EWMA Journal October 2011

Volume 11 Number 3 October 2011 Published by European Wound Management Association

PATIENTS AND PROFESSIONALS WORKING TOGETHER

The EWMA Journal ISSN number: 1609-2759 Volume 11, No 3, October, 2011 Electronic Supplement October 2011 www.ewma.org

EWMA Council

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

Jan Apelqvist

Zena Moore

President

Immediate Past President

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

Gerrolt Jukema

Corrado M. Durante

Patricia Price

Recorder

Treasurer

Secretary

EWMA web site www.ewma.org Editorial Office please contact: EWMA Secretariat Nordre fasanvej 113 2000 Frederiksberg, Denmark.

Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org Layout: Birgitte Clematide

Paulo Alves

Luc Gryson

Barbara E. den Boogert-Ruimschotel

Mark Collier

Javorka Delic

Dubravko Huljev

Nada Kecelj-Leskovec

Martin Koschnick

Eskild Winther Henneberg

Sebastian Probst

Printed by: CS Grafisk A/S, Denmark Copies printed: 12,000 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 January 2012. Prospective material for publication must be with the editors as soon as possible and no later than November 1st 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.

All articles are peer reviewed by EWMA Scientific Review Panel.

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.

All issues of EWMA Journal are CINAHL listed.

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Elia Ricci

Rytis Rimdeika

Salla Seppänen

Robert Strohal

José Verdú Soriano

CO-OPERATING ORGANISATIONS’ BOARD Christian Thyse, AFISCeP.be Tommaso Bianchi, AISLeC Elia Ricci, AIUC Aníbal Justiniano, APTFeridas Gerald Zöch, AWA Jan Vandeputte, BEFEWO Vladislav Hristov, BWA Els Jonckheere, CNC Milada Francu, CSLR Dubravko Huljev, CWA Martin Koschnick, DGfW Eskild Winther Henneberg, DSFS Salla Seppänen, FWCS Pedro Pacheco, GAIF J. Javier Soldevilla, GNEAUPP

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

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

EWMA JOURNAL SCIENTIFIC REVIEW PANEL Paulo Jorge Pereira Alves, Portugal Caroline Amery, UK Michelle Briggs, UK Stephen Britland, UK Mark Collier, UK Rose Cooper, UK B. E. den Boogert-Ruimschotel, Netherlands Javorka Delic, Serbia Corrado Maria Durante, Italy Bulent Erdogan, Turkey Madeleine Flanagan, UK Milada Franců, Czech Republic Peter Franks, UK Francisco P. García-Fernández, Spain

Luc Gryson, Belgium Marcus Gürgen, Norway Eskild W. Henneberg, Denmark Alison Hopkins, UK Gabriela Hösl, Austria Dubravko Huljev, Croatia Gerrolt Jukema, Netherlands Nada Kecelj, Slovenia Klaus Kirketerp-Møller, Denmark Karsten Knobloch, Germany Zoltán Kökény, Hungary Severin Läuchli, Schwitzerland Maarten J. Lubbers, Netherlands Sylvie Maume, France

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

5 Editorial

Sue Bale, Zena Moore

Science, Practice and Education 7 Challenges facing district nurses in the prevention of pressure ulcers Lynne Watret

12 Clinical application of stem cells in wound ­healing: A near future?

Benoit I Hendrickx

ELECTRONIC SUPPLEMENT October 2011

16 Understanding the Patient Experience: Does empowerment link to clinical practice?

Patricia Price

21 The Influence of Egyptian Propolis on Induced Burn Wound Healing in Diabetic Rats – Antibacterial Mechanism

Volume 11 Number 3 October 201 1 Published by European Wound Man agement Association

ELEC TRO NIC SUP PLEM ENT

Emad T. Ahmed, Osama M. Abo-Salem, Ali Osman

Scientific Communication 26 PURSUN UK: The Pressure Ulcer Research Service User N ­ etwork for the UK Delia Muir

28 Perspective of the European Patients’ Forum Developing Collaboration Nicola Bedlington

EBWM 30 Abstracts of recent ­Cochrane reviews Sally Bell-Syer

EWMA 34 EWMA Journal Previous Issues and Other Journals 36 EWMA 2011 Brussels Luc Gryson

38 EWMA update: EWMA Patient Outcome Group

PATIENTS

AND PRO

FESSIONAL

S WORKIN

G TOGET

HER

Patricia Price

40 Book Review

Alison Hopkins, Maarten J. Lubbers

42 Advanced Wound Care Sector (AWCS) Hans Lundgren

46 Appreciations 48 New Council members 50 EWMA Activities Update 52 EWMA Corporate Sponsors

Organisations 54 Conference Calendar 56 The Cooperating Organisations Board Meeting 2011 Zena Moore

58 MSF – Improving wound care in Africa Eric Comte

60 MSF – Wound care nurse in Cameroon Audrey Reverdi

62 AAWC – The Association for the Advancement of Wound Care Terry Treadwell

64 AISLeC – Report from the Annual Meeting 2011 Paulo Alves

66 AISLeC – The “pressure ­ulcer” phenomenon and the ­national prevalence

The October 2011 edition of EWMA Journal Electronic Supplement will consist of scientific articles from the German journals Zeitschrift für Wundheilung and Wund Management.

These articles have not previously been published in English.

The Electronic Supplement will be ­available at www.ewma.org in the ­beginning of November so please keep a close eye on the website.

Angela Peghetti

68 STW – Conference report from Belarus Leonid N. Rubanov

70 Cooperating Organisations 71 International Partner Organisations Associated Organisations EWMA Journal

2011 vol 11 no 3

WWW.EWMA.ORG 3

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Vivano. Ease of negative pressure therapy.

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For further information about clinical evidence and Vivano, please visit www.vivanosystem.info Vivano – Negative pressure therapy system

helps healing.

Why is EWMA interested in Patient and Professional Collaboration?

W

elcome to the October edition of the EWMA Journal.

I would like to introduce myself as the new editor and in doing so to thank Dr Carol Dealey for all of her hard work in developing the EWMA Journal. She had done an excellent job over the past 7 years. My hopes and aspirations are to continue to make progress in the quality of the journal and to lead the editorial team in publishing highly relevant articles that reflect the broad range of interests of our members and readership. Such interests span basic science, translational research, clinical practice, economics, patient outcomes measures and quality of life, through publishing original research, reviews, and historical papers.

In this issue of EWMA Journal we are focusing on the over all theme “Patients and professionals working together”. To introduce this theme I have asked Zena Moore, Immediate Past President, to give a brief introduction.

I hope you will find the chosen articles interesting and will enjoy reading this edition.

Sue Bale, Editor

T

he emphasis on EBP (Evidence-Based Practice) today has emerged due to changes in health service delivery, including greater emphasis on value for money, risk management, patient empowerment and the ever expanding role of information technology (Trinder 2000)1. The underlying feature of EBM (Evidence-based medicine) is “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients ...”

(Sackett et al. 1997:71)2.

This suggests that clinical decision making should, on the one hand, have cognisance of the specific evidence to support practice, but conversely should also consider the uniqueness of each patient and their individual responses to particular treatments.

Changes in the traditional, autocratic role of the doctor, combined with a better informed consumer have led to a more questioning approach to care delivery3. These changes demand of the health service increasing accountability, efficiency and effectiveness within available resources3. Therefore, those wishing to justify continued investment in current practice, or conversely, development of new innovative methods of care delivery, are expected to be explicit in their requests3. This explicitness has to include evidence-based material to support arguments appropriately, of which the patients experience is central3.

The World Health Organisation has clearly underlined the importance of patient safety in the delivery of health care today.

In doing so, the WHO emphasise the central role that patients and consumers play in guiding safe, patient focussed health care delivery. As such the importance of patient and health care professional collaboration is clear and should be integrated into daily practice, thereby ensuring that guidance from the WHO and the EU is taken on board. It is in recognizing this fundamental link between patients and professionals that EWMA is continuously working to ensure that the link becomes a reality, rather than merely rhetoric.

Zena Moore, Immediate Past President 1 Trinder L (2000) Introduction: the context of evidence-based practice. In Evidence-Based Practice a Critical Appraisal (Trinder L & Reynolds S eds.). Blackwell, Oxford pp. 1-16.

2 Sackett DL, Richardson WS, Rosenberg WMC & Haynes RB (1997) Evidence-Based Medicine: How to Practice and Teach EBM. Churchill Livingstone, New York.

3 Muir Gray JA (2000) Evidence-based public health. In Evidence-Based Practice a Critical Appraisal (Trinder L & Reynolds S eds.). Blackwell, Oxford, pp. 89-110.

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2011 vol 11 no 3

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Science, Practice and Education

European Wound Management Journal – Discussion paper

Challenges facing district nurses in the prevention of pressure ulcers INTRODUCTION The prevalence of pressure ulcers are frequently viewed in health care settings as a quality indicator.1 Depending on the strategies of health boards targets for the reduction in pressure ulcers vary from zero tolerance to a staged reduction for preventable pressure ulcers.2 Patients at risk of pressure ulcers transcend all areas of health care and are an important area of concern for all involved in the safe delivery of patient care. In order to focus resources on a preventative care package it is essential to identify those at risk of pressure ulcers. It is also important to establish those who already have pressure ulcers and carry out root cause analysis to learn how we can prevent such incidents occurring in future.3 Ultimately the goal is to channel resources and educational support into areas where patients are at their most vulnerable to ensure an equitable and safe service.

A baseline audit was carried out on the prevalence of pressure ulcers in a Health Board in the West of Scotland, which covers a major city and outlying smaller districts, with a total population of 1.1m. This area encompasses a diverse population with pockets of extreme relative deprivation together with areas of extreme affluence.

Scotland’s health is improving but remains poor compared to the rest of Europe, with an unacceptable health gap between the richest and the poorest communities.4 A sample size of 5,633 patients, who were, at that point in time, on the District Nurses’ (DN) caseload for healthcare needs, highlighted a pressure ulcer prevalence of 7%, with the majority being Grade one and two using the European Pressure Ulcer Advisory Panel (EPUAP) Grading Tool.5

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The study also served to demonstrate the complexity of the DN caseload involving patients with diverse co-morbidity health care and social needs.

RESULTS/DISCUSSION Data on the prevalence of pressure ulcers, information on those at risk of pressure ulcers and on patients’ ability to carry out activities of daily living were collected over a period of one week from each DN caseload, analysed using Surveymonkey™ and a report generated.

Origin of Pressure Ulcers Prevalence of pressure ulcers was 7% with the majority EUPUAP Grade one and two. The majority of ulcers were on the sacrum, hips and ischial tuberosities with 33% on the foot area.

The origin of severe grade three and four pressure ulcers indicated that 31% of these originated on the DN caseload whilst others were from a variety of care settings including acute, residential care, social care and self referrals in patients previously unknown to the DN for health care  (figure one).

Figure one: Grade 3 and 4 Pressure Ulcers, where they originated

Fiona M Middler, BA, Master in Primary Care, ­Clinical Effectiveness ­Coordinator

Jane Wilson, RGN RM NDNC BSc, Practice ­Development Nurse/ District Nurse Acknowledgement: All District Nurses in Greater Glasgow and Clyde Health Board All Primary Care, Greater Glasgow and Clyde Health Board

Other, 5, 16% Residential or Care Home, 4, 13%

Lynne Watret MN, PGCertTLHE, MA, RGN CNS Tissue Viability

Acute, 13, 40%

Correspondence: Lynne.watret@ ggc.scot.nhs.uk Conflict of interest: none

Own Home, 10, 31%

7

This demonstrated the need for DNs to be actively involved in a treatment model of care as well as a preventative care model for those already on their caseload. It also highlighted the importance of ensuring a collaborative approach to prevention of pressure ulcers across all health and social care settings.

Factors which contribute to increased risk of pressure ulcers It is essential to identify those at risk of pressure ulcers in order to ensure that preventative care and resources are channelled appropriately. “Pressure ulcers can be prevented in many instances; however, those who are acutely ill, have their mobility affected, are older, and have multiple co-morbidities are at greater risk.” 6 These indicators were highlighted in the study and supported in other studies on factors which increase the risk of pressure ulcer development.7,8 Identifying those at risk of developing pressure ulcers The study sought to determine how many patients were considered to be at risk of developing pressure ulcers on the caseload. The Waterlow Pressure Ulcer Risk Assessment Tool was used for this purpose.9 Of those patients assessed, 73% were identified as being at risk, however as noted 7% actually developed pressure ulcers. The study demonstrated that specialised mattresses, seat cushions, orthotic footwear and moving and handling equipment were in widespread use for prevention in those identified as at risk as well as treatment of those with established damage. Support equipment should be viewed as an adjuvant to care, however, emphasis ought to be placed on supporting the patient to self care to optimize their ability to remain independent at home.

The study did not ask if regular repositioning for pressure relief, releasing the skin following repositioning to reduce shearing forces or if 30 degree tilts were routinely carried out in those dependent patients whilst in bed. This is advocated as best practice and is reinforced at ongoing in service education across primary care. However, this would have been difficult to validate and was outside the scope of the study, since it was concerned with identifying prevalence of pressure ulcers and the risk factors of the sample size as opposed to observing clinical practice.

Age of patients Advancing age has an effect on the ability of the individual to keep mobile and some physiological impairment would be expected, which can impact on the individual carrying out activities of daily living.

The DN caseload consisted predominantly of older patients with 71% over 70 years old and, of this group,

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40% were over 80 years. The proportion of all Europeans aged 65 years and older was 16% in 2000 and will rise to 24% by 2030.10 This demonstrates the future challenges of an ageing population, with associated health care needs and the subsequent burden on resources. If risk of pressure ulcers is minimised it can “help individuals live with greater independence; to promote the client’s optimal level of well-being; and to assist the patient to remain at home, avoiding hospitalization or admission to long-term care institutions”.11

Long-term conditions and co-morbidity factors Co-morbidity factors such as degenerative disorders, mental health illness and malignancy further affect the ability of the individual to maintain independence (figure two).

Figure two: Long-term conditions and co-morbidity factors which increase risk of pressure ulcers Breakdown of Chronic Diseases identified on DNs’ Caseload n=7695 Mental Health Disorders (eg Drepession, Schizophrenia), 311, 4% Learning Disabilities, 184, 2% Rheumatoid Arthritis, 484, 6% Malignancy, 1181, 16% COPD, 549, 7%

Degenerative Disorders (eg MS, Parkinson’s, MND), 566, 7%

C.H.D,1117, 15%

Diabetes, 956, 12%

C.V.A, 680, 9% Cognitive Impairment (eg Dementia, Alzheimers), 740, 10%

Other, 927, 12%

The top three long-term conditions in the study group were cancer, coronary heart disease and diabetes. These accounted for 58% of the total group, with some patients having more than one co-morbidity problem. DNs also reported that 10% of the group had a mental health disorder which included dementia, schizophrenia and depression.

In 2010, over one-third of Europe’s population was estimated to have developed at least one long-term condition and the chronic diseases and mental health challenges in the study are also consistent with these findings.10

Mobility and continence challenges Long-term conditions and advancing age can impact on an individual’s ability to maintain independent living and

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Science, Practice and Education

sustain an acceptable quality of life. The study indicated that only 47% of the sample group were viewed as completely mobile; whilst 53% were described as having challenges in independent mobility; with 42% of this group being completely dependent on others for help in achieving some form of mobility. Of those with pressure ulcers, 33% had damage to the foot and this in turn impairs mobility and increases patient dependency.

Those who have difficulty in mobilising will also have difficulty in carrying out the activities of daily living such as toileting. “Lack of mobility and co-morbidity problems can be a contributing factor in the development of incontinence”.12 Of the patients included in the study, 53% of the DN caseload was continent. Of those with incontinence, there was a reliance on either continence garments (16%) or catheter/urosheath to maintain bladder control (22%). It is outside the scope of this study to draw any conclusions on the management of continence. However, “urinary and faecal incontinence are well-recognised as being significant causative factors in pressure ulceration” 13 and must be taken into account. Incontinence can also cause moisture lesions and it is important to differentiate between the two if an appropriate care plan is to be put in place.14,15

Nutrition as a clinical indicator in risk of pressure ulcers Patients who are dependent on others for care will also rely on others to provide their nutritional support.16 This is particularly important in patients, for example, who require palliative care or have dementia. The study observed that 57% were viewed by DNs as being an acceptable weight; with 26% underweight, whilst 17% were viewed as overweight. This was subjective and it was not within the remit of the study to analyze further levels of nutrition such as very low weight, bariatric patients or anaemia, but nonetheless this highlights an area where reliance on the patient to access or on carers to provide a healthy diet can lead to a challenge, particularly in areas of deprivation.

Effect on ability to self care The goal of home care is to ultimately maintain the patient’s quality of life and independence.17 As noted, the study identified indicators which increase the risk of patients developing pressure ulcers and thus reduce ability to self care. It is not surprising, therefore, that, in order to remain at home, patients may rely on others to help them do so, which can be independent of health care.

The study highlighted that only 34% of patients were believed to be self caring while 56% of patients required the support of relatives or informal carers to assist in the activities of daily living. Social care services were required

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for 48% of the patients. There was, therefore, an overlap within these figures with some patients receiving both informal care and additional social care support. Since, 56% of patients were reported to have co-morbidity problems it does suggest that chronic diseases will impact on the ability to be self caring. It also highlights the burden on family members to care for loved ones as they become increasingly more dependent. “The vital role of carers as major care providers must be recognised at all levels in the NHS and staff must work closely with carers as partners in providing care”.4 Identifying and monitoring those who are at risk of pressure ulcers can provide “a method to determine the self care deficits”.18 It is then necessary “to define the roles of person or nurse to meet the self care demands”.18 The expectation of the DN is to ensure systems are in place to prevent pressure ulcers developing and involvement with the patient and family members/informal carers is central to this. However, logistically, the DN cannot consistently be present to observe best practice is being carried out or positional changes are made on a regular basis.

Furthermore, those patients who self care or receive assistance from family members or other informal caregivers, may not become known to the health care system until a pressure ulcer has developed. This was highlighted in the study with reports of patients self referring to the service once a pressure ulcer had developed. This remains a challenge since “professional clinicians have no authority over these caregivers.” 17 “Pressure ulcers and pressure ulcer interventions have a significant impact on quality of life and cause substantial burden to patients”.19 Therefore greater information and creative use of media is required to target all vulnerable individuals and their carers in the prevention of pressure ulcers.

LIMITATIONS OF THE STUDY The study was intended to provide baseline information on those with pressure ulcers and to identify risk factors which increase the risk of pressure ulcers developing.

It was outside the remit of this study to ask patients’ opinions or the views of informal carers who featured prominently in patient support.

The reporting of excoriation due to incontinence was inconsistent across the sample group and proved inconclusive. It is essential to differentiate between pressure ulcer damage and skin damage due to incontinence. This has therefore highlighted an area for further study and educational support to ensure that correct care plans are  initiated to meet patient needs.

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Science, Practice and Education

IN CONCLUSION Pressure ulcers are one example of a patient safety incident, which is defined as ‘any unintended or unexpected incident, which could have or did harm a patient’. 20 Therefore, early recognition of those at risk along with implementation of a preventative care plan is essential to minimise risk of developing pressure ulcers.

The study provided a baseline of those who were at risk of pressure ulcers on the DN caseload and how many actually had developed pressure ulcers.

The study highlighted the multiple risk factors which increase the risk of patients developing pressure ulcers and the perceived effect on quality of life.

This in turn highlighted the dependency of the sample group on others to help carry out activities of daily living and the importance of informal caregivers and social care in this role.

References: 1. Baharestani, M. M., J. M. Black, et al. (2009).

“Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus.” Int Wound J 6(2): 97-104.

2. Newton H (2010) Reducing pressure ulcer incidence: CQUIN payment framework in practice. Wounds UK, 2010, 6 (3) 38,40,42-46 3. Healey F (2006) Root cause analysis for tissue viability incidents. J Tissue Viability 16(1): 12–15 4. Scottish Government (2003) Partnership for Care, Scotland’s Health White Paper. www.scotland.gov.uk 5. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. (2009) Pressure ulcer prevention recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. Washington (DC): National Pressure Ulcer Advisory Panel.

6. Wilson, M (2007) “Heel pressure ulcers – an overview of pressure relieving equipment”. Wound Essentials 2: 115-118, 120 7. Ferrell BA, Josephson K, Norvid P, et al. (2000) “Pressure ulcers among patients admitted to home health care”. J Am Geriatr Soc. 48(9):1042–7

Recommendations have been put in place from the findings of this study, based on the Scottish National Programme for prevention of pressure ulcers.21 Ongoing education for health care professionals continues to be available in the prevention and treatment of pressure ulcers.

It is essential that education and support is targeted not only towards health care staff but to all those who are involved in patient care, including the patient and family members in the prevention of pressure ulcers. This would reduce the risk of patients who are not previously known to the district nurses becoming known only once a crisis, such as a pressure ulcer, has occurred.

The challenge for the providers of health and social care is to ensure that health and social care is equipped to meet the demands on the service now and to continue to evolve to meet the expected demands of the future. m

8. Bergquist S. (2001) “Subscales, subscores, or summative score: evaluating the contribution of Braden Scale items for predicting pressure ulcer risk in older adults receiving home health care”. J Wound Ostomy Continence Nursing. 28(6):279–89.

14. McDonagh D. (2008) Moisture lesion or pressure ulcer? A review of the literature. J Wound Care; 17(11): 461-6.

9. Waterlow J. (1985) “ Pressure sores: a risk assessment card”. Nursing Times. 81(48):49–55.

16. Clark, M., J. M. Schols, et al. (2004). “Pressure ulcers and nutrition: a new European guideline.” J Wound Care 13(7): 267-72.

10. © The Economist Intelligence Unit Limited (2011) “The future of healthcare in Europe. A report from the Economist Intelligence Unit. www.eufutureofhealthcare.com 11. Shaughnessy PW, Hittle DF, Crisler KS, et al. (2002) “Improving patient outcomes of home health care: findings from two demonstration trials of outcomebased quality improvement”. J Am Geriatr Soc. 50(8):1354–64.

12. Royal college of Physicians (2009), British Geriatric Society Privacy and Dignity in Continence Care Project : Attributes of dignified bladder and bowel care in hospital and care homes (November 2009) Phase1 Report www.rcplondon.ac.uk/.../privacy-anddignity-in-continence-care-phase-1-reportnov-2009_0.pdf 13. Calianno C (2000) Assessing and preventing pressure ulcers. Adv Skin Wound Care 13(5): 244–46

15. Gibbon C. Moisture lesion or pressure ulcer? (2009) J Comm Nurs; 23(10): 11-6

17. Hughes RG (editor) (2008) “”. Patient Safety and Quality: An Evidence-Based Handbook for Nurses”.

Rockville MD. 18. Orem, D. (1971) Nursing: Concepts of Practice. St. Louis: Mosby 19. Gorecki, C., J. M. Brown, et al. (2009). “Impact of pressure ulcers on quality of life in older patients: a systematic review.” J Am Geriatr Soc 57(7): 1175-83.

20. National Patient Safety Agency (2004) Seven Steps to Patient Safety. NPSA, DH, London 21. Baxter S & Barclay A (2011) “ Preventing Pressure Ulcers Driver Diagram & Change Package”. Health Improvement Scotland http://www.healthcareimprovementscotland.org/programmes/patient_safety/ tissue_viability.aspx. tissueviability on line patient safety link

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2011 vol 11 no 3

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Science, Practice and Education

Clinical application of stem cells in wound healing: A near future?

Benoit I Hendrickx1,2 MD PhD Jan J Vranckx1, MD PhD Aernout Luttun2, PhD 1

Dept of plastic surgery, University Hospital of Leuven, Belgium; 2

Center for Molecular and Vascular Biology, University of Leuven, Belgium Correspondence: benoit.hendrickx@ uzleuven.be

Abstract Cutaneous wound healing is a complex process that involves many cell types and pathways. All skin layers need to be restored in a well organized fashion, which depends highly on decent vascularization. Deregulation of any of these elements of the wound healing cascade results in delayed healing. Intrinsically, stem cells have regeneration capacities and are therefore obvious candidates for clinical application to improve wound healing.

Many promising preclinical stem cells studies in wound healing inspire us with the desire to apply these cells clinically.

Stem cells can either be used to actively restore parts of skin or its appendages, or to stimulate wound healing in a paracrine fashion. Ideally, they should act on as many steps in the wound healing cascade as possible and be available in sufficient amounts, without any risk of malignant transformation or transmission of diseases. Here, we review possible candidates for clinical application of stem cells in wound healing strategies.

Conflict of interest: none

1. Introduction Large or complex skin defects with exposed structures such as bone, blood vessels, nerves or tendons are traditionally covered with surgical flaps.

These flaps however can result in tissue morbidity at the donor site. Many attempts have, therefore, been made to restore skin defects by in vitro cultured cells, both mature and stem cells. As stem cells, generally spoken, have the intrinsic capacity of tissue regeneration and can be expanded to large numbers, they seem to be obvious candidates for clinical application to improve wound healing and to restore skin defects.

2. Which stem cells are possible candidates?

A wide range of stem cells can be considered to improve wound healing in clinical situations. According to their differentiation status, stem cells can be divided into pluripotent (able to generate all types of cells in the human body), multipotent (able to generate a multitude of cell lines), and unipotent (committed to one specific cell lineage).

Many different cell types from any of these hierarchic levels can improve wound healing, either by direct differentiation into skin cells, by increasing vascularization (which is known to stimulate dermal and epidermal healing,1 or by the release of growth factors that stimulate angiogenesis and/ or dermal and epidermal healing. However, before clinical application can be considered, these cells should: (i) be rapidly expandable to amounts sufficient for clinical application, (ii) without the risk of malignant transformation or rejection by the immune system,2 and (iii) have a proven beneficial effect on wound healing in an animal model. a. Pluripotent progenitor cells Embryonal stem cells (ESC) ESC can theoretically differentiate into any cell in the human body, and thus into different types of skin cells, but they have never been used to this purpose so far. They have been shown to increase vascularization in sites of ischemia,3 and could therefore be considered to stimulate wound bed vascularization and subsequent healing. They have however an unlimited proliferation capacity and are therefore prone to develop tumors in vivo.4 Also, since these cells are derived from a human blastocyst-stage embryo, their clinical use is subject to ethical considerations.

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Induced pluripotent stem cells (iPSC) These pluripotent cells are obtained through reprogramming of human somatic cells with

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2011 vol 11 no 3

Silent. Gentle. Powerful. a set of specific genes,5,6 thereby circumventing the ethical restraints linked to ESC. Also, they can be used in an autologous setting, avoiding the risk of immunologic rejection. There are no reports of their use in wound healing experiments, but iPSC should have similar properties as ESC, including the risk of malignant transformation.7,8

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b. Multipotent progenitor cells Mesenchymal stem cells (MSC) MSC are a heterogeneous group of progenitor cells that exert a profound effect on wound healing by direct trans differentiation into skin cells,9 production of growth factors10 and wound contraction.11 They can be derived from many tissues, but for clinical purpose, only fat and bone marrow are acceptable sources regarding the reasonably limited donor site morbidity.

Even though some authors report transformation to tumors when the MSC are kept in culture for longtime,12,13 clinical application in lower passage numbers is safe. Moreover, these cells have immunosuppressive characteristics, which open the door for allogeneic transplantation.14 Both bone marrow15-17 and fat derived18,19 MSC have successfully been tested in preliminary clinical wound healing trials.

Multipotent adult progenitor cells (MAPC) These bone marrow derived progenitor cells are capable of inducing vascularization and epidermal healing in an animal wound healing model (unpublished results).

Since MAPC are genetically stable2 and display immunosuppressive characteristics,20 clinical application is to be considered safe.

c. Unipotent progenitor cells Taking into account the manifest link between vascularization and wound healing, the most interesting unipotent cell line is the endothelial progenitor cell (EPC) line. According to when EPC appear in culture, “early EPC” and “blood outgrowth endothelial cells (BOEC)” are acknowledged. Whereas BOEC can be expanded to large amounts, early EPC are only present in relatively small quantities, with subsequent limited clinical advantage. Both cell types can be harvested in a completely autologous fashion from peripheral blood samples and stimulate wound vascularization and epidermal healing through the secretion of growth factors.1,21,22 Moreover, BOEC improve dermal healing (1) and there is evidence that co-transplantation of BOEC and early EPC has a synergistic effect.23 When derived from peripheral blood, no karyotypic abnormalities have been detected in these cells,24 which make BOEC, or a combination of both cell types, attractive  for clinical use in chronic wounds.

EWMA Journal

2011 vol 11 no 3

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Science, Practice and Education

Table 1. Overview of progenitor cells according to their properties. See text for details. pluripotent ESC / iPSC Sufficient number of cells for clinical use Genetic stability Immune rejection Beneficial effect in animal wound healing experiments Clinical effect on human wound healing

multipotent MSC (fat/BM) MAPC

+++

++

++

+

-

--+/?

+a -c

+ -c

+b -d

+ -d

b: if harvested from peripheral blood samples

?

+

+

+

+

c: due to immunosuppressive characteristics

?

+

?

?

?

d: if used in an autologous setting

3. Conclusion Considering the inherent risk of tumor formation and the risk of immune rejection of ESC, pluripotent progenitor cells are definitely a less than optimal choice for clinical application. Moreover, the overall beneficial effect of pluripotent progenitor cells on wound healing needs further investigation. Multipotent progenitor cells provide a safe and powerful alternative. They can safely be expanded to sufficient numbers and have a broad effect on different aspects of wound healing. Both MSC and MAPC mislead

References 1. Hendrickx, B., Verdonck, K., Van den Berge, S., Dickens, S., Eriksson, E., Vranckx, J.J., and Luttun, A. Integration of blood outgrowth endothelial cells in dermal fibroblast sheets promotes full thickness wound healing. Stem Cells 28:1165-1177.

2. Hendrickx, B., Vranckx, J.J., and Luttun, A. Cellbased vascularization strategies for skin tissue engineering. Tissue Eng Part B Rev 17:13-24.

3. Yamahara, K., Sone, M., Itoh, H., Yamashita, J.K., Yurugi-Kobayashi, T., Homma, K., Chao, T.H., Miyashita, K., Park, K., Oyamada, N., et al. 2008.

Augmentation of neovascularization [corrected] in hindlimb ischemia by combined transplantation of human embryonic stem cells-derived endothelial and mural cells. PLoS One 3:e1666.

4. Odorico, J.S., Kaufman, D.S., and Thomson, J.A. 2001. Multilineage differentiation from human embryonic stem cell lines. Stem Cells 19:193-204.

5. Takahashi, K., and Yamanaka, S. 2006. Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell 126:663-676.

6. Yu, J., Vodyanik, M.A., Smuga-Otto, K., AntosiewiczBourget, J., Frane, J.L., Tian, S., Nie, J., Jonsdottir, G.A., Ruotti, V., Stewart, R., et al. 2007. Induced pluripotent stem cell lines derived from human somatic cells. Science 318:1917-1920.

7. Choi, K.D., Yu, J., Smuga-Otto, K., Salvagiotto, G., Rehrauer, W., Vodyanik, M., Thomson, J., and Slukvin, I. 2009. Hematopoietic and endothelial differentiation of human induced pluripotent stem cells. Stem Cells 27:559-567.

8. Narazaki, G., Uosaki, H., Teranishi, M., Okita, K., Kim, B., Matsuoka, S., Yamanaka, S., and Yamashita, J.K. 2008. Directed and systematic differentiation of cardiovascular cells from mouse induced pluripotent stem cells. Circulation 118:498-506.

9. Fu, X., and Li, H. 2009. Mesenchymal stem cells and skin wound repair and regeneration: possibilities and questions. Cell Tissue Res 335:317-321.

14

unipotent BOEC Early EPC a: in lower passage numbers

the host’s immune system, and can therefore be used in an “off the shelf” fashion. MSC are the only progenitor cells that have been used in preliminary clinical trials so far, and the results are promising. Both the unipotent early EPC and BOEC display a promising effect on wound healing in animal experiments, can be used autologously, and are unlikely to form tumors. Even though early EPC can be difficult to expand to sufficient amounts, they can be useful in combination with BOEC. (See table 1). m

10. Chen, L., Tredget, E.E., Wu, P.Y., and Wu, Y. 2008.

Paracrine factors of mesenchymal stem cells recruit macrophages and endothelial lineage cells and enhance wound healing. PLoS One 3:e1886.

11. Hanson, S.E., Bentz, M.L., and Hematti, P. Mesenchymal stem cell therapy for nonhealing cutaneous wounds. Plast Reconstr Surg 125:510516.

12. Miura, M., Miura, Y., Padilla-Nash, H.M., Molinolo, A.A., Fu, B., Patel, V., Seo, B.M., Sonoyama, W., Zheng, J.J., Baker, C.C., et al. 2006. Accumulated chromosomal instability in murine bone marrow mesenchymal stem cells leads to malignant transformation. Stem Cells 24:1095-1103.

13. Rubio, D., Garcia-Castro, J., Martin, M.C., de la Fuente, R., Cigudosa, J.C., Lloyd, A.C., and Bernad, A. 2005. Spontaneous human adult stem cell transformation. Cancer Res 65:3035-3039.

14. Koc, O.N., Day, J., Nieder, M., Gerson, S.L., Lazarus, H.M., and Krivit, W. 2002. Allogeneic mesenchymal stem cell infusion for treatment of metachromatic leukodystrophy (MLD) and Hurler syndrome (MPS-IH). Bone Marrow Transplant 30:215-222.

15. Badiavas, E.V., and Falanga, V. 2003. Treatment of chronic wounds with bone marrow-derived cells. Arch Dermatol 139:510-516.

16. Vojtassak, J., Danisovic, L., Kubes, M., Bakos, D., Jarabek, L., Ulicna, M., and Blasko, M. 2006.

Autologous biograft and mesenchymal stem cells in treatment of the diabetic foot. Neuro Endocrinol Lett 27 Suppl 2:134-137.

17. Yoshikawa, T., Mitsuno, H., Nonaka, I., Sen, Y., Kawanishi, K., Inada, Y., Takakura, Y., Okuchi, K., and Nonomura, A. 2008. Wound therapy by marrow mesenchymal cell transplantation. Plast Reconstr Surg 121:860-877.

19. Garcia-Olmo, D., Herreros, D., Pascual, I., Pascual, J.A., Del-Valle, E., Zorrilla, J., De-La-Quintana, P., Garcia-Arranz, M., and Pascual, M. 2009. Expanded adipose-derived stem cells for the treatment of complex perianal fistula: a phase II clinical trial. Dis Colon Rectum 52:79-86.

20. Luyckx, A., De Somer, L., Rutgeerts, O., Waer, M., Verfaillie, C.M., Van Gool, S., and Billiau, A.D. Mouse MAPC-mediated immunomodulation: Cell-line dependent variation. Exp Hematol 38:1-2.

21. Sander, A.L., Jakob, H., Henrich, D., Powerski, M., Witt, H., Dimmeler, S., Barker, J., Marzi, I., and Frank, J. 2009. Systemic Transplantation of Progenitor Cells Accelerates Wound Epithelialization and Neovascularization in the Hairless Mouse Ear Wound Model. J Surg Res. 22. Suh, W., Kim, K.L., Kim, J.M., Shin, I.S., Lee, Y.S., Lee, J.Y., Jang, H.S., Lee, J.S., Byun, J., Choi, J.H., et al. 2005. Transplantation of endothelial progenitor cells accelerates dermal wound healing with increased recruitment of monocytes/macrophages and neovascularization. Stem Cells 23:1571-1578.

23. Yoon, C.H., Hur, J., Park, K.W., Kim, J.H., Lee, C.S., Oh, I.Y., Kim, T.Y., Cho, H.J., Kang, H.J., Chae, I.H., et al. 2005. Synergistic neovascularization by mixed transplantation of early endothelial progenitor cells and late outgrowth endothelial cells: the role of angiogenic cytokines and matrix metalloproteinases.

Circulation 112:1618-1627.

24. Corselli, M., Parodi, A., Mogni, M., Sessarego, N., Kunkl, A., Dagna-Bricarelli, F., Ibatici, A., Pozzi, S., Bacigalupo, A., Frassoni, F., et al. 2008. Clinical scale ex vivo expansion of cord blood-derived outgrowth endothelial progenitor cells is associated with high incidence of karyotype aberrations. Exp Hematol 36:340-349.

18. Garcia-Olmo, D., Garcia-Arranz, M., Herreros, D., Pascual, I., Peiro, C., and Rodriguez-Montes, J.A. 2005. A phase I clinical trial of the treatment of Crohn’s fistula by adipose mesenchymal stem cell transplantation. Dis Colon Rectum 48:1416-1423.

EWMA Journal

2011 vol 11 no 3

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Understanding the Patient Experience:

Does empowerment link to clinical practice?

Patricia Price Professor of Health Science, Dean and Head of School Healthcare Studies, Cardiff University Correspondence: PricePE@cardiff.ac.uk Conflict of interest: none

Many patients with wound healing difficulties are also coping with the management of a chronic disease or chronic condition that requires them to make life-style behaviour changes, e.g., managing glucose levels through diet and exercise. Many find it difficult to make such changes, and often experience feelings of powerlessness when faced with a life time of behavioural and psychological change. Such feelings can be particularly strong when the consequences of the illness, or the resulting treatment, lead to physical changes in appearance, such as losing a breast, a limb or visual disfigurement. This paper briefly explores the importance of understanding the patient experience and the concept of empowerment – which is often considered to be a health enhancing process, and discuss whether empowerment naturally leads to increased participation in clinical decision making based on an individual negotiation of life priorities. In a time of evidence based practice, there is a growing requirement to include the patient experience as part of the portfolio of evidence – but does patient empowerment lead to changes in outcome? In order to address the topic of ‘empowerment’ we need to briefly review how the concept has developed over time before exploring the implications for clinical practice.

The concept of ‘empowerment’ was initially popularised by the Brazilian educationalist, Paulo Freire (1921-1997) who made a major contribution to educational philosophy in the 20th century; after brief careers as a lawyer and secondary school teacher, he subsequently worked in the area of adult education and became the first Director of the Department of Cultural Extension of the University of Recife (1961-1964). Much of Freire’s work is political with his most famous book ‘Pedagogy of the Oppressed’ being published in 1970.

Within his work Freire proposed that whilst ‘educator’ and ‘student’ are not on an equal footing (in terms of knowledge and often ‘status’, as in the school setting), the educator must be humble

16

enough to be willing to relearn what s/he already thinks s/he knows, through interaction with the learner. His work also stresses the importance of dialogue, working together and acknowledging the individuality of the lived experience. Those familiar with the concept of empowerment will already recognise the roots of the concept and its potential application in healthcare.

Patients are unlikely to be familiar with the work of Friere, but many will use modern technology to find out more about such terms, so it is worth noting that Wikipedia defines empowerment as:

“...increasing the spiritual, political, social or economic strength of individuals and communities. It often involves the empowered developing confidence in their own capacities…” http://en.wikipedia.org/wiki/Empowerment accessed 4th September 2011

The definition clearly captures the emphasis on the student (or patient/client in the health context) developing skills to build their confidence to achieve goals and closely reflects the definition

by Funnell and Anderson in 2004, who suggested that patients needed to be well informed, active partners and collaborators, and needed to understand how to assume responsibility for their own care.

Within the academic and clinical health literature there is very little published work on empowerment in patients with chronic or acute wounds.

However, there is a body of work on this concept in those with diabetes – which is one of the patient groups we work with, due to the complication of non-healing diabetic ulcers – so the work is of direct relevance to wound care professionals.

However, the definitions have not been static – and the concept has developed over time.

For example, Funnell et al defined empowerment in 1991 as a process “whereby patients have the

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2011 vol 11 no 3

Science, Practice and Education

knowledge, skills, attitudes and self-awareness necessary to influence their own behaviour and that of others in order to improve the quality of their lives.” (p37); they suggest that someone is empowered when they have “sufficient knowledge to make rational decisions, sufficient control and resources to implement their decision and sufficient experience to evaluate the effectiveness of those choices” (p39). However, by 2010 the same American group simplified the general definition and suggested that: “Patient empowerment is a process designed to facilitate self directed behaviour change” (Anderson and Funnell, p277), although the article does still separate the process of empowerment (when the purpose of an educational intervention is to increase the ability to think critically and act autonomously) from the outcome of that process (when the patient experiences an enhanced sense of self-efficacy which occurs as a result of the process).

The dynamic changes in these definitions indicate that the concept is both complex and multi-dimensional. Indeed some have gone so far as to argue that the whole concept is not well understood (Asimakopoulou et al 2011), that there is confusion between ‘empowerment’ and a ‘patientcentred’ approach (Holström and Roïng 2010) and that some researchers use the term as an alternative to ‘compliance’, where patients are responsible for their choices and the consequences of those choices (Aujoulat et al 2008).

Even those with a strong track record of work in this area have admitted that there isn’t an accurate understanding of ‘empowerment’ and that the concept has yet to be applied in an authentic manner across healthcare systems (Andersen and Funnell 2010). So, where does that leave us? It would appear that ‘patient empowerment’ is a term that is used frequently both in academic research and clinical practice, but it may be a term that we don’t all understand in the same way.

So, does ‘empowerment’ – however it is defined – make a difference to patient care? There is evidence as far back as 1990 from Fallowfield et al that patients with breast cancer who were allowed some choice in their treatment pathways were rated as ‘happier’; Guadagnoli and Ward (1998) in a general review described how choosing the nature and timing of treatment was important to patients – although coping skills training was considered equally important; and Taylor et al (1996) were one of the first to outline the benefits of Patient Controlled Analgesia as a technique – an area of universal success for patient involvement in their care.

Examples of success more closely related to wound care are more difficult to find. Norris et al (2001) reviewed the effectiveness of management training in Type 2 diabetes

and found that there was evidence to support an improvement in patients’ knowledge and self care skills, but this did not necessarily lead to an improvement in glycaemia control or cardiovascular risk factors (see Table 1).

Table 1: Number of studies showing improvement in outcomes following management training in diabetes (based on Norris et al 2001) Studies where ­intervention group > control

No difference ­between the groups

Patient knowledge and self-care skills

33

13

Glycaemia Control

18

36

Improved cardiovascular risk factors

18

27

In 2010 Dorresteijn et al published their updated systematic review on patient education for preventing diabetic foot ulceration, and concluded that there is insufficient robust evidence that simple patient education alone can lead to clinically relevant reduction in ulcer and amputation incidence. They also recommended that future research should focus on evaluating the effect of more comprehensive, complex interventions that could include patient education. This recommendation may reflect the complex and multi-dimensional nature of patient empowerment that may be needed for sustained behaviour change.

Given the difficulties in establishing a universally accepted definition of ‘empowerment’ and the contradictory nature of the evidence related to its value in improving clinically important outcomes, it is useful to reflect on why the concept has become so influential. For example, patient empowerment has been advanced as the health promotion model of choice (Tones and Green 2003), used as a key model for community based health promotion intervention (Piper 2009) and is embedded in the language of health policy in many countries. Indeed in 2001 UK Diabetes policy pushed to ensure that people with diabetes are empowered to enhance their personal control over the day to day management of their diabetes in a way that enables them to experience the best possible quality of life.

It is important to note that ‘patient empowerment’ has not developed in isolation, but is representative of a more general change in thinking about healthcare and the relationship between the healthcare professional and the patient.

Figure 1 places the concept of ‘empowerment’ within the wider context of societal change, which has increasingly focused on a shift away from traditional models of care (that 

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2011 vol 11 no 3

17

Science, Practice and Education

are predominantly hierarchical), to a view on health that emphasises that patients are experts in their own health, body and life style, and their lived experience can frame the route to long term, sustained behaviour change.

Figure 1: Empowerment within a wider societal context

Despite this wider societal move to greater personal responsibility, it is important to note that there are still concerns and unanswered questions about the role of empowerment within health care. As yet, it is still unclear how patient empowerment links with the move to Evidence Based Practice, as practitioners can become caught between overwhelming evidence of benefit that conflicts with the desires of the patient to chose a different treatment option; not all healthcare systems encourage patient involvement in the same way – and often this depends on how care is funded. Some patients have also started to indicate quite strongly that they favour a more paternalistic approach (Piper 2010) – indeed as long ago as 1980, Ingelfinger wrote about his despair at being given responsibility for treatment decisions about cancer.

Yet, despite these uncertainties we have to be realistic about the health challenges of the future. There are growing numbers of patients with chronic health conditions – many of which will include management that requires a major change in life style. Many of these patients are elderly and face a situation where they have to learn a lot References Anderson RM, Funnell MM (2010) Patient empowerment: Myths and misconceptions. Patient Education and Counselling 79: 277–282 Asimakopoulou K, Gilbert D, Newton P, Scambler S (2011) Back to Basics: Re-examining the role of patient empowerment in diabetes. Patient Education and Counselling; doi: 10.1016/j.pec.2011.03.017 Aujoulat I, Marcologo R, Bonadiman L, Deccache A (2008) Reconsidering patient empowerment in chronic illness: A critique of models of self-efficacy and bodily control. Social Science and Medicine 66: 1228 – 1239 Bloom D, Boersch-Supan A, McGee P, Seike A (2011) Population Aging: Fact, Challenges and Responses.

PGDA Working Paper No 71: The Harvard Initiative for Global Health www.hsph.harvard.edu/pgda/working.

Department of Health (2001) National Services Framework for Diabetes.

18

about the condition/disease itself, their own treatment plan, how behaviour can influence their condition and what behaviour changes they will need to make, whilst incorporating those changes into everyday life. Such changes are often difficult to make, they conflict with existing behaviour patterns, life projects and family priorities, and can lead to frustration for the patient and their carers at the overwhelming changes they feel they have to make to their lives.

Healthcare systems also need to consider the ways in which self management can be built into a framework of care – particularly knowing the extent of the projected increase in the elderly (Bloom et al, 2011), many of whom will present with wound problems, and the anticipated world-wide increase in diabetes (and associated complications) (Mainous et al, 2007; Lauterbach et al, 2010). These increases will happen at a time when there is likely to be a reduction in the percentage of skilled healthcare professionals (as a proportion of the population) due to the forecasted balance of numbers in the workplace compared with the proportion of the population of retirement age (Bloom et al, 2011).

It is almost inevitable that we will need to develop professional – patient partnerships, increase collaborative care and self – management education and ‘empower’ people to think critically and make informed decisions in partnership with health care professionals.

In conclusion, very little specific work on this concept has been reported in the wound management literature and we need to prioritise discussions about how we can address these issues in how we deliver care. It is clear that more work is needed on terminology and language used in this area, so that health professionals can concentrate on working with patients to maximise their outcomes and their ability to carry on leading their lives as independently as possible. There is very little doubt that we will need to work in partnership – both between professions, and between professionals and patients – if we are to make major progress in this area. m

Dorresteijn JA, Kriegsman DM, Assendelft WJ, Valk GD (2010)Patient education for preventing diabetic foot ulceration. Cochrane Database Syst Rev. May 12;(5):CD001488.

Freire P (1970) Pedagogy of the Oppressed. Continuum ISBN: 9780826412768 Funnell MM, Anderson RM, Arnold MS, Barr PA, Donnelly M, Johnson PD, Taylor-Moon, White NH (1991) Empowerment: an idea whose time has come in diabetes education. Diabetes Education: 17: 37-41 Fallowfield LJ, Hall A, Maguire GP, Baum M. (1990) Psychosocial outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ 301: 575-80 Guadagnoli E, Ward P. (1998) Patient participation in decision-making. Soc Sci Med;47: 329-39 Holstrom I, Roing M (2010) The relation between patient-centeredness and patient e­ mpowerment: A discussion on concepts. Patient Education and Counselling 79: 167-172

Ingelfinger FJ. Arrogance. N Engl J Med 1980;303: 1507-11 Lauterbach S, Kostev K, Kohlmann T (2010) Prevalence of diabetic foot syndrome and its risk factors in the UK. J Wound Care Aug; 19(8): 333-7 Mainous AG 3rd, Baker R, Koopman RJ, Saxena S, Diaz VA, Everett CJ, Majeed A (2007) Impact of the population at risk of diabetes on projections of diabetes burden in the United States: an epidemic on the way. Diabetologia May: 50(5): 934-40 Piper SM (2009) Health Promotion for Nurses: theory and practice. Abingdon: Routledge Piper SM (2010) Patient empowerment: emancipatory or technological practice? Patient Education and Counselling 79: 173-7 Taylor NM, Hall GM, Salmon P. (1996) Patients’ experiences of patient-controlled analgesia. Anaesthesia 51: 525-8 Tones K, Green S (2004) Health promotion: planning and strategies. London: Sage

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2011 vol 11 no 3

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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.

Science, Practice and Education

The Influence of Egyptian Propolis on Induced Burn Wound Healing in Diabetic Rats Antibacterial Mechanism Abstract The purpose of the current study was to determine the effectiveness of Egyptian propolis in treating diabetic burn wounds. Thirty-two male albino rats were used in this study for a treatment period of 25 days. They were divided randomly and equally into four groups. Rats in the first group had been treated with physiological saline solution (0.9% Na Cl) daily and served as the control group. While rats in the 2nd, 3rd, 4th, groups received Egyptian propolis, silver sulfadiazine* (SSD), and propolis-SSD mixture creams daily. Burn surface area and bacterial colony count were used to measure the outcomes at different time intervals. Results showed a significant reduction in both burn surface area and bacterial colony count in the creams treated groups compared to the control group. Propolis cream was more effective than SSD cream, especially on D14 and after that. Interestingly, the propolis-SSD mixture significantly decreased bacterial colony count and burn surface area compared to the propolis and SSD treated groups. It could be concluded that propolis alone or in combination with SSD is considered a unique antibacterial cream for the treatment of diabetic burn wounds.

Introduction Burns wounds are commonly infected with multiple organisms, with the additional challenge of drug resistance. Hospitals tend to employ a drug policy for the treatment of burned patients.

Gram-positive bacteria are predominant in colonization of burn wounds. In the patients with more than 40% of total body surface burned, Staphylococcus aureus was the most frequently isolated organism22.

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2011 vol 11 no 3

Wound healing is thought to be impaired in diabetic patients by different mechanisms, although recent studies have implicated a lack of Keratinocyte Growth Factor and Platelet-Derived Growth Factor function in the wound. Many of these patients have microvascular occlusive disease that may cause ischemia and impaired repair21.

Propolis is a complex resinous material collected by honeybees from buds and exudates of certain plant20. Propolis includes; fatty and phenolic acids and esters, substituted phenolic esters, flavonoids (flavones, flavanones, flavonols, dihydroflavonols, chalcones), terpenes, β-steroids, aromatic aldehydes and alcohols, and derivatives of sesquiterpenes, naphthalene and stilbenes2, 3.

Propolis has been reported to enhance immune system activities16, 17, oxygen radical scavenging14, 4, antimicrobial, cytostatic, anticarcinogenic, antiinflammatory and antitumor activities5, 15.

Emad T. Ahmed1 Osama M. Abo-Salem2 Ali Osman1 1Physical Therapy for ­ urgery Department, S Faculty of Physical Therapy, Cairo University, Egypt.

2Department

of ­ harmacology and P Toxicology, Faculty of Pharmacy, Al-Azhar Correspondence: emadtawfik72@yahoo.com

Silver sulfadiazine (SSD) is the topical agent of choice in severe burns and is used almost universally today in preference to compounds such as silver nitrate and mafenide acetate. SSD cream, while being effective, can cause systemic complications which include neutropenia, erythema sultiforme, crystalluria and methaemoglobinemia7, 9.

The aim of the present study was to investigate the healing rates of wounds treated with three topically applied creams (propolis, SSD, and propolis-SSD mixture) against physiological saline solution clinically and microbiologically in a diabetic rat model.

Experimental design and animal groups: Animals: Thirty-two adult male Albino Wistar rats were included in this study to determine the proper healing agent in the treatment of diabetic burn

Conflict of interest: none



21

wounds. All rats were admitted to the study at approximately six months of age (considered adult). Free access was allowed to standard diet, water, temperature, humidity and light period. The rat model was considered appropriate for simulating wound healing in humans. The animal model was selected for this study to provide better control over confounding variables such as diet, exercise, environmental stress and systemic disease except diabetes which affect wound healing. Four groups were used (8 animals/ group). The control group received physiological saline solution and the three treatment groups received propolis, SSD, propolis-SSD mixture creams one time/day/25 days.

Induction of diabetes: Type 1 diabetes mellitus was induced by intraperitoneal injection of streptozotocin (60 mg/kg body weight) in citrate buffer 0.1 mol/L (pH 4.2) for three successive days1.

Rats were considered diabetic if blood glucose concentrations increased to 200 or more mg/dl.

Induction of burn: Each animal was anesthetized by placing the animal into closed cage in association with a piece of cotton wetted with ether. The animals were strictly tied via four cotton threads to a wooden plate. The hair at the upper part of left hind limb was removed by hair removal cream and the skin was cleaned by a piece of cotton wetted with alcohol. The area of the skin prepared as above equaled 4 cm2 while the area intended to be burned equaled 2 cm2, however, this will ease the procedure of burning as well as measurement. The burns were induced by a rectangular metal seal with cm2 contact surface area that was heated on a flame burner to 450C and handed by a surgical forceps, then pressed immediately against the prepared skin segment for 20 seconds to produce partial thickness burns according to Kloth and Feeder12 protocols. Each animal was then caged separately and they were subjected to a normal daylight rhythm, and the room temperature varied between 32◦ C to 35 ◦ C.

Materials and Methods Topical treatment cream: The Egyptian propolis used in this study was obtained from the faculty of agriculture in Cairo, Egypt. Extracts of propolis sample were prepared and used throughout this work as described by ISLA et al11 with minor modifications. Propolis was frozen at -20°C, and ground in a chilled mortar. Then, the ground powder was extracted with ethanol (15 ml of 80% ethanol/g of propolis) with continuous stirring at room temperature for 24 hours.

The suspension was let to sediment for three days. The supernatant was then concentrated in an evaporator under

22

reduced pressure at 40°C and the residue mixed within same amount of 50% cold cream (cold cream, 12.5% spermaceti + 12% white wax + 56% liquid paraffin + 0.5% borate of soda + 19% distilled water).

2- SSD cream: 1% SSD*.

3- Propolis–SSD mixture cream: 50% of propolis cream was mixed with 50% SSD cream.

4- Physiological saline solution: Normal saline (NS) is the commonly-used term for a solution of 0.9% of Na Cl Procedure of the study: Immediately after burn, the burned areas in the first group (control group) received physiological saline solution daily, the 2nd, 3rd, and 4th groups received propolis, SSD, and propolis-SSD mixture cream respectively.

Evaluation: Burn surface area (BSA): The measurement of BSA was conducted by tracing of wound perimeter according Kloth and Feedar12. The BSA measurement was conducted by the following steps: A sterilized transparency film was placed over the ulcer.

The ulcer perimeter was traced by using the film tipped transparency marker. Each ulcer was traced three times to establish measurement reliability. After tracing, the transparency film face which faced the ulcer was cleaned by a piece of cotton and alcohol. The carbon paper was placed over the metric graph paper one mm2. The traced transparency film was placed over the carbon paper with a white paper in between, and the tracing transcribed onto the metric graph paper. The number of square millimeters on the metric graph within the wound tracing was counted to determine the BSA. The mean of the three trials was calculated and considered as BSA. The BSA measurements were taken at day 4, 8, 14, 19 and 24 days post burn.

Wound infection assessment18: Quantitative bacteria culturing of wounds was performed at different time intervals, so as not to disturb the wound environment, on day 5, 10, 15, 20 and 25. Swabs specimens for bacterial cultures were collected before cleaning of wounds by the use of sterile sticks, which were rolled over the wound each time then aseptically placed in a tube containing 5 mL of saline. Using a 100-fold dilution, finally 0.1 mL were pipetted and inoculated on nutrient Agar plate and grown aerobically at 37°C for 24 hours.

Bacterial colonies were counted at x105 bacterial organism/ mL (Paul and Gordon, 1978).

Data analysis: This study was a controlled post test experimental design with a control and a three treatment groups. Groups were

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Science, Practice and Education

compared for differences at different time intervals, ANOVA multiple comparisons followed by the Tucky Kramer post hoc test were used for comparing differences between the three treatment groups and control group. The level of significance was set at 0.05 for all statistical tests.

Results All rats in the experiment were selected with a closure blood glucose level and there was no significant difference between groups using ANOVA test (table 1).

The data in table (2) showed that all the creams used significantly reduced the bacterial colony count as compared to the physiological normal saline (PSS) treated control group. There was a significant difference between treated groups as shown in table (2).

Groups treated with a mixture of DC & PC had significantly reduced bacterial counts at all days of evaluation compared to PSS (physiological saline solution), PC and DC groups. While, PC and DC groups had significantly reduced bacterial colony counts on days 15, 20 and 25 compared to control group. Interestingly, BCC in the PC treated group was significantly lower than BCC in the group treated with DC at D15, D20 and D25.

The duration of the treatment was significantly effective in the reducing the bacterial colony count in cream treated groups, but increased in the PSS treated group (table 2). Bacterial colony counts were significantly reduced on days 15, 20 and 25 of the experiment for the groups treated with PC and DC and days 10, 15, 20 and 25 for group treated with the PC & DC mixture compared to the PSS treated group. Moreover, there was a significant difference in BCC at different time intervals between different cream treated groups.

The data in table (3) showed that all creams used significantly reduced BSA as compared to the physiological normal saline (PSS) treated control group except on D4.

PC & DC, the mixture cream, significantly reduced BSA on D14, D19 and D 24 compared to the PC and DC treated groups except PC at D14. Interestingly; BSA in the PC treated group was significantly lower than BSA in the group treated with DC on D19 and D24.

The duration of the treatment was significantly effective in reducing BSA in cream treated groups, but increased in the PSS treated group (table 3). PC and a mixture of PC & DC showed significantly reduced BSA at D14 compared to D4 and D8, and there was also a significant difference between D14, D19 and D24. On the other hand, DC induced only a significant reduction  in the WSA on D24 compared to the other days.

Table (1): Serum blood glucose level Normal rat 64.13 ± 4.04

Control 220.63 ± 6.08

PC 222.63 ± 6.82

DC 223.88 ± 12.40

DC & PC 221.25 ± 6.66

Data were expressed as Means ± SEM of 8 diabetic rats /group. C; PSS treated group, PC; propolis cream treated group, DC; SSD cream treated group, PC & DC; propolis-SSD mixture cream treated group. Significance was carried out by One-way ANOVA Tukey-Krammer test.

Table (2): Bacterial colony count (105) from experimental burns using diabetic rats, at each bandage change, following treatment (every day) with various topical creams.

Days (D) of sampling D5 D10 D15 D20 D25

Topical treatment C 229.38 ± 5.58 230.88 ± 8.33 311.75 ± 9.43†,‡ 338.25 ± 10.87†,‡ 412.38 ± 12.72†,‡,≠,#

PC 210.88 ± 7.61 212.38 ± 7.35 91.13 ± 6.30a;†,‡ 58.38 ± 4.94a;†,‡,≠ 20.50 ± 1.98a;†,‡,≠,#

DC 214.25 ± 8.52 228.00 ± 10.85 162.88 ± 14.69a,b;†,‡ 145.25 ± 6.85a,b;†,‡ 71.50 ± 6.36a,b;†,‡,≠,#

PC & DC 177.75 ± 9.15a,b,c 109.50 ± 9.40a,b,c;† 52.63 ± 5.24a,b,c;†,‡ 15.38 ± 1.96a,b,c;†,‡,≠ 10.00 ± 1.22a,c;†,‡,≠

Data were expressed as Means ± SEM of 8 diabetic rats /group.

C; PSS treated group, PC; propolis cream treated group, DC; SSD cream treated group, PC & DC; propolis-SSD mixture cream treated group. asignificantly

different versus control group; bsignificantly different versus PC group; csignificantly different versus DC group at P ≤ 0.05.

†significantly

different versus D5; ‡significantly different versus D10; ≠significantly different versus D15; different versus D20 at P ≤ 0.05.

#significantly

Significance was carried out by One-way ­ANOVA Tukey-Krammer test.

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23

Table (3): Burn areas from experimental diabetic rats, at each bandage change, following treatment (every day) with various topical creams.

Days (D) of measurements D4 D8 D14 D19 D24

Topical treatment cream Burn surface areas (BSA) (cm2) C PC 2.21 2.03 ± 0.08 ± 0.07 2.52 1.98 ± 0.09 ± 0.10a 3.04 1.69 ± 0.14†,‡ ± 0.08a;† 4.04 1.29 ± 0.13†,‡,≠ ± 0.05a;†,‡,≠ 0.86 4.13 ± 0.07a;†,‡,≠,# ± 0.10†,‡,≠

DC 2.14 ± 0.08 2.04 ± 0.09a 1.95 ± 0.08a 1.71 ± 0.14a,b 1.34 ± 0.14a,b;†,‡,≠

PC & DC 2.01 ± 0.07 1.79 ± 0.09a 1.40 ± 0.08a,c;†,‡ 0.89 ± 0.03a,b,c;†,‡,≠ 0.54 ± 0.04a,b,c;†,‡,≠,#

Data were expressed as Means ± SEM of 8 diabetic rats /group.

C; PSS treated group, PC; propolis cream treated group, DC; SSD cream treated group, PC & DC; propolis-SSD mixture cream treated group. asignificantly †significantly

at P ≤ 0.05.

different versus control group; bsignificantly different versus PC group; csignificantly different versus DC group at P ≤ 0.05. different versus D5; ‡significantly different versus D10; ≠significantly different versus D15; #significantly different versus D19

Significance was carried out by One-way ANOVA Tukey-Krammer test.

Discussion Burns and post-burn wounds are the most common skin injuries. They have been the incentive for many clinical and research centers to seek a substance which would have the basic therapeutic functions, regenerative, reparative, anti-micro-organic and anesthetic, necessary for dermatological medicaments. One of the pharmacopoeial substances that have the above-mentioned properties is propolis6.

The therapeutic effectiveness of propolis, in which the pharmacological activity results from their physicochemical properties, was confirmed by Molan20 in his research.

References 1. Abdel Wahab, Y.H., O’Harte, F.P., Ratcliff, H., McClenaghan, N.H., Barnett, C.R., Flatt, P.R. Glycation of insulin in the islets of Langerhans of normal and diabetic animals. Diabetes 45; 14891496, 1996.

2. Aga H, Shibuya T, Sugimoto T, Kurimoto M, Nakajima SH. Isolation and identification of antimicrobial compounds in Brazilian propolis. Biosci Biotechnol Biochem, 58:945–6, 1994.

3. Bankova V, Christov R, Kujumgiev A, Marcucci MC, Popov S. Chemical composition and antibacterial activity of Brazilian propolis. Z Naturforsch [C] 50:167–172, 1995.

4. Chen C. N., Weng M. S., Wu C.L., Lin J. K. Comparison of the radical scavenging activity, cytotoxic effects, and apoptosis induction in human melanoma cells by Taiwanese propolis, eCAM, (Evidence based Contemporary Alternative Medicine), 1, 175-185, 2004.

5. Duarte S., Rosalen P. L., Hayacibara M. F., Cury J. A., Bowen W. H., Marquis R. E., Rehder V. L., Sartoratto A., Ikegaki M., Koo H., Arch.Oral. Biol., 51, 15-22, 2006.

6. Gafar M., Guti L., Dumitri H. Pharmaceutical preparations with propolis extracts used in treatment of peripheric chronic paradontopathies. II In­ ternational Symphosium Apitherapy. Bukarest, 1976.

7. Gracia C.G.: An open study comparing topical silver sulfadiazine and topical silver sulfadiazine-cerium nitrate in the treatment of moderate and severe burns. Burns, 27, 67-74. 2001.

24

The plethora of therapeutic modalities used in the treatment of burn wound especially when complicated by diabetes is, in itself, testimony to the lack of efficacy of any one measure.

This study set out, therefore, to assess and compare the effect of propolis alone or in combination with SSD on diabetic burn wound healing.

The four groups were evenly balanced according to age, burn surface area, standard surgical care, and diabetes level.

The time from the moment the thermal wound was made to the beginning of repair processes in the wound

8. Grange, J. M. and Davey, R. W.: Antibacterial properties of propolis (bee glue) Journal of the Royal Society of Medicine 83, 159-160, 1990.

9. Gregory R.S., Piccolo N., Piccolo M.T., Piccolo M.S., Heggers J.P. : Comparison of propolis Skin Cream to Silver Sulfadiazine : A Naturopathic Alternative to Antibiotics in Treatment of Minor Burns. J. Altern.

Complem. Med., 8: 77-83, 2002.

10. Han MC, Durmus AS, Karabulut, and Yaman I.: Effect of Turkish propolis and sulfadiazine on burn wound healing in rats. Revue. Med. Vet. 156: 12, 624-627, 2005.

11. Isla M.I., Moreno M.I.N., Sampietro A.R., Vattuone M.A. : Antioxidant activity of Argentine propolis extracts. J. Ethnopharmacol. 76: 165-170, 2001.

12. Kloth LC, and Feedar JA, «Acceleration of Wound Healing with High Voltage Monophasic Pulsed Current» Phys Ther. 68;503-508, 1988.

experimental animals Recent Progress in Medicinal Plants, 17, 55-113, 2006.

17. Orsolic N., Basic I.,: Immunomodulation by water-soluble derivative of propolis (WSDP) a factor of antitumor reactivity J. Ethnopharmacol., 84, 265-273 2003.

18. Paul, J.W. and M.A. Gordon, 1978. Efficacy of chlorxidine surgical scrub compared to that of Hexachlorophene and Povidone-iodine. VMC/SAC., 573: 345-356.

19. Takasi, Kikuni NB; Schilr H.: Electron microscopic and microcalorimetric investigations of the possible mechanism of the antibacterial action of propolis.

Povenance planta Med., 60(3): 222-227, 1994.

20. Wander P. Taking the sting out of dentistry. Dental Practice, 25:3, 1995.

13. Molan P.C. Potential of honey in the treatment of wound and burns. Am. J. Clin. Dermatol. 2: 13-19, 2001.

21. Werner S, Breeden M, Hubner G, Greenhalgh DG, Longaker MT: Induction of keratinocyte growth factor expression is reduced and delayed during wound healing in the genetically diabetic mouse. J Invest Dermatol. 103:469–473, 1994.

14. Moreno M., Isla M., Sampietro A., Vattuone M., Comparison of the free radical-scavenging activity of propolis from several regions of Argentina J. Ethnopharmacol. 71, 109-114, 2000.

22. Winkler M., Erbs G., Muller F.E., Konig W.: Epidemiologic studies of the microbial colonization of severely burned patients. Zentralbl. Bakteriol.

Mikrobiol. Hyg. 184, 304 –320, 1987.

15. Orsi RO, Sforcin JM, Funari SR, Bankova V. Effects of Brazilian and Bulgarian propolis on bactericidal activity of macrophages against Salmonella typhimurium. Internat Immunopharmacol 2005;5:359-368 16- Orsolic N., Basic I.: Cancer chemoprevention by propolis and its polyphenolic compounds in

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Science, Practice and Education

and bacterial colony counts especially during the proliferative phase of wound healing.

varied depending on the applied remedy. Generally, all the wounds were enlarged during the first three days of treatment, which was due to wound retraction as well as splinting of wound edges by the bandaging, but the enlargement stopped increasing in the propolis, SSD, and propolis-SSD mixture cream treated group after that and continued to increase only in the control (PSS) treated group. There was also a significant reduction of BSA in the propolis treated group when compared to the SSD treated group. Moreover there was a significant reduction in BSA in the propolis-SSD mixture cream treated group when compared to either remedy alone especially at day 24.

The above BSA finding was supported by the bacterial colony count result which stated that at day 20 and day 25, it was found that either propolis or SSD is effective in reducing the bacterial colony count compared to the control group. Interestingly, it was found that the complementary mixture of both agents (propolis-SSD mixture cream) lead to superior results in comparison with strict adherence to either agent alone.

It was concluded from the above results that propolis has more antibacterial effect than the traditional antibacterial cream (SSD) and also, the unique combination of both propolis and SSD lead to superior reduction in both BSA

The findings of our study are consistent with several investigators. Han et al10 concluded that the application of propolis skin cream could be considered an alternative to the use of traditional antibiotic silver sulfadiazine (SSD).

Takasi et al.19 stated that propolis inhibits bacterial growth by preventing cell division, thus resulting in the formation of pseudo-multicellular streptococci. In addition, propolis disorganized the cytoplasm, the cytoplasmic membrane and the cell wall, caused a partial bacteriolysis and inhibited protein synthesis.

Grange and Davey8 found that propolis have antibacterial activity against a range of commonly encountered cocci and Gram-positive rods, including the human tubercle bacillus, but only limited activity against Gramnegative bacilli. These findings confirm that the antimicrobial properties of propolis possibly attributed to its high flavonoid content.

In summary, the emerging method of using both propolis and SSD in combination cream have offered a renewed hope to patients with impaired wound healing capability such as diabetic burn wound. m * Dermazine

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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

Pilonidal sinus disease: a review

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

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Can thermography predict delayed healing in pressure ulcers?

Scientific Communication

PURSUN UK The Pressure Ulcer Research Service User Network for the UK

Delia Muir on behalf of PURSUN UK Correspondence: d.p.muir@leeds.ac.uk Conflict of interest: none

Patient and Public Involvement (PPI) in health research is a rapidly growing field and many funders now require active involvement as early as the grant application stage1. This provides a challenge for researchers who must find a way to create ethical and meaningful partnerships.

We have found that involvement in pressure ulcer research is less developed than in some other research areas. This is partly due to the lack of patient groups or charities with a pressure ulcer focus. To address this we have formed PURSUN UK, a network of patients, carers and service users who have some personal experience of the prevention or treatment of pressure ulcers. The network is supported by a Patient and Public Involvement Officer at the University of Leeds. Research opportunities are sent out to members as they arise and the network is already supporting research in the region. We hope the network will grow to become a national resource.

Our Work So Far Two members of PURSUN UK sit on the PURPOSE (Pressure Ulcer Programme of Research) steering committee, to ensure the service user voice is represented at every level. In addition to this we also hold more informal meetings with a focus on service user input. As part of these meetings network members are contributing to the development of a Pressure Ulcer Risk Assessment Framework. The important perspective which network members bring is helping to shape a tool which is acceptable to patients. In addition, network members have highlighted the need to adapt the tool for use by patients and carers in the community, and the research team are integrating this in a future programme of work focussed upon implementation. The project is on-going and researchers have commented on the valuable contribution network members are making.

We are currently developing an interactive workshop which will facilitate the involvement of service users and carers in the interpretation

26

of research data; specifically looking at the Severe Pressure Ulcer strand of PURPOSE. Our members are also helping to shape future research through their involvement in funding applications and the James Lind Alliance Pressure Ulcer Partnership (JLAPUP), a research priority setting project.

We have taken a flexible, asset based approach to involvement which allows network members to take on varying roles depending on their skills, needs and the level of commitment they feel able to give. This includes providing opportunities to contribute from home where needed. Preparation workshops, based on the Patient Learning Journey Model2, support this process.

Get Involved Researchers – If you would like to involve service users and carers in your work then we can offer guidance and publicise opportunities via the network.

Service users and carers – We are looking for new network members. If you would like more information contact: Delia Muir Patient and Public Involvement Officer Clinical Trials Research Unit (CTRU) University of Leeds d.p.muir@leeds.ac.uk This article presents independent research commissioned by the National Institute for Health ­Research (NIHR) under its programme Grants for Applied research funding scheme (RPPG-0407-10056). The views expressed in this ­article are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health. m

1 Brett J, Staniszewska S, Mockford C, Seers K, Herron-Marx S, Bayliss H (2010). The PIRICOM Study: A systematic review of the conceptualisation, measurement, impact and outcomes of patients and public involvement in health and social care research. UK Clinical Research Collaboration. www.ukcrc.org/index.aspx?o=3233 2 Morris P, Dalton E, McGoverin A and Symons J. Preparing for patientcentred practice: developing the patient voice in health professional learning, In: Bradbury H, Frost N, Kilminster S, Zukas M. Beyond Reflective Practice, Routledge, Oxford, 2009.

EWMA Journal

2011 vol 11 no 3

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Scientific Communication

Perspective of the European Patients’ Forum

Developing Collaboration

Nicola Bedlington Executive Director Correspondence: nicola.bedlington@ eu-patient.eu Conflict of interest: none

Developing constructive dialogue and collaboration with healthcare professionals and other stakeholders is at the heart of the work of the European Patients’ Forum.

We were established in 2003 to ensure a strong, united and influential patients’ voice in EU healthcare policy debates. European Patients’ Forum has now grown into an umbrella body of 51 European disease-specific patient organisations and related national coalitions representing the interests of 150 million EU patients with chronic conditions.

Since 2007 European Patients’ Forum is working around five strategic goals: n To promote equal access to best quality information and healthcare for EU patients, their carers and their families n To ensure meaningful patient involvement in EU health-related policy-making, programmes and projects n To ensure patients’ perspectives, including issues around human rights and quality of life, are heard in developments at EU level on health economics and health efficacy (health, wealth and equity) n To encourage inclusive, effective and sustainable representative patient organisations n To nurture and promote solidarity and unity across the EU patients’ movement Our goals are all geared towards empowering patients and their organisation to contribute meaningfully to the EU health policy environment to achieve high quality, safe, patient-centred, and equitable healthcare for all patients in Europe.

The European Patients’ Forum has invested extensively in empowering inclusive, effective and sustainable representative patient organisations to really play an active role and contribute their expertise and experience to the EU health policy debate. And intrinsic to this is a strong relationship with health professionals based on trust, confidence and common interest.

Our Annual Conferences and Regional Advocacy Seminars1 in different parts of Europe have been central to this, and have helped towards a doubling of our membership in the last four years.

28

Our project Value +2 which explored the notion of meaningful patient involvement in EU healthrelated policy-making, programmes and projects, also had an evident impact at these three levels.

European Patients’ Forum has a forthcoming 2011 Regional Advocacy Seminar which will take place 27-28 October in Bucharest, Romania. This will be another occasion to dialogue and build up partnerships between patients and professional organisations. The seminar has a two-fold purpose: Capacity building for patient organisations’ leaders in order for them to become more empowered actors in national and European health policy arena, and strengthening cooperation between patients’ and health professionals’ organisations in national health-related policy-making.

Healthcare professionals play a key role in the empowerment of patients. In addition patients and healthcare professionals are facing common challenges. European Patients’ Forum has placed much importance in fostering alliances and good working relations with European organisations.

These include for example the European Standing Committee of Doctors (CPME), the European Federation of Nurses (EFN); the European Pharmacists Organisation (PGEU), the European Hospitals Association (HOPE), the European Health Management Association (EHMA). The May 2011 EWMA meeting was also an occasion to explore possibilities for enhanced collaboration between our respective organisations.

A key example is Information to Patients, which has been at the forefront of the EU political agenda for several years. EPF and our allies have been successful in re-focussing this towards the rights of patients to access high quality information, and the need for a comprehensive EU information to patients strategy where health literacy is a core pillar.

Together with allies, we have also successfully influenced the legislative dossiers on Pharmacovigilance and Anti-counterfeiting to make them more centred on the real-life needs of patients, such as strengthening patients’ role in reporting adverse drug reactions. European Patients’ Forum organised a lunch seminar in the European Parliament with the EU community pharmacists’ organisation PGEU, exploring the new rules and EWMA Journal

2011 vol 11 no 3

highlighting the opportunities for patients and health professionals to work together towards better patient safety and quality of care.

Patients and healthcare professionals’ partnership in EU projects have also led to important outcomes. Through the project EUNETPAS, European Patients’ Forum worked closely with all partners and contributed to the preparation of a Guidelines document on “Education and training in patient safety”, which aims to support healthcare providers at national and local levels to design, establish and evaluate training interventions in patient safety. We hope that this collaboration will continue in 2012 through a Joint Action.

The European health community also works in partnership through key forums and stakeholder groups established by EU institutions and agencies on our common initiatives: the European health policy forum, the patient safety and quality of care working group, the European Medicines Agency stakeholder forum on pharmacovigilance to name a few.

Sharing our experience and working together on policy areas, projects, and through stakeholder platforms has so far proved to be a successful way forward.

The current EU discourse on prevention and health promotion is welcome; however, we believe similar political attention must be focused on patient-centred chronic disease management, to ensure that future health systems put patients at the centre while delivering safe, high quality care that is accessible, inclusive and sustainable.

Health innovation in all its guises, if properly harnessed, can make a major contribution – and the new European Innovation Partnership on Active and Healthy Ageing will be an important litmus test and learning environment for all of us.

For health innovation to achieve its potential, ‘connectivity’ is absolutely essential. Connectivity between different sectors of industry: pharmaceuticals, medical devices, IT; connectivity between healthcare systems and social care systems, which for too long have run on separate tracks rather than providing a patient-centred care model that will support the individual throughout the life continuum and in particular older age; and connectivity between the different stakeholders – patients, health professionals, insurers, industry and policy makers.

European Patients’ Forum has made significant progress towards its goals in a relatively short time, thanks to the commitment and investment of its members and its philosophy of real partnership – moving forward together with all of the stakeholders around the policy table. European Patients’ Forum will continue to strive with our members and our allies for a Europe where all patients can access the high quality, patient-centred care they need, when they need it. www.eu-patient.eu/Events/ m 1 2

www.eu-patient.eu/Initatives-Policy/Projects/EPF-led-EU-Projects/ValuePlus/

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ABSTRACTS OF RECENT ­COCHRANE REVIEWS Publication in The Cochrane Library Issue 7, 2011

Dressings for the prevention of surgical site infection

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

Jo C Dumville, Catherine J Walter, Catherine A Sharp, Tamara Page Citation: Dumville JC, Walter CJ, Sharp CA, Page T. Dressings for the prevention of surgical site infection.

Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD003091.

DOI: 10.1002/14651858.CD003091.

Copyright © 2011 The Cochrane Collaboration. ­Published by John Wiley & Sons, Ltd. ABSTRACT Background: Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured - often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing.

Objectives: To evaluate the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011 Issue 2); Ovid MEDLINE (1950 to April Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed ­Citations, May 9, 2011); Ovid EMBASE (1980 to 2011 Week 18); EBSCO CINAHL (1982 to 6 May 2011).

There were no restrictions based on language or date of publication.

Selection criteria: Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressings with leaving wounds exposed for postoperative management of surgical wounds healing by primary intention.

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

Main results: Sixteen RCTs were included (2578 participants). All trials were at unclear or high risk of bias.

Nine trials included people with wounds resulting from surgical procedures with a contamination classification

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of ‘clean’, two trials included people with wounds resulting from surgical procedures with a ‘clean/contaminated’ contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 14 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by secondary intention.

Authors’ conclusions: At present, there is no evidence to suggest that covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or that any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and of poor quality at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

Plain language summary: No recommendations regarding type of wound dressing for the prevention of surgical site infection Millions of surgical procedures are conducted globally each year. The majority of procedures result in wounds in which the edges are brought together to heal using stitches, staples, clips or glue - this is called ‘healing by primary intention’. Afterwards, wounds are often covered with a dressing that acts as a barrier between them and the outside environment. One advantage of this may be to protect the wound from micro-organisms, and thus infection. Many different dressing types are available for use on surgical wounds, however, it is not clear whether one type of dressing is better than any other at preventing surgical site infection, or, indeed, whether it is better not to use a dressing at all.

We conducted a review of all available, relevant, evidence regarding the impact of dressings on the prevention of surgical site infections in surgical wounds healing by primary intention. The review examined data from 16 randomised controlled trials and found no evidence to suggest either that one dressing type was better than any other, or that covering these wounds with dressings at all was better, at preventing surgical site

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infection, or that any dressing type improves scarring, pain control, patient acceptability or ease of removal. It is important to note that many trials in this review were small and of poor quality, at high or unclear risk of bias. Decisions on wound dressing should be based on dressing costs and the need for management of specific symptoms e.g., absorption of exudate.

Publication in The Cochrane Library Issue 9, 2011

Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post ­injury Martha C Eliya, Grace W Banda Citation: Eliya MC, Banda GW. Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury. Cochrane Database of Systematic Reviews 2010, Issue 7.

Art. No.: CD008574. DOI: 10.1002/14651858.CD008574 Copyright © 2011 The Cochrane Collaboration.

Published by John Wiley & Sons, Ltd. ABSTRACT Background: Acute traumatic wounds are one of the common reasons why people present to the emergency department. Primary closure has traditionally been reserved for traumatic wounds presenting within six hours of injury and considered ‘clean’ by the attending surgeon, with the rest undergoing delayed primary closure as a means of controlling wound infection. Primary closure has the potential benefit of rapid wound healing but poses the potential threat of increased wound infection. There is currently no evidence to guide clinical decisionmaking on the best timing for closure of traumatic wounds.

Objectives: To determine the effect on time to healing of primary closure versus delayed closure for non bite traumatic wounds presenting within 24 hours post injury. To explore the adverse effects of primary closure compared with delayed closure for non bite traumatic wounds presenting within 24 hours post injury.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched 14 July 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (1950 to July Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 13, 2011); Ovid EMBASE (1980 to 2011 Week 27); and EBSCO CINAHL (1982 to 14 July 2011). There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: Randomised controlled trials comparing primary closure with delayed closure of non bite traumatic wounds.

Data collection and analysis: Two review authors independently evaluated the results of the searches against the inclusion criteria. No studies met the inclusion criteria for this review.

Main results: Since no studies met the inclusion criteria, neither a meta-analysis nor a narrative description of studies was possible.

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Authors’ conclusions: There is currently no systematic evidence to guide clinical decision-making regarding the timing for closure of traumatic wounds. There is a need for robust research to investigate the effect of primary closure compared with delayed closure for non bite traumatic wounds presenting within 24 hours of injury.

Plain language summary: Immediate closure or delayed closure for treating traumatic wounds in the first 24 hours following injury Acute traumatic wounds, for example tears, cuts, and scrapes, are a common reason why people go to the emergency department. Primary closure (which is bringing the edges of the wound together with stitches, adhesive tape, staples or glue) is usually used on wounds which are treated quickly (within 6 hours of injury) and which are clean of debris. Wounds can be contaminated by dirt and debris and in these cases may not be closed until later, meaning a delayed closure. If this happens, the wound is cleaned, left for two to three days, checked to see if it is still clean and then closed. This is thought to reduce the chances of becoming infected. Primary closure has the potential benefit of rapid wound healing but may lead to an increased chance of infection.

We wanted to determine the effects on healing, and any adverse effects, of immediate closure compared with delayed closure. We searched the medical literature for randomised controlled trials but found no studies which answered the question.

There is currently no evidence to suggest the best timing for closing acute traumatic wounds to promote the best healing.

Foam dressings for healing diabetic foot ulcers Jo C Dumville, Sohan Deshpande, Susan O’Meara, Katharine Speak Citation: Dumville JC, Deshpande S, O’Meara S, Speak K. Foam dressings for healing diabetic foot ulcers.

Cochrane Database of Systematic Reviews 2011, Issue 5.

Art. No.: CD009111. DOI: 10.1002/14651858.CD009111.

Copyright © 2011 The Cochrane Collaboration.

Published by John Wiley & Sons, Ltd. ABSTRACT Background: Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use.

Objectives: The review aimed to evaluate the effects of foam wound dressings on the healing of foot ulcers in people with ­diabetes.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched 10 June 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); Ovid MEDLINE (1950 to June Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 8 June, 2011); Ovid EMBASE (1980 to 2011 Week 22); EBSCO CINAHL (1982 to 3 June 2011). There were no restrictions based on language or date of publication. 

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Selection criteria: Published or unpublished randomised controlled trials (RCTs) that evaluated the effects on ulcer healing of one or more foam wound dressings in the treatment of foot ulcers in people with diabetes.

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

Main results: We included six studies (157 participants) in this review. Meta analysis of two studies indicated that foam dressings do not promote the healing of diabetic foot ulcers compared with basic wound contact dressings (RR 2.03, 95%CI 0.91 to 4.55). Pooled data from two studies comparing foam and alginate dressing found no statistically significant difference in ulcer healing (RR 1.50, 95% CI 0.92 to 2.44). There was no statistically significant difference in the number of diabetic foot ulcers healed when foam dressings were compared with hydrocolloid (matrix) dressings. All included studies were small and/or had limited follow-up times.

Authors’ conclusions: Currently there is no research evidence to suggest that foam wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however all trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.

Plain language summary: Foam dressings for healing foot ulcers in people with diabetes Diabetes, a condition which leads to high blood glucose concentrations, is a common condition with around 2.8 million people affected in the UK (approximately 3% of the population). Dressings are a widely used treatment when caring for foot ulcers in people with diabetes. There are many types of dressings that can be used, which also vary considerably in cost. Existing reviews have not found evidence that one dressing type is more effective than other types in healing foot ulcers in people with diabetes. This review (157 participants) confirms that currently there is no research evidence to suggest that foam wound dressings are more effective in healing diabetic foot ulcers than other types of dressing. Current decisions on choice of wound dressing if any, should be based where possible, on dressing costs and selecting the most useful management properties offered by each dressing type, for example, the management of wound discharge.

Pressure-relieving devices for treating heel pressure ulcers Elizabeth McGinnis, Nikki Stubbs Citation: McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD005485. DOI: 10.1002/14651858.CD005485.

Copyright © 2011 The Cochrane Collaboration.

Published by John Wiley & Sons, Ltd. ABSTRACT Background: Pressure ulcers are areas of localised damage to the skin and underlying tissue caused by pressure or shear. Pres-

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sure redistribution devices are used as part of the treatment to reduce the pressure on the ulcer. The anatomy of the heel and the susceptibility of the foot to vascular disease mean that pressure ulcers located there require a particular approach to pressure relief.

Objectives: To determine the effects of pressure-relieving interventions for treating pressure ulcers on the heel.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched 25 March 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1); Ovid MEDLINE (1948 to March Week 3 2011); Ovid EMBASE (1980 to 2011 Week 12);Ovid MEDLINE (In-Process & Other Non-Indexed Citations March 29, 2011); and EBSCO CINAHL (1982 to 25 March 2011). We applied no language or publication date restrictions.

Selection criteria: We included randomised controlled trials (RCTs) that compared the effects of pressure-relieving devices on the healing of pressure ulcers of the heel. Participants were treated in any care setting. Interventions were any pressurerelieving devices including mattresses and specific heel devices.

Data collection and analysis: Both review authors independently reviewed titles and abstracts and selected studies for inclusion.

Both review authors independently extracted data and assessed studies for risk of bias.

Main results: One study met the inclusion criteria. This study (141 participants) compared two mattress systems however losses to follow up were too great to permit reliable conclusions.

Authors’ conclusions: This review identified one small study at moderate to high risk of bias which provided no evidence to inform practice. More research is needed.

Plain language summary: Pressure-relieving devices for treating heel pressure ulcers Pressure ulcers (also known as pressure sores, decubitus ulcers and bed sores) are areas of localised damage to the skin and underlying tissue, believed to be caused by pressure, shear or friction. Pressure-relieving devices such as beds, mattresses, heel troughs, splints and pillows are used as part of the treatment to reduce or relieve the pressure on the ulcer. Heel ulcers were studied specifically as their structure is very different to the other body sites which are prone to pressure ulcers (such as the bottom) and they are more prone to diseases, such as poor circulation, which do not affect other pressure ulcer sites. We identified one study that was at moderate to high risk of bias. This study lost over half the participants to follow up. More high quality research is needed to inform the selection of pressure relieving devices to treat pressure ulcers of the heel.

Use the EWMA Journal to profile your company Deadline for advertising in the January 2012 issue is 1 November 2011

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Hydrogel dressings for healing diabetic foot ulcers Jo C Dumville, Susan O’Meara, Sohan Deshpande, Katharine Speak Citation: Dumville JC, O’Meara S, Deshpande S, Speak K. Hydrogel dressings for healing diabetic foot ulcers.

Cochrane Database of Systematic Reviews 2011, Issue 5.

Art. No.: CD009101. DOI: 10.1002/14651858.CD009101.

Copyright © 2011 The Cochrane Collaboration.

Published by John Wiley & Sons, Ltd. ABSTRACT Background: Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including hydrogel dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use.

Objectives: To assess the effects of hydrogel wound dressings compared with alternative dressings or none on the healing of foot ulcers in people with diabetes.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched 10 June 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); Ovid MEDLINE (1950 to June Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, June 8, 2011); Ovid EMBASE (1980 to 2011 Week 22) and EBSCO CINAHL (1982 to 3 June 2011). There were no restrictions based on language or date of publication.

Selection criteria: Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrogel with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes.

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

Main results: We included five studies (446 participants) in this review. Meta analysis of three studies comparing hydrogel dressings with basic wound contract dressings found significantly greater healing with hydrogel: risk ratio (RR) 1.80, 95% confidence interval (CI) 1.27 to 2.56. The three pooled studies had different follow-up times (12 weeks, 16 weeks and 20 weeks) and also evaluated ulcers of different severities (grade 3 and 4; grade 2 and grade unspecified). One study compared a hydrogel dressing with larval therapy and found no statistically significant difference in the number of ulcers healed and another found no statistically significant difference in healing between hydrogel and platelet-derived growth factor. There was also no statistically significant difference in number of healed ulcers between two different brands of hydrogel dressing. All included studies were small and at unclear risk of bias and there was some clinical heterogeneity with studies including different ulcer grades. No included studies compared hydrogel with other advanced wound dressings.

Authors’ conclusions: There is some evidence to suggest that hydrogel dressings are more effective in healing (lower grade)

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diabetic foot ulcers than basic wound contact dressings however this finding is uncertain due to risk of bias in the original studies.

There is currently no research evidence to suggest that hydrogel is more effective than larval therapy or platelet-derived growth factors in healing diabetic foot ulcers, nor that one brand of hydrogel is more effective than another in ulcer healing. No RCTs comparing hydrogel dressings with other advanced dressing types were found.

Plain language summary: Hydrogel dressings to promote diabetic foot ulcer healing Diabetes, a condition which leads to high blood glucose concentrations, is a common condition with around 2.8 million people affected in the UK (approximately 3% of the population). Dressings are a widely used treatment when caring for foot ulcers in people with diabetes. There are many types of dressings that can be used, which also vary considerably in cost. This review (five studies involving a total of 446 people) suggests that hydrogel dressings may be more effective than basic wound contact dressings in healing foot ulcers in people with diabetes although the original research may be biased. There is insufficient research comparing hydrogel with advanced dressing types to allow conclusions to be drawn regarding relative effectiveness in terms of ulcer healing. m

EWMA 2013 15-17 may 2013

COPENHAGEN Denmark

Danish Wound Healing Society

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EWMA Journal

Previous Issues

Volume 11, no 2, May 2011 The fight against biofilm infections: Do we have the knowledge and means?

Klaus Kirketerp-Møller, Thomas Bjarnsholt, Trine R. Thomsen Biofilms in wounds: An unsolved problem?

António Pedro Fonseca Diabetic foot ulcer pain: The hidden burden Sarah E Bradbury, Patricia E Price Topical negative pressure in the treatment of deep sternal infection following cardiac surgery: Five year results of first-line application protocol Martin Šimek Wounds Research for Patient Benefit: A five year programme of research in wound care Karen Lamb, Nikki Stubbs, Jo Dumville, Nicky Cullum

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

Italian

Preliminary results of experimental research on a technique for measuring skin ulcer lesions Crisci A., et al.

Effect of topical negative-pressure wound therapy on bacterial concentration in pressure lesions Preliminary results of experimental research on a technique for measuring skin ulcer lesions Crisci A., et al.

Effect of topical negative-pressure wound therapy on bacterial concentration in pressure lesions Scognamiglio R., et al.

The appropriateness of care in the management of cutaneous leg ulcers: A prospective study Baù P., et al.

Volume 11, no 1, January 2011 Who will take on Ali Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi Diabetic foot ulcer pain: The hidden burden Sarah E Bradbury, Patricia E Price The reconstructive clockwork as a 21st c­ entury concept in wound surgery Karsten Knobloch, Peter M. Vogt Anaemia in patients with chronic wounds Lotte M. Vestergaard, Isa Jensen, Knud Yderstraede A survey of the provision of e­ ducation in wound management to undergraduate nursing students Zena Moore, Eric Clarke Caring for Patients with Hard-to-Heal Wounds – Homecare Nurses’ Narratives Camilla Eskilsson Volume 10, no 3, October 2010 Rationale for compression in leg ulcers with mixed, arterial and venous aetiology Hugo Partsch Pressure ulcers in Belgian hospitals: What do nurses know and how do they feel about prevention?

D. Beeckman, T. Defloor, L. Schoonhoven, K. Vanderwee Nutritional Supplement is Associated with a Reduction in Healing Time and Improvement of Fat Free Body Mass in Patients with Diabetic Foot Ulcers P. Tatti, A.E. Barber, P. di Mauro, L. Masselli Chronic wounds, non-healing wounds or a p ­ ossible alternative?

M. Briggs Silver-impregnated dressings reduce wound c­ losure time in ­marsupialized pilonidal sinus A. Koyuncu, H. Karadaˇ, A. Kurt, C. Aydin, O. Topcu Venous leg ulcer patients with low ABPIs: How much pressure is safe and tolerable?

J. Schuren, A. Vos, J.O. Allen, Adherence to leg ulcer treatment: Changes associated with a nursing i­ntervention for c­ ommunity care settings A. Van Hecke, M. Grypdonck, H. Beele, K. Vanderwee, T. Defloor A Social Model for Lower Limb Care: The Lindsay Leg Club Model M. Clark

English

Advances in Skin & Wound Care, vol. 24, no 9, 2011 www.aswcjournal.com Outcome and Assessment Information Set Data That Predict Pressure Ulcer Development in Older Adult Home Health Patients Sandra Bergquist-Beringer, Byron J. Gajewski Special Considerations in Wound Bed Preparation 2011: An Update© R. Gary Sibbald, Laurie Goodman, Diane L. Krasner, Hiske Smart, Gulnaz Tariq, Elizabeth A. Ayello, Robert E. Burrell, David H. Keast, Dieter Mayer, Linda Norton, Richard Salcido How Does a Skilled Nursing Facility Get Reimbursed by ­Medicare?

Kathleen D. Schaum

Finnish

Haava, no. 2, 2011 www.shhy.fi The damages of fragile skin Heli Kukko Loos, break and bare Minna Kääriäinen Malign wounds in the view surgeon Päivi Salminen-Peltola Malign wounds challenge for care Arja Korhonen The treatment of skin metastasis Pia Torvinen Home alarm, which changed the life of police officer Johanna Markkanen Guidelines for Prevention and Treatment of Pressure Ulcer Helvi Hietanen Demanding and rare wounds Ansa Iivanainen & Tiina Pukki Scientific and professional posters Ansa Iivanainen & Anna Hjerppe

Volume 10, no 2, May 2010 Hyperbaric Oxygen and Wounds: A tale of two enzymes Thomas K. Hunt HBOT in evidence-based wound healing Maarten J. Lubbers Comparative analysis of two types of gelatin microcarrier beads Mohamed A Eldardiri et al.

Evidence based guidelines – how to channel relevant k­ nowledge into the hands of nurses and c­ arers Susan F. Jørgensen, Rie Nygaard Lack of due diligence in the prophylaxis of pressure ulcers?

Dr. Beate Weber, Hans-Joachim Castrup Six prevalence studies for pressure ulcers – Snapshots from Danish Hospitals Susan Bermark et al.

The Ransart Boot – An offloading device for every type of Diabetic Foot Ulcer?

I.J.Dumont et al.

The Haitian Earthquake, January 2010 John M Macdonald

Acta Vulnologica, vol. 9, no 2, 2011 www.vulnologia.it

Spanish

Helcos, vol. 22, no. 2, 2011 3rd National Survey of the Prevaslence of Pressure Ulcers in Spain 2009. Epidemiology and defining ­variables in lesions and patients Soldevilla-Agreda JJ; Torra-Bou JE; Verdu-Soriano J; Lupez-Casanova, P. Prevention and perseverance lead to tissue integrity Carrasco JM; Dumond E; Ruz A; Govez F; Gutierrez M; Montesinos P; GarcÌa-Gonzalez MA.

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

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English

Journal of Wound Care, vol. 20, no 8, 2011 www.journalofwoundcare.com

English

Nutrition and wound healing A.R. Sherman; M. Barkley Study to evaluate the effect of low-intensity pulsed electrical currents on levels of oedema in chronic non-healing wounds S. Young; S. Hampton; M. Tadej Reaching for the moon: Achieving zero pressure ulcer ­prevalence, an update I. Bales; T. Duvendack Fact or myth? Pain reduction in solvent-assisted removal of adhesive tape R. van Shaik; M.H. Rövekamp Connexins, a new target in wound treatment K.Y. Chin Malignant tumours arising in chronic leg ulcers: Three cases and a review of the literature C. Erfurt-Berge; J. Bauerschmitz English

Int. Journal of Lower Extremity Wounds vol. 10, no 3, 2011 http://ijlew.sagepub.com

Compression stockings ulcer Wolff Tumor and coagulation Matzdorff Percutaneous transluminal angio – angioplasty (PTA) of the superficial femoral artery Nikol Bridging – perioperative administration of anticoagulants Mondorf Lymphology operative part 3 The preparation of the paradigm shift in secondary ­lymphedema Cornely Incomplete segmental thrombosis Antakyali German

Differential Keratin Expression During Epiboly in a Wound Model of Bioengineered Skin and in Human Chronic Wounds S. Luo, T. Yufit, P. Carson, . Fiore, J. Falanga, X. Lin, L. Mamakos, V. Falanga Factors Affecting Gentamicin Penetration in Lower Extremity Ischemic Tissues With Ulcers M.C. Zammit, L. Fiorentino, K. Cassar, L.M. Azzopardi, G. LaFerla Principles and Technique of Foam Sclerotherapy and Its Specific Use in the Treatment of Venous Leg Ulcers M. Simka Combination of Activated Protein C and Topical Negative Pressure Rapidly Regenerates Granulation Tissue Over Exposed Bone to Heal Recalcitrant Orthopedic Wounds A. Wijewardena, E. Vandervord, S.S. Lajevardi, J. Vandervord, C.J. Jackson Characteristics of Peripheral Arterial Disease and Its Relevance to the Diabetic Population E. Faglia English

Journal of Tissue Viability, vol. 20, no 3, 2011 www.journaloftissueviability.com

Phlebologie, no 5, 2011 www.schattauer.de

Wund Management, vol. 5, no 5, 2011 English abstracts are available from www.mhp-verlag.de The impact of obesity on the development of wounds W. Tigges Medical care for patients with morbid obesity using a multidisciplinary concept of ambulant and clinical treatment U. Bonacker Obese patients exhibiting ulcus cruris venosum: Possibilities and limitations of compression therapy, a challenge for nurses, doctors and patients C. Hampel-Kalthoff, F. Schimmelfeder Operative Procedures of Bariatric Surgery – Differential ­Indication W. Tigges Collagen in wound therapy P. Al Ghazal, J. Dissemond Clinical efficacy of a new monofilament fibre-containing wound debridement product S. Bahr, et al.

Scandinavian

Studying thermal characteristics of seating materials by recording temperature from 3 positions at the seat-subject interface Z. Liu, V. Cascioli, A.I. Heusch, P.W. McCarthy How do microclimate factors affect the risk for superficial ­ pressure ulcers: A mathematical modeling study A. Gefen An evaluation of serum albumin and the sub-scores of the Waterlow score in pressure ulcer risk assessment D. Anthony, L. Rafter, T. Reynolds, M. Aljezawi Self-esteem in patients with diabetes mellitus and foot ulcers G.M. Salomé, D. Maria de Souza Pellegrino, L. Blanes, L.M. Ferreira

Wounds (SÅR) vol. 19, no 2, 2011 www.saar.dk Antimicrobial soft silicone foam dressing – Trial of new dressings for childrens’ burns Liv Hege Furnes Hilt Surgery…. or premeditated murder?

The mystery of the Varpelev Cranium has been solved Annette Frölich The Health Care Clinic – safe and professionel treatment programmes for patients with wounds and ostomy Ragne Gjestrum-Larsen Health Care Clinic at Frederiksberg Jens Fonnesbech

Make a difference in clinical practice Become a Member of EWMA

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

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

EWMA 2011 Brussels EWMA2011

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Luc Gryson President C.N.C. Clinical nursing consulting Wound management association

fter one and a half year of hard work and an outstanding collaboration between EWMA and the Belgian Federation of Wound Management organisations, the organising was completed. On May 25th 2011 the EWMA conference began at the ‘SQUAREBrussels Meeting Centre – the spectacular venue in the middle of the city centre of Brussels.

SQUARE is housed in the extensive former Palais des Congrés, an elegant, architecturally significant building originally constructed for the 1958 World Expo. Many of the original features, including expansive murals by Paul Delvaux, René Magritte and Louis van Lint, have been carefully restored and are now juxtaposed with contemporary design conceived by a leading team of European designers.

The setting for a successful conference was in place and the warm welcome and hospitality of Brussels and Belgium was extended to EWMA’s 21st conference and this was clear from the beginning.

With delegates from 67 countries represented this gave an excellent mix of cultures and health care professions, providing ideal conditions for networking. within the world of wound management professionals. In total 2,758 participants (of which 610 were exhibitors) chose to come to the EWMA 2011 conference in Brussels. I believe that

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25-27 May Brussels · Belgium

the attendants who experienced this would agree that the conference hall was filled with animated dialogues; enthusiastic networking and the wide range of splendid lectures enlarged the knowledge of many attendees. Also the enthusiasm of the companies was stimulating for all present. Brussels hosted the largest conference in the history of EWMA with more participants, exhibitors, lectures and posters ever attending.

All first time presenters were evaluated by the chairs of the sessions, and 2 presenters were in a class of their own in relation to the quality of the presentation: n Jacqueline Tam Chor Wing, Hong Kong n Stephanie Rylands, United Kingdom Among the many very high quality posters the following 4 were selected as award winners: n Gunnar Riepe, Anke Bueltemann from ­Germany n Dimitri Beeckman, Tom Defloor, Els Clays, L. Schoonhoven, K. Vanderwee from the United Kingdom n Silke Lauterbach, Karel Kostev, Kathrin Birnfeld, Lars Meyfarth from Germany n Junko Matsuo, Junko Sugama, Mayumi Okuwa, Chizuko Konya, Hiromi Sanada from Japan

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The conference was opened by EWMA President Zena Moore

The conference dinner at AUTO WORLD was held for 700 people.

A special session was the honorary lecture, this year with honorary speaker Terence Ryan, Emeritus Professor of Dermatology at Oxford University, speaking of Overgrowth and its reversal in wound healing and lymphoedema.

The theme of EWMA 2011 was Common Voice – Common Rights, which relates to the concept that all patients should have equal voice and equal rights in terms of their access to wound management. This was reflected in the Conference’s Opening session Patient Focus. And it was a central that EWMA 2011 clearly placed the focus on the patient by addressing important issues such as patient empowerment and understanding the patient experience.

The themes of the programme ranged from Nutrition, Pain, Emerging Therapies and Psychological Factors to Wound Diagnostics and Multidisciplinary Approaches.

The broad range of themes in both key sessions, workshops and free paper sessions hopefully gave the participants a greater degree of theoretical and practical understanding of issues in wound care.

The 2011 programme also offered high level scientific sessions from several other wound care organisations including The European Tissue Repair Society (ETRS) arranging the session Clinical Infections and patient’s consequences, European Federation of National Associations of Orthopaedics and Traumatology (EFORT) which arranged a session dealing with infections after orthopaedic surgery and Dystrophic Epidermolysis Bullosa Research Association (DEBRA) offering a session about Epidermolysis Bullosa.

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For Belgium the conference was an acknowledgement of the effort of 5 years intense collaboration between the French speaking and Dutch speaking wound management organisations. You could say that EWMA’s conference was the celebration of the 5 year existence of BEFEWO. The conference for sure stimulated those organisations to continue the efforts also in the future. It’s sure that EWMA Brussels will stay in people’s memories as a marking point.

The conference dinner at AUTO WORLD was held for 700 people and was quite exquisite and a unique event.

Situated in a very beautiful and luxurious building, AUTO WORLD invited the dinner quests to stroll through the history of the auto-mobile from 1886 until the seventies, having one of the most impressive collections of vintage vehicles in the world.

May 27th was the last day of the conference and the culmination of a very successful event and therefore also the time to invite everybody for EWMA’s 22nd conference in Vienna 2012.

Please visit the conference web site www.ewma2012.org for further information. We look forward to seeing you all at the EWMA 2012 Conference! m

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EWMA Patient Outcome Group large POG Evidence document and the other describes the work and objectives of the patient outcome group. The small version of the POG document was developed by Dr Brigitte Espirac and targets all relevant professionals and administrators interested in wounds, explaining the key messages in the POG document. The other Pixi is targeted more towards administrators and other policy-makers as well as industry staff who wish to know more about POG and their work.

EWMA has created a new type of publication, which will be called Pixi’s – these are short documents that provide key messages on a given topic.

The Patient Outcome Group has published two Pixi’s this year. One Pixi is a small version of the

The next full meeting of The Patient Outcome Group will take place on November 8th 2011.

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ince the last update representatives from the Patient Outcome Group have meet with both the American and the Australian Wound Associations, who are very interested in collaborating on the themes which are current promoted by the Patient Outcome Group.

For example, the American association has a similar interest in developing the evidence base for wound care and is seeking to write a document that builds on the EWMA POG publications on Evidence. The Americans will use their document to seek to influence their government in driving improvements within wound care in the United States. They will use the comprehensive work of POG as a foundation for their project and are very interested in developing and maintaining a dialogue between EWMA and the American association on this topic.

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This Pixi is a small version of the large POG Evidence document, developed by Dr Brigitte Espirac and targets all relevant ­professionals and administrators interested in wounds, explaining the key messages in the POG document.

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In the future the POG will continue to spread the message of the need to continuously strengthening the evidence in wound healing. Various groups and stakeholders are being contacted with the aim of discussing the recommendations and ways in which the document could be implemented. Furthermore the group will continue to work together to develop a common study protocol for RCT’s in wound healing and to investigate the complexity of reimbursement of wound care services in Europe.

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In June 2010 the POG published an evidence document1, which contains a detailed debate on research in wound healing including recommendations on what the minimal requirements are in order conduct high-quality, rigorous research in wound care.

This document discusses how to develop a consistent and reproducible approach to define, measure and evaluate appropriate and adequate outcomes.

1 F. Gottrup, J. Apelqvist, P. Price.

“Outcomes in controlled and comparative studies on non healing wounds – Recommendations to improve quality of evidence in wound management” Journal of Wound Care 19(6): 237-268 (Jun 2010)

Further details of the EWMA Patient Outcome Group objectives: To propose revised guidelines for clinical data collection for chronic wounds.

To create and implement consensus on clinical data collection within chronic wound care.

To participate in public debates and influence national policy making relevant for the chronic wound area.

To secure more evidence in wound care without compromising the quality of the evidence obtained.

How will EWMA POG meet the objectives To reach a true European consensus, EWMAs will approach and involve various key stakeholders at national level. The primary target groups will be research institutions and decision makers (major health care providers). Cooperating organisation will be major contributors to the pan-European discussions and well as partners in the dissemination and implementation plans.

The EWMA Patient Outcome Group has several meetings during the year. EWMA considers the discussion on how to evolve evidence in research of wound care a high priority and hopes that all members of EWMA and professionals working with wounds will contribute to the debate.

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The overall desc ribing the states in order to enhance themmEUles, and member their reco objective of theand endations outcomes groucommunity awounds care health discussionto hospital p is to facil for the use in future stud among relev itate of and, in turn, create betresearch in wound care ies: ant parties identify the n Finn Gottr in order to in Europe. care providers in rese different countries gaps in the up: The EWM arch base broad awa ter Atreatment Patient Outc options for wounds for patients all – Joining force and create reness of the ome Grou s to propose Uncovering the prevalence of wounds, theclinic time difficulties p panfunctional European al of data cond guide collection over Europe. lines for ucting trials in wou in wound care, (200 nd care toconsumption 9 vol 9 no this the Patie of health care professionals, the .

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qvist (Patricia ing article: The challenge Price):plans about future Lead- for the wound care area. of using rand in woundin The survey has been successfully completed healing (Briti omized trials sh Journal 2010) of Surgery, Marc h Denmark and over the next year more countries The group has also, in collaboration with the will join in this research. These findings contribute Eucomed Advanced Wound Care Sector Group, to the continuing discussion on the lack of clear recommended to the European Commission data on the prevalence and costs of wounds, and (Directorate General on Health and Consumhow to strengthen the research base in this area2. ers) a series of wound-related questions to be included in a national questionnaire on patient The EWMA Patient Outcome Group has as its safety. objective to facilitate a better understanding of the economic consequences of wounds. Thus The group is currently working on translating EWMA and the Patient Outcome Group have the essential document into German and French run a Health Economics Course in Copenhagen in order to spread the key messages. Currently which will be repeated as part the EWMA industry there is a Polish translation of the document, course, October 13-14th, 2011 in Budapest. which is available on the website. Furthermore, the German organisation of wound healing 2 F. Gottrup. ”EWMA Wound Surveys – Resource consumption for wound care” EWMA Journal 11(2): 60-61 (May 2011) societies (BvMed) has endorsed the document.

Future Projects In phase two POG will focus on the following projects, which will be initiated in 2011: Reimbursement in Europe A common study protocol for RCT’s in wound healing, Identify payers and reimburseincluding a definition of control ment strategies related to groups services and products in the different European countries.

Based on the POG document: Define how to report and to Objective: Map funding from conduct studies in wound patients ‘Out of Pocket’ share management. Starting point will vs. health care system / insurbe pressure ulcers and diabetic ance. foot ulcers.

Objective: To increase the quality of wound management research.

EWMA Journal

An overview of the distribution of research trials (primarily cohort studies, case studies and RCTs) in the last 5 years Define how many studies of each type and the quality of the studies (not focused on outcomes).

Objective: To increase the number of RCTs in wound management, based on the distribution of research trials.

2011 vol 11 no 3

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EWMA

Book Review Masterminding Wounds 2010

By Michael B Strauss

A Alison Hopkins Chief Executive of Accelerate CIC, Tower Hamlets, UK

t first glance, this weighty tome could be seen as an addition to books on general wound management. There are five parts covering Setting the Stage, Evaluation of Wounds, Strategic Management of Problem Wounds, Identification and Management of ‘End Stage Wounds’ and finally Prevention of New and Recurrent Wounds. There is also a comprehensive set of appendices that include key articles and sources of information.

However, with this book, the authors’ aim was to bring together their approach to wound management that has been honed over a number of years. This lends a distinctive feature of evaluation and quantifying the presenting situations that face clinicians on a daily basis. The authors describe their Master Algorithm and how it incorporates the Host-Function Score and GoalAspiration Score. They give examples of its use in the everyday clinical environment; this approach is certainly worth investigating, especially when approaching what the authors describe as ‘end stage wounds’. Another useful feature is the reviews of the different grading tools and processes in current use. The book also has a consistency that can be lacking in other general wound texts because the chapters have been written by the same au-

thors, thus themes are woven throughout the chapters.

Their speciality of diabetic foot management is a key theme running through the chapters, providing a number of thought provoking examples to highlight the section under discussion. Thus, even though the chapters have broad headings, the examples remain focussed on the authors’ experiences. However, this is also a disadvantage of the book. Unfortunately, whilst the evaluative approach can be translated into all wound types by the reader and linked to their own experience, the constant theme of diabetic or ischaemic limbs is also a limiting feature. If the reader is looking for inspiration in venous leg ulcer management or abdominal wounds, they will be disappointed. For this reviewer, the fact that venous leg ulcers were discussed within the management of ‘end stage wounds’ was rather disturbing. The book also does not aim to increase the reader’s understanding of underlying pathophysiology.

This book is certainly to be recommended to clinicians who want to revisit the way in which wound care management is evaluated and quantified. Unfortunately the cost of the book will be prohibitive to individual clinicians. m

Hyperbaric Nursing and Wound Care

By Valerie Larson-Lohr

A

Maarten J. Lubbers Netherlands

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s hyperbaric medicine has evolved as an accepted and evidence-based treatment modality, so has its management. Hyperbaric Nursing and Wound Care gives an in depth explanation of all available procedures in and around the hyperbaric chamber. It deals with history, physiology, wound care, nursing, training, research and legal implications of HyperBaric Oxygen Treatment and its management. Oxygen is the essential component of wound healing while wound ischemia is the most common cause of wound healing failure and this can be corrected through hyperbaric oxygen. For EWMA read-

ers who want to update their knowledge in this field, the chapters dealing with wound care are compulsory reading.

This book provides an easy-touse reference for routine and complicated care by HyperBaric Oxygen Treatment. Nine years ago Hyperbaric Nursing was a landmark publication. This second edition has undergone an extensive revision and update and is highly recommended, not only to nurses but to everyone interested in the field of hyperbaric medicine and wound care! m

EWMA Journal

2011 vol 11 no 3

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Discover more:

+44- (0) 800 980 8880

www.kci-medical.com

Note: Specific indications, contraindications, warnings, precautions and safety information exist for KCI products and therapies. Please consult a physician and product instructions for use prior to application. ©2010 KCI Licensing, Inc. All Rights Reserved. The MEGA BLOK blocks are used with permission of MEGA Brands, Inc. All other trademarks are proprietary to KCI Licensing, Inc., its affiliates and/or licensors. For health care professionals only. CE mark pending. DSL#10-0179 (04/10)

EWMA

Advanced Wound Care Sector (AWCS) Status Report

T

Hans Lundgren Chair of the Eucomed Advanced Wound Care Sector Group

he Eucomed AWCS group (www.eucomed.org) was founded back in June 2007, and since then we have had eighteen regular meetings. At present there are ten companies in the group: B. Braun, Covidien, ConvaTec, Integra, KCI, Mölnlycke Health Care, Paul Hartmann, Smith & Nephew, Sorbion and 3M. In addition, we work in active partnership with EWMA and Policy Action. The purpose of this paper is to give an update on different activities and events during the latest five months, i.e. from April 2011 to August 2011.

Status report SAWC (Symposium on Advanced Wound Care) The SAWC Spring 2011 was arranged in Dallas, Texas. There was a broad range of sessions and posters presented, but I will restrict my report to meetings with external stakeholders and policy makers.

CWCM (Coalition of Wound Care Manufacturers ➞ more on manufacturers’ side) The mission of the “Coalition” is to serve as an advocacy organization for a regulatory, economic and legal climate that promotes patient access to wound care products and their corresponding services. In addition they will address regulatory, government and public affairs issues that affect wound care manufacturers. In practice, the Coalition works very closely with CMS (Centers for Medicare and Medicaid Services) and FDA (Food and Drug Administration). A lot of local wound care policies will come out this year, and the priorities during 2011-2012 will focus on: n Actively engaging in NPWT (Negative Pressure Wound Therapy) issues n Working with CMS (Centers for Medicare and Medicaid Services) to address coverage for disposable products

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n Monitoring new payment systems under health care reform for any related information and take action if necessary Examples would include: • Accountable Care Organizations • Medical Homes • Innovative Payment Systems n Reviewing definitions of skin substitutes and work with ASTM (American Society for Testing and Materials) to develop a consistent definition n Monitoring comparative effectiveness initiatives and take action if necessary n Coding, Coverage and Payment for Antimicrobial Dressings

AWCS (Alliance of Wound Care Stakeholders ➞ more on clinicians’ side) The “Alliance” is a new non-profit multidisciplinary trade association of over 15 physician, clinical, and patient organizations (www.woundcare­ stakeholders.org). The Alliance meets in person at least twice a year and has monthly conference calls.

While the Alliance has been operating since 2002, the need for it to become a more formal organization was apparent due to higher visibility working with regulatory agencies and the submission of the POWER manuscript (Panel On Wound care Evidence-based Research) on wound care research principles to clinical and payer journals.

The Alliance is unique in that no other wound care trade association does the following: n Unites leading wound care clinical associations to provide collective power and expertise for lobbying legislative bodies and regulatory agencies regarding Medicare coding, coverage, and reimbursement for wound care products and services. n Tackles issues important to manufacturers: • Wound care research and comparative effectiveness, e.g. through the multidisciplinary expert panel of POWER

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2011 vol 11 no 3

• Ensure Medicare access to wound care • Critical information for the business

There were also two presentations, one from Elise Berliner on comparative effectiveness and the other from Lynn Shapiro Snyder on “Health Care Reform Issues Impacting Health Care Providers”.

AAWC (Association for the Advancement of Wound Care) (www.aawconline.org) AAWC is the pre-eminent organization for wound care in the US, and at this SAWC Spring 2011 they organized a membership meeting. AAWC does not own this conference and receives only modest revenues. Among a lot of activities it has a council that seeks to bring credibility to wound care as an identifiable specialty, continues the “Advancing the Practice” initiative by providing a professional resource center for the healthcare public, and is developing a “Patient/Caregiver Resource Center” – a dedicated portion of the AAWC website which seeks to bring patients and their caregivers together to share their stories, experiences and ideas.

EWMA Conference in Brussels This year’s EWMA Conference had the theme “Common Voice – Common Rights”, which relates to the concept that all patients should have equal voice and equal rights in terms of their access to wound management. In the opening plenary session Nicola Bedlington, EPF (European Patients’ Forum) spoke on “Patient Focus”. By this, EWMA 2011 wishes to clearly place the focus on the patient, by addressing important issues such as patient empowerment and understanding the patient situation.

What was sensational with this years’ event was that it was the largest EWMA ever, in terms of exhibitors, visitors, sessions and poster presentations. This is contrary to the declining trend for similar events within other areas. One explanation could be that the conference has broadened from a purely scientific/clinical focus to networking with scientific fellow delegates both in a vertical (45 national wound associations) and horizontal (transcontinental) direction (KOL’s from Australia, Canada, Japan and USA).

Another opportunity at big conferences, are the fringe meetings. This could be anything from a ten minutes meeting in the lobby, to a planned two hour meeting with a stakeholder. One key meeting this year was with Nicola Bedlington (EFP). The idea was to bring EPF onboard in the “Coalition in Wound Care”, which we are currently  seeking to develop.

EWMA Journal

2011 vol 11 no 3

10th Scientific Meeting of the

Diabetic Foot Study Group of the EASD

28-30 September 2012 Berlin-Potsdam, Germany

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

Uraemia



Wound healing/outcome

www.dfsg.org

EWMA

“Collaboration with Industry: Current perspectives on ethics, opportunities, and risks for national wound associations” was the topic of a presentation to the Board of EWMA Cooperating Organisations. The focus of my presentation was on Do’s and Don’ts with the key word independence. As long as HCP’s (Health Care Professionals) feel that they are independent in their relations with the industry, they are probably on the right ethical side.

eHealth Roundtable in the European Parliament On June 21, I was invited to a roundtable in the European Parliament entitled “eHealth at the heart of patient safety, efficiency and clinical governance: how can innovation benefit healthcare systems? ” lead by MEP Antonyia Parvanova.

First some background to this event: The European Commission is now preparing the second eHealth action plan, mirroring the roadmap set in the strategy “Europe 2020” including the Digital Agenda for Europe, the Innovation Union and the “eHealth Governance Initiative”.

The purpose of this roundtable was to further increase awareness of the benefits and opportunities of eHealth in the best interests of patients, healthcare systems and the society as a whole. Different speakers during the event were Andrzej Rys (DG Sanco, European Commission), Nicola

Bedlington (European Patients’ Forum) and Petra Wilson (European Governing Council of the Health ­Information Management and Systems Society).

Conclusion This debate was focusing on ICT (Information and Communication Technologies) and is very much influenced by companies such as Philips and Cisco Systems. Still there is no evidence that eHealth is cost-effective and leads to a reduction of total healthcare costs. Hopefully such evidence will be presented at the eHealth week in Copenhagen next year (2012).

Finally some quotations from the Eucomed Position Paper on eHealth (21 April 2011): n eHealth is a framework for harnessing the capabilities of ICT to enable patients to obtain better care and health outcomes, and to help healthcare systems achieve higher quality and productivity. n Innovations powered by eHealth also have the potential to drive higher quality, more productive healthcare systems that in turn provide equitable ­access to safe, user-friendly services for tens of millions of European citizens.

n eHealth drives economic growth in Europe. According to the 2010 study “Business models for eHealth” that was commissioned by the European Commission, “the European eHealth market was estimated at e14.3 billion in 2008 and is projected to reach e15.6 billion by 2012, with a compounded annual growth rate of 2.9%”.

Eucomed AWCS (Advanced Wound Care Sector) The 18th Eucomed AWCS meeting took place on 22-23 June 2011 at Eucomed’s offices in Brussels. The interest in the group is growing with two new members (Sorbion and Integra) and Systagenix participating as an observer.

We now have a total of 10 members (3M, B. Braun, Convatec, Covidien, Integra, KCI, Molnlycke Health Care, Paul Hartmann, Sorbion, Smith & Nephew) working with two partners (EWMA and Policy Action). On the agenda was election of chair (Hans Lundgren, Molnlycke) and vice-chair (Louis-François Omnes, Smith & Nephew); I am looking forward to my third two year term as chairman.

We are still struggling to get through with our strategy built on three pillars: Build a Supporting Coalition – Bring in patient groups to tie demands for market access and reimbursements specifically to patients (i.e. AWCS, EWMA, EPF and IDF) under the patronage of MEP Prodi. Active and Healthy Ageing Programme – Engage on Innovation Partnership through a campaign of awareness to increase knowledge of wound care and its ability to extend healthy living years. We will focus on the treatment and continuum of diabetes care, and to bring in the issues under the working group on “Innovation in Care and Cure”. This will be achieved through IDF (International Diabetes Federation) due to its participation as an external stakeholder in the working group, and Patient Safety Campaign – Engage on the review of the Council Recommendations (June 2009) to show where access to modern wound care is lacking.

The next meeting will take place on 9-10 ­November 2011 at the Eucomed offices in Brussels. m

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2011 vol 11 no 3

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM) in Vienna 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 2012 it is expected that students from the institutes listed below will participate in the EWMA UCM in Vienna.

ienna

EWMA 2012 23 -25 May

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:

HUB Brussels Belgium

KATHO university college Roeselare Belgium

University of Hertfordshire United Kingdom

Lithuanian University of Health Sciences Lithuania

Escola Superior de Enfermagem de Lisboa Portugal

Haute École de Santé Geneva, Switzerland

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 45

Appreciations Sue Bale Sue Bale first joined the EWMA Council in 1992 and served until 1995. She was re-elected in 2002 and was elected as EWMA ­Recorder in 2008. In this position, Sue has also served as Chair of the Scientific Committee which is not always an easy task, but one she did extremely well. Through her work, she has contributed to the continued development of the scientific profile of EWMA. Fortunately we will not be losing Sue altogether as she continues her involvement with EWMA as the Editor of the EWMA Journal.

Carol Dealey Carol Dealey joined EWMA Council in 1991 and was one of the original founders of the organisation. She has been an extremely active Council member, supporting the work of EWMA for 20 years. Carol was president of EWMA in the period of 1992-1993 where she provided the leadership and motivation to guide the organisation to grow and develop.

In more recent years Carol’s work and dedication to the EWMA Journal has been incredible and her efforts and diligence plays a crucial role in shaping the EWMA Journal of today.

Carol’s long-term commitment and strengths are noticeable throughout EWMA and we will miss her presence greatly. We know that Carol has planned to fill her extra time with her family and friends, most especially as a grandmother.

Severin Läuchli Dr. Severin Läuchli, dermato-surgeon at the Dermatology University ­Department in Zurich and president of SAfW (German Section), was elected by the Cooperating Organisations Board to join the EWMA Council in 2008. From the first meetings on, he inspired the Council with his great creativity, professionalism, kindness and potency to create strong networks.

Next to his obligations in the Council and the Education Committee, Severin was one of the central driving forces for the EWMA 2010 conference in Geneva, which became highly successful. We, the EWMA Council representatives will miss Severin not only as important contributor to the EWMA goals, but also as a friend. Good is it though that Severin decided to continue his engagement in EWMA as member of the Education Committee and different other EWMA projects where his contribution is much appreciated.

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EWMA

Maarten Lubbers Maarten Lubbers joined EWMA Council in 2008. As a general surgeon and doctor for patients on the critical care unit, Maarten is interested in infection of wounds and has written several articles regarding pressure ulcers.

He was a founding member of the European Pressure Ulcer Advisory Panel (EPUAP). During his active working live he was responsible for the treatment in the hyperbaric oxygen chamber in Amsterdam in which he successfully treated many patients suffering from severe infections. His contribution to the EWMA Council has been much appreciated and although he retired in 2011, we hope to continue the collaboration in future.

Sylvie Meaume Sylvie Meaume joined EWMA Council in 2008 and was elected by the Cooperating Organisations Board. As president of SFFPC she encouraged the collaboration between EWMA’s French speaking Cooperating Organisations.

Sylvie has a broad interest in wounds, from her background in geriatrics and job as a medical doctor. She has a strong positive impact within several educational programs and projects on wounds worldwide.

Sylvie will continue her engagement in EWMA as member of the Cooperation Organisations Board as representative of the French wound Management Organisation, SFFPC. Sylvie will remain an important member of the task force of the French speaking wound management associations of EWMA.

Marco Romanelli Marco Romanelli joined EWMA Council in 2001 and was the Treasurer from 2004 till 2007.

In 2007, Marco became the EWMA President, a position he held until 2009 whereupon he was the EWMA Immediate Past President from 20092011. As Immediate Past President Marco has also chaired the Cooperating Organisation’s Board.

Marco has in his years in Council and as President worked hard on getting EWMA and EWMA activities known also globally. EWMA has due to this, now a large number of activities and collaboration with like-minded scientific societies all over the world.

We are sure that EWMA will continue to benefit from Marco’s commitment to EWMA and the wound care area.

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2011 vol 11 no 3

47

EWMA

New Council members The EWMA Council had eight ­openings this May. It is therefore with great pleasure that we welcome the new Council members elected in Brussels May 2011.

Jan Apelqvist

Paulo Alves

Sebastian Probst (co-org elected)

Mark Collier

Elia Ricci

Javorca Delic

Sella Seppänen

Nada Kecelj-Leskovec (co-org elected)

Jose Verdu Soriano

EWMA values your opinion and would like to invite all readers to participate in shaping the organisation.

Please submit possible topics for future conference sessions.

EWMA is also interested in receiving book reviews, articles etc.

Please contact the Journal Secretariat at ewma@ewma.org

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2011 vol 11 no 3

NEW! A great step forward in the treatment of acute and chronic wounds: Kendall™ AMD antimicrobial foam border dressings Designed to manage bacteria, moisture and friction.

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• Patented “landing zone” facilitates absorption, minimizes periwound maceration, and prevents dead space by swelling directionally into the wound.

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EWMA Activities Update EFORT in Copenhagen At the 12th conference of the European Federation of National ­Associations of Orthopaedics and Traumatology (EFORT 2011), EWMA were kindly invited to host a specialty session on June 4th in Copenhagen. The specialty session was part of the continuous collaboration between EWMA and EFORT. The collaboration is aiming at an increased understanding of the clinical and scientific relations between the fields of wound management and orthopaedic surgery.

The session entitled Problem wounds – A multidisciplinary challenge was held by highly qualified speakers offering lectures that covered a variety of prevailing aspects of the area of problem wounds such as Pressure ulcer prevention, Biofilm in Diabetic Foot Ulcers, Health Economics, Wound Organisation and Evidence in wound healing.

The presentations were held by: Zena Moore, Ireland; Klaus Kirketerp-Møller, Denmark; Jan Apelqvist, Sweden; Finn Gottrup, Denmark.

The session was well received by the audience who participated ­actively in the session through discussions and left the session with new knowledge and a broader understanding of wound management in orthopeadic surgery.

In May 2011 EFORT organised a reciprocal guest session at the EWMA 2011 conference in Brussels. In 2012 EWMA will continue the good collaboration with EFORT.

EWMA 2012 The 2012 EWMA Conference takes place 23-25 May 2012 in ­Vienna Austria. The Conference is organized in cooperation with the Austrian Wound Association, AWA. The theme of the Conference is: WOUND HEALING – DIFFERENT PERSPECTIVES, ONE GOAL The 2012 programme offer key sessions such as ­Debridement, Oncology and Wounds, Diabetic Foot, Medication in wound ­healing and Negative Pressure Therapy as well high level ­scientific workshops, free paper sessions and guest s­ essions.

At the EWMA Conference 2012 participants will have the op­port­ unity to benefit from high level scientific presentations, networking with fellow delegates and speakers, exchanging of views and experiences and the opportunity to evaluate clinical practice.

Abstract submission: Mid-November 2011 - 15 January 2012 Early registration deadline: 15 March 2012 We look forward to welcoming participants from all around the world – See you in Vienna!

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Project on health economy a ­ spects of prevention of p ­ ressure ulcers The project Prevention of pressure ulcers based upon use of a new screening method and pressure sensor technologies is currently being implemented at Skejby University Hospital in Aarhus, Denmark by Anne-Birgitte Vogelsang who is a nurse, Master of Public Health and PhD student.

The project aims at evaluating: n If it is possible to reduce the incidence of pressure ulcers during hospitalisation by introducing a new and unique screening method, a few general preventive actions and ­pressure sensing technology. n Whether associated changes in working practice can reduce demands on care staff’s time.

EWMA will take part in the presentation and dissemination of the results of the project through activities such as the EWMA conference and by sharing information with the Cooperating ­Organisations and other partner organisations across ­Europe.

EWMA involvement will be followed by the EWMA Research Committee.

A more detailed description of the project and its expected ­results will be included in the January 2012 issue of the EWMA Journal.

News from Joint visit to Kuwait by WAWLC and EWMA David Keast, chair of the WAWLC Advisory Committee and John Macdonald, WAWLC General Secretary, have together with Henrik Nielsen, director of the EWMA Secretariat, visited Kuwait from the 9 -14 September 2011.

The visit has come up on the request of the Ministry of Health of Kuwait with the purpose of investigating the ­possibilities for WAWLC contributing to establishing a wound seminar as well as a diabetic foot seminar in Kuwait. Further, from Kuwait there has been expressed interest in supporting WAWLC activities in resource poor settings.

Visit to Ethiopia regarding eradication of podoconiosis WAWLC represented by Robyn Björk, Physical Therapist and Tom Serena, Vascular Surgeon, visited by early August 2011 Ethiopia.

The purpose of the visit was to meet up with focal persons of the Ethiopian Ministry of Health and the World Health Organisation and to visit local hospitals to discuss how WAWLC may support a national plan for the eradication of podoconiosis including training of practitioners at various levels.

The planned activities on eradication of podoconiosis in ­Ethiopia were the subject of a EWMA organized fundraising campaign ­during the EWMA Brussels conference. The campaign brought ­information about WAWLC and podoconiosis to the conference participants and hopefully will contribute to achieving the important objectives of WAWLC. John Macdonald

EWMA Journal

2011 vol 11 no 3

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HILL-ROM www.hill-rom.com 52

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2011 vol 11 no 3

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

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

gual: Bilin German sh & Engli hig: sprac eutsch i e w Z D sch & i l g n E

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

WWW.EWMA.ORG / EWMA2012

Organisations

Conference Calendar Conference

Theme

2011 Days City

Pisa International Diabetic Foot Courses

Oct

3-6

4th Paediatric Wound Healing Conference

Oct

Bi-Annual Conference of the Wound Management ­Association of Ireland

Country

Pisa

Italy

4

Bristol

UK

Oct

4-5

Galway

Ireland

21st ETRS Annual Meeting

Oct

5-7

Amsterdam

Netherlands

EWMA Leg Ulcer and Compression Seminars

Oct

10

Bratislava

Slovakia

EWMA Leg Ulcer and Compression Seminars

Oct

11

Vienna

Austria

EWMA Leg Ulcer and Compression Seminars

Oct

13

Budapest

Hungary

4th Latin American Conference on Ulcers

Wounds on hands in solidarity

Oct

11-14 Rio de Janeiro Brazil

EWMA Master Course 2011

Is Oedema a Challenge in Wound Healing?

Oct

13-14 Budapest

Hungary

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

Oct

13-15 Las Vegas

USA

The Polish Wound Management Association Biennial meeting

Oct

14-16 Mikołajki

Poland

Annual Meeting of Tissue Viability Nurses Association in Sweden

Oct

4th CWA symposium with international participation

Karlstad

Sweden

Oct

26-28 Primosten

Croatia

First International Pediatric Wound Care Symposium

Oct

27-29 Rome

Italy

Annual Meeting of New Zealand Wound Care Society

Nov

Wounds UK Harrogate Conference

Nov 14-16 Harrogate

UK

Nov 17-18 Oporto

Portugal

Biannual meeting of the Woundcare Consultant Society

Nov 22-23 Utrecht

Netherlands

Annual Meeting of the Danish Wound Healing Society

Nov 24-25 Kolding

Denmark

6th National Wound Care Congress of WMAT

Dec

Turkey

Annual Meeting of APTFeridas

Chronic wound – local treatment challenge for the clinician

25

New Evidences on the Diabetic Foot

2-4

1-4

Dunedin

New Zealand

Antalya

2012 16th National Conference of wound healing of CPC

Jan

15-17 Paris

France

National Wound Congress of Czech Republic

Jan

26-27 Pardubice

Czech Republic

NIFS Annual Meeting

Feb

2-3

Haugesund

Diabetes UK Professional Conference 2012

Mar

7-9

Glasgow

10th National Australian Wound Management ­Association Conference

Mar 18-22 Sydney

Australia

Tissue Viability Society 2012 Annual Conference

Apr

18-19 Kettering

UK

The Annual Spring Symposium on Advanced Wound Care (SAWC/WHS)

Apr

19-22

World Council of Enterostomal Therapists Conference

Apr

19-23 Adelaide

Australia

The German Wound Congress (ICW)

May

9-10 Bremen

Germany

22nd Conference of the European Wound Management Association

May 23-25 Vienna

Austria

13th EFORT Congress 2012

May 23-25 Berlin

Germany

DGfW Annual Meeting

Jun

Germany

4th Congress of the World Union of Wound Healing Societies

The Diabetic Foot

Better care – Better Life

Sep

UK

Atlanta ­Georgia

USA

14-16 Kassel 2-7

Norway

Yokohama

Japan

10th Scientific Meeting of Diabetic Foot Study Group (DFSG)

Sep

28-30 Potsdam

Germany

Pisa International Diabetic Foot Courses

Oct

8-11 Pisa

Italy

For web addresses please visit www.ewma.org

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EWMA Journal

2011 vol 11 no 3

NEW in vitro Evidence

What did we find living under some silver dressings?* Not all silver dressings are created equal.

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ConvaTec researchers used an in vitro bacteria-seeded agar overlay model simulating a colonized wound surface to investigate the antimicrobial activity of selected silver wound dressings. The dressings were separately applied to agar surfaces seeded with S. aureus and P. aeruginosa. After 48 hours, the dressings were removed from the agar surfaces. These photographs are representative of the visually observed results with S. aureus.

1. The Antimicrobial Activity of Silver-Containing Wound Dressings on a Simulated Colonised Wound Surface. Scientific Background Report. WHRI3415 MA162. 2011 Data on File, ConvaTec. 2. Jones S, Bowler PG, Walker M. Antimicrobial activity of silver-containing dressings is influenced by dressing conformability with a wound surface. WOUNDS. 2005;17(9):263-270.

3. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber dressing. Wound Repair Regen. 2004;12(3):288-294.

AQUACEL and Hydrofiber are registered trademarks of ConvaTec Inc. All other trademarks are the property of their respective owners. © 2011 ConvaTec Inc. AP-011145-MM [AM/EM]

The Cooperating Organisations Board Meeting 2011 Zena Moore Chair of the Cooperating Organisations Board

25-27 May Brussels · Belgium

A

s usual, the annual meeting of the EWMA Cooperating Organisations Board took place during the EWMA Conference. The Board meeting was attended by 34 Cooperating Organisations Board members. Further, representatives of the International Partner Organisations of EWMA participated as observers.

Election of new members for the EWMA Council The Board members elected two new members to serve on the EWMA Council for the next three years. In addition to contributing to the work of the Council, they will represent the Cooperating Organisations in Council.

The elected candidates are: n Sebastian Probst, SAfW-D, Switzerland n Nada Kecelj-Leskovec, WMAS, Slovenia They replace Sylvie Meaume and Severin Läuchli whose work for the EWMA Council during the last three years is acknowledged and applauded in a separate entry in this issue of the EWMA Journal.

Presentations and debates The debate sessions in 2011 focused on: n Clinical pathways: Organisation and efficiency of diagnosis & treatment (Centre of Excellence) presented by Jan Apelqvist, EWMA President Elect. n Collaboration with industry: Current perspectives on ethics, opportunities for national wound associations presented

by Hans Lundgren, Chair of the Eucomed Advanced Wound Care Sector (AWCS) Group.

The debate in groups based on the presentation by Jan Apelqvist focused on the multidisciplinary team, how to organise it and the importance of understanding what different 56

EWMA2011

Dan Heal

professions can bring to the team. Through the discussion, it was stressed that the right conditions for creating multidisciplinary teams must be created organisationally.

The discussion in groups based on the presentation by Hans Lundgren reflected on the importance of defining clear goals for associations, as well as for industry, when establishing partnerships. The need for establishing rules and for being aware of who develops the rules was stressed.

Simple rules for collaboration have been developed by Eucomed. However, it is suggested by Hans Lundgren that EWMA should consider elaborating its own set of guidelines which would be of relevance for many European wound management associations. The European Patients’ Forum also has a set of guidelines which could be explored further.

Revision of rules regarding election to Council The following additions to the election rules were approved by the Board: n In order to stand for election all nominated candidates must be present at the Cooperating Organisations Board meeting. n During the same year, a candidate for the EWMA Council can only run for either the individual election or the Cooperation Organisations Board election.

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Organisations

Follow-up on debates from the meeting in 2010 In the debate session which took place in 2010, the members of the Cooperating Organisations Board reflected on implementation strategies regarding the Patient Outcome Group (POG) document, as well as involvement in the Teach the Teachers project.

Following-up on the debate about the POG, Patricia Price, who chairs the group, informed the group that translations are under way in various European countries, including Germany, Poland and Portugal. Regarding copyright, it

Suggestions for themes and debate topics for future meetings include: n Ideas on how EWMA can facilitate an education programme with focus on regional networking, which could be a part of the Pan European programme of Education? n Focus on collaboration regarding teaching, educational development, guidelines and research programs. Suggestions about unification of different educational and actual practices in Europe.

was clarified that the POG document may be translated as long as the EWMA POG group is acknowledged in the translation.

n A discussion about future clinical trials which could improve the scientific possibilities of all European wound societies. n Focus on how to improve the connection and collaboration between the Cooperating Organisations to make better use of the potential of the engagement.

Find and discuss ideas on how to establish projects in collaboration with all Cooperating Organisations (how to collect data, education etc.).

Luc Gryson from the EWMA Education Committee informed the group about the Teach the Teachers project, which just missed being financially supported by the European Commission Lifelong Learning programme.

The knowledge gained through the development process will be used by EWMA to establish a network involving teaching institutions involved in wound management education and the EWMA Education Committee. The support of the Cooperating Organisations will be needed for identifying network participation from national teaching institutions.

Evaluation and proposals of future topics for debate The Cooperating Organisations Board meeting was evaluated by means a predesigned questionnaire circulated to the meeting participants.

The questionnaire was answered by 44% of the Board members present. The responses indicate great satisfaction of the meeting in general (80% answering good/very good) as well as the themes relating to duration (100% appropriate) and information given prior to the meeting (100% good/very good). Furthermore, 60% of the respondents highlighted “networking” as a main objective for participating in the Board meeting; about 2/3 of the respondents attended the meeting to improve the inter organisation cooperation and to develop new projects across Europe.

EWMA Journal

2011 vol 11 no 3

Guest Presentation: World Alliance on Wound and Lymphoedema Care John Macdonald, General Secretary of the World Alliance on Wound and Lymphoedema Care (WAWLC) made a presentation regarding how WAWLC can help wound and lymphoedema patients in resource-poor settings through simple methods and resources. It was described how such methods can be adapted to various levels of the healthcare system depending on the country and the resources available.

Acknowledgements I would like to thank all meeting participants for contributing to further developing the collaboration between the EWMA Cooperating Organisations.

In particular, I would like to thank Marco Romanelli for his work done as Chair of the Cooperating Organisations Board during the time he has been the EWMA Immediate Past President. I very much look forward to taking on this task during the two years to come. m

57

Improving wound care in Africa

MSF Médecins Sans Frontières Suisse

Eric Comte Medical director MSF Suisse www.msf.ch

WE NEED YOU! There is a need for effective wound care in Africa Acute or chronic wounds are a common condition, although little recognized in Africa. Besides the pathologies similar to those existing in Europe (or metabolic vascular ulcers, surgical wounds or traumatic ...), there are more specific wounds.

Tropical infectious ulcers (ulcers phagedenic, Buruli ulcer, leishmaniasis, leprosy ...) are characteristic but there are also the burns particularly related to domestic accidents in children. The ­epidemiological transition underway in many ­African countries, results in an increase in diabetic wounds and ulcers that affect the elderly, para­ plegics or end of life HIV patient.

The WHO has recently published a guide to sum up the principles of modern wound care: The WHO Buruli Group includes in its recommendations the principles of wound bed preparation.

In Africa, we also see that it is possible to use the four pillars of wound healing with different approaches. Some rely on the use of conventional dressings that are cheap and available locally.

Here we should especially mention the work of Professor Ryan for the treatment of filariasis1 and Dr. Grauwin for the treatment of leprosy2. Others aim to build on local medicine noting the use of honey or plants such as papaya. Also, MSF has developed a new approach to introduce a simplified range of modern dressings.

BURULI ULCER PROGRAM IN CAMEROON Buruli ulcer is an infectious disease than occurs in tropical regions, around slow running rivers.

The mode of transmission is still not studied enough, but it is suspected to be transmitted via micro-organisms living in slow running rivers, which enter the skin.

The symptoms start often with small nodules. The tissue below the visible part of the skin slowly dies, eventually leading to open wounds. These can spread over arms, legs and the back. Buruli ulcer is rarely lethal, but it leaves those who suffer from it with debilitating deformations of arms and legs.

Sadly patients often come at a late stage, when the open wound is already developed and too large to be easily treated.

The child’s wound is a buruli ulcer (credits – Eric Comte/MSF)

Wound care represents a real medical issue.

Unfortunately the international consensus in favour of wound bed preparation is largely ignored in Africa. The practice to dry and disinfect the wound care prevails leading to inefficient, timeconsuming and expensive sources of pain, sometimes resulting in permanent disabilities.

However, several initiatives exist that seek to ­promote a modern approach to wound care by using simple equipment suitable for resource-­ limited settings.

58

The treatment has four components: n Antibiotics – A combination of antibiotics ­(rifampicin and streptomycin or clarithromicyn) is necessary during end months to fight infection. n Wound Care – Wound care is a key element for cicatrisation. n Physiotherapy – Physiotherapy helps to prevent disabilities. n Surgery – Surgical treatment is useful for large ­debridement, skin graft or osteomylithis.

1 www.oxfordinternationalwoundfoundation.org/develop/develop4.html 2 Grauwin MY. Techniques simples de pansement de plaies et maux perforant plantaires applicables à un programme national de lutte contre la lèpre. Bulletin de l’ALLF n° 25 mai 2010. http://sfdermato. actu.com/allf/bulletin_allf_25_pages-3-a-62.pdf

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2011 vol 11 no 3

Organisations

Akonolinga is a rural district with very limited resources. The district is divided into 12 ‘health sectors’, each with its own health centre. There is one district hospital in Akonolinga town. A study done in 2007 found high prevalence rates of Buruli ulcer throughout the district, indicating that the disease is a public health problem. It was found that 25 out of 10,000 inhabitants in the ­district were infected with skin ulcers.

The MSF programme opened in 2002 to support the Ministry of Health district hospital. All medical activities to treat Buruli ulcer are conducted by a joint team of National MSF-staff and international employees. MSF offers free treatment and provides the infrastructure, equipment, and medication necessary to run the Buruli ulcer treatment programme. MSF has established an independent pharmacy in the hospital, and also provides laboratory support, organisation of surgery and sterilisation, and nutritional support to patients.

MSF staff participates in scientific meetings. MSF also trains local staff and brings foreign specialists for short periods to Akonolinga. Since 2002, the programme has treated over 900 patients.

For four years, MSF, with the help of the haute Ecole de Santé de Geneva and University Hospital of Geneva, has developed an innovative approach to its wound care programme. The aim of

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2011 vol 11 no 3

WE NEED YOUR HELP To carry out this work, we need to network with people with experience in wound care. We would like to share our experience with health care providers or institutions working in the area of wounds in the tropics.

We also need to establish courses and guidelines adapted to tropical settings with limited resources.

We will build on existing courses and guidelines.

It is difficult to find qualified personnel who can volunteer to work for at least one year in Cameroon under the auspices of a voluntary humanitarian organization. We are seeking specialist nurses in wound care and dermatologists interested in tropical medicine.

If you are interested in one of these approaches do not hesitate to contact us: MSF-Buruli@geneva.msf.org

MÉDECINS SANS FRONTIÈRES is a private international association operating in more than 75 countries with close to 400 aid programmes.

MSF provides assistance to populations in distress, to victims of natural or man-made disasters and to ­victims of armed conflict.

The organisation was awarded the Nobel Peace Prize in 1999.

MSF has been working in Cameroon for more than eight years, providing HIV / Aids-care and responding to emergencies. At present, MSF provides medical care for Buruli Ulcer.

The building is the hospital in Akonolinga.

Bulding on the left is the Buruli ward. (credits – Marcell Nimfuehr /MSF)

this project was to show that modern dressing protocols can be adapted to tropical settings.

MSF has trained doctors and nurses in Cameroon to update knowledge on the international consensus on healing.

MSF has also worked with Cameroonian colleagues to adapt a sheet description of wounds that reflects the characteristics of Buruli ulcer. Colour sheets were designed to facilitate decisionmaking on treatment methods.

MSF has also introduced a limited range of modern dressings (alginate, hydrogel, hydrocellular, Vaseline tulle).

The concepts of wound infection have been addressed to rationalize the use of antiseptics and antibiotics and attention was drawn to the struggle against oedema in order to improve cicatrisation. Modern dressings facilitate the work of nurses and improve patient comfort. They also require fewer ­dressing changes, and enable patient care by mobile teams that travel to ­villages twice a week, instead of forcing patients to come to the clinic on a daily basis.

Beyond our experience, we want to open the debate on the need in Africa to use these techniques and to remove obstacles to the development of ­modern dressings (cost and availability of products, training ...). m

www.msf.ch 59

Organisations

Wound care nurse in Cameroon – A Testimony

MSF Médecins Sans Frontières Suisse

Audrey Reverdi www.msf.ch

Much more than a nurse Audrey Reverdi worked during seven months in Akonolinga (Cameroon) – two hours east of Yaounde by road – where Médecins Sans Frontières Suisse (MSF) opened a Buruli ulcer ward.

In 2010, a team of less than ten caregivers took over 120 patients suffering from this chronic disease which causes large sores that are very difficult to heal. The young nurse explains her motivations and what she got out of this mission.

bacterium, which proliferates in the subcutaneous tissue and necrosis it. The wounds are often multiple, and therefore very difficult to treat.

The evolution of the bacterium remains an enigma. For example, a patient can have an ulcer on the left wrist that later reappears on another part of his / her body. Patients with HIV / AIDS or suffering from malnutrition have the most serious wounds, because their body is weakened.

How did you end up working in Akonolinga?

Audrey Reverdi: I trained as a nurse specializing in cancer wounds at the Curie Institute in Paris, a hospital and research institute against cancer.

I had always wanted to go on a mission after my diploma, and my trainer in Paris put me in contact with MSF. The problems posed by cancer wounds are not the same as those pertaining to Buruli ulcer. However, I have been trained on wound care in general, on scar healing and the evolution of dressings, and know how to distinguish between lab marketing and real innovations.

What did your days look like?

They seldom went according to plan! Never­ theless, I always tried to spend as much time as ­possible in the wound care room. The day usually began with a ward team briefing in order to review the health status of hospitalized patients. MSF now has protocols to treat Buruli ulcer; however, the disease is so unpredictable that nothing can ever be taken for granted. This endless battle can sometimes be quite discouraging, but it is a very interesting one.

Modern dressings have helped improve scar healing. Above all, they are more comfortable.

This is very important, because patients wear them for months at a time. When patients arrive with 20-year-old sores, healing is impossible unless you perform a graft. Therefore, you have to teach them to live with and take care of their wounds.

Education is the key to managing this illness. You have to convince local people that they have to be examined as soon as possible to avoid hospitalization. That is another fascinating aspect, as you have to raise awareness among people who are not of the same culture. In Cameroon, Buruli ulcer is considered a curse and sufferers are rejected.

Mentalities only evolve slowly.

What are the specifics of the management of Buruli ulcer?

Buruli ulcer is caused by a mycobacterium whose vector has not yet been identified. There is talk of a water flea. As for the mosquito hypothesis, it has been rather ruled out. The vector inoculates the

What did you get out of this mission?

In Cameroon, in addition to being a nurse I also had to supervise the team of the Buruli ulcer ward.

I started by observing how they worked before making the necessary adjustments. I also had to reorganize the pharmacy and make sure that protocols were implemented. I became more selfassured. I learned to defend my views and to be more aggressive.

The evolution of the bacterium ­remains an enigma. For example, a patient can have an ulcer on the left wrist that later reappears on another part of the body.

60

And on a more personal level?

It taught me to put things into perspective. In the field of oncology, death is everywhere but remains a taboo subject. In Africa, it is a painful experience, but life goes on. I don’t give the same answers anymore, be it in my work or in my ­personal life. m EWMA Journal

2011 vol 11 no 3

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Organisations

The Association for the Advancement of Wound Care AAWC Association for the Advancement of Wound Care

Terry Treadwell MD, FACS President, AAWC www.aawconline.org

Greetings from the Association for the Advancement of Wound Care (the AAWC), your wound care colleagues in the United States. The AAWC is the largest, not-for-profit, multi-specialty wound care organization in the U.S. and is dedicated to research and clinical application of evidencebased wound care. In celebrating our 15th anniversary in 2010, the organization recommitted itself to be a resource for wound care information and education for all wound care practitioners, patients, and caregivers.

Education of wound care practitioners is critical if we are to succeed in providing good care for our patients with wounds. Some wound care techniques and products have been used extensively, but research has found that many of these may be harmful to cells and tissues and that better ways to treat wounds exist. Providing evidencebased wound care information is critical for the success of today’s and tomorrow’s wound care practitioner.

Education of patients and caregivers about wounds and their treatments will help overcome one of the major factors in poor wound healing – patient compliance with wound care instructions.

Appropriate education ensures that the importance of the recommended treatment is appreciated by all and that maximum cooperation among patient, caregiver, and healthcare provider can occur. When all are “on the same page” care­ givers can encourage adherence to treatment ­recommendations and patients will understand the need for them. As a result, treatments will be more successful and all will be better satisfied with the outcome. There can never be too much education for all involved in wound care.

62

We are providing educational opportunities for our members through exciting web-based educational modules covering many subjects in wound care.

A speaker training program is also provided. Sponsored scholarships will enable members to pursue other educational opportunities and research projects. One of our more successful and exciting programs has been the Poster Grand Rounds session at the Symposium on Advanced Wound Care (SAWC), our national wound care meeting. These sessions educate members on how to organize and present wound care information via the poster format.

The organization has been at the forefront in the development of wound care guidelines for the treatment of venous and pressure ulcers.

A content-validated wound care glossary which will define wound care terms so that we shall all be speaking the same wound care language, is forthcoming. To benefit the patients and care­ givers, the AAWC has been proactive in developing patient brochures for minor wound care, venous ulcer care, and basic skin protection.

These are available on the web-site and most are also available in Spanish. Our patient and care­ giver organization working through blogs, conference calls, and timely newsletters has been very successful in providing a consistent single source of wound care information and assistance for this group. As mentioned, there is no such thing as a shortage of education.

We look forward to participating with EWMA on some of its many educational and other wound care projects as we strive to work together to spread good wound care practices and infor­ mation around the world. m

EWMA Journal

2011 vol 11 no 3

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Organisations

AISLeC Italian Nurses’ Cutaneous Wounds Association

Paulo Alves www.aislec.it

In the future as a protagonist: The research, the clinical care and the future wound care organization Report from the Annual Meeting in Bologna, May 2011 The seventh annual meeting of the Italian Nurses’ Association for the Study of Cutaneous Wounds (AISLeC) was held in Bologna, at the Palazzo dei Congressi on May 12th to 14th 2011.

Bologna, a beautiful city, is the capital city of ­Emilia-Romagna, in the Po Valley of Northern ­Italy. The city lies between the Po River and the Apennine Mountains, more specifically between the Reno River and the Savena River. More than 1000 participants attended the meeting which featured invited speakers and delegates from across Italy.

The organizing committee had chosen “In the future as a protagonist: The research, the clinical care and the future wound care organization” as the meeting’s theme.

The Wednesday morning (May 12th) program featured a pre-congress course entitled “The wound care of burns”, in which subjects such as emergency care, topical treatment, pain, rehabilitation and infection in patients with burns were debated.

The scientific program facilitated the exchange of experiences and discussion of advances in wound treatments between delegates attending the meeting. There was much discussion on the importance of evidence in wound care, and the need for further investigation.

Lecturers from Bologna, Rome, Milan, Firenze, Napoli, Trieste, and Portugal discussed medical issues with interested delegates including the new evidence in wound treatment, especially in pressure ulcers, leg ulcers, diabetic foot, burns and other injuries.

The program was divided into sessions with themes including: – Epidemiology: size of the problem – Audits, protocols and guidelines – Parallel sessions: the experiences of profile (Pressure Ulcers, Leg Ulcer, Diabetic Foot, Burns and other injuries) – The contribution of scientific societies to build a path for patients with lesions – The construction of profiles of care in wound care – Responsibilities of the institutions and the ­professionals in wound care – Practical aspects: the role of the organizations in implementation (national and international scenario) – The patient and the professional for a ­comprehensive approach to care I, Paulo Alves, represented EWMA as an invited speaker, lecturing on Implementation projects: The international scenery. I spoke about wound treatment in Europe and the experience of EWMA as a global organization. I also spoke about the role, projects and activities of EWMA focusing on its educational activities, investigation and reimbursement.

Several issues were raised by the audience, ­particularly on the different profiles of care across Europe, the differences between the qualifications of healthcare professionals and also the differen­ ces between healthcare political issues and sanitary assistance.

The feedback from conference participants was excellent. m

In addition, the meeting featured debates on policy issues such as public policies for national sanitary assistance, responsibility of the professionals in wound care, the code of ethics and the qualifications of Italian nurses in comparison with other countries.

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2011 vol 11 no 3

www.systagenix.com

AISLeC continues the research: The “pressure ulcer” phenomenon and the ­national prevalence AISLeC Italian Nurses’ Cutaneous Wounds Association

Angela Peghetti President of AISLeC www.aislec.it

BACKGROUND Research, education and development of project in order to improve the quality of care in various setting for patients with or at risk of wounds are critical matters of AISeC mission. Nationwide pressure ulcer prevalence surveys were conducted in discontinuous and not homogeneous ways. In Italy, the latest systematic epidemiologic study was conducted in community setting (home care) in 20011, while in acute care setting the latest survey was conducted in 1996.2 For this reason AISLeC decided to undertake a new national prevalence survey in the departments of medicine, long-term care and intensive care units, in order to analyze this problem and raise awareness among healthcare providers and policymakers.

OBJECTIVES The main objective of this study is to evaluate the rate of prevalence of pressure ulcers related to age, gender, anatomical site, healthcare setting and geographical area.

DESIGN Cross-sectional study SETTING AND PARTICIPANTS All patients admitted in the 24 hours before the survey day to departments of medicine / long-term care and intensive care (including cardiac intensive care units, post-surgical intensive care units etc.) were eligible. Data were collected from 3,426 patients admitted to 50 hospitals / USL (Unità ­Sanitaria Locale), for a total of 112 departments of medicine and 55 departments of intensive area.

MATERIALS AND METHODS The study was performed from 1st to 30th November 2010. The convenience sample was selected in the facilities where AISLeC delegates and regional representatives were working. This allowed to ensure a sufficiently homogeneous data collection as researchers had similar educational background and experience in conducting prevalence surveys. Data collection was performed using the form elaborated by Tuscany Region, which made also available the optical character reading software. This research aims to assess the

66

patients’ level of risk for pressure ulcer development using the Braden Scale and to describe anatomical location, number and stage of pressure ulcers, when present.

RESULTS The whole national territory was involved in the study providing data from a sufficiently representative sample: North 31.42%; Centre 61.14%; South and Islands 7.44%.

Source of prevalence data: Northern Italy • 37.59%: intensive area • 19.38%: medicine / long-term care Centre Italy • 20.78%: intensive area • 17.58%: medicine / long-term care South Italy and Islands • 41.51%: intensive area • 15.20%: medicine / long-term care Overall prevalence for intensive area: 28.94% Overall prevalence for medicine/ long-term care: 17.98% The overall prevalence rate therefore was 19.53%.

CONCLUSIONS Despite the evolution of technology and knowledge, the data obtained shows that pressure ulcers remains a significant problem that negatively affect the patients’ quality of life, especially for subjects hospitalized in intensive care units. These results require an extensive a debate at all levels: the organizations must focus on the problem and identify human and material resources to allow an effective approach to prevention; healthcare professionals do not let their guard down on this issue and involve both unlicensed assistive personnel and caregivers in the prevention process; finally, the patients have the right to receive appropriate and effective care but, above all, they need to make sure that they do not experience pressure ulcer damages during their illness.

References 1. AISLEC: Profilassi delle lesioni da decubito e cambio posturale: Ricerca multicentrica e linee guida. ANIN-NEU, 1995.

2. AISLeC, Multicentric research about regulation and aid effered in the italian hospital for prophylaxis and treatment of pressure sores, Atti Congresso EWMA 27- 29/4/97.

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2011 vol 11 no 3

Organisations

Pressure Ulcers Assessment Tools:

AISLeC Position Document ABSTRACT As health-care providers we have an ethical and professional obligation to strive for a continuous improvement in the quality of care provided to the patients, in terms of safety, effectiveness, and efficiency. Clinical decisionmaking is a key component of patient care that can be enhanced by the use of evidence-based assessment tools1 as these instruments support practitioners to systematize data collection.

To be considered evidence-based, however, clinical assessment tools must prove to possess specific clinimetric ­proprieties1 – that is validity, accuracy, reliability, usability etc.

Therefore AISLeC decided to produce this first Position Document which aims to provide a guidance on use of pressure ulcer (PU) risk assessment tool and pressure ulcer (PU) assessment tools.

For the purpose of this Document, the term PU risk assessment tool defines “an instrument able to measure the individual PU risk, establishing a score”, and the term PU assessment tool defines “an instrument able to measure changes in wound healing, establishing a score” – and not one used to classify, stage, or measure wound characteristics per se.

1. What are the tools recommended to assess adult patients and identify individual PU risk?

– For adult patients we suggest the use of Braden Scale to assess PU risk (weak recommendation).

– For adult patients we suggest the use of Norton Scale to assess PU risk (weak recommendation).

– For adult patients we suggest the use of Care Dependency Scale to assess PU risk (weak recommendation).

5. Who should carry out PU risk assessment?

– We recommend that nurses carry out PU risk assessment (strong recommendation).

– Other health care providers (eg., doctors, therapists ect) / unlicensed assistive personnel: None recommendation

2. What are the tools recommended to assess paediatric patients and identify individual PU risk?

– For paediatric patients we recommend the use of Glamorgan Scale to assess PU risk (strong recommendation).

– For paediatric patients we suggest the use of Braden Q Scale to assess PU risk (weak recommendation).

3. What are other methods / approach recommended to assess adult / paediatric patients and identify individual PU risk?

– For adult patients we recommend the use of clinical judgment to assess PU risk (strong recommendation).

– For adult patients we recommend the use of skin inspection (non-blanchable erythema) to assess PU risk (strong recommendation).

– For paediatric patients: None recommendation.

4. Does use of a PU risk assessment tool guide prevention interventions (eg., repositioning, type of support surface, etc.?)

– None recommendation

The recommendations were developed using the GRADE method (Grades of Recommendation Assessment, Development and Evaluation). The crucial point of the GRADE method is that not only the evidence, but also the balance of benefits and harms, values and preferences of the patients and costs are taken into account to determine the strength of certain recommendations in favor (or against) certain intervention or treatments.2 In summary, below are the key ­recommendations from the Position Document:

6. What are the tools recommended to assess PU and ­monitor wound healing?

– We recommend the use of PSST (or BWAT) to assess PU and monitor wound healing (strong recommendation).

– We suggest the use of PUSH Tool to assess PU and monitor wound healing (weak recommendation).

7. Does use of a PU assessment tool guide local treatment interventions (eg., dressing selection, others wound care intervention?)

– We recommend the use of PSST (or BWAT) to guide PU local treatment intervention (strong recom­ mendation).

– We suggest the use of PUSH Tool to guide PU local treatment intervention (weak recommendation).

8. Who should carry out PU ulcer assessment?

– We recommend that nurses carry out PU assessment (strong recommendation).

– Other health care providers (eg., doctors, therapists ect) / unlicensed assistive personnel: None recommendation

References 1. Flahr D, Woodbury MG, Gregorie D. Clinimetrics and wound science.

Wound Care Canada. 2005;3(2):18-20.

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2011 vol 11 no 3

2. Guyatt GH, OxmanAD, Vist GE et al. for the GRADE Working Group.

(2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336(7650):924-6.

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Organisations

Conference report from Belarus STW

Belarus Society for the Treatment of Wounds

Leonid N. Rubanov President of the Gomel Wound Management Society (Belarus)

Modern aspects of decubitus ulcers management at spinal trauma patients is the title of a con­ ference which took place in Gomel, Republic of ­Belarus, on 25 March 2011.

The conference was organised by the Society for the Treatment of Wounds (Gomel, Belarus) (STW Belarus) in collaboration with various ­government institutions, including the Ministry of Health of Republic of Belarus, the Gomel State Medical University, the Scientific and Practical Centre of Traumatology and Orthopaedics and the Administration of public health services of the Gomel region.

More than 100 doctors and nurses from all regions of Belarus as well as invited colleagues from Latvia, Lithuania, Russia, and Ukraine took part in the conference. Representation of EWMA was made by the EWMA Secretariat.

The conference was supported by local and international manufacturers and distributors of modern dressings.

The conference programme included the following topics: n The level of care of spinal trauma victims. n The problem of decubitus ulcer management at spinal trauma patients. n Modern aspects of anaesthetic and critical care of patients with a spinal trauma in early and long-term period. n Local management and operative management of decubitus ulcers. n Rehabilitation of patients with spinal trauma complicated with decubitus ulcers.

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Leading experts presented reports on the level of spinal patients care in Belarus and Russia and about the further prospects of such care development.

The EWMA Secretariat contributed to the debate with a presentation on the organizational challenges in wound management in Europe.

The second part of the conference was ­devoted to local and operative management of decubitus ulcers. Colleagues from Belarus, Lithuania and Latvia showed interesting techniques of operative wound management at spinal patients. Further, reports on the development of the wound management activities in the Republic of Belarus were presented.

At the conclusion the report about the work done by the STW Belarus was presented and approved by the audience.

The result of the conference work was acceptance of a resolution on joint development of an algorithm on prevention and management of decubitus ulcers, promotion of modern dressings and introduction of modern techniques of local and operative multidisciplinary wound management. m

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2011 vol 11 no 3

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

t

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 of 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, Nordre fasanvej 113, 2000 Frederiksberg, Denmark Tel: +45 7020 0305 Fax: +45 7020 0315 ewma@ewma.org

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

AISLeC Italian Nurses’ Cutaneous Wounds ­Association www.aislec.it

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

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

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

BEFEWO Belgian Federation of Woundcare www.befewo.org

BWA Bulgarian Wound Association www.woundbulgaria.org

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

ICW Chronic Wounds Initiative www.ic-wunden.de

LBAA Latvian Wound Treating ­Organisation

LUF The Leg Ulcer Forum www.legulcerforum.org

LWMA Lithuanian Wound Management Association www.lzga.lt

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

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

CNC Clinical Nursing Consulting – Wondzorg www.wondzorg.be

MWMA

CSLR

Macedonian Wound Management Association

Czech Wound Management Society www.cslr.cz

NATVNS

CWA

National Association of Tissue Viability Nurses, Scotland

Croatian Wound Association www.huzr.hr

NIFS

DGfW

NOVW

German Wound Healing Society www.dgfw.de

DSFS

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

FWCS Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

GAIF

Norwegian Wound Healing Association www.nifs-saar.no

Dutch Organisation of Wound Care Nurses www.novw.org

PWMA Polish Wound Management Association www.ptlr.pl

ROWMA Romanian Wound M ­ anagement Association www.artmp.ro

Associated Group of Research in Wounds www.gaif.net

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2011 vol 11 no 3

Organisations

SAfW

SWHS

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

Swedish Wound Healing Society www.sarlakning.se

TVS

SAfW

Tissue Viability Society www.tvs.org.uk

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

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

SAWMA Serbian Advanced Wound Management Association www.serbiawound.org

V&VN

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

SFFPC

Decubitus and Wound Consultants, ­Netherlands www.venvn.nl

WMAK Wound Management Association of Kosova

WMAOI

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

Wound Management A ­ ssociation of Ireland www.wmaoi.ie

SSiS

WMAS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

Wound Management Association Slovenia www.dors.si

SSOOR

WMAT

Slovak Wound Care Association www.ssoor.sk

Wound Management A ­ ssociation Turkey www.yaradernegi.net

SUMS

STW Belarus

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

Society for the Treatment of Wounds (Gomel, Belarus)

SWHS Serbian Wound Healing Society www.lecenjerana.com

UWTO Ukraine Society of Wound Treatment www.uwto.org.ua

International Partner Organisations AWMA

ILF

Australian Wound Management Association www.awma.com.au

International Lymphoedema ­Framework www.lympho.org

AAWC

NZWCS

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

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

Debra International Dystrophic Epidermolysis Bullosa Research Association

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

Associated Organisations Leg Club Lindsay Leg Club Foundation www.legclub.org

LSN The Lymphoedema Support Network www.lymphoedema.org/lsn

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

EWMA Journal

2011 vol 11 no 3

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

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5 Editorial

Sue Bale, Zena Moore

Science, Practice and Education 7 Challenges facing district nurses in the prevention of pressure ulcers Lynne Watret

12 Clinical application of stem cells in wound ­healing: A near future?

Benoit I Hendrickx

16 Understanding the Patient Experience: Does empowerment link to clinical practice?

Patricia Price

21 The Influence of Egyptian Propolis on Induced Burn Wound Healing in Diabetic Rats – Antibacterial Mechanism Emad T. Ahmed, Osama M. Abo-Salem, Ali Osman

Scientific Communication 26 PURSUN UK: The Pressure Ulcer Research Service User N ­ etwork for the UK Delia Muir

28 Perspective of the European Patients’ Forum Developing Collaboration Nicola Bedlington

EBWM 30 Abstracts of recent C ­ ochrane reviews Sally Bell-Syer

EWMA 34 EWMA Journal Previous Issues and Other Journals 36 EWMA 2011 Brussels Luc Gryson

38 EWMA update: EWMA Patient Outcome Group Patricia Price

40 Book Review

Alison Hopkins, Maarten J. Lubbers

42 Advanced Wound Care Sector (AWCS) Hans Lundgren

46 Appreciations 48 New Council members 50 EWMA Activities Update 52 EWMA Corporate Sponsors

Organisations 54 Conference Calendar 56 The Cooperating Organisations Board Meeting 2011 Zena Moore

58 MSF – Improving wound care in Africa Eric Comte

60 MSF – Wound care nurse in Cameroon Audrey Reverdi

62 AAWC – The Association for the Advancement of Wound Care Terry Treadwell

64 AISLeC – Report from the Annual Meeting 2011 Paulo Alves

66 AISLeC – The “pressure u ­ lcer” phenomenon and the ­national prevalence Angela Peghetti

68 STW – Conference report from Belarus Leonid N. Rubanov

70 Cooperating Organisations 71 International Partner Organisations Associated Organisations