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EWMA Council
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ISSN number: 1609-2759
Volume 8, No 2, May, 2008
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www.ewma.org
I]Z?djgcVad[i]Z:jgdeZVc
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Published three times a year
Marco Romanelli
President
:Y^idg^Va7dVgY
Carol Dealey, :Y^idg
Deborah Hofman, :Y^idg
:aZXigdc^XHjeeaZbZci
Peter Franks
Immediate Past President
Sue Bale
Michelle Briggs
Finn Gottrup
E. Andrea Nelson
Marco Romanelli
Zbigniew Rybak
Peter Vowden
Finn Gottrup
Recorder
Luc Gryson
Treasurer
Zena Moore
Secretary
Carol Dealey
Marcus Gürgen
:LB6lZWh^iZ
www.ewma.org
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please contact:
:LB6 Business Ofﬁce
Congress Consultants
Martensens Allé 8
1828 Frederiksberg C, Denmark.
Tel: (+45) 7020 0305
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AVndji/
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Sue Bale
Judit Daróczy
Deborah Hofman
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Position Document Editor
E. Andrea Nelson
Patricia Price
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Kailow Graphic A/S, Denmark
Copies printed: 13,000
Eg^XZh/
Distributed free of charge to members of
the European Wound Management
Association and members
of co-operating associations.
Individual subscription per issue: 7.50`
Libraries and institutions per issue: 25`
I]ZcZmi^hhjZ will be published
October 2008.
Prospective material for publication
must be with the editors
as soon as possible and
no later than 1 August 2008
The contents of articles and letters in
:LB6 Journal do not necessarily
reﬂect the opinions of the Editors
or the European Wound
Management Association.
Copyright of all published material
and illustrations is the property of
the European Wound Management
Association. However, provided prior
written consent for their reproduction
obtained from both the Author and
:LB6 via the Editorial Board of the
Journal, and proper acknowledgement
and printed, such permission will
normally be readily granted.
Requests to reproduce material
should state where material is to
be published, and, if it is abstracted,
summarised, or abbreviated, then
the proposed new text should be sent
to the :LB6Journal Editor
for ﬁnal approval.
Zbigniew Rybak
Salla Seppänen
José Verdú Soriano
8D"DE:G6I>C<DG<6C>H6I>DCH¼7D6G9
Rita Videira
Peter Vowden
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
Carolyn Wyndham-White, Switzerland
Skender Zatriqi, Kosova
Rokas Bagdonas, Lithuania
Pauline Beldon, UK
Andrea Bellingeri, Italy
Saša Borović, Serbia
Rosine van den Bulck, Belgium
Mike Clark, UK
Mark Collier, UK
Rodica Crutescu, Romania
Valentina Dini, Italy
Bülent Erdogăn, 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 Jawień, Poland
Els Jonckheere, Belgium
Aníbal Justiniano, Portugal
Martin Koschnik, Germany
Jozefa Koskova, Slovak Republic
Nastja Kucišec-Tepeš, Croatia
Aleksandra Kuspelo, Latvia
:Y^idg^Va7dVgYBZbWZgh
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
Peter Vowden, UK
:LB6?djgcVaHX^Zci^ÄXGZk^ZlEVcZa
Paulo Jorge Pereira Alves, Portugal
Zena Moore, Ireland
Caroline Amery, UK
Karl-Christian Münter, Germany
Mark Collier, UK
Pedro L. Pancorbo-Hidalgo, Spain
Bulent Erdogan, Turkey
Patricia Price, UK
Madeleine Flanagan, UK
Rytis Rimdeika, Lithuania
Milada Franců, Czech Republic
Salla Seppänen, Finland
Peter Franks, UK
José Verdú Soriano, Spain
Luc Gryson, Belgium
Rita Gaspar Videira, Portugal
Gabriela Hösl, Austria
Carolyn Wyndham-White, Switzerland
Zoltán Kökény, Hungary
Gerald Zöch, Austria
For contact information, see lll#ZlbV#dg\
'
:LB6
Journal 2008 vol 8 no 2
Dear Reader
W
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elcome to the second issue of the EWMA Journal for 2008. This is
also our conference issue, timed to coincide with the 18th Conference 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 February 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 management. 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
:LB6
Journal 2008 vol 8 no 2
(
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• Offers more for wound management than just a
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the risk of maceration
• Comforts patients over time whilst the dressing
is in situ and upon removal 1
• Gel cushions in a way that only a Gelling Foam dressing can 2
References: 1. Vanscheidt W, Münter K-C, Klövekorn W, Vin F, Gauthier J-P, Ukat A. A prospective study on the use of a non-adhesive gelling foam dressing on
exuding leg ulcers. J Wound Care 2007; 16: 261-265. 2. Bishop S. Versiva® XC™ Gelling Foam Dressing cushioning and protection claims R&D justification.
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©2008 E.R. Squibb & Sons, L.L.C. 2008. EU-08-780
www.convatec.com
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
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ldjcYhl^i]Vjidad\djh
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Abstract
Background: One of the emerging new treatments for chronic wounds is the use of autologous 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-richplasma 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 reduced in size and 14.2% were unchanged in terms
of area and condition. Recurrencies were not observed 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 recalcitrant wounds where there is lack of improvement despite treatment of underlying causes and
good local wound care. Further research in form
of controlled trials is required.
>CIGD9J8I>DC
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
G-granules located in the thrombocyte cell membrane. Growth factors work as biologic mediators
to promote cellular activity by binding to speciﬁc
cell surface receptors1,2.
Autologous growth factors from concentrated 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, Indiana). 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 information about the beneﬁts of platelet-rich-plasma
in chronic wounds.
BVgXjh<g\Zc!
MD, Senior Consultant
Surgeon
Dept.of Surgery
Sørlandet sykehus HF
4400 Flekkefjord
Norway
[email protected]
IVWaZ&#>cXgZVhZd[\gdli][VXidgXdcXZcigVi^dc^ceaViZaZig^X]eaVhbV,
<gdli][VXidg
PDGF-H
TGF-H1
VEGF
EGF
IGF
8dcXZcigVi^dc^cl]daZWaddY 8dcXZcigVi^dc^EGE
3.3 +/-0.9 ng/ml
17 +/- 8 ng/ml
35 +/- 8 ng/ml
120 +/- 42 ng/ml
155 +/- 110 pg/ml
955 +/- 1030 pg/ml
129 +/- 61 pg/ml
470 +/- 320 pg/ml
No increase
B6I:G>6AH6C9B:I=D9H
Materials
The wound healing unit at Sørlandet sykehus Flekkefjord in Norway treats about 250 patients with
chronic wounds of various origins each year. The
use of autologous platelet-rich plasma was introduced to our unit in February 2007. Since there
was limited experience with this kind of technology, 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.
0
:LB6
Journal 2008 vol 8 no 2
*
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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 diabetic 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 established method, acceptance from the local ethical committee was not needed. All patients had given their written
informed consent before entry to the study.
Methods
This 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 duration more than 8 weeks that had not shown any progress
(decrease in size, formation of granulation tissue, epithelialization) 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-brachial 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.
+
;^\jgZ(/I]ZXadiXVcWZXjiVXXdgY^c\id
ldjcYh^oZWZ[dgZWZ^c\igVch[ZggZYidi]ZldjcY#
Preparation of platelet-rich plasma
Platelet-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 produce autologous thrombin (Thrombin Processing Device,
TPD™, Thermogenesis Corp., Rancho Cordova, California). 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 platelet-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 surface 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.
:LB6
Journal 2008 vol 8 no 2
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
;^\jgZ)/EVi^Zcicg#'IVWaZ'#6cZjgd^hX]Zb^XY^VWZi^X
]ZZajaXZgeg^dgidigZVibZcil^i]eaViZaZi\Za#
;^\jgZ+/9Vn&**/I]ZldjcY]Vh]ZVaZYV[iZgild
Veea^XVi^dchd[eaViZaZi\Za!d[["adVY^c\VcY\ddYadXVa
ldjcYXVgZ#
A degradable dressing (Topkin, Biomet Europe, Dordrecht, the Netherlands) and a secondary absorbent layer
(Mepilex, Mølnlycke Health Care, Gothenborg, Sweden)
were used to cover the wounds. Treatment of the underlying wound causes such as compression therapy for venous
ulcers and off-loading for diabetic ulcers was continued.
Outcome measures
In order to assess wound healing accurately, we used digital 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.
;^\jgZ*/9Vn',/i]ZldjcYh^oZ^hgZYjXZYWn)%#
G:HJAIH
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 during the course of treatment. In both cases, Pseudomonas
species were cultured and infections successfully treated
with systemic antibiotics. Other side-effects were not recorded.
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.
9>H8JHH>DC
Wound healing is a complex process that is regulated by
interactions between a large number of cell types, extracellular 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
0
:LB6
Journal 2008 vol 8 no 2
,
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
IVWaZ'#EVi^ZciX]VgVXiZg^hi^Xh
Cg#
HZm!
V\Z
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9jgVi^dc
d[i]Z
ldjcY
10 years
LdjcY
h^oZXb
1
F, 76
Venous leg ulcer
2
3
4
M, 53
F, 64
M, 56
Neuroischemic diabetic heel ulcer
Neuroischemic diabetic heel ulcer
Traumatic leg ulcer associated
with an open distal leg fracture
Pressure ulcer, leg, associated
with spinal cord injury
Venous leg ulcer
Venous leg ulcer
Venous leg ulcer
Mixed-etiology leg ulcer
27 weeks
30 weeks
8 weeks
22.3
0.9
4.8
5
M, 39
1 year
5.6
4
7.7
16.1
Reduced by 42.9%
6
7
8
9
M, 50
F, 72
M, 44
M, 55
18 years
21 years
30 weeks
4 years
2.1
1.3
4.4
16.3
4
2
3
1
0.0
31.8
+ 4.3
14.2
0.0
69.3
13.1
38.7
M, 39
M, 35
Venous leg ulcer
Heel ulcer after cutaneous ﬂap
transfer
3 years
21 years
5.7
0.7
4
2
0.0
57.1
6.2
71.4
M, 58
M, 37
Neuropathic diabetic heel ulcer
Venous leg ulcers
36 weeks
9 years
0.4
8.0 / 1.5
1
1
50
12.5 /
46.6
50
68.8 / 80
Healed day 233
Healed day 238
Reduced by 93.2%
Deteriorated after
10 weeks
Reduced by 59.7%
Reduced by more
than 80%
(impossible to measure due to small size)
Healed by day 317
Reduced by 72% /
healed by day 35
10
11
12
13
21.8
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 healing 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 considered 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 clinical 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
-
CjbWZgd[ "X]Vc\Z "X]Vc\Z
GZhjai9ZXZbWZg
i gZVibZcih ^cVgZVVi ^cVgZVVi
'%%,
YVn,
YVn'1
22.5
27.1
Deteriorated, no signs
of epithelialization
2
23.3
49.7
Healed day 155
1
77.7
100
Healed day 30
1
2.1
16.6
Healed day 62
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 twolayer compression bandage. Nelson, et al. showed 67%
healing rates of venous ulcers within 24 weeks when using 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 platelet 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
0
:LB6
Journal 2008 vol 8 no 2
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moist wound environment, creating suitable conditions
for Pseudomonas aeruginosa growth. This is another reason 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 began 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 explanation for this. To date, there has been no determination 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 average 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 costeffective since ulcers that did not show improvement prior
to treatment healed.
Implications for Clinical Practice
The 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 platelet 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 factors prepared.
Further Research
Controlled studies with sufﬁcient sample sizes have to be
initiated. Cost-effectiveness should assessed when doing
those studies. As there are several manufacturers providing equipment for in-hospital production of platelet-rich
plasma, the different systems must be examined for differences in increase in platelets, growth factor concentrations,
preparation time, and applicability.
8DC8AJH>DC
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 variations 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 multi8
center trial.
GZ[ZgZcXZh/
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 nonhealing wounds. Successful treatment with autologous platelet-derived wound healing
factors (PDWHF). Ann Surg 1986; 204: 322-0.
4. Crovetti G, Martinelli G, Issi M, et al. Platelet gel for healing cutaneous chronic
wounds. Transus Apher Sci 2004; 30: 145-1.
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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.
:LB6
Journal 2008 vol 8 no 2
S 02 04 - * Trademark of Johnson & Johnson - X-STATIC is a registered Trademark of Noble Fiber Technologies Inc
Progressive Strength
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an optimal moist wound environment. The sustained and balanced release of silver ions kills a broad spectrum of microorganisms associated with the
bacterial colonization and infection of wounds, including MRSA, MRSE and VRE.
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The primary challenge in the treatment of exuding wounds is to maintain a moist condition
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We also developed a unique technology for continuous release of silver and ibuprofen into
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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 system, favour the growth of bacteria, and are the
origin of reactive oxygen species (ROS) 1 and
pro-inﬂammatory mediators. These agents destroy 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 hydrophobic and polymeric nature of the principal
components of wound coatings it is assumed that
the type of rinsing solution may be of particular 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 aeruginosa, followed by re- or overused ﬂasks of saline
or Ringer’s solution often contaminated by species
of the normal human ﬂora or the natural environment3. Non-sterile wound rinsing may be “costeffective” 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 conditions an in vitro model that mimics wound coatings 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”.
B6I:G>6A6C9B:I=D9H
Preparation of test wound coatings
Outdated frozen fresh plasma (FFP), anti-coagulated 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 M
CaCl2 solution was added to nine volume parts
of CPD plasma. The ﬁbrin formation started immediately after mixing of the volume parts on
the slide.
Wound rinsing solutions
Physiological saline solution (0.9% NaCl), Ringer’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 (Prontosan®) were obtained from B. Braun Melsungen
AG.
@jgi@VZ]c, Dr. rer. nat.
MSc (biology and chemistry),
PhD
K2 Hygiene Dienstleistungen
Haidstrasse 48
D-67431 Aschaffenburg,
Germany
[email protected]
I]dbVh:WZgaZ^c, Dr.med.
Dermatologe/Venerologe
- Allergologe
Fachexperte für die Zertiﬁzierung von QM-Systemen
nach EN ISO 9001:2000
Ossiacher Straße 9
D-90475 Nürnberg,
Germany
Protein measurement
Proteins were removed from the test coatings
either by dissolving or by inclusion in micellar
colloids of detergent. Dissolved proteins were detected by means of a modiﬁed Biuret reaction reagent (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 directly proportional to the protein concentration.
Denaturated proteins enclosed in micelles were
not detected by the Biuret reaction.
In vitro test design
Test 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,
0
:LB6
Journal 2008 vol 8 no 2
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30, and 60 minutes 1.5 ml aliquots were transferred to
reaction vessels and centrifuged immediately at 2,500 g
for 2 minutes. 0.1 ml supernatant was mixed with 0.1 ml
distilled 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 incubation 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 data
For retrospective analysis of wound healing processes,
medical records of 112 patients with Ulcus cruris venosum 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 (Fontaine stage  II)
Statistical evaluation
The 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 observation period was predisposed to six months and started
with admission. About 90% of wounds healed within the
observation period in both patient groups.
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Infection rates were compared and evaluated using Fischer’s
chi-square test.
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Effect of rinsing solutions on test coatings
During the incubation period of standardised test slides
(coated with either FP or ﬁbrin) the protein concentration
in all three wound rinsing solutions increased almost linearly, 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 ﬁgures 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 enclosing them in micelles (see ﬁgure 3). Micellar colloids
show strong refraction and hence turbidity in the PHMB/
Betaine containing solution increased during incubation
time.
:LB6
Journal 2008 vol 8 no 2
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i]ZiZhihZg^Zhl^i]
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Effect of rinsing solutions on wound healing
All 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 procedure 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 compared 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 ± 1.41
compared to 3.31 ± 1.32 months (p < 0.001).
VV[iZggZbdk^c\XdckZci^dcValdjcYYgZhh^c\h
IVWaZ&#LdjcY]ZVa^c\gViZh^ceVi^ZcihigZViZYl^i]Y^[[ZgZciineZh
d[ldjcYg^ch^c\hdaji^dch@VeaVc"BZ^Zg"bZi]dY
number of patients
rinsing solution
time scale
end of 1st month
end of 2nd month
end of 3rd month
end of 4th month
end of 5th month
end of 6th month
53
59
saline or Ringer’s
PHMB / Betaine
wound healing rate (%)
2
7
9
29
28
59
51
81
68
93
89
97
W'%b^cjiZhaViZgV[iZgXaZVch^c\jh^c\E=B7VcY7ZiV^cZ
XdciV^c^c\ldjcYg^ch^c\hdaji^dc
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).
Xi]gZZYVnhaViZgV[iZggZbdk^c\d[ldjcYYgZhh^c\h
9>H8JHH>DC
When proteins are dissolved in water each protein molecule is included in a structured hydration sheath of water
molecules which prevents aggregate formation and precipitation. Saline and Ringer’s solution, both regularly used
in wound care practices, contain monovalent and bivalent 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
0
:LB6
Journal 2008 vol 8 no 2
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^ceVi^ZcihigZViZYl^i]Y^[[ZgZciineZh
d[g^ch^c\hdaji^dch/E=B7VcY
7ZiV^cZXdciV^c^c\ldjcYg^ch^c\
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salt concentrations (exact ionic strength*) destabilize the
hydration sheaths of proteins resulting in aggregate formation 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 solution 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 model 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 containing 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 solution5,6,7.
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 antiseptics 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 process and requires a sophisticated local wound management.
The most important point is to follow the recommendations of moist wound treatment as deﬁned by Falanga8
and Sibbald9. Typically, neutral physiological solutions
are used for that purpose. However, PHMB/Betaine containing wound rinsing solutions may be superior to salt
solutions.
Betaine forms micelles and improves solubilisation of hydrophobic material from wounds. Poly(hexamethylenbigu
anide)hydrochloride (PHMB) is an antimicrobial agent
widely used as a preservative in commercial and industrial 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 effective 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.
&+
:LB6
Journal 2008 vol 8 no 2
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
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.
8DC8AJH>DCH
In wound treatment “cleanliness“ (no coatings, reduction
of detritus, removal of necrotic tissues, low microbial bioburden) is generally considered an important factor for
improving secondary wound healing without major problems. 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 attention 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
8
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-Behandlung? 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
:LB6
Journal 2008 vol 8 no 2
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an international perspective
Abstract
Background: 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 experiences 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, British 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 uncomfortable with medication use and the Canadian group
were anxious about ﬁnancial loss and apprehensive 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.
>CIGD9J8I>DC
Chronic wound pain is associated with negative
mood, decreased activities of daily living, sleep
disturbance, reduced mobility and social withdrawal1,2,3,4,5. Qualitative research in this area
has identiﬁed numerous aspects of pain and discomfort which have a negative impact on qual-
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 lifestyle and a sense of conﬁnement3. These feelings
are often ampliﬁed by sleep disturbance and can
eventually result in social withdrawal in some instances8. There is a strong connection between
pain and an individual’s sense of well-being. Negative 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 having 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.
G:H:6G8=9:H><C6C9B:I=D9H
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 experience 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 current experience of discomfort/pain related to their
wound were invited to participate. The inclusion
criteria were deliberately broad in order to capture
:a^oVWZi]?BjY\Z,
MSc, BSc, MChS, SRCh,
D.Pod.M1
Hnak^ZBZVjbZ! MD2
@Zk^cLdd! RN, MSc3
G<VgnH^WWVaY! MD,
FRCPC, MEd3
EVig^X^V:Eg^XZ! PhD, BA
(Hons), AFBPsS CHPsychol1
1. Wound
Healing Research
Unit, School of Medicine,
Cardiff University, Wales,
United Kingdom
2. Service de Gérontologie,
Hôpital Charles Foix,
Ivry sur Seine, France
3. Wound Healing Clinic,
Women’s College Hospital,
University of Toronto,
Canada
8dggZhedcYZcXZid/
Elizabeth Mudge
Cardiff University
Department of Wound
Healing
Upper Ground Floor
Heath Park
Cardiff
CF14 4XN
[email protected]
0
:LB6
Journal 2008 vol 8 no 2
&.
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
6eeZcY^m&#;D8JH<GDJEHX]ZYjaZ$Egdbeih
EV^cViYgZhh^c\X]Vc\ZegdXZYjgZ^ceVi^Zcihl^i]X]gdc^XldjcYh
E6GI&·&=djg
I^bZ
*"&%b^cjiZh
E]VhZ
>cigdYjXi^dc
(%")%b^cjiZh
DeZce]VhZ
(Open discussion around
experiences of living with
a wound including pain
experiences)
&%b^cjiZh
7gZV`GZ[gZh]bZcih
Egdbeih
Introductions
Outline aims of project
Experience of living with a wound
Experience of pain
Intensity and description of pain
Timing of discomfort / pain
Impact of pain / discomfort on everyday living
(including employment and impact on other family members)
E6GI'·&=djg
(%")%b^cjiZh
*b^cjiZh
9^gZXiZYXdckZghVi^dc
LgVe"JeVcY8adhZ
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 change
Other 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 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 information 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 healing, who explained the aim of the group, conﬁrmed conﬁdentiality 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 representing 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.
0
:LB6
Journal 2008 vol 8 no 2
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
G:HJAIH
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 perceived 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 during 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 someone is eating my ﬂesh, like a dog biting me. It hurts
terribly”
Quality of Life
The impact of pain revealed a number of psychological 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 between 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 (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 isolation:
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 someone 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 isolated
The participants portrayed stigmatisation caused by having 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 morphine … 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”
Participant (France) – “I haven’t been able to go walking outside for about six months. I can’t get down
the stairs any more”
''
0
:LB6
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HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
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 ampliﬁed 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 image
Aesthetic 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 deprivation
Sleep 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 system
Frustration with the healthcare system was reported to
have a negative inﬂuence on wound-related pain experience for some of the participants and was the focus of
considerable discussion in the Canadian group. Particular
issues concerning frequent turn around of nurses, inconsistency 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 understanding 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 change
Anticipation of the dressing change produced a mixture of
positive and negative emotions, but having a fresh dressing put on the wound was generally perceived to be a very
painful and fearful time for the participants and represented 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 patients took some form of analgesia before their appointment. 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 pro0
cedures was intensiﬁed by past memories:
:LB6
Journal 2008 vol 8 no 2
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13125
References:
1. Data on file 0707052
2. Data on file 0711086
3. Data on file 0711087
4. Journal of Woundcare (2006), Vol 15, No. 7
July 2006
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
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 afterwards 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 procedure was made worse if the ulcer was left exposed/uncovered 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 reported that they felt the dressing change procedure could
be improved by continuity of care, regular or familiar
healthcare professionals and having a good support network.
Medication
Concern 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 analgesia 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”
Infection
Overwhelmingly the greatest perceived concern in all
three countries was that of infection and this was ampliﬁed 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”
9>H8JHH>DC
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 woundrelated pain and spontaneous intermittent bursts of intense 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 appearance, 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 research 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 appear 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 expecta0
'+
:LB6
Journal 2008 vol 8 no 2
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HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
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 cultural 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 assumed 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.
8DC8AJH>DC
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 reminder 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.
GZ[ZgZcXZh
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.
E]aZWdad\n .: 83-86
2. Price P. An holistic approach to wound pain in patients with chronic leg ulceration.
LdjcYh (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. HXVcY^cVk^Vc
?djgcVad[8Vg^c\HX^ZcXZ (2001) &*(3): 235-43.
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
8
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.
12. Douglas V. Living with a chronic leg ulcer: an insight into patients’ experiences
and feelings. ?djgcVad[LdjcY8VgZ (2001) &% (9): 355-360
13. Krasner D. Painful venous ulcers: themes and stories about living with the pain
and suffering. ?LdjcYDhidbn8dci^cZcXZCjghe (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. ?djgcVad[9^VWZiZhVcY^ih8dbea^XVi^dch. (2007)
'&: 227-236.
4. Price P and Harding KG. Measuring Health Related Quality of Life in Patients with
Chronic Leg Ulcers. LdjcYh (1996) - (3): 91-94
15. Briggs M, Closs SJ. Patients’ perceptions of the impact of treatments and products
on their pain experience of leg ulcer pain. ?djgcVad[LdjcY8VgZ (2006) &*8):
333-337.
5. Walshe C. Living with a venous leg ulcer: a descriptive study of patients’ experiences.
?djgcVad[6YkVcXZYCjgh^c\(1995) ''(6): 1092-100.
16 Stemler S. An overview of content analysis. EgVXi^XVa6hhZhhbZciGZhZVgX]VcY
:kVajVi^dc# , (17): 1-9.
6. Krasner D. The chronic wound pain experience: a conceptual model. DhidbnVcY
LdjcYBVcV\ZbZci(1995) )&(3): 20-35.
17. Newell R. Body-image disturbances: cognitive behaviour formulation and intervention. ?djgcVad[6YkVcXZYCjgh^c\ (1991) &+: 1400-1405
7. Pieper B and DiNardo E. Reasons for non-attendance for the treatment of Venous
Ulcers in an inner-city clinic. ?LdjcYDhidbnVcY8dci^cZcXZCjgh^c\#(1998)
'*(4): 180-6.
18. Noles SW, Cash TF, Winstead BA. Body image, physical attractiveness and depression. ?djgcVad[8dchjai^c\VcY8a^c^XVaEhnX]dad\n(1985)*((1): 88- 94.
8. Noonan L, Burge SM. Venous leg ulcer: is pain a problem? E]aZWdad\n (1998) &(:
14-19.
9. Charles H. ‘The impact of leg ulcers on patients’ quality of life’ Egd[Zhh^dcVaCjghZ
(1995) &% (9) : 571-574
10. Hamer, C. Cullum N.A. Roe B.H. Patients’ perceptions of chronic venous leg ulcers.
?djgcVad[LdjcY8VgZ (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. ?djgcVad[LdjcY
8VgZ (2005) &) (2): 53-57.
'-
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.
?djgcVad[8a^c^XVaCjgh^c\ (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. ?djgcVad[LdjcY8VgZ
(2003) &' (9): 336-340
21. Hofman D, Ryan T, Arnold F et al. Pain in venous leg ulcers. ?djgcVad[LdjcY8VgZ
(1997) + (5): 222-224
:LB6
Journal 2008 vol 8 no 2
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T. +49 (0) 209 95 71 88 0 · F. +49 (0) 209 95 71 88 20 · [email protected]
Q The patient gains:
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Q The clinician gains:
Faster healing means fewer
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©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 registered
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overview of current evidence
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Chronic wounds are characterised by duration,
prolonged inﬂammation, increased risk of infection and are associated with either a local or
systemic altered physiological state. Slough is an
impediment to healing in these wounds as it provides a stimulus for inﬂammation, the optimal
culture medium for bacterial proliferation, impedes epithelial edge advancement, and impairs
visualisation of the wound bed1,2. Additionally it
increases exudate production and malodour3.
Many case studies and randomised controlled 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 combined 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.
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 ammonia which, in itself, is necrotizing and can impair oxygenation of the tissues by raising the pH16.
Alkalinity supports the activity levels of many proteases 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 correlated with non-healing19-21.
JC9:GHI6C9>C<HADJ<=
Slough is a form of necrotic tissue which is visible on the surface of the wounds as moist, loose,
stringy tissue, typically yellow and represents a
complex mixture of ﬁbrin, deoxyribonucleo-protein, serous exudate, leucocytes and bacteria14.
This tissue tends to accumulate continually in
chronic wounds because such wounds generally
result from underlying and uncorrected pathogenic abnormalities such as diabetes mellitus or
venous insufﬁciency1. Slough is related to the inﬂammatory phase of wound healing when dead
cells accumulate in exudate but the body normally
keeps pace with the it’s build up through a natural 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 material15.
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 functions, leading to the eventual tissue breakdown,
seen in chronic wounds23. This continual breakdown 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 systematic 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
:LB6
Journal 2008 vol 8 no 2
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.
<Zdg\^cV<Zi]^c
PhD, HE Dip Wound healing,
RGN, Dip Anatomy,
Dip Physiology, Lecturer
Research Centre
Faculty of Nursing and
Midwifery
Royal College of Surgeons
in Ireland
123 St Stephens Green
Dublin 2, Ireland
[email protected]
0
(&
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 debrided are well documented1,2 and can be summarised into
4 key areas as in Table 1.
IVWaZ&/6YkVciV\Zhd[ldjcYYZWg^YZbZci
LdjcY[VXidgh EdiZci^VadjiXdbZ
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 taken 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.
=DC:N6C9LDJC9=:6A>C<
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 increasing 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. In
vitro studies have investigated the variability in antimicrobial 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 organisms 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.
B:I=D9HD;LDJC99:7G>9:B:CI
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 painless 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 produce 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 debridement of necrotic tissue, decreased deposition of granulation 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 potential 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.
=DL=DC:N8DCIG>7JI:HID
LDJC99:7G>9:B:CI
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 movement 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] proposed 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
:LB6
Journal 2008 vol 8 no 2
HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
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 contribute to the inﬂammatory phase and play a role in wound
debridement. The effect of Manuka, pasture and artiﬁcial honey on production of reactive oxygen intermediates
(ROIs), and Tissue Necrosis Factor alpha (TNFG) release
in human monocytic cells demonstrated a spontaneous
release of TNF-G 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 signiﬁcantly 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 effectively removing slough from both acute and chronic wounds.
A pilot study using Honeysoft® (Mediprof, The Netherlands) 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 applied 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
0
(described below) addressed this issue10.
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HX^ZcXZ!EgVXi^XZVcY:YjXVi^dc
One hundred and eight patients with venous ulcers in
which r 50% of the wound bed was covered in slough
were randomly assigned to either Manuka honey dressing or Hydrogel therapy10. Wounds were dressed weekly
for four weeks and compression therapy continued in all
cases. The performance of both agents was highly clinically 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. Future studies investigating desloughing efﬁcacy of topical
agents should provide details of how outcomes were evaluated, 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.
1 Himel H. Wound Healing: focus on the chronic
wound. Wounds. 1995;supp A(5):70A-7A.
2 Baharestani M. The clinical relevance of debridement. Heidelberg: Springer-Verlag 1999.
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 reducing 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 contact 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 guidelines 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 particular Manuka honey meets many of these requirements
although cost beneﬁt analysis of its use as a debriding
agent is lacking.
8DC8AJH>DC
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 maintaining a moist environment; antimicrobial properties
which reduces the potential for production of bacterial
8
endotoxins.
11 Colin D, Kurring PA, Quinlan D. Managing
sloughy pressure sores. Journal of Wound Care.
1996;5(10):444-6.
3 Dealey C. The care of wounds: a guide for nurses.
3rd ed: Blackwell Publishing 2005.
12 Thomas S, Fear M. Comparing two dressings for
wound debridement. Journal of Wound Care.
1993;2(5):272-4.
4 Efem SEE. Clinical observations on the wound healing properties of honey. British Journal of Surgery.
1988;75:679-81.
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.
5 Green AE. Wound healing properties of honey. British
Journal of Surgery. 1988;75(12):1278.
14 Thomas AM, Harding KG, Moore K. The structure
and composition of chronic wound eschar. Journal of
Wound Care. 1999;8(6):285-7.
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, hydroxyurea-induced leg ulcer with honey. J Dermatol
Treat. 2001;12:33-6.
9 Van der Weyden EA. The use of honey for the treatment 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 Controlled Trial. Paper presented at 17th EWMA Conference: 2-4 May 2007: Glasgow, UK. EWMA Journal
- Supplement, 2007, vol 7, May, p 28.
()
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. Proteases 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 clinical 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 Assessment 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 scientiﬁc 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 effectiveness and cost-effectiveness of debriding agents in
treating surgical wounds healing by secondary intention. 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;75:198205.
:LB6
Journal 2008 vol 8 no 2
Drinaghan, Knocknarea, Sligo, Ireland
/WG
To: President, European Wound Management Association
Re: Research Grant
Date: 22/04/2007
Dear 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 properties. Beekeeping in the United States agricultural
handbook number 335. 1980 October.
30 Cooper R, Molan P, Harding KG. Antibacterial activity of honey against strains of Staphylococcus aureus
from infected wounds. Journal of Royal Society of
Medicine. 1999;92:283-5.
<Zdg\^cV<Zi]^c
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.
40 Ahmed A, Hoekstra M, Hage J, Karim R. Honeymedicated dressing: transformation of an ancient
remedy into modern therapy. Annals of Plastic
Surgery. 2003;50(2):143-8.
32 French V, Cooper R, Molan P. The antibacterial
activity of honey against coagulase-negative staphylococci. Journal of Antimicrobial Chemotherapy.
2005;56:228-31.
41 Okeniyi J, Olubanjo O, Ogunlesi T, Oyelami O. Comparison of healing in incised abscess wounds with
honey and EUSOL dressing. The Journal of Alternative and Complementary medicine. 2005;11(3):5113.
33 Sieggreen M, Malkebust J. Debridement: choices and
challenges. Advances in wound care. 1997;10(2):327.
42 Gray D. Mesitran Ointment Case Studies. Wounds
Uk Honey Supplement. 2005;1(3):32-5.
34 Davies P. Current thinking on the management of
necrotic and sloughy wounds. Professional Nurse.
2004;19(10):34-6.
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.
35 Thomas S. Functions of a wound dressing in: Wound
Management and Dressings. London: The Pharmaceutical Press. 1990.
44 NICE. Guidance on the use of debriding agents and
specialist wound care clinics for difﬁcult to heal surgical wounds. National Institute for Clinical Excellence,
Technology Appraisal Guidance -No 24. 2001(24).
:LB6
Journal 2008 vol 8 no 2
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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.
31 Cooper R, Molan P, Harding KG. The sensitivity of
honey to Gram-positive cocci of clinical signiﬁcance
isolated from wounds. Journal of Applied Microbiology. 2002;93(5):857-63.
36 Cooper RA. How does honey heal wounds? In: Munn
P, Jones R, eds. Honey and Healing. United Kingdom: International Bee Research Association. 2001.
MICROSPHERES FOR MEDICINE & BIOTECHNOLOGY
www.polyheal.co.il
(*
:7LB
ABSTRACTS OF RECENT
COCHRANE REVIEWS
Publication in The Cochrane Library Issue 2, 2008:
K^iVb^c8[dgegZkZci^c\VcYigZVi^c\
iZiVcjh[Review]
HVaan7Zaa"HnZg, 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]
=Zb^a~=!@d^kjaVII
I]Z8dX]gVcZ9ViVWVhZd[HnhiZbVi^XGZk^Zlh
To be published in Issue 2, 2008 Copyright © 2005
The Cochrane Collaboration. Published by John Wiley
& Sons, Ltd./
67HIG68I
7VX`\gdjcY/Tetanus is a severe infection that can be
prevented by vaccination. In developing countries
vaccination coverage is not always high and in developed countries cases may still occur, particularly in
elderly people owing to their reduced immunoprotection. 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.
DW_ZXi^kZh/To assess the prophylactic and therapeutic
effect of vitamin C in tetanus.
HZVgX]higViZ\n/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.
HZaZXi^dcXg^iZg^V/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.
9ViVXdaaZXi^dcVcYVcVanh^h/Both review authors
independently extracted data from trial reports.
BV^cgZhjaih/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 stratiﬁed 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%).
6ji]dgh¼XdcXajh^dch/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 treatment.
EaV^caVc\jV\ZhjbbVgn/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 treatments 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 interpretation of the ﬁndings. Vitamin C cannot be recommended 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.
>ciZgb^iiZciecZjbVi^XXdbegZhh^dc[dg
igZVi^c\kZcdjhaZ\jaXZgh[Updated Review]
CZahdc:6!BVc^G!KdlYZc@
I]Z8dX]gVcZ9ViVWVhZd[HnhiZbVi^XGZk^Zlh
To be published in Issue 2, 2008 Copyright © 2005
The Cochrane Collaboration. Published by John Wiley
& Sons, Ltd./
67HIG68I
7VX`\gdjcY/Intermittent pneumatic compression
(IPC) is a mechanical method of delivering compression 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.
0
(+
:LB6
Journal 2008 vol 8 no 2
We call it QuadraFoam because
“Healing-Cleansing-AbsorbingMoisturising-Comfortable-EasyFast-Acting Dressing” just
didn’t seem as catchy.
®
QuadraFoam. The ﬁrst 4-in-1 dressing formulation.
PolyMem, the only QuadraFoam dressing, simpliﬁes your work and improves
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.
Find your local distributor at www.PolyMem.eu.
www.PolyMem.eu
PolyMem and QuadraFoam are trademarks of Ferris Mfg. Corp., registered or pending in the US Patent and Trademark
Ofﬁce and in other countries. © 2008 Ferris Mfg. Corp. All rights reserved. 16W300 83rd St., Burr Ridge, IL 60527
MKL-218,0706
:7LB
DW_ZXi^kZh/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.
HZVgX]higViZ\n/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.
HZaZXi^dcXg^iZg^V/Randomised controlled studies either
comparing IPC with control (sham IPC or no IPC) or comparisons between IPC treatment regimens, in venous ulcer management were included.
9ViVXdaaZXi^dcVcYVcVanh^h/Data extraction and assessment
of study quality were undertaken by one author and checked by
a second.
BV^cgZhjaih/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 bandages 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).
6ji]dgh¼XdcXajh^dch/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.
EaV^caVc\jV\ZhjbbVgn/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. Intermittent 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.
(-
Ide^XVacZ\Vi^kZegZhhjgZ[dgigZVi^c\X]gdc^X
ldjcYh[Updated Review]
JWW^c`9I!LZhiZgWdhH?!:kVch9!AVcYA!KZgbZjaZc=/
I]Z8dX]gVcZ9ViVWVhZd[HnhiZbVi^XGZk^Zlh
To be published in Issue 2, 2008 Copyright © 2005 The Cochrane
Collaboration. Published by John Wiley & Sons, Ltd./
6WhigVXi/7VX`\gdjcY/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.
DW_ZXi^kZh/To assess the effects of TNP on chronic wound
healing.
HZVgX]higViZ\n/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.
HZaZXi^dcXg^iZg^V/All randomised controlled trials which evaluated
the effects of TNP on people with chronic wounds.
9ViVXdaaZXi^dcVcYVcVanh^h/Selection of the trials, quality assessment, data abstraction, and data synthesis were done by two
authors independently. Disagreements were solved by discussion.
BV^cgZhjaih/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.
6ji]dgh¼XdcXajh^dch/Trials comparing TNP with alternative treatments 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.
EaV^caVc\jV\ZhjbbVgn/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.
:LB6
Journal 2008 vol 8 no 2
(2,.(9<'3(44,0*4%(0(;5)31/ $)(5$&<$2$5(05('41)54,.,&10($'+(4,7(5(&+01.1*:
5+$5&10)13/451(7(3:&3(7,&(1)5+(4-,0!+,45(&+01.1*:4($.45+(8160'/$3*,04
23(7(05,0*(96'$5()31/423($',0*10515+(4633160',0*4-,0&$64,0*/$&(3$5,10
1/(5,/(45+(*(05.(45516&+,45+(/145$4463('
$)(5$&5(&+01.1*:,4$.415+(3($4108+:2$5,(05464,0*(2,.(9'3(44,0*4)((.4,*0,;
&$05.:.(442$,010'3(44,0*3(/17$.!+,4&1/%,0('8,5+(9&(..(05).6,'/$0$*(/(05
/$-(5+((2,.(93$0*($0())(&5,7(8160'&$3(/$0$*(/(05&+1,&(
540,&(51%(*(05.(54(7(00,&(351%(463(
#+,5(7,'(0&()13$53$6/$5,&41)54,.,&10(8160''3(44,0*64(#160'4"
#+,5(#160'4"71.01
!+(=.0.:&-(($.5+$3(0$/($0'.1*1$0'(2,.(9<$3(3(*,45(3('53$'(/$3-41)=.0.:&-(($.5+$3(
=.0.:&-(($.5+$3(26%.19
=5(%13* 8('(0+10(
888/1.0.:&-(&1/
Wound Dressings
:LB6
LdgaYJc^dcd[LdjcY=ZVa^c\HdX^
9dj\aVhBXFjZZc
T
he third meeting of the World
Union of Wound Healing Societies is truly a partnership between wound care associations (including 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 development of wound care as a clinical specialty.
That is “One Problem – One Voice”.
Congress 2008 provides a forum for the dissemination 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 professionals 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 provides an opportunity not only to network but also
to work together for the beneﬁt of all wound healers on a global basis. This will be accomplished
through a preconference day, three plenary sessions, 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
6C>CI:GK>:LL>I=I=:8=6>GD;I=:LDGA9JC>DC8DC<G:HH'%%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 efﬁcacy, efﬁciency and effectiveness to form a framework
for best clinical practice. The synthesis of these three
major pillars of evidence-informed practice will provide clinicians with a new and comprehensive way of
reviewing their practice and ensuring their care is patient 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
)%
problems. The keynote addresses will echo the importance of evidence and patient care. An expert panel
will discuss the clinical signiﬁcance of evidence-based
medicine; Stephen Lewis will examine healthcare systems, advocacy and AIDS in Africa; and Marla Shapiro, 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 according to the type of information, from guidelines to preclinical 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 information in a quick and easy Web-based format.
:LB6
Journal 2008 vol 8 no 2
Zi^Zh8dc\gZhh'%%This is not a one-time effort! Through a continued partnership with our Platinum Sponsors this will be an ongoing initiative for the World Union. Under the stewardship
of Professor R. Gary Sibbald, during his tenure as President, 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.
GZ\^hiZgcdlideVgi^X^eViZ
^ci]^h\gdjcY"WgZV`^c\Xdc\gZhh
lll#ljl]h'%%-#Xdb
:A:8IGDC>8
HJEEA:B:CI
B6N'%%KdajbZCjbWZg'
BVn'%%EjWa^h]ZYWn
:jgdeZVc
LdjcYBVcV\ZbZci
6hhdX^Vi^dc
67HIG68IH
proliferated throughout the meeting in a logical, easy-tofollow agenda.
:LB6'%%-Æ&)"&+B6NÆA>H7DCÆEDGIJ<6A
18th Conference of the European Wound Management Association
LdjcYBVcV\ZbZci•LdjcY=ZVa^c\
·GZhedch^W^a^inVcY6Xi^dch
LLL#:LB6#DG<$:LB6'%%Organised by
the European Wound Management Association in cooperation with
the Portuguese Wound Management Associations APTFeridas and GAIF
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 following 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.
I]ZBVn'%%-ZY^i^dcd[i]Z
:LB6?djgcVa:aZXigdc^X
HjeeaZbZciXdch^hihd[Vaa
i]ZVXXZeiZYVWhigVXih[dg
i]Z:LB6'%%-8dc[ZgZcXZ
^cA^hWdc#
>i^hY^k^YZY^cid&)%DgVa
egZhZciVi^dchVcY(,+EdhiZg
egZhZciVi^dchVcY^i^hedhh^WaZ
idYdlcadVY^cY^k^YjVa
VWhigVXihVhlZaaVhi]ZZci^gZ
hjeeaZbZci^cXajY^c\Vaai]Z
VWhigVXihVilll#ZlbV#dg\
Q: What’s next for the WUWHS?
GS: Toronto 2008 is a key step in building the WUWHS as an international association. After the congress, we will focus on disseminating the educational
toolkits developed at the meeting and sharing expertise
between associations.
LLL#:LB6#DG<
:LB6
Journal 2008 vol 8 no 2
:LB6 Journal
Previous Issues
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BVnZgIZcZc]Vjh
International Journals
The section on International Journals is part of
EWMA’s attempt to exchange information on
wound healing in a broad perspective.
:c\a^h]
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Journal 2008 vol 8 no 2
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)(
:LB6Corporate Sponsor Contact Data
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a holistic approach
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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 lll#ZlbV#dg\
It is possible to obtain permission to translate the
EWMA Position Documents into other languages.
Please contact EWMA Business Ofﬁce.
For further details contact
MEP Ltd, 53 Hargrave Road,
London N19 5SH.
www.mepltd.co.uk
or
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Congress Consultants,
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Denmark
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Fax: +45 7020 0315
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:LB6
Journal 2008 vol 8 no 2
)*
8dc[ZgZcXZh
Conference Calendar
Conference
Theme
2008
7th National Australian Wound Management
Association Conference
Dreams, Diversity, Disasters
May
SAfW 5th Congress (National)
18th Conference of the European Wound
Management Association (EWMA 2008)
Wound Healing – Wound Management
– Responsibility and Actions
9th Congress of the European Society for Pediatric
Dermatology
7-10
Darwin
Australia
May
8
Morges
Switzerland
May
14-16
Lisbon
Portugal
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
Jun
13-14
Koblenz
Germany
Jun
15-19
Ljubljana
Slovenia
Deutsche Gesellschaft für Wundheilung und
Wundbehandlung
17th World Council of Enterostomal Therapists
meeting
Stoma care, Wound Management &
Incontinence
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 assocation
Jun
23-25
Kosova
ETRS 18th Annual Meeting
Joint Meeting with the Tissue Viability Unit
of Malta
Sep
10-12
Malta
Sep
11-13
Lucca
Italy
7th Scientiﬁc Meeting of the Diabetic Foot Study
Group (DFSG) of the EASD
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
Wounds UK
Nov
5° Congresso Nazionale AISLeC
EBN e Wound Care: Nuove Frontiere
WMAT 3rd National Congress
Chinnai
India
Harrogate
UK
Nov
13-15
Napoli
Italy
Nov
27-29
Cesme, Izmir
Turkey
2009
6th EADV Spring Symposium
19th Conference of the European Wound Management Association
Healing, Education, Learning and Preventing
in Wound Care
Apr
23-26
Bucharest
Romania
May
20-22
Helsinki
Finland
Bled
Slovenia
Berlin
Germany
8th Scientiﬁc Meeting of the Diabetic Foot Study
Group (DFSG) of the EASD
Sep
18th EADV Congress
Oct
7-11
;dglZWVYYgZhhZheaZVhZk^h^illl#ZlbV#dg\
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Become a member of the :jgdeZVcLdjcYBVcV\ZbZci6hhdX^Vi^dc
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.
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LLL#:LB6#DG<
)+
:LB6
Journal 2008 vol 8 no 2
Dg\Vc^hVi^dch
SEBINKO
Hungarian
Association for the
Improvement of Care
of Chronic Wounds
and Incontinentia
Contact: Dr. Maria Hok
[email protected]
[email protected]
www.sebinko.hu
&hiVccdjcXZbZci
XVaa[dgVWhigVXih
&&i]8dc[ZgZcXZd[H:7>C@D
IViVW{cnV'%%-#
&+"&,#d`iWZg#
I]ZYZkZadebZcid[Xa^c^XVa
kVa^Y^inVcYWZhiegVXi^XZh
gZfj^gZbZcih
The Hungarian H:7>C@D Association was
established in 1996 to improve the care of
incontinent patients and people with chronic or
non-healing wounds. It is a nationwide, voluntary 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 institutions.
We have developed strong working relationships with the instigators and practitioners of
the nationwide consensus. Amongst them one
can ﬁnd professional politicians, members of
Parliament, members of medical and nursing
colleges, leaders of professional and civil
organisations, health industry professionals,
universities and practitioners and practicing
teams.
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 improvement 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, correspondence, 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 documentation and data processing and the
training of institutional coordinators for decubitus and incontinence.
The focus of our consensus is the pressure
ulcer: the prevention and treatment of decubitus.
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.
Our association is consciously supporting the
following values of professional help and care
in wound management: -reservation or reestablishment of the self-care of patients, -security -pain minimisation -infection-free treatment
-cost effectiveness in wound treatment.
EWMA2009
20-22 May
Helsinki · Finland
Organised by the European Wound Management Association
in cooperation with the Finnish Wound Care Society FWCS
Dg\Vc^hVi^dch
SWHS
Serbian Wound
Healing Society
www.lecenjerana.com
The HZgW^VcLdjcY=ZVa^c\HdX^Zin 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 involvement 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.
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 professionalism, initiated intensive presence of wound
care companies in Serbia. Some new
appeared and those already present
increased there activities.
250 doctors and nurses attended our education 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 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
In 2007, Society published ﬁrst issue, volume 1 and coordinated approach to the area of
and 2 of the journal “Rane” (Wounds). The
Wound Management is our priority.
7th Scientiﬁc Meeting of the
Conference theme
Diabetic Foot
Study Group
Advancement
of knowledge
on all aspects of
diabetic foot care
of the EASD
Main subjects during conference:
. Epidemiology
. Basic and clinical science
. Diagnostics
. Classiﬁcation
. Foot clinics
. Biomechanics, Osteoarthropathy
. Orthopaedic surgery
. Infection
. Revascularisation
. Uraemia
. Wound healing/outcome
11-13 September 2008
Lucca, Italy
www.dfsg.org
)-
:LB6
Journal 2008 vol 8 no 2
COPA FOAM DRESSINGS OUTPERFORM
THE LEADING COMPETITION IN FLUID
CAPACITY
0
15
9
8
7
COPA FOAM DRESSINGS PROVIDE
MAXIMUM PATIENT COMFORT
8
Absorptive capacity (cc/in2)
higher figure is more absorbent
7.8
30
Softness (N/cm) lower figure is softer
20.7
45
60
6
75
5
4.8
4
90
105
3
2.7
2
120
1
135
0
150
COPA
Alleryn
Polymem
120.5
COPA
Alleryn
Polymem
Cooperating Organisations
AFIScep.be
GNEAUPP
Wound Management
Association in Belgium
Grupo Nacional para el Estudio y
Asesoramiente en Ulceras por Presión y
Heridas Crónicas
www.gneaupp.org
AISLeC
Italian Nurse Association for
the Study of Cutaneous Wounds
www.aislec.it
AIUC
Italian Association for Cutaneous Ulcers
www.aiuc.it
APTFeridas
GWMA
Greek Wound Management Association
ICW
Initiative Chronische Wunden
www.ic-wunden.de
LBAA
Portuguese Wound
Management Association
www.aptferidas.com
Latvian Wound Treating Organisation
AWA
LUF
Austrian Wound Association
www.a-w-a.at
The Leg Ulcer Forum
www.legulcerforum.org
BFW
LWMA
Belgian Federation of Woundcare
www.befewo.org
Lithuanian Wound
Management Association
CNC
Clinical Nursing Consulting – Wondzorg
www.wondzorg.be
CSLR
Czech Wound Management Society
www.cslr.cz
CWA
Croatian Wound Management
Association
www.kbd.hr/index.php?id=799
MSKT
Hungarian Lymphoedema and
Wound Managing Society
www.euuzlet.hu/mskt/
NATVNS
National Association of Viability Nurse
Specialists (Scotland)
www.natvns.com
NIFS
DGfW
Deutsche Gesellschaft für Wundheilung
www.dgfw.de
DWHS
Danish Wound Danish Wound Healing Society
Healing Society
www.dsfs.org
FWCS
Finnish Wound Care Society
www.suomenhaavanhoitoyhdistys.ﬁ
Norwegian Wound Healing Association
www.nifs-saar.no
NOVW
Dutch Organisation of Wound Care
Nurses
www.novw.org
PWMA
Polish Wound Management Association
www.ptlr.pl
ROWMA
GAIF
Grupo Associativo de Investigacão
em Feridas
www.gaif.net
Romanian Wound Management
Association
www.artmp.ro
SAfW
Swiss Association for Wound Care
www.safw.ch
www.safw-romande.ch
*%
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Journal 2008 vol 8 no 2
Dg\Vc^hVi^dch
SEBINKO
SAWMA
Hungarian Association for the Improvement of Care of Chronic Wounds and
Incontinentia
www.sebinko.hu
Serbian Advanced Wound Management
Association
SFFPC
Tissue Viability Nurses Association
www.tvna.org
TVNA
La Société Française et Francophone de
Plaies et Cicatrisations
www.sffpc.org
TVS
Tissue Viability Society
www.tvs.org.uk
SSiS
WMAI
Swedish Wound Care Nurses Association
www.sarsjukskoterskor.se
Wound Management Association of
Ireland
www.wmaoi.org
SSOOR
Slovak Wound Management Association
WMAK
SUMS
Wound Management Association of
Kosova
Iceland Wound Healing Society
www.sums-is.org
WMAS
Slovenian Wound Management
Association
SWHS
Serbian Wound Healing Society
www.lecenjerana.com
WMAT
SWHS
Wound Management Association
Turkey
www.yaradernegi.org
Swedish Wound Healing Society
www.sarlakning.se
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Associated Organisations
Leg Club
LF
LSN
Lindsay Leg Club Foundation
www.legclub.org
Lymphoedema Framework
www.lymphoedemaframework.org
The Lymphoedema
Support Network
www.lymphoedema.org/lsn
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[email protected]
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