EWMA Journal October 2013

Volume 13 Number 2 October 2013 Published by European Wound Management Association

The EWMA Journal ISSN number: 1609-2759 Volume 13, No 2, October, 2013 The Journal of the European Wound Management Association Published twice a year

EWMA Council Salla Seppänen

Jan Apelqvist

President

Immediate Past President

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

Dubravko Huljev

Gerrolt Jukema

Secretary

Scientific Recorder

José Verdú Soriano Treasurer

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

Paulo Alves

Sue Bale

Mark Collier

Javorka Delic

Ann-Mari Fagerdahl

Georgina Gethin

Luc Gryson

Arkadiusz Jawien

Nada Kecelj-Leskovec

Martin Koschnick

Knut Kröger

EWMA Journal Editor

Layout: Birgitte Clematide Printed by: CS Grafisk A/S, Denmark Copies printed: 10.000 Prices: The EWMA Journal is distributed in hard copies to members as part of their EWMA membership.

EWMA also shares the vision of an “open access” philosophy, which means that the journal is freely available online.

Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published in April 2014. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than January 15th 2014.

The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association.

All scientific articles are peer reviewed by EWMA Scientific Review Panel.

Copyright of published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval.

All issues of EWMA Journal are CINAHL listed.

2

Magdalena Annersten Gershater

Severin Läuchli

Sebastian Probst

Elia Ricci

Rytis Rimdeika

Robert Strohal

COOPERATING ORGANISATIONS’ BOARD Esther Armans Moreno, AEEVH Christian Thyse, AFISCeP.be Tommaso Bianchi, AISLeC Roberto Cassino, AIUC Ana-Maria Iuonu, AMP Romania Aníbal Justiniano, APTFeridas Gilbert Hämmerle, AWA Jan Vandeputte, BEFEWO Vladislav Hristov, BWA Els Jonckheere, CNC Lenka Veverková, CSLR Ivana Vranjkovic, CWA Arne Buss, DGfW Bo Jørgensen, DSFS Heidi Castrén, FWCS Pedro Pacheco, GAIF

J. Javier Soldevilla, GNEAUPP Christian Münter, ICW Aleksandra Kuspelo, LBAA Susan Knight, LUF Loreta Pilipaityte, LWMA Corinne Ward, MASC Hunyadi János, MSKT Suzana Nikolovska, MWMA Anne Wilson, NATVNS Øystein Karlsen, NIFS Louk van Doorn, NOVW Arkadiusz Jawie´n, PWMA Severin Läuchli, SAfW (DE) Hubert Vuagnat, SAfW (FR) Goran D. Lazovic, SAWMA Mária Hok, SEBINKO

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

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

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

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

B glis iling h & ua Sp l an ish

En

24th Conference of the European Wound Management Association 4 Editorial

Science, Practice and Education 7 Risk assessment scales for ­pressure ulcers in intensive care units: A systematic review with meta-analysis F. P. García-Fernández et al.

15 Pressure-time integral of elastic versus inelastic bandages

EWMA GNEAUPP n

H. Partsch, G. Mosti

19 VERUM – A European approach for successful venous leg ulcer healing R. Brambilla et al.

25 Effect of topical h ­ aemoglobin on venous leg ulcer healing

14-16 May

2014

M. Arenbergerova et al.

32 The effects of an arginine-enriched oral nutritional supplement on chronic wound healing in non-malnourished patients J. Schols et al.

adrid · Spain

35 Efficacy of honey gel in the treatment of chronic lower leg ulcers O. Tellechea et al.

Scientific Communication 41 IWC – Consensus recommendation – Recommendations for ­compression therapy for p ­ atients with venous ulcers B. Assenheimer et al.

49 Evaluation of education and training in Croatia T. Sinoži´c et al.

56 Report on the Pilot Professional Supplementary ­Vocational ­Education Module Wound Management I. S. Bakhtina et al.

Cochrane Reviews 59 Abstracts of recent ­Cochrane reviews Sally Bell-Syer

EWMA 66 EWMA Journal previous issues and other journals 68 Book review: Wound Healing and Skin Integrity S. Bale

70 EWMA 2013 in Copenhagen, Denmark G. Jukema, E. W. Henneberg

76 EWMA Appreciations and new EWMA Council Members

Innovation, know-how and technology in wound care

S. Seppänen

79 GNEAUPP Activities J. J. Soldevilla Agreda

82 EWMA 2013: Nordic Diabetic Foot Task Force K. K. Møller, M. Löndahl

84 EWMA as a partner in United4Health Z. Moore

86 EWMA 2013: The Russian spoken symposium R. Rimdeika

89 The University Conference Model – The journey so far M. Flanagan

Registration and abstract submission open from November 2013 Deadline abstract submission 1 January 2014 Early registration deadline 15 March 2014

92 EWMA NEWS 94 EWMA’s commitment to wound care advocacy across Europe S. Seppänen

96 Cooperating Organisations Board meeting

European Wound Management Association Asociatión Europea para el manejo de las heridas ewma@ewma.org

Z. Moore

98 EWMA Corporate Sponsors

Organisations 99 Conference Calendar

Spanish Group for the study and advice on pressure ulcers and chronic wounds

100 WAWLC: Wound care in r­ esource-poor settings E. Comte, H. Vuagnat

101 WAWLC: NPWT the sustainable way D. Zurovcik, G. Mody, R. Riviello

102 EWMA Guest Session at the EFORT 2013 conference

Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas

Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas

F. Gottrup

104 Australian Wound Management Association B. McGuiness

106 The Association for the Advancement of Wound Care (AAWC)

www.ewma2014.org

R. J. Snyder

108 Wound Management Association-Romania (AMP) A. M. Iuonut

110 Cooperating Organisations

3

Haemoglobin´s healing powers: Just 3 from thousands of successfully healed wounds.

Patient: 85 years, female. Arterial crural ulcer Existed for 7 years before Granulox

Get into contact: service@sastomed.de Phone: +49 (0)5401 365 1910 Before Granulox

After 22 weeks

Patient: 65 years, female. Amputation wound Existed for 8 weeks before Granulox

Before Granulox

After 8 weeks

Patient: 44 years, male. Surgical wound Existed for 9 weeks before Granulox

Before Granulox Reimbursable | PZN 9595753 Sales force: +49 (0)5401 365 1910 www.granulox.de

After 4 weeks

Haemoglobin Spray

Editorial

Organisational challenges in wound care

D

uring the last year, I have tried to learn the ropes from the previous EWMA president, Jan Apelqvist. I would like to take this opportunity to thank him for all of his great achievements, his innovative approach to leadership, and for increasing EWMA’s influence in the health care sector.

I plan to continue these efforts during my tenure as president from 2013 to 2015. In addition, my contributions to the development of EMWA will focus on the following objectives: n To strengthen EWMA’s position as an advocate of multidisciplinary approaches to wound care; n To facilitate self-care and work towards empowering patients and their informal carers to make decisions concerning treatment, and contribute to the facilitation of self-care; n To continue to advocate that the EU agenda ­recognizes wound care; n To strengthen cooperation between national and international wound care societies and to work actively to support wound care s­ ocieties, ­particularly in Russia and neighbouring ­countries; n To promote evidence-based wound care and to facilitate the development of wound care by health professionals, based on the best available evidence; n To engage professionals such as psycho­ therapists, occupational therapists, nutritionists, and podiatrists in the work of EWMA and to increase the number of EWMA members from these professions.

EWMA Journal

2013 vol 13 no 2

To face these organisational challenges, I am depending on you – the wound community – to contribute and collaborate. Partners must include the wound care industry, as well as patients and clinicians working in the field of wound management across Europe.

We can reach the above objectives with a simple toolset that includes: n Continuing efforts to promote the use of ­multidisciplinary teams in wound care and to document the advantages of this model of ­organisation; n Supporting the development of wound care training and education across Europe, including facilitating the collaboration and sharing of ­experiences between education professionals; n Strengthening collaboration with research ­institutions such as the Cochrane Collaboration and the Joanna Briggs Institute; n Supporting meta-analysis and the synthesis of research with scholarships/grants; n Further strengthening EWMA’s cooperation with national organisations and supporting ­international cooperation between wound care societies.

In the years to come, EWMA will tirelessly pursue these goals and will continue to advocate better care for wound patients and also to support cost-effective approaches to treatment. Recognizing that these fundamental organisational improvements are feasible, EWMA will continuously work to ensure that such health care improvements become a reality, rather than mere rhetoric.

Salla Seppänen, EWMA President

5

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sorbion sana Primary dressing for low to moderately exuding wounds.

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s ilable a a v a o r Als ulti sta sana m

Science, Practice and Education

Risk assessment scales for ­pressure ulcers in intensive care units: A systematic review with meta-analysis SUMMARY Aims: To identify risk assessment scales for pressure ulcers that have been used in critical care units. Determine which of them have been validated according to validity, predictive capacity and reliability criteria, developing, where possible, aggregate indicators.

Methods: Systematic review of the clinical literature with meta-analysis. The main international health science databases were searched for prospective studies on the validity and/or predictive capacity of pressure ulcers risk assessment scales published between 1962 and 2009 in any language and with a loss to follow-up of less than 25%. We excluded grey literature, reviews, and retrospective and crosssectional studies. The methodological quality of the studies was assessed according to the guidelines of the Critical Appraisal Skills Programme.

The indicators analysed were validity, effect size (RR – relative risk) and reliability. When two or more valid original studies were found, a meta-analysis was conducted using the random effect model followed by a sensitivity analysis.

Results: A total of 255 articles were found. These articles identified 16 risk assessment scales designed specifically for ICUs. Twenty-six (26) studies measure the validity of these scales. Only three scales have been validated by more than one study (NM Bienstein, Cubbin-Jackson, JacksonCubbin). Four general scales have also been validated in ICUs (Braden, Norton, BM Choi Song-and Waterlow). Waterlow and NM Bienstein are not valid due to their low sensitivity. The CubbinJackson, Jackson-Cubbin and Norton scales present very similar predictive validity data, but have only been tested with very small samples. The Braden scale presents the best test results in ICUs, with adequate parameters and predictive validity.

Conclusions: We recommend the use of the Braden Scale for the pressure ulcer risk assessment in critical care units. Other scales, such as the CubbinJackson, Jackson-Cubbin, Norton or BM Choi-Song scales, may be useful but need to be tested in larger numbers of patients.

Keywords: Pressure ulcer, risk assessment scales, intensive care units, systematic review, metaanalysis.

EWMA Journal

2013 vol 13 no 2

Introduction Even in the 21st century, pressure ulcers (PUs) remain a living epidemic and cause of alarm for our health and social services and for the entire welfare society1 and must therefore be treated as a major health concern that affects all classes of patients regardless of their social category2 and at all levels of care3.

Pressure ulcers are particularly relevant in the context of critical care (intensive care units – ICUs), where their incidence is very high. The first data on pressure ulcer incidence in ICUs were published by Nancy Bergstrom in 19874 and revealed the true severity of the problem, reporting an incidence of 40%.

Since then, perhaps the most important study on pressure ulcer epidemiology in the United States of America was conducted by Janet Cuddigan in 2001, and is included in the document entitled Pressure ulcers in America: prevalence, incidence and implications for the future, presenting epidemiological data on PUs in ICUs. Incidence rates vary between 5.2% and 45%, while prevalence ranges between 22% and 28.7%.

In Spain, national prevalence studies conducted in 2001, 2005 and 2009 showed how the problem of PUs has been increasing globally, from 13.16% in 2001 to 24.20% in 2009. The increase in prevalence has been particularly strong in neonatal and paediatric ICUs, rising from 18.1% to 33.3%5-7.

Pressure ulcer prevention is essential, even more so bearing in mind that at least 95% of PUs can be prevented, as demonstrated by Pam Hibbs almost three decades ago8. The scientific community has emphatically acknowledged that prevention is possible.

Inadequate treatment of PUs can have ethical and legal implications for professionals and institutions.

The first step in prevention is risk assessment, which aims to identify people who require prevention and the specific factors that put them at risk.

Although there was until recently a strong debate on how risk should be assessed, evidence seems to clearly indicate that scales have significant advantages  over clinical judgment9-11.

Francisco Pedro García-Fernández1 Pedro L. PancorboHidalgo2 J. Javier Soldevilla Agreda3 Mª del Carmen Rodríguez Torres4 1Nurse. PhD, University of Jaén 2Director

of the Nursing Department. Faculty of Health Sciences, University of Jaén

3Geriatric Nursing.

University of La Rioja 4Nurse. Masters in Chronic Wound Care.

Jaén Hospital Complex

Correspondence: pacopedro@gneaupp.org Conflict of interest: none

7

Nevertheless, this debate, which seems to be have been closed within the context of general inpatient care, seems not to have been clearly resolved in the context of critical care. Doubts often exist in ICUs regarding the type of scale to use. Is it better to use validated general scales? Or is it better to use specific scales in ICUs even if they have not been validated? Has any specific scale been validated for ICUs? No thorough and comprehensive review of literature has yet been published to answer these questions. This research (conducted as part of a larger study) therefore aims to address the aforementioned research questions.

The proposed objectives were to: 1. Identify pressure ulcer risk assessment scales that have been used in the context of critical care.

2. Determine which of these scales have been validated according to predictive validity, predictive capacity and reliability criteria, developing aggregate indicators where possible.

Method Design: Systematic review of available scientific literature on pressure ulcer risk assessment scales developed for ICUs or general care units validated in that context.

Search methods: The search was conducted on the following databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, Centre for Reviews and Dissemination of the University of York, Latin American and Caribbean Center on Health Sciences (LILACS), CUIDEN Plus (Fundación Index Spain), Spanish Medical Index (Índice Médico Español – IME), Current Contents, EBSCO On line, InterSciencia (Wiley), ScienceDirect, Pascal, ProQuest, Springer.

A specific search strategy was conducted adapted to each database, including at least the following descriptors: “decubitus ulcer” or “pressure ulcer” or “pressure sores” or “bed sores” and “risk assessment”. No language limitations were established for the search and in the final selection articles published in English, Spanish, French, Portuguese, Italian and German were obtained. Additionally, a reverse search was conducted based on the bibliographical references of the studies selected. When necessary, the authors of the studies were contacted directly to request additional validation data.

The review included studies published between 1962 and December 2009 that met the following criteria: the studies had to have an instrument to assess pressure ulcer risk, with a clinical trial or prospective study design, with patient follow-up, presenting the results of clinical validation indicators or calculating these if possible. The following were excluded: descriptive studies, unpublished studies (grey literature), retrospective or cross-sectional

8

Figure 1. Flow diagram of the process of identifying and including references for the systematic review.

studies and prospective studies with a percentage of loss to follow-up over 25%12 and studies involving patients with pressure ulcers upon admission.

Methodological quality: The methodological quality of the studies identified in the literature search using the CASP (Critical Appraisal Skills Programme).

Data extraction: Data were extracted by a researcher and checked by another independently (to avoid errors). The data were collected on an ad hoc sheet that included the following variables: n For all studies: study citation (author and year of publication), scale and cut-off point, type of facility, sampling method used, sample size, number of patients lost, average age, follow-up period, lowest category of ulcers included and whether the study analysed predictive validity and/or capacity and/or reliability. n Predictive validity analysis: number of valid samples, pressure ulcer incidence, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), effectiveness or correct percentage and area under the ROC curve. n Predictive capacity analysis: relative risk (including a CI of 95%). n Reliability analysis: correlation (Pearson’s index or Intra-class correlation coefficient) and/or agreement between authors.

Data synthesis: An aggregated analysis was conducted on the scales with two or more valid studies using the random effects model13. Heterogeneity was calculated using the Q statistic13 and was complemented by calculating the values

EWMA Journal

2013 vol 13 no 2

Science, Practice and Education Table 1: Scales designed specifically for UCI No. Yeara Scale 1

1991 Cubbin-Jackson

Type of patientsb

Construction criteriac

Scored

Cut-off Definition pointe of termsf

Original name

Country

Pressure area risk calculator

United Kingdom Adult/elderly patients Previous scales

Reverse

≤24

Reverse

2

1991 Norton Mod. Bienstein Norton Modified Scale by Bienstein

Germany

≤24

Partial

3

1993 Batson

United Kingdom Adult/elderly patients Clinical research Functions

No

None

Pressure area scoring system

Adult/elderly patients Previous scales

Partial

4

1993 Pediatric risk

Pediatric risk assessment chart

United Kingdom Paediatric patients

Direct

≥10

None

5

1995 DUPA

Decubitus Ulcer Potential Analyzer

United States

Reverse

No

None

6

1995 Sunderland

Pressure sore risk calculator.

City Hospitals Sunderland (ITU)

United Kingdom Adult/elderly patients Previous scales + Reverse Clinical research

≤35

Partial

7

1996 Braden Q

Q Scale for Predicting Pediatric Pressure Ulcer Risk

United States

Paediatric patients

Previous scales

Reverse

≤23

Clear

8

1996 Oakland

Patient Assessment tool for assessing United States patients at risk for development of pressure related breakdown.

Paediatric patients

Previous scales

Direct

≥6

Clear

9

1997 NSRAS

The Neonatal Skin Risk Assessment Scale

United States

Paediatric patients

Previous scales

Reverse

≤5

Clear

Paediatric score

United Kingdom Paediatric patients

Risk factors

Direct

No

None

United Kingdom Paediatric patients

No information

10 1998 Cockett

Previous scales

Adult/elderly patients Previous scales

11 1998 Pattold

The Pattold pressure scoring system

Direct

≥15

None

12 1999 Jackson-Cubbin

The revised Jackson/Cubbin Pressure United Kingdom Adult/elderly patients Previous scales Area Risk Calculator

Reverse

≤29

Partial

13 2000 4-factor model

4-factor model

Germany

Adult/elderly patients Previous scales + risk factors

Functions

No

None

14 2001 EVARUCI

Escala de Valoración Actual del Riesgo de desarrollar Ulceras por presión en Cuidados Intensivos.

Spain

Adult/elderly patients Experts

Direct

No

Clear

15 2008 Compton

Nursing skin assessment

Germany

16 2008 Suriadi-Sanada

S.S. Scale (Suriadi and Sanada scale) Japan

Adult/elderly patients Clinical research Functions

No

None

Adult/elderly patients Clinical research Functions

≥4

None

a Year: Year in which the first article describing the scale was published. b Type of patients: Patients in which the scale attempts to predict pressure ulcer risk (adult/elderly patients or paediatric patients [neonates or children]) c Construction criteria: Built based on clinical research, previous scales, risk factors, expert criteria or prior literature. d Score: Direct (higher score greater risk); Reverse (lower score greater risk) or Functions (Functions o risk equations). There may be combinations of scores that are direct or reverse but which must perform mathematical functions. e Cut-off point: Original score defined by the authors as from which risk is deemed to exist and which prompts the adoption of preventive measures.

This cut-off point may have been modified subsequently by other researchers for specific or general contexts. “No” indicates that this point is not described. f Definition of terms: Clear (there is a clear and unambiguous operative definition of the factors), Partial or Ambiguous (factors are defined but not completely or there may be confusion), None (factors are not defined).

H and I2 14,15. In cases of high heterogeneity, a sensitivity analysis was performed in the meta-analysis, removing the studies that fell outside the upper and lower bands of the Galbraith plot. Similar results in terms of both direction and magnitude of the effect and statistical significance indicated that the analysis was robust.

The existence of selection bias was measured by conducting Begg16 and Egger17 tests with the funnel plot. No bias was deemed to exist when the value p > 0.05.

Results Figure 1 shows the flowchart of results included and excluded for the analysis of the validity of the different scales.

Of the 255 studies identified, 229 were eliminated for various reasons (because they were reviews or cross-sectional studies, did not present validation data, bias, etc.).

Twenty-six (26) studies contained useful information for the analysis of the validity and/or predictive capacity and/ or reliability of the scales4,18-42.

EWMA Journal

2013 vol 13 no 2

These studies identified sixteen (16) risk assessment scales specifically designed for ICUs19,20,22,33,38,43-53. The characteristics of these scales are presented in Table 1. Most of the critical-care scales were developed in the US or the UK, but some were also developed in Germany, Spain and Japan.

62.5% were developed for adults and the rest for children. Half of them were built based on previous scales, 18.75% based on clinical research, 12.5% based on mixed methods (research and previous scales) and the rest based on risk factors (6.25%), experts (6.25%) or no information was provided in this respect. Most (43.75%) are reverse scales (higher score lower risk), followed by direct score scales (higher score greater risk) (31.25%), while the remainder (25%) are mathematical functions.

50% of the scales did not define terms, 25% had partially defined terms and only 25% had clearly defined  terms.

9

Table 2. Assessment studies included: design and characteristics.

No. Author(s)/Year

8

Bergstrom et al 1987 4

Scale and cut-off point

Centre

Sampling method

Braden £16

Hospital (Intensive Care)

Systematic

No. Lost Average Monitoring period ­ atients p age included (years) 60

0

58.5

Minimum VA PC stage

R

2 weeks

I

Yes No *(Yes)

19 Salvadalena et al. 1992 18

Braden £18 Hospital (ICU) Convenience Clinical judgement

100

1

72

Stay in ICU

I

Yes Yes *(Yes)

24 Jiricka et al. 1995 19

Braden £14 DUPA £22

Hospital (ICU) Convenience

85

0

42

Stay in ICU

I

Yes No *(Yes)

25 Lowery 1995 20

Sunderland <28

Hospital (ICU) Convenience

15

0

ND

Stay in ICU

I

Yes No *(Yes)

28 Pröß et al. 1996 21

Bienstein <23

Hospital (ICU) Convenience

111

0

ND

10 days

I

Yes No *(Yes)

NSRAS ³5

Hospital (NPICU)

32

0

RN

3 weeks/release

I

Yes Yes *(Yes)

37 Westrate et al. 1998 23

Waterlow ³15

Hospital (ICU) Systematic

594

0

58.8

Length of stay in ICU

I

Yes No *(Yes)

2001 24

Jackson £29 Waterlow ³10

Hospital (ICU) Systematic

314 188

0

57.5

Length of stay in ICU

I

Yes No *(Yes)

50 Curley et al. 2003 25

Braden Q <16

Hospital (NPICU)

Convenience

322

0

3

2 weeks or until ­release

I

Yes No *(Yes)

52 Lee et al. 2003 26

Cubbin £26 Norton £14 Song-Choi (BMS) £24

Hospital (ICU) Convenience

125

13

62

Release/transfer/death

I

Yes No *(Yes)

54 González et al. 2004 27

EVARUCI >10

Hospital (ICU) Convenience

30

0

ND

ND

55 Seongsook et al. 2004 28

Braden £16 Cubbin £24 Douglas £ 18

Hospital (ICU) Convenience

125

13

62

Release/transfer/death

I

Yes Yes *(Yes)

56 Aizpitarte et al. 2005 29

Waterlow ³10

Hospital (ICU) Convenience

91

0

60.5

ND

I

Yes No *(Yes)

Braden £16 Cubbin £24

Hospital (ICU) Convenience

39

0

65

2 or more days

I

Yes No *(Yes)

63 Suriadi et al. 2006 31

Braden £ 16 Multi-Pad Pres.

Evaluator >40 mmHg

Hospital (ICU) Systematic

105

ND

48.5

1 week

I

Yes Yes *(Yes)

64 Feuchtinger et al. 2007 32

Braden £ 16 Bienstein £ 23 4- factors ³2

Hospital (ICU) Convenience

53

0

62

4 weeks

I

Yes No *(Yes)

68 Compton et al. 2008a 33

Compton 0.5

Hospital (UCI) Convenience

698

0

66

3 or more days

I

Yes No *(Yes)

69 Compton et al. 2008b 34

Waterlow ³10

Hospital (UCI) Convenience

698

0

66

3 or more days

I

Yes Yes *(Yes)

30 Huffines & Logsdon

45 Boyle & Green

62 Machado et al.

1997 22

2006 30

2008 35

Convenience

ND

No No

No

Braden £ 16

Hospital (UCI) Convenience

48

0

49

2 or more days

I

Yes No *(Yes)

71 González et al. 2008 36

EVARUCI >10

Hospital (UCI) Convenience

97

35

67.7

Until release or ­appearance of PU

I

Yes No *(Yes)

72 Kosmidis & Koutsouki 2008 37

Braden £ 14 Jackson £34

Hospital (UCI) Convenience

71

0

ND

3 or more days

I

Yes No *(Yes)

76 Suriadi et al. 2008 38

Suriadi-Sanada >4 Hospital (UCI) Convenience

253

0

48.9

3 or more days

I

Yes No *(Yes)

77 Almirall et al. 2009 39

Norton £ 14

Hospital (UCI) Convenience

351

0

64.9

2 or more days

I

Yes No

Braden £ 14 Cubbin £28 Song (BMS) £21

Hospital (UCI) Convenience

219

0

58.1

Until release or ­appearance of PU

I

Yes No *(Yes)

81 Kottner & Dassen 2009 41

Braden £16 Hospital (UCI) Convenience Waterlow ³10 Clinical judgement

45

0

68.4

ND

83 Uzun et al. 2009 42

Braden £ 16

186

0

59.9

2 or more days

70 Fernandes & Caliri

80 Kim et al.

2009 40

Hospital (UCI) Convenience

ND

II

No Yes

Yes

No

Yes No *(Yes)

VA = Validity PC = Predictive capacity R = Reliability ND: No data *(Yes)= The calculation was performed by researchers using the primary data of the authors.

10

EWMA Journal

2013 vol 13 no 2

Science, Practice and Education Table 3. Accumulated analysis of validity indicators (random effects model) No. studiesa

Scale

Valid sample Sensitivity (%) Specificity (%) PPVb (%) NPVc (%) Efficiencyd (%) ROCe

Bienstein

2

164

43.37

85.89

86.30

43.37

55.74

ND

Braden (UCI)

11

1077

87.42

38.06

48.85

81.38

59.31

0.90

Cubbin-Jackson

3

370

85.31

73.04

58.68

90.37

75.93

ND

Jackson-Cubbin

2

259

85.29

41.30

29.32

90.70

51.55

ND

Norton (UCI)

2

463

94.24

42.83

25.25

96.86

53.21

ND

Song-Choi (UCI)

2

331

97.00

48.83

38.80

99.05

61.88

0.81

Waterlow (UCI)

4

1697

69.11

43.43

18.26

88.80

46.68

0.59

a Number of studies included in the meta-analysis b PPV = Positive Predictive Value c NPV = Negative Predictive Value d Efficiency = Percentage of correctly classified patients e ROC= Area under the ROC (Receiver-Operator Curve)

Table 4. Meta-analysis of pressure ulcer risk indicators (random effects model) No. studiesa Valid sample

Scale

RRb

IC 95%c

Q (p value)d

He

I2 (%)f

1085 813

3.27 2.86

1.76-6.05 1.80-4.54

29.48 (p=0.009) 8.77 (p=0.36)

1.05

8.78

Braden (ICU)

11 9

BM Song-Choi (ICU)*

2

331

14.14

3.35-59.54

1.53 (p=0.22)

1.23*

35

Cubbin-Jackson

3 2

370 151

8.63 5.24

3.02-24.66 2.67-10.29

5.65 (p=0.05) 0.35(p=0.55)

1.68 0.59

64.60 0

Jackson-Cubbin

2

259

3.16

1.49-6.71

0.001 (p=0.99)

0.03

0

Norton (ICU)

2

463

9.46

3.52-25.40

0.49 (p=0.48)

0.7

0

NM Bienstein

2

164

1.52

1.11-2.10

0.09 (p=0.76)

0.30

0

Waterlow (ICU)

4

789

1.60

1.19-2.17

0.20 (p=0.98)

0.45

0

a Number of studies included in the meta-analysis b RR= Relative Risk c Confidence Interval of 95% (upper or lower limit) d Heterogeneity with the Q value (p value) e Value H= < 1.2 low heterogeneity; between 1.2-1.5 mean heterogeneity; >1.5 high heterogeneity f Value I2 = 0-25% low inconsistency; 26-50% medium inconsistency; >50% high inconsistency. *High heterogeneity. No sensitivity analysis possible. Unconsolidated data.

The characteristics of these studies are presented in Table 2. Together with the 16 specific scales developed for ICUs, validation studies were found for another five general scales: Norton54, Waterlow55, Douglas56, Braden4 and Braden Mod. Song Choi57.

Seven scales had only one study and could therefore not be considered as valid. These were the Douglas scale and six specific scales: Sunderland, Braden Q, NSRAS, EVARUCI, Compton and Suriada-Sanada.

Seven scales could therefore be considered as having been validated in critically ill patients. Three were specific scales (Cubbin-Jackson, Norton Mod. Bienstein and Jackson-Cubbin) and four general scales (Norton, Waterlow, Braden and Braden Mod. Song Choi). Data aggregation was in these scales.

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Tables 3 and 4 present aggregate validity and predictive capacity data.

The most tested scale is the Braden scale, which has been tested with a large number of patients and offers adequate sensitivity, NPV, efficiency and area under the curve. The RR value of the scale is also adequate with well-defined confidence intervals.

The Waterlow scale has also been tested in an adequate number of patients but its sensitivity, efficiency and area under the curve are very low, hence its validity is low. Its predictive capacity is also low.

The remaining scales – BM Choi Song, Cubbin-Jackson, Jackson-Cubbin, Norton, NM Bienstein – have been tested in very small numbers of patients for their data to be considered adequate. The Cubbin-Jackson scale presents adequate validity indicators and although its RR is high, its CI is too wide. 

11

Table 5. Reliability analysis Valid sample

Reliabilitya

Salvadalena et al. 1992

99

0.90

EVARUCI

González et al. 2004

30

0.97

NSRAS

Huffines & Logsdon 1997

32

0.97

Waterlow (ICU)

Compton et al. 2008 b

698

0.59

Kottner & Dassen 2009

45

0.36/0.51

Scale

Author/Year

Braden (ICU)

a Reliability

In terms of reliability (Table 5), all the scales present good values but have been tested in very small samples, except the Waterlow scale, which has been tested in a large sample of patients but presents easily the worst reliability values, which are below 0.6 in both studies.

Discussion We believe that the methodology employed in this study allowed us to identify, obtain the full text of and analyse all the studies related with PU assessment scales identified since 1962.

A large number of scales built specifically for ICUs for both adults and children were identified. Virtually none of them have been validated. Only the Cubbin-Jackson, Jackson-Cubbin and Norton Mod. Bienstein scales have been validated, albeit with very small samples. More solid validity data are available for the general scales (Braden and Waterlow) in the context of critical patient care than for the specific scales.

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2. García-Fernández F, Lopez Casanova P, Pancorbo Hidalgo P, Verdú Soriano J. Anecdotario histórico de las heridas crónicas: Personajes ilustres que la han padecido. Rev Rol Enf2009;32(1):60-3.

3. Papanikolaou P, Clark M, Lyne PA. Improving the accuracy of pressure ulcer risk calculators: some preliminary evidence. Int J Nurs Stud2002 2002;39:187-94.

4. Bergstrom N, Demuth PJ, Braden B. A clinical trial of the Braden scale for predicting pressure sore risk.

Nursing Clinics of North America1987;22(2):417-28.

measured using the Pearson’s index or the Intra-class correlation coefficient.

In general, the studies are very homogeneous. Data aggregation was possible in seven scales (three specific and four general). Two required sensitivity analyses to improve the heterogeneity and consistency of the studies.

This analysis confirms the trend of the meta-analysis.

It establishes few changes, improves confidence intervals and presents homogeneous and consistent final values.

With the current data, neither the Waterlow scale nor the NM Bienstein scale seem adequate given their low sensitivity. These scales also present the worst predictive capacity (RR).

The BM Choi Song scale presents the best sensitivity and NPV, but has only been tested in very small samples of patients. It also presents the best RR value, but its high heterogeneity means that it cannot be taken into consideration.

Two scales are actually very similar, despite being long considered to be the same scale. These are the CubbinJackson44 and Jackson-Cubbin51 scales, the latter being a

9. Pancorbo Hidalgo PL, García-Fernández FP, IMª LM, Alvarez Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs2006;54(1):94-110.

10. García-Fernández FP, Pancorbo Hidalgo PL, Soldevilla Agreda JJ. Escalas de valoración del riesgo de desarrollar úlceras por presión. Gerokomos2008;19(3):40-8.

11. García Fernández FP. Escalas de valoración del riesgo de desarrollar úlceras por presión. Revisión sistemática con meta-análisis. Jaén.: Universidad de Jaén.; 2011.

12. Sackett D, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine: How to practice and teach EBM. London.: Churchill Livingstone; 1997.

13. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials1986 Sep;7(3):177-88.

5. Torra i Bou JE, Rueda Lopez J, Soldevilla Agreda JJ, Martinez Cuervo F, Verdú Soriano J. Primer Estudio Nacional de Prevalencia de Úlceras por Presión en España. Epidemiología y variables definitorias de las lesiones y pacientes. Gerokomos2003;14(1):37-47.

14. Higgins JP, SG T. Quantifying heterogeneity in a metaanalysis. Stat Med 2002;21:1539-58.

6. Soldevilla Agreda J, Torra i Bou J, Verdú Soriano J, Martinez Cuervo F, Lopez Casanova P, Rueda Lopez J, et al. Segundo estudio nacional de prevalencia de ulceras por presión en España, 2005. Epidemiologia y variables definitorias de las lesiones y pacientes.

Gerokomos2006;17(3):154-72.

16. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics1994 Dec;50(4):1088-101.

7. Verdú Soriano J, Soldevilla Agreda JJ, Torra i Bou JE. Epidemiología de las Ulceras por Presión en España: Resultados del 3er Estudio Nacional de Prevalencia VIII Simposio Nacional sobre Úlcera por Presión y Heridas Crónicas; Santiago de Compostela: GNEAUPP; 2010.

8. Hibbs P. Pressure sores: a system of prevention.

Nursing Mirror1982;4:25-9.

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15. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ2003 Sep 6;327(7414):557-60.

17. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ1997 Sep 13;315(7109):629-34.

18. Salvadalena GD, Snyder ML, Brogdon KE. Clinical trial of the Braden scale on an acute care medical unit. J ET Nurs1992;19:160-5.

19. Jiricka MK, Ryan P, Carvalho MA, Bukvich J. Pressure ulcer risk factors in an ICU population. Am J Crit Care1995 Sep;4(5):361-7.

20. Lowery MT. A pressure sore risk calculator for intensive care patients: “the Sunderland experience”.

Intensive and critical care nursing1995;1:344-53.

21. Prölß J, Elbers P, Caspers A. Entwicklung einer Dekubitusrisikoskala für Intensivpatienten. Intensive and critical care nursing1996;4:260-71.

22. Huffines B, Logsdon M. The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Issues in comprehensive pediatric nursing1997;20:103-14.

23. Weststrate JTM, Hop WCJ, Aalbers AGJ, Vreeling AWJ, Bruining HA. The clinical relevance of the Waterlow pressure sore risk scale in the ICU. Intensive Care Med1998;24:815-20.

24. Boyle M, Green M. Pressure sores in intensive care: defining their incidence and associated factors and assessing the utility of two pressure sore risk assessment tools. Aust Crit Care2001;14(1):24-30.

25. Curley MAQ, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients.

The Braden Q scale. Nursing Research2003;52(1):22-33.

26. Lee Y, Jeong I, Jeon S. A comparative study on the predictive validity among pressure ulcer risk assessment scales. Taehan Kanho Hackhoe Chi2003;33(2):162-9.

27. Gónzalez-Ruiz J, García-Granell C, Gónzalez-Carrero A, López Fernández - Peinado MI, Ortega Castro E, R; V-V, et al. Escala de valoración del riesgo de úlceras por presión en cuidados intensivos (EVARUCI). Metas Enferm2004;7:27-31.

28. Seongsook J, Ihnsook J, Younghee L. Validity of pressure ulcer risk assessment scales; Cubbin and Jackson, Braden, and Douglas scale. Int J Nurs Stud2004;41(2):199-204.

29. Aizpitarte Pegenaute E, Galdiano Fernández A, Zugazagoitia Ciarrusta N, Margall Coscojuela M, Asiain Erro M. Úlceras por presión en cuidados intensivos: valoración del riesgo y medidas de prevención. Enferm Intensiva2005;16(4):153-63.

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modification of the former developed in 1999 by Christine Jackson. Both have identical sensitivity and NPV but better efficiency than the original scale. The original version also has a higher RR value, but its confidence interval is too wide. Both scales have been tested in too few patients to be considered as adequate.

The Norton scale presents similar results to the previous scales, offering good sensitivity and NPV, good RR values albeit with a very wide confidence intervals, and has been tested in a small numbers of patients.

The Braden Scale has undergone the most comprehensive validation process in the context of ICU. It offers a good balance between sensitivity, NPV, efficiency and RR with a tight confidence interval. It also has a good RR value, has been tested in a sufficient number of patients and presents tight confidence intervals.

Reliability has mainly been measured using Pearson’s R statistic. In our opinion, this is not a good method for estimating inter-observer reliability because it fails to take into account cases of random coincidence, prompting higher correlation values and forcing researchers to use the weighted Kappa index as an adequate estimator or the Intra-class correlation interval to correct this random effect.

Reliability data could not be aggregated due to the lack of studies. The Waterlow scale once again presents the lowest parameters. In any case, reliability studies have been tested in very few patients.

Conclusions n 16 scales developed specifically for use in intensive care were identified, but only three have two or more validation studies. n Four general scales (Norton, Waterlow, Braden and Braden Mod. Choi Song) have also been validated in ICUs. n The Braden scale is recommended for assessing risk in critical care patients. n Other scales (e.g. Cubbin-Jackson, Jackson-Cubbin, Norton or BM by Choi Song) may be useful but further validation studies are required. n There are no data to recommend a specific scale in neonatal-paediatric ICUs. Recommendations for future research Many scales have been developed for ICU patients. Existing scales should be assessed before new ones are developed.

It would be useful to compare results obtained with the Braden and Cubbin-Jackson scales in the same patients treated in critical care in order to compare their effectiveness.

Some of the scales developed for children need to be validated. m

30. Machado S, De Castilho S, Oliveira B. Evaluation of risk assessment scales for decubitus ulcer in intensive care patients. Online Brazilian Journal of Nursing2006;5(2).

38. Suriadi, Sanada H, Sugama J, Thigpen B, Subuh M. Development of a new risk assessment scale for predicting pressure ulcers in an intensive care unit.

Nursing in a critical care2008;13(1):34-43.

47. Quigley S, Curley MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers. Journal of the society of pediatric nurses1996;1:7-18.

31. Suriadi, Sanada H, Sugama J, Thigpen B, Kitagawa A, Kinosita S, et al. A new instrument for predicting pressure ulcer risk in an intensive care unit. J Tissue Viability2006;16(3):21-6.

39. Almirall Solsona D, Leiva Rus A, Gabasa Puig A. La escala APACHE III: Un factor pronóstico en la aparición de úlceras por presión en una unidad de cuidados intensivos. Enferm Intensiva2009;20(3):95-103.

48. Garvin G. Wound and skin care for the PICU. Critical care nursing Quartely1997;20(1):62-71.

32. Feuchtinger J, Halfens R, Dassen T. Pressure ulcer risk assessment immediately after cardiac surgery-does it make a difference? A comparison of three pressure ulcer risk assessment instruments within a cardiac surgery population. Nurs Crit Care2007;12(1):42-9.

33. Compton F, Hoffmann F, Hortig T, Staub M, Frey J, Zidek W, et al. Pressure ulcer predictors in ICU patients: nursing skin assessment versus objective parameters. J Wound Care2008;17(10):417-24.

34. Compton F, Strauss M, Hortig T, Frey J, Hoffmann F, Zidek W, et al. Validity of the Waterlow scale for pressure ulcer risk assessment in the intensive care unit: a prospective analysis of 698 patients. Pflege Z2008;21(1):37-48.

40. Kim E, Lee S, Lee E, Eom M. Comparison of the predictive validity among pressure ulcer risk assessment scales for surgical ICU patients.

Australian Journal of Advanced Nursing2009;26(4):87-94.

41. Kottner J, Dassen T. Pressure ulcer risk assessment in critical care: Interrater reliability and validity studies of the Braden and Waterlow scales and subjective ratings in two intensive care units. Int J Nurs Stud2009:[Epub ahead of print].

42. Uzun O, Aylaz R, Karadag E. Prospective study: Reducing pressure ulcers in intensive care units at a Turkish medical center. J Wound Ostomy Continence Nurs2009;36(4):404-11.

35. Fernandes L, Caliri M. Using the Braden and Glasgow scales to predict pressure ulcer risk in patients hospitalized at intensive care units. Rev Latino-am Enfermagem2008;16(6):973-8.

43. Bienstein C. Risikopatienten erkennen mit der erweiterten Nortonskala. In: Dekubitus D, editor.

Prophylaxe -Therapie 2. Frankfurt/Main: Verlag Krankenpflege; 1990.

36. González-Ruiz J, Núñez-Méndez P, Balugo-Huertas S, Navarro de la Peña L, García-Martín M. Estudio de validez de la escala de valoración actual del riesgo de desarrollar úlceras por presión en cuidados intensivos (EVARUCI). Enferm intensiva2008;19(3):123-31.

44. Cubbin B, Jackson C. Trial of a pressure area risk calculator for intensive therapy patients. Intensive Care Nursing1991;7:40-4.

37. Kosmidis D, Koutsouki S. Pressure ulcers risk assessment scales in ICU patients: validity comparison of Jackson/Cubbin (revised) and Braden scales.

Nosileftiki2008;47(1):86-95.

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45. Battson S, Adam S, Gareth H, Quirke S. The development of a pressure area scoring system for critically ill patients: a pilot study. Intensive Crit Care Nurs1993;9(3):146-51.

46. Bedi A. A tool to fill the gap. Developing a wound risk assessment chart for children. Professional Nurse1993:112-20.

49. Cockett A. Paediatric pressure sore risk assessment. J Tissue Viability1998;8(1):30.

50. Olding L, Paterson J. Growing concern. Nursing Times1998;94(38):75-9.

51. Jackson C. The revised Jackson/Cubbin pressure area risk calculator. Intensive and critical care nursing1999;15:169-75.

52. Halfens RJG, Van Achterberg T, Bal RM. Validity and reliability of the Braden scale and the influence of other risk factors: a multi-centre prospective study. Int J Nurs Stud2000;37:313-9.

53. González Ruiz JM, García García P, González Carrero AA, Heredero Blázquez MT, Martín Díaz R, Ortega Castro E, et al. Presentación de la escala de valoración actual del riesgo de desarrollar úlceras por presión en cuidados intensivos (E.V.A.R.U.C.I.).

Enfermería científica2001(228 - 229):25 - 31.

54. Norton D, Exton-Smith A, McLaren R. An investigation of geriatric nursing problems in hospital.

National Corporation for the care of old people.

London: Curchill Livingstone; 1962.

55. Waterlow J. A risk assessment card. Nursing Times1985;81(49):51-5.

56. Prichard V. Calculating the risk. Nursing Times1986;2(19):59-61.

57. Song M, Choi K. Factors predicting development of decubitus ulcers among patients admitted for neurological problems. Taehan Kanho Hackhoe Chi1991;21(1):16-26.

13

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Science, Practice and Education

EWMA 2013 COPENHAGEN 15 -17 May · 2013 Short paper Submitted to the EWMA Journal, based on an oral presentation at the Annual EWMA Conference in ­Copenhagen, May 2013

Pressure-time integral of elastic versus inelastic bandages: Practical implications

Abstract Background: After the application of any compression device the pressure drops in a variable fashion.

Aim: to compare the pressure drop over time and the pressure-time integral (PTI) of inelastic short-stretch bandages (SSBs) with those of elastic four-layer bandages (4LBs) Material and Methods: We treated 24 patients with venous leg ulcers with either SSBs or 4LBs and measured the interface pressure at the B1 point under the bandages daily for 1 week with the patients in the supine and standing positions. We defined the PTI as the area under the pressure curves calculated by summing the daily trapezoidal areas over 7 days.

Results: SSBs applied with initial pressure 56% greater than that of 4LBs resulted in only 16% greater PTI. SSBs produced lower PTIs than 4LBs applied with the same initial pressure, because SSBs lost pressure more rapidly than 4LBs. Conclusion: SSBs need to be applied with 25% more initial pressure than 4LBs to achieve the same PTI. The PTI is more useful than the initial application pressure for characterising compression dosages.

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Introduction Most clinical trials with compression devices neglect the fact that the pressure exerted by a compression device corresponds to its therapeutic dosage1. Several instruments are now available to measure the compression pressure on the extremities2. Compression pressure is not a static parameter, however; it fluctuates with changes in body position and with movement, declining over time as a result of oedema removal and compression-material fatigue. The initial pressure dose applied by a compression device to an extremity diminishes to a variable degree after several days, depending on the textile properties of the device, the consistency and configuration of the extremity (oedema), and the mobility and activity of the patient. The pressure-time integral (PTI) is a more relevant estimate of the pressure dosage over time than is a single pressure measurement immediately following the application of a compression device, because the PTI describes the pressure applied by the device over the entire period during which the device is active.

Methods Twenty-four patients with venous leg ulcers gave informed consent to wear pressure sensors under their compression bandages, which were changed routinely every week. An experienced bandager (GM) applied short-stretch bandages (SSBs) (Rosidal sys®) to 12 patients and four-layer bandages (4LBs) (Profore®) to the other 12 patients. We attached flat plastic probes which filled with 2 mL air (Picopress®, Microlab Italia) to measure the pressure under the bandages at the B1 point where the muscular part and the tendinous part of the medial gastrocnemius muscle meet. We wrapped the stiff connecting tube of the probe in cotton wool to avoid skin irritation. We measured the pressure every afternoon for 1 week while the patients were supine and standing. Most patients were admitted to the hospital, and we encouraged them to walk as much as possible. We estimated the pressure dose applied each day by the compression devices by calculating the pressure-time integral (PTI): the sum of the daily trapezoidal areas under  the daily pressure curves.

Hugo Partsch1, M.D.

Giovanni Mosti2 1Emeritus

Professor of ­Dermatology, Medical University of ­Vienna, Austria 2Department

of Angiology, Clinica Barbantini Lucca, Italy Correspondence: Hugo.Partsch@ meduniwien.ac.at Conflict of interest: none

15

Figure 1: Daily interface pressure under SSBs and 4LBs on patients in the (a) supine and (b) standing positions;

Figure 1a

PTI / d = Pressure Time Integral per day

Figure 1b

Statistics: We computed the mean PTIs with standard deviations and coefficients of variation and performed non-parametric statistical comparisons between the two bandage types using Mann Whitney tests. We defined statistical significance as: * p < 0.05; ** p < 0.01; *** p < 0.001.

Results We applied the SSBs with 56% more initial pressure than that of the 4LBs*** (Fig. 1). The mean pressure of the SSBs while the patients were supine dropped significantly more than that of the 4LBs over the course of the week*** (Fig. 1a). The coefficients of variation in the pressure trended higher for the SSBs than they did for the 4LBs, although the difference was not statistically significant. Both bandage types exerted more pressure while the patients were standing than they did while the patients were supine (Fig. 1b). The difference between the standing and supine pressures corresponds to the static-stiffness index (SSI), which was significantly higher for the SSBs than for the 4LBs***. All of the SSI values for the 4LBs were greater than 10, however, characterising the 4LBs as being rather stiff, although the components are all elastic3. The mean PTI per day of the SSBs (40, 75 Âą 4, 04 mmHg) was higher than that of the 4LBs (35, 13 Âą 2, 69 mmHg)** (Fig. 2).

16

Discussion SSBs lose more pressure over time compared with elastic materials, because the recoiling ability of the elastic material allows them to adjust to volume changes in the leg. The pressure loss is a major disadvantage of inelastic short-stretch material and, combined with improper bandage application by persons unfamiliar with the material, is probably the main reason for unfavourable outcomes in ulcer-healing clinical trials. Even experienced nurses who lack specific training in SSB application often apply SSBs too loosely4. Moreover, although the difference was not statistically significant, we found that the coefficients of variation for the SSBs tended to be higher than those for the 4LBs, suggesting that reproducible pressures are easier to obtain using 4LBs. The recommended initial pressure for a compression bandage on the leg is around 40 mmHg5. This is a good recommendation for elastic material, especially because higher pressures are not well tolerated and may even cause skin damage. Inelastic bandages should be applied with more initial pressure, however, because their initial pressure substantially declines after application. Inelastic bandages will have a lower PTI than elastic bandages applied with the

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PTI 37,5/h

Figure 2: Mean PTIs of the two bandage types

same initial pressure, resulting in the need to change them more often, every 2-3 days.

PTI 37,5/h

In this study, we applied SSBs with a much higher initial pressure than we applied with 4LBs, leading to a significantly higher PTI for the SSBs over the 1-week period. All of the pressures that we used were, even 1 Figure 3: Continuous interface pressures over 1 h on a leg in the sitting position; week after the initial application, in the upper curve: two stockings superimposed; lower curve: SSB. To obtain an equal high range (40-60 mmHg) or the very PTI, the SSB needs to be applied with higher initial pressure. high range (> 60 mmHg) of well tolerated, haemodynamically efficient pressures6,7.

From our PTI values, we calculated that an SSB would need to be applied with more than 50 mmHg Conclusions initial pressure to achieve a PTI in the same range as that Studies of compression therapies should not only measure of a 4LB. To demonstrate, we applied an SSB to the leg the initial pressure as a snapshot, but they should also of a patient in a sitting position and measured the interconsider the distribution of the pressure dose over time face pressure continuously for 1 h, showing that inelastic by calculating the PTI. Inelastic material needs to be material (Coban 2®) with a starting pressure of 50 mmHg wrapped with an initial pressure greater than 50 mmHg to obtain PTI values over a 1-week period comparable to produced the same PTI as that produced by two elastic ® those of elastic materials applied with a starting pressure stockings (38 mmHg; Mediven ulcer kit ; Fig 3). of 40 mmHg. m Two components, oedema reduction and material fatigue, are mainly responsible for the loss of compression-device pressure. We repeated the experiment shown in Fig. 3, wrapping a bottle instead of a patient’s leg with Coban 2 References material, and found that the pressure dropped from 54 1 Mosti G. Elastic stockings versus inelastic bandages for ulcer healing: to 49 mmHg (-9%), which is much less than the pressure a fair comparison? Phlebology. 2012 Feb;27(1):1-4.

2 Partsch H, Mosti G. Comparison of three portable instruments to measure dropping from 52 to 37 mmHg (-29%) on the patient’s compression pressure. Int Angiol. 2010 Oct;29(5):426-30. leg. Thus, we estimated that about 9% of the pressure drop 3 Mosti G, Mattaliano V, Partsch H. Influence of different materials in multicomponent bandages on pressure and stiffness of the final bandage. Dermatol Surg. 2008 on the patient’s leg was caused by material fatigue and the May;34(5):631-9. other 20% was caused by oedema reduction.

4 Keller A, Müller ML, Calow T, Kern IK, Schumann H. Bandage pressure measurement and training: simple interventions to improve efficacy in compression bandaging. Int Wound J. 2009 Oct;6(5):324-30.

It is important to realise that the measured pressure values, SSI and PTI, are parameters describing the physical properties of compression systems and should not be automatically translated into parameters describing clinical efficacy. While higher pressures correlate significantly with improved venous pumping function8,9, limb-volume reduction may correlate negatively with very high bandage pressures in patients with oedema10.

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5 European Wound Management Association (EWMA). Position Document: Understanding compression therapy. London: MEP Ltd, 2003.

6 Partsch H, Clark M, Mosti G, Steinlechner E, Schuren J, Abel M,et al. Classification of compression bandages: practical aspects. Dermatol Surg. 2008 May;34(5):600-9.

7 Mosti G, Partsch H. Inelastic bandages maintain their hemodynamic effectiveness over time despite significant pressure loss. J Vasc Surg. 2010 Oct;52(4):925-31.

8 Partsch H. Improving the venous pumping function in chronic venous insufficiency by compression as dependent on pressure and material. Vasa. 1984;13(1):58-64 9 Mosti G, Mattaliano V, Partsch H. Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux.

Phlebology. 2008;23(6):287-94.

10 Partsch H, Damstra RJ, Mosti G. Dose finding for an optimal compression pressure to reduce chronic edema of the extremities. Int Angiol. 2011 Dec;30(6):527-33.

17

“An integrated part of wound management.”

Debrisoft® removes debris effectively in a quick and easy way stimulates wound healing by protecting newly formed tissue

2000215 0913 e

improves quality of life being almost painless

Science, Practice and Education

VERUM – A European Approach for ­Successful Venous Leg Ulcer Healing: Implementation of a Comprehensive ­Therapy Concept (VERUM ) in Daily ­Practice 13

Abstract Background: Successful healing of venous leg ulcers can only be achieved with a combination of compression therapy and moist wound healing1. Therefore, this treatment strategy is recommended by therapy guidelines; however, implementation in daily practice is thought to be, at the least, complicated or even impossible.

Aim: The main aim of this study was to determine whether a clear treatment strategy is helpful for the implementation of a holistic therapy concept. In order to generate additional information about the practicability and implementation of holistic therapy concepts necessary for successful healing of venous leg ulcers, a comprehensive therapy concept consisting of compression therapy and moist wound care was implemented in daily medical practice in different countries.

Methods: Sixty-three patients from Germany, Italy, and Austria were treated for 12 weeks in daily medical practice with phase-adapted moist wound dressings, bacteria-binding wound dressings, and short-stretch compression bandages in the initial oedema phase, followed by compression treatment using a compression stocking system with high stiffness characteristics.

Findings: Approximately 85% of wounds were significantly reduced in size, and 53% of wounds healed completely within 12 weeks.

The patients’ well-being was substantially improved, leading to high compliance. As the majority of patients had not experienced any progress in healing for extended periods of time due to their complicated health situation or ineffective treatment, these results were rated very positively by patients and physicians. In addition, the bacteria-binding wound dressing allowed infected wounds to be treated without antibiotics.

Conclusion: Holistic therapy concepts offer significant advantages and can be successfully implemented in daily practice independent of national or local wound care traditions.

Introduction Clinical data indicate that compression accelerates the healing process of venous leg ulcers2, and wound-healing rates are far superior in patients treated with compression than in those treated without compression3,4. Thus, to improve the healing process, clinical guidelines recommend treatment of venous or mixed venous ulcers (0.6> ABI <0.9) with high pressure of 30 to 40 mmHg at the ankle5. On the other hand, 50% of all patients with venous leg ulcers heal completely within 3 months following treatment with moist wound healing, and 70% of the cases within 1 year with this strategy6. Therefore, the concept of moist wound management in combination with compression is considered the most effective approach; yet, these findings do not receive adequate attention in actual daily practice7,8,9,10.

In Germany in 2002, only an estimated 10%-20% of patients with chronic wounds received moist wound therapy8, and as many as 25% of patients with venous leg ulcers failed to receive compression therapy7. These findings were confirmed by a survey of 45,975 patients on the use of compression therapy in combination with contemporary moist wound management, as the study showed that patients with chronic leg ulcers did not always receive optimal treatment in Germany8.

Even though the general consensus is that successful healing does not depend on the quality of a single product alone but rather on the interaction of all products within a comprehensive therapy concept, such concepts are not consistently implemented in daily practice. Most likely, this occurrence is not due to the complexity of the therapy concepts alone, which can make their implementation difficult, but rather due to the lack of previous experience with the combined use of multiple woundhealing and compression products.

In an effort to gain further experience in the implementation of complex therapy concepts for treatment of venous leg ulcers, 63 patients in Germany, Italy, and Austria were treated with compression therapy and moist wound dressings. The objective of this multicentre evaluation was not only to assess the performance and ef-

Roberto Brambilla, MD, Istituti Clinici Zucchi (Monza, Italy) Daniele Aloisi, MD, Poliambulatorio ­Mengoli (Bologna, Italy) Iris Weingard, MD, Venenzentrum Freiburg (Freiburg, Germany) Marco Fioruzzi, MD, Policlinico San Marco (Zingonia, Italy) Thomas Heisterkamp MD, Dermatologische-­ Phlebologische Praxis GESCHER (Gescher, Germany) Edith Janthur, MD, Venenzentrum SAARLOUIS (Saarlouis, ­Germany) Peter Kurz Wound management nurse, Wund Pflege Management GmbH (Bad Pirawarth, Österreich) Katrin Will PhD, scientific referent, therapy concept/compression therapy, BSN Medical GmbH, (Hamburg, Germany Correspondence: Katrin.will@ bsnmedical.com Conflict of interest: The article has been ­supported by a research grant from BSN.

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Figure 1: A 6-month-old Ulcus cruris venosum of a 74-year-old patient who was also diagnosed with other risk factors including contact ­sensitization and obesity.

The ulcer showed signs of ­infection and red wound edges.

Treatment was initiated on 15th June 2010 (a).

Full wound healing was achieved on 30th August 2010 (b).

1a 1b

fectiveness of the wound care and compression products but also to investigate the efficacy of the overall therapy concept under conditions of routine medical care.

Methods Region The multicentre case studies were conducted on a noninterventional basis at several phlebological surgeries and wound care centres in Italy (Roberto Brambilla, Istituti Clinici Zucchi, Monza; Daniele Aloisi, Poliambulatorio Mengoli, Bologna; and Marco Fioruzzi, Policlinico San Marco, Zingonia), in Germany (Dr. Iris Weingard, Venenzentrum Freiburg, Freiburg; Dr. Thomas Heisterkamp, Dermatologisch-Phlebologische Praxis Gescher, Gescher;, and Dr. Edith Janthur, Venenzentrum SAARLOUIS, Saarlouis) and in Austria (Peter Kurz, Wund Pflege Management GmbH, Bad Pirawarth).

Time Frame In accordance with the predefined observation schedule, the baseline visit was followed by a maximum of five follow-ups within a 12-week period. The total period of observation varied from 6-12 weeks, depending on the status of the individual patient and wound-healing progress.

Aetiology Only patients with ulcers of venous aetiology were included. Many patients also suffered from other diseases, including diabetes (15.9%), cancer (7.9%), and hypertension (11%). The majority of the patients had additional risk factors, such as allergies. Every patient had at least one chronic ulcer. According to the contra-indications, patients with arterial leg ulcers, recent deep vein thrombosis, or cardiac insufficiency were excluded. The patient anklebrachial index (ABI) differed from 0.8 to 1.1. None of the patients showed any signs of arterial occlusive disease. In 31.7% of cases, the body mass index (BMI) was > 28 kg/ m2 (obese patients). Patient age varied between 41 and 92 years, and 58.7% of the patients were women (37/63).

20

Wound Status Only venous leg ulcers of less than 1 year were included.

The size of the ulcers varied from 10 to 90 mm in length and from 5 to 98 mm in width at baseline (length, 28.3 ± 21.6 mm (mean ± standard deviation); width, 16.7 ± 16.8 mm; resulting wound surface area, 5.1 ± 12.0 cm2).

Approximately 43% of the wounds showed signs of infection/biofilm (redness, itching, pain, or odour), and 80% of the wounds exhibited red wound edges.

Data Management During this evaluation, wound status and healing was documented on the basis of clinical standard parameters.

Initial set up of the protocol and questionnaires as well as the data collection was supervised by an external clinical laboratory. The wound status was documented by photo and with a description at the beginning of the study (baseline) and at each subsequent visit. Relevant parameters included the size and appearance of the wound (phases of wound healing, exudation, and signs of infection) as well as the peri-wound skin. Complete healing was defined as full closure of the wound. Furthermore, the evaluation included a patient Quality-of-Life (QoL) survey that was based on the Tübingen Questionnaire11, in which patients were asked about the degree of impairment they experienced in their routine activities, such as lifting and carrying heavy objects, standing for extended periods of time, light/heavy household and gardening chores, and walking and climbing stairs.

At the final visit, the attending physician provided a final assessment of the outcome as well as the therapy concept.

The computer-aided documentation during the study was performed by the investigators and evaluation staff at the centres. The data were evaluated by means of descriptive statistics.

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2a

2b

Figure 2: A 3-month-old Ulcus cruris venosum of a 59-year-old patient who was diagnosed with disturbed perfusion. The ulcer showed signs of infection and red wound edges.

Treatment was initiated on 19th April 2011 (a). Wound closure was achieved on 31st May 2011 (b).

Wound Treatment and Compression Therapy Before applying the high stiffness compression stocking system (JOBST® UlcerCARETM, BSN medical GmbH) the oedema had to be reduced to allow selection of correct stocking size. For this purpose short-stretch compression bandages (in Germany and Austria, Comprilan was used, and in Italy, Comprilan or Tensoplast [BSN medical GmbH] was used) were applied for up to one week depending on the extent of the oedema. The bandages were applied by experienced staff. According to the local protocol, the wounds were always cleaned, and the wound edges protected with a polymeric solution (e.g., Cutimed® Protect, [BSN medical GmbH]) before application of the wound dressing and compression. For exuding wounds, a superabsorbent polyurethane foam dressing (Cutimed® Siltec range, BSN medical GmbH) was used. In the case where signs of infection were noted, a bacteria-binding dressing (Cutimed® Sorbact® [BSN medical GmbH]) was placed directly on the wound and then covered with the foam dressing. In these cases, after normalisation of the wound, the bacteria-binding dressing was applied as a preventive measure. At the beginning, the wound dressings were changed daily, while later, the dressings were changed less frequently depending on the status of the wound (e.g., signs of infection or wound fluid). At subsequent visits following reduction of the oedema, wounds were treated similarly, but a compression stocking system (40 mmHg) was applied instead of the compression bandages. Instructions for use included use of the liner for 24 h and the upper-stocking for 12h. All wounds were treated regularly depending on the status of the wound but the complete questionnaire and patient survey were assessed, and pictures were taken only after 2 weeks (optional) and after 4, 8, and 12 weeks.

Results At the baseline, the wound status of the majority of leg ulcers was rather complicated: 82% of the wounds showed inflammation, 4% were covered by necrosis, and 59% were covered by slough. Heavy exudate was reported in 24.1% of the ulcers, and moderate exudate levels were observed in 75.9% of the wounds. In addition, 93% of all patients showed a pronounced redness of the wound edges.

During routine examination, infections were suspected in 48% of the patients due to the presence of classical signs, including redness, pain, and odour. In cases of suspected infection, a bacteria-binding dressing was applied during the observation period. The intended therapy was, therefore, implemented without the use of antibiotics. Furthermore, an overall reduction of redness was observed over the course of the wound treatment in these cases.

Individual differences in wound size reduction (length, width, and depth) were observed after 2, 4, 8, and 12 weeks according to analysis with the Wilcoxon test together with photo documentation. In 85% of cases, either a reduction in wound size or complete healing of the wounds was achieved. In cases where complete healing was not achieved, wound size reductions ranged from 43.8% to 92.4%. Examples are shown in Figures 1 and 2.

In addition, 65.5% of the patients reported illnessrelated limitations in daily activities, and 24.1% even characterized their situation as mostly or completely impaired. The individual illness-related limitations in daily activities varied, likely depending on the severity of the oedema, pain, and wound status. The analysis of the Tübinger Questionnaire revealed a shift from high to low impairment during the period of the observation and from low to no impairment in tasks such as lifting objects, walking, standing, and household and gardening chores.

Spontaneous reports of improvement in general were also noted, as patients experienced substantial improvement in 

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Science, Practice and Education

their wound status and well-being. These improvements resulted in a high degree of patient compliance. Only one patient did not comply with the programme, and none of the other patients asked for premature discontinuation of treatment.

Physicians rated the use of a stocking system very positively but pointed out that oedema reduction by means of compression bandages is very important to ensure an optimal fit of the stocking system. As in typical clinical practice, treatment adaptations were necessary for individual patients. Three patients experienced an increase in swelling after initial reduction of their oedema, rendering the compression system too tight. One patient developed an adverse reaction to one of the components of the wound dressing (redness and itching in the contact region of the wound dressing). Two patients developed an infection during the observational period and had to be treated systemically. In two other cases, no healing progress was achieved within 12 weeks. This scenario indicates that the patients were likely resistant to this therapy, and the patients were thus treated differently. Another patient experienced a massive deterioration of his general health status (acute erysipelas) at the beginning of the observation period, resulting in additional treatment; however, no causal relationship with the therapy concept could be established. One patient was considered a drop-out, as he failed to follow the physicianâ&#x20AC;&#x2122;s instructions by switching to a different product for one week without permission.

As a result, he did not wear the compression stocking system as recommended, which resulted in deterioration in wound status.

Overall, the therapy concept was rated very positively. Both patients and physicians reported that they would use it again. In combination with close monitoring and guidance of the patients, the therapy concept resulted in a high degree of patient satisfaction and compliance.

Discussion Currently, the combination of moist wound management and compression is acknowledged as the most effective approach for treating venous leg ulcers3,4. Therefore, it is surprising that this therapy concept is given little attention in actual daily practice, even in highly developed countries such as Germany7,8,9,10. To our knowledge, data regarding the implementation of this approach into daily practice in other European countries are not available, and thus, this lack of implementation is presumably not an issue only in Germany. Insufficient knowledge of the selection of compatible compression and wound manage-

22

ment products may underlie the lack of implementation of this fundamental scientific knowledge in daily practice.

The scope of this evaluation was to determine whether a clear treatment concept is helpful for the implementation of a holistic concept. Therefore, a set of well-adapted products was selected, and application of these products was carefully explained. In our opinion, it is important that the wound care products work reliably under compression. The choice of super-absorbent polyurethane foam dressings with skin-friendly silicone was based on the fact that this type of wound dressing maintains a moist environment in wounds even under compression under 40 mmHg. Indeed, we observed very good fluid handling by the wound dressings (moist wound-healing conditions with no maceration). In addition, atraumatic dressing changes (no pain and no sticking to the wound) were achieved. We also recommend protection of the wound edges for additional safety.

Since wound infections hinder progress in wound healing in our opinion antimicrobial control is a very important part of the treatment concept. Therefore, we included a bacteria-binding wound dressing, which binds bacteria irreversibly via a physical mode of action12. The bound bacteria are inactive and unable to replicate and are removed with each dressing change, reducing the overall bacterial load without the risk of cytotoxicity or bacterial resistance12. Our results show that the bacteria-binding dressings work well in concert with the foam dressings even under 40 mmHg. Therefore, the bacteria-binding dressing is a helpful tool for controlling wound infections.

Despite the prevalence of different local treatment protocols, all physicians implemented the treatment concept successfully, and the high number of different products presented no hindrance to implementation of the treatment into daily practice. Positive healing results in 85% of the cases confirmed previous scientific evidence that the combined use of moist wound management and compression systems provides an adequate therapy concept for treating venous leg ulcers3. As the majority of patients had not experienced any progress in healing for extended periods of time before this study, even small improvements were considered a success.

In the many cases where an infection was suspected, the achieved wound healing results can be considered very positive. Also, in these cases, the therapy could be followed without interruption or the use of antibiotics (with exception of two patients). Furthermore, the compression stocking systems, which were easy to don and were operator-independent, were appreciated by both patients and physicians.

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In conclusion, we observed that a clear and easy-to-understand therapy concept increases patient satisfaction and QoL and leads to a high patient compliance and acceptance by physicians. With a trend toward shortened hospitals stays and ambulant treatment of wound patients, the need for simplified treatment concepts increases. Our example encourages implementation of this therapy concept into daily practice, and additional clinical evidence in support of such concept is warranted in order to increase the number of adequately treated venous leg ulcers. m Implications for Clinical Practice n This therapy concept together with close monitoring and guidance of patients achieves good healing results. n Even complex therapy concepts can successfully be integrated into daily practice. n The therapy concept could be implemented independently of local treatment traditions. n The therapy concept improved patient Qualityof-Life and as a result patient compliance.

Further Research n Further case studies are planned in the UK and USA to support these observations. n Further case studies with bigger wounds are planned, keeping in mind the increasing number of ambulant patients with big wounds and the earlier discharge of patients into self-management in the future.

THE EWMA

adrid · Spain

UNIVERSITY

CONFERENCE MODEL (UCM)

in Madrid

EWMA n GNEAUPP 2014

The EWMA UCM programme offers students of wound management from institutes of higher education across Europe the opportunity to take part of their academic studies whilst participating in the EWMA Conference.

The opportunity of participating in the EWMA UCM is available to all teaching institutions with wound ­management courses for health professionals.

The UCM programme at the EWMA 2014 Conference in ­Madrid will offer networking ­opportunities between the students from various UCM groups, UCM Lectures as well as assignments and workshops arranged specifically for the UCM students.

EWMA strongly encourages teaching institutions and students from all countries to benefit from the possibilities of international networking and access to lectures by many of the most experienced wound management experts in the world.

Yours sincerely

Dubravko Huljev Chair of the Education Committee

References 1. Dissemond J. Compression therapy in treatment of Ulcus cruris venosum. Dt Ärztebl 2005; 102:2788–2792 2. Klode J, Körber A, Wax C, Dissemond J. Results of a enquiry concerning the compression therapy and moist wound care including 45 975 patients with Ulcus cruris venosum. ZfW 2009; 3:152-158.

Participating institutions:

3. Wong IKY, Lee DTE, Thompson DR. A randomized controlled study comparing modern wound care alone or in combination with short- or long stretch bandages in treatment of venous leg ulcer. Vasomed 2006; 4: 149-150.

4. Partsch H, Flour M, Smith PC; Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence.

Under the auspices of the IUP. International Compression Club. Int Angiol. 2008 Jun;27(3):193- 219.

Donau Universität Krems Austria

Haute École de Santé Geneva, Switzerland

HUB Brussels Belgium

Lithuanian University of Health Sciences Lithuania

University of Hertfordshire United Kingdom

Universidade Católica Portuguesa Porto, Portugal

5. Benigni. J.P., Echegut P., Mourmaren M. Uhl J. F. and Cornu-Thenard Compression stockings for treating venous leg ulcers FLEBOLOGÍA Y LINFOLOGÍA - LECTURAS VASCULARES7:17 / 4 2012 6. Dissemond J. Ulcus cruris – Basics, Diagnostics und Therapy. 3 Auflage. Bremen: UNI-MED Verlag 2009.

7. O’Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers. Cochrane Database Sys Rev 1,2009; CD000265.

8. Grams LF. Medical care situation in case of chronic wounds: A study analyzing the medical care of patients with Ulcus cruris on the basis of therapy guidelines and medical evidence in the area of Hamburg. http://www.sub.uni-hamburg.de/opus/ volltexte/2009/4236/pdf/Dissertation zur VersorgungsqualitaetchronischerWunden. pdf. 2008.

9. Panfil EM, Mayer H, Junge W et al. Wound care of chronic wounds in the ambulatory treatment – Pilotstudie. Pflege 2002; 15: 169-176.

10. Rüggeberg JA, Golbach U. Medical care of patients with chronic wounds in Germany. Results of a enquiry. BDC Online, www.bdc.de.2007.

11. Klyscz T, Jünger M, Schanz S et al. Lebensqualität bei chronisch venöser Insuffizienz (CVI). Ergebnisse einer Untersuchung mit dem neu entwickelten Tübinger Fragebogen zur Messung der Lebensqualität von CVI-Patienten (TLQCVI). Hautarzt 1998; 49: 372-381.

12. Ljungh Å, Yanagisawa N, Wadström T. JOURNAL OF WOUND CARE 2006; 4, 15 13. Abbreviations VERUM Venous Return Ulcer Management

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2013 vol 13 no 2

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

Vivano Safety. And Simplicity. 速

The VivanoTec negative pressure unit by HARTMANN is the central component of the Vivano system for successful negative pressure treatment of wounds. Its low weight means it can be used either on the move or in hospitals. Thanks to its intuitive menu navigation, the VivanoTec negative pressure unit combines easy usage with highly precise treatment settings and the necessary reliability, thus guaranteeing a high level of safety and user-friendly handling.

Science, Practice and Education

Effect of topical ­haemoglobin on venous leg ulcer healing Abstract Background: The improvement of oxygenation is gaining increasing attention as an important aspect in modern wound care. The aim of such complementary care is to improve and accelerate wound healing.

Patients and Methods: A solution comprised of purified haemoglobin was added to the standard wound care of subjects with a venous leg ulcer and compared to a control group administered a saline solution without haemoglobin. Each group consisted of 36 randomly chosen patients. The duration of the treatment was 13 weeks and the primary end point was the reduction of wound size or wound closing.

Results: In the group treated with the haemoglobin solution, an average wound size reduction of 53% was obtained, whereas no statistically significant reduction in wound size was observed in the control group.

Conclusion: The addition of a haemoglobin solution in the wound care of venous leg ulcers resulted in a marked improvement of wound healing compared to the control group.

Keywords: haemoglobin, oxygen, venous leg ulcer, wound healing

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Introduction Chronic wounds are wounds that show no tendency to heal after 8-12 weeks1,2. The incidence of chronic wounds has recently increased, particularly in older patients, with venous leg ulcers being one of the most common chronic wounds1.

In many cases, prolonged oxygen deficiency (hypoxia) to the skin and subcutaneous tissues is associated with chronic wounds3,4. Tissue hypoxia is considered a common aetiology for the pathological processes in wound healing disorders, particularly in patients with peripheral arterial occlusive disease (pAOD), chronic venous insufficiency (CVI), and diabetes mellitus4,5,6,7,8,9.

Oxygen is vital for wound healing, as more oxygen is needed for a large number of processes during all phases of wound healing (inflammation, granulation, neoangiogenesis, reepithelisation, and tissue reorganisation)10,11,12. Therefore, improving the oxygen supply to chronic hypoxic wounds in particular becomes increasingly important 3,10,11,12,13,14. In addition to treating underlying diseases, such as pAOD, CVI, or diabetes mellitus, further medical treatment approaches such as local normobaric and systemic hyperbaric oxygen treatment as well as other topical treatments with subsequent oxygen release are used in clinical settings8,14,15,16.

One principle means of supplying necessary oxygen to a chronic wound is external administration. However, this is precluded by the exudate from the wound bed, which is a very effective diffusion barrier to oxygen. As moist treatment of chronic wounds is the current treatment standard5,6,7, concepts for improving oxygen diffusion have been investigated. To this end, Barnikol et al.17 exploits the principle of haemoglobin-mediated facilitated oxygen diffusion in aqueous solutions by applying haemoglobin to the wound bed as an aqueous solution. In addition to the free diffusion of oxygen, which is otherwise limited by the fluid barrier, the addition of haemoglobin possibly results in considerably improved facilitated diffusion18. Carrier molecules that are well-suited for this include mammalian haemoglobins, which are watersoluble and are capable of transporting oxygen outside of red  blood cells17,18,19 (Fig. 1).

Monika Arenbergerova1

Peter Engels2

Spyros Gkalpakiotis1

Zora Dubská1

Petr Arenberger1 1Department of ­Dermatology, 3rd Faculty of Medicine, Charles University, Prague, Ruská 87, 100 34 Prague 10, Czech Republic 2EngelsConsult,

51429 Bergisch Gladbach, Germany Correspondence: arenbergerova@email.cz Conflict of interest: Some material and figures has been provided by SastoMed

25

n

Fig. 1: Haemoglobin as an oxygen transporter (A) The wound exudate presents a barrier to oxygen exchange, ­effectively blocking any external oxygen supply to the wound.

(B) The haemoglobin applied via the spray is evenly distributed throughout the wound exudate, binds ambient oxygen, and transports it to the wound bed (based on the principle of facilitated diffusion)18.

This study investigated the effect of a haemoglobin solution on wound healing of venous leg ulcers for a period of 13 weeks compared with a control group that did not receive the haemoglobin solution. The results confirm the therapeutic potential of the haemoglobin solution to improve wound healing when treating patients with venous leg ulcers.

Material and methods Haemoglobin solution The purified haemoglobin used in this study was produced from porcine blood and formulated as an aqueous 10% solution (10% carbonylated haemoglobin, 0.7% phenoxyethanol, 0.9% NaCl, 0.05% N-acetylcysteine, 88.35% water). After virus-removal filtration and sterile filtration, the solution was provided as a ready-to-use spray in bag-on-valve canisters. This haemoglobin spray supplies the wound bed tissue with oxygen via diffusion for an extended period of time17,20 and does not contain any pharmaceutically active ingredients; its mode of action is based only on physical oxygen transport. The haemoglobin spray was applied to the wound bed following meticulous wound cleaning and disinfection. Subsequently, the wound was dressed with a thin, air-permeable nanofibre textile.

Study design This clinical study was a prospective, randomised, singleblind, monocentric study embedded in grant study no.

IGA NS/10093-4/2008 sponsored by the Czech Ministry of Health. The Ethics Committee of Prague 10 Faculty Hospital gave a positive opinion for the grant study.

The overall sample size calculation was based on comparison of wound size between the haemoglobin therapy arm and the placebo and was performed using East 5.4 software under the assumption that a group sequential design would be implemented with one final analysis for the wound size. The following assumptions were made when estimating the required sample size: 26

A 1:1 randomization scheme for haemoglobin therapy and placebo arms n An overall 5%, two-sided risk of erroneously claiming the superiority of haemoglobin therapy in the presence of no true underlying difference (i.e. overall Type I error) n A 90% chance of successfully claiming superiority of haemoglobin therapy in the presence of a true ­underlying difference (i.e. Type II error).

In order to show a 20% reduction in wound size in the haemoglobin arm versus the placebo in the final analysis, the required number of patients to achieve 90% power for rejecting the null hypothesis if the alternative hypothesis is true is 72. To achieve this, an estimated total of 72 subjects (36 subjects in each arm) would need to be enrolled, leading to implementation of final analyses 13 weeks after the start of the study. The study presented here consists, therefore, of two groups with a total of 72 subjects recruited over a period of 4 months.

Thirty-six patients were included in Group 1 (haemoglobin group). Application of the haemoglobin solution was integrated into the treatment regimen before the wound was covered with a dressing. The 36 subjects in the comparator group (Group 2) were treated analogously to the Group 1 subjects, but without application of the haemoglobin solution.

Based on clinical experience, the primary objective of this study was to investigate the effect of the haemoglobin spray on the size of the wound surface area during the 13-week treatment period. The safety of the treatment was evaluated as the secondary parameter.

The attending doctor whom evaluated the wound surface area and assessed the condition of the wound were blinded. In contrast, the nurses involved in treatment and wound care were not blinded.

Inclusion criteria: Patients were >18 years of age, had a venous leg ulcer a minimum of 1.6 cm in all directions and a maximum wound surface area of 50 cm² persisting for >8 weeks. Patients had an ankle brachial index (ABI) of more than 0.8 to rule out an arterial cause of the ulcer.

Further diagnostic procedures for precise characterisation of the patients were colour duplex ultrasonography and measurement of pedal pulses with normal arterial values.

Exclusion criteria: Vasculitis, non-venous leg ulcer, treatment with systemic antibiotics, corticosteroids, or other oral immunosuppressants before or during course of the study, and pregnancy.

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Treatment Each subject received compression therapy during the day according to the current guidelines in the Czech Republic based on previous clinical experience; compression therapy was initiated 2 weeks prior to study inclusion.

Although there were no particular specifications for the compression bandage, the same compression bandages (Ideal/Hartmann) were used for all patients, which were applied at a constant circumference at the ankle to ensure adequate compression pressure. Continuation of the compression therapy over the entire treatment period was an integral element of the treatment and was monitored correspondingly.

The subjects were hospitalised for the first 2 weeks of treatment, which corresponds to the average hospitalisation time of patients with venous leg ulcers. After this period, the subjects were treated at home by study nurses.

The wound dressings were changed daily according to the standardized study protocol. After cleaning with saline, the haemoglobin solution was sprayed onto the wounds of the Group 1 subjects. In Group 2, the wound was treated in the same way as in Group 1, but a 0.9% saline solution (without haemoglobin) was applied in place of the haemoglobin solution. The wounds were then dressed with a nanofibre dressing used at the hospital (Nanotextile, Elmarco, Liberec, Czech Republic) and fixed with gauze. Subjects wore their compression bandage during the day, but not at night, according to the guidelines of the Czech Republic, in order to avoid an additional burden to patients.

After the study ended, patients were asked to visit the investigator once a week for a follow-up examination. If the wound had not fully closed by the end of the study, patients were offered continuing treatment; several patients (11 in Group 1 and 31 in Group 2) took advantage of this offer.

Analysis of wound surface area changes The wound margins were marked on a triple-layer transparent sterile film, electronically scanned, and the wound surface area measured by computer-aided analysis. The surface area on the day of inclusion in the study (T=0) was used as a baseline. Thereafter, the surface area was measured after wound cleansing on days 7, 14, 21, 28, 35, 42, 49, 56, 63, 70, 77, 84, and 91. Wound sizes in both treatment groups were analysed statistically by analysis of variance (ANOVA) to determine whether the differences before and after treatment were significant. Post-hoc Bonferroni tests were applied to highly significant differences (i.e. p<0.001).

Furthermore, the quality of the wound was assessed during the regular check-ups, and parameters such as

Table 1: Summary of demographic data of the study subjects

No. subjects Drop outs Average age (years) Female (%) Average duration of ulcer (range) Average ulcer size at start of study (cm2)

Group 1 (haemoglobin) N=36 2 65 69.4 2 years (3 months-6 years)

Group 2 (control) N=36 5 59 58.3 2 years (3 months-6 years)

18.7±9.9

17.5±9.3

wound coating (necrotic tissue, fibrin coating), granulation, epithelisation, and pain relief using a visual analog scale (VAS) (0=pain-free, 10=maximum imaginable pain) were recorded21. Photographs were taken of the wounds at inclusion and over the course of treatment.

Adverse events The subjects’ safety was ensured during the study according to the European standards for clinical trials on medicinal devices in human subjects. The causality of adverse events (AE) was defined as an event a) caused by the treatment, b) possibly caused by the treatment, or c) independent of the wound treatment given with/without haemoglobin. All AEs that occurred during the study were immediately reported and documented.

Results Group demographics Seventy-two patients (64% female and 36% male) were included in this study and divided into 2 groups of 36 subjects each (Table 1). The mean age of the subjects in Group 1 (69% female, 31% male) was 65 years and in Group 2 (58% female, 42% male) was 59 years. The mean period over which the treated chronic wounds had persisted was 2 years (3 months–6 years). Of the 72 patients included in the trial, 65 were treated for the entire period of 13 weeks. In Group 1, two of the subjects could not be treated for the whole study period: one was admitted to the hospital due to liver disease, and another had to discontinue treatment due to a severe wound infection.

In Group 2, one subject was excluded after 9 weeks due to non-compliance and another four asked to discontinue the treatment prematurely after 9 or 10 weeks because they did not respond to the treatment.

Changes in wound surface area Changes to the wound surfaces were examined over the treatment period of 13 weeks in both groups (Figs. 2A-C).

The mean wound surface area of the subjects in Group 1 was 18.7 cm² at study inclusion. During the 13 weeks of treatment, the mean reduction in the wound surface area was 53.4% (p<0.0001). Overall, 33 subjects showed 

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2013 vol 13 no 2

27

Fig. 2: Mean change in wound size over 13 weeks.

Group 1 ( ) is the treatment group (haemoglobin solution applied) and Group 2 ( ) is the control group (0.9% NaCl solution applied). The wound surface area (cm2) in both groups was observed for 13 weeks and measured at the start of the study and after 4, 8, and 13 weeks of treatment.

The ana­lysis of the change in the wound surface area showed a continuous and ­statistically significant reduction in the wound surface area for Group 1 (week 0=18.6 cm² and week 13=10.2 cm², p<0.0001), while Group 2 showed a slight increase in wound surface area (week 0=17.5 cm² and week 13=20.2 cm²). Significant differences between the two groups are also shown (p values are indicated).

(A) Change in the mean wound surface area (cm²).

(B) Reduction in the wound surface area (cm²).

(C) Mean values of relative wound reduction (%). The mean wound reduction in Group 1 was 53% and the mean wound increase in Group 2 was 21%.

NS=not significant

order to obtain a more detailed analysis of the effect of the change in wound surface area on healing speed over the treatment period, the data from Group 1 were divided into three subgroups according to initial wound size (5–15 cm², >15–25 cm², and >25 cm²), and the decrease in surface area over time was determined (Fig. 3A and B). All three subgroups showed a parallel and constant decrease over the entire 13-week period (Fig. 3A). Figure 3B shows the absolute values of the reduction in surface area of the three subgroups in cm². The mean value of absolute reduction in surface area after 13 weeks was 11.5 cm² for wounds that had been larger than 25 cm², and 8.5 cm²

Group 1 (haemoglobin): mean (±SD) weeks 4 and 8, NS week 13, p<0.01

Group 2 (control): mean (±SD)

a positive tendency to heal, with a significant reduction in the wound surface area over the study period. One of these 33 subjects achieved complete wound closure after 12 weeks of treatment, while one subject exhibited a slight enlargement of the wound surface area over the entire observation period (10.4%). The mean wound surface area of the subjects in Group 2 was 17.5 cm² at inclusion.

In this group, a mean enlargement of the wound surface area to 20.2 cm² was observed over the treatment period.

Fig. 3: Changes in wound surface area of three subgroups of Group 1 based on the wound surface area at study start.

Group 1 was divided into the following sub-groups: a) 5-15 cm² ( ), b) >15-25 cm² ( ), and c) >25 cm² ( ).

The graphs show the changes in wound surface areas and the ­absolute figures for the reduction in the surface area (mean ±SD).

(A) Change in wound size over 13 weeks (cm²) showing a continuous reduction in size over time.

(B) Mean decrease in wound size over 13 weeks (cm²) showing a larger reduction in surface area for large wounds from baseline than for small wounds.

Overall, 14 of the 31 subjects treated over the entire study period showed a slight reduction in wound surface area (mean and SD of the difference was 88% and 13%, respectively); in contrast, 17 subjects showed an increase in wound surface area (mean and SD of the difference was 139% and 38%, respectively). Comparison of the average mean wound size reduction between both groups at the beginning and end of the study revealed a statistically significant reduction in wound size in Group 1 at the end of the study (p>0.0001).

Effect of wound surface area on healing speed The mean reduction of the wound surface area in Group 1 over the entire treatment period was 53% (Fig. 2C). In

28

Wound size 5-15 cm²

Wound size 15-25 cm²

EWMA Journal

Wound size >25 cm²

2013 vol 13 no 2

Science, Practice and Education Subject 12 (treated wound is marked)

Subject 17

Fig. 4: The course of wound healing over 13 weeks of two subjects in Group 1.

(A) Wounds at the start of the study. (B) Wounds after 6 weeks. (C) Wounds upon completion of the study.

for wounds initially between 15 and 25 cm². Wounds that were smaller than 15 cm² showed a mean reduction of 5.7 cm². The resulting mean reduction in wound surface area over the 91-day period was 6.3 mm²/day for wounds measuring 5-15 cm², 9.3 mm²/day for wounds measuring >15-25 cm², and 12.6 mm²/day for wounds >25 cm². Taking all the wounds treated into account, this corresponds to a 9.3 mm² reduction in wound surface area per day. As an example, Figure 4 shows the course of wound healing over 13 weeks for two subjects in Group 1.

Wound quality Additional clinical aspects of wound healing in venous leg ulcers in the two groups were evaluated to determine the quality of wound healing. The parameters described above in “Treatment” (necrotic tissue, fibrin coating, granulation, and epithelisation) were recorded on days 0, 15, 42, and 91. By day 91, the subjects in Group 1 had a marked reduction in necrotic tissue (48%) and fibrin coating (42%), and a marked increase in granulation tissue (75%) and epithelisation (78%) compared to mean values on day 0. In contrast, the subjects in Group 2 had a 17% and 12% reduction in necrotic tissue and fibrin coating, respectively, whereas granulation tissue increased by 18% and epithelisation by 7% from day 0 to day 91.

The subjects in both groups also rated pain intensity on a VAS on days 0, 15, 42, and 91. The subjects in Group 1 showed a mean reduction in pain intensity of 68% (p<0.01) from day 0 (VAS=5.8) to day 91 (VAS=0.1).

The reduction in pain intensity for subjects in Group 2 were 7% (p>0.05) from a mean baseline value of VAS=5.1 on day 0 to VAS=4.8 on day 91 (Fig. 5).

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2013 vol 13 no 2

Adverse events One subject in Group 1 was admitted to hospital with liver disease, which was unrelated to the treatment. Four cases of AEs were reported in Group 2. One subject complained of a burning sensation in the wound, one had rhinitis, and two developed a mild headache. However, these events were classified as being independent of the treatment and did not lead to drop-out from the study.

Discussion Chronic wound healing is a complex process in which different phases of wound healing interact10,11,12. One essential factor in the wound healing process is an adequate oxygen supply. However, many chronic wounds have inadequate oxygen perfusion due to underlying diseases such as CVI or pAOD, among others, leading to tissue hypoxia. If such a hypoxic state persists for a prolonged period of time, a wound healing disorder usually occurs if a wound develops. In these cases, many normal processes are either retarded or stagnated, including pathogen defence, cell proliferation during the granulation or epithelisation phases, or synthesis of the extracellular matrix3,10,11,12. 

Fig. 5: Assessment of pain intensity.

Subjects in both groups ­rated pain intensity on days 0, 15, 42, and 91 using a VAS. A marked decrease in VAS among subjects treated with the haemoglobin spray (Group 1) can be observed in comparison to the control group (Group 2).

29

Science, Practice and Education

In addition to mandatory treatment of the primary disease to revascularise the tissues, an external oxygen supply to the wound is of great interest in the field of wound treatment3,8,13,14,15,16,17. Here, we used a haemoglobin solution to treat wounds based on the premise that haemoglobin improves oxygen transport through the wound exudate to the wound bed by facilitated diffusion20, 21. In this study, patients with a venous leg ulcer that, despite prior lege artis wound care, did not show any significant improvement, were included, whereas patients with chronic wounds of a different aetiology were not included in the interest of group homogeneity. However, it may be expected that patients with arterial occlusive disease, for instance, would also respond positively to haemoglobin therapy, particularly patients with critical limb ischemia22,23, but further studies are needed.

Though compression therapy was used during the study for all subjects, the effect of the therapy on the observed haemoglobin treatment results was minimised by the fact that both groups had already been treated with compression therapy before the start of the study, and continued the treatment consistently during the study.

We found that the majority of the subjects in Group 1 treated with the haemoglobin solution had a significant and continual healing tendency. The continual healing tendency was independent of the initial wound surface area size, and was comparable in the three wound size cohorts analysed. In addition to the marked reduction in wound surface area, the subjects in Group 1 also showed a reduction in scab volume and fibrin coating, and a marked

Literature 1 Dissemond J (2012) Ulcus cruris – Genese, Diagnostik und Therapie. 4. Aufl: Uni-med, Bremen, S. 15-48 2 Raffetto JD (2010) The definition of the venous ulcer.

J Vasc Surg 52 (5 Suppl): 46S-49S 3 Beckert S, Küper M, Königsrainer A (2008) Sauerstoff und Wundheilung. ZfW 4:232-238 4 Jünger M, Steins A, Hahn M, Häfner HM (2000) Microcirculatory dysfunction in chronic venous insufficiency (CVI). Microcirculation 7(6 Pt 2): S3-12 5 Deutsche Diabetes Gesellschaft. Evidenzbasierte Leitlinie – Diagnostik, Therapie, Verlaufskontrolle und Prävention des diabetischen Fußsyndroms, Update 2008: www.deutsche-diabetes-gesellschaft. de / redaktion / mitteilungen / leitlinien / Uebersicht_leitlinien_evidenzbasiert.php 6 Deutsche Gesellschaft für Angiologie / Gesellschaft für Gefäßmedizin. Leitlinien zur Diagnostik und Therapie der peripheren arteriellen Verschlusskrankheit (PAVK): www.awmf.org / leitlinien / detail / ll / 065-003.html 7 Deutsche Gesellschaft für Phlebologie. Leitlinien der Deutschen Gesellschaft für Phlebologie – Diagnostik und Therapie des Ulcus cruris venosum, Version 8 – 2008: www.phlebology.de/Deutsche-Gesellschaft-furPhlebologie/diagnostik-und-therapie-des-ulcus-crurisvenosum.html

30

increase in granulation tissue and epithelisation. Wound pain also decreased over the course of the study in Group 1 subjects.

We demonstrated that a haemoglobin solution can be used easily and safely to treat venous leg ulcers, results that are supported by case reports17 and an open market authorisation study in Mexico22. Haemoglobin can stimulate wound healing and have a potent adjunctive effect on the healing process. The treatment described here is a suitable alternative or adjunct to other topical forms of wound treatment as it is effective and causes no undesirable side effects. Furthermore, topical use of haemoglobin for a broader spectrum of medical indications is conceivable. Clinical studies including different wound types are needed to further support the emerging evidence of the broad benefit of haemoglobin adjunct therapy in wound care.

Summary: The amount of oxygen supplied to a wound plays an important role in successful treatment of chronic ulcers of the lower limb, such as venous leg ulcers. Therefore, the oxygen supply to the wound bed is an important addon procedure for successful wound treatment. This study demonstrated the positive effect of topical administration of a haemoglobin solution on wound healing in patients with a venous leg ulcer. m Acknowledgements This study was supported by a research grant (No. IGA NS/100934/2008) from the Czech Ministry of Health.

The haemoglobin spray and the illustrations in Figure 1 were kindly ­provided by SastoMed GmbH.

8 Gordillo GM, Sen CK (2009) Evidence-based recommendations for the use of topical oxygen therapy in the treatment of lower extremity wounds. Int J Low Extrem Wounds 8(2):105-111

17 Barnikol WKR, Teslenko A, Pötzschke H (2005) Eine neue topische Behandlung chronischer Wunden mit Hämoglobin und Sauerstoff: Verfahren und erste Ergebnisse. ZfW 10(3):98-108

9 Hile C, Veves A (2003) Diabetic neuropathy and microcirculation. Curr Diab Reports. 3: 446-451

18 Wittenberg JB (1966) The molecular mechanism of hemoglobin-facilitated oxygen diffusion. J Biol Chem 241(1):104-114

10 Schreml S, Szeimies RM, Prantl L et al. (2010) Oxygen in acute and chronic wound healing. Br J Dermatol 163:257-268 11 Sen CK (2009) Wound healing essentials: Let there be oxygen. Wound Repair Reg 17: 1-18 12 Rodriguez PG, Felix FN, Woodley DT et al. (2008) The role of oxygen in wound healing: A review of the literature. Derm Surg 34:1159-1169 13 Feldmeier JJ, Hopf HW, Warriner RA 3rd et al.

(2005) UHMS position statement: topical oxygen for chronic wounds. Undersea Hyperb Med 32(3):157168 14 Dissemond J, Körber A, Jansen T et al. (2005) Sauerstoff in der Therapie des Ulcus cruris. ZfW 6: 252-256.

15 Kranke P, Bennett MH, Martyn-St James M et al.

(2012) Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. CD004123 16 Tawfick W, Sultan S (2009) Does topical wound oxygen (TWO2) offer an improved outcome over conventional compression dressings (CCD) in the management of refractory venous ulcers (RVU)? A parallel observational comparative study. Eur J Vasc Endovasc Surg 38(1):125-132

19 Scholander PF (1960) Oxygen transport through hemoglobin solutions. Science 131:585-590 20 Arenberger P, Engels P, Arenbergerova M et al.

(2011) Clinical results of the application of a hemoglobin spray to promote healing of chronic wounds. GMS Krankenhaushyg Interdiszip 6(1):Doc05.Epub 2011Dec15 21 Kammerlander G, Assadian O, Eberlein T et al.

(2011) A clinical evaluation of the efficacy and safety of singlet oxygen in cleansing and disinfecting stagnating wounds. J Wound Care 20:149-158 22 Setacci C, De Donato G, Setacci F, Chisci E (2010) Ischemic foot: definition, etiology and angiosome concept. J Cardiovasc Surg. 51(2):223-231 23 Hafner J, Schaad I, Schneider E, Seifert B, Burg G, Cassina PC (2000) Leg ulcers in peripheral arterial disease (arterial leg ulcers): impaired wound healing above the threshold of chronic critical limb ischemia.

J Am Acad Dermatol. 43(6):1001-8.

EWMA Journal

2013 vol 13 no 2

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AQUACEL.com/foam *As demonstrated in vitro 1. The antimicrobial activity of AQUACEL™ Ag Foam adhesive using a simulated shallow wound microbial model. Microbiological Application. WHRI3771 MA221. 2013. Data on file, ConvaTec. 2. In vitro testing of AQUACEL™ Ag Foam and Competitor Dressings – Intimate Contact. Market Support. WHRI3661 MS100. 2013. Data on file, ConvaTec. 3. Waring MJ, Parsons D. Physico-chemical characterisation of carboxymethylated spun cellulose fibres. Biomaterials.

2001;22(9):903-912. 4. Cook L, Baker C. AQUACEL™ Foam dressing: A case study demonstrating its effectiveness in managing the complications of wound exudate under compression bandaging. Poster presented at: Wounds UK Conference. November 12-14, 2012, Harrogate. ®/ TM AQUACEL and Hydrofiber are trademarks of ConvaTec Inc. All other trademarks are property of their respective owners. ©2013 ConvaTec Inc. AP-013501-MM

EWMA 2013 COPENHAGEN 15 -17 May · 2013 Short paper Submitted to the EWMA Journal, based on an oral presentation at the Annual EWMA Conference in ­Copenhagen, May 2013

Jos Schols1 Prof. MD, PhD

Jacques Neyens1,2 PT, PhD Armand Rondas1,3 MD, MSc

The effects of an arginine-enriched oral nutritional supplement on chronic wound healing in non-malnourished patients: A multicentre case study in the ­Netherlands Aim Although many wounds heal without delay or complications, the healing of both acute and chronic wounds may be affected by intrinsic factors (e.g. comorbidities and inadequate blood supply) and/or extrinsic factors (e.g. infection and insufficient nutrition) (Vowden et al. 2008).

In contrast to acute wounds, chronic wounds are more complicated; the biology of the healing process is significantly different (Demling 2009).

In the last decade, novel wound-healing interventions have been developed, but delayed wound healing is still a major burden for health care in general and patients in particular. Skin regeneration is a vital aspect of wound healing, facilitated by adequate nutrition. Nutritional support, therefore, plays a pivotal role in wound healing. Based on the results of a previous randomized controlled trial in patients with pressure ulcers (PUs) (van Anholt 2010), we explored the effect of a specific

arginine-enriched oral nutritional supplement (ONS) in patients with PUs, diabetic foot ulcers (DFUs), or leg ulcers (LUs) on wound healing.

The primary outcome parameters were: 1) wound healing progress, i.e. wound size reduction, and 2) patient concordance and appreciation of the specific ONS. Methods Design: a case report study, approved by a medical ethics committee and with patient informed consent, was conducted in two nursing homes and one ambulatory wound centre in the Netherlands.

Twenty-two non-malnourished patients (i.e. with a normal body mass index [BMI] and no signs of undesired weight loss) with a PU, DFU, or LU present for at least three weeks, were included. All participants were offered one to three servings per day of a specific ready-to-drink arginine-enriched ONS (per one 200 ml serving: 250 kcal, 20 g

Martin van Leen1,4 MD 1Caphri-Department

of Health Services Research, Maastricht University, Maastricht, The Netherlands

Patient characteristic (N=22) Mean age (range)

72,8 years (52-95)

Gender

7 Male, 15 Female

De Riethorst Stromenland, Raamsdonksveer, The Netherlands

Mean BMI (range)

24,8 (20-38)

Mobility

Chairfast (N=8), Walks occasionally (N=9), Walks frequently (N=5)

Existence of wound

<4 weeks (N=3), >1 month <3 months (N=5), >3 months (N=14)

Zorggroep, Venlo, The Netherlands

Wound type

PU (N=7), DFU (N=2), Arterial LU (N=5), Venous LU (N=8)

2Stichting

3De

Table 1: Patient characteristics and pressure ulcer, diabetic foot ulcer, and leg ulcer healing

4Avoord,

Etten-Leur, The Netherlands

Conflict of interest: none

Mean wound size at start (range) 11 cm2 (1-46) ONS per day

1 bottle (N=7), 2 bottles (N=14), 3 bottles (N=1)

Healing (N=20) Completely healed

N=8

Partly healed*

N=8

No effect

N=4

Unable to follow up

N=2

*unable to follow up with one patient after 4 weeks BMI: body mass index PU: pressure ulcer DFU: diabetic foot ulcer LU: leg ulcer

32

EWMA Journal

2013 vol 13 no 2

Science, Practice and Education

Overall, the daily ONS, on average two servings per day (400 ml), were fully consumed (100% concordance), and in all cases, the patientsâ&#x20AC;&#x2122; appreciation of the ONS was good.

protein, 3 g L-arginine, 250 mg vitamin C, 38 mg vitamin E (a-TE), 9 mg zinc, 1.5 mg carotenoids) in addition to their regular diet and standard wound care, for a maximum of twelve weeks. Patient characteristics, information on wound size (cm2), product intake, patient product appreciation, and photographs were collected each month.

Conclusions Extra nutritional support with a specific ready-to-drink arginine-enriched ONS has already proven effective in healing PUs (van Anholt 2010), and, according to our data presented here, appears to be beneficial for healing other types of chronic ulcers as well. Therefore, it is advisable to perform more in-depth research on this nutritional intervention in patients with different types of chronic wounds.

m

Results Eight males and fourteen females with a mean age of 80 years were included. The main diagnoses involved were PU (n=7), DFU (n=2), arterial LU (n=5), and venous LU (n=8). At the beginning of the study, the wounds had been present between <1 month and >3 months. Within 7 to 12 weeks, complete healing occurred in eight ulcers (4 PUs, 1 DFU, 3 venous LUs), eight ulcers showed clear signs of healing through partial wound size reduction ranging from 35% to 75% (one PU, one DFU, three arterial LUs, three venous LUs), and four ulcers remained unchanged (two arterial LUs, two venous LUs). Two PU patients were lost to follow-up (one deceased, one admitted to hospital).

Patient characteristics and wound healing over the course of the study are depicted in Table 1.

References Demling, R. 2009. Nutrition, anabolism, and the wound healing process: an overview.

Eplasty [Online] 9(9). van Anholt, R. et al. 2010. Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. Nutrition 26, pp. 867872.

Vowden, P. et al. 2008. Wound complexity and healing. European Wound Management Association {EWMA}, Position Document: Hard-to-Heal wounds: a holistic approach. London: MEP Ltd.

A

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en sion op

v 2013 o N 1 ď ˝ 1 Aug

15th EFORT Congress

A combined congress with BOA sessions (British Orthopaedic Association)

London, United Kingdom: 4 - 6 June 2014

Main Theme: Patient Safety Highlights in Orthopaedics & Traumatology

www.efort.org/london2014 EFORT_London_145x205_EWMA_Abstracts.indd 1

Key dates

Abstract submission & registration opens: 1 August 2013 Abstract submission closes: 1 November 2013 Early Registration Deadline: 31 January 2014 On-site rates apply: 16 May 2014 09/09/2013 13:50:00

PRO EN PREVENTION Can you afford the impact of not using our proven prevention?

✔ The only dressing supported by results of randomised controlled trials1,2 ✔ Significant reduction in pressure ulcer incidence3,4,5,* ✔ Substantial cost savings4,6,11,12,* ✔ Combats 4 extrinsic causes of pressure ulcers7,8,9,10,*

SHEAR

PRESSURE

MICRO-CLIMATE

FRICTION

Find out more www.molnlycke.com/puprevention References: 1. Kalowes P. et al. Use of a soft silicone, self-adherent, bordered foam dressing to reduce pressure ulcer formation in high risk patients: a randomized clinical trial. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore, Maryland, United States of America. 2012. 2. Santamaria N. et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial. International Wound Journal 2013; doi: 10.1111/iwj.12101. 3. Brindle C.T. and Wegelin J.A. Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. Journal of Wound Ostomy & Continence Nursing. 2012; 39(2):133-142. 4. Cherry C. and Midyette P. The Pressure Ulcer Prevention Care Bundle: a collaborative approach to preventing hospital-acquired pressure ulcers. Poster presentation at Magnet Research Day, Alabama, United States of America. 2010. 5. Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. Journal of Wound Ostomy & Continence Nursing 2012;39(2):143-145.

6. Padula W. et al. Improving the Quality of Pressure Ulcer Care With Prevention, A Cost-Effectiveness Analysis. Medical Care. 2011; 49(4). 7. Call, E. Pederson, J., Bill, B.Craig Oberg PhD, Martin Ferguson- Pell PhD, Wounds -2013, 25(4):94103. 8. Call, E. Pederson, J., Bill, B. In vitro comparison of the prophylactic properties of two leading commercially available wound dressings. Poster presentation at Symposium on Advanced Wound Care Fall, Baltimore, Maryland, United States of America. 2012. 9. Call, E. Black J., Clark M. ,Alves P., Brindle T., Dealey C. Santa Maria, N International Panel Studies Creation of Guidance on Dressing Use in Prevention of Pressure Ulcers poster presentation SAWC spring 2012.

10. Call, E., et al Microclimate Impact of Prophylactic dressings using In Vitro Body analog method. Wounds -2013, 25(4):94-103. 11. Santamaria, N et al A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border trial . Oral presentation EWMA Copenhagen May 2013. 12. Kalowes, P., et al, A. Use of a soft silicone, self-adherent, bordered foam dressing to reduce pressure ulcer formation in high risk patients: a randomized clinical trial. Oral presentation EWMA Copenhagen May 2013. *In addition to current prevention protocols.

Science, Practice and Education

Efficacy of honey gel in the treatment of chronic lower leg ulcers: A prospective study Abstract Chronic leg ulcers are a common medical problem among elderly patients and have a dramatic impact on quality of life as a result of pain, disability, and social isolation.

Regardless of their cause, chronic leg ulcers remain difficult to treat. In recent years, there has been increasing interest in the use of honey as a therapeutic agent.

Objective: To evaluate the efficacy of honeybased dressings in the treatment of chronic leg ulcers.

Methods: Ten patients with chronic (mean duration 3.3 years) leg ulcers who had received non-honey based treatments with no improvement were included in this study.

A honey gel dressing was applied twice a week as the only treatment.

Results: Seven patients experienced complete healing of their leg ulcers. The remaining three patients showed a significant reduction in wound size, which was achieved in a mean time of 101 days (range 28-174 days).

Conclusion: Honey-based dressings appear to be an efficient and easy to use treatment for leg ulcers.

Key words: Chronic lower leg ulcer, venous leg ulcer, dressings, honey gel

Introduction Lower leg ulcers affect 15-18 out of 10,000 adults in developed countries, with venous leg ulcers (VLUs) representing up to 84% of all leg ulcer cases (Watson, 2011).

These ulcers have an important impact on the quality of life and health of patients (Cullum, 2000). Treatment of VLU patients also has a significant economic impact; the annual cost of treatment of VLUs in the UK and Sweden is estimated to be between 1,300-2,500 Euros per patient.

Costs increase for lesions with long healing times or for larger ulcerations, as well as for ulcers that are defined as “difficult to treat” (Ragnarson Tennvall, 2005). Difficult to treat cases can cause significant morbidity (Faria, 2011), seriously impact the patient’s quality of life (GonzálezConsuegra, 2011), and consequently increase treatment costs.

Evidence-based treatment options for VLUs include leg elevation, compression therapy, topical (active) dressings, pentoxifylline, and aspirin therapy. Surgical management can be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures (Collins, 2010).

In clinical practice surgery is rarely an option due to the nature of the pathology in the lower limb.

Instead, common treatment options include compression therapy as standard care in combination with a variety of dressings, although meta-analyses have not yet identified the ideal dressing type (Palfreyman, 2006; O’Meara, 2009). The recent resurgence of the use of honey in wound management (Al-Waili, 2011) triggered our prospective study of the efficacy of honey-based treatment in the management of venous leg ulcers.

Study design In this prospective study we evaluated the efficacy of a honey gel dressing in a group of patients with difficult to treat VLUs. Patients with lower leg ulcers who presented at the University Hospital between February and October 2010 were recruited for this study. All patients with chronic lower leg ulcers, regardless of ulcer depth, area, or presence of infection, were included. Patients were randomly selected for treatment as outpatients with consultation or for inpatient treatment. Exclusion criteria were

EWMA Journal

2013 vol 13 no 2

Oscar Tellechea M.D., Ph.D. 2 Ana Tellechea, D.Sc.1 Vera Teixeira, M.D.2 Fatima Ribeiro, RN2 1Neurosciences and Cellbiology centre, University of Coimbra, Coimbra, Portugal 2Dermatology

Service, Hospitals of the University of Coimbra, Coimbra, Portugal Correspondence: oetellechea@gmail.com Conflict of interest: none



35

Table 1: Clinicopathological characteristics of patients and ulcers General information Underlying pathology Etiology 2 75 Y F X Polycythemia vera 1 0 3 65 Y M Smoker 0 0 0 0 4 65 Y M X CRI, dialysis, awaiting kidney transplant 5 75 Y F 1 0 6 81 Y F X 1 0 7 78 Y F X TEP (pulmonary 1 0 thromboembolism) 8 57 Y M 0 0 9 10

83 Y 67 Y

M F

X

X

-

1 1

0 0

0 1 0

0 0 1

0 0 0

X X X

0 0 0

0 0 0

0 0 0

X X

0

0

0 0

0 0

post trauma 0 0

X X

Y: years old F: female M: male

unlikelihood of wound improvement due to cutaneous necrotizing vasculitis, lower limb cellulitis, or severe lower limb arterial insufficiency.

Patients The study included ten patients: six females and four males with an average age of 73 years (age range 57-83).

Underlying pathologies included diabetes mellitus (n=3), hypertension (n=4), and a range of other factors that influence wound healing (Table 1). Seven patients had venous ulcers, one had a mixed venous and arterial ulcer, one had a post-trauma ulcer, and one had an ulcer related to diabetes mellitus (Table 1). Standard criteria for the diagnosis of leg ulceration were used.

Leg ulcers had been present in these patients for an average of 3.3 years (range: 2 months-5 years). During that period, patients were treated with a range of products and techniques in primary care centres without improvement (Tables 2 & 3). For our study, the patients themselves before initiation of the honey gel treatment were used as controls. To ensure that application of honey gel was the only variable, the same wound management regimen that was followed in the pre-study treatment period was applied during our study, except that honey gel was now used as a topical dressing (Moghazy, 2010). Patients consented to the honey gel regimen prior to the start of the study.

During the treatment period no compression therapy was performed in any patient.

Materials The honey gel (L-Mesitran Soft, Triticum, NL) used in this study contains 40% medical-grade honey, ultra-purified hypoallergenic medical grade lanolin (Medilan), polyethylene glycol, and Vitamins C and E. All of these ingredients have individual beneficial effects on wound management and healing (Cutting, 2005) and the honey product as a whole has proven antibacterial efficacy (Stephen-Haynes, 2011).

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Fig 1. Patient 3. Ulcer pathology before honey gel treatment.

Fig 2. Patient 3. Complete healing of the wound after 7 months of honey gel treatment.

Methods Patients were treated only with honey gel. The honey gel was applied twice weekly d directly over the wound and covered with a sterile cotton dressing. Compression was not used during the period of treatment with the honey gel.

During the observation period the patients were seen for consultation at weeks 2, 4, and on a monthly basis thereafter. Ulcer size was measured using the Opsite Flexigrid® system.

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Lateral, posterior (right side) 1,2,3,4,5 z1 Left internal malleolus 1,2,3,4,5,9 23 Left external malleolus 1,2,3,4,5 29,6 Injury next to the lap of the 1st metatarsal 4,5,8 1,5 Left supramaleolar 1,4,7,10 2,5 Right external malleolus 1,3,4,6 3,6 One-third distal right leg, circumferential 3,4,5 67,6 One-third distal right leg, anterior 1,2,3,4 1 Right internal malleolus 3,4 6,9 Right internal malleolus 1,4,5,9 54,3

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Hydrocolloid

2

Calcium Alginate

3

Allevyn

4

Aquacel AG

5

Activated charcoal

6

Fat gauze

7

Vaseline salicylated 10%

8

Silver sulfadiazine

9

HZN Reducol Gel

10

2006; Stephen-Haynes, 2011). It is particularly important that the honey used for wound care is free from residues and sterilized, because honey can contain clostridial spores in addition to non-pathogenic Bacillus spp. Only gamma irradiation effectively sterilizes honey without reducing its efficacy (Postmes, 1993; Molan, 1996) and the use of non-sterilized honey samples cannot be justified (Cooper, 2009).

The honey gel used in this study may also have a direct positive effect on wound healing. Du Toit (2009) examined the cell morphological effects of honey- and silverimpregnated dressings on two key cellular components of wound healing, keratinocytes and fibroblasts, using an 

Period of treatment with honey gel (days)

Reduction in wound size

Fold acceleration of healing time

Table 4: Honey gel treatment End of the treatment

Discussion A primary factor contributing to the chronic nature of VLUs is poly-microbial biofilm infection, where several bacterial species colonize the wound. The most common organisms found in VLU biofilms include various anaerobes, Staphylococcus (Wolcott, 2009), and Pseudomonas aeruginosa (Jacobsen, 2011). The honey-based product used in our study has a known broad-spectrum antibacterial effect, which could have contributed to the accelerated healing. In vitro research using antibiotic-resistant clinical isolates and extended spectrum b-lactamase (ESBL)producing strains of bacteria showed that this honey gel is highly effective and has stronger antibacterial activity than other honey products (Manuka) (Stobberingh, 2010; Stephen-Haynes, 2011). The efficacy of honey in wound healing is further attributed to its low pH, its ability to produce hydrogen peroxide, and its osmotic action (Molan,

1

Wound size at the end of the treatment (cm2)

Results A reduction in wound size was observed in all patients in a mean time of 101 days (range: 28-174 days) (Table 4).

Seven patients showed complete healing of the wound and the mean degree of reduction of ulcer extension was 90%, ranging from less than 10% to 100% (Table 4).

Patient 7, who showed the smallest reduction in wound size, complained of pain after application of the honey gel and abandoned the study.

Hydrogel

Initiation of treatment

Dermocorticoids (betametasone valerate cream) and emollients were applied to the peri-wound area when necessary. No topical or systemic antibiotics were used.

Adverse reactions, including subjective unfavourable symptoms, were registered when present.

EWMA Journal

Wound size at the start of honey gel treatment (cm2)

1,825 1,278 1,825 730 730 1,460 1,825 61 1,095 1,095

Previous Treatment

Patient #

Presence of ulcers prior to honey gel treatment (days)

5.0 3.5 5.0 2.0 2.0 4.0 5.0 0.2 3.0 3.0

Table 3

Previous treatments

Presence of ulcers prior to honey gel treatment (years)

1 2 3 4 5 6 7 8 9 10

Location

Patient #

Table 2: Characteristics of ulcer at initiation of honey treatment

1 2 3 4 5 6 7 8 9 10

16-06-2010 04-10-2010 18-03-2010 25-05-2010 08-02-2010 15-04-2010 15-06-2010 18-05-2010 06-04-2010 26-05-2010

0 8.4 0 0 0 0 59.7 0 0 27

29-09-2010 25-11-2010 28-10-2010 01-07-2010 30-05-2010 25-10-2010 20-07-2010 16-06-2010 30-09-2010 26-07-2010

103 51 220 36 112 190 35 28 174 60

100% 63% 100% 100% 100% 100% 12% 100% 100% 50%

18 25 8 20 7 8 52 2 6 18

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Table 5: Previous studies on the efficacy of honey in VLU tretament Author

Type of study

Olabanji (2000) Natarajan (2001) Alcaraz (2002) Dunford (2004)

Comparative study Case report Case report Four-centre feasibility

Number Study of patients period 50 4 weeks 1 until healing 1 until healing 40 12 weeks

Schumacher Case report (2004) van der Weyden Case report (2005)

6

Timmons (2008)

Case report

1

Jull (2008)

Community-based, open-label randomised trial Case report

368

Gethin (2009)

Prospective, multicentre, open label randomised controlled trial

108

Kegels (2011)

Retrospective study

22

Sare (2008)

1

3

in vitro tissue explant culture model and found that the honey-impregnated dressings promoted new tissue regeneration. A second study comparing silver-sulphadiazine with the honey gel used in our study reported similar findings; the honey gel significantly stimulated re-epithelialisation, whereas silver sulphadiazine significantly reduced it (Boekema, 2013). In support of these findings, Rossiter et al. (2010) showed that honey products stimulated angiogenesis in vitro in an investigation of the influence of honey on growth of the tubular length of rat aorta.

Several previous studies (Table 5, 601 patients) have reported that honey-based wound management has positive effects on wound healing, ulcer size, and patient comfort.

However, when compared to standard methods or other comparative methods, honey has not been shown to superior to these methods significant difference in wound healing. This might reflect the type of honey used in these studies (Jull, 2008), the study design (Firth, 2010), and the complexity of VLU management.

However, we did see a significant improvement in wound healing in our study. The patients’ previous treatments were less effective (Table 2) than honey treatment (Table 4), with an observed shortening of healing time from an average of 3.3 years to 101 days. The honey gel was used in monotherapy. Only emollients and, when indicated, topical corticosteroids were allowed as complementary treatment on the peri-ulcerous skin, and in no circumstance were antibiotics or antiseptics used.

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Outcome

Reduction in wound size was significantly different.

MRSA was eradicated from the ulcer and rapid healing was successfully achieved.

The patient’s wounds improved with the honey-based dressing.

Overall, ulcer pain and size decreased significantly, and odorous wounds were deodorised promptly. until No significant difference from conventional methods healing recorded. until Honey was found to be an effective antibacterial, healing ­anti-inflammatory, and deodorizing dressing, with total healing of the ulcer achieved. until Honey promoted the removal of slough, encouraging healing the formation of granulation tissue and epithelial ­tissue growth 12 weeks Honey-impregnated dressings promoted healing, however, not significantly more than usual care. until Promotion of healing occurred in all instances with healing a reduction in the incidence of infection, reduction in pain, and the provision of comfort.

12 weeks Increased incidence of healing, effective ­desloughing, and a lower incidence of infection than the ­control. until Infected wounds were controlled within a few days. healing All the wounds progressed to healing without any ­adverse effects.

Similar results were obtained in a recent retrospective study in which 22 patients with lower extremity ulcerations had delayed healing, in part attributed to application of povidone iodine or fusidic acid, and 50% of the wounds were infected. After treatment with honey-based products, all cases progressed to healing (Kegels, 2011).The use of honey may therefore have a place in VLU treatment (Jull, 2013). Antibiotics are not recommended because there is no evidence that the routine use of systemic antibiotics promotes VLU healing. In addition, in light of the increasing problem of bacterial resistance to antibiotics, current prescribing guidelines recommend that antibacterial preparations should only be used in cases of clinical infection and not for bacterial colonisation (O’Meara, 2010).

Honey gel treatment may also be superior to traditional treatments because it is easier for patients to administer.

The patients in our study showed low compliance with compression bandage treatment during the pre-study treatment period because a lack of local health facilities, advanced patient age, and the low economic status of the patients often precluded maintenance of correct compression treatment. In contrast, application of honey gel to the wound surface was easy and could be accomplished by the patients themselves or by a relative without specialised skills, as previously reported (Smaropoulos, 2011). Patients were therefore able to follow the treatment protocol provided no adverse effects occurred.

Another advantage of honey-based treatment is that it requires fewer materials and the procedure is less time EWMA Journal

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Science, Practice and Education

consuming than traditional methods, which has the potential to reduce treatment costs. The reduction in health care costs might be expected when the faster healing times are taken into consideration. In addition, although the present study did not analyse quality of life data, the patients welcomed the faster wound healing with honeybased treatment. We therefore believe that honey-based treatments of VLUs should be more seriously considered for the treatment of leg ulcer patients.

Limitations The small number of patients and the use of the patients themselves as the treatment controls are limitations of this study.

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Conclusion We believe that honey gel treatment may provide a practical and well-tolerated treatment for the management of lower leg venous ulcers, particularly when patient compliance with compression therapy is poor. m

Read our author guidelines at www.ewma.org/english/authorguide

Acknowledgement The authors wish to thank the patients who volunteered in this study.

References Alcaraz A, Kelly J. (2002) Treatment of an infected venous leg ulcer with honey dressings. Br J Nurs.

11(13):859-60, 862, 864-6 Al-Waili N, Salom K, Al-Ghamdi AA (2011) Honey for wound healing, ulcers, and burns; data supporting its use in clinical practice. Scientific World Journal 11:766-87 Boekema B, Pool L, Ulrich M (2013) The effect of a honey based gel and silver sulphadiazine on bacterial infections of in vitro burn wounds. Burns 39(4):754-759 Collins L, Seraj S (2010) Diagnosis and treatment of venous ulcers. Am Fam Physician. 81(8):989-96 Cooper RA, Jenkins L (2009) A comparison between medical grade honey and table honeys in relation to antimicrobial efficacy. Wounds 21(2):29-36 Cullum N, Nelson EA, Fletcher AW, Sheldon TA (2000) Compression bandages and stockings for venous leg ulcers. Cochrane Database Syst Rev. 2000;(2):CD000265.

Jacobsen JN, Andersen AS, Sonnested MK, Laursen I, Jorgensen B, Krogfelt KA (2011) Investigating the humoral immune response in chronic venous leg ulcer patients colonised with Pseudomonas aeruginosa. Int Wound J. 8(1):33-43 doi: 10.1111/j.1742-481X.2010.00741.x.

Epub 2010 Nov 19

Postmes T, Van den Boogaard T, Hazen M (1993) Honey for wounds, ulcers and skin graft preservation. The Lancet Vol 341; March 20:756-757

Jull A, Walker N, Parag V, Molan P, Rodgers A (2008) Randomized clinical trial of honey-impregnated dressings for venous leg ulcers British Journal of Surgery 95: 175-182

Rossiter K, Cooper AJ, Voegeli D, Lwaleed B (2010) Honey promotes angiogeneic activity in the rat aortic ring assay. Journal of Wound Care 19(10):440-446

Jull AB, Walker N, Deshpande S (2013) Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2013 Feb 28;2:CD005083. doi: 10.1002/14651858.

CD005083.pub3.

Kegels F (2011) Clinical evaluation of honey-based products for lower extremity wounds in a home care setting.

Wounds UK 7(2):46-53

Cutting K, Davies P (2005) Natural therapeutic agents for the topical management of wounds. Wounds UK Supplement 1(3):4-13

Moghazy AM, Shams ME, Adly OA, Abbas AH, El-Badawy ME, Elsakka DM, Hassan SA, Abdelmohsen WS, Ali OS, Mohamed BA (2010) The clinical and cost effectiveness of bee honey dressing in the treatment of diabetic foot ulcers. Diabetes Research and Clinical Practice 89:276-281

Dunford CE, Hanano R (2004) Acceptability to patients of a honey dressing for non-healing venous leg ulcers. J Wound Care 13(5):193-7

Molan PC, Allen KL (1996) The effect of gammairradiation on the antibacterial activity of honey. J Pharm Pharmacol. 48(11):1206-9

DuToit DF, Page B (2009) An in vitro evaluation of the cell toxicity of honey and silver dressings. Journal of Wound Care 18(9):383-389

Molan PC (2006) The evidence supporting the use of honey as a wound dressing. Int J Low Extrem Wounds 5(1); 40-54

Faria E, Blanes L, Hochman B,Mesquita Filho M, Ferreira L (2011) Health-related Quality of Life, Self esteem, and Functional Status of Patients With Leg Ulcers. Wounds 23(1):4-10

Natarajan S, Williamson D, Grey J, Harding KG, Cooper RA (2001) Healing of an MRSA-colonized, hydroxyureainduced leg ulcer with honey. J Dermatolog Treat.

12(1):33-6

Firth J, Nelson EA, Hale C, Hill J, Helliwell P (2010) A review of design and reporting issues in self-reported prevalence studies of leg ulceration. J Clin Epidemiol.

63(8):907-13

Olabanji JK, Tijani LA, Oluwatosin OM, Onyechi HU, ­Oluwatosin OA (2000) A comparison of topical honey and phenytoin in the treatment of chronic leg ulcers. African Journal of Medicine and Medical Sciences 29(1):31-34

Gethin G, Cowman S (2009) Manuka honey vs. hydrogel-a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. J Clin Nurs. 18(3):466-74.

Epub 2008 Aug 23.

O’Meara S, Cullum NA, Nelson EA. (2009) Compression for venous leg ulcers. Cochrane Database Syst Rev. 21;(1):CD000265

González-Consuegra RV, Verdú J (2011). Quality of life in people with venous leg ulcers: an integrative review. J Adv Nurs. 67(5):926-44. doi: 10.1111/j.13652648.2010.05568.x

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O’Meara S, Al-Kurdi D, Ologun Y, Ovington LG (2010) Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 20;(1):CD003557 Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA. (2006) Dressings for healing venous leg ulcers. Cochrane Database Syst Rev. Jul 19;3:CD001103

Ragnarson Tennvall G, Hjelmgren J (2005) Annual costs of treatment for venous leg ulcers in Sweden and the United Kingdom. Wound Repair Regen. 13(1):13-8

Sare JL (2008) Leg ulcer management with topical medical honey. Br J Community Nurs. 13(9):S22, S24, S26 passim.

Schumacher HH (2004) Use of medical honey in patients with chronic venous leg ulcers after split-skin grafting. J Wound Care 13(10):451-2 Smaropoulos E, Romeos S, Dimitriadou C (2011) Honeybased therapy for paediatric burns and dermal trauma compared to standard hospital protocol. Wounds UK 7(1):33-40 Stephen-Haynes J, Callaghan R (2011) Properties of honey: its mode of action and clinical outcomes. Wounds UK 7(1):54-57 Stobberingh EE (2010) Antibacterial activity of honey against ESBL -producing strains. Report by the department of Medical Microbiology University of Maastricht, The Netherlands.

Timmons J (2008) Treatment of a bilateral necrotic leg ulcer with Mesitran. Wounds UK 4(4):129 van der Weyden EA (2005) Treatment of a venous leg ulcer with a honey alginate dressing. Br J Community Nurs. Suppl:S21, S24, S26-7 Watson JM, Kang’ombe AR, Soares MO, Chuang LH, Worthy G, Bland JM, Iglesias C, Cullum N, Torgerson D, Nelson EA; VenUS III team (2011) VenUS III: a randomised controlled trial of therapeutic ultrasound in the management of venous leg ulcers. Health Technol Assess.

15(13):1-192 Wolcott RD, Gontcharova V, Sun Y, Dowd SE (2009) Evaluation of the bacterial diversity among and within individual venous leg ulcers using bacterial tag-encoded FLX and Titanium amplicon pyrosequencing and metagenomic approaches. BMC Microbiology 9:226 doi:10.1186/1471-2180-9-226

39

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Scientific Communication

Consensus recommendation Recommendations for ­compression therapy for ­patients with venous ulcers

Preface The basis for successful treatment of venous ulcers is an adequate compression therapy. The compression bandage compresses the limb, thus leading to the resorption of the fluid found in the tissue by the veins and lymphatic vessels through which the fluid is then drained away towards the heart. The application of a bandage requires some experience, however it has to be learned by doctors, qualified nursing personnel and the patients’ next of kin as a matter of principle. The aim should be to successfully come up with a bandage which does not slip and which attains an effective compression without causing pressure damage or deformations to the limb. As a rule, the indication for the application of a compression bandage is to be determined by a doctor since he also takes responsibility for paying attention to the contraindication.

The following essential principles for applying a compression bandage on the leg should be taken into account irrespective of the material used and the preferred technique of tying.

Everybody who applies a compression bandage must know the potential side effects of compression. Every time the bandage is changed, the leg should be carefully inspected for possible pressure marks, skin changes and atypical swellings which have appeared as a result of lacings around the area.

The recommendations of ICW on compression therapy apply only to patients with a venous ulcer. Compression of the lymphoedema, for instance, is not taken into consideration. These recommendations are regarded as a supplement to the existing guidelines of other professional associations and should serve the wound specialist as a basis for discussion with relatives of the affected people and colleagues, and also with doctors and health insurance companies.

The contents of these recommendations are approved by an external expert and would be defended by ICW as such in the event of a legal dispute.

Prof. K. Kröger and B. Assenheimer on behalf of the ICW

Initiative for Chronic Wounds e.V. Pölle 27/28 06484 Quedlinburg

The following experts have contributed to this Consensus Recommendation: B. Assenheimer, Tübingen Prof. Dr. med. M. Augustin, Hamburg Dr. H. Braunwarth, Hamburg A. Bültemann, Hamburg Prof.Dr. med. E. Debus,Hamburg V. Gerber, Rheine C. Hampel-Kalthoff, Dortmund Dr. H.-D. Hoppe, Quedlinburg U. Imkamp, Magdeburg Prof. Dr. med Michael Jünger, Greifswald Prof. Dr.med.K. Kröger, Krefeld N. Matscheko, München D. Meyer, Hamburg Dr. K.-C. Münter, Hamburg Prof. Dr., Osterbrink, Salzburg Primarius Prof. Dr. med. H. Partsch,Wien Prof. Dr.med. R. U. Peter, Ulm K. Protz, Hamburg Prof. Dr. med. Rabe, Bonn PD.Dr. med.G.Riepe,Boppard H.W. Röhlig, Oberhausen Dr. M. Schimmelpfennig, Kassel N.Scholz, Bad Oeynhausen G. Schröder, Uslar PD Dr. med. A. Schwarzkopf, Bad Bocklet W. Sellmer, Hamburg

Recommendations for compression Initiative for Chronic Wounds e.V. 2009/2010 ww.icwunden.de

T

he basis for successful treatment of the venous ulcers is an adequate compression therapy. This causes a steady increase in the venous reflux. The diameter of the veins is narrowed by the consistent pressure applied on the veins, thereby almost doubling the speed of the blood flow. Furthermore, the compression forms a stable counter-support for the leg musculature.

This intensifies the pumping mechanism of the muscles, a fact which in turn leads to an improvement in the venous reflux even into the deeperlying vessels. Toxins are washed away through this improved drainage and oedemas are reduced. If used well, compression can in the short run lead to peripheral decongestion of the veins and to the prevention of tissue deformation or the complete and natural healing of ulcerations in the long run. 

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41

Recommendations for compression therapy for patients with venous ulcers

Principles of compression therapy The compression bandage compresses the limb, thus leading to the resorption of the fluid found in the tissue by the veins and lymphatic vessels through which the fluid is then drained away towards the heart. To attain this effect, the compression must be sufficiently strong and should reduce in strength from the distal to the proximal end.

On the other hand the compression should be used in a regulated manner and must not be so strong as to cause pressure damage.

The compression pressure created by the compression bandage is determined by the bandage material and the manner in which the bandage is tied. A compression bandage is not an immobilizing bandage. Patients with a compression bandage should and may move normally and they should make themselves active. This movement improves the effect of the compression bandage – especially by activating the ankle joint and calf-muscle pump, alleviates pain and reduces the risk of possible injury through the compression.

Compression and movement The pressure created by compression narrows the vessels in a physical manner and in that way increases the blood flow rate. This effect can only be effective with proper motion. Therefore the patient has to be encouraged to move with a compression bandage on and to carry out gymnastic exercises, such as rotating and wiggling the foot.

Guidelines recommend controlled walking exercises under compression therapy for patients with venous ulcer in order to prevent the stiffening of the ankle joint and to activate the calf-muscle pump.

Working pressure and resting pressure Distinguishing between working pressure and resting pressure is necessary for purposes of applying compression therapy: The compression bandage exerts resting pressure on the resting limb. It corresponds to the force which the applied bandage exerts when trying to contract. Resting pressure can only be defined when the muscles are relaxed.

The working pressure is the pressure which arises during motion through the interaction between muscle tension and the compression bandage. It arises from the resistance which the bandage exerts on the muscle movement. The less the bandage gives way in that process, the higher the working pressure. The two pressures depend both on the material used, the number of bandage rounds applied and the force with which the compression bandage was applied. Since the working pressure is produced by active muscle tension, the working pressure is always higher than the resting pressure.

42

BANDAGE MATERIALS Elastic bandages should be used as bandage materials, such as the so-called “ideal” bandage (a cotton elastic short-stretch-bandage according to DIN 61631) or the non-shrink bandage (made of natural and synthetic fibres), both of which can be cohesive (sticking on itself ) or adhesive (sticky). Compression bandages have a material strength of 0.56 - 1.19 mm when in an unstretched condition and are made of polyamide, elastane, cotton, elastodiene and viscose in different compositions. The bandages normally come in widths of 6, 8, 10, 12 cm and in lengths of 5, 6, 7 m.

Stiffness Stiffness refers to the ability of the bandage to remain rigid and to withstand the changes in the geometry of the calf musculature when under strain. A more stiff bandage leads to high pressure peaks of 60-80 mmHg within the bandage when the calf musculature is strained and hence makes efficient retrograde venous blood flow possible.

Short-stretch Short-stretch-bandages are defined as bandages with only low elasticity (40-90 % short-stretch).

They are characterized by a high working pressure and a low resting pressure.

Resting pressure of 40-60 mmHg can be realized with short-stretch-bandages; however the pressure does not remain at that level after applying the bandage. When in motion and/or during oedema reduction, the pressure decreases over the first 24 hours. Due to loss of pressure it might often become necessary to apply a new bandage, especially during the early stages of treatment, to prevent the bandage from slipping. At the beginning dressings with short-stretch-bandages should therefore generally be controlled in short periods (2 to 3 times a week) and if necessary renewed, in case of an easy reduction of the edema at least once a day.

The manufacturer’s instructions should be followed when taking care of the bandages. The material loses strength not only when the bandage is being applied but also through washing. The following care instructions usually apply: n Bandages can be boiled at temperatures of 95°C and can be re-used approx. 30 times; worn-out bandages are not useful any more and should be replaced n Use mild detergent for washing n Don’t wash with fabric softeners n Lay the bandages flat over the laundry rack to dry; don’t dry them using the heater or the laundry dryer!

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Scientific Communication

Long-stretch Long-stretch-bandages are defined as bandages with high elasticity (150-200% long-stretch). They exert high resting and low working pressure. This means that the bandage would stretch during active movement and hence no resistance and reflux-inducing effect can occur during muscle contraction. Due to their ability to adapt to changes in the limb form and movement, they can sustain the pressure for several days. The use of a single long-stretch-bandage for purposes of applying a strong compression is not recommended due to the risk of damages caused by pressure.

Long-stretch bandages entail additional risk particularly for immobile patients. Due to the high resting pressure, severe constrictions can occur in the case of longer resting phases.

Bandaging systems The market offers ready-made bandaging systems consisting of several components. In the process short- and long-stretch-bandages are partly used in combination. The bandaging systems have the advantage that one does not have to master complex compression techniques. These systems consist of two, three or four components and usually contain padding, compression and fixation bandages.

They can remain in place for up to seven days depending on the clinical presentation, they seldom slip and they continuously maintain the pressure exerted at the time of attachment up to the time of next bandage replacement, depending on the state of decongestion. During the maintenance phase these ready-made bandaging systems can stay in place for up to 7 days. This advantage cannot, however, be used in the case of pronounced oedemas during the decongestion phase and in the case of florid ulceration. Many bandaging systems are not re-usable.

There are no studies regarding the cutaneous compati­ bility of a compression bandage. Allergy against polyamide, elastane, cotton or viscose in the form of urticaria (immediate-type allergy) or in the form of contact eczema (delayed-type allergy) is rare. More often you get cases of allergy against latex or against substances containing rubber caused by compression bandages containing elastodiene or by cohesive bandages coated with latex. Coloured bandages should be avoided because of the increased risk of allergy. A hint at this point: If there is a case of known allergy against silicone one can resort to silicone-free compression bandages and compression bandaging sets.

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2013 vol 13 no 2

COMPRESSION BANDAGES It is misleading to talk about layers in connection with the application of a compression bandage. Since there is always overlapping of the individual bandage rounds applied, at least two layers of the bandage material lie on top of one another in a given spot of the bandaged leg such that there is nothing like a single-layer-bandage. In that regard every compression bandage is multilayered.

It is therefore better to talk of components. Components refer to the individual products like the padding and the elastic bands which are used for applying the compression bandage. Such a multi-component-system comprises for instance: n a tubular bandage n a padded bandage: made of orthopaedic cotton wool or washable/re-usable foam material n an attachment bandage, in order to create a basis for the compression

n at least two elastic bandages with a mild to moderate compression

Since the number of components used can vary, the attained contact pressure of each individual compression bandage also varies considerably.

The contact pressure on the ankle for an ankle size of 1825 cm should reach about 35-40 mmHg. Unfortunately there is no established method for measuring or checking the contact pressure of a compression bandage in everyday clinical situations. One should be rather cautious when applying the bandage on patients who are being dressed for the first time and only increase the contact pressure carefully during the second and third replacement of the bandage.

APPLICATION OF A BANDAGE The application of a bandage requires some experience, however it has to be learned by doctors, qualified nursing personnel and the patients’ next of kin as a matter of principle. The aim should be to successfully come up with a non-slipping bandage with an effective compression without causing pressure damage or deformations to the limb. Only the least number of patients can practically carry out effective self-dressing since elderly people and those with reduced mobility in particular cannot reach  their foot when the leg is stretched out straight.

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Recommendations for compression therapy for patients with venous ulcers

As a rule, the indication for applying a compression bandage is to be determined by a doctor since he also takes responsibility for paying attention to the contra­indication.

The strength of the compression to be applied must correspond to the aim of the therapy and in that way be adapted to the stage of treatment. We therefore distinguish between the: n therapy phase of the treatment (control of the chronically venous insufficiency, oedema reduction and the healing of the ulcer), and n maintenance phase (prevention of an oedema and healing of the ulcer, avoidance of an ulcer relapse).

The compression must be a little stronger in the therapy phase than in the maintenance phase. The aim is to reduce the oedema and/or to heal the ulcer. The compression bandage must be applied more frequently in the therapy phase than in the maintenance phase. With pronounced oedema and prompt decongestion, the bandage slips and must be replaced even several times daily in individual cases. Replacement of the bandage for up to two times a day is necessary even in the case of a heavily exuding ulcer, despite the use of fluid-absorbing wound-dressing and absorbent dressing pad. By using a proper and professional compression the exudation will decrease, the lower leg is decongested and the changing intervals can be extended.

The maintenance phase is defined by the attainment of a stable condition. The oedema should have been removed and the ulcer should have healed or should at least have entered into a stable phase of healing. In the absence of an oedema the tissue can give in to the bandage sparingly and the pressure effect on the tissue and on the bone edges (tibia, ankle joint) is greater. It is for this reason that the compression in the maintenance phase should only be so strong as not to cause renewed oedema. An ulcer which has not yet healed completely can be treated further using damp surgical dressing. Since these bandages can be left on the wound for some days and the leg does not show any more oedema, one can leave a compression bandage in place for some days during the maintenance phase.

The length of time that the compression bandage can be left on also depends on the material used. Short-stretchbandages generally give way within the first couple of hours and do not exert any consistent pressure. Moreover they slip easily. Therefore, in most cases they have to be applied afresh each day. Bandaging systems can be used for up to seven days. For some years now the market has also been offering ready-made stocking systems as an alternative for this medical condition, and they have to be 44

worn over the wound dressing. Custom-made compression stockings are to be prescribed as a relapse prophylaxis only after the ulcer has healed.

The compression bandage can be taken off at night if the ulcer has healed and if the leg is well-decongested, since the legs lie at heart level in bed during the night and are refreshed next morning. For these patients, however, one should primarily strive for an adjustment from the compression bandage to a compression stocking.

Ready-made stocking systems These consist mainly of two components, an under-stocking which protects the wound dressing and holds it in place, and a classic elastic stocking which exerts pressure.

This type of stockings is a feasible alternative to the compression bandage, particularly among patients with venous ulcers in the stable healing phase. These ready-made stocking systems are therefore also referred to as bandage stockings. In the case of pronounced oedema in the decongestion phase such a stocking system is not recommendable since it has to be adjusted like a compression stocking, even if it is by just a few single measurements. The advantages of such a stocking made of two components consist in the fact that the under-stocking with its lower resting pressure can be left on even at night to safeguard the wound dressing, and during day the compression stocking then exerts the necessary pressure for healing the ulcer. In addition, the wearing comfort increased the quality of life, though with a few limitations in as far as shoe and clothing selection are concerned. Bandage stockings have an approval as technical aids and therefore do not fall under the medical budget. In a comparative study involving compression bandages and compression stockings the ulcerations healed faster under therapy with compression stockings.

Bandage stockings are not indicated for patients without ulcers in the stable maintenance phase. Such patients should be provided with classical medical compression stockings.

Bandaging techniques There is a wide variety of individual bandaging techniques usually backed up by proper names which give clear instructions on how to go about them. The superiority of any one particular bandaging technique has not been proved, however, since comparative random studies on specific medical conditions have not been carried out with different bandaging techniques. Everybody should use the bandaging technique which he has learned best under specialized supervision in an appropriate training course with a fair share of practical work.

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The minimum requirements for material used for a lower leg compression bandage on a normally formed lower leg are: Padding cotton wool or a foam material bandage and at least two short-stretch-bandages adjusted to the breadth corresponding to the limb size, e.g. 8 cm and 10 cm. Ideally a fixation bandage or a tubular bandage holds the padding in place. No adequate compression bandage can be applied using a single short-stretch-bandage. n As to whether yet a third bandage is required depends on the size and length of the lower leg. Every additional bandage increases the stiffness of the compression bandage n The additional use of a long-stretch-bandage depends on the magnitude of the oedema and can be useful during the decongestion phase, while in the maintenance phase it is not necessary in most cases (exceptions can be lymphatic oedema in stage III and IV). n The question of whether the bandages are tied in a synchronous or counter-rotational manner is a matter of individual choice.

The following essential principles for applying a compression bandage on the leg should be taken into account irrespective of the material used and the preferred tying technique: n A compression bandage should always start as far as possible distally. The compression bandage therefore begins in the foot area right from the metatarso phalangeal joint, follows the course of the toes and encompasses the heel. n When tying the bandage the foot should always be kept in a functional position (= at a right angle to the calf). n Fix the starting end of the bandage with two circular routes n The breadth of the bandage should not be larger than the diameter of the body part to be wrapped, i.e. with shoe size 36, for example, one will need a bandage of 6 cm at the foot and then bandages of 8-10 cm width from the lower leg upwards depending on the circumference; at least two bandages are needed. n The bandages should lie in the hand with the unrolled part facing up and pointing outwards so that it can be unrolled well (= when unrolling look at the bandage angle) n When applying the bandage, one has to guide it directly along the leg while pulling lightly. In that way the material will lie evenly against the leg. If you pull the bandage too strongly the two bandage edges will be stretched disproportionately and there will be a danger of developing furrows, tension b ­ listers, nerval injuries and decubital necrosis.

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n The pressure which the bandage exerts must be stronger in the ankle area and decrease slowly towards the knee, that is to say the pressure decreases from the distal to proximal point.

If the bandage is pulled evenly this decrease in pressure is attained automatically over the increasing circumference of the leg. One should avoid applying the bandage more tightly in particular sections of the leg either consciously or unconsciously. That increases the pressure in those areas and leads to fluid build-up in the distal area, thereby increasing the risk of thrombosis. n The use of pressure pads and pellotes can further increase the effectiveness of the compression effect. n The use of staples that accompany many bandages, also called mothers-in-law, poses a risk of injury. If the staples are bent open or if they are used in a place where the bandage is not thick enough, they can pierce through the bandage and injure the skin. Besides, they can come loose and injure the patient lying in bed! n Adequate cushioning of protruding bones offers protection against pressure injuries. Therefore one has to think of under-padding for every compression (e.g. with padded cotton wool or re-usable bandages made of foam material). However, one can also do without the under-padding in the case of well-fitting bandages and compliant patients.

Under-padding: When carrying out under-padding special attention has to be paid to the areas behind and beneath the ankles, the anterior edge of the tibia and the fibula head. Improper bandaging can lead to the development of furrows, blisters, pressure ulcers, skin necrosis and nerval pressure injuries. n A tubular bandage of two and a half up to three times the length of the lower leg is worn up to the popliteal cavity n The projecting end at the foot is given to the patient to handle, if it is possible for him, or put between the toes or placed over the user’s shoulder

n An under-padding wrapping consisting of cotton wool or re-usable foam material bandages is then placed over the tubular bandage and it ends at a distance of two fingers’ width below the popliteal cavity

n The starting point of the compression bandage is at the metatarso phalangeal joint for short-stretch-bandages n At the finishing point of the bandaging the tubular bandage is turned over the dressing in the knee area and the end facing the foot is then pulled up to the popliteal cavity and fastened using adhesive tape strips. 

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Recommendations for compression therapy for patients with venous ulcers

The padding used to attain optimized pressure distribution should be distinguished from the under-padding meant to prevent bruises. n Since the leg has an uneven form, pressure cannot be exerted evenly on it, for instance at the point where the ankle juts out. In order to level out such anatomical irregularities, special pressure pads, so-called pelottes, can be used.

During the therapy phase one should be mindful of how long the compression bandage has to be left on at night too. If the patient continues walking around at night after the removal of the compression bandage, or if he gets up frequently at night or if he moves for a long time in the morning without a compression bandage, then it may not often be possible to achieve consistent decongestion.

It is not necessary in most cases to leave the compression bandage on at night during the maintenance phase.

If the compression bandage is taken off for the night, it should be replaced as much as possible just before getting up the following morning. Replacing the bandage later allows the formation of oedema to resume even in the maintenance phase and hence ruins the outcome.

Due to the anatomy of the ankle joint, uniform compression is difficult in this area. The compression bandage runs from the medial malleolus or lateral malleolus respectively to the Achilles tendon. In the process, the protruding ankles prevent an effective compression of the area behind the ankles. If the leg is swollen together with the ankle joint, this fact is not given any consideration during the initial decongestion. With increasing decongestion, and especially during the maintenance phase, care has to be taken, however, to make sure that even the area around the Achilles tendon becomes oedema free. For that purpose it is necessary to pad the concave areas behind the ankle joint. For strong and rather round legs, a folded pad or a kidney-shaped pad made of foam material, or a cushioning tampon is sufficient for padding the area behind the medial and lateral malleolus. In the case of profoundly projecting ankles it is necessary, however, to fill out the concave area behind the ankle joints with a fitting pelotte because oedema fluid will otherwise keep on accumulating there.

Attention should also be devoted to a florid ulcer when applying the compression bandage. If the ulcer lies in the concave area behind the ankle joints, additional padding of the area is by all means necessary. If the ulcer is located over a bone, e.g. the tibial crest, excessive pressure can easily be exerted, such that it becomes necessary to apply additional padding using cotton wool or foam material.

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Complications arising from the application of a compression bandage

Everybody who applies a compression bandage should know the complications, potential side effects and dangers of compression. Every time the bandage is changed, the leg should be carefully inspected for possible pressure marks, skin changes and atypical swellings which have appeared as a result of lacings around the area. The reduction in oedema during the decongestion phase should be documented by measuring the size of the leg. This aspect of measuring is of little significance in the maintenance phase. n Pain is always an alarm signal. A compression bandage which hurts must always be removed. A freshly applied bandage can by all means be perceived as being too tight by patients with fresh thrombosis or a florid ulcer within the first minutes of application, but it should not be painful. If the pain felt by the patient does not subside within a few minutes or if it does not improve after a few steps, then the bandage should be taken off. Unfortunately there is no objective sign which indicates that the compression bandage sits optimally. n The assumption that one can check the right compression pressure by the fact that the toes will first turn slightly blue when the bandage is applied but then assume their natural colour again when one walks, has not been corroborated. It is true that this appearance of the natural skin colour when walking shows that there is sufficient blood circulation at this moment, however it does not reveal how the situation will unfold in the next 24 or 48 hours. n Pressure marks and redness of the skin under a compression bandage appear mainly in the areas of the tibial edge, the ankle joint, the Achilles tendon and the back of the foot. Risk factors include reduced sensation/ pain sensation, long-term use of steroids and the existence of a chronic illness (e.g. rheumatoid arthritis) in connection with reduced mobility, loss of calf muscles and foot-/ ankle deformation. All pressure marks are a pointer to a too strong localized compression or insufficient padding. n As in the case of a cast, a compression bandage can also cause local damage to the peroneus nerve at the level of the fibula head. One should be mindful of good padding in this area as well as a fresh occurrence of a weak foot dorsiflexion.

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Contraindications for the application of a compression bandage

Advanced peripheral arterial occlusive disease, acute decompensated heart failure and phlegmasia coerulea dolens (severe progression of venous thrombosis with total occlusion of all veins of a transverse section) are defined as absolute contraindication. Relative contraindications are: severe sensory disorders (paraesthesia) of the extremities, advanced peripheral neuropathy (e.g. in the case of diabetes mellitus), intolerance to dressing material and a yet compensated peripheral arterial occlusive disease. One would usually not apply a compression bandage to these patients. If there is a clinical indication for a compression bandage for such a patient, a critical risk-benefit analysis is required. n If an arterial perfusion disorder is not ruled out, no compression bandage should be applied. Properly tactile foot pulses speak against arterial perfusion disorder, but they don’t provide conclusive proof. The ankle-brachialpressure-index must be determined in each individual case. A sufficiently compensated peripheral circulatory disorder does not represent any contraindication for the application of a compression bandage. However, such patients need special supervision. Loss of colour in the toes and reports of pain can be taken as a sign of a too tight bandage and the bandage has to be taken off. In borderline cases the compression bandage should be removed after two to four hours and the leg should be examined for pressure marks. Patients with arterial circulatory disorders often tolerate a compression ban­ dage only during the day when the leg is suspended but not at night when the leg is lying in bed. In such cases the compression bandage has to be removed at night.

n Diabetic polyneuropathy makes the patient not to feel a bandage which is too tight or padding which is not sufficient. It is possible to have a properly applied compression bandage even in the case of diabetic polyneuropathy, but since there is no feedback from the patient regarding pain and pressure marks, there is a higher risk of inflicting injury to the tissue. In this situation too there is nothing else one can do other than to remove the compression bandage again after two to four hours and to examine the leg for pressure marks

n A florid infection (phlegmon, abscess) represents a contraindication for a compression bandage.

The chronic heart failure often existent in elderly people does not represent a contraindication, but it requires increased supervision. If compression therapy is necessary in these cases, the quantity of fluid which can be realized has to be considered. The decongestion should be intensified gradually and the compression bandage should be applied in a well-regulated manner. One should start with only a distal compression in one extremity, for example. In many cases patients with heart insufficiency benefit from a compression bandage which when applied during day prevents the swelling up of the legs. The fact that there is no build-up of oedema reduces or removes nycturia as a sign of the nocturnal fluid redistribution.

Compression therapy has to be used only with caution in the case of bedridden patients. The cause of oedema build-up in bedridden patients is seldom the disturbed venous or lymphatic reflux. The legs lie at the level of the heart and the gravitational force does not become effective.

Bedridden patients often suffer from muscle degradation and have a higher risk of developing pressure induced lesions irrespective of possible compression bandages.

Even a well-applied compression bandage can increase this risk. The need for a compression bandage for bedridden patients therefore always requires special indication and supervision.

Moreover there is no muscular activity, and therefore compression alone would not work. The intermittent compression proves to be of good help in this case. m

Literature World Union of Wound Healing Societies (WUWHS). Principles of best practice: ­Compression for venous ulcer. A consensus document, London: MEP Ltd, 2008.

Wienert V, Waldermann F, Zabel M, Rabe E, and Jünger M. Guideline: Phlebological compression bandage, Phlebology 2004 33 4: 131-134.

Diagnostics and Therapy of the venous ulcer – S3-Guideline, AWMF 2008 Guideline: „Medical compression stockings“ of the German Society for Phlebology: www.uni-duesseldorf.de/awmf/ll/037-004.htm Guidelines: Intermittent pneumatic compression (IPK or AIK); AWMF-GuidelinesRegister No. 037/007 Update of the technical aids register for product group 17 (Technical aids for ­compression therapy) according to § 128 SGB V in the Federal Gazette No. 3 of 5th January 2006 published by the National Associations of Health Insurance Funds: www.g-k-v.com Protz, Kerstin (2009): Modern wound care, Practical knowledge, 5th edition, Urban & Fischer Publishing Company, Munich Protz, K. (2008): Compression – basis for therapy success, in: Health-care professions for “Leg ulcers”, p. 24 pp., Urban Vogel, Munich German network for quality development in health-care (DNQP) ed. (2008): Expert standard care of people with chronic wounds, Osnabrück

Heart failure is always cited in medical literature as a systemic contraindication. However only the acute decompensated heart failure represents a contraindication since the body cannot cope with extra fluid in such a situation.

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German League for Veins e.V.: www.venenliga.de ICW e.V., (2006) Guidelines for venous ulcers 2006, ed. Initiative for Chronic Wounds (ICW e.V.), Muglerdruck, www.icwunden.de ICW e.V., Not every „open leg“ requires the same treatment; Part 2 – Chronic venous insufficiency (CVI) and the venous ulcer (UCV), Specialized information for affected people and their relatives, 2008, ICW e.V. (ed.), Muglerdruck, www.icwunden.de

47

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Scientific Communication

Evaluation of education and training in the field of care and treatment of patients with chronic wound and stoma in Croatian family medicine Abstract Background: General practitioner is a part of the multidisciplinary team in wound healing and continuous medical education is required.

Aim: to determine the knowledge of general practitioners before and after the education and training in the field of care and treatment of patients with chronic wound and stoma in family medicine.

Methods: 234 general practitioners attended the one day seminar on care and treatment of patients with chronic wound and stoma organized by the Association of Teachers in General Practice/ Family Medicine in six Croatian cities. The practitioners were asked to take two identical tests before and after the education and training.

Results: 169 doctors (RR 72%) took the test. The results achieved on the test significantly improved following the education and training (7 [95% C.I. 7-8] vs.

9 [95% C.I. 9-10], P<0.001). The smallest percentage of correct answers was given when asked about the TIME concept (10%) and about the stages of the wound healing (50%); whereas other questions were answered correctly.

Conclusions: Education and training in the field of care and treatment of patients with chronic wound and stoma in family medicine was successful. Continuous systematical education and training in family medicine in the field of wound management is essential.

Key words: education, medical, continuing, family practice, general practitioners, stoma, wound healing.

Introduction A number of health care professionals, specialists in different fields and with different levels of education, as well as nonhealthcare professionals, are included in the care of chronic wound patients, thus forming a multidisciplinary team that is not only responsible for the course and the outcome of the treatment but also for the quality of life of the patients1.

General practitioner/family doctor (GP/FD) is also a part of the team with the task of preventing, diagnosing, monitoring and anticipating complications and relapses, as well as a complete recovery of chronic wound patients, with the overall care continuing even after the wound has healed; or is a part of the palliative care2.

GP/FD in Croatia is, unlike in some other health care systems, the so-called gatekeeper to the system; for a patient they are first-contact health care professionals that determine both diagnostic and therapy procedures that are to be conducted and members of the team of associates involved in the care of a patient3. It is precisely because of the many tasks required during care that continuing, organized education and training of doctors, their teams, nurses and home care nurses in the field of wound management is needed.

In recent years, courses and workshops on wound management have been organized by professional associations such as: The Association of Teachers in General Practice/Family Medicine Croatia (ASTGP/FM, cro.DNOOM), The Croatian Association of Family Doctors (cro. HDOD), The Croatian Association of Family Medicine (cro. HUOM), The Coordination of Croatian Family Medicine (cro. KoHOM); as part of various professional seminars and conferences of family medicine doctors. Doctors have shown significant interest in acquiring new knowledge and skills and have indicated numerous problems they encounter in their everyday practice with wound patients; and part of those problems originates from inadequate specific education.

Undergraduate and postgraduate education do not provide sufficient knowledge and skills to offer quality, complex, personalized care organized according to holistic principles; and this deficiency is therefore compensated through programs of continuing medical education (CME). CME education is designed to suit the needs of GPs/FDs in terms of place, time, range and topic selection. In order to ensure its efficient implementation, in 1998 The Association of Teachers in General

Tamara Sinoži´c1 MD, GP/FD Ksenija Baždari´c2 PhD, research fellow Jadranka Kovacevi´c1 MD, GP Milica Kati´c3 PhD, MD, Professor 1Family medicine practice Tamara Sinoži´c MD,GP Moš´cenicka Draga, Croatia 2Department

of Medical Informatics, Rijeka University School of Medicine, Rijeka, Croatia

3Department of Family Medicine, Zagreb University School of Medicine, Zagreb, Croatia

Correspondence: tamara.sinozic@ ri.t-com.hr Conflict of interest: none

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Practice / Family Medicine (ASTGP/FM) was founded.

The activities of the ASTGP/FM are based on improvement and development of education in the field of general practice/family medicine4. One of the projects by ASTGP/ FM during 2010/2011 was a series of courses and workshops on Care and Treatment of Patients with Chronic Wound and Stoma in Family Medicine in Croatia.

AIM To determine the knowledge of general practitioners before and after the education and training in the field of care and treatment of patients with chronic wound and stoma in family medicine.

Methods As a part of the project “Workshop in Your Neighborhood” the ASTGP/FM organized during the 2010/2011 seminars in six Croatian cities.

Participants Participants were GPs from Zagreb (capital city), Bjelovar (inland) and Pula, Rijeka, Zadar and Šibenik (all four on the Adriatic coast). Doctors were notified of the education via webpage of the ASTGP/FM www.dnoom.org, where regular updates and information about topics, contents, and venues of all continuous medical education (CME) courses are available.

Coastal cities were chosen because GPs of these areas provide care for the people living on islands and most of them are elderly. Because of the geographical distance and insufficient maritime connectivity patients are mainly oriented to the treatment and care provided by own GP and nurses/home care nurses.

Procedure The aim of the seminar was to familiarize general practitioners with the holistic approach in the field of care and treatment of patients with chronic wound. In creating the content of the seminar recent literature by both domestic and international experts in the field of wound management was used; as well EWMA and Croatian Wound Association (cro. HUR) position documents5-19.

The content of the seminar was verified by ASTGP/FM President Biserka Bergman Markovi´c MD, GP, PhD and ASTGP/FM Vice-President Milica Kati´c MD, GP, PhD. The seminar was registered and accepted by the Croatian Medical Chamber (cro. HLK) as a form of continuous medical education.

The seminar lasted one day, for 6 hours, and it was divided in two parts: theoretical part and three workshops.

In the first part of the seminar there was an introductory segment about the chronic wound definition, prevalence, physiological mechanisms and healing stages. In continuation, the emphasis was put on the biopsychosocial 50

approach in care and treatment of patients with wound.

Special emphasis was put on those patients whose wounds manifest difficulty in healing, as well as on the possibilities of intervention by family doctors.

Four groups of etiologically most common wounds were underscored: venous leg ulcer, decubitus, diabetic foot ulcer and pressure ulcer. Using photodocumentation a description of wound with typical localizations was shown and current classifications, basic risk-factors for the development of such wounds and the most common complications were given. Basic diagnostic and therapy procedures were shown, and for each of the wound types, an overview of the role of the family doctor in the care and treatment of the patient was given.

Atypical wounds were presented itemized and with corresponding photodocumentation.

As introduction to subsequent workshops, basic principles of localized treatment were explained, i.e. practical preparation of the bottom part of the wound – TIME principle and compressive therapies.

In the second segment of the theoretical part of the seminar basic groups of wound dressings were shown, mechanisms which are at work at different stages of healing and different application possibilities were presented.

An overview of cost benefits in usage the modern wound dressings was given.

The third part focused on stoma and peristomal skin treatment and care with the presentation of the most common complications and their management. Also, the work of some of the regional Associations of Stoma Patients was presented.

In the conclusion of the theoretical part, numerous tasks that a family doctor treating a chronic wound patient has to perform were discussed.

After the break, group workshops began. In accordance to the principles of problem based learning, using examples of real patients and original photodocumentation, three workshops were organized: – localized treatment with wound dressing presentation and correct application – compressive therapies with devices presentation (compressive stockings, bandages and multilayer systems) and practicing in pairs – treatment and care of stoma and peristomal skin with ostomic supplies presentation The GPs were asked to take identical test consisting of ten questions before and after the education.

The test The test questions about: definition of chronic wound, prevalence of different type of wounds, stages of wound healing, TIME concept, wound healing factors, description of venous leg ulcer, absolute contraindications for EWMA Journal

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Table 1. Percentage of correct answers achieved on the test ­before and after the education in wound management Question

Figure 1. Mean score achieved on the test before and after the education in wound management (7 [95% C.I. 7-8] vs.

9 [95% C.I. 9-10], p<0.001).

compression therapy, complications of diabetic foot ulcer, definition of pressure ulcer and local complications of peristomal skin.

The test has facial validity, i.e. the validity of the test was determined by the inspection of the questions from the experts in the field of chronic wound and family medicine8,14,16-18.

Statistical analysis Categorical variables are expressed as frequencies and relative frequencies; frequencies before and after the education were compared with the non-parametric McNemar test.

Continuous variables are expressed as mean and standard deviation; differences between the two groups were compared with the paired t-test.

A p value of less than 0.05 was considered significant.

Data were analyzed using the MedCalc statistical software, version 11.2.0.0 (MedCalc Inc., Mariakerke, Belgium).

Results 234 general practitioners attended the seminar what is approximately 10% of all Croatian GPs20 and 169 GPs (RR 72%) took both tests, before and after the education in wound management. As the test was voluntary and at the end of the education, of all GPs 65 (28%) did not fulfill both tests. GPs were from Zagreb 35 (21%), Bjelovar 13 (8%), Pula 18 (11%), Rijeka 58 (34%), Zadar 27 (16%) and Šibenik 18 (11%).

The results achieved on the test significantly improved following the education and training (7 [95% C.I. 7-8] vs. 9 [95% C.I. 9-10], p<0.001).

The smallest percentage of correct answers was given when asked about the TIME concept (11%) and about the stages of the wound healing (50%); whereas other questions were for the most part answered correctly. The EWMA Journal

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Chronic wound – definition Prevalence Stages of wound healing TIME concept Wound healing factors Leg venous ulcer – description Absolute contraindications for ­compression therapy Diabetic foot ulcer – complications Pressure ulcer – definition Local complications of peristomal skin

Correct answers (%)

Statistics

Before After education ­education

p

72 76 50 11 97 81

97 96 86 69 99 96

<0.001 <0.001 <0.001 <0.001 0.375 <0.001

79 88 86 92

86 90 90 97

0.031 0.541 0.248 0.039

highest percentage of correct answers was given when asked about wound healing factors (97% and 99%) and local complications of peristomal skin (92% and 97%).

The rate of correct answers in 7 questions significantly increased, whereas the majority of the practitioners answered the remaining three questions correctly (>85%).

The biggest change in correct answers was when asked about TIME concept (58%) and stages of wound healing (36%), whereas the smallest change was when asked about wound healing factors (2%) and complications of diabetic foot ulcer (2%).

Discussion According to the European definition of general practice/ family medicine GPs are specialist physicians trained to provide, directly or with help of others, comprehensive and continuing care to every individual irrespective of age, sex and illness21.

Patient-oriented care, personalized care based on biopsychosocial approach principles treats every illness/ change, including wounds and healing process, requiring the doctor to know and be familiar with many specific skills and knowledge; and is therefore a complex professional task.

What are the specific tasks of general practitioner/family doctor in treatment and care of patients with chronic wound?

Assessment of patients with higher risk of developing chronic wound and delayed healing is essential while still at the pre-ulcerous stage. Upon determining patients at risk, it is necessary to perform adequate diagnostic and therapy procedures and preventive measures.

Acute wounds and subjective symptoms need to be adequately treated, complications prevented, and the ones  already present noticed in time and treated.

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2nd International Course on The Neuropathic Osteoarthropathic Foot (Charcot Foot Course) Advanced Postgraduate Course, Rheine, Germany

10 -12 April, 2014

The international course will be based on the expertise gathered from 12 consecutive years of providing national courses on the Diabetic Foot.

The main focus are practical sessions in small groups to train the diagnostic and treatment skills necessary for the interdisciplinary treatment of Charcot patients.

The course will be held at the Mathias-Spital in Rheine.

The courses are open to anyone involved in the treatment or management of Neuropathic ­Osteoarthropathic Foot patients.

Number of participants: 25-50 Language: English

www.charcotfootcourses.org 52

To ensure quality care it is necessary to create a team of health care professionals, specialists in different fields and with different levels of education, as well as nonhealthcare professionals. One of the doctors’ tasks is to achieve coordination within the team, in order to ensure its optimum in both patient care and fulfilment of their numerous needs.

It is essential to provide place, time, and means for localized wound treatment, whether in doctor’s office or in homecare.

A very important role in the team belongs to the patients themselves. All our activities serve to empower them for treatment.

Nurses are another very important part of the team.

The largest number of nurses in primary care teams in Croatia has secondary or higher level of professional education, whereas the number of Registered nurses with a five-year university education is still relatively small.

When referring to non-healthcare professionals, members of the multidisciplinary team, we are usually referring to members of the immediate or extended family of the patient, their neighbors, members of numerous associations like; pensioners’ associations, intergenerational solidarity associations, religious communities, as well as members of institutional organizations such as: the Department of Social Services and the Red Cross.

The non-healthcare professionals take on multiple roles which change depending on the needs of the patient. Most often they involve helping patients perform their daily tasks: bathing, eating, preparing meals, going for a walk, cleaning home; and less frequently, direct assistance in the process of wound care and treatment; like putting on compression stockings and bandages.

They also have an important role in supporting social activities, both in preserving those that already exist and in accepting new ones. Psychological support in the form of conversations and talks, joint reading and socializing, playing board games and so on; alleviates signs of anxiety, depression and feelings of isolation and loneliness, as well as stigmatization most patients experience.

Sometimes financial support is required in order to ensure both access to various aids not covered by basic health insurance, and fulfillment of basic life needs: paying rent and bills, buying groceries, and so on.

It is important that the individuals and/or representatives of associations that offer their assistance and help be informed on the basic requirements and needs of wound patients, that they be offered advice about the best possible way of helping, and that their competence and roles in such multidisciplinary teams be determined.

The family doctor is expected to treat all other comorbid disorders, which most commonly include, cardiovascular diseases, diabetes, malnutrition, depression, incontinence EWMA Journal

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Scientific Communication

and so on. The doctor’s duty is to inform the patient and/ or their family about the nature of the illness, its course and possible outcomes, about the diagnosis, treatment and risks involved. Whenever possible, supportive psychotherapy needs to be conducted and the familiar mechanism “doctor as medicine” used. After the wound has healed, specific procedures aimed at preventing wound relapse during continuous care should be conducted.

In treatment and care of chronic wound patients, the family doctor bears responsibility towards the health care system as a whole because they are using evidence-based medicine (EBM) to achieve not only good therapy results, but also to meet the conditions of efficiency.

According to the basic rights stated in the Health Care Act and Regulations on Orthopedic and Other Devices, the patient needs to be provided with various products for local wound treatment, compressive therapy, orthopedic devices, enteral nutrition products; and the doctor’s task is to ensure administrative implementation of those rights.

One of the ways to ensure the fulfillment of such complex demands is continuous training and education.

We are very pleased with the turnout of GPs/FDs (10% of all Croatian GPs) at continuing education courses on care and treatment of patients with chronic wound and stoma. It is indicative of the interest for CME, but also of the extent of problems they encounter in their everyday practice.

By testing doctors before and after the education we wanted to assess its effectiveness. We have determined the existing knowledge in the field of wound management and during the course we offered contents we believe were lacking, and are important in understanding wound management.

Overall results after the education are significantly better than those before the education; therefore we can be satisfied with the outcome.

As it was shown, the worst test results were related to lack of knowledge about the components of the TIME concept i.e. wound bed preparation in practice; and to physiological stages of the wound healing. Those concepts were thoroughly explained during courses and workshops with the help of case reports from personal practice with photo-documentation of wounds of patients with chronic wounds of different etiology.

For the theoretical part relevant literature from the field as well as recommendations from Position document of European Wound Management Association (EWMA) “Wound Bed Preparation in Practice” with detailed explanation of the TIME acronym were used22.

With respect the other eight questions; doctors gave mostly satisfactory answers, both before and after the education. Answers to the question about the prevalence of chronic wound patients; and the offered answers were

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venous leg ulcer, diabetic foot ulcer, pressure ulcer and other etiologies; were not surprising because we do not have prevalence and incidence data for Croatia, and we are using the data from other European countries instead23,24.

Only diabetic foot ulcer wounds are reported to the Registry of Patients with Diabetes, so called CroDiab Register, with the Croatian National Institute of Public Health25.

They demonstrated satisfactory level of knowledge answering to the questions: absolute contraindications for compression therapy, complications of diabetic foot ulcer, definition of pressure ulcer and about of complications of peristomal skin.

These results are a partial indicator of direction in terms of future courses and workshops design. In order to maintain satisfactory turnout of GPs/FDs, and according to online research results CME was 6,9-8,8% of total CME consumed in 2008 and is predicted to rise to 50% in the next 7-10 years26; we will be planning further activities in CME in the form of e-learning. The aim is to create an interactive workshop with the possibility of active participation of every single GP/FD with peer consultation and/or one of the elected members of licensed specialists in the field of wound management; members of multidisciplinary team27. In October 2012, under the organization of The Croatian Institute for Telemedicine, telemedical education has been launched dealing with hypostatic ulcer: clinical picture, wound estimation and principles of the treatment; for practices on islands and in geographically isolated areas28.

Earlier research has shown that for GPs/FDs the best way of education is the combination of theoretical and practical parts for the entire primary health care team: GP/FD, nurse and home care nurse, and the education will therefore try to adapt to the needs29.

In the system of education of all medical fields, starting with high-school education, undergraduate studies and postgraduate studies, it is necessary to systematically implement much more contents dealing with wound management. Among other things, this will help to raise awareness of health care professionals for the problem of wound care and treatment which is surely to grow in the following years due to the increase in average life expectancy and senior population.

The limitations of the study are that this investigation is an evaluation of the success of the training event rather than a test of the GPs wound care knowledge base. Also, we did not follow the GPs prospectively after the training, so the results of a test immediately administered after an educational event without follow may indicate what has been absorbed by the clinicians concerned. Future investigations should include a more detailed analysis of the  wound care management.

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Scientific Communication

During the year 2010/2011 a research was conducted among family medicine doctors relative to treatment and care of chronic wound patients in Primorsko-Goranska County. It was a pilot-project and its continuation is planned for 2014. The results of the research relative to education were presented at the ASTGP/FM conference in Zagreb held between 15th and 17th March 2013.30.

91 doctor has taken part in the research, which is a turnout of 40%. 62 doctors (68%) participated in the additional training on wound management, most of them as a part of organization of manufacturers of medical products and equipment for wound management. Also, a large number of doctors attended various types of continuous medical education and training; while the smallest percentage represents those who have chosen individual education and training of their own preference. More than 90% of family doctors wishes to continue their education and training; most of them have expressed interest in combined theoretical and practical education, and it is also indicative to note that more than 20% has expressed a desire for online education and training.

Once again, this has confirmed the interest of family doctors in this particular field. It should be pointed out that in the last three years all family medicine offices have made an effort in informatization and have been keeping electronic patient charts with implemented form about

wound assessment and local therapy; also, storing photodocumentation of wounds has been made possible.

Since 2012, doctors have been using electronic ways for setting up specialist appointments and arranging hospitalization (cro. e-narucivanje) which makes the procedure considerably shorter. In regional centers, dermatology wards are equipped with color Doppler ultrasound systems, dermatologists have received additional education and training in the field of Doppler ultrasound diagnostics of blood vessel diseases which consequently improved and accelerated etiological diagnostics of wounds.

Health care professionals as well as patients have been given access to electronic consultations by the experts Croatian Wound Association (cro. HUR).

Conclusion The education and training in the field of care and treatment of patients with chronic wound and stoma was successful as the results before and after the test were significantly different. Hopefully, practitioners will use acquired knowledge in everyday practice.

It is essential to continue systematical education and training in family medicine in the field of wound management and in that direction education should go on in collaboration with Croatian Wound Association and other professional associations of family medicine. m

References 1 Apelqvist J. EWMA Focus on Multidisciplinarity in Wound Management. EWMA Journal 2012; 12(2):66.

2 World Organization of National Colleges, Academies and Academic Associations of General Practitioners/ Family Physicians Europe. The European Definition of General Practice/Family Medicine; 2002, p.6.

3 Budak A. i sur. Obiteljska medicina. Zagreb: Gandalf; 2000, p.21.

4 Društvo nastavnika op´ce/obiteljske medicine. O Društvu ASTGP/FM. http://dnoom.org (4th Nov, 2012).

5 Pavi´c P, Šarlija M, Ajduk M, Šalamon T. Periferna arterijska bolest i kronicna venska insuficijencija kao vode´ci uzroci kronicnog vrijeda donjih ekstremiteta.

Acta Med Croatica, 63 (Supl.4) 2009. p 39-45.

6 Soldo-Beli´c A, Bulat V, Rajaci´c N, Tunukovi´c S. Kronicna rana-zdravstveni, ekonomski i socijalni problemi. U: Šitum M, Soldo-Beli´c A. Kronicne rane.

Zagreb: Naklada Slap; 2006.p.9-17 7 Hancevi´c J. i sur. Kronicna rana-dekubitus i ulcus cruris. Zagreb:Naklada Slap; 2010. p.15.

8 European Pressure Ulcer Advisory panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers quick reference guide Washington DC: National Pressure Ulcer Advisory Panel;2009. p.1-43.

9 Damjanov I, Juki´c S, Nola M. Patologija. Zagreb: Medicinska naklada;2008. p.62 8.

10 Kovac Z.Cjelovito reagiranje suprotstavljenih regulacijskih mehanizama. U: Gamulin S, Maruši´c M, Kovac Z. Patofiziologija (knjiga II) 6. Zagreb, Medicinska naklada; 2005. p.504-11 11 Vurnek M. Psihološki aspekti kronicnih rana.U: ŠitumM, Soldo-Beli´c A.Kronicne rane.Zagreb: Naklada Slap; 2006.p.205-211

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12 Pavi´c P, Šarlija M, Ajduk M, Šalamon T. Periferna arterijska bolest i kronicna venska insuficijencija kao vode´ci uzroci kronicnog vrijeda donjih ekstremiteta.

Acta Med Croatica, 63 (Supl.4) 2009.p.39-45

22 Falanga V.Wound bed preparation: science applied to practice. In: European Wound Management Association (EWMA) Position document: Wound Bed Preparation in Practice. London, MEP; 2004. p. 2-5.

13 Vukeli´c M, Franji´c BD, De SyoD, Lovricevi´c I, Hudorovi´c N. Periferna arterijska bolest. U: Šitum M, Soldo-Beli´c A. Kronicne rane. Zagreb: Naklada Slap;2006.p. 47-53

23 Rabe E, Pannier F. What Have We Learned from the Bonn Vein Study? Phlebolymphology 2006; 13 (4). p.188-193.

14 TASC Working Group: Management of Peripheral Arterial Disease. TransAtlantic Inter-Society Consensus (TASC II) Eur J Endovasc Surg 2007,33 (suppl 1): p.1-75.

15 Marinovi´c- Kuliši´c S, Lipozenci´c J. Kronicna venska insuficijencija-etiologija, patogeneza i klinicka slika U:Lipozenci´c J, Marinovi´c-Kuliši´c S. Kronicna venska insuficijencija-nove dijagnosticke i terapijske smjernice.Zagreb:Medicinska naklada; 2009.p.1-3 16 Mosti G, Mattaliano V, Polignano R, Masina M.Compression therapy in the treatment of leg ulcers.Acta vulnologica 2009; Vol.7.N.3: p.1-20 17 Partsch H, Flour M, Coleridge Smith P. i sur.

Indications for compression therapy in venous and lymphatic disease.Consensus based on experimental data and scientific evidence. International Angiology 2008;27: p.193-219 18 European Wound Management Association EWMA Position document. Understanding compression therapy.European Wound Management Association.

London: MEP Ltd;2003. p.9-13 19 Budi S, Žic R, Rudman F.i sur. Potkoljenicni vrijed-uzroci, lijecenje i rekonstrukcija.Acta Med Croat 2009;63(Supl.4): p.47-54 20 Hrvatski zavod za javno zdravstvo. Hrvatski zdravstveno-statisticki ljetopis za 2010.godinu, Zagreb 2011. www.hzjz.hr/publikacije/hzs_ljetopis/index.htm (15th Oct, 2012).

21 The European definition of general practice/family medicine. WONCA Europe, 2002. p.6

24 Deli´c J. The Incidence and Etiological Distribution of Chronic Wounds in Serbia. EWMA Conference Common Voice – Common Rights 25-27 May Brussels 2011.EWMA Journal Suppl. 2011;11(2): p.72.

25 Poljicanin T, Metelko Ž, Šekerija M. Nacionalni registar osoba sa še´cernom boleš´cu CroDiab.

Hrvatski zavod za javno zdravstvo, Izvješ´ce za 2011., Zagreb 2012; www.hzjz.hr/publikacije/crodiabreg2011.pdf (4th Nov, 2012).

26 Harris JM Jr, Sklar BM, Amend RW, Novalis-Marine C. The Growth, Characteristics, and Future of Online CME. J Contin Educ Health Prof. 2010; 30(1): p.

3-10.

27 Shermann A. Continuing Medical Education Methodology: Current Trends and Applications in Wound Care. J Diabetes Sci Technol 2010; 4(4): p.

853-6.

28 Republika Hrvatska. Hrvatski Zavod za Telemedicinu. e-Usavršavanje www.ztm.hr (4th Nov, 2012).

29 Sinoži´c T. Organizacija skrbi o bolesniku s potkoljenicnim vrijedom-potrebe, problemi i rješenja na nivou primarne zdravstvene zaštite. Acta Med Croat 2009; 63(Supl. 4): p.139-144.

30 Sinoži´c T, Dimini´c-Lisica I. Bolesnik s bolestima perifernog krvožilnog sustava i kronicnom ranom u ordinaciji lijecnika obiteljske medicine. Zbornik radova Kongr.DNOOM. Zagreb; 2013: p.361-376

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www.systagenix.com References: 1. Sibbald, R.G. et al. Iodine Made Easy. Wounds International 2011; 2(2). 2. Langley, S.R.N. INADINE* wound dressings speed healing, reduce patient discomfort and cuts costs by almost 40%. Burns 1989 Vol.15. 3. Vowden, P. and Cooper, R.A . An integrated approach to managing wound infection Position Document: Management of wound infection. European Wound Management Association (EWMA). London: MEP Ltd, 2006 4. Balmforth, V. INADINE Povidone Iodine non adherent dressing as a treatment for superficial wounds infected with Methicillin resistant Staphylococcus aureus. Case Study, 1996. 5. Gordon, J. Clinical significance of methicillin-sensitive and methicillin resistant Staphylococcus aureus in UK hospitals and the relevance of povidone iodine in their control. Postgrad. Med J. 1993, 69(3):106-116. 6. Hill, K.E. et al. An in vitro model of chronic wound biofilms to test wound dressings and assess antimicrobial susceptibilities. J Antimicrob Chemother 2010:1195-1206. 7. Campbell, N. and Campbell, D. et al. Evaluation of a non-adherent, povidone–iodine dressing in a case series of chronic wounds. Journal of Wound Care, Vol 22, No 8, August 2013.

8. Witkowski, K. Practice Improvements Related to the Use of Antimicrobial/Antiseptic Products. Poster CAWC 2011. 9. Langley, S.R.N. INADINE® wound dressings speed healing, reduce patient discomfort and cuts costs by almost 40%. Burns 1989 Vol.15.

Report on the Pilot Professional Supplementary ­Vocational Education Module Wound Management

Irina S. Bakhtina M.D., Ph.D. Dean

Irina N. Balandina Senior lecturer of nursing

Irina A. Kopysova Head of simulation laboratory, senior lecturer of nursing Elena A. Maltceva Head of marketing and foreign affairs department Elena Frolova M.D., Ph.D.

Federal State Educational Institution The St. Petersburg ­Postgraduate School of Nursing of the Federal Medical ­Biological Agency

56

T

he St. Petersburg Center for Postgraduate Education of the Russian Federal Medical Biological Agency (FMBA) sponsored its first practice-oriented modular course, entit­ led “Wound Management.” The course ran from April 3-16, 2013.

The curriculum for this professional module was developed by the faculties of the Federal State Educational Institution of Supplementary Vocational Education and the St. Petersburg Postgraduate School of Nursing of the FMBA. The program was designed for use in the postgraduate training of nurses, feldshers (physician’s assistants [PAs]), and midwives, with both basic and advanced courses on ‘Scrub Nursing,’ ‘Emergency Care,’ ‘Surgical Nursing,’ ‘Trauma Nursing’, and ‘Occupational Health.’ The module was attended by representatives of both the nursing staffs of the healthcare institutions that report directly to the Russian FMBA and the faculties of nursing schools. The total number of participants was 15 students.

A competence-based multidisciplinary approach to wound treatment and care is at the core of this module. In the educational process, active teaching techniques combined with informational communication technologies and simulations were utilised. Didactic and training sessions were conducted in the auditoria and simulation lab, respectively, at the Center for Postgraduate Education. Sessions employed the use of high-tech simulation equipment, dummies, and mannequins and were directed by members of some of the leading healthcare institutions in St. Petersburg, such as L.G. Sokolov of Clinical Hospital-122, who is affiliated with the FMBA (Vascular Surgery Unit, Center for Ambulatory Surgery), Leningrad Regional Clinical Hospital (Central Sterilization), and the Diabetes Center.

The greatest interest of the participants in the Wound Management Program was aroused by the following topics: n Algorithms for the prevention and treatment of pressure ulcers (sores) n Modern approaches to wound care n Modern dressing materials n Management of infected wounds n Trauma and injury first aid n Diabetic foot care n Trophic ulcers, wound care, and the use of ­compression bandages n Modern approaches to presterilization, cleaning, and performance of the Central ­Sterilization Unit The main subjects covered in the hands-on ­sessions and master classes were: n Aseptic work and washing; sterile dressing ­(putting on sterile clothes); stocking sterile tables with instruments (aseptically ­arranging instruments on a table); placing dressings into a KSK (round sterilizer ­dressing box) n Working at the Central Sterilization Unit; disinfection; presterilization cleaning; sterilization; preparation and storage of materials n Management of postoperative infected wounds; abscess incision and drainage; ­treatment of p ­ urulent wounds n Nursing care of purulent infections; special ­issues (peculiar features) associated with delivering care to patients with surgical infections n Mechanism of providing care to patients with diabetic foot syndrome; developing and introducing an intervention sheet; diabetic ulcers; assistance in selecting appropriate footwear

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Scientific Communication

Salla Seppänen visited the course and gave a presentation on EWMA activities and the collaborations between EWMA cooperating wound care organisations.

n n n n

n n

Strategy for utilising compression therapy; use of bandages, compressing items and devices Educating patients on routine trophic ulcer care and the techniques of applying compression bandages Trophic ulcer care; dressing techniques Educating patients, family members, caregivers, and volunteers on pressure ulcer (sore) prevention and care Desmurgy: methods and techniques of dressings and dressing classification Practice of podiatry (practicum on podiatry): examination of the patient’s feet (evaluating the sensitivity of distal portions of the feet [vibration, temperature and tactile sensation]); prophylactic podiatric care; client-centred care planning (developing an individual program for dealing with the patient); patient education in foot care (techniques for proper foot care)

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By participating in the curriculum of this modular course, professionals learned to independently develop and implement in practice a plan to care for the patient with acute and chronic wounds of various aetiologies. Participants also learned to select and use modern dressings in the course of wound care and learned how to provide first aid.

During the practical, hands-on sessions, participants learned and demonstrated practical skills and knowledge in accordance with algorithms followed in their respective healthcare institutions. At the concluding meeting, the final round table discussion was held in order to develop proposals for optimisation and further implementation of this modular course.

We thank all participants in the modular course, its trainers, heads of clinic departments and all of the practicing professionals who took an active part in implementing this pilot project!

The next “Wound Management” educational course is scheduled for October 2013. For more details, please, visit the web site at www.nursing.edu.ru. m 57

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Cochrane Reviews

ABSTRACTS OF RECENT ­COCHRANE REVIEWS Publication in The Cochrane Library Issue 4, 2013

Alginate dressings for venous leg ulcers Susan O’Meara, Marrissa Martyn-St James Citation example: O’Meara S, Martyn-St James M. ­Alginate dressings for venous leg ulcers. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD010182. DOI: 10.1002/14651858.CD010182.

Copyright © 2013 The Cochrane Collaboration. ­Published by John Wiley & Sons, Ltd. ABSTRACT Background: Venous leg ulcers are a common and recurring type of chronic, complex wound associated with considerable cost to patients and healthcare providers. To aid healing, primary wound contact dressings are usually applied to ulcers beneath compression devices. Alginate dressings are used frequently and there is a variety of alginate products on the market, however, the evidence base to guide dressing choice is sparse.

Objectives: To determine the effects of alginate dressings compared with alternative dressings, non-dressing treatments or no dressing, with or without concurrent compression therapy, on the healing of venous leg ulcers.

Search methods: We searched The Cochrane Wounds Group Specialised Register (searched 30 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11); The NHS Economic Evaluation Database (NHS EED) (The Cochrane Library 2012, Issue 5); Ovid MEDLINE (1946 to November Week 2 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations November 29, 2012); Ovid EMBASE (1980 to 2011 Week 11); and EBSCO CINAHL (1982 to 23 November 2012). There were no restrictions based on language or date of publication Selection criteria: Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any type of alginate dressing in the treatment of venous ulcers were included Data collection and analysis: Two review authors independently performed study selection, data extraction and risk of bias assessment. Meta-analysis was undertaken when deemed feasible and appropriate.

Main results: Five RCTs (295 participants) were included in this review. Overall risk of bias was high for two RCTs and unclear for three. One RCT compared different proprietary alginate dressings (20 participants), three compared alginate and hydrocolloid dressings (215 participants), and one compared alginate and plain non-adherent dressings (60 participants). Follow-up periods were six weeks in three RCTs and 12 weeks in two. No statistically significant between-group differences were detected for any comparison, for any healing outcome. Meta-analysis was feasible for one comparison (alginate and hydrocolloid dressings), with data from two RCTs (84 participants) pooled for complete healing at six weeks: risk ratio 0.42 (95% confidence interval 0.14 to 1.21). Adverse event profiles were generally similar between groups (not assessed for alginate versus plain non-adherent dressings).

Authors’ conclusions: The current evidence base does not suggest that alginate dressings are more or less effective in the healing of venous leg ulcers than hydrocolloid or plain non-adherent dressings, and there is no evidence to indicate a difference between different proprietary alginate dressings. However, the RCTs in this area are considered to be of low or unclear methodological quality. Further, good quality evidence is required from well designed and rigorously conducted RCTs that employ - and clearly report on - methods to minimise bias, prior to any definitive conclusions being made regarding the efficacy of alginate dressings in the management of venous leg ulcers.

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

Plain language summary: Alginate dressings for venous leg ulcers Venous leg ulcers are a common and recurring type of chronic or complex wound which can be distressing for patients and costly to healthcare providers. Compression therapy, in the form of bandages or stockings, is considered to be the cornerstone of venous leg ulcer management. Dressings are applied underneath bandages or stockings with the aim of protecting the wound and providing a moist environment to aid healing. Alginate dressings contain substances derived from seaweed and are one of several types of wound dressings available. We evaluated the evidence from five randomised controlled trials that compared either different brands of alginate dressings, or alginate dressings with other types of dressings. In terms of wound healing, we found no good evidence to suggest that there is any 

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difference between different brands of alginate dressings, nor between alginate dressings and hydrocolloid or plain non-adherent dressings. Adverse events were generally similar between treatment groups (but not assessed for alginate versus plain non-adherent dressings). Overall, the current evidence is of low quality. Further, good quality evidence is required before any definitive conclusions can be made regarding the use of alginate dressings in the management of venous leg ulcers.

Publication in The Cochrane Library Issue 5, 2013

Flavonoids for treating venous leg ulcers Christopher Scallon, Sally EM Bell-Syer, Zoriah Aziz Citation example: Scallon C, Bell-Syer SEM, Aziz Z. Flavonoids for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2007, Issue 2.

Art. No.: CD006477. DOI: 10.1002/14651858.CD006477.

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Venous leg ulcers are a major health burden: annually, in the UK alone, they contribute an estimated cost to the NHS of GBP 400 million. Flavonoids are a diverse group of naturally-occurring venotonic compounds that address certain microcirculatory parameters involved in venous leg ulcer pathophysiology.

Objectives: To evaluate the clinical effects of flavonoids on the healing of venous leg ulcers.

Search methods: We searched the Cochrane Wounds Group Specialised Register (searched 11 February 2013); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1); Ovid MEDLINE (1950 to January Week 5 2013); Ovid MEDLINE (In-Process & Other NonIndexed Citations, February 8, 2013); Ovid EMBASE (1980 to 2013 Week 06); and EBSCO CINAHL (1982 to 8 February 2013). No date or language restrictions were applied. We checked reference lists of included trials, and contacted pharmaceutical companies.

Selection criteria: Randomised controlled trials (RCTs) that investigated the efficacy of any flavonoid-containing compound on venous leg ulcer healing in adults.

Data collection and analysis: Two review authors independently assessed trials for the review and disagreements were referred to a third author. All rejected articles were double-checked by a third author. Assessment of risk of bias and data extraction were performed independently by two authors, discrepancies were resolved by referring to the third author.

Main results: Of the nine studies (1075 participants): five investigated Micronised Purified Flavonoid Fraction (MPFF), and four investigated hydroxyethylrutosides (HR).

Meta-analysis involving 723 participants from five trials – four of which were characterised by poor reporting – showed more venous leg ulcers were healed in the MPFF groups than in the control groups (RR 1.36; 95% CI 1.07 to 1.74). However, 60

the most rigorously conducted trial, which was at low risk of bias, did not show any additional benefit of MPFF (RR 0.94; 95% CI 0.73 to 1.22). Since this trial was unpublished, the possibility of publication bias in trials involving flavonoids must be acknowledged. Overall, the quality of reporting of trials on HR was also poor. Pooling three trials, all at unclear risk of bias, involving 279 participants showed a statistically significant effect in favour of HR with respect to number of ulcers healed (RR 1.70; 95% CI 1.24 to 2.34).

Authors’ conclusions: Although the overall estimate of the number of healed ulcers appeared to show a significant effect in favour of flavonoids (both MPFF and HR), this result needs to be interpreted cautiously, as most of these trials were poorly reported, and so had an unclear risk of bias for randomisation, allocation concealment, blinding and methods for addressing incomplete outcome data. There was also a possibility of publication bias.

Plain language summary: Flavonoids for treating venous leg ulcers Venous leg ulcers (which appear as open sores) can be caused by a blockage or breakdown in the veins of the legs. Compression of the leg, using bandages or hosiery (stockings), is known to help heal venous ulcers. Flavonoids, which are commonly used as food supplements, occur in a variety of plant-based foods and beverages, including cocoas, chocolates, teas and red wines. They are sometimes used to try to promote ulcer healing in the leg. This review of clinical trials concluded that there is some evidence to show that flavonoids can help heal venous leg ulcers, however, many trials were not reported well, and we could not know for certain whether the apparently beneficial effects were real or not. This meant that we could not draw firm conclusions, or recommend routine use of flavonoids for people with leg ulcers. Larger and better conducted trials are needed to assess the true clinical effect of flavonoids.

Publication in The Cochrane Library Issue 5, 2013

Foam dressings for venous leg ulcers Susan O’Meara, Marrissa Martyn-St James Citation example: O’Meara S, Martyn-St James M. Foam ­dressings for venous leg ulcers. Cochrane Database of ­Systematic Reviews 2012, Issue 6.

Art. No.: CD009907. DOI: 10.1002/14651858.CD009907 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Venous leg ulcers are a common and recurring type of chronic or complex wound that are associated with considerable cost to patients and to healthcare providers. Primary wound contact dressings are usually applied beneath compression devices with the aim of aiding healing. Foam dressings are used frequently, and a variety of foam products is available on the market. The evidence base to guide dressing choice, however, is sparse.

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Cochrane Reviews

Objectives: To determine the effects of foam dressings on the healing of venous leg ulcers Search methods: In October 2012 we searched The Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of ABSTRACTs of Reviews of Effects (DARE) (The Cochrane Library); the Economic Evaluation Database (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL. There were no restrictions based on language or date of publication.

Selection criteria: We included published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any type of foam dressing in the treatment of venous ulcers.

Data collection and analysis: Two review authors independently performed study selection, data extraction and risk of bias assessment. Meta-analysis was undertaken when deemed fea­ sible and appropriate.

Main results: Twelve RCTs (1023 participants) reporting 14 comparisons were included in this review. There was no difference in healing outcomes between hydrocellular foam dressings and polyurethane foam dressings (three RCTs). Pooled data across five RCTs (418 participants) showed no statistically significant difference between foam dressings and hydrocolloid dressings in the proportion of ulcers healed at 12 to 16 weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.81 to 1.22). No statistically significant between-group differences in healing outcomes were detected when foam dressings were compared with: paraffin gauze (two RCTs); hydrocapillary dressing (one RCT); knitted viscose dressing (one RCT); and protease modulating matrix (one RCT). No statistically significant between-group differences in the proportion of participants experiencing adverse events were detected when hydrocellular foam dressings were compared with polyurethane foam dressings, or when foam dressings were compared with hydrocapillary, hydrocolloid, or knitted viscose dressings (one RCT for each comparison). Six RCTs were considered as being at overall high risk of bias, and the remaining six RCTs were considered to be at overall unclear risk of bias. No included RCT had an overall low risk of bias.

Authors’ conclusions: The current evidence base does not suggest that foam dressings are more effective in the healing of venous leg ulcers than other wound dressing treatments. The evidence in this area is of low quality. Further evidence is required from well-designed and rigorously-conducted RCTs, that employ methods to minimise bias and report them clearly, before any definitive conclusions can be made regarding the efficacy of foam dressings in the management of venous leg ulcers.

Plain language summary: Foam dressings for venous leg ulcers Venous leg ulcers are a common and recurring type of chronic wound. Compression therapy (bandages or stockings) is used to treat venous leg ulcers. Dressings that aim to protect the wound and provide a moist environment to aid ulcer healing are applied beneath compression devices. Foam dressings are one of several types of dressing available. We evaluated the evidence from 12 randomised controlled trials that either compared different types of foam dressings, or compared foam dressings with other types

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of wound dressings. We found no evidence to suggest that polyurethane foam dressings are significantly better or worse than hydrocellular foam dressings in venous leg ulcer healing. Similarly, we found no evidence to suggest that foam dressings are significantly better or worse than other types of dressings (paraffin-impregnated gauze dressings, hydrocapillary dressings, hydrocolloid dressings, knitted viscose dressings, or protease-modulating matrix dressings), for the healing of venous leg ulcers. We found insufficient evidence to draw any conclusions regarding: adverse events, quality of life, costs, pain, or dressing performance. Overall, the current evidence is of low or unclear methodological quality. This limits the making of any specific recommendations regarding the use of foam dressings. Further, good quality evidence is required before definitive conclusions can be made regarding the role of foam dressings in the management of venous leg ulcers.

Publication in The Cochrane Library Issue 6, 2013

Antibiotic prophylaxis for preventing burn wound infection Leticia A Barajas-Nava, Jesús López-Alcalde, Marta Roqué i Figuls, Ivan Solà, Xavier Bonfill Cosp Citation example: Barajas-Nava LA, López-Alcalde J, Roqué i Figuls M, Solà I, Bonfill Cosp X. Antibiotic prophylaxis for preventing burn wound infection. Cochrane Database of Systematic Reviews 2010, Issue 10.

Art. No.: CD008738. DOI: 10.1002/14651858.CD008738.

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: Infection of burn wounds is a serious problem because it can delay healing, increase scarring and invasive infection may result in the death of the patient. Antibiotic prophylaxis is one of several interventions that may prevent burn wound infection and protect the burned patient from invasive infections.

Objectives: To assess the effects of antibiotic prophylaxis on rates of burn wound infection.

Search methods: In January 2013 we searched the Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE – In-Process & Other Non-Indexed Citations (2013); Ovid EMBASE; EBSCO CINAHL and reference lists of relevant articles. There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: All randomised controlled trials (RCTs) that evaluated the efficacy and safety of antibiotic prophylaxis for the prevention of BWI. Quasi-randomised studies were excluded.

Data collection and analysis: Two review authors independently selected studies, assessed the risk of bias, and extracted relevant data. Risk ratio (RR) and mean difference (MD) were estimated for dichotomous data and continuous data, respectively. When 

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sufficient numbers of comparable RCTs were available, trials were pooled in a meta-analysis to estimate the combined effect.

Main results: This review includes 36 RCTs (2117 participants); twenty six (72%) evaluated topical antibiotics, seven evaluated systemic antibiotics (four of these administered the antibiotic perioperatively and three administered upon hospital admission or during routine treatment), two evaluated prophylaxis with non absorbable antibiotics, and one evaluated local antibiotics administered via the airway.

The 11 trials (645 participants) that evaluated topical prophylaxis with silver sulfadiazine were pooled in a meta analysis.

There was a statistically significant increase in burn wound infection associated with silver sulfadiazine compared with dressings/ skin substitute (OR = 1.87; 95% CI: 1.09 to 3.19, I2 = 0%).

These trials were at high, or unclear, risk of bias. Silver sulfadiazine was also associated with significantly longer length of hospital stay compared with dressings/skin substitute (MD = 2.11 days; 95% CI: 1.93 to 2.28).

Systemic antibiotic prophylaxis in non-surgical patients was evaluated in three trials (119 participants) and there was no evidence of an effect on rates of burn wound infection. Systemic antibiotics (trimethoprim-sulfamethoxazole) were associated with a significant reduction in pneumonia (only one trial, 40 participants) (RR = 0.18; 95% CI: 0.05 to 0.72) but not sepsis (two trials 59 participants) (RR = 0.43; 95% CI: 0.12 to 1.61).

Perioperative systemic antibiotic prophylaxis had no effect on any of the outcomes of this review.

Selective decontamination of the digestive tract with nonabsorbable antibiotics had no significant effect on rates of all types of infection (2 trials, 140 participants). Moreover, there was a statistically significant increase in rates of MRSA associated with use of non-absorbable antibiotics plus cefotaxime compared with placebo (RR = 2.22; 95% CI: 1.21 to 4.07).

There was no evidence of a difference in mortality or rates of sepsis with local airway antibiotic prophylaxis compared with placebo (only one trial, 30 participants).

Authors’ conclusions: The conclusions we are able to draw regarding the effects of prophylactic antibiotics in people with burns are limited by the volume and quality of the existing research (largely small numbers of small studies at unclear or high risk of bias for each comparison). The largest volume of evidence suggests that topical silver sulfadiazine is associated with a significant increase in rates of burn wound infection and increased length of hospital stay compared with dressings or skin substitutes; this evidence is at unclear or high risk of bias. Currently the effects of other forms of antibiotic prophylaxis on burn wound infection are unclear. One small study reported a reduction in incidence of pneumonia associated with a specific systematic antibiotic regimen.

Plain language summary: Antibiotics to prevent burn wounds becoming infected Burn injuries are a serious problem. They are associated with a significant incidence of death and disability, multiple surgical procedures, prolonged hospitalisation, and high costs of health care.

Various antibiotics are used with the aim of reducing the risk of infection in burn patients before it occurs. Some antibiotics are used locally on the skin (topical treatments), others are taken orally, or by injection, and affect the whole body (systemic

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treatments). It is not clear if prophylactic antibiotics are beneficial.

Thirty six studies involving 2117 participants are included in this review. The studies compared people with burns who were given antibiotics with people also with burns who received either an inactive treatment (placebo), no treatment, wound dressings, or another topical preparation or antibiotic. Twenty-six trials (72%) evaluated topical antibiotics and smaller numbers evaluated antibiotics given orally, intravenously or via the airway.

Most studies were small and of poor quality.

There was some evidence that a particular antibiotic (silver sulfadiazine) applied directly to the burn actually increases the rates of infection by between 8% and 80%. Otherwise there was not enough research evidence about the effects of antibiotics to enable reliable conclusions to be drawn.

Publication in The Cochrane Library Issue 7, 2013

Linezolid versus vancomycin for skin and ­ soft tissue infections Jirong Yue, Bi Rong Dong, Ming Yang, Xiaomei Chen, Taixiang Wu, Guan J Liu Citation example: Yue J, Dong BR, Yang M, Chen X, Wu T, Liu GJ. Linezolid versus vancomycin for skin and soft tissue infections. Cochrane Database of Systematic Reviews 2009, Issue 4.

Art. No.: CD008056. DOI: 10.1002/14651858.CD008056 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. ABSTRACT Background: The morbidity and treatment costs associated with skin and soft tissue infections (SSTIs) are high. Linezolid and vancomycin are antibiotics that are commonly used in treating skin and soft-tissue infections, specifically those infections due to methicillin-resistant Staphylococcus aureus (MRSA).

Objectives: To compare the effects and safety of linezolid and vancomycin for treating people with SSTIs. Search methods: In May 2013 we conducted searches of the following databases: Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also contacted manufacturers for details of unpublished and ongoing trials. We scrutinised citations within all obtained trials and major review articles to identify any additional trials.

Selection criteria: We included all randomised controlled trials (RCTs) comparing linezolid with vancomycin in the treatment of SSTIs. Data collection and analysis: Two review authors independently selected trials, assessed risk of bias and extracted data. The primary outcomes were clinical cure, microbiological cure, and SSTI-related and treatment-related mortality. We performed subgroup analyses according to age, and whether the infection was due to MRSA

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Cochrane Reviews

Main results: We included nine RCTs (3144 participants). Linezolid was associated with a significantly better clinical (RR 1.09, 95% CI 1.03 to 1.16) and microbiological cure rate in adults (RR 1.08, 95% CI 1.01 to 1.16). For those infections due to MRSA, linezolid was significantly more effective than vancomycin in clinical (RR 1.09, 95% CI 1.03 to 1.17) and microbiological cure rates (RR 1.17, 95% CI 1.04 to 1.32). No RCT reported SSTIrelated and treatment-related mortality. There was no significant difference in all-cause mortality between linezolid and vancomycin (RR 1.44, 95% CI 0.75 to 2.80). There were fewer incidents of red man syndrome (RR 0.04, 95% CI 0.01 to 0.29), pruritus (RR 0.36, 95% CI 0.17 to 0.75) and rash (RR 0.27, 95% CI 0.12 to 0.58) in the linezolid group compared with vancomycin, however, more people reported thrombocytopenia (RR 13.06, 95% CI 1.72 to 99.22), and nausea (RR 2.45, 95% CI 1.52 to 3.94) when treated with linezolid. It seems, from the available data, that length of stay in hospital was shorter for those in the linezolid group than the vancomycin group. The daily cost of outpatient therapy was less with oral linezolid than with intravenous vancomycin. Although inpatient treatment with linezolid cost more than inpatient treatment with vancomycin per day, the median length of hospital stay was three days shorter with linezolid. Thus, total hospital charges per patient were less with linezolid treatment than with vancomycin treatment.

There was some evidence that a particular antibiotic (silver sulfadiazine) applied directly to the burn actually increases the rates of infection by between 8% and 80%. Otherwise there was not enough research evidence about the effects of antibiotics to enable reliable conclusions to be drawn.

Authors’ conclusions: Linezolid seems to be more effective than vancomycin for treating people with SSTIs, including SSTIs caused by MRSA. The available evidence is at high risk of bias and is based on studies that were supported by the pharmaceutical company that makes linezolid. Further well-designed, independently-funded, RCTs are needed to confirm the available evidence.

ABSTRACT Background: There is no consensus regarding whether the peritoneum should be closed or left open during non-obstetric operations involving laparotomy. Neither is there consensus about the method of closure of the peritoneum (continuous suture versus interrupted suture). If closing the peritoneum could be omitted without complications, or even with benefit for patients, this could result in reductions in the cost of abdominal operations by reducing both the number of sutures used and the operating time.

Plain language summary: Antibiotic drugs for treating skin and soft tissue infections Skin and soft tissue infections such as impetigo, abscesses, ulcers, and surgical site infections are common infections of the skin. For serious skin and soft tissue infections involving the deeper tissues, the death rate and treatment costs are high. Linezolid and vancomycin are antibiotics that are effective in treating skin and soft tissue infections, particularly infections caused by bacteria that have developed resistance to some antibiotics.

This review identified nine RCTs, with a total of 3144 participants, and compared treatment with linezolid against treatment with vancomycin for skin and soft tissue infections. Linezolid was found to be more effective than vancomycin for treating these infections. There were fewer skin complications in the group that were treated with linezolid. There were no differences between the two groups in the number of reported deaths, and those treated with linezolid had shorter lengths of hospital stay than those treated with vancomycin. The daily cost of outpatient therapy was less with oral linezolid than with intravenous vancomycin, although for inpatient treatment, linezolid was more expensive than vancomycin. Well-designed trials will be required in future to confirm these results, as the trials from which these conclusions were drawn were of poor methodological quality, at high risk of bias, and were funded by the pharmaceutical company that makes linezolid.evaluated antibiotics given orally, intravenously or via the airway. Most studies were small and of poor quality.

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Publication in The Cochrane Library Issue 7, 2013

Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations Kurinchi Selvan Gurusamy, Etienne Cassar Delia, Brian R Davidson Citation example: Gurusamy KS, Cassar Delia E, Davidson BR. Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations. Cochrane Database of Systematic Reviews 2013, Issue 3.

Art. No.: CD010424. DOI: 10.1002/14651858.CD010424 Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Objectives: To compare the benefits and harms of parietal peritoneal closure compared with no parietal peritoneal closure in patients undergoing non-obstetric abdominal operations.

Search methods: In Februrary 2013 we searched the The Cochrane Wounds Group Specialised Register (searched 14 February 2013); The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1); The Database of ABSTRACTs of Reviews of Effects (2013, Issue 1); Ovid MEDLINE (1946 to February Week 1, 2013); Ovid EMBASE (1974 to 2013 Week 06); and EBSCO CINAHL 1982 to 8 February 2013).

Selection criteria: We included only randomised controlled trials (RCTs) comparing peritoneal closure with no peritoneal closure in patients (adults and children) undergoing non-obstetric abdominal operations. All relevant RCTs irrespective of language, publication status, publication year, or sample size were included in the analysis.

Data collection and analysis: Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing the binary outcomes between the groups, and mean difference (MD) with 95% CI for comparing the continuous outcomes. We performed the meta-analysis using both a fixed-effect model and a random-effects model. Intention-to-treat analysis was performed  whenever possible.

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Cochrane Reviews

Main results: Five trials involving 836 participants randomised to peritoneal closure (410 participants) and no peritoneal closure (426 participants) were included in this review. All the trials were at high risk of bias. All the trials included participants undergoing laparotomy (open surgery). Four of the five trials used catgut or chromic catgut for peritoneal closure. Three trials involved vertical incisions and two trials involved transverse incisions.

None of the trials reported 30-day mortality. There was no significant difference in the one-year mortality between the two groups (RR 1.11; 95% CI 0.56 to 2.19) in the only trial that reported this outcome. The only serious peri-operative adverse event reported was burst abdomen, which was reported by three trials. Overall, 10/663 (1.5%) of participants developed burst abdomen. There was no significant difference in the proportion of participants who developed burst abdomen between the two groups (RR 0.71; 95% CI 0.22 to 2.35). The same three trials reported the proportion of participants who developed incisional hernia. Details of the follow-up period were only available for one trial, and so we were unable to calculate the incidence rate.

Overall, 17/663 (2.5%) of participants developed incisional hernia. There was no significant difference in the proportion of participants who developed incisional hernia between the two groups (RR 0.92; 95% CI 0.37 to 2.28). None of the trials reported quality of life; the incidence rate of, or proportion of participants who developed, intestinal obstruction due to adhesions; or re-operation due to incisional hernia or adhesions. Only one trial reported the length of hospital stay, and this trial did not include readmissions in its calculations. There was no significant difference in the length of hospital stay between the two groups (MD 0.40 days; 95% CI -0.51 to 1.31).

Authorsâ&#x20AC;&#x2122; conclusions: There is no evidence for any short-term or long-term advantage in peritoneal closure for non-obstetric operations. If further trials are performed on this topic, they should have an adequate period of follow-up and adequate measures should be taken to ensure that the results are not subject to bias.

Plain language summary: Surgical closure of the lining of the abdominal cavity versus no closure for reducing wound complications after operations unrelated to childbirth The peritoneum is the inner lining of the abdomen (tummy).

After surgery, when closing the abdomen, some surgeons stitch

the peritoneum together because they think this increases the strength of the wound. Others do not stitch the peritoneum together because they think it is unnecessary, increases operating costs through use of additional stitching material, increases operating time, and may increase pain. So, whether to close the peritoneum, and method of closure (continuous running stitches versus interrupted stitches) are controversial in operations not related to childbirth. We addressed these controversies by performing a thorough search of the medical literature for trials that compared closing and not closing the peritoneum after abdominal operations not related to childbirth. We included only randomised controlled trials without limiting trials according to language or year of publication, or number of participants in the study. Two review authors independently identified the trials and extracted information.

We identified five trials involving 836 participants who had open abdominal operations. Peritoneal closure was done in 410 participants and not done in 426. All trials had a high risk of bias. Only one trial reported the proportion of participants who died up to one year after the operation, and there was no significant difference between the closure and non-closure groups.

Three trials reported major wound breakdown (burst abdomen), which requires emergency surgery. Overall, 10/663 participants (1.5%) developed burst abdomen, with no significant difference in proportions between the two groups. Three trials reported minor wound breakdown (incisional hernia), that may require surgery. Overall, 17/663 participants (2.5%) developed incisional hernia; again there was no significant difference between the two groups.

None of the trials reported on important outcomes, such as quality of life; the occurrence of intestinal obstruction (caused by intestines sticking to themselves and the abdominal wall (adhesions)); or the proportion of participants who had surgery to fix incisional hernia or adhesions. Only one trial reported length of hospital stay, and showed no significant difference between the groups, but did not include readmissions in its calculations.

There does not appear to be any evidence for a short-term or long-term advantage in peritoneal closure in operations not related to childbirth. However, the trials were at high risk of bias, which can lead to false conclusions. Interestingly, our findings are similar to those of another research group who performed a similar review for operations related to childbirth. m

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Published by EUROPEAN WOUND MANAGEMENT ASSOCIATION

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EWMA Journal

Previous Issues

Volume 13, no 1, April 2013 The Biofilm-forming capacity of s­ taphylococcus aureus from chronic wounds can be useful for determining Wound-Bed Preparation methods Y. Yarets, L. Rubanov, I. Novikova, N. Shevchenko In vitro efficacy of various topical antimicrobial agents against multidrug-resistant bacteria M. Hajská, L. Slobodníková, H. Hupková, J. Koller The mTOR inhibitors and the skin wound healing F. Benhadou, V. del Marmol A Review of Evidence for Negative Pressure Wound Therapy (NPWT) use Post Spinal Surgery R. A. Atkinson, K. J. Ousey, S. Lui, J. B. Williamson A randomized study on the effectiveness of a new pressurerelieving ­mattress overlay for the prevention of pressure ulcers in elderly patients at risk E. Ricci, C. Roberto, A. Ippolito, A. Bianco, M. T. Scalise Motorcycle ride position, venous return, and symptoms of ­chronic venous insufficiency Ellie Lindsay, P. Vowden, K. Vowden, J. Megson Archagathus – History’s first wound expert E. Ricci

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

Italian

Complicated wounds in the age of web 2.0: new perspectives in patient management Carbonari A., Gioacchini M., Bolletta E., Pupita G., Pierangeli M., Grassetti L., Di Benedetto G., Scalise A. Pain and skin ulcers: analysis from patients’ point of view through a focused interview Scapicchio C., Catenacci P., Lupi S. Role of periwound transcutaneous oximetry in leg ulcers assessment Failla G., Majani A., Cannavò A., Ardita G., Finocchiaro P., Mugno F., Attanasio L., Palumbo F. P., Di Salvo M. M. Review: Rationale for the use of silver sulfadiazine in the treatment of infected chronic skin wounds Giraldi E., Zorzi L.

Volume 12, no 3, October 2012 Therapeutic strategies for diabetic foot ulceration RJ Hinchliffe, JRW Brownrigg Offloading the diabetic foot: Evidence and clinical decision making S.A. Bus Soft-tissue complications during treatment of children with congenital clubfoot A. Baindurashvili, V. Kenis, Y. Stepanova An evolution in Medical Tapes: From Latex to Acrylic L. Gryson Bacteria and fungus binding mesh in negative pressure wound therapy – A review of the biological effects in the wound bed M. Malmsjö, S. Lindstedt, R. Ingemansson, L. Gustafsson

English

Finnish

Haava, no. 2, 2013 www.shhy.fi Upset with Wounds or Wounds with Mixed Ethiology Milla Kallio Arterial Diseases and Wounds Arjaleena Ilo Local Treatment of Arterial Wounds Tiina Pukki Challenges and Problem Solving in Home Care Piia Grek-Stjernberg Multi- Methods and Evidence Based Practice Anna-Liisa Salminen Greetings from EWMA – focus on wound care competences, multiprofessional cooperation and patient’s best Salla Seppänen Wound Care Experts –Authorisation enables the career development Ansa Iivanainen

Volume 12, no 1, January 2012 How to rate the wound d ­ ebridement trauma?

Jan Stryja Ensuring equitable wound management education within the Australian context Jan Rice Low wound prevalence and cost burden: The impact of a multidisciplinary wound specialist team Alison Hopkins, Fran Worboys, John Posnett The results of a comprehensive wound audit in a UK primary care trust Alison Hopkins, Fran Worboys Pressure ulcer programme of research – PURPOSE Nixon J, Wilson L.M, Coleman S, Gorecki C, Muir D, Pinkney L, Keen J, Briggs M, McGinnis E, Stubbs N, Dealey C, Nelson A The skin’s own bacteria may a ­ ggravate inflammatory and ­occlusive changes in atherosclerotic arteries of lower limbs Waldemar L. Olszewski, Piotr Andziak, M. Moscicka-Wesolowska, Bozenna Interewicz, Ewa Swoboda, Ewa Stelmach

Advances in Skin & Wound Care, vol. 26, no 9, 2013 www.aswcjournal.com Prospective Study on the Treatment of LowerExtremity Chronic Venous and Mixed Ulcers Using Tissue-Engineered Skin Substitute Made by the Self-assembly Approach Olivier Boa et.al.

Dakin’s Solution: Past, Present, and Future Jeffrey M. Levine The Charcot Foot: Neuropathic Osteoarthropathy Fran Game, William Jeffcoate

Volume 12, no 2, May 2012 A structured approach to s­ urgical treatment in deep i­nfection in diabetic foot Cedomir S Vucetic, et.al.

Endothelial progenitor cells, a unipotent stem cell, involved in neovascularization of wound healing in diabetic foot ulcer Jacqueline Chor Wing Tama, et.al.

Bacteriophages for the treatment of severe infections: – a ‘new’ option for the future?

Daniel De Vos, et.al.

Developing evidence-based ways of working: – Employing interdisciplinary team w ­ orking to improve patient outcomes in diabetic foot ulceration – our experience Kristien Van Acker Exploring the characteristics of a v­ enous leg ulcer that contribute to the emotional distress experienced by patients Jessica Walburn, et.al.

Acta Vulnologica, vol. 11, no 2, 2013 www.vulnologia.it

Spanish

Helcos, vol. 24, no. 2, 2013 Risk assessment scales for pressure ulcer in intensive care units: a systematic reviewe with metaanalysis Francisco P. García-Fernandez et al.

Redefiniton of the concept and management of moisture injuries. A conceptual and methodological approach for improving the management of Moisture Associated Skin Damages (MASD) Joan-Enric Torra i Bou et al.

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

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EWMA Journal

2013 vol 13 no 2

EWMA English

International Wound Journal, vol. 10, no 4, 2013 www.wiley.com Regenerative surgery of the complications with Morton’s neuroma surgery: use of platelet rich plasma and hyaluronic acid B De Angelis, L Lucarini, F Orlandi, A Agovino, A Migner, V Cervelli, V Izzo, C Curcio Clinical outcome and microvascular blood flow in VAC®- and Sorbalgon®-treated peri-vascular infected wounds in the groin after vascular surgery – an early interim analysis S Acosta, C Monsen, M Dencker Non-invasive assessment of negative pressure wound therapy using high frequency diagnostic ultrasound: oedema reduction and new tissue accumulation SR Young, S Hampton, R Martin A home-based progressive resistance exercise programme for patients with venous leg ulcers: a feasibility study J O’Brien, H Edwards, I Stewart, H Gibbs The effectiveness of intralesional injection of platelet-rich plasma in accelerating the healing of chronic ulcers: an experimental and clinical study D Dionyssiou, E Demiri, P Foroglou, A Cheva, N Saratzis, C Aivazidis, G Karkavelas Reconstruction of infected and denuded scrotum and penis by combined application of negative pressure wound therapy and split-thickness skin grafting Z Jing-Chun, X Chun-Jing, Y Jia-Ao, S Kai

English

Lithuanian

English

Lietuvos chirurgija, Issue 1-2, Volume 10, 2012 www.chirurgija.lt Perioperative fluid therapy: Old problems, new solutions Andrijauskas A, et al.

Laparoscopic restoration of intestinal continuity after Hartmann’s procedure Stasinskas A, Stanaitis J Postoperative reduction pain with dexamethasone after laparoscopic colon surgery Tikuisis R, Miliauskas P, Samalavicius NE, Zurauskas A Analgesic effect of intrathecal morphine in laparoscopic colon surgery Miliauskas P, Tikuisis R, Samalavicius NE, Zurauskas A Gallstone ileus: retrospective review of 14 cases and case report Juodeikis Z, Stanaitis J, Stasinskas A Varicocele treatment by the microsurgical method Zotov T, Sukys D

EWMA Journal

2013 vol 13 no 2

Wound Repair and Regeneration, vol. 21, no 5, 2013 www.wiley.com Circulating levels of matrix metalloproteinases and tissue inhibitors of metalloproteinases in patients with incisional hernia Nadia A. Henriksen et al.

Autologous skin substitute for hard-to-heal ulcers: Retrospective analysis on safety, applicability, and efficacy in an out­patient and hospitalized setting Chantal S. Blok et al.

High bacterial load in negative pressure wound therapy (NPWT) foams used in the treatment of chronic wounds Erlangga Yusuf et al.

Durability of healing from spray-applied cell therapy with human allogeneic fibroblasts and keratinocytes for the treatment of chronic venous leg ulcers: A 6-month follow-up Robert S. Kirsner et al.

Scandinavian

Wounds (SÅR) vol. 21, no 2, 2013 www.saar.dk Diabetes, Foot ulcers, Depression and Anxiety Britta Østergaard Melby Prevalence survey as an evaluation of pressure ulcer project Åse Fremmelevholm Tips and tricks for photographing wounds with a digital compact camera Nis Kentorp Guideline for compression therapy in chronic venous insufficiency and oedema caused by cardiovascular dysfunction Anette Bruun and others National implementation of telemedicine in wound assessment Eskild W. Henneberg

German

Wund Management, vol. 7, no 4, 2013 English abstracts are available from www.mhp-verlag.de

Journal of Wound Care, vol. 22, no 9, 2013 www.journalofwoundcare.com Is it time to re-appraise the role of compression in non-healing venous leg ulcers?

J.F. Guest, H. Charles, K.F. Cutting Maggot debridement therapy for the treatment of diabetic foot ulcers: a meta-analysis Tian, X.M. Liang, G.M. Song, Y. Zhao, X.L. Yang Methodological recommendations for comparative research on the treatment of chronic wounds S.S. Sonnad, J.C. Goldsack, P. Mohr, S. Tunis A pilot study on the potential of remote support to enhance wound care for nursing-home patients Vowden, P. Vowden Nurses’ attitudes and perceived barriers to pressure ulcer prevention in Jordan A. Tubaishat, M. Aljezawi, M. Al Qadire

Phlebologie, no 4, 2013 www.schattauer.de Treatment of chronic wounds J. Dissemond Treatment pathways for patients with chronic wounds in Germany. Results of a prospective study in 100 patients with chronic leg ulcers M. Stoffels-Weindorf; H. von der Stück; J. Klode; J. Dissemond Wound dressings in chronic wound therapy S. Schreml; S. M. Klein; P. Babilas; S. Karrer Modern wound surgery – Surgical treatment options Example: Therapy-resistant venous leg ulcers I. Stoffels; J. Dissemond; J. Klode Compliance and non-compliance in the treatment of chronic wounds – An overview including therapists’ concerns A. Risse Venous leg ulcer caused by obesity-associated dependency syndrome M. Doerler; P. Altmeyer; M. Stücker

Journal of Tissue Viability, vol. 22, no 3, 2013 www.journaloftissueviability.com Pressure redistribution devices: What works, at what cost and what’s next?

M.J. Clancy Location-dependent depth and undermining formation of ­pressure ulcers Y. Takahashi , et al.

Percutaneous flexor tenotomy for preventing and treating toe ulcers in people with diabetes mellitus A. Rasmussen, U. Bjerre-Christensen, T.P. Almdal, P. Holstein Not just quantity: Gluteus maximus muscle characteristics in ­able-bodied and SCI individuals – Implications for tissue viability G.A. Wu , K.M. Bogie TexiCare: An innovative embedded device for pressure ulcer prevention. Preliminary results with a paraplegic volunteer O. Chenu , N. Vuillerme , M. Bucki , B. Diot , F. Cannard , Y. Payan

English

German

Review: Physical cold atmospheric pressure plasma as promising option for treatment of chronic wounds A. Kramer et al.

Review: Practical aspects of the short bowel syndrome – a proposal for the management of fluid intake and diet J. Neuhaus, M. Henning, K. Schweins, W. Niebel Review: Pilonidal sinus – the procedure according to Lord Millar as an alternative to the simple excision as standard treatment J. Neuhaus, E. Malamutmann, W. Niebel German

Zeitschrift für Wundheilung, vol. 18, April, 20132 www.dgfw.de Main problems at the interfaces in medical care of people with chronic wounds A. Buß, S. Strupeit, N. Lahmann The way out of the vacuum of evidence. Randomized, controlled trial for negative pressure wound therapy of diabetic food wounds by order of the statutory health ­insurance companies D. Seidel, E. A. M. Neugebauer und die DiaFu-Studiengruppe Electrical stimulation of ankle joint ulcers leading to complete wound closure H. Sorg, K. Knobloch, P. M. Vogt WTELQ – Assessment of quality of life based on wound- and therapy-induced impairments S. Strupeit, G. Bauernfeind

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Book Review Wound Healing and Skin Integrity Title: Wound Healing and Skin Integrity: Principles and Practice Editor: Madeleine Flanagan Wiley-Blackwell 2013 www.wiley.com ISBN – 978-0-470-65977 298 pages

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Sue Bale Editor of EWMA Journal ewma@ewma.org www.ewma.org

n compiling this book the Editor has successfully orchestrated a plethora of international experts to share their knowledge and experience. It has been brought together in such a way as to make its reading seamless, with useful diagrams and colour illustrations throughout. This book is written for health care professionals from all backgrounds wishing to learn more about wound management, skin integrity and dermatology, and it comprehensively achieves this aim. The Editor and authors as experts from across the globe, adopt an evidence-based approach to guiding busy clinical staff, and have produced a succinct and easy to read text. The consistence structure supports this approach whereby each chapter begins with an overview of the key issues, where relevant includes clear explanations of underlying aetiology and practical Practice Points and diagrams.

Additionally, readers are directed towards further reading to support the fully referenced chapters.

The main body of the text is divided into three sections: ‘Principles of Best Practice’; ‘Challenging Wounds’ and ‘Improving Skin Integrity Services’.

This approach enables the reader to understand the fundamental aspects of the skin & wounds, physiology, skin integrity assessment, wound management, wound infection & other complications within the context of the usefulness and role of evidence and how clinical decisions are made.

Section 1 provides a backdrop for the main body of the book’s content by exploring the role of evidence and best practice; assessing and maintaining skin integrity, physiology, management, infection and psychology.

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In Section 2: Challenging Wounds, almost half of the book’s content is dedicated to the discussion of those aetiologies most commonly encountered in clinical practice, as well as more unusual situations. This is a comprehensive section covering pressure ulcers, diabetic foot ulcers, lower limb ulcers, lymphoedema, malignant wounds, skin disease, dermatology surgical wounds, and most interestingly neglected wounds. As a source of information it is invaluably thorough, providing a resource for the wide range of health care professionals involved in the assessment, management and delivery of wound care.

Section 3 provides a refreshing move towards acknowledging the importance of the quality of patient care. It considers matters such as the impact of health economics; cost, best practice wound prevention, service redesign, clinical patient outcomes. In doing so this book sets the previous two sections in the context of wider health care delivery and argues for, in its final chapter, the adoption of the best, most effective technologies and services. Here, the authors explore the history of wound dressings and technologies and the emergence of specialised, multidisciplinary clinical services. A fitting conclusion for a book that is written for health care professionals that are interested in wound management, skin integrity and dermatology. m

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Venous Leg Ulcer Therapy

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85%

Teaming up for more success.

A European case study of BSN medical showed that the combination of Advanced Wound Care and Compression Therapy significantly improved 85 % of venous leg ulcers and completely healed 53 % of all cases within 12 weeks.* With its products Cutimed ® Sorbact ®, Cutimed ® Siltec, JOBST ® Comprifore and JOBST ® UlcerCARE TM, BSN medical enables effective management of venous leg ulcers while offering ease of use for doctors and patients – the perfect combination for optimal wound healing and high patient compliance. *Currently in preparation: A European Approach for Successful Venous Leg Ulcer Healing (VERUM).

BSN medical GmbH · Quickbornstraße 24 · 20253 Hamburg · www.bsnmedical.com

Cutimed ® Sorbact ® Cutimed ® Siltec JOBST ® Comprifore JOBST ® UlcerCARE TM

EWMA 2013 in · Copenhagen · Denmark

T Gerrolt Jukema EWMA Scientific Recorder www.ewma.org

Eskild W. Henneberg DSFS Chair www.saar.dk

he 23rd Conference of the European Wound Management Association (EWMA) was held in Copenhagen, Denmark on 15-17 May 2013. With over 3,200 delegates from no less than 79 countries, Copenhagen 2013 proved more successful than any previous EWMA event, attracting the highest number of attendees in the history of the association. The convenience of the Bella Center and the beautiful spring weather made Copenhagen the perfect setting.

The active involvement of the Danish Wound Healing Society (DSFS) played a major role in the success of the EWMA 2013 conference. This collaboration has been outstanding, and on behalf of EWMA we would like to extend our thanks, both to DSFS as a whole and to the board representatives, in particular, who dedicated a great deal of time over the past year to planning the EWMA conference.

The conference theme, Organisation and Cooperation in Copenhagen, reflects the essence of successful wound management: cooperation between caregivers from different professions and between patients and caregivers. This was reflected in the conference’s opening session, which emphasized the importance of working across disciplines by featuring speakers from fields as diverse as patient safety and oncology and from locations as far away as Australia and the USA. The conference had many highlights. One of them occurred when honorary speaker Professor Finn Gottrup gave a magnificent overview of the development of wound management over the last few decades. He earned this distinction due to his tireless efforts and lifetime commitment to wound healing. Finn Gottrup is also the chair of

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the new EWMA document Antimicrobials and Non-healing Wounds – Evidence, Controversies and Suggestions, which was presented at the conference and will hopefully be one of the conference’ lasting contributions. The presentation highlighted current knowledge regarding the use of antimicrobials, particularly for non-healing wounds; however, there was also discussion of controversial antimicrobial topics and how to proceed in the future.

During the conference, the different chairs ­evaluated first-time international presenters.

The evaluation group decided that the first-time presenter award should go to this speaker for the high quality of their presentation, which stood out as particularly outstanding: No: 131: Zohreh Annabestani (Iran): Assessment of comorbidity of peripheral arterial disease with venous insufficiency in diabetic ­patients.

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The conference programme’s key sessions and workshops covered a wide variety of topics. The 10 key sessions addressed topics such as regenerative medicine, home care for wounds, vascularization and amputation, and how to improve patient safety with a zero tolerance to pressure ulcers, among others. The 14 workshops explored practical approaches to specific wound management topics, dealing with issues such as maggot therapy and debridement. In addition, the Scientific Committee accepted 389 abstracts for poster presentations and 146 for oral presentations in the free paper sessions.

All abstracts and e-posters from EWMA 2013 are available at www.ewma.org.

For more pictures from EWMA 2013 please visit: www.ewma.org/english/ewma-conferences/photo-gallery/ ewma-2013-copenhagen In total, almost 750 scientific presentations were given at the conference by international key speakers, free paper presenters, poster presenters, workshop leaders, and speakers in satellite symposia. It is impossible to describe here all the innovations, outcomes, results, and novel techniques presented. It was encouraging to see the high standard

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of these presentations and to reflect upon the continued strong interest in wound healing across Europe. Our heartfelt appreciation goes out to all the speakers, presenters, and organisers who actively participated in the sessions.

Over the duration of the event, three poster presentations were recognised as outstanding by the EWMA Scientific Committee, and one first-time presenter was also awarded a prize. We congratulate all the prize winners, and thank them for keeping our profession’s standards so high.

The conference programme also included guest sessions from a large number of wound care-related organisations, including the Dystrophic Epidermolysis Bullosa Research Association (DEBRA), the European Pressure Ulcer Advisory Panel (EPUAP), and the European Tissue Repair Society (ETRS). EWMA considers such collaborations an important step in driving the wound care agenda forward. DEBRA arranged a session on the challenging situations encountered when treating Epidermolysis Bullosa (EB) and presented related wound care guidelines. Our year-long partner, ETRS, organised a session dealing with wound infection and biofilm formation, and EPUAP held an interesting session on support surfaces, microclimate,  and skin conditions.

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Several other collaborating partner organisations contributed to the scientific programme as well. The European Society for Clinical Nutrition and Metabolism (ESPEN) arranged a key session dealing with wound management and nutrition. The World Alliance for Wound and Lymphedema Care (WAWLC) organised an entire day focusing on wound care in resource-poor settings, collaborating with Médecins sans Frontières (MSF) and the Step by Step Project, which aims to improve diabetic foot care in the developing world.

Full day symposia were also held for other issues. The Russian Symposium started on Wednesday and included presentations on organisational aspects of providing modern wound care, such as implementation of guidelines, obtaining reimbursement for services, and teaching practitioners and students. On Thursday, the Nordic Diabetic Foot Symposium highlighted the Nordic Countries’ current status in regards to implementing diabetic foot care best practices. On the last day of the conference, EWMA wanted to introduce the developments and discussions concerning e-health. Therefore international experts in

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e-health, researchers, and end users, representing clinical staff as well as patients, were invited to share their experiences and perspectives on introducing e-health in routine wound care. You can read more about the outcome of the EWMA Symposiums and partners on the next pages in this issue.

When mentioning the great success of EWMA 2013 ­conference, it is also important to stress industry’s large contribution. The exhibition hall hosted over 90 companies, organisations, and associations for EWMA participants to visit. The industry-sponsored scientific symposia were of great value, and the Scientific Committee is thankful to all of the industry partners whose cooperation also contributed to making Copenhagen 2013 such a success.

Copenhagen 2013 was undoubtedly an enjoyable and informative experience for all participants. EWMA’s highest priorities are bringing together the European wound healing community and, perhaps most importantly, creating and strengthening links between national associations striving to raise the profile of wound management within

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This year the poster award committee decided to award three posters:

No. 532: Melissa Ward, Australia

No. 391: Att Nitibhon, Thailand

their respective countries. In addition, social events, including Tuesday night in the Bella Center and the main evening event held in the beautiful Langelinie Pavillon – overlooking Copenhagen harbour – provided great opportunities for informal networking.

The Copenhagen conference ended with an interview of the hosts of next year’s conference, the Grupo Nacional Para El Estudio Y Asesoramiento En Ulceras Por Presión Y Heridas Crónicas (GNEAUPP). The 24th EWMA conference will be held 14-16 May 2014, in Madrid, Spain (www. ewma2014.org). It is obvious to all that GNEAUPP is keen to develop the growing strength and visibility of the EWMA conference, which is becoming a major platform for developing consensus and driving the wound management agenda forward, across Europe and the rest of the world. m See you all in Madrid for the EWMA-GNEAUPP 2014 conference, 14-16 May! www.ewma2014.org EWMA Journal

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No. 378: Nina Bækmark, Denmark

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VISIT EWMA · GNEAUPP 2014 IN MADRID, SPAIN PRELIMINARY PROGRAMME In 2014 the conference will offer more sessions than ever before. The scientific programme will consist of varied key sessions, workshops, lectures, full-day streams, guest sessions, and satellite symposia and will offer an international blend of scientists from Europe as well as the rest of the world.

KEY SESSIONS EWMA-GNEAUPP 2014 includes a mixture of new topics important to the European wound community and topics that have had enormous appeal during previous EWMA conferences. Sessions deal with advancing education and research related to the epidemiology, pathology, diagnosis, prevention, and management of wounds.

The key sessions this year cover EWMA focus areas including: n Multidisciplinary Perspectives n Wound Care in the Home Care Sector n e-Health and Wound Care n The Diabetic Foot n From Evidence to Reality in Wound Healing n Pressure Ulcers n Surgical Site Infection n Trauma Wounds n The Role of Oxygen and Hypoxia in Wound Healing

EWMA workshops are interactive and give participants an opportunity to address and elaborate on aspects of particular interest within the themes of the individual sessions.

The full-day streams and guest sessions are particularly popular among EWMA conference delegates, as they foster more in-depth presentations and discussions within a field.

For more information about abstract submission, terms and conditions, and programme updates, please see the conference website: www.ewma2014.org.

ABSTRACT SUBMISSION Abstracts for free paper and poster presentations play a very important role in the conference programme. We hope that many of you will wish to share your work at the 2014 conference.

In order to submit an abstract for EWMA 2014, please visit www.ewma2014.org. Guidelines on how to submit the abstract will be provided when you enter the abstract submission system. All abstracts should be submitted online at www.ewma2014.org. Before you submit your abstract, please read the conditions for abstract submission carefully.

Abstracts for oral presentations, posters, and electronic poster presentations on any topic in wound healing and management are welcomed. Primary categories are:

n Infection in a Broad perspective n Vascular Wounds n Patient Perspectives

WORKSHOPS A number of workshops will be offered at EWMAGNEAUPP 2014. Workshops are typically held in a smaller setting than key sessions and free paper sessions.

The workshops will cover topics including:

Acute Wounds – Antimicrobials – Basic Science – Burns – Devices & Intervention – The Diabetic Foot – Dressings – Education – e-Health – Health Economics & Outcomes – Home Care – Infection – Leg Ulcers – Negative Pressure Wound Therapy – Nutrition – Pain – Pressure Ulcers – ­Prevention – Quality of life – Wound Assessment – ­ Case Studies (Posters Only) – Professional Communication (Posters Only)

n Debridement n Pain Management and Pain Relief when Dealing with

Wounds n Problems in Diagnosing Wound Infections in Chronic Wounds n Paediatric Wounds n The Importance of Nutrition n All You Want to Know about Maggot Therapy n Focus on Podiatry and How Do We Treat Diabetic Patients n Biofilms n The Use of Information Technology n Skincare Complications

Abstract submission deadline: 1 January 2014.

Registration fees Category

Before 15 15 March- After 1 May March 2014 1 May 2014 2014

Full conference registration: EWMA and GNEAUPP Members1 Non-members 1-day registration Conference dinner2

€ 385 € 460 € 250 € 90

€ 450 € 525 € 275 € 90

€ 500 € 575 € 325 € 90

1. Members of EWMA or one of EWMA’s cooperating organisations see (ewma.org/english/cooperating-organisations/cooperating-organisations.html) 2. Tickets for the conference dinner Thursday 15 May are not included in the registration fee and are non-refundable. Please note: Limited number of seats.

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24th Conference of the European Wound Management Association

B glis iling h & ua Sp l an ish

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EWMA GNEAUPP 14-16 May 2014 n

adrid · Spain · Espa˜na Innovation, know-how and technology in wound care Registration and abstract submission open from November 2013

European Wound Management Association Asociatión Europea para el manejo de las heridas ewma@ewma.org

Deadline abstract submission 1 January 2014

Spanish Group for the study and advice on pressure ulcers and chronic wounds Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas

www.ewma2014.org

Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas

Early registration deadline 15 March 2014

Sergio Juán Jordán Foundation for investigation and study on chronic wounds fundación sergio juán jordán para la Investigación y el estudio de las heridas crónicas

Fundación Sergio Juán Jordán para la Investigación y el Estudio de las Heridas Crónicas

Technical Secretariat

gneaupp2014ewma@bocemtium.com

www.gneaupp.org

Appreciations Zena Moore (Ireland) Zena Moore has been an extremely active council member since she joined the EWMA Council in 2002. She has supported the work of EWMA for more than a decade. Zena was Honorary Secretary 2007-2009 and EWMA president from 2009-2011 and provided leadership and motivation that helped the organisation to grow and develop. Zena’s work for EWMA has focused on education and her hard work and diligence have been crucial in shaping the educational paths that are now available in EWMA. She brought a high level of professionalism and dedication to her position as Honorary Secretary and President.

As chair of the Educational Committee, the Cooperating Organisation Board, and the Cooperating Organisations Liaison Group, Zena has contributed to the continued development of the scientific profile of EWMA and to the growth of expertise in the EWMA projects and groups.

Zena’s strong communication skills and impressive ability to lead different working groups have contributed to EWMA’s success.

Her professionalism and dedication to achieving a positive outcomes of the things she engages in will be greatly missed by the EWMA Council. The Council will also miss her ability to make people smile, and to believe in project goals. Her skill as an advocate for a clear message and getting to the point has been extremely important to the success of internal and external EWMA projects (e.g., both in term of her commitment in the Executive Committee, Editorial Board, Scientific Committee, Advocacy Group, Research Committee, and the Patient Outcome Group).

As the list implies Zena has worked tirelessly to ensure that EWMA remains a key society for professionals in wound healing.

Zena’s long-term commitment and her strengths are noticeable throughout EWMA and we will miss her presence greatly. Fortunately, we won’t be losing her altogether, because she will continue as chair of the Multidisciplinary document and the Education Committee. She will also participate in other EWMA projects where her contribution is much appreciated. Zena, we know that you will continue to be actively engaged with various committees.

We hope that one day, you will return to the Council.

by Salla Seppänen

Corrado M. Durante (Italy) Corrado was the EWMA Recorder from 2010-1013. The duties of this position can be challenging, but Corrado did a very good job. The EWMA Council ­greatly appreciates his contribution.

The EWMA Council will miss Corrado not only as an important contributor to the achievement of EWMA goals, but also as a good friend. Corrado has been actively engaged in the Scientific and the ­Executive Committees of EWMA. He has also been an effective EWMA ambassador by showcasing our activities to groups ­outside the wound community. We are sure that EWMA will continue to benefit from Corrado’s commitment to the ­organisation and to the field of wound care.

We will miss Corrado’s positive attitude and his valuable contributions to EWMA Council discussions. Corrado, we have ­appreciated your commitment and we ­sincerely hope that you will continue to contribute to EWMA goals, and that you will participate in future projects.

Finally, I would like to personally, and on behalf of the EWMA Council, thank Zena for her compassion and efforts in EWMA, and for her friendship, kindness, and great sense of humour.

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New EWMA Council Members

Luc Gryson

Barbara den Boogert-Ruimschotel (The Netherlands) Barbara was elected by the Cooperating Organisations Board to join the EWMA Council for the 2010-2013 period. Since her first meeting, she has inspired the Council with her great creativity, kindness, and skill at creating strong networks. Her contribution to the Council has been much appreciated and the EWMA Council representatives hope to continue collaborating with her as a representative of the V&VN Decubitus and Wound Consultants (V&VN).

Being part of the Education Committee and the Patient Panel is only the bare bones of Barbara’s contribution, and does not ­truly capture her accomplishments.

Barbara has leveraged her expertise as an educator and has brought her innovative ideas and creativity to EWMA groups and projects (e.g. the Multidisciplinary document). She contributes ­insightful comments to ­discussions and brings a lot of ­humour to meetings.

Barbara will remain engaged with EWMA in the years to come through her engagement in the Education Committee.

On behalf of the EWMA Council members, I wish you good luck, Barbara and we look forward to collaborating with you in the future.

Severin Läuchli

Robert Strohal

Knut Kröger

Arkadiusz Jawien

The individual members and the Cooperating Organisations’ Board elected five EWMA Council members during EWMA 2013 in May in Copenhagen: n Luc Gryson (Belgium) n Severin Läuchli (Switzerland) n Robert Strohal (Austria) [Re-elected] n Arkadiusz Jawien (PWMA, Poland) (Elected by the EWMA Cooperating Organisations) n Knut Kröger (ICW, Germany) (Elected by the EWMA Cooperating Organisations)

Salla Seppänen

Jan Apelqvist

José Verdú Soriano

The President elect, Salla Seppänen (Finland), took over as the new EWMA President.

Jan Apelqvist (Sweden) stepped down as President and became Immediate Past President.

After the Annual General Meeting, the new EWMA Council elected José Verdú Soriano (Spain) as the new EWMA Treasurer.

The EWMA Council welcomes the new members and looks forward to working together with them.

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Journal of Wound Care (JWC) is the leading source of tissue viability research and information. JWC is essential reading for all specialists who wish to enhance their practice and stay ahead of developments in wound management and tissue viability.

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JWC is indexed on Medline, Scopus, CINAHL and was recently awarded its first Impact Factor of 1.906 from Thomson Reuters indicating that JWC continues to lead the field in wound-care research and practice as the foremost international wound-care journal.

“The Journal of Wound Care is an extremely valuable resource that contains a wealth of peer-reviewed papers detailing the latest advances in wound care research.

A must read for clinicians, academics and researchers who want to advance their own knowledge/practice and keep abreast of the wound care literature.”

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Is it time to re-appraise the role of compression in non-healing VLUs? Methodological recommendations for comparative research on wound treatments The potential of remote support to enhance wound care Wound pruritus: prevalence, aetiology and treatment Maggot debridement therapy for the treatment of DFUs: a meta-analysis Nurses’ attitudes and perceived barriers to pressure ulcer prevention in Jordan

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EWMA

GNEAUPP ACTIVITIES The next EWMA-GNEAUPP congress, to be held in Madrid in 2014, will coincide with the 20th anniversary of the National Advisory Group for the Study of Pressure Ulcers and Chronic Wounds (GNEAUPP). It is an independent interdisciplinary scientific group whose primary aims are to: n Bring together and combine the efforts of all health professionals who may have an interest in the study of pressure ulcers and chronic wounds. n Strengthen and encourage the image and representation of these professionals in the field of chronic wound care by whatever means deemed appropriate. n Stimulate and consolidate training as well as technical, cultural and academic aspects of their sphere, respecting trade union and professional norms. It is a private, not-for-profit organisation with no trade union involvement. n Guide, advise and cooperate with public and private organisations and institutions that work in the field of pressure ulcers and other chronic wounds, seeking improvements at both a personal and collective level for members. n Sustain mutually beneficial relationships with groups at home and abroad working in this field. n Organise cultural, social and scientific events related to pressure ulcers and other chronic wounds to raise awareness and understanding. n Maintain links among all interested professionals in the interests of personal professional improvement. n Stimulate awareness of the group’s activities, work and experiences via magazines or whatever publications are considered appropriate.

Specifically, the group’s task list has grown to include: n Defining the scale of the problem of pressure ulcers and other chronic wounds and, in particular, their epidemiological, economic, ethical and legal significance.

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n

Raising awareness about the gravity of these problems to hopefully reduce the incidence and prevalence of pressure ulcers and other chronic wounds. n Assisting families in their role as caregivers with preventative measures. n Collaborating in the fielding, discussion and dissemination of scientific knowledge, allowing diverse professionals in the field of pressure ulcers and other chronic wounds to develop a safe and integral approach based on the latest scientific evidence.

The GNEAUPP currently has 4700 members who are health professionals from various disciplines, although most are nursing professionals.

The ­steering committee, in charge of all activities and services, is a body entirely altruistic in nature.

This association is a constituent member of the Conferencia Nacional de Consenso sobre Ulceras de Extremidad Inferior (CONUEI), the European Pressure Ulcer Advisory Panel (EPUAP), and the Sociedad Iberolatinoamerica sobre Ulceras y Heridas (SILAUHE) and cooperates with the European Wound Management Association (EWMA).

José Javier Soldevilla Agreda President of GNEAUPP www.gneaupp.org

Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas

Please read more about EWMA-GNEAUPP 2014 on the Spanish conference website: www.ewma2014.org/es/

A BRIEF HISTORY OF ACTIVITIES In its 19 years of existence, the GNEAUPP has ­promoted the following: n The creation of the Fundación Sergio Juan Jordán para la Investigación y el Estudio de las Heridas Crónicas, conforming with the Law 50/2002 of 26 December 2002, Royal Decree 1337/2005 of 11 November and other regulations in force, independent legal entity, whose principal objectives are to: a) Improve the health and quality of life of patients with chronic wounds and of their caregivers by encouraging preventative care and better treatments. b) Contribute to research into the prevention and treatment of chronic wounds. c) Advise patients, family caregivers, professionals, scientific groups, pharmaceutical companies, public and private entities of any nationality, as well as assist them in arising  matters related to the foundation.

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Council members and friends at the last GNEAUPP meeting in Seville 2012

d) Organise events, conferences and any function that promotes training and awareness between health professionals and society in general regarding chronic wounds as a health problem and the advances in research into their prevention and treatment.

n The organisation of nine national symposiums on pressure ulcers and chronic wounds aimed particularly towards health professionals from different care levels who are seeking to address these health problems by updating their skill set.

The most recent symposium that occurred in Seville in November 2012 involved more than 1,000 delegates, and 500 scientific issues were tabled and d ­ iscussed. n

Eight summer schools and six national gatherings of pressure ulcer committees, with more specific activities aimed at groups specialised in this subject from different organisations and institutions. n Promotion and distribution of the Tarragona Manifesto (November 2007) and the Declaration of Arnedillo (November 2009), calling to social and professional attention the health and social impact of pressure ulcers, the ease of prevention and the necessity for firm institutional policies aimed at prevention and the development of bodies of influential professionals assuring greater attention. n

The “Stop a las UPP” campaign (between 2010 and 2013), which is of great social and professional significance, with the aim of informing the general public about the true scale of this terrible health 80

problem. This project has involved numerous initiatives, including: – Sending informational posters on the theme of ­prevention measures to health professionals at all ­Spanish hospitals.

– Recruitment of a patron for the campaign (the actor Javier Cámara).

– Distribution of the awareness video by Javier Cámara with the help of the film production company “El Deseo”.

– Distribution of the “lip dub” video produced during the last Summer school in Cuenca, in which all the attendants participated.

– Photo stop: request for support from public personalities to allow their pictures to be used in publicity for the campaign.

– Participation in interviews and social media.

– Periodic publication of information by the communication cabinet during the years 2010 to 2013.

– Active and continued participation in social networks (e.g., Facebook and Twitter).

– Joint actions with similar scientific associations from Europe and Latin America (e.g., The Rio de Janeiro Declaration, announcement of the first World “Prevention of Pressure Ulcers” Day). n Four national studies on the prevalence of pressure ulcers (2001, 2005, 2009, and 2013, respectively), a national study on the prevalence of leg ulcers (2003), the only relevant epidemiological benchmarks in Spain and two studies on the economic and legal dimensions of pressure ulcers in

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Spain. These studies demonstrated the scale of Spain’s pressure ulcer problem and have provided a platform for the epidemiological vigilance of the same. As a result of these data, the Health Ministry’s 2006 National Health Quality Plan included, as its objective number 8, the prevention of pressure ulcers in accordance with patient safety. The results of the latest study, along with prevalence tendencies, will be announced at the Madrid conference. In particular, the effects of the financial crisis on the prevalence of pressure ulcers will become apparent. n

Gerokomos, the scientific magazine specialised in these matters that has been published by the Sociedad Española de Enfermería Geriátrica nonstop since 1990, the driving force behind the dissemination of knowledge in our field and on the Ibero-American stage. n The announcement of research grants in the many subjects related to chronic wounds and participation in research activities aimed at raising awareness of preventative and therapeutic aspects of these conditions, which have such a devastating effect on our society. n

Enduring cooperation with the relevant industry to develop new preventative and therapeutic products related to chronic wounds. training in different academic activities (e.g., seminars and postgraduate courses) provided by the Escuela de Investigación y Formación en Heridas (www.escueladeheridas.org).

Active participation, in partnership with Cantabria University, in the scientific and ­academic development of two Masters degrees in Advanced Management and Research of Chronic Wound Care (2011-2012, 2012-2013) and an expert university course.

n Publication and maintenance of a web site (www. gneaupp.org) with information strictly limited to professionals (product catalogue) as well as various open access sections and many technical documents covering different aspects of these conditions that are in great demand by patients and voluntary caregivers. n Expert accreditation in Spain and Latin America; the mailing list, being open to the public, has already helped people get free help from relevant experts. n Creation of GNEAUPP Technical and Positioning Documents, based on the latest scientific evidence that has helped to gather a body of specific knowledge regarding the multiple aspects of these problems. n

List of titles. The list is composed of many professional works. n Accreditation of the Clinical Practice and Clinical Documents guides requested by public and private health institutions from Spain and abroad. n Contacts and advice with the National Health System Quality Plan, to highlight the gravity of the problem; hence, its inclusion in the current National Plan. n During this last year, an application has been developed (Helcos®), based on e-health, for smartphones for wound management. This project is likely to be ready for launch at the Madrid Congress in 2014.

n Tailored

n Conferences and other training activities in various regions of Spain organised by public and private institutions, aimed towards health professionals, patient associations and families of affected patients or people considered at risk for developing the conditions. n Close cooperation with patient organisations, associations of affected family members (e.g., Asociación Española de Epidermolisis Bullosa, ASPAYM, and Asociación Española de Familiares de Enfermos de Alzheimer) and also with small local groups. n Help and advice via our internet mailing list to the many

Furthermore, the Sociedad Iberolatinoamericana sobre Ulceras y Heridas (SILAUHE), of which we are a part, along with many other scientific organisations from various countries, has over the last 5 years created five events that have been met with much interest, including the Rio de Janeiro declaration on the fundamental right to pressure ulcer prevention and, on November 20, 2012, the 1st global prevention of pressure ulcers day, which was observed in approximately 20 countries of the Ibero-American region.

The current star project is called “Heridas solidarias”, which seeks to help patients who are disadvantaged because of factors such as geographical situation, economic status or lack of easy access to a health care system. Initiating detailed actions (e.g., providing materials, people and local education), helping dispensaries in Tucuman (Argentina) and with other projects in South America and Africa.

The recent creation of an international network under the protection of the World Health Organisation is another instrument that brings to life our organisation’s objectives. m

professionals, organisations, patients and family members requesting specific advice concerning therapy and prevention.

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NORDIC DIABETIC FOOT Establishment and Further Perspectives

Klaus Kirketerp Møller Chair of the Nordic Diabetic Foot Task Force

Magnus Löndahl Chair of the Nordic Diabetic Foot Symposium

Introduction Since 2011, the EWMA and the International Working Group on the Diabetic Foot (IWGDF) have engaged in a number of activities to advocate for the systematic implementation of Diabetic Foot guidelines. Since the autumn of 2012, these two groups have focused on launching a number of activities to target the gap between international recommendations and actual practices in the Nordic countries.

Background and Objectives Access to high quality diabetic foot care in the Nordic countries is highly dependent on geographical location. Although efforts have been made to govern central principles and policy recommendations, significant decentralization exists and results in local implementations of clinical best practice that are often fragmented and incomplete. While textbook examples of multidisciplinary diabetic foot care can be found in the rural and remote communities, urban regions of the same country may face challenges in the orchestration and implementation of the recommended management regimen. Consequently, these geographic variations in the provision of high quality care challenge the fundamental goal of the Nordic Health Care systems, which is to ensure equal access to care for all citizens.

This variation in care is the impetus for the decision to establish The Nordic Diabetic Foot Task Force. The main objective of this task force is to actively advocate for the systematic implementation of best practice diabetic foot care guidelines in the Nordic countries. In practice, this main objective will be achieved by initiating and supporting various national-level activities that highlight the gap between the implementation of guideline recommendations and actual clinical practice.

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In addition, a biennial Nordic Diabetic Foot Symposium will be established to provide a forum to share and disseminate practical examples of local successes of best practice. The first symposium will take place in Lund, Sweden in November 2014. This symposium will seek involvement from all categories of health care workers involved in diabetic foot care across the Nordic countries.

Nordic Diabetic Foot Symposium at EWMA 2013 To launch the establishment of the Nordic Diabetic Foot Task Force, a full day symposium was integrated into the EWMA 2013 conference programme to focus on the implementation of clinical guidelines for diabetic foot care in the Nordic countries. The symposium was titled “We know how to treat and prevent: Why don’t we do it everywhere?”

The objective of this “Nordic Diabetic Foot Day” was to highlight the current status of the implementation of best practice diabetic foot care as recommended by the international diabetic foot guidelines in the Nordic countries, and discuss how the systematic and widespread implementation of these best practices can be achieved. The list of speakers comprised international and local expert clinicians as well as high-level health administrators and specialists in health policy research. The sessions attracted a large number of interested participants.

In addition, the EWMA conference also hosted a lunch meeting for key stakeholders to discuss the steps necessary to move towards a systematic implementation of best practice diabetic foot care in the Nordic countries. This meeting, which was attended by 18 Nordic and international experts representing clinical organisations and policy-level institutions, was a great success. The conclusions from this lunch meeting formed the basis for the open panel debate that concluded the symposium.

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TASK FORCE The purpose of this open panel debate was to answer the question: “What are the most urgent steps that need to be taken to move the implementation agenda forward?”

Another important result from the meeting was the broad support among all participating experts for the establishment of a Nordic Diabetic Foot Task Force. The conclusions from the meeting have contributed directly to the design of the organisational structure and scope formulation of this task force.

Klaus Kirketerp-Møller from Denmark (KKM) and Magnus Löndahl from Sweden (ML) were appointed the chair and co-chair, respectively, for both the Nordic Diabetic Foot Task Force and the Nordic Diabetic Foot Symposium.

Project Organisation and Partners The overall strategic planning and prioritization of the Nordic Diabetic Foot project will be conducted by the steering committee of the Nordic Diabetic Foot Task Force. The steering committee will comprise national and international diabetic foot experts who represent the following organisations: n National wound associations in the ­Nordic countries n National diabetes societies n The International Working Group on the Diabetic Foot (IWGDF) n European Association for the Study of ­Diabetes (EASD) n EWMA National working groups in each of the Nordic countries will be formed to develop and manage project activities. These national working groups will be composed of experts who represent clinical expertise within the fields of orthopaedic surgery, cardiovascular surgery, endocrinology, and

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the subspecialty of diabetology as well as national wound care and podiatrist organisations. Policy makers, health administrators, and industry representatives will also be involved as dialogue partners.

The Nordic Diabetic Foot Task Force will be formalised during the first meeting of the steering committee, which is planned for October/ November 2013. The national working groups will also be established at this meeting.

The biennial Nordic Diabetic Foot symposium will be used as a forum for sharing knowledge of best practice and in this way aid in the promotion of guideline implementation. The symposium is thus an important tool to achieve the main objective of the project.

Next Steps Since the conference in May, the Nordic Diabetic Foot Task Force has been focused on gaining financial support to start the project activities.

Furthermore, an initial strategy meeting between the Chair and Co-chair has been conducted, and the first steering committee meeting will meet in October/November 2013.

In parallel, plans for the first Nordic Diabetic Foot Symposium are underway, and the symposium website will be launched within a month.

Further Perspectives As the first network of its kind, the Nordic Diabetic Foot Task Force will bring together national and international wound care clinicians from multidisciplinary backgrounds in a unique collaboration to promote the systematic implementation of diabetic foot guidelines in the Nordic countries.

Beyond this Nordic perspective, our wish and hope is that the work and success of this collaborative network will inspire the establishment of similar initiatives in other countries or regions to achieve a global implementation of the diabetic foot guidelines. m 83

EWMA as a partner in

Zena Moore Chair of the EWMA 2013 eHealth Symposium ewma@ewma.org www.ewma.org

Introduction As a partner in the European Union (EU)-funded United4Health project, EWMA has committed to developing a dissemination model for the purpose of demonstrating how knowledge regarding various aspects of eHealth can be communicated to an international audience of health care clinicians from a multidisciplinary background.

Overall motivation for EWMA’s participation In recent years, telemedicine has been increasingly utilised as a communication tool to help clinicians deliver more effective and efficient wound care.

However, until now the pattern of telemedicine implementation throughout Europe has been fragmented. One reason for this limited implementation of telemedicine might be that information regarding what may be achieved by applying these new technologies has not been systematically disseminated to the healthcare scientific communities, who are the end-users of such technologies.

ABOUT THE United4Health PROJECT United4Health builds on the Renewing Health project, which is currently validating a number of innovative telemedicine services. United4Health will utilize and expand these results and further deploy these telemedicine ­services to 15 regions across Europe in order to guarantee aggregation of data and comparability of results.

All service solutions adopt a patient-centred approach and involve the ­telemonitoring and treatment of patients with chronic diseases, such as ­diabetes, chronic obstructive pulmonary disease, or cardiovascular disease.

Services are designed to give patients a central role in the management of their disease, through fine-tuning the choice and dosage of interventions, thereby promote concordance with treatments, and enhancing the detection of early signs of patient deterioration. The effectiveness of the solutions will be evaluated using the Model for Assessment of Telemedicine (MAST) methodology, which has become the method of choice for evaluating health care projects.

Funding program: ICT Policy support programme, Pilot Type A ­Requested project coverage: 5M€. (Total project cost 11,3M€) ­Project period: 01.01.2013 - 01.01.2016 (Duration 36 months).

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BACKGROUND eHealth and ICT can play key roles in enhancing the capacity of health care practitioners to face the challenges associated with aging populations, more people living with chronic conditions, and growing demand for high-quality services, all set in the context of the finite resources now available.

It is envisioned that utilisation of eHealth will result in higher quality health care that is safer and more responsive to patient needs at lower costs. In some countries, the use of eHealth has already moved from local isolated pilot projects to large-scale ­national implementation plans.

The use of various new technologies in health care delivery is here a reality and will continue to affect the way health care is delivered.

In order to fuel a general interest in the use of these new technologies, EWMA considers it crucial that information about the capabilities and limitations of telemedicine reach a critical mass of the clinicians who are actively involved in day-to-day wound care. Only after the potential benefits of telemedicine are communicated to the end-users can real bottom-up demand for these services escalate. Increased demand will be essential to fuel the political and legal processes that must be influenced before the widespread and systematic implementation of these technologies can become a reality throughout Europe. It is against this background that plans for the United4Health dissemination models are being developed.

Developing a dissemination model Due to its experience in multidisciplinary collaboration and disseminating research evidence, EWMA is able to take a leading role within the United4Health consortium in developing a generic model demonstrating how to reach endusers with information regarding the benefits of eHealth and barriers to their implementation.

Since the launch of United4Health in January 2013, the main focus of EWMA’s activities within the project has been to develop and pilot some of the main components of this dissemination model for example: Primary elements of the dissemination model: 1) An eHealth symposium held at the EWMA conference 2) An eHealth guidance document

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eHealth Symposium at EWMA 2013 At its 2013 conference, EWMA had the opportunity to offer a full-day symposium relating eHealth to wound care.

The purpose of the symposium was to give the participants a clear understanding of the benefits of eHealth and the barriers to implementation of these new technologies in day-to-day care.

With this purpose, international experts, researchers, and end-users representing clinical staff and patients were invited to share their experiences and perspectives on introducing eHealth in routine wound care. The symposium was titled “Transforming health care delivery with new technology: The case of wound care.”

The symposium began with an overall discussion about how new technologies in general are expected to affect the way care will be delivered in the future and then moved on to case presentations that demonstrated how telemedicine has already been integrated into day-to-day wound care delivery in several European countries. The two subsequent sessions focused on how application of telemedicine is transforming the way care is being delivered and consequently how this leads to new patient and provider roles. The final session covered “real” users and all health care workers along the service delivery chain as well as patients and system developers were invited to give their perspectives on the pros and cons of using telemedicine.

In the final session of the day the discussions focussed on how to apply a sound methodological quality approach to research when evaluating the effect of telemedicine.

A workshop offering practical demonstrations of some of the technologies currently available on the market was also integrated into the program. The workshop concluded by pointing out what the future might bring (e.g., the integration of distant-monitoring sensors into bandages).

In order to demonstrate for other clinical communities how the various components of the symposium were put together, a short film about the event is currently in the making. The eHealth symposium was developed in close collaboration between EWMA and the Region of Southern Denmark.

Guidance document: eHealth in wound care By creating a guidance document on eHealth in wound care, EWMA wishes to offer clinicians clinical practice a brief overview of the main topics of concern within the field.

The guidance document will: n Be the starting point for a common language about eHealth within the wound-care community; n Serve as a useful tool for clinicians to get a rapid and structured overview of the key issues, including the benefits of eHealth technologies and the barriers to their implementation in routine wound care; EWMA Journal

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Point out key aspects to consider when designing studies of the effect of eHealth technologies and ensure that researchers pay attention to methodological pitfalls related to research in this area.

The goal is to present the final document at the EWMA conference in Madrid in 2014 and at international conferences within the domain of eHealth in general.

The guidance document will also be promoted to professional societies in other medical fields in order to demonstrate how a medical society can actively support its members by providing short and structured overviews of the key eHealth issues within their field.

Long-term perspectives Once the major components of the dissemination model have been assembled and the model has been pilot tested, EWMA has committed to approach other clinical communities in order to encourage and motivate them to disseminate eHealth information to their members and related stakeholders. In this perspective, through its commitment to the United4Health project, EWMA can be seen as taking a leading role in the design and development of models demonstrating how information about the potential benefits of eHealth and barriers to its implementation can reach a broad international audience of end-users. m

TERMINOLOGY1 eHealth: Covering in broad terms health care activities carried out over distance by means of Information and Communication ­Technologies (ICT). The term covers a range of services, such as electronic health records, telemedicine, consumer health informatics, virtual health care teams, use of mobile devices for collection of patient-level data for distant monitoring, software solutions for scheduling an appointment, etc.

Telecare: Remote and automatic (passive) monitoring of changes in an individual’s condition or lifestyle, including emergencies, to enable people to remain independent in their own homes by ­providing person-centred technologies to support the individual and/ or their caregivers. Examples: movement sensors, fall sensors, and bed/chair occupancy sensors.

Telehealth: The remote exchange of data between a patient and health care professional(s) to assist in the diagnosis and management of health conditions. Examples: remote blood pressure monitoring, blood glucose monitoring, and medication reminders.

Telemedicine: Remote transmission of patient information to a ­clinician for expert diagnosis and/or management.

Examples: MRI, X-rays, symptom reports.

1 There are no commonly accepted definitions of the listed terms. Usage of the terms varies, and the terminology presented in this folder is based on definitions found in WHO publications, PowerPoint presentations by highly acclaimed experts, review papers on the topic, and Wikipedia.

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EWMA 2013

THE RUSSIAN SPOKEN SYMPOSIUM Background and objectiveS

Since 2006, EWMA has engaged in various activities to support and advocate the implementation of modern wound care in Russia and the neighbouring countries of Belarus and Ukraine to provide Russian wound patients Rytis Rimdeika Chair of the EWMA 2013 Russian Symposium ewma@ewma.org www.ewma.org

with access to the international standards of best practice wound care.

To reach this objective, activities to date have ­focused on the following: n Disseminating information about international standards of best treatment practices; n Increasing awareness among physicians, nurses, and decision-makers about the challenges and opportunities of chronic wound treatment;

n Establishing network opportunities and facilitating contacts between clinicians in countries where Russian is widely spoken and the rest of Europe to encourage knowledge sharing and multidisciplinary collaboration.

EWMA conference 2013: One important strategy to reach the objectives of these advocacy activities has been to involve Russian-speaking participants in the annual EWMA conference through the Russian symposium. As in 2009 and 2012, the Russian symposium activities were integrated as part of the annual EWMA conference program. The symposium spanned two full days of presentations and was offered with simultaneous Russian and English translations.

The program included high-level clinical scientific presentations as well as presentations on organisational aspects of modern wound care management, including the implementation of guidelines, the reimbursement of services, and wound care education. In addition, selected sessions from the main EWMA conference programme were

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provided with simultaneous Russian and English translations.

In addition to the scientific programme, the symposium also provided unique networking opportunities to exchange experiences and evaluate practices with other key opinion leaders and practitioners.

Including the first EWMA-supported meeting offered in Russian by the Lithuanian Wound Management Association in 2006, the 2013 conference is the fourth in which EWMA has successfully arranged special conference activities for a Russian-speaking audience. This success is reflected by the fact that an increasing number of researchers and clinicians from the Russian-speaking region participate in EWMA conference activities.

This year, a total of 132 participants originated from Russian-speaking countries, and 8% of all abstracts submitted to the general programme were authored by Russian-speaking participants.

The Russian symposium concluded with a final panel debate among selected key opinion leaders to discuss the steps necessary to move forward with the implementation of best practice wound care in Russian-speaking countries and the main implementation barriers that currently exist.

A closed key stakeholder meeting was arranged as a follow-up to this debate. The purpose of this meeting was to define an implementation strat-

egy for EWMA’s continued advocacy work in the Russian-speaking region and decide which activities to prioritize in the first phase of the project. The meeting included participants from general wound experts and diabetic foot experts from the Russian-speaking region as well as EWMA council representatives and industry partners.

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ference activities provides evidence that the EWMA is successfully engaging Russian-speaking participants in discussions and research topics on modern wound care that are important agenda items not only in Russian-speaking countries, but also in other parts of Europe.

EWMA conference 2014: The EWMA 2014 Conference will be held in Madrid, Spain. EWMA encourages participants from the Russianspeaking region to submit their abstracts and posters for the general programme by the 1 January 2014 deadline.

As a special offer to the Russian-speaking audience, the 2014 conference programme will include a series of workshops designed to specifically address topics of interest among Russian-speaking countries.

Other Activities planned for 2013-2014 EWMA will continue to actively collaborate with local wound care organisations and participate in national wound care meetings through EWMA guest sessions.

Upcoming appearances by EWMA clinicians and Secretariat staff in national wound conferences in the region include: n An EWMA presentation at the annual Russian Burns Association meeting from 13-16 Oct 2013. n An Epidermolysis Bullosa workshop/seminar in Moscow hosted by Rytis Rimdeika and the Russian foundation “Bella” as a continuation of the Russian Burns Association meeting in October 2013; n An EWMA presentation by Rytis Rimdeika at the 2013 “Clean Wounds” Conference in Kazan, Russia;

n EWMA guest sessions at future wound conferences in Russia (Clean Wounds 2014 and others), the Ukraine (UWTO), and Belarus (SWH Belarus).

EWMA will plan these guest sessions, invite speakers, and offer Russian and English translations.

Visit EWMA on our Social Media platforms Follow us and get the latest ­updates about EWMA activities:

www.facebook.com/ EWMA.Wound

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

Twitter: @ewmatweet

Thanks to all supporting partners

EWMA wishes to thank all supporting partners that have helped make these activities possible: Hartmann, Lohmann & Rauscher, Schülke Mayr.

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COME ON DAY 1 FOR THE WHS‐only MEETING DAY. STAY FOR THE BROAD SPECTRUM OF BASIC AND CLINICAL RESEARCH AND EVIDENCE‐BASED PRACTICE!

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THE UNIVERSITY CONFERENCE MODEL:

THE JOURNEY SO FAR Introduction The University Conference Model (UCM) has set a precedent for increasing international participation in wound education at the European Wound Management Association (EWMA) conference since its development in 2007 (Flanagan 2007).

Over 300 students worldwide have successfully participated in this unique and stimulating initiative, which provides participants with additional interactive learning activities that complement the main EWMA scientific programme. Participation in the UCM has recently extended beyond Europe to students from countries as diverse as Iran, Portugal, Slovenia, the United Arab Emirates, Greece, the United Kingdom, Lithuania, Iceland, Czech Republic, Taiwan, and Switzerland, and is supported by a growing number of educational institutions, including the University of Hertfordshire, the Lithuanian University of Health Sciences, HUB Brussels, Danube University (Austria), and the Catholic University of Portugal.

Donau Universität Krems Austria

Haute École de Santé Geneva, Switzerland

HUB Brussels Belgium

Lithuanian University of Health Sciences Lithuania

University of Hertfordshire United Kingdom

Universidade Católica Portuguesa Porto, Portugal

The UCM has proven to be an immensely successful way for universities with EWMA-approved wound management courses to utilise the EWMA conference programme as a supplement to their curriculum. Following the intense 3-day EWMA 2013 conference, UCM participants engaged in

a range of additional interactive online learning activities and complete a study programme developed by the course directors from their respective educational institutions. Because the study programmes varied across institutions, students participated in a variety of learning activities, including small group sessions with peers from their own institution and larger plenary sessions with participants from other institutions. Participants were actively engaged throughout the conference by attending selected sessions during the scientific programme, such as workshops, debates, plenary sessions, satellite symposia, and free paper sessions, as well as activities related to the other learning opportunities available at the conference.

Madeleine Flanagan Principal Lecturer, Postgraduate Medicine, University of Hertfordshire, UK. Cordinator of the University of Hertfordshire UCM group

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

VOICES FROM THE FIELD A total of 52 students from 6 universities ­participated in the UCM activities at the 2013 EWMA conference in Copenhagen.

During the 3-day conference, UCM ­participants followed a programme of activities organised by the university coordinators as a supplement to the main EWMA scientific p ­ rogramme.

Although participants are c­ hallenged to remain focused over an intense 3-day period, the ­concept of the UCM is considered a successful setting for learning.

This year in Copenhagen, UCM students also attended an informal pre-conference session, which provided an opportunity to discuss planned conference activities and network with other participants as well as the UCM group facilitators. This pre-conference session was specifically designed to improve networking opportunities among the participants and facilitate group cohesion. Participants were encouraged to share their best practices and compare service provisions and clinical issues from their respective countries. This pre-conference session therefore provided many participants with a unique opportunity to learn about international practices and understand the cultural context of wound management in different countries. 

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The UCM approach has been enthusiastically accepted by participants from all disciplines, including doctors, nurses, pharmacists, and podiatrists, and is flexible enough to support undergraduate students who are preparing for professional practice as well as experienced postgraduate clinicians. The participants in the UCM programme bring a wealth of professional experience, which greatly enhances the learning opportunities that are available during the conference. Most participants are experienced health professionals who specialise in wound management and value the excellent networking opportunities that the UCM programme provides. The success of the UCM programme has promoted the collaboration of inter-professional teams within a multi-cultural context and created a network of professional wound care specialists.

Facilitating adult learning The teaching and learning styles implicit in the UCM are centred on the principles of adult learning that were pioneered by Knowles, which are recognised today as the values underlying modern adult educational theory (Knowles 1980). As adult learners, health professionals expect continuing education to be personalised, clinically relevant, problem-based, and self-directed (Atherton 2005). One benefit of the ‘real world’ environment of the Although the intensity of the programme received some criticism, participants reported an overall satisfaction with the UCM activities. Feedback from participants mentioned the professional yield, network opportunities, knowledge exchange, and presentation of new information and tools as ­highlights. Participants also reported that the UCM provided: – inspiration to undertake a research study and submitting abstracts for future conferences.”

– “insights into different health care systems in Europe and viewing new innovations in products with an open but critical mind.”

– “a deeper understanding and appreciation for other wound care practitioners from around the world.”

EWMA conference is that the UCM enhances the participant’s ability to operate as both an experienced clinician and independent learner. Although some elements of the participant’s timetable is pre-determined, the programme includes significant flexibility in the choice of symposiums, workshops, and free paper session to provide the participant with a uniquely individual learning experience, which one participant says “fits exactly with where I am currently professionally as a wound specialist”.

Students in UCM programmes consistently report that this approach enables the development of critical thinking

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and creativity, which is a significant part of the learning process (Melby; Wichmann 2012). In contrast to passively accepting research findings as presented by speakers during the plenary sessions, students are encouraged to debate and challenge presenters in the UCM programme and reflect on the value of these sessions during post-session group discussions. Another advantage of the UCM learning experience is that the knowledge gained is not confined to the formal conference programme, but extends into the social events and additional activities, such as the poster judging session and the exhibition review exercise. One of the most popular sessions, which was introduced last year, is the Industry Symposia Review Exercise. This session was conducted during a plenary session with students from all participating universities and stimulated lively debate in a safe and confidential environment.

Academic staff from participating universities were available throughout the conference to support their students.

In recent years, academic staff have also enjoyed working together in teaching teams to facilitate research critiquing workshops, which have been evaluated positively by participants. Students report many advantages of these teaching teams, including exposure to teachers from different countries and the opportunity to share and appreciate diverse perspectives.

Evaluation and reflection Student feedback is a key component of the UCM, and participants are expected to submit a written critical evaluation of their learning experience. Constructive criticism from participants has enabled UCM facilitators to improve the student experience year after year. Such feedback has indicated that students particularly value the following features of the UCM: n Meeting and sharing best practices with international colleagues n Participating in a dynamic mix of learning activities during a major international conference n Developing critical appraisal skills n Experiencing the expertise of an international wound care community In the words of one student, “These experienced speakers presented a ‘real life’ view of best practice, current opinion, debate, and evidence base which was both inspiring and challenging, and reinforced my drive, motivation, and determination to develop my practice and local wound management services.”

The intensity and pace of the learning activities can be a challenge for the students. Although the programme includes time for informal networking with peers, colleagues,

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EWMA 2013 UCM group photo

and wound care experts, time constraints often limit these interactions. In addition, although most sessions are positively evaluated by students, the risk of information overload is a significant challenge for both students and UCM facilitators. The sheer volume of scheduled activities is a positive aspect of the UCM programme, but can leave students and facilitators physically and mentally exhausted by the end of the conference.

Different parts of the programme have different value to different participants. Presentation styles, language abilities, and the personal relevance of sessions influence the overall experience of the individual. However, less polished

MD Ernest Zacharevskij and MD Gediminas Samulenas, UCM participants from Lithuania at EWMA 2013 in Copenhagen: Participating in the UCM activities was a pleasure and great experience. This was my second time participating, and each year we improve our ­analytical skills and, ­notably, learn to obtain more benefit from the conference sessions. The UCM modules help students develop an independent attitude to the information presented at the ­conference and critically assess innovations, new products, and recent recommendations in wound healing. I like to compare the UCM to a school where participants are educated about how to be an optimal listener.

The UCM is a great activity that accelerates our development and enriches our knowledge by filling all the gaps while remaining focused on the basics. We are grateful for the opportunity to ­participate in the UCM activities. For us, the UCM provides not only a path to advanced knowledge, but is also a great inspiration! Thank you!

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presentations provide opportunities for UCM facilitators to encourage analytical comments, reflection, and debate in a confidential, relaxed, and safe atmosphere.

Conclusion Students and teachers unanimously agree that the UCM is a positive and dynamic experience that maximises learning opportunities at the EWMA conference. The UCM has also provided some students with the opportunity to present in the free paper sessions, which facilitates their ability to gain confidence as active participants and establish their own expertise in wound management.

From the outset, the UCM appears to have fulfilled its ambitions to be an effective, collaborative, educational approach that demonstrates the achievements that are possible when subject specialists, academics, clinicians, and industry representatives work together to provide a unique and clinically relevant learning experience. The uniqueness of the UCM was summarized in the opening session at this year’s conference in Copenhagen: “This initiative gives EWMA an outstanding perspective as it doesn’t only attract international students, but also provides them with a framework for learning”. Plans are already underway for more universities to participate in the UCM at next year’s EWMA Conference in Madrid. m

References Atherton J S (2005) Learning and Teaching: Knowles’ andragogy: an angle on adult learning [On-line] UK: Available: www.learningandteaching.info/learning/knowlesa.htm Flanagan, M. (2007): Evaluating the pilot of the first course delivered using the EWMA University Conference Model at the EWMA Conference Glasgow, May 2007. EWMA Journal Vol. 7, no. 3, October 2007 Knowles, M. S. (1980): The modern practice of adult education: From pedagogy to andragogy. Englewood Cliffs: Prentice Hall/Cambridge.

Melby, B. Ø, Wichmann, S. (2012): EWMA UCM Experience 2012. EWMA Journal Vol. 12, no. 3, October 2012

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Home Care – Wound Care

EWMA NEWS

Antimicrobials and Non-Healing Wounds

During the Home Care – Wound Care key session at EWMA 2013 in Copenhagen, the background for publishing the Home Care – Wound Care ­document was presented by Dr. Sebastian Probst, chair of the Home Care – Wound Care working group.

To exemplify the issues and challenges of wound treatment, two Danish studies regarding the outcomes and economic aspects of outgoing wound specialist nurses providing treatment in patients’ own homes were presented followed by a panel discussion.

Dr. Sebastian Probst, presented the background for publishing the Home Care – Wound Care d ­ ocument

available for free download The EWMA Document on Antimicrobials was published in Journal of Wound Care (JWC) and is available for free ­download at www.ewma.org.

In this document leading wound experts describe the controversies surrounding the use of antimicrobials (antibiotics and non-antibiotics) in wound management and how to increase interest in ways to solve these problems for the future use of antimicrobials.

Proactive Dissemination The launch of this document is not the end – it is the beginning!

The intention of the document is to present a platform of viewpoints from which we can generate messages for different stakeholders, including patients, health professionals, policy makers, politicians, industry, and hospital administrators.

EWMA takes this commitment seriously and, in addition to ­presenting the document at conferences, we aim to give the document a long meaningful life through various dissemination and advocacy activities.

This fall, an executive summary and short policy paper providing clear recommendations for policy makers will be published.

The presentations demonstrate that the management of chronic wounds in Europe has undergone a dramatic shift in the location of service delivery from the hospital towards home care settings. As a result, the number of hospital facilities and the number of hospital beds have decreased. Patients are more often being treated at home. Agencies that provide home care do not only supply products but equally various services, including the support, advice, and training for patients and relatives.

The document is planned to be published in spring 2014.

Among other things, it will include a set of recommendations for the minimum requirements regarding wound care in a home care setting and results from a survey recently conducted among EWMA Cooperating Organisations aimed at mapping the approach to organising wound care in home care settings in different European countries.

UPCOMING PROJECTS IN 2014 -2015:

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Pressure Ulcers in Spain

Guidance document on eHealth in wound care

The project will advocate for implementation in 1-2 selected regions of internationally recognised pressure ulcer guidelines as well as for the ­continued allocation of funding for the use of modern wound care products for treatment and prevention of pressure ulcers.

The document will provide an overview of commonly used terminology and eHealth technology currently ­prevailing.

The document will highlight main aspects to be considered when implementing these technologies in daily clinical practice and undertaking research within this field.

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Multidisciplinary Treatment

Wound Survey Denmark:

scheduled for publication in 2014

The article Point Prevalence of wounds and cost impact in the acute and community setting in Denmark was published in August in the Journal of Wound Care (JWC; Volume 22, Issue 8, 07 Aug 2013, pp 413-422).

EWMA believes in a multidisciplinary approach to wound care because this is the key to developing the most appropriate trajectory of care for patients with wounds. Indeed, adopting a multidisciplinary approach to wound care embraces the underlying principles of patient safety and ethics in health care delivery; i.e., that individuals with wounds have the right to expect that they will receive the correct care from the most appropriate health care professional, who is trained and competent to provide the specific care planned.

To promote the use of a multidisciplinary approach to wound care, the Multidisciplinary Treatment Project is now launched and we are proud to announce that the document will be produced as a truly global project, written and published in full collaboration with the Association for the Advancement of Wound Care (AAWC) in the USA and the Australian Wound Management Association (AWMA).

The overall goal of this pioneering project is to provide a structure for the adoption of a multidisciplinary approach to wound care. To achieve this goal, we intend to map the challenges and barriers facing multidisciplinary teams and identify the basic criteria that must be fulfilled for a multidisciplinary approach in the context of different healthcare systems.

The author group is working on the project at the present time and the document is scheduled for publication in early 2014.

– read the article

The article investigates the wound-related costs for two Danish hospitals and home care services in the corresponding municipalities. It was found that the total annual costs for treatment (including hospitalisation) amounted to approximately 1.6-1.8% of the annual budgets for the hospitals and 1.52.4% for the municipalities, findings that are in line with previous studies from the United Kingdom. The main cost factors were hospitalisation costs and staff time, and the level of costs related to wound care once again underscores the importance of securing better wound prevention and treatment.

The ‘Wound Survey Denmark’ is part of the EWMA Patient Outcome Group’s initiative to support better evidence in wound care. With the ‘Wound Surveys’, EWMA aims to investigate the resource costs of wounds in different European countries, thereby accumulating further evidence in the long term to support decision making regarding possible structural changes to wound management procedures.

The study in Denmark was supported financially by the TrygFonden foundation, and “Fonden til støtte af sygdomsramte erhvervssaktive borgere”. Unrestricted educational grants have been given by Convatec, Mölnlycke Healthcare, KCI and Smith & Nephew.

The authors of the wound survey study are: Finn Gottrup, Prof, MD1; Eskild Henneberg, MD2; Rikke Trangbæk, RN2; Nina Bækmark, RN3; Kristina Zøllner, RN3; Jan Sørensen, MD3 1. Copenhagen Wound Healing Center, Bispebjerg Hospital, Copenhagen, Denmark 2. The Wound Center, Department of Vascular Surgery, Regionshospitalet Viborg, Viborg, Denmark 3. The Wound Team, Hillerød Hospital, Hillerød, Denmark

DEBRIDEMENT DOCUMENT now translated into German and Italian The EWMA Debridement document, which was published in ­Journal of Wound Care (JWC) in January 2013, has now been translated into German by ICW and Italian by AISLeC. The two new versions of the documents are also available ­online at www.ewma.org. Further translations are currently being ­prepared by several EWMA Cooperating Organisations.

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EWMA’s commitment to

WOUND CARE ADVOCACY ACROSS EUROPE

Salla Seppänen, EWMA President and Chair of the EWMA Advocacy Group ewma@ewma.org www.ewma.org

EWMA continues its commitment to work towards the acknowledgement of wounds as an important patient safety concern across Europe.

At present, both the European Parliament and EU Commission has a strong focus on this aspect and are working with EWMA and the European Pressure Ulcer Advisory Panel (EPUAP) trying to ensure that pressure ulcers are given top priority.

Presentation on 30 May 2013 to the European Parliament Represented by Professor Zena Moore EWMA was invited to present on the topic of “Prevention of Healthcare-Associated Infections” at the Workshop on Patient Safety1 organised by the European Parliament on 30 May 2013.

Professor Moore focused her presentation on the basic epidemiology of wound care, including the prevalence and incidence rates of pressure ulcers. She emphasized that an estimated 4-5% of total annual health care budgets are related to pressure ulcer management. Professor Moore stressed the importance of multidisciplinary teamwork as well as education and training as important aspects of the patient safety agenda.

The purpose of the workshop was to provide a forum in which to propose amendments to the European Parliament’s draft initiative report on ‘Patient Safety’ in preparation for a discussion with the Committee on Environment, Public Health, and Food Safety (ENVI) on 20 June 2013. Following the workshop, members of the European Parliament had the opportunity to propose amendments for the draft report. Proposed amendments included text pieces that will establish the prevention of pressure ulcers as one practice to increase patient safety.

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EWMA will follow the progress of the draft report until its expected final approval at the end of October 2013. The final report will provide guidance for a future revision of the recommendations of the European Commission regarding patient safety. It is therefore crucial that the EWMA continues to raise awareness about wound care among politicians and policy makers by promoting the prevention of pressure ulcers for patient safety.

Continued Focus on Active and Healthy Ageing At the EU Commission level EWMA works on patient safety and other key aspects of organisation of wound care through initiatives such as the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA). EWMA has been a partner of the EIP-AHA since its start in 2012.

The EWMA attended the most recent meeting of the EIP-AHA in Brussels on 7 June 2013 along with more than 100 members representing health care associations, institutions, and regions across Europe. This meeting provided the first opportunity for the 9 established working groups to meet.

EWMA is participating in the working groups on Workforce Development and Care Pathways.

These two working groups focus on areas in which EWMA can contribute to the agenda as well as increase its network.

The working group on Care Pathways will initially focus on elaborating a care pathway for Chronic Respiratory Disease, but wound care has been proposed as a future area of focus, and EWMA has committed to contribute to this activity. It is expected that the upcoming EWMA document on Multidisciplinary Approaches To Wound Care will provide the first steps towards a clarification of the role of care pathways within wound care.

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EWMA expects to contribute to the working group on Workforce Development with experiences from the work of the Education Committee as well as the European Teacher Network, which was established in 2012.

For further information about the EIP-AHA, please visit: http://ec.europa.eu/research/innovation-union/index_ en.cfm?section=active-healthy-ageing Pressure Ulcers and Patient Safety in Spain EWMA is currently together with GNEAUPP (The Spanish National Group for Studies and Advisory on Pressure Ulcers and Chronic Wounds) preparing a project which will put focus on pressure ulcers, patient safety, and austerity measures in Spain.

The project, on which the European Pressure Ulcer Advisory Panel (EPUAP) will also become a partner, aims to advocate for the implementation of internationally recognised pressure ulcer guidelines in 1-2 selected regions of Spain. The project will also advocate for the continued allocation of funding towards the use of modern wound care products for the treatment and prevention of pressure ulcers.

The project will be started in 2013, and include presentations during the EWMA-GNEAUPP 2014 conference on 14-16 May in Madrid. The project is expected to be completed in 2014. m 1 Meeting materials are available at: http://www.europarl.europa.eu/document/ activities/cont/201305/20130524ATT66710/20130524ATT66710EN.pdf

Make a difference in clinical practice Become a Member of EWMA

Benefits of your EWMA Membership: n You make a difference in clinical practice within wound management in Europe n Right to vote and stand for EWMA Council n EWMA Journal sent directly to you two times a year n EWMA news and statements sent directly to you n A discount on your registration fee for EWMA Conferences n Right to apply for EWMA travel grants n Yearly membership fee € 25 n Yearly membership fee for members of cooperating organisations € 10

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

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COOPERATING ORGANISATIONS BOARD MEETING

A

t this year’s Cooperating Organisations Board Meeting I had, as the chair, the pleasure of welcoming a total of 48 participants, including 37 Cooperating Organisation Board Members or appointed substitutes and 11 representatives of the EWMA Council, invited speakers, and visitors.

Zena Moore Past chair of the ­Cooperating­ Organisations Board ewma@ewma.org www.ewma.org

Cooperating Organisation representatives in the EWMA Council The two candidates for the EWMA Council were Arkadiusz Jawien (PWMA, Poland) and Knut Kröger (ICW, Germany). No election took place because there were only two candidates presented for two vacancies. On behalf of the EWMA Council, I welcome the two new members for the next 3 years of work and collaboration.

Barbara den Boogert-Ruimschotel stepped down as Council member. Her work for the EWMA Council is acknowledged in a separate entry in this

issue of the EWMA Journal. Dubravko Huljev also ends his term as Council member elected by the Cooperating Organisations, but continues in the EWMA Council as he was elected Honorary Secretary in 2012.

Presentations and debate sessions The following presentations took place during the board meeting: n Feedback to the Cooperating Organisation’s Board on activities carried out during the latest year, facilitated by Barbara den Boogert-Ruimschotel and Dubravko Huljev. n Information about future EWMA conferences and project activities, presented by Zena Moore. n UCM Survey, presented by Zena Moore. n Presentation of the EWMA Home Care Wound Care project and possibilities for involvement of the Cooperating Organisations, by Sebastian Probst, Council Member and Chair of the working group

EWMA Council member Dubravko Huljev is presenting the latest EWMA activities

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Debate Session during the meeting

n

The Patient Safety Agenda: EWMA activities at the European level and possibilities for involvement of the Cooperating Organisations, by Zena Moore

During the presentation on EWMA future conferences and project activities, Zena Moore announced that EWMA 2015 will be held in London, United Kingdom, in collaboration with TVS (Tissue Viability Society). Furthermore, EWMA 2016 will take place in Bremen, Germany, in collaboration with Chronic Wounds Initiative (ICW).

The group debate sessions focused on: 1) The Home Care Wound Care project, and 2) The Patient Safety Agenda of EWMA. These debate sessions were characterised by animated discussions among the groups and provided many constructive comments and ideas on how to get the Cooperating Organisations involved in the projects.

Two groups discussed how the Cooperating Organisations might contribute to the EWMA Home Care Wound Care Project. The participants thought it important that the patient’s perspective is included. Furthermore, they emphasised that ideally there should be three versions of the document: a patient-friendly version, a professional version, and a version for institutions.

Two other groups focused on the Patient Safety Agenda and how the Cooperating Organisations can actively contribute to driving the agenda across Europe. They considered it important that everyone gets involved through their local media and by raising public awareness. Additionally, the different organisations should collect information about the current situation on a national level.

Evaluation of the board meeting The Cooperating Organisations Board meeting was evaluated by the Board members through an on-line survey.

In general there was great satisfaction with the meeting (70% found the meeting good or very good, 90% thought that the duration of the meeting was appropriate, 90% were very satisfied with the information given prior to the meeting).

Some pointed out the language barrier as an issue.

Therefore, it would be a good idea for a moderator to guide the group debates in future meetings.

Suggestions for themes and debate topics for future meetings include: n The process of adopting EWMA guidelines in the Cooperating Organisations n Themes of patient well-being or living with chronic wounds and how to continue to raise the agenda of chronic wound care with key stakeholders. n Models of clinical practice in wound management n Telemedicine n The multidisciplinary team n EWMA and politics, WHO Acknowledgements I would like to thank all meeting participants for their constructive and progressive input and for their contributions to continued development and collaboration between the EWMA Cooperating Organisations.

I would also like to take this opportunity to wish my successor as Chair of the Cooperating Organisations Board, Jan Apelqvist, very good luck in the job. Go n-éirí an bóthar leat (may you succeed on the road; Irish Gaelic).

m

For a full list of the EWMA Cooperating organisations please visit the website: www.ewma.org/english/cooperating-organisations EWMA Journal

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EWMA

Corporate Sponsors Corporate A BSN medical GmbH www.bsnmedical.com www.cutimed.com

Coloplast www.coloplast.com

ConvaTec Europe www.convatec.com

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KCI Europe Holding B.V. www.kci-medical.com

Lohmann & Rauscher www.lohmann-rauscher.com

Flen Pharma NV www.flenpharma.com

Mölnlycke Health Care Ab www.molnlycke.com

Sorbion AG www.sorbion.com

Systagenix Wound Management www.systagenix.com

Corporate B ArjoHuntleigh www.ArjoHuntleigh.com

DryMax www.absorbest.se/ drymax-woundcare

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MediWound Ltd. www.mediwound.com

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Abbott Nutrition www.abbottnutrition.com

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Drawtex www.drawtex.com

Nutricia Advanced Medical Nutrition www.nutricia.com

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Laboratoires Urgo www.urgo.com

Welcare Industries SPA www.welcaremedical.com

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Organisations

Conference Calendar Conferences

Theme

12th National Wound Management Conference of The Wound Management Association of Ireland (WMAI)

2013

Days

City

Country

Oct

1-2

Cork

Ireland

Pisa International Diabetic Foot Courses 2013

Management of the Diabetic Foot

Oct

2-5

Pisa

Italy

Annual Conference of the Dutch Organisation of Woundprofessionals (NOVW)

Players in Wound Care

Oct

7-8

Ede

The Netherlands

11th School of Wounds by the Associative Group of Research in Wounds (GAIF)

Oct

9-12

Peniche

Portugal

WundD•A•CH Congress 2013 (AWA, ICW & SAfW)

Oct

10-12

Friedrichshafen Germany

Oct

15

XVI Wound Congress of the Hungarian Wound-management Association (MSKT)

Oct

IV International Symposium of the Croatian Wound Association (CWA) VI Ibero-Latin American Congress about Ulcers and Wounds (SILAUHE)

The 7th National Congress of Wound Care (BEFEWO in collaboration with CNC & AFISCeP.be)

Uccle

Belgium

17-18

Budapest

Hungary

Oct

17-19

Primosten

Croatia

Oct

23-25

Santiago

Chile

Oct

23-25

Reims

France

IV Brazilian Congress of Wound Care (SOBENFeE)

Nov

12-15

João Pessoa, Paraíba

Brazil

15th Anniversary of the Portuguese Association for the Treatment of Wounds (APTFeridas)

Nov

21-22

Exponor (Porto) Portugal Toledo

23rd European Tissue Repair Society Annual Meeting (ETRS)

From good practice to practice of wound care

Stem Cells and Regenerative Medicine

III Congress of the Spanish Society of Wounds (SEHER)

Nov

21-23

14th Congress of the Woundcare Consultant Society (WCS)

Nov

26-27

Spain

8th National Wound Care Conference of the Wound Management Association of Turkey (WMAT)

Nov

28-1

Antalya

Turkey

Symposium of the Serbian Wound Healing Society (SWHS)

Dec

15

Belgrade

Serbia

The Netherlands

2014 18th National Conference of the French and Francophone ­Society of Wounds and Wound Healing (SFFPC) XI National Conference of the Czech Wound Management ­Society (CSLR)

Interdisciplinary collaboration in the treatment of wounds and skin defects

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

Jan

19-21

Paris

France

Jan

23-24

Pardubice

Czech Republic

Jan

30-31

Helsinki

Finland

Annual Conference of the Norwegian Wound Care Society (NIFS)

Multidisciplinary approach to wound management in primaryand specialist care

Feb

6

Tromsø

Norway

2nd International Course on The Neuropathic Osteoarthropathic Foot (Charcot Foot Course)

Advanced Postgraduate Course

Apr

10-12

Rheine

Germany

Apr

23-27

Orlando

Florida

May

7-10

Brisbane

Australia

24th Conference of the European Wound Management ­Association (EWMA)

May

14-16

Madrid

Spain

15th European Federation of National Associations of ­ Orthopaedics and Traumatology (EFORT)

Jun

4-6

London

United Kingdom

Spring Symposium on Advanced Wound Care and Wound Healing Society (SAWC) 10th National Conference of the Australian Wound ­Management Association (AWMA)

A gold standard: Research and clinical practice

Annual Congress 2014

Biofilm Procedures Course

Jun

Copenhagen

Denmark

17th Annual European Pressure Ulcer Advisory Panel (EPUAP) Meeting

Aug

26-29

Stockholm

Sweden

Diabetic Foot Study Group (DFSG) 2014

Sep

12-14

Bratislava

Slovakia

24th European Tissue Repair Society Annual Meeting (ETRS),

Oct

Edinburgh

United Kingdom

Pisa International Diabetic Foot Courses 2014

Oct

Pisa

Italy

For web addresses please visit www.ewma.org

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WAWLC World Alliance for Wound and Lymphoedema Care

Eric Comte Medical director MSF Suisse www.msf.ch

Hubert Vuagnat, MD Department of Medical ­Rehabilitation and Palliative care, Geneva University Hospitals, Switzerland WAWLC Treasurer www.wawlc.org

Wound Care in ­Resource-Poor Settings This year, the EWMA continued its commitment to the topic of wound care in resource-poor settings by providing the World Alliance for Wound and Lymphedema Care (WAWLC) with the fantastic opportunity to organise a full day “WAWLC Stream” at the 2013 EWMA Conference in Copenhagen. This WAWLC Symposium included two sessions that were organised in collaboration with “Médecins sans Frontières” (MSF) and a guest session that was organised in collaboration with Step

by Step, the International Diabetes Foundation’s diabetic foot care programme in the developing world, chaired by Prof. Karel Bakker.

The first MSF session, which was chaired by Dr. Hubert Vuagnat from Geneva University Hospitals, focused on the use of negative pressure wound therapy (NPWT) for wound treatment in resourcepoor settings. The NPWT technique is an important tool in the wound treatment arsenal, but is viewed as too sophisticated and costly for use in this type of environment. Four speakers shared their positive clinical experiences with NPWT: Dr. John Macdonald, who set up a wound care clinic widely using the help of NPWT in Haïti in the aftermath of the 2010 devastating earthquake; Dr. Corrado Durante, who is an army surgeon with practice in war theater and field hospital experience; Dr. Daniel Stoffel, who has 10 years of experience with NPWT in Lambarene’s hospital in Gabon (Africa); and Dr. Danielle Zurovick, an MIT engineer whose experience with the development of a simple and cheap mechanical NPWT device is presented in a short article on the next page. This cumulative experience clearly demonstrates that NPWT is both usable and useful and should therefore be considered for wound treatment in resource-poor settings.

The WAWLC Symposium included a guest session by the Step by Step programme, which was chaired by Prof. Karel Bakker.

This session focused on the successes and future of this diabetic foot programme and featured a presentation about the “Train the Foot Trainer” programme, which was delivered by Dr. Stephan Morbach, Dr. Nalini Campillo, and Prof. Maimouna Ndour Mbaye.

Two additional sessions, which were chaired by WAWLC President, Dr. David Keast, featured experiences in wound care from around the world, including presentations from Dr. Kingsley Asiedu, Head of the WHO Neglected Tropical Diseases programme, and abstracts submitted by collaborators and contributors to the WAWLC programme from ­Australia, Haiti, and Switzerland.

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WAWLC Symposium participants sharing knowledge and experinces on wound care in ressource poor settings

The second MSF coordinated session was a roundtable discussion of more than 20 experts worldwide to debate the minimum material that is needed to constitute a standard wound care kit, which would be used in the field by either NGOs or the World Health Organization (WHO). This roundtable was led by Dr. Eric Comte, the medical director of MSF Switzerland, who contacted most of the invited participants prior to the meeting to develop a preliminary list of materials through a two-round DELPHI method. Three-quarters of the list were discussed during the roundtable; the remainder of the list was left to be settled through internet sessions. In addition to the types of material to be included in the kit, other details were also discussed, such as the quantity of materials to include, as well as the possibility of dividing the kit to deliver material to more than one health centre or to provide an individual with material for a given number of dressings. The roundtable also debated the crucial question of necessary training and instruction. Although the invited participants agreed that the development of a standard kit is difficult, all agreed that a standard kit is a necessity to establish advanced wound treatment as part of humanitarian interventions.

These two MSF sessions as well as the entire WAWLC Symposium clearly demonstrated both the necessity of introducing advanced wound care in resource-poor settings and the willingness of individuals and societies to do so. m

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Organisations

NPWT the sustainable way WAWLC World Alliance for Wound and Lymphoedema Care

Danielle Zurovcik1 PhD in Mech. Eng. CEO & Founder at WiCare Gita Mody, MD2 Robert Riviello, MD2 1Worldwide

Innovative Healthcare (WiCare), Cambridge, MA,

2Department

of Surgery, Brigham and Women’s Hospital, Boston, MA www.WAWLC.org

Negative pressure wound therapy (NPWT), the application of low vacuum pressure to an open wound bed, has been proven to promote healing in acute and chronic wounds. Although the value of NPWT has been recognised as being desirable across global settings, its use is currently limited to high-end treatment in hospitals in the developed world.

NPWT devices are not widely accessible due to many constraints: they cost approximately €11.5-15.3K / device ($15-20K / device) or €76.6 /day ($100 / day) for a period of 4 weeks to 4 months; they require more than 70 Watts of ­electrical power; training is necessary because of their complex computer interfaces; and they are not portable due to their bulky size (approximately 16.4e3 cm3; 1000 in3) and weight (approximately 4.5 kg; 10 lbs).

We have developed a patent-pending device called the Wound-Pump that costs less than €2.3 ($3) to manufacture, requires no electricity, is ­simple to use, and is very portable, being smaller than a soda can (~328 cm3; 20 in3) and weighing less than 0.23 kg (0.5 lb). Application of the Wound-Pump is simple: the wound dressing is changed, the mechanical pump is compressed by hand, and then three days later, these two steps are repeated.

Danielle Zurovcik (left) and Dr. Gita Mody (right) monitor the Wound-Pump on one of their patients at University Central Hospital of Kigali (CHUK).

EWMA international Partner Organisation EWMA Journal

Our team strongly believes that in order to design truly global solutions that reach the largest patient population, part of the development work must physically take place in low-resource settings (LRSs) to identify problems that could not be predicted in a laboratory or developed world hospital setting and develop appropriate solutions.

2013 vol 13 no 2

The Wound-Pump technology was deployed during the Earthquake Relief Effort in Haiti in 2010 and tested in a phase I clinical study in Rwanda in 2011- 2012. These clinical efforts verified the via­ bility of the Wound-Pump, including its safety, proper device functionality, and ease of clinical training.

An important aspect of streamlining WoundPump development has been the strong integration of clinical and engineering expertise in our multi­ disciplinary field teams, which has ensured immediate feedback and necessary design iterations.

We have applied over 90 Wound-Pump dressings and have treated patients from many vulnerable populations, such as post-partum women and patients suffering from HIV / AIDs. The treated wounds have encompassed both acute and chronic conditions, including burns and graft sites. Our results with the Wound-Pump to date have demonstrated effective NPWT with maintenance of negative pressure and effective drainage of wound exudate.

Wounds treated with the Wound-Pump are qualitatively healthy in appearance. Nursing staff have been extremely receptive, noting that wounds are maintained in a cleaner environment than with ­regular gauze dressings and appear healthy after Wound-Pump treatment. The nurses find that the time invested in applying the Wound-Pump ­dressing system once every 3 days (compared with replacing gauze dressings daily) is worth their efforts. Patients who have had effective Wound-Pump dressings request on-going application of the Wound-Pump system due to their preference for a dressing that remains dry, has to be changed less often, and promotes healing.

We continue to target the long-term sustainability of the Wound-Pump and have confirmed its affordability and local manufacturing options in global markets. The Wound-Pump can reduce healthcare costs where NPWT is already widely available, while providing a NPWT option in areas where it is currently not available.

The Wound-Pump1 is a strong example of the substantial impact that reverse engineering and sustainable design practices can have in the healthcare space. m 1 As a result of our efforts, Zurovcik launched Worldwide Innovative Healthcare (WiCare). WiCare is a for-profit company that exercises responsible design and engineering at the core of its business. WiCare is breaking down the barriers to affordable global medical devices, paving the way to a new medical device paradigm; one that expands high-end treatment availability and significantly reduces healthcare costs. The Wound-Pump is the first device in WiCare’s affordable product pipeline.

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Organisations

EWMA Guest Session at the EFORT 2013 Conference Presentation of the EWMA Antimicrobial Document Finn Gottrup Chair of the EWMA ­Antimicrobial Document Author group ewma@ewma.org www.ewma.org

The EWMA stand on the EFORT 2013 ­conference in Istanbul.

I

n June EWMA presented the ­recently published Antimicrobial Document at the 14th conference of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) in Istanbul, Turkey.

With more than 6,800 participants, the EFORT conference provided an excellent forum to communicate with a large number of orthopaedics. The session took place as part of the continued collaboration by EFORT and EWMA about exchange of conference presentations. Its objective was to increase awareness about nonhealing wound management within the field of orthopaedic surgery.

The session presenters included three of the seven authors that produced the Antimicrobial Document: Editor Finn Gottrup (Denmark), Jan Apelqvist (Sweden), and Rose Cooper (UK).

As project chair and document editor Finn Gottrup opened the session with a presentation on the background and structure of the antimicrobial

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project. Rose Cooper followed-up with a discussion about the involvement of biofilm and bioburden in the antimicrobial treatment of wounds. Jan Apelqvist closed the session with a discussion about current treatment strategies and future directions for the use of antibiotics and non-antibiotics in wound care.

Through this session, which was well received by the participating EFORT delegates, EWMA continues its dedication to the spread of knowledge about antimicrobial use in wound care. Further, EWMA is proud to be able to contribute to the EFORT conference by being one of the partner organisations involved in the Specialty Societies meeting arranged by EFORT. EWMA brings a multidisciplinary and multiprofessional approach to the table. m

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2013 vol 13 no 2

ANNUAL CONFERENCE AND EXHIBITION 14-16 NOVEMBER 2013 ACC LIVERPOOL

Only 6 weeks to go – book now!

With over 1000 delegates and 70 exhibitors registered, the 2013 conference is set to be our biggest yet.

Here’s just a quick reminder why you should attend: • • • • • • • •

Hear from world class podiatry professionals Access to the largest podiatry exhibition in Europe Learn hands-on skills and updates that you can take back to the clinic Opportunity to attend over 50 specialist sessions covering all aspects of podiatry Most cost effective means of updating your CPD portfolio – up to 28 CPD points available Meet, network and have fun with colleagues and peers Enjoy the wide variety of attractions, restaurants, shopping and nightlife Liverpool has to offer Meet with Society and College staff and learn about developments, initiatives and improvements

Social events Tickets are running out for all social events so book yours now to avoid disappointment:

Comedy night

Thursday 14 November, The Supper Club Delegates will enjoy a hilarious line-up of comedians, a complimentary drink on arrival and simple basket meal.

Tickets are £20. Places are limited so early booking is advised.

Party in a pod

Rides on Liverpool Wheel, Thursday 14 November We are offering delegates the opportunity to ‘party in a pod’ on the Liverpool Wheel adjacent to the ACC. Enjoy a glass of champagne with friends and colleagues whilst taking in the fantastic views of the city.

Tickets are £10.

Conference dinner and party

Friday 15 November, St Georges Hall The conference dinner and party will take place at St Georges Hall, a magnificent venue featuring a beautiful main banqueting hall with stunning chandeliers and stained glass windows. The venue offers a fantastic setting for the event. The evening will incorporate a drinks reception, three course dinner with wine, live Beatles music and dancing.

Dress code: Lounge suits.

Tickets are £55 for members and £75 for non members.

To view the full conference programme or to register visit www.scpconference.com call +44(0)20 8832 7311 or email scp@profileproductions.co.uk

Organisations

Australian Wound Management Association AWMA

Australian Wound Management Association

NEWS UPDATE Over the last few months AWMA has been invited to participate in a number of important activities.

Dr. Bill McGuiness President of AWMA www.awma.com.au

SCOPING STUDY A scoping study exploring wound management in aged care and funded by the Australians government has commenced and AWMA has been invited to nominate 3 representatives and identify addi­ tional agencies that should participate. The project is being coordinate by The Medical Specialist ­Services Branch of the Medical Benefits Division.

This group determines the health care services that will be funded by the government so we are hopeful that we may be able to secure subsidy for compression therapy. It is anticipated that the study will be completed by July 2014.

MEETING WITH ROYAL COLLEGE OF GENERAL PRACTICE (RACGP) We were able to meet with the president of the RACGP in August. This provided an opportunity to highlight the AWMA guidelines as a resource for general practice. We were also able to garnish support for the AWMA awareness campaign and invite the RACGP to participate in the federal government scoping study.

EWMA international Partner Organisation

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WOUND HEALTH INDEX Over the past three years AWMA has been working towards the establishment of a national data source for chronic wounds. This data set would help quantify the extent of the problem, highlight developing trends and enable clinicians to benchmark practice.

In collaboration with the Wound innovation CRC a small working group was formed to explore the option. It was agreed that any data repository should draw from existing data sets in preference to the development of a new database. To date this group has established a minimum data set (MDS) for the data collection and are now seeking funding for a pilot study to explore the feasibility of extracting the MDS from an existing a de-identified data base from a major provider of community based wound care into the chronic wound registry.

Position paper on Multidisciplinary wound care AWMA has been invited by EWMA to co-author a position paper of multidisciplinary wound care in collaboration with the AAWC. AWMA will focus on the barriers and facilitators to developing such teams. Work has commenced and the first meeting with be held in Las Vegas in September 2013.

In addition to these new opportunities work has continued on the current AWMA initiatives NEW AWMA STRUCTURE Information provided by each state and territory groups has been compiled and areas of consensus identified. There was universal agreement about the functions at each level and the need for the new national association. Opinions concerning the distribution of membership funds demonstrated a degree of variation. A workshop held in August has now determine the overarching structure of the new AWMA and assistance is now being sought from relevant professionals to help realise this vision.

AWMA 2014 CONFERENCE Be there or be sorry. The 2014 AWMA conference will be held on the Gold Coast of Australia and will celebrate 20 years of AWMA. A number of exciting events are planned to help us celebrate as well as a number of international keynote speakers that will help set the future of wound care for the next two years. Abstract have opened so it is time to put pen to paper (or fingers to key boards). Further information can be found at www.awma2014.com.au I look forward to the many outcomes that will results from the above activities and hopefully ­seeing some of our European colleagues at the conference.

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Submit your next paper to

Phlebologie Organ der Deutschen Gesellschaft für Phlebologie Organ der Schweizerischen Gesellschaft für Phlebologie, Bulletin de la Société Suisse de Phlébologie Organ der Arbeitsgemeinschaft Dermatologische Angiologie der Deutschen Dermatologischen Gesellschaft Organ des Berufsverbandes der Phlebologen e.V.

Als Forum für die europäische phlebologische Wissenschaft widmet sich die CME-zertifizierte Zeitschrift allen relevanten phlebologischen Themen in Forschung und Praxis: Neue diagnostische Verfahren, präventivmedizinische Fragen sowie therapeutische Maßnahmen werden in Original- und Übersichtsarbeiten diskutiert.

Die offiziellen Mitteilungen und Leitlinien der Deutschen Gesellschaft für Phlebologie werden regelmäßig publiziert, verschiedene Foren bieten Gelegenheit zum Erfahrungsaustausch zwischen Klinik und Praxis.

redaktion@phlebologieonline.de

www.phlebologieonline.de

Organisations

AAWC NEWS AAWC Association for the Advancement of Wound Care

Robert J. Snyder DPM, MSc, CWS President, AAWC www.aawconline.org

The Association for the Advancement of Wound Care (AAWC) exists to be the leader in interprofessional wound healing and tissue preservation.

Be sure to join AAWC on Facebook and Linked In.

EWMA international Partner Organisation

Thank you for the opportunity to provide the ­readers of the EWMA journal with updated news about the Association for the Advancement of Wound Care (AAWC). My term as the first podiatrist President of AAWC has given our Board of ­Directors a platform to address the escalating ­epidemic of diabetic foot complications and to ­foster amputation prevention. In support of this platform, two new guidelines are under development for wound infection and diabetic foot ulcers.

Additionally, by promoting an interprofessional approach and working in tandem with other organizations, we are initiating a meaningful network and creating a pathway to help diminish the suffering of individuals with this disease. We are honored to have partnered with EWMA and the Australian Wound Management Association (AWMA) to ­develop a paper on the multidisciplinary approach to wound care. Further, we continue our partnership with Health Volunteers Overseas (HVO) to ­provide wound and lymphedema education in ­Haiti, Peru, Cambodia and India. We continue to work with US-based organizations such as NPUAP and Indian Health Services on many worthy projects. These opportunities strengthen dialogue and cohesiveness among professional organizations and societies involved in the wound care space.

With dedication to knowledge exchange, AAWC is particularly proud of our Speakers Bureau program as it provides opportunities for AAWC members to spread the word about quality, evidence-based wound care. The Speakers Bureau has a growing database of wound care experts from diverse fields of healthcare, many of whom hold certifications in wound care.

Last but not least, I am proud to announce the new AAWC Shire Fellowship Grant in Wound Healing and Research. Made possible by an unrestricted grant from Shire, the AAWC is pleased to be able to provide two $50,000 fellowship support grants for the 2014 - 2015 academic year. The grants will ­provide fellowship support for two (2) physician ­fellows (MD, DO, DPM) who will learn the intri­ cacies of clinical practice and perform research in an academic and / or clinical setting that is dedi­ cated to the multidisciplinary approach to wound care.

Thank you so much for allowing me to share our current activities and projects with our global partners.

Best regards

AAWC is proud to announce a 60% increase in membership over the last two years. With over 2150 members, our commitment to community, collaboration and equal partnership is still ­paramount. AAWC provides numerous educational benefits to our professional members. AAWC ­considers people with wounds and their lay-care­ givers part of the wound care “team”. To support them, patients and lay-caregivers are provided free lifetime membership with their own unique set of benefits.

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 EWMA Secretariat at ewma@ewma.org

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October 24-27, 2013 See complete details online including continuing education statements, learning objectives, session descriptions, faculty credentials, information for submitting poster and oral abstracts, and registration information at

SymposiumOnWoundCare.com

Presented by

In Collaboration with

Wound Management Association-Romania AMP

Asociatja pentru Managementul Pla˘gilor România

Ana-Maria Iuonut President, AMP Romania www.ampromania.ro

EWMA Cooperating Organisation

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Wound Management Association-Romania (WMA-R) is a non-profit organisation that was founded in 2012. From the beginning, the European Wound Management Association encouraged the establishment of WMA-R and its initiatives.

The main purpose of the association is to promote the principles, standards, procedures, and current methods used worldwide in wound care and prevention and to ensure efficient communication among all contributors to the health care system.

WMA-R currently has over 30 members from the medical and nursing fields, working in general ­surgery, plastic surgery, vascular surgery, palliative care, home care facilities, and even psychiatry.

To achieve its purpose WMA-R aims to meet the following objectives: n Facilitate the exchange of ideas, solutions, and technical processes among medical and nursing specialists and with members of other NGOs interested in the field from Romania and abroad; n Organise training and other events at the national and international level; n Ensure access to quality documentation and dissemination of useful information in the field of wound care; n Initiate and conduct research projects in the field of wound care; n Provide material and logistical support to follow up on ideas and perform actions that lead to the understanding, development, improvement, and application of best practices in wound care; n Develop educational programs according to international standards in the area of wound care and prevention; n Develop partnerships with similar organisations in Romania and abroad.

Communication among members of WMA-R is maintained through a monthly newsletter that informs this academic community on events ­organised by the association. This information is also sent to other members of the health care ­system (e.g., doctors, nurses, pharmacists) and interested companies with the intention of highlighting the importance of this area of practice.

We are anticipating a Journal but to achieve this we have to wait for the organisation to develop further and mature. Meanwhile, we strive to maintain an active association website (www.ampromania.ro) to offer information and feedback to our members and stakeholders.

WMA-R COURSES, TRAINING, AND HANDS-ON SESSIONS Since establishment of the association a series of training courses at different levels, designed to ­provide basic information and advanced training, has been provided in several cities. In collaboration with the Order of Nurses, Midwives, and Medical Assistants in Romania, universities, industry representatives, and other NGOs we have organised the following courses and workshops: n “Using modern dressings in hard-to-heal wounds” (Timisoara-2012) n “Wound bed preparation” (Bucuresti-2012, Timisoara-2013) n “Using modern dressings in hard-to-heal wounds” (Targu-Mures-2013) n “Current methods for wound debridement” (Cluj-Napoca-2013).

Trainees (physicians and nurses) were interested in the pathophysiology of acute and chronic wound healing, assessment, and treatment targets ­according to the T.I.M.E. algorithm. Discussions were mainly focused on issues related to the use and selection of specific wound care products and devices. During the debridement workshop, ­lecturers, students, and sponsors combined efforts to develop an outstanding activity.

Sponsorships have brought classical and modern methods of wound debridement and management to workshop participants. All methods of debridement available worldwide were demonstrated by lecturers with experience in the field and trainees had the chance to participate in hands-on sessions with most of the debridement techniques currently used in wound management. This was the first time that some of these methods had been presented and demonstrated in Romania.

EDUCATION Future projects need to cover the considerable gap between what constitutes wound management in Romania and what constitutes wound management abroad. Although the role of the wound care ­specialist (who may be a nurse or physician) is expanding dramatically worldwide, practices in Romania currently have limited resources to make the necessary progress and meet this level of care.

In Romania, the standard education on wound care given to all medical staff provides only a brief ­training on some basic principles and does not emphasise the benefits of modern dressings and devices available in this field. It is important to ­optimise this situation because nurses and resident

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Organisations

Current methods for wound debridement – workshop Cluj-Napoca-2013

physicians spend a significant amount of their working time performing these procedures. In Romania there are only a few more advanced educational programs, which are short and struggle to offer enough information to develop critical thinking in this area. The limited access to such p ­ rograms leads to inconsistent and incomplete knowledge and erroneous perception of some concepts. Dressing wounds with modern products is generally performed using the limited information provided by the industry and is not supported by evidence-based practice. The scope of practice in wound management for health care providers also p ­ resents a challenge due to variation in the competency of professionals to perform advanced skills.

RESEARCH Research into wound management in Romania is inadequate, especially in nursing where there is no consolidated tradition of research. Therefore, our efforts are focused on building an appropriate knowledge base in research methodology and providing up-to-date knowledge on wound management. With this aim we have started to involve nurses and physicians in the creation of educational programs, motivating them to read and translate relevant literature and share it during various meetings. We intend to collaborate with other NGOs to develop and organise training sessions in order to involve nurses in research projects. After this mission is accomplished, the research programs will start with some investigations into the prevalence of different wound types.

On the other end of the scale, we seek to support medical staff involved in more advanced research (academic staff and postgraduate students), aiming to create a common platform to confront the problems encountered in wound management.

PRACTICE Wound management in clinical practice constantly raises challenges, mostly caused by a shortage of funds in the health system; often, sophisticated plastic surgery techniques are performed while basic care is somehow neglected. ­Paradoxical situations are frequently encountered, for ­example in well-equipped medical facilities there is not ­sufficient knowledge to use the facilities, whereas in other facilities well-trained medical staff struggle to obtain ­adequate equipment and materials for their patients.

The hope that there will be sufficient materials and trained staff in each facility is a goal that will stretch over many years.

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Things happen slowly, and meanwhile we spin into a vicious circle in which the companies support educational programs in the hope that it will sway the sale of products, but lack of funds push aside the problem of wound care and treatment, and dressings for our patients continue to consist of only gauze and iodine. Lack of standards and guidelines for the care and treatment of different types of wounds is an on-going challenge for health professionals, who act mainly based on experience derived from the routine application of the same methods.

WMA-R’s FUTURE PROJECTS In Romania, interest in wound treatment and care has grown over the last years. There are small groups of enthusiastic people (nurses and physicians) who choose to be involved in the area of wound management development and have started to work together in different small projects. One of these projects involves translating the Pressure Ulcers Prevention and Treatment Guidelines and sharing its recommendations with all Romanian medical professionals.

With the support of A.P.U.P.A., in August of this year a ­delegation of 10 Romanian nurses attended the 16th Annual European Pressure Ulcer Advisory Panel Meeting in Vienna, Austria, to acquire adequate information on this topic.

The assimilated information has prepared us for 2014, when review guidelines for the management of pressure ulcers will be published and we will provide a translation.

Before that, in November 2013 we will hold the 1st Conference of WMA-R, where we want to draw public attention to the problems of pressure ulcers and celebrate “Stop Pressure Ulcers Day”. In addition, we will hold elections for the future president of WMA-R. Our association is trying to involve more health care specialists in wound management because we believe that this topic will be best approached by a multidisciplinary team.

We expect this conference to be attended by a large number of professionals involved in this field, and hope that their enthusiasm will elicit rapid changes in wound management in Romania through involvement in specific educational programs and research and the development of new guidelines and procedures. We hope that their scientific work will empower our academic community to become a valid partner with health care authorities, decision makers, our patients, and other stakeholders in order to develop health policies that are based on the reality of the situation in Romanian and supported by scientific evidence. m

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Cooperating Organisations

CWA Croatian Wound Association www.huzr.hr

AEEVH Spanish Association of Vascular Nursing and Wounds www.aeevh.es

DGfW German Wound Healing Society www.dgfw.de

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

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

AISLeC

FWCS

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

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

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

GAIF Associated Group of Research in Wounds www.gaif.net

GNEAUPP

AMP Romania Wound Management Association Romania www.ampromania.ro

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

APTFeridas

ICW

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

AWA

Chronic Wounds Initiative www.ic-wunden.de

LBAA

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

Latvian Wound Treating O ­ rganisation

BEFEWO LUF

Belgian Federation of Woundcare www.befewo.org

The Leg Ulcer Forum www.legulcerforum.org

BWA

LWMA

Bulgarian Wound Association www.woundbulgaria.org

Lithuanian Wound Management Association www.lzga.lt

CNC

MASC

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

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

CSLR Czech Wound Management Society www.cslr.cz

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

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

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

International Partner Organisations AWMA

ILF

Australian Wound Management Association www.awma.com.au

International Lymphoedema ­Framework www.lympho.org

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

CAWC Canadian Association of Wound Care www.cawc.net

Debra International

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

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

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

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

SILAUHE Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

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

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Organisations

MWMA

STW Belarus

Macedonian Wound Management Association

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

NATVNS National Association of Tissue Viability Nurses, S ­ cotland

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

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

PWMA Polish Wound Management Association www.ptlr.pl

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

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

SAWMA Serbian Advanced Wound Management Association www.lecenjerana.com

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

SEHER The Spanish Society of Wounds www.sociedadespanolaheridas.es

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

SWHS Serbian Wound Healing Society www.lecenjerana.com

SWHS Swedish Wound Healing Society www.sarlakning.se

TVS Tissue Viability Society www.tvs.org.uk

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

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

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

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

SFFPC

WMAK

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

Wound Management Association of Kosova

SSiS

Wound Management Association Slovenia www.dors.si

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

SSOOR Slovak Wound Care Association www.ssoor.sk

WMAS

WMAT Wound Management A ­ ssociation Turkey www.yaradernegi.net

Other Collaborators DFSG

ICC

Diabetic Foot Study Group www.dfsg.org

International Compression Club www.icc-compressionclub.com

EADV

MSF

European Academy of Dermatology and Venereology www.eadv.org

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

ETRS European Tissue Repair Society www.etrs.org

Médecins Sans Frontières www.msf.org

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

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

Eucomed Eucomed Advanced Wound Care Sector Group www.eucomed.org

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4 Editorial

Science, Practice and Education

7 Risk assessment scales for p ­ ressure ulcers in intensive care units: A systematic review with meta-analysis F. P. García-Fernández et al.

15 Pressure-time integral of elastic versus inelastic bandages H. Partsch, G. Mosti

19 VERUM – A European approach for successful venous leg ulcer healing R. Brambilla et al.

25 Effect of topical h ­ aemoglobin on venous leg ulcer healing M. Arenbergerova et al.

32 The effects of an arginine-enriched oral nutritional supplement on chronic wound healing in non-malnourished patients J. Schols et al.

35 Efficacy of honey gel in the treatment of chronic lower leg ulcers O. Tellechea et al.

Scientific Communication

41 IWC – Consensus recommendation – Recommendations for ­compression therapy for p ­ atients with venous ulcers B. Assenheimer et al.

49 Evaluation of education and training in Croatia T. Sinoži´c et al.

56 Report on the Pilot Professional Supplementary V ­ ocational ­Education Module Wound Management I. S. Bakhtina et al.

Cochrane Reviews

59 Abstracts of recent C ­ ochrane reviews Sally Bell-Syer

EWMA

66 EWMA Journal previous issues and other journals 68 Book review: Wound Healing and Skin Integrity S. Bale

70 EWMA 2013 in Copenhagen, Denmark G. Jukema, E. W. Henneberg

76 EWMA Appreciations and new EWMA Council Members S. Seppänen

79 GNEAUPP Activities J. J. Soldevilla Agreda

82 EWMA 2013: Nordic Diabetic Foot Task Force K. K. Møller, M. Löndahl

84 EWMA as a partner in United4Health Z. Moore

86 EWMA 2013: The Russian spoken symposium R. Rimdeika

89 The University Conference Model – The journey so far M. Flanagan

92 EWMA NEWS 94 EWMA’s commitment to wound care advocacy across Europe S. Seppänen

96 Cooperating Organisations Board meeting Z. Moore

98 EWMA Corporate Sponsors

Organisations

99 Conference Calendar 100 WAWLC: Wound care in ­resource-poor settings E. Comte, H. Vuagnat

101 WAWLC: NPWT the sustainable way D. Zurovcik, G. Mody, R. Riviello

102 EWMA Guest Session at the EFORT 2013 conference F. Gottrup

104 Australian Wound Management Association B. McGuiness

106 The Association for the Advancement of Wound Care (AAWC) R. J. Snyder

108 Wound Management Association-Romania (AMP) A. M. Iuonut

110 Cooperating Organisations