77 mg/l versus 72 ± 76 mg/l in non-diabetic patients (p=0.853). Anaemia and albumin The mean value of albumin was analyzed in patients with and without anaemia, respectively. The mean value of albumin in patients with anaemia was 33.9 ± 5.5 g/l versus 39.2 ± 5.1 g/l in patients without anaemia (p<0.0001), see table 1. Anaemia and renal function Kidney function could be estimated in 49.3 %. Among these 51.4 % had impaired kidney function, defined as a CrCl less than 70 ml/min calculated from Cockcroft and Gault. In this group 35 patients had anaemia, while in the group of patients with normal kidney function, 23 patients had anaemia (p=0.048) – see table 2 and 3. Anaemia and diabetes Forty four percent of the admitted patients had diabetes. The mean value of haemoglobin in patients with diabetes was 7.44 ± 1.27 mmol/l (11.99 ± 2.05 g/dl) versus 7.42 ± 1.25 mmol/l (11.95 ± 2.01 g/dl) in patients without diabetes (ns), see table 3.

Anaemic patients Non-anaemic patients 68 ± 16 61 ± 17 98 ± 84 42 ± 53 33.9 ± 5.5 39.2 ± 5.1 132 ± 126 105 ± 78

p=0.007 p<0.0001 p<0.0001 p=0.071

Table 2: Anaemia and renal function, no. of patients.

Renal Function Total

Impaired Normal

Anaemia Yes No 35 18 23 28 58 46

Total 53 51 104

The mean value of creatinine in patients with diabetes was 141 ± 131 µmol/l versus 102 ± 80 µmol/l in patients without diabetes (p=0.014). The patients with diabetes did not differ from the patients without diabetes when comparing CRP, albumin and kidney function. The difference in mean haemoglobin between the group of patients with normal and impaired kidney function was significant (p<0.0001).

Anaemia and MCV/MCHC MCV and MCHC were measured in 17.3 % of the patients. Of those patients in whom they were recorded 95 % had a normochromic and normocytic anaemia.

Discussion Few studies have addressed the prevalence of anaemia in patients with chronic wounds.1,2,3,4,5 Studies from Denmark and Italy indicate that anaemia is related to chronic disease.1,2,3 The Danish study showed a positive correlation between size of the chronic ulcer and the degree of anaemia.1 The Italian studies compared haemoglobin levels in patients with pressure wound.2,3 The fact that anaemic patients had significantly higher CRP and lower albumin indicates that patients with anaemia have a higher degree of inflammation,5,6 although the level of albumin is confounded by a number of other factors, such as nutrition, infection (severe), kidney and liver disease.7,8 However, the synthesis of albumin is negatively correlated to inflammation,6 and the catabolism of albumin may be increased under inflammatory conditions.7,8 CRP is a marker of acute and chronic inflammation and infection.9 In this study, inflammation is highly prevalent in those patients with anaemia, indicating that anaemia in this population is associated with chronic disease.10,11,12 Many of the patients admitted to the wound healing centre

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Table 3: Anaemia vs. renal function and diabetes, no. of patients. Impaired renal function Diabetes

Anaemia 35 56

No anaemia 18 37

p=0.048 p=0.211

have a complicating infection of the chronic wound, thus needing admission to hospital. In order to differentiate between inflammation and infection, patients need to have both CRP and white blood cells analysed. This has not been done in this study. The admission charts had no reference to the nutritional status of the patients. A study from Iceland showed a prevalence of anaemia of 36.7 % among 60 patients admitted to a geriatric ward.13 The patients were significantly older, had lower albumin levels, a higher erythrocyte sedimentation rate and were more often malnourished.13 They conclude that a reduced levels of albumin and prealbumin is likely to be a consequence of anaemia or an inflammation process rather than a underlying cause of anaemia.13 For stratification MCV and MCHC were measured and 95 % of the patients turned out to have normochromic and normocytic anaemia, also pointing to anaemia of chronic disease, as also noted by Weiss and Goodnough.11

obesity are common among patients admitted to the centre from which these data originated. A further limitation is that the Cockcroft and Gault equation has a tendency to overestimate the glomerular filtration rate (GFR). 17 In order to distinguish between anaemia of renal origin and anaemia of chronic disease, the variables listed below needs to be measured and the renal function needs to be estimated or measured.

The strength of this study is weakened by the fact, that MCV and MCHC were only measured in 17.3 % of the patients with anaemia, while none of the patients had P-Fe, P-ferritin and P-transferrin measured. Thus, the conclusion is less substantiated. There was a significantly higher number of patients with impaired renal function among those with anaemia. The renal function was estimated in 49.3 %. An estimate of the renal function, using for example Cockcroft and Gault, is practical in the everyday clinical setting,14,15,16 but some limitations should be stressed: muscle wasting, race, diet, neuromuscular disease and amputation all affect the creatinine concentration.17 Also, Cockcroft and Gaultâ&#x20AC;&#x2122;s equation has been found less accurate in obese patients compared to other equations17. Amputation and

Anaemia in people with diabetes has been investigated in several studies showing that diabetics have a higher prevalence of anaemia of renal origin compared to nondiabetics at the same level of renal impairment.18,19 Our data showed no significant difference in mean haemoglobin level between diabetics and non-diabetics. Also, the prevalence of diabetes was no higher in patients with impaired renal function. The only significant difference between diabetics and non-diabetics was a higher creatinine level in the former. Many of the patients admitted to the wound healing centre have co-morbidity such as impaired renal function, diabetes and heart disease. These conditions are associated with an increased risk of gastrointestinal bleeding. One study found that treatment with oral anticoagulants, treatment for heart failure, treatment with oral corticosteroid, treatment for diabetes, and smoking were all independent risk factors for peptic ulcer bleeding.20 Several studies have found that patients with chronic renal failure have an increased risk of, in particular, upper gastrointestinal bleeding.21,22,23,24 In this study 55.2 % had anaemia. The aetiology of anaemia is related to the wound itself, chronic disease, iron deficiency or impaired renal function. In order to clarify the aetiology further blood analyses must be performed including a number of variables (i.e. P-ferritin, P-iron, P-transferrin, MCV, MCHC, haemoglobin, haematocrit) in future studies. Further blood tests can be considered in order to evaluate both nutrition and a possible nutritional cause of the anaemia (i.e. folic acid, cobalamin, prealbumin). Further, all patients admitted to hospital must be î&#x201A;Š weighed at admission.

Implications for clinical practice All patients should be weighed upon admission to hospital and routine haematology analyzed. In case of anaemia, p-iron, p-ferritin, p-transferrin, mean corpuscular volume, mean corpuscular haemoglobin, folic acid, and cobalamin should be analyzed in order to characterize the anaemia more thoroughly.

Further research Stratification of anaemia in all patients with chronic wounds could be a clue to evaluation of co-morbidity which is frequent among these patients. Focusing on renal insufficiency, gastrointestinal morbidity, cancer and nutritional status may prove valuable in diagnosing and treating anaemia in this very heterogeneous group.

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Conclusion This study has demonstrated a prevalence of anaemia of 55.2 % among patients admitted to a central wound healing centre. Anaemia in chronic disease is characterized by disturbed iron homeostasis, disturbed erythropoietin synthesis and decreased erythrocyte lifespan associated with inflammation. Our study showed a significantly higher CRP and lower albumin level in patients with anaemia, and this supports the conclusion that most of the patients suffer from anaemia related to chronic disease. However, some patients present with anaemia due to impaired renal

function or both. Anaemia of gastrointestinal origin has also been found more frequently among this group of patients, but this was not evaluated in this retrospective study. We suggest that all patients with complicated wounds in need of in-hospital treatment should have routine blood tests performed including haematology and renal function variables, and all patients admitted to hospital must be weighed on admission. In case of anaemia, an aetiological stratification is mandatory. m

References

13 Ramel A, Jonsson PV, Bjornsson S et.al.: Anaemia, nutritional status, and inflammation in hospitalized elderly. Nutrition. 2008 Nov-Dec;24(11-12):1116-22.

1 Thomsen JF, Worm AM: Anaemia in crural ulcers. Ugeskrift for laeger. 1986 Feb 17;148(8):446-7. 2 Fuoco U, Scivoletto G, Pace A, et.al: Anaemia and serum protein alteration in patients with pressure ulcers. Spinal Cord. 1997 Jan;35(1):58-60. 3 Scivoletto G, Fuoco U, Morganti B et.al: Pressure sores and serum dysmetabolism in spinal cord injury patients. Spinal Cord. 2004 Aug;42(8):473-6. 4 Schraibman IG, Stratton FJ: Nutritional status of patients with leg ulcers. J R Soc Med. 1985 Jan;78(1):39-42. 5 Raffoul W, Far MS, Cayeux MC et.al: Nutritional status and food intake in nine patients with chronic low-limb ulcers and pressure ulcers: importance of oral supplements. Nutrition. 2006 Jan;22(1):82-8.

14 Prigent A: Monitoring renal function and limitations of renal function tests. Semin Nucl Med. 2008 Jan;38(1):32-46. 15 Tidman M, Sjöström P, Jones I: A comparison of GFR estimating formulae based upon s-cystatin C and s-creatinine and a combination of the two. Nephrol Dial Transplant. 2008 Jan;23(1):154-60. 16 Riche M le, Zemlin AE, Erasmus RT et.al: An audit of 24-hour creatinine clearance measurements at Tygerberg Hospital and comparison with prediction equation. S Afr Med J. 2007 Oct;97(10):968-70. 17 Stevens LA, Coresh J, Greene T et.al.: Assessing Kidney Function – Measured and Estimated Glomerular Filtration Rate. N Engl J Med 2006 Jun 8;354(23):2473-83.

6 Don BR, Kaysent G: Serum albumin: Relationship to inflammation and nutrition. Semin Dial. 2004 Nov-Dec;17(6):432-7.

18 Thomas S, Ramperstad M: Anaemia in diabetes. Acta Diabetol. 2004 Mar;41 Suppl 1:S13-7.

7 Quinlan GJ, Martin GS, Evans TW: Albumin: biochemical properties and therapeutic potential. Hepatology 2005 Jun;41(6):1211-9.

19 Al-Khoury S, Afzali B, Shah N, et.al: Anaemia in diabetic patients with chronic kidney disease – prevalence and predictors. Diabetologia. 2006 Jun;49(6):1183-9.

8 Soeters PB: Rationale for albumin infusions. Curr Opin Clin Nutr Metab Care 2009 May;12(3):258-64.

20 Weil J, Langman MJ, Wainwright P et.al.: Peptic ulcer bleeding: accessory risk factors and interactions with non-steroidal anti-inflammatory drugs. Gut 2000 Jan;46(1):27-31.

9 Pepys MB: C-reactive protein fifty years on. Lancet. 1981 Mar 21;1(8221):653-7. 0 Jacober ML, Mamoni RL, Lima CS et.al: Anaemia in patients with cancer: role of inflammatory activity on iron metabolism and severity of anaemia. Med Oncol. 2007; 24(3):323-9. 11 Weiss G, Goodnough LT: Anaemia of chronic disease. N Engl J Med. 2005 Mar;352(10):1011-1023. 12 Fitzsimons EJ, Brock JH: The anaemia of chronic disease. BMJ. 2001 Apr 7;322(7290):811-2.

21 Chalasani N, Cotsonis G, Wilcox CM: Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia. Am. J. Gastroenterol. 1996 Nov;91(1):2329-32. 22 Wasse H, Gillen DL, Ball AM et.al.: Risk factors for upper gastrointestinal bleeding among end-stage renal disease patients. Kidney Int. 2003 Oct;64(4):1455-61. 23 Lepère C, Cuillerier E, Van Gossum A et.al.: Predictive factors of positive findings in patients explored by push enteroscopy for unexplained GI bleeding. Gastrointest. Endosc. 2005 May;61(6):709-714. 24 Zuckerman GK, Cornette GL, Clouse RE et.al.: Upper gastrointestinal bleeding in patients with chronic renal failure. Ann. Intern. Med. 1985 May;120(5):588-92.

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Science, Practice and Education

A survey of the provision of education in wound management to undergraduate nursing students INTRODUCTION Wounds and their associated problems have challenged health care providers for centuries (Moore & Cowman 2005). Despite this longevity, they continue to be a problem, with an estimated 1 1.5% of the population suffering with a wound at any given point in time (Posnett et al. 2009). Changing population demographics and the projected increase in the number of older persons suggests that the number of wounds is set to increase correspondingly, considering the association between older age and chronic disease (Moore & Cowman 2005). Economic appraisal of the provision of wound care indicates that wounds are a significant drain on health care resources. Indeed, it is proposed that 4% of the total health care expenditure is spent on the provision of wound care and interestingly, 41% of these costs are associated with nursing time (Posnett et al. 2009). The majority of wounds are managed in the community setting (Moore & Cowman 2005) and between 20%30% of community nursing time is spent on the provision of wound care (O Keeffe 2006). Wounds also impact negatively on health related quality of life, with pain being one of the most frequent issues of concern reported by patients (Spilsbury et al. 2007). Other problems experienced include nausea, fatigue, depression, sepsis, psychological disturbances, loss of function, loss of mobility and personal financial cost (Herber et al. 2007). Thus, the presence of a wound is a very difficult experience for the individual, one which impacts on all of the activities of daily living. Pre-registration education in wound management An Bord Altranais (ABA) the Irish Nursing Board, outlines that the purpose of undergraduate nurse education is that, on qualification, the individual should be equipped with the knowledge and skills necessary to practice as a competent professional nurse (ABA 2005). Competence is defined as the ability of the registered nurse to practice safely and EWMA Journal

2011 vol 11 no 1

effectively, fulfilling his/her professional responsibility within his/her scope of practice (ABA 2005). In addition to being competent to carry out their roles, nurses must develop and maintain competency and must also acknowledge the limitations of their competency (ABA 2005). Education provides the knowledge and skills necessary to carry out effective wound management (Moore & Price 2004). Not only does education heighten the awareness of the problem of wounds, but education also provides the framework to develop and maintain competency (Moore & Price 2004). All registered nurses are answerable for their own actions undertaken during the course of their duties. Education provides the framework for each nurse to ensure that the actions they take are justifiable and appropriate (ABA 2005). For many years there has been an argument that from the beginning of nurse education there appears to be a inconsistency between what is taught regarding wound management and what the content of this education should be (Beitz et al. 1998, Gould 1992). Almost 20 years ago, Gould (1992) carried out an exploratory study to test this hypotheses and in doing so assessed the amount of education nurses received relating to pressure ulcer prevention and management at undergraduate level. Using a postal survey, Gould (1992) surveyed 13 schools of nursing, information was elicited regarding aspects of prevention and treatment of pressure ulcers that was routinely taught. Further clarification was sought to determine why this particular information was selected and how it related to current literature of the time. Gould (1992) identified that education on pressure ulcers was inadequate and poorly taught, highlighting gaps between education and clinical practice. This questioned the appropriateness of educational strategies and, as such, the preparedness of newly qualified nurses for this aspect of practice (Ayello & Meaney 2003, Wilborn et al. 2009). This question still remains largely unanswered today, where discrepancies between

Dr. Zena Moore, PhD, MSc, FFNMRCSI, PG Dip, Dip Management, RGN, Lecturer in Wound Healing & Tissue Repair and Research Methodology Faculty of Nursing & Midwifery, RCSI, Dublin, Ireland zmoore@rcsi.ie Mr Eric Clarke Lecturer in Informatics, RCSI, Dublin, Ireland eclarke@rcsi.ie

On behalf of EWMA Education Committee and the Teach the Teacher Consortium. Conflict of interest: none

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current best practice guidelines and the content of undergraduate education continue to persist (Ayello et al. 2010). The significance of this is that the newly qualified nurse may not feel empowered to make appropriate clinical decisions in wound management and as such will not be in control of their own nursing practice. This in turn impacts negatively on clinical outcomes, adding to the burden of both the patient and society as a whole. It is based on this background that the Teach the Teachers education development group, of the European Wound Management Association (EWMA), conducted a survey of the EWMA Cooperating Societies. The rationale for conducting the study was to determine if the argument pertaining to the gap between the theoretical instruction and the practice of wound management was justified. The aim of the survey was, therefore, to elicit the current provision of undergraduate nursing education in wound management across Europe.

METHODS A cross section descriptive survey design was employed to gather data using a predesigned questionnaire. The questionnaire was based upon the education modules previously developed and validated by EWMA and a review of the literature. Content and face validity were determined using the expert members of the Teach the Teachers education development group. The questionnaire elicited information using both closed and open ended questions, data were at nominal and ordinal level. The questionnaire was designed and distributed online using a commercial service (Surveymonkey) which is hosted externally to RCSI. The only person who had access to the full data base was the primary administrator (EC). All responses were anonymised before data analysis. The invitation to participate was sent in November 2009, to 68 persons in 35 countries, representing the Cooperating Organisations of EWMA. Two further reminders were sent in December 2009, to capture those who did not respond to the initial call. RESULTS A response rate of was 80% was realised, with participants representing 28 of the 35 countries surveyed. As was expected, 60% of the respondents had a nursing or an education background. Satisfaction with undergraduate education in wound management Eighty seven per cent of respondents suggested that they were not satisfied with the time allocated to wound management education. Indeed, more specific details regarding the amount of time allocated demonstrated that, in 36

60% of cases, between two hours and one day in the total undergraduate programme are set aside for this aspect of the nursing undergraduate curriculum. The majority of respondents (83%) felt that undergraduate nurses do not receive sufficient education on wound management. Furthermore, 86% and 91% respectively, felt that pressure ulcer prevention and diabetic foot ulceration needed more attention. Overall, 77% felt that the content of nursing undergraduate wound management education was not adequate. The majority of respondents (68%) also highlighted that more resources for teaching were needed, including further training in wound management for those involved in programme delivery.

The content of undergraduate education in wound management As would be expected, the common wound types encountered such as pressure ulcers, leg ulcers and diabetic foot ulcers were all included in the majority of curricula, as were surgical, burn and trauma wounds. However, less than half the respondents identified that cancer wounds, lymphoedema and wounds of unusual aetiologies were addressed. The respondents were also asked to indicate if specific aspects of wound management were included in the curricula. Many respondents suggested that anatomy, pathophysiology, assessment, pain, risk factor management, wound management and management of infection were addressed. However, this finding was not consistent across programmes. For example, pain and management of infection were not addressed according to 30% and 29% of respondents respectively; furthermore, health economics and rehabilitation services were not included in the curriculum in 65% and 48% of cases respectively. Curriculum delivery The majority of the respondents suggested that the education is generally provided using face to face lectures (88%) and practical demonstrations (52%). Other aspects of blended learning, such as discussion forums and online lectures were rarely embraced. In addition, simulation, hands on interactive sessions and role play were infrequently utilized. Similar findings were noted for education provision in the clinical environment, with teaching in the wound clinic, bedside teaching, face to face lectures and practical demonstrations being the most commonly cited. Competency assessment The vast majority of respondents (82%) suggested that studentsâ&#x20AC;&#x2122; competency in wound assessment was not assessed during their undergraduate training. Assessment was reported to take place mainly in the form of a written examination or written assignment used to assess the studentâ&#x20AC;&#x2122;s knowledge. A small percent of respondents (28%) EWMA Journalâ&#x20AC;&#x201A;

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reported using assessment of student-patient interactions and practical demonstrations by the student.

proaches utilised vary enormously in terms of content, mode of delivery and assessment strategies employed. These findings are in keeping with the arguments that prevail within the literature (Ayello & Meaney 2003, Wilborn et al. 2009) and the work of Caliri et al. (2003) who surveyed 3rd and 4th year undergraduate student nurses. Caliri et al. (2003) identified that they had low knowledge scores pertaining to pressure ulcer prevention. However, students who had attended specific wound management education programmes or who actively sought information via online resources scored consistently higher on knowledge tests. This suggests that it is those who stretch themselves beyond the core curriculum that gain the necessary knowledge attainment. These findings pose a challenge for the future provision of wound management, when one bears in mind that that the purpose of undergraduate nurse education is that, on qualification, the individual should be equipped with the knowledge and skills necessary to practice as a competent professional nurse (ABA 2005). Indeed, Funkesson et al. (2007), when exploring nurses’ reasoning process during pressure ulcer prevention care planning, noted that experience, knowledge and an in depth understanding of the patient were important variables influencing decision making. Furthermore, individual characteristics of the nurse influenced their ability to problem solve within the clinical setting. Of these characteristics, the content of education

General comments from respondents The respondents were asked if they had any general comments about the provision of education on wound management. The comments received suggest a lack of a systematic approach to this aspect of the curriculum, for example, respondent 1 wrote: “We don’t have a common program for nurses in wound care. That means that some schools have a lot of subjects covered, while others have nothing at all”. A further respondent suggested that the teacher themselves had a major influence over the nature of education provided, for example: “The content and methods depends on the interest of the teacher” (respondent 2). This is supported by another respondent who said “Education is not complete it depends on the interests of the educator and accepted program” (respondent 3). These comments were largely similar to all those received, displaying diversity in the approach to wound management education, in addition to the significant role of the teacher.

Discussion The survey indicates that the respondents do not feel that the student nurse is adequately prepared for the practice of wound management. Furthermore, the educational ap-

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Using electrical stimulation to treat scars Effect of elasticity on sub-bandage pressure in two bandaging systems: a RCT Why do wound dressings have a potential analgesic effect? Predicting which organisms might cause infection in a resource-poor setting Potential effects of honey on angiogenesis: an animal study A bizarre presentation of necrotising fasciitis in the cervicofacial region Severe hidradenitis suppurativa: a case report Psychological profile of patients with neglected malignant wounds Marjolin’s ulcer in the natal cleft mimics anal canal carcinoma Reconstruction of a chronic late post-nephrectomy wound

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received and the level of academic attainment were central determinants of effective decision making. The importance of knowledge in facilitating effective clinical decision making is well alluded to in the literature (Kallman & Suserud 2009, Pancorbo-Hidalgo et al. 2007, Smith & Waugh 2009, Tweed & Tweed 2008). The quality of knowledge gained is therefore a key consideration in ensuring that the nurse is delivering care that is appropriate for individual patients (Ayello & Lyder 2007). Demographic forecasts suggest that in the next 50 years there will be three times more older persons living in our world (U.S. Census Bureau 2004). Indeed, by the year 2050, it is estimated that older individuals will comprise almost 17% of the global population compared to 7% in 2002 (U.S. Census Bureau 2004). The older population appears to be at greater risk of the development of chronic wounds due to the likelihood of underlying neurological and cardiovascular problems (Bliss 1990). Therefore, the problem of wounds is set to increase in tandem with forecasted changes in demographics. The costs associated with wound care are considerable and a lack of standardised policies and education strategies compound this cost and contribute to increased morbidity and mortality of patients (Harding & Boyce 1998). Lindohlm et al (1999) identified that limited availability of both adequately trained personnel and agreed standards to guide practice compounds the suffering of patients and increases costs in an already overstretched health budget. With limitations in resources and an increasing demand on service delivery, the choice of the most appropriate, effective treatments are paramount to the success of the health service (Levin 2001). In order to guarantee that this is a real possibility, greater attention needs to be given to ensuring that newly qualified nurses are equipped with the knowledge and skills necessary to provide safe, effective wound care.

Conclusion On qualification the nurse should be equipped with the knowledge and skills necessary to practice as a competent professional. The literature espouses with arguments pertaining to discrepancies between current best practice guidelines and the content of undergraduate education. The significance of this is that the newly qualified nurse may not feel empowered to make appropriate clinical decisions in wound management and, as such, will not be in control of their own nursing practice. This, in turn, impacts negatively on clinical outcomes, adding to the burden of both the patient and society as a whole. A survey was conducted to determine if the argument pertaining to the gap between the theoretical instruction and the practice of wound management was justified. Sixty

eight persons in 35 countries were invited to participate in a survey exploring the provision of undergraduate nursing wound management education. The findings indicate that the respondents do not feel that the student nurse is adequately prepared for the practice of wound management. Furthermore, the educational approaches utilised vary enormously in terms of content, mode of delivery and assessment strategies employed. These findings pose a challenge for the future provision of wound management, when one considers that for wound management to be effective the individual needs to have adequate knowledge and skills. Thus it is argued that greater attention needs to be given to the provision of undergraduate wound management education in order that newly qualified nurses are in a position to practice competently. m

References An Bord Altranais (2005) Requirements and standards for nurse registration education programmes, 3rd edn (Altranais AB ed.). An Bord Altranais, Dublin. Ayello EA & Lyder CH (2007): Protecting patients from harm: preventing pressure ulcers in hospital patients. Nursing 37, 36-40. Ayello EA & Meaney G (2003): Replicating a survey of pressure ulcer content in nursing textbooks. Journal of Wound Ostomy and Continence Nursing 30, 266-271. Ayello EA, Zulkowski KM & Capezuti E (2010): Pressure ulcer content in undergraduate programs. Nursing Outlook 58, e4. Beitz JM, Fey J & O Brien D (1998): Perceived need for education vs. actual knowledge of pressure ulcer care in a hospital nursing staff. MedSurg Nursing 7, 293-301. Bliss M (1990) Geriatric medicine In Pressure sores: clinical practice and scientific approach (Bader DL ed.). Macmillan, London, pp. 65-80. Caliri M, Miyazaki M & Pieper P (2003): Knowledge of Pressure Ulcers by Undergraduate Nursing Students in Brazil. Ostomy and Wound Management 49. Funkesson KH, Anbäcken EM & Ek AC (2007): Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. International Journal of Nursing Studies 44, 1109-1109. Gould D (1992): Teaching students about pressure sores. Nursing Standard 18, 28-31. Harding KG & Boyce DE (1998) Wounds: The Extent of the Burden. In Wounds Biology and Management (Leaper D & Harding KG eds.). Oxford University Press, Oxford, pp. 1-4. Herber OR, Schnepp W & Rieger MA (2007): A systematic review of the impact of leg ulceration on patients’ quality of life Health and Quality of Life Outcomes 5, 44. Kallman U & Suserud BO (2009): Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment - a survey in a Swedish healthcare setting. Scand J Caring Sci 23, 334-341. Levin A (2001): The Cochrane Collaboration. Annals of Internal Medicine 135, 309-312. Lindohlm C, Bergsten A & Berglund E (1999): Chronic Wounds and Nursing Care. Journal of Wound Care 8, 5-10. Moore Z & Cowman S (2005): The need for EU standards in wound care: an Irish survey. Wounds UK 1, 20-28. Moore Z & Price PE (2004): Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. Journal of Clinical Nursing 13, 942-951. O Keeffe M (2006) The prevalence of pressure ulcers in the Irish community setting. In Pressure Ulcer Guidelines. A Pocket Guide (Smith & Nephew ed.). Smith & Nephew Ltd, Dublin. Pancorbo-Hidalgo PL, García-Fernández FP, López-Medina IM & López-Ortega MJ (2007): Pressure ulcer care in Spain: nurses’ knowledge and clinical practice. Journal of Advanced Nursing 58, 327-338. Posnett J, Gottrup F, Lundgren H & Saal G (2009): The resource impact of wounds on health-care providers in Europe. Journal of Wound Care 18, 154-161. Smith D & Waugh S (2009): An assessment of registered nurses’ knowledge of pressure ulcers prevention and treatment. The Kansas Nurse 84, 3-5. Spilsbury K, Nelson A, Cullum N, Iglesias C, Nixon H & Mason S (2007): Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. Journal of Advanced Nursing 57, 494-504. Tweed C & Tweed M (2008): Intensive care nurses’ knowledge of pressure ulcers: development of an assessment tool and effect of an educational program. American Journal of Critical Care 17, 338-347. U.S. Census Bureau (2004) International population reports WP/02, global population profile, 2002-2004 (U.S. Census Bureau ed.). U.S. Government Printing Office, Washington DC. Wilborn D, Halfens R & Dassen T (2009): Evidence-based education and nursing pressure ulcer prevention textbooks: does it match? Worldviews on Evidence-Based Nursing 6, 167-172.

EWMA Journal

2011 vol 11 no 1

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Caring for Patients with Hard-to-Heal Wounds – Homecare Nurses’ Narratives

Camilla Eskilsson PhD Student University of Borås, School of Health Sciences. Contact: camilla.eskilsson@hb.se Conflict of interest: none

This short paper is based on my presentation at the EWMA conference in Geneva May 26-28th, 2010. (Abstract no. 82, Free Paper Session). The study is more thoroughly described in a full article (Eskilsson, 2010).

is further illuminated by the following four constituents, Taking Responsibility, Showing Respect for the Whole Person, Being Confident in Order to Offer Confidence, and Seeing Time and Place as Important.

Introduction and aim People who suffer from hard-to-heal wounds are often treated at home. Patients have described how their lifeworld changes as a consequence of their wounds. Their suffering concerns feelings of isolation, imprisonment in one’s body, pain and being ashamed of malodorous wounds1,2,6,7,8 explain how nurses describe how they are affected by treating patients with malodorous exuding wounds. There is still a lack of studies from the caregiver perspective in the context of homecare in Sweden. Therefore, the aim of this study is to describe how homecare nurses experience care for patients with hard-to-heal wounds.

Taking Responsibility: Nurses feel responsible for their patients and for healing their wounds, alleviating their pain and instilling hope in them. Nurses speak on their patients’ behalf and play an important role as they point out the importance of mutual trust between nurses and physicians. Unfortunately, nurses report a lack of interest from the physicians so their collaboration is not as good as it could be. Their responsibility is not always easy to handle. When patients are not responsive to recommended care, nurses need to accept that and find alternative solutions. If there is a risk of amputation, it has been described as a mourning process. The nurse-patient relationship tends to be strengthened if the nurse has the courage to stand by the patient’s side, even if the nurse is deeply affected by this grief. To handle this burdensome situation, nurses share their experience with their colleagues in terms of reflection during their normal work. They describe how their responsibility is hard to fulfil since their time is limited and the number of patients is high, so they become forced to distance themselves and only carry out isolated measures. Their responsibility to heal wounds is sometimes an unattainable dream but nevertheless they feel unsuccessful if that healing fails.

Method This study has a lifeworld phenomenological approach2. By using this approach, I tried to meet the complexity of the phenomenon, “caring for patients with hard-to-heal wounds”. The phenomenological approach is characterised by openness for the phenomenon and ongoing critical reflection of its meanings. This follows the whole process, from data collection to analysis. The inclusion criteria were nurses in home care with experience of caring for patients with hard-to-heal wounds. The heads of two home care districts were given permission to inform them about the study. Seven nurses agreed to participate after verbal and written information. Interviews were conducted, transcribed and analysed5. Results The essential meaning of the phenomenon, “caring for patients with hard-to-heal wounds” is characterised by a tension between burdensome yet enriching care. Nurses try to handle this tension by using tools and strategies such as reflection, acceptance and distance. The essential meaning 40

Presented at the 20th Conference of the European Wound Management Association May 2010 Geneva, Swizerland

It’s like a failure, sort of // I mean, they were helped and their wounds were supposed to heal // but I couldn’t save this one, really, and it feels like when you were little and you wanted to be a superhero and fix it, you want it to end well, but that’s not always the case … yeah, it’s like a failure, sort of.

Showing Respect for the Whole Person: As a way of showing respect, the nurses describe how they try to identify boundaries for the patients’ integrity. They make the wound dressing sensitive so that the patient does not feel pain or shame. It is important to see the whole person and not only EWMA Journal

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Science, Practice and Education

the wound. One nurse described it as if the focus was transferred from the wound to the whole person. This holistic view is further illustrated when nurses point out the importance of instilling hope, spreading a positive spirit and supporting the patient’s positive attitude. This promotes the wound healing as well as giving a sense of well-being. You don’t always know which dressing is the best for that particular wound, and at the same time it’s the body and soul that heal the wound, not the dressing.

In respect to the patient and to their own limitations, nurses struggle to find an invisible boundary to be personal but not private. The more experience they have the easier it is to handle this issue. Being Confident in order to Offer Confidence: Confidence is experienced as ambiguous; nurses need to feel confident themselves in order to offer confidence to a patient. Where nurses have experience of mutual trust with their patients; then their relationship is deep and gives both of them confidence. They are further strengthened by increased knowledge, experience and support from physicians. Once again cooperation is pointed out as crucial but not always satisfactory. I think it doesn’t seem as if they [physicians] think it is fun; often they hand over a great deal of responsibility to the nurses.

Confidence is challenged when nurses lose control over a situation. Even if they know they are not irreplaceable, they feel anxious and disappointed when a patient’s wound gets worse due to lack of continuity. Sometimes they feel frustrated and not confident in letting the patient go when the wound is healed and the caring relationship comes to an end. Seeing Time and Place as Important: Care in a patient’s home and caring for patients with hard-to-heal wounds is both enriching and burdensome. A home can be ergonomically and hygienically inappropriate. Wound dressing is time-consuming, and with the potentially unsuitable environment and sometimes strenuous working positions it can be burdensome. Nurses can find it hard going to treat a patient and feel a relief when the meeting is over. To some extent, working environment might play a role // you know that you’re going to get incredibly tired in your back because you have to stand in such a way that you almost get... crazy, because it hurts so much and you get stiff // and you build this up before you even get there // and when you’re done you can finally feel like... (Int: Relief when you’re leaving?) Yeah, that’s right, a relief.

Limited time is frustrating. Caring for patients with hardto-heal wounds takes a lot of time and results in consequences for the rest of the nurses’ duty. Different strategies EWMA Journal

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are described for handling stress. Some nurses are focused and present when meeting with the patient. Others feel as if they are already on their way to the next one. On the other hand, the home-environment and the time-consuming care are also contributing factors to describing it as enriching care. In a patient’s own home, s/he is experienced as a whole person and not merely a wound. The nurse-patient relationship deepens over time through multiple visits. This is something that makes nurses’ work enriching.

Conclusions In the heart of this burdensome yet enriching care, there needs to be confidence both in the nurse and in the patient. Some key words for this confidence could begin with the letter C: n Cooperation with Communication: Good cooperation between the different professions around the patient depends on good communication. It is necessary for caregivers to act like a team with the patient in focus. It might be necessary to clarify roles and responsibilities for the different professions and create forums for more constructive communication. n Competence strengthens the nurses’ confidence and contributes to satisfaction in the caring action. Learning and caring can be supported by supervised reflection4. Thereby the burdensome aspects of care can be shared and handled in a constructive way. n C as in seeing: This study was conducted from the nurses’ perspective but nevertheless the patient is always the lead actor and should always be in focus. Can it be better described than as one of the nurses said in the interviews? ... here’s a leg that’s more or less rotten, but it’s on her, it’s her leg, and then she needs to feel that we respect the whole of her ... that, I think, is respect... I want her to feel that we do the best we can and that we respect her as a whole person – that, I think, is really important. m

References 1. Briggs, M. & Flemming, K (2007). Living with leg ulceration: a synthesis of qualitative research. Journal of Advanced Nursing 59-(4), 319-328. 2. Dahlberg, K., Dahlberg, H. & Nyström, M. (2008). (2nd ed.). Reflective lifeworld research. Lund: Studentlitteratur. 3. Ebbeskog, B. & Ekman, S.-L. (2001). Elderly Persons´ Experiences of Living with Venous Leg Ulcer: Living in a Dialectal Relationship Between Freedom and Imprisonment. Scandinavian journal of caring sciences, 15, 235-243. 4. Ekebergh, M. (2007). Lifeworld-based reflection and learning: a contribution to the reflective practice in nursing and nursing education. Reflective Practice, 8(3), 331-343. 5. Eskilsson, C., & Carlsson, G. (2010). Feeling confident in burdensome yet enriching care: Community nurses describe the care of patients with hard-to-heal wounds. International Journal Of Qualitative Studies On Health And Well-Being, 5(3). Retrieved October 19, 2010, from http://www.ijqhw.net/index.php/qhw/article/view/5415 6. Haram, R. & Nåden, D. (2003). Hvordan pasienter opplever å leve med leggsår. Vård i Norden 23 (68) 2, 16-21. 7. Lindahl, E., Norberg, A., & Söderberg, A. (2008). The Meaning of Caring for People With Malodorous Exuding Ulcers. Journal of Advanced Nursing, 62(2), 163-171. 8. McMullen, M. (2004). The relationship between pain and leg ulcers: a critical review. British Journal of Nursing 13(19), 30-36.

EBWM

ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 8, 2010

Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds

Sally Bell-Syer, MSc Managing Editor Cochrane Wounds Group Department of Health Sciences University of York United Kingdom sembs1@york.ac.uk Conflict of interest: none

Anne Eskes, Dirk T Ubbink, Maarten Lubbers, Cees Lucas, Hester Vermeulen Citation: Eskes A, Ubbink DT, Lubbers M, Lucas C, Vermeulen H. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD008059. DOI: 10.1002/14651858.CD008059. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Hyperbaric oxygen therapy (HBOT) is used as a treatment for acute wounds (such as those arising from surgery and trauma) however the effects of HBOT on wound healing are unclear. Objectives: To determine the effects of HBOT on the healing of acute surgical and traumatic wounds. Search strategy: We searched the Cochrane Wounds Group Specialised Register (25 August 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3), Ovid MEDLINE (1950 to August Week 2 2010 ), Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 24, 2010), Ovid EMBASE (1980 to 2010, Week 33) and EBSCO CINAHL (1982 to 20 August 2010). Selection criteria: Randomised controlled trials (RCTs) comparing HBOT with other interventions or comparisons between alternative HBOT regimens. Data collection and analysis: Two review authors conducted selection of trials, risk of bias assessment, data extraction and data synthesis independently. Any disagreements were referred to a third review author. Main results: Three trials involving 219 participants were included. The studies were clinically heterogeneous, therefore a meta-analysis was inappropriate. One trial (48 participants with burn wounds undergoing split skin grafts) compared HBOT with usual care and reported a significantly higher complete graft survival associated with HBOT (95% healthy graft area risk ratio (RR) 3.50; 95% confidence interval (CI) 1.35 to 9.11). A second trial (36 participants with crush injuries) reported significantly more wounds healed with HBOT than with sham HBOT (RR 1.70; 95% CI 1.11

to 2.61) and fewer additional surgical procedures required with HBOT: RR 0.25; 95% CI 0.06 to 1.02 and significantly less tissue necrosis: RR 0.13; 95% CI 0.02 to 0.90). A third trial (135 people undergoing flap grafting) reported no significant differences in complete graft survival with HBOT compared with dexamethasone (RR 1.14; 95% CI 0.95 to 1.38) or heparin (RR 1.21; 95% CI 0.99 to 1.49). Many of the predefined secondary outcomes of the review, including mortality, pain scores, quality of life, patient satisfaction, activities daily living, increase in transcutaneous oxygen pressure (TcpO2), amputation, length of hospital stay and costs, were not reported. All three trials were at unclear or high risk of bias. Authors’ conclusions: There is a lack of high quality, valid research evidence regarding the effects of HBOT on wound healing. Whilst two small trials suggested that HBOT may improve the outcomes of skin grafting and trauma these trials were at risk of bias. Further evaluation by means of high quality RCTs is needed. Plain language summary Hyperbaric oxygen therapy for acute surgical and traumatic wounds Acute surgical and traumatic wounds occur as a result of a trauma or surgical procedures and whilst many heal uneventfully, sometimes poor local blood supply, infection, damage to the blood vessels, or a combination of factors results in acute wounds taking longer to heal. Hyperbaric oxygen therapy (HBOT), which involves placing the patient in an airtight chamber and administering 100% oxygen for respiration, at a pressure greater than 1 atmosphere, is sometimes used with the aim of speeding wound healing. The aim is to bathe all fluids, tissues and cells of the body in a high concentration of oxygen. This review did not find any high quality research evidence showing that HBOT is beneficial for wound healing. Two poor quality studies suggested benefits associated with HBOT. The first in patients with crush injuries, showed improved wound healing and fewer adverse outcomes. The second reported improved survival of split skin grafts. A third trial reported no benefits associated with HBOT for skin grafts. Further, better quality research is needed to determine the effects of HBOT on wound healing.

EWMA Journal

2011 vol 11 no 1

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Cyanoacrylate microbial sealants for skin preparation prior to surgery Allyson Lipp, Cheryl Phillips, Paul Harris, Iwan Dowie Citation: Lipp A, Phillips C, Harris P, Dowie I. Cyanoacrylate microbial sealants for skin preparation prior to surgery. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD008062. DOI: 10.1002/14651858.CD008062. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Surgical site infections are a continuing concern in health care. Microbial sealant is a liquid applied to the skin immediately before surgery. It is thought to contribute to reducing surgical site infections by sealing in the skin flora to prevent contamination and infection of the surgical site. Objectives: To assess the effects of the preoperative application of microbial sealants (compared with no microbial sealant) on the rates of surgical site infection in people undergoing clean surgery. Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), Ovid MEDLINE (1950 to April Week 3 2010), Ovid MEDLINE – In-Process & Other Non-Indexed Citations (searched 10 May 2010), Ovid EMBASE (1980 to 2010 Week 18) and EBSCO CINAHL (1982 to 10 May 2010). We searched bibliographies and contacted manufacturers of microbial sealants for unpublished studies. There were no restrictions based on language, date or publication status. Selection criteria: Randomised controlled trials (RCTs) were eligible for inclusion if they involved people undergoing clean surgery in an operating theatre and compared the use of preoperative microbial sealants with no microbial sealant. Data collection and analysis: All review authors independently extracted data on the characteristics, risk of bias and outcomes of the eligible trial. Main results: One small trial (177 participants undergoing hernia repair) met the inclusion criteria. There was no statistically significant difference in the rates of surgical site infection (three patients in the control group developed a surgical site infection compared with none in the intervention group; risk ratio (RR) 0.17, 95% CI 0.01 to 3.19, P = 0.23). Authors’ conclusions: There is currently insufficient evidence as to whether the use of microbial sealants reduces the risk of surgical site infection in people undergoing clean surgery and further rigorous RCTs are required.

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Plain language summary Cyanoacrylate microbial sealants for skin preparation prior to surgery Surgical site infection is a serious complication of surgery. Microbial sealant is a liquid applied to the surface of the skin immediately before surgery to seal in any bacteria living on the skin that may pose a risk of infection. Before applying the sealant the skin  EWMA Journal

2011 vol 11 no 1

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at the operation site is usually prepared with a solution of 10% povidone-iodine. Only one eligible randomised trial was identified that compared the impact on surgical site infection rates of sealant compared with no sealant; this trial was too small to detect any important difference in surgical site infection rates as statistically significant therefore further research is needed.

Publication in The Cochrane Library Issue 12, 2010

Risk assessment tools for the prevention of pressure ulcers Zena EH Moore, Seamus Cowman Citation: Moore ZEH, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub2. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. This is an updated review for which there have been new searches and a new trial added to the review. ABSTRACT Background: Pressure ulcer risk assessment is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines, however it is not known whether using a risk assessment tool makes a difference to patient outcomes. We conducted a review to clarify the role of pressure ulcer risk assessment in clinical practice. Objectives: To determine whether using structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers. Search strategy: For this first update, we searched the Cochrane Wounds Group Specialised Register (searched 21 September 2010); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3); Ovid MEDLINE (2007 to September Week 1 2010); Ovid MEDLINE - In-Process & Other Non-Indexed Citations (September 20, 2010) and Ovid EMBASE (2007 to 2010 Week 37) and EBSCO CINAHL (2007 to 17 September 2010).

Main results: For the original review, no studies were identified that met the inclusion criteria. For this first update, we identified and included one small, cluster randomised study. The study included 256 people randomised by ward into three groups in which the methods of risk assessment were: the Braden pressure ulcer risk assessment tool and training; unstructured risk assessment and training; and unstructured risk assessment alone. There was no statistically significant difference between the groups in terms of pressure ulcer incidence however the study was underpowered to detect a clinically important difference in pressure ulcer incidence. Authors’ conclusions: One small RCT was identified which evaluated the effect of risk assessment on patient outcomes; there was no statistically significant difference in pressure ulcer incidence between patients who were assessed using structured risk assessment compared with those receiving unstructured risk assessment. Methodological limitations of this study prevent firm conclusions regarding whether the use of structured, systematic pressure ulcer risk assessment tools, in any healthcare setting, reduces the incidence of pressure ulcers. The effect of structured risk assessment tools on pressure ulcer incidence needs to be evaluated. Plain language summary Risk assessment tools used for preventing pressure ulcers Pressure ulcers (also known as bed sores, pressure sores and decubitus ulcers) are areas of localised injury to the skin, underlying tissue or both, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure ulcers mainly occur in people who have limited mobility, nerve damage or both. Pressure ulcer risk assessment is part of the process used to identify individuals at risk of developing a pressure ulcer. Risk assessments generally use checklists and their use is recommended by pressure ulcer prevention guidelines. This update of the review found one study that was eligible for inclusion. The study found no difference in the number of new pressure ulcers that developed in individuals assessed using structured risk assessment compared with unstructured risk assessment. However, there were methodological limitations with this study. Therefore, to date, very little research has studied the effect of risk assessment and we are unable to draw any firm conclusions. m

Selection criteria: Randomised controlled trials (RCTs) comparing the use of structured, systematic, pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools. Data collection and analysis: Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for eligibility, obtained full versions of potentially relevant studies and screened these against the inclusion criteria.

EWMA Journal

2011 vol 11 no 1

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EWMA Journal

Previous Issues

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

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

English

Buerger Disease (Thromboangiitis Obliterans): A Clinical Diagnosis Peter Highlander, Charles C. Southerland, Eric VonHerbulis, Aldo Gonzalez Improving the Detection of Pressure Ulcers Using the TMI ImageMed System David Judy, Brian Brooks, Kristopher Fennie, Courtney Lyder, Claude Burton Negative-Pressure Wound Therapy for Musculoskeletal Tumor Surgery Vasileios I. Sakellariou, Andreas F. Mavrogenis, Panayiotis J. Papagelopoulos

Finnish

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

Volume 9, no 3, October 2009 Alcohol-based hand-rub versus t raditional surgical scrub and the risk of surgical site infection Mohammed Y. Al-Naami Woundswest: Identifying the prevalence of wounds within western Australia’s public health system Nick Santamaria, Keryln Carville, Jenny Prentice An exploration of current practice in n ursing documentation of pressure ulcer prevention and management Julie Jordan O Brien Dressings and Topical Agents for T reating Donor Sites of Split-Skin Grafts Sanne Schreuder et al.

Haava, no. 4, 2010 www.shhy.fi Thema: Woud care products Treatment of burned skin, wounds and healthy skin: Development of cleaning towel with Plurogen Neal Koller Resin form spruce to wound care Hannu Saraja Continuing development in management of wound exudate Johanna Takkunen Positive effects by negative pressure Johanna Takkunen Magic of green dressing Eira Nikkilä

English

International Wound Journal, vol. 8, issue 1, 2011 www.interscience.wiley.com/journal Genetic and epigenetic events in diabetic wound healing Haloom Rafehi, Assam El-Osta, Tom C Karagiannis Economic evaluation of Vacuum Assisted Closure Therapy for the treatment of diabetic foot ulcers in France Sarah J Whitehead, VÈronique L Forest-Bendien, Jean-Louis Richard, Serge Halimi, Georges Ha Van, Paul Trueman Investigating the humoral immune response in chronic venous leg ulcer patients colonised with Pseudomonas aeruginosa Jasper N Jacobsen, Anders S Andersen, Michael K Sonnested, Inga Laursen, Bo Jorgensen and Karen A Krogfelt

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

Advances in Skin & Woundcare, vol. 24, no 1, 2011 www.aswcjournal.com

English

International Journal of Lower Extremity Wounds vol. 9, no, 4, 2010 http://ijlew.sagepub.com A Difficult Case of Necrotizing Fasciitis Caused By Acinetobacter baumannii Bartolo Corradino, Francesca Toia, Sara di Lorenzo, Adriana Cordova, Francesco Moschella Hydrosurgery: Alternative Treatment Technique for Management of Chronic Osteomyelitis and Septic Arthritis of Hallucial Joint of a Juvenile Foot Mayukh Bhattacharyya, Helen Bradley, Bruno E. Gerber Abscesses That Did Not Respond to Just Incision Drainage and Antibiotics Anupma Jyoti Kindo, Sidharth Giri, Shalinee Rao, Arcot Rekha Squamous Cell Carcinoma Masquerading as a Trophic Ulcer in a Patient With Hansen’s Disease Sandhya Venkatswami, S. Anandan, Nikilesh Krishna, C.D. Narayanan

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

EWMA Journal

2011 vol 11 no 1

EWMA English

English

Journal of Tissue Viability, vol. 20, no 1, 2011 www.journaloftissueviability.com

Rane (Wound) journal www.lecenjerana.com

The impact of tilting on blood fl ow and localized tissue loading S.E. Sonenblum , S.H. Sprigle Pressure ulcers in Jordan: A point prevalence study A. Tubaishat , D. Anthony , M. Saleh The effects of soybean agglutinin binding on the corneal endothelium and the re-establishment of an intact monolayer following injury – A short review S.R. Gordon

In every edition of the journal we publish 6 original studies. Also, we publish infromations about new therapies, reports from congresses, EWMA meetings and etc.

Journal of Wound Care, vol. 20, no 1, 2011 www.journalofwoundcare.com Simple wound care facilitates full healing in post-earthquake Haiti F.J. Stephenson Does the postoperative dressing regimen affect wound healing after hip or knee arthroplasty? A. Collins Retrospective study of pressure ulcer prevalence in Dutch general hospitals since 2001 Y. Amir, J. Meijers, R. Halfens Heel damage and epidural analgesia: is there a connection? C.M. Loorham-Battersby, W. McGuiness Topical negative pressure (TNP) as an adjunct to compression for healing chronic venous ulcers D.C. Kieser, J.A. Roake, C. Hammond, D.R. Lewis Survey of fungi and yeast in polymicrobial infections in chronic wounds S.E. Dowd, J. Delton Hanson, E. Rees et al

Dutch

Content of one of journals Surgical treatment of diabetic foot Prof. Dr Vucetic and associates Examination of correlation between risk factors of venous ulceration on apparence granulation and time of healing, Prim. Dr Delic Symposium about pressure ulcer Prim. Dr Huljev Importance of treatment of anemy with patients with ulceration Dr Calija Activities of nurses in prevention and treatment of pressure ulceration nurse Milutinovic Importance of continuing education – Study education on Slovenia nurse Nesovic

English

Basic fibroblast growth factor is beneficial for postoperative color uniformity in split-thickness skin grafting Sadanori Akita, Kozo Akino, Aya Yakabe, Katsumi Tanaka, Kuniaki Anraku, Hiroki Yano, Akiyoshi Hirano Salvaging diabetic foot through debridement, pressure alleviation, metabolic control, and antibiotics Francisco G. Cabeza de Vaca, Alejandro E. Macias, Welsy A. Ramirez, Juan M. Munoz, Jose A. Alvarez, Juan L. Mosqueda, Humberto Medina, Jose Sifuentes-Osornio The effectiveness of the Australian Medical Sheepskin for the prevention of pressure ulcers in somatic nursing home patients: A prospective multicenter randomized-controlled trial Patriek Mistiaen, Wilco Achterberg, Andre Ament, Ruud Halfens, Janneke Huizinga, Ken Montgomery, Henri Post, Peter Spreeuwenberg, Anneke L. Francke

Dutch Journal of Woundcare NTVW, vol 6. no 1, 2011 www.ntvw.nl Interview: Dr. Zena Moore, “My goal is to get the EWMA involved in the clinical practice of wound care” ‘Woundcare needs structure and a documented approach” Day to Day practice of woundcare nurses in Belgian Nursinghome

German

Introduction of the Dutch Advisory Board Woundcare Presentation of all members and main goal Scientific: Healing process of hard to heal wounds Andriessen A

Lietuvos chirurgija, vol.8, no 3, 2010 www.chirurgija.lt Measuring T cell reactivity for predicting heart transplant rejection Malickaite R, Jurgauskiene L, Simanaviciene S, Maneikiene V V, Sudikiene R, Rucinskas K Cardiac transplantation in pediatric patients: experience of Vilnius Cardiac Surgery center Sudikiene R, Malickaite R, Lebetkevicius V, Tarutis V, Rucinskas K, Sirvydis V Current clinical guidelines for cardiac resynchronization therapy: the experience of Vilnius Cardiology – Angiology center Maneikiene V, Marinskis G, Aidietis A, Aidietiene S, Celutkiene J, Rucinskas K, Sirvydis V, Laucevicius A

English

Wund Management, vol. 4, no 6, 2010 English abstracts are available from www.mhp-verlag.de The role of podiatry in prevention and treatment of diabetic foot syndrome (DFS) – the „foot perestrioka” in Germany C. Zemlin Orthonyxia – nail correction braces W. Knörzer Case reports for the application of nail braces B. Mittenzwei

Report: Surgical treatment of pressure ulcers

English

Wound Repair and Regeneration, vol. 18, no 6, 2010 www.wiley.com

Phlebologie, no 5, 2010 www.schattauer.de Long Therm results and analysis of correlations 5 years after varicose vein stripping Faubel et. al. Guideline Diagnosis and treatment of the Varicose vein disease Kluessa et. al. Guideline Diagnosis and treatment of the Ulcus cruris venosum (Venous ulcer) – Short version Gallenkemper

EWMA Journal

2011 vol 11 no 1

Swedish

Tidskriften Sår vol. 4, no 4, 2010 Team hjälper patienten – men kräver mycket av personalen Pär Eliasson Att förbättra vården: pennans makt Anne Hindhede Alla sår ska ha en såransvarig Ylva Haraldsdotter

Scandinavian

Wounds (SÅR) vol. 18, no 4, 2010 www.saar.dk Improved quality of life for people with chronic venous leg ulcers – an ethnographic study Ana Maria D’Auchamp Wound organisation in ”Region Sjælland” no nurses, no treatment! Nurse in a medical practice – lack of dialogue and sparring Jens Fonnesbech

EWMA

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM)

in Brussels Since 2007, EWMA has successfully offered students of wound management from institutes of higher education across Europe the opportunity to take part of academic studies whilst participating in the EWMA Conference. In 2011 it is expected that students from the institutes listed below will participate in the EWMA UCM in Brussels. The opportunity of participating in the EWMA UCM is available to all teaching institutions with wound management courses for health professionals. EWMA strongly encourages teaching institutions and students from all countries to benefit from the possibilities of international networking and access to lectures by many of the most experienced wound management experts in the world. Yours sincerely

Zena Moore, Chair of the EWMA Education Committee, EWMA President

Participating institutions: Portugal Haute École de Santé Geneva, Switzerland

KATHO university college Roeselare Belgium

University of Hertfordshire United Kingdom UK

HUB Brussels Belgium

Escola Superior de Enfermagem de Lisboa

Universidade Católica Portuguesa Porto, Portugal

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

EWMA Journal

2011 vol 11 no 1

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EWMA DOCUMENTS In May 2010 the following EWMA Document was published:

Outcomes in controlled and compara tive studies on non-healin g wounds

Outcomes in controlled and comparative studies on non healing wounds – Recommendations to improve q uality of evidence in wound m anagement The document is written by members of the EWMA Patient Outcome Group, based on common discussions in the group.

Recommenda tions to impr ove the qual of evidence in ity wound manag ement

A EWMA Patie

nt Outcome G

roup Documen

EWMA front cover.

indd 5

20/5/10 13:14: 26

Other EWMA documents e.g. Position Documents can be downloaded from www.ewma.org and are available in English, French, German, Italian and Spanish. It is possible to obtain permission to translate the EWMA Documents into other languages. Please contact EWMA Secretariat for permission. Please note that the EWMA Position Documents express the view of EWMA at the time for publication of the document. Titles of Position Documents: Pain at wound dressing changes – Spring 2002 Understanding compression therapy – Spring 2003 Wound bed preparation in practice – Spring 2004 Identifying criteria for wound infection – Autumn 2005 Management of wound infection – Spring 2006 Topical negative pressure in wound management – Spring 2007 Hard-to-heal wounds: a holisitc approach – Spring 2008

For further details contact: EWMA Secretariat, Martensens Allé 8, 1828 Frederiksberg, Denmark Tel: +45 7020 0305 Fax: +45 7020 0315 ewma@ewma.org

EWMA

Review

MICROBIOLOGY OF WOUNDS Edited by Steven Percival and Keith Cutting. CRC Press: Boca Raton, U.S. 2010. www.crcpress.com

dited by two well-known scientists and health professionals, Dr Percival and Dr Cutting, this is one of the newest books on this topic at this time. Both editors have considerable knowledge and experience of the field of wounds and especially on all topics related to bacteria on wounds. Both, also, are surrounded by a large and experienced panel of contributors, most of them involved in and leading the new paradigm of biofilmology of wounds. The book is divided into 13 chapters from an overview of microbiology and biofilms to factors affecting impaired healing and antimicrobial interventions from different points of view. With a very easy to read and understand writing style, the authors cover the topic well, from the general concepts to the more complex, in-depth knowledge: n In chapter 1 there is a very good résumé of microbiology in general which is then linked to the concept of biofilms and the impli cations for public and medical health. n Chapter 2 is about human skin and microbial flora. It includes a review of the anatomy of human skin and the interactions with normal flora, highlighting the most common species that inhabit the skin and the relations with normal states or infections, and also their role in the interactions with the host and the immune system. n Going through chapters 3 and 4 the focus is on wounds, the third on wounds in general as an introduction and the fourth a deeper examination of burns. Differences and diagnoses of wounds are addressed here. n Chapter 5 delves into the complexity of the healing process both normal and altered. Each of the phases and cells and molecules EWMA Journal

2011 vol 11 no 1

José Verdú Soriano PhD, MSc Nurs, BSc Nurs, DUE-RN Member of EWMA Editorial Board Conflict of interest: none

involved in the healing process are explained, linking with the aetiology of chronic wounds and delayed healing. n In chapter 6 the classic concepts of chronic wound infections related to the biofilm paradigm as a parallelism are addressed. The controversial aspect of sampling of wounds for microbiological diagnostic is explained here with the difficulties and the differences in the process. n Chapter 7 is a debate about classical chronic wound classifications as venous, diabetic or pressure ulcers. It is stated that those classifications are problematic: “… division of wounds based on aetiologies is becoming recognized as incomplete and is very unsatisfying …” Reflections on the common factor of all of them are mentioned and the role of biofilms on wounds starts here: “The observation that biofilm is prevalent in chronic wounds and rare in acute wounds challenges the position that biofilm is the common element related to the chronic inflammatory  state”.

n Chapter 8 presents an in-depth lecture about biofilms, and their implications on wound healing. The evidence of biofilm on chronic wounds is established and an explanation of how a biofilm infection is characterised is offered. n Chapter 9 is an interesting review of enzymes and, especially, the group of proteases and the factors that lead to matrix metalloproteinase stimulation. Again this chapter links the topic with bacterial biofilms. n In chapter 10 there is an explanation of the stages of acute wound healing in relation to both innate and adaptive immune responses which are responsible for clearing infection from the wound site and in preventing subsequent infection. The immune processes that occur when systemic and local factors lead to the development of a chronic wound are also described, together with bacterial strategies and mechanisms for evading the immune system including the development of a biofilm that can further inhibit or evade the immunological response. n The remaining three chapters (11-13) are dedicated to antimicrobial interventions. Chapter 11 explains all the possibilities in general; chapter 12 is dedicated to Wound Dressings and Other Topical Treatment Modalities in Bioburden Control, and finally, chapter 13 is the authors’ comparison between basic wound care and advanced technologies but taking into account all the factors that are involved in managing chronic wounds. Examples, for instance, silver impregnated wound dressings as an advanced wound technology, are explained. In this book you’ll find a mix of classic and up to date information about microbiology and chronic wounds. I believe that this is an easy way to introduce the amazing world of biofilmology; a new paradigm that is emerging in the study of wounds and is, in the next years, likely to change our understanding and the manner of how we treat wounds. m

Management of the Diabetic Foot Theory & Practice 4 Day Course, 3 - 6 October 2011 Pisa, Italy This 4 day theoretical course & practical training gives participants a thorough introduction to all aspects of diagnosis, management and treatment of the diabetic foot. Lectures will be combined with practical sessions held in the afternoon at the diabetic foot clinic at the Pisa University Hospital. Lectures will be in agreement with the International Consensus on the Diabetic Foot & Practical Guideline on the Management and Prevention on the Diabetic Foot.

This course is endorsed by EWMA.

www.diabeticfootcourses.org 52

EWMA

Pisa International Diabetic Foot Course 2010 The 2nd Diabetic Foot Course, “Management of the Diabetic Foot”, was held in Pisa, Italy, 4-7 October 2010.

he key objectives of the course were, firstly, to increase the knowledge and operative skills in the management of the diabetic foot. Secondly, to support the establishment of multidisciplinary diabetic foot clinics or departments based on the recommendations of the International Consensus Document, and, thirdly, to facilitate international consensus on the structure of treatment of the diabetic foot. The course structure aimed to combine theory with practical training. Theoretical lectures were held in the mornings and practical sessions were held in the afternoons in the specialised diabetic foot clinic at the University Hospital of Pisa. By combining lectures from different specialists and training in the clinic, the aim was for the course participants to gain insight in both the theory of the field and the practical methods used in the clinic. The participants in the course included clinicians with various professions such as endocrinologists, vascular and orthopaedic surgeons, specialised nurses, chiropodists, podiatrists and other healthcare professional.

Thirty-seven participants from 16 different countries, 9 international faculty members and 14 national faculty members took part in the 2010 course. An evaluation survey and general comments during the course suggested great satisfaction with the outcome of the course, especially emphasizing the benefits of combining practice and theory in the course. The participants found that the theoretical lectures were very interesting. Likewise the practical hands-on sessions were very popular, giving the participants new angles to their particular fields of expertise. Finally the course provided an excellent forum for the exchange of knowledge, for exploring ways to handle the problems in the field of diabetic foot and for discussions among the participants and with the faculty. Hopefully the participants gained a lot of knowledge which they can apply to their own field in their own countries. m

Alberto Piaggesi MD, Professor, Endocrinologist Director of the Diabetic Foot Section of the Pisa University Hospital Dept of Endocrinology and Metabolism University of Pisa Pisa Italy Course organiser Conflict of interest: none

Participants and faculty members in the 2010 Course.

Testimonials on video from participants and faculty members in the 2010 Course are available on: http://diabeticfootcourses.org/courseprogramme/testimonials-2010.html The 3rd Diabetic Foot Course will be held in Pisa 3-6 October 2011. Further information is available on www.diabeticfootcourses.org or by contacting the Course Secretariat: info@diabeticfootcourses.org

EWMA Journal

2011 vol 11 no 1

EWMA

LEG ULCER & COMPRESSION SEMINARS 2011

Finn Gottrup Chair EWMA Patient Outcome Group

Hugo Partsch ICC President Conflict of interest: none

EWMA and the International Compression Club (ICC) in collaboration are proud to announce a sequence of seminars on the subject of leg ulceration and compression therapy. The ICC continuously argues that compression therapy is an extremely effective treatment modality, the efficacy of which is frequently underestimated or neglected. There are important areas in medicine in which compression therapy could be beneficial to patients but is not used because of lack of knowledge of the prescribers. Likewise, there are countries in which compression therapy has no tradition and is unknown to patients who could profit from it. In 2007 EWMA initiated, and has since supported and contributed to, the implementation of the Central & Eastern European Leg Ulcer Project (LUP) carried out by project teams and wound associations in Slovenia, Poland and the Czech Republic. Through a combination of improved training of nurses and physicians and access to knowledge and modern materials, in particular for compression therapy, the project has generated clear results in terms of improved treatment and healing of leg ulcers. OBJECTIVES & TARGET GROUPS

with Leg Ulceration and Compression Therapy. Decision-makers on issues relating to prevention and treatment of leg ulceration will also benefit from participating. Companies will be offered the opportunity to exhibit during the seminars. VENUES

The seminars will take place in three capital cities situated along the Danube River in the Central European region: n Bratislava, Slovakia, 10 October 2011 (In collaboration with the Slovak Wound Care Association (SSOOR) n

Vienna, Austria, 11 October 2011

(In collaboration with the Austrian Wound A ssociation (AWA)

Budapest, Hungary, 13 October 2011

(In collaboration with the Hungarian Wound Care Society (MSKT) and the Hungarian Association for the Improvement in Care of Chronic Wounds and Incontinentia (SEBINKO)

Preliminary programme 08:30 Registration 09:30 Welcome & introduction 09:45 Lectures: 1. Setting the scene: What are we talking about 2. How big is the problem? Outcome and evidence 3. Who is suffering from this? 10:45 Coffee break and exhibition 11:15 Compression: 1. When? – Differential diagnosis, investigations 2. How? – Compression materials 3. Why? – How does compression work?

The main objectives of the seminars are to: n Provide a status on the current treatment of Leg Ulceration and use of compression therapy in the countries and regions where the seminars take place. n Introduce the ICC guidelines for compression therapy and discuss how a national implementation of the guidelines could take place. n Present the key findings of the EWMA Leg Ulcer Project teams in Poland, Slovenia and the Czech Republic and discuss how the results can be used for improving treatment of leg ulcers in other countries.

REGISTRATION AND FURTHER INFORMATION

The faculty will consist of international speakers and local experts in the field of Leg Ulceration and Compression Therapy. The seminars target as key participants physicians, nurses and industry representatives working

Please visit www.ewma.org/ewma-icc-seminar for updated information regarding the Leg Ulceration and Compression seminars. The seminars will be conducted in English and local languages with simultaneous translation. On-line registration will open by 1 April 2011.

12:45 Lunch and exhibition 13:15 Satellite Symposium 14:15 Parallel workshops, supported by the industry: 1. Clinical and instrumental diagnosis 2. Compression bandages 3. Ulcer kits 15:00 Coffee break and exhibition 15:30 What is the situation in the host country and what should be done? 16:00 Closing

EWMA Journal

2011 vol 11 no 1

BRATISLAVA 10 OCTOBER VIENNA 11 OCTOBER BUDAPEST 13 OCTOBER A draft programme of the Leg Ulcer & Compression Seminars in each country will be available on the website www.ewma.org/ewma-icc-seminar during January 2011 and will be updated regularly.

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

Organised by: EWMA & International Compression Club (ICC)

EWMA

EWMA Activities Update The EWMA Patient Outcome Group The Patient Outcome Group published a document in Journal of Wound Care in June 2010, which discusses the issues of outcomes in wound care research. The document sets up recommendations on what needs to be done in order to improve evidence in wound care and how to meet an accepted level of rigour for studies in wound management. Furthermore, the document discusses how to develop a consistent and reproducible approach to define, evaluate and measure appropriate and adequate outcomes in RCTs as well as other clinical studies. EWMA considers the discussion on how to evolve evidence in research of wound care a high priority and hope that all members of EWMA and professionals working with wounds will c ontribute to this debate. Right now the group is working on how to disseminate the document and to continue the discussion with relevant professionals and administrators which EWMA hopes will lead to a general European consensus on evidence in wound management. For further information about the EWMA Patient Outcome Group, please visit http://ewma.org/ english/patient-outcome-group.html. Any questions concerning the Patient Outcome Group or the document can be sent to the EWMA Secretariat: ewma@ewma.org The document can be downloaded free of charge from www.ewma.org.

EFORT / EWMA EWMA and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) continues the collaboration in 2011 by organising mutual guest sessions at the annual conferences.

EFORT at EWMA At EWMA 2011 in Brussels (May 25-27, 2011) EFORT will organise a guest symposium Thursday 26 May 14.30-15.30. The title of the symposium is: When you can see metal through the wound: Infection after orthopaedic s urgery. Chairman: MER Dr Oliver Borens

From Biofilm to Implant Infection Speaker: PD Dr Andrej Trampuz, CHUV Lausanne

Is there a way to destroy bacterial biofilm with an orthopaedic implant in situ? Speaker: Prof Dr Klaus Kirketerp-Møller, Hvidovre Hospital

How to treat local infection with visible implant after osteosynthesis Speaker: MER Dr Oliver Borens, CHUV Lausanne

www.ewma2011.org

EWMA at EFORT Likewise at the EFORT conference in Copenhagen (June 1-4, 2011), EWMA in cooperation with the Diabetic Foot Study Group (DFSG) will have a joint session Saturday 4 June 08:00-09:30. The session will be a part of a special “Foot and Infection” string that particular day at the conference. The EWMA/DFSG session is entitled Problem wounds – a multidisciplinary challenge. Chairman: Zena Moore Pressure ulcer prevention Speaker: Zena Moore, PhD, MSc, RCSI, Ireland

Biofilm in diabetic foot ulcers Speaker: Klaus Kirketerp-Møller, Dr, Hvidovre Hospital, Denmark

Health Economics and outcome in wound healing Jan Apelqvist, MD, PhD, University of Malmö, Sweden

Wound organisation and evidence in wound healing Finn Gottrup, Prof, Bispebjerg Hospital, Denmark

www.efort.org/copenhagen2011

EWMA Journal

2011 vol 11 no 1

21st Conference of the European Wound Management Association 21 Congrès de l’Association Européenne de Soins de Plaies

EWMA 2011 25 -27 May

25 -27 mai

Brussels · Belgium

Bruxelles · Belgique

gual: Bilin French sh & ée Engli ultan m i s n s ctio nçai Tradu lais et Fra Ang

Organised by the European Wound Management Association in cooperation with:

Organisé par: L’Association Européenne de Soins de Plaies (EWMA) qui sera organisée en coopération avec:

Francophone Nurses’ Association in Stoma Therapy, Wound Healing and Wound Belgian Federation of Woundcare CNC Wound Management Association

WWW.EWMA.ORG/EWMA2011

Corporate Sponsor Contact Data Corporate A

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

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

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

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

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

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

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

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

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

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

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

Use the EWMA Journal to profile your company Deadline for advertising in the May 2011 issue is 15 March 2011

EWMA Journal

2011 vol 11 no 1

EWMA

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

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

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

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

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

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

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

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

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

Polyheal Ltd. 42 Hayarkon St. 81227 Yavne Israel Tel: +972 8 932 4000 Fax: +972 8 932 4001 www.polyheal.co.il

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

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

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

Phytoceuticals Zollikerstrasse 44 8008 Zurich Switzerland Tel: +41 43 499 15 66 Fax: +41 43 499 15 67 www.phytoceuticals.ch

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

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

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

2011 vol 11 no 1

Organisations

Conference Calendar Conferences

Theme

2011

Days

City

Country

Annual Meeting of the CNC VZW Wound Management Association

Feb

17-18

Kortrijk

Belgium

Annual Meeting of Lithuanian Wound Management Association (LWMA)

Feb

Kaunas

Lithuania

Mar

Manchester

United Kingdom

Apr

5-6

Kettering

United Kingdom

The 24th Annual symposium on Advanced Wound care and Wound healing society (SAWC/WHS)

Apr

14-17

Dallas

USA

Annual Meeting of the Austrian Wound Association (AWA)

Apr

29-30

Salzburg

Austria

Annual Meeting of the Chronic Wounds Initiative (ICW)

May

11-12

Bremen

Germany

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

May

12-14

Bologna

Italy

May

25-27

Brussels

Belgium

12th EFORT Congress

Jun

1-4

Copenhagen

Denmark

International Lymphoedema Framework Conference Towards Global implementation of Best Practice – Opportunities and Challenges

Jun

16-18

Toronto

Canada

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

Guidelines and quality standards of Fascinating Biotechnology

Jun

23-25

Hannover

Germany

14th Annual European Pressure Ulcer Meeting (EPUAP)

Pressure Ulcer Research Achievements Translated to Clinial Guidelines

AugSep

31-2

Oporto

Portugal

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

Biofilm and Health Economics in Bone and Joint Infections

Sep

15-17

Copenhagen

Denmark

Pisa International Diabetic Foot Courses

Oct

3-6

Pisa

Italy

EWMA Leg Ulcer and Compression Seminars

Oct

Bratislava

Slovakia

EWMA Leg Ulcer and Compression Seminars

Oct

Vienna

Austria

EWMA Leg Ulcer and Compression Seminars

Oct

Budapest

Hungary

Oct

13-14

Budapest

Hungary

First International Pediatric Wound Care Symposium

Oct

27-29

Rome

Italy

Biannual meeting of the Woundcare Consultant Society

Nov

22-23

Utrecht

Netherlands

23-25

Vienna

Austria

Annual meeting of Journal of Wound Care Tissue Viability Society Conference 2011

Making a Difference for a Shared Vision for Multi-Disciplinary Research, Practice and Policy

21st Conference of the European Wound Management Association (EWMA)

Common Voice – Common Rights

EWMA Master Course 2011

Is Oedema a Challenge in Wound Healing?

2012 22nd Conference of the European Wound Management Association

May

For web addresses please visit www.ewma.org

EWMA values your opinion and would like to invite all readers to participate in shaping the organisation. Please submit possible topics for future conference session and notifications on relevant conferences and projects across Europe. EWMA is also interested in receiving book reviews, articles etc. Please contact the EWMA Secretariat ewma@ewma.org

EWMA Journal

2011 vol 11 no 1

· EW

IA T I O N

E U R OP EA

E· RS

MASTER COU MA

· M A NA GE M E

·A

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

13-14 October 2011 · Budapest, Hungary

Is Oedema a Challenge in Wound Healing? The course will bridge theory and practice and a broad range of topics will be addressed, including: n n n n n n n n

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

Participants in the EWMA Master Course will be entitled to CME Credits.

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

www.ewma.org/woundcourse

The annual meeting of GAIF;

GAIF

Associated Group of Research in Wounds

João Gouveia GAIF www.gaif.net

A STEP FORWARD The annual conference of Grupo Associativo de Investigação em Feridas (GAIF) was held May 20th-21st, 2010, at the Conference Center, Pavilhão Atlântico, in Lisbon. A wide participation of mainly nurses, doctors and pharmacists brought the number of visitors to over 1,200 with 28 sponsors adding to the attendance. The international guest speakers were all highly acclaimed people in their field: Professor Hugo Partsch, Dr. Michael Edmonds, Professor Phil Bowlers, Professor Patricia Grocott, Dr. Maarten Lubbers (EWMA), Alison Hopkins and Fran Worboys, and Dr. Othon Kriticos. Local speakers included opinion leaders such as Elaine Pina, Professor Vaz Carneiro, and Professor Pedro Ferreira, among other prestigious, speakers. A range of healthcare related topics were pre sented in the conference including discussions on important tools for all healthcare professionals involved in wound treatment such as the validation of Martin-Payne Classification and the validation of SGA.

During the conference Michael Edmonds pre sented the concept of ILegx (Interdisciplinary Leg Initiative), which GAIF is now disseminating to all healthcare professionals. Also, Maarten Lubbers presented the methodology adopted for the development and dissemination of the new NPUAP/EPUAP guidelines as well as discussing the recommendations for prevention of pressure ulcers in ER. In addition, Patricia Grocott addressed delegates on the several possible ways of management of malignant wounds allowing the audience to access the latest knowledge in this field. The National Project for Prevalence of Pressure Ulcers and Leg Ulcers was presented. This project is a partnership between GAIF, CWISUC and UMP. This event was highly positive and successful, underlining the important role of GAIF as a vital organization in wound care research in Portugal. m

MEMORIAL It is with great sadness that the EWMA Secretariat received the news of João Gouveia death in October. João was a great collaborator for EWMA. His contribution to not only EWMA, but wound healing in general has been greatly appreciated. João Carlos Gouveia Ferreira was the Chairman of the GAIF (Grupo Associativo de Investigação em Feridas, Associated Group of Research in Wounds, Portugal), and as a nurse at Health Center of Pampilhosa da Serra, he published numerous scientific articles and lectured at various events and conferences. João Gouveia was as in his role as acting president of GAIF a great collaborator for EWMA – Especially, but not only, in the organisation of the EWMA 2008 Conference i Lisbon, Portugal. He will be dearly missed. EWMA send their thoughts to João’s wife, Cristina Miguéns.

EWMA Journal

2011 vol 11 no 1

Organisations

The International Lymphoedema Framework ILF

The International Lymphoedema Framework

Agnès Carrot International Lymphoedema Framework Coordination agnes.carrot@cricp.org.uk www.lympho.org

The International Lymphoedema Framework (ILF) was established as a UK charity in 2009 and is proud to announce it has recently gained partnership with EWMA. Developed from a project aiming at bringing together the main stakeholders involved in the management of lymphoedema in the United Kingdom in 2002, ILF rapidly spread to become an international project with an objective to support individual countries develop a long-term strategy for lymphoedema management. A new structure and the development of ILF Frameworks In order to implement its vision for the future, ILF has strived this year to build a strong and new structure consisting in a board of Directors, an International Advisory Board, an Executive Team and a series of Committees in charge of implementing the strategy defined by the Board of Directors. Currently these committees reflect ILF’s field of competencies and main actions such as Best Practice, Conference, Dataset, Developing countries, Education, International, Patient Advocacy, Publications, Research and Development. In parallel, ILF believes that the way forward to a better management of lymphoedema worldwide is extended through effective partnerships with: n international organisations (such as World Health Organisation, World Alliance for Wound and Lymphedema Care, The Global Alliance to Eliminate Lymphatic Filariasis) n groups of practitioners n patients associations n industry n expert practitioners and researchers in the field of lymphoedema n National Lymphoedema Frameworks Projects ILF is pleased to work with official frameworks partners which are currently the American Lymphoedema Framework Project (ALFP), the Canadian Lymphedema Framework (CLF) and ILF Japan. Some other Frameworks initiatives have emerged in the past months in France, Australia, Denmark and Sweden. There has also been a will and a need to create many other partnerships in Europe and the rest of the world. In 2010, ILF representatives have been visiting some of its existing Frameworks partners in Japan and Canada but have also created new opportunities of work after visits in South Africa and Scandinavia for example.

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2011 vol 11 no 1

Main Objectives Since its launch, ILF has been driven by three key elements that encompass its vision and plan of action: best practices, research and data. In the near future, the ILF Best Practice Committee will go through a systematic and continuous review of research to ensure that Best Practices are up to date and that evidence-based practise is implemented. ILF will work in partnership with Frameworks to undertake systematic reviews of key subjects. It will finally develop a consensus methodology to ensure that the Best Practices are adapted to the context of care in each country to allow adoption by them. Simultaneously, research studies will be engaged on an international scale. Finally and in order to implement an international dataset that all frameworks contribute to and that answers fundamental questions such as the size and complexity of lymphoedema and produces treatment outcomes to help profile of lymphoedema to be raised globally, ILF is starting to use electronic means including web based solutions which include a dataset and electronic means of collecting data for other studies. 2011 ILF Conference in Toronto, Canada: The next opportunity to network with Key Opinion Leaders from around the World Following last year’s conference success in Brighton, UK, the 3rd ILF Conference will be held on June 16-18, 2011, at the Marriott Eaton Centre in Toronto, Canada. This conference will be facilitated thanks to the hosting partnership between ILF, the Canadian Lymphedema Framework and the Lymphedema Association of Ontario (LAO). There will be two major launches in the field of Lymphoedema: the ILF Best Practice Document, 2nd Edition in partnership with the American Lymphedema Framework Project (ALFP) and the ILF Lymphoedema Dataset, in partnership with ILF Japan and the ALFP. Delegates and keynote speakers are expected from around the world and the programme is built on our vision around Best Practices, Data and Research. The scientific programme will be adapted to specific needs of international lymphoedema experienced and non experiences practitioners, international patients and patients’ advocates. To find out about all the industry sponsoring, education, promotion and networking opportunities please visit www.lympho.org m

Organisations

News from WAWLC WAWLC World Alliance for Wound and Lymphoedema Care

John M Macdonald MD, FACS General Secretary World Alliance for Wound and Lymphedema Care Department of Dermatology and Cutaneous Surgery Miller School of Medicine, University of Miami www.wawlc.org

The World Alliance for Wound and Lymphoedema Care (WAWLC), which was presented in the EWMA Journal 2010 Vol. 10 No 1, held its annual meeting in Geneva on the 16-18 November 2010 with the main objective of analysing activities during 2010 and planning ahead for 2011.

n Establishment of two not for profit foundations: WAWLC-USA and WAWLC-Geneva. The WAWLC-USA was created to handle donations from Haiti for the seminar and will be retained to facilitate North American fund raising.

For any information about WAWLC organisation, activities and member organisations please visit www.wawlc.org

SELECTED TOPICS DISCUSSED AT THE GENEVA MEETING

Summary of WAWLC events in 2010 n WAWLC Wound and Lymphedema seminar, Port-au-Prince, Haiti, July 7-9. 35 physicians and 14 nurses from Haiti received Certificates of Achievement. Faculty: Terry Treadwell, MD, FACS, Barbara Bates-Jensen, PhD, RN, Janice Young, RN, BSN, MPH, CWON, John M Macdonald MD, FACS. n White Paper “Wound and Lymphoedema Management” published in 1,000 copies in May by the World Health Organization (WHO), available for download at http://whqlibdoc.who. int/publications/2010/9789241599139_eng. pdf. The white paper was used as text book for the training seminar in Haiti. n Presentations on WAWLC given at the following wound events: SAWC Fall & spring meetings; EWMA Geneva Conference; American Podiatric Medical Association; Advances in Skin and Wound Care; Argentina wound and lymphedema conference; International Lymphoedema Framework Brigh ton Conference; AMSUS (USA Military Medical Convention); UBUNTU meeting South Africa; CAWC Board Spring meeting.

Economy In 2010 WAWLC has received financial contributions for a total of USD 41,000. Funds have been spent to cover expenses related to: Realisation of the training seminar in Haiti including faculty travelling expenses; Travelling expenses related to: A) The General Secretary presenting WAWLC at the UBUNTU conference in South Africa and B) The Executive Board participating in the Geneva meeting; The technical support for constructing a donation module for the WAWLC website. At the end of 2010 WAWLC has a balance of approximately USD 10,000. Membership Membership categories and annual fees were discussed and will be established by early 2011. Secretariat WAWLC activities are currently based entirely on the voluntary work of representatives of the organisations which have established WAWLC and the General Secretary. WAWLC will in 2011 need a coordinator who can support the General Secretary and coordinate the activities of the WAWLC working groups.

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2011 vol 11 no 1

WAWLC Meetings in 2011 The 2011 Annual Meeting is scheduled to take place in Geneva on the 16-18 November. The next WAWLC Executive Board and Advisory Board meeting will be in Brussels, Belgium, during the EWMA Conference 26-28 May. WAWLC will also hold a meeting at the ILF seminar in Toronto, Canada 16-18 June. Working Groups The four working groups are now chaired as follows: n Country Support Group: Jan Rice (La Trobe University, Australia) n Program Development Group: Terry Treadwell (Association for the Advancement of Wound Care, U.S.A) n Advocacy & Fundraising: Henrik J. Nielsen (EWMA Secretariat) n Research, Monitoring and Evaluation: Christine Moffat (International Lymphoedema Framework) Agenda for 2011 n Robyn Bjork, MPT, WCC, CLT has presented her recent work with Podoconiosis in Ethiopia. A proposal for a future training program and intervention in Ethiopia, under the auspices and support of WAWLC has been elaborated. n The Kuwait Ministry of Health has sent a request to WAWLC to conduct a site visit to Kuwait in February 2011. It is intended that WAWLC will conduct two educational programs in Kuwait in 2011. n WAWLC has received a request from Uganda for educational support. It is intended that this initiative be developed by Wound Healing A ssociation of South Africa under the direction of Liezl Naude and Hiske Smart. n WAWLC will in 2011 as a minimum be represented at the following meetings: SFFPC Paris, France; Eucomed AWCS, Paris, France; SAWC in Dallas, Texas; EWMA 2011 Brussels, Belgium; SOBEST, Recife, Brazil; ILF in Toronto, Canada, ILS in Malmoe, Sweden. n Collaboration with WHASA post UBUNTU at the Wounds International, Cape Town conference in February: – Algorithm/flow chart on basic treatment for wounds specifically designed for Africa. This will be printed on posters and distributed. The WAWLC logo will accompany the WHASA logo. – A “grassroots” training session (4 hours). WAWLC will be listed as a co-sponsor and will be represented by 2 WAWLC members on the faculty. – A T-shirt Walk-a-thon for WAWLC. T-shirts will be sold with the WAWLC name and the emblazoned ”WALK the WAWLC for Wound Care”. All money collected will go to WAWLC. m

EWMA Journal

2011 vol 11 no 1

22nd Conference of the European Wound Management Association

EWMA 2012 23 -25 May · 2012

ienna · Austria

Organised by the European Wound Management Association in cooperation with: Austrian Wound Association, AWA

WWW.EWMA.ORG

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

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

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

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

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

BEFEWO Belgian Federation of Woundcare www.befewo.org

BWA Bulgarian Wound Association www.woundbulgaria.org

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

ICW Chronic Wounds Initiative www.ic-wunden.de

LBAA Latvian Wound Treating Organisation

LUF The Leg Ulcer Forum www.legulcerforum.org

LWMA Lithuanian Wound Management Association www.lzga.lt

MASC Maltese Association of Skin and Wound Care http://mwcf.madv.org.mt/default. asp?contad=About

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

CNC Clinical Nursing Consulting – Wondzorg www.wondzorg.be

MWMA

CSLR

Macedonian Wound Management Association

Czech Wound Management Society www.cslr.cz

NATVNS

CWA

National Association of Tissue Viability Nurses, Scotland

Croatian Wound Association www.huzr.hr

NIFS

DGfW

NOVW

German Wound Healing Society www.dgfw.de

DSFS

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

FWCS Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

GAIF

Norwegian Wound Healing Association www.nifs-saar.no

Dutch Organisation of Wound Care Nurses www.novw.org

PWMA Polish Wound Management Association www.ptlr.pl

ROWMA Romanian Wound M anagement Association www.artmp.ro

Associated Group of Research in Wounds www.gaif.net

EWMA Journal

2011 vol 11 no 1

Organisations

SAfW

SWHS

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

Serbian Wound Healing Society www.lecenjerana.com

SWHS

SAfW

Swedish Wound Healing Society www.sarlakning.se

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

TVS

SAWMA

Tissue Viability Society www.tvs.org.uk

Serbian Advanced Wound Management Association www.serbiawound.org

URuBiH

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

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

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

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

WMAOI Wound Management A ssociation of Ireland www.wmaoi.org

SSiS Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

WMAK

SWCA

WMAS

Wound Management Association of Kosova

Slovak Wound Care Association www.ssoor.sk

Wound Management Association Slovenia www.dors.si

WMAT

SUMS

Wound Management A ssociation Turkey

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

WMS (Belarus) Wound Management Society

International Partner Organisations AWMA

Debra International www.debra-international.org

NZWCS

AAWC

ILF

SOBENFeE

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

International Lymphoedema Framework www.lympho.org

Brazilian Wound Management Association www.sobenfee.org.br

Australian Wound Management Association www.awma.com.au

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

Associated Organisations

EWMA Journal

Leg Club

LSN

Lindsay Leg Club Foundation www.legclub.org

The Lymphoedema Support Network www.lymphoedema.org/lsn

2011 vol 11 no 1

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

Science, Practice and Education

6 Who will take on

Ali Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi,

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

25 The reconstructive clockwork as a 21st century concept in wound surgery Karsten Knobloch, Peter M. Vogt

29 Anaemia in patients with chronic wounds

Lotte M. Vestergaard, Isa Jensen, Knud Yderstraede

35 A survey of the provision of e ducation in wound management to undergraduate nursing students Zena Moore, Eric Clarke

40 Caring for Patients with Hard-to-Heal Wounds – Homecare Nurses’ Narratives Camilla Eskilsson

EBWM

42 Abstracts of Recent Cochrane Reviews Sally Bell-Syer

EWMA

46 International Journals Previous Issues 51 Microbiology of Wounds – a Review José Verdú Soriano

53 Pisa International Diabetic Foot Course 2010 Alberto Piaggesi

54 Leg Ulcer & Compression Seminars 2011 Finn Gottrup, Hugo Partsch

58 EWMA Activities Update 58 Corporate Sponsor Contact Data

Organisations

60 Conference Calendar 62 The annual meeting of GAIF – a Step Forward João Gouveia

63 The International Lymphoedema Framework Agnès Carrot

64 News from WAWLC John M Macdonald

66 Cooperating Organisations 67 International Partner Organisations 67 Associated Organisations