EWMA Journal Vol 11 No 1

Volume 11Number 1January 2011

Published byEuropeanWound ManagementAssociation

FOCUS ON

THE BELGIAN WOUND HEALING SOCIETIES

Jan ApelqvistPresident Elect

EWMA Council

The EWMA JournalISSN number: 1609-2759

Volume 11, No 1, January, 2011

Electronic Supplement Januaryr 2011www.ewma.org

The Journal of the EuropeanWound Management Association

Published three times a year

Editorial BoardCarol Dealey, Editor

Deborah Hofman, Editor Electronic Supplement

Sue BaleFinn Gottrup

Martin KoschnickZena Moore

Marco RomanelliZbigniew Rybak

José Verdú SorianoRita Gaspar Videira

Peter Vowden

EWMA web sitewww.ewma.org

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EWMA SecretariatMartensens Allé 8

1828 Frederiksberg C, Denmark.Tel: (+45) 7020 0305Fax: (+45) 7020 0315

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Copies printed: 13,000

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in hard copies to members as part of their EWMA membership.

EWMA also shares the vision of an “open access” philosophy,

which means that the journal is freely available online.

Individual subscription per issue: 7.50€

Libraries and institutions per issue: 25€

The next issue will be published in May 2011. Prospective material for

publication must be with the editors as soon as possible and no later

than 15 March 2011.

The contents of articles and letters inEWMA Journal do not necessarily reflect

the opinions of the Editors or the European Wound Management Association.

Copyright of all published materialand illustrations is the property of

the European Wound ManagementAssociation. However, provided prior

written consent for their reproduction, including parallel publishing

(e.g. via repository), obtained from EWMA via the Editorial Board of the Journal,

and proper acknowledgement and printed, such permission will normally

be readily granted. Requests to reproduce material should state

where material is to be published, and, if it is abstracted, summarised,

or abbreviated, then the proposed new text should be sent to the

EWMA Journal Editor for final approval.

Dubravko Huljev

Robert StrohalRytis Rimdeika

Corrado M. DuranteTreasurer

Martin Koschnick

CO-OPERATING ORGANISATIONS’ BOARD

Reyes Carpintero-Pablos, AFISCeP.be

Andrea Bellingeri, AISLeC

Alessandro Scalise, AIUC

Aníbal Justiniano, APTFeridas

Gerald Zöch, AWA

Luc Gryson, BFW

Vladislav Hristov, BWA

Els Jonckheere, CNC

Milada Francu, CSLR

Dubravko Huljev, CWA

Hans Martin Seipp, DGfW

Eskild Winther Henneberg, DSFS

Anna Hjerppe, FWCS

J. Javier Soldevilla, GNEAUPP

Christian Münter, ICW

Aleksandra Kuspelo, LBAA

Mark Collier, LUF

Kestutis Maslauskas, LWMA

Corinne Ward, MASC

Hunyadi János, MST

Suzana Nikolovska, MWMA

Alison Johnstone, NATVNS

Marcus Gürgen, NIFS

Louk van Doorn, NOVW

Arkadiusz Jawien, PWMA

Rodica Crutescu, ROWMA

Severin Läuchli, SAfW

Hubert Vuagnat, SAfW

Goran D. Lazovic, SAWMA

Mária Hok, SEBINKO

Sylvie Meaume, SFFPC

Christina Lindholm, SSIS

Jozefa Košková, SSOOR

Guðbjörg Pálsdóttir, SUMS

Saša Borovic, SWHS

Magnus Löndahl, SWHS

Michael Clark, TVS

Jasmina Begic-Rahic, URuBiH

Barbara E. den Boogert-Ruimschotel, V&VN

Skender Zatriqi, WMAK

Georgina Gethin, WMAOI

Sandi Luft, WMAS

Bülent Erdogan, WMAT

Leonid Rubanov, WMS (Belarus)

For contact information, see www.ewma.org

Editorial Board MembersSue Bale, UK

Carol Dealey, UK (Editor)

Finn Gottrup, Denmark

Deborah Hofman, UK

Martin Koschnik, Portugal

Zena Moore, Ireland

Marco Romanelli, Italy

Zbigniew Rybak, Poland

José Verdú Soriano, Spain

Rita Gaspar Videira, Portugal Peter Vowden, UK

Paulo Jorge Pereira Alves, Portugal

Caroline Amery, UK

Michelle Briggs, UK

Mark Collier, UK

Bulent Erdogan, Turkey

Madeleine Flanagan, UK Milada Francu, Czech Republic

Peter Franks, UK

Francisco P. García-Fernández, Spain

Luc Gryson, Belgium

Alison Hopkins, UK

Gabriela Hösl, Austria

Zoltán Kökény, Hungary

Christian Münter, Germany

Andrea Nelson, UK

Pedro L. Pancorbo-Hidalgo, Spain Hugo Partsch, Austria

Patricia Price, UK

Rytis Rimdeika, Lithuania

Salla Seppänen, Finland

Carolyn Wyndham-White, Switzerland

Gerald Zöch, Austria

EWMA Journal Scientific Review Panel

Luc Gryson

Patricia PriceSecretary

Sue BaleRecorder

Carol DealeyEWMA Journal Editor

Barbara E. den Boogert-Ruimschotel

Paulo Alves

Zena MoorePresident

Marco RomanelliImmediate Past President

Gerrolt Jukema

Sylvie MeaumeMaarten J. Lubbers

Severin LäuchliEskild Winther Henneberg

2

www.ewma.org

Science, Practice and Education

Organisations

EWMA

EBWM

ELECTRONIC SUPPLEMENT JANUARY 2011

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

WWW.EWMA.ORG

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

Contents 1. Francophone Nurses Association in Stoma Therapy, Healing

and Wounds (AFISCeP) 2. Italian Association for the study of Cutaneous Ulcers (AIUC) 3. Portuguese Association for the Treatment of Wounds (APTFeridas) 4. Croation Wound Association (CWA) 5. European Pressure Ulcer Advisory Panel (EPUAP) 6. Lithuanian Wound Management Association (LWMA) 7. National Association of Tissue Viability Nurses in Scotland

(NATVNS) 8. Norwegian Wound Healing Association (NIFS) 9. Dutch Organisation for Wound Care Nurses (NOVW) 10. Polish Wound Management Association (PWMA) 11. Icelandic Wound Healing Society (SUMS) 12. Serbian Wound Healing Society (SWHS) 13. Wound Management Association of Turkey (WMAT) 14. Danish Wound Healing Society (DWHS)

EWMA Journal 2011 vol 11 no 1 3

6 Who will take onAli Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi,

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

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

29 Anaemia in patients with chronic woundsLotte M. Vestergaard, Isa Jensen, Knud Yderstraede

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

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

42 Abstracts of Recent Cochrane ReviewsSally Bell-Syer

46 International Journals Previous Issues

51 Microbiology of Wounds – a ReviewJosé Verdú Soriano

53 Pisa International Diabetic Foot Course 2010Alberto Piaggesi

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

56 EWMA Activities Update

58 Corporate Sponsor Contact Data

60 Conference Calendar

62 The annual meeting of GAIF – a Step ForwardJoão Gouveia

63 The International Lymphoedema FrameworkAgnès Carrot

64 News from WAWLCJohn M Macdonald

66 Cooperating Organisations

67 International Partner Organisations

67 Associated Organisations

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

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

http://www.ewma.org

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Dear Readers

As we start 2011 may I wish all the readers of EWMA Journal a very Happy and Peaceful New Year. One thing I have noticed as I get older is that the years go by ever faster and 2010 was no exception. Sadly, we also lose friends as time

goes by and in 2010 João Gouveia died too soon after a valiant struggle against illness. He was an important person in helping to establish wound care activity in Portugal and more can be read about his contribution on page 62. Our thoughts are very much with his wife and family at this difficult time.

Despite all the problems of the world economy, EWMA had a very successful confer-ence in 2010 in Geneva. Conferences are always a great opportunity to hear about new research and developments, but unfortunately, not everyone can attend them all. This edition of the journal showcases some of the papers presented at the conference and allows those of you who were not able to attend to learn more about the work currently being undertaken. I think you will find several thought-provoking papers in this issue on areas not generally considered such as pain in diabetic foot ulcers and anaemia found in patients with chronic wounds.

However, we also have to look forward to what is ahead in 2011. One thing that is very obvious is that there is much activity in wound healing in the form of national and international societies. Some are very new such as the Ukranian Wound Treatment Organisation (UWTO) and others are more established such as Associated Group for Research in Wounds (GAIF) a Portuguese society. Some are really flourishing in the international arena such as the International Lymphoedema Framework.

It is very encouraging to see so much activity and dedication being given to improving the way we manage wounds and organise the delivery of care. I would encourage you to look at the Electronic Supplement as well as the later pages in the Journal to see how much is happening in Europe and elsewhere. EWMA currently has 46 Cooperating Organisations from 35 European countries as well as 6 International Partner Organisa-tions and 2 Associated Organisations (patient groups). Compared to when EWMA was first founded this is a massive increase, for which EWMA may take some credit as we have given assistance in the form of advice and provision of speakers for conferences to a number of different societies. I know that Council Members who have represented EWMA at national conferences have found it exciting to be present at the launch of a new society and enjoyed the opportunity to meet those involved.

This month we are especially highlighting wound management in Belgium in preparation for our conference in Brussels in May. This year our theme is “Common voice – com-mon rights”. I hope you will agree that this is a very appropriate theme for a conference held in the city so closely associated with the European Union. So put the dates: 25-27 May in your diary and plan to be there.

Carol Dealey, Editor


INTRODUCTIONChronic wounds cause great trouble for soci-ety. They are usually related to some chronic systemic disease or age. In developed countries with aging populations these chronic wounds are a real burden. Health care specialists world-wide have worked hard to solve the issue of chronic wounds.

On the other hand, acute wounds are mostly related to trauma and post-surgical complica-tions. For instance, 74% of deaths by traffic accidents in the 1990s were seen in developing countries.1 In addition, work-related accidents and post-surgical wound complications are also frequently seen in developing countries which have low quality labour security precautions and less efficient health care facilities. These figures all add up to a large total. Severity of the trauma and any underlying chronic dis-ease, as in chronic wounds, worsen the case. Wound care specialists sometimes encounter acute wounds that many are reluctant to treat. Some may be even life threatening.

This group of patients is trapped in between clinics. Sometimes they have to stay in an emergency clinic for days. No particular clinic takes the responsibility. There are some fac-tors that make some physicians reluctant to take care of this group. These patients occupy hospital beds and qualified personnel for a long time. Complications to which they are prone increase the mortality rate of the clinic. This is the usual case in many centres. This paper ad-dresses the problem presenting four cases from three different clinics to illustrate the situation.

Ali Barutcu, Professor Dr

Dokuz Eylul University Medical Faculty Depart-

ment of Plastic Reconstruc-tive and Aesthetic Surgery,

Izmir, Turkey

Aydin O. Enver, Associate Professor Dr

Ataturk University Medical Faculty Department of

Plastic Reconstructive and Aesthetic Surgery,

Erzurum, Turkey

Top Husamettin, Associate Professor Dr

Trakya University Medical Faculty Department of

Plastic Reconstructive and Aesthetic Surgery, Edirne,

Turkey

Violeta Zatrigi, Professor Dr

Pristine University Medical Faculty Department of

Plastic Reconstructive and Aesthetic Surgery, Pristine,

Kosovo

Correspondence:[email protected]

Conflict of interest: none

Who will take on

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

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


mailto:bapras%40alibarutcu.com?subject=


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

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

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

3. Case A 52 years old male, had a right leg above knee amputation and consequent hip disarticulation due to Burger disease and wound dehiscence. He had a history of diabetes and heavy smoking. He was given systemic antibiotics and serial debridement was performed. During debridement by general surgery, the peritoneum cavity was exposed and plastic surgeons transposed internal oblique muscle flap to the defect. Vacuum assisted closure was used to prepare the wound for definitive closure. After 10 days of vacuum there was no sign of improvement and the sepsis was evident. The patient died of septic shock due to peritonitis (Fig-3).

4. CaseA 42 years old male had a crush injury of the left leg and Gustillo type IIIA open proximal tibial fracture. The orthopaedics department reduced the fracture and used steel plates for fixation. After the operation wound de-hiscence complicated the wound. The patient did not have diabetes or any other metabolic disease that could hamper wound healing. The defect medial gastrocnemius

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

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

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


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

DISCUSSIONAs trauma is the main reason for acute wounds, trauma management should be a priority in the emergency room. Vital organ injuries and haemodynamic instabilities are the main concerns for the trauma team. Postoperative wound dehiscence is another reason for acute wounds. In this case systemic diseases gain more importance. Metabolic disor-ders like diabetes, renal failure, and cardiovascular diseases are usually the complicating factors in such patients. Treat-ment of complicating factors during the management of these patients may delay wound care.

All cases had acute wounds which were resistant to treat-ment related to systemic diseases or infection. They were managed by more than one discipline but not by a team. However this does not imply that anyone takes the re-sponsibility. Severity of the trauma and wound engage these patients to an unfavourable group. Like chronic wound care, acute wound care also needs the efforts of a united team.2 This team should have some regular and vital members like nursing and nutrition specialists. Un-derlying diseases and injury location should define other

members of the team. For example, an orthopaedist and a plastic surgeon in case 1; an endocrinologist, a plastic surgeon, a general surgeon and an urologist for case 2; an orthopaedist, an endocrinologist and a plastic surgeon in case 3. Where needed specialists may be recruited for the team. One of the members should take the responsibility to make the definitive treatment according to the injury type and location.

In this unfavourable group of patients, wound bed prepa-ration should be the goal of treatment until definitive intervention. Vacuum assisted wound closure has been the main means of treatment for the given patients. 3,4 Early onset of vacuum treatment, even immediately after the haemostasis in the emergency room, may be considered. Vacuum treatment may be beneficial during treatment of vital problems; this gains the wound management team valuable time for treatment.

EWMA lectures have provided consensus on many prob-lems and widely accepted guidelines on chronic wounds.5,6 However, such a protocol is not available for these un-favourable acute wounds. Societies should delineate the guidelines for acute wound management with EWMA taking the lead. m

References

1 Odero, W., Garner, P. and Zwi, A., Road traffic injuries in developing countries: a comprehensive review of epidemiological studies. Tropical Medicine & International Health, 2: 445–460, 1997.

2 Gottrup F., Nix D. P., Bryant R. A. The Multidisciplinary Team Approach to Wound Management. In: Bryant R. A., Nix D. P. editors. Acute & Chronic Wounds: Current Management Concepts, Third edition, USA: Mosby; 2007. P.23-38

3 Nelson E.A., “Vacuum Assisted closure for chronic wounds: A review of the evidence”, EWMA Journal 2007 vol. 7, no.3 pp 5-11

4 Vigs et.al., “A systematic review of topical negative pressure therapy for acute and chronic wounds.”, Br. J. Surg 2008; 95: 685-692

5 Janssen H. J.,”Integrated system of chronic wound care healing- creating, managing and cost reduction”, EWMA Journal 2007 vol. 7, no.3 pp19-21

6 Karel Bakker, “The Importance of International Consensus Guidelines on the Management of the Diabetic Foot” EWMA Journal 2009, vol. 9 no:3, pp 40-41

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



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Patricia E Price, PhD Professor and Dean of Healthcare Studies, Cardiff UniversityDepartment of Dermato-logy and Wound Healing, Cardiff University

Correspondence: Sarah Bradbury Research NurseDept. of Dermatology and Wound HealingRoom 13 Upper Ground FloorSchool of MedicineHeath ParkCardiff



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

INTRODUCTIONThere is growing awareness that pain is a preva-lent problem amongst patients with many types of wounds 1,2,3,4, yet wound pain is often ignored, inappropriately assessed and badly managed 5. Whilst position documents from EWMA 6 and WUWHS 7 acknowledged that wound pain is an area of concern requiring more consideration, a lack of suitable robust studies means there remains an insufficient evidence base from which to for-mulate decisions regarding patient care. There is limited evidence addressing pain from wounds of aetiologies other than VLU, or at times other than dressing changes.

Pain from diabetic foot ulcers (DFU) is a particu-larly under-researched area, possibly due to the as-sumption that patients experience little pain from DFU due to peripheral sensory neuropathy. There is limited knowledge of the prevalence of diabetic patients experiencing specific ulcer-related pain, their perception of it, resulting limitations, or how it should be managed.

Neuropathic pain is often assumed to be the only type of pain experienced by DFU pa-tients 8,9,10, which fails to acknowledge that pain may be specifically associated with ulceration. UK clinical guidelines 11 and advisory literature of-fered by the International Diabetes Federation (IDF) for the assessment and management of DFU does not consider pain at all, except as an indicator of infection.

Abraham 12 declared the specific challenge with pain from diabetic wounds is the potential for multiple aetiologies of that pain, each requir-ing thorough consideration to manage patients appropriately. Pain may result from infection, Charcot Arthropathy or Osteomyelitis 13,14,15, as well as painful neuropathy. Some research also suggests entrapment of the tibial nerve, or Tarsal Tunnel Syndrome, may be a cause of neuropathic pain in DFU, especially when pain is worse at night 16. Sibbald et al. 17 consider pain in the DFU itself uncommon except as a symptom of these complications. Although it is well-documented that these factors often cause pain in an insensate

Diabetic foot ulcer pain:

The hidden burden (Part one)


foot, there still appears to be no evi-dence to suggest patients with DFU do not experience nociceptive pain, procedural pain or other experiences of non-cyclic or cyclic acute pain as de-scribed by Krasner’s Chronic Wound Pain Model 18.

Ribu et al. 19 found that 75% of 127 patients with DFU reported pain on walking/standing and/or pain at night. No statistical difference was found for pain in the presence of in-fection and Osteomyelitis. Results in-dicated a high percentage of patients with peripheral neuropathy still expe-rienced pain, although a significantly higher percentage of patients who re-ported pain most or all of the time had evidence of significant ischaemia com-pared with patients without pain. A negative effect on QoL was also found for patients experiencing pain.

Bengtsson et al. 20 found 53% of 101 patients reported wound-related pain either occasionally or continu-ously. The presence of pain did not vary between aetiologies, and patients with clinical signs of infection were excluded, highlighting the error of as-suming that pain only occurs in the presence of such complications.

The issues highlighted within the literature search prompted the performance of a cross-sectional, explora-tory study to investigate the presence and characteristics of DFU pain and the potential effect on QoL. The study aimed to gain information on the number of patients at-tending one specialist diabetic foot clinic who experienced DFU pain; determine if a relationship existed between ulcer pain and specific aetiologies of DFU; explore the type and intensity of pain experienced, and examine current management strategies being utilised. The final aim was to investigate how ulcer pain impacts on QoL.

The study’s aims defined the need to collect quantita-tive data on the presence and characteristics of DFU pain and qualitative information regarding patients’ views on QoL issues. The study was therefore conducted in two phases. As the first phase determined that DFU pain was a problem, the second stage regarding QoL was deemed necessary. As the subject area was so new, it could not initially be assumed that enough patients would identify DFU pain to warrant further study. The first phase of the study is presented here.

Table 1: Inclusion/Exclusion Criteria

Inclusion criteria Exclusion criteriaOver eighteen years of age Dementia or learning / communication

difficultiesDiagnosis of Diabetes Mellitus Problems with vision making question-

naire completion difficultOne or more foot ulcers below the malleolus Surgical or amputation woundsWilling and able to complete a simple pain questionnaire

Table 2: Diabetes Characteristics by Aetiology

N (n=14) NI (n=13) I (n=1) Total (n=28)Type of Diabetes:Type I 2 0 0 2Type 2 12 13 1 26Mean Duration of Diabetes (years) 14.3 24.6 5 18.8No. of Diabetes-Related Complications:0 3 0 0 31 6 0 0 62 5 6 1 123 0 3 0 34 0 3 0 35 0 1 0 1Type of Diabetes-Related Complications:Cardiovascular Disease 6 11 1 18Peripheral Vascular Disease 0 13 1 14Retinopathy 5 7 0 12Nephropathy 2 4 0 6Minor Amputation 2 3 0 5

(N=Neuropathic, NI=Neuro-Ischaemic, I=Ischaemic)

METHODSA quantitative exploratory cross-sectional design using a local audit to collect data at a single time point provided a ‘snap-shot’ of occurrences within the sample 21.

Consecutive patients attending over an eight week period were assessed for inclusion (See Table 1 for inclu-sion/exclusion criteria). This time period was decided on with consideration to the average number of patients seen within the clinic that could provide an idea of the scope of the problem from which to draw reasonable conclusions. Patients with active infection, Osteomyelitis or Charcot Arthropathy were included to determine if a specific cor-relation between DFU pain and these complications ex-isted. This provided a more representative sample as large numbers of patients seen in specialist diabetic foot clinics regularly encounter these problems, thus reflecting the realities of clinical practice.

A clinical assessment tool was devised to facilitate data collection of simple demographics and take a thorough clinical history of patients’ diabetes and foot ulcer(s). The tool was positively reviewed by colleagues prior to com-mencing the audit to obtain feedback on its ease of use in the clinic setting.



Diagnosis of aetiology was made following full vascular and neurological assessment and foot inspection, guided by the recommendations of the International Working Group on the Diabetic Foot 22. A wound assessment was performed using standardised criteria, and the ulcer(s) were assessed for the presence of infection, Osteomyelitis and Charcot Arthropathy. Following the assessment, the wounds were classified using the University of Texas Clas-sification System (UTCS) 23. Type of footwear, frequency of podiatry visits and referrals made to a specialist pain practitioner were also recorded.

Pain was assessed using a modified version of the Short-Form McGill Pain Questionnaire (SF-MPQ) 24 which captures the nature and intensity of pain, thus assisting in identifying if certain pain characteristics are associated with DFU. The patient was asked to give specific consid-eration to any pain in, or immediately surrounding, the ulcer only. The aim was to ascertain if the pain was specifi-cally ulcer-related and not primarily of neuropathic origin.

Verbal informed consent was obtained from each pa-tient prior to completion of the SF-MPQ. As the informa-tion being gathered was for audit purposes and within the realms of normal clinical practice, formal ethical approval was not required.

The audit data was summarised and classified accord-ing to ulcer aetiology. The VAS scores were measured on a 0-100mm scale and analysed using an independent t-test to compare the pain scores by type of DFU, as this was the primary outcome. The other comparisons are presented descriptively to avoid over analysis of the same outcome due to the relatively small sample number included in the study. The results of the SF-MPQ were analysed as outlined in the original articles on the full MPQ and the SF-MPQ by Melzack 25,24.

RESULTSTwenty-eight patients were recruited into the audit from March-May 2007. The majority of the patients were male (n=22). The overall sample was aged 43-92 years (mean 67.5, sd 13.56). Table 2 indicates the diabetes history.

DFU HistoryFifty percent of patients presented with an ulcer(s) of neu-ropathic aetiology (n=14), and 46% with neuro-ischaemic aetiology (n=13). Only one patient had a purely ischae-mic ulcer. Mean ulcer duration of 48 weeks (sd 66.21, range 1–234 weeks). Ulcers were classified using UTCS and indicated a range of scores from A1 to D3, the most common being A1 (29%). Some problems with clinician understanding of the UTCS were identified when results were compiled, making analysis of any correlation between DFU pain and increasing DFU severity using the Texas scores unreliable.

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AnalgesiaSixteen patients (57%) were taking regular oral analgesia, including drugs for neuropathic pain while 43% (n=6) of patients with neuropathic ulceration were taking some form of analgesia compared with 69% (n=9) of neuro-ischaemic patients.

The type of analgesia used by patients suffering with DFU pain ranged from simple analgesics to opiate anal-gesia (See Table 3). The main types of analgesia used were mild opiates in the form of Tramadol or Codeine-based preparations, which are normally used to manage mild to moderate pain. In addition to this, three neuropathic patients were taking Gabapentin, an anticonvulsant often used to manage neuropathic pain.

Analgesia was not always taken specifically for ulcer-related pain. In patients reporting some degree of DFU pain, 63% (n=15) were taking analgesia, while nine pa-tients (38%) who recorded DFU pain took no analgesia. Two patients had previously been seen by a Pain Specialist due to pain related to their diabetic foot problems.

Presence of DFU PainEighty-six percent of patients (n=24) reported some degree of DFU pain on the SF-MPQ. The overall possible score obtainable using the descriptors and VAS components of the SF-MPQ is 142. Higher scores indicate higher pain levels. The range of scores obtained across the sample was 0-91.

Of the patients reporting DFU pain, 39% (n=11) had neuropathic foot ulcers (NFU) and 50% (n=12) had neuro-ischaemic ulcers (NIU). The patient with a purely ischaemic ulcer also reported pain. For comparative pur-poses only the neuropathic and neuro-ischaemic groups will be used. The results of the ischaemic patient will be considered as part of the overall group.

Fourteen percent of patients (n=4) reported no ulcer pain on the SF-MPQ, scoring 0 on both the pain descrip-tors and VAS elements. Of these, three had NFU and one had NIU. A further six patients (25%) reported pain in the bottom 10% of overall recorded scores (=9), four with NFU and two with NIU.

Figure 1: Reported SF-MPQ

pain descriptors

Table 3: Analgesia taken by Aetiology

Analgesia No. Of patients Neuropathic Neuro-ischaemic IschaemicCo-Dydramol 2 0 1 1

Co-Codamol 4 1 3 0

Tramadol 4 1 2 1

Paracetamol 3 1 2 1

Gabapentin 3 3 0 0

Diclofenac 1 0 1 0

Oxycontin 1 1 0 0

Characteristics of DFU PainFigure 1 shows all types of pain on the SF-MPQ recorded by the sample. The first ten descrip-tors indicate the sensory component of the pain sensation, and the final four, the affective component. Aching was the most commonly reported sensory type of DFU pain (n=14), with tiring/exhausting the most common affective descriptor (n=10).

Figure 2 compares pain descriptors used by patients with neuropathic and neuro-ischaemic


aetiology. Despite reporting similar types of pain, there tended to be a higher frequency for the neuro-ischaemic patients across both the sensory and affective components.

Pain IntensityVAS Scores obtained across the whole sample were from 0-73, with an average score of 26.4 (sd 24.3). Of those who recorded pain, 46% (n=13) recorded pain levels >40mm using the VAS, a level indicating moderate to severe pain intensity requiring immediate review and intervention 7.

For the neuropathic group, the mean VAS score was 21.6 (sd 24.6, range 0–73). Seven patients recorded scores in the bottom 10% (=7). For the neuro-ischaemic group, the mean score was 32.2 (sd 24.6, range 0–67). Three patients recorded scores in the bottom 10%. The patient

with an ischaemic ulcer recorded a VAS score of 27. There was no statistically significant difference between the groups (t=-1.1, df = 1, p=0.27).

Figures 3 and 4 indicate the reported pain intensity for each pain descriptor using the SF-MPQ by aetiology. Across the sample mild pain was reported 84 times, mod-erate pain 44 times and severe pain 12 times.

Pain and DFU-Related ComplicationsOf the patients included in the study, 64% (n=18) present-ed with one or more DFU-related complications (Table 4). Eight patients with clinical signs of ulcer infection were taking systemic antibiotics, five patients with suspected Osteomyelitis were referred for further investigations, and five had confirmed Osteomyelitis, three of whom were

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

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



chronic. One patient of the eight with Charcot Arthropa-thy had an active Charcot during assessment.

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

Pain and Pressure-Relieving FootwearEighteen patients (64%) wore some form of pressure-relieving footwear, resulting in an average VAS score of 26.9 (sd 23.9) versus 25.4 (sd 26.3) for those who wore normal shop-bought footwear. The average overall SF-MPQ score for these groups was 33.2 (sd 28.2) versus 31.0 (sd 32.3) respectively.

Pain and Podiatry InputTwenty patients (71%) regularly attended a podiatrist for DFU assessment, review and management. The average VAS score for these patients was 25.0 (sd 23.8), with an average overall SF-MPQ score of 31.1 (sd 28.4), versus 29.9 (sd 26.9) and 35.9 (sd 33.0) for those who received no regular podiatric input.

Figure 4: Reported SF-MPQ

pain intensity for neuro-ischaemic ulcer aetiology

Table 4: DFU-Related Complications

DFU-related complication No. Of patientsInfection 2

(Neuro-Ischaemic = 2)Infection + Osteomyelitis 4

(Neuropathic = 1, Neuro-Ischaemic = 3)Infection + Non-Active Charcot 3

(Neuropathic = 2, Neuro-Ischaemic = 1)Infection + Osteomyelitis + Non-Active Charcot

2

(Neuropathic = 1, Neuro-Ischaemic = 1)Osteomyelitis 4

(Neuropathic = 1, Neuro-Ischaemic = 3)Non-Active Charcot 2

(Neuropathic = 1, Ischaemic = 1)Active Charcot 1

(Neuropathic = 1)

DISCUSSIONFewer patients were recruited than estimated as a result of the inclusion criteria. This small sample number makes it difficult to generalise the findings. This is also true due to the spe-cialist, complex patient population from which they were chosen, but the sample did reflect the documented epidemiology for people with diabetic foot disease 26. More positively, such complex patients may be representative of many populations with diabetic foot disease due to the complex nature of the disease itself.

There were similar numbers with NFU and NIU, concurring with previous work es-timating 25-50% of DFU are neuro-ischae-mic 27,28,29. Ischaemic aetiology is grossly un-


der-represented within the sample – therefore no analysis was made of pain experienced by these patients.

The increased duration of diabetes and number of complications experienced by the neuro-ischaemic group compared with the neuropathic group could suggest they were generally in poorer health.

PVD in a neuropathic patient leads to an increased risk of ulceration, difficulty in healing, and poorer overall out-comes 30,31 suggesting the neuro-ischaemic group is more complex. One aim of this audit was to see if this led to an increase in DFU pain levels or a difference in the type of pain experienced. The UTCS would have assisted in determining this as it categorizes wounds by severity, but due to classification errors the collected data was unsuit-able for analysis.

Presence of DFU PainThese results support the findings of Ribu et al. 19 and Bengtsson et al. 20 in that DFU pain is a problem, as well as supporting the qualitative work on HRQoL of patients with DFU, where pain was often raised as an issue 32,33,34,35.

More patients with NIU reported pain than NFU, although it should be noted that this was not statistically significant. Laing 14 suggests that ischaemic ulcers are usu-ally painful to the touch, so the presence of ischaemia and associated increase in ulcer severity may contribute to the sensation of specific ulcer pain. Conversely, Bengtsson et al. 20 found no difference between the presence of pain and aetiology.

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

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



Eleven patients with NFU reported pain, contrasting with previous opinion that most NFU are painless. Fur-thermore, neuro-ischaemic patients also have an essentially insensate foot, albeit with added ischaemia, yet still appear to experience DFU pain. One neuro-ischaemic patient reported no pain, suggesting ischaemia does not always lead to ulcer pain, although there is danger in inferring too much from a single case. More certainty of the effect of ischaemia on the experience of DFU pain could be determined by a larger study with a comparable group of patients with purely ischaemic ulceration.

Ribu et al. 19 had similar results with the majority of patients with no pain being those with an insensate foot, although this was also the case for many with pain. They also concluded that ischaemia was more common in those who reported pain, although a direct relationship between the two variables again cannot be assumed.

Characteristics of DFU PainAnalysis of terms used to describe the nature of DFU pain should be interpreted with caution due to the small sample size and the purely exploratory nature of the study. The results obtained are also difficult to place into context as there is little previous research into the issue, and none at all using a tool like the SF-MPQ.

The most frequently used descriptors for DFU pain had elements common to both nociceptive and neuro-pathic pain, as is often the case for patients with chronic wounds 36. When determining the best method for as-sessing DFU pain, one concern was that patients would be unable to isolate the DFU pain from other sources of pain, such as neuropathy or ischaemia. Subjects often de-scribed nociceptive pain using descriptors such as aching and throbbing, which are typically related to tissue dam-age, giving some indication that this isolation occurred.

Some descriptors are commonly associated with par-ticular types of pain, but none consistently or reliably. The SF-MPQ is not designed to assess neuropathic pain specifi-cally and so may not include descriptors for all types of associated pain. However, those descriptors reported most frequently are not those most specific to pure neuropathic pain, i.e. shooting or stabbing. This is again opposed to the common view of DFU as being painless or only associated with neuropathic pain 8,9,10,14.

The neuropathic and neuro-ischaemic groups reported similar types of pain. Patients with NIU reported pain that was more frequent, severe, and varied in type than patients with purely NFU, contrasting to Bengtsson et al. 20, who reported little difference in pain intensity be-tween aetiologies.

Affective descriptors of DFU pain assess the emotional aspects of the pain experience. The neuro-ischaemic group was more likely to use affective descriptors, suggesting DFU pain associated with neuro-ischaemia can be more emotionally or psychologically challenging. This is an im-portant factor impacting on QoL.

There is inconsistency in the results of some SF-MPQs, possibly bearing upon its internal validity. Two patients reported no pain for any descriptors on the questionnaire but scored 2 out of 100 on the VAS scale – this is certainly due to the accepted margin of error which occurs when us-ing VAS scales. Their scores could not be discounted, but could have led to a slightly larger number being reported as experiencing DFU pain than is actually the case, but also an underestimate of pain on a mean basis. Another patient reported severe pain for two descriptors, and mod-erate for two descriptors, yet recorded a VAS score of 1, suggesting a lack of understanding by the patient and/or a poor explanation from the clinician on VAS completion.

Figure 7: SF-MPQ pain intensity

for patients without DFU-related complications



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Although the SF-MPQ has been demonstrated as valid, reliable and easy to use 24,37,38, it has never been used for assessment of DFU pain and therefore its validity cannot be absolutely certain.

Pain and DFU-Related ComplicationsWhen considering the impact of DFU-related complica-tions on pain, it should be noted that there being more patients with complications than without could potentially skew results. It proved beyond the scope of this audit to detect any correlation between specific complications and DFU pain as they rarely occurred independently and the group numbers were too small.

It should be acknowledged that five patients only had a suspected diagnosis of Osteomyelitis. Despite a high specificity and sensitivity for the probing to bone test used for diagnosis of Osteomyelitis 39,40, the results of further investigations would have been preferential when deter-mining in which comparative group the patient was to be included for analysis. This highlights a problem with the audit’s cross-sectional methodology as collecting data at a single time point meant there was no follow-up of the patients to determine if Osteomyelitis was confirmed.

Interestingly, the four patients in the sample who reported no pain all had one or more DFU-related complication(s), indicating that the absence of DFU pain was not associated with an absence of complications. It also highlights the complexity of assessing DFU as normal clinical signs, such as pain and tenderness due to wound infection, are often absent 41.

There is little difference in the mean VAS scores be-tween those with and without complications, contrast-ing with commonly presented views within the literature which indicate DFU pain is only associated with com-plications 11,17. This supports the work of Ribu et al. 19 and Bengtsson et al. 20, as the latter study excluded pa-tients with complications. There was no difference in the number of times severe pain was reported by each group, although patients with complications reported moderate and mild intensity more often. When considering overall SF-MPQ scores, patients without complications actually recorded slightly higher mean scores than those with com-plications, again contrary to previous views. It is therefore clinically inappropriate to assume DFU pain does not ex-ist except in the presence of complications or advancing disease, although the intensity of the pain might differ.

Patients with complications used more affective de-scriptors for their pain than those without pain, indicat-ing that the emotional effect of pain and complications combined is more intense. This could be due to the anxiety such patients may feel when told that they have an infec-tion, Osteomyelitis or Charcot Arthropathy. These issues are an added complication to the existing DFU, presenting

a further risk of future problems, such as foot deformity, reduced mobility or amputation.

Management of DFU PainFindings regarding analgesic use are similar to those of Ribu et al. 19 showing a higher percentage of patients re-porting DFU pain were taking analgesia than those with-out. It is difficult to draw implications for analgesic use in DFU pain here as many patients were taking analgesia for other problems. As 57% were taking analgesia at assess-ment, it is possible that concomitant analgesic use could lead to underestimation of DFU pain.

As found with studies looking at VLU and use of an-algesics, there were patients experiencing DFU pain that took no form of pain relief – as with the Ribu et al. 19 study, this suggests DFU pain management requires the same attention as other types of wound pain.

More patients with NIU taking analgesia than those with NFU could indicate that presence of ischaemia in the neuro-ischaemic foot is the main factor for the increase in severity of DFU pain, therefore requiring more treatment with analgesics. It could, however, be a coincidence due to the large number within the sample requiring analgesia for other problems. The pilot study by Bengtsson et al. 20 found little difference between analgesic use for the two groups, and, as that study was using much larger numbers than this audit, this suggests any results should be inter-preted with caution.

Callus build-up causing raised foot pressures 42 could potentially cause DFU pain. The average VAS and overall SF-MPQ scores were less for those who attended regular podiatry appointments, suggesting regular debridement could contribute to decreasing pain levels. The groups were however not comparable in terms of size.

Pressure-relieving footwear could provide pain relief due to decreased pressure and contact with the ulcer sur-face. The results did not support this theory as average VAS and overall SF-MPQ scores for patients wearing some form of pressure-relieving footwear were slightly higher than for those wearing normal shop-bought footwear. However, the difference was very small and again, the groups were not entirely comparable in size.

Identifying or excluding other factors such as painful neuropathy caused by tibial nerve entrapment which could be causing pain is also useful when formulating an appro-priate management plan. Although not common, surgery involving neurolysis of the tibial nerve may be helpful in this group (Dellon, 1988), and so exclusion of this as a root cause of any ulcer pain, perhaps by elicitation of Tinel’s sign with percussion behind the medial malleolus, may be useful during any further investigations of this topic.


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

tention. As with other types of wound pain, inadequate use of analgesia is a problem warranting more investigation.

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

References

1. Dallam L, Smyth C, Jackson BS, Krinsky R, O’Dell C, Rooney J, Badillo C, Amelia E, Ferrara L, Freeman K (1995) Pressure Ulcer Pain: Assessment and Quantification Journal of Wound, Ostomy and Continence Nursing 22: 211-218

2. Hofman D, Ryan TJ, Arnold F, Cherry GW, Lindholm C, Bjellerup M, Glynn C (1997) Pain in Venous Leg Ulcers Journal of Wound Care 6 (5) 222-224

3. Lindholm C, Bergsten A, Berglund E (1999) Chronic Wounds and Nursing Care Journal of Wound Care 8 (1) 5-10

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

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

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

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

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

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

10. Driver VR, Landowski MA, Madsen JL (2007) Neuropathic Wounds: The Diabetic Wound In: Bryant RA, Nix DP (Eds.) Acute and Chronic Wounds: Current Manage-ment Concepts 3rd Edn St. Louis: Mosby, pp 307-335

11. National Institute of Clinical Excellence (2004) Type 2 Diabetes: Prevention and Management of Foot Problems Retrieved July 12th 2008 from NICE website: http://www.nice.org.uk/nicemedia/pdf/CG010NICE guideline.pdf

12. Abraham SE (2006) Pain Management in Wound Care Podiatry Management June/July 165-168

13. Armstrong DG, Todd WF, Lavery LA, Harkless LB, Bushman TR (1997) The Natural History of Acute Charcot’s Arthropathy in a Diabetic Foot Specialty Clinic Diabetic Medicine 14: 357-363

14. Laing P (1998) The Development and Complications of Diabetic Foot Ulcers American Journal of Surgery 176: 11S-19S

15. Freedman G, Cean C, Duron V, Tarnovskaya A, Brem H (2003) Pathogenesis and Treatment of Pain in Patients with Chronic Wounds Surgical Technology Interna-tional 11: 168-179

16. Dellon L (1988) A Cause for Optimism in Diabetic Neuropathy Annals of Plastic Surgery 20 (2) 103-105

17. Sibbald RG, Katchky A, Queen D (2006) Medical Management of Chronic Wound Pain Wounds UK 2 (4) 74-89

18. Krasner D (1995) The Chronic Wound Pain Experience: A Conceptual Model Ostomy/Wound Management 41 (3) 20-25

19. Ribu L, Rustoen T, Birkeland K, Hanestad BR, Paul SM, Miaskowski C (2006) The Prevalence and Occurrence of Diabetic Foot Ulcer Pain and its Impact on Health-Related Quality of Life The Journal of Pain 7 (4) 290-299

20. Bengtsson L, Jonsson M, Apelqvist J (2008) Wound-Related Pain is Underestimated in Patients with Diabetic foot Ulcers Journal of Wound Care 17 (10) 433

21. Greenhalgh T (2001) How to Read a Paper: The Basics of Evidence Based Medicine 2nd Edn. London: BMJ Books

22. International Working Group on the Diabetic Foot (2007) International Consensus on the Diabetic Foot & Practical Guidelines on the Management and the Prevention of the Diabetic Foot Interactive DVD launched at the 5th International Symposium on the Diabetic Foot May 2007. Available at www.idf.org/bookshop

23. Lavery LA, Armstrong DG, Harkless LB (1996) Classification of Diabetic Foot Wounds The Journal of Foot and Ankle Surgery 35 (6) 528-531

24. Melzack R (1987) The Short-Form McGill Pain Questionnaire Pain 30: 191-197

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

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

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

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

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

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

31. Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJM (2001) Comparison of Two Diabetic Foot Ulcer Classification Systems: The Wagner and the University of Texas System Diabetes Care 24: 84-88

32. Brod M (1998) Quality of Life Issues in Patients with Diabetes and Lower Extremity Ulcers: Patients and Care Givers Quality of Life Research 7: 365 – 372

33. Ashford RL, McGee P, Kinmond K (2000) Perception of Quality Of Life by Patients with Diabetic Foot Ulcers The Diabetic Foot 3 (4) 150-155

34. Ribu L, Wahl A (2004) Living with Diabetic Foot Ulcers: a Life of Fear, Restrictions, and Pain Ostomy/Wound Management 50 (2) 57-67

35. Watson-Miller S (2006) Living with a Diabetic Foot Ulcer: A Phenomenological Study Journal of Clinical Nursing 15: 1336-1337

36. Doughty DB (2006) Strategies for Minimizing Chronic Wound Pain Advances in Skin and Wound Care 19 (2) 82-85

37. Helme RD, Katz B, Gibson S, Corran T (1989) Can Psychometric Tools be used to Analyse Pain in a Geriatric Population? Clinical Experimental Neurology 26: 113-117

38. McDonald DD, Weiskopf CS (2001) Adult Patients’ Postoperative Pain Descriptions and Responses to the Short-Form McGill Pain Questionnaire Clinical Nursing Research 10 (4) 442-452

39. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW (1995) Probing to Bone in Infected Pedal Ulcers: A Clinical Sign of Underlying Osteomyelitis in Diabetic Patients Journal of the American Medical Association 273: 721-723

40. Lavery LA, Peters EJG, Armstrong DG, Lipsky BA (2007) Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis: Reliable or Relic? Diabetes Care 30 (2) 270-274

41. Edmonds ME, Foster A (2004) The Use of Antibiotics in the Diabetic Foot American Journal of Surgery 187 (5, Supplement 1) 25S – 28S

42. Young MJ, Cavanagh PR, Thomas G, Johnson MN, Murray HJ, Boulton AJM (1992) Effect of Callus Removed on Dynamic Foot Pressures in Diabetic Patients Diabetic Medicine 9:75-77



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Karsten Knobloch, FACS, MD, PhD

Peter M. Vogt, MD, PhD

Plastic, Hand and Recon-structive Surgery, Hannover Medical School, Germany




Wound surgery involves both compre-hensive wound bed preparation and wound closure. There is no doubt

that radical early debridement of a given wound will provide the best fundament for a proper soft tissue reconstruction. It enables the wound to go through the normal wound healing phases.

All chronic wounds lasting longer than three months should be considered for surgical evalu-ation with biopsies taken to determine bacterial count/invasiveness. The surgical goal of debri-dement is to reach a level of normal, well-vas-cularized tissue with removal of non-vital tissue remnants. There are a number of variations of debridement procedures – surgical, mechanical, enzymatical, autolytic or biological. However, the focus of the following presentation is the reconstruction of a debrided wound by surgical means, when conservative measures have failed or are deemed inappropriate.

Stephen Mathes and Foad Nahai introduced the reconstructive ladder in 1982 in their book “Clin-ical applications for muscle and musculocutaneous flaps”. It was thought to guide the reconstructive surgeon in the management of a surgical defect or chronic wound progressing from simple to more complex procedures.

The conventional reconstructive ladder ad-dressing tissue defects begins with primary and secondary closure of wounds followed by autolo-gous skin grafting, regional and local pedicled flaps, tissue expansion and free tissue transfer1. Selection of an appropriate technique is based on its ability to satisfy the particular reconstructive requirements of the defect. Success in reconstruc-tive surgery requires coverage and restoration of form, contour and function. Depending on local capillary circulation, direct closure or skin grafts as well as local flaps often provide sufficient cov-erage. However, as soon as local circulation is

impaired in a given local wound, such as in case of radiation vasculitis, local random-pattern flaps generally have the very same vascular impairment as the nearby wound. Thus, a flap with a distant vascular pedicle should be selected in this regard. Besides coverage, form and contour should be considered to obtain the best reconstructive result. While shallow wounds might be covered by split-thickness skin grafts, deeper soft tissue defects might necessitate muscle or musculocutaneous flaps to improve contour in addition to coverage.

In order to overcome the step-wise approach of the aforementioned reconstructive ladder, the reconstructive elevator has been introduced. It is thought to allow ascending directly to the chosen level of reconstructive complexity by Gottlieb and Krieger2. They believed that to think sequentially, as is the case with the reconstructive ladder, is no longer sufficient. In their opinion, reconstructive surgery calls for parallel rather than simple se-quential thinking in terms of reconstructive goals. They quote the following case: “Consider the case

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

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


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

In order to overcome the shortcomings of the reconstruc-tive ladder, Mathes and Nahai proposed a new paradigm, “the reconstructive triangle”4.

plantation medicine with encouraging early and mid-term clinical results5. Notably, plastic reconstructive surgeons have a long tradition in transplantation medicine6. Pad-gett7 and Brown and McDowell8 were among the first to perform human skin transplantation in monozygotic twins. In 1942, failure of skin allografts as a potential “al-lergic response or immunity three weeks after grafting” was hypothesized. Rejection was studied on skin homografts by plastic surgeons. Murray, a plastic surgeon, performed the first successful human kidney transplantation in 19559 and reported the use of azathioprine for immunosuppres-sion eight years later10. In case of recent composite tissue allotransplantation, however, short and long term prob-lems such as potential tumour induction by immuno-suppression and chronic rejection are to be considered. Given the fact that patients receiving CTA have already undergone various reconstructive procedures, the patients often gain tremendous improvement in quality of life. Following the European Union (EU) directive 2004/23/EC, which came into effect in German law by August 1, 2007, the question arises whether hand, arm or face trans-plantations are tissue or organ transplantations11. Given the current allocation procedures and procurement issues in CTA we believe that CTA has much more in common with organ than mere tissue transplantation. Nonethe-less, CTA might develop as an important adjunct in the reconstructive armamentarium of modern reconstructive surgeons in the not too distant future.

RoboticsA further evolving field is robotics like the Da Vinci system for surgeons and the Penelope assistant robot which found their way into the clinical Operating Room. While even microsurgical anastomosis has been performed using the Da Vinci system, the total amount of time and resources spent is beyond being practical today. The role of the robot in the operating theatre is increasing, such as in robot-assisted radical prostatectomies12, for primary or recurrent oropharnygeal carcinoma13, in right hemicolectomy14 or nephrectomy15.

Tissue Engineering and RegenerationRegeneration and Tissue Engineering are of distinct and genuine interest in reconstructive surgery. Free fat transfer as lipofilling has attracted significant at-tention in the very last years16. Adipose-derived stem cell transfer is able not only to improve contour, but also im-prove overlying skin17 with potential widespread future application in reconstructive surgery.

A combination therapy using fat grafting and platelet-rich plasma has been applied to 20 patients suffering chronic lower-extremity ulcers18. Using the combined approach,

Figure 2. Reconstructive elevator to directly approach the

level of reconstructive choice for a given soft tissue defect proposed

by Gottlieb and Krieger.

Figure 3. The reconstructive triangle with the three corners flaps, microsurgery, and tissue expansion suggested by Mathes and Nahai.

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


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

Reconstructive clockworkComprehensive care is usually achieved at best in a team approach. A given reconstructive problem is reasonably addressed by a combination of various reconstructive tech-niques if one alone is not able to fully succeed. Having said that the combination of reconstructive procedures is feasible and clinically relevant, the aforementioned evolv-ing fields of composite tissue allotransplantation (CTA), robotics and regeneration/tissue engineering will be, and sometimes are already, an integral part of daily reconstruc-tive procedures. While the abovementioned metaphors of the reconstructive ladder as well as the reconstructive elevator do not allow intuitively combining various recon-structive measures from different echelons, we would like to propose a novel thought on this issue.

We consider these novel techniques, CTA, robotics and regeneration/tissue engineering as potential future integral parts of a reconstructive sequence, which is not neces-sarily consecutive but simultaneous. Given the integral

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

References 1 Mathes S, Nahai F. Clinical application for muscle and musculocutaneous flaps.

Mosby, St. Louis, 1982; 3.

2 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994;93(7):1503-4.

3 Bennett N, Choudhary S. Why climb a ladder when you can take the elevator? Plast Reconstr Surg 2000;105(6):2266.

4 Mathes SJ, Nahai F. Reconstructive surgery: Principles, anatomy and technique. London: Churchill Livingstone, 1997, 11-12.

5 Brandacher G, Ninkovic M, Piza-Katzer H, Gabl M, Hussl H, Rieger M, Schocke M, Egger K, Loescher W, Zelger B, Ninkovic M, Bonatti H, Boesmueller C, Mark W, Margreiter R, Schneeberger S. The Innsbruck hand transplant program: update at 8 years after the first transplant. Transplant Proc 2009;41(2):491-4.

6 Knobloch K, Vogt PM. Plastic surgeons’ tradition in transplantation medicine in light of composite tissue allotransplantation. J Am Coll Surg 2009;209(5):674.

7 Padgett EC. Is iso-skin grafting practicable?, South Med J 1932;25:895.

8 Brown JB, and McDowell F. Epithelial healing and the transplantation of skin. Ann Surg 1942;115:1166–1177.

9 Murray JE, Merrill JP, Harrison JH. Renal homotransplantations in identical twins. Surg Forum1955; 6:432.

10 Murray JE, Merrill JP, Harrison JH, Wilson RE, Dammin GJ. Prolonged survival of human-kidney homografts by immunosuppressive drug therapy. N Engl J Med 1963;269:126–129.

11 Knobloch K, Vogt PM, Rennekampff HO. Composite tissue allotransplantation (CTA): organ or tissue transplantation? Handchir Mikrochir Plast Chir 2009;41(4):205-9.

12 Carlsson S, Nilsson AE, Schumacher MC, Jonsson MN, Volz DS, Steineck G, Wiklund PN. Surgery-related complications in 1253 robot-assisted and 485 open retropubic radical prostatectomies at the Karolinska University Hospital, Sweden. Urology 2010;75(5):1092-7.

13 Dean NR, Rosenthal EL, Carroll WR, Kostrzewa JP, Jones VL, Desmon RA, Clemons L, Magnuson JS. Robotic-assisted surgery for primary or recurrent oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 2010;136(4):380-4.

14 De Souza AL, Prasad LM, Park JJ, Marecik SJ, Blumetti J, Abcarian H. Robotic assistance in right hemicolectomy: is there a role? Dis Colon Rectum 2010;53(7):1000-6.

15 Rogers C, Laungani R, Krane LS, Bhandari A, Bhandari M, Menon M. Robotic nephrectomy for the treatment of benign and malignant disease. BJU Int 2008;102(11):1660-5.

16 Rennekampff HO, Reimers K, Gabka CJ, Germann C, Giunta RE, Knobloch K, Machens HG, Pallua N, Überreiter K, Heimburg D, Vogt PM. Current perspective and limitations of autologous fat transplantation – “consensus meeting” of the German Society of Plastic, Reconstructive and Aesthetic Surgeons at Hannover, September 2009. Handchir Mikrochir Plast Chir 2010;42(2):137-42.

17 Mojallal A, Lequeux C, Shipkow C, Breton P, Foyatier JL, Braye F, Damour O. Improvement of skin quality after fat grafting : clinical observation and an animal study. Plast Reconstr Surg 2009;124:765-74.

18 Cervelli V, Gentile P, Grimaldi M. Regenerative surgery: use of fat grafting combined with platelet-rich plasma for chronic lower-extremity ulcers. Aesthetic Plast Surg 2009;33(3):340-5.

19 Chen TM, Tsai JC, Burnouf T. A novel technique combining platelet gel, skin graft, and fibrin glue for healing recalcitrant lower extremity ulcers. Dermatol Surg 2010;36(4):453-60.

20 O’Connell SM, Impeduglia T, Hessler K, Wang XJ, Carroll RJ, Dardik H. Autologous platelet-rich fibrin matrix as cell therapy in the healing of chronic lower-extremity ulcers. Wound Repair Regen 2008;16(6):749-56.

21 Danielsen P, Jörgensen B, Karlsmark T, Jorgensen LN, Agren MS. Effect of topical autologous platelet-rich fibrin versus no intervention on epithelisation of donor sites and meshed split-thickness skin autografts: a randomized clinical trial. Plast Reconstr Surg 2008;122(5):1431-40.

22 Knobloch K, Vogt PM. The reconstructive sequence in the 21st century. A reconstructive clockwork. Chirurg 2010;81(5):441-6.

Figure 4. Reconstructive clockwork of the 21st century.



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ABSTRACTBackground: The clinical observation was made that a number of patients with reduced haemo-globin levels were admitted to the Centre for Wound Healing, Odense University Hospital, but the real prevalence was not known. Objective: This retrospective study was designed to quantify the prevalence of anaemia in patients admitted for the first time at the University Cen-tre for Wound Healing, Odense University Hos-pital, for a period of 15 months. Methods: Sex, age, diabetes status, haemoglobin, C-reactive protein, creatinine, albumin, mean cor-puscular volume, mean corpuscular haemoglobin and weight were registered. The renal function was estimated. Haemoglobin was differentiated according to sex.Results: Two hundred and thirteen patients par-ticipated in total - 57 % being male. Fifty five percent had anaemia. Patients with anaemia had a significantly higher C-reactive protein and lower albumin (p<0.0001).Conclusion: Anaemia was found to be related to chronic disease, renal insufficiency or a combina-tion of these. All patients having a complicated wound in combination with anaemia should be more thoroughly investigated on admission and further blood analyses taken in order to classify the anaemia.

INTRODUCTIONThe objective of this work was to clarify the preva-lence of anaemia in patients admitted to a large University Centre dedicated to the treatment of complicated wounds (Centre for Wound Heal-ing Odense University Hospital [WH-OUH]). A retrospective study for a period of 15 months was carried out. Outcome variables included the number of patients with anaemia and whether some subgroups of patients had a significantly lower haemoglobin level (i.e. diabetes, renal insuf-ficiency). Also, different variables (e.g. C-reactive protein [CRP], creatinine level) were analyzed for association with anaemia.

Lotte M. Vestergaard, M.D.

Roskilde University Hospital, Department of Anaesthes-iology.

Isa Jensen, M.D. Odense University Hospital, University Centre for Wound Healing

Knud Yderstraede, M.D., PhD Odense University Hospital, Department of Endocrinology

Work is attributed to Centre for Wound Healing, Odense University Hospital, Odense, Denmark.



Anaemia in patients with chronic wounds

METHODS All patients admitted to WH-OUH for the first time over a period of 15 months were registered. Re-admissions were not included. Variables re-corded were: gender, age, diabetic status, renal function, MCV (mean corpuscular volume), MCH (mean corpuscular haemoglobin), CRP, haemoglobin, serum creatinine, albumin, and weight. The renal function was estimated using the Cockcroft and Gault formula: Creatinine clearance (CrCl)=([140-age] x weight[kg]) x con-stant/serum creatinine[µmol/L]), constant = 1.23 in men, and 1.04 in women.

All data were collected from admission nota-tions via the electronic patient charts. The weight was collected from data in anaesthetic chart for-mulas in about 50 % of the patients as only three patients had their weight determined on admis-sion. Anaemia was defined as a value of ≤ 7.0 mmol/l (11.5 g/dl) in women and a value ≤ 8.0 mmol/l (13 g/dl) in men according to local refer-ence values.

A literature search was performed using the PubMed/Medline database, search terms being: “anaemia and chronic wounds”, “anaemia and chronic ulcers”, “anaemia and wound healing”, “anaemia and diabetes”, “anaemia and nutrition”, “albumin and inflammation”, “gastrointestinal bleeding and chronic disease” and “nutrition and healing”.

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





RESULTSA total of 213 individuals were admitted during the pe-riod (57 % male). Fifty five percent of the patients were diagnosed with anaemia on admission. The mean value of haemoglobin for men was 7.63 ± 1.25 mmol/l (12.29 ± 2.01 g/dl) and the mean haemoglobin for anaemic men was 6.77 ± 1.15 mmol/l (10.91 ± 1.85 g/dl). The mean haemoglobin for women was 7.16 ± 1.10 mmol/l (11.53 ± 1.77 g/dl) and the mean haemoglobin for anaemic women was 6.62 ± 1.06 mmol/l (10.66 ± 1.71 g/dl).

The age span was 27 to 98 years, with a mean value of 65 years. The age average in the anaemic patients was significantly higher (p = 0.007) compared to the age aver-age in the non-anaemic patients (68 ± 16 years versus 61 ± 17 years – see table 1).

Anaemia and CRPThe mean value of CRP in patients with anaemia was 98 ± 84 mg/l, while in patients without anaemia it was 41 ± 53 mg/l (p<0.0001), see Table 1. The mean value of CRP in diabetic patients was 74 ± 77 mg/l versus 72 ± 76 mg/l in non-diabetic patients (p=0.853).

Anaemia and albuminThe mean value of albumin was analyzed in patients with and without anaemia, respectively. The mean value of al-bumin in patients with anaemia was 33.9 ± 5.5 g/l versus 39.2 ± 5.1 g/l in patients without anaemia (p<0.0001), see table 1.

Anaemia and renal functionKidney function could be estimated in 49.3 %. Among these 51.4 % had impaired kidney function, defined as a CrCl less than 70 ml/min calculated from Cockcroft and Gault. In this group 35 patients had anaemia, while in the group of patients with normal kidney function, 23 patients had anaemia (p=0.048) – see table 2 and 3.

Anaemia and diabetes Forty four percent of the admitted patients had diabetes. The mean value of haemoglobin in patients with diabetes was 7.44 ± 1.27 mmol/l (11.99 ± 2.05 g/dl) versus 7.42 ± 1.25 mmol/l (11.95 ± 2.01 g/dl) in patients without diabetes (ns), see table 3.

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

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

DISCUSSIONFew studies have addressed the prevalence of anaemia in patients with chronic wounds.1,2,3,4,5 Studies from Den-mark and Italy indicate that anaemia is related to chronic disease.1,2,3 The Danish study showed a positive correla-tion between size of the chronic ulcer and the degree of anaemia.1

The Italian studies compared haemoglobin levels in patients with pressure wound.2,3

The fact that anaemic patients had significantly higher CRP and lower albumin indicates that patients with anae-mia have a higher degree of inflammation,5,6 although the level of albumin is confounded by a number of other fac-tors, such as nutrition, infection (severe), kidney and liver disease.7,8 However, the synthesis of albumin is negatively correlated to inflammation,6 and the catabolism of albu-min may be increased under inflammatory conditions.7,8 CRP is a marker of acute and chronic inflammation and infection.9 In this study, inflammation is highly prevalent in those patients with anaemia, indicating that anaemia in this population is associated with chronic disease.10,11,12 Many of the patients admitted to the wound healing centre

Table 1: Anaemia, age, CRP, albumin and creatinine.

Anaemic patients Non-anaemic patientsAge (mean, ± SD) 68 ± 16 61 ± 17 p=0.007CRP (mean, ± SD) 98 ± 84 42 ± 53 p<0.0001Albumin (mean, ± SD) 33.9 ± 5.5 39.2 ± 5.1 p<0.0001Creatinine (mean, ± SD) 132 ± 126 105 ± 78 p=0.071

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

AnaemiaYes No Total

Renal Function Impaired 35 18 53Normal 23 28 51

Total 58 46 104


have a complicating infection of the chronic wound, thus needing admission to hospital. In order to differentiate between inflammation and infection, patients need to have both CRP and white blood cells analysed. This has not been done in this study.

The admission charts had no reference to the nutri-tional status of the patients. A study from Iceland showed a prevalence of anaemia of 36.7 % among 60 patients ad-mitted to a geriatric ward.13 The patients were significantly older, had lower albumin levels, a higher erythrocyte sedi-mentation rate and were more often malnourished.13 They conclude that a reduced levels of albumin and prealbumin is likely to be a consequence of anaemia or an inflamma-tion process rather than a underlying cause of anaemia.13

For stratification MCV and MCHC were measured and 95 % of the patients turned out to have normochro-mic and normocytic anaemia, also pointing to anaemia of chronic disease, as also noted by Weiss and Goodnough.11

The strength of this study is weakened by the fact, that MCV and MCHC were only measured in 17.3 % of the patients with anaemia, while none of the patients had P-Fe, P-ferritin and P-transferrin measured. Thus, the conclusion is less substantiated.

There was a significantly higher number of patients with impaired renal function among those with anaemia. The renal function was estimated in 49.3 %. An estimate of the renal function, using for example Cockcroft and Gault, is practical in the everyday clinical setting,14,15,16 but some limitations should be stressed: muscle wasting, race, diet, neuromuscular disease and amputation all af-fect the creatinine concentration.17 Also, Cockcroft and Gault’s equation has been found less accurate in obese patients compared to other equations17. Amputation and

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

Anaemia in people with diabetes has been investigated in several studies showing that diabetics have a higher prevalence of anaemia of renal origin compared to non-diabetics at the same level of renal impairment.18,19 Our data showed no significant difference in mean haemo-globin level between diabetics and non-diabetics. Also, the prevalence of diabetes was no higher in patients with impaired renal function. The only significant difference between diabetics and non-diabetics was a higher creati-nine level in the former.

Many of the patients admitted to the wound healing centre have co-morbidity such as impaired renal function, diabetes and heart disease. These conditions are associated with an increased risk of gastrointestinal bleeding.

One study found that treatment with oral anticoag-ulants, treatment for heart failure, treatment with oral corticosteroid, treatment for diabetes, and smoking were all independent risk factors for peptic ulcer bleeding.20 Several studies have found that patients with chronic re-nal failure have an increased risk of, in particular, upper gastrointestinal bleeding.21,22,23,24

In this study 55.2 % had anaemia. The aetiology of anaemia is related to the wound itself, chronic disease, iron deficiency or impaired renal function. In order to clarify the aetiology further blood analyses must be performed including a number of variables (i.e. P-ferritin, P-iron, P-transferrin, MCV, MCHC, haemoglobin, haematocrit) in future studies. Further blood tests can be considered in order to evaluate both nutrition and a possible nutritional cause of the anaemia (i.e. folic acid, cobalamin, prealbu-min). Further, all patients admitted to hospital must be weighed at admission.

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

Anaemia No anaemiaImpaired renal function 35 18 p=0.048Diabetes 56 37 p=0.211


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

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


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


References

1 Thomsen JF, Worm AM: Anaemia in crural ulcers. Ugeskrift for laeger. 1986 Feb 17;148(8):446-7.

2 Fuoco U, Scivoletto G, Pace A, et.al: Anaemia and serum protein alteration in patients with pressure ulcers. Spinal Cord. 1997 Jan;35(1):58-60.

3 Scivoletto G, Fuoco U, Morganti B et.al: Pressure sores and serum dysmetabolism in spinal cord injury patients. Spinal Cord. 2004 Aug;42(8):473-6.

4 Schraibman IG, Stratton FJ: Nutritional status of patients with leg ulcers. J R Soc Med. 1985 Jan;78(1):39-42.

5 Raffoul W, Far MS, Cayeux MC et.al: Nutritional status and food intake in nine patients with chronic low-limb ulcers and pressure ulcers: importance of oral supplements. Nutrition. 2006 Jan;22(1):82-8.

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

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

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

9 Pepys MB: C-reactive protein fifty years on. Lancet. 1981 Mar 21;1(8221):653-7.

0 Jacober ML, Mamoni RL, Lima CS et.al: Anaemia in patients with cancer: role of inflammatory activity on iron metabolism and severity of anaemia. Med Oncol. 2007; 24(3):323-9.

11 Weiss G, Goodnough LT: Anaemia of chronic disease. N Engl J Med. 2005 Mar;352(10):1011-1023.

12 Fitzsimons EJ, Brock JH: The anaemia of chronic disease. BMJ. 2001 Apr 7;322(7290):811-2.

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

14 Prigent A: Monitoring renal function and limitations of renal function tests. Semin Nucl Med. 2008 Jan;38(1):32-46.

15 Tidman M, Sjöström P, Jones I: A comparison of GFR estimating formulae based upon s-cystatin C and s-creatinine and a combination of the two. Nephrol Dial Transplant. 2008 Jan;23(1):154-60.

16 Riche M le, Zemlin AE, Erasmus RT et.al: An audit of 24-hour creatinine clearance measurements at Tygerberg Hospital and comparison with prediction equation. S Afr Med J. 2007 Oct;97(10):968-70.

17 Stevens LA, Coresh J, Greene T et.al.: Assessing Kidney Function – Measured and Estimated Glomerular Filtration Rate. N Engl J Med 2006 Jun 8;354(23):2473-83.

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

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

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

21 Chalasani N, Cotsonis G, Wilcox CM: Upper gastrointestinal bleeding in patients with chronic renal failure: role of vascular ectasia. Am. J. Gastroenterol. 1996 Nov;91(1):2329-32.

22 Wasse H, Gillen DL, Ball AM et.al.: Risk factors for upper gastrointestinal bleeding among end-stage renal disease patients. Kidney Int. 2003 Oct;64(4):1455-61.

23 Lepère C, Cuillerier E, Van Gossum A et.al.: Predictive factors of positive findings in patients explored by push enteroscopy for unexplained GI bleeding. Gastrointest. Endosc. 2005 May;61(6):709-714.

24 Zuckerman GK, Cornette GL, Clouse RE et.al.: Upper gastrointestinal bleeding in patients with chronic renal failure. Ann. Intern. Med. 1985 May;120(5):588-92.

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function or both. Anaemia of gastrointestinal origin has also been found more frequently among this group of patients, but this was not evaluated in this retrospective study.

We suggest that all patients with complicated wounds in need of in-hospital treatment should have routine blood tests performed including haematology and renal function variables, and all patients admitted to hospital must be weighed on admission. In case of anaemia, an aetiological stratification is mandatory. m

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Mr Eric ClarkeLecturer in Informatics,RCSI,Dublin,[email protected]

On behalf of EWMA Education Committee and the Teach the Teacher Consortium.


INTRODUCTIONWounds and their associated problems have chal-lenged health care providers for centuries (Moore & Cowman 2005). Despite this longevity, they continue to be a problem, with an estimated 1 - 1.5% of the population suffering with a wound at any given point in time (Posnett et al. 2009). Changing population demographics and the projected increase in the number of older per-sons suggests that the number of wounds is set to increase correspondingly, considering the as-sociation between older age and chronic disease (Moore & Cowman 2005).

Economic appraisal of the provision of wound care indicates that wounds are a significant drain on health care resources. Indeed, it is proposed that 4% of the total health care expenditure is spent on the provision of wound care and inter-estingly, 41% of these costs are associated with nursing time (Posnett et al. 2009). The majority of wounds are managed in the community setting (Moore & Cowman 2005) and between 20%-30% of community nursing time is spent on the provision of wound care (O Keeffe 2006).

Wounds also impact negatively on health relat-ed quality of life, with pain being one of the most frequent issues of concern reported by patients (Spilsbury et al. 2007). Other problems experi-enced include nausea, fatigue, depression, sepsis, psychological disturbances, loss of function, loss of mobility and personal financial cost (Herber et al. 2007). Thus, the presence of a wound is a very difficult experience for the individual, one which impacts on all of the activities of daily living.

Pre-registration education in wound managementAn Bord Altranais (ABA) the Irish Nursing Board, outlines that the purpose of undergraduate nurse education is that, on qualification, the individual should be equipped with the knowledge and skills necessary to practice as a competent professional nurse (ABA 2005). Competence is defined as the ability of the registered nurse to practice safely and

A survey of the provision of education in wound management to undergraduate nursing students

effectively, fulfilling his/her professional responsi-bility within his/her scope of practice (ABA 2005). In addition to being competent to carry out their roles, nurses must develop and maintain compe-tency and must also acknowledge the limitations of their competency (ABA 2005).

Education provides the knowledge and skills necessary to carry out effective wound manage-ment (Moore & Price 2004). Not only does education heighten the awareness of the prob-lem of wounds, but education also provides the framework to develop and maintain competency (Moore & Price 2004). All registered nurses are answerable for their own actions undertaken dur-ing the course of their duties. Education provides the framework for each nurse to ensure that the actions they take are justifiable and appropriate (ABA 2005).

For many years there has been an argument that from the beginning of nurse education there appears to be a inconsistency between what is taught regarding wound management and what the content of this education should be (Beitz et al. 1998, Gould 1992). Almost 20 years ago, Gould (1992) carried out an exploratory study to test this hypotheses and in doing so assessed the amount of education nurses received relating to pressure ulcer prevention and management at undergraduate level. Using a postal survey, Gould (1992) surveyed 13 schools of nursing, informa-tion was elicited regarding aspects of prevention and treatment of pressure ulcers that was routinely taught. Further clarification was sought to deter-mine why this particular information was selected and how it related to current literature of the time.

Gould (1992) identified that education on pressure ulcers was inadequate and poorly taught, highlighting gaps between education and clinical practice. This questioned the appropriateness of educational strategies and, as such, the prepar-edness of newly qualified nurses for this aspect of practice (Ayello & Meaney 2003, Wilborn et al. 2009). This question still remains largely unanswered today, where discrepancies between


mailto:zmoore%40rcsi.ie?subject=

mailto:eclarke%40rcsi.ie?subject=

current best practice guidelines and the content of un-dergraduate education continue to persist (Ayello et al. 2010). The significance of this is that the newly qualified nurse may not feel empowered to make appropriate clini-cal decisions in wound management and as such will not be in control of their own nursing practice. This in turn impacts negatively on clinical outcomes, adding to the burden of both the patient and society as a whole.

It is based on this background that the Teach the Teachers education development group, of the European Wound Management Association (EWMA), conducted a survey of the EWMA Cooperating Societies. The ra-tionale for conducting the study was to determine if the argument pertaining to the gap between the theoretical instruction and the practice of wound management was justified. The aim of the survey was, therefore, to elicit the current provision of undergraduate nursing education in wound management across Europe.

METHODSA cross section descriptive survey design was employed to gather data using a predesigned questionnaire. The ques-tionnaire was based upon the education modules previ-ously developed and validated by EWMA and a review of the literature. Content and face validity were determined using the expert members of the Teach the Teachers ed-ucation development group. The questionnaire elicited information using both closed and open ended questions, data were at nominal and ordinal level.

The questionnaire was designed and distributed on-line using a commercial service (Surveymonkey) which is hosted externally to RCSI. The only person who had access to the full data base was the primary administrator (EC). All responses were anonymised before data analysis.

The invitation to participate was sent in November 2009, to 68 persons in 35 countries, representing the Co-operating Organisations of EWMA. Two further remind-ers were sent in December 2009, to capture those who did not respond to the initial call.

RESULTSA response rate of was 80% was realised, with partici-pants representing 28 of the 35 countries surveyed. As was expected, 60% of the respondents had a nursing or an education background.

Satisfaction with undergraduate education in wound management Eighty seven per cent of respondents suggested that they were not satisfied with the time allocated to wound man-agement education. Indeed, more specific details regard-ing the amount of time allocated demonstrated that, in

60% of cases, between two hours and one day in the total undergraduate programme are set aside for this aspect of the nursing undergraduate curriculum.

The majority of respondents (83%) felt that under-graduate nurses do not receive sufficient education on wound management. Furthermore, 86% and 91% respec-tively, felt that pressure ulcer prevention and diabetic foot ulceration needed more attention. Overall, 77% felt that the content of nursing undergraduate wound management education was not adequate. The majority of respondents (68%) also highlighted that more resources for teaching were needed, including further training in wound manage-ment for those involved in programme delivery.

The content of undergraduate education in wound managementAs would be expected, the common wound types encoun-tered such as pressure ulcers, leg ulcers and diabetic foot ulcers were all included in the majority of curricula, as were surgical, burn and trauma wounds. However, less than half the respondents identified that cancer wounds, lymphoedema and wounds of unusual aetiologies were addressed.

The respondents were also asked to indicate if spe-cific aspects of wound management were included in the curricula. Many respondents suggested that anatomy, pathophysiology, assessment, pain, risk factor manage-ment, wound management and management of infection were addressed. However, this finding was not consistent across programmes. For example, pain and management of infection were not addressed according to 30% and 29% of respondents respectively; furthermore, health econom-ics and rehabilitation services were not included in the curriculum in 65% and 48% of cases respectively.

Curriculum deliveryThe majority of the respondents suggested that the educa-tion is generally provided using face to face lectures (88%) and practical demonstrations (52%). Other aspects of blended learning, such as discussion forums and online lectures were rarely embraced. In addition, simulation, hands on interactive sessions and role play were infre-quently utilized. Similar findings were noted for education provision in the clinical environment, with teaching in the wound clinic, bedside teaching, face to face lectures and practical demonstrations being the most commonly cited.

Competency assessmentThe vast majority of respondents (82%) suggested that students’ competency in wound assessment was not as-sessed during their undergraduate training. Assessment was reported to take place mainly in the form of a written examination or written assignment used to assess the stu-dent’s knowledge. A small percent of respondents (28%)


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

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

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

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proaches utilised vary enormously in terms of content, mode of delivery and assessment strategies employed. These findings are in keeping with the arguments that prevail within the literature (Ayello & Meaney 2003, Wilborn et al. 2009) and the work of Caliri et al. (2003) who surveyed 3rd and 4th year undergraduate student nurses. Caliri et al. (2003) identified that they had low knowledge scores pertaining to pressure ulcer prevention. However, students who had attended specific wound man-agement education programmes or who actively sought information via online resources scored consistently higher on knowledge tests. This suggests that it is those who stretch themselves beyond the core curriculum that gain the necessary knowledge attainment.

These findings pose a challenge for the future provision of wound management, when one bears in mind that that the purpose of undergraduate nurse education is that, on qualification, the individual should be equipped with the knowledge and skills necessary to practice as a competent professional nurse (ABA 2005). Indeed, Funkesson et al. (2007), when exploring nurses’ reasoning process during pressure ulcer prevention care planning, noted that expe-rience, knowledge and an in depth understanding of the patient were important variables influencing decision mak-ing. Furthermore, individual characteristics of the nurse influenced their ability to problem solve within the clinical setting. Of these characteristics, the content of education


received and the level of academic attainment were central determinants of effective decision making. The impor-tance of knowledge in facilitating effective clinical deci-sion making is well alluded to in the literature (Kallman & Suserud 2009, Pancorbo-Hidalgo et al. 2007, Smith & Waugh 2009, Tweed & Tweed 2008). The quality of knowledge gained is therefore a key consideration in en-suring that the nurse is delivering care that is appropriate for individual patients (Ayello & Lyder 2007).

Demographic forecasts suggest that in the next 50 years there will be three times more older persons living in our world (U.S. Census Bureau 2004). Indeed, by the year 2050, it is estimated that older individuals will comprise almost 17% of the global population compared to 7% in 2002 (U.S. Census Bureau 2004). The older population appears to be at greater risk of the development of chronic wounds due to the likelihood of underlying neurologi-cal and cardiovascular problems (Bliss 1990). Therefore, the problem of wounds is set to increase in tandem with forecasted changes in demographics.

The costs associated with wound care are considerable and a lack of standardised policies and education strategies compound this cost and contribute to increased morbid-ity and mortality of patients (Harding & Boyce 1998). Lindohlm et al (1999) identified that limited availability of both adequately trained personnel and agreed standards to guide practice compounds the suffering of patients and increases costs in an already overstretched health budget. With limitations in resources and an increasing demand on service delivery, the choice of the most appropriate, effective treatments are paramount to the success of the health service (Levin 2001). In order to guarantee that this is a real possibility, greater attention needs to be given to ensuring that newly qualified nurses are equipped with the knowledge and skills necessary to provide safe, effective wound care.

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

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

References

An Bord Altranais (2005) Requirements and standards for nurse registration education programmes, 3rd edn (Altranais AB ed.). An Bord Altranais, Dublin.

Ayello EA & Lyder CH (2007): Protecting patients from harm: preventing pressure ulcers in hospital patients. Nursing 37, 36-40.

Ayello EA & Meaney G (2003): Replicating a survey of pressure ulcer content in nursing textbooks. Journal of Wound Ostomy and Continence Nursing 30, 266-271.

Ayello EA, Zulkowski KM & Capezuti E (2010): Pressure ulcer content in undergraduate programs. Nursing Outlook 58, e4.

Beitz JM, Fey J & O Brien D (1998): Perceived need for education vs. actual knowledge of pressure ulcer care in a hospital nursing staff. MedSurg Nursing 7, 293-301.

Bliss M (1990) Geriatric medicine In Pressure sores: clinical practice and scientific approach (Bader DL ed.). Macmillan, London, pp. 65-80.

Caliri M, Miyazaki M & Pieper P (2003): Knowledge of Pressure Ulcers by Undergraduate Nursing Students in Brazil. Ostomy and Wound Management 49.

Funkesson KH, Anbäcken EM & Ek AC (2007): Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. Interna-tional Journal of Nursing Studies 44, 1109-1109.

Gould D (1992): Teaching students about pressure sores. Nursing Standard 18, 28-31.

Harding KG & Boyce DE (1998) Wounds: The Extent of the Burden. In Wounds Biology and Management (Leaper D & Harding KG eds.). Oxford University Press, Oxford, pp. 1-4.

Herber OR, Schnepp W & Rieger MA (2007): A systematic review of the impact of leg ulceration on patients’ quality of life Health and Quality of Life Outcomes 5, 44.

Kallman U & Suserud BO (2009): Knowledge, attitudes and practice among nursing staff concerning pressure ulcer prevention and treatment - a survey in a Swedish healthcare setting. Scand J Caring Sci 23, 334-341.

Levin A (2001): The Cochrane Collaboration. Annals of Internal Medicine 135, 309-312.

Lindohlm C, Bergsten A & Berglund E (1999): Chronic Wounds and Nursing Care. Journal of Wound Care 8, 5-10.

Moore Z & Cowman S (2005): The need for EU standards in wound care: an Irish survey. Wounds UK 1, 20-28.

Moore Z & Price PE (2004): Nurses’ attitudes, behaviours and perceived barriers towards pressure ulcer prevention. Journal of Clinical Nursing 13, 942-951.

O Keeffe M (2006) The prevalence of pressure ulcers in the Irish community setting. In Pressure Ulcer Guidelines. A Pocket Guide (Smith & Nephew ed.). Smith & Nephew Ltd, Dublin.

Pancorbo-Hidalgo PL, García-Fernández FP, López-Medina IM & López-Ortega MJ (2007): Pressure ulcer care in Spain: nurses’ knowledge and clinical practice. Journal of Advanced Nursing 58, 327-338.

Posnett J, Gottrup F, Lundgren H & Saal G (2009): The resource impact of wounds on health-care providers in Europe. Journal of Wound Care 18, 154-161.

Smith D & Waugh S (2009): An assessment of registered nurses’ knowledge of pressure ulcers prevention and treatment. The Kansas Nurse 84, 3-5.

Spilsbury K, Nelson A, Cullum N, Iglesias C, Nixon H & Mason S (2007): Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. Journal of Advanced Nursing 57, 494-504.

Tweed C & Tweed M (2008): Intensive care nurses’ knowledge of pressure ulcers: devel-opment of an assessment tool and effect of an educational program. American Journal of Critical Care 17, 338-347.

U.S. Census Bureau (2004) International population reports WP/02, global population profile, 2002-2004 (U.S. Census Bureau ed.). U.S. Government Printing Office, Washing-ton DC.

Wilborn D, Halfens R & Dassen T (2009): Evidence-based education and nursing pressure ulcer prevention textbooks: does it match? Worldviews on Evidence-Based Nursing 6, 167-172.



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Camilla Eskilsson PhD Student

University of Borås, School of Health Sciences.

Contact: [email protected]


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

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

METHOD This study has a lifeworld phenomenological ap-proach2. By using this approach, I tried to meet the complexity of the phenomenon, “caring for patients with hard-to-heal wounds”. The phenom-enological approach is characterised by openness for the phenomenon and ongoing critical reflec-tion of its meanings. This follows the whole proc-ess, from data collection to analysis. The inclusion criteria were nurses in home care with experience of caring for patients with hard-to-heal wounds. The heads of two home care districts were given permission to inform them about the study. Sev-en nurses agreed to participate after verbal and written information. Interviews were conducted, transcribed and analysed5.

RESULTS The essential meaning of the phenomenon, “car-ing for patients with hard-to-heal wounds” is char-acterised by a tension between burdensome yet enriching care. Nurses try to handle this tension by using tools and strategies such as reflection, acceptance and distance. The essential meaning

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

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

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

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

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

Presented at the 20th Conference

of the European Wound Management Association

May 2010Geneva, Swizerland



the wound. One nurse described it as if the focus was transferred from the wound to the whole person. This holistic view is further illustrated when nurses point out the importance of instilling hope, spreading a positive spirit and supporting the patient’s positive attitude. This promotes the wound healing as well as giving a sense of well-being.

You don’t always know which dressing is the best for that partic-ular wound, and at the same time it’s the body and soul that heal the wound, not the dressing.

In respect to the patient and to their own limitations, nurses struggle to find an invisible boundary to be personal but not private. The more experience they have the easier it is to handle this issue.

Being Confident in order to Offer Confidence: Confi-dence is experienced as ambiguous; nurses need to feel confident themselves in order to offer confidence to a pa-tient. Where nurses have experience of mutual trust with their patients; then their relationship is deep and gives both of them confidence. They are further strengthened by increased knowledge, experience and support from physi-cians. Once again cooperation is pointed out as crucial but not always satisfactory.

I think it doesn’t seem as if they [physicians] think it is fun; of-ten they hand over a great deal of responsibility to the nurses.

Confidence is challenged when nurses lose control over a situation. Even if they know they are not irreplaceable, they feel anxious and disappointed when a patient’s wound gets worse due to lack of continuity. Sometimes they feel frustrated and not confident in letting the patient go when the wound is healed and the caring relationship comes to an end.

Seeing Time and Place as Important: Care in a patient’s home and caring for patients with hard-to-heal wounds is both enriching and burdensome. A home can be ergo-nomically and hygienically inappropriate. Wound dressing is time-consuming, and with the potentially unsuitable environment and sometimes strenuous working positions it can be burdensome. Nurses can find it hard going to treat a patient and feel a relief when the meeting is over.

To some extent, working environment might play a role // you know that you’re going to get incredibly tired in your back be-cause you have to stand in such a way that you almost get... cra-zy, because it hurts so much and you get stiff // and you build this up before you even get there // and when you’re done you can finally feel like... (Int: Relief when you’re leaving?) Yeah, that’s right, a relief.

Limited time is frustrating. Caring for patients with hard-to-heal wounds takes a lot of time and results in conse-quences for the rest of the nurses’ duty. Different strategies

are described for handling stress. Some nurses are focused and present when meeting with the patient. Others feel as if they are already on their way to the next one.

On the other hand, the home-environment and the time-consuming care are also contributing factors to de-scribing it as enriching care. In a patient’s own home, s/he is experienced as a whole person and not merely a wound. The nurse-patient relationship deepens over time through multiple visits. This is something that makes nurses’ work enriching.

CONCLUSIONSIn the heart of this burdensome yet enriching care, there needs to be confidence both in the nurse and in the pa-tient. Some key words for this confidence could begin with the letter C:n Cooperation with Communication: Good cooperation

between the different professions around the patient depends on good communication. It is necessary for caregivers to act like a team with the patient in focus. It might be necessary to clarify roles and re-sponsibilities for the different professions and create forums for more constructive communication.

n Competence strengthens the nurses’ confidence and contributes to satisfaction in the caring action. Learning and caring can be supported by supervised reflection4. Thereby the burdensome aspects of care can be shared and handled in a constructive way.

n C as in seeing: This study was conducted from the nurses’ perspective but nevertheless the patient is always the lead actor and should always be in focus. Can it be better described than as one of the nurses said in the interviews?

... here’s a leg that’s more or less rotten, but it’s on her, it’s her leg, and then she needs to feel that we respect the whole of her ... that, I think, is respect... I want her to feel that we do the best we can and that we respect her as a whole person – that, I think, is really important. m

References

1. Briggs, M. & Flemming, K (2007). Living with leg ulceration: a synthesis of qualitative research. Journal of Advanced Nursing 59-(4), 319-328.

2. Dahlberg, K., Dahlberg, H. & Nyström, M. (2008). (2nd ed.). Reflective lifeworld research. Lund: Studentlitteratur.

3. Ebbeskog, B. & Ekman, S.-L. (2001). Elderly Persons´ Experiences of Living with Venous Leg Ulcer: Living in a Dialectal Relationship Between Freedom and Imprison-ment. Scandinavian journal of caring sciences, 15, 235-243.

4. Ekebergh, M. (2007). Lifeworld-based reflection and learning: a contribution to the reflective practice in nursing and nursing education. Reflective Practice, 8(3), 331-343.

5. Eskilsson, C., & Carlsson, G. (2010). Feeling confident in burdensome yet enriching care: Community nurses describe the care of patients with hard-to-heal wounds. International Journal Of Qualitative Studies On Health And Well-Being, 5(3). Retrieved October 19, 2010, from http://www.ijqhw.net/index.php/qhw/article/view/5415

6. Haram, R. & Nåden, D. (2003). Hvordan pasienter opplever å leve med leggsår. Vård i Norden 23 (68) 2, 16-21.

7. Lindahl, E., Norberg, A., & Söderberg, A. (2008). The Meaning of Caring for People With Malodorous Exuding Ulcers. Journal of Advanced Nursing, 62(2), 163-171.

8. McMullen, M. (2004). The relationship between pain and leg ulcers: a critical review. British Journal of Nursing 13(19), 30-36.


http://www.ijqhw.net/index.php/qhw/article/view/5415

ABSTRACTS OF RECENT COCHRANE REVIEWS

Publication in The Cochrane Library Issue 8, 2010

Hyperbaric oxygen therapy for treating acute surgical and traumatic woundsAnne Eskes, Dirk T Ubbink, Maarten Lubbers, Cees Lucas, Hester Vermeulen Citation: Eskes A, Ubbink DT, Lubbers M, Lucas C, Vermeulen H. Hyperbaric oxygen therapy for treating acute surgical and traumatic wounds. Cochrane Data-base of Systematic Reviews 2009, Issue 4. Art. No.: CD008059. DOI: 10.1002/14651858.CD008059. Copyright © 2010 The Cochrane Collaboration. Pub-lished by John Wiley & Sons, Ltd.

ABSTRACTBackground: Hyperbaric oxygen therapy (HBOT) is used as a treatment for acute wounds (such as those arising from surgery and trauma) however the effects of HBOT on wound healing are unclear.

Objectives: To determine the effects of HBOT on the healing of acute surgical and traumatic wounds.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (25 August 2010), the Cochrane Central Register of Controlled Trials (CEN-TRAL) (The Cochrane Library 2010, Issue 3), Ovid MEDLINE (1950 to August Week 2 2010 ), Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 24, 2010), Ovid EMBASE (1980 to 2010, Week 33) and EBSCO CINAHL (1982 to 20 August 2010).

Selection criteria: Randomised controlled trials (RCTs) comparing HBOT with other interventions or compari-sons between alternative HBOT regimens.

Data collection and analysis: Two review authors con-ducted selection of trials, risk of bias assessment, data extraction and data synthesis independently. Any disa-greements were referred to a third review author.

Main results: Three trials involving 219 participants were included. The studies were clinically heterogene-ous, therefore a meta-analysis was inappropriate. One trial (48 participants with burn wounds under-going split skin grafts) compared HBOT with usual care and reported a significantly higher complete graft sur-vival associated with HBOT (95% healthy graft area risk ratio (RR) 3.50; 95% confidence interval (CI) 1.35 to 9.11). A second trial (36 participants with crush inju-ries) reported significantly more wounds healed with HBOT than with sham HBOT (RR 1.70; 95% CI 1.11

to 2.61) and fewer additional surgical procedures required with HBOT: RR 0.25; 95% CI 0.06 to 1.02 and significantly less tissue necrosis: RR 0.13; 95% CI 0.02 to 0.90). A third trial (135 people undergoing flap grafting) reported no significant differences in com-plete graft survival with HBOT compared with dexam-ethasone (RR 1.14; 95% CI 0.95 to 1.38) or heparin (RR 1.21; 95% CI 0.99 to 1.49). Many of the predefined secondary outcomes of the review, including mortality, pain scores, quality of life, patient satisfaction, activities daily living, increase in transcutaneous oxygen pressure (TcpO2), amputation, length of hospital stay and costs, were not reported. All three trials were at unclear or high risk of bias.

Authors’ conclusions: There is a lack of high quality, valid research evidence regarding the effects of HBOT on wound healing. Whilst two small trials suggested that HBOT may improve the outcomes of skin grafting and trauma these trials were at risk of bias. Further evaluation by means of high quality RCTs is needed.

Plain language summaryHyperbaric oxygen therapy for acute surgical and traumatic woundsAcute surgical and traumatic wounds occur as a result of a trauma or surgical procedures and whilst many heal uneventfully, sometimes poor local blood supply, infection, damage to the blood vessels, or a combina-tion of factors results in acute wounds taking longer to heal. Hyperbaric oxygen therapy (HBOT), which involves placing the patient in an airtight chamber and administering 100% oxygen for respiration, at a pres-sure greater than 1 atmosphere, is sometimes used with the aim of speeding wound healing. The aim is to bathe all fluids, tissues and cells of the body in a high concentration of oxygen. This review did not find any high quality research evidence showing that HBOT is beneficial for wound healing. Two poor quality studies suggested benefits associated with HBOT. The first in patients with crush injuries, showed improved wound healing and fewer adverse outcomes. The second reported improved sur-vival of split skin grafts. A third trial reported no bene-fits associated with HBOT for skin grafts. Further, better quality research is needed to deter-mine the effects of HBOT on wound healing.

Sally Bell-Syer, MSc

Managing Editor Cochrane Wounds Group

Department of Health Sciences

University of YorkUnited Kingdom

[email protected]


EBWM


Cyanoacrylate microbial sealants for skin preparation prior to surgeryAllyson Lipp, Cheryl Phillips, Paul Harris, Iwan Dowie Citation: Lipp A, Phillips C, Harris P, Dowie I. Cyanoacrylate microbial sealants for skin preparation prior to surgery. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD008062. DOI: 10.1002/14651858.CD008062. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACTBackground: Surgical site infections are a continuing concern in health care. Microbial sealant is a liquid applied to the skin immediately before surgery. It is thought to contribute to reduc-ing surgical site infections by sealing in the skin flora to prevent contamination and infection of the surgical site.

Objectives: To assess the effects of the preoperative application of microbial sealants (compared with no microbial sealant) on the rates of surgical site infection in people undergoing clean surgery.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), Ovid MEDLINE (1950 to April Week 3 2010), Ovid MEDLINE – In-Process & Other Non-Indexed Cita-tions (searched 10 May 2010), Ovid EMBASE (1980 to 2010 Week 18) and EBSCO CINAHL (1982 to 10 May 2010). We searched bibliographies and contacted manufacturers of micro-bial sealants for unpublished studies. There were no restrictions based on language, date or publication status.

Selection criteria: Randomised controlled trials (RCTs) were eli-gible for inclusion if they involved people undergoing clean sur-gery in an operating theatre and compared the use of preopera-tive microbial sealants with no microbial sealant.

Data collection and analysis: All review authors independently extracted data on the characteristics, risk of bias and outcomes of the eligible trial.

Main results: One small trial (177 participants undergoing her-nia repair) met the inclusion criteria. There was no statistically significant difference in the rates of surgical site infection (three patients in the control group developed a surgical site infection compared with none in the intervention group; risk ratio (RR) 0.17, 95% CI 0.01 to 3.19, P = 0.23).

Authors’ conclusions: There is currently insufficient evidence as to whether the use of microbial sealants reduces the risk of sur-gical site infection in people undergoing clean surgery and fur-ther rigorous RCTs are required.

Plain language summaryCyanoacrylate microbial sealants for skin preparation prior to surgerySurgical site infection is a serious complication of surgery. Micro-bial sealant is a liquid applied to the surface of the skin immedi-ately before surgery to seal in any bacteria living on the skin that may pose a risk of infection. Before applying the sealant the skin

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

Publication in The Cochrane Library Issue 12, 2010

Risk assessment tools for the prevention of pressure ulcersZena EH Moore, Seamus CowmanCitation: Moore ZEH, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub2. Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.This is an updated review for which there have been new searches and a new trial added to the review.

ABSTRACTBackground: Pressure ulcer risk assessment is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is rec-ommended by many international pressure ulcer prevention guidelines, however it is not known whether using a risk assess-ment tool makes a difference to patient outcomes. We con-ducted a review to clarify the role of pressure ulcer risk assess-ment in clinical practice.

Objectives: To determine whether using structured, systematic pressure ulcer risk assessment tools, in any health care setting, reduces the incidence of pressure ulcers.

Search strategy: For this first update, we searched the Cochrane Wounds Group Specialised Register (searched 21 September 2010); the Cochrane Central Register of Controlled Trials (CEN-TRAL) (The Cochrane Library 2010, Issue 3); Ovid MEDLINE (2007 to September Week 1 2010); Ovid MEDLINE - In-Process & Other Non-Indexed Citations (September 20, 2010) and Ovid EMBASE (2007 to 2010 Week 37) and EBSCO CINAHL (2007 to 17 September 2010).

Selection criteria: Randomised controlled trials (RCTs) compar-ing the use of structured, systematic, pressure ulcer risk assess-ment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools.

Data collection and analysis: Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for eligibility, obtained full versions of potentially relevant studies and screened these against the inclusion criteria.

Main results: For the original review, no studies were identified that met the inclusion criteria. For this first update, we identified and included one small, cluster randomised study. The study included 256 people randomised by ward into three groups in which the methods of risk assessment were: the Braden pressure ulcer risk assessment tool and training; unstructured risk assess-ment and training; and unstructured risk assessment alone. There was no statistically significant difference between the groups in terms of pressure ulcer incidence however the study was underpowered to detect a clinically important difference in pressure ulcer incidence.

Authors’ conclusions: One small RCT was identified which eval-uated the effect of risk assessment on patient outcomes; there was no statistically significant difference in pressure ulcer inci-dence between patients who were assessed using structured risk assessment compared with those receiving unstructured risk assessment. Methodological limitations of this study prevent firm conclusions regarding whether the use of structured, systematic pressure ulcer risk assessment tools, in any healthcare setting, reduces the incidence of pressure ulcers. The effect of structured risk assessment tools on pressure ulcer incidence needs to be evaluated.

Plain language summaryRisk assessment tools used for preventing pressure ulcersPressure ulcers (also known as bed sores, pressure sores and decubitus ulcers) are areas of localised injury to the skin, under-lying tissue or both, usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure ulcers mainly occur in people who have limited mobility, nerve damage or both. Pressure ulcer risk assessment is part of the process used to identify individuals at risk of developing a pres-sure ulcer. Risk assessments generally use checklists and their use is recommended by pressure ulcer prevention guidelines. This update of the review found one study that was eligible for inclusion. The study found no difference in the number of new pressure ulcers that developed in individuals assessed using structured risk assessment compared with unstructured risk assessment. However, there were methodological limitations with this study. Therefore, to date, very little research has studied the effect of risk assessment and we are unable to draw any firm conclusions. m


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AZ_HRT_A4_Wundmanagement_engl_NEU.indd 1 25.11.10 09:40

EWMA Journal Previous Issues

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

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

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

Buerger Disease (Thromboangiitis Obliterans): A Clinical DiagnosisPeter Highlander, Charles C. Southerland, Eric VonHerbulis, Aldo GonzalezImproving the Detection of Pressure Ulcers Usingthe TMI ImageMed SystemDavid Judy, Brian Brooks, Kristopher Fennie, Courtney Lyder, Claude BurtonNegative-Pressure Wound Therapy for Musculoskeletal Tumor SurgeryVasileios I. Sakellariou, Andreas F. Mavrogenis, Panayiotis J. Papagelopoulos

English

Haava, no. 4, 2010www.shhy.fi

Thema: Woud care products

Treatment of burned skin, wounds and healthy skin: Development of cleaning towel with Plurogen Neal KollerResin form spruce to wound care Hannu SarajaContinuing development in management of wound exudate Johanna TakkunenPositive effects by negative pressureJohanna TakkunenMagic of green dressingEira Nikkilä

Finnish

Volume 10, no 1, January 2010

Systematic review of Repositioning for the Treatment of Pressure UlcersZena Moore, Seamus Cowman Analysis of wound care in nursing care homes as part of a district-wide wound care auditPeter Vowden, Kathryn VowdenChronic leg ulcers among the Icelandic population Guðbjörg Pálsdóttir, Ásta Thoroddsen Cross-sectional Survey of the Occurrence of Chronic Wounds within Capital Region in FinlandAnita MäkeläThe EWMA Teach the Teacher ProjectZena Moore

Volume 10, no 3, October 2010

Rationale for compression in leg ulcers with mixed, arterial and venous aetiologyHugo PartschPressure ulcers in Belgian hospitals: What do nurses know and how do they feel about prevention?D. Beeckman, T. Defloor, L. Schoonhoven, K. Vanderwee Nutritional Supplement is Associated with a Reduction in Healing Time and Improvement of Fat Free Body Mass in Patients with Diabetic Foot UlcersP. Tatti, A.E. Barber, P. di Mauro, L. MasselliChronic wounds, non-healing wounds or a possible alternative?M. BriggsSilver-impregnated dressings reduce wound closure time in marsupialized pilonidal sinusA. Koyuncu, H. Karadaˇ, A. Kurt, C. Aydin, O. TopcuVenous leg ulcer patients with low ABPIs: How much pressure is safe and tolerable?J. Schuren, A. Vos, J.O. Allen,Adherence to leg ulcer treatment: Changes associated with a nursing intervention for community care settingsA. Van Hecke, M. Grypdonck, H. Beele, K. Vanderwee, T. DefloorA Social Model for Lower Limb Care: The Lindsay Leg Club ModelM. Clark

Volume 10, no 2, May 2010

Hyperbaric Oxygen and Wounds: A tale of two enzymesThomas K. HuntHBOT in evidence-based wound healingMaarten J. LubbersComparative analysis of two types of gelatin microcarrier beads Mohamed A Eldardiri et al.Evidence based guidelines – how to channel relevant knowledge into the hands of nurses and carersSusan F. Jørgensen, Rie NygaardLack of due diligence in the prophylaxis of pressure ulcers?Dr. Beate Weber, Hans-Joachim CastrupSix prevalence studies for pressure ulcers – Snapshots from Danish HospitalsSusan Bermark et al.The Ransart Boot – An offloading device for every type of Diabetic Foot Ulcer?I.J.Dumont et al.The Haitian Earthquake, January 2010 John M Macdonald

International Journal of Lower Extremity Wounds vol. 9, no, 4, 2010http://ijlew.sagepub.com

A Difficult Case of Necrotizing Fasciitis Caused By Acinetobacter baumanniiBartolo Corradino, Francesca Toia, Sara di Lorenzo, Adriana Cordova, Francesco MoschellaHydrosurgery: Alternative Treatment Technique for Management of Chronic Osteomyelitis and Septic Arthritis of Hallucial Joint of a Juvenile FootMayukh Bhattacharyya, Helen Bradley, Bruno E. GerberAbscesses That Did Not Respond to Just Incision Drainage and AntibioticsAnupma Jyoti Kindo, Sidharth Giri, Shalinee Rao, Arcot RekhaSquamous Cell Carcinoma Masquerading as a Trophic Ulcer in a Patient With Hansen’s DiseaseSandhya Venkatswami, S. Anandan, Nikilesh Krishna, C.D. Naray-anan

English

International Wound Journal, vol. 8, issue 1, 2011www.interscience.wiley.com/journal

Genetic and epigenetic events in diabetic wound healingHaloom Rafehi, Assam El-Osta, Tom C KaragiannisEconomic evaluation of Vacuum Assisted Closure Therapy for the treatment of diabetic foot ulcers in FranceSarah J Whitehead, VÈronique L Forest-Bendien, Jean-Louis Richard, Serge Halimi, Georges Ha Van, Paul TruemanInvestigating the humoral immune response in chronic venous leg ulcer patients colonised with Pseudomonas aeruginosaJasper N Jacobsen, Anders S Andersen, Michael K Sonnested, Inga Laursen, Bo Jorgensen and Karen A Krogfelt

English

Volume 9, no 3, October 2009 Alcohol-based hand-rub versus traditional surgical scrub and the risk of surgical site infectionMohammed Y. Al-NaamiWoundswest: Identifying the prevalence of wounds within western Australia’s public health systemNick Santamaria, Keryln Carville, Jenny PrenticeAn exploration of current practice in nursing documentation of pressure ulcer prevention and managementJulie Jordan O BrienDressings and Topical Agents for Treating Donor Sites of Split-Skin GraftsSanne Schreuder et al.


EWMA

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

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

English

Wund Management, vol. 4, no 6, 2010 English abstracts are available from www.mhp-verlag.de

The role of podiatry in prevention and treatment of diabetic foot syndrome (DFS) – the „foot perestrioka” in Germany C. ZemlinOrthonyxia – nail correction braces W. Knörzer Case reports for the application of nail braces B. Mittenzwei

German

Rane (Wound) journalwww.lecenjerana.com

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

Content of one of journalsSurgical treatment of diabetic footProf. Dr Vucetic and associatesExamination of correlation between risk factors of venous ulceration on apparence granulation and time of healing,Prim. Dr DelicSymposium about pressure ulcer Prim. Dr HuljevImportance of treatment of anemy with patients with ulcerationDr CalijaActivities of nurses in prevention and treatment of pressure ulcerationnurse MilutinovicImportance of continuing education – Study education on Slovenianurse Nesovic

Wounds (SÅR) vol. 18, no 4, 2010www.saar.dkImproved quality of life for people with chronic venous leg ulcers – an ethnographic studyAna Maria D’AuchampWound organisation in ”Region Sjælland” no nurses, no treatment! Nurse in a medical practice – lack of dialogue and sparringJens Fonnesbech

Scandinavian

Dutch Journal of Woundcare NTVW, vol 6. no 1, 2011www.ntvw.nl

Interview: Dr. Zena Moore, “My goal is to get the EWMA involved in the clinical practice of wound care”

‘Woundcare needs structure and a documented approach”Day to Day practice of woundcare nurses in Belgian Nursinghome

Introduction of the Dutch Advisory Board WoundcarePresentation of all members and main goal

Report: Surgical treatment of pressure ulcers

Scientific: Healing process of hard to heal woundsAndriessen A

Dutch

Journal of Wound Care, vol. 20, no 1, 2011www.journalofwoundcare.com

Simple wound care facilitates full healing in post-earthquake HaitiF.J. StephensonDoes the postoperative dressing regimen affect wound healing after hip or knee arthroplasty?A. CollinsRetrospective study of pressure ulcer prevalence in Dutch general hospitals since 2001Y. Amir, J. Meijers, R. HalfensHeel damage and epidural analgesia: is there a connection?C.M. Loorham-Battersby, W. McGuinessTopical negative pressure (TNP) as an adjunct to compres-sion for healing chronic venous ulcersD.C. Kieser, J.A. Roake, C. Hammond, D.R. LewisSurvey of fungi and yeast in polymicrobial infections in chronic woundsS.E. Dowd, J. Delton Hanson, E. Rees et al

English

Tidskriften Sår vol. 4, no 4, 2010

Team hjälper patienten – men kräver mycket av personalenPär EliassonAtt förbättra vården: pennans maktAnne HindhedeAlla sår ska ha en såransvarigYlva Haraldsdotter

Swedish

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

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

English

Phlebologie, no 5, 2010www.schattauer.de

Long Therm results and analysis of correlations 5 years after varicose vein strippingFaubel et. al.Guideline Diagnosis and treatment of the Varicose vein diseaseKluessa et. al.Guideline Diagnosis and treatment of the Ulcus cruris venosum (Venous ulcer) – Short versionGallenkemper

English

Lietuvos chirurgija, vol.8, no 3, 2010www.chirurgija.lt

Measuring T cell reactivity for predicting heart transplant rejectionMalickaite R, Jurgauskiene L, Simanaviciene S, Maneikiene V V, Sudikiene R, Rucinskas KCardiac transplantation in pediatric patients: experience of Vilnius Cardiac Surgery centerSudikiene R, Malickaite R, Lebetkevicius V, Tarutis V, Rucinskas K, Sirvydis V Current clinical guidelines for cardiac resynchronization therapy: the experience of Vilnius Cardiology – Angiology centerManeikiene V, Marinskis G, Aidietis A, Aidietiene S, Celutkiene J, Rucinskas K, Sirvydis V, Laucevicius A

English


Since 2007, EWMA has successfully offered students of wound management from institutes of higher education across Europe the opportunity to take part of aca-demic studies whilst participating in the EWMA Conference. In 2011 it is expected that students from the institutes listed below will participate in the EWMA UCM in Brussels.

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

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

Yours sincerely

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

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM)

in Brussels

Participating institutions:

Haute École de Santé Geneva, Switzerland

HUB BrusselsBelgium

KATHO university college RoeselareBelgium

Escola Superior de Enfermagem de Lisboa

Portugal

University of Hertfordshire United Kingdom

UK

Universidade Católica Portuguesa Porto, Portugal

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

EWMA


http://www.ewma.org

mailto:ewma%40ewma.org?subject=

How is it possible to achieve better patient outcomes and reduce costs?

Join us for our symposia on the 25 and 26 May 2011.

* At smith&nephew we seek imaginative solutions that improve wound outcomes for patients and at the same time conserve resources for healthcare systems.

Wound ManagementSmith & Nephew Medical Ltd101 Hessle RoadHull HU3 2BN

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©Smith & Ndphew February 201126395

For further details contact: EWMA Secretariat, Martensens Allé 8, 1828 Frederiksberg, Denmark

Tel: +45 7020 0305Fax: +45 7020 [email protected]

In May 2010 the following EWMA Document was published:

Outcomes in controlled and comparative studies on non healing wounds – Recommendations to improve quality of evidence in wound management

The document is written by members of the EWMA Patient Outcome Group, based on common discussions in the group.

Other EWMA documents e.g. Position Documents can be downloaded from www.ewma.org and are available in English, French, German, Italian and Spanish.It is possible to obtain permission to translate the EWMA Documents into other languages.Please contact EWMA Secretariat for permission.

Please note that the EWMA Position Documents express the view of EWMA at the time for publication of the document.

Titles of Position Documents:Pain at wound dressing changes – Spring 2002Understanding compression therapy – Spring 2003Wound bed preparation in practice – Spring 2004Identifying criteria for wound infection – Autumn 2005Management of wound infection – Spring 2006Topical negative pressure in wound management – Spring 2007Hard-to-heal wounds: a holisitc approach – Spring 2008

EWMA DOCUMENTS

Outcomes in controlled and comparative studies on non-healing woundsRecommendations to improve the quality of evidence in wound management

A EWMA Patient Outcome Group Document

EWMA front cover.indd 5

20/5/10 13:14:26

http://www.ewma.org

José Verdú SorianoPhD, MSc Nurs, BSc Nurs, DUE-RNMember of EWMA Editorial Board


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

Edited by two well-known scientists and health professionals, Dr Percival and Dr Cutting, this is one of the newest

books on this topic at this time. Both editors have considerable knowledge and experience of the field of wounds and especially on all topics related to bacteria on wounds. Both, also, are surrounded by a large and experienced panel of contributors, most of them involved in and leading the new paradigm of biofilmology of wounds.

The book is divided into 13 chapters from an overview of microbiology and biofilms to factors affecting impaired healing and antimi-crobial interventions from different points of view.

With a very easy to read and understand writing style, the authors cover the topic well, from the general concepts to the more complex, in-depth knowledge:

n In chapter 1 there is a very good résumé of microbiology in general which is then linked to the concept of biofilms and the impli-cations for public and medical health.

n Chapter 2 is about human skin and microbi-al flora. It includes a review of the anatomy of human skin and the interactions with normal flora, highlighting the most common species that inhabit the skin and the relations with normal states or infections, and also their role in the interactions with the host and the immune system.

n Going through chapters 3 and 4 the focus is on wounds, the third on wounds in general as an introduction and the fourth a deeper examination of burns. Differences and diag-noses of wounds are addressed here.

n Chapter 5 delves into the complexity of the healing process both normal and altered. Each of the phases and cells and molecules

involved in the healing process are ex-plained, linking with the aetiology of chron-ic wounds and delayed healing.

n In chapter 6 the classic concepts of chronic wound infections related to the biofilm paradigm as a parallelism are addressed. The controversial aspect of sampling of wounds for microbiological diagnostic is explained here with the difficulties and the differences in the process.

n Chapter 7 is a debate about classical chronic wound classifications as venous, diabetic or pressure ulcers. It is stated that those clas-sifications are problematic: “… division of wounds based on aetiologies is becoming recognized as incomplete and is very unsatis-fying …” Reflections on the common factor of all of them are mentioned and the role of biofilms on wounds starts here: “The obser-vation that biofilm is prevalent in chronic wounds and rare in acute wounds challenges the position that biofilm is the common ele-ment related to the chronic inflammatory state”.

Review

MICROBIOLOGY OF WOUNDS

EWMA


n Chapter 8 presents an in-depth lecture about biofilms, and their implications on wound healing. The evidence of biofilm on chronic wounds is established and an explanation of how a biofilm infection is characterised is of-fered.

n Chapter 9 is an interesting review of en-zymes and, especially, the group of proteases and the factors that lead to matrix metal-loproteinase stimulation. Again this chapter links the topic with bacterial biofilms.

n In chapter 10 there is an explanation of the stages of acute wound healing in relation to both innate and adaptive immune responses which are responsible for clearing infection from the wound site and in preventing sub-sequent infection. The immune processes that occur when systemic and local factors lead to the development of a chronic wound are also described, together with bacterial strategies and mechanisms for evading the immune system including the development of a biofilm that can further inhibit or evade the immunological response.

n The remaining three chapters (11-13) are dedicated to antimicrobial interventions. Chapter 11 explains all the possibilities in general; chapter 12 is dedicated to Wound Dressings and Other Topical Treatment Modalities in Bioburden Control, and finally, chapter 13 is the authors’ compari-son between basic wound care and advanced technologies but taking into account all the factors that are involved in managing chronic wounds. Examples, for instance, silver impregnated wound dressings as an advanced wound technology, are explained.

In this book you’ll find a mix of classic and up to date information about microbiology and chronic wounds. I believe that this is an easy way to introduce the amazing world of biofil-mology; a new paradigm that is emerging in the study of wounds and is, in the next years, likely to change our understanding and the manner of how we treat wounds. m

This 4 day theoretical course & practical training gives participants a thorough intro-duction to all aspects of diagnosis, manage-ment and treatment of the diabetic foot.

Lectures will be combined with practical sessions held in the afternoon at the diabetic foot clinic at the Pisa University Hospital.

Lectures will be in agreement with the International Consensus on the Diabetic Foot & Practical Guideline on the Management and Prevention on the Diabetic Foot.

This course is endorsed by EWMA.

Management ofthe Diabetic FootTheory & Practice4 Day Course, 3 - 6 October 2011Pisa, Italy

www.diabeticfootcourses.org

52

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

The key objectives of the course were, firstly, to increase the knowledge and operative skills in the management of

the diabetic foot. Secondly, to support the es-tablishment of multidisciplinary diabetic foot clinics or departments based on the recommen-dations of the International Consensus Docu-ment, and, thirdly, to facilitate international consensus on the structure of treatment of the diabetic foot.

The course structure aimed to combine theory with practical training. Theoretical lectures were held in the mornings and practi-cal sessions were held in the afternoons in the specialised diabetic foot clinic at the University Hospital of Pisa. By combining lectures from different specialists and training in the clinic, the aim was for the course participants to gain insight in both the theory of the field and the practical methods used in the clinic.

The participants in the course included clinicians with various professions such as endo-crinologists, vascular and orthopaedic surgeons, specialised nurses, chiropodists, podiatrists and other healthcare professional.

Thirty-seven participants from 16 different countries, 9 international faculty members and 14 national faculty members took part in the 2010 course.

An evaluation survey and general comments during the course suggested great satisfaction with the outcome of the course, especially em-phasizing the benefits of combining practice and theory in the course. The participants found that the theoretical lectures were very interesting. Likewise the practical hands-on sessions were very popular, giving the partici-pants new angles to their particular fields of expertise. Finally the course provided an excel-lent forum for the exchange of knowledge, for exploring ways to handle the problems in the field of diabetic foot and for discussions among the participants and with the faculty. Hope-fully the participants gained a lot of knowledge which they can apply to their own field in their own countries. m

Alberto PiaggesiMD, Professor, Endocrinologist

Director of the Diabetic Foot Section of the Pisa University HospitalDept of Endocrinology and MetabolismUniversity of PisaPisaItaly

Course organiser


Pisa International Diabetic Foot Course 2010

Participants and faculty members in the 2010 Course.

Testimonials on video from participants and faculty members in the 2010 Course are available on:http://diabeticfootcourses.org/ course-programme/testimonials- 2010.html

The 3rd Diabetic Foot Course will be held in Pisa 3-6 October 2011. Further information is available on www.diabeticfootcourses.org or bycontacting the Course Secretariat: info@ diabeticfootcourses.org

EWMA


http://diabeticfootcourses.org/<00AD>course-programme/testimonials-<00AD>2010.html

http://diabeticfootcourses.org/<00AD>course-programme/testimonials-<00AD>2010.html

http://www.diabeticfootcourses.org

mailto:info%40%C2%ADdiabeticfootcourses.org?subject=

EWMA and the International Compression Club (ICC) in collaboration are proud to announce a sequence of seminars on the subject of leg ulcera-tion and compression therapy.

The ICC continuously argues that compres-sion therapy is an extremely effective treatment modality, the efficacy of which is frequently un-derestimated or neglected. There are important areas in medicine in which compression therapy could be beneficial to patients but is not used because of lack of knowledge of the prescribers. Likewise, there are countries in which compres-sion therapy has no tradition and is unknown to patients who could profit from it.

In 2007 EWMA initiated, and has since sup-ported and contributed to, the implementation of the Central & Eastern European Leg Ulcer Project (LUP) carried out by project teams and wound associations in Slovenia, Poland and the Czech Republic. Through a combination of improved training of nurses and physicians and access to knowledge and modern materials, in particular for compression therapy, the project has generated clear results in terms of improved treatment and healing of leg ulcers.

OBJECTIVES & TARGET GROUPSThe main objectives of the seminars are to:n Provide a status on the current treatment

of Leg Ulceration and use of compression therapy in the countries and regions where the seminars take place.

n Introduce the ICC guidelines for compres-sion therapy and discuss how a national implementation of the guidelines could take place.

n Present the key findings of the EWMA Leg Ulcer Project teams in Poland, Slovenia and the Czech Republic and discuss how the re-sults can be used for improving treatment of leg ulcers in other countries.

The faculty will consist of international speakers and local experts in the field of Leg Ulceration and Compression Therapy.

The seminars target as key participants physi-cians, nurses and industry representatives working

with Leg Ulceration and Compression Therapy. Decision-makers on issues relating to prevention and treatment of leg ulceration will also benefit from participating.

Companies will be offered the opportunity to exhibit during the seminars.

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

Association (SSOOR)

n Vienna, Austria, 11 October 2011 (In collaboration with the Austrian Wound Association

(AWA)

n Budapest, Hungary, 13 October 2011 (In collaboration with the Hungarian Wound Care

Society (MSKT) and the Hungarian Association for the Improvement in Care of Chronic Wounds and Inconti-nentia (SEBINKO)

PRELIMINARY PROGRAMME

08:30 Registration

09:30 Welcome & introduction

09:45 Lectures:1. Setting the scene: What are we talking about 2. How big is the problem? Outcome and evidence3. Who is suffering from this?

10:45 Coffee break and exhibition

11:15 Compression:1. When? – Differential diagnosis, investigations2. How? – Compression materials3. Why? – How does compression work?

12:45 Lunch and exhibition

13:15 Satellite Symposium

14:15 Parallel workshops, supported by the industry:1. Clinical and instrumental diagnosis 2. Compression bandages 3. Ulcer kits

15:00 Coffee break and exhibition

15:30 What is the situation in the host country and what should be done?

16:00 Closing

Finn Gottrup

Chair EWMA Patient Outcome Group

Hugo Partsch

ICC President


LEG ULCER & COMPRESSION SEMINARS 2011

REGISTRATION AND FURTHER INFORMATION Please visit www.ewma.org/ewma-icc-seminar for updated information regarding the Leg Ulceration and Compression seminars.

The seminars will be conducted in English and local languages with simultaneous translation.

On-line registration will open by 1 April 2011.

EWMA


http://www.ewma.org/ewma-icc-seminar

Organised by: EWMA & International Compression Club (ICC)

BRATISLAVA 10 OCTOBER

VIENNA 11 OCTOBER

BUDAPEST 13 OCTOBER



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

http://www.ewma.org/ewma-icc-seminar

EWMA

EWMA Activities Update

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

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

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

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

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

www.ewma2011.org

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

Pressure ulcer preventionSpeaker: Zena Moore, PhD, MSc, RCSI, Ireland

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

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

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

www.efort.org/copenhagen2011

The EWMA Patient Outcome Group

The Patient Outcome Group published a document in Journal of Wound Care in June 2010, which discusses the issues of outcomes in wound care research.

The document sets up recommendations on what needs to be done in order to improve evidence in wound care and how to meet an accepted level of rigour for studies in wound management. Furthermore, the document discusses how to develop a consistent and reproducible approach to define, evaluate and measure appropriate and adequate outcomes in RCTs as well as other clinical studies.

EWMA considers the discussion on how to evolve evidence in research of wound care a high priority and hope that all members of EWMA and professionals working with wounds will contribute to this debate.

Right now the group is working on how to disseminate the document and to continue the discussion with relevant professionals and administrators which EWMA hopes will lead to a general European consensus on evidence in wound management.

For further information about the EWMA Patient Outcome Group, please visit http://ewma.org/english/patient-outcome-group.html.

Any questions concerning the Patient Outcome Group or the document can be sent to the EWMA Secretariat: [email protected]

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


http://www.efort.org/copenhagen2011

http://ewma.org/english/patient-outcome-group.html

http://ewma.org/english/patient-outcome-group.html

mailto:ewma%40ewma.org?subject=

Organised by the European Wound Management Associationin cooperation with:

EWMA 201125-27 MAY Brussels · Belgium

WWW.EWMA.ORG/EWMA2011

21st Conference of the European Wound Management Association

21 Congrès de l’Association Européenne de Soins de Plaies

25-27 MAIBruxelles · Belgique

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

Francophone Nurses’ Association in Stoma Therapy, Wound Healing and Wound

Belgian Federation of Woundcare

CNC Wound Management Association

Bilingual:

English & French

Traduction simultanée

Anglais et Français

http://www.ewma.org/ewma2011

Wound ManagementSmith & Nephew Medical Ltd101 Hessle RoadHull, HU3 2BNUnited KingdomTel: +44 (0) 1482 225181Fax: +44 (0) 1482 328326www.smith-nephew.com/wound

Sorbion AGIm Suedfeld 1148308 Senden GermanyTel.: +49 (0) 2536 34 400 400Fax: +49 (0) 2536 34 400 410www.sorbion.com

Systagenix Wound ManagementGargraveNorth YorkshireBD23 3RXUnited KingdomTel: +44 1756 747200Fax: +44 1756 747590 www.systagenix.com

Corporate A

Abbott Nutrition200 Abbott Park RoadAbbott Park Illinois 60064USATel: +1 (614) 624-7485 Fax: +1 (614) 624-7899www.abbottnutrition.com

ConvaTec EuropeHarrington HouseMilton Road, Ickenham, UxbridgeUB10 8PUUnited KingdomTel: +44 0 1895 62 8300Fax: +44 0 1895 62 8362www.convatec.com

Covidien154, Fareham Road PO13 0AS GosportUnited KingdomTel: +44 1329 224479 Fax: +44 1329 224107www.covidien.com

Paul Hartmann AGPaul-Hartmann-StrasseD-89522 HeidenheimGermanyTel: +49 0 7321 / 36-0Fax: +49 0 7321 / 36-3636www.hartmann.info

KCI Europe Holding B.V.Parktoren, 6th floorvan Heuven Goedhartlaan 111181 LE AmstelveenThe Netherlands.Tel: +31 0 20 426 0000Fax: +31 0 20 426 0097www.kci-medical.com

Lohmann & RauscherP.O. BOX 23 43 NeuwiedD-56513 GermanyTel: +49 0 2634 99-6205Fax: +49 0 2634 99-1205www.lohmann-rauscher.com

Mölnlycke Health Care AbBox 13080402 52 Göteborg, SwedenTel: +46 31 722 30 00Fax: +46 31 722 34 01www.molnlycke.com

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

Corporate Sponsor Contact Data

Use the EWMA Journal

to profile your company

Deadline for advertising

in the May 2011 issue is

15 March 2011


B. Braun Medical 204 avenue du Maréchal Juin92107 Boulogne BillancourtFranceTel: +33 1 41 10 75 66Fax: +33 1 41 10 75 69www.bbraun.com

BSN medical GmbHQuickbornstrasse 2420253 HamburgTel: +49 40/4909-909Fax: +49 40/4909-6666www.bsnmedical.comwww.cutimed.com

Curea Medical GmbHMünsterstraße 61-6548565 SteinfurtGermanyTel: +49 36071 9009500Fax: +49 36071 9009599www.curea-medical.de

Flen pharma NVBlauwesteenstraat 87 2550 KontichBelgiumTel.: +32 3 825 70 63Fax: +32 3 226 46 58www.flenpharma.com

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

3M Health CareMorley Street, LoughboroughLE11 1EP LeicestershireUnited KingdomTel: +44 1509 260 869Fax: +44 1 509 613326www.mmm.com

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

AOTI Ltd.Qualtech HouseParkmore Business Park WestGalway, IrelandTel: +353 91 660 310Fax: +353 1 684 9936www.aotinc.net

ArjoHuntleigh310-312 Dallow RoadLutonLU1 1TD United KingdomTel: +44 1582 413104Fax: +44 1582 745778www.ArjoHuntleigh.com

Corporate B

EWMA

Life Wave9 Hashiloach St.P.O.B. 7242Petach Tikvah 49514IsraelTel: +972-3-6095630Fax: +972-3-6095640www.life-wave.com

Nutricia Advanced Medical NutritionSchiphol Boulevard 1051118 BG Schiphol AirportThe Netherlandswww.nutricia.com

Organogenesis Switzerland GmbHBaarerstrasse 2 CH-6304 Zug SwitzerlandTel: +41 41 727 67 89www.organogenesis.com

PhytoceuticalsZollikerstrasse 448008 ZurichSwitzerlandTel: +41 43 499 15 66Fax: +41 43 499 15 67 www.phytoceuticals.ch

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

Argentum Medical LLCSilver Antimicrobial Dressings2571 Kaneville CourtGeneva, Illinois 60134U.S.A.Tel: +1 630-232-2507Fax: +1 630-232-8005www.silverlon.com

Laboratoires Urgo42 rue de Longvic B.P. 15721304 Chenôve FranceTel: +33 3 80 54 50 00 Fax: +33 3 80 44 74 52www.urgo.com

Welcare Industries SPAVia dei Falegnami, 705010 Orvieto ( TR )ItaliaTel: +39 0763-316353Fax +39 0763-315210www.welcaremedical.com


Conference CalendarConferences Theme 2011 Days City Country

Annual Meeting of the CNC VZW Wound Management Association

Feb 17-18 Kortrijk Belgium

Annual Meeting of Lithuanian Wound Management Association (LWMA)

Feb 25 Kaunas Lithuania

Annual meeting of Journal of Wound Care Mar 10 Manchester United Kingdom

Tissue Viability Society Conference 2011 Making a Difference for a Shared Vision for Multi-Disciplinary Research, Practice and Policy

Apr 5-6 Kettering United Kingdom

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

Apr 14-17 Dallas USA

Annual Meeting of the Austrian Wound Association (AWA)

Apr 29-30 Salzburg Austria

Annual Meeting of the Chronic Wounds Initiative (ICW)

May 11-12 Bremen Germany

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

May 12-14 Bologna Italy

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

Common Voice – Common Rights May 25-27 Brussels Belgium

12th EFORT Congress Jun 1-4 Copenhagen Denmark

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

Jun 16-18 Toronto Canada

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

Guidelines and quality standards of Fascinating Biotechnology

Jun 23-25 Hannover Germany

14th Annual European Pressure Ulcer Meeting (EPUAP)

Pressure Ulcer Research Achievements Translated to Clinial Guidelines

Aug-Sep

31-2 Oporto Portugal

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

Biofilm and Health Economics in Bone and Joint Infections

Sep 15-17 Copenhagen Denmark

Pisa International Diabetic Foot Courses Oct 3-6 Pisa Italy

EWMA Leg Ulcer and Compression Seminars Oct 10 Bratislava Slovakia

EWMA Leg Ulcer and Compression Seminars Oct 11 Vienna Austria

EWMA Leg Ulcer and Compression Seminars Oct 13 Budapest Hungary

EWMA Master Course 2011 Is Oedema a Challenge in Wound Healing? Oct 13-14 Budapest Hungary

First International Pediatric Wound Care Symposium Oct 27-29 Rome Italy

Biannual meeting of the Woundcare Consultant Society

Nov 22-23 Utrecht Netherlands

2012

22nd Conference of the European Wound Management Association

May 23-25 Vienna Austria

Organisations

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

Please submit possible topics for future conference session and notifications on relevant conferences and projects across Europe. EWMA is also interested in receiving book reviews, articles etc.

Please contact the EWMA Secretariat [email protected]

For web addresses please visit www.ewma.org


· EWMA MASTER COURSE·EU

RO

PEAN· WOUND ·MANAGEMENT· A

SSO

CIA

TIO

N

EWMA MASTER COURSE

www.ewma.org/woundcourse

IS OEDEMA A CHALLENGE IN WOUND HEALING?

13-14 October 2011 · Budapest, Hungary

Advanced theoretical and practical sessions related to oedema and wound healing.

The course will bridge theory and practice and a broad range of topics will be addressed, including: n Oedema as a problem in different types of wounds and

what impact it hasn The pathophysiology of oedeman Psycho-social impact of oedeman Methods for diagnosing different types of oedeman Prevention and managementn Development of evidence based outcome measurement

of oedema in wound healingn Infectionn Associated skin complications Participants in the EWMA Master Course will be entitled to CME Credits.

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

http://www.ewma.org/woundcourse

João GouveiaGAIF

www.gaif.net

GAIF Associated Group

of Research in Wounds

The annual conference of Grupo Associativo de Investigação em Feridas (GAIF) was held May 20th-21st, 2010, at the Conference Center, Pavilhão Atlântico, in Lisbon. A wide participation of mainly nurses, doctors and pharmacists brought the number of visitors to over 1,200 with 28 spon-sors adding to the attendance. The international guest speakers were all high-ly acclaimed people in their field: Professor Hugo Partsch, Dr. Michael Edmonds, Professor Phil Bowlers, Professor Patricia Grocott, Dr. Maarten Lubbers (EWMA), Alison Hopkins and Fran Wor-boys, and Dr. Othon Kriticos. Local speakers included opinion leaders such as Elaine Pina, Pro-fessor Vaz Carneiro, and Professor Pedro Ferreira, among other prestigious, speakers.

A range of healthcare related topics were pre-sented in the conference including discussions on important tools for all healthcare professionals involved in wound treatment such as the validation of Martin-Payne Classification and the validation of SGA.

During the conference Michael Edmonds pre-sented the concept of ILegx (Interdisciplinary Leg Initiative), which GAIF is now disseminating to all healthcare professionals. Also, Maarten Lubbers presented the methodology adopted for the development and dissemination of the new NPUAP/EPUAP guidelines as well as discussing the recommendations for prevention of pressure ulcers in ER. In addition, Patricia Grocott addressed dele-gates on the several possible ways of management of malignant wounds allowing the audience to access the latest knowledge in this field.

The National Project for Prevalence of Pressure Ulcers and Leg Ulcers was presented. This project is a partnership between GAIF, CWISUC and UMP. This event was highly positive and successful, underlining the important role of GAIF as a vital organization in wound care research in Portugal.� m

The annual meeting of GAIF;

A STEP FORWARD

MEMORIAL It is with great sadness that the EWMA Secretariat received the news of João Gouveia death in October.

João was a great collaborator for EWMA. His contribution to not only EWMA, but wound healing in general has been greatly appreciated.

João Carlos Gouveia Ferreira was the Chairman of the GAIF (Grupo Associativo de Investigação em Feridas, Associated Group of Research in Wounds, Portugal), and as a nurse at Health Center of Pampilhosa da Serra, he published numerous scientific articles and lectured at various events and conferences.

João Gouveia was as in his role as acting president of GAIF a great collaborator for EWMA – Especially, but not only, in the organisation of the EWMA 2008 Conference i Lisbon, Portugal.

He will be dearly missed. EWMA send their thoughts to João’s wife, Cristina Miguéns.


Organisations

The International Lymphoedema Framework (ILF) was established as a UK charity in 2009 and is proud to announce it has recently gained part-nership with EWMA.Developed from a project aiming at bringing together the main stakeholders involved in the management of lymphoedema in the United Kingdom in 2002, ILF rapidly spread to become an international project with an objective to support individual countries develop a long-term strategy for lymphoedema management.

A new structure and the development of ILF Frameworks In order to implement its vision for the future, ILF has strived this year to build a strong and new structure consisting in a board of Directors, an International Advisory Board, an Executive Team and a series of Committees in charge of imple-menting the strategy defined by the Board of Directors. Currently these committees reflect ILF’s field of competencies and main actions such as Best Practice, Conference, Dataset, Developing countries, Education, International, Patient Advo-cacy, Publications, Research and Development. In parallel, ILF believes that the way forward to a better management of lymphoedema worldwide is extended through effective partnerships with:n international organisations (such as World

Health Organisation, World Alliance for Wound and Lymphedema Care, The Global Alliance to Eliminate Lymphatic Filariasis)

n groups of practitionersn patients associationsn industry n expert practitioners and researchers in the field

of lymphoedema n National Lymphoedema Frameworks Projects

ILF is pleased to work with official frameworks partners which are currently the American Lym-phoedema Framework Project (ALFP), the Canadian Lymphedema Framework (CLF) and ILF Japan. Some other Frameworks initiatives have emerged in the past months in France, Australia, Denmark and Sweden. There has also been a will and a need to create many other partnerships in Europe and the rest of the world. In 2010, ILF representatives have been visiting some of its exist-ing Frameworks partners in Japan and Canada but have also created new opportunities of work after visits in South Africa and Scandinavia for example.

Agnès Carrot

International Lymphoedema Framework Coordination

[email protected]

www.lympho.org

ILFThe International

Lymphoedema Framework

The International Lymphoedema Framework

Main ObjectivesSince its launch, ILF has been driven by three key elements that encompass its vision and plan of action: best practices, research and data. In the near future, the ILF Best Practice Committee will go through a systematic and continuous review of research to ensure that Best Practices are up to date and that evidence-based practise is imple-mented. ILF will work in partnership with Frame-works to undertake systematic reviews of key sub-jects. It will finally develop a consensus methodol-ogy to ensure that the Best Practices are adapted to the context of care in each country to allow adoption by them. Simultaneously, research studies will be engaged on an international scale. Finally and in order to implement an interna-tional dataset that all frameworks contribute to and that answers fundamental questions such as the size and complexity of lymphoedema and pro-duces treatment outcomes to help profile of lym-phoedema to be raised globally, ILF is starting to use electronic means including web based solu-tions which include a dataset and electronic means of collecting data for other studies.

2011 ILF Conference in Toronto, Canada: The next opportunity to network with Key Opinion Leaders from around the WorldFollowing last year’s conference success in Brighton, UK, the 3rd ILF Conference will be held on June 16-18, 2011, at the Marriott Eaton Centre in Toronto, Canada. This conference will be facili-tated thanks to the hosting partnership between ILF, the Canadian Lymphedema Framework and the Lymphedema Association of Ontario (LAO). There will be two major launches in the field of Lymphoedema: the ILF Best Practice Document, 2nd Edition in partnership with the American Lymphedema Framework Project (ALFP) and the ILF Lymphoedema Dataset, in partnership with ILF Japan and the ALFP. Delegates and keynote speakers are expected from around the world and the programme is built on our vision around Best Practices, Data and Research. The scientific programme will be adapt-ed to specific needs of international lymphoedema experienced and non experiences practitioners, international patients and patients’ advocates.

To find out about all the industry sponsoring, education, promotion and networking opportuni-ties please visit www.lympho.org m


http://[email protected]

http://www.lympho.org

http://www.lympho.org

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

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

Summary of WAWLC events in 2010n WAWLC Wound and Lymphedema seminar,

Port-au-Prince, Haiti, July 7-9. 35 physicians and 14 nurses from Haiti received Certificates of Achievement. Faculty: Terry Treadwell, MD, FACS, Barbara Bates-Jensen, PhD, RN, Janice Young, RN, BSN, MPH, CWON, John M Macdonald MD, FACS.

n White Paper “Wound and Lymphoedema Management” published in 1,000 copies in May by the World Health Organization (WHO), available for download at http://whqlibdoc.who.int/publications/2010/9789241599139_eng.pdf. The white paper was used as text book for the training seminar in Haiti.

n Presentations on WAWLC given at the following wound events: SAWC Fall & spring meetings; EWMA Geneva Conference; American Podiatric Medical Association; Advances in Skin and Wound Care; Argentina wound and lymphedema conference; International Lymphoedema Framework Brigh-ton Conference; AMSUS (USA Military Medical Convention); UBUNTU meeting South Africa; CAWC Board Spring meeting.

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

SELECTED TOPICS DISCUSSED AT THE GENEVA MEETING

EconomyIn 2010 WAWLC has received financial contribu-tions for a total of USD 41,000.

Funds have been spent to cover expenses related to: Realisation of the training seminar in Haiti including faculty travelling expenses; Travelling expenses related to: A) The General Secretary pre-senting WAWLC at the UBUNTU conference in South Africa and B) The Executive Board partici-pating in the Geneva meeting; The technical sup-port for constructing a donation module for the WAWLC website.

At the end of 2010 WAWLC has a balance of approximately USD 10,000.

MembershipMembership categories and annual fees were dis-cussed and will be established by early 2011.

Secretariat WAWLC activities are currently based entirely on the voluntary work of representatives of the organi-sations which have established WAWLC and the General Secretary.

WAWLC will in 2011 need a coordinator who can support the General Secretary and coordinate the activities of the WAWLC working groups.

WAWLC World Alliance for Wound and Lymphoedema

Care

News from WAWLC

John M Macdonald MD, FACS

General SecretaryWorld Alliance for Wound

and Lymphedema Care

Department of Dermatology and Cutaneous Surgery

Miller School of Medicine, University of Miami

www.wawlc.org

Organisations


http://www.wawlc.org

http://whqlibdoc.who.int/publications/2010/9789241599139_eng.pdf



WAWLC Meetings in 2011The 2011 Annual Meeting is scheduled to take place in Geneva on the 16-18 November. The next WAWLC Executive Board and Advisory Board meeting will be in Brussels, Belgium, during the EWMA Conference 26-28 May. WAWLC will also hold a meeting at the ILF seminar in Toronto, Canada 16-18 June.

Working GroupsThe four working groups are now chaired as follows:n Country Support Group:

Jan Rice (La Trobe University, Australia)n Program Development Group: Terry Treadwell

(Association for the Advancement of Wound Care, U.S.A)

n Advocacy & Fundraising: Henrik J. Nielsen (EWMA Secretariat)

n Research, Monitoring and Evaluation: Christine Moffat (International Lymphoedema Framework)

Agenda for 2011n Robyn Bjork, MPT, WCC, CLT has presented her

recent work with Podoconiosis in Ethiopia. A pro-posal for a future training program and interven-tion in Ethiopia, under the auspices and support of WAWLC has been elaborated.

n The Kuwait Ministry of Health has sent a request to WAWLC to conduct a site visit to Kuwait in Febru-ary 2011. It is intended that WAWLC will conduct two educational programs in Kuwait in 2011.

n WAWLC has received a request from Uganda for educational support. It is intended that this initia-tive be developed by Wound Healing Association of South Africa under the direction of Liezl Naude and Hiske Smart.

n WAWLC will in 2011 as a minimum be represented at the following meetings: SFFPC Paris, France; Eucomed AWCS, Paris, France; SAWC in Dallas, Texas; EWMA 2011 Brussels, Belgium; SOBEST, Recife, Brazil; ILF in Toronto, Canada, ILS in Malmoe, Sweden.

n Collaboration with WHASA post UBUNTU at the Wounds International, Cape Town conference in February:

– Algorithm/flow chart on basic treatment for wounds specifically designed for Africa. This will be printed on posters and distributed. The WAWLC logo will accompany the WHASA logo.

– A “grassroots” training session (4 hours). WAWLC will be listed as a co-sponsor and will be represented by 2 WAWLC members on the faculty.

– A T-shirt Walk-a-thon for WAWLC. T-shirts will be sold with the WAWLC name and the emblazoned ”WALK the WAWLC for Wound Care”. All money collected will go to WAWLC. m

EWMA 201223-25 May · 2012

WWW.EWMA.ORG

22nd Conference of the European Wound Management Association

ienna · Austria

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


http://www.ewma.org

AFIScep.beFrancophone Nurses’ Association in Stoma Therapy, Wound Healing and Woundswww.afiscep.be

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

AIUCItalian Association for the study of Cutaneous Ulcerswww.aiuc.it

APTFeridasPortuguese Association for the Treatment of Woundswww.aptferidas.com

AWAAustrian Wound Associationwww.a-w-a.at

BEFEWOBelgian Federation of Woundcarewww.befewo.org

BWABulgarian Wound Associationwww.woundbulgaria.org

CNCClinical Nursing Consulting – Wondzorgwww.wondzorg.be

CSLRCzech Wound Management Societywww.cslr.cz

CWACroatian Wound Associationwww.huzr.hr

DGfWGerman Wound Healing Societywww.dgfw.de

Danish WoundHealing Society

DSFSDanish Wound Healing Societywww.saar.dk

FWCSFinnish Wound Care Societywww.suomenhaavanhoitoyhdistys.fi

GAIF Associated Group of Research in Woundswww.gaif.net

Cooperating Organisations

GNEAUPPNational Advisory Group for the Study of Pressure Ulcers and Chronic Woundswww.gneaupp.org

ICWChronic Wounds Initiativewww.ic-wunden.de

LBAALatvian Wound Treating Organisation

LUFThe Leg Ulcer Forumwww.legulcerforum.org

LWMALithuanian Wound Management Associationwww.lzga.lt

MASCMaltese Association of Skin and Wound Carehttp://mwcf.madv.org.mt/default.asp?contad=About

MSTHungarian Wound Care Societywww.euuzlet.hu/mskt/

MWMAMacedonian Wound Management Association

NATVNSNational Association of Tissue Viability Nurses, Scotland

NIFSNorwegian Wound Healing Associationwww.nifs-saar.no

NOVWDutch Organisation of Wound Care Nurseswww.novw.org

PWMAPolish Wound Management Associationwww.ptlr.pl

ROWMARomanian Wound Management Associationwww.artmp.ro


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

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

SAWMASerbian Advanced Wound Management Associationwww.serbiawound.org

SEBINKOHungarian Association for the Improvement in Care of Chronic Wounds and Incontinentiawww.sebinko.hu

SFFPCThe French and Francophone Society of Wounds and Wound Healingwww.sffpc.org

SSiSSwedish Wound Care Nurses Associationwww.sarsjukskoterskor.se

SWCASlovak Wound Care Associationwww.ssoor.sk

SUMSIcelandic Wound Healing Societywww.sums-is.org

SWHS Serbian Wound Healing Societywww.lecenjerana.com

SWHSSwedish Wound Healing Societywww.sarlakning.se

TVSTissue Viability Societywww.tvs.org.uk

URuBiHAssociation for Wound Management of Bosnia and Herzegovinawww.urubih.ba

V&VNDecubitus and Wound Consultants, Netherlandswww.venvn.nl

WMAOIWound Management Association of Irelandwww.wmaoi.org

WMAKWound Management Association of Kosova

WMASWound Management Association Slovenia www.dors.si

WMATWound Management Association Turkey

WMS (Belarus)Wound Management Society

For more information about EWMA’s Cooperating Organisations

please visit www.ewma.org

Associated Organisations

Leg ClubLindsay Leg Club Foundationwww.legclub.org

LSNThe Lymphoedema Support Networkwww.lymphoedema.org/lsn

International Partner Organisations

AWMA Australian Wound Management Associationwww.awma.com.au

Debra Internationalwww.debra-international.org

NZWCSNew Zealand Wound Care Societywww.nzwcs.org.nz

AAWCAssociation for the Advancement of Wound Carewww.aawconline.org

ILFInternational Lymphoedema Frameworkwww.lympho.org

SOBENFeEBrazilian Wound Management Association www.sobenfee.org.br

Organisations



Organisations

EWMA

EBWM

6 Who will take onAli Barutcu, Aydin O. Enver, Top Husamettin, Violeta Zatrigi,

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

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

29 Anaemia in patients with chronic woundsLotte M. Vestergaard, Isa Jensen, Knud Yderstraede

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

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

42 Abstracts of Recent Cochrane ReviewsSally Bell-Syer

46 International Journals Previous Issues

51 Microbiology of Wounds – a ReviewJosé Verdú Soriano

53 Pisa International Diabetic Foot Course 2010Alberto Piaggesi

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

58 EWMA Activities Update

58 Corporate Sponsor Contact Data

60 Conference Calendar

62 The annual meeting of GAIF – a Step ForwardJoão Gouveia

63 The International Lymphoedema FrameworkAgnès Carrot

64 News from WAWLCJohn M Macdonald

66 Cooperating Organisations

67 International Partner Organisations

67 Associated Organisations

EWMA Journal Vol 11 No 1

Documents

Transcript of EWMA Journal Vol 11 No 1