bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the dissemination and implementation of a nutritional guideline for pressure ulcer care
Authors: Meijers J.M.M. , Schols J.M.G.A. , Jackson P.A. , Langer G. , Clark M. , Halfens R.J.G.
Published: May 2014

Objective:

In 2004 the European Pressure Ulcer Advisory Panel nutritional working group developed a nutritional guideline for pressure ulcer prevention and treatment. This study investigated the degree to which the guideline was disseminated and implemented in clinical practice.

Method:

A cross-sectional study was undertaken in health-care organisations in the Netherlands, Germany and the UK. A printed, standardised questionnaire which followed Rogers’ model of the innovation-decision process was developed, translated and distributed to 1087 health-care organisations.

Results:

The response rate was 33% (n=363). Sixty-one per cent of respondents knew of the guideline. Twenty-five per cent had applied it to their clinical practice and used it for nutritional screening. The main barrier to the provision of nutritional support appeared to be lack of knowledge and skills.

Conclusion:

One year after its dissemination, more than half of respondents knew of the guideline, with one in four applying it to their practice. The guideline was better disseminated and implemented in the Netherlands and UK than in Germany, where only 4% of participants had used it.

Declaration of interest:

Numico Netherlands gave EPUAP an unrestricted educational grant.
Evaluation of pH measurement as a method of wound assessment
Authors: Shukla V.K. , Shukla D. , Tiwary S.K. , Agrawal S. , Rastogi A.
Published: May 2014

Objective:

To assess variations in wound pH levels and explore the relationship between wound pH and the state of wound healing.

Method:

Fifty patients with acute or chronic wounds attending the wound clinic at University Hospital, Varanasi, India were included. Wound pH was measured using litmus paper strips and recorded weekly. Other parameters recorded were the wound condition, exudate level and culture.

Results:

The baseline pH of most of the wounds was greater than 8.5. As the wound condition improved and exudate levels decreased, the pH reduced to less than 8.0. Fifty-eight per cent of the wounds were culture positive, and an association was observed between the type of organism present and the wound pH.

Conclusion:

Wound pH measurements can be performed efficiently and are non-invasive, causing no discomfort to the patient. As the wounds healed, the pH reduced. This change in pH can help predict the likelihood of wound healing.

Declaration of interest:

None.
Clinical and microbiological efficacy of MDT in the treatment of diabetic foot ulcers
Authors: Tantawi T.I , Gohar Y.M , Kotb M.M , Beshara F.M , El-Naggar M.M
Published: May 2014

Objective:

To assess the clinical and microbiological efficacy of maggot debridement therapy (MDT) in the management of diabetic foot ulcers unresponsive to conventional treatment and surgical intervention.

Method:

Consecutive diabetic patients with foot wounds presenting at the vascular surgery unit and the diabetic foot unit of Alexandria Main University Hospital were selected for MDT. Lucilia sericata medicinal maggots were applied to the ulcers for three days per week. Changes in the percentage of necrotic tissue and ulcer surface area were recorded each week over the 12-week follow-up period. Semiquantitative swab technique was used to determine the bacterial load before and after MDT.

Results:

The sample comprised 10 patients with 13 diabetic foot ulcers. The mean baseline ulcer surface area was 23.5cm2 (range 1.3–63.1), and the mean percentage of necrotic tissue was 74.9% (range 29.9–100). Complete debridement was achieved in all ulcers in a mean of 1.9 weeks (range 1–4). Five ulcers (38.5%) were completely debrided with one three-day MDT cycle. The mean reduction in ulcer size was significant at 90.2%, and this occurred in a mean of 8.1 weeks (range 2–12). The mean weekly reduction in ulcer size was 16.1% (range 8.3–50). Full wound healing occurred in 11 ulcers (84.6%) within a mean of 7.3 weeks (range 2–10). The bacterial load of all ulcers reduced sharply after the first MDT cycle to below the 105 threshold, which facilitates healing.

Conclusion:

The results highlight the potential benefits of MDT in diabetic wound care in developing countries. MDT was proved to be a rapid, simple and efficient method of treating these ulcers.

Declaration of interest:

None.
Efficacy and efficiency of a streamlined multidisciplinary foot ulcer service
Authors: Hellingman A.A. , Smeets H.J.
Published: May 2014

The structure of a multidisciplinary foot care service was modified to ensure that patient consultations were only attended by the relevant team members. This audit showed the streamlined service still achieved excellent patient outcomes
Influence of bioengineered skin substitutes on diabetic foot ulcer and venous leg ulcer outcomes
Authors: Barber C. , Watt A. , Pham C. , Humphreys K. , Penington A. , Mutimer K. , Edwards M. , Maddern G.
Published: May 2014

This systematic review indicates that bioengineered skin substitutes with a dermal component may improve healing outcomes in diabetic foot ulcers and venous leg ulcers. However, better designed trials with longer follow-up periods are needed
Impact of adhesive surgical tape and wound dressings on the skin, with reference to skin stripping
Authors: Cutting K.F.
Published: May 2014

Age- and disease-related factors can cause the skin to become susceptible to damage, particularly at dressing change. This review recommends ways of avoiding skin trauma when removing adhesive dressings and surgical tapes
Phase 2 study of a new Hydrofiber dressing for superficial chronic or acute wounds
Authors: Faucher N. , Ehrler S. , Vin F. , Dugré T.
Published: May 2014

Objective:

To evaluate the safety and performance of Medicel Tulle Dressing (MTD) in subjects with chronic or acute wounds left to heal by secondary intention.

Method:

This 28-day, multi-centre, single-arm clinical study was conducted at seven sites in France. Thirty patients with a chronic (n=20) or acute wound (n=10) were treated with MTD and gauze as a secondary dressing. Study treatment lasted 28 days or until healing.

Results:

Mean baseline wound area was 14.8cm2. There were 103 clinic dressing changes and 220 home dressing changes. Seven adverse events were reported in five subjects, including one treatment-related adverse event of dry scab. No adherence was reported for 66% of clinic dressing changes and 53% of home dressing changes. No trauma was reported for 96% of clinic dressing changes. Mean reduction in wound size was 7.0cm2.

Conclusion:

In this study, MTD demonstrated good safety results. Additional study is warranted to confirm the clinical utility of MTD in the management of chronic or acute wounds left to heal by secondary intention.

Declaration of interest:

This study was supported by ConvaTec, a division of ER Squibb & Sons, New Jersey, US.
Exudate management: a patient-centred approach
Authors: Dowsett C.
Published: May 2014

This article, the first in a series of three, explores exudate management using a patient-centred approach. It outlines the challenges in achieving an optimum moisture balance and the implications for the patient when this does not occur
Pulse oximetry index: a simple arterial assessment for patients with venous disease
Authors: Bianchi J. , Zamiri M. , Loney M. , McIntosh H. , Dawe R.S. , Douglas W.S.
Published: May 2014

Objective:

To provide additional safety data comparing ankle brachial pressure index (ABPI) and pulse oximetry (Lanarkshire Oximetry Index, LOI) as measures of arterial circulation in patients with venous disease of the leg.

Method:

A total of 107 (195 legs) attending hospital leg ulcer clinics participated in this prospective open study. We attempted to measure brachial and foot arterial pressures in all patients using both the handheld Doppler method (ABPI) and pulse oximeter method (LOI). Features of patients with limbs in which either the ABPI or LOI could not be assessed were documented. ABPI and LOI values were compared, and agreement between the two assessment methods was assessed.

Results:

We found the LOI measurement to be a simpler technique than Doppler ABPI measurement, with an endpoint less prone to the subjective variability associated with the Doppler method. Of the 195 legs assessed, we obtained LOI in 10 in which an ABPI could not be recorded. LOI could not be recorded in only one leg. There was a linear association (p<0.001) and fair agreement (?=0.303) between LOI and ABPI in the 184 legs in which both ratios could be measured. There was no evident tendency for LOI to read either low or high compared with ABPI.

Conclusion:

Pulse oximetry LOI is a simple alternative to Doppler ABPI in the screening of patients for arterial disease that could be a contraindication to, or require modification of, compression therapy. It can be measured in some legs that cannot be assessed by Doppler ultrasound.

Declaration of interest:

None.
Split-skin graft in the management of diabetic foot ulcers
Authors: Mahmoud S.M. , Mohamed A.A. , Mahdi S.E.I. , Ahmed M.E.
Published: May 2014

Objective:

To compare the effects of split-thickness skin grafts versus a conservative wound dressing on the healing times of diabetic foot ulcers and the length of hospital stay.

Method:

In this prospective case-controlled study, 50 patients consented to skin grafting (graft group) and 50 preferred to be managed by conservative dressings (control group). Wound management in both groups was standardised with regard to the dressing materials (which comprised a multilayer dressing including paraffin gauze and diluted povidone-iodine soaked gauze), wound care and surgeon involvement. Graft take, ulcer recurrence rate and donor-site morbidity were assessed. Healing times and the length of hospital stay were compared between the two groups.

Results:

A 100% skin graft take was recorded in 84% of the patients on the fifth postoperative day and in 62% on weeks 3 and 8. All patients in the graft group healed completely, but 8% had an ulcer recurrence and 4% a superficial infection within the following year. The mean healing time and mean length of hospital stay were significantly less in the graft group compared with the control group (p<0.001), reflecting results of similar studies.

Conclusion:

Split-skin grafting is an effective method of managing diabetic foot ulcers as, compared with the conservative dressings used in this study, it reduced healing times and the length of hospital stay, while donor-site morbidity was minimal.

Declaration of interest:

None.
Use of barrier products in the prevention of adhesion formation following surgery
Authors: Darmas B.
Published: May 2014

Postoperative adhesion formation is a significant health-care problem with no universally accepted method of prevention. Barrier methods of prevention have been extensively tested and licensed, and this article examines the evidence
Prevalence of wounds in a community care setting in Ireland
Authors: McDermott-Scales L. , Cowman S. , Gethin G.
Published: May 2014

Objective:

To establish the prevalence of wounds and their management in a community care setting.

Method:

A multi-site, census point prevalence wound survey was conducted in the following areas: intellectual disability, psychiatry, GP practices, prisons, long-term care private nursing homes, long-term care, public nursing homes and the community/public health (district) nursing services on one randomly selected day. Acute services were excluded. Formal ethical approval was obtained. Data were collected using a pre-piloted questionnaire. Education was provided to nurses recording the tool (n=148). Descriptive statistical analysis was performed.

Results:

A 97.2% response rate yielded a crude prevalence rate of 15.6% for wounds across nursing disciplines (290/1,854 total census) and 0.2% for the community area (290/133,562 population statistics for the study area). Crude point prevalence ranged from 2.7% in the prison services (7/262 total prison population surveyed) to 33.5% in the intellectual disability services (72/215 total intellectual disability population surveyed). The most frequent wounds recorded were pressure ulcers (crude point prevalence 4%, 76/1,854 total census; excluding category l crude point prevalence was 2.6%, 49/1,854 total census), leg ulcers (crude point prevalence 2.9%, 55/1,854 total census), self-inflicted superficial abrasions (crude point prevalence 2.2%, 41/1,854 total census) and surgical wounds (crude point prevalence 1.7%, 32/1,854 total census).

Conclusion:

These results support previous international research in that they identify a high prevalence of wounds in the community. The true community prevalence of wounds is arguably much higher, as this study identified only wounds known to the nursing services and excluded acute settings and was conducted on one day.

Declaration of interest:

None.
The PREPARE pilot RCT of home-based progressive resistance exercises for venous leg ulcers
Authors: Jull A. , Parag V. , Walker N. , Maddison R. , Kerse N. , Johns T.
Published: May 2014

Objective:

To establish the feasibility of conducting a home-based progressive resistance exercise programme to improve calf muscle pump function in community-based patients with venous leg ulcers.

Method:

Participants were randomised to receive a 12-week progressive resistance exercise programme using heel raises in addition to compression. The control was usual care in addition to compression. Randomisation was stratifi ed by ulcer duration and ulcer size. Air plethysmography was used to determine changes in calf muscle pump function from baseline. Changes in ulcer parameters were measured using the SilhouetteMobile device.

Results:

Forty participants were randomised. There were significantly greater improvements in ejection fraction of the calf muscle in the exercise group compared with the control (usual care) group (mean difference 18.5%, 95% CI 0.03 to 36.6%, p<0.05). Other parameters improved in the exercise group but the mean differences were not significant. Adherence with prescribed exercises was 81% and there was no significant difference in the numbers reporting adverse events. There were also no significant differences in ulcer healing parameters (change in area, percentage change in area, number healed at 12 weeks, time to healing).

Conclusion:

A community-based randomised trial of progressive resistance exercise is feasible. The prescribed exercises appeared to increase ejection fraction, but the effect of exercise on ulcer healing requires further investigation.

Declaration of interest:

The study was funded by the Health Research Council of New Zealand. ARANZ Medical provided access to a SilhouetteMobile device.
Pyoderma gangrenosum: from misdiagnosis to recognition, a personal perspective
Authors: Hemp L. , Hall S.
Published: May 2014

Successful treatment of pyoderma gangrenosum depends on prompt diagnosis. Here, a patient describes how an inaccurate diagnosis resulted in severe pain and delayed treatment, with a markedly negative effect on quality of life
Use of a biological extracellular matrix wound therapy to heal complex, chronic wounds
Authors: Rando T.
Published: May 2014

This small case series involved four patients with vascular impairment and multiple comorbidities whose wounds had not responded to standard treatment. Use of this novel therapy help initiate wound healing and improve quality of life
Using a novel wound model to investigate the healing properties of products for superficial wounds
Authors: Wigger-Alberti W. , Kuhlmann M. , Ekanayake S. , Wilhelm D. , Buettner H. , Callaghan T. , Wilhelm K.P.
Published: May 2014

Objective:

To establish a new wound model that can induce uniform abrasions and use it to assess the healing properties of a range of products commonly applied to these wounds.

Method:

Ten healthy volunteers were enrolled into an open-label, randomised, intra-individual comparison pilot study. Five standardised, superficial abrasions were induced on their forearms by repeatedly scrubbing the skin with a surgical brush until the first signs of uniform glistening and punctuate bleeding were observed. Three products that promote a moist wound environment (polyurethane, hydrocolloid, hydrogel) and two standard plasters were randomly allocated to the test areas.

Results:

Evaluation of wound healing on days 2, 5, 8 and 14 ±1 showed best results for the polyurethane and hydrocolloid plasters. Visible re-epithelialisation was recorded on days 5 and 8. More than 50% of the wound area had closed. Video microscope images support these findings. The investigator and volunteers assessed cosmetic outcomes on day 31 ±2. Best results were obtained for the polyurethane and hydrocolloid products, which had high mean scores close to the maximum of 10. Histological examination of biopsies taken from the abrasions of two volunteers showed the dermis remained intact, making the model highly suitable for the study of superficial wounds.

Conclusion:

Uniform and identical standardised wounds created using an abrasive brush technique can be used to reliably detect differences in the performance of plasters intended for superficial wounds. In general, products that promote a moist wound environment produced better results than those that promote a dry wound environment, with an earlier onset of healing and better healing outcomes. Superficial cutaneous wounds treated with polyurethane or hydrocolloid products demonstrated superior rates of re-epithelialisation and overall cosmetic outcomes.

Declaration of interest:

This study was funded by Beiersdorf AG. Neither author has any interest in the sponsor's commercial activities.
The resource costs of wound care in Bradford and Airedale primary care trust in the UK
Authors: Vowden K. , Vowden P. , Posnett J.
Published: May 2014

Objective:

To estimate the resource costs of providing wound care for the 488,000 catchment population of the Bradford and Airedale primary care trust (PCT).

Method:

A wound survey was carried out over a one-week period in March 2007 covering three hospitals in two acute trusts, district nurses, nursing homes and residential homes within the geographical area defined by the PCT. The survey included information on the frequency of dressing change, treatment time and district nurse travel time. The resource costs of wound care in the PCT were estimated by combining this information with representative costs for the UK National Health Service and information on dressing spend.

Results:

Prevalence of patients with a wound was 3.55 per 1000 population. The majority of wounds were surgical/trauma (48%), leg/foot (28%) and pressure ulcers (21%). Prevalence of wounds among hospital inpatients was 30.7%. Of these, 11.6% were pressure ulcers, of which 66% were hospitalacquired. The attributable cost of wound care in 2006–2007 was £9.89 million: £2.03 million per 100,000 population and 1.44% of the local health-care budget. Costs included £1.69 million spending on dressings, 45.4 full-time nurses (valued at £3.076 million) and 60–61 acute hospital beds (valued at £5.13 million).

Conclusion:

The cost of wound care is significant. The most important components are the costs of wound-related hospitalisation and the opportunity cost of nurse time. The 32% of patients treated in hospital accounted for 63% of total costs. Putting in place care pathways to avoid hospitalisation and avoiding the development of hospital-acquired pressure ulcers and other wound complications are important ways to reduce costs.

Declaration of interest:

John Posnett is an employee of Smith & Nephew.
A joint collaboration: international pressure ulcer guidelines
Authors: Dealey C.
Published: May 2014

After four years in development, the EPUAP and the NPUAP are ready to release their joint, international, evidence-based pressure ulcer guidelines. This article considers the practice implications of a selection of the new guideline's statements.
Laboratory findings on the exudate-handling capabilities of cavity foam and foam-film dressings
Authors: Thomas S.
Published: May 2014

Objective

To compare the fluid-handling properties of a range of commonly used absorbent foam dressings. Results were analysed to generate broad estimates of wear time, using previously published data for the rate at which exudate is produced by various wound types.

Method

Test data were produced by an independent, accredited test facility using a series of standard test systems, and submitted to the author for review and interpretation.

Results

Absorbency values for the cavity foam dressings tested ranged from 11 to 16 grams per 10cm2 sample under the specified test conditions. The increase in dressing volume ranged from 71% to 206%, although this did not always correlate directly with absorbency values. Foam-film dressing tests revealed large variations in product performance. The total fluid handling capacity of dressings (the sum of absorbency and evaporative loss) ranged from approximately 7 to 26 grams per sample. These differences are largely due to variations in permeability of the film backing layer, which ranged from approximately 2000 to 20 000g/m2/24h. Compression reduced the absorbency of most dressings but it appeared to enhance the performance of one product (possibly through ensuring contact between the test sample and the simulated wound bed). 9 of the 11 sheet dressings tested were estimated to be capable of managing normal levels of wound exudate for 48 hours, based solely on their absorbency figures. Considering the additional effects of moisture vapour permeability, theoretical wear time increases to five days in a number of instances.

Conclusion

The laboratory data suggest considerable differences in the clinical performance of dressings. Making a number of assumptions as stated in the text, predicted values for clinical performance were generated. These estimates show marked differences between dressings.

Declaration of interest

This report was produced by the author for a professional fee, from BSN, as a medical device consultant and medical writer using test data generated independently by an accredited laboratory. The author had no involvement either with the choice of test methods, or the range of dressings included in the study, and has no fi nancial interests in any of the products concerned.
Reflections on the recommendations of the EWMA Patient Outcome Group document
Authors: Ashby R. , Bland J.M. , Cullum N. , Dumville J. , Hall J. , Kang'ombe A. , Madden M. , O'Meara S. , Soares M. , Torgerson D. , Watson J.
Published: May 2014

Last month, JWC published recommendations on improving the quality of evidence in wound management. In response, the Wounds Research Group from the University of York and Richard White, Professor of Tissue Viability, outline their very different perspectives on the type of evidence needed in tissue viability
TGF-β in wound healing: a review
Authors: Douglas H.E.
Published: May 2014

TGF-β, a growth factor involved in various stages of the wound healing process, exists in three different isoforms. Experimental models have shown these isoforms to be functionally different and one of them, TGF-β3, has the potential to reduce scarring in clinical practice. This literature review explores the role of TGF-β in wound healing, examining the research to date.
Simple wound care facilitates full healing in post-earthquake Haiti
Authors: Stephenson F.J.
Published: May 2014

The author provides an insight into the basic health care needs of two spinal cord injury patients who were cared for in a specially set up 25-bedded spinal cord injury unit in Haiti. While focusing on their extreme wound care requirements, the author highlights the need for adequate fluid, nutrition, hygiene and aseptic technique. Both patients were victims of the January 2010 earthquake in Port au Prince, Haiti. The author describes the basic wound care strategy for a patient with a category IV sacral pressure ulcer and another with a broken down thoracic spine surgical wound with visible metal work. This article describes how simple wound care effected the complete healing of large sacral pressure ulcers and broken down spinal surgical wounds without the need for further surgical intervention.
Manuka honey as an effective treatment for chronic pilonidal sinus wounds
Authors: Thomas M. , Hamdan M. , Hailes S. , Walker M.
Published: May 2014

Objective:

A retrospective study to investigate the effectiveness of topical manuka honey in the treatment of chronic or recurrent pilonidal sinus disease (PSD), assessing the ability of this simple dressing technique to achieve complete wound healing, the time taken to achieve healing and the recurrence rate.

Method:

All patients who received manuka honey dressing therapy following surgical intervention for chronic or recurrent PSD were identified over a 4-year period. In a retrospective review of case notes, data were collected on patient sex, age, nature of surgical procedures performed, time to achieve complete wound healing, and recurrences after completion of honey therapy.

Results:

Seventeen patients were eligible for inclusion in the study. Mean time to commence honey therapy post-surgery was 93 days (5–517 days; median 33 days); 15 patients achieved complete wound healing, in a mean time of 65 days (14–264 days; median 49 days). Honey was discontinued in one patient due to an adverse event, and two patients experienced recurrence several months after completing honey therapy.

Conclusion:

Manuka honey dressing therapy provides an effective topical treatment for chronic/recurrent PSD. Further research is necessary to determine the optimum dressing protocol.

Declaration of interest:

The authors have no conflicts of interest to declare. There were no external sources of funding for this study.
Chronic plantar ulcer secondary to congenital indifference to pain
Authors: Simpson A. , Graham M.E. , Williams J.
Published: May 2014

Congenital indifference to pain (CIP) is a rare condition characterised by painless injuries beginning in early life, with normal sensory exam findings. Young people with inexplicable, painless chronic wounds may present to the plastic surgeon for surgical management. Given the young age of onset and high likelihood of postoperative failure, alternative options for closure of non-healing wounds should be considered. We present the case of a 17-year-old boy with congenital indifference to pain and successful management of his longstanding plantar ulcer.
Silver and nanoparticles of silver in wound dressings: a review of efficacy and safety
Authors: Wilkinson L.J. , White R.J. , Chipman J.K.
Published: May 2014

Wound infections present a significant clinical challenge, impacting on patient morbidity and mortality, with significant economic implications. Silver-impregnated wound dressings have the potential to reduce both wound bioburden and healing time. The silver ion Ag+ is the active antimicrobial entity; it can interfere with thiol (−SH) groups and provoke the generation of reactive oxygen species (ROS), a major contributor to its antibacterial efficacy. Recently, silver nanoparticles have gained considerable interest in wound bioburden reduction and in anti-inflammation, as they can release Ag+ ions at a greater rate than bulk silver, by virtue of their large surface area. If released from dressings, they also have the potential to cross biological compartments. This review aims to consolidate recent findings as to the efficacy and safety of different formulations of silver used as an antiseptic agent in dressings, summarising the features of silver nanomaterials, with particular attention to the dose-dependencies for biological effects, highlighting the need for information on their uptake and potential biological effects.
Bacterial translocation from the gastrointestinal tract in healthy and injured rats
Authors: Nikitenko V.I. , Stadnikov A.A. , Kopylov V.A.
Published: May 2014

Objective: To study the phenomenon of asymptomatic penetration of bacteria from the gastrointestinal tract into various tissues of healthy rats and rats with skin wounds and closed fractures at different doses and with different species of bacteria. Method: Healthy rats and rats with full-thickness skin wounds and closed femoral fractures were given varying doses of radiolabeled bacteria (S. aureus 209P or B. subtilis 534) per os in doses of up to 1010 bacteria per 1kg of body mass. Six hours later, these animals were euthanised and, together with blood smears, tissue samples of liver, spleen, stomach, small and large intestine, lung, hypothalamus, posterior pituitary gland, epinephros and skin and muscle from the wound site were subjected to bacteriological and histological analysis. Results: In total, 99 rats were used for the experiments.viable bacteria were found to systemically penetrate into the tissues of the internal organs in 45 healthy animals, 27 rats with incisions and 27 rats with fractures. In healthy animals, viable bacteria mostly accumulated in the stomach wall, the mucous membranes of the small intestine, the mesenteric lymph nodes and in the spleen and liver. Translocation was registered in uninjured animals receiving 1×106 and more bacteria per 1kg of rat's weight and in injured rats receiving 1×104 bacteria and more. Bacteria penetrated the local tissues at both wound sites (skin wounds and fracture sites). Conclusion: Bacterial translocation is a protective mechanism that gives the immune system constant contact with external antigens, although it can contribute to the spreading of infection in an organism. In healthy animals, small amounts of bacteria penetrate systemically from the tract and small intestine into the tissues of the spleen and liver. During injury, translocated bacteria also appear at the focus of injury. Conflict of interest: None.
Minor amputation in patients with diabetes mellitus and severe foot ulcers achieves good outcomes
Authors: Svensson H. , Apelqvist J. , Larsson J. , Lindholm E. , Eneroth M.
Published: May 2014

Objective: To analyse the outcome of minor amputations (through, or distal to, the ankle joint) in patients with diabetes. Method: All diabetic patients in a defined population undergoing one or more minor amputation between 1982 and 2006 were investigated according to a standardised protocol and were followed until final outcome (healing or death). A total of 410 consecutive amputations in 309 patients with a median age of 73 (32-93) years were identified. Results: In 94% of amputations, deep infection (39%) and/or gangrene (55%) was present. Severe peripheral vascular disease or critical limb ischaemia was present in 61% of amputations. 261/410 (64%) of the amputations healed at a level below the ankle joint; 69/410 (17%) healed after a re-amputation above the ankle joint; in 76/410 of amputations (19%), the patient died before healing could occur. In surviving patients, 79% of the amputations healed below the ankle. Median healing time for amputations that healed below the ankle was 26 (2-250) weeks; 21% of amputations required a re-amputation above the ankle. None of the analysed parameters excluded the possibility of healing below the ankle. Conclusion: In this population-based survey, the goal of avoiding major amputation was achieved in almost two thirds of minor amputations, but at the price of long healing times. In almost all amputations, the patient had deep infection and/or gangrene. In spite of this, 64% of all amputations, and 79% of amputations in surviving patients, healed at a level below the ankle. This indicates that minor amputations in these patients are worthwhile. Declaration of interest: None.
Vitamins and cutaneous wound healing
Authors: Sinno S. , Lee D.S. , Khachemoune A.
Published: May 2014

Background: Vitamins have long been thought to modulate the various stages of wound healing through a variety of proposed mechanisms. Our goal was to investigate relevant studies examining the role of different vitamins in wound healing. Methods: MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched for basic science and clinical studies examining the role of vitamins as adjuncts in wound healing. Results: Mechanisms of action for each of the vitamins are reviewed. It was suggested by many of the studies that the major vitamins A, C, E, D, K, and B have demonstrated utility as adjuncts in wound care in basic science and clinical trials. Conclusion: There is a vast amount of literature on the effect of vitamins on wound healing at the basic science level. Further understanding and controlled trials will help better understand how to utilize vitamins in wound care. Declaration of interest: none.
Fact or myth? Pain reduction in solvent-assisted removal of adhesive tape
Authors: van Schaik R. , Rovekamp M.H.
Published: May 2014

•Objective: To determine if solvent-assisted tape removal reduces pain when compared with dry tape removal.

•Method: A double-blinded comparative study was performed, in which commonly used solvents, namely water, alcohol, peanut oil, sunflower oil, and Leukotape remover (BsN medical), were applied to six zinc oxide adhesive tapes (Leukoplast, BsN medical), 10cm long, 2.5cm wide that had been placed on the volar side of each forearm of adult volunteers. One tape was left dry. Pain was measured using a visual analogue scale (vAs) and statistically analysed.

•Results: There were no statistically significant differences in vas pain scores between the used substances when compared with the dry tape (p=0.39). The use of oil (peanut and sunflower) caused remains of adhesive to occur significantly more often (p < 0.05).

•Conclusion: Applying substances to ease pain associated with the removal of adhesive tapes does not lead to a reduction of pain when compared with dry tape.

•Conflict of interest: none.
Extended leg infection of diabetic foot ulcers: risk factors and outcome
Authors: Adam K.M. , Mahmoud S.M. , Mahadi S.I. , Widatalla A.H. , Shawer M.A.G. , Ahmed M.E.
Published: May 2014

Objective:

To identify the risk factors for extension of infection to the leg in diabetic foot ulcers (DFU) and to evaluate its role as a prognostic measure regarding limb salvage and healing time.

Method:

This retrospective case-control study took place in Jabir Abu Eliz Diabetic (JADC) during 2006–2008. Forty-eight patients diagnosed with a diabetic foot ulcer (DFU) with the infection extending to the leg (case group) were compared with an equal number of patients with a DFU without extension (control group). risk factors for extension were identified by univariate analysis and both groups were compared with regard to limb salvage and healing time.

Results:

Previous history of toe amputation was more frequent in the case group (p=0.004). the case group patients were significantly more likely to present with fever (p=0.01), pallor (p=0.02), confusion (p=0.04), and necrosis (p=0.004). Ulcers located in the heel were more frequent in the case group when compared with controls (p=0.0001) while more toes ulcers were found in the control group (p=0.001). A significant number of patients in the case group had an ulcer of more than 5cm diameter compared with those in the control group (p=0.001). the total number of patients presented with severe disease (Wagner grade 3–5) was significantly more in the case group compared with controls (p=0.004). patients with severe infection (grade 4) were more in the case group compared with the controls (p=0.04). there were no significant differences between the two groups with regard to major and minor amputation rate. the case group had a longer duration of healing when compared with the controls. seventy-five per cent of the controls healed by 6 months (n=31) compared with 22% in the case group (n=8; p=0.001).

Conclusion:

Toe amputation, wound located in the heel, wound size more than 5cm and advanced Wagner grade (3–5) and severe sepsis, grade 4, may be considered as risk factors for extension of infection to the leg in DFU. However, this extension did not carry a poor prognostic value to the final outcome if adequate therapeutic measures were followed.

Conflict of interest:

None.
Why use topical antiseptics?
Authors: Cutting Keith F.
Published: May 2014

Not all wounds heal in a timely fashion at an expected rate. In many cases, this delay in healing occurs because an infection is present. In some cases, the infection manifests as a wound biofilm, with the wound developing a subtle form of inflammation. In such instances, topical treatment with antiseptics is warranted. This article describes when they need to be used
Case series of sural island flaps used for soft-tissue defects of the distal-third lower extremity
Authors: Steffner R.J. , Spiguel A. , Ranieri J. , Suk M. , Yoo B.J.
Published: May 2014

Objective:

To establish the sural island fasciocutaneous flap as an initial consideration for distal third lower-extremity soft tissue coverage and to provide non-plastic surgeons with a procedure they can perform on their own.

Method:

Literature on reverse sural island fasciocutaneous flaps was reviewed and summarised. We then assessed our case series of sural island flaps from 2008–2011 and looked to provide our operative technique and patient outcomes.

Results:

Nine patients, aged 12–70 years old, with greater than 1 year follow-up, were reviewed. Five patients had diabetes, peripheral vascular disease, or smoked tobacco. All patients healed their soft tissue coverage with minimal complication and were able to accommodate normal footwear.

Conclusion:

Reverse sural island flaps are resilient flaps that should be considered as an alternative to free muscle transfer, for distal third lower extremity coverage.

Declaration of interest:

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
Risk of diabetic foot ulceration during treatment with insulin glargine and NPH insulin
Authors: Kostev K. , Dippel F.W. , Rockel T. , Siegmund T.
Published: May 2014

Objective:

To evaluate the effect of the long-acting basal insulin analog glargine compared with neutral protamine Hagedorn (NPH) insulin on the incidence of diabetic foot ulceration (DFU) in patients with diabetes in Germany.

Method:

A retrospective cohort study was performed using a representative German database (IMS Disease Analyzer) of patients with type 2 diabetes, who started a basal insulin therapy with either insulin glargine or NPH insulin, between July 2000 and September 2007, and continued this therapy for at least 24 months, and whose data were continuously documented. The occurrence of DFU was recorded beginning in the third year after therapy initiation and Kaplan-Meier curves were generated and compared using log-rank tests. Cox proportional hazard models were used to estimate the adjusted hazard ratio (HR) and 95% confidence intervals (CI) for the incidence of DFU.

Results:

Patients who fulfilled the inclusion criteria (n=23 395) had started either on insulin glargine (n=9638) or on NPH insulin (n=13 757). After adjustment for demographic and clinical variables, it was demonstrated that the relative risk to diabetes patients of developing DFS is 64% lower with insulin glargine than with NPH insulin therapy (HR=0.611; p=0.0405).

Conclusion:

The results suggest that, compared with NPH insulin, insulin glargine therapy significantly reduces the risk of DFS in patients with diabetes under real life conditions. Prospective long-term trials are needed to confirm these secondary data analysis results.

Declaration of interest:

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
The impact of water mattresses on incidence of PUs in patients with spinal cord injuries in Nigeria
Authors: Nwadinigwe C.U. , Anyaehie U.E. , Onyegbule E.C.
Published: May 2014

Objective:

To evaluate the impact of water mattresses on the incidence of pressure ulcers and length of hospitalisation in patients with spinal cord injuries in Nigeria.

Method:

A retrospective review was conducted of all patients who presented and were managed for complete traumatic spinal cord injury between January 2005 and December 2008. This period included 2 years prior to, and 2 years following, the introduction of water mattresses to the ward; patients from these periods were grouped as A and B, respectively. Information collated from the medical records included demographic data, wound aetiology, time to presentation, level of injury, complications, treatment, and duration of hospitalisation and follow-up. Outcome measures were presence or absence of pressure ulcers and length of hospital stay.

Results:

In total, 201 patients were treated within the study period. Of these, 99 patients met the inclusion criteria; 35 patients (19 paraplegics and 16 tetraplegics) were managed between 2005 and 2006 (group A), while 64 patients (28 paraplegics and 36 tetraplegics) were managed in 2007 and 2008 (group B). The age range of the included patients was 9–76 years (39.0 ± 4.6 years and 41.5 ± 3.2 years for groups A and B, respectively) and all were male. Patient characteristics were similar for the two groups; however, there was a significant difference between the two groups in terms of presence of pressure ulcers, deteriorating of existing ulcers and condition of the patient on discharge (p < 0.05).

Conclusion:

The majority of pressure ulcers are preventable and a simple support surface, such as water mattresses, can reduce the incidence and magnitude of pressure ulceration, thus reducing hospital stay.

Declaration of interest:

The authors do not have any financial relationship with any organisation that manufactures water mattresses, either locally or overseas. There were no external sources of funding for this study.
Effect of a DACC dressing on the growth properties and proliferation rate of cultured fibroblasts
Authors: Falk P. , Ivarsson M.L.
Published: May 2014

• Objective: To study the morphology and proliferation of cultured fibroblasts in combination with an experimental wound-healing model using cultured fibroblasts, with and without the presence of a hydrophobic, dialkyl carbamoyl chloride (DACC) dressing (Sorbact; Abigo Medical AB). • Method: Human dermal fibroblasts were cultured and cell morphology and viability were investigated. Proliferation was investigated using an XTT assay. An experimental wound-healing model was employed, whereby mechanical damage was inflicted to the surface of cultured fibroblasts. The healing and closure of the wound was then monitored with and without the presence of the DACC dressing. • Results: Fibroblasts did not adhere easily to the dressing material. The presence of the DACC dressing increased the average proliferation rate of cultured fibroblasts by 50% compared with the untreated control medium (p < 0.05). The DACC dressing significantly increased the healing rate by more than 100% after 72 hours (p < 0.05) in the experimental model of wound healing, compared with the medium only. • Conclusion: The enhanced wound healing observed in different types of wounds using the DACC dressing might be explained by an increase in cell growth and proliferation rate of cells in the wound area. • Declaration of interest: This work was supported by ABIGO Medical AB, Sweden. All expenses for cell culture materials and technical work performed at the laboratory was funded by ABIGO. The authors have no conflicts of interest to declare.
Fifteen pressure ulcers presenting in a known paediatric case of histiocytoma of the spine
Authors: Lunawat A. , Prajapati R.M. , Somani A. , Sanghvi J. , Singh S. , Charles N.
Published: May 2014

Patients with profound sensorimotor deficits following spinal trauma/post spinal surgery are vulnerable to develop pressure ulceration. Here we present an unusual case of multiple pressure ulcers in an 11-year-old paraplegic child, with histiocytoma of the spine at the T1–T3 level. Although multiplicity of ulcers is not uncommon, this was the first case, in our institute, in which such a large number of pressure ulcers were encountered in a child. Successful management, using a multidisciplinary approach, led to improved quality of life and, at follow-up of more than 1 year, the child has not developed any new pressure ulcers, and neither is there any recurrence.
Relative cost-effectiveness of a skin protectant in managing venous leg ulcers in the UK
Authors: Guest J.F. , Taylor R.R. , Vowden K. , Vowden P.
Published: May 2014

Objective:

To estimate the clinical and cost-effectiveness of using a skin protectant (Cavilon No Sting Barrier Film [NSBF] or Cavilon Durable Barrier Cream [DBC]; 3M) compared with not using a skin protectant in the management of venous leg ulcers (VLUs), in the UK.

Method:

A decision model was constructed depicting the patient pathways and associated management of a cohort of patients with and without a Cavilon formulation, plus dressings and compression. The model was based on the case records of a cohort of matched patients from The Health Improvement Network (THIN) database, who were first diagnosed with a VLU between 1 Jan 2008 and 31 Dec 2009. The model estimated the costs and outcomes of patient management over 6 months and the cost-effectiveness of using a Cavilon formulation relative to not using a skin protectant.

Results:

Patients' mean age was 80.2 years and 61% were female. Sixty-five per cent (n=166) of Cavilon patients received NSBF, and 35% received DBC. Between 6% and 9% of VLUs were healed at 6 months and 53–66% became infected. Healing was affected by a patient's age (OR: 0.944 for each additional year), but not by gender, level of exudate or wound size. There was a significantly greater reduction in wound size among patients in the NSBF group than in the other two groups (p < 0.001). Additionally, there was no significant difference in the initial wound size of those VLUs that did and did not heal in the two Cavilon groups; however, initial size of the VLUs that healed in the control group was significantly smaller than those that did not (p<0.001). Resource use was similar between the three groups. Patients were predominantly managed by practice nurses, with a mean 37–38 nurse visits over the study period. Patients' dressings were changed, on average, every 4–5 days, with a mean of 3 dressings under a compression bandage. The total 6-monthly NHS cost of managing a VLU was ∼£2200. Practice nurse visits were the primary cost driver, accounting for up to 58% of the 6-monthly NHS cost, whereas dressings accounted for < 10% of the cost.

Conclusion:

Use of NSBF leads to significantly greater wound size reduction than that observed in the other two groups and may facilitate the healing of larger wounds without increasing costs. Hence, use of NSBF for peri-wound skin protection in patients with exuding VLUs is the preferred treatment strategy.

Declaration of interest:

This study was sponsored by 3M Health Care, manufacturers of Cavillon NSBF and Cavillon DBC. However, the authors have no other conflicts of interest that are directly relevant to the content of this manuscript, which remains their sole responsibility.
Pyoderma gangrenosum: guideline for wound practitioners
Authors: Ratnagobal S. , Sinha S.
Published: May 2014

Pyoderma gangrenosum (PG) is an atypical ulceration of the skin with unknown aetiology, usually associated with autoimmune systemic illnesses and haematological malignancies. Diagnosis is based on clinical suspicion and exclusion of other conditions. Treatment options vary greatly, ranging from conservative local and systemic immunosuppression to surgical measures, including amputation, but none is shown to be universally effective. Currently no guideline regarding escalation of treatment exists. Based on a review of the current literature and three illustrative cases of PG, a working treatment guideline is presented for wound practitioners.