ZbZci - EWMA · Vanscheidt W, Münter K-C, Klövekorn W,Vin F, Gauthier J-P, Ukat A.A prospective...

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EWWORLDS WITHIN WOUND HEALIN

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José Verdú Soriano

EWMA CouncilISSN number: 1609-2759

Volume 8, No 2, May, 2008

www.ewma.org

Published three times a year

Carol Dealey, Deborah Hofman,

Sue BaleMichelle Briggs

Finn GottrupE. Andrea NelsonMarco RomanelliZbigniew Rybak

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will be publishedOctober 2008.

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no later than 1 August 2008

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Management Association.

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Christina Lindholm Patricia PriceE. Andrea NelsonChristine MoffattPosition Document Editor

Peter FranksImmediate Past President

Marco RomanelliPresident

Deborah HofmanCarol DealeyEWMA Journal Editor

Marcus GürgenJudit DaróczySue Bale

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Zbigniew Rybak Rita VideiraSalla Seppänen Peter Vowden

Rokas Bagdonas, Lithuania

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Mike Clark, UK

Mark Collier, UK

Rodica Crutescu, Romania

Valentina Dini, Italy

Bülent Erdogan, Turkey

Milada Francu, Czech Republic

Kátia Furtado, Portugal

Georgina Gethin, Ireland

Finn Gottrup, Denmark

Luc Gryson, Belgium

Marcus Gürgen, Norway

Mária Hok, Hungary

Gabriela Hösl, Austria

Hunyadi János, Hungary

Arkadiusz Jawien, Poland

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M.A. Lassing-Kroonenberg, the Netherlands

Goran Lazovic, Serbia

Christina Lindholm, Sweden

Sandi Luft, Slovenia

Christine Moffatt, UK

Sonia Muzikants, Sweden

Karl-Christian Münter, Germany

Guðbjörg Pálsdóttir, Iceland

Salla Seppänen, Finland

José Verdú Soriano, Spain

Luc Tèot, France

Anne Wilson, UK

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Skender Zatriqi, Kosova

For contact information, see

Carol Dealey, UK (Editor)

Sue Bale, UK

Michelle Briggs, UK

Finn Gottrup, Denmark

Deborah Hofman, UK

E. Andrea Nelson, UK

Marco Romanelli, Italy

Zbigniew Rybak, Poland

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Paulo Jorge Pereira Alves, Portugal

Caroline Amery, UK

Mark Collier, UK

Bulent Erdogan, Turkey

Madeleine Flanagan, UK

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Peter Franks, UK

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Gabriela Hösl, Austria

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Zena Moore, Ireland

Karl-Christian Münter, Germany

Pedro L. Pancorbo-Hidalgo, Spain

Patricia Price, UK

Rytis Rimdeika, Lithuania

Salla Seppänen, Finland

José Verdú Soriano, Spain

Rita Gaspar Videira, Portugal

Carolyn Wyndham-White, Switzerland

Gerald Zöch, Austria

Journal 2008 vol 8 no 2

Dear Reader

Welcome to the second issue of the EWMA Journal for 2008. This is also our conference issue, timed to coincide with the 18th Confer-ence of the European Management Society in Lisbon and given to

all conference delegates. It also means that the electronic supplement for this issue comprises the abstracts for all the papers and posters being presented at the conference. I believe that this provides readers with a great opportunity to see the wide range of developments in wound management research that will be presented at the conference.

Of course our readership does not just comprise conference delegates as we have a circulation of 13,000 as the Journal is sent to all our members and also to all our 40 cooperating organisations. It is important not to forget those who access the journal via the internet as this is increasing in number. In November 2007 there were 960 hits for Issue 3 rising to 1881 hits in Febru-ary 2008 for the same issue as well as a further 1205 hits for the first issue of 2008. It would appear that once internet users find the journal website they find it sufficiently useful to revisit it.

The purpose of the Journal is to provide a mix of scientific and clinical papers alongside news of developments in wound care in Europe. I believe that this issue more than fulfils this remit. Three of the papers provide details of studies looking at different methods of wound management, all from different angles and stages in development. For example, Marcus Gürgen reports a small study investigating the use of autologous platelet-rich plasma for chronic wounds which is at the early stages of investigating this product. Thomas Eberlein and Kurt Kähn have investigated methods of wound cleansing, an area worthy of more investigation. I must particularly mention the paper by Georgina Gethin as she was the recipient of a EWMA award to support her PhD studies. It is always encouraging to see the outcome of awards as it helps to reinforce their value, particularly as so few are available for studies in wound healing and management. The fourth research paper is on another important topic: wound-related pain and it is encouraging to see an international study looking at it from the patients’ perspective.

As well as news from some of our co-operating societies, there is information about the World Union of Wound Healing Societies (WUWHS) conference in Toronto in June. As EWMA is one of the co-operating societies for the WUWHS meeting and a member of the WUWHS, it is good to have this opportunity to share further details about the conference, which we hope will be a great success. It would seem that this summer is a great opportunity for learning more about the latest developments in wound healing and manage-ment. For those of you not fortunate enough to be able to attend the EWMA conference and/or the WUWHS conference we hope to bring you reports from both conferences in the next issue of the Journal and some of the best conference papers in the next few issues.

So may I wish you an interesting and productive time over the next few months, remembering that we are always interested in receiving papers on all aspects of wounds, their prevention and management. Full details of the instructions for authors can be found on our website: www.ewma.org.

Carol Dealey, EWMA Journal Editor


®/TM The following are trade marks of E.R. Squibb & Sons, L.L.C.: Versiva, Versiva XC and Hydrofiber. ConvaTec is an authorised user.©2008 E.R. Squibb & Sons, L.L.C. 2008. EU-08-780

References: 1. Vanscheidt W, Münter K-C, Klövekorn W, Vin F, Gauthier J-P, Ukat A. A prospective study on the use of a non-adhesive gelling foam dressing onexuding leg ulcers. J Wound Care 2007; 16: 261-265. 2. Bishop S. Versiva® XC™ Gelling Foam Dressing cushioning and protection claims R&D justification.WHRI2749 MS002 June 2005. Data on file, ConvaTec.

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MD, Senior Consultant Surgeon

Dept.of Surgery Sørlandet sykehus HF4400 FlekkefjordNorway

[email protected]

AbstractBackground: One of the emerging new treat-ments for chronic wounds is the use of autolo-gous platelet-rich plasma. However, there is little experience with this kind of treatment as well as limited proof of its effectiveness. Aim: The aim of this study was to gain further information about the benefits of platelet-rich-plasma in chronic wounds.Materials and methods: Thirteen patients with 14 chronic wounds were enrolled in an open label prospective study. The wounds included had not shown signs of epithelialization over a period of four weeks despite treatment of underlying causes and standard local wound care.Results: After treatment with platelet-rich plasma, 50% of the wounds had healed, 35.7% had re-duced in size and 14.2% were unchanged in terms of area and condition. Recurrencies were not ob-served during the follow-up period of an average of 34.5 weeks (range 6,5 weeks-52 weeks).Conclusion: The use of autologous platelet-rich plasma should be reserved for treatment of recal-citrant wounds where there is lack of improve-ment despite treatment of underlying causes and good local wound care. Further research in form of controlled trials is required.

Wound healing is a complex process mediated by interacting molecular signals involving mediators and cellular events. Platelets play two important roles in wound healing: hemostasis and initiation of wound healing. After platelet activation and clot formation, growth factors are released from

-granules located in the thrombocyte cell mem-brane. Growth factors work as biologic mediators to promote cellular activity by binding to specific cell surface receptors1,2.

Autologous growth factors from concentrat-ed platelet suspensions have been used to treat chronic wounds for more than twenty years3,

however, there is still a lack of research to prove their effectiveness. However, a few studies with small sample sizes showed promising results with complete wound healing rates between 37.5% and 66%4,5,6.

Eppley, et al. determined platelet numbers and growth factor concentration in platelet-rich plasma produced by one commercially avalaible system (GPS® II, Biomet Biologics, Warsaw, In-diana). They found an 8-fold increase in platelets compared to whole blood. The concentration of growth factors varied from patient to patient, but increased with increasing platelet numbers (Table 1)7.

The aim of this study was to gain further infor-mation about the benefits of platelet-rich-plasma in chronic wounds.

PDGF- 3.3 +/-0.9 ng/ml 17 +/- 8 ng/mlTGF- 1 35 +/- 8 ng/ml 120 +/- 42 ng/mlVEGF 155 +/- 110 pg/ml 955 +/- 1030 pg/mlEGF 129 +/- 61 pg/ml 470 +/- 320 pg/mlIGF No increase

MaterialsThe wound healing unit at Sørlandet sykehus Flek-kefjord in Norway treats about 250 patients with chronic wounds of various origins each year. The use of autologous platelet-rich plasma was intro-duced to our unit in February 2007. Since there was limited experience with this kind of technol-ogy, we decided to do a prospective open-label study on all patients treated during 2007.

From February 2007 until December 2007, 13 patients with 14 recalcitrant leg and foot ulcers of various aetiologies were included in the study.


The sample consisted of 3 females and 10 males with an average age of 52.1 years (range 35-76). The largest groups of wound diagnoses were venous leg ulcers (n=6) and dia-betic foot ulcers (n=3). The average duration of the ulcers was 6.8 years (range 2 months-21 years).

Since treatment with platelets is regarded as an estab-lished method, acceptance from the local ethical commit-tee was not needed. All patients had given their written informed consent before entry to the study.

MethodsThis was a prospective open label study to look at the effects of treatment with autologous platelet-rich plasma.

Inclusion criteria were chronic wounds with a dura-tion more than 8 weeks that had not shown any progress (decrease in size, formation of granulation tissue, epitheli-alization) over a four-week period despite treatment of the underlying causes and appropriate local wound treatment. Wounds had to be free for necrosis. The ankle-brachial pressure index (ABPI) had to be more than 0.6.

Ulcers that showed evident clinical signs of infection or were exudating heavily, were excluded.

Determination of ankle-brachial pressure index was done on all patients.

Venous leg ulcers were assessed by clinical features and by measuring the ankle-brachial pressure index .

All diabetic ulcers were assessed with both ankle-bra-chial pressure and toe pressure. An ABPI < 0,8 and toe pressures less than 30-50 mmHg indicated arterial disease. Neuropathy was examined by testing sensibility in diabetic feet with a 10-g-Semmes-Weinstein-monofilament and a 128 MHz-tuning fork.

Wounds were also assessed in terms of formation of granulation tissue, moisture balance, and infection. These assessments were used to describe the wounds as improved, unchanged or deteriorated.

Preparation of platelet-rich plasmaPlatelet-rich plasma gel to treat wounds was prepared by using a desktop centrifugation system (Gravitational platelet separation system, GPS® II, Biomet Biologics Inc., Warsaw, Indiana) and a reaction chamber to pro-duce autologous thrombin (Thrombin Processing Device, TPD™, Thermogenesis Corp., Rancho Cordova, Cali-fornia). Making platelet-rich plasma starts by drawing a volume of 55 ml blood from the patient and mixing it with 5 ml citrate. The blood is then transferred to the GPS®-disposable which is placed in a centrifuge. It is spun at 3200 rpm for 15 minutes. During centrifugation, blood is separated into three different fractions: platelet-poor plasma, platelets and white blood cells, and red blood cells (Figure 1). The platelet-poor plasma and the concentrated platelets and white blood cells are drawn from the tube using separate ports. Thrombin is produced by mixing platelet-poor plasma with an ethanol/CaCl2-reagent in the TPD™ reaction chamber. Platelet concentrate and thrombin are then drawn into seperate syringes, the plate-let-thrombin ratio at 10:1. The syringes are connected using a Y-connector. When mixed, thrombin activates the platelets. The result is a platelet gel that sticks to the sur-face of the wound when applied. Growth factors are also released upon platelet activation. Three different methods can be used to apply platelet gel onto wounds. Using the Y-connector, thrombin and platelet concentrate can be sprayed as a steady stream into the wounds. This method fits best to fill cavity wounds. It is also possible to attach a special tip to the Y-connector, which applies the mixture as a fine spray onto more shallow or large wounds. A third possibility is to create a clot in a sterile container, and then transfer the clot as a whole or cut into pieces into the wound (Figure 2, 3). As more experience with this type of treatment was aquired, the latter was preferred due to less leakage, more stable clotting and better utilization of the amount of platelet gel.


A degradable dressing (Topkin, Biomet Europe, Dor-drecht, the Netherlands) and a secondary absorbent layer (Mepilex, Mølnlycke Health Care, Gothenborg, Sweden) were used to cover the wounds. Treatment of the underly-ing wound causes such as compression therapy for venous ulcers and off-loading for diabetic ulcers was continued.

Outcome measuresIn order to assess wound healing accurately, we used dig-ital planimetry (Visitrak, Smith & Nephew, Hull, UK) to measure wound sizes. Digital measurements of the ulcers size were routinely taken on day 7 and day 28. As wounds were followed-up, wound tracings were performed about every four weeks.

The primary endpoint was time to healing, and the secondary endpoint was reduction in ulcer size if wounds had not healed.

Wounds were measured at day 0 with digital planimetry and showed an average wound size of 6.7 cm2 (range 0.4 cm2 -22.3 cm2).

On day 7 after treatment, ulcer size had reduced by an average of 31.4% (range 2.1%-77.7%) in 11 of 14 wounds. Two wounds were unchanged in size, and 1 wound had increased in size by 4.3%. 13 wounds were clinically assessed as improved, and 1 as unchanged.

After 28 days, 1 wound had healed completely. Of the remaining ulcers, 12 had decreased in size to an average of 55.2% (range 6.2%-80%) of their original size. All of those were clinically assessed as improved. One wound remained unchanged in both size and condition.

The number of treatments with platelet-derived growth-factors varied from 1-4 (average 2.1 treatments).

Follow-up continued for an average of 8.4 months (range 1.5-12). Two ulcers showed signs of infection dur-ing the course of treatment. In both cases, Pseudomonas species were cultured and infections successfully treated with systemic antibiotics. Other side-effects were not re-corded.

Seven (50%) of the ulcers healed within an average of 153 days (range 30-317). Of the non-healed wounds, 2 (13.3%) showed signs of improvement within the first 4 weeks, but have since deteriorated. The remaining 5 (35.7%) of the wounds continued to show improvement and are between 68.7% and 6.8% of their original size. (Table 2) Recurrencies were not observed.

Wound healing is a complex process that is regulated by interactions between a large number of cell types, extracel-lular matrix proteins and mediators such as cytokines and growth factors. Lack of balance between these interactions may result in a chronic wound. One possible cause of imbalance in the wound healing process is high bacterial


counts leading to a prolonged inflammatory response with high levels of cytokines. This leads to increased production of matrix metalloproteases. High matrix metalloprotease activity results in uncontrolled breakdown of extracellular matrix and growth factors8. If measures are not taken to re-establish the balance between the factors involved, a chronic wound fails to heal.

About 88% of all wounds treated at our wound heal-ing unit heal when the underlying causes are treated and good local wound care is established9. For the remaining wounds, advanced wound-healing strategies can be consid-ered in order to obtain wound closure. A common feature of these advanced strategies is an attempt to influence the bioactive wound environment by, for example, lowering pH-values, applying extracellular matrix, binding matrix metalloproteases, or, in the case of platelet-rich plasma, by increasing numbers of growth factors.

Despite the fact that concentrated platelets have been used to treat chronic wounds for more than 20 years, there is a lack of high-quality studies describing their use in the literature. Literature findings do not allow to draw a clear conclusion on the use of platelet concentrates. Senet, et al. used frozen autologous platelets that had no significant adjuvant effect on healing of chronic venous leg ulcers10.Reutter, et al. found neoangiogenetic abilities to platelet derived wound healing factors, but not any significant clin-ical advantage11. Human recombinant epidermal growth factor failed to significantly enhance re-epithelialization in venous leg ulcers12. However, other publications showed encouraging clinical results with the use of growth factors

1 F, 76 Venous leg ulcer 10 years 21.8 1 22.5 27.1 Deteriorated, no signs of epithelialization

2 M, 53 Neuroischemic diabetic heel ulcer 27 weeks 22.3 2 23.3 49.7 Healed day 1553 F, 64 Neuroischemic diabetic heel ulcer 30 weeks 0.9 1 77.7 100 Healed day 304 M, 56 Traumatic leg ulcer associated

with an open distal leg fracture8 weeks 4.8 1 2.1 16.6 Healed day 62

5 M, 39 Pressure ulcer, leg, associated with spinal cord injury

1 year 5.6 4 7.7 16.1 Reduced by 42.9%

6 M, 50 Venous leg ulcer 18 years 2.1 4 0.0 0.0 Healed day 2337 F, 72 Venous leg ulcer 21 years 1.3 2 31.8 69.3 Healed day 2388 M, 44 Venous leg ulcer 30 weeks 4.4 3 + 4.3 13.1 Reduced by 93.2%9 M, 55 Mixed-etiology leg ulcer 4 years 16.3 1 14.2 38.7 Deteriorated after

10 weeks10 M, 39 Venous leg ulcer 3 years 5.7 4 0.0 6.2 Reduced by 59.7%11 M, 35 Heel ulcer after cutaneous flap

transfer21 years 0.7 2 57.1 71.4 Reduced by more

than 80%(impossible to meas-ure due to small size)

12 M, 58 Neuropathic diabetic heel ulcer 36 weeks 0.4 1 50 50 Healed by day 31713 M, 37 Venous leg ulcers 9 years 8.0 / 1.5 1 12.5 /

46.668.8 / 80 Reduced by 72% /

healed by day 35

in in both venous and diabetic ulcers13,14,15,16. Crovetti, et al., McAleer, et al., and Steenvorde, et al. reported wound closure rates in recalcitrant ulcers between 37.5% and 66%4,5,6. The results of this small sample of patients show that 50% of all wounds healed.

Treatment with platelet-rich plasma was reserved for patients with wounds that had not healed despite the use of other treatment strategies. Some of these prior treatments lasted for many years as the average duration of ulcers treated in this study (6.8 years) shows. In those cases, the use of platelet-rich plasma not only lead to wound closures, but also to improved the healing time. The average healing time for the wounds that closed was less than 6 months. 42,8% of 7 venous ulcers in this study healed within 6 months after treatment with platelet-rich plasma and two-layer compression bandage. Nelson, et al. showed 67% healing rates of venous ulcers within 24 weeks when us-ing four-layer compression therapy and 49% healing rates when using single-layer compression therapy17. However, it might be difficult to compare outcomes because of the low number of patients included in the present study.

Two minor complications in form of infection with Pseudomonas aeruginosa were observed. Both wounds were cultured for Pseudomonas aeruginosa prior to plate-let gel treatment. In both cases, platelet-rich plasma was sprayed on the wounds. The clot that forms in the wound after spraying does not seem to be as stable as the clot produced in a sterile container. There is also some leakage when spraying, which may contribute to an excessively


moist wound environment, creating suitable conditions for Pseudomonas aeruginosa growth. This is another rea-son why the external clot is preferred over the spraying technique.

One final reason that the externally-created clot is preferred is that less platelet concentrate is lost during application. When spraying platelet concentrate onto a smaller and/or more shallow wound, some often has to be discarded because it seeps beyond the edges of the wound. An externally-created clot can easily be cut or formed in accordance to ulcer size and fashion. Thus a larger amount of growth factors are retained in the wound bed to benefit the healing process.

No pattern in the speed of wound healing could not be discerned. Some wounds showed rapid progression of healing after application of concentrated platelet gel, but later slowed down, and in some cases the wounds be-gan deteriorating again. Other wounds did not seem to demonstrate any early healing after treatment, but showed significant progress by the end. There is no plausible ex-planation for this. To date, there has been no determina-tion of a standard treatment frequency or duration. The treatment program of Crovetti, et al. recommends weekly application of platelet gel. Complete healing was achieved in 9 wounds with an average of 10 applications4. In this study, wound closure occured in 7 wounds with an aver-age of 1.7 platelet gel applications. Crovetti, et al. used a different system to prepare platelet gel, which may have resulted in different concentrations of platelets and growth factors that were applied to the wounds.

A possible treatment protocol based on the experiences gained during this study is to repeat the application of platelet gel at least 3 times over a 6- to 9-week period, and to measure wound sizes regularly. If the wound does not show progress 4-6 weeks after cessation of treatment, a new course of three applications is recommended.

A single treatment cost about 900 Euro, which makes it a costly method. The time needed for preparation and application of platelet-rich plasma is about 90 minutes.

However, the use of autologous platelets seems to be cost-effective since ulcers that did not show improvement prior to treatment healed.

Implications for Clinical PracticeThe preparation and application of platelet-rich plasma can be considered in case of non-healing wounds who do not respond to treatment of the underlying causes and good local wound care. The procedure of preparing plate-let gel is easy to learn and reliable. Platelet gel prepared as an external clot seems to be easier to handle. It probably also allows better utilization af the amount of growth fac-tors prepared.

Further ResearchControlled studies with sufficient sample sizes have to be initiated. Cost-effectiveness should assessed when doing those studies. As there are several manufacturers provid-ing equipment for in-hospital production of platelet-rich plasma, the different systems must be examined for differ-ences in increase in platelets, growth factor concentrations, preparation time, and applicability.

The use of platelet-rich plasma can be an option when treating recalcitrant wounds of differing aetiologies. It should be reserved to wounds that do not show any progress after 6 months with treatment of wound aetiology and standard wound care.

Further research in the field is required. Controlled studies with sufficient sample sizes are needed to prove the efficacy of platelet-rich plasma to treat wounds. Such studies should focus on outcomes as well as for varia-tions in platelet counts, growth factor concentrations, and applicability and cost-effectiveness. The results of this study encourage the author to try to start a Norwegian multi-center trial.

1. Ernesto C. Clinical review 35: Growth factors and their potential clinical value. J Clin Endocrinol Metabol 1992; 75: 1-4.

2. Rothe M, Falanga V. Growth factors. Arch Dermatol 1989; 125: 1390-1398.

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

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

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

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

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

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

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


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related companies. © 2007-11. All rights reserved Coloplast A/S, 3050 Denmark.

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The main problems related to non-healing wounds are poor cleansing and insufficient attention to bio-burden especially in outpatient wound care where about 90% of chronic wounds are treated. Wound coatings activate the innate immune sys-tem, favour the growth of bacteria, and are the origin of reactive oxygen species (ROS)1 and pro-inflammatory mediators. These agents de-stroy viable tissue and trigger massive granulocyte accumulation in the microvasculature resulting in obstruction of microcirculation at the wound edges2. Thus, the aim of wound cleansing should be complete removal of all non-vital materials. Thorough and gentle wound cleansing is crucial for proper wound bed preparation allowing the wound to heal faster.

Wound cleansing by rinsing is routinely used in wound bed preparation. Considering the hy-drophobic and polymeric nature of the principal components of wound coatings it is assumed that the type of rinsing solution may be of particu-lar importance to the effectiveness of cleansing. Wound coatings contain denaturated proteins, lipids from cell debris, and cross-linked fibrin all in need of a surface tension reducing agent for removal and solubilisation.

In home care the first choice “solution” for wound cleansing is often non-sterile tap water usually contaminated with Pseudomonas aerugi-nosa, followed by re- or overused flasks of saline or Ringer’s solution often contaminated by species of the normal human flora or the natural environ-ment3. Non-sterile wound rinsing may be “cost-effective” at first glance however it is definitely not state-of-the-art of wound management.

To compare the cleansing efficiencies of wound rinsing solutions under controlled testing condi-tions an in vitro model that mimics wound coat-ings was developed. Removal of test coatings were analysed using saline, Ringer’s solution and a special wound rinsing solution containing Poly(hexamethylenbiguanide)hydrochloride (PHMB) and a Betaine surfactant. Subsequently the in vitro

results were verified by a retrospective analysis of healing processes of chronic wounds of the type “Ulcus cruris venosum”.

Preparation of test wound coatingsOutdated frozen fresh plasma (FFP), anti-coagu-lated and stabilised with CPS (citrate, phosphate, dextrose) was thawed, applied to diagnostic slides (adhesive design) and dried on them overnight. For fibrin formation one volume part of 1.8 MCaCl2 solution was added to nine volume parts of CPD plasma. The fibrin formation started im-mediately after mixing of the volume parts on the slide.

Wound rinsing solutionsPhysiological saline solution (0.9% NaCl), Ring-er’s infusion solution (0.860% NaCl, 0.030% KCl, and 0.033% CaCl2·2H2O) and a solution containing 0.1% Polyhexamethylene Biguanide and 0.1% Undecylenamidopropyl Betaine (Pron-tosan®) were obtained from B. Braun Melsungen AG.

Protein measurementProteins were removed from the test coatings either by dissolving or by inclusion in micellar colloids of detergent. Dissolved proteins were de-tected by means of a modified Biuret reaction rea-gent (Roti®-Quant universal, Carl Roth GmbH & Co. KG). Soluble proteins formed complexes of a violet colour with copper ions of the reagent (see figure 1). The extinction at 503 nm was di-rectly proportional to the protein concentration. Denaturated proteins enclosed in micelles were not detected by the Biuret reaction.

In vitro test designTest slides with dried-on blood plasma or fibrin were placed in histological staining troughs filled with test solutions. Each test preparation was accompanied in parallel by a blind preparation (rinsing solution without test slides). After 2.5,


30, and 60 minutes 1.5 ml aliquots were transferred to reaction vessels and centrifuged immediately at 2,500 gfor 2 minutes. 0.1 ml supernatant was mixed with 0.1 mldistilled water and 0.8 ml protein reagent. The extinction was measured within 30 minutes at 503 nm (Beckman DU-600 photometer). After subtraction of blind values the extinction values of probes were plotted against in-cubation time. For calibration plots 0.1 ml test solution, 0.1 ml of a bovine serum albumin (BSA) solution, and 0.8 ml protein reagent were mixed.

Clinical dataFor retrospective analysis of wound healing processes, medical records of 112 patients with Ulcus cruris veno-sum were evaluated. Wounds of patients were routinely cleansed using PHMB and Betaine containing rinsing solution (n=59) or saline and Ringer’s solution (n=53) respectively. The time to wound healing in both groups was compared statistically.Inclusion (+) / exclusion (-) criteria were:+ wound at least three months old+ confirmed diagnosis “Ulcus cruris venosum”+ wound treatment according to the recommendations

of “moist wound treatment”+ compression therapy in cases of venous ulcers by

short stretch bandaging+ clear documentation of the type of rinsing solution

used during wound treatment– persistent, severe arterial circulation disorders (Fon-

taine stage II)

Statistical evaluationThe time to wound healing data were analysed using the Kaplan-Meier method and the means of the two patient groups were compared with the log rank test. In both patient groups there were no drop-outs. The total obser-vation period was predisposed to six months and started with admission. About 90% of wounds healed within the observation period in both patient groups.

Infection rates were compared and evaluated using Fischer’s chi-square test.

Effect of rinsing solutions on test coatingsDuring the incubation period of standardised test slides (coated with either FP or fibrin) the protein concentration in all three wound rinsing solutions increased almost lin-early, thus meaning that no saturation was reached under the test conditions. Concentrations of dissolved protein were lowest in Ringer’s solution and 3.5 times (FFP) and 5 times (fibrin) higher in saline. Most proteins were solved in Prontosan®. Compared with saline, the concentrations were 25% (FFP) and 75% (fibrin slides) higher (see fig-ures 2a and 2b).

In contrast to saline and Ringer’s solution the PHMB/Betaine containing wound rinsing solution disintegrated test coatings and solubilised denaturated proteins by en-closing them in micelles (see figure 3). Micellar colloids show strong refraction and hence turbidity in the PHMB/Betaine containing solution increased during incubation time.


Effect of rinsing solutions on wound healingAll wounds were cleansed by thorough and gentle rinsing using either a special wound rinsing solution or saline/Ringer’s solution. The effect of a simple cleansing proce-dure is shown in figures 4 a-c.

There were significant differences between the two patient groups concerning wound healing. In the group treated with PHMB/Betaine containing wound rinsing solution the wound healing rate was faster. After three months already 60% (n=35) of wounds were healed com-pared to 28% (n=15) in the group treated with saline or Ringer’s solution (see table 1). At the end of the observation period of six months the healing rates in both groups were proved satisfactory (97% and 89%). Mean time to healing in the PHMB/Betaine group was superior to the saline/Ringer’s solution group (see figure 4). In the latter there was a healing delay of more than one month: 4.42 ± 1.41compared to 3.31 ± 1.32 months (p < 0.001).

number of patients 53 59rinsing solution saline or Ringer’s PHMB / Betainetime scale wound healing rate (%)end of 1st month 2 7end of 2nd month 9 29end of 3rd month 28 59end of 4th month 51 81end of 5th month 68 93end of 6th month 89 97

During the period of wound treatment infection rates were 3% (n=2) in the PHMB/Betaine group compared to 13% (n=7) in the saline/Ringer’s solution group (p = 0.056).

When proteins are dissolved in water each protein mol-ecule is included in a structured hydration sheath of water molecules which prevents aggregate formation and precipi-tation. Saline and Ringer’s solution, both regularly used in wound care practices, contain monovalent and biva-lent salt ions (Na+, Ca++ or Cl-) which bind many water molecules (about 185 for monovalent ions) and therefore compete with proteins for the water molecules. Increasing


salt concentrations (exact ionic strength*) destabilize the hydration sheaths of proteins resulting in aggregate forma-tion and precipitation (salting-out effect). In particular salts with polyvalent ions like Ca++ in Ringer’s solution reduce the solubility of proteins4.

In an in vitro model for wound coatings (FFP/fibrin on adhesive glass slides) differences between wound rinsing solutions with regard to protein solubilisation could be demonstrated. Ringer‘s solution, which contains 2.2 mM divalent calcium ions was less effective than saline solu-tion in dissolving denaturated proteins. Compared with saline, only 20-30% of the amount of protein dissolved in Ringer‘s solution. A PHMB and Betaine containing special wound rinsing solution which does not contain any salt additive was most suitable for dissolving proteins from test coatings. The Betaine surfactant improved protein removal by disintegration of coatings and formation of micellar colloids.

Results obtained by using the in vitro wound coating mod-el were verified by retrospective analysis of chronic wounds (venous leg ulcers). Improved cleansing efficiency should also improve wound healing by reducing oxidative stress and levels of pro-inflammatory mediators in the wounds. Actually this hypothesis was supported by retrospective clinical data. Wounds treated with PHMB/Betaine con-taining wound rinsing solution revealed superior wound healing. Mean time to healing was about three instead of four months. Obviously the local wound milieu favoured the occurrence of reparative processes when rinsed with PHMB/Betaine solution. These findings are consistent with recent reports on effects of PHMB/Betaine solu-tion5,6,7.

Another effect for better wound healing was the reduced infection rate in the PHMB/Betaine treated patient group (3% versus 13%, p = 0.056). Due to low overall infection rates in the wound care unit the difference did not reach the significance level of 5% (p < 0.05). Infections were treated by infusion of antibiotics. In both groups local an-tiseptics were not applied during the period of observation. Low infection rates during wound management reduce complications in wound care, improve wound healing rates and bring down costs. Considering that infection rates below 2% are difficult to realise 3% in the PHMB/Betaine group are near the optimum.

Wound healing is a highly complicated multifactorial proc-ess and requires a sophisticated local wound management. The most important point is to follow the recommenda-tions of moist wound treatment as defined by Falanga8

and Sibbald9. Typically, neutral physiological solutions are used for that purpose. However, PHMB/Betaine con-taining wound rinsing solutions may be superior to salt solutions.

Betaine forms micelles and improves solubilisation of hy-drophobic material from wounds. Poly(hexamethylenbiguanide)hydrochloride (PHMB) is an antimicrobial agent

widely used as a preservative in commercial and in-dustrial settings. The most common use is as an algicide, fungicide, and sanitizer in swimming pool systems. In medicine PHMB was introduced by Willenegger in 199410

as an antiseptic in abdominal surgery. Over the past years end-use (ready-to-use) wound care products containing PHMB have been successfully launched including wound rinsing solutions, wound gels and dressings.

Special features qualify PHMB for growing and ef-fective application in wound care management. To begin with PHMB is very active against bacteria and Candida in

* The ionic strength I of a salt is half the sum of the terms obtained by multiplying concentration ci and charge z1 of the dissolved ions.


low concentrations (0.01 to 0.1% (w/v)). In addition, the acute toxicity of PHMB is low for both oral and dermal use. The no observable effect levels (NOEL) in dogs are 90 mg/kg bw/day for systemic toxicity and 45 mg/kg bw/day for chronic toxicity (oral route both). For individual cases slight or moderate dermal irritations and/or allergic type reactions were reported. However, compared with other antimicrobial agents the safety margin of PMHB is extremely high11.

In wound treatment “cleanliness“ (no coatings, reduction of detritus, removal of necrotic tissues, low microbial bio-burden) is generally considered an important factor for improving secondary wound healing without major prob-lems. This fact applies to both acute and chronic wounds. National and international professional associations and societies recommend accepted standard procedures for optimal wound cleansing and wound bed preparation to obtain favourable conditions for healing. Particular atten-tion is given to the risk of infection and to break the vicious circle of colonisation, infection and non-healing.

In this context and in order to achieve the necrosis- and detritus-free state of the wound great care must be taken

to ensure that there is no damage or harm to vital and especially to naturally functional important structures. Keeping this objective in mind, the application of PHMB/Betaine containing wound rinsing solutions seems to be a highly appropriate concept in supporting these effects and to promote wound healing.

References

1. James TJ, Hughes MA, Cherry GW, Taylor RP. Evidence of oxidative stress in chronic venous ulcers. Wound Rep Reg 2003; 11: 172-176

2. Kaehn K. Entzündungsreaktionen des Endothels und chronische Wunden. Zeitschrift für Wundheilung 2004; 4: 161-165

3. Gouveia JCF. Is it safe to use saline solution to clean wounds? EWMA Journal 2007; 2: 7-12

4. Lehninger AL (ed). Biochemistry, 6th printing; Part1, Chapter 7: Proteins – behaviour in solution. Worth Publishers N.Y. 1972

5. Eberlein T, Fendler H, Andriessen A. Prontosan®-Lösung oder Standard-Behand-lung? Die Schwester Der Pfleger 2006; 9: 2-4

6. Horrocks A: Prontosan wound irrigation and gel: management of chronic wounds. Br J Nurs. 2006; 15: 1224-1228

7. Kramer A, Roth B, Müller G. Rudolph P, Klöcker N. Influence of the antiseptic agents Polyhexanide and Octenidine on FL cells and on healing of experimental superficial aseptic wounds in piglets. Skin Pharmacol Physiol 2004; 17: 141-146

8. Falanga V. Classification for Wound Bed Preparation and Stimulation of Chronic Wounds. Wound Repair and Regeneration 2000; 8: 347–352

9. Sibbald RG, Williamson D, Orstedt HL, Campbell K, Keast D, Krasner D, Sibbald D. Preparing the Wound Bed – Debridement, Bacterial Balance, and Moisture Balance. Ostomy Wound Management 2000; 46: 14–35

10. Willenegger H. Klinische Erfahrungen mit einem neuen Antiinfektivum. Hygiene Medizin 1994; 4: 227-233

11. Kramer A. Stellenwert der Infektionsprophylaxe und –therapie mit lokalen Antiinfektiva: 15-25. In: Kramer A, Wendt M, Werner H-P (eds.). Möglichkeiten und Perspektiven der klinischen Antiseptik. mhp-Verlag GmbH Wiesbaden 1995


AbstractBackground: Chronic wound healing is generally a long and uncomfortable process. Consequently, an understanding of wound-related pain from the patients’ point of view and evaluation of the effect of pain on a persons’ daily life is fundamental to their holistic management. Aim: The aim of the study was to involve patients in discussion about their wound-related pain ex-periences in order to inform the development of a questionnaire, based on the views of patients from different cultural backgrounds. This study represented one of the preliminary phases of an international survey which aimed to collect data on patient’s wound-related pain experiences; from 15 countries world-wide.Method: An international qualitative study was conducted in patients presenting with chronic wounds to identify those aspects of wound-related pain which created most concern. French, Brit-ish and Canadian patients with chronic wounds participated in a series of focus group studies.Results /Findings: Although a number of similar patient issues were apparent in all three countries, specific cultural differences were also observed: the French group expressed particular concern with body image, the British group were uncomfort-able with medication use and the Canadian group were anxious about financial loss and apprehen-sive of the healthcare system. Conclusion: Wound-related pain can have a huge impact on a persons’ everyday life and as such each patient’s needs should be recognised and considered.

Chronic wound pain is associated with negative mood, decreased activities of daily living, sleep disturbance, reduced mobility and social with-drawal1,2,3,4,5. Qualitative research in this area has identified numerous aspects of pain and dis-comfort which have a negative impact on qual-

an international perspective

,MSc, BSc, MChS, SRCh, D.Pod.M1

MD2

RN, MSc3

MD, FRCPC, MEd3

PhD, BA (Hons), AFBPsS CHPsychol1

1. Wound Healing Research Unit, School of Medicine, Cardiff University, Wales, United Kingdom2. Service de Gérontologie, Hôpital Charles Foix, Ivry sur Seine, France3. Wound Healing Clinic, Women’s College Hospital, University of Toronto, Canada

Elizabeth MudgeCardiff UniversityDepartment of Wound HealingUpper Ground FloorHeath ParkCardiffCF14 4XN

[email protected]

ity of life among patients with chronic wounds6.Activities that are important to the maintenance of daily functioning such as working, walking, standing and climbing stairs can often exacerbate pain in wounds5,7 and thus lead to restricted life-style and a sense of confinement3. These feelings are often amplified by sleep disturbance and can eventually result in social withdrawal in some in-stances8. There is a strong connection between pain and an individual’s sense of well-being. Nega-tive emotions such as anger, sadness, hopelessness and despair are common in cases where a painful wound is seen to control a person’s existence3,9. It is therefore not surprising to find that a substantial proportion (37.5%) of patients with venous leg ulcers described pain as the worst aspect of hav-ing an ulcer10. Various studies of patients with venous leg ulcers11,12,13 and diabetic foot ulcers14

indicate that pain is significantly associated with diminished quality of life and forms a person’s foremost concern in their care15.

Four focus groups, each involving five or six patients (total number of participants = 23: 10 male, 13 female) with chronic leg ulceration or diabetic foot ulceration were conducted in France, the United Kingdom and Canada. Focus groups were chosen as this method can elicit a wealth of opinions and emotional processes within a group context. Purposive, non-probabilistic sampling was used to identify specific people who had ex-perience of discomfort and/or pain related to their chronic wound. Only adult patients (18+ years of age) with an active ulcer of over 6 weeks were invited to participate. There were no exclusion related to a predetermined level of intensity of pain experienced at the time of the focus groups, but only those who had some previous or cur-rent experience of discomfort/pain related to their wound were invited to participate. The inclusion criteria were deliberately broad in order to capture


the full range of experiences related to discomfort/pain and using a purposeful sample was deemed appropriate in order to fully explore the participants’ pain experiences.

Following ethical approval and identification through appropriate healthcare staff, patients were sent an infor-mation sheet about the study followed by a telephone call one week later. Those patients interested in participating and who had provided written consent were asked attend a specified non-clinical location for a two-hour focus group meeting.

Each focus group was run by one or two facilitators with experience in psychological aspects of wound heal-ing, who explained the aim of the group, confirmed con-fidentiality and emphasized that the focus would be on talking to each other rather than to the researchers. The same schedule (see appendix 1) was followed in all three countries in order to ensure consistency between groups.

The first part of the discussion concentrated on general wound-related pain experiences whereas in the second phase the facilitators focused the discussion around the topic of discomfort and/or pain during the dressing change procedure. Pre-determined open questions/prompts were used to facilitate conversation.

The discussions were tape recorded. The content of the tapes were transcribed by one researcher, confirmed by a second researcher and verified by the participants at each location. The discussion transcriptions were evaluated by means of content analysis16 which enabled systematic identification of a number of emergent themes represent-ing the participant’s responses. Separate analyses were conducted for each group and reliability of themes was verified by a second researcher. The overall results were then further evaluated between the three countries.

IntroductionsOutline aims of project

(Open discussion around experiences of living with a wound including pain experiences)

Experience of living with a woundExperience of painIntensity and description of painTiming of discomfort / painImpact of pain /discomfort on everyday living (including employment and impact on other family members)

Parts of the dressing change process – are they different in terms of discomfort / pain experience?

• Anticipation of dressing change• Dressing removal• Cleansing• Application of new dressing• Location of the dressing change procedure

– (e.g.: home, outpatient clinic or inpatient clinic)• Involvement of the patient in the process

Residual pain following changeOther aspects of wound related pain e.g.:

• Infection• Surrounding skin

Other aspects of treatment related to pain e.g.:• Use of particular dressings• Antibiotics

What makes the experience worse?What improves the experience?

What strategies help?• Is the patient able to self help?• Where does patient go to find information on strategies to manage

pain/ discomfort?Open question to ensure that all the issues important to the patients and relevant to the topic have been covered.


The participants in all three countries agreed that pain was a constant feature of their wounds but that it varied in intensity throughout the day. Constant pain was per-ceived by one of the French participants to change one’s appearance; “It shows in the face”, whereas in the Canadian and UK groups, adjectives such as “burning”, “throbbing”and “shooting” were used to describe their everyday pain. A more intense and sudden pain was also vividly described which caught the participants off guard at any time dur-ing the day or night. This pain was considered far more distressing than their “ordinary pain” and was described as follows:

Participant (France) – “It’s as if I have a bar behind my thigh and someone is pressing it against me and tightening it up”

Participant (UK) – “It’s like an iron band with spikes pressing hard”

Participant (Canada) – “Tremendous pain, I crawl on all fours”

Participant (France) – “I have the sensation that some-one is eating my flesh, like a dog biting me. It hurts terribly”

Quality of LifeThe impact of pain revealed a number of psychologi-cal processes that were common regardless of gender or culture. Many participants felt that wound-related pain reduced their confidence in carrying out everyday tasks and in maintaining social and recreational activities. These feelings manifested themselves by a sense of isolation and a loss of identity which reinforced an awareness that their lives had irreversibly changed:

Participant (France) – “It’s only goodbye”Participant (UK) – “It feels like we are been taken over

to a different route in life than the one we expected” Participant (Canada) – “You think it’s never going to

end”

It appeared difficult for the participants to distinguish be-tween the impact of the ulcer and the repercussions of the pain. Nevertheless, a number of points were emphasised. All of the participants had encountered difficulties with walking and many were afraid of falling:

Participant (France) – “I haven’t been able to go walk-ing outside for about six months. I can’t get down the stairs any more”

Participant (UK) – “I always look down when I walk; I am so afraid I am going to fall”

Participant (Canada) – “Walking becomes worse as neuropathy slowly progresses and you’re unable to weight-bare. I cry like a baby and I am unable to deal with it”

Driving a car had become difficult or impossible for most of the participants thus increasing their sense of isola-tion:

Participant (France) – “I recently started driving again. But I cannot drive for long, as I can no longer feel my foot on the pedal”

Participant (UK) – “Because of the pain I cannot drive anymore”

Participant (Canada) – “You are at the mercy of some-one else”

This loss of mobility was perceived by the participants as preventing them from independently performing various tasks of daily living which greatly reduced their sense of well-being and their overall quality of life.

Feeling isolatedThe participants portrayed stigmatisation caused by hav-ing a chronic ulcer. In addition to the negative appearance of the wound and the dressings, pain also contributed to feelings of marginalisation:

Participant (France) – “If I haven’t got my mor-phine … at those times, I just don’t want to see anybody”

Participant (UK) – “I had to drop from things I really enjoy”

Participant (Canada) – “When in severe pain I do not want to say anything or talk to my family”

Social isolation was frequently linked to a sense of shame:

Participant (France) – “I no longer go out because I am ashamed of my stick and my slippers, and above all I am afraid of falling over …I don’t go anywhere unless someone comes with me. I stay at home”


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Moreover the participants linked their mood state directly to their wound which was described by one participant as a “depressing disease”. Such emotions were possibly ampli-fied by a common tendency for not wanting to “burden”or “bore” friends or relatives with their feelings:

Participant (France) – “It’s not difficult to talk about it but I don’t want to share this painful experience with those close to me”

Participant (UK) – “You cannot whinge too much to friends otherwise you will not have any friends …you have to keep it to yourself ”

Participant (Canada) – “I am not a complainer …I don’t want to be a burden”

Participant (UK) – “A lot of people did not know of my problem for 20 years; I kept it to myself ”

The participants even intimated that they would avoid speaking to their caregivers or healthcare practitioners about their pain, particularly if they had been seeing them for many years as they felt that they had “said it all before”.

Body imageAesthetic considerations toward both the wound and the dressing further impacted on the participants’ quality of life and these were strongly linked with social isolation. Negative body image was passionately discussed among the French group:

Participant (France) – “A leg ulcer is very ugly” Participant (France) – “It (the dressing) certainly

isn’t feminine. That’s why I always wear trousers”Participant (France) – “The bandage is lighter in

colour than my leg and is not at all attractive. I avoid going out”

Embarrassment concerning body image was augmented by wound odour:

Participant (France) – “A woman sitting beside me in a waiting-room said about another patient; ‘That woman doesn’t wash, for sure.’ It’s awful isn’t it?”

Sleep deprivationSleep deprivation was a common discussion point within all the groups and had an overwhelming impact upon their ability to cope with pain and their quality of life:

Participant (France) – “At night sometimes it is so bad that I wake up”

Participant (UK) – “Every night you’d be rubbing your leg, you don’t know what to do, I get up in the night and walk about, anything, then go back to bed”

Participant (Canada) – “I am constantly watching the news or clock for distraction at night”

Healthcare systemFrustration with the healthcare system was reported to have a negative influence on wound-related pain experi-ence for some of the participants and was the focus of considerable discussion in the Canadian group. Particular issues concerning frequent turn around of nurses, incon-sistency of care, misunderstanding of pain and lack of information caused the participants to loose faith in their healthcare system:

Participant (Canada) – “Healthcare providers are geared toward acute injuries; they have no under-standing of chronic ulcers”

Furthermore, financial concerns due to time taken off work to attend healthcare appointments or misunderstanding of their condition led to much anxiety and distress:

Participant (Canada) – “My work cut off my pension (because they did not consider me to be disabled enough)”

Dressing changeAnticipation of the dressing change produced a mixture of positive and negative emotions, but having a fresh dress-ing put on the wound was generally perceived to be a very painful and fearful time for the participants and represent-ed a permanent reminder of the existence of their wound. Favourable aspects arose from the fact that changing the dressing relieved the compression, allowed them to bathe their feet and legs or take a shower, observe any changes in the wound and to see the nurse who, in some cases, would be the only social contact of the day.

Dressing the wound was linked to pain and many pa-tients took some form of analgesia before their appoint-ment. Pain was particularly intense when the dressing had adhered to the wound and also during cleansing of the ulcer. In some instances fearful anticipation of these pro-cedures was intensified by past memories:


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Participant (France) – “When she scrapes, that’s the worst moment …”

Participant (UK) – “Once you disturb it when you do a dressing you’ve got to wait at least half an hour af-terwards for it to settle down where you just

don’t want to move from the spot”Participant (Canada) – “When the blade comes out,

that’s when my pain level goes through the roof”

Some participants stated that the dressing change proce-dure was made worse if the ulcer was left exposed/uncov-ered for long periods of time and this was linked to a fear and a misunderstanding of infection. Such concerns were amplified by a sense that there were inadequate numbers of staff or resources and that the dressing change procedure was out of their control. However, many participants re-ported that they felt the dressing change procedure could be improved by continuity of care, regular or familiar healthcare professionals and having a good support net-work.

MedicationConcern about long term use or reliance on pain-relieving medication and fear of poly pharmacy was highlighted by the UK participants and created prominent discussion in this group. Those participants who took ‘pain-killers’ reported that the possibility of delay of the dressing change would cause anxiety which was based on fear that their an-algesia could wear off. Many of the participants admitted to using alcohol to calm their nerves yet were concerned about stigma associated with addiction to pain-relieving medication or getting so used to taking tablets that they would lose their effect:

Participant (UK) – “I don’t like taking a lot of tablets, not through choice, some tablets make me sick …I mean you take all these tablets over the years and it says do not take alcohol and you think oh what the hell, a glass of red wine will do wonders”

Participant (UK) – I’ve just stopped now (taking analgesics) and try to tolerate the pain you know because you just don’t know what these (tablets) are doing to your insides over the years”

InfectionOverwhelmingly the greatest perceived concern in all three countries was that of infection and this was ampli-fied by the knowledge that infection intensified pain. The participants expressed constant fear of infection and this was particularly prominent during the dressing change

procedure, as many believed that their wound was only at risk of infection when it was uncovered:

Participant (France) – “It’s excruciating, it’s awful”Participant (UK) – “It never sees the light of day so

how does it get infected?”Participant (Canada) – “You live in fear of getting an

infection, you do everything you can and then they say you have an infection and you start the battle all over again”

It is impossible for patients to forget about their chronic wounds when their everyday life tends to revolve around their condition. The combined effect of persistent wound-related pain and spontaneous intermittent bursts of in-tense pain are debilitating and distressing for patients yet, although the participants in this study found it difficult to cope with the unpredictable nature of their pain, they were reluctant to talk about it with friends and family. An insidious progression toward marginalisation and isolation appeared to be a direct result of pain and as a consequence impacted on the participants’ ability to carry out everyday activities. This was amplified by negative physical appear-ance, odour, uncertainty of the healthcare system, and misunderstanding and fear of infection.

The participants in this study, particularly those in the French group, emphasised feelings of shame about the appearance of their wound/dressings and accentuated that pain led to negative facial expression, subdued body appearance and a reluctance to socialise. Psychological re-search in the area of body image reinforces the view that attractiveness is valued highly within all societies and that the less conventionally attractive receive less in the way of support from others which can result in a decrease in self esteem and negative self-image17. Furthermore a definite relationship has been observed between depression and negative body image18. Studies of health-related quality of life suggest that patients with chronic conditions adapt over time to their altered lifestyle4, however it would ap-pear that the participants in this study were reluctant to accept their new status in society.

Ineffective treatment of pain is a constant finding in the research19 and never being completely free of pain may have a significant influence on a person’s evaluation of their healthcare in general. This is perhaps enhanced in patients with chronic wounds due to a limited understanding of their condition9, an over-reliance on other people and a tendency to base current perceptions (particularly of the dressing change process) on previous negative experiences. Yet for some of the participants an unrealistic expecta-


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tion that pain should be tolerated was preferable to the perceived stigma of becoming reliant on pain relieving medication.

Fear of infection appeared to be a constant source of anxiety among all the participants regardless of cul-tural background and these feelings were reinforced by inadequate explanation of the cause of infection. There is little evidence of the impact of wound-related pain on factors such as hope and optimism but it could be as-sumed that constant episodes of unexplained infection and persistent pain would have a negative influence on a person’s emotional health or their ability to maintain an optimistic outlook. Participants in this study were known to have a history of pain, and consequently may not be truly representative of all patients with chronic wounds. However, research has indicated that substantial numbers of patients report pain as one of the worst aspects of their condition20,21.

The impact of pain on a person’s life is a multifaceted and individual experience and its overall effect should never be underestimated. Patients’ day to day lives are permanently dictated by their condition which presents a constant re-minder that they have a wound. Pain is ever-present and at times can be difficult to tolerate, leading to difficulties in carrying out daily tasks, a reduced feeling of well-being and social isolation. A conflict of interest can exist when the trajectory of patient management is focused on healing yet the patients’ aspirations are to feel pain-free so that they can take up everyday activities once more.

Implications for clinical practice• The impact of pain plays a huge part of the patients’

life.• Each individual patient’s needs should be recognised

and re-evaluated regularly.• Giving patient’s the opportunity to talk about their

pain experiences with others who understand can be extremely comforting.

Further Research• A questionnaire has been developed based on the

results from this study and this has been used in an international survey which aimed to collect data on patient’s wound-related pain experiences; from 15 countries world-wide.

Potential Conflict of Interest: This work is supported by an unrestricted educational grant from Mölnlycke Health Care.

Acknowledgements: The authors would like to thank the participants, nurses and staff at Hôpital Charles Foix, Ivry-sur-Seine, France, the Wound Healing Research Unit, Cardiff University, Wales, UK and Women’s College Hospital, Toronto, Ontario, Canada.

1. Franks PJ, Moffatt CJ, Connolly M, Bosanquet N, Oldroyd M, Greenhalgh RM, McCollum CN. (1994). Community Leg Ulcer Clinics: Effect on quality of life.

: 83-86

2. Price P. An holistic approach to wound pain in patients with chronic leg ulceration. (2005) (3): 55-57

3. Ebbeskog B, Ekman SL. Elderly persons’ experiences of living with venous leg ulcer: living in a dialectal relationship between freedom and imprisonment.

(2001) (3): 235-43.

4. Price P and Harding KG. Measuring Health Related Quality of Life in Patients with Chronic Leg Ulcers. (1996) (3): 91-94

5. Walshe C. Living with a venous leg ulcer: a descriptive study of patients’ experiences. (1995) (6): 1092-100.

6. Krasner D. The chronic wound pain experience: a conceptual model. (1995) (3): 20-35.

7. Pieper B and DiNardo E. Reasons for non-attendance for the treatment of Venous Ulcers in an inner-city clinic. (1998)

(4): 180-6.

8. Noonan L, Burge SM. Venous leg ulcer: is pain a problem? (1998) :14-19.

9. Charles H. ‘The impact of leg ulcers on patients’ quality of life’ (1995) (9) : 571-574

10. Hamer, C. Cullum N.A. Roe B.H. Patients’ perceptions of chronic venous leg ulcers. (1994) (2): 99-101.

11. Hareendran, A. Bradbury, A. Budd, J. Geroulakos, G. Hobbs, R. Kenkre, J. Simonds, T. Measuring the impact of venous leg ulcers on quality of life.

(2005) (2): 53-57.

12. Douglas V. Living with a chronic leg ulcer: an insight into patients’ experiences and feelings. (2001) (9): 355-360

13. Krasner D. Painful venous ulcers: themes and stories about living with the pain and suffering. e (1998) (3): 158-68.

14. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T. Health-related quality of life among patients with diabetes and foot ulcers: association with demographic and clinical characteristics. . (2007)

: 227-236.

15. Briggs M, Closs SJ. Patients’ perceptions of the impact of treatments and products on their pain experience of leg ulcer pain. (2006) 8):333-337.

16 Stemler S. An overview of content analysis. (17): 1-9.

17. Newell R. Body-image disturbances: cognitive behaviour formulation and interven-tion. (1991) : 1400-1405

18. Noles SW, Cash TF, Winstead BA. Body image, physical attractiveness and depres-sion. (1985) (1): 88- 94.

19. Persoon, A. Heinen, M.M. van der Vleuten, C.J.M. de Rooij, M.J. van de Kerkhof, P.C.M. van Achterberg, T. Leg ulcers: a review of their impact on daily life.

(2004) : 341-354.

20. Nemeth KA, Harrison MB, Graham ID, Burke S. Pain in pure and mixed aetiology venous leg ulcers: a three phase point prevalence study. (2003) (9): 336-340

21. Hofman D, Ryan T, Arnold F et al. Pain in venous leg ulcers. (1997) (5): 222-224


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Find out more during EWMA at the KCI Booth and at the KCI Symposium©2007 KCI Licensing, Inc. All Rights Reserved. All trademarks designated herein are property of KCI, its affiliates and licensors. Those KCI trademarks designated with the “®”, “TM” or “*” symbol are registeredin at least one country where this product/work is commercialized, but not necessarily in all such countries. Most KCI products referenced herein are subject to patents and pending patents.

PhD, HE Dip Wound healing, RGN, Dip Anatomy, Dip Physiology, Lecturer

Research CentreFaculty of Nursing and MidwiferyRoyal College of Surgeons in Ireland123 St Stephens GreenDublin 2, Ireland

[email protected]

Chronic wounds are characterised by duration, prolonged inflammation, increased risk of in-fection and are associated with either a local or systemic altered physiological state. Slough is an impediment to healing in these wounds as it pro-vides a stimulus for inflammation, the optimal culture medium for bacterial proliferation, im-pedes epithelial edge advancement, and impairs visualisation of the wound bed1,2. Additionally it increases exudate production and malodour3.

Many case studies and randomised control-led trials (RCTs) report the efficacy of honey in rapidly removing slough from a variety of wound aetiologies4-10. There is however, variability in the type of honey used and the method of outcome evaluation thus reducing the potential for com-bined evaluation of efficacy, except in the case of Manuka honey10. This limitation applies to other RCTs which have evaluated the efficacy of topical agents to deslough wounds11-13.

Slough is a form of necrotic tissue which is vis-ible on the surface of the wounds as moist, loose, stringy tissue, typically yellow and represents a complex mixture of fibrin, deoxyribonucleo-pro-tein, serous exudate, leucocytes and bacteria14.This tissue tends to accumulate continually in chronic wounds because such wounds generally result from underlying and uncorrected patho-genic abnormalities such as diabetes mellitus or venous insufficiency1. Slough is related to the in-flammatory phase of wound healing when dead cells accumulate in exudate but the body normally keeps pace with the it’s build up through a natu-ral process of autolysis. Autolytic debridement of slough is achieved by the body as it generates an endogenous system capable of natural removal of unwanted material15. During the normal wound healing process leukocytes enter the wounds with removal of devitalised tissue and foreign mate-rial15.

overview of current evidence

Persistent necrotic tissue in the wound provides a nidus for infection which in turn is associated with the release of bacterial exotoxins into the wound, consequently, inducing a continuous state of early inflammation and preventing the progression onto healing (Himel 1995). Some bacteria produce am-monia which, in itself, is necrotizing and can im-pair oxygenation of the tissues by raising the pH16.Alkalinity supports the activity levels of many pro-teases in wound fluid, consequently promoting degradation of the extracellular matrix (ECM) and key functional molecules such as growth factors of the wound17,18. An elevated alkaline environment, as recorded in chronic wounds is invariability cor-related with non-healing19-21.

Slough and necrotic tissue also cause hypoxia in the wound area which inhibits development of granulation tissue and slows re-epithelization (Konig et al. 2005). Furthermore, migration of lymphocytes and macrophages is hampered in the presence of slough or necrotic tissue12,22.

A prolonged inflammatory response and the lack of regulation of protease activity in chronic wounds results in degradation of the components of the extra cellular matrix by the same processes that normally have protective and restorative func-tions, leading to the eventual tissue breakdown, seen in chronic wounds23. This continual break-down of wound tissue is visible as slough in the wound bed.

It therefore follows that wound healing is delayed in its presence and while many topical treatment options are available for its removal, to date, systematic reviews have concluded that no one agent has demonstrated superior efficacy over another and there are no studies which compare debriding with no debriding24,25. In one systemat-ic review, however, of the management of diabetic there is evidence to suggest that hydrogel increases the healing of diabetic foot ulcers compared with gauze or standard wound care but it is not clear if


this effect is due to debridement26. Moreover, while there are no studies of debridement versus no debridement it is not clear what percentage of the wound should be covered in slough to significantly affect wound healing.

The advantages to wound healing when wounds are deb-rided are well documented1,2 and can be summarised into 4 key areas as in Table 1.

Extent Allows visualisation of full depth and extent of the wound

Consequence Reduces the possibility for infection, sepsis, or amputation. Decreases exudate and malodour.

Investigation Allows tissue samples or culture swabs to be tak-en from depth of wound. Facilitates visualisation of all structures exposed in the wound

Outcome Removes impediments to wound healing such as debris, slough, bacteria, and exudate.

Honey has been used in wound management for over 4500 years27. Its use declined in the early 1900s with the advent of antibiotics and a move towards ‘modern’ wound treatment options. A renewed interest in its use in wound management in the last two decades is evidenced by in-creasing numbers of in vitro and in vivo studies within the literature28. However, honey is not a generic entity. The variation in colour, taste, consistency, water content and acidity is due to both the plant species and the foraging bee together with the local climate and soil characteristics29. Invitro studies have investigated the variability in antimicro-bial properties, and have demonstrated clear differences in the efficacy of honey as an antibacterial agent with Manuka honey demonstrating efficacy against a wide range of or-ganisms including; Methicillin resistant staphylococcus aureus (MRSA) and vancomycin resistant enterococcus (VRE)30-32. Currently, no clinical studies are published in which direct comparison of different honeys used in wounds have been made.

There are many excellent texts which outline the options for wound debridement and it would not be prudent to revisit these here. The method used is dependent on the aetiology of the wound, the skills, expertise, knowledge, and resources of the clinician together with patient and clinician treatment goals. The principle mode of action of honey in wound debridement is through autolysis and thus will be explored here.

Autolytic debridement is dependent on the local wound environment, in particular the state of wound hydration; but also the wound temperature, pH and enzymatic co-

factors availability15. Autolytic is the most selective form of debridement, it requires minimal clinical training, is pain-less and although slow, it leaves a clearly demarcated line between the living and dead tissue15,33. It does however, require at least some level of exudate to be effective15. A limitation of this method is that older populations pro-duce decreased amounts of endogenous proteases, such as collagenase in their wound fluid1. Baherastani2 argues that this resultant decreased production and activity of endogenous collagenase may lead to insufficient debride-ment of necrotic tissue, decreased deposition of granula-tion tissue and matrix remodelling as well as decreased proliferation and migration of keratinocytes. A further limitation of this method is that it is not recommended for clinically infected wounds or in those with a high po-tential for anaerobic infection or if there is ischaemia of the limb or digits2,15,34.

Autolytic debridement occurs to some extent in all wounds, is a highly selective process whereby macrophages phagocytise bacteria and endogenous proteolytic enzymes such as collagenase, elastase, myeloperoxidase liquefy and spontaneously separate necrotic tissue and pseudoeschar from healthy tissue2. The wounds own fluid contains macrophages, and neutrophils that digest and solubilize necrotic tissue33.

Honey is a highly osmolar substance35,36. Colloidal honey has a low osmotic pressure and when applied to wounds, goes through a physiological change37. When in contact with wound tissue, the hygroscopic quality of the honey permits dilution by the tissue fluids, so that the colloidal sugar passes into molecular solution, the osmotic pressure increases and plasmolysis becomes more active37. The high osmolarity supports the outflow of fluid from deep wound tissue to the surface tissue aiding cleansing, debridement and reducing oedema and decreasing pain35,36. Moist dressings (such as honey) allow endogenous enzymes in the wound fluid to liquefy necrotic tissue selectively33.

Chirife et al. (1983) investigated this ‘outflow of fluid’ and concluded that the application of sugar promotes move-ment of water from an area of high concentration to an area of low concentration thus, contributing to wound cleansing. It is argued that this osmotic pressure could possibly dehydrate delicate new cells in the wound and thus delay healing27. Conversely, Chirife et al. [38] pro-posed that in living organisms, a flux of water from the inner regions replaces water as fast as it is transferred from the surrounding cells to the wound surface; consequently external tissue remains wet, and the healing process is not adversely affected. Cooper (2001) supports this theory, as


movement of fluid in response to this osmotic pull leads to improvement in the microcirculation and increased levels of dissolved oxygen and nutrients.

Of all the cells involved in the wound healing process, monocytes are one of the most important as they contrib-ute to the inflammatory phase and play a role in wound debridement. The effect of Manuka, pasture and artifi-cial honey on production of reactive oxygen intermediates (ROIs), and Tissue Necrosis Factor alpha (TNF ) release in human monocytic cells demonstrated a spontaneous release of TNF- from resting monocytic cells in vitro in the presence of Manuka and pasture honey; but not with artificial honey39. The authors of the latter study suggested that an unidentified component within these honeys may be responsible and that honey modulated the activation of monocytic cells in vitro without affecting viability and this modulation gives inhibitory and stimulatory effects39.This would suggest that Manuka honey is a stimulus for wound debridement as it supports the cells necessary for this action.

Autolytic debridement is pH sensitive and research has shown that the application of Manuka honey can signifi-cantly reduce surface pH of chronic non-healing wounds

over a two week period (p < 0.001)19. Whether this effect would contribute to preventing the build up of slough or facilitate its removal is not clear but a reduction in 0.1 pH unit was associated with an 8.1% reduction in wound size (p < 0.029)19.

The literature records many case studies of honey effective-ly removing slough from both acute and chronic wounds. A pilot study using Honeysoft® (Mediprof, The Nether-lands) reported on thirteen complex wounds of varying aetiologies which were effectively debrided with reduced exudate, malodour and improved epithelization over three weeks40. This rapid debridement was also achieved when a local honey (Nigerian) was used in the treatment of 43 cases of pyomyositis abscess in children41. Honey was ap-plied daily and the authors reported shorter duration of antibiotic use and hospital study when honey was used. Other single case studies report rapid debridement of between 2 days and three weeks in a variety of wound aetiologies when honey dressings were used7,9,42. As case studies do not prove a cause and effect relationship and as the types of honey varied between cases, a more robust approach to quantifying efficacy is required. One RCT (described below) addressed this issue10.

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One hundred and eight patients with venous ulcers in which 50% of the wound bed was covered in slough were randomly assigned to either Manuka honey dress-ing or Hydrogel therapy10. Wounds were dressed weekly for four weeks and compression therapy continued in all cases. The performance of both agents was highly clini-cally significant as the mean wound area covered in slough decreased to 29% in honey group vs 43% in hydrogel (p 0.065). While this was not an equivalence study it does quantify the desloughing efficacy of both agents when slough was the predominant tissue type. This study adds to our body of knowledge as it investigated a specific sub-set of venous ulcers i.e. having > 50% slough in wound bed and quantified the expected healing rates after 12 weeks. A further important finding in the latter study was that wounds in which >50% slough was removed by week 4 had a greater probability of healing at week 12 (CI 1.92, 9.7, RR 3.3, p 0.029). This supports the expert opinion that removal of slough promotes healing.

Direct comparison of desloughing efficacy of Manuka honey with other studies is limited as slough was not the predominant tissue type in other studies, the method of outcome evaluation was very subjective and the duration of the studies was very short11-13. Based on these studies, honey can be said to be slower than larvae but faster than some hydrogels, enzymatic agents, or hydrocolloids. Fu-ture studies investigating desloughing efficacy of topical agents should provide details of how outcomes were evalu-ated, monitor patients up to 12 weeks and have slough as the predominant tissue type. In so doing, efficacy and impact on healing can be determined.

Foul odour is associated with necrotic tissue and is usually caused by superficial bacterial colonisation. Malodour is distressing for patients and indeed may affect compliance with treatment regimes. Large case series and individual case studies have reported honey as very effective in reduc-ing malodour in chronic sloughy wounds40,43.

To maintain optimal effect of honey as a topical agent, it is recommended that honey should stay in contact with the wound. The ability of honey to maintain wound con-tact and deslough is influenced by the type of secondary dressing, type of honey dressing used, level of exudate and the frequency of dressing change28. NICE44 guide-lines recommend that choice of debriding agent should be based on impact on comfort, odour control and other aspects relevant to patient acceptability. Lewis25 further recommends that selection of debriding agents should be guided by good evidence and cost. Honey and in par-ticular Manuka honey meets many of these requirements although cost benefit analysis of its use as a debriding agent is lacking.

Honey can be considered as an effective desloughing agent, particularly in chronic wounds. The mode of action while not completely understood, incorporates; natural cleansing through the osmotic pressure it generates at the wound surface; reduction in surface pH thus reducing potential for protease activity; autolytic debridement through main-taining a moist environment; antimicrobial properties which reduces the potential for production of bacterial endotoxins.

1 Himel H. Wound Healing: focus on the chronic wound. Wounds. 1995;supp A(5):70A-7A.

2 Baharestani M. The clinical relevance of debride-ment. Heidelberg: Springer-Verlag 1999.

3 Dealey C. The care of wounds: a guide for nurses. 3rd ed: Blackwell Publishing 2005.

4 Efem SEE. Clinical observations on the wound heal-ing properties of honey. British Journal of Surgery. 1988;75:679-81.

5 Green AE. Wound healing properties of honey. British Journal of Surgery. 1988;75(12):1278.

6 Hejase MJ, Simonin JE, Bihrle R, Coogan CL. Genital Fournier’s gangrene: experience with 38 patients. Urology. 1996;47(5):734-9.

7 Dunford C, Cooper RA, Molan PC. Using honey as a dressing for infected skin lesions. Nursing Times. 2000;96(NTPLUS 14):7-9.

8 Natarajan S, Williamson D, Grey J, Harding KG, Cooper RA. Healing of an MRSA-colonised, hy-droxyurea-induced leg ulcer with honey. J Dermatol Treat. 2001;12:33-6.

9 Van der Weyden EA. The use of honey for the treat-ment of two patients with pressure ulcers. British Journal of Community Nursing. 2003;8(12):S14-20.

10 Gethin G, Cowman S. Manuka honey vs Hydrogel to deslough venous leg ulcers: A Randomised Control-led Trial. Paper presented at 17th EWMA Confer-ence: 2-4 May 2007: Glasgow, UK. EWMA Journal - Supplement, 2007, vol 7, May, p 28.

11 Colin D, Kurring PA, Quinlan D. Managing sloughy pressure sores. Journal of Wound Care. 1996;5(10):444-6.

12 Thomas S, Fear M. Comparing two dressings for wound debridement. Journal of Wound Care. 1993;2(5):272-4.

13 Wayman J, Nirojogi V, Walker A, Sowinski A, Walker M. The cost effectiveness of larval therapy in venous ulcers. Journal of Tissue Viability. 2000;10(3):91-4.

14 Thomas AM, Harding KG, Moore K. The structure and composition of chronic wound eschar. Journal of Wound Care. 1999;8(6):285-7.

15 Ayello E, Cuddigan J. Debridment: controlling the necrotic/cellular burden. Advances in skin and wound care. 2004;17(2):66-75.

16 Leveen H, Falk G, Borek B, Diaz C, Lynfield Y, Wynkoop B, et al. Chemical acidification of wounds An adjuvant to healing and the unfavourable action of alkalinity and ammonia. Annals Surgery. 1973 December;178(6):745-50.

17 Greener B, Hughes A, Bannister N, Douglass J. Pro-teases and pH in chronic wounds. Journal of Wound Care. 2005;14(2):59-61.

18 Trengove N, Stacy M, Maculey S, Bennett N, Gibson J, Burslem F, et al. Analysis of the acute and chronic wound environments: the role of proteases and their inhibitors. Wound Repair and Regeneration. 1999 November-December;7:442-52.

19 Gethin G, Cowman S. Change in pH of chronic wounds when a honey dressing is used. International Wound Journal. 2007;in press.

20 Tsukada K, Tokunaga K, Iwama T, Mishima Y. The pH changes of pressure ulcers related to the healing process of wounds. Wounds: a compendium of clini-cal research and practice. 1992;4(1):16-20.

21 Romanelli M, Schipani E, Piaggesi A, Barachini P. Evaluation of surface pH on venous leg ulcers under Allevyn dressings. London: The Royal Society of Medicine Press 1997.

22 Morrison M, Moffatt C. A Colour Guide to the As-sessment and Management of Leg Ulcers. 2nd ed. London: Mosby 1994.

23 Schultz G, Mozingo D, Romanelli M, Claxton K. Wound healing and TIME: new concepts and scien-tific applications. Wound Repair and Regeneration. 2005;13(4):S1-S11.

24 Bradley M, Cullum N, Sheldon T. The debridement of chronic wounds: A systematic review. Health Technology Assessment. 1999 September 1999;3(17 Pt 1).

25 Lewis R, Whiting P, ter Riet G, O’Meara S, Glanville J. A rapid and systematic review of the clinical effec-tiveness and cost-effectiveness of debriding agents in treating surgical wounds healing by secondary inten-tion. Health Technology Assessment. 2001;5(14).

26 Smith J. Debridement of diabetic foot ulcers. The Cochrane database of systematic reviews 2002:Art. No. CD003556. DOI: 10.1002/14651858.

27 Forrest R. Early history of wound treatment1. Journal of Royal Society of medicine. 1982 March;75:198-205.


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Drinaghan, Knocknarea, Sligo, Ireland

To: President, European Wound Management AssociationRe: Research Grant

Date: 22/04/2007Dear Prof Vowden,

In 2003 I was the proud recipient of a research grant from EWMA at the conference in Pisa, Italy. This grant of 10,000 was made towards my research on the use of Manuka honey in venous ulceration.

As a consequence of this grant I was able to continue with my studies which up to that point has been completed without funding. Following this, I applied to the Health Research Board of Ireland for a clinical research fellowship in nursing and midwifery and was granted this in 2004. The international review process for this application recognised the grant aid that was already received. The research board recommended that my studies continue to PhD which they would fund accordingly.

After almost 5 years of study the RCT which compared Manuka honey to a standard agent to deslough venous ulcers will be presented for the first time at the EWMA conference in Glasgow. Throughout the course of my studies I have completed other research on wound measuring, wound pH and wound assessment, and again I have presented these through EWMA conference and journal.

In each publication and in each presentation I have been proud to acknowledge the grant aid from EWMA and wish to thank you for the contribution this organisation has made to my studies and career. On my return to Ireland from Glasgow I look forward to finalising and submitting my PhD thesis.

Thanking you again

28 Molan P. The evidence supporting the use of honey as a wound dressing. Lower Extremity Wounds. 2006;5(1):40-54.

29 White JW, Doner LW. Honey composition and prop-erties. Beekeeping in the United States agricultural handbook number 335. 1980 October.

30 Cooper R, Molan P, Harding KG. Antibacterial activ-ity of honey against strains of Staphylococcus aureus from infected wounds. Journal of Royal Society of Medicine. 1999;92:283-5.

31 Cooper R, Molan P, Harding KG. The sensitivity of honey to Gram-positive cocci of clinical significance isolated from wounds. Journal of Applied Microbiol-ogy. 2002;93(5):857-63.

32 French V, Cooper R, Molan P. The antibacterial activity of honey against coagulase-negative sta-phylococci. Journal of Antimicrobial Chemotherapy. 2005;56:228-31.

33 Sieggreen M, Malkebust J. Debridement: choices and challenges. Advances in wound care. 1997;10(2):32-7.

34 Davies P. Current thinking on the management of necrotic and sloughy wounds. Professional Nurse. 2004;19(10):34-6.

35 Thomas S. Functions of a wound dressing in: Wound Management and Dressings. London: The Pharma-ceutical Press. 1990.

36 Cooper RA. How does honey heal wounds? In: Munn P, Jones R, eds. Honey and Healing. United King-dom: International Bee Research Association. 2001.

37 Seymore F, West F. Honey - its role in medicine. Medical Times. 1951;79(2):104-7.

38 Chirife J, Herszage L, Joseph A, Kohn E. In vitro study of bacterial growth inhibition in concentrated sugar solutions; Microbiological basis for the use of sugar in treating infected wounds. Antimicrobial Agents and Chemotherpy. 1983;23(5):766-73.

39 Tonks A, Cooper RA, Price AJ, Molan PC, Jones KP. Stimulation of TNF-alpha release in monocytes by honey. Cytokine. 2001;14(4):240-2.

40 Ahmed A, Hoekstra M, Hage J, Karim R. Honey-medicated dressing: transformation of an ancient remedy into modern therapy. Annals of Plastic Surgery. 2003;50(2):143-8.

41 Okeniyi J, Olubanjo O, Ogunlesi T, Oyelami O. Com-parison of healing in incised abscess wounds with honey and EUSOL dressing. The Journal of Alterna-tive and Complementary medicine. 2005;11(3):511-3.

42 Gray D. Mesitran Ointment Case Studies. Wounds Uk Honey Supplement. 2005;1(3):32-5.

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

44 NICE. Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgi-cal wounds. National Institute for Clinical Excellence, Technology Appraisal Guidance -No 24. 2001(24).


, MSc

Review Group Co-ordinator Cochrane Wounds Group

Department of Health Sciences

Area 2 Seebohm Rowntree Building

University of York York,

United Kingdom

[email protected]

ABSTRACTS OF RECENT COCHRANE REVIEWSPublication in The Cochrane Library Issue 2, 2008:

[Review]

To be published in Issue 2, 2008 Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Tetanus is a severe infection that can be prevented by vaccination. In developing countries vaccination coverage is not always high and in devel-oped countries cases may still occur, particularly in elderly people owing to their reduced immunoprotec-tion. It has been estimated that there are about one million cases of tetanus per year globally. In animal studies, vitamin C protected against various infections. In a study with rats, vitamin C protected against tetanus toxin.

To assess the prophylactic and therapeutic effect of vitamin C in tetanus.

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, issue 4), MEDLINE (1950 to January 2008), EMBASE (1980 to 2008 Week 03), the Cochrane Wounds Group Specialised Register (January 2008), the Cochrane Infectious Diseases Group Specialised Register (June 2007), and the reference lists of relevant reviews and monographs.

We included controlled trials of vitamin C as a prevention or treatment for tetanus, whether or not placebo controlled, in any language, published or unpublished. Two authors independently made inclusion decisions.

Both review authors independently extracted data from trial reports.

One single trial was eligible for inclusion. This non randomised, controlled, unblinded treatment trial involved 117 tetanus patients and was undertaken in Bangladesh. Vitamin C at a dosage of 1 g/day was administered intravenously alongside conventional treatment. At recruitment, the participants were strati-fied into two age groups and the results were reported by age. In the children aged 1 to 12 years (n = 62), vitamin C treatment was associated with a 100% reduction in tetanus mortality (95% confidence interval from -100% to -94%). In people aged 13 to 30 years

(n = 55), vitamin C treatment was associated with a 45% reduction in tetanus mortality (95% confidence interval from -69% to -5%).

A single, non randomised, poorly reported trial of vitamin C as a treatment for tetanus suggests a considerable reduction in mortality. However, concerns about trial quality mean that this result must be interpreted with caution and vitamin C cannot be recommended as a treatment for tetanus on the basis of this evidence. New trials should be carried out to examine the effect of vitamin C on tetanus treat-ment.

Tetanus is a disease caused by tetanus toxin, which is produced by the bacterium Clostridium tetani. This bacterium typically infects penetrating wounds contaminated by foreign material such as soil. In developing countries, poor hygiene after childbirth may cause tetanus in newborn babies. Even though vaccination has dramatically decreased the burden of tetanus, there are still about one million cases per year globally. We found one controlled trial that examined whether 1 gram per day of intravenous vitamin C would help in the treatment of tetanus patients. Vitamin C was used alongside standard treat-ments for tetanus. Intravenous vitamin C reduced mortality of children aged between 1 and 12 with tetanus by 100% and mortality of 13 to 30 year old patients by 45%. The trial was not properly conducted and therefore great caution is required in the interpre-tation of the findings. Vitamin C cannot be recom-mended as a treatment for tetanus on the basis of this single study. Further investigation of the role of vitamin C in tetanus treatment is warranted.

[Updated Review]


Intermittent pneumatic compression (IPC) is a mechanical method of delivering compres-sion to swollen limbs that can be used to treat venous leg ulcers and limb swelling due to lymphoedema. This review analyses the evidence for the effectiveness of IPC as a treatment for venous leg ulcers.


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healing by effectively cleansing, filling, absorbing, and moistening wounds

throughout the healing continuum. Finally, a dressing that lives up to its name.

Visit booth Q1 at EWMA and booth 1313 at WUWHS to receive a complimentary

case study along with a set of PolyMem samples.

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To determine whether IPC increases the healing of venous leg ulcers. To determine the effects of IPC on health related quality of life of venous leg ulcer patients.

We searched the Cochrane Wounds Group Specialised Register (December 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4, 2007; Ovid MEDLINE - 2006 to November Week 2 2007; Ovid EMBASE - 2006 to 2007 Week 49 and Ovid CINAHL - 2006 to December Week 1 2007.

Randomised controlled studies either comparing IPC with control (sham IPC or no IPC) or compari-sons between IPC treatment regimens, in venous ulcer manage-ment were included.

Data extraction and assessment of study quality were undertaken by one author and checked by a second.

Seven randomised controlled trials (including 367 people in total) were identified. Only one trial reported both allocation concealment and blinded outcome assessment. In one trial (80 people) more ulcers healed with IPC than with dressings (62% vs 28%; p=0.002). Four trials compared IPC with compression against compression alone. The first of these trials (45 people) found increased ulcer healing with IPC plus compression than with compression alone (relative risk for healing 11.4, 95% Confidence Interval 1.6 to 82). The remaining three trials (122 people) found no evidence of a benefit for IPC plus compression compared with compression alone. One small trial (16 people) found no difference between IPC (without additional compression) and compression band-ages alone. One trial compared different ways of delivering IPC (104 people) and found that rapid IPC healed more ulcers than slow IPC (86% vs 61%; log rank p=0.003).

IPC may increase healing compared with no compression, but it is not clear whether it increases healing when added to treatment with bandages, or if it can be used instead of compression bandages. Rapid IPC was better than slow IPC in one trial. Further trials are required to determine whether IPC increases the healing of venous leg ulcers when used in modern practice where compression therapy is widely used.

Venous leg ulcers (open sores) can be caused by a blockage or breakdown in the veins of the leg. Compression, using bandages or hosiery (stockings), can help heal ulcers. However, they do not always work, and some people are not willing or able to wear them. Intermittent pneumatic compression (IPC) uses an air pump to inflate and deflate an airtight bag wrapped around the leg. This technique is also used to stop blood clots developing during surgery. However, the review of trials found conflicting evidence about whether or not IPC is better than compression bandages and hosiery. Intermit-tent pneumatic compression (IPC) is better for healing leg ulcers than no compression but it is uncertain if it improves healing when bandages or hosiery are already used.

[Updated Review]


Chronic wounds mainly affect the elderly and those with multiple health problems. Despite the use of modern dressings, some of these wounds take a long time to heal, fail to heal, or recur, causing significant pain and discomfort to the person and cost to health services. Topical negative pressure (TNP) is used to promote healing of surgical wounds by using suction to drain excess fluid from wounds.

To assess the effects of TNP on chronic wound healing.

For this second update of this review we searched the Cochrane Wounds Group Specialised Register (December 2007), The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 4, 2007, Ovid MEDLINE - 1950 to November Week 2 2007, Ovid EMBASE - 1982 to 2007 Week 50 and Ovid CINAHL - 1980 to December Week 1 2007. In addition, we contacted authors, companies, manufacturers, and distributors to identify relevant trials and information.

All randomised controlled trials which evaluated the effects of TNP on people with chronic wounds.

Selection of the trials, quality assess-ment, data abstraction, and data synthesis were done by two authors independently. Disagreements were solved by discussion.

Two trials were included in the original review. A further five trials were included in this second update resulting in a total of seven trials involving 205 participants.The seven trials compared TNP with five different comparator treatments. Four trials compared TNP with gauze soaked in either 0.9% saline or Ringer’s solution. The other three trials compared TNP with hydrocolloid gel plus gauze, a treatment package comprising papain-urea topical treatment, and cadexomer iodine or hydrocolloid, hydrogels, alginate and foam. These data do not show that TNP significantly increases the healing rate of chronic wounds compared with comparators. Data on secondary outcomes such as infection rate, quality of life, oedema, hospitalisation and bacterial load were not reported.

Trials comparing TNP with alternative treat-ments for chronic wounds have methodological flaws and data do demonstrate a beneficial effect of TNP on wound healing however more, better quality research is needed.

Topical negative pressure (TNP) therapy is the application of negative pressure across a wound to aid wound healing. The pressure is thought to aid the drainage of excess fluid, reduce infection rates and increase localised blood flow. TNP is also known as vacuum assisted closure (VAC) and sealed surface wound suction. Seven trials compared TNP with either moistened gauze dressings or other topical agents and found no difference in effects. One very small, poor quality trial (7 wounds) showed a reduction in wound volume and depth in favour of TNP. There is no valid or reliable evidence that topical negative pressure increases chronic wound healing.


Wound Dressings

Dr. Gary Sibbald, president-elect of the World Union of Wound Healing Societies (WUWHS) and chair of the third meeting, discusses the innovative structure of the meeting with the International Wound Journal.

Q: What is unique and innovative about the third congress of the WUWHS? GS: The organising principle of the Toronto 2008 meeting is the evaluation of the evidence base in wound care, which will be considered in the context of effi-cacy, efficiency and effectiveness to form a framework for best clinical practice. The synthesis of these three major pillars of evidence-informed practice will pro-vide clinicians with a new and comprehensive way of reviewing their practice and ensuring their care is pa-tient focused

Q: How does the scientific program support this innovative design? GS: The scientific program is divided into streams that provide an in-depth review of a range of clinical

The third meeting of the World Union of Wound Healing So-cieties is truly a partnership be-

tween wound care associations (includ-ing EWMA), wound care publishers and also industry.

As individuals we all participate, in one way or another, in the creation and dissemination of knowledge in the field of wound care. All share the common problem of treating wounds and together provide a unified voice to ensure the de-velopment of wound care as a clinical specialty. That is “One Problem – One Voice”.

Congress 2008 provides a forum for the dis-semination of evidence informed practice on a global basis. The primary goal of Congress 2008 is to present the wound care evidence base and transfer the knowledge, skills, and attitudes for improved patient outcomes.

Treating acute and chronic wounds is an ongoing challenge for health care profes-sionals in all corners of the world. Social, economic, and technological differences, however, can create a vast divide in global approaches to wound care.

Congress 2008 embraces the multicultural, multidisciplinary nature of its audience and pro-vides an opportunity not only to network but also to work together for the benefit of all wound heal-ers on a global basis. This will be accomplished through a preconference day, three plenary ses-sions, and 10 concurrent streams each with 100 educational sessions.

A web-based initiative, established prior to this Congress, facilitating a review and appraisal of the wound care evidence, resulted in concise evidence statements and this evidence has been

problems. The keynote addresses will echo the impor-tance of evidence and patient care. An expert panel will discuss the clinical significance of evidence-based medicine; Stephen Lewis will examine healthcare sys-tems, advocacy and AIDS in Africa; and Marla Sha-piro, MD, will focus on life/work balance and her own experiences. The closing plenary session will present highlights from each stream, and provide participants with a congress overview.

Toronto 2008 also takes a pioneering approach to evidence, choosing to evaluate evidence quality accord-ing to the type of information, from guidelines to pre-clinical data. This methodology allows a broader range of knowledge to be considered in developing a clinical strategy, and it is being used in the development of a comprehensive set of evidence-based summaries on all major topics in wound care. These summaries provide clinicians with rapid access to up-to-date practical in-formation in a quick and easy Web-based format.


•

18th Conference of the European Wound Management Association

Organised by the European Wound Management Association in cooperation with the Portuguese Wound Management Associations APTFeridas and GAIF

proliferated throughout the meeting in a logical, easy-to-follow agenda.

This is not a one-time effort! Through a continued part-nership with our Platinum Sponsors this will be an ongo-ing initiative for the World Union. Under the stewardship of Professor R. Gary Sibbald, during his tenure as Presi-dent, the initiative will be a legacy of the WUWHS. This is not the end, merely the beginning!

As a global community of wound care specialists, we need to share our insights, data, and awareness of common wound care concerns and solutions. When we do this, we can build new initiatives to advance wound care practices and to improve patient outcomes globally. The following is the perspective of the Chair of the Congress.

Q: To which healthcare professionals will this congress be of interest? GS: Toronto 2008 is being hosted by the University of Toronto, with the active participation of the follow-ing co hosting groups: the Canadian Association of Wound Care, Canadian Association of Enterostomal Therapists, Registered Nurses Association of Ontario, National Pressure Ulcer Advisory Panel, and American Professional Wound Care Association. The scientific program will be relevant to all clinicians irrespective of professional background , researchers, and teachers working in the field of wound healing and tissue repair caring for patients with wounds of all aetiologies.

Q: What’s next for the WUWHS?GS: Toronto 2008 is a key step in building the WU-WHS as an international association. After the con-gress, we will focus on disseminating the educational toolkits developed at the meeting and sharing expertise between associations.


Journal Previous Issues

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


Corporate A

Holtedam 1-3 DK-3050 HumlebækDenmarkTel: +45 49 11 15 88 Fax: +45 49 11 15 80www.coloplast.com

Harrington HouseMilton RoadIckenham, UxbridgeUB10 8PUUnited KingdomTel: +44 (0) 1895 62 8300Fax: +44 (0) 1895 62 8362www.convatec.com

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

GargraveNorth YorkshireBD23 3RXUnited KingdomTel: +44 1756 747200Fax: +44 1756 747590 www.jnjgateway.com

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

1 Lancaster ParkNewborough RoadNeedwoodBurton on TrentStaffordshireDE13 9PDTel: +44 (0) 8450 606 707 Fax: +44 (0) 1283 576808www.activahealthcare.co.uk

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

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.com

Parktoren, 6th floorvan Heuven Goedhartlaan 111181 LE AmstelveenThe Netherlands.Tel: +31 (0) 20 426 0000Fax: +31 (0)20 426 0097www.kci-medical.com

P.O. BOX 23 43 NeuwiedD-56513GermanyTel: +49 (0) 2634 99-6205Fax: +49 (0) 2634 99-1205www.lohmann-rauscher.com

Box 13080402 52 Göteborg, SwedenTel: +46 31 722 30 00Fax: +46 31 722 34 08www.molnlycke.com

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

Corporate Sponsor Contact DataCorporate B


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

Kreuzlingerstrasse 5CH-8574 LengwilSwitzerlandTel: +41 71 6868 900Fax: +41 71 6868 901www.sanuwave.com

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

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

42 rue de Longvic B.P. 15721300 Chenôve FranceTel: (+33) 3 80 44 70 00 Fax: (+33) 3 80 44 71 30www.urgo.com

For further details contact MEP Ltd, 53 Hargrave Road, London N19 5SH. www.mepltd.co.uk

orEWMA Business Office, Congress Consultants, Martensens Allé 8, 1828 Frederiksberg, Denmark

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

a holistic approachEditor: Christine Moffatt

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

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


Conference CalendarConference Theme 2008

7th National Australian Wound Management Association Conference

Dreams, Diversity, Disasters May 7-10 Darwin Australia

SAfW 5th Congress (National) May 8 Morges Switzerland

18th Conference of the European Wound Management Association (EWMA 2008)

Wound Healing – Wound Management– Responsibility and Actions

May 14-16 Lisbon Portugal

9th Congress of the European Society for Pediatric Dermatology

May 15-17 Athens Greece

5th EADV Spring Symposium Dermatology Bridging the Continents May 22-25 Istanbul Turkey

WUWHS - 3rd Congress Wound Care Efficacy, Effectiveness & Efficiency

Jun 4-8 Toronto Canada

Deutsche Gesellschaft für Wundheilung und Wundbehandlung

Jun 13-14 Koblenz Germany

17th World Council of Enterostomal Therapists meeting

Stoma care, Wound Management & Incontinence

Jun 15-19 Ljubljana Slovenia

6th World Congress of the IACD Jun 18-20 Lisbon Portugal

Oxford – European Wound Healing Summer School Different aspects of patient wound management based on therapy innovation and clinical research

Jun 18-21 Oxford UK

Wound Management Association of Kosova Training workshop with new Kosova assoca-tion

Jun 23-25 Kosova

ETRS 18th Annual Meeting Joint Meeting with the Tissue Viability Unit of Malta

Sep 10-12 Malta

7th Scientific Meeting of the Diabetic Foot Study Group (DFSG) of the EASD

Sep 11-13 Lucca Italy

17th EADV Congress Sep 17-21 Paris France

VII Congresso Nazionale AIUC La terapia dell’ulcera cutanea: “Un ponte tra tradizione e innovazione”

Sep 24-27 Rome Italy

11th Conference of SEBINKO The Development of Clinical Validy and Best Practices Requirements

Oct 16-17 Tatabánya Hungary

2nd World Congress of TeleDermatology Healty Present and Healthier Future Oct 16-18 Chinnai India

Wounds UK Nov Harrogate UK

5° Congresso Nazionale AISLeC EBN e Wound Care: Nuove Frontiere Nov 13-15 Napoli Italy

WMAT 3rd National Congress Nov 27-29 Cesme, Izmir Turkey

2009

6th EADV Spring Symposium Apr 23-26 Bucharest Romania

19th Conference of the European Wound Manage-ment Association

Healing, Education, Learning and Preventing in Wound Care

May 20-22 Helsinki Finland

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

Sep Bled Slovenia

18th EADV Congress Oct 7-11 Berlin Germany

MembershipBecome a member of the

and you will receive EWMA position documents annually and EWMA Journal three times a year.In addition, you will have the benefit of obtaining the membership

discount, which is normally 15%, when registering for the EWMA Conferences.A membership only costs 25 EUR a year.


The Hungarian Association was established in 1996 to improve the care of incontinent patients and people with chronic or non-healing wounds. It is a nationwide, volun-tary organisation. In the beginning, its members were mainly nurses, but today it has doctors and whole institutions amongst its members: 180 private and 16 whole staff insti-tutions.

Our mission statement is as follows: The aim of the SEBINKO Association is to develop a wide scope nationwide cooperation and consensus in the fields of chronic wound prevention and treatment and the improve-ment of the treatment of incontinence. This we support by developing, teaching and training scientific methods. We are striving to reach our goals through continuous information flow, the SEBINKO magazine, conferences, correspond-ence, training programmes, and tenders, together with wide-scale cooperation and professional help. We support the development of planned wound treatment and incontinence treatment programmes developed by institutes and responsible, reliable nursing care in the fields of wound treatment and healing. We put special emphasis on the topic of unified docu-mentation and data processing and the training of institutional coordinators for decu-bitus and incontinence.

Our association is consciously supporting the following values of professional help and care in wound management: -reservation or rees-tablishment of the self-care of patients, -secu-rity -pain minimisation -infection-free treatment -cost effectiveness in wound treatment.

We have developed strong working relation-ships with the instigators and practitioners of the nationwide consensus. Amongst them one can find professional politicians, members ofParliament, members of medical and nursing colleges, leaders of professional and civil organisations, health industry professionals, universities and practitioners and practicing teams.

The focus of our consensus is the pressure ulcer: the prevention and treatment of decu-bitus.

At our 10th Anniversary Conference in 2006 we set out our aims for the following 3 years for our members and association: The development of clinical validity and best practice requirements. To achieve this the most important areas of focus will be the development of everyday practices, continuous evaluation, renewal of the nursing research methods, development of training and evidence research.

As a result of our cooperation in EWMA we are hoping to develop methods and share information to improve the healing of our patients and the motivation of the members of our association.

SEBINKOHungarian

Association for the Improvement of Care

of Chronic Wounds and Incontinentia

Contact: Dr. Maria Hok [email protected]

[email protected]

www.sebinko.hu

EWMA200920-22 MayHelsinki · Finland

Organised by the European Wound Management Association in cooperation with the Finnish Wound Care Society FWCS

The was established in December 2006 in Belgrade as an effort for the organized and coordinated approach to the area of wound management. The Society promotes multidisciplinary involve-ment and cooperation among medical care providers dedicated to wound management.

We are proud to be a EWMA cooperating organization since 2007.

SWHS is the first institution in Serbia that spreads modern attitudes in the area of wound healing. Through the activities of the chronic wound treatment school and workshops we educate doctors and nurse how to treat patients with wounds.

250 doctors and nurses attended our educa-tion modules so far. But, our credo is quality in front of quantity. We limit groups to 30 to 40 participants, so lectures are interactive and workshops are real hands on.

In 2007, Society published first issue, volume 1 and 2 of the journal “Rane” (Wounds). The

7th Scientific Meeting of the

Diabetic Foot Study Groupof the EASD

11-13 September 2008

Lucca, Italy

www.dfsg.org

Advancementof knowledgeon all aspects ofdiabetic foot care

Main subjects during conference:Epidemiology

Basic and clinical science

Diagnostics

Classification

Foot clinics

Biomechanics, Osteoarthropathy

Orthopaedic surgery

Infection

Revascularisation

Uraemia

Wound healing/outcome

Conference theme

intention is to create a place for experience and knowledge exchange. Authors from neighboring countries are welcomed to submit papers.

We started with a new activity in 2008 – TELEULCER. Teleulcer offers doctors and nurses a possibility to present selected cases of wounds and to get advices about the initial treatment and treatment plan from experts. Teleulcers is available on the Society web site – www.lecenjerana.com.

Our enthusiasm and high level of profession-alism, initiated intensive presence of wound care companies in Serbia. Some new appeared and those already present increased there activities.

In the future we plan to continue with the intensive activities. We are looking forward to establish cooperation with the regional wound healing associations. Naturally, reaching high EWMA standards of organized and coordinated approach to the area of Wound Management is our priority.

SWHSSerbian Wound Healing Society

www.lecenjerana.com


COPA FOAM DRESSINGS OUTPERFORMTHE LEADING COMPETITION IN FLUIDCAPACITY9

8

7

6

5

4

3

2

1

0COPA Alleryn Polymem

8

4.8

2.7

Absorptive capacity (cc/in2)higher figure is more absorbent

COPA FOAM DRESSINGS PROVIDEMAXIMUM PATIENT COMFORT

15

30

45

60

75

90

105

120

135

150COPA Alleryn Polymem

7.820.7

120.5

Softness (N/cm) lower figure is softer0

AFIScep.beWound Management Association in Belgium

AISLeCItalian Nurse Association for the Study of Cutaneous Woundswww.aislec.it

AIUCItalian Association for Cutaneous Ulcerswww.aiuc.it

APTFeridasPortuguese Wound Management Associationwww.aptferidas.com

AWAAustrian Wound Associationwww.a-w-a.at

BFWBelgian Federation of Woundcarewww.befewo.org

CNCClinical Nursing Consulting – Wondzorgwww.wondzorg.be

CSLRCzech Wound Management Societywww.cslr.cz

CWACroatian Wound ManagementAssociationwww.kbd.hr/index.php?id=799

DGfWDeutsche Gesellschaft für Wundheilungwww.dgfw.de

Danish WoundHealing Society

DWHSDanish Wound Healing Societywww.dsfs.org

FWCSFinnish Wound Care Societywww.suomenhaavanhoitoyhdistys.fi

GAIFGrupo Associativo de Investigacãoem Feridaswww.gaif.net

Cooperating Organisations

GNEAUPPGrupo Nacional para el Estudio y Asesoramiente en Ulceras por Presión y Heridas Crónicaswww.gneaupp.org

GWMAGreek Wound Management Association

ICWInitiative Chronische Wundenwww.ic-wunden.de

LBAALatvian Wound Treating Organisation

LUFThe Leg Ulcer Forumwww.legulcerforum.org

LWMALithuanian Wound Management Association

MSKTHungarian Lymphoedema and Wound Managing Societywww.euuzlet.hu/mskt/

NATVNSNational Association of Viability Nurse Specialists (Scotland)www.natvns.com

NIFSNorwegian Wound Healing Associationwww.nifs-saar.no

NOVWDutch Organisation of Wound Care Nurseswww.novw.org

PWMAPolish Wound Management Associationwww.ptlr.pl

ROWMARomanian Wound ManagementAssociationwww.artmp.ro

SAfWSwiss Association for Wound Carewww.safw.chwww.safw-romande.ch


SEBINKOHungarian Association for the Improve-ment of Care of Chronic Wounds and Incontinentiawww.sebinko.hu

SFFPCLa Société Française et Francophone de Plaies et Cicatrisationswww.sffpc.org

SSiSSwedish Wound Care Nurses Associationwww.sarsjukskoterskor.se

SSOORSlovak Wound Management Association

SUMSIceland Wound Healing Societywww.sums-is.org

SWHSSerbian Wound Healing Societywww.lecenjerana.com

SWHSSwedish Wound Healing Societywww.sarlakning.se

SAWMASerbian Advanced Wound Management Association

TVNATissue Viability Nurses Associationwww.tvna.org

TVSTissue Viability Societywww.tvs.org.uk

WMAIWound Management Association of Irelandwww.wmaoi.org

WMAKWound Management Association of Kosova

WMASSlovenian Wound ManagementAssociation

WMATWound Management AssociationTurkeywww.yaradernegi.org

[email protected]

Associated Organisations

Leg ClubLindsay Leg Club Foundationwww.legclub.org

LFLymphoedema Frameworkwww.lymphoedemaframework.org

LSNThe Lymphoedema Support Networkwww.lymphoedema.org/lsn


ZbZci - EWMA · Vanscheidt W, Münter K-C, Klövekorn W,Vin F, Gauthier J-P, Ukat A.A prospective...

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