EWMA Journal October 2012 by EWMA European Wound Management Association

Volume 12 Number 3 October 2012 Published by European Wound Management Association

ORGANISATION IN WOUND HEALING

FOCUS ON

Danish Wound Healing Society

The EWMA Journal ISSN number: 1609-2759 Volume 12, No 3, October, 2012 The Journal of the European Wound Management Association Published twice a year

EWMA Council Jan Apelqvist President

Salla Seppänen

Zena Moore

President Elect

Immediate Past President

Gerrolt Jukema

Dubravko Huljev

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

Corrado M. Durante Treasurer

Scientific Recorder

Secretary

EWMA web site www.ewma.org Editorial Office please contact: EWMA Secretariat Nordre Fasanvej 113 2000 Frederiksberg, Denmark Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org

Paulo Alves

Sue Bale

Barbara E. den Boogert-Ruimschotel

Mark Collier

Javorka Delic

Georgina Gethin

Magdalena Annersten Gershater

Nada Kecelj-Leskovec

Martin Koschnick

EWMA Journal Editor

Ann-Mari Fagerdahl

Layout: Birgitte Clematide Printed by: CS Grafisk A/S, Denmark Copies printed: 9000 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 April 2013. Prospective material for publication must be with the editors as soon as possible and no later than January 15th 2013. The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. All scientific articles are peer reviewed by EWMA Scientific Review Panel. Copyright of published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval. All issues of EWMA Journal are CINAHL listed.

Sebastian Probst

Elia Ricci

Rytis Rimdeika

CO-OPERATING ORGANISATIONS’ BOARD Christian Thyse, AFISCeP.be Christian Münter, ICW Tommaso Bianchi, AISLeC Aleksandra Kuspelo, LBAA Roberto Cassino, AIUC Susan Knight, LUF Aníbal Justiniano, APTFeridas Loreta Pilipaityte, LWMA Gerald Zöch, AWA Corinne Ward, MASC Jan Vandeputte, BEFEWO Hunyadi János, MSKT Vladislav Hristov, BWA Suzana Nikolovska, MWMA Els Jonckheere, CNC Anne Wilson, NATVNS Lenka Veverková, CSLR Kristin Bergersen, NIFS Nastja Kucišec-Tepeš, CWA Louk van Doorn, NOVW Arne Buss, DGfW Arkadiusz Jawień, PWMA Bo Jørgensen, DSFS Severin Läuchli, SAfW (DE) Anna Hjerppe, FWCS Hubert Vuagnat, SAfW (FR) Pedro Pacheco, GAIF Goran D. Lazovic, SAWMA J. Javier Soldevilla, GNEAUPP Mária Hok, SEBINKO

José Verdú Soriano

Robert Strohal

F. Xavier Santos Heredero, SEHER Sylvie Meaume, SFFPC Susanne Dufva, SSIS Jozefa Košková, SSOOR Leonid Rubanov, STW (Belarus) Guðbjörg Pálsdóttir, SUMS Cedomir Vucetic, SWHS Serbia Magnus Löndahl, SWHS Sweden Alison Hopkins, TVS Jasmina Begić-Rahić, URuBiH Zoya Ishkova, UWTO Barbara E. den Boogert-Ruimschotel, V&VN Julie Jordan O’Brien, WMAI Skender Zatriqi, WMAK Nada Kecelj Leskovec, WMAS Mustafa Deveci, WMAT

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

Magdalena Annersten Gershater, Sweden Georgina Gethin, Ireland Luc Gryson, Belgium Eskild W. Henneberg, Denmark Alison Hopkins, UK Gabriela Hösl, Austria Dubravko Huljev, Croatia Gerrolt Jukema, Netherlands Nada Kecelj, Slovenia Klaus Kirketerp-Møller, Denmark Zoltán Kökény, Hungary Martin Koschnick, Germany Severin Läuchli, Schwitzerland Maarten J. Lubbers, Netherlands Sylvie Meaume, France Zena Moore, UK

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

EWMA 2013

13 Offloading the diabetic foot: Evidence and clinical decision making

15 -17 May · 2013 · Copenhagen · Denmark

Science, Practice and Education RJ Hinchliffe, JRW Brownrigg

S.A. Bus

17 Soft-tissue complications during treatment of children with congenital clubfoot A. Baindurashvili, V. Kenis, Y. Stepanova

21 An evolution in Medical Tapes: From Latex to Acrylic L. Gryson

27 Bacteria and fungus binding mesh in negative pressure wound therapy – A review of the biological effects in the wound bed M. Malmsjö, S. Lindstedt, R. Ingemansson, L. Gustafsson

33 Conservative Sharp Wound Debridement – State of play in Australia J. C. Rice

Cochrane Reviews 40 Abstracts of recent cochrane reviews S. Bell-Syer

EWMA 42 EWMA Journal Previous Issues an Other Journals 44 EWMA 2012 in Vienna G. Zöch, G. Jukema

48 DSFS – What can we do? What will we do? J. Fonnesbech

52 The Cooperating Organisations Board Meeting 2012, Vienna Z. Moore

54 The Austrian Diabetic Foot Symposium G. Köhler

58 Symposium for russian speakers at EWMA 2012 Vienna R. Rimdeika

61 EWMA UCM experience, Vienna 2012 – An evaluation B. Ø. Melby, S. Wichmann

64 The UCM in Switzerland: Development and prospects L. Chabal, C. Wyndham-White

66 EWMA News 68 The EWMA Teacher Network – a report Zena Moore

70 The EWMA Patient Panel

6 Therapeutic strategies for diabetic foot ulceration

5 Editorial

GAN

S. Seppänen

23rd Conference of the European Wound Management Association

ISATION AND ENH P

OPERA ION IN CO T

73 Advocacy for better wound management in Europe J. Apelqvist

74 EUCOMED – Outlook and programmes for wound care in UK and USA H. Lundgren

76 EWMA Corporate sponsors

Organisations

Abstract

deadline: 1 January 2013

77 Conference Calendar 78 AAWC – Association for the Advancement of Wound Care R. J. Snyder

80 SEHER – The Spanish S ociety of Wounds X. S. Heredero

82 UWTO– Ukrainian Wound Treatment Organisation G. Kozinets, Z. Ishkova

84 SILAUHE – Iberolatinoamerican Society of Ulcers and Wounds M. Blanck, J. J. Soldevilla

86 EWMA Cooperating Organisations

Organised by the European Wound Management Association in cooperation with the Danish Wound Healing Society · www.saar.dk

WWW.EWMA.ORG / EWMA2013

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Wound management organisation – the on-going challenge in Europe

his issue of the EWMA Journal focuses on the host country of the EWMA 2013 Conference: Denmark. The Danish Wound Management Association presents its efforts to meet some of the challenges related to providing the best possible care for wound patients in hospitals as well as in the home care sector. Most of these challenges are related to the organisational aspects of care. The Danish Wound Management Association was one of the first organisations to develop a model for multidisciplinary and intersectoral organisation of wound management. This model has become widely recognised throughout the world. Multidisciplinary wound management centres have been widely implemented in Denmark, but there is still room for improvement; especially within the home care sector. Establishing efficient wound management is an on-going challenge all over Europe. EWMA is c ontinuously looking for new ways to meet this challenge. Recently EWMA joined the European Innovation Partnership on Active and Healthy Ageing (AHAIP) established by the European Commission. EWMA uses this collaboration to a dvocate the importance of a multidisciplinary and integrated care for elderly people suffering from non healing wounds. You can read more about this initiative in this issue of the EWMA Journal.

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Another opportunity for securing specialised wound care throughout Europe is further utilisation of modern technologies. In recent years Denmark has moved towards greater use of e-health services. Telemedicine systems developed for wound management offer improved wound care in home care settings outside the most populated a reas. This is expected to lead to a significant r eduction in the cost of wound management within the Danish municipalities. This focus on organisation of care and collaboration between various sectors has been a primary focus of the Danish organisation for many years, which made it the natural choice of theme and title for the EWMA 2013 Conference: Organisation and Cooperation in Copenhagen. This topic will be reflected in several activities during the conference, such as key sessions on e-health and multidisciplinary treatment, and sessions targeting home care nurses without specialisation in wound management. In this and the next issue of the EWMA Journal we will offer various articles leading up to the conference sessions and activities. We look forward to discussing these topics with you at the conference. Jan Apelqvist, EWMA President and Eskild Henneberg, DSFS President

Therapeutic strategies for diabetic foot ulceration

RJ Hinchliffe Senior Lecturer, Consultant in Vascular Surgery

JRW Brownrigg NIHR Academic Clinical Fellow in Vascular Surgery St George’s Vascular Institute, St George’s Healthcare NHS Trust, London United Kingdom Correspondence: jrwbrownrigg@gmail.com Conflict of interest: none

Introduction / epidemiology The increasing worldwide prevalence of diabetes mellitus (DM) has resulted in an inevitable rise in diabetes-related complications. Diabetic foot ulceration (DFU) precedes >85% of major amputations in patients with diabetes and despite evidence to suggest that targeted interventions resulting from multidisciplinary care can reduce limb loss,1 progress to date has been slow. The National Diabetes Audit conducted in the UK estimates that the risk of a person with diabetes undergoing a lower extremity amputation is 23-fold higher than that of a person without diabetes.2 Whilst the number and incidence of amputations have fallen in an ageing population without diabetes, those in patients with type 2 diabetes have risen.3 In 2010-2011 there were 72,459 hospital admissions for diabetes-related foot complications, costing the National Health Service in England and Wales an estimated £639 million to £662 million.4, 5 Observational data from the Eurodiale study of all patients presenting with DFU to 14 specialised foot centres in Europe suggests marked variation in patterns of referral, the use of casting and vascular assessment and intervention between centres and countries.6 Of concern is that gaps in the use of evidence-based therapies highlighted by Eurodiale are likely to be far wider outside of specialised centres. A lack of both multidisciplinary diabetic foot clinics and appropriate re-imbursement schemes in many European countries are barriers to achieving good care. This review focuses on recent evidence-based guidelines, in particular those produced by the International Working Group on the Diabetic Foot (IWGDF), to help clinicians make treatment decisions in the management of DFU.

Pathology in DFU The aetiology of diabetic foot ulceration is multifactorial, involving a complex interplay between distal polyneuropathy (motor, sensory and autonomic), microangiopathy and peripheral arterial disease (PAD). Ulceration typically follows abnormal loading or trauma of the neuropathic foot, which may be poorly perfused due to PAD, rendering it less able to heal. Wound repair may be further impaired by virtue of various biological factors inherent to diabetes, including impaired humoral immunity and abnormal inflammatory responses.7, 8 Infection in DFU is more common than in other types of chronic wounds and contributes to failure to heal, especially in the presence of PAD.9 Diabetes is no longer considered an occlusive small vessel disease, but involves several functional abnormalities of the microvasculature including an increase in arterio-venous shunting and impaired vasoreactivity.10 The growth of new blood vessels in response to ischaemia is also impaired in DM,11 resulting in reduced formation of collateral vessels and a more profound perfusion deficit. The distribution of PAD in patients with diabetes is characteristically distal and diffuse, with a greater prevalence of crural disease and long arterial occlusions.12-14 Evaluation There are robust data to demonstrate that multidisciplinary care of patients with DFU reduces amputation rates. Guidance from the National Institute for Health and Clinical Excellence and Diabetes UK is consistent in recommending prompt recognition of foot ulceration and rapid assessment in a specialised limb salvage unit.15, 16 Krishnan et al observed a 62% reduction in major amputations in a catchment general population following the introduction of a multidisciplinary foot team at Ipswich Hospital, UK.1 Early inter-

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of toe-brachial index (TBI).18 Once PAD is diagnosed, the severity of the perfusion deficit and its impact on ulcer healing should be assessed. With respect to ankle pressures, an ABI of <0.6 corresponds to a significant impairment in wound healing (Figure 1),19 and an ABI of >0.6 has a poor predictive value for severity of ischaemia and warrants the measurement of toe pressures. A low probability of wound healing due to poor perfusion should prompt further investigations to establish the distribution of PAD. Figure 1. Schematic estimate of the probability of healing of foot ulcers and minor amputations in relation to ankle blood pressure, toe blood pressure, and transcutaneous oxygen pressure (TcPo2) based on selected reports. From Apelqvist J, Bakker K, van Houtum WH, Schaper NC. Practical guidelines on the management and prevention of the diabetic foot. Diabetes Metab Res Rev 2008;24:S181S187.

vention is critical given the difficulty in managing larger ulcers; in a study of 534 patients referred to a tertiary diabetic foot clinic with critical limb ischaemia (CLI) and a foot lesion, an ulcer area >5cm2 predicted both failure to heal and amputation.17 Peripheral arterial disease PAD is present in >50% of patients with DFU and its presence must be excluded. Diagnosing PAD in patients with diabetes can be difficult as symptoms and signs are frequently masked by co-existing distal symmetrical polyneuropathy. Furthermore, most patients with DFU present to primary care or internal medicine clinicians or podiatrists who often lack expertise in the diagnosis of PAD. IWGDF guidelines recommend that, in addition to a thorough history for symptoms of arterial insufficiency, all patients with DFU should undergo hand-held Doppler evaluation of both pedal pulses, measurement of ankle-brachial index (ABI) and, in cases of diagnostic uncertainty, measurement

Duplex ultrasonography (DUS), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) all enable imaging of the lower-limb arteries in a non-invasive manner and each technique has its advantages and drawbacks. DUS and MRA avoid the need for iodinated contrast, which can be problematic in patients with diabetes and a high prevalence of diabetic nephropathy. CTA is faster and more comfortable for patients than MRA, although image interference from calcified arteries can make interpretation difficult. Digital subtraction angiography remains the gold standard imaging modality for evaluating the distribution of PAD when revascularisation is planned and has the advantage of allowing simultaneous endovascular intervention. Its main drawback is the risk of contrast-induced nephropathy. The decision to revascularise the ulcerated foot is complex. Multiple factors influence wound healing in diabetes and only those patients with a perfusion deficit will derive any benefit from revascularisation. Patients with mild PAD and adequate perfusion measurements (ABI 0.6, TcPO2 >50mmHg) should be initially managed with optimal wound care and a 6-week period of observation.20 In large ulcers and in those with infection, the expected outcome of conservative treatment is poor and earlier vascular intervention may be required. In cases where PAD is contributing towards impaired wound healing then all ambulatory patients should be considered for revas

References 1. Krishnan S, Nash F, Baker N, Fowler D, Rayman G. Reduction in diabetic amputations over 11 years in a defined UK population: benefits of multidisciplinary work and continuous prospective audit. Diabetes Care 2008;31:99-101. 2. Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, Millett C. Changes in incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008. Diabetes care 2010;33:2592-2597 3. National Diabetes Audit Executive Summary 2009-10 The NHS Information Centre 2011 4. Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 2012;55:1919-25. 5. Kerr M. Foot care in diabetes: the economic case for change. www.diabetes.nhs.uk/ document.php?o=3400. 6. Prompers L, Huijberts M, Apelqvist J, et al. Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study. Diabet Med 2008;25:700-707. 7. Martin JM, Zenilman JM, Lazarus GS. Molecular microbiology: new dimensions for cutaneous biology and wound healing. J Investig Dermatol 2010;130:38-48.

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8. Blakytny R, Jude E. The molecular biology of chronic wounds and delayed healing in diabetes. Diabet Med 2006;23:594-608. 9. Prompers L, Schaper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The Eurodiale Study. Diabetologia 2008;51:747-755. 10. Abularrage CJ, Sidawy AN, Aidinian G, Singh N, Weiswasser JM, Arora S. Evaluation of the microcirculation in vascular disease. J Vasc Surg 2005;42:574-81. 11. Abaci A, Oguzhan A, Kahraman S, et al. Effect of diabetes mellitus on formation of coronary collateral vessels. Circulation 1999; 99: 2239±2242. 12. LoGerfo FW, Conrad MC. Large and small artery occlusion in diabetics and nondiabetics with severe vascular disease. Circulation 1967;36:83-91. 13. Faglia E, Favales F, Quarantiello A, et al. Angiographic evaluation of peripheral arterial occlusive disease and its role as a prognostic determinant for major amputation in diabetic subjects with foot ulcers. Diabetes Care 1998;21:625-630. 14. Jude EB, Oyibo SO, Chalmers N, Boulton AJ. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetes Care 2001;24: 1433-1437.

cularisation, with the exception of the severely frail (life expectancy <6 months), the functionally impaired, those with an unsalvageable foot or those where the ulcer is not impairing quality of life. Ulcer/ wound management There are several simple yet important principles of wound bed management, which should be adhered to in DFU. Regular inspection, cleaning with saline, removal of surface debris with sharp debridement and protection of regenerating tissue are paramount. Controlling exudate to maintain a moist environment can be achieved with a simple, inert dressing in most cases.21 The evidence to support the use of a particular dressing or topical therapy for the ulcer bed is thin. Providing a comprehensive environment to improve healing with debridement, offloading and antibiotics in the presence of infection is superior to the use of a novel, and often expensive, dressing. Offloading Biomechanical factors play an important role in the aetiology of DFU and the cornerstone of early management in neuropathic plantar ulcers is offloading pressure with appropriate footwear, removable devices or total contact casts (TCCs). The efficacy of prescribed footwear and removable devices is dependent on patient compliance and, probably for this reason, the TCC has demonstrated superior results in randomised trials,22 and is recommended by the IWGDF as first-choice treatment.23 A perception of increased risk of falls with TCCs appears to be unfounded.24, 25 Despite all this, only 18% of approximately 600 patients with a plantar foot ulcer in the Eurodiale study were treated with TCCs.6 Callus formation contributes to abnormal loading and failure to heal, and debridement should be routinely provided by trained podiatrists. Debridement is beneficial for reducing plantar pressures,26, 27 although this has yet to be confirmed in randomised trials.

15. National Institute for Health and Clinical Excellence. Diabetic Foot Problems: Inpatient Management of Diabetic Foot Problems. Clinical guideline 119. 2011:http://guidance.nice.org.uk/GC119 [accessed14 August 2012]. 16. Diabetes UK. Putting Feet First: Commissioning Specialist Services for the Management and Prevention of Diabetic Foot Disease in Hospitals. www.diabetes.org.uk/ Documents/Reports/Putting_Feet_First_010709.pdf [accessed14 August 2012].17. Uccioli L, Gandini R, Giurato L, et al. Long-term outcomes of diabetic patients with critical limb ischaemia followed in a tertiary referral diabetic foot clinic. Diabetes Care 2010;977-982. 18. Schaper NC, Andros G, Apelqvist J, et al. Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot, 2011. Diabetes Metab Res Rev 2012; 28:236-237. 19. Apelqvist J, Bakker K, van Houtum WH, Schaper NC. Practical guidelines on the management and prevention of the diabetic foot. Diabetes Metab Res Rev 2008;24:S181-S187. 20. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-weel prospective trial. Diabetes Care 2003;26:1879-1882.

Dressings/ Topical therapies Despite their widespread use, the quality of published reports supporting the application of topical therapies in DFU is poor. The IWGDF and a Cochrane review identified no good quality randomised controlled trials (RCTs) reporting healing outcomes from which to produce clinical guidelines. 28, 29 Bioengineered skin grafts have demonstrated favorable results in a prospective RCT involving more than 300 patients receiving a dermal fibroblast culture30 A greater proportion of patients receiving the bioengineered skin achieved complete healing at 12 weeks (30% vs 18%), however the healing rates in the control group were lower than expected. Although negative pressure wound therapy (NPWT) has been extensively adopted in the treatment of chronic wounds, much of the supporting evidence is based on industry-funded trials. More than half of studies have not been reported and unpublished data are largely inaccessible.31 One well-designed, industry supported RCT of 342 patients with an ulcer >2cm2 reported promising outcomes.32 NPWT was associated with reduced time to wound closure, increased incidence of healing by 16 weeks and reduced incidence of minor amputation. Further study is, however, needed to justify the use of NPWT in routine clinical practice. A marked benefit in terms of healing is unlikely given most wounds take months to heal and NPWT is only applied for a short period of time. Hyperbaric oxygen therapy (HBO) has also been used with limited supporting evidence. Two double-blinded RCTs have provided stronger justification for HBO in selected patients although issues of cost-effectiveness, patient selection and timing of treatment remain. The larger of the RCTs involved patients with either no evidence of PAD or unreconstructable disease and demonstrated significantly improved ulcer healing at 12 months in the intervention group: 25/48 (52%) versus 12/42 (27%); p=0.03.33

21. Game FL, Hinchliffe RJ, Apelqvist J, et al. Specific guidelines on wound and wound-bed management 2011. Diabetes Metab Res Rev 2012;28(S1):232-233. 22. Armstrong DG, Nguyen HC, Lavery et al. Offloading the diabetic foot: a randomised clinical trial. Diabetes Care 2001;24:1019-1021. 23. Bus SA, Valk GD, van Deursen RW, et al. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev 2008;24(S1):162-180. 24. Armstrong DG, Nguyen HC, Lavery LA, van Schie CHM, Boulton AJM, Harkless LB. Off-loading the diabetic foot wound. A randomised clinical trial. Diabetes Care 2001;24(6):1019-1022. 25. Armstrong DG, Lavery LA, Wu S, Boulton AJM. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds. A randomised controlled trial. Diabetes Care 2005;28(3):551-554. 26. Pitei DL, Foster A, Edmonds M. The effect of regular callus removal on foot pressures. J Foot Ankle Surg 1999;38:251-255. 27. Young MJ, Cavanagh PR, Thomas G, Johnson MM, Murray H, Boulton AJ. The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabet Med 1992;9:55-57.

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Medical management Infection / antibiotics Infection of a foot ulcer represents a major threat to limb and life and must be recognised and treated promptly. The diagnosis of diabetic foot infection is based on clinical findings; superficial wound cultures are not useful and should not be treated, as bacterial colonisation appears to be ubiquitous in DFU. Infection may spread to involve underlying bone in around a fifth of cases (osteomyelitis), which is associated with a worse outcome. Bone biopsy for histopathology and culture remains the “gold standard” for diagnosing osteomyelitis, however, this procedure is not routinely performed in clinical practice.34 Results from both histopathology and culture may be misleading where appropriate expertise is not available. The IWGDF has produced guidelines for the diagnosis and treatment of diabetic foot infections based on the severity of infection.19 Ulcers with superficial infection should be treated with debridement and oral antibiotics aimed at Staphylococcus aureus and streptococci. Targeted therapy against gram +ve cocci has been shown to be equally effective as broader spectrum regimens, 35 even in the presence of osteomyelitis, which will respond to antibiotics in most cases. Deep infection, characterised by purulent discharge or fullness in the plantar space36 necessitates urgent debridement of necrotic tissue including infected bone, and revascularisation if indicated. Intravenous broad-spectrum antibiotics should target Gram-positive and negative microorganisms, including anaerobes. Signs of life and limb threatening infection include bullae, ecchymoses, soft tissue crepitus and rapid spread of infection. 37 In the Eurodiale cohort, investigators observed a markedly negative impact of infection on ulcer healing that was confined to patients with PAD. These findings emphasise

the need for studies evaluating the effects of early revascularisation on control of infection and different antibiotic regimens in PAD.9 Modifying cardiovascular risk DM is recognised as a key risk factor for the development of cardiovascular disease (CVD) and mortality from CV causes is » 2-fold higher compared with individuals without DM.38 A recent meta-analysis suggests that a history of DFU may increase this risk still further, reporting excess all-cause mortality compared to patients with diabetes but without a history of DFU. 39 A report by Young et al suggests this excess risk in DFU can be attenuated by intensive CVD risk modification.40 In a foot clinic population, five year mortality fell from 48% to 27% following introduction of a protocol incorporating CV risk screening and administration of an antiplatelet agent, statin and antihypertensive where indicated. Vascular Intervention The importance of a multidisciplinary decision involving clinicians offering expertise in revascularisation cannot be underestimated. Revascularisation in patients with diabetes can be technically difficult by virtue of the distal distribution of disease, impaired collateral formation and vessel calcification. Data pooled by the IWGDF from 19 studies of patients with DFU and PAD showed a median limb salvage rate of 85% at one year.41 Half of patients with DFU and PAD can expect to be alive at five years and mortality rises to 50% in two years following a major amputation.42 Patients with co-existing chronic kidney disease (CKD) fare worse and the severity of CKD has been shown to correspond with poor outcomes and mortality following revascularisation.43 There are no scoring systems which reliably predict outcome in patients with DFU and PAD undergoing revascularisation procedures. 

28. Bergin S, Wraight P. Silver based wound dressings and topical agents for treating diabetic foot ulcers. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005082. DOI: 10.1002/14651858.CD005082.pub2. 29. Hinchliffe RJ, Valk GD, Apelqvist J, et al. A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 2008;24:S119-S144. 30. Marston WA, Hanft J, Norwood P, Pollak R. The efficacy and safety of dermagraft in improving the healing of chronic diabetic foot ulcers. Results of a prospective randomised trial. Diabetes Care 2003;26:1701-1705. 31. Pienemann F, McGauran N, Sauerland S, Lange S. Negative pressure wound therapy: potential publication bias caused by lack of access to unpublished study results data. BMC Med Res Methodol;8:4. 32. Blume PA, Walters J, Payne W, Ayala J, Lantis J. Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers. Diabetes Care 2008;31:631-636. 33. Londahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care 2010;33:998-1003.

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34. Lipsky BA, Peters EJG, Senneville E, et al. Expert opinion on the management of infections in the diabetic foot. Diabetes Metab Res Rev 2012;28:163-178. 35. Lipsky BA, Itani K, Norden C. Treating foot infections in diabetic patients: a randomised, multicenter, open-label trial of linezolid versus ampicillin sulbactam/ amoxicillin-clavulanate. Clin Infect Dis 2004; 38: 17–24. 36. Boulton AJ, Meneses P, Ennis WJ. Diabetic foot ulcers: a framework for prevention and care. Wound Repair Regen 1999;7:7-16. 37. Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. J Diabetes Complications 2000;13:254-63. 38. Preis SR, Hwang SJ, Coady S, et al. Trends in all-cause and cardiovascular disease mortality among women and men with and without diabetes mellitus in the Framingham Heart Study, 1950 to 2005. Circulation. 2009;119: 1728–1725. 39. Brownrigg JRW, Davey J, Holt PJ, et al. The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis. Diabetologia. 2012 (Epub ahead of print) 40. Young MJ, McCardle JE, Randall LE, Barclay JI. Improved survival of diabetic foot ulcer patients 1995-2008. Possible impact of aggressive cardiovascular risk management. Diabetes Care 2008;31:2143-2147.

Science, Practice and Education

There are no randomised trial data comparing surgical bypass and endovascular techniques in selected patients with diabetes, however, in patients with diabetes and an ischaemic foot ulcer, these techniques appear to offer equivalent outcomes where revascularisation is successful.44, 45 Endovascular techniques performed under local anaesthesia are lower-risk than bypass surgery, cost considerably less and are an appropriate initial approach to restoring perfusion. Surgical bypass has the advantage of increased durability when autologous vein is used but patients with multiple comorbidities and a short life expectancy (6-12 months) are unlikely to realise this benefit. Prevention Foot examination focusing on the presence of peripheral neuropathy, PAD and abnormal foot anatomy can predict risk of developing a diabetic foot ulcer.46, 47 In the UK, screening for foot disease in diabetes is undertaken by primary care physicians who stratify patients with diabetes according to their risk of ulceration. Evidence to support the effectiveness of such screening programmes and complex interventions (education, podiatry, orthoses) in reducing both the risk of foot ulceration and mortality is still lacking.48, 49 Classification and outcomes (reporting) Interpreting studies evaluating healing in DFU is made difficult by poor classification of PAD and ulcer characteristics. The Wagner classification should be avoided and more recent systems used (The University of Texas Wound classification system or the Size (Area and Depth), Sepsis, Arteriopathy, and Denervation score).50, 51 A universal classification system of diabetic foot ulcers would enable consistent reporting among studies to guide the

development of novel therapies. To this end, the European Wound Management Association (EMWA) has produced a set of recommendations for standardised reporting of outcomes in studies of wound management,52 which would enhance the external validity of research in this field and allow fair comparison between centres. Trial outcomes in DFU should include ulcer healing, which has been shown to be of particular importance to patients with diabetes. Patients with active ulceration report poorer health-related quality of life than those who have undergone successful minor lower extremity amputation.53 The balance of risk and benefit for interventions in diabetic foot disease is probably best assessed through a combination of endpoints including mortality, amputation, healing and re-ulceration. Conclusions Studies evaluating the effectiveness of therapies in DFU are of mostly poor methodological quality in part because of the complexity of disease and inherent problems with study design. The Eurodiale study has highlighted gaps between current clinical practice and the best available evidence for treatment. To achieve improved outcomes with respect to healing, amputation and mortality, treatment in primary care and hospital settings should aim to adhere to the available guidelines. Particular emphasis should be placed on early recognition of DFU and rapid assessment by a specialized limb salvage team. m

41. Hinchliffe RJ, Andros G, Apelqvist J, et al. A systematic review of the effectiveness of revascularisation of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev 2012;28:179-217.

48. Jeffcoate WJ. Stratification of foot risk predicts the incidence of new foot disease, but do we yet know that the adoption of routine screening reduces it? Diabetologia 2011;54:991-993.

42. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care 2003;26:491-494.

49. Dorresteijn JAN, Kriegsman DMW, Valk GD. Complex interventions for preventing diabetic foot ulceration. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007610. DOI: 10.1002/14651858.CD007610.pub2.

43. Owens CD, Ho KJ, Kim S, Schanzer A, Lin J, Matros E. Refinement of survival prediction in patients undergoing lower extremity bypass surgery: stratification by chronic kidney disease classification. J Vasc Surg 2007;45:944-52. 44. Albers M, Romiti M, Brochado-Neto FC, De Luccia N, Pereira CA. Meta-analysis of popliteal-to-distal vein bypass grafts for critical ischaemia: revised version. J Vasc Surg 1997;26:517-538. 45. Romiti M, Albers M, Brochado-Neto FC, Durrazo AE, Pereira CA, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischaemia. J Vasc Surg 2006;43:498-503 46. Abbott CA, Carrington AL, Ashe H, et al: The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19:377–384, 2002. 47. Monteiro-Soares M, Boyko EJ, Ribiero J, Ribiero I, Dinis-Ribiero M. Risk stratification systems for diabetic foot ulcers: a systematic review. Diabetologia 2011;54:1190-1199.

50. Macfarlane RM, Jeffcoate WJ. Classification of diabetic foot ulcers. The S(AD) SAD system. Diabetic Foot 1999;2:123-131. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35:528-31. 51. Armstrong DG, Lavery LA, Harkless LB: Validation of a diabetic wound classification system: the contribution of depth, infection, ischemia to risk of amputation. Diabetes Care 1998;21:855–859. 52. Gottrup F, Apelqvist J, Price P. Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management. JWC 2010;19:237-68. 53. Hogg FRA, Peach G, Price P, Thompson MM, Hinchliffe RJ. Measures of healthrelated quality of life in diabetes-related foot disease: a systematic review. Diabetologia 2012;55:552-565.

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Science, Practice and Education

Offloading the diabetic foot:

Evidence and clinical decision making

echanical pressures on the foot during walking are elevated in patients who have diabetes and who are compli cated with neuropathy and foot deformity. These elevated pressures are an important risk factor for the development of diabetic foot ulcers.1;2 For this reason, the reduction of pressure, or “offloading”, has become an important component in the prevention and treatment of foot ulcers in this patient group. To offload the diabetic foot, different techniques have been developed and used over the last 30 years. The conservative treatment modalities include casting, such as the total contact cast (TCC) and cast shoe, prefabricated below-the-knee removable walkers, different types of footwear such as forefoot offloading shoes, therapeutic footwear, and athletic footwear, and felted-foam dressings.

The TCC and removable walkers have by far the best offloading capacity of all modalities, with peak foot pressures that can be reduced up to an average 80% compared to a control shoe condition.3 This is most likely an important component in the efficacy of these devices to heal plantar foot ulcers.4-6 Other treatment options, such as footwear, reduce peak pressure to a much smaller degree, between 20% and 50% compared to control, and therefore show a lower efficacy in healing plantar diabetic foot ulcers.4;7 In 2007, the International Working Group on the Diabetic Foot developed and published evidencebased guidelines on the use of offloading for ulcer prevention and healing.8 The evidence to support the use of offloading for healing foot ulcers is clear.9 The TCC is the preferred treatment, and if not available removable walkers should be used

S.A. Bus, PhD Academic Medical Center Department of Rehabilitation University of Amsterdam Amsterdam, The Netherlands Correspondence: s.a.bus@amc.uva.nl Conflict of interest: none



Figure 1. Plantar pressure distribution diagrams shown for a diabetic patient with severe limited joint mobility in the hallux. Right is the pressure distribution shown with wearing a total contact cast (TCC), left with wearing therapeutic footwear. Notice the large pressure reduction achieved in the TCC (no warm colors visible). Below shows the healing of a neuropathic foot ulcer in 10 weeks time with the TCC. EWMA Journal

2012 vol 12 no 3

Science, Practice and Education

to heal the ulcer. Preferably, these removable devices are made irremovable, simply by wrapping co-band or a tierap around the device, to force continuous use of the device which promotes ulcer healing.6;10 Only when below the knee devices are contra-indicated, should cast shoes or forefoot offloading shoes be recommended to offload the foot. The evidence is also clear in that conventional or standard therapeutic footwear should not be used for offloading foot ulcers, and no evidence exists to support the use of (temporary) custom-made footwear for ulcer healing. More studies are needed to better define the role of surgical offloading interventions. The evidence is, however, in large contrast to what is used for offloading diabetic foot ulcers in clinical practice. Studies from the US and Europe show that the most effective devices are used the least. In the US, the TCC is the preferred treatment in only 2% of centres and the most common modality used is to modify the footwear of the patient (47%).11 In Europe, specialized centres vary greatly in the use of casting techniques to offload the ulcer.12 Some centres, like in Germany, do not use casting at all, whereas others treat more than 60% of their ulcers with a TCC or cast shoe. Fortunately, in Germany reimbursement policies have recently changed with the result that reimbursement is now provided for TCC treatment, which will probably boost the use of the TCC for offloading the diabetic foot. Again, (temporary) footwear was the most commonly used modality.

Now available at: http://shop.idf.org Price Euro 20.00 (+ shipping) 14

Figure 2. Fully custom-made therapeutic footwear commonly prescribed to diabetic patients with foot deformity who are at high risk of foot ulceration.

This gap between evidence and practice has to be bridged. Cavanagh and Bus have recently suggested ways to do this.3;13;14 It starts with the adoption of the above international guidelines by national professional societies. These societies play an important role in promoting widespread implementation of these guidelines in clinical practice. Furthermore, expectation on time to healing should be changed with those responsible for ulcer treatment. Time to healing does not seem an explicit target in ulcer treatment. Neuropathic plantar foot ulcers can heal in 6-8 weeks time, and this should be the reference for treatment of any such ulcer. Additionally, the burden of financial responsibility should be changed for neuropathic ulcers that do not heel within 12 weeks time to a ‘no cure no pay’ reimbursement system. And requirements for demonstrated efficacy of offloading should be introduced. If such a policy requires specialized referral centres where trained personnel, skills, and equipment are available, then these should be established. Finally, the use of any device for which no evidence exists should be discouraged, since many effective treatments already exist. One of the main reasons that many different modalities are used in clinical practice to offload the ulcer is simply because they are available and have been developed and marketed specifically for the diabetic foot, without any evidence to support their use in clinical practice. Because poor offloading is poor treatment, this practice should be changed. The evidence-base to support interventions to prevent foot ulcers is still not large.9 Regular calls removal has become common practice and patients should be urged not to walk barefoot. But the widespread prescription of therapeutic footwear is not yet supported by a large amount of evidence, despite that clinical opinion favours the use of this type of footwear above any other kind of treatment.

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Recent data suggests that a structured approach to custom footwear prescription based on previous prescription algorithms15 can certainly reduce the risk for foot ulceration in diabetes16, but more well-designed prospective trials are urgently needed to draw stronger conclusions on this aspect. Prophylactic surgery of the foot may be another option, but no definitive statement can be made about the efficacy and safety of these procedures. In summary, offloading plays an important role in healing and preventing foot ulcers in patients with diabetes. Clinical decision making in treating plantar diabetic foot ulcers should be determined more by the widely available and convincing evidence, than by personal beliefs, patient’s preferences, and by the simple fact that other options are available. Additionally, a larger focus should be on the role of offloading in preventing foot ulcers in diabetes with the goal to establish a larger evidence-base for making treatment choices in this area of foot care. m

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This is an article that is jointly published in EWMA Journal and the Journal of Wound Technology. References 1 Pham H, Armstrong DA, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify people at high risk for diabetic foot ulceration. Diabetes Care 2000 May;23(5):606-11. 2 Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A. Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care 1998 October;21(10):1714-9. 3 Cavanagh PR, Bus SA. Off-loading the diabetic foot for ulcer prevention and healing. J Vasc Surg 2010 September;52(3 Suppl):37S-43S. 4 Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care 2001 June;24(6):1019-22. 5 Mueller MJ, Diamond JE, Sinacore DR, Delitto A, Blair VP, III, Drury DA et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care 1989 June;12(6):384-8. 6 Katz IA, Harlan A, Miranda-Palma B, Prieto-Sanchez L, Armstrong DG, Bowker JH et al. A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care 2005 March;28(3):555-9. 7 Chantelau E, Breuer U, Leisch AC, Tanudjaja T, Reuter M. Outpatient treatment of unilateral diabetic foot ulcers with ‘half shoes’. Diabet Med 1993 April;10(3):267-70. 8 Bus SA, van Deursen RWM, Valk GD, Caravaggi C, Armstrong DG, Hlavacek P et al. Evidence-based Guideline on Footwear and Offloading for the Diabetic Foot. International Working Group on the Diabetic Foot. DVD available at www idf org/ bookshop 2007. 9 Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavacek P et al. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev 2008 May;24 Suppl 1:S162-S180. 10 Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA et al. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care 2007 March;30(3):586-90. 11 Wu SC, Jensen JL, Weber AK, Robinson DE, Armstrong DG. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care 2008 November;31(11):2118-9.

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12 Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, Bakker K et al. Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study. Diabet Med 2008 June;25(6):700-7. 13 Cavanagh PR, Bus SA. Off-loading the diabetic foot for ulcer prevention and healing. Plast Reconstr Surg 2011 January;127 Suppl 1:248S-56S. 14 Cavanagh PR, Bus SA. Off-loading the diabetic foot for ulcer prevention and healing. J Am Podiatr Med Assoc 2010 September;100(5):360-8. 15 Dahmen R, Haspels R, Koomen B, Hoeksma AF. Therapeutic footwear for the neuropathic foot: an algorithm. Diabetes Care 2001 April;24(4):705-9. 16 Rizzo L, Tedeschi A, Fallani E, Coppelli A, Vallini V, Iacopi E et al. Custom-Made Orthesis and Shoes in a Structured Follow-Up Program Reduces the Incidence of Neuropathic Ulcers in High-Risk Diabetic Foot Patients. Int J Low Extrem Wounds 2012 February 15.

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EWMA Journal

2012 vol 12 no 3

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Science, Practice and Education

Soft-tissue complications during treatment of children with congenital clubfoot Abstract Background: Serial casting in children with congenital clubfoot is a standard management protocol. The Ponseti method has become popular during the last decade. This method consists of serial casting, percutaneous Achilles tenotomy and wearing of the abduction splint. Aim: The aim of the study was to assess the risk of soft-tissue damage during early treatment of children with congenital clubfoot in order to avoid possible complications. Method: In a consequential series of 180 children with congenital clubfoot (248 feet) we assessed the number of soft-tissue complications. Correlation of the incidence of complication with age of the child, severity of initial deformity, and details of treatment protocol were assessed. Results: Soft tissue lesions were observed in 49 feet (19.7%). A young age at the beginning of treatment did not enhance the risk of a lesion to occur. Severity of the initial deformity was observed to be the most important prerequisite for the occurrence of soft-tissue lesions. In children, treated with the Ignacio Ponseti method we detected fewer complications in terms of soft-tissue lesions. Conclusion: Soft tissue damage during Ponseti casting is associated with poor clinical treatment result and may have a predictive value for poor treatment outcome.

Introduction Congenital clubfoot is one of the most common congenital orthopaedic disorders. The incidence of clubfoot in a total population is 1-2 per 1000 newborns1. Serial casting in children with congenital clubfoot is a standard treatment for the management of this severe orthopaedic disorder1. During the last decade non-surgical management of children with congenital clubfoot became more popular because of a well introduced method, pioneered by Ignacio Ponseti2,3,4. This method consists of serial casting performed on special biomechanically and anatomically based principles, percutaneous tenotomy of the Achilles tendon, followed by long-lasting wear time of a special abduction splint (braces). Popularity of the Ponseti casting method brings to light some problems, not related to the main orthopaedic condition, but interfering with the course of treatment. Casting starts usually immediately after birth of the child. Depending on the specific skin and soft tissue condition of the newborns, clinicians face numerous problems. Pressure on the skin over bony prominences under casting is inevitable. In the cases of severe deformity the duration of casting and stiffness of the foot are possible sources of a higher risk of soft tissue damage. Therefore surgical management may be the method of choice in some of the complicated cases.

1Alexey Baindurashvili, MD PhD, Professor 2Dr. 3Dr.

Vladimir Kenis, Yulia Stepanova

1Director, The Turner cientific and Research S Institute for Children’s Orthopedics Saint-Petersburg, Russia 2Head

of department of Foot and Ankle surgery,

3Surgeon, Paediatric Orthopaedic Institute n.a. H. Turner Saint-Petersburg, Russia.

Correspondence: kenis@mail.ru Conflict of interest: none

Aim of the study To assess the risk of soft-tissue damage during early treatment of children with congenital clubfoot when using the Ponseti casting method in order to avoid possible complications, and improve treatment outcomes. Material and methods In a consequential series of 180 children with congenital clubfoot (N=248 feet) we assessed the number of soft-tissue complications. The age at the beginning of treatment was from 7 days to 1 year. The duration of management was from 3 to 12 weeks. We determined the groups depending on severity  of the damage (Fig. 1-3):

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1. Superficial damage: – Skin irritation – Maceration 2. Deep damage – Acute (pressure ulcer) – Chronic (persistent pressure ulcer) Correlation of the incidence of complications with the age of the child, severity of the initial deformity, and details of the treatment protocol were assessed. Results Soft tissue lesions were observed in 49 feet (19.7%). In cases of bilateral clubfoot, the incidence of bilateral soft tissue lesions was 72%. Superficial lesions occurred in 37 cases (75%), deep lesions were observed in 12 cases (25%). We could not find the incidence of soft-tissue damage to be correlated to the age of the child (Table 1). Deep lesions were more common in children older than six months of age. The incidence and severity of soft-tissue damage during early treatment of children with congenital clubfoot showed a positive correlation with severity of the initial deformity (Table 2). The severity of the initial deformity was assessed with the Pirani scale, widely used for assessment of clubfoot. This scale is based on clinical evaluation and has a good reproducibility and reliability. As shown in Table 2, the incidence of soft tissue lesions was significantly higher in children with severe clubfoot. Deep lesions were also more often observed in children with severe clubfoot. We divided the main causes of soft tissue lesions in children treated for clubfoot in three groups: 1. Caused by specific features of the method: lesions are in the areas of definitive pressure during the casting (lateral aspect of the talus head, posterior aspect of lateral malleolus). These lesions may be caused also by forced casting. They occurred in n=15 cases.

Figure 1: Skin irritation on the dorsum of the foot

Figure 2: A pressure ulcer in the supra-calcaneal area

Table 1: Soft tissue damage occurrence and the age of the child Age 0-3 months 3-6 months 6-9 months 9-12 months

Superficial lesions Deep lesions 14 (17%) 3 (4%) 10 (13.5%) 4 (5.5%) 8 (18.5%) 2 (4.5%) 5 (16.5%) 3 (10%)

Total 17 (21%) 14 (19%) 10 (23%) 8 (26.5%)

Table 2: Incidence and severity of soft-tissue damage in children with different severity of the initial deformity Initial Pirani score Superficial lesions Deep lesions > 4 points 19 (51%) 8 (66.5%) 2-4 points 12 (32.5%) 4 (33.5%) <2 points 6 (16.5%) * 0 * - P<0.05

Total 27 (55%) 16 (32.5%) 6 (12.5%)* Figure 3: A persistent ulcer in the calcaneal area

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Science, Practice and Education

Figure 4: Incidence of soft tissue lesions during the 3-years study period

2. Caused by improper casting: lesions are not in the areas of definitive pressure during casting (dorsal part of the foot, calcaneal area, medial malleolus). This type of lesions occurred in n=14 cases. 3. Caused by defects of daily care. Damage to the cast, softening, contamination of the cast can lead to skin problems. Improper positioning of the baby (with the legs in cast hanging down) can increase pressure, maceration and swelling. Lesions are not on the foot, mostly in the areas of the margins of the cast (groin, posterior aspect of the thigh, toes). These lesions occurred in n=20 cases. In order to evaluate whether it is an effective way to diminish the incidence of the soft tissue lesions during the course of clubfoot casting, we assessed the annual incidence of the lesions during the 3-years study period (Fig. 4). This “learning curve” demonstrated a marked decrease of the incidence of soft tissue lesions from year to year, mostly expressed by the lower rate of the second group – caused by improper casting. We also hypothesized that acquired soft tissue lesions can alter the protocol of treatment and influence the results. We evaluated course and final results of treatment by weekly Pirani score assessment in our studied group compared with the control group consisting of the rest of patients without soft tissue lesions. The data presented in Fig. 5 demonstrated a delayed rate of correction in the group of children with skin damage compared to the control group. The treatment result was better in the control group. It is difficult to associate this difference with the direct influence of skin problems on the rate and results of clubfoot correction. It is necessary to take into account, that soft tissue damage is also associated with severity of initial deformity as was shown earlier. These data demonstrated that soft tissue damage during Ponseti casting is associated with a

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Figure 5: Course of treatment by weekly Pirani score assessment for the study group and the control group

poor clinical treatment result and may have a predictive value for poor outcome. Limitations of the study include limited number of patients and descriptive clinical assessment. Further study with a more systematic and quantitative approach to measurement of soft tissue damage will give more precise data. Clinical efficiency of the Ponseti method compared to “traditional” casting was demonstrated in numerous studies. We also compared results of the Ponseti method and “traditional” casting in terms of skin complications. Total incidence of soft tissue lesions was markedly higher in the “traditional” group, but deep complications had relatively similar occurrence. Conclusion Soft-tissue damage during early treatment of children with congenital clubfoot is a common complication. Young age at the beginning of treatment does not enhance the risk of tissue damage occurrence. Severity of the initial deformity is estimated as the most important prerequisite for the occurrence of soft-tissue lesions. In children treated with the Ignacio Ponseti method we observed fewer complications in terms of soft-tissue lesions. Soft tissue damage during Ponseti casting is associated with poor treatment result and may have a predictive value for poor outcome. Effective casting in accordance with the Ponseti principles and the use of quality casting materials helps to prevent severe complications. m References 1. Noonan, K.J. Nonsurgical management of idiopathic clubfoot / K.J. Noonan, B.S. Richards // J. Am. Acad. Orthop. Surg. 2003. no 11. p. 392-402. 2. Herzenberg, J.E. Ponseti versus traditional methods of casting for idiopathic clubfoot / J.E. Herzenberg, C. Radler, N. Bor // J. Pediatr. Orthop. 2002. no 22. p. 517-521. 3. Ponseti, I.V. Congenital Clubfoot: Fundamentals of Treatment / I.V. Ponseti // Oxford, Oxford University Press. 1996. 140 p. 4. Zwick, E.B. Comparison of Ponseti versus surgical treatment for idiopathic clubfoot: a short–term preliminary report /E.B. Zwick, T. Kraus, C. Maizen, G. Steinwender, W.E. Linhart // Clin. Orthop. Relat. Res. 2009. no 467(10). p. 2668-2676.

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Science, Practice and Education

An evolution in Medical Tapes:

From Latex to Acrylic

mproving patient care and controlling costs are universal goals of healthcare clinicians and administrators around the world. Significant time, resources and energy are devoted to preventing adverse events, reducing infection rates and selecting products based on clinical evidence. A plethora of medical devices have been introduced to improve patient care and its related costs, however a relatively simple and commonly used medical device is often overlooked: the use of more patient-friendly and less expensive skin adhesive for medical tapes. Natural rubber latex tapes: the first medical adhesives The earliest medical skin adhesives were made of natural rubber latex, a substance derived from a milky, viscous sap harvested from rubber trees and then refined into a soft adhesive polymer. Natural rubber latex delivers high adhesion in both wet and dry conditions; it forms a very tight bond by seeping into crevices of the skin and anchoring itself in the epidermal layer. In addition to its use on patients, the same natural rubber latex tapes are used in many healthcare facilities to label laboratory bottles, seal boxes etc. Natural rubber latex adhesives are sold in multiple forms and referred to by many names, including rubber adhesive tapes (RAT tapes), cloth tapes, or cloth adhesive tapes (CAT tapes). They may also be known as zinc oxide tapes if they contain that additive. For purposes of this discussion, all medical tapes containing natural rubber adhesives or natural rubber latex are referred to as natural rubber latex tapes. Although natural rubber latex tapes met the needs of the medical community for many years and even today remain the standard medical adhesive tape in many countries, they are now considered far from ideal. They are well known to cause skin injuries and allergic reactions1-3 that can affect

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both patients and healthcare workers; in fact, these irritations and sensitizations can be so common that many of them go unrecorded. Traumatic skin injuries due to medical tapes Skin reactions to tapes can be classified into two groups: traumatic skin injuries and allergic reactions.1-3 Traumatic skin injuries can occur in response to mechanical factors, such as friction, skin stripping, maceration, chemical irritation or tension of the skin. The resulting dermatitis usually causes a burning sensation of relatively short duration and is localized at the site of tape contact.2 These conditions can be extremely painful for patients, especially those with fragile and atrisk skin, such as infants, children and the elderly – the most vulnerable patient populations.

Luc Gryson CNC wound management association Director WZC Clep Correspondence: luc.gryson@telenet.be Conflict of interest: none

Skin stripping This partial thickness injury occurs when the bond between the tape and the skin is stronger than the bond between the skin’s epidermal and dermal layers. Consequently, when the tape is removed, the epidermis remains attached to the tape, resulting in epidermal damage or a painful area of exposed dermis (see Figure 1).This is a special concern when a highly aggressive adhesive such as natural rubber latex tape is removed from  fragile skin.

Figure 1. Skin stripping injury

Tension injuries When tapes are stretched before placement on the skin, the skin below the tape can become distended. As the tape resists stretching or regains its original shape, the skin’s epidermis begins to lift. This causes tension blisters (typically at the ends of the tape) or skin tears on joints, as shown in Figure 2. This is a particular concern for tapes that have a sturdy, unyielding cloth backing and aggressive adhesive. Polatsch et al 14 retrospectively reviewed a series of hundred and three patients with hip fractures to determine the incidence of tape blister. The authors reported that 21.4% of the patients had developed blisters due to medical tapes however, they found no statistical significances of patient age, sex, number of medical co morbidities, nutritional status and type of surgery associated with risk for developing tape blisters. Chemical Irritation Irritation or non-allergic contact dermatitis can result when chemical irritants, such as skin preps are trapped between the tape and the skin. Skin preps are products applied to the skin, to increase adhesion of the tape to the skin. As in Figure 3, the injured area may look reddened, swollen, blistered or weeping. The greater a tape’s occlusion factor, the more likely a patient will experience dermatitis. Many rubber tapes are highly occlusive and present a significant risk of skin irritation. Maceration When a layer of film or plastic is applied to skin, it disrupts the skin’s natural function, blocking pores and preventing the release of moisture. After a prolonged period of time, maceration can occur, leaving the skin looking white or gray as well as softened and wrinkled. Maceration can leave skin more permeable and susceptible to damage from friction and irritants. The risk of maceration is directly linked to the breathability of the medical tape; most natural rubber tapes have low breathability and present a high risk for maceration. Skin reactions to excessive adhesive residue Along with skin sensitization and irritation, a common complaint associated with the use of natural rubber latex tapes is excessive adhesive residue. Removal of this residue may require strong adhesive cleansers or vigorous scrubbing, which can further irritate or sensitize injured skin and make subsequent procedures, such as further taping or catheter insertion, more difficult and painful for the patient.

Figure 2. Tension blister injury

Figure 3. Non-contact dermatitis

Figure 4. Allergic contact dermatitis

Allergic reactions to natural rubber latex Allergic reactions to adhesive tapes are generally due to rubber that has been incorporated with the adhesive.2,3 Accelerators used in the manufacture of finished rubber products and antioxidants for rubber preservation have been identified as likely sensitizers.2 Figure 4 shows an example of allergic contact dermatitis. Unlike the burning sensation of a traumatic skin injury, allergic reactions can cause severe itching. These reactions, which can become even worse after the tape is removed, often spread beyond the area of tape contact.2 Severe reactions may even include sudden onset of anaphylactic shock, which can be life-threatening.4

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Science, Practice and Education

Allergic sensitivity to rubber (latex) is an increasing problem, particularly among patients who have been hospitalized multiple times, as well as among healthcare providers. The U.S. Centers for Disease Control and Prevention (CDC) estimates that one in ten people are sensitive to latex,5 while the U.S. Occupational Safety and Health Administration (OSHA) estimates that eight to twelve percent of healthcare workers have latex sensitivity.4 Once a person becomes sensitized to latex, he or she is unable to safely use products containing latex. Human skin is not like red wine (IT DOESN’T GET BETTER WHEN MATURED…)

For more than half a century patients have been treated with a plethora of medical tapes. Yet, as a surface on which to use medical adhesives, the skin poses many challenges (e.g. desquamation, oily substances, hair etc...). The physiological functions of the skin include protection against mechanical and chemical irritation. However, application of medical adhesive tapes used in hospitals occasionally causes skin injuries because of the adhesive agent and the mechanical stimulation that occurs during removal of the tape. In particular, as the skin of older individuals shows physiological deterioration because of aging, older people are more susceptible to skin injuries caused by tape application13. (Konya, 2010) Aging skin undergoes progressive degenerative change. Structural and physiologic changes that occur as a natural consequence of intrinsic aging combined with the effects of a lifetime of ongoing cumulative extrinsic damage and environment insult (e.g. overexposure to solar radiation) can produce a marked susceptibility to dermatologic disorders in the elderly. As skin ages, the vasculature progressively atrophies. The supporting dermis also deteriorates, with collagen and elastin fibers becoming sparse and increasingly disordered. These changes leave the elderly increasingly susceptible to both vascular disorders such as stasis dermatitis and skin injuries such as pressure ulcers and skin tears, with a steadily decreasing ability to effect skin repair (Farage, 2009)12. Interestingly another study of Konya et al13 (Konya, 2010) investigated the status of skin injuries in older people (mean age 82 - 83years) and reported a cumulative incidence rate of 15.5%. However the authors acknowledge that while skin functions are considered to decline in association with aging, diabetes mellitus and renal diseases, no significant differences were observed in the relationship between the presence or absence of skin injuries and these diseases in older patients aged 65 or older. This is

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probably attributable to the large individual differences in physical factors among older people, which are influenced by lifelong personal habits. With an increasing elderly population it is inevitable that preserving skin integrity becomes a challenge of health care professionals and the economic consequences that go together with it. Switching to safer medical tapes Healthcare facilities have the opportunity to address these concerns by switching from natural rubber latex tapes, which are known to cause skin injuries,1-3 to a newer class of medical tapes, called acrylate adhesive tapes. Medical tapes using acrylate adhesives were developed specifically to address the concerns of skin injury and pain caused by natural rubber latex tapes. Acrylate medical adhesive tapes were first introduced in the 1960s by 3M Company (St. Paul, MN, U.S.). While natural rubber latex is a harvested substance, acrylates are manufactured. This allows for greater control in material selection and processing. Materials used to produce acrylate adhesives are designed for use on humans and are selected to provide an optimized mix of performance characteristics. Acrylates can be manufactured with a better balance between hard and soft polymers, which results in strong bonding to the skin but does not reach the deep layers of skin cells. Equally important, acrylate types do not incorporate the sensitizing accelerators or antioxidants that have proven so problematic for many patients – thus reducing the risk of allergic dermatitis.2 Clinical advantages of acrylate tapes An extensive portfolio of acrylate medical tapes has been developed and introduced globally, thanks to advancements in both adhesive and backing material technologies. These products address a wide range of clinical needs, from treating the most sensitive skin to offering the highest degree of securement. In use for over 50 years, the acrylate class of adhesives has demonstrated reliable adhesion and performance, and has been adopted for use as the standard securement solution for the healthcare industry. Acrylate adhesive tapes offer higher breathability and greater stretch, and are less irritating to the skin than natural rubber latex tapes. As a result, patients experience less itching and discomfort and find acrylate tapes to be more comfortable during wear.9 The highest quality acrylate tapes are hypoallergenic. In addition, latex-free acrylate tapes are safer for both patients and healthcare workers. 

Science, Practice and Education

are expected to continue11 which will undoubtedly affect countless rubber-based products, including natural rubber latex tapes. Acrylate adhesives offer financial advantages that go beyond procurement costs. By replacing natural rubber latex tapes with acrylate tapes, facilities may see reductions in the usage of materials such as adhesive removers and skin barriers. In addition, decreasing the incidence of skin injuries can save costs associated with treatment, such as antibiotics and nursing time. Table 1. A comparison of minimum prices for rubber and acrylate tapes in nine countries. No rubber tape was priced lower than the most common paper tape.

Since its introduction, this class of adhesives has undergone multiple innovations, resulting in a wide range of tape offerings including paper, silk and soft cloth backings. These provide clinicians with an extensive range of options to best meet the specific needs of their patient populations. Newer Technology at Lower Cost With all the advantages acrylate tapes offer compared to natural rubber latex tapes, one might expect acrylate tapes to cost more. However, a survey of tape prices revealed that natural rubber latex tapes are some of the highest priced tapes on the market. Table 1 shows a comparison of minimum prices for cloth (rubber) tape and paper (acrylate) tape in four countries.9 No rubber tape was priced lower than the most frequently used paper tape and in multiple instances, acrylate tapes cost significantly less. Price increases for natural rubber tapes have largely been driven by the global shortage of natural rubber and by volatility in rubber commodity markets. Prices for natural rubber have increased 300% since 2004.10 Demand shows no sign of lessening, and these shortages and price increases

An opportunity to improve skin safety while reducing costs Healthcare facilities and providers worldwide constantly seek to improve patient safety and care; this is, after all, the fundamental charge of the healthcare profession. Although economic realities dictate that costs of providing care be carefully managed, there is at least one measure that can be taken to increase the quality of care while lowering costs: specifically, switching from rubber medical tapes to acrylate medical tapes. By doing so, healthcare facilities can decrease the incidence of traumatic skin injuries, as well as reduce the risk of allergic reactions in patients and healthcare workers. Adopting proven, newer adhesive technologies is a simple and cost-effective means to advance patient safety goals while improving the patient experience. m

References 1. Sidi, E., and Hincky, M., Allergic Sensitization to Adhesive Tape: Experimental Study With a Hypoallergenic Adhesive Tape, J Invest Derm 29:81-90 (Aug) 1957.

9. 3M Internal Data.

2. Fisher, A., Rubber: Common Cause of Allergic Contact Dermatitis, Cutis 1:345-354 (Aug) 1965.

11. Fessler, D., The Biggest Shortage That Nobody is Talking About, Investment U, March 2011, www.investmentu.com/2011/March/the-natural-rubber-shortage.html.

3. Orentreich, N., Berger, R.A., and Auerbach, R., Anhidrotic Effects of Adhesive Tapes and Occlusive Film, Arch Derm 94:709-711 (Dec) 1966. 4. Healthcare Wide Hazards, Latex Allergy, Occupational Safety and Health Administration, U.S. Department of Labor, http://www.osha.gov/SLTC/etools/hospital/ hazards/latex/latex.html. 5. Latex allergy prevention. Premier, Inc., www.premierinc.com/safety/topics/latex_ allergy/#Introduction. 6. Lober et al. Southern Med J. 39:1444-6, 1991.

10. Thomson Reuters, Commodities Data, November 2011.

12. Farage, M. A. (2009). Clinical implications of aging skin: cutaneous disorders in the elderly. American journal of clinical dermatology, 10 (2), 73 - 86. 13. Konya. (2010). Skin Injuries caused by medical adhesive tape in older people and associated factors. Journal of Clinical Nursing, 19, 1236-1242. 14. Polatsch, D. B. (2004). Tape Blisters that Develop After Hipe Fracture Surgery: A Retrospective Series and a Review of the Literature. The American Journal of Orthopedics, 452-456.

7. White, et al. Primary Intention. 9(4):138-149, 2001. 8. McGough-Csarny, et al. Ostomy Wound Manage. 44(3A):14S-25S, 1998.

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References: 1. Dykes PJ et al. Effect of adhesive dressings on the stratum corneum of the skin. Journal of Wound Care, 2001. 2. Waring M et al. An evalutation of the skin stripping of wound dressing adhesives. Journal of Wound Care, vol 22, No 9, September, 2011. 3. White R. A Multinational survey of the assessment of pain when removing dressings. Wounds UK 2008. The Mölnlycke Health Care name and logo, Mepitel® Film and Safetac® are registered trademarks of Mölnlycke Health Care AB. © Copyright (2011) Mölnlycke Health Care. All rights reserved. Mölnlycke Health Care AB, Box 13080, SE-402 52 Göteborg, Sweden. Phone + 46 31 722 30 00.

Science, Practice and Education

Bacteria and fungus binding mesh in negative pressure wound therapy A review of the biological effects in the wound bed Abstract In recent years, intensive research has been conducted to investigate the biological effects of negative-pressure wound therapy (NPWT) on the wound bed and to find ways to optimize the use of this technology. The mechanisms by which NPWT may lead to accelerated wound healing include the creation of a moist environment, drainage of exudate, reduction of tissue oedema, contraction of the wound edges, mechanical stimulation of the wound bed, blood flow changes in the wound edges, stimulation of angiogenesis and formation of granulation tissue. The choice of wound filler partly determines the effects of NPWT on the wound bed. Foam and gauze are the most frequently used wound fillers for NPWT. Bacteria and fungus binding mesh (Sorbact®) constitutes an interesting new alternative wound filler. In light of the lack of a randomized, controlled trial, this review provides some insight on some of the latest preclinical findings regarding the choice of wound filler to optimize NPWT for the individual wound.

Introduction Negative pressure wound therapy (NPWT) is increasingly used to treat hard-to-heal wounds and has been shown to improve healing outcomes in many wound types, including orthopedic trauma1, soft tissue trauma2, skin grafts3, flaps, pressure ulcers4, venous leg ulcers5, vascular surgery wounds, diabetic foot ulcers6, burns7, wound dehiscence, in abdominal8 and thoracic surgery9 and surgical infections10. Initially, the wound is filled with a wound filler (commonly foam or gauze) to allow pressure to be transmitted and evenly distributed to the bottom of the wound. The wound is then sealed with an adhesive drape and a drain is connected to a vacuum pump that applies the negative pressure. Wound fluid is withdrawn by the negative pressure and collected in a canister. NPWT accelerates wound healing by initiating a cascade of interrelated biological reactions that ultimately lead to wound healing. NPWT has been found to create a moist wound healing environment11, drain exudate12-14, reduce tissue edema15, contract wound edges12-14, mechanically stimulate the wound bed16-18, alter blood flow in the wound edges13, 19-22 and stimulate angiogenesis23, 24 and the formation of granulation tissue13. The biological effects of NPWT are represented in Figure 1. The negative pressure level The most commonly used negative pressure level is -125 mm Hg13. However, more recent studies have shown that the maximum biological effects on the wound edges, in terms of wound contraction,25 regional blood flow26 and the formation of granulation tissue27, are obtained at -80 mmHg. A recent case report28 show that negative pressure levels lower than -125 mm Hg indeed result in excellent wound healing. When using NPWT to treat poorly perfused tissue (e.g., diabetic foot ulcers and thin skin transplants), ischemia may develop in the wound tissue and the patient can

1Malin

Malmsjö MD, PhD Professor and Senior Consultant

2Sandra

Lindstedt MD, PhD

2Richard

Ingemansson

MD, PhD 1Lotta Gustafsson MD, PhD 1Department of Ophthalmology 2Department

of Cardiothoracic Surgery, Lund University and Skåne University Hospital, Lund, Sweden Correspondence: malin.malmsjo@med.lu.se Conflict of interest: This review was supported by Abigo Medical AB

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2012 vol 12 no 3

experience pain during treatment29. Thus, it may be advantageous to use a lower level of negative pressure in the treatment of sensitive, poorly perfused tissue. Negative 40 mmHg is the pressure level at which about half the maximum blood flow effect is achieved26, and may be a suitable negative pressure level to try in these types of wounds. The use of negative pressures higher than -80 mmHg does not provide any additional effects on wound edge microvascular blood flow26. Drainage may be improved at -125 mmHg25, and this level of negative pressure could be used for the first few days to treat high-output wounds, after which the negative pressure may be lowered once the amount of exudate lessens.

Figure 1. Application of NPWT: First, the wound is debrided. The wound then is filled with a material that will deliver negative pressure to the wound bed – in this case, foam. The wound is sealed with an adhesive plastic drape and a drain is connected to the vacuum pump. The pressure applied by the vacuum pump is propagated through the wound filler to the wound bed, leading to the removal of exudate. Some of the biological effects of the therapy are illustrated in the image. Blood flow close to the wound edge (white) decreases; whereas, hyperperfusion is seen further away (red). The wound is contracted and fluid is evacuated through the drainage tube.

The wound filler Foam and gauze are the most frequently used wound fillers in NPWT (Figure 2 and 3). Nearly all foam used for NPWT is made of polyurethane and has an open cell structure with a pore size of 400 - 600 µm. The gauze is a type of cotton gauze (AMD gauze)30. It is believed that the wound filler may determine the effects on wound healing. Bacteria and fungus binding mesh (Sorbact®) may constitute an interesting alternative (Figure 2 and 3). The pathogen binding mesh is a woven acetate material that is coated with dialkyl carbomoyl chloride (DACC). Such mesh makes use of the hydrophobic interaction to remove pathogens.31. Bacteria and fungus binding mesh is known to adsorb and inactivates a wide range of bacteria, e.g. Staphylococcus aureus and Pseudomonas aeruginosa, as well as fungi, and has been shown to reduce the microbial load without the development of resistance among microorganisms. The biological effects on the wound edge by NPWT, using bacteria and fungus binding mesh as compared to conventional wound fillers (foam and gauze), is being reviewed and summarized in this article.

Pressure transduction and wound fluid drainage The function of the wound filler is to transmit the negative pressure from the vacuum pump and tubing to the wound bed. It has been shown that the negative pressure is equally well transmitted through bacteria and fungus binding mesh (Sorbact®), foam and gauze16, 32 . The negative pressure affects only the tissue in direct contact with the wound filler and does not extend to deeper structures. It is therefore important to place the wound filler in all areas of the wound where the effect of the negative pressure is desired33. When draining fluid from a deep wound pocket the entire pocket needs to be filled with the dressing. In these circumstances, it may be easier to use pathogen binding mesh or gauze, than foam, because of the moldability and ease of application to irregular wounds32, 34. Another advantage with using bacteria and fungus binding mesh or gauze is that granulation tissue does not grow into these materials and there is less risk of the wound filler getting stuck in the wound27.

References

7. Kamolz LP, Andel H, Haslik W, Winter W, Meissl G, Frey M. Use of subatmospheric pressure therapy to prevent burn wound progression in human: first experiences. Burns 2004; 30(3):253-8.

1. Bollero D, Carnino R, Risso D, Gangemi EN, Stella M. Acute complex traumas of the lower limbs: a modern reconstructive approach with negative pressure therapy. Wound Repair Regen 2007; 15(4):589-94. 2. Stannard JP, Robinson JT, Anderson ER, McGwin G, Jr., Volgas DA, Alonso JE. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2006; 60(6):1301-6. 3. Scherer LA, Shiver S, Chang M, Meredith JW, Owings JT. The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg 2002; 137(8):930-3; discussion 933-4. 4. Joseph E, Hamori C, Bergman S, Roaf E, Swann N. A new prospective randomized trial of Vacuum assisted closure versus standard therapy of chronic nonhealing wounds. Wounds 2000; 12:60-7. 5. Vuerstaek JD, Vainas T, Wuite J, Nelemans P, Neumann MH, Veraart JC. State-ofthe-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg 2006; 44(5):1029-37; discussion 1038. 6. Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005; 366(9498):1704-10.

8. Wild T, Stortecky S, Stremitzer S, Lechner P, Humpel G, Glaser K, Fortelny R, Karner J, Sautner T.Abdominal dressing -- a new standard in therapy of the open abdomen following secondary peritonitis?]. Zentralbl Chir 2006; 131 Suppl 1:S111-4. 9. Sjogren J, Gustafsson R, Nilsson J, Malmsjo M, Ingemansson R. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional treatment. Ann Thorac Surg 2005; 79(6):2049-55. 10. Ozturk E, Ozguc H, Yilmazlar T. The use of vacuum assisted closure therapy in the management of Fournier’s gangrene. Am J Surg 2009; 197(5):660-5; discussion 665. 11. Banwell PE. Topical negative pressure therapy in wound care. J Wound Care 1999; 8(2):79-84. 12. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38(6):563-76; discussion 577. 13. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg 1997; 38(6):553-62.

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Figure 2: Photos of bacteria and fungus binding mesh (Sorbact®), foam and gauze before the dressing is applied to the wound.

The suction force generated by the negative pressure leads to active drainage of exudate from the wound. Wound fluid is known to be efficiently removed by foam and pathogen binding mesh while more fluid is retained in gauze32. The reason for this may be that both foam and the pathogen binding mesh are hydrophobic allowing the fluid to pass through the material. The wound fluid removal is advantageous as it reduces cytokines and other compounds that are inhibitory to wound healing, such as proteolytic enzymes and metalloproteinases35, 36. NPWT instillation technique is now beginning to be used more frequently. By automatically delivering topical solutions to the wound site, the NPWT instillation technique combines the proven benefits of NPWT with the advantages of instillation therapy37-39.

Figure 3: Representative photos of the wound during treatment with a negative pressure wound therapy using bacteria and fungus binding mesh (Sorbact®), foam and gauze.

Mechanical effects One of the fundamental effects of NPWT is believed to be the deformation of the wound edge tissue as the wound contracts (macrodeformation)23, 30, 40. It has been shown that the wound contraction is similar for pathogen bind-

ing mesh (Sorbact®) and gauze, while slightly greater for foam32, as a result of its slightly more open and spongy texture. The wound bed and wound filler also interact on a microscopic level (microdeformation). The wound bed is drawn into the pores of the foam or in-between the threads of the gauze and pathogen binding mesh18. Histological examination of cross sections of the wound bed after NPWT using bacteria and fungus binding mesh, foam and gauze has shown that these materials all result in microdeformation of the wound bed41. These mechanical effects are thought to result in shearing forces at the wound–dressing interface, which affect the cytoskeleton18, and initiate a signalling cascade that ultimately leads to granulation tissue formation and wound healing. The pulling together of the wound edges by negative pressure may be important for the entire wound-healing process, as early reduction in the size of the wound has been shown to be correlated with improved  final wound healing42.

14. Morykwas MJ, Simpson J, Punger K, Argenta A, Kremers L, Argenta J. Vacuumassisted closure: state of basic research and physiologic foundation. Plast Reconstr Surg 2006; 117(7 Suppl):121S-126S.

20. Wackenfors A, Gustafsson R, Sjogren J, Algotsson L, Ingemansson R, Malmsjo M. Blood flow responses in the peristernal thoracic wall during vacuum-assisted closure therapy. Ann Thorac Surg 2005; 79(5):1724-30; discussion 1730-1.

15. Lu X, Chen S, Li X, al. e. The experimental study of the effects of vacuum-assisted closure on edema and vessel permeability of the wound. Chinese Journal of Clinical Rehabilitation 2003; 7:1244-5.

21. Wackenfors A, Sjogren J, Gustafsson R, Algotsson L, Ingemansson R, Malmsjo M. Effects of vacuum-assisted closure therapy on inguinal wound edge microvascular blood flow. Wound Repair Regen 2004; 12(6):600-6.

16. Malmsjo M, Ingemansson R, Martin R, Huddleston E. Negative-pressure wound therapy using gauze or open-cell polyurethane foam: similar early effects on pressure transduction and tissue contraction in an experimental porcine wound model. Wound Repair Regen 2009; 17(2):200-5.

22. Timmers MS, Le Cessie S, Banwell P, Jukema GN. The effects of varying degrees of pressure delivered by negative-pressure wound therapy on skin perfusion. Ann Plast Surg 2005; 55(6):665-71.

17. Borgquist O, Gustafsson L, Ingemansson R, Malmsjo M. Micro- and macromechanical effects on the wound bed of negative pressure wound therapy using gauze and foam. Ann Plast Surg 2010; 64(6):789-93. 18. Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP. Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plast Reconstr Surg 2004; 114(5):1086-96; discussion 1097-8. 19. Kairinos N, Voogd AM, Botha PH, Kotze T, Kahn D, Hudson DA, Solomons M. Negative-pressure wound therapy II: negative-pressure wound therapy and increased perfusion. Just an illusion? Plast Reconstr Surg 2009; 123(2):601-12.

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23. Chen SZ, Li J, Li XY, Xu LS. Effects of vacuum-assisted closure on wound microcirculation: an experimental study. Asian J Surg 2005; 28(3):211-7. 24. Greene AK, Puder M, Roy R, Arsenault D, Kwei S, Moses MA, Orgill DP. Microdeformational wound therapy: effects on angiogenesis and matrix metalloproteinases in chronic wounds of 3 debilitated patients. Ann Plast Surg 2006; 56(4):418-22. 25. Borgquist O, Ingemansson R, Malmsjo M. The influence of low and high pressure levels during negative-pressure wound therapy on wound contraction and fluid evacuation. Plast Reconstr Surg 2011; 127(2):551-9. 26. Borgquist O, Ingemansson R, Malmsjo M. Wound edge microvascular blood flow during negative-pressure wound therapy: examining the effects of pressures from -10 to -175 mmHg. Plast Reconstr Surg 2010; 125(2):502-9.

Blood flow effects The effects on blood flow resulting from NPWT are local and vary depending on the distance from the wound edge (see Figure 1)20. Blood flow decreases close to the edge of the wound (within about 5 mm) and increases farther away from the wound edge (about 25 mm)20, 21, 26. The increase in blood flow has been shown to be similar for bacteria and fungus binding mesh (Sorbact®), and foam and gauze, while the decrease in blood flow is more pronounced with foam than with the other materials32. This combination of increased and decreased blood flow is believed to be advantageous in the wound healing process. Increased blood flow may lead to improved oxygen and nutrient supply to the tissue, as well as improved penetration of antibiotics and removal of waste products. Blood flow reduction in the superficial tissue occurs in response to the negative pressure compressing the tissue surface43, 44. The mechanism behind the increase in blood flow has not yet been identified, but it has been speculated that the negative pressure causes a force in the tissue that opens up the vascular bed, increasing flow. There are both advantages and disadvantages of the hypoperfusion caused by NPWT. It is well-known that reduced blood flow stimulates angiogenesis and granulation tissue formation, which in turn facilitate the process of wound healing12, 45. However, several clinical problems are associated with hypoperfusion. In tissues with already impaired circulation, the further decrease in blood flow may result in ischemia, and it has been suggested that NPWT should be applied with caution to tissues with compromised vascularity19. Some advocate that NPWT is contraindicated if there is any doubt about the vascularity of the tissue46, 47. The way in which NPWT is administered should therefore be based on the type of wound and its vascularity. Two different strategies can be used to tailor NPWT to alter the degree of hypoperfusion generated in the wound edge: changing the negative pressure level, or the type of

wound filler. Pathogen binding mesh and gauze caused less pronounced hypoperfusion than foam, which may be the result of the smaller degree of wound contraction than with foam. The use of foam may be beneficial in maximizing hypoperfusion thus stimulating angiogenesis, while bacteria and fungus binding mesh or gauze may be preferable when the vascularization of the tissue is in doubt, and there is a risk of ischaemia.

27. Borgquist O, Gustafsson L, Ingemansson R, Malmsjo M. Tissue Ingrowth Into Foam but Not Into Gauze During Negative Pressure Wound Therapy. Wounds 2009; 21(11):302-9.

35. Yager DR, Nwomeh BC. The proteolytic environment of chronic wounds. Wound Repair Regen 1999; 7(6):433-41.

28. Nease C. Using low pressure, negative pressure wound therapy for wound preparation and the management of split-thickness skin grafts in three patients with complex wounds. Ostomy Wound Manage 2009; 55(6):32-42. 29. Hurd T, Chadwick P, Cote J, Cockwill J, Mole TR, Smith JM. Impact of gauze-based NPWT on the patient and nursing experience in the treatment of challenging wounds. Int Wound J 2010. 30. Campbell PE, Smith GS, Smith JM. Retrospective clinical evaluation of gauze-based negative pressure wound therapy. Int Wound J 2008; 5(2):280-6. 31. Borgquist O, Ingemansson R, Lindstedt S, Malmsjo M.In Process Citation]. Lakartidningen 2011; 108(46):2372-5. 32. Malmsjo M, Ingemansson R, Lindstedt S, Gustafsson L. Comparison of bacteria and fungus-binding mesh, foam and gauze as fillers in negative pressure wound therapy - pressure transduction, wound edge contraction, microvascular blood flow and fluid retention. Int Wound J 2012. 33. Torbrand C, Ingemansson R, Gustafsson L, Paulsson P, Malmsjo M. Pressure transduction to the thoracic cavity during topical negative pressure therapy of a sternotomy wound. Int Wound J 2008; 5(4):579-84. 34. Jeffery LC. Advanced wound therapies in the management of severe military lower limb trauma: a new perspective. Eplasty 2009; 9:e28.

Granulation tissue formation Granulation tissue is the combination of small vessels and connective tissue that forms in the wound bed. It provides a matrix that allows epidermal cells to migrate over the bed of the wound. NPWT is known to accelerate the formation of granulation tissue compared to conventional therapy13. The amount and character of the granulation tissue differ depending on the type of wound filler17, 27, 41, 48. The granulation tissue formed under foam is thick but fragile, while that under gauze is thinner but denser17, 27, 48. The granulation tissue formed under bacteria and fungus binding mesh has properties between that of foam and gauze41. The wound filler for NPWT may thus be chosen to suit particular wounds49. Thick granulation tissue is beneficial for fast wound healing, but may lead to problems such as fibrosis, scarring and contractures as the wound heals48. Foam is thus suitable for wounds that benefit from thick granulation tissue and where scarring does not pose a problem, for example, in sternotomy wounds50, or fasciotomy wounds in upper or lower limb compartment syndrome where contraction is beneficial51, and in acute wounds with large tissue loss providing a bridging therapy1, 2. Gauze has become especially popular among plastic surgeons for wound-bed preparation before grafting52, and is the filler of choice when the cosmetic result is more important than the speed of wound healing, or in cases where scar tissue may restrict movement, for example,

36. Armstrong DG, Jude EB. The role of matrix metalloproteinases in wound healing. J Am Podiatr Med Assoc 2002; 92(1):12-8. 37. Fleischmann W, Russ M, Westhauser A, Stampehl M.Vacuum sealing as carrier system for controlled local drug administration in wound infection]. Unfallchirurg 1998; 101(8):649-54. 38. Lehner B, Fleischmann W, Becker R, Jukema GN. First experiences with negative pressure wound therapy and instillation in the treatment of infected orthopaedic implants: a clinical observational study. Int Orthop 2011; 35(9):1415-20. 39. Timmers MS, Graafland N, Bernards AT, Nelissen RG, van Dissel JT, Jukema GN. Negative pressure wound treatment with polyvinyl alcohol foam and polyhexanide antiseptic solution instillation in posttraumatic osteomyelitis. Wound Repair Regen 2009; 17(2):278-86. 40. Etöz A ÖY, Özcan M. The use of negative pressure wound therapy on diabetic foot ulcers: a preliminary controlled trial. Wounds 2004(16):264-9. 41. Malmsjo M, Lindstedt S, Ingemansson R, Gustafsson L. Use of bacteria and fungus binding mesh in negative pressure wound therapy provides significant granulation tissue without tissue ingrowth. Eplasty In press. 42. Lavery LA, Barnes SA, Keith MS, Seaman JW, Jr., Armstrong DG. Prediction of healing for postoperative diabetic foot wounds based on early wound area progression. Diabetes Care 2008; 31(1):26-9.

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wound bed and the wound filler, when the clinician anticipates such complications56, 57. It is now known that the degree of ingrowth differs depending on the type of wound filler used for NPWT. Wound bed tissue grows into the foam, but not into pathogen binding mesh (Sorbact®) or gauze (Figure 4)41. This is probably due to differences in the physical properties of the dressings and the interaction between tissue and dressing at a microscopic level14. Figure 4: Representative hematoxylin-eosin stained sections of biopsies from wound beds after 72 hours of NPWT using bacteria and fungus binding mesh (Sorbact®), foam or gauze. The ingrowth of tissue into the foam is indicated by arrows. No such ingrowth can be seen in the pathogen binding mesh or gauze.

over joints. Bacteria and fungus binding mesh (Sorbact®) produces a granulation tissue with characteristics between those formed with foam and gauze, providing clinicians with another wound filler option in their efforts to obtain optimal healing effects. Ingrowth A number of complications are associated with tissue ingrowth into foam. Firstly, the patient may experience pain during dressing changes as the ingrown tissue is torn away from the wound53, requiring the administration of strong analgesics54, 55. Secondly, wound-bed disruption and mechanical tissue damage may arise as the foam is removed from the wound bed during dressing changes. Thirdly, pieces of foam may become stuck in the wound bed and, if not removed, will act as foreign bodies that may impede wound healing. It is therefore common that a non-adherent wound contact layer is placed between the 43. Kairinos N, Solomons M, Hudson DA. The paradox of negative pressure wound therapy--in vitro studies. J Plast Reconstr Aesthet Surg; 63(1):174-9. 44. Kairinos N, Solomons M, Hudson DA. Negative-pressure wound therapy I: the paradox of negative-pressure wound therapy. Plast Reconstr Surg 2009; 123(2):58998; discussion 599-600. 45. Petzina R, Gustafsson L, Mokhtari A, Ingemansson R, Malmsjo M. Effect of vacuum-assisted closure on blood flow in the peristernal thoracic wall after internal mammary artery harvesting. Eur J Cardiothorac Surg 2006; 30(1):85-9. 46. Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) Device: a review. Am J Clin Dermatol 2005; 6(3):185-94. 47. Attinger CE, Janis JE, Steinberg J, Schwartz J, Al-Attar A, Couch K. Clinical approach to wounds: debridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plast Reconstr Surg 2006; 117(7 Suppl):72S-109S. 48. Fraccalvieri M. Negative Pressure Wound Therapy (NPWT) using gauze and foam: histological, immuno-histochemical and ultrasonography morphological analysis of the granulation tissue and scar tissue. Preliminary report of a clinical study. Int Wound J May 2011; Aug(8(4)):355-64. 49. Malmsjö M, Borgquist O. NPWT settings and dressing choices made easy. Wounds International 2010; 1(3). 50. Gustafsson RI, Sjogren J, Ingemansson R. Deep sternal wound infection: a sternal-sparing technique with vacuum-assisted closure therapy. Ann Thorac Surg 2003; 76(6):2048-53; discussion 2053.

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Individual optimization of treatment Today, the negative pressure level, the wound filler material (foam or gauze) and the mode (continuous, intermittent, or variable) by which the pressure is applied can be tailored to the individual wound. Results of in vivo research carried out during the past few years on the mechanisms involved have shown how the healing process can be influenced by varying these parameters. Much of this research has been carried out on pigs, but interestingly, experienced clinicians have come to the same conclusions when it comes to treating patients. Knowledge of how to tailor the differ parameters of the NPWT to the individual wound is now beginning to be employed in patient care to minimize complications (such as ischemia and pain) and to optimize outcome. Conclusions Bacteria and fungus binding mesh (Sorbact®) is an interesting alternative wound filler in NPWT. It produces a significant amount of granulation tissue in the wound bed, more than with gauze, without the problems of ingrowth, as is the case with foam. Furthermore, bacteria and fungus binding mesh has the advantage of being easy to apply, like gauze, to irregular and deep pocket wounds. Efficient wound fluid removal in combination with its pathogen binding properties makes hydrophobic mesh an interesting alternative wound filler in NPWT. m 51. Zannis J, Angobaldo J, Marks M, DeFranzo A, David L, Molnar J, Argenta L. Comparison of fasciotomy wound closures using traditional dressing changes and the vacuum-assisted closure device. Ann Plast Surg 2009; 62(4):407-9. 52. Chariker ME, Gerstle TL, Morrison CS. An algorithmic approach to the use of gauze-based negative-pressure wound therapy as a bridge to closure in pediatric extremity trauma. Plast Reconstr Surg 2009; 123(5):1510-20. 53. Malmsjo M, Gustafsson L, Lindstedt S, Ingemansson R. Negative pressure wound therapy-associated tissue trauma and pain: a controlled in vivo study comparing foam and gauze dressing removal by immunohistochemistry for substance P and calcitonin gene-related peptide in the wound edge. Ostomy Wound Manage 2011; 57(12):30-5. 54. Franczyk M, Lohman RF, Agarwal JP, Rupani G, Drum M, Gottlieb LJ. The impact of topical lidocaine on pain level assessment during and after vacuum-assisted closure dressing changes: a double-blind, prospective, randomized study. Plast Reconstr Surg 2009; 124(3):854-61. 55. Krasner DL. Managing wound pain in patients with vacuum-assisted closure devices. Ostomy Wound Manage 2002; 48(5):38-43. 56. Blakely M, Weir D. The innovative use of Safetac soft silicone in conjunction with negative pressure wound therapy: three case studies. poster at SAWC 2007. 57. Dunbar A, Bowers DM, Holderness H, Jr. Silicone net dressing as an adjunct with negative pressure wound therapy. Ostomy Wound Manage 2005; 51(11A Suppl):21-2.

“Highly absorbent – easy to use.”

Vliwasorb® adhesive The self-adhesive superabsorber optimal treatment, especially of difficult-to-dress areas of the body better quality of life thanks to optimal exudate management

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Science, Practice and Education

Conservative Sharp Wound Debridement – State of play in Australia

ABSTRACT Background: As part of a Masters in Wound Care I undertook a survey of nurses examining where they obtained their skills in debridement and schools of nursing to determine whether they were conducting formal theoretical and/ or practical training in this subject. Method: A convenience sample was drawn from registered nurses in Australia. – Group 1 were those nurses considered advanced practice nurses, working towards Nurse Practitioner status or currently have the portfolio of Nurse Practitioner-Wound care – Group 2 were those nurses employed within a community nursing service currently employed under the title of CNS or CNC wound care A second questionnaire was sent to all Heads of School or Faculty of Nursing within Australia. Results: Community Nurse response rate - 70% (n=14). Nurse Practitioner response 100% (n=12). Heads of Schools of Nursing response rate - 66% (n=8). The nurse clinicians surveyed do debride wounds and see this skill as being necessary. The Schools of Nursing results indicated that while most universities teach the theory of wound debridement, few teach the skill. Conclusions: There is however a need to develop a specific module that can be taken as a stand alone subject for those wishing to learn and utilise debridement skills in their portfolios as NPs in wound care or CNC in wound management.

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INTRODUCTION The cleansing of wounds in order to remove non viable tissue and contaminants is considered an integral part of wound management1. Wound care continues to be a major part of community nurses work2. Some wound types are known to be associated with necrotic or senescent tissue - these wound types may include foot wounds in those suffering diabetes, pressure injuries and ulcers on lower legs. Advances in the sciences have seen the development of many new wound care products and devices designed to promote wound healing. Despite these advances Flanagan 3 believes there is a clinical practice knowledge deficit in optimising wound healing concepts. Debridement is a process, described by a number of authors, necessary to aid the healing process of chronic wounds3, 4, 5, 6. Whilst the majority of authors agree that debridement is a necessary intervention they often neglect to provide a clear indication of the personnel that should carry out the activity, the level of education required and the context specific interventions required when performing this task. The titles used to describe the clinician who should attend wound debridement include- skilled clinician, advanced practice nurse (APN), clinical nurse specialist (CNS), clinical nurse consultant (CNC) or Nurse Practitioner (NP)7, 8, 9, 10.

Jan C. Rice MWoundCare (Monash), RN, FAWMA World of Wounds, Nursing & Midwifery Department Faculty of Health Sciences La Trobe University Prahran, Victoria Australia Correspondence: j.rice@latrobe.edu.au Conflict of interest: None

AIMS & OBJECTIVES The purpose of this research was twofold: 1. to identify if within Australia, Universities were training nurses in the theory and skill practice of conservative sharp wound debridement in either the undergraduate and /or postgraduate curriculum 2. to survey nurses who would be considered at the level required to perform conservative sharp wound debridement within their daily practice in order to  ascertain their current practices

LITERATURE REVIEW A literature search was performed using the key words: skilled clinician, nurse specialist, tissue viability nurse, advanced nurse and Nurse Practitioner with wound debridement, wound cleansing, wound bed preparation and wound infection.

Relevance of debridement to wound healing Although the field of wound management as a speciality is relatively young, there is considerable literature about wound debridement as a necessary intervention in order to expedite wound healing11, 12, 13,. Kirshen, Woo, Ayello, and Sibbald14 state the basis of good wound care is founded upon maintaining the wound free of necrotic tissue. Sibbald et al10 have provided 13 recommendations for practice in preparing the wound bed. The recommendations included the need to debride healable wounds, remove necrotic and non viable tissue, as well as to assess the wound for bacterial balance and infection. Bergstrom, Bennett and Carlson15 define Conservative Sharp Wound Debridement (CSWD) as the removal of necrotic tissue from a wound using sharp instruments. Carville16 states that CSWD is a term used by nurses to describe the removal of small pieces of necrotic tissue using sterile, sharp instruments during the dressing procedure so that over time, the wound bed becomes free of this potential source of bioburden. Titles and scope of practice Flanagan17 highlighted that new posts were emerging in the wound care field but there was discourse about roles and responsibilities. Understanding the title and role is important when assigning extra responsibilities, such as sharp wound debridement. A CNS is an advanced practice nurse, with graduate preparation from a program that prepares CNSs; this may be formal or informal within a hospital setting18. An NP is a registered nurse who has completed specific advanced nursing education (generally a master’s degree) and training in the diagnosis and management of common as well as complex medical conditions. The NP is expected to work autonomously and collaboratively in the extended clinical role19. Who should debride? The literature concerning just who should perform wound debridement is not clear. Ayello13 refers to the clinician debriding wounds but makes no mention of the designation. Sibbald 20 states that “before clinicians embark on debridement of chronic wounds they must ensure that they have the necessary skills to perform the task, the skill is within their scope of practice and there is agency or institutional policy in place to support them”. 34

Dowsett21 refers to nurses having the skills to move the wound bed along a continuum to healing using a variety of methods including debridement. Preece 22 continues the theme stating that this procedure can result in complications and should only be performed by nurses who have appropriate training and have had their competencies assessed. Gottrup23 states that doctors, nurses and podiatrists can perform sharp debridement however each must practice within the rules and regulations of their countries. Mulder24 believes that “sharp debridement should only be done by an experienced professional whose licensure and credentials permit him or her to perform this type of debridement”. Leaper25 highlights that using scalpels and or scissors, to debride a wound, is a very selective process with rapid results and only skilled practitioners should undertake the procedure however again there is no explanation of what constitutes this skill set—what training and knowledge is required to be called a skilled practitioner. Shannon26 was able to demonstrate nurses’ ability to both perform sharp wound debridement, and achieve a reduction in the number of clinical visits, when using this technique to clean a wound. Assessing tissue is a skill in itself and Inlow27 supports the notion that debridement requires knowledge and skills by highlighting that not all necrotic tissue should be debrided. This is a very important point when considering the signing off of sharp wound debridement competency. It is not just the skill of cutting off non viable tissue but knowing just what to cut and what to leave. Rusche, Besuner, Partsch and Berning28 state that competency is a process whereby nurses apply their knowledge as they demonstrate the skills and abilities necessary to care for patients. Debridement competencies clearly define the skills and knowledge required to safely care for patients with wounds in order to assist the healing process. Protocols, guidelines, documents Guyatt and Rennie29 state that best evidence is the randomised controlled trial (RCT). No RCT was found in this literature search, however, in an attempt to meet the gap between scientifically supported approaches to care and day-to-day practice, leading experts in the wound care have developed ‘Best Practice Guidelines” or ‘Consensus Documents”30, 20. In Australia Templeton31 has produced an article “Promoting Evidence-Based Nursing Practice – Wound Bed Preparation” for the South Australian District Nurses’ newsletter. In December 2008 as part of an initiative within Victoria, clinicians within rural Victoria have written a statement on performing conservative sharp wound debridement 32. The Wound Care Association of NSW Incor-

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Figure 1. Year of graduation

porated has published a number of standards of practice in which Standard Five deals with wound debridement 33. METHOD Data collection Ethics approval was granted by all participating groups. Survey Methodology A convenience sample was drawn from registered nurses in Australia. The nurses were divided into two groups and sent a questionnaire of 19 questions: Group 1 – nurses considered advanced practice nurses, working towards Nurse Practitioner status or currently have the portfolio of NP-Wound care. Australia has only very recently accepted the protected title of NP so when undertaking this study the numbers were quite small. Group 2 – nurses employed within a community nursing service currently employed under the title of CNS or CNC wound care. Within the healthcare systems- public or private - the title of CNS or CNC wound care has also only recently been adopted. Wound management is still striving to be recognised as a specific speciality requiring dedicated personnel. The community nursing service surveyed employs over 1000 nurses, however there were only 20 CNS or CNCs within this group. A second questionnaire of five questions was sent to all Schools or Faculties of Nursing within Australia. To maintain privacy and ensure no coercion of those completing the survey, the surveys were sent or delivered in sealed envelopes to the two participating agencies and directly to the Heads of Nursing for distribution to those invited to participate. The sealed envelopes contained an explanatory note, the questionnaire and a return self addressed stamped envelope.

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Figure 2. Frequency of debridement

RESULTS Results of Advance Practice Nurses Survey Response rate CNS/CNC-70% (n=14). Response rate NP - 100% (n=12). Sample demographics Q. 1: What year did you complete your training? As expected the NP cohort had graduated some time ago with the most recent graduate being in the year 2000 and the earliest graduating in 1976. The year of graduation amongst the NP group was evenly distributed (see Figure 1). The community nursing cohort had a higher frequency of recent graduates than the NP group, and the distribution identified two distinct groupings (see Figure1). Q.2: What sector do you work in? The options were acute care, aged care, community, rehabilitation or across a number of sectors. As anticipated the majority of respondents were working in community settings. The majority of wound care in Australia occurs in community settings. Q.3: What wound management training have you had? Answer options included formal structured courses through Universities, seminars, training through Technical and Further Education (TAFE) colleges or in-services. Both groups sought knowledge from a variety of sources. The NP group being mentored by a surgeon had the ability also to be trained in conservative sharp wound debridement by him and this was clearly the case in the survey responses. Community nurses sought their knowledge in this procedure from seminars, state conferences, and peer respected clinicians who conduct education into wound  management within their own state.

Debridement practices Q.4: Do you debride wounds using CSWD principles? The majority of respondents (88.5%, n=23) indicated that they practice the skill of conservative sharp wound debridement. This practice was equally represented within the two groups (see Figure 2).

NP Count 1 1 8 1

1 instrument 2 instruments 3 instruments 4 instruments

CN % 9.1 9.0 72.8 9.1

Count 4 8

% 33.3 66.6

Table 1. Number of instruments used by each group

Q.5: What sharp instruments do you use? Debridement can be performed using a variety of instruments and it was particularly interesting to note that the majority of NPs use at least three instruments to debride (72.7% n=8) whereas the community nurses tended to use one or two instruments only (see Table 1). The NPs used scalpels, scissor and curettes. The community nurses used scalpel and scissors only. Q.6: On a weekly basis what percentage of wounds in your care would require CSWD? Whilst equal numbers (n=4) in each group indicated that they were required to debride at least 50% of the wounds they consulted upon (see Table 2), a higher percentage of wounds managed by the NP group require debridement as compared to the community nurses (see Table 3). Q.7: On a scale of 1-10 (10 being very skilled) where do you rate your current skill level? The NP group rated themselves highly as one would expect given that they are required to perform this skill frequently within their normal daily workloads (see Table 4). The community nurses on the other hand also rated themselves relatively high despite a lack of requirement to perform debridement regularly. Q.8: If you do not debride, why not? The options for responses were lack of confidence, lack of training, organisation does not permit nurses to attend this, do not have patients requiring debridement. Whilst both groups performed CSWD some respondents did suggest that they may perform this procedure more frequently if they had more training. Training of conservative sharp wound debridement Q.9: What level of nurse should have this skill? When respondents were asked who should be trained there was a clear preference for it to be restricted to the Division One Registered Nurse with greater than four years’ experience (see Table 5). Both groups also had one respondent confirming that a Division Two Registered Nurse with greater than five years’ experience could be trained to perform this procedure (refer to Table 4). The question stimulated respondents to add more in the comments section, with the NPs stating that anyone with appropriate training could perform conservative

All nurse clinicians Frequency Percent Valid

Missing Total

< 10% 20% 30% 40% 50% >50% Total 0

4 9 1 2 4 2 22 4 26

15 35 4 8 15 8 85 15 100

Valid Percent 18 41 5 9 18 9 100

Cumulative Percent 18 59 64 73 91 100

Table 2. Percentage frequency of skill requirement each week by all clinicians

NP < 10% 20% 30% 40% 50% >50%

CNC

Count 1 5

% 9.1 45.5

1 3 1

9.1 27.3 9.1

Count 3 4 1 1 1 1

% 27.3 36.4 9.1 9.1 9.1 9.1

Table 3. Comparison of frequency of skill requirement between two nursing groups

NP Scale rate 5 6 7 8 9 10

Count 1

% 9.1

1 2 5 2

9.1 18.2 45.5 18.2

Count 2 3 2 2 3

% 16.7 25.0 16.7 16.7 25.0

Table 4. Self skill rating

NP Div 1 Div 1 with > 4 years Div 2 > 5 years

Count 2 6 1

CN % 22.2 66.7 11.1

Count 3 10 1

% 21.43 71.4 7.1

Table 5. Who should perform conservative sharp wound debridement

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sharp wound debridement as they felt years of experience does not always equate to skill. Q.10: How often do you think the skill is required for nurses working in community settings? The groups were similar in their comments about debridement skills being required for community nurses. Of the NPs who responded 41% (n=5) felt that this skill is required by community nurses and this was verified by the community nurses as 57% (n=8) stated that it is a skill required all of the time. Q. 11: Where did you learn CSWD skill? Both groups sought knowledge from a variety of sources (see Figure3). The NP group were trained in conservative sharp wound debridement by their mentor who was a surgeon. Community nurses sought their knowledge in this procedure from seminars, state conferences, and peer respected clinicians. Q.12: Are you aware of any undergraduate/postgraduate nursing programs that include conservative sharp wound debridement (theory and skills practice) as part of the curriculum? None of the respondents were aware of any formal training programs available as either undergraduate or postgraduate level. Q.13: Who do you think should teach this skill? There was an equal distribution of thoughts on just who should teach this skill. Participants agreed that a surgeon would be the most appropriate (65.3% n=17) although NPs and RN Division One with experience were also identified as suitable (76.9% n=20). Q14: Is there a need for a nationally accredited training program? There was a one hundred percent consensus (n=26) that there is a need for a nationally recognised training program to instruct future nurses in CSWD. Q.15: If you answered yes to question 14, how urgent is this need? Community nurses demonstrated an urgency for this training, with over 75% (n=9) of them requesting that this be developed within six months. Q.16: Should this training program be included in the current general nurse training curriculum? This question saw a mixed response. The NPs were quite clear that the skill was more a post graduate skill with 83% (n=10) answering no to the question. The community nurses were split on this question with 42%(n=6) wanting it included in the general training, 50%(n=7) stating that is should not be included and one was undecided. EWMA Journal

2012 vol 12 no 3

Figure 3. Type of training in debridement received by each group

Q.17 Should this training be offered only as a postgraduate program within tertiary institutions? There was no significant difference between the groups. The NPs generally felt those who required this skill would seek out the training as a stand alone module. There was a general agreement that some form of accreditation would be of benefit. Q.18 What topics should be included in a CSWD training program, you may select any number of topics or all. The answers included – anatomy, pain management, local anaesthetics, tissue identification, handling sharp instruments, and other methods of achieving wound debridement. The responses here were as anticipated 100% stated all topics should be included – there were also some suggestions of legality and professional indemnity insurance as other topics to be included in a training program. Results of Heads of School of Nursing survey Twelve surveys were sent to the Heads of Schools of Nursing at Universities listed on the web within Australia. Eight surveys were returned. The response rate of 66% is considered excellent although it must be remembered that the numbers of questionnaires sent out was small and so it would not be difficult to obtain a good rating. The findings that some universities do teach the theory of wound debridement in both undergraduate and post graduate training was of note, however of the three universities responding affirmatively to teaching the theory, only one teaches the skills of this practice. The respondents state that large classroom numbers allows for the theory to be taught but understanding the importance of clinical judgement in effective decision making establishing  competence in large groups is almost impossible. 37

Science, Practice and Education

Heads of Schools of Nursing were asked whether they saw a need for a nationally recognised training program in conservative sharp wound debridement. There was a compelling positive response to this question with only one answering in the negative. Two of the respondents did state that the training should be focused at postgraduate level. One respondent felt that this skill is absolutely necessary for remote area nurses. Another positive respondent wanted there to be one-on-one expert guidance at the clinical level in undergraduate training to ensure safety. There was an overall impression that the skill of conservative sharp wound debridement should only be undertaken by advance practice nurses who have considerable clinical experience. SUMMARY Wound debridement is a skill required by advance practice nurses engaged in community wound care. There is currently no formally recognised nationally endorsed training program in Australia to equip the newer graduate nurses advancing their practice. There are several workshops conducted by key clinicians around Australia but even those who have attended this type of training are requesting a more recognised type of training. The current curriculum within the general nurse training package does not

REFERENCES 1. Falanga, V. Science of wound management. Handbook Wound Bed Preparation (6356woundbedprep/cmcbklt/global/0601):2004. 2. Strachan. V., Prentice, J., Newall, N., Elmes, R., Carville, K., Santamaria, N., & Della, P. WoundsWest wound prevalence survey 2007 state-wide report overview. Ambulatory Care Services. Department of Health: Perth, Western Australia; 2007. 3. Flanagan, M. The philosophy of Wound Bed Preparation in clinical practice. Smith& Nephew Medical Ltd. 2003:1-34. 4. Edmonds, M., Foster, A.V.M., & Vowden, P. Wound bed preparation for diabetic foot ulcers. European Wound Management Association Position Document: Wound bed Preparation in Practice. London: MEP Ltd. 2004; 6-11. 5. Enoch, S., & Price, P. Cellular, molecular and biochemical differences in the pathophysiology of healing between acute wounds, chronic wounds and wounds in the aged. WorldWideWounds . 2004. http://www.worldwidewounds.com (10 October 2005) 6. Harvey, C. Wound healing. Orthopaedic Nursing. 2005; 24 (20): 143-175. 7. Poston, J. Sharp debridement of devitalized tissue: the nurse’s role. British Journal of Nursing. 1996; 5 (11): 655-662. 8. Flanagan, M. A profile of the specialist in tissue viability in the UK. Journal of Wound Care. 1997; 6(2): 85-87. 9. Hutton, D.J. The Clinical Nurse Specialist in tissue viability services. Journal of Wound Care. 1997; 6(2): 88-90. 10. Sibbald, G., Williamson, D., Orstead, H., Campbell, K., Keast, D., Krasner, D., et al. Preparing the wound bed-Debridement, bacterial balance, and moisture balance. Ostomy Wound Management. 2000; 46(11): 14-35. 11. Williams, D., Enoch, S., Miller, D., Harris, K., Price, P., & Harding, K.G. Effect of sharp debridement using curette on recalcitrant non-healing venous

include such training and neither is there scope or reason to include it. There is however need to develop a specific module that can be taken as a stand alone subject for those wishing to learn and utilise the skill in their portfolios as NPs in wound care or CNC in wound management. The generability and reliability of this project can be questioned due to low numbers. However the author travels throughout Australia lecturing and can confidently say that debridement by nurses is lacking. The Australian Wound Management National Conference (March 2012) held a workshop meeting to discuss this problem and the consensus of over 150 attendees was that more needs to be done in the area of training and skills acquisition. Of note, also, is that since this project was commenced the number of NPs specialising in wound care has more than doubled. m

Implications for clinical practice A specific training module in CSWD is required for nurses working in community settings. Further research What is required within the CSWD module should be based on a consensus needs and competencies developed to assess the skills of the clinicians practising CSWD.

ulcers: a concurrently controlled, prospective cohort study. Wound Repair and Regeneration. 2005; 13(2): 131-137.

23. Gottrup, F. Wound Debridement (Ed.). The Oxford European Wound Healing Course Handbook. Postif Press: Oxford; 2002.

12. Baharestani, M., Gottrup, F., Holstein, P., & Vanscheidt, W. (Eds.). The Clinical relevance of debridement. Germany: Springer-Verlag; 1999.

24. Mulder, G. Evaluating and managing the diabetic foot: An overview. Advances in Skin & Wound Care. 2000; 13(1): 33-36.

13. Ayello, E., & Cuddigan, J. Debridement: Controlling necrotic/cellular burden. Advances in Skin &Wound Care. 2004; 17 (2): 66-75.

25. Leaper, D. Sharp technique for wound debridement. 2002. www.worldwidewounds.com/2002/december/ leaper/Sharp-debridement.html (30 July 2006).

14. Kirshen, C., Woo, K. Ayello, E., & Sibbald, G. Debridement: A vital component of wound bed preparation. Advances in Skin& Wound Care. 2006; 19 (9): 506-517.

26. Shannon, R., Harris, C., Harley, C., Kozell, K., Woo, K., Alavi, A., et al. The importance of sharp debridement in foot ulcer care in the community: A cost -benefit evaluation. Wound Care Canada. (2007; 5 (1) Supp: 51-52.

15. Bergstrom, N., Bennett, M.A., Carlson, C.E., et al. Treatment of Pressure Ulcers. Clinical Practice Guideline Number 15. AHCPR Publication No. 95-0652. Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Rockville, MD. 1994. 16. Carville, K. Wound care manual (5th ed). Osborne Park, Western Australia: Silver Chain Foundation; 2005. 17. Flanagan, M. Education and the development of specialist practice. Journal of Wound Care.1998; 7(6): 304-305. 18. Sparacino, P. S. A. The clinical nurse specialist. In A. B. Hamric, J. A. Spross & C. M. Hanson (Eds.), Advanced practice nursing: An integrative approach. 3rd ed. St. Louis: Elsevier; 2005. P. 415-446. 19. Australian Nursing & Midwifery Council National Competency Standards for the Nurse Practitioner. Dickson, ACT.Australia; 2006. 20. Sibbald, G., Orstead, H., Coutts, P. & Keast, D. Best practice recommendations for preparing the wound bed : Update 2006. Advances in Skin and Wound Care. 2007; 20 (7): 390-405. 21. Dowsett, C. The role of the nurse in wound bed preparation. Nursing Standard. 2002; 16 (44): 69-76. 22. Preece, J. Wound Care. Sharp debridement: the need for training and education. Nursing Times. 2003; 99 (25): 54-55.

27. Inlow, S., Orstead, H., & Sibbalid, G. Best practices for the prevention, diagnosis, and treatment of diabetic foot ulcers. Ostomy Wound Management. 2000; 46 (11): 55-68. 28. Rusche, J.D., Beusner, P., Partusch, S.K., & berring, P.A. Competency program development across merged healthcare network. Journal for Nurses in Staff Development. 2001; 17(5): 234-242. 29. Guyatt, G., & Rennie, D. (Eds.). Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, IL: American Medical Association; 2002. 30. Carney, D., & Bristline, B. Validating nursing competencies using a fair format. Journal for Nurses in Staff Development. 2008; 24 (3): 124-128. 31. Templeton, S. (2004). Wound bed preparation. The pursuit of excellence newsletter. No 30. RDNS South Australia. Retrieved from www.rdns.org. au/research_unit/POE.shtml, (20 April2008). 32. Taylor, P. Wound Management Conservative Sharp Debridement. Benalla District Memorial Hospital procedure manual. 2008. Email correspondence received 18/12/08. 33. Wound Care Association of NSW. Standard 5-Wound debridement. Retrieved from www.ciap.health.nsw. gov.au/wcansw (23 July 2008).

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The chemistryâ&#x20AC;&#x2122;s right! Thanks to all the and symposium visitors MA 2012! participants at EW

When it comes to NPWT, the foam makes all the difference. The question of whether all NPWT products promote wound healing in the same way led to animated discussions during the HARTMANN symposium at the EWMA. The basis of the discussion was a comparative study 1,2 by HARTMANN, which showed that not all foams are created equal. Significant differences in inflammatory reactions indicate that different foams can accelerate wound healing at varying rates. This is important information that will help us to make NPWT even more economic. Vivano. Safety. And Simplicity.

More information is available at vivanosystem.info Source: 1 Croizat et al., Journal of Investigative Dermatology (2011) 131: S134. 2 Walch et al., Wound Repair and Regeneration (2011) 19: A91.

ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 6, 2012

Scalpel versus electrosurgery for abdominal incisions Kittipat Charoenkwan, Narain Chotirosniramit, Kittipan Rerkasem

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

Citation example: Charoenkwan K, Chotirosniramit N, Rerkasem K. Scalpel versus electrosurgery for abdominal incisions. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005987. DOI: 10.1002/14651858.CD005987 Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background: Scalpels or electrosurgery can be used to make abdominal incisions. The potential benefits of electrosurgery include reduced blood loss, dry and rapid separation of tissue, and reduced risk of cutting injury to surgeons, though there are concerns about poor wound healing, excessive scarring, and adhesion formation. Objectives: To compare the effects on wound complications of scalpel and electrosurgery for making abdominal incisions. Search methods: We searched the Cochrane Wounds Group Specialised Register (searched 24 February 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2); Ovid MEDLINE (1950 to February Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 23 February 2012); Ovid EMBASE (1980 to 2012 Week 07); and EBSCO CINAHL (1982 to 17 February 2012). We did not apply date or language restrictions. Selection criteria: Randomised controlled trials (RCTs) comparing the effects on wound complications of electrosurgery with scalpel use for the creation of abdominal incisions. The study participants were patients undergoing major open abdominal surgery, regardless of the orientation of the incision (vertical, oblique, or transverse) and surgical setting (elective or emergency). Electrosurgical incisions included those in which the major layers of abdominal wall, including subcutaneous tissue and musculoaponeurosis (a strong sheet of fibrous connective tissue that serves as a tendon to

attach muscles), were made by electrosurgery, regardless of the techniques used to incise the abdominal skin and peritoneum. Scalpel incisions included those in which all major layers of abdominal wall including skin, subcutaneous tissue, and musculoaponeurosis, were incised by a scalpel, regardless of the techniques used on the abdominal peritoneum. Data collection and analysis: We independently assessed studies for inclusion and risk of bias. One review author extracted data which were checked by a second review author. We calculated risk ratio (RR) and 95% confidence intervals (CI) for dichotomous data, and difference in means (MD) and 95% CI for continuous data. We examined heterogeneity between studies. Main results: We included nine RCTs (1901 participants) which were mainly at unclear risk of bias due to poor reporting. There was no statistically significant difference in overall wound complication rates (RR 0.90, 95% CI 0.68 to 1.18), nor in rates of wound dehiscence (RR 1.04, 95% CI 0.36 to 2.98), however both these comparisons are underpowered and a treatment effect cannot be excluded. There is insufficient reliable evidence regarding the effects of electrosurgery compared with scalpel incisions on blood loss, pain, and incision time. Authors’ conclusions: Current evidence suggests that making an abdominal incision with electrosurgery may be as safe as using a scalpel. However, these conclusions are based on relatively few events and more research is needed. The relative effects of scalpels and electrosurgery are unclear for the outcomes of blood loss, pain, and incision time. Plain language summary: Using a scalpel compared with electrosurgery for making surgical incisions in the abdomen During abdominal operations, surgeons may need to make cuts (incisions) in the body. This can either be done by using scalpels or electrosurgery. A scalpel is an extremely sharp bladed instrument used to cut the skin and underlying tissue. Electrosurgery is a method of separating tissues using electricity. An electrical current is passed from the tip of the instrument which causes the tissue to rapidly heat up. As they heat up, the cells burst and vaporise. The surgeon will move the instrument along the tissue, causing more cells to be destroyed and a cut, or incision, to be created. The  EWMA Journal

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potential benefits of using electrosurgery include reducing the amount of blood lost, dry and rapid separation of tissues, and a reduced risk of surgeons accidentally cutting themselves. The disadvantages of this technique include the possibility of poor wound healing, there are concerns that large or excessive scars may form, and it is thought that there is the potential for an increase in the risk of adhesions forming. Adhesions are potentially painful links of tissue that develop between the site of the incision and organs or other surfaces in the abdomen. This review found that making an abdominal incision using electrosurgery appeared to be as safe as using a scalpel although more research is needed to draw a firm conclusion. There was not enough evidence to draw conclusions on a decrease in blood loss, pain, or the time taken to make the cut.

Publication in The Cochrane Library Issue 8, 2012

Compression for preventing recurrence of venous ulcers E Andrea Nelson, Sally EM Bell-Syer Citation example: Nelson EA, Bell-Syer SEM. Compression for preventing recurrence of venous ulcers. Cochrane Database of Systematic Reviews 2000 , Issue 4 . Art. No.: CD002303. DOI: 10.1002/14651858.CD002303 . Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background: Up to 1% of adults will have a leg ulcer at some time. The majority of leg ulcers are venous in origin and are caused by high pressure in the veins due to blockage or weakness of the valves in the veins of the leg. Prevention and treatment of venous ulcers is aimed at reducing the pressure either by removing/repairing the veins, or by applying compression bandages/stockings to reduce the pressure in the veins. The majority of venous ulcers heal with compression bandages, however ulcers frequently recur. Clinical guidelines therefore recommend that people continue to wear compression, usually in the form of hosiery (tights, stockings, socks) after their ulcer heals, to prevent recurrence. Objectives: To assess the effects of compression (socks, stockings, tights, bandages) in preventing the recurrence of venous ulcers. If compression does prevent ulceration compared with no compression, then to identify whether there is evidence to recommend particular levels of compression (high, medium or low, for example), types of compression, or brands of compression to prevent ulcer recurrence after healing. Search methods: For this update we searched The Cochrane Wounds Group Specialised Register (searched 1 March 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2); Ovid MEDLINE (1950 to February Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, February 29, 2012); Ovid EMBASE (1980 to 2012 Week 08); and EBSCO CINAHL (1982 to 1 March 2012).

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Selection criteria: Randomised controlled trials evaluating compression bandages or hosiery for preventing the recurrence of venous ulcers. Data collection and analysis: Two review authors undertook data extraction and risk of bias assessment independently. Main results: Four trials (979 participants) were eligible for inclusion in this review. One trial in patients with recently healed venous ulcers (n = 153) compared recurrence rates with and without compression and found that compression significantly reduced ulcer recurrence at six months (Risk ratio (RR) 0.46, 95% CI 0.27 to 0.76). Two trials compared high-compression hosiery (equivalent to UK class 3) with moderate-compression hosiery (equivalent to UK class 2). The first study (n=300) found no significant reduction in recurrence at five years follow up with high-compression hosiery compared with moderate-compression (RR 0.82, 95% CI 0.61 to 1.12). The second study (n = 338) assessed ulcer recurrence at three years follow up and found that high-compression hosiery reduced recurrence compared with moderate-compression (RR 0.57, 95% CI 0.39 to 0.81). Statistically significant heterogeneity precluded meta-analysis of the results from these studies. Patient-reported compliance rates were reported in both trials;,there was significantly higher compliance with mediumcompression than with high-compression hosiery in one and no significant difference in the second. A fourth trial (166 patients) found no statistically significant difference in recurrence between two types of medium (UK class 2) compression hosiery (Medi versus Scholl: RR 0.74, 95% CI 0.45 to 1.2). No trials of compression bandages for preventing ulcer recurrence were identified. Authors’ conclusions: There is evidence from one trial that compression hosiery reduces rates of reulceration of venous ulcers compared with no compression. Results from one trial suggest that recurrence is lower in high-compression hosiery than in medium-compression hosiery at three years whilst another trial found no difference at 5 years. Rates of patient intolerance of compression hosiery were high. There is insufficient evidence to aid selection of different types, brands, or lengths of compression hosiery. Plain language summary: Compression hosiery (stockings) for preventing venous leg ulcers returning Venous leg ulcers (open wounds on the lower leg) can be caused by a blockage or breakdown in the veins of the legs. Compression, using bandages or hosiery (stockings), can help heal most of these ulcers and is also widely used after healing to prevent ulcers returning. One small trial confirms that compression reduces ulcer recurrence compared with no compression. There is some evidence that people wearing high rather than moderate-compression hosiery are less likely to get a new ulcer. It is not clear whether moderate strength hosiery is better tolerated than high compression. There is, therefore, some evidence that compression hosiery might prevent ulcers, but the evidence is not strong. m

EWMA Journal

Previous Issues

Volume 12, no 2, May 2012 A structured approach to s urgical treatment in deep infection in diabetic foot Cedomir S Vucetic, et.al. Endothelial progenitor cells, a unipotent stem cell, involved in neovascularization of wound healing in diabetic foot ulcer Jacqueline Chor Wing Tama, et.al. Bacteriophages for the treatment of severe infections: – a ‘new’ option for the future? Daniel De Vos, et.al. Developing evidence-based ways of working: – Employing interdisciplinary team w orking to improve patient outcomes in diabetic foot ulceration – our experience Kristien Van Acker Exploring the characteristics of a v enous leg ulcer that contribute to the emotional distress experienced by patients Jessica Walburn, et.al. Development of a wound healing index for chronic wounds Juan Carlos Restrepo-Medrano, et.al.

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

Evaluation of the Antiseptic Efficacy and Local Tolerability of a Polihexanide-Based Antiseptic on Resident Skin Flora Dianne Egli-Gany, Florian H.H. Brill, Matthias Hintzpeter, Simone Andrée, Viktoria Pavel Prospective Cohort Study on Surgical Wounds Comparing a Polyhexanide-Containing Biocellulose Dressing with a Dialkyl-CarbamoylChloride-Containing Hydrophobic Dressing Anna Marie Nielsen, Anneke Andriessen A Retrospective Study Evaluating Silver-Impregnated Dressings on Cesarean Wound Healing Sheila A. Connery, Katheryne L. Downes, Caroline Young Sickle Cell Disease and Leg Ulcers Barry Ladizinski, Andrea Bazakas, Nisha Mistry, Afsaneh Alavi, R. Gary Sibbald Richard Salcido

Volume 12, no 1, January 2012 How to rate the wound d ebridement trauma? Jan Stryja Ensuring equitable wound management education within the Australian context Jan Rice Low wound prevalence and cost burden: The impact of a multidisciplinary wound specialist team Alison Hopkins, Fran Worboys, John Posnett The results of a comprehensive wound audit in a UK primary care trust Alison Hopkins, Fran Worboys Pressure ulcer programme of research – PURPOSE Nixon J, Wilson L.M, Coleman S, Gorecki C, Muir D, Pinkney L, Keen J, Briggs M, McGinnis E, Stubbs N, Dealey C, Nelson A The skin’s own bacteria may a ggravate inflammatory and occlusive changes in atherosclerotic arteries of lower limbs Waldemar L. Olszewski, Piotr Andziak, M. Moscicka-Wesolowska, Bozenna Interewicz, Ewa Swoboda, Ewa Stelmach Problem with the post burn wound pain: Chronic profiles Laima Juozapaviciene, Rytis Rimdeika, Aurika Karbonskiene Volume 11, no 3, October 2011 Challenges facing district nurses in the prevention of pressure ulcers Lynne Watret Clinical application of stem cells in wound h ealing: A near future? Benoit I Hendrickx Understanding the Patient Experience: Does empowerment link to clinical practice? Patricia Price The Influence of Egyptian Propolis on Induced Burn Wound Healing in Diabetic Rats – Antibacterial Mechanism Emad T. Ahmed, Osama M. Abo-Salem, Ali Osman PURSUN UK: The Pressure Ulcer Research Service User Network for the UK Delia Muir Perspective of the European Patients’ Forum Developing Collaboration Nicola Bedlington 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

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

Advances in Skin & Wound Care, vol. 25, no 9, 2012 www.aswcjournal.com

Finnish

Haava, no. 2, 2012 www.shhy.fi Biofilm – parsites in chronic wound, Part 1 Mikko Tuuliranta Atypical Wound Infections Leena Berg Prevention of Wound Infections Tarja Kaija The Principles of Wound Treatment Arja Korhonen The Difficulty of the Choice in the Jungle of the Local Treatment Products in the Wound Care Mervi Niskanen, Marjo Palkamo Cavities and Fistulas – Local Treatment Merja Lausmaa The Measurement of Ankle –Brachial Index Saara Penttinen, Tiina Pukki

Spanish

Helcos, vol. 23, no. 2, 2012 Classification of diabetic foot lesions, an unsolved problem González de la Torre H., Mosquera Fernández A., Quintana Lorenzo M. L., Perdomo Pérez E., Quintana Montesdeoca M. del P. Ankle-arm index as a predictor of vascular mortality Arévalo Manso J. J., Juárez Martín B., Gala Chacón E., Rodríguez Martínez C.

English

International Wound Journal, vol. 9, no 4, 2012 www.wiley.com National approaches to wound treatment and prevention D Queen, K Harding MicroRNA signature in diabetic wound healing: Promotive role of miR-21 in fibroblast migration R Madhyastha, et al. Oxidant and antioxidant events during epidermal growth factor therapy to cutaneous wound healing in rats Z Kalay, SC Cevher An update review on risk factors and scales for prediction of deep sternal wound infections A Buja, et al. Multidrug-resistant organisms, wounds and topical antimicrobial protection PG Bowler, et al. Role of silicone derivative plus onion extract gel in presternal hypertrophic scar protection: A prospective randomized, double blinded, controlled trial K Jenwitheesuk, et al. Prevalence of immune disease in patients with wounds presenting to a tertiary wound healing centre VK Shanmugam, et al. A randomised comparative trial on the use of a hydrogel with tepescohuite extract in the treatment of venous leg ulcers L Lammoglia-Ordiales, et al. EWMA Journal

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Int. Journal of Lower Extremity Wounds vol. 11, no 3, 2012 http://ijlew.sagepub.com Leg Ulcer as a Complication of a Posttraumatic Tibial Arteriovenous Fistula Treated by Endovascular Approach With Stent-Graft Placement Martín Rabellino, et al. A Successful Rescue of Systematic Inflammatory Response Syndrome Resulting From Severe Wound Infection Ming Tian, et al. Combination of Negative Pressure Wound Therapy and Hyalomatrix Application for Soft Tissue Defect of the Great Toe Yusuf Kenan Coban Three-Dimensional Reconstruction of Computed Tomography Scan Images for Estimating Skull Damage in Electrical Burned Patients Jian Chen, et al.

English

Dutch

Interview: President MAX broadcasting Jan Slagter: ‘We aim to improve the position of the elderly’ Interview: Ass. Professor Bastian Krom,ACTA Amsterdam: ‘Biofilm from the source’ Interview: Dr. Tom Schneider, IvHG Hyperbaric Medicine insufficiently know with practitioners Professor Christine Moffatt presents Best Practice Document on Compression Therapy at ILF Montpellier 2012 Comment on investigation Radboud University Nijmegen Holland: Predictable report on Dutch woundcare does woundcare no good. German

Journal of Wound Care, vol. 21, no 8, 2012 www.journalofwoundcare.com Taking the trauma out of wound care: the importance of undisturbed healing M. Rippon, P. Davies, R. White Fifteen pressure ulcers presenting in a known paediatric case of histiocytoma of the spine A. Lunawat, et al. An overview of biofilm and its detection in clinical samples M.R. Alavi, A. Stojadinovic, M.J. Izadjoo Well-wound therapy: Use of NPWT to prevent laparotomy breakdown M. Dutton, K. Curtis Relative cost-effectiveness of a skin protectant in managing venous leg ulcers in the UK J.F. Guest, R.R. Taylor, K. Vowden, P. Vowden Pain related to maggot debridement therapy K.Y. Mumcuoglu, E. Davidson, A. Avidan, L. Gilead

Scandinavian

Wounds (SÅR) vol. 20, no 3, 2012 www.saar.dk Excessive use of antibiotics for patients suffering with non-healing wounds Marcus Gürgen Pressure ulcers on the way out of Skejby Hospital 70 days without pressure ulcers! Hospital Thy-Mors is altogether so close to being without pressure ulcers Intelligent sheets – a brilliant teaching tool Jens Fonnesbech

German

Wund Management, vol. 6, no 4, 2012 English abstracts are available from www.mhp-verlag.de Relationship between incidence and pevalence of pressure ulcer and genereal condition of patients at the University Hospital of Essen M. Nonnemacher, C. Dahlmann, J. Peters, J. Weiß, H. Schneider, W. Niebel Pressure Ulcer: Quality management in clinical practice A. Hauss Pressure sores in children – an underestimated problem in pediatrics N. Möller-Woltmade Wound dressings – What is selled in the outpatient area? K. Kröger Relation between pressure, friction and pressure ulcer categories: A secondary data analysis of hospital patients using CHAID methods – A Summary Nils Lahmann, Jan Kottner Movement means life – Lack of physical activity causes bedsore F. J. Baisc Pressure ulcer management by the nursing stuff at the University hospital of Essen I. Maier, P. Runge-Werner, B. Lottko, M. Henning, Ch. Dahlmann

Leczenie Ran Issue 2, vol. 9, 2012

Polish

Modern rules of pressure ulcers conservative treatment M. Sopata, E. Tomaszewska, A. Kotlinska-Lemieszek Principles and techniques of peripheral nerve surgery A. Chrapusta Pressure ulcers – physiotherapy in the treatment process E. Mikotajewska Retrospective analysis and evaluation of risk factors connected with wound infection occurrence of elderly patients who underwent surgery between 2006-2008 in the Department of Thoracic Surgery of Hospital of Lung Diseases and Tuberculosis in Bystra P. Rogozinski, K. Brulinski, E. Malinowski, M. Kucharzewski Breast reconstruction – the women’s motivation and the level of satisfaction with surgery E. Mazurek Lithuanian

Lietuvos chirurgija, Issue 1-2, Volume 10, 2012 www.chirurgija.lt Perioperative fluid therapy: Old problems, new solutions Andrijauskas A, et al. Laparoscopic restoration of intestinal continuity after Hartmann’s procedure Stasinskas A, Stanaitis J Postoperative reduction pain with dexamethasone after laparoscopic colon surgery Tikuisis R, Miliauskas P, Samalavicius NE, Zurauskas A Analgesic effect of intrathecal morphine in laparoscopic colon surgery Miliauskas P, Tikuisis R, Samalavicius NE, Zurauskas A Gallstone ileus: retrospective review of 14 cases and case report Juodeikis Z, Stanaitis J, Stasinskas A Varicocele treatment by the microsurgical method Zotov T, Sukys D

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Phlebologie, no 5, 2012 www.schattauer.de Pathogenesis and therapy of chronic venous disease – New insights into the structure and function of the vascular wall Nees et al. Updated Guideline: Diagnosis of Venous phlebodynamometry Rabe et al Updated guideline: Diagnosis of Venous venous occlusion plethysmography using strain gauges Gerlach et al Updated guideline: Diagnosis of Venous light reflection Rheography / photoplethysmography Pannier et al The medical compression stocking between muscular and athletic performance enhancement Marshall / Wienert Diameter of the common femoral vein and find phlebedema in women A. Dyszynska, TJ Dyszynski, M. Marshall, Z. Lewandowski

Journal of Tissue Viability, vol. 21, no 3, 2012 www.journaloftissueviability.com Achieving consensus in pressure ulcer reporting C. Dealey, T. Chambers, P. Beldon, M. Benbow, J. Fletcher, S. Fumarola, H. Guy, J. Nixon, J. Price, K. Purser, N. Stubbs, L. Way, K. Weafer, Members of TVS Pressure Ulcer Working Group A prospective randomised study comparing the jubilee dressing method to a standard adhesive dressing for total hip and knee replacements N.G. Burke, C. Green, G. McHugh, N. McGolderick, C. Kilcoyne, P. Kenny Repeated administration of exogenous Sodium-hyaluronate improved tendon healing in an in vivo transection model A. Oryan, A. Moshiri, A.H. Meimandi Parizi, A. Raayat Jahromi

English

NTVW vol. 7, no 8, 2012 www.ntvw.nl

German

Zeitschrift für Wundheilung, vol. 17, June, 2012 www.dgfw.de Message from the Congress President Message from the Vice President of Technology University of Central Hessen Greetings from the Mayor of the city of Kassel Greetings from the speaker of the SPD parliamentary group Hessen, social and health policy Scientific Program Overview General Information on DGfW Sponsors and Exhibition Abstracts

EWMA 2012 IN VIENNA EWMA 2012 was held from 23-25 May in the Austrian capital of Vienna and was the culmination of many months of fruitful collaboration between EWMA and the Austrian Wound Association (AWA).

Gerald Zöch AWA Congress President www.a-w-a.at

Gerrolt Jukema EWMA Recorder www.ewma.org

ienna

EWMA 2012

With more than 2900 participants from 67 countries, 772 scientific presentations including satellite symposia and a large number of committee and projects meetings, the EWMA 2012 conference was the largest conference in the history of EWMA. This was possible because we were building on the success of EWMA’s many previous conferences. A special session was this year’s Honorary Lecture, with honorary speakers Christine Moffatt, United Kingdom, and Hugo Partsch, Austria. Both were honoured for their work within the field of compression. Christine Moffatt presented “The impact of compression on patients and health care organisations” and Hugo Partsch presented “What about compression pressure?”. Two types of prizes were awarded during EWMA 2012: The First Time International Presenter Prize awarded for an oral free paper presentation by a presenter who has never presented internationally before: n No: 70 Felizitas Novotny, Germany: Anticoagulant in autologous platelet concentrates n No 163: Anne Ankerstjerne Rasmussen, Denmark: Organizational and pedagogical considerations when implementing the Danish clinical guideline Among the many high quality posters the following four were selected for the Poster Prizes: Paper posters n No. 144: Ljubiša Paden et.al., Slovenia n No. 88: Kyle Turton, et.al., UK Electronic posters (E-posters) n No. 334: Hanne Vogensen et.al., Denmark n No. 346: Michael Backhouse et.al., UK

Christine Moffatt and Hugo Partsch

All abstracts are available on: www.ewma.org The theme of EWMA 2012 was Wound Healing – Different Perspectives, One Goal, which emphasized the importance of different perspectives on wound healing, the point of view of the patients as well as the health care professionals. The theme was reflected in the opening plenary session as well as a number of workshops and key sessions throughout the conference. Building on EWMA’s project supporting Russian speaking countries, a 1-day Russian Symposium with a record high number of participants and presentations from Ukraine, Belarus and Russia was held. EWMA will continue its efforts to strengthen development in the region and, in addition to other activities, will have another Russian spoken symposium at EWMA 2013 in Copenhagen, Denmark Another 1-day symposium, the Austrian Diabetic Foot Symposium (24th May 2012), set a new milestone for EWMA in being able to facilitate an important collaboration between Austria and the International Working Group on the Diabetic EWMA Journal

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The Poster Prizes: Paper posters No. 144: Ljubiša Paden et.al., Slovenia No. 88: Kyle Turton, et.al., United Kingdom Electronic posters No. 334: Hanne Vogensen et.al., Denmark No. 346: Michael Backhouse et.al., United Kingdom

Foot (IWGDF). The participants enjoyed presentations on a number of European examples of implementing the IWGDF guidelines for the treatment of diabetic foot ulcers. The 2012 programme also offered a large number of guest sessions from several other wound care organisations including The European Tissue Repair Society (ETRS), the Dystrophic Epidermolysis Bullosa Research Association (DEBRA), the European Burns Association (EBA) and a joint session between EWMA and the European Pressure Ulcer Advisory Panel (EPUAP) on “One Goal – One Guidelines: Implementing the International EPUAP/ NPUAP Guidelines Across the World”. EWMA Journal

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The conference dinner was held at the Hofburg Palace. The historical Hofburg Palace was the imperial residence for centuries and dates back to the 13th century. Now we take the opportunity to thank all the participants speakers, sponsors and exhibitors who made this year’s conference so special! After the Austrian experience we are encouraged to invite everybody to join EWMA’s 23rd conference in Copenhagen, Denmark 15-17 May 2013. EWMA Conferences are as strong as the participants are. It is you with your experience who can help develop future patient care. Stay informed and visit the conference web site www. ewma2013.org for further information or keep updated on EWMA’s social media. We look forward to seeing you all again at the EWMA 2013 Conference! m 45

23rd Conference of the European Wound Management Association

EWMA 2013

GAN

15 -17 May · 2013 · Copenhagen · Denmark

ISATION AND ENH P

OPERA ION IN CO T

tract deadline: 1 January 2013 New abs

Organised by the European Wound Management Association in cooperation with the Danish Wound Healing Society · www.saar.dk

WWW.EWMA.ORG / EWMA2013

VISIT EWMA 2013 PRELIMINARY PROGRAMME The programme will be a mixture of plenary sessions, key sessions, workshops, guest sessions and satellite symposia.

Abstracts for oral presentation, poster and electronic poster presentation can be submitted for any topic in Wound Healing and Wound Management.

KEY SESSIONS

Primary categories are: n Acute Wounds n Basic Science n Devices & Intervention n Diabetic Foot n Dressings n Education n Health Economics & Outcome n Infection n Leg Ulcer n Nutrition n Pain n Pressure Ulcer n Prevention n Quality of life n Wound Assessment n Case Studies (posters only) n Professional Communication (posters only)

The key sessions will deal with advancement of education and research in relation to epidemiology, pathology, diagnosis, prevention and management of wounds. n Opening session: n n n n n

Multidisciplinarity and organisation of care Antimicrobial in wound care Home Care – Wound Care

E-health in wound care Regenerative medicine Health economy: Evidence and standards in wound care n Diabetic foot n Leg ulcers n Patient safety – pressure ulcer

ABSTRACT SUBMISSION In 2012 EWMA received the highest number of abstracts in its conference history. Abstracts for free paper and poster presentations play a very important role in the conference programme. We hope that many of you will wish to share your work at the 2013 conference and will submit your a bstracts before 1 January 2013. In order to submit an abstract for EWMA 2013, please visit www.ewma.org/ewma2013. Guidelines on how to submit the abstract will be provided when you enter the abstract submission system. Only electronic submissions are accepted.

in Copenhagen, Denmark

Before you submit your abstract, please read the conditions for abstract submission carefully. The conditions can be found on www.ewma.org/ewma2013 or directly by scanning the code:

Abstract submission deadline: 1 January 2013. Notification on acceptance/rejection: March 2013

Registration fees Category Full conference registration: EWMA Members1 Members of DSFS2 Non-members One day registration: 1-day registration Danish Day, symposium by DSFS: Danish Day, members of DSFS2 Danish Day, non-members Conference dinner3

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Before 15 March 2013

15 March1 May 2013

After 1 May 2013

€ 385 € 330 € 460

€ 450 € 380 € 525

€ 500 € 430 € 575

€ 250

1. Members of EWMA or one of EWMA’s cooperating organisations see (http://ewma.org/english/ cooperating-organisations/ cooperating-organisations.html) 2. For members of DSFS only.

€ 200 € 250 € 95

€ 225 € 275 € 95

€ 275 € 325 € 95

3. Tickets for the conference dinner Thursday 16 May are not included in the registration fee and are non-refundable. Please note: Limited number of seats.

DSFS What can we do? What will we do?

Jens Fonnesbech Journalist with the DSFS and NIFS wound magazine SÅR www.saar.dk

The DSFS Pressure Ulcer Lady for education purpose

he Danish Wound Healing Society (DSFS) is one of the oldest wound societies in the world – however the society is not characterised by old men and governesses. Renewed strength keeps the association on track and contributes to its most central aspect: to strengthen correct and effective wound treatment in the country. The society remains the only central provider of new knowledge and practical skills within the wound area. Through its history DSFS has focused on developing the model which is now the widely accepted model for effective wound healing in the world: a multidisciplinary and intersectoral wound department including specialised wound nurses, dermatologists, vascular surgeons, plastic surgeons, podiatrists and orthotists which organizes wound management and shares knowledge across the country. So far the model is used in the largest cities of the country, so there is still a lot of work to be done with regards to securing that good wound care is available throughout the country. When the new president took over the board in 2012 he made it clear that the efforts to achieve this should be continued. This is completely in line with the recommendations of the former president. Likewise, the multidisciplinary approach to wound management is completely reflected in the association’s board, consisting of nurses, doctors and clinicians with other specialities.

Instructions, guidelines and communication tools In relation to the association’s efforts to disseminate knowledge about the prevention and treatment of wounds, the DSFS has produced a series of booklets which, in a concentrated and accessible form, provides best practice guidance for nurses and doctors with regards to diagnosis and treatment of wounds. In collaboration with the industry the society has published a wound pain algorithm that provides an easy tool for improved patient dialogue. The objective is to understand the causes of wound pain and thereby achieve quality in wound as well as pain management. The algorithm involves the patient in the healing process and may thereby shorten the treatment time as pain potentially prolongs the healing period. The association has also developed a wound algorithm with brief advice and guidance on wound diagnosis and treatment. The wound algorithm is intended as a guidance document and provides a simplified description of complex wound conditions. A Doppler guide explains how to measure an ankle/arm index with the objective to assess whether the patient has signs of arterial insufficiency or whether the leg can endure compression therapy. With regards to these aspects of wound management, uniform guidelines for measurement are essential for the daily clinical practice. These guidelines and algorithms are designed in handy, foiled formats, ready for daily use, and can be downloaded from the association’s website: www.saar.dk. This also applies, for example, to the presentation of EPUAP’s guidelines for the prevention and treatment of pressure ulcers. National efforts against pressure ulcers The most recent initiative has been to fight pressure ulcers throughout the country. Investigations show a significant spread in the prevalence data for pressure ulcers. According to these data 13 to 43 % of the hospitalised patients in Denmark

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EWMA

The most recent initiative has been to fight pressure ulcers throughout the country.

DSFS organises seminars and conferences on opportunities within e-health treatment. Here you can see wound treatment by photo transfer via mobile phone.

develop a pressure ulcer to a mild or more severe degree and sources indicate that up to 50% of these wounds develop after hospitalisation. That is why there is a need for joint efforts. The effectiveness of this initiative is shown in preliminary data from selected hospitals which, based on the dedicated efforts of the staff, have succeeded in completely preventing the development of pressure ulcers. The latest report reveals that 70 days have passed since the last pressure ulcer developed in the hospital. This result is obtained by following a methodology used in a hospital in Wales. The focus is on screening of all patients at admission. During the screening you must clarify the patient’s mobility, possible incontinence, nutrition etc. and examine whether the patient has pressure ulcers or pressure marks in all relevant places on the body. Based on this the staff evaluates the patient’s general risk of developing pressure ulcers. By these efforts a set of common rules and scales for the assessment and description of pressure ulcers are established which then result in common efforts to fight pressure ulcers. As part of the initiative all regions were required to report on the development of pressure ulcers. As expressed by the head of the national campaign “We can reduce the number and we will reduce the number of pressure ulcers”. Municipalities and regions upgrade – also with regards to use of IT and telemedicine Activities are initiated all over Denmark with very good results. For example, the municipalities of Viborg and Køge have, for several years, worked hard to eliminate pressure ulcers. In Køge they have succeeded in reducing the incidence to 0.26 per 1000 inhabitants, compared

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to the national average of 0.7 pressure ulcers per 1000 inhabitants. In the municipality of Viborg the incidence of pressure ulcers has decreased by 23.7% from 2010 to 2011. The efforts of the municipalities will focus on new workflows, bedside training, education of wound care nurses, networking and e-learning. Both in the hospital and in a home care setting there is a need to develop new procedures, educate staff members to pay attention to new methods of prevention and treatment, reflect on their own practice and involve patients by giving them shared responsibility for the wound healing process. A part of this endeavor is the development of measurement tools with web-based e-learning portals that allow the staff to measure development in the wound area: how many wounds are there, which types, how long is the healing period, etc.? This type of tool enables comparisons, identifies areas that require attention and supports e-learning activities related to wound management. There are great opportunities in that direction once the general  level of IT skills amongst groups of staff are raised.

The Danish Health Care system Health care systems in Scandinavia, including the Danish system, are primarily public (private treatment only covers approximately 5% of inpatient beds). In the secondary sector, all health-care investigations, drugs and devices are offered free of charge to the patients. In the primary sector different reimbursement policies regarding drugs and devices exist. This means that only a very small part of the health care budget is covered by private insurance or consumer payment. For further information: www.euro.who.int/__data/assets/pdf_ file/0004/160519/e96442.pdf

EWMA

The magazine SÅR is published four times a year in cooperation with The Norwegian Wound Healing Society, NIFS.

This also relates to the use of telemedicine which currently attracts many resources in Denmark and which the Danish Government is confident will lead to savings of financial resources as well as inconveniences for municipalities and patients. The government is expecting a saving potential of approximately 330 millions DKK (44.3 mill EUR) once the technology has been implemented. In Odense, Aarhus and Copenhagen trials are being conducted in telemedicine where patients wounds are diagnosed while home care nurses and doctors are advised in treatment procedures by photo transfer via mobile phone and registration of patient data in an electronic database. DSFS follows this development closely and the association organises seminars and conferences on opportunities within this area.

Danish Wound Survey estimating prevalence and cost of wounds In 2010 DSFS was involved in a wound survey initiated by EWMA. The survey takes the form of a point prevalence study carried out in two hospitals in Viborg and Hilleroed and two municipalities located within the catching populations of the two hospitals respectively. The survey identifies the total number and type of wounds treated in each setting at the time of the survey and provides an estimate of the amount of clinician time and inpatient bed-days directly attributable to wound care at an organisational level. This type of information highlights the importance of specialist wound care expertise, by illustrating the prevalence of wounds among hospital and community patients and the significant proportion of available resources which are devoted to wound complications, many of which could be avoided. The article presenting the results of the survey is expected to be ready for publication by the end of 2012.

Within one area, however, the association has so far been stranded. This concerns the involvement of general practitioners in the prevention and treatment of wounds. In practice wounds are most often only seen and evaluated by consultation nurses and only in a few municipalities has the cooperation between home care and general practitioners been running smoothly so far. The board of DSFS is paying close attention to the development within this area. Knowledge and visions DSFS supports important research within wounds, encouraging theses and PhD dissertations to be written on key issues within wound management, such as bacterial biofilms, treatment with maggots, the influence of tobacco smoking on wound healing, cancer wounds and honey and about growth factors in wound healing. The latest research results are presented regularly at DSFS meetings. As the latest acquisition DSFS has initiated a study on the communication between wound practitioners in the primary and secondary sectors and an assessment of the communication flow between practitioners and wound patients. The study takes the form of a poll and is expected to be presented at next year’s EWMA conference in Copenhagen. A vital part of the dissemination of knowledge is the magazine “SÅR”. This is published four times a year. New initiatives, new ways to organize care and learning, scientific papers and minutes of meetings and conferences in Denmark and abroad are permanent features in the magazine. In this magazine municipal wound nurses and doctors, primarily from the major university hospitals, present their point of view on the different aspects. The Norwegian Wound Healing Society, NIFS, is a co-producer of the magazine and provides similar information from the Norwegian wound management society. This information is an essential part of the continued development of a strong interdisciplinary and intersectoral approach to wound management. A magazine is expensive, and the continued successful publication of the magazine has a background in the benevolent support from the wound care companies in relation to the DSFS conferences and advertising in the magazine. Improving wound management is not necessary cost demanding. By gathering resources and adding quality in order to avoid development, improvements in nonhealing ulcers can be achieved and expenses to the public health care budget reduced. Diabetic foot ulcers will especially, in the years to come, require significant attention as the number of diabetics is expected to grow explosively. DSFS has plenty of things to take care of ... m

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The Cooperating Organisations Board Meeting 2012 Vienna, 24 May 2012

T Zena Moore Chair of the Cooperating Organisations Board www.ewma.org

ienna

EWMA 2012

he annual meeting of the EWMA Cooperating Organisations Board, during the EWMA Conference in Vienna, was a successful meeting with interesting presentations and good debates. The meeting was attended by 33 Cooperating Organisation Board Members, or appointed substitutes, as well as EWMA Council members, invited speakers and visitors. The new elected member for EWMA Council The members of the Cooperating Organisation’s Board elected Ann-Mari Fagerdahl, SSIS, Sweden to the EWMA Council for the next three years. Ann-Mari Fagerdahl replaces Eskild W. Henneberg whose work for the EWMA Council is acknowledged in a separate entry in this issue of the EWMA Journal.

Presentations and debate sessions The following presentations took place during the Board meeting: n Experiences and ideas on collaboration with patients, presented by Salla Seppänen, chair of the EWMA Patient Panel. n Objectives and activities of a patient organisation, presented by Dr. Rainer Riedl, President of DEBRA International.

Presentation and the development of the EPUAP guidelines, presented by Dimitri Beeckman, member of the EPUAP Board of Trustees. n Impressions from membership of the EWMA Council by Eskild Henneberg, Chairman of the Danish Wound Healing Society. n Presentation of the STOP Pressure Ulcers initiative by Jose Verdu Soriano, GNEAUPP. The debate in groups focused on A) The issues of the Patient Panel established by EWMA and B) The presentation on the EPUAP guidelines. The presentation by Salla Seppänen emphasized the challenge of working with patients in wound care where patients’ organisations are rarely seen. The picture is very different for a rare disease like Epidermolysis Bullosa (EB) where patient organisation is well developed, originally initiated by a group of parents of children born with EB. While EWMA will investigate, through a survey, the experience of the Cooperating Organisations in working with patients, the Cooperating Organisations agreed to follow-up on the establishment of the EWMA Patient Panel by informing their national constituencies about this initiative. Patient conferences could also be considered in connection with national wound conferences. The presentation by Dimitri Beeckman focused on how the Cooperating Organisation can contribute to the national implementation of the EPUAP guidelines. The discussion in groups emphasized, amongst other things, the need for a patient version of the guidelines and the importance of using social media in the dissemination of the guidelines. In connection with the debate about the EPUAP pressure ulcer guidelines Jose Verdu Soriano, during his presentation, encouraged the Cooperating Organisation representatives to plan activities for the international STOP Pressure Ulcers Day taking place on the 16 November 2012.

Debate session during the meeting

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COOPERATING ORGANISATION’S WORKSHOP 2012

A workshop focusing on activities of the Cooperating Organisations took place for the first time during the 2012 conference. This new initiative was aimed at providing all EWMA Cooperating Organisations with an opportunity to present their activities and working experiences to all interested conference participants. A call for abstracts for this specific activity was made before the conference to the Cooperating Organisations and responded to by seven associations. Through a process of voting by the Cooperating Organisations Board representatives from the following four Cooperating Organisations were asked to make presentation in the workshop: TVS (UK): Involving the members of the organisation in the making of a consensus document on pressure ulcers. WMAI (Ireland): A national survey of the efficacy of a wound care organisation in dissemination of clinical practice guidelines. PWTA (Poland): Quality of life in patients with lower limb u lceration – Skindex-29 questionnaire study.

Finally, Eskild W. Henneberg, in his presentation, highlighted the importance of taking an active part in the work and projects of the EWMA Council and standing committees. Revision of rules regarding election to Council These clarifications of the rules were presented and approved by the Board: n A Cooperating Organisation can not nominate a new candidate for the Council election taking place at the Cooperating Organisations Board meeting if it is already represented at the EWMA Council by a member elected by the Cooperating Organisations Board. n After the end of the 3-year term of a Cooperating Organisations Board elected member of Council, the same organisation must respect a 1-year break before again nominating a candidate for the Cooperating Organisations Board election for Council. Evaluation of the Board meeting The Cooperating Organisations Board meeting was evaluated by the Board members through an on-line survey. The questionnaire was answered by almost 50% of the Board members present at the Board meeting. In general the responses indicate great satisfaction with the meeting (85% answered good/very good, 76% think that the duration of the meeting was appropriate and 100% indicate that the information given prior to the meeting was good/very good). In accordance with evaluations of former meetings, a large majority of the respondents highlighted “networking” as a main objective for participating in the Board meeting, while about half of the respondents attended the meeting to improve their European cooperation and to develop new projects. Suggestions for themes and debate topics for future meetings include: n Set aside more time for presentations by associations who are new to the Cooperating Organisations community n Development of a wound researcher’s network n How to build a business case for clinicians m Acknowledgements I would like to thank all meeting participants for contributing to further developing the collaboration between the EWMA Cooperating Organisations and for their constructive and progressive inputs.

CWA (Croatia): Brief Outline of the Work of the Croatian Wound Association. The workshop is planned as an annual activity during the conference. Responding to a request made by the Cooperating Organisations, in 2013 the call for abstracts will be circulated in January in order to give all Cooperating Organisations a better opportunity for elaborating abstracts for the session. Debate session during the meeting EWMA Journal

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The Austrian Diabetic Foot Symposium

Gerd Köhler MD Medical University Graz Department of Internal Medicine Division of Endocrinology and Metabolism Correspondence: Gerd.Koehler@ klinikum-graz.at www.a-w-a.at

ienna

EWMA 2012

Aim of the Symposium As a special event on the recent EWMA Conference in Vienna, EWMA organized “The Austrian Diabetic foot symposium” in collaboration with the Austrian Wound Management Association (AWA). The overall aim of the “Austrian Diabetic Foot Symposium” was to support the AWA and existing centres of excellence in Austria in their mission to achieve better organisation of diabetic foot treatment in Austria. The focus of the symposium was to highlight potential gains from the implementation of multidisciplinary treatment models and to illustrate possible solutions to the organisational challenges related to implementation of these treatment structures in different health care settings. With a starting point in experiences and lessons learned so far throughout Europe the goal was to agree on a set of recommendations regarding an improvement of the current treatment situation in Austria. A full day was reserved for the topic and the program was planned in collaboration between the AWA (the Austrian Wound Management Association), the IWGDF (the International Working Group of the Diabetic Foot) and EWMA. The group of speakers and panellists comprised experts from the international diabetic foot community. As a special gesture to the Austrian participants they were offered a complementary copy of the guidelines DVD. Content of the program The day started with a session hosted by the IWGDF and included presentations about the overall concept of the multidisciplinary treatment approach. Also included was a presentation on the idea behind the “International consensus guidelines on the management and prevention of the diabetic foot”. To provide practical examples of the implementation of a multidisciplinary approach into different organisational contexts, the program moved on to a session presenting various approaches to implementation as seen in Belgium, Germany, Britain and Italy.

The final session included a presentation of the successful management of the organisational challenges related to treatment of the diabetic foot patients in a region of Austria (Styria/Graz). To round up the presentations held during the symposium the results achieved in Europe so far were summed up. To end the day a panel debate was arranged to give experts from around Europe the opportunity to pass on their advice on Austria’s progression towards nationwide implementation of the interdisciplinary approach to diabetic foot treatment. Conclusions from the panel debate The advice presented during the panel debate covered a broad spectrum of pre-conditions that need to be in place if large scale implementation of the multidisciplinary foot clinics is to be successful. The advice included: Guidelines n Implementation of guidelines emphasising annual screening of the feet for early risk detection of diabetes patients in primary care. n Keeping screening simple and easy to implement in daily practice. n Implementation of guidelines emphasising referral patterns. Education Wide spread diabetic foot education of nurses and podiatrists.

Formal certifications n Securing that training courses are officially approved. n Securing certification of the diabetic foot clinics as this gives more legitimacy to practice and power to influence treatment structures. In addition this may inspire other centres to aim for a similar certification. Quality control Formalising quality control in order to report results of the treatment provided.

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Panel debate: From the left Karel Bakker (NL), Gerald Zöch (AUT), Thomas Pieber (AUT), Edward Jude (GB), Vilma Urbancic-Rovan (SLV), Kristien Van Acker (BE), Maximilian Spraul (D), Valerio Vallini (IT), Jan Apelqvist (SWE), Moderator: Andrew Boulton (GB)

Multidisciplinary and cross sectorial collaboration n Establishing close collaboration with home care settings as more and more patients are treated in their homes. This is essential for achieving optimal treatment results. n Establishing a network of specialists who share your interests. n Making sure you have staff members who are genuinely interested in the diabetic foot. Partner up with policy makers and politicians “Money talk”: Convince politicians that prevention is cheaper than amputation. n Partner up with policy makers and politicians in early phases to make sure they understand and recognise the problem. They represent the key to securing reimbursement of services related to diabetic foot care.

to implement new treatment structures in countries where the diabetic foot treatment is not yet part of the established health care system. To make progress with this agenda, Kristien Van Acker, the vice president of IWGDF, encouraged fellow colleagues around Europe to be patient when fighting for the cause: “Be persistent and keep repeating your messages”. In line with this the president of EWMA, Jan Apelqvist, provided a closing remark with the following advice: “Keep in mind there are no silver bullets. Think big, but start small”.

Between the panelists there was an overall agreement that implementation of multidisciplinary treatment structures can benefit from experiences made in those regions or countries in Europe where this has already taken place successfully. There is no doubt that it is a challenging task

The situation in Austria today In Austria 70% of the diabetic patients are currently treated by general practitioners (GPs). In order to prevent serious diabetic foot problems adequate and systematic screening for diabetic foot problems in the primary care as well as well established referral mechanisms is required. However, today the screening and treatment for diabetic neuropathy as well as patient education about the risk of complication is not adequately reimbursed by the health care system. Consequently neither GPs, nor patients pay adequate attention to prevention of diabetic foot complications. However this is not the only problem related 

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to diabetic foot care; When general practitioners with a diabetic foot patient wish to refer the patient to a multidisciplinary center, they do not know to which clinic the patient should be referred as there are currently very few centers in Austria.

1st International Course on The Neuropathic Osteoarthropathic Foot (Charcot) Advanced Postgraduate Course, Rheine, Germany

15-17 November, 2012

The regional government of Styria covers Austria’s five diabetic foot centers. These centers are based on the international accepted standards for interdisciplinary treatment. All diabetic foot ulcers that have not healed within three weeks can be referred to these centers. This model was chosen regardless of the actual reimbursement situation of the Austrian health care system. Specialists within the diabetic foot treatment services in Austria agree that the goals should be to improve the education of patients and health care professionals, ensure the reimbursement of screening and treatment of the diabetic foot in primary care, and establish diabetic foot centers all over Austria. What happened after the symposium? The symposium held during the EWMA 2012 Conference gained national attention when Radio Österreich, in the radio program “Wissen Aktuel”, broadcasted interviews with the local Diabetic Foot Expert Prof. Thomas Pieber from Graz and international experts representing the IWGDF, Dr. Karel Bakker and Dr. Kristien Van Acker.

The international course will be based on the expertise gathered from 10 consecutive years of providing national courses on the Diabetic Foot. The main focus are practical sessions in small groups to train the diagnostic and treatment skills necessary for the interdisciplinary treatment of Charcot patients. The course will be held at the Mathias-Spital in Rheine. The courses are open to anyone involved in the treatment or management of Neuropathic Osteoarthropathic Foot patients. Number of participants: 25-50

Since the conference, the Austrian organisation has worked hard to continue to advocate for better diabetic foot care. A direct dialogue between the Austrian project group and the Austrian Ministry of Health (MoH) has been established. A first meeting took place in August and a follow up meeting is planned in the near future. At the first meeting with the MoH the overall concept for the establishment of structured diabetic foot care was presented and discussed. Before it can take further actions the MoH is waiting for an evaluation of the current situation of diabetic patients. This evaluation is under development. The Austrian organisation hopes that concrete plans for further steps towards implementation of better diabetic foot care will be agreed at the next meeting. m

Language: English

www.charcotfootcourses.org

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EWMA

SYMPOSIUM FOR RUSSIAN SPEAKERS

ienna

at the EWMA 2012 Vienna conference EWMA 2012

D Rytis Rimdeika MD, PhD, Professor of Plastic Surgery Department of Plastic and Reconstructive Surgery, Lithuanian University, Lithuania EWMA Council Member Chair of the Russian Symposium 2012 Correspondence: rytis.rimdeika@ kaunoklinikos.lt

uring the EWMA 2012 conference one of the auditoria was dedicated to an all day scientific program presented in Russian. The Symposium for Russian Speakers attracted more than 180 Russian-speaking participants from different countries. The recurrence of a symposium for Russian speaking clinicians is currently being planned for the EWMA 2013 Copenhagen Conference. The 2013 symposium programme will again be planned in cooperation with the wound associations in Russia, Belarus and Ukraine. It will include sessions with a scientific focus as well as sessions focusing on the organisation of wound care in countries where Russian is widely spoken. The establishment of meetings in the Russian language started as an initiative of the Lithuanian Wound Management Association (LWMA) in 2006. This EWMA based activity was planned to improve the exchange of knowledge and experience in wound management between medical specialists in the countries of the EU and Eastern Europe who, due to a number of circumstances, do not use English as a tool for professional communication. The LWMA initiative was supported by the Finnish Wound Care Society (FWCS) at EWMA 2009 in Helsinki, where a similar sym-

Professor A. Baindurashvili, Professor B. Paramonov, Dr. Z. Moore, Dr. R. Strohal, Professor T. Tamm, Professor A. Alekseev and Professor R. Rimdeika, Dr. L. Rubanov, Professor G. Kozynets, Professor E. Fistal

posium was promoted to help the establishment of wound associations in Belarus, Russia and Ukraine. The period of 2009-2011 was very successful – associations were established in all the mentioned countries, they started to grow and organize their national meetings, and joined EWMA as Cooperating Organisations. Last year the initiative was taken by the Austrian Wound Association (AWA) for the organisation of a symposium for Russian speakers at the EWMA 2012 conference in Vienna. The scientific program was organised by the associations from Belarus, Russia and Ukraine together with the LWMA and AWA. The symposium for Russian speakers was followed by activities in Russian across the conference. These included translations by several companies of their satellite sessions and workshops as well as a simultaneous translation into Russian of the European Burns Association guest session. The scientific program included sessions on paediatric wounds, burns, chronic ulcers, pressure ulcers, wound infection, diabetic foot and advanced technologies. Presentations were given by renowned specialists in wound care; Professors A. Alekseev (Russia), A. Baindurashvili (Russia), B. Paramonov (Russia), G. Kozynets (Ukraine), T. Tamm (Ukraine), and Dr. L. Rubanov (Belarus). The Invited Lecture was given by Professor F. Gottrup (Denmark). The concluding session of the symposium was dedicated to a summary of the achievements and the further presentations were given by the presidents of the associations, Professors A. Baindurashvili, A. Alekseev, G. Kozynets and Dr. L. Rubanov. In addition a discussion was held by the chairs of the sessions, together with Dr. Z. Moore (EWMA immediate past president), members of EWMA Council: Dr. R. Strohal (AWA) and Professor R. Rimdeika (LWMA). m

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EWMA

An evaluation of the

EWMA UCM EXPERIENCE 2012 from two Danish students

e are two Danish nurses studying a postgraduate skin integrity course at the University of Hertfordshire, who attended the EWMA University Conference Model (UCM) in Vienna, and we want to share our experiences because we think this year has been an experience of a lifetime. The University Conference Model (UCM) is an innovative approach that combines attendance at a major conference with an accredited academic study. The content and outcomes of the course are matched against sessions and activities on the EWMA conference programme and additional educational activities are planned around the conference programme (Flanagan 2011, Flanagan and Law 2012). This year the UCM programme at EWMA focused on increasing the networking opportunities between the students from various UCM groups all over Europe participating in the Conference. The group from University of Hertfordshire included 10 clinicians from six different countries. It was a great experience for all of us to get to know and network with different nationalities within the group as well as with other international groups. The EWMA conference theme this year was: “Wound Healing – Different perspectives, one goal” and approximately 2800 delegates attended. We have both attended a EWMA conference before, but this time we felt more focused and eager to learn and network with the students in the group as well as with other delegates and international students at the conference. When attending an international conference it is difficult to work out which sessions to go to, but this year we got help from the course leader and principal lecturers from the University. We felt that the use of an international conference pro-

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gramme to deliver knowledge in a structured way was a well thought out idea and the EWMA conference was a good choice to deliver the modules “Enhancing Skin Integrity Skills & Treatment” and “Consolidating Specialist Practice”. EWMA’s International Conference Board members are all experienced practitioners, researchers and authors in the field of wound management and therefore guarantee the quality of learning (EWMA Abstracts Book 2011, 2012). The conference was intense with a lot of opportunities to attend different oral presentations and free papers, including learning from the poster exhibition and activities in the exhibition hall. There were more than 600 scientific presentations; most were of high quality, and the speakers were experienced and knowledgeable about wound management. Some participants, both speakers and conference delegates, were also experts in wound management and research. It was very interesting to have the opportunity to meet them and discuss best wound practice in their country of origin. Eight universities had brought UCM students to the conference this year which, for the first time, allowed our tutors to get involved with all of the UCM students who came together to participate in joint activities. Belonging to both the University of Hertfordshire group and the bigger UCM student group during the conference was motivating. When we discussed and reflected critically on the scientific programme and our own clinical practice, we learned so much of value from the tutors, who facilitated teaching and learning activities, and from other international students studying using the UCM approach. In many sessions our assumptions about clinical practice issues were confirmed and if not we gained a new perspective, because belonging to an international group seemed to facilitate learning at a higher level.

Britta Østergaard Melby Head Nurse and Clinical Wound Specialist Copenhagen Wound Healing Centre Bispebjerg University Hospital Sjælland, Denmark

Sanne Wichmann Head nurse and clinical wound specialist Odense Centre of Wound Healing Odense University Hospital Fyn, Denmark Correspondence: sanne.wichmann@ gmail.com



EWMA

Selection of the UCM atudents, Vienna 2012

As UCM students, we were provided with an individualised study programme full of international practice development activities such as evaluating the effectiveness of exhibitor’s stands at the exhibition and critiquing the posters on display which we did with other UCM students from different European Universities. The quality of posters varied, but our overall impression was good. Some posters were very clear and those were the ones we preferred. The electronic posters, giving the authors the opportunity to communicate their message in five slides, were introduced this year. These e-posters were of different quality and the one which ultimately won the poster prize was especially good and to the point. Students also got a choice of free papers to attend as well as satellite symposiums sponsored by the healthcare industry. As novice students in a dynamic learning situation such as the EWMA conference, we found that we were inspired by the skilled professionals around us, who became important role models to us as we listened, watched, learned and reflected. One of the big advantages of the UCM approach at the EWMA conference is that UCM students are recognised as expert practitioners in their own right and have the opportunity to network with key opinion leaders attending the conference. In the exhibition hall we interviewed a senior marketing manager of a global wound care business about the value of a commercial company attending the conference and explored how being there helped promote business. 62

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

During the exhibition activity, planned by our tutors, we were asked to collect and review educational materials given out at the exhibition stands. Some stands used interactive learning and videos whereas others used simple printed information. Our impression was that the health care industry at the conference certainly used its know ledge of how to promote its products and how to catch practitioners’ interest in many different ways. One of the interesting activities planned by our tutors involved interviewing another conference delegate to find out about the health care system in their country. It was really interesting to learn about the health care systems in other European countries and was an eye-opener, because wound care in Europe is managed and organized in many different ways and to different standards! This exercise gave us a fantastic opportunity to become familiar with another health care system and to put our own country’s healthcare system into perspective as well as providing a really good networking opportunity. Conclusion One of the key things we learned from this year’s conference from our supervising tutors was to identify and ask for the evidence used to support exhibitor’s products and new approaches to treatment. Our experience from studying at the conference is that industry colleagues are very EWMA Journal

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interested in providing evidence to support their products. We learned that it is challenging to plan effective RCTstudies and can be difficult to provide quality evidence in wound healing. We see the UCM approach as a way to educate wound care practitioners studying at a university in a real world setting. UCM students can also facilitate bridge building between industry, clinical practice, research and practitioners in different countries in Europe. It became obvious to us during the conference that practitioners should tell industry colleagues what is needed to help patients with chronic wounds so that they can help find a workable solution and that we should all work together and have common goals for our patients. As UCM students we learned to be more critical of research results, and our tutors taught us to ask for the evidence and to critically appraise studies by reading about the methodology used rather than jumping straight to the study conclusions. The UCM model is an excellent opportunity for networking nationally and internationally. The schedule of activities was busy resulting in sore feet and the need for early nights. Our advice is to remember to bring a backpack to carry your things and to wear comfortable shoes - a hard learned lesson as being a UCM student at EWMA means being on your feet from early morning to the evening! Finally, we want to thank the teaching team from the University of Hertfordshire for providing a great, positive teaching and supervision experience as we participated in the University Conference Model; and a big thank you to them for acting on the evaluation of last year’s UCM study program to make it even better this year. Next year we won’t need to be studying the UCM but would like to come along to see if we can help out and meet old friends. We look forward to meeting a lot of EWMA UCM students in Bella Center, Copenhagen, Denmark in 2013. Last but not at least, we want to thank Coloplast A/S Denmark for sponsoring our participation as UCM students at the EWMA conferences in 2011 and 2012. Without their support this fantastic opportunity would not have been possible. m

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM) in Copenhagen

EWMA 2013 COPENHAGEN 15 -17 May · 2013

The EWMA UCM programme offers students of wound management from institutes of higher education across Europe the opportunity to take part of their academic studies whilst participating in the EWMA Conference. The opportunity of participating in the EWMA UCM is available to all teaching institutions with wound management courses for health professionals. The UCM programme at the EWMA 2013 Conference in Copenhagen will offer networking opportunities between the students from various UCM groups, UCM Lectures as well as assignments and workshops arranged specifically for the UCM students. EWMA strongly encourages teaching institutions and students from all countries to benefit from the possibilities of international networking and access to lectures by many of the most experienced wound management experts in the world. Yours sincerely

Zena Moore, Chair of the Education Committee, Immediate Past President Participating institutions:

Donau Universität Krems Austria

Haute École de Santé Geneva, Switzerland

Escola Superior de Enfermagem de Lisboa Portugal

HUB Brussels Belgium

KATHO university college Roeselare Belgium

Lithuanian University of Health Sciences Lithuania

Metropolitan University College Denmark

University of Hertfordshire United Kingdom

Universidade Católica Portuguesa Porto, Portugal

References: Bale, S. (2012), EWMA Abstracts book, Volume 12, number 2, May 2012. Dealey, C. (2011), EWMA Abstracts book, Volume 11, number 2, May 2011. Flanagan, M. (2011), University conference model Portfolio, EWMA Conference, Brussels, University of Hertfordshire, UK. Flanagan, M. (2012), University conference model Portfolio, EWMA Conference, Vienna, University of Hertfordshire, UK. Flanagan, M. (2011), Enhancing Skin Integrity Skills, Handbook, University of Hertfordshire, UK. Law, C. (2012), Consolidating Specialist Practice, Handbook, University of Hertfordshire, UK.

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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

THE

UCM

(University Conference Model)1

IN SWITZERLAND: DEVELOPMENT AND PROSPECTS The UCM module OFFERED BY THE UNIVERSITY OF APPLIED SCIENCES – GENEVA: FEATURES AND RESULTS

Laurent Chabal Stomal therapist, Specialized Nurse in wound care, lecturer and coordinator of Swiss French UCMs. University of Applied Sciences, Nursing Department, Geneva.

Carolyn Wyndham-White Senior Lecturer, Specialized Clinical Nurse2 Haute École de Santé Geneva, Switzerland Correspondence: l.chabal@bluewin.ch

Background and objectives The first Swiss module was offered in 2010. It was designed as part of the post-graduate course: “Interdisciplinary treatment of wounds and tissue viability”. This course has been conducted since 2005 at a certificate level. From 2013 it will be integrated in the diploma level programme. Ever since the Swiss French certificate level course was introduced, the regional wound conference4 day (or the Swiss day held during the EWMA 2010 Conference) has been incorporated in the training. This allows post graduate students to develop critical approaches and positions in the field as well as stimulate their interest in research activities. It also meets the demands for increasing requirements with regards to expected student outcomes and stimulates individual motivation and networking at national and international levels. Motivated individuals who are not receiving ongoing wound care and tissue viability education, but have relevant professional experience within the chosen topic may also participate. The first Swiss module attracted 11 students with the following backgrounds: n One physician (GP) from a Swiss French rehabilitation center. n Eight nurses specializing in wound care (seven holders of a Certificate of Advanced Studies, one holding a University Degree in wounds and healing) from various Swiss French cantons and various health care facilities (independent, home care, medical-social facilities, private clinics, regional hospitals, university hospitals, specialized professional associations). One clinical nurse. n One nurse in charge of managing wounds within an institution. The following year, only one nursing student with a University Degree in wound care and tis-

sue viability enrolled. Language difficulties, difficulties obtaining free time for training from employers and lack of financial support largely explain this.

Structure and content of the Swiss module The Swiss UCM module offers students the opportunity to plan their individual programme, based on a selected topic covered at the annual EWMA conferences. If students have similar topics, a shared course is suggested to them. The aim of this approach is to stimulate individual investment in the conference sessions (such as plenary sessions, open paper sessions, About the EWMA UCM

Since piloting the EWMA University Conference Model (UCM) in Glasgow in 2007, this education activity has consistently been evaluated as very successful by the participating students and their coordinators. This unique model combines attendance at the annual EWMA Conference with academic study at a university of the student’s own choice and has arisen from a pragmatic desire at future EWMA conferences to: – Combine academic study with existing professional development activities – Enable maximum utilisation of expert knowledge & skills – Utilise excellent facilities & learning resources The students get the opportunity to discuss the value of conference contributions with their teacher, update and supplement their skills and knowledge, expand their professional network and discover pragmatic means that could enhance their field of practice and improve the quality of care. As the UCM courses are offered via a university, students can obtain ECTS3 credits. Consequently, the UCM provides an original and unique opportunity to validate the attendance at a specialized international conference as a short specialized postgraduate training course. EWMA will continue to develop the specific programme for UCM students offered during the conference to maximize the student outcome of the conference and secure exchange of knowledge as well as networking between students. These objectives are supported by common workshops, exercises and social events involving all UCM student groups. Read more about the EWMA UCM and previous student evaluations at www.ewma.org/english/ education/ewma-ucm.html EWMA Journal

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symposia, workshops, posters, exhibition stands) based on the selected topic. This chosen “conference pathway” is validated by the university coordinator who provides support to students throughout the conference. A portfolio serves as support for the students to record the attended sessions, take notes and collect information about the requirements and conditions for module validations. A formal meeting with the university coordinator is organized for Swiss students. This meeting is held to receive feedback from students with regards to the progress of their planned programmes, answer possible questions and make adjustments in the programme if needed. This meeting is also open for French speaking UCM students enrolled via other universities. After the conference the students are given three months to complete a written report, based on their conference participation and experience, including: n Motivations for choosing the specific topic and its relationship to practice. n Prior knowledge of the student about the chosen topic. n Added learning outcomes of the conference (with critical analysis of the collected content) and additional research to identify updated materials available about the topic. n Concrete proposals for practical methods and applications that may be implemented in a daily clinical context. For the first modules offered, this report had to be presented either in written or oral form to a supervisor from the student’s workplace. This way a double review was conducted allowing both the university and the workplace supervisor to bring in added value via their feedback. In the case of failure to pass the module, a new attempt was allowed. If the report was not handed in, the students did not obtain the associated ECTS credits. In conclusion, the UCM module offered by the University of Applied Sciences – Geneva, allows students to: n Select a topic of interest and focus their attendance and follow-up on the conference on this issue. n Study the topic chosen by detailed research; n Highlight the assumptions of and concrete actions needed to improve their professional qualifications; n Form the basis of positioning themselves as an expert within wound care and tissue viability; n Meet and share knowledge with other professionals and students; n Strengthen their professional network by access to online forums for communication between former UCM students and coordinators. EWMA Journal

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Develop skills for a reflective approach to existing work and the ability to produce additional work and research of relevance within their field of interest.

Continuation and development of the Swiss UCM module Since the first UCM module offered in Switzerland efforts have been made to improve the structure which has already proven its relevance and quality. For our new course starting in 2013 we have incorporated the UCM module in the Diploma of Advanced Studies (DAS) education module “Expertise in wound care and tissue viability” which will allow more students to enroll. Moreover it is now possible to complete the course independently and be credited for subsequent cumulatively accredited university education. This revised concept was presented in a free session during the EWMA 2012 conference in Vienna. We have also presented the previous Swiss concept and experience during the World Conference of Stomal Therapists5 in Phoenix, USA, in 2010, and at the Wound Healing Conference (CPC) in Paris in 2011. Based on our experience, we are convinced that this type of concept can be transferred to other conferences. For the new course, the requirements related to the completion of the report were revised to be consistent with the complete course offered. Thus, the presentation of the report before a supervisor from the workplace of the student has been cancelled as this type of evaluation was already covered in another module. With regards to costs related to participation in the Swiss UCM module, it should be mentioned that the course registration fee include the conference registration fee. The search for financial support to fund travelling and accommodation of students remains to be done with our partners: industry sponsors, local associations etc. An alternative module offered within the framework of the wound conference to be held in France targeting nonEnglish speaking students will also be initiated in 2013. Both UCM modules remain open to other students from other French-speaking countries. In collaboration with our Swiss German colleagues we hope to welcome these students to the Swiss UCM module in the years to come. In the meantime we will continue our evaluation of the module to secure continued development of the programme offered. m 1 2 3 4 5

www.ewma.org/english/education/ewma-ucm.html www.heds-ge-ch/portail/welcome.nsf/pages/fc_plaies_cicatrisationsF www.optra.net/fr/formations/ects.html http:safw-romande.ch www.wcetn.org

EWMA NEWS New EWMA Council Members

Ann-Mari F agerdahl (Sweden)

Magdalena Annersten Gershater (Sweden)

Georgina Gethin (Ireland)

Martin Koschnick (Germany)

Gerrolt Jukema (Netherlands)

Rytis Rimdeika (Lithuania)

Mentor Programme EWMA is able to offer writing support for novice researchers or non native English speakers who would like help reaching the standard of English required for publication or help with writing an academic paper. The mentors are experienced writers who agree to collaborate with the author with the aim of producing an article in line with standard quality criteria with regards to structure, content and language. If you choose to enter the mentor programme, the conditions are as follows: n The mentor will work with the author to finalise a draft article based on the available scientific reviews and general guidance on how to write a good article; n The mentor will enter into a formalised c ollaboration with the mentee in relation to the article and must therefore be included as co-author of the article; n It will be highlighted in the article that the author has received support from a mentor via the EWMA Journal Mentor Programme.

Whether EWMA can provide a mentor for a specific article will depend on the availability of a qualified mentor at the relevant time. For further information about the EWMA membership programme, please contact the EWMA Secretariat. Sue Bale, EWMA Journal Editor

EWMA is pleased to announce the result of the EWMA 2012 Elections for individual members and the Cooperating Organisation’s Board. This year there were five vacancies in Council available to individual members of EWMA. The results were Rytis Rimdeika (Lithuania), Gerrolt Jukema (Netherlands), and Martin Koschnick ( Germany) were re-elected to Council while Magdalena Annersten Gershater (Sweden) and Georgina Gethin (Ireland) were elected to Council for the first time. In the election to the Cooperating Organisation’s Board there was one vacancy, to which Ann-Mari Fagerdahl (Sweden) was elected. In addition, Salla Seppänen (Finland) was elected as President Elect and will step up as President in 2013. Dubravko Huljev (Croatia) became the new Secretary after Patricia Price (United Kingdom) who stepped down. The EWMA Council welcomes its new members and looks forward to working with them.

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Appreciations

Council Members Leaving, May 2012

Luc Gryson became a member of EWMA Council in 2006 and held the honorary post of EWMA Treasurer between 2007-2010. Luc has a great amount of expertise within the area of wound care with focus on leg ulcers, nutrition and SkinTears, among others. He has shown a great commitment to EWMA by actively participating in the Education Committee, the Patient Outcome Group, the Scientific Committee and the Scientific Review Panel. As the Co-president of the Belgian Federation of Wound Care (BEFEWO) and through his involvement in other wound associations he has achieved great success and experience from which the EWMA Council has gained much. In particular in relation to the EWMA 2011 conference held in Brussels in collaboration with the Belgian wound organisations BEFEWO, Afiscep and CNC, where Luc played a significant role. Luc has also contributed to a deeper understanding and contribution to the financial infrastructure and stability of EWMA. His presence in EWMA Council has been of great value and I thank him for his strong commitment. I am sure that Luc will continue being a part of EWMA in the years to come. Eskild W. Henneberg joined EWMA Council in 2009 as a representative elected by the Cooperating Organisations of EWMA. In addition to having represented The Danish Wound Healing Society (DSFS) in the Cooperating Organisations Board, Eskild has also been – and still is – a member of the EWMA Scientific Committee and the Scientific Review Panel. With his expertise in vascular surgery and wound healing in general, Eskild has shown great commitment and interest in bringing his innovative ideas and creativity to different EWMA projects and most recently to the EWMA Wound Survey, which was piloted in Denmark. His skilled eye for the ethics and rules of EWMA has been of great value during the years. His contribution to the EWMA Council has been much appreciated and I look forward to his continuing input in the Scientific Committee and to the collaboration with the Danish Wound Healing Society focusing with regards to EWMA 2013 in Copenhagen. Patricia Price joined EWMA Council in 2005 and was, among many other posts, EWMA’s Honorary Secretary from 2009-2012. During her time in EWMA Council she has been very active and a highly valued member of the Executive Committee, Scientific Committee, Education Committee and the Patient Outcome group (20112014), which she is currently chairing and into which she has put a lot of effort. Patricia’s skills in coordinating and leading working groups have been very much appreciated during her years in EWMA. The success of these and the Council meetings are much dedicated to her professionalism and her focused way to achieve results and consensus. Through her work, she has contributed to the continued development of the scientific profile of EWMA. Patricia is one of the central driving forces for the publication of the POG Evidence document. Her skills in advocating a clear message for outsiders and getting to the point are renowned and evident. I would like to thank you for your contribution and your commitment, which are noticeable throughout EWMA. Your commitment is much appreciated and we sincerely hope that you will continue to contribute to the goals of EWMA and participate in future projects. Jan Apelqvist, EWMA President EWMA Journal

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The EWMA Teacher Network Report from the first meeting held in May 2012

T Zena Moore Chair of the EWMA Education Committee www.ewma.org

he first meeting of the EWMA Teacher Network was held during the EWMA 2012 Conference. Prior to the meeting an invitation was sent to all contacts from European educational institutions. In total 37 wound management teachers asked to be included in the network and 26 of these were able to attend the first meeting. The primary objectives of the meeting were to share expectations and ideas for the network, to define current challenges and acknowledge the need for knowledge sharing within the European educational institutions offering wound management education.

Based on this; two activities for the first year (2012-2013) were defined and agreed on: n The network will examine the existing prequalification (undergraduate) programmes and standard competence levels on wound management for nurses throughout Europe. This will be done by a survey forwarded to all relevant institutions in Europe. Based on the survey results members of the Teacher Network will agree on standard learning outcomes for undergraduate nurse students on the topic of wound management.

The network will initiate a dissemination of the relevant wound management guidelines with the recommendation that they be followed to all relevant educational institutions. The objective is to ensure that wound management education is based on the best practice as defined by the primary wound management organisations in Europe and that nurse students throughout Europe are familiar with existing guidance. EWMA looks forward to initiating these activities during autumn 2012. I would like to thank all the participants at the first meeting of the EWMA Teacher Network for their great contribution to the discussions and planning at the meeting. The EWMA Teacher Network is open to all active wound management teachers interested in sharing their experience and supporting the continuous development of wound management education within Europe. The next meeting of the network will be held during the EWMA 2013 Conference 15-17 May in Copenhagen, Denmark. Please contact the EWMA Secretariat at ewma@ewma.org for further information about the network or how to join.

Group discussions during the first Teacher Network meeting, May 2012.

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PolyMem’s unique formulation has the ability to reduce patients’ total wound pain experience while actively encouraging healing1,2,3

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 S k i n Te a r s  B u r n s  F r a g i l e S kin 

References: 1. Sessions R. Examining the Evidence for a Drug free Dressing’s Ability to Decrease Wound Pain. Poster Presentation. Clinical Symposium on Advances in Skin & Wound Care. October 2008. Las Vegas, NV USA. 2. Stenius M. Fast Healing of Pressure Ulcers in Spinal Cord Injured (SCI) People Through the Use of PolyMem® Dressings. Poster Presentation. EWMA. May 2008. Lisbon, Portugal. 3. Tamir J, Haik J. Polymeric Membrane Dressings for Skin Graft Donor Sites: 4 Years Experience on 800 Cases. Poster Presentation. Clinical Symposium on Advances in Skin & Wound Care. October 2008. Las Vegas, NV USA.

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EWMA

EWMA PATIENT PANEL

T Salla Seppänen Chair of EWMA Patient Panel, EWMA President Elect www.ewma.org

EWMA Patient Panel

he establishment of the EWMA Patient Panel was decided by the EWMA Council in March 2012 and presented at the Cooperating Organisations Board meeting during the Vienna conference. The aim of this panel is, amongst others, to formally recognise the role of the patient as an important resource in the work of the interdisciplinary wound care team. Further, it will allow EWMA to maintain a continuous and active dialogue with patient representatives. The Panel will be set down over the next six months and is scheduled for inauguration at EWMA 2013 in Copenhagen. The Patient Panel will consist of members of the EWMA Council as well as representatives of European associations working with patient involvement. A group of patients representing different countries and wound aetiologies may be created and support the Patient Panel as an expert advisory body. The Panel will actively involve the EWMA Cooperating Organisations in reaching patients in different settings across Europe. The Cooperating Organisations will be asked to assist the EWMA Council and Secretariat in setting-up contact to patient groups as well as to overcome language barriers. Therefore, the first activity of the panel is to ask all EWMA Cooperating Organisations to fill in a brief questionnaire to uncover any existing organisations of wound patients in their countries. By means of the questionnaire EWMA wishes to strengthen its understanding about which tools are available for European wound patients and if there are local or national organisations or associations who currently supports their cause. In the longer term the goals to be reached by the EWMA Patient Panel are to strengthen the role of the patient in wound management and facilitate a dialogue to uncover ineffective treatment due to lack of patient involvement and empowerment.

Visit EWMA on our Social Media platforms Follow us and get the latest updates about the EWMA 2013 Conference as well as other EWMA activities:

www.facebook.com/ EWMA.Wound

www.linkedin.com/company/ european-wound-managementassociation

Twitter: @ewmatweet

I would like to encourage all EWMA Cooperating Organisations and individual EWMA members to contact the EWMA Secretariat if you have knowledge of patient activities in your country, which you consider relevant to the work of the Patient Panel. m

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Say hello to SNaP.

My partner in healing. The SNaP® Wound Care System combines the portability of advanced wound dressings with the proven efficacy of negative pressure therapy in a discreet design that won’t get noticed. o

Small, silent, lightweight design disappears under clothes

Demonstrated non-inferiority in wound healing outcomes for patients completing at least 4 weeks of therapy1

The SNaP ® System interferes significantly less with overall activity, sleep and social interactions than the V.A.C.® System1

Active healing that’s out of sight. www.spiracur.com Spiracur Inc. 1180 Bordeaux Drive Sunnyvale, CA 94089 +1.408.701.5300 1. Armstrong, D. G., W. A. Marston, et al. “Comparative Effectiveness of Mechanically and Electrically Powered Negative Pressure Wound Therapy Devices: A Multicenter Randomized Controlled Trial.” Wound Rep Reg 2012; 20: 332-341. Spiracur, SNaP and SNaP & Design are registered trademarks of Spiracur Inc. U.S. and certain foreign patents pending. www.spiracur.com/legal ©2012 Spiracur Inc. All rights reserved.

EWMA DOCUMENTS EWMA will publish three new documents in 2012 and 2013: EWMA document on Debridement

EWMA Document on Antimicrobials

This document will provide an updated overview of the various debridement options. It will offer a clarification of the principal role of debridement and define the possibilities and limitations for standard and new debridement options. The document is expected ready for publication in November 2012.

This document will meet the on-going discussion across Europe concerning the issues and controversies of the use of antimicrobials in wound treatment. The document will be launched at the EWMA 2013 Conference.

Clinical study guidelines on non healing wounds The guidelines will include a checklist with relevant research questions, frequent mistakes and links to other relevant sources of information. With these guidelines the POG group aims to support the recommendations included in the 2010 POG document on evidence and outcomes: Outcomes in controlled and comparative studies on non healing wounds – Recommendations to improve quality of evidence in wound management

Outcomes in controlled and comparat ive studies on non-healin g wounds Recom

mendations to improve the of evidence in quality wound manage ment

A EWMA Patient

Planned Projects:

EWMA front cover.indd

Outcome Group

Document

20/5/10 13:14:26

EWMA is planning two projects in 2013: Home Care – Wound Care and Multidisciplinary Treatment

All EWMA Documents can be downloaded from www.ewma.org For further details contact: EWMA Secretariat, Nordre Fasanvej 113, 2000 Frederiksberg, Denmark · Tel: +45 7020 0305 · Fax: +45 7020 0315 · ewma@ewma.org

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Advocacy for better wound management in Europe

ith the objective of advocating for the implementation of better wound management practices across Europe, EWMA is involved in the European Innovation Partnership on Active and Healthy Ageing (AHAIP) set down by the European Commission. The overall objective of the Partnership is to increase the healthy lifespan of EU citizens by two years by 2020, by improving the health and quality of life of older people, improving the sustainability and efficiency of care systems and creating growth and market opportunities for businesses. This engagement is one of the activities originating from the EWMA collaboration with the Eucomed Advanced Wound Care Sector Group.

About AHAIP AHAIP is a new initiate by the European Commission which brings together a wide array of stakeholders from the public and private sectors, to work in a collaborative and voluntary way on shared interests, activities and projects. The partnership focuses on three overall areas of activity,1 of which EWMA has committed itself to becoming actively involved in the area “Care & Cure”. Specifically, EWMA has entered the Action Group established to explore the theme “Capacity building and replicability of successful integrated care systems”. For further reading about AHAIP please visit http://ec.europa.eu/research/innovation-union/ index_en.cfm?section=active-healthy-ageing The Action Group on Integrated Care and the Expected Role of EWMA The aim of the Action Group in which EWMA is involved is to “Reduce avoidable/unnecessary hospitalisation of older people with chronic conditions through the effective implementation of integrated care programmes and chronic disease management models”.

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The Action Group is formed around European regions and institutions which are already engaged in the implementation of integrated care activities, and have committed themselves to contributing to AHAIP.2 The role of EWMA in the Action Group is to contribute experience, contacts and network to the implementation activities taking place. While the specific content of the Action Plan is still being developed, the expectation is that EWMA may contribute to the work of the Action Group on, as a minimum: n Organisational coordination to achieve integrated care pathways of chronic conditions - Care pathway redesign (Process optimisation by the identification of standardised protocols, procedures and activity workflows); n Workforce Development, Education and Training of Formal & Informal Carers - Re-design of workforce roles - Effective functioning of multidisciplinary team by introduction of integrated ICT innovative tools and solutions - Participatory environment of multidisciplinary team functioning - Reinforcement of the role of nurse, social workers and volunteers (community professionals) in the provision of integrated care

Jan Apelqvist EWMA President Chair of the EWMA Advocacy group www.ewma.org

EWMA considers AHAIP a significant window of opportunity for establishing wound management on the agenda at the European policy level as well as for promoting our messages regarding focus on multidisciplinary treatment and the cost of wounds. m 1 A) Prevention, screening & early diagnosis; B) Care & Cure and C) Active ageing & independent living 2 Examples include: The Scottish Centre for Telehealth and Telecare (Coordinated by NHS24), which is the appointed coordinator of the “Care & Cure” Action Group; “The Department of Health and Consumer Affairs of the Basque Government” and “The European Platform for Patients’ Organisations, Science and Industry”, which are both coordinators of sub-working groups.

Outlook and programmes for wound care in UK and USA Eucomed Advanced Wound Care Sector Group (AWCS) perspectives

Hans Lundgren Chair of the Eucomed Advanced Wound Care Sector Group Correspondence: Hans.Lundgren@ molnlycke.com www.eucomed.org

he Eucomed AWCS group (www.eucomed.org) was founded back in June 2007, and since then we have had twenty-two regular meetings. At present there are eight companies in the group: B. Braun, Covidien, ConvaTec, KCI, Mölnlycke Health Care, Paul Hartmann, Smith & Nephew, and Sorbion. In addition we work in active partnership with EWMA and Policy Action. The purpose of this paper is to give an update of the health care winds that are blowing in the UK and USA, with a focus on advanced wound care.

Regulatory & Standards Ensure industry positions on MDD (Medical Device Directive) Revision are reflected in the UK input to “Formal Proposal”. Establish clear and structured relationship with MHRA (Medicines and Healthcare Products Regulatory Agency) Devices Division. n Ethics & Compliance Establish ABHI Code of Business Practice as standard for NHS interactions with suppliers. Develop member employee accreditation system for interaction with NHS. All representatives from medical device companies need to have an accreditation (£5000 per representative). n

The next step for the Eucomed AWCS group will be to deliberate on a partnership with ABHI.

April 2012, Visit to ABHI (Association of British Healthcare Industries, www.abhi.org.uk) ABHI is a very active and well-recognized tradeorganization, which has recently started a sector group for Advanced Wound Management (AWM). Current members of this group are 3M, Convatec, Covidien, Smith & Nephew and Systagenix.

April 2012, SAWC (Symposium on Advanced Wound Care) The SAWC Spring 2012 was arranged in Atlanta, Georgia, USA. There was a broad range of sessions and posters presented, but I will restrict my report to meetings with external stakeholders and policy makers.

ABHI 2012 priorities: n UK Market Create industry position on procurement and gain NHS (National Health Service) agreement. Adopt industry leadership role on implementation of IHAW (Innovation Health and Wealth). n International Develop industry position on trade support mechanisms and influence government. Minimise barriers to trade with China, Brazil and India.

CWCM (Coalition of Wound Care Manufacturers) 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, it will focus on regulatory, government and public affairs issues that affect wound care manufacturers.

In practice, the Coalition presents industry information for – Congress

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– Regulatory agencies e.g. Centers for Medicare and Medicaid Services (CMS) and its contractors: Durable Medical Equipment Medicare Administrative Contractor (DME MAC), A/B MAC Medical Directors and Pricing Data Analysis Contractor (PDAC) – Food and Drug Administration (FDA), State Medicaid Agencies, Agency for Healthcare Research and Quality (AHRQ) and Medicare Payment Advisory Commission (MedPAC). These federal agencies control the coding, coverage and payment rules under Medicare and Medicaid for wound care products. The current landscape includes challenges to the Health Reform, and deficit reduction within/without an economic recovery. There is much uncertainty in the time to come including: – The Presidential election (Nov 2012) and its potential effect on the next Congress, the next CMS and the next FDA – The Medicare programs of 2013 and beyond – Physician Payment Sunshine Act The Sunshine Act will influence the wound care business directly · Requires each “applicable manufacturer” to report each “payment or other transaction of value” made to a “covered recipient” i.e. “physician” or “teaching hospital” · Research-related payments i.e. made in connection with research on or clinical investigation of a new product or new application of an existing product · CMS has proposed a complex reporting structure for research-related payments – The FDA of 2013 and beyond – What Can Make a Difference for All Health Care Costs? · Changes in the way health services are delivered · Payment methods that bundle payments; pay for efficiencies or savings; aggregate payments · Changes in consumer engagement and consumer preferences · Health care workforce · Political/fiscal discipline · Is your product part of the solution or part of the problem? · Who are the innovators and are they your best friend? – Accountable Care Organisations (ACO) · ACOs are health care teams working together · Wound care is a team work · Pioneer ACO Model Participants (currently there are 32 organizations selected to participate) EWMA Journal

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· Innovation Advisors Program (IAP) · Currently there are 73 individuals selected to participate

AWCS (Alliance of Wound Care Stakeholders, www.woundcarestakeholders.org). The “Alliance” was founded 10 years ago, and became a 501 (c)(6) trade association in 2011. The case for transforming into a non-profit trade association are mainly: higher visibility working with regulatory agencies, (submission of POWER (Panel On Wound care Evidence-based Research) manuscript to payer and clinical journals, and) lobbying activities make the Alliance better suited for (c)(6) status.

There are three different membership categories: – Clinical associations (16 different American associations, of which AAWC, Association for the Advancement of Wound Care, is one) – Non-clinical associations (currently two members: American Association of Wound Care Management, and Coalition of Wound Care Manufacturers) – Non-clinical business entities (currently 12 different companies). The Agency for Healthcare Research and Quality (AHRQ) is dedicated to improving the quality, safety, efficiency, and effectiveness of health care for all Americans. It is one of 12 agencies within the U.S. Department of Health and Human Services. Working with the public and private sectors, AHRQ builds the knowledge base for what works, and what does not work, in health and health care and translates this knowledge into every day practice and policymaking. Focus areas: – Evidence-based Practice Centers – review and synthesize scientific evidence for conditions or technologies that are costly, common or important to the Medicare and Medicaid programs. – Three technology assessments focusing on wound care under review: · Pressure ulcers · Venous stasis ulcers · Skin Substitutes

Summary: As you can see, the US network of wound care stakeholders is complex but also very fragmented. There are many challenges in the US healthcare system, leading to a considerable uncertainty in the near- and intermediate-term future. m

Corporate Sponsors Corporate A KCI Europe Holding B.V. www.kci-medical.com

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

ConvaTec Europe www.convatec.com

Lohmann & Rauscher www.lohmann-rauscher.com

Sorbion AG www.sorbion.com

Covidien (UK) Commercial Ltd.

Mölnlycke Health Care Ab www.molnlycke.com

Systagenix Wound Management www.systagenix.com

Paul Hartmann AG www.hartmann.info

Ferris Mfg. Corp. www.PolyMem.eu

Corporate B B. Braun Medical www.bbraun.com

DryMax www.drymax.com

SastoMed www.sastomed.com

3M Health Care www.mmm.com BSN medical GmbH www.bsnmedical.com www.cutimed.com Abbott Nutrition www.abbottnutrition.com

Advanced BioHealing, Inc. www.AdvancedBioHealing.com

Flen Pharma NV www.flenpharma.com Argentum Medical LLC www.silverlon.com

Nutricia Advanced Medical Nutrition www.nutricia.com Söring www.soering.com

Chemviron www.chemvironcarbon.com Organogenesis Switzerland GmbH www.organogenesis.com

AOTI Ltd. www.aotinc.net

ArjoHuntleigh www.ArjoHuntleigh.com

Curea Medical GmbH www.curea-medical.de

Phytoceuticals www.1wound.info

Laboratoires Urgo www.urgo.com

Welcare Industries SPA www.welcaremedical.com

Drawtex www.drawtex.com EWMA Journal

2012 vol 12 no 3

Organisations

Conference Calendar Conferences

Theme

City

Country

3-6

Bydgoszcz

Poland

Linking clinical expertise in EB Oct

5-7

Salzburg

Austria

1st National Multidisciplinary Congress for Wound Professionals

Oct

8-9

Ede

Netherlands

Pisa International Diabetic Foot Courses

Oct

8-11

Pisa

Italy

National Congress of the Belgian Federation of Wound Care (BEFEWO)

Oct

Uccle

Belgium

4th Scientific Congress of the Polish Wound Management Association (PWMA) 1st EB-CLINET Conference

XV Congress of Hungarian Wound Care Society (MSKT)

2012

Days

Oct

18-19 Budapest

Hungaria

Oct

24-26 Primosten

Croatia

Symposium of Portuguese Association for the Treatment of Wounds (APTFeridas) 2012

Oct

25-26 Porto

Portugal

Annual Meeting of the Icelandic Wound Healing Society (SumS)

Oct

HUR Symposium

Atypical wounds

Iceland

Wounds UK Harrogate 2012

Sharing Best Practice

Nov

12-14 Harrogate

United Kingdom

Bi-annual Meeting of GNEAUPP

Ulceras por Presión y Heridas Crónicas

Nov

14-16 Sevilla

Spain

4th Inter-regional Conference

Wound: Current issues of pathogenesis and treatment

Nov

15-16 Novgorod

Russia

Nov

15-17 Rheine

Germany

The Neuropathic Osteoarthropathic Foot (Charcot Foot Course) Biennial Meeting of the Danish Wound Healing Society (DSFS)

Pressure Ulcers with a focus on prevention

Nov

22-23 Kolding

Denmark

International Congress for Wound Management of the Serbian Wound Healing Society (SWHS)

Chronic Wounds, Current Treatment Outcomes

Nov

23-24 Belgrade

Serbia

Nov

29-30 Kiev

Ukraine

Annual meeting of Ukrainian Wound Treatment Organisation (UWTO)

2013 Annual Conference of The French and Francophone Society of Wounds and Wound Healing (SFFPC)

Jan

20-22 Paris

France

X National Conference of the Czech Wound Management Society (CSLR)

Jan

24-25 Pardubice

Czech Republic

XVI National Wound Management Conference of the Finnish Wound Care Society (FWCS)

JanFeb

31-1

Helsinki

Finland

Feb

7-8

Oslo

Norway

Annual Meeting of the Norwegian Wound Healing Society (NIFS)

Traumatic and Surgical Wounds

Wound Congress of Clinical Nursing Consulting (CNC) – Wondzorg

Feb

Swedish Wound Care Nurses Association (SSiS) Annual Conference

Apr

15-16 Stockholm

Sweden

Annual Conference of Tissue Viability Society (TVS)

Apr

17-18 Kettering

United Kingdom

Spring Symposium on Advanced Wound Care and Wound Healing Society (SAWC)

May

23rd Conference of the European Wound Management Association (EWMA)

Organisation and Cooperation in Copenhagen

Diabetic Foot Study Group (DFSG) 2013 Pisa International Diabetic Foot Courses 2013

Management of the D iabetic Foot

7-8

Denver

USA

May

15-17 Copenhagen

Denmark

Sep

20-22 Barcelona

Spain

Oct

2-5

Pisa

Italy

For web addresses please visit www.ewma.org

Submit your paper to EWMA Journal www.ewma.org EWMA Journal

2012 vol 12 no 3

Published by EUROPEAN WOUND MANAGEMENT ASSOCIATION

Organisations

AAWC NEWS AAWC Association for the Advancement of Wound Care

Robert J. Snyder DPM, MSc, CWS President, AAWC

It is my pleasure to provide an update to the readers of the EWMA Journal on the recent affairs of the Association for the Advancement of Wound Care (AAWC). As the first podiatrist President of the AAWC and with support from the AAWC Board of Directors, it was agreed that creating a platform to address the escalating epidemic of diabetic foot complications and promoting amputation prevention are worthwhile endeavours for the AAWC to pursue. By promoting a multidisciplinary approach and working in tandem with organisations such as Save a Leg, Save a Life (SALSAL) and the American Diabetes Association, among others, we can initiate a meaningful network, strengthen our efforts, and create a pathway to help diminish the suffering of individuals with this disease.

www.aawconline.org

As a secondary benefit, this initiative could open the door to increased corporate support and grants to help our organisation grow, while also furthering our AAWC Global Volunteers program. I am also pleased to report that an evidenced based guideline concerning foot ulcers in patients with diabetes is planned.

EWMA international Partner Organisation

The AAWC Global Volunteers program remains ongoing and represents our organisation’s dedication to foster good works by providing training to clinicians in resource poor areas worldwide. This program is open to all members of the AAWC. When the program was established, we developed a partnership with Health Volunteers Overseas (HVO) that initially focused on areas of the world relying on little to no medical infrastructure. This required the development of wound care training modules suitable to each country that could be translated to the meaningful care of patients. To augment this initiative, AAWC will now expand this successful model to the United States. An aging population within our country, coupled with a dramatic increase in diabetes and related conditions, creates an environment where our expertise and resources are critical.

Join AAWC at a discounted rate for clinicians through December 31, 2012! Low rates for students and retired clinicians! Industry memberships are available! Please visit www.aawconline.org

Lastly but by no means least, we will be organising a “One Voice” initiative to develop dialogue and cohesiveness between many of the professional organisations and societies involved in the wound care field. We are already working with EWMA on a project paper regarding the importance and necessity of the multidisciplinary approach to wound care. Discussions regarding shared concerns and goals among many organisations could lead to consensus on various wound care related topics worldwide. Here in the US, we expect this initiative to ultimately allow our professionals to speak to patients, payers, and US governmental agencies with “one voice”. With potential changes and uncertainty as to how medical care will be rendered and reimbursed in our country in the future, these accords remain critical in ensuring our survival. We look forward to our collaboration with EWMA as we move into the next phase of the AAWC’s plans. Our mission is to be a leader in interdisciplinary wound healing and tissue preservation. If you are not a member, please consider joining at a discounted rate for clinicians through December 31, 2012. There are also low rates for students and retired clinicians, and industry memberships are also available. Please view the many financial and other benefits offered and join at www.aawconline.org. n

EWMA Journal

2012 vol 12 no 3

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bolog e l h P o t er er.de

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Organisations

Sociedad Española de Heridas SEHER The Spanish Society of Wounds

Xavier Santos Heredero President of SEHER (Sociedad EspaÒola de Heridas) PhD, MD, Chief of the Department of Plastic Surgery and Professor of Surfery at the University Hospital MonteprÌncipe, Madrid, Spain www.sociedad espanolaheridas.es

SEHER is a non-profit scientific organization founded in 2008. The aim of SEHER is to bring all professionals involved in wound care together in a partnership with the following objectives: n Promote excellence in research, education, prevention, care and treatment of all kinds of wounds. n Promote the concept of a multidisciplinary approach in the management of wounds, while safeguarding the areas of competence of each professional group. n Encourage a constant promotion of the knowledge of the health professionals involved. n Cooperate with other associations or groups whose goals are to improve the quality of the management of wounds. n Spread among the population procedures and behaviours which help to improve the treatment and care of wounds. In order to achieve and promote these objectives SEHER organizes and sponsors a number of scientific activities. An annual Congress on Wounds and Healing (Congreso de Heridas y Cicatrización) will take place every year. The first was in 2011 and the second in 2012; more than 1500 professionals attended each one. In the Congresses an effort is made to invite pre-eminent experts in the different fields of wound healing, both international and national. Plenary sessions give the delegates the opportunity to learn the most up to date approaches to the hot topics in wound management and research. Round tables are designed to discuss different aspects on five main topics: diabetic foot, pressure ulcers, burns, vascular wounds and surgical wounds. A program of workshops gives the delegates the chance to have real hands-on sessions on basic and advanced techniques in wound management. The average figures of the past two Congresses was 80 speakers, 95 free communications and 112 posters. Our next Congress will take place in autumn 2013 in Madrid.

EWMA Cooperating Organisation

In addition to the Congress, SEHER organizes and sponsors a number of instructional scientific meetings such as annual courses on Scientific Methodology, Plastic Surgery and Diabetic Foot. For next spring it has scheduled a Symposium in Barcelona on Negative Pressure Therapy. SEHER leads the Academia SEHER de Cuidado de Heridas (SEHER Academy on Wound Management). The Academy is the means by which SEHER teaches and improves the knowledge and skills level

of professionals dealing with wounds. It has five areas: Burns, pressure ulcers, vascular wounds and surgical wounds and uses a mixed methodology including virtual and on site learning. The program is modular based so ultimately the professional can add modules to his curriculum to end in a university masters degree. Heridas & Cicatrización (H&C) is the journal of SEHER. Issue number 1 was published in 2010 and to date ten issues have been released. Each issue features between nine and ten papers. Each issue has at least one review paper presenting the state of the art opinion on different topics on wound healing. In addition, there are three to four original articles from both national and international authors, and there is also a paper which focuses on the role of a multidisciplinary team approach to wound management. Every issue also presents some clinical cases and a press review with comments on relevant papers which have appeared in other journals. Every paper has an English abstract. SEHER supports different research projects in the field of wound management such as proteases in chronic wounds, infection in diabetic foot, dermal substitutes in burns, physiopathology of scars. In Spain wounds have traditionally been managed by nurses, mainly because of the disinterest of doctors. SEHER is trying to involve more medical specialties in wound management as we believe that wounds must be approached and treated by a multidisciplinary team. In the last years some Wounds Units have been developed in hospitals and are achieving excellent results in terms of lowering morbidity, hospitalization, and economic costs. All the activities of SEHER are focused on encouraging more and more professionals to participate in this multidisciplinary approach to wound management. Spain is currently living in a deep economic crisis and health care cannot escape its repercussions. Economic cuts in the budgets dramatically affect health providers in wound care; more and more health products are being removed from the catalogue of financed materials by the national health system. SEHER, as a scientific organization, is willing to become a valid interlocutor with the health authorities to provide information and advice, and to work with the decision makers to develop a health policy supported by scientific foundations. n

EWMA Journal

2012 vol 12 no 3

See the complete details online including continuing education statements, learning objectives, session descriptions, faculty credentials, information for submitting oral and poster abstracts, and registration information.

2-K041

Organisations

The Ukrainian Wound Treatment Organisation (UWTO)

UWTO Ukrainian Wound Treatment Organisation

The Ukrainian Wound Treatment organisation was founded in 2009. Nowadays UWTO has over 110 active members. Among them are medical professionals and doctors from a range of specialties such as surgeons, burn specialists, podiatrists, vascular surgeons, plastic surgeons, hospital nurses and caseworkers. Currently, the population of Ukraine is 45.660 mio. people. The administrative division is 24 regions, plus the Autonomous Republic of Crimea. Ukraine has four towns – Kiev, Kharkov, Odessa, and Dnepropetrovsk; the population of each of these is more than one mio. people. The UWTO has local subdivisions in 16 regions of the 24.

Conferences

Georgij Kozinets Professor, M.D. UWTO Vice-President

Zoya Ishkova Executive Director of UWTO www.uwto.org.ua

EWMA Cooperating Organisation

The UWTO has its own annual Conference. To date it has held 12 conferences which makes it apparent that the conferences were held before the creation of UWTO. This in turn means that the problem of wound care has been around and recognised for a long time; in the present and in the past. The next Annual Conference of UWTO will be held in the P.L. Schupik National Academy of Postgraduate Education in Kiev, November, 29-30, 2012. The conferences are very popular as illustrated by the fact that they are attended by a large number of specialists involved in wound treatment and its challenges – burn specialists, surgeons, vascular surgeons, micro vascular surgeons, plastic surgeons and other healthcare professionals. During the conferences there are discussions covering the problems of rendering assistance to patients with wounds of different etiologies, discussions investigating the wound development process under the different conditions of surgical treatment, and the influence of wounds on the development of systemic inflammatory response. In addition, other discussion topics include: – Factor analysis of the systemic inflammatory response development and multiple organ failure; – Mechanisms of the development of inflammatory complications and staging of sepsis development; – Decision making and recommendations for the practitioners on the treatment of wounds of varying etiologies wounds; – Treatment of different etiology wounds during a war period.

Wound management system in Ukraine

Research programs and projects

We have also developed methods of conservative and surgical rehabilitation of patients with cicatricial deformation and contractures, and conducted research studies observing the influence of autologous adipocytes (stem cells) and platelet-derived growth factors on the processes of reversed development of cicatricial tissue. n

The research programs on wounds treatment foresee different schools taking part in inflammatory reactions development pathogenesis studies and researching conditions of blood circulation for reparative regeneration with usage of different medical preparations: antiseptics, biologic and syn82

thetic coverings, different methods of surgical treatment with usage of complex grafts with axial or perforant types of blood circulation. In addition educational programs on the treatment of wounds of different etiologies were developed. These programs are taught within departments of burns and plastic surgery in higher education institutions of postgraduate education. Presentations of the research results on the conditions of wounds healing or their surgical renewal studies are made within the framework of the annual UWTO Conference. Annual conferences of regional surgeons are also held, to which leading specialists are invited as guest speakers.

Currently there exists a staged system of wounds treatment to ensure the correct rendering of qualified medical aid to suit the level of wound. This is done in stages through regional hospitals and healthcare, where anti-shock activities and first surgical treatments are carried out. The wounds which are not large are treated locally, but those patients with complicated wounds who need special methods of surgical treatment are moved for specialist treatment into clinics. In these institutions patients receive highly specific treatment including usage of modern complex methods of surgical reconstruction of soft tissues defects. Nowadays wounds treatment in Ukraine utilises modern antiseptics, medical preparations of osmotic action with antibacterial effect, biological coatings developed in Ukraine and foreign synthetic coatings for dermal wounds healing.

Opportunities and challenges In Ukraine there is a lack of modern coatings for the development of reparative regeneration of deep dermal and subfascial injuries. We also lack cellular technologies for the activation of reparative regeneration of deep wounds; thus definition and usage of cellular factors of reparative regeneration are being actively developed. The investigations on cultivating allogeneic keratinocytes for the renewal of cutaneous covering integrity are currently being carried out. We are developing and implementing methods of deep wounds treatment utilising tissue compound complexes during dermotension, grafts with axial type of blood circulation and perforant vessels for different injured body regions.

EWMA Journal

2012 vol 12 no 3

Call for Papers Journal of Tissue Viability Journal of Tissue Viability is a quarterly journal concerned with all aspects of the occurrence and treatment of wounds, ulcers and pressure sores including patient care, pain, nutrition, wound healing, research, prevention, mobility, social problems and management. The Journal particularly encourages papers covering skin and skin wounds but will consider articles that discuss injury in any tissue. Articles that stress the multi-professional nature of tissue viability are especially welcome. We seek to encourage new authors as well as well-established contributors to the fi eld - one aim of the journal is to enable all participants in tissue viability to share information with colleagues. We are excited to invite you to publish in Journal of Tissue Viability, an international, peer reviewed journal.

ISSN: 0965-206X

Official Journal of the Tissue Viability Society.

For more information visit: www.journaloftissueviability.com

Editor in Chief: D. Bader, Southampton, UK

TYPES OF PAPERS

International editorial board:

• Clinical Study • Basic Research Study • Case Report • Review Articles • Letters to the Editor

ABSTRACTED & INDEXED IN: • BioInfoBank Library • Medline • PubMed • Science Direct • Scopus

C. Dealey, UK L. Edsberg, USA A. Gefen, Israel S. Hagisawa, Japan A. Nelson, UK J. Nixon, UK H. Partsch, Austria M. Romanello, Italy L. Schoonhoven, Netherlands L. Stockton, UK J. Swaine, Australia T. Young, UK

Submit your paper online now! http://ees.elsevier.com/jtv

SILAUHE Iberolatino american Society of Ulcers and Wounds

Mara Blanck President SILAUHE

J. Javier Soldevilla Vicepresident SILAUHE www.silauhe.org

Constituent Act Signatories of the SILAUHE. November 2008

The Iberolatinoamericana Ulcers and Wounds Society (SILAUHE) was created in Tarragona (Spain) in November 2008, with the object of furthering and defending within the scope of the area regarding treatment of ulcers and other injuries and those responsible for their care, treatment, ethics, and ethical aspects, as well as the dignity and cultural technical prestige of these healthcare professionals, and the scientific and research development on these processes in all the member countries. The purpose of this society is proposed within a regime of freedom, autonomy, representativeness and participation of its partners. Membership of SILAUHE is made up of representatives from the different registered associations and legally constituted scientific groups or commissions of health organizations in the countries of the network area dedicated to or interested in tasks related to ulcers and wounds.

The last General Assembly was held in September; where members of this association with full rights, the countries of Argentina, Brazil, Chile, Spain, Italy, Mexico, Portugal and Uruguay met. Furthermore we were pleased to confirm cooperation with two new associations and possibly many other interested contacts from numerous countries. From May 2012 EWMA has accepted SILAUHE’s inclusion as an International Partner Organization. This wide geographical area of America and Latin Europe maintains historical, cultural, socio-economic and linguistic ties with deep roots, incorporating nearly seven hundred million people. The heterogeneity in the care of the different health care systems of these countries has developed into noticeable differences in the care of patients with wounds. No doubt the close relationship that SILAUHE is going to establish between member countries will serve to improve the quality of care,

EWMA international Partner Organisation

Since the 1st Symposium on Pressure Ulcers and Chronics Wounds in T arragona (Spain) in 2008 in conjunction with the wound care associations of each country, there have been three other Symposiums in Brazil (Rio de Janeiro), Salvador (Bahia) and Mexico (Puebla). The 5th Congress was held in Montevideo (Uruguay).

EWMA Journal

2012 vol 12 no 3

Organisations

as well as research related to these health problems, through large epidemiological projects in the area. From its website (www.silauhe.org) SILAUHE is trying to harmonize a tool for liaison between the various associations that make up SILAUHE and future work for training activities, etc. SILAUHE is currently working on the development of procedures for accreditation for scientific activities and technical documents in this network. . This will help move forward the request from the OPS/WHO, for the creation within SILAUHE of an Ulcers and Wounds Network. A formal network of professionals dedicated to the theme of wounds and wound care, which will develop, create and share information, experience, and successful practices and thereby enrich wound care services in all the member countries.

SILAUHE ASSOCIATIONS

APTFeridas (Associação Portuguesa de Tratamento de Feridas)

Conferenza Italiana per lo Studio e la Ricerca sulle Ulcere, Piaghe, Ferite e la Riparazione Tessutale

GNEAUPP (Grupo Nacional para el Estudio y Asesoramiento en Ulceras por Presión y Heridas Crónicas)

It is a strategy of cooperation, solidarity and synergy among scientific societies, institutions, organisations and programs concerned with the development of knowledge, care, management and research in the prevention and treatment of ulcers and other wounds.

The General Assembly of the SILAUHE, held in Rio de Janeiro in October 2011, agreed on the text of the Declaration of Rio de Janeiro, Preventing Ulcers Pressure is a Universal Right, and translated it into several languages. In addition, as well as calling for the 1st World Day for the Pressure Ulcers Prevention to be held on November 16, 2012, SILAUHE is inviting members to organize celebrations in different countries in our region. Similarly the invitation was extended to European organisations, such as EWMA and EPUAP, who agreed to join this world day. There will be numerous and diverse activities scheduled for that day in the different consenting countries. n

ELCOS (Sociedade Portuguesa de Feridas y Cicatrización)

Comisión permanente de enfermería Secretaría de Salud (Mexico)

GAIF (Grupo Associativo de Investigação em Feridas)

SCUH (Sociedad Científica Uruguaya de Heridas)

GEHUPP (Grupo de Estudio de Heridas y Úlceras

por Presión – Tucumán – Argentina)

SOBENFeE (Sociedade Brasileira de Enfermagem em Feridas e Estética)

Sociedad Chilena de Heridas y Cicatrización

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 two 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 Journal

2012 vol 12 no 3

Cooperating Organisations AFIScep.be

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

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

FWCS

AISLeC

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

Italian Nurses’ Cutaneous Wounds A ssociation www.aislec.it

GAIF

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

Associated Group of Research in Wounds www.gaif.net

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

ICW

AWA

Chronic Wounds Initiative www.ic-wunden.de

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

LBAA

BEFEWO

Latvian Wound Treating O rganisation

Belgian Federation of Woundcare www.befewo.org

LUF

BWA

The Leg Ulcer Forum www.legulcerforum.org

Bulgarian Wound Association www.woundbulgaria.org

LWMA

CNC

Lithuanian Wound Management Association www.lzga.lt

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

CSLR

MASC

Czech Wound Management Society www.cslr.cz

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

CWA

MSKT

Croatian Wound Association www.huzr.hr

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

DGfW

MWMA

German Wound Healing Society www.dgfw.de

Associated Organisations

Macedonian Wound Management Association

International Partner Organisations AWMA

ILF

Lindsay Leg Club Foundation www.legclub.org

Australian Wound Management Association www.awma.com.au

International Lymphoedema Framework www.lympho.org

LSN

AAWC

NZWCS

The Lymphoedema Support Network www.lymphoedema.org/lsn

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

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

Debra International

SILAUHE

Leg Club

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

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

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

European Federation of National Associations of O rthopaedics and Traumatology www.efort.org

Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

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

EWMA Journal

2012 vol 12 no 3

Organisations

NATVNS

STW Belarus

National Association of Tissue Viability Nurses, Scotland

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

NIFS Norwegian Wound Healing Association www.nifs-saar.no

NOVW Dutch Organisation of Wound Care Nurses www.novw.org

PWMA Polish Wound Management Association www.ptlr.pl

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

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

SAWMA Serbian Advanced Wound Management Association www.lecenjerana.com

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

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

SWHS Serbian Wound Healing Society www.lecenjerana.com

SWHS Swedish Wound Healing Society www.sarlakning.se

TVS Tissue Viability Society www.tvs.org.uk

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

UWTO Ukrainian Wound Treatment Organisation www.uwto.org.ua

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

SEHER The Spanish Society of Wounds www.sociedadespanolaheridas.es

SFFPC

WMAI Wound Management A ssociation of Ireland www.wmai.ie

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

WMAK

SSiS

WMAS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

SSOOR Slovak Wound Care Association www.ssoor.sk

Wound Management Association of Kosova

Wound Management Association Slovenia www.dors.si

WMAT Wound Management A ssociation Turkey www.yaradernegi.net

Other Collaborators DFSG

Eucomed

Diabetic Foot Study Group www.dfsg.org

Eucomed Advanced Wound Care Sector Group www.eucomed.org

EADV

ICC

European Academy of Dermatology and Venereology www.eadv.org

EBA European Burns Association www.euroburn.org

EPUAP European Pressure Ulcer Advisory Panel www.epuap.org ETRS

ETRS European Tissue Repair Society www.etrs.org

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2012 vol 12 no 3

International Compression Club www.icc-compressionclub.com

MSF Médecins Sans Frontières www.msf.org

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

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

5 Editorial

Science, Practice and Education

6 Therapeutic strategies for diabetic foot ulceration RJ Hinchliffe, JRW Brownrigg

13 Offloading the diabetic foot: Evidence and clinical decision making S.A. Bus

17 Soft-tissue complications during treatment of children with congenital clubfoot A. Baindurashvili, V. Kenis, Y. Stepanova

21 An evolution in Medical Tapes: From Latex to Acrylic L. Gryson

27 Bacteria and fungus binding mesh in negative pressure wound therapy – A review of the biological effects in the wound bed M. Malmsjö, S. Lindstedt, R. Ingemansson, L. Gustafsson

33 Conservative Sharp Wound Debridement – State of play in Australia J. C. Rice

Cochrane Reviews

40 Abstracts of recent c ochrane reviews S. Bell-Syer

EWMA

42 EWMA Journal Previous Issues an Other Journals 44 EWMA 2012 in Vienna G. Zöch, G. Jukema

48 DSFS – What can we do? What will we do? J. Fonnesbech

52 The Cooperating Organisations Board Meeting 2012, Vienna Z. Moore

54 The Austrian Diabetic Foot Symposium G. Köhler

58 Symposium for russian speakers at EWMA 2012 Vienna R. Rimdeika

61 EWMA UCM experience, Vienna 2012 – An evaluation B. Ø. Melby, S. Wichmann

64 The UCM in Switzerland: Development and prospects L. Chabal, C. Wyndham-White

66 EWMA News 68 The EWMA Teacher Network – a report Zena Moore

70 The EWMA Patient Panel S. Seppänen

73 Advocacy for better wound management in Europe J. Apelqvist

74 EUCOMED – Outlook and programmes for wound care in UK and USA H. Lundgren

76 EWMA Corporate sponsors

Organisations

77 Conference Calendar 78 AAWC – Association for the Advancement of Wound Care R. J. Snyder

80 SEHER – The Spanish S ociety of Wounds X. S. Heredero

82 UWTO– Ukrainian Wound Treatment Organisation G. Kozinets, Z. Ishkova

84 SILAUHE – Iberolatinoamerican Society of Ulcers and Wounds M. Blanck, J. J. Soldevilla

86 EWMA Cooperating Organisations