EWMA Journal October 2008

Volume 8 Number 3 October 2008 Published by European Wound Management Association

THE EWMA UNIVERSITY CONFERENCE MODEL

READ ALL ABOUT IT INSIDE

EWMA Council

The EWMA Journal ISSN number: 1609-2759 Volume 8, No 3, October, 2008 Electronic Supplement October 2008: www.ewma.org The Journal of the European Wound Management Association Published three times a year

Marco Romanelli

Editorial Board Carol Dealey, Editor Deborah Hofman, Editor Electronic Supplement

President

Michelle Briggs Finn Gottrup E. Andrea Nelson Marco Romanelli Zbigniew Rybak Peter Vowden

Sue Bale Recorder

Luc Gryson

Zena Moore

Carol Dealey

Finn Gottrup

Treasurer

Secretary

EWMA web site www.ewma.org Editorial Office please contact: EWMA Business Office Congress Consultants Martensens Allé 8 1828 Frederiksberg C, Denmark.

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

Paulo Alves

Jan Apelqvist

EWMA Journal Editor

Marcus Gürgen

Layout: Birgitte Clematide Printed by: Kailow Graphic A/S, Denmark Copies printed: 13,000 Prices: Distributed free of charge to members of the European Wound Management Association and members of co-operating associations.

Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published January 2009.

Prospective material for publication must be with the editors as soon as possible and no later than 1 November 2008 The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association.

Copyright of all published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction obtained from both the Author and EWMA via the Editorial Board of the Journal, and proper acknowledgement and printed, such permission will normally be readily granted.

Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval.

Severin Läuchli

Maarten J. Lubbers

Sylvie Meaume

E. Andrea Nelson

Patricia Price

Salla Seppänen

José Verdú Soriano

Rita Videira

Peter Vowden

CO-OPERATING ORGANISATIONS’ BOARD Pauline Beldon, UK Andrea Bellingeri, Italy Saša Borović, Serbia Rosine van den Bulck, Belgium Mike Clark, UK Mark Collier, UK Rodica Crutescu, Romania Bülent Erdogăn, Turkey Milada Francu, Czech Republicl Kiro Georgievski, Macedonia Georgina Gethin, Ireland Finn Gottrup, Denmark João Gouveia, Portugal

Luc Gryson, Belgium Marcus Gürgen, Norway Mária Hok, Hungary Gabriela Hösl, Austria Dubravko Huljev, Croatia Hunyadi János, Hungary Arkadiusz Jawień, Poland Els Jonckheere, Belgium Aníbal Justiniano, Portugal Susan Knight, UK Martin Koschnik, Germany Jozefa Koskova, Slovak Republic Aleksandra Kuspelo, Latvia Ton Lassing, the Netherlands

Editorial Board Members Carol Dealey, UK (Editor) Michelle Briggs, UK Finn Gottrup, Denmark Deborah Hofman, UK E. Andrea Nelson, UK Marco Romanelli, Italy Zbigniew Rybak, Poland Peter Vowden, UK

EWMA Journal Scientific Review Panel Paulo Jorge Pereira Alves, Portugal Zena Moore, Ireland Caroline Amery, UK Karl-Christian Münter, Germany Mark Collier, UK Pedro L. Pancorbo-Hidalgo, Spain Bulent Erdogan, Turkey Patricia Price, UK Madeleine Flanagan, UK Rytis Rimdeika, Lithuania Milada Franců, Czech Republic Salla Seppänen, Finland Peter Franks, UK José Verdú Soriano, Spain Luc Gryson, Belgium Rita Gaspar Videira, Portugal Gabriela Hösl, Austria Carolyn Wyndham-White, Switzerland Zoltán Kökény, Hungary Gerald Zöch, Austria

Goran Lazovic, Serbia Christina Lindholm, Sweden Magnus Löndahl, Sweden Sandi Luft, Slovenia Kestutis Maslauskas, Lithuania Sylvie Meaume, France Karl-Christian Münter, Germany Guðbjörg Pálsdóttir, Iceland Alessandro Scalise, Italy Salla Seppänen, Finland José Verdú Soriano, Spain Anne Wilson, UK Carolyn Wyndham-White, Switzerland Skender Zatriqi, Kosova

For contact information, see www.ewma.org

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EWMA

Journal 2008 vol 8 no 3

Dear Reader

I 3 Editorial

Carol Dealey

Science, Practice and Education 5 Eucomed – Advanced Wound Care Sector (AWCS).

Positioning of advanced wound care Hans Lundgren

11 A Laboratory Survey of the Antimicrobial Properties of ­Honey-Containing Dressings Rowena Jenkins

17 Topical negative pressure versus ­conventional treatment of deep sternal wound infection in cardiac surgery Martin Šimek

23 Quality of Life in the Patients with Chronic Leg Ulcers – A Preliminary Report Veronika Slonkova

25 Compression therapy for venous leg ulcers – how to get more value for money Susan F. Jørgensen

EBWM 32 Abstracts of recent ­Cochrane Reviews Sally Bell-Syer

EWMA 38 EWMA Journal Previous Issues 38 International Journals 40 The EWMA University Conference Model: Lessons learned from Lisbon Zena Moore

42 EWMA2008 First Time presenter 44 EWMA Travel Grants 47 EWMA 2008 – a very successful ­conference in Lisbon!

Finn Gottrup

52 EWMA Corporate Sponsor Contact Data 54 WUWHS 2008 Marco Romanelli

Conferences 56 Conference Calendar

Organisations 57 ICW-activities 58 Cooperating Organisations 59 Associated Organisations

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Journal 2008 vol 8 no 3

t seems no time since we were anticipating the EWMA Conference in Lisbon, closely followed by the World Union of Wound Healing Societies (WUWHS) meeting in Toronto. It is fair to say that both meetings were very successful and provided great opportunities to make contact with colleagues in other countries to discuss wound care issues. One of the things that stood out for me in Lisbon was the excitement of the students involved in the University Conference Model. Most students attending a university course at whatever level do not get the chance to attend a local conference as part of their course, let alone an international one. So this opportunity which allowed them to hear a considerable number of internationally renowned speakers as well as getting to know students from other countries is unparalleled.

For those of you who are not quite sure what the EWMA University Conference Model actually is, there are more details in Zena Moore’s report on pages 40-41. However, the short answer is that a participating university running a wound management course uses the conference to form one of their modules. The course leader selects relevant lectures, free papers and workshops and so on for the students so that they fulfill the specific requirements of their course. The course leader and students meet regularly throughout the conference to discuss what they have learnt. Needless to say, the conference is a lot of hard work for the course leaders!

Moving onto the WUWHS meeting, we have a formal report from the meeting on page 54. In addition, I would like to give my personal congratulations to three of EWMA’s Past Presidents who were presented with Life Time Achievement Awards at the conference.

They were Christine Moffat, George Cherry and Finn Gottrup. They have all made major contributions to wound healing and management in their different ways over the years as well as to EWMA and it was very nice to see this being recognized at the meeting.

This issue of the Journal has our usual mixture of scientific papers, reports and news items.

We also have something completely new in the Electronic Supplement: papers from the Polish journal “Leczenie Ran” (Wound Management) translated into English. Although we have occasionally translated a paper into English so it can be shared with a wider audience, this is the first time that we have had a collection of papers translated. The purpose is to showcase some of the research and developments in wound healing being undertaken in one country and only published in the language of that country. It allows our readership to learn more about the country in relation to wound management and gives the research greater exposure. We intend to dedicate one electronic supplement a year to this venture, utilizing interested journals of EWMA’s Cooperating Organisations. I am indebted to Deborah Hofman, the Electronic Supplement Editor, for her hard work in facilitating the selection process, checking the translations and so on. Deborah selected 10 abstracts of papers relevant to the EWMA Journal published over the last two years. They were then read by the Editorial Board who selected the best five papers for the Supplement. We welcome any comments from readers on this venture.

Another new venture that is discussed within the pages of this issue is the formation of an Advanced Wound Care Sector (AWCS) within the European Medical Technology Association (EUCOMED). As can be seen in the paper by Hans Lundgren, this is an interesting new venture to try and raise awareness of the burden of chronic wounds within the European Union. EWMA is an active partner in this project and it is only by developing this type of collaborative partnership with the wound care industry that we can hope to get chronic wounds onto the agenda in Brussels. A number of unsuccessful initiatives have been undertaken over the years with much the same goals. However, AWCS has a carefully planned strategy which would seem to have a greater potential for success. I know that I have written optimistically in the past about the possibility of the European Commission funding research in wound healing and wound management and never seen my hopes materialize, but maybe, just maybe, this new venture will be successful and we will be able to undertake some of the large multi-centre studies that are necessary to provide us the type of evidence we need to support our clinical practice.

Carol Dealey 3

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Science, Practice and Education

Eucomed – Advanced Wound Care Sector (AWCS)

EWMA2008

Presented at the 18th Conference of the European Wound Management Association, 14-16 May 2008, Lisbon, Portugal

Positioning of advanced wound care

Abstract Background: For companies in the wound care sector, the lack of a common voice in Europe has hindered the visibility and promotion of the industry to political and policy decision-makers, and the creation of a regional awareness of the issues around chronic wounds. With the mechanisms of healthcare systems being different within the EU Member States, a common EU approach and collaboration within the industry is essential.

Strategy: The industry solution has been to create a sector group for Advanced Wound Care (AWCS) under the auspices of Eucomed (European Medical Technology Industry Association). This sector group will also work in active partnership with the European Wound Management Association (EWMA).

Objective: The overall objective of the sector group is to raise the profile of advanced wound care, and bring it into the context of current and future social healthcare issues under debate.

Goals: Short term goals (less than 1 year) n Present a ‘Burden-of-Illness Paper’ on chronic wounds in Europe n Present an article around ‘Evidence in Wound Care’ n Participate in a ‘Clinical Working Group’ to evaluate outcome measures other than just healing efficacy n Arrange a ‘Wound Care Session’ in Brussels n Initiate a ‘Data Collection Programme’ of wound care epidemiology in selected countries n Position the ‘Best Evidence Standpoint’ to the 3Ps (payers, practitioners and patients) Medium term goals (1-3 years) n Educational activities about health economics, cost-effectiveness and patient related outcomes n Continuation of the ‘Data Collection Programme’ to a number of European countries

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Journal 2008 vol 8 no 3

n Scoping and defining the trends within ‘Primary vs. Secondary Care’ (Cost consequence analysis) Long term goals (2-5 years) n To promote and get acceptance of ‘Innovation in Wound Care’ Conclusion: Modern wound management is complex and could have a huge impact on a patient’s everyday life. Therefore it is important that all involved parties work together to minimize the patient suffering and to optimize health care costs for the entire society.

INTRODUCTION Eucomed (www.eucomed.org) is a trade organization for medical technology companies and national associations in Europe. It is based in Brussels with a broad network and many various focus groups within e.g. patient safety, regulatory affairs, economic affairs, home care and now also advanced wound care.

Modern wound care is complex and furthermore supported by opaque and heterogeneous funding and reimbursement systems. The health care sector is full of ongoing “projects”, “official reports” and “reorganizations”. They have their place, but much of tomorrow’s success can only come from wrestling with real and concrete issues like: What is evidence? How should evidence be measured? What is the value proposition of a new technology? Etc. The purpose of this article is to give a description of the fruitful collaboration between practitioners, represented by EWMA and the wound care industry (represented by companies from Eucomed). Group members: Hans Lundgren (Chairman, Mölnlycke Health Care), Johannes G. Böttrich (B. Braun), Kristina Jensen (Coloplast), Ameer Ally (ConvaTec), David Hibbitt (Covidien), Julie Bjerregaard (EWMA), Finn Gottrup (EWMA), Luc Gryson (EWMA), Henrik J. Nielsen (EWMA), Laurent Metz (Johnson &

Hans Lundgren Medical Director Mölnlycke Sweden Hans.Lundgren@ molnlycke.com

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Science, Practice and Education

Johnson), Achim Vogel (Paul Hartmann) and John Posnett (Smith & Nephew).

Founded in June 2007 with the support of a White Paper1, the AWCS group has had six regular meetings resulting in the creation of a goal and strategy plan.

POSITIONING OF ADVANCED WOUND CARE Chronic wound management is not only about a single dressing, it is much more than that. By definition any device/dressing does not have any pharmacological effect in itself but must by applied by a practitioner on a patient with a chronic wound. What makes it then so complicated? Because in the real clinical world there are various diagnostic and prognostic instruments, differentiated procedures and application techniques, different knowledge and habits of the practitioners, and very often old patients with all sorts of comorbidities. All these ingoing variables make the treatment so complex and thus the patient outcomes so unforeseeable and uncertain. This outlook also means that any patient with a chronic wound is unique and consequently should be treated with the most suitable tools/dressings.

For many people in the inner circle (health care professionals and wound care companies) these daily conditions are well-known but for the outer circle (politicians, policy makers, purchasing managers, patients etc.) they are often completely unknown. That is why we must present advanced wound care in a daily environment, where the dressing is not a simple consumable but a specially designed tool for the clinicians in their multidisciplinary treatment of wounds and chronic ulcers. By this approach you will see that the dressings are only a small part of the total costs and the combination device + clinician + patient must be seen as a health technology. So by defining advanced wound care as a medical technology we can enter the scene of HTA (Health Technology Assessment) discussions. A consequence of that will be that we can bring the evidence debate to a higher and more scientific level and also to reach a broader target audience. Eucomed has recently published a HTA Position Paper2.

SHORT TERM GOALS Burden-of-Illness Paper To get a stable foundation for our work and discussions, Prof. John Posnett (S&N) is working on a ‘Burden-ofIllness Paper’ in chronic wounds (venous ulcers, pressure ulcers and diabetic ulcers) in Europe. The data collection and literature search have focused on quality of life, prevalence and cost of treatment in France, Germany, Italy,

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Spain, UK and a number of smaller countries. The overall argumentation will be illustrated by examples/data from the literature. Geographical spread has a priority to the extent possible (not cost data from all countries).

Efforts should be made to connect the study to the reimbursement discussion with key points such as, n Access is a key issue, e.g. pressure ulcers can be prevented if the right products are used. n Making sure that the proper products are available to people – essential to decrease total costs.

Article on ‘Evidence in Wound Care’ In the continuing evidence debate, Prof. Finn Gottrup has published a letter in the British Medical Journal3 where he proposed the establishment of a clinical working group to address the controversial issue of evidence in wound care. As a follow-up to this letter, Prof. Finn Gottrup will write an article to highlight the published evidence of the benefits of advanced wound care interventions compared to traditional products.

EWMA Patient Outcome Group Supported by the Eucomed AWCS group, EWMA has decided to start a clinical working group to address the ongoing evidence debate as to the level of clinical evidence required to justify the use of modern wound dressings and their reimbursement. Both industry and clinicians have been invited to join the group which is established on the basic idea that industry and clinicians should cooperate on common goals.

Wound Care Session The goal of the AWCS group is to feature modern wound care and the ongoing work in the sector group, with the ‘Burden-of-Illness Paper’ as a central piece. Market access is also a key issue, because there are too many obstacles when companies are trying to get new innovative products into the market. Both demand for evidence to introduce new products but also to keep products on the market.

The competition for a slot-time in Brussels is fierce, and it is always difficult to reach the right target audience due to other lobbying activities. One possibility to create awareness and educate around chronic wound care is through a separate breakfast/lunch/dinner event to relevant target audience at the European Parliament, the  Commission or other policy decision-makers.

EWMA

Journal 2008 vol 8 no 3

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• Gel cushions in a way that only a Gelling www.convatec.com Foam dressing can 2

References: 1. Vanscheidt W, Münter K-C, Klövekorn W, Vin F, Gauthier J-P, Ukat A. A prospective study on the use of a non-adhesive gelling foam dressing on exuding leg ulcers. J Wound Care 2007; 16: 261-265. 2. Bishop S. Versiva® XC™ Gelling Foam Dressing cushioning and protection claims R&D justification.

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Science, Practice and Education

MEDIUM TERM GOALS Data Collection Programme Epidemiology studies should be conducted in as many European countries as possible. Based on a common protocol, the studies should be limited to prevalence and costs. E.g. start with leg ulcers – like the EWMA Eastern European leg ulcer project, but without the implementation part (too complicated and expensive to do in all countries).

The standardized tool (protocol) should n Include information about who treats and outcomes n Show prevalence in all countries n Use the Eastern European implementation study to show what can be done to limit costs related to chronic wounds n Connect with prevalence figures in all countries to show how costly chronic wounds are Educational activities Education about health economics, cost-effectiveness, quality of life and patient outcomes is needed. EWMA will define a curriculum in cooperation with the AWCS group, identifying the different aspects of wound care relevant for company staff.

Courses will be held in Brussels (European course) and as national courses (arranged in cooperation with the national organizations). The course could be over several days with the possibility for attendants to choose for participation some or all days, depending on the specific need.

Primary vs. Secondary Care We should try to scope and define the trends within primary and secondary care. Which are the definitions of acute vs. chronic wounds? Is primary care more cost-effective than hospital care? If yes, is the health care sector willing to invest in early diagnosis and prognostic instruments to reduce the treatment time and total costs? (costconsequence analysis).

Is there any correlation between acute and chronic wound healing? E.g. can we use evidence from acute wounds in the chronic wounds area?

because of the constant pressure on health care budgets.

That is why all the above activities and projects are so important and must be tackled in joint efforts and combined operations.

At the same time the industry is worried about the bottlenecks and the opacity of the reimbursement process, which make investments in research, innovation and product development risky and hazardous.

Finally, the evolution and multifold support of innovations within wound care are imperative to improve patient outcomes and in extension the socio-economic conditions.

ETHICS IN THE COLLABORATION BETWEEN INDUSTRY AND CLINICIANS At all meetings and collaboration between companies and health care professionals, ethics and the code of conduct are essential. The AWCS group follows the ‘Eucomed Ethics and Guiding Principles’ which are signed by ­participants at all meetings. (www.eucomed.be/abouteucomed/ethics.aspx) CONCLUSION This paper only represents a synopsis of all the challenges and opportunities in modern wound management, but the key message is that real and lasting results can only be achieved through a broad collaboration between all active and interested stakeholders in the health care sector. Many problems and defiances in wound care are common for the whole sector, and can not be solved by a single system participant. Therefore we need an interaction between practitioners and the industry, and this AWCS group is the visual evidence of such initiative.

It is my hope that this group will be a significant contributor to the safety and well-being of patients in the wound care sector and also to take a leading position in the improvement of health care systems. m References 1. Eucomed AWCS White Paper, October 2007.

2. Eucomed HTA Position Paper, June 2008.

3. Gottrup F. Evidence controversy in wound management. BMJ online 3 March 2008.

LONG TERM GOALS Innovation in Wound Care Continuously there will be a strong demand for rapid patient access to effective, reliable and safe technologies, which only can be materialized through innovative wound management. On the other hand, innovative medtechs are subject to increasing scrutiny before being reimbursed,

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EWMA

Journal 2008 vol 8 no 3

Do you speak with your patients about wound pain?

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A secondary dressing needs to be applied to keep the non-adhesive Biatain Ibu dressing in place

New evidence confirms the advantages of Biatain Ibu1

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Wound pain challenges a patient’s quality of life.

of the foam dressing Biatain Ibu1,3,4,5,6. Thanks to

However, until recently the debate has focused on

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1. Domenech et al. Effect of an ibuprofen-releasing foam dressing on wound pain: a real-life RCT. Journal of Wound Care 2008;17(8):342-348. 2. Woo et al. Assessment and management of persistent (chronic) and total wound pain. International Wound Journal 2008;5:205–215. 3. Durante et al. Improved health related activities of daily living for patients with wound pain treated with an ibuprofen foam dressing. Poster presented at EWMA 2007. 4. Flanagan et al. Case series investigating the experience of pain in patients with chronic venous leg ulcers treated with a foam dressing releasing ibuprofen. World Wide Wounds 2006. 5. Jørgensen et al. Addressing venous leg ulcer with a new ibuprofen releasing and pain-reducing foam dressing. Poster presented at EWMA 2007. 6. Schäfer et al. Effects of a foam dressing with ibuprofen on exuding, painful wounds: quality of life parameters from an international, comparative real life study. Poster presented at EWMA 2008 & WUWHS 2008. 7.Jørgensen et al. Pain and quality of life for patients with venous leg ulcers: Proof of concept of the efficacy of Biatain-Ibu, a new pain reducing wound dressing. Wound repair and regeneration 2006;14(3):233-239. 8.Steffansen & Herping. Novel wound models for characterizing the effects of exudates levels on the controlled release of ibuprofen from foam dressings. Poster presented at EWMA 2007.

Coloplast and Biatain are registered trademarks of Coloplast A/S or related companies. © 2007-08. All rights reserved Coloplast A/S, 3050 Denmark.

CALL FOR ABSTRACTS

ABSTRACT DEADLINE 15 JANUARY 2009

Science, Practice and Education

EWMA2008

Presented at the 18th Conference of the European Wound Management Association, 14-16 May 2008, Lisbon, Portugal

A Laboratory Survey of the Antimicrobial Properties of ­Honey-Containing Dressings

Abstract Background: Many new sterile honey impregnated wound dressings have recently become available for clinical use. These dressings contain different honey formulations, and therefore differing antibacterial efficacy.

Aim: To investigate the antimicrobial properties of six licensed wound dressings containing honey.

Method: 2 x 2 cm samples of each of six honey containing dressings were applied to the surface of bioassay plates seeded with overnight broth cultures of bacteria. The organisms tested: Staphylococcus aureus NCTC 6571, EMRSA-15 NCTC 13142 and a clinical isolate of Pseudomonas aeruginosa. The plates were incubated at 37°C for 24 hours. Zones of inhibition were measured and corrected zone sizes calculated, the plates were prepared in duplicate on three separate occasions.

Results: Two dressings gave negligible zones of inhibition with each of the three test organisms.

The remaining four dressings gave distinct zones of inhibition with all organisms, staphylococci were found to be more sensitive to honey than pseudomonads.

Conclusion: The dressings that caused inhibition of the test organisms all contained manuka honey at relatively high concentrations. The dressings that did not give rise to zones of inhibition contained other honeys at lower concentrations. The type and concentration of honey in wound dressings influences efficacy in vitro.

Introduction Honey has been used since ancient times as not only a food source but also a medicinal product and was used routinely in British hospitals up until the 1970s, however with the advent of antibiotics use of honey was reduced and eventually lost from mainstream medicine. Since the advent of antibiotic resistance there has been a growing

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Journal 2008 vol 8 no 3

need for wound management products that can act as an alternative to antibiotics1.

Honey has several advantages as a wound therapy product, showing broad spectrum antimicrobial activity against bacteria, protozoa and some viruses2-6. It has also been reported to improve wound healing, stimulate wound healing factors, remove sloughy tissue and reduce wound odour79. There are several reasons for the antimicrobial action. Honey has a high sugar content leading to high osmolarity in the wound, removing water available for bacteria, and it also has a low pH unsuitable for the growth of most wound infecting pathogens. Some honeys generate hydrogen peroxide on dilution in a wound and others contain phytochemicals which may account for their antimicrobial activity10.

Honey wound products have now been on the market in the UK since 2004 and several brands are available. Not all of the dressings produced are the same; they can be made of differing materials: gauze, tulle, mesh, polyethylenevinylacetate, alginate or hydrogel. They contain different types of honey such as Leptospermum honeys (manuka and jelly bush), others use buckwheat or unspecified honeys in their dressings. Some of the dressings also contain formulations adding components such as aloe vera and cod liver oil. These differing products need comparative analysis to ensure that informed decisions can be made when selecting them for clinical practice.

Methods Test Organisms n Staphylococcus aureus NCTC 6571 (Oxford staph) n Epidemic methicillin-resistant Staphylococcus aureus (EMRSA-15) NCTC 13142 n Pseudomonas aeruginosa (clinical isolate)

Rowena Jenkins Neil Burton, Rose Cooper, University of Wales Institute Cardiff Corresponding author: R. E. Jenkins, Centre for Biomedical ­Sciences, Cardiff School of Health ­Sciences, University of Wales Institute Cardiff, Western Avenue, Cardiff CF5 2YB UK r.jenkins7@uwic.ac.uk

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Table 1. Semi-quantitative growth of 3 species of bacteria on the upper surface of six dressings (barrier effect) NG = no growth from upper surface of ­dressing after subculture onto new medium; + = light growth, ++ = growth, +++ = heavy growth.

All three Leptospermum ­honey impregnated calcium alginates were effective ­barriers against strikethrough of staphylococci.

Dressings

Oxford Staphylococcus aureus

EMRSA

P. aeruginosa

NG

NG

+++

NG

NG

+++

NG

NG

+++

NG

++

+++

+

+

+++

+

++

+++

Leptospermum impregnated calcium alginate 1 Leptospermum impregnated calcium alginate 2 Leptospermum impregnated calcium alginate 3 Leptospermum impregnated tulle Buckwheat impregnated mesh Multifloral impregnated mesh

Figure 1. Zones of inhibition caused by six wound dressings against EMRSA-15.

Zones of inhibition were observed around dressings 1-4 the Lepto­spermum honey impregnated dressings indicating that the test organisms were inhibited.

No zones of inhibition seen around dressings 5 and 6 the buckwheat and multi floral honey impregnated dressings.

Figure 2. Zones of inhibition caused by each of six dressings against three species of bacteria.

Solid line indicated Staphylococcus aureus most sensitive to the dressings ­giving largest zones of inhibition. Dashed line indicates zones of inhibition against EMRSA-15. Solid filled bars indicate zones of inhibition seen against ­Pseudomonas aeruginosa, much smaller zones seen, indicating less sensitivity to the honey impregnated dressings.

Dressings: Six different commercial honey ­impregnated dressings were used in the study: 1. Leptospermum impregnated calcium alginate 2. Leptospermum impregnated calcium alginate 3. Leptospermum impregnated calcium alginate 4. Leptospermum impregnated tulle 5. Buckwheat impregnated mesh 6. Multi floral impregnated mesh

Test methods Zone of inhibition: This tests measures the release of antimicrobial agents from dressings, it is an adaptation of a technique used to determine the antimicrobial sensitivity of organisms, by Thomas & McCubin, 2003.

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Test cell suspensions were prepared from 24 hour broth cultures of each organism, diluted with sterile broth to give optical density readings between 0.5 and 1 using a spectrophotometer (Cecil Instruments, Cambridge, UK) at wavelength 540nm. Sterile molten Tryptic Soy Agar (TSA) (Oxoid, Cambridge, UK) 200ml was inoculated with 0.2ml of the broth culture and poured into bio assay plates. Samples of the dressings cut to 2 x 2 cm squares were placed evenly on the plates once set and incubated overnight at 37°C. After incubation plates were examined for zones of inhibition, if one was detected the length and width were measured in mm.

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Journal 2008 vol 8 no 3

Science, Practice and Education Table 2. Semi-quantitative growth of three organisms on the lower surface of six dressings Dressings Leptospermum impregnated calcium alginate 1 Leptospermum impregnated calcium alginate 2 Leptospermum impregnated calcium alginate 3 Leptospermum impregnated tulle Buckwheat impregnated mesh Multi floral impregnated mesh

Oxford Staphylococcus aureus

EMRSA

P. aeruginosa

+

++

+++

NG

+

+++

+

+

+++

+

++

+++

+++

+++

+++

+++

+++

+++

Figure 3. The antimicrobial barrier effect of dressing 4, Leptospermum impregnated tulle tested against Staphylococcus aureus.

Figure 3. Leptospermum honey impregnated tulle showed zones of inhibition against S. aureus at 24 hours (picture on left). However after subculture of dressing underside (top plate) and upper surface of dressing (bottom plate) viable organisms were seen indicating that the inhibition effect was bacteriostatic.

Barrier effect of dressings: Samples of each dressing were tested on lawn plates prepared of each test organism on Petri dishes and incubated overnight at 37°C. The sample was then removed using sterile forceps and placed onto the surface of a sterile TSA plate and left for 5 minutes in the same orientation. A second set of sterile forceps was then used to lift the dressing; it was then inverted and

EWMA

Journal 2008 vol 8 no 3

NG = no growth under dressing after sub­culture onto new medium; + = light growth, ++ = growth, +++ = heavy growth.

Mode of action shown to be bacteriostatic from all ­dressings against all species of bacteria except Leptospermum honey impregnated ­calcium alginate 2 showing bactericidal action against S. aureus.

Figure 4. The antimicrobial barrier effect of dressing 2, Leptospermum honey impregnated calcium alginate 2 tested against Staphylococcus aureus.

Leptospermum impregnated calcium alginate 2 shows zone of inhibition against S. aureus (picture on left). After sub culture of dressing underside (top plate) and upper surface of dressing (bottom plate) effect was shown to be bactericidal, because no viable bacteria were recovered.

placed onto another sterile TSA plate. After five minutes the dressing was discarded and the plates incubated at 37°C for 24 hours (Edwards-Jones, 2006). Aseptic technique was used throughout; experiments were performed  in duplicate on three separate occasions.

13

Results Zone of inhibition: Both the buckwheat honey impregnated dressing and the multi floral honey impregnated dressing (5 and 6) showed no zones of inhibition against any species of bacteria. The Leptospermum honey impregnated dressings (1-4) gave zones of inhibition against all three species of bacteria (Figure 1). The staphylococci were more sensitive to this honey than the Pseudomonas aeruginosa (Figure 2).

Barrier effect of Dressings: There was no observed growth of either strain of Staphylococcus on the upper surface of the calcium alginate dressings, indicating that all three dressings were acting as a barrier preventing migration of bacteria from the surface of the TSA plate to the upper surface of the dressing (Table 1). The buckwheat and multi floral honey impregnated dressings allowed some translocation of bacteria from the surface of the plate to the upper surface of the dressings, indicating these dressings were not such an effective barrier (Table 1). The Pseudomonas aeruginosa penetrated through to the upper surface of all the dressings (Table 1). This experiment showed that mode of action was mainly bacteriostatic, dressings which had shown large zones of inhibition all allowed growth of organisms from the underside of the dressing once transferred onto fresh agar plates (Figure 3). The exception to this was Leptospermum honey impregnated calcium alginate number two which did not give rise to any colonies once transferred onto fresh plates, it therefore demonstrated a bactericidal mode of action against S. aureus (Figure 4) and (Table 2).

Discussion Health care associated infections continue to be a major problem in the health care environment, especially with an increase in the prevalence of antibiotic resistance. These infections can lead to delayed healing and increased morbidity, higher hospital costs and increased risk of spread of infection.

This in vitro study was designed to allow comparison of efficacy between the selected dressings as antibacterial devices and barriers.

The results of this study demonstrate that all of the Leptospermum honey impregnated dressings possessed sufficient antimicrobial activity to inhibit the growth of all the organisms tested. This result is not surprising in view of the known broad spectrum activity of Leptospermum honey.

The lack of zones of inhibition from the buckwheat and the multi floral honey impregnated dressings reinforces the importance of selecting the appropriate dressing for each wound individually. Not all honey impregnated dressings make antibacterial claims, and have greater potential for stimulating healing rather than having antiseptic properties.

The importance of careful dressing choice is again emphasized by the results of the barrier test; the Leptospermum honey impregnated tulle gave large zones of inhibition similar to those of the alginates, however only the alginates prevented migration of the staphylococci through the dressing therefore making honey impregnated alginates a more appropriate dressing if trying to prevent the spread of antibiotic resistant staphylococci into the environment or between individuals12. There could be several reasons why the other three dressings did not provide a barrier: the concentration of honey within the dressings may have been low, the antibacterial activity of the honey may have been too low, and the dispersal of honey within the dressings may have been inconsistent. In the case of the motile bacteria they could have penetrated from around the edges in.

The methods described here using zone of inhibition and barrier tests gave us semi quantifiable data (no kill rates) but allowed us to see that the honey impregnated dressings had differing modes of action on the bacteria tested13. Both bactericidal and bacteriostatic modes of action were observed, this again is probably due to the differing formulations and concentration of honey used within the dressings.

References: 1. Cutting, K. F. (2007). “Honey and Contemporary Wound Care: An Overview.” Ostomy Wound Management 53(11): 49-54.

7. Gethin, G. and S. Cowman (2008). “Case series of uses of Manuka honey in leg ulceration.” International Wound Journal 2(1): 10-15.

2. Al-Waili, N. S. and K. Y. Saloom (2004). “Topical honey application vs acyclovir for the treatment of recurrent herpes simplex leisons.” Medical Science Monitor 10(8): mt94-98.

8. Weyden, V. D. (2003). “The use of honey for the treatment of two patients with pressure ulcers.” British Journal of Community Nursing 8(12): S14-20.

3. Cooper RA, Molan PC, Harding KG (1999). “Antibacterial activity of honey against strains of Staphylococcus aureus from infected wounds.” Journal of the Royal Society of Medicine 92(6): 283-285.

4. Cooper R A, Molan PC, Harding KG (2002). “The sensitivity to honey of Gram-positive cocci of clinical significance isolated from wounds.” J Appl Microbiol 93(5): 857-63.

5. Willix D J, Molan PC, Harfoot CG. (1992). “A comparison of the sensitivity of wound-infecting species of bacteria to the antibacterial activity of manuka honey and other honey.” J Appl Bacteriol 73(5): 388-94.

6. Simon, A., K. Traynor, et al. (2008). “Medical Honey for Wound Care – Still the ‘Latest Resort’?” eCAM Advance Access: 1-9.

14

9. Thomas, S. and P. McCubbin (2003). “A comparison of the antimicrobial effects of four silver-containing dressings on three organisms.” Journal of Wound Care 12(3): 101-107.

10. Bogdanov S, Ruoff K, Oddo LP. (2004). “Physicochemical methods for the characterisation of unifloral honeys: a review.” Apidologie 35: S4-S17.

11. Thomas, S. and P. McCubbin (2003). “An in vitro analysis of the antimicrobial pro­perties of 10 silvercontaining dressings.” Journal of Wound Care 12(8): 305-308.

12. Edwards-Jones, V. (2006). “Antimicrobial and barrier effects of silver against methicillin resistant Staphylococcus aureus.” Journal of Wound Care 15(7): 285-290.

13. Thorn, R. M. S., J. Greenman, et al. (2005). “In vitro method to assess the antimicrobial activity and potential efficacy of novel types of wound dressings.”

Journal of Applied Microbiology 99: 895-901.

14. Holland, K. T. and W. Davis (1985). “A note on an in vitro test system to compare the bactericidal properties of wound dressings.” J. Appl. Bact 59: 61-63.

15. Cooper, R. A. (2007). “Iodine revisited.” International Wound Journal 4: 124-137.

16. Cooper, R. A. (2008). “Using honey to inhibit wound pathogens.” Nursing Times 104(3): 46-49.

17. Molan, P. and J. A. Betts (2004). “Clinical usage of honey as a wound dressing: an update.” Journal of Wound Care 13(9): 353-356.

18. Maeda, Y., A. Loughrey, et al. (2008). “Antibacterial activity of honey against community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA).”

Complementary Therapies in Clinical Practice 14: 77-82.

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Journal 2008 vol 8 no 3

Science, Practice and Education

Limitations of the Study: The bacteria tested here were grown in pure culture and it is likely that this does not closely representing the multi microorganism environment of a wound. The pH and oxygen availability of the wound would also be different to that of the agar plates14. Care must be taken when taking in vitro data into the clinical environment, as this study investigated the antimicrobial properties of these dressings and therefore did not take into account the wound healing properties or fluid handling capacity of the dressings. The results here show that Lepto­ spermum impregnated honey dressings have more effective antimicrobial properties than those impregnated with buckwheat or multi floral honeys and that the alginates were more effective as barriers. These results could vary if tested with a different model in vitro or if tested in vivo, as there would be more variables15.

Conclusion There is much evidence for honey as both an antibacterial and a wound healing agent and therefore impregnated dressings are desirable16-18. It has been demonstrated in this in vitro test that the Leptospermum honey impregnated calcium alginates exhibited not only effective antibacterial activity but also worked efficiently as barriers to staphylococcal spread. It also revealed that although all the dressDMS 1205-6 Intern.PressMap.EWMAad

2/24/06

2:07 PM

ings are honey impregnated, that there were differences in the properties of these dressings. Great care should be taken in selecting the appropriate one for use in a clinical situation.

Implications for Clinical Practice n Care should be taken when selecting a dressing to ensure that it is appropriate for the use intended.

Those dressings with highest antibacterial activity may not give highest wound healing activity. n Leptospermum calcium alginates have potential as an effective barrier to prevent spread of MRSA through the dressing.

Further Research: n Future research could investigate the performance of these dressings under a different model system. n There is a need to explore the other wound healing properties of dressings to get a view of the efficacy of the dressings as a whole. m

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Science, Practice and Education

EWMA2008

Presented at the 18th Conference of the European Wound Management Association, 14-16 May 2008, Lisbon, Portugal

Topical negative pressure ­versus conventional treatment of deep sternal wound infection in cardiac surgery

Abstract Background: Deep sternal wound infection is a devastating, potentially life-threatening complication following cardiac surgery. It is associated with a significant increase in morbidity and mortality and also with a significant utilization of hospital resources.

Aim: We sought to compare clinical outcomes, in-hospital mortality and 1-year survival of two different treatment modalities of deep sternal wound infection - topical negative pressure and conventional therapy.

Methods: Prospective analysis of 62 consecutive patients treated for deep sternal infection at our institution. A total of 28 patients (February 2002 through October 2004) underwent conventional treatment and 34 patients (November 2004 through October 2007) underwent the application of topical negative pressure. Clinical and wound care outcomes of both treatment strategies – focusing on therapeutic failure rate in-hospital and 1-year mortality – were compared.

Results: Topical negative pressure was associated with a significant lower failure rate of the primary therapy (p<0.05), a shortening of the intensive care unit stay (p<0.001), and, particularly, a decrease in the length of hospital stay (p<0.05) and the 1-year mortality (p<0.05). Comparable overall length of the therapy, in-hospital stay and the risk of wire-related fistulas after the chest reconstruction were found.

Conclusion: Topical negative pressure is a superior method of treatment for deep sternal wound infection, based on lower therapeutic failure rate, significant decrease in hospital stay, and the decrease of 1-year mortality rate, compared with the conventional therapy methods.

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Journal 2008 vol 8 no 3

Introduction Deep sternal wound infection (DSWI) is considered one of the most feared complications following a median sternotomy. It affects 0.5% to 5% of patients (1). This carries a considerable mortality rate ranging from 10% to 40%, long-term morbidity of survivors and almost three times higher cost than uncomplicated surgery. This represents a challenging problem for modern cardiac surgery (2, 3). Several treatment strategies have been adopted for the treatment of DSWI including surgical debridement with closed irrigation, open dressing with delayed chest reconstruction, and more recently, the application of topical negative pressure (TNP) followed by subsequent chest closure (4,5,6,7). However, there is little consensus among surgical teams on the ideal management of DSWI (8).

Methods Between 2002 and 2007, 62 patients underwent treatment of DSWI at our institution. The diagnosis of DSWI was based on the guidelines of the Centre for Disease Control since 1996 (9). From March 2002 to October 2004, 28 patients underwent conventional treatment (CONV group) of DSWI involving one-step surgical debridement followed by chest rewiring and closed irrigation with antiseptics for six to eight days. Consequently, from November 2004 to December 2007, 34 patients were primarily scheduled for the application of TNP (TNP groups). In this group, surgical debridement with repetitive application of TNP (Vacuum-assisted closure™, KCI Austria GmbH) was carried out. The detailed therapeutic protocol has been described previously (7,10,11,12). Once the wound bed was found free of infection, covered by well-vascularised granulation tissue, and the C-reactive protein level dropped to 50 mg/l, the chest was reclosed (11,12). Periprocedural, wound care characteristics and clinical outcomes were collected in a prospective manner. In addition, all patients had a 1-year follow-up for the

1Martin

Šimek MD,

1Roman

Hájek MD PhD, Fluger MD, 2Bohumil Zálešák MD, 2Martin Molitor MD PhD, 1Vladimir Lonský MD PhD FECTS, 1Jana Grulichová, 3Katerina Langová PhD 1Ivo

1Department of Cardiac ­Surgery 2Department of Plastic and Aesthetic Surgery 3Department of Medical ­Biophysics and Statistics University Hospital and ­Palacky University Faculty of Medicine, Olomouc, Czech Republic

Corresponding author: Martin Šimek, MD Department of Cardiac Surgery University Hospital and ­Palacky University Faculty of Medicine I. P. Pavlova 6, 775 20 Olomouc, Czech Republic martin.simek@c-mail.cz



17

Table 1. Demographics and operative characteristics Age (years) BMI (kg/m2) Male/female ratio (%) DM (%) COPD (%) Immunosuppressive therapy Renal impairment (creatinine>120 mmol/l) LVEF (%) CABG/valve/combined procedure (%) Mean operation time (min) Mean XC time (min) Mean ECC time (min) Postoperative blood loss (ml) Emergency surgery (%) BMI – body mass index DM – diabetes mellitus COPD – chronic obstructive pulmonary disease

evaluation of long-term morbidity and mortality. Local ethic committee approval was obtained for the protocol of the application of TNP to the open chest in 2004.

Statistical analysis Statistical analysis was performed with SPSS for Windows (version 14, SPSS Inc. Chicago, USA). Continuous variables are expressed as mean ± SD. Categorical variables are presented as absolute numbers in addition to percentages.

Categorical data was compared by X2 test and Fisher exact test. Student´s t test or Mann-Whitney test were used to compare continuous data. Survival was plotted using the Kaplan-Meier method for all patients. A p-value of less than 0.05 was considered significant. Analysis was based on the intention-to-treat principle.

Results Comparing demographic and operative characteristics, no significant differences were found between both groups (Table 1). Likewise, comparable number of patients underwent reopening of the chest for bleeding or cardiac tamponade (12% vs. 8%, NS) in the intermediate postoperative course, however, in the TNP group there was a higher number of later chest revisions for mechanical sternal instability prior to DSWI compared with the CONV group (44% vs. 21%, p<0.05). The various treatment strategies for DSWI reflected the differences in the length of primary therapy (14.3±7.6 vs. 6.8±2.1 days, p<0.001) and number of revision/dressing changes (5.4±2.3 vs. 1.0±0.0, p<0.001) in favour of the CONV group. Nevertheless, this strategy was associated with a significant failure rate of the primary therapy in comparison with TNP (5.8% vs. 39.2%, p<0.05). Where recurrence of DSWI after the definitive chest closure occurred, two patients (5.8%) from the TNP group were treated again by TNP (rescue therapy). In the case of conventional therapy 18

TNP 66.4±9.8 29.7±4.2 52.9/47.1 52.9 32.4 14.7 23.5 44.7±12.9 72.7/6.1/21.2 215.3±42.7 56.7±30.6 88.2±39.7 949.3±617.7 14.7

CONV 71.2±7.9 30.7±3.8 67.9/32.1 60.7 25.0 10.7 35.7 46.3±9.7 78.6/7.1/14.3 235.0±52.5 47.6±24.8 83.4±41.6 697.1±297.8 14.3

LVEF – left ventricle ejection fraction CABG – coronary artery bypass grafting XC – cross clamp

P Value NS NS NS NS NS NS NS NS NS NS NS NS NS NS

ECC – extracorporeal circulation NS – statistically non-significant

Table 2. Predominant wound microorganisms Staphylococcus aureus (%) CoNS (%) MRSA (%) Streptococcus species (%) Escherichia coli (%) Klebsiella species (%) Pseudomonas aeruginosa (%) Enterococcus species (%)

TNP 38.2 32.8 2.9 5.8 2.9 5.8 5.8 5.8

CONV 42.8 39.2 0 3.6 3.6 3.6 7.2 0

p Value NS NS NS NS NS NS NS NS

CoNS – coagulase negative staphylococcus MRSA – methiciline-resistant staphylococcus NS – statistically non-significant

failure, nine patients (32.1%) underwent a repeated closed irrigation and in two patients (7.1%) the chest was left open for multiple wet to dry dressing changes. The overall therapy characteristics including the primary therapy as well as subsequent therapy, showed a comparable length of the therapy (14.9±7.9 vs. 14.3±11.9 days, NS) and the in-hospital stay (40.2±16.3 vs. 48.8±29.2 days, NS). Of the spectrum of organisms cultivated from the wounds, gram-positive strains dominated in both groups. However, no differences in the proportional presentation of each microorganism were found (Table 2).

Regarding in-hospital mortality, TNP therapy led to a significant reduction in comparison with the conventional therapy (5.8% vs. 25.0%, p<0.05). In the TNP group only two patients were lost - one patient (2.9%) was lost immediately after the initial surgical debridement for intractable bleeding from an injured right ventricle, and one died of multiple organ failure due to severe sepsis. Conversely, six patients (21.4%) from the CONV group died of multiple organ failure due to an overwhelming sepsis, and one patient (3.6%) of bleeding from an eroded venous graft.

Similarly, significantly lower 1-year mortality was achieved in the TNP group according to the comparison analyEWMA

Journal 2008 vol 8 no 3

Science, Practice and Education Table 3. Therapy characteristics and outcomes Time to presentation of DSWI (days) Need for readmission for DSWI (%) Length of primary therapy (days) Failure of primary therapy (%) Overall length of therapy (days) Overall No. of revision/dressing changes In-ICU stay (hours) In-hospital stay (days) In-hospital mortality (%) Multiple organ failure (%) Intractable bleeding (%) 1-year mortality (%) Fistula (%)

TNP 17.5±15.0 28.6 14.3±7.6 5.8 14.9±7.9 5.4±2.3 209.6±331.3 40.2±16.3 5.8 2.9 2.9 14.7 14.7

CONV 13.8±16.3 50.0 6.8±2.1 39.2 14.3±11.9 1.8±1.2 516.1±449.5 48.8±29.2 21.4 17.8 3.6 39.2 10.7

p Value NS <0.05 <0.001 <0.05 NS <0.001 <0.001 NS <0.05 <0.05 NS <0.05 NS

ICU – intensive care unit NS – statistically non-significant

Figure 1.

Kaplan-Meier ­analysis of the 1-year survival.

sis (14.7% vs. 39.2, p<0.05), whereas the 1-year plotted survival analysis using the Kaplan-Meier method showed borderline significance (p=0.05, Figure 1). Late woundrelated morbidity including the incidence of wire-related fistula during the one year follow-up was comparable in both groups (14.7% vs. 10.7%, NS). Detailed therapy characteristics and clinical outcomes are summarized in Table 3.

Discussion Prior to the TNP era, two treatment modalities for DSWI had been widely used and described as a conventional treatment (2, 8) - open chest technique where, after the initial surgical debridement, repetitive wet to dry dressing changes and topical antiseptics are applied, and closed irrigation technique, where surgical debridement is followed by sternum reclosure as a one-step procedure with irrigation of antiseptics through in-dwelling drains (2, 4).

A chest left opened causes a mechanical sternal instability which requires not only prolonged artificial pulmonary ventilation but also represents a considerable risk of intractable bleeding from injured right ventricle or venous grafts. Moreover, prolonged immobilization, specific resEWMA

Journal 2008 vol 8 no 3

pirator-related complications and the need for flap transfer to cover residual defects create the main disadvantages of the open chest therapy (2, 8). Conversely, closed irrigation, a single-step procedure preserving the sternal stability with no need for plastic chest reconstruction, seems to be an optimal therapy (2, 5). However, there is a considerable risk of re-infection due to osteosynthetic material, drainage gullies forms, and deep bone involvement is particularly heavy to deal with (2, 8). Although recently, several authors reported improved results of these methods, an increase in the long-term morbidity and mortality remained (4, 5, and 13).

TNP has recently gained popularity in many wound care settings, however, its exact mechanism of action on wound healing has not been fully explained yet (14). Experimental studies, clinical experience and some recent randomized studies have shown TNP can result in acceleration of granulation tissue building, reduction of wound surface area, decreased local and interstitial tissue oedema, and increased perfusion of the peri- and wound area (14, 15). Diminished bacterial load or modulation of bacterial species together with the reduction of the amount of metalloproteinase detected in the wound bed also strongly suggest that the effect of TNP on wound healing processes is more fundamental than adjunct (16,17).

TNP therapy has been used in cardiac surgery since 1997 (7), and has brought a unique dimension to DSWI treatment (18). Even in the absence of sternal closure, applied negative pressure of 125 mm Hg effectively stabilizes the chest, thus allowing immediate postoperative extubation and mobilization of the patient (18, 19). Additionally, a significant increase of microvascular circulation preferably in the muscular layer has been described during TNP therapy even when the left internal mammary artery has  been harvested for bypass grafting (20, 21).

19

Science, Practice and Education

Although the popularity of TNP in cardiac surgery is growing, only few studies comparing TNP with conventional treatment have been conducted (22, 23). However, superiority of TNP has been proved in terms of reduction of primary therapy failure and in-hospital mortality. Moreover, the first available data of long-term analysis showed reduction of the long-term mortality; a better quality of life in comparison with the conventional therapy (24).

Presented comparative studies showed that the conventional therapy of DSWI is associated with an unacceptable high risk of failure. Additionally, those patients who had required further surgery because of the primary therapy failure had also been at considerably high risk of prolonged ICU-, in-hospital stay, and particularly an increased risk of in-hospital mortality. TNP requires multiple surgical procedures including debridement and foam dressing changes, however, the overall length of the therapy as well as the hospital stay is shown to be comparable with the conventional therapy if the additional therapy for the primary failure has been included. The risk to right ventricle or grafts injury was comparably rare in both techniques, but nevertheless, represented a fatal consequence of DSWI. The TNP group showed a statistically significant decrease in primary therapy failure (p<0.05), ICU stay, in-hospital mortality (p<0.05), and 1-year mortality (p<0.05) when compared with the CONV group.

We are aware that the small number of enrolled patients and the asynchronously acquired groups of patients are a limitation of this study. Calculated statistical power of

applied tests reached 0.641, whereas to achieve its proper value (>0.850) at least 90 patients should be enrolled into the study. However, in both groups the demographic and operative data were comparable and the patients were followed-up prospectively in the same fashion.

References

12. Simek M, Nemec P, Zalesak B, et al. Vacuum-assisted closure in the treatment of sternal wound infection in the cardiac surgery. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub, 2007;15:295-299.

1. Lepelletier D, Perron S, Bizouarn P, et al. Surgical-site infection after cardiac surgery: Incidence, microbiology, and risk factors. Infect Control Hosp Epidemiol 2005; 26:466-72.

2. Francel TJ, Kouchoukos NT. A rational approach to wound difficulties after ­sternotomy: The problem. Ann Thorac Surg 2001;72:1411-8.

3. Mokhtari A, Sjögren J, Nilsson J, Gustafsson R, Malmsjö M, Ingemansson R. The cost of vacuum-assisted closure therapy in treatment of deep sternal wound infection. Scand Cardiovasc J. 2008;42:85-9.

4. Ascherman JA, Patel SM, Malhotra SM, Smith CR. Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: Refinements in technique and outcomes analysis. Plast Reconstr Surg 2004;114:676-83.

Conclusion Results suggested the superiority of TNP over closed irrigation in the treatment of DSWI following cardiac surgery.

Very low therapeutic failure rate, significant decrease in hospital stay, and the lower 1-year mortality were achieved

by TNP. Implications for Clinical Practice TNP is the most effective treatment for deep sternal infection after cardiac surgery n TNP is associated with significant decrease in ­therapy failure rate, hospital stay, and 1-year ­mortality in comparison with conventional therapy n TNP should be widely accepted as a first-line ­treatment strategy for DSWI in cardiac surgery Further Research n Multi-centre prospective randomized trial comparing TNP with the conventional therapy n Influence of individual wound-healing risk factors and microbiological agents on effectiveness of TNP therapy. m

13. Toumpoulis IK, Anagnostopoulos CE, Derose JJ Jr, Swistel DG. The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting.

Chest 2005;127:464-71.

14. Banwell PE, Musgrave M. Topical negative pressure therapy: mechanisms and indications. Int Wound J. 2004;1:95-106.

15. Ubbink DT, Westerbos SJ, Nelson EA, Vermeulen H. A systematic review of topical negative pressure therapy for acute and chronic wounds. Brit J Surg 2008;95:685-692.

16. Mouës CM, van Toorenenbergen AW, Heule F, Hop WC, Hovius SE. The role of topical negative pressure in wound repair: expression of biochemical markers in wound fluid during wound healing. Wound Repair Regen. 2008;6:488-94.

5. Kirsch M, Mekontso-Dessap A, Houel R, Giroud E, Hillion ML, Loisance DY. Closed drainage using redon catheters for poststernotomy mediastinitis: Results and risk factors for adverse outcome Ann Thorac Surg 2001;71:1580-6.

17. Mouës CM, Vos MC, van den Bemd GJ, Stijnen T, Hovius SE. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial.

Wound Repair Regen. 2004;12:11-7.

6. Doss M, Martens S, Wood JP, Wolff JD, Baier Ch, Moritz A. Vacuum-assisted suction drainage versus conventional treatment in the management of poststernotomy osteomyelitis. Eur J Cardiothorac Surg 2002;22:934-38.

18. Argenta LC, Morykvas MJ, Marks MW, et al. Vacuum-assisted closure: State of art.

Plast Reconstruct Surg 2006;117: 127-42S.

7. Fleck TM, Fleck M, Moidl R, et al. The vacuum-assisted closure system for the treatment of deep sternal wound infection after cardiac surgery. Ann Thorac Surg 2002;74:1596-600 8. Schimmer C, Sommer P, Bensch M, Elert M, Leyh R. Management of poststernotomy mediastinitis: experience and results of different therapy modalities. Thorac Cardiovasc Surg 2008;56:200-4.

9. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. The hospital infection control practise advisory committee. Guidelines for prevention of surgical site infection. Infect Control Hosp Epidemiol 2002;20:247-78 10. Sjoegren J, Malmsjoe M, Gustafsson R, Ingemansson R. Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm. Eur J Cardiothoracic Surg 2006;30: 898-905.

11. Gustafsson RI, Johnsson P, Algotsson L, Blomquist S, Ingemansson R. Vacuum-assisted closure therapy guided by C-reactive protein level in patients with deep sternal wound infection. J Thorac Cardiovasc Surg 2002;123:895-900.

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19. Gustafsson R, Sjögren J, Malmsjö M, Wackenfors A, Algotsson L, Ingemansson R. Vacuum-assisted closure of the sternotomy wound: respiratory mechanics and ventilation. Plast Reconstr Surg 2006;117:1167-76.

20. Petzina R, Gustafsson L, Mokhtari A, Ingemansson R, Malmsjö M. Effect of vacuumassisted closure on blood flow in the peristernal thoracic wall after internal mammary artery harvesting. Eur J Cardiothorac Surg 2006;30:85-9.

21. Petzina R, Ugander M, Gustafsson L, et al. Hemodynamic effects of vacuum-assisted closure therapy in cardiac surgery: assessment using magnetic resonance imaging. J Thorac Cardiovasc Surg 2007;133:1154-62.

22. Fuchs U, Zittermann A, Stuetten B, Groening A, Minami K, Koefer R. Clinical outcome of patients with deep sternal infection managed by vacuum-assisted closure compared to conventional therapy with open packing: A retrospective analysis. Ann Thorac Surg 2005;79:526-31.

23. Sjoegren J, Gustafsson R, Nilsson J, Malmsjoe M, Ingemansson R. Clinical outcome after poststernotomy mediastinitis: Vacuum-assisted closure versus conventional treatment. Ann Thorac Surg 2005;79:2049-55 24. Sjögren J, Nilsson J, Gustafsson R, Malmsjö M, Ingemansson R. The impact of vacuum-assisted closure on long-term survival after post-sternotomy mediastinitis.

Ann Thorac Surg. 2005;80:1270-5.

EWMA

Journal 2008 vol 8 no 3

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Science, Practice and Education

EWMA2008

Presented at the 18th Conference of the European Wound Management Association, 14-16 May 2008, Lisbon, Portugal

Quality of Life in the Patients with Chronic Leg Ulcers – A Preliminary Report

Abstract

Aim: Leg ulcers represent an important health problem because their prevalence in western countries varies from 0.6 to 3.6 per 10001. A survey among leg ulcer patients carried out in the Czech Republic in 2006 revealed that more than 3% respondents suffer or had suffered from leg ulcers, either currently or in the past2. In last years, many studies evaluated quality of life of leg ulcer patients which is decreased as it was showen by many of these studies3-5. The aim of this preliminary study was to collect data about quality of life of the patients with chronic leg ulcers in the Czech Republic .

Methods: A special questionnaire focused on quality of life of patients with chronic leg ulcers was developed in our department of dermatology. A questionnaire is divided in 6 parts, the questions are aimed at pain, physical, social and psychological impact, at daily activities and at aspects of treatment. 30 patients (8 men and 22 women) have been included in the study so far, with mean age 68.0 years (range 47-87 years). Mean ulcer duration was 29.3 months (range 4-120 months).

Most patients (63%) had leg ulcers of venous origin, 37% had mixed leg ulcers. Psychometric data of our questionnaire are part of a study to establish the reliability/validity of the tool and they will be published later.

Results: Pain is the most dominant negative experience of leg ulcer patients6-10. In our study, 97% reported ulcer pain. 47% experienced pain during the night, 29% reported pain during the day and 23% reported pain both during the day

and night. 26.2% patients described the pain located in the wound bed, 13.6% reported pain in the area surrounding the wound. Most patients, 60.2%, reported pain both in the wound bed and in the surrounding area. 66% reported persistent pain, 19.5% reported pain with activity, 36% described pain at dressing change. Mean pain intensity score was 5.43 (using numerical rating scale as an assessment of pain intensity). Pain may lead to sleep disturbance11. In our study, 43.7% patients reported disturbed sleep every night or very often. According to literature12,13, chronic leg ulcers may negatively influence daily activities.

74.9% patients experienced moderate restrictions in leisure activities and 59.3% reported moderate restrictions in household duties. Many patients have problems with their clothing style, they usually wear long skirts or trousers12. 44.6% patients reported partial or complete change of their clothing style (especially women). The patients usually have to wear larger size of shoes especially because of compression bandages. In our study, 38.9% patients had to change their shoes completely and 41.6% changed their shoes partially.

Social impact of leg ulcers is also considerable12.

80.6% reported certain social isolation caused by problems connected with their leg ulcer. Psychological aspects are very important11, our patients often complained about bad mood ,they described depression and feelings of hopelessness.

Conclusions: Leg ulcers can influence nearly every aspect of the patient’s life. Therefore the care must be more intensively focused on quality of life of these patients. m

Veronika Slonkova, MD, Ass.Prof. Vladimir Vasku, MD Department of Dermato­ venereology, St.Anna University Hospital Brno, Czech Republic Corresponding author + reprint requests: Veronika Slonkova, MD, ­Department of Dermato­ venereology, St.Anna University Hospital, Pekarska 53, 656 91 Brno, Czech Republic veronika.slonkova@fnusa.cz

References 1. Nemeth KA, Harrison MB, Graham ID, Burke S. Understanding venous leg ulcer pain: results of a longitudinal study. Ostomy/ Wound Manage 2004;50(1):34-46.

5. Franks PJ, Moffatt CJ, Doherty DC, Smithdale R, Martin R. Longer-term changes in quality of life in chronic leg ulceration. Wound Rep Reg 2006;14:536-541.

10. Krasner D. Painful venous ulcers: themes and stories about their impact on quality of life. Ostomy/Wound Management 1998;44(9):38-49.

2. Kucera Z. Leg ulcer prevalence in the Czech Republic: Omnibus survey results 2006. EWMA Journal 2006;6(2):28-29.

6. Briggs M, Bennett MI, Closs SJ, Cocks K. Painful leg ulceration: a prospective, longitudinal cohort study.

Wound Rep Reg 2007;15:186-191.

11. Douglas V. Living with a chronic leg ulcer: an insight into patient’s experience and feelings. J Wound Care 2001;10:355-360.

3. Flanagan M, Vogensen H, Haase L. Case series investigating the experience of pain in patients with chronic venous leg ulcers treated with a foam dressing releasing ibuprofen. World Wide Wounds 2006;available from URL: htp://worldwidewounds.com/2006/april/Flanagan/ Ibuprofen.html

7. Moffatt CJ., Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective.

EWMA Position Document: Pain at wound dressing changes 2002;2-7.

12. Persoon A, Heinen MM, Vleuten CJM, Rooij MJ, Kerkhof PCM, Achterberg T. Leg ulcers: a review of their impact on daily life. J Clin Nurs 2004;13:341-354.

4. Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. Quality of life in chronic leg ulcer patients. An assessment according to the Nottingham Health Profile. Acta Derm Venereol (Stockh) 1993;73:440-443.

9. Jorgensen B, Friis GJ, Gottrup F. Pain and quality of life for patients with venous leg ulcers: proof of concept of the efficacy of Biatain-Ibu, a new pain reducing wound dressing. Wound Rep Reg 2006;14:233-239

EWMA

Journal 2008 vol 8 no 3

8. Cooper SM, Hofman D.,Burge SM. Leg ulcers and pain, a review. Lower Extremity Wounds 2003;2:189-197

13. Heinen MM, van Achterberg T, Scholte op Reimer W, van de Kerkhof PCM, de Laat E. Venous leg ulcer patients: a review of the literature on lifestyle and painrelated interventions. J Clin Nurs 2004;13:355-366.

23

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References: 1. Data on file 0707052 2. Data on file 0711086 3. Data on file 0711087 4. Journal of Woundcare (2006), Vol 15, No. 7 July 2006

Science, Practice and Education

EWMA2008

Presented at the 18th Conference of the European Wound Management Association, 14-16 May 2008, Lisbon, Portugal

Compression therapy for venous leg ulcers – how to get more value for money

Abstract Background: Compression therapy is a time consuming and often inefficient service delivered by nurses in homecare.

EWMA guidelines for the management of leg ulcers and expert opinions seem to have had little impact on the daily practice.

Hypothesis/aim: Evidence-based guidelines can be implemented in primary health care and deliver more value for money. By meeting the standards you can obtain better patient compliance and quicker wound healing.

Methods: Six different types of compression, cost of material and cost of manpower are compared in three different patient cases. This comparison is linked to the EWMA standards.

Results: Compression therapy must be kept simple and must succeed in the hands of a large group of non-specialised nurses and other healthcare professionals.

1. Reduce oedema with disposable multilayered bandages or inelastic lined bandages (use sub-bandage pressure measuring device) or elastic bandages with indicators.

2. Proceed to compression hosiery when the oedema has been treated and the ulcer is less exudating.

Conclusions: We wonder why the EWMA guidelines have not been widely implemented and ask the following question: Is it due to lack of knowledge or is the reason that prescribing authorities fail to consider the socio-economical implications?

Introduction In the western world approximately 10% of the population will suffer from chronic venous insufficiency and approximately 1% of the population will develop venous leg ulcers and need compression therapy (1).

EWMA

Journal 2008 vol 8 no 3

The recommended standards for the treatment of venous leg ulcers and mixed arterial and venous leg ulcers are (2): Superficial venous insufficiency; 60% healed in 3 months and 15 % recurrences within 1 year Mixed insufficiency; 40% healed in 3 months and 40% recurrences within 1 year Studies have shown that a 97% healing rate can be obtained in four weeks (3) In an average community in Denmark the healing rate for venous leg ulcers is estimated to be approximately 40% in 12 weeks (3) plus a high recurrence of up to75% the first year after healing.(4) The healing time for venous leg ulcers can be unnecessarily prolonged by many years especially where compression therapy is ineffective.

These numbers indicate potential room for improvement. The incidence of venous leg ulcers in the population will increase, as a consequence of an increase in the numbers of elderly people in the decades to come. It is necessary to make effective improvements in this area, considering the quality of life for these many patients – as a study from the southern part of Denmark has shown (5) Furthermore it is imperative to find new methods so that the communities get more value for money, since the major part of the treatment of venous leg ulcers takes place in the primary health care sector. ‘New health care issues – focus on competency development’ – the Danish communities’ national association (KL) latest publication along with the Danish government’s quality reform (www.kvalitetsreform.dk) and the Danish nurses’ union’s many publications concerning quality development in the healthcare system all stress these facts.

Susan F. Jørgensen Rie Nygaard, Tissue viability nurses, KvaliCare www.kvalicare.dk suj@zealandcare.dk

A decade ago studies in Sweden showed that approximately five million dressing changes for leg ulcers took place per year which is equivalent to a cost of approximately 1 million kroner, equivalent  to 1333 mill Euro. (6) 25

Practice today In Denmark non-disposable inelastic bandages have commonly been used for the treatment of venous leg ulcers.

The benefit is that patient can keep the bandages on at night – the bandages only need changing every third day and not necessarily in the busy mornings. However, inelastic bandages need to be washed every time they are changed to ensure optimal effect. For immobile patients elastic bandages have often been chosen due to their high pressure when resting. Many patients in Denmark do not have a Doppler or toe pressure index measured before compression therapy is prescribed. Removing the bandages at night has been widely recommended, to reduce the theoretical risk of suppressing the arterial flow (4, 6). However, elastic bandages need to be reapplied in the morning, before the patient gets out of bed. When the ulcers are healed compression therapy is continued with hosiery.

This practice had been common in Denmark until the late 90s when modern multilayer bandages were introduced to the Danish market and gained acceptance. As a new initiative, hosiery treatment kits are being introduced for patients with leg ulcers, and intermittent compression therapy is gaining a foothold.

Often practice today in Denmark shows a large insecurity and lack of knowledge of how to apply and maintain different types of bandages. High staff turnover in the primary healthcare sector (estimated to be 25% per year by the Danish communities national association KL) results in a high demand for education of all personnel treating wounds to keep them updated on applying the correct type of compression therapy and maintaining the bandages.

Compression therapy can be carried out with many different products in Denmark today. We have based the following overview (figure 1) on a questionnaire asking which products were available in their areas completed by 25 nurses responsible for wound care in their home areas in West Zealand, Denmark. In line 6, for instance, you can see that in four areas nurses have a choice of using either inelastic bandages or multi-layer bandages for their patients. Note that four nurses work for local GPs and two are employed at the local hospitals.

To one question “Do you think that there is a need for increasing the quality of prevention and treatment of venous leg ulcers in your own area to ensure evidence-based nursing and treatment?” 24 of the 25 nurses have answered “Yes”.

The study can be seen on www.kvalicare.dk.

Value for money “How to obtain more value for money” is a highly relevant question in healthcare systems in general. Concerning “treatment of venous leg ulcers and mixed arterial and venous ulcers” we need to consider which type of compression therapy to choose, based on studies on efficiency and socio-economics.

Demands to be met for compression therapy; High level of safety High patient compliance Highest healing rate Sustainable sub-bandage pressure Socio-economical (Personnel time spent, bandages, lost earnings) EWMA, European Wound Management Association published the Position Document “Understanding compression therapy” in 2002. This document was developed by a panel of international experts (7) and includes a recom­ mended management pathway. The above mentioned issues are taken into account. See figure 2.

High level of safety Compression must be applied with the correct sub-bandage pressure cf. ankle-brachial pressure index ABPI. If elastic, inelastic or multi-layer bandages are used, the outcome depends on the applying nurse’s estimate of how to apply the bandage, resulting in possible ineffective treatment if the bandages are applied too loosely and risking severe injury if the bandages are applied too tightly. This risk can be avoided by using bandages with pressure indicators and/or by teaching staff how to apply the bandages with a sub-bandage pressure measuring device, which can also

Figure 1 Combinations of Compression therapy available Hosiery Elastic bandages Inelastic bandages Elastic and inelastic bandages Elastic and multi-layer bandages Inelastic and multi-layer bandages Inelastic bandages + others Elastic, inelastic and multi-layer bandages Elastic multi-layer bandages and hosiery Inelastic, elastic multi-layer bandages + others

26

Number of communities (Two hospitals and four GPs included) 1 1 3 3 2 4 1 7 2 1 EWMA

Journal 2008 vol 8 no 3

Science, Practice and Education Figure 2

The diagram is organized in assessment, diagnosis, recommendations for treatment and outcomes.

Assessment must include ankle-brachial pressure index ABPI or toe pressure index, confirmation of the diagnosis venous disease and investigations to exclude other disorders. Treatment is determined depending on the diagnosis.

Unfortunately these recommendations are not commonly used.

be used in routine clinical practice ( Kikuhime ) (8,9,10).

Hosiery provides the highest level of assurance for correct sub-bandage pressure (8). This treatment does not require further training except putting on and removing the hosiery. This means that personnel already taking care of the patient in his/her home can apply the compression without risking the quality of the compression treatment – including patients suffering from leg ulcers. Often the patient will be able to take off the hosiery themselves before bedtime and when showering.

High patient compliance Patient compliance is closely connected with the level of knowledge and motivation of the patient with a leg ulcer (9). Patient information, guidance in self care and participation in the treatment are therefore important factors.

It is important to aim for optimal freedom of movement during treatment. Movement of the foot and activation of the ankle and calf muscle seems to be better when hosiery is worn rather than when bandages are used. (10) A further advantage of using hosiery is that the patient is able to use his or her own footwear – which often can be an issue when using some bandages.

Improved patient compliance, assurance of correct subbandage pressure with faster healing and easier working conditions for healthcare personnel are all good reasons for changing to hosiery as soon as possible when treating venous leg ulcers and mixed arterial and venous ulcers.

Highest healing rate There is a connection between healing rates and type of compression, but conclusions are difficult to draw. For instance, a search in the Cochrane library has shown that a healing rate of 84% in 12 weeks can be obtained using hosiery compared to using inelastic bandages which showed a rate of 53% in 12 weeks. (11) A comparison of elastic and inelastic bandages showed a healing rate of 35% for inelastic bandages compared with 58% for elastic bandages. (12) Multi-layer bandages have obtained a healing rate of 75% compared to usual treatment (13). As stated in a status article in 2001 (14) many studies have been carried out with few participants and different conditions making a comparison difficult.

These studies cannot be directly compared due to different conditions but they do indicate that multi-layer bandages and hosiery, which are recommended in the EWMA document (7), lead to the highest healing rates.

Sustainable sub-bandage pressure To be effective the bandage must sustain the pressure it is applied with. In the Danish wound care magazine SÅR (2003 no 2) and EWMA Journal (autumn 2004) an article has been published “Watch the pressure – it drops!” (8) This article is a study of the pressure conditions under the bandages over time. Here are some results from the study (figure 3); 

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Journal 2008 vol 8 no 3

27

Figure 3 Type of compression bandage Sub-bandage pressure measured on appliance Inelastic bandage 52 mmHg (100%)

Sub-bandage pressure measured 3 hours after appliance 29 mmHg (56%)

Sub-bandage pressure measured 11 hours after appliance 26 mmHg (50%)

Elastic bandage Hosiery

36 mmHg (86%) 32 mmHg (84%) 5 hours after appliance

30 mmHg (71%) 32 mmHg (84%)

42 mmHg (100%) 38 mmHg (100%)

It clearly shows that hosiery is sustaining the sub-bandage pressure over time more efficiently.

As far as we know no similar studies have been carried out on multi-layer bandages.

Figure 4 Patient 1 self sufficient person Type of compression Inelastic bandage Disposable. 40 mmHg Inelastic bandage Non disposable. 40 mmHg Elastic bandage Non disposable. 40 mmHg Multi-layer bandages Disposable. 40 mmHg Hosiery Kit Liner + stocking. 10 + 30 mmHg Hosiery Sigvaris 503. 34-46 mmHg

Applied by Health care personnel

Taken off by Health care personnel

Washed by –

Price / month 280.34 €

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Patient

Patient

678,94 €

Health care personnel

Patient

Patient

1001,03 €

Health care personnel

Health care personnel

–

256,79 €

Patient

Patient

Patient

245,74 €

Patient

Patient

Patient

277,79 €

Taken off by Health care personnel

Washed by –

Price / month 280,34 €

Patient

Patient

678,94 €

Patient

Patient

1001,03 €

Health care personnel

–

256,79 €

Patient

Patient

245,74 €

Health care personnel

Patient

449,87 €

Taken off by Health care personnel

Washed by –

Price / month 280,34 €

Health care personnel

Health care personnel

901.31 €

Health care personnel

Health care personnel

1160,83 €

Health care personnel

–

256,79 €

Health care personnel

Health care personnel

503,87 €

Health care personnel

Health care personnel

535,92 €

Patient 2 partially self sufficient person Type of compression Applied by Inelastic bandage Health care personnel Disposable. 40 mmHg Inelastic bandage Health care personnel Non disposable. 40 mmHg Elastic bandage Health care personnel Non disposable. 40 mmHg Multi-layer bandages Health care personnel Disposable. 40 mmHg Hosiery Kit Patient Liner + stocking.10 + 30 mmHg Hosiery Health care personnel Sigvaris 503. 34- 46 mmHg Patient 3 health care requiring person Type of compression Applied by Inelastic bandage Health care personnel Disposable. 40 mmHg Inelastic bandage Health care personnel Non disposable. 40 mmHg Elastic bandage Health care personnel Non disposable. 40 mmHg Multi-layer bandages Health care personnel Disposable. 40 mmHg Hosiery Kit Health care personnel Liner + stocking. 10 + 30 mmHg Hosiery Health care personnel Sigvaris 503. 34-46 mmHg

28

EWMA

Journal 2008 vol 8 no 3

Science, Practice and Education

Socio-economical aspects In order to create an overview of the cost of different compression treatments we have calculated the costs of six different types of compression bandages compared by three different theoretical patient categories (figure 4).

The calculation is carried out in the period from the 2nd to the 6th week of treatment where we assume that the oedema has been efficiently treated with compression bandages and the ulcer has reached a moderate exudate level (as photo).

Transportation is one of the major aspects of the nursing time consumption. It makes a difference whether the treating person walks from flat to flat in an apartment block or drives many kilometres by car from house to house. The extent of the problem is even larger for the distances between patients on the Faroe Islands or in the outer reaches of our neighbouring countries Norway, Sweden and Finland.

It is evident that if you follow the EWMA guidelines an economical advantage is obtained. (7) Multi-layer bandages or hosiery are the best choices.

Discussion Based on this study, EWMA guidelines, economical calculations and the results by Jünger, one might suggest handling the issues around compression therapy in venous ulcers as follows: 1. Reduction of oedema by using multi-layer bandage systems 2. Patients who do not tolerate multi-layer bandage systems: use inelastic or elastic bandages with indicators or applied with sub-bandage-pressure measuring device.

For the comparison we have used the ­products shown in figure 5.

The comparison shows that the costs of using the various types of compression differ widely. The smallest difference lies in the choice of compression – the largest difference occurs due to the difference in personnel time spent. This has previously been shown in a cost benefit analysis using multi-layer bandages in the primary healthcare sector. (15) It is of course essential for the expenses that the healing rate is high.

As soon as the UE is slim, the oedema has disappeared and the ulcer exudate has decreased, measure the limb and apply the hosiery for ulcer treatment. Stockings ensure the highest safety. Stockings cannot be applied with a wrong sub-bandage pressure since the hosiery has been measured individually. Hosiery is efficient and sustains pressure over time, is economical to use and gives the highest degree of compliance. Many patients can often manage the stocking themselves either with an application system or by using a two stocking system. Often a carer, who is helping the elderly with other things as well, can help with the application. The patients can use normal footwear and hosiery is more discrete to wear than other types of compression, which carries the additional benefit of improved patient  self esteem. (body image)

Figure 5 Inelastic bandage disposable Actico from Activa Healthcare Inelastic bandage non disposable Comprilan from Smith & Nephew Elastic bandage Dauer from Lohmann & Rauscher Multi-layer bandage ProGuide from Smith & Nephew Hosiery Kit Liner + stocking Activa Hosiery Kit from Activa

Hosiery class 3 (3C) Sigvaris 503 from Simonsen & Weel

EWMA

Journal 2008 vol 8 no 3

These cohesive bandages are new on the Danish Market. Can be worn up to one week and do not need washing. A padding layer under the bandage is required.

The bandages are to be changed every 3rd day or more frequently (8).

The bandages need to be washed at every change.

The bandages have to be taken off at night due to high resting pressure.

The bandages need washing at approximately every 3rd changing or when stained.

To be applied in the morning before the patient gets out of bed.

The package includes a foam bandage for the wound.

The multi-layer bandage can be kept on for up to one week and is disposable.

The kit is new on the Danish market. It consists of a 10 mmHg liner + 30 mmHg ­stocking. The advantage of this combination is that the patient can sleep with the liner on – keeping the wound bandage in place – and maintaining a 10 mmHg pressure at night. This solution also provides the advantage of the stocking being easier to apply when the smooth liner is in place first.

An application system is needed when putting this hosiery.

In the example we have used easy glide.

29

Science, Practice and Education

This regimen can be implemented in most home care settings.

Patients who are seen in wound care centres and who often suffer more complicated wounds must be treated by highly qualified tissue viability nurses. In these cases you need not consider that compression has to succeed in the hands of a large group of nurses with different qualifications, which is the case in the communities. But when the patients are discharged from the wound care centre and the community nurses take over, there is an urgent need to rethink how to continue the compression therapy in order to avoid set backs and recurrence. In some countries – like Denmark – it makes a difference in the communities – from a financial point of view – whether or not the hosiery has to be used for treatment or for prevention of leg ulcers.

When used for prevention the patients get the hosiery for free, but when used for treatment the rules vary from one community to the other since the stockings have to be supplied from the nurses’ depot of wound care products.

In some communities the treatment stocking systems are regarded as another type of compression bandage system, which belongs in the depot - and the patient is reimbursed.

But in others the stocking systems are seen as preven-

tion since stockings have not traditionally been used for treatment of ulcers. This means that the patients have to pay themselves, which in practice means a barrier to implementation of stocking systems despite the fact that the systems save a lot of manpower and ensure more value for money. This problem needs to be solved in the best interest of the overall economy especially when it comes to nursing hours.

The studies in Germany by Michael Jünger have shown that compression hosiery lead to quicker wound healing in many cases (10). Franks and Moffatt argued that ‘effectiveness and cost effectiveness of compressions bandages should be shown” (16) and stated that the ‘time has come to evaluate how to deliver this service with the purpose of avoiding unnecessary waste and suffering due to inadequate treatment.’

One can’t help wondering why these expert opinions and the EWMA guidelines for management of venous leg ulcers published four years later in 2002, are still not being followed and implemented widely.

Lack of knowledge may be one reason, and lack of focus on health-economics by prescribing authorities another.

Acknowledgements This project was sponsored by Sponsor: AdvaNordic Medical Group, Søleddet 15, 4180 Sorø. AdvaNordic supports Activa products in Denmark.

“Wound infection scares me on a daily basis. It is one of the most challenging aspects of wound management today - a major contributor to healthcare costs around the world, and the cause of significant distress to patients and carers.”

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After this study, a new consensus document has ­presented at WUWHS world conference in Toronto 2008 – Compression in venous leg ulcers – A consensus document. – The consensus is available on www.wuwhs.org m

EWMA Membership Become a member of the European Wound Management Association

Implications for clinical practice • Safe, socio-economical, evidence-based ­compression therapy can be delivered by a large group of non-specialised nurses, carers and the patients themselves.

• Oedema and exudating venous ulcers should be bandaged according to standards and as soon as possible you should proceed to treatment with hosiery.

• Prescribing authorities must consider socio­economical issues when compression therapy has to succeed in the hands of a large group of non specialised nurses, carers and patients in primary health care sector.

List of references 1) Struckmann, J. Venøs Insufficiens, 3rd edition Frederiksberg Servier Denmark A/S 2001.

2) Kjær M. 2004 nov. 2006 http://www.sårbogen.dk/saarbogen/underside.asp?MIId=119 3) Olofsson B et al. Optimerad kompression ger bättre resultat, Läkartidningen 1996 vol 93 no. 51-52 4) Gottrup F., Olsen L. Sår – Baggrund, diagnose og behandling.

Copenhagen Munksgaard 1996

and you will receive EWMA position documents ­annually and EWMA Journal three times a year.

In addition, you will have the benefit of obtaining the membership discount, which is normally 15%, when registering for the EWMA Conferences.

The most important aspect of becoming a member of EWMA is the influence this membership can give you.

As a EWMA ­member you can vote and even stand for election for the EWMA Council, which will give you direct influence on future developments within European wound healing.

Please register as a EWMA member at

5) Corydon-Petersen L., Jelnes, R., Iversen, S.P. Det kan gøres bedre, Rapport CVU Sønderjylland 2006 6) Lindholm, C., Sår, Denmark Gads forlag 2005 7) Marston W, Vowden K compression therapy: a guide to safe practice Understanding Compression Therapy 2002. EWMA, Position document page13

WWW.EWMA.ORG

8) Satpathy A, Hayes S, Dodds S Is compression bandaging accurate?

The routine use of interface pressure measurements in compression bandaging of venous leg ulcers, Phlebology 2006; 21: 36-40 9) Partsch H, The static stiffness index: A simple method to assess the elastic property of compression material in vivo. Dermatol Surg 2005; 31:625-630 10) Jelnes R Erfaringer med Kikuhime subbandage trykmåler, SÅR, no 2 2002 11) Larsen, A.M., Tag trykket, det falder!, Sår, 2003 no. 2 12) Antonovsky A, Helbredets mysterium.3rd edition Denmark Hans Reitzels Forlag a/s 2004 13) Jünger M, Wollina U., Kohnen R. Rabe E., Efficacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below-knee compression bandage: results from a prospective, randomized, multicentre trial. Current Medical research and opinions vol. 20 no. 10 2004, 1613-1623

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14) Partsch H., Horakova M.A. Compression stockings for the treatment of venous leg ulcers. Wiener Medizinische Wochenschrift 1994; 144:242-249 15) Wienert V. Evidensbassierte Ulcus-Therapie mit elastischen Binden Ulcus cruris – eine Bestandsaufnahme 2004 16) Taylor AD, Taylor RJ, Marcuson RW, (1998) Prospective comparison of healing rates and therapy costs for conventional and four-layer high-compression bandaging treatments of venous leg ulcers 17) Karlsmark T, Kjær ML, Nørregaard S. Er der indikation for kompressionsbandage eller – strømpe ved behandling af venøse bensår. Ugeskrift for læger. 2001; 163(15):2126-28 18) Heegaard Lone, Analyse af Cost-Benefit ved anvendelse af flerlags-bandage i primærsektoren (2003) 19) Peter J. Franks, Christine J. Moffatt, Effectiveness and cost effectiveness of compression bandages should be shown. BMJ 1998;317:1079 (17 October)

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ABSTRACTS OF RECENT ­COCHRANE REVIEWS Publication in The Cochrane Library Issue 3, 2008

Debridement for surgical wounds

Sally Bell-Syer, MSc Review Group Co-ordinator Cochrane Wounds Group Department of Health Sciences Area 2 Seebohm Rowntree Building University of York York, United Kingdom sembs1@york.ac.uk

Nancy Dryburgh, Fiona Smith, Jayne Donaldson, Melloney Mitchell The Cochrane Database of Systematic Reviews To be published in Issue 3, 2008 Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Surgical wounds that become infected are often debrided because clinicians believe that removal of this necrotic or infected tissue will expedite wound healing. There are numerous methods available but no consensus on which one is most effective for surgical wounds.

Objectives: The aim of this review is to determine the effect of different methods of debridement on the rate of debridement and healing of surgical wounds.

Search strategy: We developed a search strategy to search the following electronic databases: Wounds Group Specialised Trials Register (searched 3/3/08) , Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2008, issue 1), MEDLINE (1950 to February Week 3 2008), EMBASE (1980 to 2008 Week 09) and CINHAL (1982 to February Week 4 2008). We checked the citations within obtained studies to identify additional papers and also relevant conference proceedings. We contacted manufactures of wound debridement agents to ascertain the existence of published, unpublished and ongoing trials. Our search was not limited by language or publication status.

Selection criteria We included relevant randomised controlled trials (RCT) with outcomes including at least one of the following: time to complete debridement, or time to complete healing.

Data collection and analysis Two authors independently reviewed the abstracts and titles obtained from the search, two extracted data independently using a standardised extraction sheet, and two independently assessed methodological quality. One author was involved in all stages of the data collection and extraction process, thus ensuring continuity.

Main results Five RCTs were eligible for inclusion; all compared treatments for infected surgical wounds and reported

32

time required to achieve a clean wound bed (complete debridement). One trial compared an enzymatic agent (Streptokinase/streptodornase) with saline-soaked dressings and reported the time to complete debridement. Four of the trials compared the effectiveness of dextranomer beads or paste with other products (different comparator in each trial) to achieve complete debridement. Meta analysis was not possible due to the unique comparisons within each trial. One trial reported that dextranomer achieved a clean wound bed significantly more quickly than Eusol, and one trial comparing enzymatic debridement with saline-soaked dressings reported that the enzyme treated wounds were cleaned more quickly. However methodological quality was poor in these two trials.

Authors’ conclusions There is a lack of large, high quality published RCTs evaluating debridement per se or comparing different methods of debridement for surgical wounds, to guide clinical decision making.

Plain language summary Debridement for surgical wounds Following surgery most surgical wounds heal naturally with no complications. However, complications such as infection and wound dehiscence (opening) can occur which may result in delayed healing or wound breakdown. Infected surgical wounds may contain dead (devitalised) tissue. Removal of this dead tissue (debridement) from surgical wounds is believed to enable wound healing. Many methods are available to clinicians to debride surgical wounds. This review showed that there is insufficient valid research evidence to recommend any one particular method.

There is a clear need for more research into which method is most effective, in removing dead tissue from surgical wounds that have become infected.

Risk assessment tools for the prevention of pressure ulcers Zena EH Moore, Seamus Cowman The Cochrane Database of Systematic Reviews To be published in Issue 3, 2008 Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Pressure ulcer risk assessment is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use EWMA

Journal 2008 vol 8 no 3

EBWM

of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines however it is not known whether using a risk assessment tool makes a difference to patient outcomes. A review was conducted to clarify the role of pressure ulcer risk assessment in clinical practice.

Objectives: The objective of this review was to determine whether using structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers.

Search strategy: The following databases were searched: MEDLINE (January 1966 to April Week 3, 2008); EMBASE (1974 to Week 17, 2008); CINAHL (1982 to April Week 4, 2008); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 2, 2008); The Wounds Group Specialised Register (searched 29/4/2008). There were no restrictions on articles on the basis of language or date of publication.

Selection criteria: Randomised controlled trials (RCTs) comparing the use of structured, systematic, pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools were considered for this review.

Data collection and analysis: Titles and, where available, abstracts of the studies identified by the search strategy were assessed by two authors independently for their eligibility. Full versions of potentially relevant studies were obtained and screened against the inclusion criteria by two authors independently.

Main results: No studies were identified that met the inclusion criteria.

Authors’ conclusions: Despite the widespread use of risk assessment tools for the assessment of individuals’ risk of developing pressure ulcers, no randomised trials exist that compare them with unaided clinical judgement or no risk assessment in terms of rates of pressure ulceration. Therefore, we cannot conclude whether the use of structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers. The effect of structured risk assessment tools on pressure ulcer incidence needs to be evaluated.

Plain language summary Risk assessment tools used for preventing pressure ulcers Pressure ulcers (also known as bed sores, pressure sores and decubitus ulcers) are localised areas of tissue damage caused by excess pressure, shearing or friction forces. Pressure ulcers mainly occur in people who have limited mobility and/or nerve damage. Pressure ulcer risk assessment is part of the process used to identify individuals at risk of developing a pressure ulcer.

Risk assessments generally use checklists and their use is recommended by pressure ulcer prevention guidelines. The authors found no studies that were eligible for inclusion in the review.

Therefore, we do not know whether conducting a risk assessment makes any difference to the number of new pressure ulcers that occur.

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Journal 2008 vol 8 no 3

Publication in The Cochrane Library Issue 4, 2008

Mupirocin ointment for preventing Staphylo­ coccus aureus infections in nasal carriers Miranda van Rijen, Marc Bonten, Richard Wenzel, Jan Kluytmans This record should be cited as: van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006216. DOI: 10.1002/14651858.CD006216.

ABSTRACT Background: Staphylococcus aureus (S. aureus) is the leading nosocomial (hospital acquired) pathogen in hospitals throughout the world. Traditionally, control of S. aureus has been focused on preventing cross-infection between patients, however, it has been shown repeatedly that a large proportion of nosocomial S. aureus infections originate from the patient’s own flora. Nasal carriage of S. aureus is now considered a well defined risk factor for subsequent infection in various groups of patients. Local antibiotic treatment with mupirocin ointment is often used to eradicate nasal S. aureus.

Objectives: To determine whether the use of mupirocin nasal ointment in patients with identified S. aureus nasal carriage reduced S. aureus infection rates.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (May 2008), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 2 2008), MEDLINE (1950 to May 2008), EMBASE (1980 to May 2008) and CINAHL (1982 to May 2008). To identify unpublished trials, abstract books from major scientific meetings (ICAAC, ESCMID and SHEA) were handsearched, researchers and manufacturers of mupirocin were contacted and other electronic databases were searched (SIGLE, ASLIB Index, mRCT, USA Clinical Trials).

Selection criteria: Randomised controlled trials (RCTs) comparing nasal mupirocin with no treatment or placebo or alternative nasal treatment in the prevention of S. aureus infections in nasal S. aureus carriers were included.

Data collection and analysis: Titles, abstracts and full-text articles of studies retrieved from the search process were independently assessed by two authors for inclusion. From included studies a data extraction form was made and the quality of the trial was assessed. The primary outcome was the S. aureus infection rate (any site). Secondary outcomes were time to infection, mortality, adverse events and infection rate caused by micro-organisms other than S. aureus.

Main results: Nine RCTs involving 3396 participants met the inclusion criteria. Patient populations varied and several types of nosocomial S. aureus infection were described including bacteraemia, exit-site infections, peritonitis, respiratory tract infections, skin infections, surgical site infections (SSI) and urinary tract infections. After pooling the eight studies that compared mupirocin with placebo or with no treatment, there was a statistically significant reduction in the rate of S. aureus infection associated with intranasal mupirocin (RR 0.55, 95% CI 0.43 to 0.70).

A planned subgroup analysis of surgical trials demonstrated a significant reduction in the rate of nosocomial S. aureus infec33

EBWM

tion rate associated with mupirocin use (RR 0.55, 95% CI 0.34 to 0.89) however this effect disappeared if the analysis only included surgical site infections caused by S. aureus (RR 0.63, 95% CI 0.38 to 1.04), possibly due to a lack of power. The infection rate caused by micro-organisms other than S. aureus was significantly higher in patients treated with mupirocin compared with control patients (RR 1.38 95% CI 1.118 to 1.72).

Authors’ conclusions: In people who are nasal carriers of S. aureus, the use of mupirocin ointment results in a statistically significant reduction in S. aureus infections.

Plain language summary Using mupirocin ointment to reduce staphylococcus aureus infection rates in people who are nasal carriers of staphylococcus aureus. Staphylococcus aureus (S. aureus) is the main hospital acquired pathogen and although the focus has been on preventing cross-infection between patients, it has been shown that a large number of S. aureus infections start from the patient’s own flora. Nasal carriage of S. aureus is a risk factor for infection in hospital patients and using a local antibiotic treatment of mupirocin ointment is often used to eradicate nasal S.aureus. It has been found that if people are nasal carriers of S. aureus then using mupirocin ointment reduces the level of S aureus infections.

Dressings for superficial and partial thickness burns Jason Wasiak, Heather Cleland, Fiona Campbell This record should be cited as: Wasiak J, Cleland H, Campbell F. Dressings for superficial and partial thickness burns. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD002106. DOI: 10.1002/14651858.CD002106.pub2.

ABSTRACT Background: An acute burn wound is a complex and evolving injury. Extensive burns produce, in addition to local tissue damage, systemic consequences. Treatment of partial thickness burn wounds is directed towards promoting healing, and a wide variety of dressings is currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings. Dressing selection should be based on their effects of healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered.

Objectives: To assess the effects of burn wound dressings for superficial and partial thickness burns.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (Searched 29/5/08); The Cochrane Central Register of Controlled Trials (CENTRAL) – The Cochrane Library Issue 2 2008; Ovid MEDLINE – 1950 to May Week 3 2008; Ovid EMBASE – 1980 to 2008 Week 21 and Ovid CINAHL 1982 to May Week 4 2008.

Selection criteria: All randomised controlled trials (RCTs) that evaluated the effects of burn wound dressings for superficial and partial thickness burns.

Data collection and analysis:

34

Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion.

Main results: A total of 26 RCTs are included in this review and most were methodologically poor. A number of dressings appear to have some benefit over other products in the management of superficial and partial thickness burns. This benefit relates to time to wound healing, the number of dressing changes and the level of pain experienced. The use of biosynthetic dressings is associated with a decrease in time to healing and reduction in pain during dressing changes. The use of silver sulphadiazine (SSD) as a comparator on burn wounds for the full duration of treatment needs to be reconsidered, as a number of studies showed delays in time to wound healing and increased number of dressing applications in patients treated with SSD dressings.

Authors’ conclusions: There is a paucity of high quality RCTs on dressings for superficial and partial thickness burn injury. The studies summarised in this review evaluated a variety of interventions, comparators and clinical endpoints. Despite some potentially positive findings, the evidence, which largely derives from trials with methodological shortcomings, is of limited usefulness in aiding clinicians in choosing suitable treatments.

Plain language summary Dressings for treating superficial and partial thickness burns Superficial burns are those which involve the epidermal skin layer and partial thickness burns involve deeper damage to structures such as blood vessels and nerves. There are many dressing materials available to treat these burns but none have strong evidence to support their use. Evidence from small trials, many with methodological limitations, suggests that superficial and partial thickness burns may be managed with hydrocolloid, silicon nylon, antimicrobial (containing silver), polyurethane film and biosynthetic dressings. There was no evidence to support the use of silver sulphadiazine.

Honey as a topical treatment for wounds Andrew B Jull, Anthony Rodgers, Natalie Walker This record should be cited as: Jull AB, Rodgers A, Walker N. Honey as a topical treatment for wounds. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD005083. DOI: 10.1002/14651858.CD005083.

ABSTRACT Background: Honey is a viscous, supersaturated sugar solution derived from nectar gathered and modified by the honeybee, Apis mellifera. Honey has been used since ancient times as a remedy in wound care. Evidence from animal studies and some trials has suggested honey may accelerate wound healing.

Objectives: The objective was to determine whether honey increases the rate of healing in acute wounds (burns, lacerations and other traumatic wounds) and chronic wounds (venous ulcers, arterial ulcers, diabetic ulcers, pressure ulcers, infected surgical wounds).

Search strategy: We searched the Cochrane Wounds Group Specialised Register (May 2008), CENTRAL (May 2008) and several other electronic databases (May 2008). Bibliographies

EWMA

Journal 2008 vol 8 no 3

were searched and manufacturers of dressing products were contacted for unpublished trials.

Selection criteria: Randomised and quasi randomised trials that evaluated honey as a treatment for any sort of acute or chronic wound were sought. There was no restriction in terms of source, date of publication or language.

Wound healing was the primary endpoint.

Data collection and analysis: Data from eligible trials were extracted and summarised using a data extraction sheet by one author and independently verified by a second author.

Main results: 19 trials (n=2554) were identified that met the inclusion criteria. In acute wounds, three trials evaluated the effect of honey in acute lacerations, abrasions or minor surgical wounds and nine trials evaluated the effect the honey in burns. In chronic wounds two trials evaluated the effect of honey in venous leg ulcers and one trial in pressure ulcers, infected post-operative wounds, and Fournier’s gangrene respectively. Two trials recruited people with mixed groups of chronic or acute wounds.

The poor quality of most of the trial reports means the results should be interpreted with caution, except in venous leg ulcers. In acute wounds, honey may reduce time to healing compared with some conventional dressings in partial thickness burns (WMD -4.68 days, 95%CI -4.28 to -5.09 days). All the included burns trials have originated from a single centre, which may have impact on replicability. In chronic wounds, honey in addition to compression bandaging does not significantly increase healing in venous leg ulcers (RR 1.15, 95%CI 0.96 to 1.38). There is insufficient evidence to determine the effect of honey compared with other treatments for burns or in other acute or chronic wound types.

Authors’ conclusions: Honey may improve healing times in mild to moderate superficial and partial thickness burns compared with some conventional dressings. Honey dressings as an adjuvant to compression do not significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence to guide clinical practice in other areas.

Plain language summary Honey as a topical treatment for acute and chronic wounds Honey is a viscous, supersaturated sugar solution derived from nectar gathered and modified by the honeybee, Apis mellifera. Honey has been used since ancient times as a remedy in wound care. More recently trials have evaluated the effects of using honey to help wound healing in both acute wounds (for example burns, lacerations) and chronic wounds (for example venous leg ulcers, pressure ulcers).

Although honey may improve healing times in mild to moderate superficial and partial thickness burns compared with some conventional dressings, it was found that honey dressings used alongside compression therapy do not significantly increase leg ulcer healing at 12 weeks. There is insufficient evidence to guide clinical practice for other wound types. m

ELECTRONIC SUPPLEMENT OCTOBER 2008 The October edition of the EWMA Journal Electronic Supplement consists of ­scientific articles from the Polish Journal Leczenie Ran (Wound Management), which have not previously been ­published in English.

Leczenie Ran is published in cooperation with one of EWMA’s Cooperating Organisations, the Polish Wound Management Association (www.ptlr.pl).

Contents Early assessment of abdominal wound healing after surgical treatment due to ulcerative colitis and rectal cancer: ­single-center experience Analysis of the flora of venous and diabetic ulcerations Evaluation of efficiency of compression therapy in enhancement of venous leg ulcer healing in patients after surgical treatment Plethysmographic features of venous reflux and impaired venous outflow do not influence the results of treatment of venous leg ulcers Pyoderma gangrenosum – one of the causes of lower limb ulcers www.ewma.org/english/ewma-journal/ electronic-supplement.html

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EWMA

EWMA Position Document 2008

We regret to inform our readers that the references published for the paper entitled Treatment of chronic wounds with autologous platelet-rich plasma in EWMA Journal, Vol 8, No 2 are incorrect.

The correct references are listed below.

References: 1. Davidson JM. Growth factors: the promise and the problems. Int J Low Extrem Wounds 2007;6:8-10.

Hard-to-heal wounds

2. Pietrzak WS, Eppley BL. Platelet rich plasma: biology and new technology. J Craniofac Surg 2005;16: 1043-54.

a holistic approach

Editor: Christine Moffatt The seventh European Wound Management ­Association position document will be launched in May 2008 at the EWMA congress ‘Wound Management · Wound Healing – Responsibility and Actions’, to be held in Lisbon, Portugal, 14-16 May 2008.

The document will be available in English, French, German, Italian and Spanish, and can be downloaded from www.ewma.org It is possible to obtain permission to translate the EWMA Position Documents into other languages.

Please contact EWMA Business Office.

Previous Position Documents:

For further details contact MEP Ltd, 53 Hargrave Road, London N19 5SH. www.mepltd.co.uk or EWMA Business Office, Congress Consultants, Martensens Allé 8, 1828 Frederiksberg, Denmark Tel: +45 7020 0305 Fax: +45 7020 0315 ewma@ewma.org

3. Knighton DR, Ciresi K, Fiegel VD, et al. Classification and treatment of chronic nonhealing wounds. Successful treatment with autologous platelet-derived wound healing factors (PDWHF). Ann Surg 1986; 204: 322-0.

4. Crovetti G, Martinelli G, Issi M, et al. Platelet gel for healing cutaneous chronic wounds. Transus Apher Sci 2004; 30: 145-1.

5. McAleer JP, Kaplan E, Persich G. Efficacy of concentrated autologous platelet-derived growth factors in chronic lower-extremity wounds. J Am Podiatr Med Assoc 2006; 96 :482-8.

6. Steenvorde P, van Doorn LP, Naves C., et al. Use of autologous platelet-rich fibrin on hard-to-heal wounds. J Wound Care 2008; 17: 60-3.

7. Eppley BL, Woodall JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: implications for wound healing. Plast Reconstr Surg 2004; 114: 1502-8.

8. Mast BA, Schultz GS. Interactions of cytokines, growth factors, and proteases in acute and chronic wounds. Wound Repair Regen 1996; 4: 411-420.

9. Gürgen M. The TIME wound management system used on 100 patients at a wound clinic. In: Dealey C, editor; Proceedings of the 17th Conference of the European Wound Management Association; 2007, May 2-4; Glasgow, UK. European Wound Healing Association; 2007. p.133.

10. Senet P, Bon FX, Benbunan M, et al. Randomized trial and local biological effect of autologous platelets used as adjuvant therapy for chronic venous leg ulcers. J Vasc Surg 2003; 38: 1342-8.

11. Reutter H, Bort S, Jung MF, et al. Questionable effectiveness of autologous platelet growth factors (PDWHF) in treatment of venous ulcers of the leg. Hautarzt 1999; 50: 859-65.

12. Falanga V, Eaglstein WH, Bucalo B, et al. Topical use of human recombinant epidermal growth factor (h-EGF) in venous ulcers. J Dermatol Surg Oncol 1992; 18: 604-6.

13. Coerper S, Köveker G, Flesch I, et al. Ulcus cruris venosum: surgical debridement, antibiotic therapy and stimulation with thrombocytic growth factors. Langenbecks Arch Chir 1995; 380: 102-7.

14. Herouy Y, Mellios P, Bandemir E, et al. Autologous platelet-derived wound healing factor promotes angiogenesis via alphavbeta3-integrin expression in chronic wounds. Int J Molecular Med 2000; 6: 515-9.

15. Mazzucco L, Medici D, Serra M. The use of autologous platelet gel to treat difficult-to-heal wounds: a pilot study.

Transfusion 2004; 44: 1013-18 16. Margolis DJ, Kantor J, Santanna J. Effectiveness of platelet releasate for the treatment of diabetic neuropathic foot ulcers. Diabetes Care 2001; 24: 483-8.

17. Nelson EA, Prescott RJ, Harper DR, et al. A factorial, randomized trial of pentoxifylline or placebo, four-layer or single-layer compression, and knitted viscose or hydrocolloid dressing for venous ulcers. J Vasc Surg 2007; 45: 134-41.

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Journal 2008 vol 8 no 3

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The solution? In a separate survey, 93% of 3034 patients said they preferred dressings with SafetacÂŽ technology because they are less painful2. The new 2008 WUWHS Principles of Best Practice guidelines also refer to Safetac technology for atraumatic dressing removal. Which means you can make your patients feel a lot better by choosing the dressings that are less painful2 and that professionals prefer3 â&#x20AC;&#x201C; dressings with patented Safetac technology.

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Order your full copy of the new 2008 WUWHS guidelines at www.molnlycke.com

For more information about Safetac technology, please visit www.safetac.com

Patented SafetacÂŽ technology is available exclusively on MepilexÂŽ wound dressings, MepitelÂŽ and other selected MĂślnlycke Health Care dressings.

The MĂślnlycke Health Care name and logo, SafetacÂŽ, MepilexÂŽ wound dressings and MepitelÂŽ are registered trademarks of MĂślnlycke Health Care AB. MĂślnlycke Health Care AB (publ.), Box 13080, SE-402 52 GĂśteborg, Sweden. Phone + 46 31 722 30 00. www.molnlycke.com

1. Price P et al. Findings of an International Pain Survey.

Submitted to International Wound Journal 2008 2. White R., Wounds UK 2008; Vol 4, No 1 3. Data on ďŹ le

EWMA Journal

International Journals

Previous Issues

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

Volume 8, no 21, May 2008 Treatment of chronic wounds with autologous platelet-rich plasma Marcus Gürgen Polyhexanide (PHMB) and Betaine in wound care management Kurt Kaehn, Thomas Eberlein Patients’ experience of w ­ ound-related pain: An international perspective Elizabeth J Mudge Efficacy of honey as a desloughing agent: overview of current evidence Georgina Gethin Abstracts of recent ­Cochrane Reviews Sally Bell-Syer

English

Advances in Skin & Wound Care, vol. 21, no 9, 2008 www.aswcjournal.com Expedited Wound Healing with Noncontact, LowFrequency Ultrasound Therapy in Chronic Wounds: A Retrospective Analysis Steven J. Kavros; David A. Liedl; Andrea J. Boon; Jenny L. Miller; Julie A. Hobbs; Karen L. Andrews Skin and Wound Care: Important Considerations in the Older Adult Madhuri Reddy

Finnish

Haava, no 3, 2008 www.suomenhaavanhoitoyhdistys.fi Mechanism of Pain Eero Vuorien Patient’s Experience Can Be Make Visible by Documentation Marjo Kauppila Pain – stimulus, experience, feeling Challenges of Children’s Pain Management Päivi Järvinen Pain Management in First Aid Timo Jama Difference in Treatment of Surgical Wound – When the wound was healed and unhealed Mikko Tuuliranta Pain Management in Bullet Wounds Pia Volmanen Pain as a Partner of Wound Patient Sirpa Arvonen The Development Project of Pain Management in Surgical Hospital of Turku University Hospital Kristiina Kuusniemi The Implementation of Outpatient Clinic for Paitients with Pain in Helsinki University Hospital Anna-Maija Koivusalo

Volume 8, no 1, January 2008 Problem drug injecting: Wound care, harm reduction and social impact Angela D Guild Larval therapy in the treatment of diabetic foot wounds – A review of the literature Frank L Bowling Opinion piece: Wound healing in hot climates Terence J Ryan Developing research capacity and capability in skin breakdown Jim Dick

Volume 7, no 3, October 2007 Vacuum assisted closure for chronic wounds: a review of the evidence E. Andrea Nelson General practitioner support to care homes: collaboration with a tissue viability nurse specialist and prescribing support pharmacist Lynne Watret, Rachel Bruce Integrated system of chronic wound care healing – creating, managing and cost reduction Heinz J. Janßen, Roland Becker Guidelines for the management of partial-­thickness burns in general hospital-recommen­dation of a European working party Bjarne Alsbjørn, Annelea Buntzen Diabetic Foot Ulcer – From Fiction to Management.

The development of global guidelines Jan Apelqvist, Karel Bakker, Gerlof D Valk Wound Healing in Medieval England Carol Dealey Development of Clinical Practice Guideline on Pressure Ulcers Katrien Vanderwee

Volume 7, no 2, May 2007 Is it safe to use saline ­solution to clean wounds?

João C. F. Gouveia, Cristina I. M. Miguéns, Célia L. S. Nogueira, Marta I. P. Alves The cost of pressure ulceration Peter J Franks Epidemiology of wounds treated in Community Services in Portugal Elaine Pina Improving wound assessment through the p ­ rovision of digital c­ ameras across a Primary Care Trust Alison Hopkins The use of telemedicine in wound care Rolf Jelnes Lord Joseph Lister: the rise of antiseptic surgery and the modern place of a ­ ntiseptics in wound care David Leaper

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

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Feridas, vol. 1, no 3, 2008 EWMA Education Role in Europe Zena Moore – Overview of the EWMA 2008 – Speaking with... Aneeke Adriesen – Events Schedule – Wound Care News

English

The International Journal of Lower Extremity Wounds vol. 7, no 3, 2008 http://ijlew.sagepub.com Evidence, Guidelines: Where Is It All Going?

Raj Mani Evidence-Based Medicine and the Management of the Chronic Wound: Is It Enough?

Thanh Dinh, Aristidis Veves Pathologic Scars: An Overview of Surgical Strategies Luc Téot Avotermin: A Novel Antiscarring Agent Piyush Durani, Nick Occleston, Sharon O'Kane, Mark W. J. Ferguson Intralesional Cryosurgery for the Treatment of ­Hypertrophic Scars and Keloids Following Aesthetic Surgery: The Results of a Prospective O ­ bservational Study Yaron Har-Shai, Wifred Brown, Daniel Labbé, Anne Dompmartin, Irina Goldine, Tamir Gil, Issa Mettanes, Norbert Pallua Basal Cell Carcinoma Is Not Granulation Tissue in the Venous Leg Ulcer Aleksandar Jankovic, Ivana Binic, Milanka Ljubenovic

EWMA

Journal 2008 vol 8 no 3

EWMA

English

International Wound Journal, Vol. 5, Issue 3, June 2008 www.blackwellpublishing.com Use of chlorhexidine-impregnated patch at pin site to reduce local morbidity: the ChIPPS Pilot Trial Stephanie C Wu, Ryan T Crews, Charles Zelen, James S Wrobel, David G Armstrong What are the most effective interventions in preventing diabetic foot ulcers?

Lawrence A Lavery, Edgar JG Peters, David G Armstrong Physiological changes in tissues denervated by spinal cord injury tissues and possible effects on wound healing Laurie M Rappl Mathematical model for wound healing following autologous keratinocyte transplantation Regina Renner, Isabell Teuwen, Carl Gebhardt, Jan C Simon Treatment with bone marrow-derived stromal cells ­accelerates wound healing in diabetic rats David S Kwon, Xiaohua Gao, Yong Bo Liu, Deborah S Dulchavsky, Andrew L Danyluk, Mona Bansal, Michael Chopp, Kevin McIntosh, Ali S Arbab, Scott A Dulchavsky, Subhash C Gautam In vivo microvascular response of murine cutaneous muscle to ibuprofen-releasing polyurethane foam Andrej Ring, Ole Goertz, Gert Muhr, Hans-Ulrich Steinau, Stefan Langer A prospective study of blanchable erythema among university hospital patients Chie Konishi, Junko Sugama, Hiromi Sanada, Mayumi Okuwa, Chizuko Konya, Tomoe Nishizawa, Kimi Shimamura Povidone–iodine: use in hand disinfection, skin preparation and antiseptic irrigation Piyush Durani, David Leaper Intermittent pneumatic compression in immobile patients Hugo Partsch

English

Journal of Wound Care, April issue, vol. 17, no 4, 2008 www.journalofwoundcare.com; jwc@emap.com Biofilms and chronic wound inflammation Effect of an ibuprofen-releasing foam dressing on wound pain: a real-life RCT A review of the physical, biological and clinical properties of a bacterial cellulose wound dressing Microbial investigation of venous leg ulcers Speculating to accumulate: reducing the cost of wound care by appropriate dressing selection

Rane, vol. 2, no. 1, June 2008 Available online at www.lecenjerana.com Compression therapy Justina Somrak Skin aging in chronic venous insufficiency Javorka Delić About Croatian Wound Management Association Dubravko Huljev Morden concepts in chronic wound treatment Bosiljka Rajskov, Tanja Radovanović, Mirko Vidović Treatment of the complex pressure ulcer in patient with spinal cord lesion – case report Radoje Cobeljić

Serbian

Scandinavian

Wounds (SÅR) vol.16, no 3, 2008 www.saar.dk Quality of life for diabetics with foot ulcers in the Research Centre for Wound Healing, Bispebjerg Hospital, Denmark Britta Østergaard Melby Telemedicine without borders – using telemedicine for wound management between hospital doctors and GPs in remote areas Anna Marie Nielsen

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Journal 2008 vol 8 no 3

English

Wound Repair and Regeneration, vol 16, no 5 2008 Reducing wound pain in venous leg ulcers with Biatain Ibu: A randomized, controlled double-blind clinical investigation on the performance and safety Finn Gottrup; Bo Jørgensen; Tonny Karlsmark; R. Gary Sibbald; Rytis Rimdeika; Keith Harding; Patricia Price; Vanessa Venning; Peter Vowden; Michael Jünger; Stephan Wortmann; Terttu-Liisa Ahokas; Karel Ettler; Monika Arenbergerova The optimal temperature of first aid treatment for partial thickness burn injuries Leila Cuttle; Margit Kempf; Olena Kravchuk; Gael E. Phillips; Julie Mill; Xue-Qing Wang; Roy M. Kimble, Basic fibroblast growth factor accelerates and improves second-degree burn wound healing Sadanori Akita; Kozo Akino; Toshifumi Imaizumi; Akiyoshi Hirano Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy Stephanie K. Beidler; Christelle D. Douillet; Daniel F. Berndt; Blair A. Keagy; Preston B. Rich; William A. Marston Primary dermal fibroblasts derived from sdc-1 deficient mice migrate faster and have altered av integrin function Rosalyn A. Jurjus; Yueyuan Liu; Sonali Pal-Ghosh; Gauri Tadvalkar; Mary Ann Stepp Antisense inhibition of connective tissue growth factor (CTGF/CCN2) mRNA limits hypertrophic scarring without affecting wound healing in vivo Mark Sisco; Zol B. Kryger; Kristina D. O’Shaughnessy; Peter S. Kim; Greg S. Schultz; Xian-Zhong Ding; Nakshatra K. Roy; Nicholas M. Dean; Thomas A. Mustoe Comparison of the effects of collagenase and extract of Centella asiatica in an experimental model of wound healing: an immunohistochemical and histopathological study Aylin Türel Ermertcan; Sevinc Inan; Serap Ozturkcan; Cemal Bilac; Serap Cilaker Exogenous metallothionein-IIA promotes accelerated healing after a burn wound Natalie M. Morellini; Natalie L. Giles; Suzanne Rea; Katharine F. Adcroft; Sian Falder; Carolyn E. King; Sarah A. Dunlop; Lyn D. Beazley; Adrian K. West; Fiona M. Wood; Mark W. Fear

German

Wund Management, vol. 2, no 4, 2008 English abstracts are available from www.mhp-verlag.de drugs and wound healing K. Kröger influence of thyroid gland function on wound healing H. Lahner Thrombangiitis obliterans/Burger disease F. Santosa

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

Please submit possible topics for future conference sessions.

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

Please contact the Journal Secretariat at ewma@ewma.org

39

The EWMA University Conference Model:

EWMA2008 LISBON

Zena Moore Dept. of Nursing and Midwifery Royal College of Surgeons in Ireland Dublin, Ireland zmoore@rcsi.ie

Lessons learned from Lisbon

Introduction The members of the EWMA education committee have been aware for some time that health professionals are seeking alternative approaches to professional development and have created a unique model that combines attendance at the annual EWMA Conference with academic study at a university of their own choice. This model is called the EWMA University Conference Model (EWMA UCM) and has arisen from a pragmatic desire at future EWMA conferences to: n Combine academic study with existing ­professional development activities n Enable maximum utilisation of expert knowledge & skills n Utilise excellent facilities & learning ­resources The EWMA UCM was piloted in Glasgow in May 2007, proving highly successful. The second EWMA UCM took place in Lisbon in May 2008, where the success of the programme surpassed all expectations. The challenge ahead is now to use the student evaluations and lessons learned from Lisbon to prepare for another successful EWMA UCM course in Helsinki in 2009.

For participation in the Helsinki course, EWMA welcomes all teaching institutions who find the description of the EWMA UCM programme interesting to contact the EWMA Business Office at ewma@ewma.org

Evaluation of EWMA UCM Lisbon 2008 EWMA was delighted to see a total of 110 students from teaching institutions in Belgium (Centre of Continuing & Professional Development), Ireland (Royal College of Surgeons Ireland), Portugal (Universidade Atlântica, ESS Setúbal and Universidade dos Açores), Switzerland (Haute école de Santé, Geneva) and the United Kingdom (University of Hertfordshire) undertake the EWMA UCM in Lisbon 2008.

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Participants practising on pigs' feet at the debridement workshop.

The students added a unique dimension, contributing positively to the overall success of the conference. Feedback from the students, a central component in the future development of the EWMA UCM, was facilitated through an open forum and the completion of written evaluation forms.

One of the highlights of the feedback includes a strong sense of the importance of being a part of an international group where the opportunity to share different practice experiences is facilitated.

The challenges of achieving evidence based practice were also considered an important issue, with the EWMA UCM facilitating open discussion of these challenges. Furthermore, the students were pleased to discover that they were not isolated in seeking the best answers to wound care problems.

Indeed that fact that there is much debate on the subject, especially among “experts” was a reassurance. The emphasis, throughout the conference, on critical appraisal of research evidence for its application to clinical practice was also highlighted as important. This skill is central to enabling the student address the variety of clinical problems faced each day in their individual practices. Overall, the student found the programme to be a rewarding, valuable experience, one which they would have no hesitation recommending to others.

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EWMA

Why should you undertake the EWMA UCM? The EWMA conference brings together international experts in the field of wound healing and provides a dynamic platform for â&#x20AC;&#x2DC;real worldâ&#x20AC;&#x2122; research, professional debate and networking opportunities and presentation of the latest practice developments. It is an ideal educational environment to provide registered studentâ&#x20AC;&#x2122;s with a challenging, analytical conference experience from which they can develop reflective practice skills and is one that cannot hope to be replicated by any one individual university.

Making use of the educational opportunities available at the EWMA conference will allow registered students to explore the wider perspectives of wound management from an international perspective.

The overall aims of the programme are to facilitate the student to: n Identify the process and concepts involved in the conduct of research in wound management n Increase their understanding of the dissemination of research findings n Critically appraise the outcomes of research and its applicability in clinical practice n Identify key priorities in the delivery of wound management services n Understand the importance of European dimensions and diversity in wound management

n Understand the importance of a multidisciplinary approach to wound management n Actively participate in National and International networking in wound management n Identify key competencies required in wound management and the resources necessary for the development of these competencies. n Seek and critically appraise materials necessary to maintain their own competence in wound management.

Conclusion In the light of the epidemiological, financial and human costs associated with wound management, there is a need for practitioners to have in depth knowledge and skills in the provision of effective, efficient, evidence-based practice for individuals suffering from the most common chronic wounds encountered. The EWMA UCM aims to achieve this by providing a medium where students, from a wide variety of clinical backgrounds and cultural experiences, can come together to hear, confront and debate the latest evidence in wound care. This unique learning experience strengthens the link between theory and practice, facilitating the development of enhanced skills and knowledge in chronic wound management. We look forward to seeing you in Helsinki in May 2009 where you can share in this highly rewarding experience. m

Part of the group of EWMA UCM students in Lisbon

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EWMA

First Time presenter EWMA2008 LISBON

First time presenter Hilde Fagervik-Morton, Cardiff University, United Kingdom

QUALITATIVE RESPONSES TO PAIN BETWEEN COUNTRIES Aim: Cross- (and within-) cultural variations in clinical practice can have an impact on professional- patient interaction; implicate beliefs about health, illness and expectations for the professional- patient relationship, and health communication preferences.

Methods: This cross-sectional international survey collected the self-reported views of patients using a specifically designed questionnaire developed from issues relevant to patients captured through focus groups. Results were obtained for 2018 patients from 15 different countries across Europe, North America and Australia, with a mean age of 68.6 years (st dev 15.4), and a mean wound duration of 19.6 months (st dev 51.8). When asked two questions related to reducing pain at dressing-related procedures, responses were given by 1523 patients in relation to their own/carersâ&#x20AC;&#x2122; involvement, and by 1344 patients in relation to health care professionalsâ&#x20AC;&#x2122; involvement.

Results: 40.4% of patients felt that neither they nor their carer or health care professional could do anything to ease the pain experienced during dressing related procedures. However, it is not clear as to whether this was due to patientsâ&#x20AC;&#x2122; feeling resigned to the situation and the treatment provided or due to not knowing of anything that could benefit them. Further, many patients made suggestions in relation to the procedure and handling of the wound to reduce discomfort and pain; wanting careful and gentle treatment, to soak/ moisten the dressing before removal, to be consulted, listened to, communicated with and distracted from the dressing related procedures, not having the wound touched or scrubbed, to have consistent quality of care, for the procedure to be carried out slowly, for the wound to be washed with water and to have the dressings changed regularly.

Conclusions: These results highlight the importance of identifying and incorporating a patient's concerns into their goals for treatment, participants involved in the treatment, and patterns of communicating health information to improve and facilitate positive health outcomes.

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EWMA

Journal 2008 vol 8 no 3

Negative Pressure

Positive Outcomes

The innovative WoundASSIST ÂŽ TNP system provides cost effective and easy to use topical negative pressure wound therapy, enabling access to the therapy for patients across all healthcare settings.

Advanced therapies can be effective but these may also be bulky or costly and this can force compromise.

WoundASSIST TNP system now gives the option of TNP therapy to patients in multiple care settings who may otherwise have not been able to access the therapy.

ÂŽ

www.easytnp.com

EWMA

EWMA Travel Grants EWMA is committed to the advancement of wound care and wound ­management in Europe and it encourages international understanding and learning between nurses, doctors and other healthcare workers. Therefore, EWMA provides travel grants to young practitioners who wish to develop their skills within wound care and wound management abroad.

The travel grants will primarily be given for educational purposes or clinical experiences outside the applicants’ own countries. Novice practitioners have priority, but more experienced applicants are also accepted.

Requirements: • Applicants must have been a member of EWMA for 1 year.

• The grants are limited to travelling within Europe.

• The maximum amount that can be applied for per applicant is 3000 EUR • All grant receivers must write a report of 1-2 pages about their stay abroad.

This report will be published in EWMA Journal How to apply: 1. Write a letter in English to EWMA stating a. the purpose of your travels b. what you aim to achieve during your travels c. where you are traveling to (address(es), institution(s) etc.) d. dates and duration of your stay 2. Attach a letter of acceptance from centre/institution to be visited 3. Address the letter to Zena Moore, Chair of the Travel Grant Committee and send the letter and the letter of acceptance e­ lectronically and via regular post to: EWMA Business Office c/o Congress Consultants Martensens Allé 8 DK-1828 Frederiksberg C Denmark ewma@ewma.org Deadline for submission of applications is 15 February 2009 You will receive notification of whether or not you have been given a travel grant by 15 March 2009.

After your travels: 1. It is obligatory to write a report (1-2 pages) about your travels and what your outcome of the stay was.

This report will be published in EWMA Journal.

2. Please send this report to EWMA Business Office Fur forther information about travel grants please contact EWMA Business Office at ewma@ewma.org

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M

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MJ

CJ

CMJ

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NEW C H R O N I C

URGO

W O U N D S

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RE-TRIGGERING THE HEALING PROCESS

URGO

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Protease-inhibiting lipido-colloid dressings containing NOSF

The Urgo Start range consists of two protease-inhibiting dressings impregnated with NOSF: Urgotul® Start and UrgoCell® Start.

NOSF is an innovative compound, combined with a lipido-colloid TLC matrix (Urgotul® Start), or an absorbent lipido-colloid TLC matrix (UrgoCell® Start). NOSF inhibits excess proteinases and promotes the action of growth factors.

The Urgo Start range is indicated for the treatment of all types of low-exuding (Urgotul® Start) and exuding (UrgoCell® Start) chronic wounds after debridement, particularly if delayed healing is clinically suspected. w w w. u r g o s t a r t . c o m

EWMA

EWMA 2008 EWMA2008 LISBON

– a very successful ­conference in Lisbon!

T

he EWMA 2008 conference was held 14-16 May at Lisbon Congress Centre in Lisbon, Portugal. It was organised in cooperation with the two Portuguese wound management associations APTFeridas and GAIF and the theme of the conference was: Wound Mangement & Wound Healing – Responsibility and Actions

The conference was attended by just over 2300 participants mostly from all over Europe, but there were also participants from as far away as Angola, Israel, Japan and USA among others. In all 34 International speakers gave presentations in 8 key sessions on topics such as, Malignant Ulcers – Multidisciplinary Treatment, Measuring Infection in Surgical Wounds, Immunosupression and Chronic Wounds – Friend or Foe? among others.

EWMA received more than 600 abstracts of which 379 were accepted as poster presentations and 107 as free paper presentations. These can now be downloaded from the conference web site www.ewma.org/ewma2008. Other activities include workshops on e.g. Paediatric Wound Care and Decision Making for Patients with Complex Wound Problems.

The first time presenter award was given to: Hilde Fagervik-Morton, United Kingdom: Qualitative responses to Pain Between Countries The awards for best posters were given to: Veronika Woskova, Czech Republic The Neuropad: A Simple Test to Evaluate Diabetic Neuropathy and Risk of Diabetic Foot Ulcer Anna Marie Nielsen, Denmark Methods for Evaluation of Bacterial Contamination as a Result of Treatment with High Pressure Irrigation Pedro Pacheco, Portugal Compression Therapy in Treating Venous Ulcers in a Healthcare Sub Region

Javier Hernández Toledo, Spain Clinical Evidence of Infection and its Correlation with the Microbiological Diagnosis in Diabetic Foot Wounds Poster Prizes given to Centres This year the poster award committee decided to award centres with poster prizes, as each centre has contributed a number of high class posters across a range of topics, involving a team of people. The following centres were awarded poster prizes: • University of Pisa, Italy • University of Essen, Germany • Polish Academy of Sciences, Warsaw, Poland All of EWMA’s 42 Cooperating Organisations met at the Cooperating Organisations Board Meeting held on Thursday 15 May in Lisbon. This is one area where EWMA continues to develop its activities in the collaboration with wound healing and management associations across Europe. Since this time last year, EWMA has welcomed the Wound Management Association of Kosova (WMAK) and the Slovak Association for Open Wounds Curing (SSOOR) as Cooperating Organisations. In terms of networking as well as direct access to contemporary knowledge and scientific resource persons within wound management, the Cooperating Organisations are crucial partners.

The work on education activities coordinated by the Education Committee, chaired by Zena Moore, remains central to EWMA. Many courses are built on the EWMA Modules and endorsed by EWMA. Furthermore, we have now seen that the EWMA UCM (University Conference Model) piloted in Glasgow, this year in Lisbon, has developed into a full programme where approximately 120 students from four European countries have studied part of their curriculum during the Conference.

The EWMA 2008 Conference was a great opportunity for colleagues and friends from all over Europe (and other parts of the world) to meet. We look forward to our next conference in Helsinki in May 2009. www.ewma.org/ewma2009 Finn Gottrup, EWMA Recorder 

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The exhibition was well-visited as was the Poster area on the balcony above the exhibtion.

With so many participants attending EWMA 2008, the registration desk was very busy â&#x20AC;&#x201C; especially on the first day.

Carolyn Wyndham-White uses the opportunity to network with Hubert Vuagnat and a colleague at the Conference Evening at Convento do Beato

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EWMA

EWMA2008 LISBON

Zena Moore, Marco Romanelli and Salla Seppänen.

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Pedro Pacheco, Portugal

Anna Marie Nielsen, Denmark

Javier Hernรกndez Toledo, Spain

Veronika Woskova, Czech Republic

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EWMA

Elain Pina, GAIF, Portugal

José Verdú Soriano, Spain and Filomena Pinheiro da Mota, Portugal

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Corporate Sponsor Contact Data Corporate A

Coloplast Holtedam 1-3 DK-3050 Humlebæk Denmark Tel: +45 49 11 15 88 Fax: +45 49 11 15 80 www.coloplast.com

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

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

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

KCI Europe Holding B.V. Parktoren, 6th floor van Heuven Goedhartlaan 11 1181 LE Amstelveen The Netherlands.

Tel: +31 (0) 20 426 0000 Fax: +31 (0)20 426 0097 www.kci-medical.com

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

Mölnlycke Health Care Ab Box 13080 402 52 Göteborg, Sweden Tel: +46 31 722 30 00 Fax: +46 31 722 34 08 www.molnlycke.com

Smith & Nephew Po Box 81, Hessle Road HU3 2BN Hull, United Kingdom Tel: +44 (0) 1482 225 181 Fax: +44 (0) 1482 328 326 www.smith-nephew.com

Use the EWMA Journal to profile your company Deadline for advertising in the February 2009 issue is 1 December 2008

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

Activa Healthcare Ltd 1 Lancaster Park Newborough Road Needwood, Burton on Trent Staffordshire DE13 9PD United Kingdom Tel: +44 (0) 8450 606 707 Fax: +44 (0) 1283 576808 www.activahealthcare.co.uk

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

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

Ferris Mfg. Corp.

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

Journal 2008 vol 8 no 3

EWMA

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

NEW Corporate B Sponsor

…WITH PEOPLE IN MIND Sanuwave AG Kreuzlingerstrasse 5 CH-8574 Lengwil Switzerland Tel: +41 71 6868 900 Fax: +41 71 6868 901 www.sanuwave.com

Sorbion AG Hobackestraße 91 D-45899 Gelsenkirchen Tel: +49 (0)2 09-95 71 88-0 Fax: +49 (0)2 09-95 71 88-20 www.sorbion.com

Synergy Healthcare (UK) Limited Wound Care 1 Western Avenue Matrix Park Buckshaw Village, Chorley Lancashire PR7 7NB United Kingdom Tel: +44 1772 299900 Fax: +44 1772 299901 www.synergyhealthcareplc.com

Laboratoires Urgo 42 rue de Longvic B.P. 157 21300 Chenôve France Tel: (+33) 3 80 44 70 00 Fax: (+33) 3 80 44 71 30 www.urgo.com

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ArjoHuntleigh is a global medical equipment supplier ­offering its customers a broad range of integrated solutions for the care of people with reduced mobility and related conditions.

The ArjoHuntleigh product portfolio encompasses medical equipment and integrated solutions for patient handling and hygiene, medical beds and therapeutic surfaces, wound healing and therapy, DVT prevention, disinfection and diagnostics.

At the centre of our activities we place the residents and ­patients that are cared for using our equipment.

We also place great value on the welfare of healthcare ­professionals that care for them. Our products, programmes and services are designed with these people in mind.

Our aim is to provide solutions that: • improve the quality of life for residents/patients • create a better working environment for nursing staff • reduce the cost of care.

ArjoHuntleigh have been providing cost-effective solutions to healthcare providers throughout the world for more than 25 years. During this time, patients have benefited from our highly effective and technologically advanced medical devices, designed to prevent and treat both complex and chronic wounds; including pressure ulcers, leg ulcers and non-healing surgical wounds.

We believe that the best formula for achieving optimum ­patient outcomes requires a multidisciplinary approach.

We involve end-users and seek expert opinion at all stages of product evolution; from the initial design through ­clinical investigation to the delivery of comprehensive solutions which include education, training, competency assessment and outcome measurement.

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Conferences

The man with the red cap: Garry Sibbald

WUWHS 2008 EWMA was one of the supporting societies for the 3rd Congress of The World Union of Wound Healing Societies which took place in Toronto, Canada, 4-8 June 2008. EWMA was well ­represented as many of the Council members were on the international conference faculty and spoke at the conference. In addition, three of our past presidents, Christine Moffatt, George Cherry and Finn Gottrup received Lifetime Achievement Awards, for which they must be congratulated.

More than 3,000 from all over the world participated in the congress, and made it a truly world wide wound meeting.

The programme was divided into 10 streams: • Pressure Ulcers • Diabetic Foot Ulcers • Ostomy/ Continence/ Skin Care • Leg Ulcers • Acute Wounds • Complex Wounds • Global Perspectives • Free Papers • Canadian Perspectives in Wound Care • Research The streams allowed people to customize their own programme, and benefit from the many parallel sessions although at times it could be difficult to choose among the many sessions.

54

EWMA also had an information booth at the congress.

Side by side with the Australian Wound Management Association and the European Tissue Repair Society, the EWMA information booth demonstrated that EWMA is one of the key players within wound care. The booths were situated within the large exhibition area which was the central point of the centre, and where lunch and coffee were served. Many well-known and less well known companies were exhibiting at the congress providing a useful resource for the delegates Toronto and the congress centre were perfect for the world meeting. It was easy to find the many meeting rooms in the congress centre and many hotels were in walking distance from the centre.

The “Taste of Toronto Reception” at the Fairmont Royal York Hotel reflected the different nationalities in the many different buffets and many participants enjoyed an evening with food, drinks and music.

We are pleased to announce that The 4th WUWHS Congress will be held in Tokyo, Japan in 2012. As ever, EWMA expects to be involved and to support the organisers for this meeting.

Marco Romanelli

EWMA

Journal 2008 vol 8 no 3

S 02 04 - * Trademark of Johnson & Johnson - X-STATIC is a registered Trademark of Noble Fiber Technologies Inc

Progressive Strength

SILVERCEL* dressing uses new hydro-alginate technology to complement the effectiveness of silver release. It is a dressing that becomes stronger as it absorbs, facilitating removal from the wound. Clinically tested, SILVERCEL* dressing encourages healing even in very wet wound situations by providing an optimal moist wound environment. The sustained and balanced release of silver ions kills a broad spectrum of microorganisms associated with the bacterial colonization and infection of wounds, including MRSA, MRSE and VRE.

Conferences

Conference Calendar Conference

Theme

2008

Days

City

Country

Lindsay Leg Club Foundation Leg Club Conference

The Art & Science of Nursing in the 21st Century

Oct

1-2

Worcester

UK

NOVW Annual Meeting

Op weg naar een betere wondzorg

Oct

8

UniPlaza te Culemborg

Netherlands

11th Conference of SEBINKO

The Development of Clinical Validy and Best Practices Requirements

Oct

2nd World Congress of TeleDermatology

Healty Present and Healthier Future

3rd Interdisciplinary School in Wound Healing Annual Meeting: SumS

Diabetic Foot Ulcers

16-17 Tatabánya

Hungary

Oct

16-18 Chinnai

India

Oct

23-24 Southampton

UK

Oct

24

Reykjavik

Iceland

VII Simposio Nacional de Úlceras por Presión y Heridas y globalización Heridas Crónicas.

Nov

12-14 Tarragona

Croatian Wound Association Symposium

Nov

13-15 Stubicke Toplice, Croatia Zagreb

Decubitus

Spain

5° Congresso Nazionale AISLeC

EBN e Wound Care: Nuove Frontiere

Nov

13-15 Napoli

Italy

Danish Wound Healing Society (DSFS) Annual Meeting

Manifestation ved medicinsk sygdom

Nov

20-21 Svendborg

Denmark

3rd European Academy of Wound Technology / French Session

Nov

24-26 Elancourt

France

WMAT, Wound Management Association of ­Turkey. 3rd National Congress

Nov

27-29 Cesme, Izmir

Turkey

2009 NIFS The Norwegian Wound Association

Wound Infections

Feb

First International Lymphoedema Framework Conference

International Lymphoedema Framework ­Conference

Apr

21-23 Royal Ascot, Berkshire

UK

6th EADV Spring Symposium

Apr

23-26 Bucharest

Romania

WHS (Wound Healing Society) Symposium on Advanced Wound Care 2009

April

26-29 Grapevine, Texas USA

April

27-28 Llandudno

Wales

May

9-19

Germany

TVS Annual Conference

Care – Science and Practice

ICW National Congress

5-6

Bodø

Bremen

Norway

19th Conference of the European Wound ­Management Association

Healing, Education, Learning and Preventing in Wound Care

May

20-22 Helsinki

Finland

AWA & SAfW. AWA Annual Meeting

Treatment of Wounds: Recommendationes for best practice in wound healing

Jun

19-20 Zürich

Switzerland

Annual National Congress of the DGfW

Lymphology and Compression

ETRS and WHS joint meeting European Burns Association Congress

EBA 2009

EPUAP

12th. Annual European Pressure Ulcer Meeting

Jun

25-27 Kassel

Germany

Aug

25-29 Limoges

France

Sep

2-5

Sep

3-5

Lausanne Amsterdam

Netherlands

Bled

Slovenia

Berlin

Germany

8th Scientific Meeting of the Diabetic Foot Study Group (DFSG) of the EASD

Sep

18th EADV Congress

Oct

7-11

Nov

10-11 Harrogate

Wounds UK

Wound Care Conference

Switzerland

UK

For web addresses please visit www.ewma.org

NEW EWMA WEB SITE EWMA has a new web site, the address is the same, but the design, navigation and content has improved.

You can now search for and download all EWMA conference abstracts, view pictures from previous EWMA Conferences in the photo gallery, read about the EWMA Projects: Patient Outcome Group and Leg Ulcer Project, read about the EWMA University Conference Model (UCM), find information about EWMA Travel Grants and much more.

WWW.EWMA.ORG 56

EWMA

Journal 2008 vol 8 no 3

Organisations

ICW-activities

ICW Initiative Chronische Wunden www.ic-wunden.de

The ICW has been active throughout the year 2008 in its 13 local groups where members try to optimize the care of patients with chronic wounds in their region. Each group provides educational activities for its members and guests but the main purpose is the discussion of the everyday ­problems people with chronic wounds and caregivers meet in their practice.

The ICW courses were held in more than 80 venues in all parts of Germany with 15 to 25 participants in each course. Those who passed the courses in previous years successfully are now engaged in continuing education in order to recertify their diploma after 5 years.

Our last national congress proved extremely successful with more than 2000 participants, mostly registered nurses of all specialities.

The currently elected new board of ICW now plans the congress 2009 which will be held from 9th to 19th May in Bremen â&#x20AC;&#x201C; come and see!

The Executive Committee of ICW.

8th Scientific Meeting of the

Diabetic Foot Study Group of the EASD September 2009 Bled, Slovenia

www.dfsg.org

Cooperating Organisations AFIScep.be

GNEAUPP

AISLeC

ICW

AIUC

LBAA

APTFeridas

LUF

Francophone Nurses Association in Stoma Therapy, Wound Healing and Wounds

Assoication of Nurses for the Study of Cutaneous Ulcers www.aislec.it

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

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

AWA

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

BFW

Belgian Federation of Woundcare www.befewo.org

CNC

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

CSLR

Czech Wound Management Society www.cslr.cz

CWA

Croatian Wound Association www.kbd.hr/index.php?id=799

DGfW

German Wound Healing Society www.dgfw.de

DWHS

Danish Wound Danish Wound Healing Society Healing Society www.dsfs.org

FWCS

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

GAIF

Associated Group of Research in Wounds www.gaif.net

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

Chronic Wounds Initiative www.ic-wunden.de

Latvian Wound Treating ­Organisation

The Leg Ulcer Forum www.legulcerforum.org

LWMA

Lithuanian Wound Management Association

MST

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

MWMA

Macedonian Wound Management Association

NATVNS

National Association of V ­ iability Nurse Specialists (Scotland) www.natvns.com

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

ROWMA

Romanian Wound ­Management Association www.artmp.ro

SAfW

Swiss Association for Wound Care www.safw.ch www.safw-romande.ch

58

EWMA

Journal 2008 vol 8 no 3

Organisations

SAWMA

SWHS

SEBINKO

TVNA

Serbian Advanced Wound Management Association

Swedish Wound Healing Society www.sarlakning.se

Tissue Viability Nurses ­Association www.tvna.org

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

TVS

Tissue Viability Society www.tvs.org.uk

SFFPC

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

WMAI

Wound Management A ­ ssociation of Ireland www.wmaoi.org

SSiS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

WMAK

Wound Management Association of Kosova

SSOOR

WMAS

Slovak Association for Wound Care

Wound Management Association Slovenia

SUMS

Iceland Wound Healing ­Society www.sums-is.org

WMAT

SWHS

Wound Management A ­ ssociation Turkey www.yaradernegi.org

Serbian Wound Healing Society www.lecenjerana.com

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

Associated Organisations Leg Club

Lindsay Leg Club Foundation www.legclub.org

LF

Lymphoedema Framework www.lymphoedemaframework.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

Present your national wound management organisation or write a report about your organisation’s latest meeting. ewma@ewma.org

Deadline for submitting papers for the January 2009 issue is 1 November 2008

EWMA

Journal 2008 vol 8 no 3

59

3 Editorial

Carol Dealey

Science, Practice and Education 5 Eucomed – Advanced Wound Care Sector (AWCS).

Positioning of advanced wound care Hans Lundgren

11 A Laboratory Survey of the Antimicrobial Properties of ­Honey-Containing Dressings Rowena Jenkins

17 Topical negative pressure versus ­conventional treatment of deep sternal wound infection in cardiac surgery Martin Šimek

23 Quality of Life in the Patients with Chronic Leg Ulcers – A Preliminary Report Veronika Slonkova

25 Compression therapy for venous leg ulcers – how to get more value for money Susan F. Jørgensen

EBWM 32 Abstracts of recent ­Cochrane Reviews Sally Bell-Syer

EWMA 38 EWMA Journal Previous Issues 38 International Journals 40 The EWMA University Conference Model: Lessons learned from Lisbon Zena Moore

42 EWMA2008 First Time presenter 44 EWMA Travel Grants 47 EWMA 2008 – a very successful ­conference in Lisbon!

Finn Gottrup

52 EWMA Corporate Sponsor Contact Data 54 WUWHS 2008 Marco Romanelli

Conferences 56 Conference Calendar

Organisations 57 ICW-activities 58 Cooperating Organisations 59 Associated Organisations